White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Lead, Blood (Adult) SO

Facility

$68.00

Service Code	CPT 83655
Hospital Charge Code	1601228
Hospital Revenue Code	301
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$44.20
Rate for Payer: Aetna Commercial	$12.72
Rate for Payer: Aetna Medicare	$18.16
Rate for Payer: Amerigroup CHIP/Medicaid	$4.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.11
Rate for Payer: Amerigroup Medicare	$12.11
Rate for Payer: BCBS of TX Blue Advantage	$19.98
Rate for Payer: BCBS of TX Blue Essentials	$23.98
Rate for Payer: BCBS of TX Medicare	$12.11
Rate for Payer: BCBS of TX PPO	$26.76
Rate for Payer: Cash Price	$59.84
Rate for Payer: Cash Price	$59.84
Rate for Payer: Cigna Medicaid	$12.11
Rate for Payer: Cigna Medicare	$12.11
Rate for Payer: Employer Direct Commercial	$12.11
Rate for Payer: Humana Medicare/TRICARE	$12.11
Rate for Payer: Molina CHIP/Medicaid	$12.11
Rate for Payer: Molina Dual Medicare/Medicaid	$12.11
Rate for Payer: Molina Medicare	$12.11
Rate for Payer: Multiplan Auto	$44.20
Rate for Payer: Multiplan Commercial	$44.20
Rate for Payer: Multiplan Workers Comp	$44.20
Rate for Payer: Parkland Medicaid	$12.11
Rate for Payer: Scott and White EPO/PPO	$15.14
Rate for Payer: Scott and White Medicare	$12.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.11
Rate for Payer: Superior Health Plan EPO	$12.11
Rate for Payer: Superior Health Plan Medicare	$12.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.11
Rate for Payer: Universal American Medicare	$12.11
Rate for Payer: Wellcare Medicare	$12.11
Rate for Payer: Wellmed Medicare	$12.11

LEAD PACING CPSR

Facility

$3,487.60

Service Code	HCPCS C1778
Hospital Charge Code	8420456
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

LEAD PACING CPSR

Facility

$3,487.60

Service Code	HCPCS C1778
Hospital Charge Code	8420456
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

LEAD PACING INGEIVITY 7840

Facility

$6,677.68

Service Code	HCPCS C1898
Hospital Charge Code	8428499
Hospital Revenue Code	278
Min. Negotiated Rate	$1,669.42
Max. Negotiated Rate	$3,338.84
Rate for Payer: Aetna Commercial	$2,003.30
Rate for Payer: Cash Price	$5,876.36
Rate for Payer: Cigna Commercial	$1,669.42
Rate for Payer: Multiplan Auto	$3,338.84
Rate for Payer: Multiplan Commercial	$3,338.84
Rate for Payer: Multiplan Workers Comp	$3,338.84
Rate for Payer: Scott and White EPO/PPO	$3,338.84

LEAD PACING INGEIVITY 7840

Facility

$6,677.68

Service Code	HCPCS C1898
Hospital Charge Code	8428499
Hospital Revenue Code	278
Min. Negotiated Rate	$600.99
Max. Negotiated Rate	$3,338.84
Rate for Payer: Aetna Commercial	$2,003.30
Rate for Payer: Amerigroup CHIP/Medicaid	$600.99
Rate for Payer: BCBS of TX Blue Advantage	$2,003.30
Rate for Payer: BCBS of TX Blue Essentials	$2,403.96
Rate for Payer: BCBS of TX PPO	$2,671.07
Rate for Payer: Cash Price	$5,876.36
Rate for Payer: Multiplan Auto	$3,338.84
Rate for Payer: Multiplan Commercial	$3,338.84
Rate for Payer: Multiplan Workers Comp	$3,338.84
Rate for Payer: Scott and White EPO/PPO	$3,338.84
Rate for Payer: Superior Health Plan EPO	$908.16

LEAD PACING INGEVITY 7841

Facility

$6,677.69

Service Code	HCPCS C1898
Hospital Charge Code	144777
Hospital Revenue Code	275
Min. Negotiated Rate	$600.99
Max. Negotiated Rate	$3,338.84
Rate for Payer: Aetna Commercial	$2,003.31
Rate for Payer: Amerigroup CHIP/Medicaid	$600.99
Rate for Payer: BCBS of TX Blue Advantage	$2,003.31
Rate for Payer: BCBS of TX Blue Essentials	$2,403.97
Rate for Payer: BCBS of TX PPO	$2,671.08
Rate for Payer: Cash Price	$5,876.37
Rate for Payer: Multiplan Auto	$3,338.84
Rate for Payer: Multiplan Commercial	$3,338.84
Rate for Payer: Multiplan Workers Comp	$3,338.84
Rate for Payer: Scott and White EPO/PPO	$3,338.84
Rate for Payer: Superior Health Plan EPO	$908.17

LEAD PACING INGEVITY 7841

Facility

$6,677.69

Service Code	HCPCS C1898
Hospital Charge Code	144777
Hospital Revenue Code	275
Min. Negotiated Rate	$1,669.42
Max. Negotiated Rate	$3,338.84
Rate for Payer: Aetna Commercial	$2,003.31
Rate for Payer: Cash Price	$5,876.37
Rate for Payer: Cigna Commercial	$1,669.42
Rate for Payer: Multiplan Auto	$3,338.84
Rate for Payer: Multiplan Commercial	$3,338.84
Rate for Payer: Multiplan Workers Comp	$3,338.84
Rate for Payer: Scott and White EPO/PPO	$3,338.84

LEADWIRE 33135BT

Facility

$227.00

Hospital Charge Code	145282
Hospital Revenue Code	272
Rate for Payer: Cash Price	$199.76

LEADWIRE 33135BT

Facility

$227.00

Hospital Charge Code	145282
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$147.55
Rate for Payer: Aetna Commercial	$124.85
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$199.76
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan EPO	$30.87

LEADWIRE 33136BT

Facility

$380.95

Hospital Charge Code	145281
Hospital Revenue Code	272
Rate for Payer: Cash Price	$335.24

LEADWIRE 33136BT

Facility

$380.95

Hospital Charge Code	145281
Hospital Revenue Code	272
Min. Negotiated Rate	$34.29
Max. Negotiated Rate	$247.62
Rate for Payer: Aetna Commercial	$209.52
Rate for Payer: Amerigroup CHIP/Medicaid	$34.29
Rate for Payer: BCBS of TX Blue Advantage	$114.28
Rate for Payer: BCBS of TX Blue Essentials	$137.14
Rate for Payer: BCBS of TX PPO	$152.38
Rate for Payer: Cash Price	$335.24
Rate for Payer: Multiplan Auto	$247.62
Rate for Payer: Multiplan Commercial	$247.62
Rate for Payer: Multiplan Workers Comp	$247.62
Rate for Payer: Scott and White EPO/PPO	$190.48
Rate for Payer: Superior Health Plan EPO	$51.81

LEADWIRE -DISPOSABLE 33136TR

Facility

$42.31

Hospital Charge Code	144399
Hospital Revenue Code	272
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$27.50
Rate for Payer: Aetna Commercial	$23.27
Rate for Payer: Amerigroup CHIP/Medicaid	$3.81
Rate for Payer: BCBS of TX Blue Advantage	$12.69
Rate for Payer: BCBS of TX Blue Essentials	$15.23
Rate for Payer: BCBS of TX PPO	$16.92
Rate for Payer: Cash Price	$37.23
Rate for Payer: Multiplan Auto	$27.50
Rate for Payer: Multiplan Commercial	$27.50
Rate for Payer: Multiplan Workers Comp	$27.50
Rate for Payer: Scott and White EPO/PPO	$21.16
Rate for Payer: Superior Health Plan EPO	$5.75

LEADWIRE -DISPOSABLE 33136TR

Facility

$42.31

Hospital Charge Code	144399
Hospital Revenue Code	272
Rate for Payer: Cash Price	$37.23

Legionella Antigen Urine

Facility

$358.00

Service Code	CPT 87449
Hospital Charge Code	4107912
Hospital Revenue Code	306
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$232.70
Rate for Payer: Aetna Commercial	$12.58
Rate for Payer: Aetna Medicare	$17.97
Rate for Payer: Amerigroup CHIP/Medicaid	$4.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.98
Rate for Payer: Amerigroup Medicare	$11.98
Rate for Payer: BCBS of TX Blue Advantage	$19.77
Rate for Payer: BCBS of TX Blue Essentials	$23.72
Rate for Payer: BCBS of TX Medicare	$11.98
Rate for Payer: BCBS of TX PPO	$26.48
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cigna Medicaid	$11.98
Rate for Payer: Cigna Medicare	$11.98
Rate for Payer: Employer Direct Commercial	$11.98
Rate for Payer: Humana Medicare/TRICARE	$11.98
Rate for Payer: Molina CHIP/Medicaid	$11.98
Rate for Payer: Molina Dual Medicare/Medicaid	$11.98
Rate for Payer: Molina Medicare	$11.98
Rate for Payer: Multiplan Auto	$232.70
Rate for Payer: Multiplan Commercial	$232.70
Rate for Payer: Multiplan Workers Comp	$232.70
Rate for Payer: Parkland Medicaid	$11.98
Rate for Payer: Scott and White EPO/PPO	$14.98
Rate for Payer: Scott and White Medicare	$11.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.98
Rate for Payer: Superior Health Plan EPO	$11.98
Rate for Payer: Superior Health Plan Medicare	$11.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.98
Rate for Payer: Universal American Medicare	$11.98
Rate for Payer: Wellcare Medicare	$11.98
Rate for Payer: Wellmed Medicare	$11.98

Legionella Antigen Urine

Facility

$358.00

Service Code	CPT 87449
Hospital Charge Code	4107912
Hospital Revenue Code	306
Rate for Payer: Cash Price	$315.04

Legionella Culture

Facility

$229.00

Service Code	CPT 87081
Hospital Charge Code	4108701
Hospital Revenue Code	306
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$148.85
Rate for Payer: Aetna Commercial	$6.96
Rate for Payer: Aetna Medicare	$9.94
Rate for Payer: Amerigroup CHIP/Medicaid	$2.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.63
Rate for Payer: Amerigroup Medicare	$6.63
Rate for Payer: BCBS of TX Blue Advantage	$10.94
Rate for Payer: BCBS of TX Blue Essentials	$13.13
Rate for Payer: BCBS of TX Medicare	$6.63
Rate for Payer: BCBS of TX PPO	$14.65
Rate for Payer: Cash Price	$201.52
Rate for Payer: Cash Price	$201.52
Rate for Payer: Cigna Medicaid	$6.63
Rate for Payer: Cigna Medicare	$6.63
Rate for Payer: Employer Direct Commercial	$6.63
Rate for Payer: Humana Medicare/TRICARE	$6.63
Rate for Payer: Molina CHIP/Medicaid	$6.63
Rate for Payer: Molina Dual Medicare/Medicaid	$6.63
Rate for Payer: Molina Medicare	$6.63
Rate for Payer: Multiplan Auto	$148.85
Rate for Payer: Multiplan Commercial	$148.85
Rate for Payer: Multiplan Workers Comp	$148.85
Rate for Payer: Parkland Medicaid	$6.63
Rate for Payer: Scott and White EPO/PPO	$8.29
Rate for Payer: Scott and White Medicare	$6.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.63
Rate for Payer: Superior Health Plan EPO	$6.63
Rate for Payer: Superior Health Plan Medicare	$6.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.63
Rate for Payer: Universal American Medicare	$6.63
Rate for Payer: Wellcare Medicare	$6.63
Rate for Payer: Wellmed Medicare	$6.63

Legionella Culture

Facility

$229.00

Service Code	CPT 87081
Hospital Charge Code	4108701
Hospital Revenue Code	306
Rate for Payer: Cash Price	$201.52

Legionella Pneumophila 1, IgM SO

Facility

$169.00

Service Code	CPT 86713
Hospital Charge Code	1701218
Hospital Revenue Code	302
Rate for Payer: Cash Price	$148.72

Legionella Pneumophila 1, IgM SO

Facility

$169.00

Service Code	CPT 86713
Hospital Charge Code	1701218
Hospital Revenue Code	302
Min. Negotiated Rate	$5.97
Max. Negotiated Rate	$109.85
Rate for Payer: Aetna Commercial	$16.06
Rate for Payer: Aetna Medicare	$22.95
Rate for Payer: Amerigroup CHIP/Medicaid	$5.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.30
Rate for Payer: Amerigroup Medicare	$15.30
Rate for Payer: BCBS of TX Blue Advantage	$25.24
Rate for Payer: BCBS of TX Blue Essentials	$30.29
Rate for Payer: BCBS of TX Medicare	$15.30
Rate for Payer: BCBS of TX PPO	$33.81
Rate for Payer: Cash Price	$148.72
Rate for Payer: Cash Price	$148.72
Rate for Payer: Cigna Medicaid	$15.30
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Employer Direct Commercial	$15.30
Rate for Payer: Humana Medicare/TRICARE	$15.30
Rate for Payer: Molina CHIP/Medicaid	$15.30
Rate for Payer: Molina Dual Medicare/Medicaid	$15.30
Rate for Payer: Molina Medicare	$15.30
Rate for Payer: Multiplan Auto	$109.85
Rate for Payer: Multiplan Commercial	$109.85
Rate for Payer: Multiplan Workers Comp	$109.85
Rate for Payer: Parkland Medicaid	$15.30
Rate for Payer: Scott and White EPO/PPO	$19.12
Rate for Payer: Scott and White Medicare	$15.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.30
Rate for Payer: Superior Health Plan EPO	$15.30
Rate for Payer: Superior Health Plan Medicare	$15.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.30
Rate for Payer: Universal American Medicare	$15.30
Rate for Payer: Wellcare Medicare	$15.30
Rate for Payer: Wellmed Medicare	$15.30

LENEVA INJECTABLE ADIPOSE MATRIC 1.5CC

Facility

$7,084.34

Service Code	HCPCS J3590
Hospital Charge Code	145564
Hospital Revenue Code	636
Min. Negotiated Rate	$637.59
Max. Negotiated Rate	$4,604.82
Rate for Payer: Amerigroup CHIP/Medicaid	$637.59
Rate for Payer: BCBS of TX Blue Advantage	$2,125.30
Rate for Payer: BCBS of TX Blue Essentials	$2,550.36
Rate for Payer: BCBS of TX PPO	$2,833.74
Rate for Payer: Cash Price	$6,234.22
Rate for Payer: Multiplan Auto	$4,604.82
Rate for Payer: Multiplan Commercial	$4,604.82
Rate for Payer: Multiplan Workers Comp	$4,604.82
Rate for Payer: Scott and White EPO/PPO	$3,542.17
Rate for Payer: Superior Health Plan EPO	$963.47

LENEVA INJECTABLE ADIPOSE MATRIC 1.5CC

Facility

$7,084.34

Service Code	HCPCS J3590
Hospital Charge Code	145564
Hospital Revenue Code	636
Min. Negotiated Rate	$1,771.08
Max. Negotiated Rate	$3,542.17
Rate for Payer: Cash Price	$6,234.22
Rate for Payer: Cigna Commercial	$1,771.08
Rate for Payer: Scott and White EPO/PPO	$3,542.17

LENEVA INJECTABLE ADIPOSE MATRIX 3CC

Facility

$14,021.08

Service Code	HCPCS J3590
Hospital Charge Code	145565
Hospital Revenue Code	636
Min. Negotiated Rate	$3,505.27
Max. Negotiated Rate	$7,010.54
Rate for Payer: Cash Price	$12,338.55
Rate for Payer: Cigna Commercial	$3,505.27
Rate for Payer: Scott and White EPO/PPO	$7,010.54

LENEVA INJECTABLE ADIPOSE MATRIX 3CC

Facility

$14,021.08

Service Code	HCPCS J3590
Hospital Charge Code	145565
Hospital Revenue Code	636
Min. Negotiated Rate	$1,261.90
Max. Negotiated Rate	$9,113.70
Rate for Payer: Amerigroup CHIP/Medicaid	$1,261.90
Rate for Payer: BCBS of TX Blue Advantage	$4,206.32
Rate for Payer: BCBS of TX Blue Essentials	$5,047.59
Rate for Payer: BCBS of TX PPO	$5,608.43
Rate for Payer: Cash Price	$12,338.55
Rate for Payer: Multiplan Auto	$9,113.70
Rate for Payer: Multiplan Commercial	$9,113.70
Rate for Payer: Multiplan Workers Comp	$9,113.70
Rate for Payer: Scott and White EPO/PPO	$7,010.54
Rate for Payer: Superior Health Plan EPO	$1,906.87

Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure)

Facility

$10,000.00

Service Code	CPT 27685
Hospital Charge Code	36027685
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

LENS MORGAN -- DHF

Facility

$648.34

Hospital Charge Code	80326200
Hospital Revenue Code	270
Min. Negotiated Rate	$58.35
Max. Negotiated Rate	$421.42
Rate for Payer: Aetna Commercial	$356.59
Rate for Payer: Amerigroup CHIP/Medicaid	$58.35
Rate for Payer: BCBS of TX Blue Advantage	$194.50
Rate for Payer: BCBS of TX Blue Essentials	$233.40
Rate for Payer: BCBS of TX PPO	$259.34
Rate for Payer: Cash Price	$570.54
Rate for Payer: Multiplan Auto	$421.42
Rate for Payer: Multiplan Commercial	$421.42
Rate for Payer: Multiplan Workers Comp	$421.42
Rate for Payer: Scott and White EPO/PPO	$324.17
Rate for Payer: Superior Health Plan EPO	$88.17

Know your out-of-pocket cost for care.

All Charges