White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ld pacing fineline 4469

Facility

$2,945.78

Service Code	HCPCS C1898
Hospital Charge Code	110096
Hospital Revenue Code	275
Min. Negotiated Rate	$736.44
Max. Negotiated Rate	$1,472.89
Rate for Payer: Aetna Commercial	$883.73
Rate for Payer: Cash Price	$2,592.29
Rate for Payer: Cigna Commercial	$736.44
Rate for Payer: Multiplan Auto	$1,472.89
Rate for Payer: Multiplan Commercial	$1,472.89
Rate for Payer: Multiplan Workers Comp	$1,472.89
Rate for Payer: Scott and White EPO/PPO	$1,472.89

ld pacing fineline 4469

Facility

$2,945.78

Service Code	HCPCS C1898
Hospital Charge Code	110096
Hospital Revenue Code	275
Min. Negotiated Rate	$265.12
Max. Negotiated Rate	$1,472.89
Rate for Payer: BCBS of TX PPO	$1,178.31
Rate for Payer: Cash Price	$2,592.29
Rate for Payer: Multiplan Auto	$1,472.89
Rate for Payer: Multiplan Commercial	$1,472.89
Rate for Payer: Multiplan Workers Comp	$1,472.89
Rate for Payer: Scott and White EPO/PPO	$1,472.89
Rate for Payer: Superior Health Plan EPO	$400.63
Rate for Payer: Aetna Commercial	$883.73
Rate for Payer: Amerigroup CHIP/Medicaid	$265.12
Rate for Payer: BCBS of TX Blue Advantage	$883.73
Rate for Payer: BCBS of TX Blue Essentials	$1,060.48

LD PACING FINELINE 4470

Facility

$2,765.06

Service Code	HCPCS C1898
Hospital Charge Code	110097
Hospital Revenue Code	275
Min. Negotiated Rate	$691.26
Max. Negotiated Rate	$1,382.53
Rate for Payer: Aetna Commercial	$829.52
Rate for Payer: Cash Price	$2,433.25
Rate for Payer: Cigna Commercial	$691.26
Rate for Payer: Multiplan Auto	$1,382.53
Rate for Payer: Multiplan Commercial	$1,382.53
Rate for Payer: Multiplan Workers Comp	$1,382.53
Rate for Payer: Scott and White EPO/PPO	$1,382.53

LD PACING FINELINE 4470

Facility

$2,765.06

Service Code	HCPCS C1898
Hospital Charge Code	110097
Hospital Revenue Code	275
Min. Negotiated Rate	$248.86
Max. Negotiated Rate	$1,382.53
Rate for Payer: Aetna Commercial	$829.52
Rate for Payer: Amerigroup CHIP/Medicaid	$248.86
Rate for Payer: BCBS of TX Blue Advantage	$829.52
Rate for Payer: BCBS of TX Blue Essentials	$995.42
Rate for Payer: BCBS of TX PPO	$1,106.02
Rate for Payer: Cash Price	$2,433.25
Rate for Payer: Multiplan Auto	$1,382.53
Rate for Payer: Multiplan Commercial	$1,382.53
Rate for Payer: Multiplan Workers Comp	$1,382.53
Rate for Payer: Scott and White EPO/PPO	$1,382.53
Rate for Payer: Superior Health Plan EPO	$376.05

LD PM CAPSURFX NOVUS5076 -- DHF

Facility

$3,487.60

Service Code	HCPCS C1898
Hospital Charge Code	82418658
Hospital Revenue Code	278
Min. Negotiated Rate	$313.88
Max. Negotiated Rate	$1,743.80
Rate for Payer: Aetna Commercial	$1,046.28
Rate for Payer: Amerigroup CHIP/Medicaid	$313.88
Rate for Payer: BCBS of TX Blue Advantage	$1,046.28
Rate for Payer: BCBS of TX Blue Essentials	$1,255.54
Rate for Payer: BCBS of TX PPO	$1,395.04
Rate for Payer: Cash Price	$3,069.09
Rate for Payer: Multiplan Auto	$1,743.80
Rate for Payer: Multiplan Commercial	$1,743.80
Rate for Payer: Multiplan Workers Comp	$1,743.80
Rate for Payer: Scott and White EPO/PPO	$1,743.80
Rate for Payer: Superior Health Plan EPO	$474.31

LD PM CAPSURFX NOVUS5076 -- DHF

Facility

$3,487.60

Service Code	HCPCS C1898
Hospital Charge Code	82418658
Hospital Revenue Code	278
Min. Negotiated Rate	$871.90
Max. Negotiated Rate	$1,743.80
Rate for Payer: Aetna Commercial	$1,046.28
Rate for Payer: Cash Price	$3,069.09
Rate for Payer: Cigna Commercial	$871.90
Rate for Payer: Multiplan Auto	$1,743.80
Rate for Payer: Multiplan Commercial	$1,743.80
Rate for Payer: Multiplan Workers Comp	$1,743.80
Rate for Payer: Scott and White EPO/PPO	$1,743.80

LD PM TENDRIL STS 2088TC

Facility

$3,408.55

Service Code	HCPCS C1898
Hospital Charge Code	40087421
Hospital Revenue Code	278
Min. Negotiated Rate	$852.14
Max. Negotiated Rate	$1,704.28
Rate for Payer: Aetna Commercial	$1,022.56
Rate for Payer: Cash Price	$2,999.52
Rate for Payer: Cigna Commercial	$852.14
Rate for Payer: Multiplan Auto	$1,704.28
Rate for Payer: Multiplan Commercial	$1,704.28
Rate for Payer: Multiplan Workers Comp	$1,704.28
Rate for Payer: Scott and White EPO/PPO	$1,704.28

LD PM TENDRIL STS 2088TC

Facility

$3,408.55

Service Code	HCPCS C1898
Hospital Charge Code	40087421
Hospital Revenue Code	278
Min. Negotiated Rate	$306.77
Max. Negotiated Rate	$1,704.28
Rate for Payer: Aetna Commercial	$1,022.56
Rate for Payer: Amerigroup CHIP/Medicaid	$306.77
Rate for Payer: BCBS of TX Blue Advantage	$1,022.56
Rate for Payer: BCBS of TX Blue Essentials	$1,227.08
Rate for Payer: BCBS of TX PPO	$1,363.42
Rate for Payer: Cash Price	$2,999.52
Rate for Payer: Multiplan Auto	$1,704.28
Rate for Payer: Multiplan Commercial	$1,704.28
Rate for Payer: Multiplan Workers Comp	$1,704.28
Rate for Payer: Scott and White EPO/PPO	$1,704.28
Rate for Payer: Superior Health Plan EPO	$463.56

LD PM TENDRL SDX1488T/46 -- DHF

Facility

$6,608.24

Service Code	HCPCS C1898
Hospital Charge Code	82402280
Hospital Revenue Code	278
Min. Negotiated Rate	$594.74
Max. Negotiated Rate	$3,304.12
Rate for Payer: Aetna Commercial	$1,982.47
Rate for Payer: Amerigroup CHIP/Medicaid	$594.74
Rate for Payer: BCBS of TX Blue Advantage	$1,982.47
Rate for Payer: BCBS of TX Blue Essentials	$2,378.97
Rate for Payer: BCBS of TX PPO	$2,643.30
Rate for Payer: Cash Price	$5,815.25
Rate for Payer: Multiplan Auto	$3,304.12
Rate for Payer: Multiplan Commercial	$3,304.12
Rate for Payer: Multiplan Workers Comp	$3,304.12
Rate for Payer: Scott and White EPO/PPO	$3,304.12
Rate for Payer: Superior Health Plan EPO	$898.72

LD PM TENDRL SDX1488T/46 -- DHF

Facility

$6,608.24

Service Code	HCPCS C1898
Hospital Charge Code	82402280
Hospital Revenue Code	278
Min. Negotiated Rate	$1,652.06
Max. Negotiated Rate	$3,304.12
Rate for Payer: Aetna Commercial	$1,982.47
Rate for Payer: Cash Price	$5,815.25
Rate for Payer: Cigna Commercial	$1,652.06
Rate for Payer: Multiplan Auto	$3,304.12
Rate for Payer: Multiplan Commercial	$3,304.12
Rate for Payer: Multiplan Workers Comp	$3,304.12
Rate for Payer: Scott and White EPO/PPO	$3,304.12

LD QUARTET QUADPLR 1458Q -- DHF

Facility

$21,084.34

Service Code	HCPCS C1900
Hospital Charge Code	40088007
Hospital Revenue Code	278
Min. Negotiated Rate	$5,271.08
Max. Negotiated Rate	$10,542.17
Rate for Payer: Aetna Commercial	$6,325.30
Rate for Payer: Cash Price	$18,554.22
Rate for Payer: Cigna Commercial	$5,271.08
Rate for Payer: Multiplan Auto	$10,542.17
Rate for Payer: Multiplan Commercial	$10,542.17
Rate for Payer: Multiplan Workers Comp	$10,542.17
Rate for Payer: Scott and White EPO/PPO	$10,542.17

LD QUARTET QUADPLR 1458Q -- DHF

Facility

$21,084.34

Service Code	HCPCS C1900
Hospital Charge Code	40088007
Hospital Revenue Code	278
Min. Negotiated Rate	$1,897.59
Max. Negotiated Rate	$10,542.17
Rate for Payer: Aetna Commercial	$6,325.30
Rate for Payer: Amerigroup CHIP/Medicaid	$1,897.59
Rate for Payer: BCBS of TX Blue Advantage	$6,325.30
Rate for Payer: BCBS of TX Blue Essentials	$7,590.36
Rate for Payer: BCBS of TX PPO	$8,433.74
Rate for Payer: Cash Price	$18,554.22
Rate for Payer: Multiplan Auto	$10,542.17
Rate for Payer: Multiplan Commercial	$10,542.17
Rate for Payer: Multiplan Workers Comp	$10,542.17
Rate for Payer: Scott and White EPO/PPO	$10,542.17
Rate for Payer: Superior Health Plan EPO	$2,867.47

LD RELIANCE 4 FRONT 0675

Facility

$21,686.75

Service Code	HCPCS C1899
Hospital Charge Code	141578
Hospital Revenue Code	275
Min. Negotiated Rate	$1,951.81
Max. Negotiated Rate	$10,843.38
Rate for Payer: Aetna Commercial	$6,506.02
Rate for Payer: Amerigroup CHIP/Medicaid	$1,951.81
Rate for Payer: BCBS of TX Blue Advantage	$6,506.02
Rate for Payer: BCBS of TX Blue Essentials	$7,807.23
Rate for Payer: BCBS of TX PPO	$8,674.70
Rate for Payer: Cash Price	$19,084.34
Rate for Payer: Multiplan Auto	$10,843.38
Rate for Payer: Multiplan Commercial	$10,843.38
Rate for Payer: Multiplan Workers Comp	$10,843.38
Rate for Payer: Scott and White EPO/PPO	$10,843.38
Rate for Payer: Superior Health Plan EPO	$2,949.40

LD RELIANCE 4 FRONT 0675

Facility

$21,686.75

Service Code	HCPCS C1899
Hospital Charge Code	141578
Hospital Revenue Code	275
Min. Negotiated Rate	$5,421.69
Max. Negotiated Rate	$10,843.38
Rate for Payer: Aetna Commercial	$6,506.02
Rate for Payer: Cash Price	$19,084.34
Rate for Payer: Cigna Commercial	$5,421.69
Rate for Payer: Multiplan Auto	$10,843.38
Rate for Payer: Multiplan Commercial	$10,843.38
Rate for Payer: Multiplan Workers Comp	$10,843.38
Rate for Payer: Scott and White EPO/PPO	$10,843.38

L&D Tx Proph Diag Ea Addl IVP Drug 96375 BCE

Facility

$330.00

Service Code	CPT 96375
Hospital Charge Code	301192
Hospital Revenue Code	260
Rate for Payer: Cash Price	$290.40

L&D Tx Proph Diag Ea Addl IVP Drug 96375 BCE

Facility

$330.00

Service Code	CPT 96375
Hospital Charge Code	301192
Hospital Revenue Code	260
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$214.50
Rate for Payer: Aetna Commercial	$181.50
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$29.48
Rate for Payer: BCBS of TX Blue Essentials	$35.24
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$39.30
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Scott and White EPO/PPO	$0.78
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

L&D Tx Proph Diag Injection SQ or IM 96372 BCE

Facility

$280.00

Service Code	CPT 96372
Hospital Charge Code	301168
Hospital Revenue Code	260
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$154.00
Rate for Payer: Aetna Medicare	$96.64
Rate for Payer: Amerigroup CHIP/Medicaid	$25.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$64.43
Rate for Payer: Amerigroup Medicare	$64.43
Rate for Payer: BCBS of TX Blue Advantage	$105.22
Rate for Payer: BCBS of TX Blue Essentials	$125.78
Rate for Payer: BCBS of TX Medicare	$64.43
Rate for Payer: BCBS of TX PPO	$140.29
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cigna Commercial	$145.94
Rate for Payer: Cigna Medicaid	$11.23
Rate for Payer: Cigna Medicare	$64.43
Rate for Payer: Employer Direct Commercial	$64.43
Rate for Payer: Humana Medicare/TRICARE	$64.43
Rate for Payer: Molina CHIP/Medicaid	$11.23
Rate for Payer: Molina Dual Medicare/Medicaid	$64.43
Rate for Payer: Molina Medicare	$64.43
Rate for Payer: Multiplan Auto	$182.00
Rate for Payer: Multiplan Commercial	$182.00
Rate for Payer: Multiplan Workers Comp	$182.00
Rate for Payer: Parkland Medicaid	$11.23
Rate for Payer: Scott and White EPO/PPO	$1.15
Rate for Payer: Scott and White Medicare	$64.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.23
Rate for Payer: Superior Health Plan EPO	$64.43
Rate for Payer: Superior Health Plan Medicare	$64.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$64.43
Rate for Payer: Universal American Medicare	$64.43
Rate for Payer: Wellcare Medicare	$64.43
Rate for Payer: Wellmed Medicare	$64.43

L&D Tx Proph Diag Injection SQ or IM 96372 BCE

Facility

$280.00

Service Code	CPT 96372
Hospital Charge Code	301168
Hospital Revenue Code	260
Rate for Payer: Cash Price	$246.40

L&D Tx Proph Diag Seq IVP Same Drug 96376 BCE

Facility

$330.00

Service Code	CPT 96376
Hospital Charge Code	301200
Hospital Revenue Code	260
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$214.50
Rate for Payer: Aetna Commercial	$181.50
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: BCBS of TX Blue Advantage	$41.39
Rate for Payer: BCBS of TX Blue Essentials	$49.48
Rate for Payer: BCBS of TX PPO	$55.19
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Scott and White EPO/PPO	$165.00
Rate for Payer: Superior Health Plan EPO	$44.88

L&D Tx Proph Diag Seq IVP Same Drug 96376 BCE

Facility

$330.00

Service Code	CPT 96376
Hospital Charge Code	301200
Hospital Revenue Code	260
Rate for Payer: Cash Price	$290.40

L&D Tx Prophylactic Diag IVP Drug 96374 BCE

Facility

$360.00

Service Code	CPT 96374
Hospital Charge Code	301184
Hospital Revenue Code	260
Rate for Payer: Cash Price	$316.80

L&D Tx Prophylactic Diag IVP Drug 96374 BCE

Facility

$360.00

Service Code	CPT 96374
Hospital Charge Code	301184
Hospital Revenue Code	260
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$444.05
Rate for Payer: Aetna Commercial	$198.00
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup CHIP/Medicaid	$32.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$68.97
Rate for Payer: BCBS of TX Blue Essentials	$82.45
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$91.96
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$444.05
Rate for Payer: Cigna Medicare	$196.02
Rate for Payer: Employer Direct Commercial	$196.02
Rate for Payer: Humana Medicare/TRICARE	$196.02
Rate for Payer: Molina Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
Rate for Payer: Multiplan Auto	$234.00
Rate for Payer: Multiplan Commercial	$234.00
Rate for Payer: Multiplan Workers Comp	$234.00
Rate for Payer: Scott and White EPO/PPO	$3.51
Rate for Payer: Scott and White Medicare	$196.02
Rate for Payer: Superior Health Plan EPO	$196.02
Rate for Payer: Superior Health Plan Medicare	$196.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$196.02
Rate for Payer: Universal American Medicare	$196.02
Rate for Payer: Wellcare Medicare	$196.02
Rate for Payer: Wellmed Medicare	$196.02

LD WIRE EKG -- DHF

Facility

$75.74

Hospital Charge Code	80326150
Hospital Revenue Code	270
Rate for Payer: Cash Price	$66.65

LD WIRE EKG -- DHF

Facility

$75.74

Hospital Charge Code	80326150
Hospital Revenue Code	270
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$49.23
Rate for Payer: Aetna Commercial	$41.66
Rate for Payer: Amerigroup CHIP/Medicaid	$6.82
Rate for Payer: BCBS of TX Blue Advantage	$22.72
Rate for Payer: BCBS of TX Blue Essentials	$27.27
Rate for Payer: BCBS of TX PPO	$30.30
Rate for Payer: Cash Price	$66.65
Rate for Payer: Multiplan Auto	$49.23
Rate for Payer: Multiplan Commercial	$49.23
Rate for Payer: Multiplan Workers Comp	$49.23
Rate for Payer: Scott and White EPO/PPO	$37.87
Rate for Payer: Superior Health Plan EPO	$10.30

Lead, Blood (Adult) SO

Facility

$68.00

Service Code	CPT 83655
Hospital Charge Code	1601228
Hospital Revenue Code	301
Rate for Payer: Cash Price	$59.84

Know your out-of-pocket cost for care.

All Charges