White Rock Medical Center

All Charges

Charge

Type

Setting

Price

EXTR RETRV BALLOON -- DHF

Facility

$809.66

Hospital Charge Code	80322191
Hospital Revenue Code	272
Min. Negotiated Rate	$72.87
Max. Negotiated Rate	$582.96
Rate for Payer: Amerigroup CHIP/Medicaid	$72.87
Rate for Payer: BCBS of TX Blue Advantage	$242.90
Rate for Payer: BCBS of TX Blue Essentials	$291.48
Rate for Payer: BCBS of TX PPO	$323.86
Rate for Payer: Cash Price	$550.57
Rate for Payer: Cigna Medicaid	$582.96
Rate for Payer: Molina CHIP/Medicaid	$582.96
Rate for Payer: Multiplan Auto	$526.28
Rate for Payer: Multiplan Commercial	$526.28
Rate for Payer: Multiplan Workers Comp	$526.28
Rate for Payer: Parkland Medicaid	$582.96
Rate for Payer: Scott and White EPO/PPO	$404.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$582.96
Rate for Payer: Superior Health Plan EPO	$110.11

*Ext Study Levels -> Duplex Scan Extremity Veins Complete Bilateral

Facility

$2,850.00

Service Code	HCPCS 93970
Hospital Charge Code	7100332
Hospital Revenue Code	921
Rate for Payer: Cash Price	$1,938.00

*Ext Study Levels -> Duplex Scan Extremity Veins Complete Bilateral

Facility

$2,850.00

Service Code	HCPCS 93970
Hospital Charge Code	7100332
Hospital Revenue Code	921
Min. Negotiated Rate	$230.86
Max. Negotiated Rate	$2,052.00
Rate for Payer: Amerigroup CHIP/Medicaid	$256.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$855.00
Rate for Payer: BCBS of TX Blue Essentials	$1,026.00
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$1,140.00
Rate for Payer: Cash Price	$1,938.00
Rate for Payer: Cash Price	$1,938.00
Rate for Payer: Cash Price	$1,938.00
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,052.00
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$2,052.00
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$1,852.50
Rate for Payer: Multiplan Commercial	$1,852.50
Rate for Payer: Multiplan Workers Comp	$1,852.50
Rate for Payer: Parkland Medicaid	$2,052.00
Rate for Payer: Scott and White EPO/PPO	$230.86
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,052.00
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

*Ext Study Levels -> Extremity Study Bilateral 1-2 Levels

Facility

$720.00

Service Code	HCPCS 93922
Hospital Charge Code	7150844
Hospital Revenue Code	921
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$518.40
Rate for Payer: Amerigroup CHIP/Medicaid	$64.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$216.00
Rate for Payer: BCBS of TX Blue Essentials	$259.20
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$288.00
Rate for Payer: Cash Price	$489.60
Rate for Payer: Cash Price	$489.60
Rate for Payer: Cash Price	$489.60
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$518.40
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$518.40
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$468.00
Rate for Payer: Multiplan Commercial	$468.00
Rate for Payer: Multiplan Workers Comp	$468.00
Rate for Payer: Parkland Medicaid	$518.40
Rate for Payer: Scott and White EPO/PPO	$101.58
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$518.40
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

*Ext Study Levels -> Extremity Study Bilateral 1-2 Levels

Facility

$720.00

Service Code	HCPCS 93922
Hospital Charge Code	7150844
Hospital Revenue Code	921
Rate for Payer: Cash Price	$489.60

*Ext Study Levels -> Extremity Study Bilateral 3+ Levels

Facility

$1,579.00

Service Code	HCPCS 93923
Hospital Charge Code	6620804
Hospital Revenue Code	921
Min. Negotiated Rate	$142.11
Max. Negotiated Rate	$1,136.88
Rate for Payer: Amerigroup CHIP/Medicaid	$142.11
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$473.70
Rate for Payer: BCBS of TX Blue Essentials	$568.44
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$631.60
Rate for Payer: Cash Price	$1,073.72
Rate for Payer: Cash Price	$1,073.72
Rate for Payer: Cash Price	$1,073.72
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$1,136.88
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$1,136.88
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$1,026.35
Rate for Payer: Multiplan Commercial	$1,026.35
Rate for Payer: Multiplan Workers Comp	$1,026.35
Rate for Payer: Parkland Medicaid	$1,136.88
Rate for Payer: Scott and White EPO/PPO	$160.75
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,136.88
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

*Ext Study Levels -> Extremity Study Bilateral 3+ Levels

Facility

$1,579.00

Service Code	HCPCS 93923
Hospital Charge Code	6620804
Hospital Revenue Code	921
Rate for Payer: Cash Price	$1,073.72

Eye Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107073
Hospital Revenue Code	306
Rate for Payer: Cash Price	$210.12

Eye Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107073
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$222.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$92.70
Rate for Payer: BCBS of TX Blue Essentials	$111.24
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$123.60
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cigna Medicaid	$222.48
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$222.48
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$222.48
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.48
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility

$2,223.53

Service Code	APR-DRG 0821
Min. Negotiated Rate	$2,096.42
Max. Negotiated Rate	$2,223.53
Rate for Payer: Amerigroup CHIP/Medicaid	$2,096.42
Rate for Payer: Cigna Medicaid	$2,096.42
Rate for Payer: Molina CHIP/Medicaid	$2,096.42
Rate for Payer: Parkland Medicaid	$2,096.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,223.53

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility

$13,236.32

Service Code	APR-DRG 0824
Min. Negotiated Rate	$12,479.66
Max. Negotiated Rate	$13,236.32
Rate for Payer: Amerigroup CHIP/Medicaid	$12,479.66
Rate for Payer: Cigna Medicaid	$12,479.66
Rate for Payer: Molina CHIP/Medicaid	$12,479.66
Rate for Payer: Parkland Medicaid	$12,479.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,236.32

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility

$4,262.61

Service Code	APR-DRG 0822
Min. Negotiated Rate	$4,018.94
Max. Negotiated Rate	$4,262.61
Rate for Payer: Amerigroup CHIP/Medicaid	$4,018.94
Rate for Payer: Cigna Medicaid	$4,018.94
Rate for Payer: Molina CHIP/Medicaid	$4,018.94
Rate for Payer: Parkland Medicaid	$4,018.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,262.61

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility

$7,617.33

Service Code	APR-DRG 0823
Min. Negotiated Rate	$7,181.89
Max. Negotiated Rate	$7,617.33
Rate for Payer: Amerigroup CHIP/Medicaid	$7,181.89
Rate for Payer: Cigna Medicaid	$7,181.89
Rate for Payer: Molina CHIP/Medicaid	$7,181.89
Rate for Payer: Parkland Medicaid	$7,181.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,617.33

EZDILATE BALLOON DILATOR 11-12-13

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993920
Hospital Revenue Code	272
Rate for Payer: Cash Price	$763.78

EZDILATE BALLOON DILATOR 11-12-13

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993920
Hospital Revenue Code	272
Min. Negotiated Rate	$101.09
Max. Negotiated Rate	$808.70
Rate for Payer: Amerigroup CHIP/Medicaid	$101.09
Rate for Payer: BCBS of TX Blue Advantage	$336.96
Rate for Payer: BCBS of TX Blue Essentials	$404.35
Rate for Payer: BCBS of TX PPO	$449.28
Rate for Payer: Cash Price	$763.78
Rate for Payer: Cigna Medicaid	$808.70
Rate for Payer: Molina CHIP/Medicaid	$808.70
Rate for Payer: Multiplan Auto	$730.08
Rate for Payer: Multiplan Commercial	$730.08
Rate for Payer: Multiplan Workers Comp	$730.08
Rate for Payer: Parkland Medicaid	$808.70
Rate for Payer: Scott and White EPO/PPO	$561.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$808.70
Rate for Payer: Superior Health Plan EPO	$152.76

EZDILATE BALLOON DILATOR 13.5-14.5

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993922
Hospital Revenue Code	272
Min. Negotiated Rate	$101.09
Max. Negotiated Rate	$808.70
Rate for Payer: Amerigroup CHIP/Medicaid	$101.09
Rate for Payer: BCBS of TX Blue Advantage	$336.96
Rate for Payer: BCBS of TX Blue Essentials	$404.35
Rate for Payer: BCBS of TX PPO	$449.28
Rate for Payer: Cash Price	$763.78
Rate for Payer: Cigna Medicaid	$808.70
Rate for Payer: Molina CHIP/Medicaid	$808.70
Rate for Payer: Multiplan Auto	$730.08
Rate for Payer: Multiplan Commercial	$730.08
Rate for Payer: Multiplan Workers Comp	$730.08
Rate for Payer: Parkland Medicaid	$808.70
Rate for Payer: Scott and White EPO/PPO	$561.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$808.70
Rate for Payer: Superior Health Plan EPO	$152.76

EZDILATE BALLOON DILATOR 13.5-14.5

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993922
Hospital Revenue Code	272
Rate for Payer: Cash Price	$763.78

EZDILATE BALLOON DILATOR 6-7-8

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993912
Hospital Revenue Code	272
Min. Negotiated Rate	$101.09
Max. Negotiated Rate	$808.70
Rate for Payer: Amerigroup CHIP/Medicaid	$101.09
Rate for Payer: BCBS of TX Blue Advantage	$336.96
Rate for Payer: BCBS of TX Blue Essentials	$404.35
Rate for Payer: BCBS of TX PPO	$449.28
Rate for Payer: Cash Price	$763.78
Rate for Payer: Cigna Medicaid	$808.70
Rate for Payer: Molina CHIP/Medicaid	$808.70
Rate for Payer: Multiplan Auto	$730.08
Rate for Payer: Multiplan Commercial	$730.08
Rate for Payer: Multiplan Workers Comp	$730.08
Rate for Payer: Parkland Medicaid	$808.70
Rate for Payer: Scott and White EPO/PPO	$561.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$808.70
Rate for Payer: Superior Health Plan EPO	$152.76

EZDILATE BALLOON DILATOR 6-7-8

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993912
Hospital Revenue Code	272
Rate for Payer: Cash Price	$763.78

EZDILATE BALLOON DILATOR 8.5-9.5-10

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993923
Hospital Revenue Code	272
Rate for Payer: Cash Price	$763.78

EZDILATE BALLOON DILATOR 8.5-9.5-10

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993680
Hospital Revenue Code	272
Rate for Payer: Cash Price	$763.78

EZDILATE BALLOON DILATOR 8.5-9.5-10

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993923
Hospital Revenue Code	272
Min. Negotiated Rate	$101.09
Max. Negotiated Rate	$808.70
Rate for Payer: Amerigroup CHIP/Medicaid	$101.09
Rate for Payer: BCBS of TX Blue Advantage	$336.96
Rate for Payer: BCBS of TX Blue Essentials	$404.35
Rate for Payer: BCBS of TX PPO	$449.28
Rate for Payer: Cash Price	$763.78
Rate for Payer: Cigna Medicaid	$808.70
Rate for Payer: Molina CHIP/Medicaid	$808.70
Rate for Payer: Multiplan Auto	$730.08
Rate for Payer: Multiplan Commercial	$730.08
Rate for Payer: Multiplan Workers Comp	$730.08
Rate for Payer: Parkland Medicaid	$808.70
Rate for Payer: Scott and White EPO/PPO	$561.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$808.70
Rate for Payer: Superior Health Plan EPO	$152.76

EZDILATE BALLOON DILATOR 8.5-9.5-10

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993680
Hospital Revenue Code	272
Min. Negotiated Rate	$101.09
Max. Negotiated Rate	$808.70
Rate for Payer: Amerigroup CHIP/Medicaid	$101.09
Rate for Payer: BCBS of TX Blue Advantage	$336.96
Rate for Payer: BCBS of TX Blue Essentials	$404.35
Rate for Payer: BCBS of TX PPO	$449.28
Rate for Payer: Cash Price	$763.78
Rate for Payer: Cigna Medicaid	$808.70
Rate for Payer: Molina CHIP/Medicaid	$808.70
Rate for Payer: Multiplan Auto	$730.08
Rate for Payer: Multiplan Commercial	$730.08
Rate for Payer: Multiplan Workers Comp	$730.08
Rate for Payer: Parkland Medicaid	$808.70
Rate for Payer: Scott and White EPO/PPO	$561.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$808.70
Rate for Payer: Superior Health Plan EPO	$152.76

ezetimibe 10 mg Tab

Facility

$9.00

Service Code	HCPCS J3490
Hospital Charge Code	77560850
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$6.48
Rate for Payer: Amerigroup CHIP/Medicaid	$0.81
Rate for Payer: BCBS of TX Blue Advantage	$2.70
Rate for Payer: BCBS of TX Blue Essentials	$3.24
Rate for Payer: BCBS of TX PPO	$3.60
Rate for Payer: Cash Price	$6.12
Rate for Payer: Cigna Medicaid	$6.48
Rate for Payer: Molina CHIP/Medicaid	$6.48
Rate for Payer: Multiplan Auto	$5.85
Rate for Payer: Multiplan Commercial	$5.85
Rate for Payer: Multiplan Workers Comp	$5.85
Rate for Payer: Parkland Medicaid	$6.48
Rate for Payer: Scott and White EPO/PPO	$4.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.48
Rate for Payer: Superior Health Plan EPO	$1.22

ezetimibe 10 mg Tab

Facility

$9.00

Service Code	HCPCS J3490
Hospital Charge Code	77560850
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.12

Know your out-of-pocket cost for care.

All Charges