White Rock Medical Center

All Charges

Charge

Type

Setting

Price

88329 AP Bill Surgical Intraoperative Consult

Facility

$141.00

Service Code	HCPCS 88329
Hospital Charge Code	1800416
Hospital Revenue Code	312
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$125.27
Rate for Payer: Amerigroup CHIP/Medicaid	$14.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$42.30
Rate for Payer: BCBS of TX Blue Essentials	$50.76
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$56.40
Rate for Payer: Cash Price	$95.88
Rate for Payer: Cash Price	$95.88
Rate for Payer: Cash Price	$95.88
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$101.52
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$101.52
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
Rate for Payer: Multiplan Auto	$91.65
Rate for Payer: Multiplan Commercial	$91.65
Rate for Payer: Multiplan Workers Comp	$91.65
Rate for Payer: Parkland Medicaid	$101.52
Rate for Payer: Scott and White EPO/PPO	$42.35
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$101.52
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

88329 AP Bill Surgical Intraoperative Consult

Facility

$141.00

Service Code	HCPCS 88329
Hospital Charge Code	1800416
Hospital Revenue Code	312
Rate for Payer: Cash Price	$95.88

88331 AP Bill Frozen single specimen

Facility

$333.00

Service Code	HCPCS 88331
Hospital Charge Code	1800283
Hospital Revenue Code	312
Rate for Payer: Cash Price	$226.44

88331 AP Bill Frozen single specimen

Facility

$333.00

Service Code	HCPCS 88331
Hospital Charge Code	1800283
Hospital Revenue Code	312
Min. Negotiated Rate	$39.13
Max. Negotiated Rate	$361.78
Rate for Payer: Amerigroup CHIP/Medicaid	$39.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$171.15
Rate for Payer: Amerigroup Medicare	$171.15
Rate for Payer: BCBS of TX Blue Advantage	$99.90
Rate for Payer: BCBS of TX Blue Essentials	$119.88
Rate for Payer: BCBS of TX Medicare	$171.15
Rate for Payer: BCBS of TX PPO	$133.20
Rate for Payer: Cash Price	$226.44
Rate for Payer: Cash Price	$226.44
Rate for Payer: Cash Price	$226.44
Rate for Payer: Cigna Commercial	$361.78
Rate for Payer: Cigna Medicaid	$239.76
Rate for Payer: Cigna Medicare	$171.15
Rate for Payer: Employer Direct Commercial	$171.15
Rate for Payer: Humana Medicare/TRICARE	$171.15
Rate for Payer: Molina CHIP/Medicaid	$239.76
Rate for Payer: Molina Dual Medicare/Medicaid	$171.15
Rate for Payer: Molina Medicare	$171.15
Rate for Payer: Multiplan Auto	$216.45
Rate for Payer: Multiplan Commercial	$216.45
Rate for Payer: Multiplan Workers Comp	$216.45
Rate for Payer: Parkland Medicaid	$239.76
Rate for Payer: Scott and White EPO/PPO	$124.92
Rate for Payer: Scott and White Medicare	$171.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$239.76
Rate for Payer: Superior Health Plan EPO	$171.15
Rate for Payer: Superior Health Plan Medicare	$171.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$171.15
Rate for Payer: Universal American Medicare	$171.15
Rate for Payer: Wellcare Medicare	$171.15
Rate for Payer: Wellmed Medicare	$171.15

88332 AP Bill Frozen add'l block

Facility

$278.00

Service Code	HCPCS 88332
Hospital Charge Code	1800291
Hospital Revenue Code	312
Min. Negotiated Rate	$21.68
Max. Negotiated Rate	$200.16
Rate for Payer: Amerigroup CHIP/Medicaid	$21.68
Rate for Payer: BCBS of TX Blue Advantage	$83.40
Rate for Payer: BCBS of TX Blue Essentials	$100.08
Rate for Payer: BCBS of TX PPO	$111.20
Rate for Payer: Cash Price	$189.04
Rate for Payer: Cash Price	$189.04
Rate for Payer: Cigna Medicaid	$200.16
Rate for Payer: Molina CHIP/Medicaid	$200.16
Rate for Payer: Multiplan Auto	$180.70
Rate for Payer: Multiplan Commercial	$180.70
Rate for Payer: Multiplan Workers Comp	$180.70
Rate for Payer: Parkland Medicaid	$200.16
Rate for Payer: Scott and White EPO/PPO	$67.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$200.16
Rate for Payer: Superior Health Plan EPO	$37.81

88332 AP Bill Frozen add'l block

Facility

$278.00

Service Code	HCPCS 88332
Hospital Charge Code	1800291
Hospital Revenue Code	312
Rate for Payer: Cash Price	$189.04

88334 AP Bill Immediate Smear Touch Prep Add'l

Facility

$165.00

Service Code	HCPCS 88334
Hospital Charge Code	1802628
Hospital Revenue Code	312
Rate for Payer: Cash Price	$112.20

88334 AP Bill Immediate Smear Touch Prep Add'l

Facility

$165.00

Service Code	HCPCS 88334
Hospital Charge Code	1802628
Hospital Revenue Code	312
Min. Negotiated Rate	$22.44
Max. Negotiated Rate	$118.80
Rate for Payer: Amerigroup CHIP/Medicaid	$22.52
Rate for Payer: BCBS of TX Blue Advantage	$49.50
Rate for Payer: BCBS of TX Blue Essentials	$59.40
Rate for Payer: BCBS of TX PPO	$66.00
Rate for Payer: Cash Price	$112.20
Rate for Payer: Cash Price	$112.20
Rate for Payer: Cigna Medicaid	$118.80
Rate for Payer: Molina CHIP/Medicaid	$118.80
Rate for Payer: Multiplan Auto	$107.25
Rate for Payer: Multiplan Commercial	$107.25
Rate for Payer: Multiplan Workers Comp	$107.25
Rate for Payer: Parkland Medicaid	$118.80
Rate for Payer: Scott and White EPO/PPO	$68.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.80
Rate for Payer: Superior Health Plan EPO	$22.44

88341 AP Bill Surg IPX (Add'l Antibody)

Facility

$402.00

Service Code	HCPCS 88341
Hospital Charge Code	1841001
Hospital Revenue Code	312
Rate for Payer: Cash Price	$273.36

88341 AP Bill Surg IPX (Add'l Antibody)

Facility

$402.00

Service Code	HCPCS 88341
Hospital Charge Code	1841001
Hospital Revenue Code	312
Min. Negotiated Rate	$36.73
Max. Negotiated Rate	$289.44
Rate for Payer: Amerigroup CHIP/Medicaid	$36.73
Rate for Payer: BCBS of TX Blue Advantage	$120.60
Rate for Payer: BCBS of TX Blue Essentials	$144.72
Rate for Payer: BCBS of TX PPO	$160.80
Rate for Payer: Cash Price	$273.36
Rate for Payer: Cash Price	$273.36
Rate for Payer: Cigna Medicaid	$289.44
Rate for Payer: Molina CHIP/Medicaid	$289.44
Rate for Payer: Multiplan Auto	$261.30
Rate for Payer: Multiplan Commercial	$261.30
Rate for Payer: Multiplan Workers Comp	$261.30
Rate for Payer: Parkland Medicaid	$289.44
Rate for Payer: Scott and White EPO/PPO	$112.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$289.44
Rate for Payer: Superior Health Plan EPO	$54.67

88342 AP Bill Surg IPX (First Antibody)

Facility

$561.00

Service Code	HCPCS 88342
Hospital Charge Code	1800457
Hospital Revenue Code	312
Rate for Payer: Cash Price	$381.48

88342 AP Bill Surg IPX (First Antibody)

Facility

$561.00

Service Code	HCPCS 88342
Hospital Charge Code	1800457
Hospital Revenue Code	312
Min. Negotiated Rate	$41.80
Max. Negotiated Rate	$403.92
Rate for Payer: Amerigroup CHIP/Medicaid	$41.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$171.15
Rate for Payer: Amerigroup Medicare	$171.15
Rate for Payer: BCBS of TX Blue Advantage	$168.30
Rate for Payer: BCBS of TX Blue Essentials	$201.96
Rate for Payer: BCBS of TX Medicare	$171.15
Rate for Payer: BCBS of TX PPO	$224.40
Rate for Payer: Cash Price	$381.48
Rate for Payer: Cash Price	$381.48
Rate for Payer: Cash Price	$381.48
Rate for Payer: Cigna Commercial	$361.78
Rate for Payer: Cigna Medicaid	$403.92
Rate for Payer: Cigna Medicare	$171.15
Rate for Payer: Employer Direct Commercial	$171.15
Rate for Payer: Humana Medicare/TRICARE	$171.15
Rate for Payer: Molina CHIP/Medicaid	$403.92
Rate for Payer: Molina Dual Medicare/Medicaid	$171.15
Rate for Payer: Molina Medicare	$171.15
Rate for Payer: Multiplan Auto	$364.65
Rate for Payer: Multiplan Commercial	$364.65
Rate for Payer: Multiplan Workers Comp	$364.65
Rate for Payer: Parkland Medicaid	$403.92
Rate for Payer: Scott and White EPO/PPO	$131.07
Rate for Payer: Scott and White Medicare	$171.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$403.92
Rate for Payer: Superior Health Plan EPO	$171.15
Rate for Payer: Superior Health Plan Medicare	$171.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$171.15
Rate for Payer: Universal American Medicare	$171.15
Rate for Payer: Wellcare Medicare	$171.15
Rate for Payer: Wellmed Medicare	$171.15

88360 AP Bill Surg Manual Quant IHC

Facility

$501.00

Service Code	HCPCS 88360
Hospital Charge Code	1802586
Hospital Revenue Code	310
Min. Negotiated Rate	$49.69
Max. Negotiated Rate	$361.78
Rate for Payer: Amerigroup CHIP/Medicaid	$49.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$171.15
Rate for Payer: Amerigroup Medicare	$171.15
Rate for Payer: BCBS of TX Blue Advantage	$150.30
Rate for Payer: BCBS of TX Blue Essentials	$180.36
Rate for Payer: BCBS of TX Medicare	$171.15
Rate for Payer: BCBS of TX PPO	$200.40
Rate for Payer: Cash Price	$340.68
Rate for Payer: Cash Price	$340.68
Rate for Payer: Cash Price	$340.68
Rate for Payer: Cigna Commercial	$361.78
Rate for Payer: Cigna Medicaid	$360.72
Rate for Payer: Cigna Medicare	$171.15
Rate for Payer: Employer Direct Commercial	$171.15
Rate for Payer: Humana Medicare/TRICARE	$171.15
Rate for Payer: Molina CHIP/Medicaid	$360.72
Rate for Payer: Molina Dual Medicare/Medicaid	$171.15
Rate for Payer: Molina Medicare	$171.15
Rate for Payer: Multiplan Auto	$325.65
Rate for Payer: Multiplan Commercial	$325.65
Rate for Payer: Multiplan Workers Comp	$325.65
Rate for Payer: Parkland Medicaid	$360.72
Rate for Payer: Scott and White EPO/PPO	$148.82
Rate for Payer: Scott and White Medicare	$171.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$360.72
Rate for Payer: Superior Health Plan EPO	$171.15
Rate for Payer: Superior Health Plan Medicare	$171.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$171.15
Rate for Payer: Universal American Medicare	$171.15
Rate for Payer: Wellcare Medicare	$171.15
Rate for Payer: Wellmed Medicare	$171.15

88360 AP Bill Surg Manual Quant IHC

Facility

$501.00

Service Code	HCPCS 88360
Hospital Charge Code	1802586
Hospital Revenue Code	310
Rate for Payer: Cash Price	$340.68

88361 AP Bill Send Out Tumor IHC

Facility

$352.36

Service Code	HCPCS 88361
Hospital Charge Code	9050993
Hospital Revenue Code	310
Min. Negotiated Rate	$50.39
Max. Negotiated Rate	$761.14
Rate for Payer: Amerigroup CHIP/Medicaid	$50.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$360.08
Rate for Payer: Amerigroup Medicare	$360.08
Rate for Payer: BCBS of TX Blue Advantage	$105.71
Rate for Payer: BCBS of TX Blue Essentials	$126.85
Rate for Payer: BCBS of TX Medicare	$360.08
Rate for Payer: BCBS of TX PPO	$140.94
Rate for Payer: Cash Price	$239.60
Rate for Payer: Cash Price	$239.60
Rate for Payer: Cash Price	$239.60
Rate for Payer: Cigna Commercial	$761.14
Rate for Payer: Cigna Medicaid	$253.70
Rate for Payer: Cigna Medicare	$360.08
Rate for Payer: Employer Direct Commercial	$360.08
Rate for Payer: Humana Medicare/TRICARE	$360.08
Rate for Payer: Molina CHIP/Medicaid	$253.70
Rate for Payer: Molina Dual Medicare/Medicaid	$360.08
Rate for Payer: Molina Medicare	$360.08
Rate for Payer: Multiplan Auto	$229.03
Rate for Payer: Multiplan Commercial	$229.03
Rate for Payer: Multiplan Workers Comp	$229.03
Rate for Payer: Parkland Medicaid	$253.70
Rate for Payer: Scott and White EPO/PPO	$147.60
Rate for Payer: Scott and White Medicare	$360.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$253.70
Rate for Payer: Superior Health Plan EPO	$360.08
Rate for Payer: Superior Health Plan Medicare	$360.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$360.08
Rate for Payer: Universal American Medicare	$360.08
Rate for Payer: Wellcare Medicare	$360.08
Rate for Payer: Wellmed Medicare	$360.08

88361 AP Bill Send Out Tumor IHC

Facility

$352.36

Service Code	HCPCS 88361
Hospital Charge Code	9050993
Hospital Revenue Code	310
Rate for Payer: Cash Price	$239.60

88374 AP Bill Morph Analysis Comp Asst Each Probe

Facility

$741.00

Service Code	HCPCS 88374
Hospital Charge Code	7038374
Hospital Revenue Code	310
Rate for Payer: Cash Price	$503.88

88374 AP Bill Morph Analysis Comp Asst Each Probe

Facility

$741.00

Service Code	HCPCS 88374
Hospital Charge Code	7038374
Hospital Revenue Code	310
Min. Negotiated Rate	$135.82
Max. Negotiated Rate	$533.52
Rate for Payer: Amerigroup CHIP/Medicaid	$135.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$171.15
Rate for Payer: Amerigroup Medicare	$171.15
Rate for Payer: BCBS of TX Blue Advantage	$222.30
Rate for Payer: BCBS of TX Blue Essentials	$266.76
Rate for Payer: BCBS of TX Medicare	$171.15
Rate for Payer: BCBS of TX PPO	$296.40
Rate for Payer: Cash Price	$503.88
Rate for Payer: Cash Price	$503.88
Rate for Payer: Cash Price	$503.88
Rate for Payer: Cigna Commercial	$361.78
Rate for Payer: Cigna Medicaid	$533.52
Rate for Payer: Cigna Medicare	$171.15
Rate for Payer: Employer Direct Commercial	$171.15
Rate for Payer: Humana Medicare/TRICARE	$171.15
Rate for Payer: Molina CHIP/Medicaid	$533.52
Rate for Payer: Molina Dual Medicare/Medicaid	$171.15
Rate for Payer: Molina Medicare	$171.15
Rate for Payer: Multiplan Auto	$481.65
Rate for Payer: Multiplan Commercial	$481.65
Rate for Payer: Multiplan Workers Comp	$481.65
Rate for Payer: Parkland Medicaid	$533.52
Rate for Payer: Scott and White EPO/PPO	$355.75
Rate for Payer: Scott and White Medicare	$171.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$533.52
Rate for Payer: Superior Health Plan EPO	$171.15
Rate for Payer: Superior Health Plan Medicare	$171.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$171.15
Rate for Payer: Universal American Medicare	$171.15
Rate for Payer: Wellcare Medicare	$171.15
Rate for Payer: Wellmed Medicare	$171.15

88377 AP Bill Send Out HER2 FISH

Facility

$684.00

Service Code	HCPCS 88377
Hospital Charge Code	8890540
Hospital Revenue Code	310
Rate for Payer: Cash Price	$465.12

88377 AP Bill Send Out HER2 FISH

Facility

$684.00

Service Code	HCPCS 88377
Hospital Charge Code	8890540
Hospital Revenue Code	310
Min. Negotiated Rate	$160.59
Max. Negotiated Rate	$492.48
Rate for Payer: Amerigroup CHIP/Medicaid	$160.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$171.15
Rate for Payer: Amerigroup Medicare	$171.15
Rate for Payer: BCBS of TX Blue Advantage	$205.20
Rate for Payer: BCBS of TX Blue Essentials	$246.24
Rate for Payer: BCBS of TX Medicare	$171.15
Rate for Payer: BCBS of TX PPO	$273.60
Rate for Payer: Cash Price	$465.12
Rate for Payer: Cash Price	$465.12
Rate for Payer: Cash Price	$465.12
Rate for Payer: Cigna Commercial	$361.78
Rate for Payer: Cigna Medicaid	$492.48
Rate for Payer: Cigna Medicare	$171.15
Rate for Payer: Employer Direct Commercial	$171.15
Rate for Payer: Humana Medicare/TRICARE	$171.15
Rate for Payer: Molina CHIP/Medicaid	$492.48
Rate for Payer: Molina Dual Medicare/Medicaid	$171.15
Rate for Payer: Molina Medicare	$171.15
Rate for Payer: Multiplan Auto	$444.60
Rate for Payer: Multiplan Commercial	$444.60
Rate for Payer: Multiplan Workers Comp	$444.60
Rate for Payer: Parkland Medicaid	$492.48
Rate for Payer: Scott and White EPO/PPO	$488.85
Rate for Payer: Scott and White Medicare	$171.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$492.48
Rate for Payer: Superior Health Plan EPO	$171.15
Rate for Payer: Superior Health Plan Medicare	$171.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$171.15
Rate for Payer: Universal American Medicare	$171.15
Rate for Payer: Wellcare Medicare	$171.15
Rate for Payer: Wellmed Medicare	$171.15

8880012

Facility

$4,018.07

Service Code	HCPCS C1734
Hospital Charge Code	991130
Hospital Revenue Code	278
Min. Negotiated Rate	$361.63
Max. Negotiated Rate	$2,893.01
Rate for Payer: Amerigroup CHIP/Medicaid	$361.63
Rate for Payer: BCBS of TX Blue Advantage	$1,205.42
Rate for Payer: BCBS of TX Blue Essentials	$1,446.51
Rate for Payer: BCBS of TX PPO	$1,607.23
Rate for Payer: Cash Price	$2,732.29
Rate for Payer: Cigna Medicaid	$2,893.01
Rate for Payer: Molina CHIP/Medicaid	$2,893.01
Rate for Payer: Multiplan Auto	$2,009.04
Rate for Payer: Multiplan Commercial	$2,009.04
Rate for Payer: Multiplan Workers Comp	$2,009.04
Rate for Payer: Parkland Medicaid	$2,893.01
Rate for Payer: Scott and White EPO/PPO	$2,009.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,893.01
Rate for Payer: Superior Health Plan EPO	$546.46

8880012

Facility

$4,018.07

Service Code	HCPCS C1734
Hospital Charge Code	991130
Hospital Revenue Code	278
Min. Negotiated Rate	$1,004.52
Max. Negotiated Rate	$2,009.04
Rate for Payer: Cash Price	$2,732.29
Rate for Payer: Cigna Commercial	$1,004.52
Rate for Payer: Multiplan Auto	$2,009.04
Rate for Payer: Multiplan Commercial	$2,009.04
Rate for Payer: Multiplan Workers Comp	$2,009.04
Rate for Payer: Scott and White EPO/PPO	$2,009.04

88SYN005

Facility

$8,463.86

Hospital Charge Code	990961
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,755.42

88SYN005

Facility

$8,463.86

Hospital Charge Code	990961
Hospital Revenue Code	272
Min. Negotiated Rate	$761.75
Max. Negotiated Rate	$6,093.98
Rate for Payer: Amerigroup CHIP/Medicaid	$761.75
Rate for Payer: BCBS of TX Blue Advantage	$2,539.16
Rate for Payer: BCBS of TX Blue Essentials	$3,046.99
Rate for Payer: BCBS of TX PPO	$3,385.54
Rate for Payer: Cash Price	$5,755.42
Rate for Payer: Cigna Medicaid	$6,093.98
Rate for Payer: Molina CHIP/Medicaid	$6,093.98
Rate for Payer: Multiplan Auto	$5,501.51
Rate for Payer: Multiplan Commercial	$5,501.51
Rate for Payer: Multiplan Workers Comp	$5,501.51
Rate for Payer: Parkland Medicaid	$6,093.98
Rate for Payer: Scott and White EPO/PPO	$4,231.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,093.98
Rate for Payer: Superior Health Plan EPO	$1,151.08

89060 AP Bill Synovial Crystals

Facility

$145.00

Service Code	HCPCS 89060
Hospital Charge Code	1600303
Hospital Revenue Code	300
Rate for Payer: Cash Price	$98.60

Know your out-of-pocket cost for care.

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