White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial

Facility

$10,000.00

Service Code	CPT 26045
Hospital Charge Code	36026045
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial

Facility

$11,906.64

Service Code	HCPCS 26045
Hospital Charge Code	9900313
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,096.52

Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial

Facility

$11,906.64

Service Code	HCPCS 26045
Hospital Charge Code	9900313
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$8,096.52
Rate for Payer: Cash Price	$8,096.52
Rate for Payer: Cash Price	$8,096.52
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$8,572.78
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$8,572.78
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$8,572.78
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,572.78
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

FDL IMPLANT SYSTEM, 5.5 MM

Facility

$15,012.05

Service Code	HCPCS C1734
Hospital Charge Code	992253
Hospital Revenue Code	278
Min. Negotiated Rate	$3,753.01
Max. Negotiated Rate	$7,506.02
Rate for Payer: Cash Price	$10,208.19
Rate for Payer: Cigna Commercial	$3,753.01
Rate for Payer: Multiplan Auto	$7,506.02
Rate for Payer: Multiplan Commercial	$7,506.02
Rate for Payer: Multiplan Workers Comp	$7,506.02
Rate for Payer: Scott and White EPO/PPO	$7,506.02

FDL IMPLANT SYSTEM, 5.5 MM

Facility

$15,012.05

Service Code	HCPCS C1734
Hospital Charge Code	992253
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.08
Max. Negotiated Rate	$10,808.68
Rate for Payer: Amerigroup CHIP/Medicaid	$1,351.08
Rate for Payer: BCBS of TX Blue Advantage	$4,503.61
Rate for Payer: BCBS of TX Blue Essentials	$5,404.34
Rate for Payer: BCBS of TX PPO	$6,004.82
Rate for Payer: Cash Price	$10,208.19
Rate for Payer: Cigna Medicaid	$10,808.68
Rate for Payer: Molina CHIP/Medicaid	$10,808.68
Rate for Payer: Multiplan Auto	$7,506.02
Rate for Payer: Multiplan Commercial	$7,506.02
Rate for Payer: Multiplan Workers Comp	$7,506.02
Rate for Payer: Parkland Medicaid	$10,808.68
Rate for Payer: Scott and White EPO/PPO	$7,506.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,808.68
Rate for Payer: Superior Health Plan EPO	$2,041.64

FDP, Plasma SO

Facility

$190.00

Service Code	HCPCS 85362
Hospital Charge Code	1600642
Hospital Revenue Code	305
Rate for Payer: Cash Price	$129.20

FDP, Plasma SO

Facility

$190.00

Service Code	HCPCS 85362
Hospital Charge Code	1600642
Hospital Revenue Code	305
Min. Negotiated Rate	$2.69
Max. Negotiated Rate	$136.80
Rate for Payer: Amerigroup CHIP/Medicaid	$2.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.89
Rate for Payer: Amerigroup Medicare	$6.89
Rate for Payer: BCBS of TX Blue Advantage	$57.00
Rate for Payer: BCBS of TX Blue Essentials	$68.40
Rate for Payer: BCBS of TX Medicare	$6.89
Rate for Payer: BCBS of TX PPO	$76.00
Rate for Payer: Cash Price	$129.20
Rate for Payer: Cash Price	$129.20
Rate for Payer: Cigna Medicaid	$136.80
Rate for Payer: Cigna Medicare	$6.89
Rate for Payer: Employer Direct Commercial	$6.89
Rate for Payer: Humana Medicare/TRICARE	$6.89
Rate for Payer: Molina CHIP/Medicaid	$136.80
Rate for Payer: Molina Dual Medicare/Medicaid	$6.89
Rate for Payer: Molina Medicare	$6.89
Rate for Payer: Multiplan Auto	$123.50
Rate for Payer: Multiplan Commercial	$123.50
Rate for Payer: Multiplan Workers Comp	$123.50
Rate for Payer: Parkland Medicaid	$136.80
Rate for Payer: Scott and White EPO/PPO	$8.61
Rate for Payer: Scott and White Medicare	$6.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$136.80
Rate for Payer: Superior Health Plan EPO	$6.89
Rate for Payer: Superior Health Plan Medicare	$6.89
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.89
Rate for Payer: Universal American Medicare	$6.89
Rate for Payer: Wellcare Medicare	$6.89
Rate for Payer: Wellmed Medicare	$6.89

Febrile Antibody Profile SO

Facility

$145.00

Service Code	HCPCS 86757
Hospital Charge Code	9152986
Hospital Revenue Code	302
Rate for Payer: Cash Price	$98.60

Febrile Antibody Profile SO

Facility

$145.00

Service Code	HCPCS 86757
Hospital Charge Code	9152986
Hospital Revenue Code	302
Min. Negotiated Rate	$7.55
Max. Negotiated Rate	$104.40
Rate for Payer: Amerigroup CHIP/Medicaid	$7.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19.35
Rate for Payer: Amerigroup Medicare	$19.35
Rate for Payer: BCBS of TX Blue Advantage	$43.50
Rate for Payer: BCBS of TX Blue Essentials	$52.20
Rate for Payer: BCBS of TX Medicare	$19.35
Rate for Payer: BCBS of TX PPO	$58.00
Rate for Payer: Cash Price	$98.60
Rate for Payer: Cash Price	$98.60
Rate for Payer: Cigna Medicaid	$104.40
Rate for Payer: Cigna Medicare	$19.35
Rate for Payer: Employer Direct Commercial	$19.35
Rate for Payer: Humana Medicare/TRICARE	$19.35
Rate for Payer: Molina CHIP/Medicaid	$104.40
Rate for Payer: Molina Dual Medicare/Medicaid	$19.35
Rate for Payer: Molina Medicare	$19.35
Rate for Payer: Multiplan Auto	$94.25
Rate for Payer: Multiplan Commercial	$94.25
Rate for Payer: Multiplan Workers Comp	$94.25
Rate for Payer: Parkland Medicaid	$104.40
Rate for Payer: Scott and White EPO/PPO	$24.19
Rate for Payer: Scott and White Medicare	$19.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$104.40
Rate for Payer: Superior Health Plan EPO	$19.35
Rate for Payer: Superior Health Plan Medicare	$19.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$19.35
Rate for Payer: Universal American Medicare	$19.35
Rate for Payer: Wellcare Medicare	$19.35
Rate for Payer: Wellmed Medicare	$19.35

fecal collector w/clamp

Facility

$16.21

Hospital Charge Code	131924
Hospital Revenue Code	270
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$11.67
Rate for Payer: Amerigroup CHIP/Medicaid	$1.46
Rate for Payer: BCBS of TX Blue Advantage	$4.86
Rate for Payer: BCBS of TX Blue Essentials	$5.84
Rate for Payer: BCBS of TX PPO	$6.48
Rate for Payer: Cash Price	$11.02
Rate for Payer: Cigna Medicaid	$11.67
Rate for Payer: Molina CHIP/Medicaid	$11.67
Rate for Payer: Multiplan Auto	$10.54
Rate for Payer: Multiplan Commercial	$10.54
Rate for Payer: Multiplan Workers Comp	$10.54
Rate for Payer: Parkland Medicaid	$11.67
Rate for Payer: Scott and White EPO/PPO	$8.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.67
Rate for Payer: Superior Health Plan EPO	$2.20

fecal collector w/clamp

Facility

$16.21

Hospital Charge Code	131924
Hospital Revenue Code	270
Rate for Payer: Cash Price	$11.02

Fecal Fat, Qualitative SO

Facility

$99.00

Service Code	HCPCS 82705
Hospital Charge Code	1630029
Hospital Revenue Code	301
Rate for Payer: Cash Price	$67.32

Fecal Fat, Qualitative SO

Facility

$99.00

Service Code	HCPCS 82705
Hospital Charge Code	1630029
Hospital Revenue Code	301
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$71.28
Rate for Payer: Amerigroup CHIP/Medicaid	$1.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.10
Rate for Payer: Amerigroup Medicare	$5.10
Rate for Payer: BCBS of TX Blue Advantage	$29.70
Rate for Payer: BCBS of TX Blue Essentials	$35.64
Rate for Payer: BCBS of TX Medicare	$5.10
Rate for Payer: BCBS of TX PPO	$39.60
Rate for Payer: Cash Price	$67.32
Rate for Payer: Cash Price	$67.32
Rate for Payer: Cigna Medicaid	$71.28
Rate for Payer: Cigna Medicare	$5.10
Rate for Payer: Employer Direct Commercial	$5.10
Rate for Payer: Humana Medicare/TRICARE	$5.10
Rate for Payer: Molina CHIP/Medicaid	$71.28
Rate for Payer: Molina Dual Medicare/Medicaid	$5.10
Rate for Payer: Molina Medicare	$5.10
Rate for Payer: Multiplan Auto	$64.35
Rate for Payer: Multiplan Commercial	$64.35
Rate for Payer: Multiplan Workers Comp	$64.35
Rate for Payer: Parkland Medicaid	$71.28
Rate for Payer: Scott and White EPO/PPO	$6.38
Rate for Payer: Scott and White Medicare	$5.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$71.28
Rate for Payer: Superior Health Plan EPO	$5.10
Rate for Payer: Superior Health Plan Medicare	$5.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.10
Rate for Payer: Universal American Medicare	$5.10
Rate for Payer: Wellcare Medicare	$5.10
Rate for Payer: Wellmed Medicare	$5.10

Fecal WBC

Facility

$171.00

Service Code	HCPCS 89055
Hospital Charge Code	1611888
Hospital Revenue Code	300
Rate for Payer: Cash Price	$116.28

Fecal WBC

Facility

$171.00

Service Code	HCPCS 89055
Hospital Charge Code	1611888
Hospital Revenue Code	300
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$123.12
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.27
Rate for Payer: Amerigroup Medicare	$4.27
Rate for Payer: BCBS of TX Blue Advantage	$51.30
Rate for Payer: BCBS of TX Blue Essentials	$61.56
Rate for Payer: BCBS of TX Medicare	$4.27
Rate for Payer: BCBS of TX PPO	$68.40
Rate for Payer: Cash Price	$116.28
Rate for Payer: Cash Price	$116.28
Rate for Payer: Cigna Medicaid	$123.12
Rate for Payer: Cigna Medicare	$4.27
Rate for Payer: Employer Direct Commercial	$4.27
Rate for Payer: Humana Medicare/TRICARE	$4.27
Rate for Payer: Molina CHIP/Medicaid	$123.12
Rate for Payer: Molina Dual Medicare/Medicaid	$4.27
Rate for Payer: Molina Medicare	$4.27
Rate for Payer: Multiplan Auto	$111.15
Rate for Payer: Multiplan Commercial	$111.15
Rate for Payer: Multiplan Workers Comp	$111.15
Rate for Payer: Parkland Medicaid	$123.12
Rate for Payer: Scott and White EPO/PPO	$5.34
Rate for Payer: Scott and White Medicare	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$123.12
Rate for Payer: Superior Health Plan EPO	$4.27
Rate for Payer: Superior Health Plan Medicare	$4.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.27
Rate for Payer: Universal American Medicare	$4.27
Rate for Payer: Wellcare Medicare	$4.27
Rate for Payer: Wellmed Medicare	$4.27

FEMALE REPRODUCTIVE SYSTEM INFECTIONS

Facility

$9,591.16

Service Code	APR-DRG 5314
Min. Negotiated Rate	$9,042.88
Max. Negotiated Rate	$9,591.16
Rate for Payer: Amerigroup CHIP/Medicaid	$9,042.88
Rate for Payer: Cigna Medicaid	$9,042.88
Rate for Payer: Molina CHIP/Medicaid	$9,042.88
Rate for Payer: Parkland Medicaid	$9,042.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,591.16

FEMALE REPRODUCTIVE SYSTEM INFECTIONS

Facility

$2,267.28

Service Code	APR-DRG 5311
Min. Negotiated Rate	$2,137.67
Max. Negotiated Rate	$2,267.28
Rate for Payer: Amerigroup CHIP/Medicaid	$2,137.67
Rate for Payer: Cigna Medicaid	$2,137.67
Rate for Payer: Molina CHIP/Medicaid	$2,137.67
Rate for Payer: Parkland Medicaid	$2,137.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,267.28

FEMALE REPRODUCTIVE SYSTEM INFECTIONS

Facility

$5,037.36

Service Code	APR-DRG 5313
Min. Negotiated Rate	$4,749.40
Max. Negotiated Rate	$5,037.36
Rate for Payer: Amerigroup CHIP/Medicaid	$4,749.40
Rate for Payer: Cigna Medicaid	$4,749.40
Rate for Payer: Molina CHIP/Medicaid	$4,749.40
Rate for Payer: Parkland Medicaid	$4,749.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,037.36

FEMALE REPRODUCTIVE SYSTEM INFECTIONS

Facility

$3,314.74

Service Code	APR-DRG 5312
Min. Negotiated Rate	$3,125.25
Max. Negotiated Rate	$3,314.74
Rate for Payer: Amerigroup CHIP/Medicaid	$3,125.25
Rate for Payer: Cigna Medicaid	$3,125.25
Rate for Payer: Molina CHIP/Medicaid	$3,125.25
Rate for Payer: Parkland Medicaid	$3,125.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,314.74

FEMALE REPRODUCTIVE SYSTEM MALIGNANCY

Facility

$6,537.82

Service Code	APR-DRG 5303
Min. Negotiated Rate	$6,164.08
Max. Negotiated Rate	$6,537.82
Rate for Payer: Amerigroup CHIP/Medicaid	$6,164.08
Rate for Payer: Cigna Medicaid	$6,164.08
Rate for Payer: Molina CHIP/Medicaid	$6,164.08
Rate for Payer: Parkland Medicaid	$6,164.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,537.82

FEMALE REPRODUCTIVE SYSTEM MALIGNANCY

Facility

$4,035.17

Service Code	APR-DRG 5302
Min. Negotiated Rate	$3,804.50
Max. Negotiated Rate	$4,035.17
Rate for Payer: Amerigroup CHIP/Medicaid	$3,804.50
Rate for Payer: Cigna Medicaid	$3,804.50
Rate for Payer: Molina CHIP/Medicaid	$3,804.50
Rate for Payer: Parkland Medicaid	$3,804.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,035.17

FEMALE REPRODUCTIVE SYSTEM MALIGNANCY

Facility

$3,173.29

Service Code	APR-DRG 5301
Min. Negotiated Rate	$2,991.89
Max. Negotiated Rate	$3,173.29
Rate for Payer: Amerigroup CHIP/Medicaid	$2,991.89
Rate for Payer: Cigna Medicaid	$2,991.89
Rate for Payer: Molina CHIP/Medicaid	$2,991.89
Rate for Payer: Parkland Medicaid	$2,991.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,173.29

FEMALE REPRODUCTIVE SYSTEM MALIGNANCY

Facility

$9,751.09

Service Code	APR-DRG 5304
Min. Negotiated Rate	$9,193.67
Max. Negotiated Rate	$9,751.09
Rate for Payer: Amerigroup CHIP/Medicaid	$9,193.67
Rate for Payer: Cigna Medicaid	$9,193.67
Rate for Payer: Molina CHIP/Medicaid	$9,193.67
Rate for Payer: Parkland Medicaid	$9,193.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,751.09

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

$7,317.09

Service Code	APR-DRG 5142
Min. Negotiated Rate	$6,898.81
Max. Negotiated Rate	$7,317.09
Rate for Payer: Amerigroup CHIP/Medicaid	$6,898.81
Rate for Payer: Cigna Medicaid	$6,898.81
Rate for Payer: Molina CHIP/Medicaid	$6,898.81
Rate for Payer: Parkland Medicaid	$6,898.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,317.09

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

$12,513.25

Service Code	APR-DRG 5143
Min. Negotiated Rate	$11,797.93
Max. Negotiated Rate	$12,513.25
Rate for Payer: Amerigroup CHIP/Medicaid	$11,797.93
Rate for Payer: Cigna Medicaid	$11,797.93
Rate for Payer: Molina CHIP/Medicaid	$11,797.93
Rate for Payer: Parkland Medicaid	$11,797.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,513.25

Know your out-of-pocket cost for care.

All Charges