White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Eosinophil Urine

Facility

$138.00

Service Code	HCPCS 87205
Hospital Charge Code	4108705
Hospital Revenue Code	306
Rate for Payer: Cash Price	$93.84

Eosinophil Urine

Facility

$138.00

Service Code	HCPCS 87205
Hospital Charge Code	4108705
Hospital Revenue Code	306
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$99.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.27
Rate for Payer: Amerigroup Medicare	$4.27
Rate for Payer: BCBS of TX Blue Advantage	$41.40
Rate for Payer: BCBS of TX Blue Essentials	$49.68
Rate for Payer: BCBS of TX Medicare	$4.27
Rate for Payer: BCBS of TX PPO	$55.20
Rate for Payer: Cash Price	$93.84
Rate for Payer: Cash Price	$93.84
Rate for Payer: Cigna Medicaid	$99.36
Rate for Payer: Cigna Medicare	$4.27
Rate for Payer: Employer Direct Commercial	$4.27
Rate for Payer: Humana Medicare/TRICARE	$4.27
Rate for Payer: Molina CHIP/Medicaid	$99.36
Rate for Payer: Molina Dual Medicare/Medicaid	$4.27
Rate for Payer: Molina Medicare	$4.27
Rate for Payer: Multiplan Auto	$89.70
Rate for Payer: Multiplan Commercial	$89.70
Rate for Payer: Multiplan Workers Comp	$89.70
Rate for Payer: Parkland Medicaid	$99.36
Rate for Payer: Scott and White EPO/PPO	$5.34
Rate for Payer: Scott and White Medicare	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$99.36
Rate for Payer: Superior Health Plan EPO	$4.27
Rate for Payer: Superior Health Plan Medicare	$4.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.27
Rate for Payer: Universal American Medicare	$4.27
Rate for Payer: Wellcare Medicare	$4.27
Rate for Payer: Wellmed Medicare	$4.27

EP CARDIAC MAPPING

Facility

$5,323.00

Service Code	HCPCS 93609
Hospital Charge Code	4610600
Hospital Revenue Code	480
Min. Negotiated Rate	$479.07
Max. Negotiated Rate	$3,832.56
Rate for Payer: Amerigroup CHIP/Medicaid	$479.07
Rate for Payer: BCBS of TX Blue Advantage	$1,596.90
Rate for Payer: BCBS of TX Blue Essentials	$1,916.28
Rate for Payer: BCBS of TX PPO	$2,129.20
Rate for Payer: Cash Price	$3,619.64
Rate for Payer: Cigna Medicaid	$3,832.56
Rate for Payer: Molina CHIP/Medicaid	$3,832.56
Rate for Payer: Multiplan Auto	$3,459.95
Rate for Payer: Multiplan Commercial	$3,459.95
Rate for Payer: Multiplan Workers Comp	$3,459.95
Rate for Payer: Parkland Medicaid	$3,832.56
Rate for Payer: Scott and White EPO/PPO	$2,661.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,832.56
Rate for Payer: Superior Health Plan EPO	$723.93

EP CARDIAC MAPPING

Facility

$5,323.00

Service Code	HCPCS 93609
Hospital Charge Code	4610600
Hospital Revenue Code	480
Rate for Payer: Cash Price	$3,619.64

EP COMP STUDY W/INDUCTN

Facility

$10,248.00

Service Code	HCPCS 93620
Hospital Charge Code	4610620
Hospital Revenue Code	480
Rate for Payer: Cash Price	$6,968.64

EP COMP STUDY W/INDUCTN

Facility

$10,248.00

Service Code	HCPCS 93620
Hospital Charge Code	4610620
Hospital Revenue Code	480
Min. Negotiated Rate	$922.32
Max. Negotiated Rate	$16,562.21
Rate for Payer: Amerigroup CHIP/Medicaid	$922.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Amerigroup Medicare	$7,835.21
Rate for Payer: BCBS of TX Blue Advantage	$9,829.14
Rate for Payer: BCBS of TX Blue Essentials	$11,771.42
Rate for Payer: BCBS of TX Medicare	$7,835.21
Rate for Payer: BCBS of TX PPO	$14,831.99
Rate for Payer: Cash Price	$6,968.64
Rate for Payer: Cash Price	$6,968.64
Rate for Payer: Cash Price	$6,968.64
Rate for Payer: Cigna Commercial	$16,562.21
Rate for Payer: Cigna Medicaid	$7,378.56
Rate for Payer: Cigna Medicare	$7,835.21
Rate for Payer: Employer Direct Commercial	$7,835.21
Rate for Payer: Humana Medicare/TRICARE	$7,835.21
Rate for Payer: Molina CHIP/Medicaid	$7,378.56
Rate for Payer: Molina Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Molina Medicare	$7,835.21
Rate for Payer: Multiplan Auto	$6,661.20
Rate for Payer: Multiplan Commercial	$6,661.20
Rate for Payer: Multiplan Workers Comp	$6,661.20
Rate for Payer: Parkland Medicaid	$7,378.56
Rate for Payer: Scott and White EPO/PPO	$5,124.00
Rate for Payer: Scott and White Medicare	$7,835.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,378.56
Rate for Payer: Superior Health Plan EPO	$7,835.21
Rate for Payer: Superior Health Plan Medicare	$7,835.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Universal American Medicare	$7,835.21
Rate for Payer: Wellcare Medicare	$7,835.21
Rate for Payer: Wellmed Medicare	$7,835.21

EP DRUG FOLLOW-UP STUDY

Facility

$7,552.00

Service Code	HCPCS 93624
Hospital Charge Code	4610630
Hospital Revenue Code	480
Min. Negotiated Rate	$679.68
Max. Negotiated Rate	$16,562.21
Rate for Payer: Amerigroup CHIP/Medicaid	$679.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Amerigroup Medicare	$7,835.21
Rate for Payer: BCBS of TX Blue Advantage	$2,265.60
Rate for Payer: BCBS of TX Blue Essentials	$2,718.72
Rate for Payer: BCBS of TX Medicare	$7,835.21
Rate for Payer: BCBS of TX PPO	$3,020.80
Rate for Payer: Cash Price	$5,135.36
Rate for Payer: Cash Price	$5,135.36
Rate for Payer: Cash Price	$5,135.36
Rate for Payer: Cigna Commercial	$16,562.21
Rate for Payer: Cigna Medicaid	$5,437.44
Rate for Payer: Cigna Medicare	$7,835.21
Rate for Payer: Employer Direct Commercial	$7,835.21
Rate for Payer: Humana Medicare/TRICARE	$7,835.21
Rate for Payer: Molina CHIP/Medicaid	$5,437.44
Rate for Payer: Molina Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Molina Medicare	$7,835.21
Rate for Payer: Multiplan Auto	$4,908.80
Rate for Payer: Multiplan Commercial	$4,908.80
Rate for Payer: Multiplan Workers Comp	$4,908.80
Rate for Payer: Parkland Medicaid	$5,437.44
Rate for Payer: Scott and White EPO/PPO	$3,776.00
Rate for Payer: Scott and White Medicare	$7,835.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,437.44
Rate for Payer: Superior Health Plan EPO	$7,835.21
Rate for Payer: Superior Health Plan Medicare	$7,835.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Universal American Medicare	$7,835.21
Rate for Payer: Wellcare Medicare	$7,835.21
Rate for Payer: Wellmed Medicare	$7,835.21

EP DRUG FOLLOW-UP STUDY

Facility

$7,552.00

Service Code	HCPCS 93624
Hospital Charge Code	4610630
Hospital Revenue Code	480
Rate for Payer: Cash Price	$5,135.36

EP EVAL AICD LEADS INIT

Facility

$1,882.00

Service Code	HCPCS 93640
Hospital Charge Code	4610640
Hospital Revenue Code	480
Min. Negotiated Rate	$169.38
Max. Negotiated Rate	$1,355.04
Rate for Payer: Amerigroup CHIP/Medicaid	$169.38
Rate for Payer: BCBS of TX Blue Advantage	$564.60
Rate for Payer: BCBS of TX Blue Essentials	$677.52
Rate for Payer: BCBS of TX PPO	$752.80
Rate for Payer: Cash Price	$1,279.76
Rate for Payer: Cigna Medicaid	$1,355.04
Rate for Payer: Molina CHIP/Medicaid	$1,355.04
Rate for Payer: Multiplan Auto	$1,223.30
Rate for Payer: Multiplan Commercial	$1,223.30
Rate for Payer: Multiplan Workers Comp	$1,223.30
Rate for Payer: Parkland Medicaid	$1,355.04
Rate for Payer: Scott and White EPO/PPO	$941.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,355.04
Rate for Payer: Superior Health Plan EPO	$255.95

EP EVAL AICD LEADS INIT

Facility

$1,882.00

Service Code	HCPCS 93640
Hospital Charge Code	4610640
Hospital Revenue Code	480
Rate for Payer: Cash Price	$1,279.76

ePHEDrine 50 mg/ml 1 ml vial

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78406597
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

ePHEDrine 50 mg/ml 1 ml vial

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78406597
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Epidermal Autograft Face/Neck/Hf/G First 100 Sq cm

Facility

$5,070.00

Service Code	HCPCS 15115
Hospital Charge Code	7150914
Hospital Revenue Code	361
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$3,447.60
Rate for Payer: Cash Price	$3,447.60
Rate for Payer: Cash Price	$3,447.60
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$3,650.40
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$3,650.40
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$3,650.40
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,650.40
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Epidermal Autograft Face/Neck/Hf/G First 100 Sq cm

Facility

$5,070.00

Service Code	HCPCS 15115
Hospital Charge Code	7150914
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,447.60

Epidermal Autograft Trnk/Arms/Legs First 100 Sq cm

Facility

$5,206.00

Service Code	HCPCS 15110
Hospital Charge Code	7150912
Hospital Revenue Code	361
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$3,540.08
Rate for Payer: Cash Price	$3,540.08
Rate for Payer: Cash Price	$3,540.08
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$3,748.32
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$3,748.32
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$3,748.32
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,748.32
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Epidermal Autograft Trnk/Arms/Legs First 100 Sq cm

Facility

$5,206.00

Service Code	HCPCS 15110
Hospital Charge Code	7150912
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,540.08

Epidural Ea Addl 15 Min BCE

Facility

$625.00

Hospital Charge Code	320020
Hospital Revenue Code	370
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$450.00
Rate for Payer: Amerigroup CHIP/Medicaid	$56.25
Rate for Payer: BCBS of TX Blue Advantage	$187.50
Rate for Payer: BCBS of TX Blue Essentials	$225.00
Rate for Payer: BCBS of TX PPO	$250.00
Rate for Payer: Cash Price	$425.00
Rate for Payer: Cigna Medicaid	$450.00
Rate for Payer: Molina CHIP/Medicaid	$450.00
Rate for Payer: Multiplan Auto	$406.25
Rate for Payer: Multiplan Commercial	$406.25
Rate for Payer: Multiplan Workers Comp	$406.25
Rate for Payer: Parkland Medicaid	$450.00
Rate for Payer: Scott and White EPO/PPO	$312.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$450.00
Rate for Payer: Superior Health Plan EPO	$85.00

Epidural Ea Addl 15 Min BCE

Facility

$625.00

Hospital Charge Code	320020
Hospital Revenue Code	370
Rate for Payer: Cash Price	$425.00

Epidural First 60 Min BCE

Facility

$4,210.00

Hospital Charge Code	320019
Hospital Revenue Code	370
Min. Negotiated Rate	$378.90
Max. Negotiated Rate	$3,031.20
Rate for Payer: Amerigroup CHIP/Medicaid	$378.90
Rate for Payer: BCBS of TX Blue Advantage	$1,263.00
Rate for Payer: BCBS of TX Blue Essentials	$1,515.60
Rate for Payer: BCBS of TX PPO	$1,684.00
Rate for Payer: Cash Price	$2,862.80
Rate for Payer: Cigna Medicaid	$3,031.20
Rate for Payer: Molina CHIP/Medicaid	$3,031.20
Rate for Payer: Multiplan Auto	$2,736.50
Rate for Payer: Multiplan Commercial	$2,736.50
Rate for Payer: Multiplan Workers Comp	$2,736.50
Rate for Payer: Parkland Medicaid	$3,031.20
Rate for Payer: Scott and White EPO/PPO	$2,105.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,031.20
Rate for Payer: Superior Health Plan EPO	$572.56

Epidural First 60 Min BCE

Facility

$4,210.00

Hospital Charge Code	320019
Hospital Revenue Code	370
Rate for Payer: Cash Price	$2,862.80

Epidurography, radiological supervision and interpretation

Facility

$10,000.00

Service Code	CPT 72275
Hospital Charge Code	36072275
Hospital Revenue Code	360
Min. Negotiated Rate	$140.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$140.93
Rate for Payer: BCBS of TX Blue Essentials	$169.11
Rate for Payer: BCBS of TX PPO	$188.76
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00

Epidurography, radiological supervision and interpretation

Facility

$3,540.00

Service Code	HCPCS 72275
Hospital Charge Code	9900898
Hospital Revenue Code	360
Min. Negotiated Rate	$140.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$318.60
Rate for Payer: BCBS of TX Blue Advantage	$140.93
Rate for Payer: BCBS of TX Blue Essentials	$169.11
Rate for Payer: BCBS of TX PPO	$188.76
Rate for Payer: Cash Price	$2,407.20
Rate for Payer: Cash Price	$2,407.20
Rate for Payer: Cash Price	$2,407.20
Rate for Payer: Cigna Medicaid	$2,548.80
Rate for Payer: Molina CHIP/Medicaid	$2,548.80
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$2,548.80
Rate for Payer: Scott and White EPO/PPO	$1,770.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,548.80
Rate for Payer: Superior Health Plan EPO	$481.44

Epidurography, radiological supervision and interpretation

Facility

$3,540.00

Service Code	HCPCS 72275
Hospital Charge Code	9900898
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,407.20

EPINEPHrine 0.1 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J0169
Hospital Charge Code	78435731
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

EPINEPHrine 0.1 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J0169
Hospital Charge Code	78435731
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Know your out-of-pocket cost for care.

All Charges