White Rock Medical Center

All Charges

Charge

Type

Setting

Price

INSRT/REPOSTN ELECT SNGL/DUAL AICD

Facility

$41,346.00

Service Code	CPT 33249
Hospital Charge Code	2300127
Hospital Revenue Code	360
Min. Negotiated Rate	$663.64
Max. Negotiated Rate	$81,352.25
Rate for Payer: Aetna Commercial	$22,740.30
Rate for Payer: Aetna Medicare	$45,131.62
Rate for Payer: Amerigroup CHIP/Medicaid	$21,852.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,087.75
Rate for Payer: Amerigroup Medicare	$30,087.75
Rate for Payer: BCBS of TX Blue Advantage	$53,912.01
Rate for Payer: BCBS of TX Blue Essentials	$64,565.28
Rate for Payer: BCBS of TX Medicare	$30,087.75
Rate for Payer: BCBS of TX PPO	$81,352.25
Rate for Payer: Cash Price	$36,384.48
Rate for Payer: Cash Price	$36,384.48
Rate for Payer: Cash Price	$36,384.48
Rate for Payer: Cigna Commercial	$68,157.46
Rate for Payer: Cigna Medicaid	$21,852.74
Rate for Payer: Cigna Medicare	$30,087.75
Rate for Payer: Employer Direct Commercial	$30,087.75
Rate for Payer: Humana Medicare/TRICARE	$30,087.75
Rate for Payer: Molina CHIP/Medicaid	$21,852.74
Rate for Payer: Molina Dual Medicare/Medicaid	$30,087.75
Rate for Payer: Molina Medicare	$30,087.75
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	$21,852.74
Rate for Payer: Scott and White EPO/PPO	$663.64
Rate for Payer: Scott and White Medicare	$30,087.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,852.74
Rate for Payer: Superior Health Plan EPO	$30,087.75
Rate for Payer: Superior Health Plan Medicare	$30,087.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,087.75
Rate for Payer: Universal American Medicare	$30,087.75
Rate for Payer: Wellcare Medicare	$30,087.75
Rate for Payer: Wellmed Medicare	$30,087.75

INSRT/REPOSTN ELECT SNGL/DUAL AICD

Facility

$41,346.00

Service Code	CPT 33249
Hospital Charge Code	2300127
Hospital Revenue Code	360
Rate for Payer: Cash Price	$36,384.48

INSRT SUBQ CAR RHYTHM MNTR

Facility

$18,217.00

Service Code	CPT 33285
Hospital Charge Code	2300090
Hospital Revenue Code	481
Min. Negotiated Rate	$138.95
Max. Negotiated Rate	$19,257.46
Rate for Payer: Aetna Commercial	$8,755.00
Rate for Payer: Aetna Medicare	$11,654.54
Rate for Payer: Amerigroup CHIP/Medicaid	$1,639.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,769.69
Rate for Payer: Amerigroup Medicare	$7,769.69
Rate for Payer: BCBS of TX Blue Advantage	$12,761.89
Rate for Payer: BCBS of TX Blue Essentials	$15,283.70
Rate for Payer: BCBS of TX Medicare	$7,769.69
Rate for Payer: BCBS of TX PPO	$19,257.46
Rate for Payer: Cash Price	$16,030.96
Rate for Payer: Cash Price	$16,030.96
Rate for Payer: Cash Price	$16,030.96
Rate for Payer: Cigna Commercial	$17,600.59
Rate for Payer: Cigna Medicaid	$5,760.21
Rate for Payer: Cigna Medicare	$7,769.69
Rate for Payer: Employer Direct Commercial	$7,769.69
Rate for Payer: Humana Medicare/TRICARE	$7,769.69
Rate for Payer: Molina CHIP/Medicaid	$5,760.21
Rate for Payer: Molina Dual Medicare/Medicaid	$7,769.69
Rate for Payer: Molina Medicare	$7,769.69
Rate for Payer: Multiplan Auto	$11,841.05
Rate for Payer: Multiplan Commercial	$11,841.05
Rate for Payer: Multiplan Workers Comp	$11,841.05
Rate for Payer: Parkland Medicaid	$5,760.21
Rate for Payer: Scott and White EPO/PPO	$138.95
Rate for Payer: Scott and White Medicare	$7,769.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,760.21
Rate for Payer: Superior Health Plan EPO	$7,769.69
Rate for Payer: Superior Health Plan Medicare	$7,769.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,769.69
Rate for Payer: Universal American Medicare	$7,769.69
Rate for Payer: Wellcare Medicare	$7,769.69
Rate for Payer: Wellmed Medicare	$7,769.69

INSRT SUBQ CAR RHYTHM MNTR

Facility

$18,217.00

Service Code	CPT 33285
Hospital Charge Code	2300090
Hospital Revenue Code	481
Rate for Payer: Cash Price	$16,030.96

INST BIOPSY DISP -- DHF

Facility

$249.70

Hospital Charge Code	80812290
Hospital Revenue Code	272
Rate for Payer: Cash Price	$219.74

INST BIOPSY DISP -- DHF

Facility

$249.70

Hospital Charge Code	80812290
Hospital Revenue Code	272
Min. Negotiated Rate	$22.47
Max. Negotiated Rate	$162.30
Rate for Payer: Aetna Commercial	$137.34
Rate for Payer: Amerigroup CHIP/Medicaid	$22.47
Rate for Payer: BCBS of TX Blue Advantage	$74.91
Rate for Payer: BCBS of TX Blue Essentials	$89.89
Rate for Payer: BCBS of TX PPO	$99.88
Rate for Payer: Cash Price	$219.74
Rate for Payer: Multiplan Auto	$162.30
Rate for Payer: Multiplan Commercial	$162.30
Rate for Payer: Multiplan Workers Comp	$162.30
Rate for Payer: Scott and White EPO/PPO	$124.85
Rate for Payer: Superior Health Plan EPO	$33.96

INS TEMP BLAD CTH COMPLX

Facility

$919.00

Service Code	CPT 51703
Hospital Charge Code	4619901
Hospital Revenue Code	360
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$505.45
Rate for Payer: Aetna Medicare	$214.29
Rate for Payer: Amerigroup CHIP/Medicaid	$57.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$142.86
Rate for Payer: Amerigroup Medicare	$142.86
Rate for Payer: BCBS of TX Blue Advantage	$116.75
Rate for Payer: BCBS of TX Blue Essentials	$139.82
Rate for Payer: BCBS of TX Medicare	$142.86
Rate for Payer: BCBS of TX PPO	$176.17
Rate for Payer: Cash Price	$808.72
Rate for Payer: Cash Price	$808.72
Rate for Payer: Cash Price	$808.72
Rate for Payer: Cigna Commercial	$323.61
Rate for Payer: Cigna Medicaid	$57.79
Rate for Payer: Cigna Medicare	$142.86
Rate for Payer: Employer Direct Commercial	$142.86
Rate for Payer: Humana Medicare/TRICARE	$142.86
Rate for Payer: Molina CHIP/Medicaid	$57.79
Rate for Payer: Molina Dual Medicare/Medicaid	$142.86
Rate for Payer: Molina Medicare	$142.86
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	$57.79
Rate for Payer: Scott and White EPO/PPO	$3.15
Rate for Payer: Scott and White Medicare	$142.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$57.79
Rate for Payer: Superior Health Plan EPO	$142.86
Rate for Payer: Superior Health Plan Medicare	$142.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$142.86
Rate for Payer: Universal American Medicare	$142.86
Rate for Payer: Wellcare Medicare	$142.86
Rate for Payer: Wellmed Medicare	$142.86

INS TEMP BLAD CTH COMPLX

Facility

$919.00

Service Code	CPT 51703
Hospital Charge Code	4619901
Hospital Revenue Code	360
Rate for Payer: Cash Price	$808.72

INST ENDO KITTNER DISP -- DHF

Facility

$45.58

Hospital Charge Code	80814155
Hospital Revenue Code	270
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$29.63
Rate for Payer: Aetna Commercial	$25.07
Rate for Payer: Amerigroup CHIP/Medicaid	$4.10
Rate for Payer: BCBS of TX Blue Advantage	$13.67
Rate for Payer: BCBS of TX Blue Essentials	$16.41
Rate for Payer: BCBS of TX PPO	$18.23
Rate for Payer: Cash Price	$40.11
Rate for Payer: Multiplan Auto	$29.63
Rate for Payer: Multiplan Commercial	$29.63
Rate for Payer: Multiplan Workers Comp	$29.63
Rate for Payer: Scott and White EPO/PPO	$22.79
Rate for Payer: Superior Health Plan EPO	$6.20

INST ENDO KITTNER DISP -- DHF

Facility

$45.58

Hospital Charge Code	80814155
Hospital Revenue Code	270
Rate for Payer: Cash Price	$40.11

INSTR STAPLER SUREFORM 60

Facility

$2,406.20

Hospital Charge Code	8690510
Hospital Revenue Code	272
Min. Negotiated Rate	$216.56
Max. Negotiated Rate	$1,564.03
Rate for Payer: Aetna Commercial	$1,323.41
Rate for Payer: Amerigroup CHIP/Medicaid	$216.56
Rate for Payer: BCBS of TX Blue Advantage	$721.86
Rate for Payer: BCBS of TX Blue Essentials	$866.23
Rate for Payer: BCBS of TX PPO	$962.48
Rate for Payer: Cash Price	$2,117.46
Rate for Payer: Multiplan Auto	$1,564.03
Rate for Payer: Multiplan Commercial	$1,564.03
Rate for Payer: Multiplan Workers Comp	$1,564.03
Rate for Payer: Scott and White EPO/PPO	$1,203.10
Rate for Payer: Superior Health Plan EPO	$327.24

INSTR STAPLER SUREFORM 60

Facility

$2,406.20

Hospital Charge Code	8690510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,117.46

INSTRUMENT, FRAZIER 10 FR -- DHF

Facility

$152.04

Hospital Charge Code	81855504
Hospital Revenue Code	270
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$98.83
Rate for Payer: Aetna Commercial	$83.62
Rate for Payer: Amerigroup CHIP/Medicaid	$13.68
Rate for Payer: BCBS of TX Blue Advantage	$45.61
Rate for Payer: BCBS of TX Blue Essentials	$54.73
Rate for Payer: BCBS of TX PPO	$60.82
Rate for Payer: Cash Price	$133.80
Rate for Payer: Multiplan Auto	$98.83
Rate for Payer: Multiplan Commercial	$98.83
Rate for Payer: Multiplan Workers Comp	$98.83
Rate for Payer: Scott and White EPO/PPO	$76.02
Rate for Payer: Superior Health Plan EPO	$20.68

INSTRUMENT, LAPAROSCOPIC LIGASURE 5 HND ACTV 37CM -- DHF

Facility

$2,457.37

Hospital Charge Code	80811300
Hospital Revenue Code	272
Min. Negotiated Rate	$221.16
Max. Negotiated Rate	$1,597.29
Rate for Payer: Aetna Commercial	$1,351.55
Rate for Payer: Amerigroup CHIP/Medicaid	$221.16
Rate for Payer: BCBS of TX Blue Advantage	$737.21
Rate for Payer: BCBS of TX Blue Essentials	$884.65
Rate for Payer: BCBS of TX PPO	$982.95
Rate for Payer: Cash Price	$2,162.49
Rate for Payer: Multiplan Auto	$1,597.29
Rate for Payer: Multiplan Commercial	$1,597.29
Rate for Payer: Multiplan Workers Comp	$1,597.29
Rate for Payer: Scott and White EPO/PPO	$1,228.68
Rate for Payer: Superior Health Plan EPO	$334.20

INSTRUMENT, POOLE STERILE -- DHF

Facility

$152.04

Hospital Charge Code	81855504
Hospital Revenue Code	270
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$98.83
Rate for Payer: Aetna Commercial	$83.62
Rate for Payer: Amerigroup CHIP/Medicaid	$13.68
Rate for Payer: BCBS of TX Blue Advantage	$45.61
Rate for Payer: BCBS of TX Blue Essentials	$54.73
Rate for Payer: BCBS of TX PPO	$60.82
Rate for Payer: Cash Price	$133.80
Rate for Payer: Multiplan Auto	$98.83
Rate for Payer: Multiplan Commercial	$98.83
Rate for Payer: Multiplan Workers Comp	$98.83
Rate for Payer: Scott and White EPO/PPO	$76.02
Rate for Payer: Superior Health Plan EPO	$20.68

INSTRUMENT, POOLE STERILE -- DHF

Facility

$152.04

Hospital Charge Code	81855504
Hospital Revenue Code	270
Rate for Payer: Cash Price	$133.80

INSTRUMENT, YANKAUER BULB TIP W/O VENT -- DHF

Facility

$41.57

Hospital Charge Code	81855553
Hospital Revenue Code	270
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$27.02
Rate for Payer: Aetna Commercial	$22.86
Rate for Payer: Amerigroup CHIP/Medicaid	$3.74
Rate for Payer: BCBS of TX Blue Advantage	$12.47
Rate for Payer: BCBS of TX Blue Essentials	$14.97
Rate for Payer: BCBS of TX PPO	$16.63
Rate for Payer: Cash Price	$36.58
Rate for Payer: Multiplan Auto	$27.02
Rate for Payer: Multiplan Commercial	$27.02
Rate for Payer: Multiplan Workers Comp	$27.02
Rate for Payer: Scott and White EPO/PPO	$20.78
Rate for Payer: Superior Health Plan EPO	$5.65

INSTRUMENT, YANKAUER RIGID OPEN TIP -- DHF

Facility

$41.57

Hospital Charge Code	81855553
Hospital Revenue Code	270
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$27.02
Rate for Payer: Aetna Commercial	$22.86
Rate for Payer: Amerigroup CHIP/Medicaid	$3.74
Rate for Payer: BCBS of TX Blue Advantage	$12.47
Rate for Payer: BCBS of TX Blue Essentials	$14.97
Rate for Payer: BCBS of TX PPO	$16.63
Rate for Payer: Cash Price	$36.58
Rate for Payer: Multiplan Auto	$27.02
Rate for Payer: Multiplan Commercial	$27.02
Rate for Payer: Multiplan Workers Comp	$27.02
Rate for Payer: Scott and White EPO/PPO	$20.78
Rate for Payer: Superior Health Plan EPO	$5.65

Insulin Antibodies SO

Facility

$120.00

Service Code	CPT 86337
Hospital Charge Code	1701424
Hospital Revenue Code	302
Rate for Payer: Cash Price	$105.60

Insulin Antibodies SO

Facility

$120.00

Service Code	CPT 86337
Hospital Charge Code	1701424
Hospital Revenue Code	302
Min. Negotiated Rate	$8.35
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$22.49
Rate for Payer: Aetna Medicare	$32.12
Rate for Payer: Amerigroup CHIP/Medicaid	$8.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.41
Rate for Payer: Amerigroup Medicare	$21.41
Rate for Payer: BCBS of TX Blue Advantage	$35.33
Rate for Payer: BCBS of TX Blue Essentials	$42.39
Rate for Payer: BCBS of TX Medicare	$21.41
Rate for Payer: BCBS of TX PPO	$47.32
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cigna Medicaid	$21.41
Rate for Payer: Cigna Medicare	$21.41
Rate for Payer: Employer Direct Commercial	$21.41
Rate for Payer: Humana Medicare/TRICARE	$21.41
Rate for Payer: Molina CHIP/Medicaid	$21.41
Rate for Payer: Molina Dual Medicare/Medicaid	$21.41
Rate for Payer: Molina Medicare	$21.41
Rate for Payer: Multiplan Auto	$78.00
Rate for Payer: Multiplan Commercial	$78.00
Rate for Payer: Multiplan Workers Comp	$78.00
Rate for Payer: Parkland Medicaid	$21.41
Rate for Payer: Scott and White EPO/PPO	$26.76
Rate for Payer: Scott and White Medicare	$21.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.41
Rate for Payer: Superior Health Plan EPO	$21.41
Rate for Payer: Superior Health Plan Medicare	$21.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.41
Rate for Payer: Universal American Medicare	$21.41
Rate for Payer: Wellcare Medicare	$21.41
Rate for Payer: Wellmed Medicare	$21.41

insulin glargine 100 units/mL Subcut Soln 10 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	79510212
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

insulin glargine 100 units/mL Subcut Soln 10 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	79510212
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

insulin isophane-insulin regular 70 units-30 units/mL human recombinant Subcut Susp 10 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	77634169
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

insulin isophane-insulin regular 70 units-30 units/mL human recombinant Subcut Susp 10 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	77634169
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

insulin lispro 100 units/mL Subcut Soln 3 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	77634397
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

Know your out-of-pocket cost for care.

All Charges