White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MEDICAL BACK PROBLEMS WITHOUT MCC

Facility

$18,359.70

Service Code	MSDRG 552
Min. Negotiated Rate	$7,498.34
Max. Negotiated Rate	$18,359.70
Rate for Payer: Aetna Commercial	$10,870.88
Rate for Payer: Aetna Medicare	$14,625.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,750.35
Rate for Payer: Amerigroup Medicare	$9,750.35
Rate for Payer: BCBS of TX Blue Advantage	$7,498.34
Rate for Payer: BCBS of TX Blue Essentials	$9,297.42
Rate for Payer: BCBS of TX Medicare	$9,750.35
Rate for Payer: BCBS of TX PPO	$10,330.87
Rate for Payer: Cigna Commercial	$12,445.94
Rate for Payer: Cigna Medicare	$9,750.35
Rate for Payer: Employer Direct Commercial	$9,750.35
Rate for Payer: Humana Medicare/TRICARE	$9,750.35
Rate for Payer: Molina Dual Medicare/Medicaid	$9,750.35
Rate for Payer: Molina Medicare	$9,750.35
Rate for Payer: Multiplan Auto	$18,359.70
Rate for Payer: Multiplan Commercial	$18,359.70
Rate for Payer: Multiplan Workers Comp	$18,359.70
Rate for Payer: Scott and White EPO/PPO	$8,455.12
Rate for Payer: Scott and White Medicare	$9,750.35
Rate for Payer: Superior Health Plan EPO	$9,750.35
Rate for Payer: Superior Health Plan Medicare	$9,750.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,750.35
Rate for Payer: Universal American Medicare	$9,750.35
Rate for Payer: Wellcare Medicare	$9,750.35
Rate for Payer: Wellmed Medicare	$9,750.35

Medical Nutrition Therapy Intl 15 min

Facility

$120.00

Service Code	CPT 97802
Hospital Charge Code	8500183
Hospital Revenue Code	942
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$80.27
Rate for Payer: Aetna Commercial	$66.00
Rate for Payer: Amerigroup CHIP/Medicaid	$10.80
Rate for Payer: BCBS of TX Blue Advantage	$60.20
Rate for Payer: BCBS of TX Blue Essentials	$71.97
Rate for Payer: BCBS of TX PPO	$80.27
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Multiplan Auto	$78.00
Rate for Payer: Multiplan Commercial	$78.00
Rate for Payer: Multiplan Workers Comp	$78.00
Rate for Payer: Scott and White EPO/PPO	$60.00
Rate for Payer: Superior Health Plan EPO	$16.32

Medical Nutrition Therapy Intl 15 min BCE

Facility

$120.00

Service Code	CPT 97802
Hospital Charge Code	8500183
Hospital Revenue Code	942
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$80.27
Rate for Payer: Aetna Commercial	$66.00
Rate for Payer: Amerigroup CHIP/Medicaid	$10.80
Rate for Payer: BCBS of TX Blue Advantage	$60.20
Rate for Payer: BCBS of TX Blue Essentials	$71.97
Rate for Payer: BCBS of TX PPO	$80.27
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Multiplan Auto	$78.00
Rate for Payer: Multiplan Commercial	$78.00
Rate for Payer: Multiplan Workers Comp	$78.00
Rate for Payer: Scott and White EPO/PPO	$60.00
Rate for Payer: Superior Health Plan EPO	$16.32

Medical Nutrition Therapy Intl 15 min BCE

Facility

$120.00

Service Code	CPT 97802
Hospital Charge Code	8500183
Hospital Revenue Code	942
Rate for Payer: Cash Price	$105.60

Medical NutTherapy Intl 15 min Cardiac

Facility

$120.00

Service Code	CPT 97802
Hospital Charge Code	6019905
Hospital Revenue Code	942
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$80.27
Rate for Payer: Aetna Commercial	$66.00
Rate for Payer: Amerigroup CHIP/Medicaid	$10.80
Rate for Payer: BCBS of TX Blue Advantage	$60.20
Rate for Payer: BCBS of TX Blue Essentials	$71.97
Rate for Payer: BCBS of TX PPO	$80.27
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Multiplan Auto	$78.00
Rate for Payer: Multiplan Commercial	$78.00
Rate for Payer: Multiplan Workers Comp	$78.00
Rate for Payer: Scott and White EPO/PPO	$60.00
Rate for Payer: Superior Health Plan EPO	$16.32

Medical Nuttherapy Intl 15 Min Cardiac BCE

Facility

$120.00

Service Code	CPT 97802
Hospital Charge Code	6019905
Hospital Revenue Code	942
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$80.27
Rate for Payer: Aetna Commercial	$66.00
Rate for Payer: Amerigroup CHIP/Medicaid	$10.80
Rate for Payer: BCBS of TX Blue Advantage	$60.20
Rate for Payer: BCBS of TX Blue Essentials	$71.97
Rate for Payer: BCBS of TX PPO	$80.27
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Multiplan Auto	$78.00
Rate for Payer: Multiplan Commercial	$78.00
Rate for Payer: Multiplan Workers Comp	$78.00
Rate for Payer: Scott and White EPO/PPO	$60.00
Rate for Payer: Superior Health Plan EPO	$16.32

Medical Nuttherapy Intl 15 Min Cardiac BCE

Facility

$120.00

Service Code	CPT 97802
Hospital Charge Code	6019905
Hospital Revenue Code	942
Rate for Payer: Cash Price	$105.60

Med Nutrition Therapy Re-Eval per 15 Min

Facility

$102.00

Service Code	CPT 97803
Hospital Charge Code	8500191
Hospital Revenue Code	942
Min. Negotiated Rate	$9.18
Max. Negotiated Rate	$68.56
Rate for Payer: Aetna Commercial	$56.10
Rate for Payer: Amerigroup CHIP/Medicaid	$9.18
Rate for Payer: BCBS of TX Blue Advantage	$51.42
Rate for Payer: BCBS of TX Blue Essentials	$61.46
Rate for Payer: BCBS of TX PPO	$68.56
Rate for Payer: Cash Price	$89.76
Rate for Payer: Cash Price	$89.76
Rate for Payer: Multiplan Auto	$66.30
Rate for Payer: Multiplan Commercial	$66.30
Rate for Payer: Multiplan Workers Comp	$66.30
Rate for Payer: Scott and White EPO/PPO	$51.00
Rate for Payer: Superior Health Plan EPO	$13.87

Med Nutrition Therapy Re-Eval per 15 Min BCE

Facility

$102.00

Service Code	CPT 97803
Hospital Charge Code	8500191
Hospital Revenue Code	942
Rate for Payer: Cash Price	$89.76

Med Nutrition Therapy Re-Eval per 15 Min BCE

Facility

$102.00

Service Code	CPT 97803
Hospital Charge Code	8500191
Hospital Revenue Code	942
Min. Negotiated Rate	$9.18
Max. Negotiated Rate	$68.56
Rate for Payer: Aetna Commercial	$56.10
Rate for Payer: Amerigroup CHIP/Medicaid	$9.18
Rate for Payer: BCBS of TX Blue Advantage	$51.42
Rate for Payer: BCBS of TX Blue Essentials	$61.46
Rate for Payer: BCBS of TX PPO	$68.56
Rate for Payer: Cash Price	$89.76
Rate for Payer: Cash Price	$89.76
Rate for Payer: Multiplan Auto	$66.30
Rate for Payer: Multiplan Commercial	$66.30
Rate for Payer: Multiplan Workers Comp	$66.30
Rate for Payer: Scott and White EPO/PPO	$51.00
Rate for Payer: Superior Health Plan EPO	$13.87

MEDTRONIC ENDURANT II AAA 16X10

Facility

$29,668.67

Hospital Charge Code	8484499
Hospital Revenue Code	278
Min. Negotiated Rate	$7,417.17
Max. Negotiated Rate	$14,834.34
Rate for Payer: Aetna Commercial	$8,900.60
Rate for Payer: Cash Price	$26,108.43
Rate for Payer: Cigna Commercial	$7,417.17
Rate for Payer: Multiplan Auto	$14,834.34
Rate for Payer: Multiplan Commercial	$14,834.34
Rate for Payer: Multiplan Workers Comp	$14,834.34
Rate for Payer: Scott and White EPO/PPO	$14,834.34

MEDTRONIC ENDURANT II AAA 16X10

Facility

$29,668.67

Hospital Charge Code	8484499
Hospital Revenue Code	278
Min. Negotiated Rate	$2,670.18
Max. Negotiated Rate	$14,834.34
Rate for Payer: Aetna Commercial	$8,900.60
Rate for Payer: Amerigroup CHIP/Medicaid	$2,670.18
Rate for Payer: BCBS of TX Blue Advantage	$8,900.60
Rate for Payer: BCBS of TX Blue Essentials	$10,680.72
Rate for Payer: BCBS of TX PPO	$11,867.47
Rate for Payer: Cash Price	$26,108.43
Rate for Payer: Multiplan Auto	$14,834.34
Rate for Payer: Multiplan Commercial	$14,834.34
Rate for Payer: Multiplan Workers Comp	$14,834.34
Rate for Payer: Scott and White EPO/PPO	$14,834.34
Rate for Payer: Superior Health Plan EPO	$4,034.94

MEDTRONIC ENDURANT II AAA 16X16

Facility

$28,012.04

Hospital Charge Code	8484504
Hospital Revenue Code	278
Min. Negotiated Rate	$7,003.01
Max. Negotiated Rate	$14,006.02
Rate for Payer: Aetna Commercial	$8,403.61
Rate for Payer: Cash Price	$24,650.60
Rate for Payer: Cigna Commercial	$7,003.01
Rate for Payer: Multiplan Auto	$14,006.02
Rate for Payer: Multiplan Commercial	$14,006.02
Rate for Payer: Multiplan Workers Comp	$14,006.02
Rate for Payer: Scott and White EPO/PPO	$14,006.02

MEDTRONIC ENDURANT II AAA 16X16

Facility

$28,012.04

Hospital Charge Code	8484504
Hospital Revenue Code	278
Min. Negotiated Rate	$2,521.08
Max. Negotiated Rate	$14,006.02
Rate for Payer: Aetna Commercial	$8,403.61
Rate for Payer: Amerigroup CHIP/Medicaid	$2,521.08
Rate for Payer: BCBS of TX Blue Advantage	$8,403.61
Rate for Payer: BCBS of TX Blue Essentials	$10,084.33
Rate for Payer: BCBS of TX PPO	$11,204.82
Rate for Payer: Cash Price	$24,650.60
Rate for Payer: Multiplan Auto	$14,006.02
Rate for Payer: Multiplan Commercial	$14,006.02
Rate for Payer: Multiplan Workers Comp	$14,006.02
Rate for Payer: Scott and White EPO/PPO	$14,006.02
Rate for Payer: Superior Health Plan EPO	$3,809.64

MEDTRONIC ENDURANT II AAA 16X24

Facility

$29,668.67

Hospital Charge Code	8484494
Hospital Revenue Code	278
Min. Negotiated Rate	$2,670.18
Max. Negotiated Rate	$14,834.34
Rate for Payer: Aetna Commercial	$8,900.60
Rate for Payer: Amerigroup CHIP/Medicaid	$2,670.18
Rate for Payer: BCBS of TX Blue Advantage	$8,900.60
Rate for Payer: BCBS of TX Blue Essentials	$10,680.72
Rate for Payer: BCBS of TX PPO	$11,867.47
Rate for Payer: Cash Price	$26,108.43
Rate for Payer: Multiplan Auto	$14,834.34
Rate for Payer: Multiplan Commercial	$14,834.34
Rate for Payer: Multiplan Workers Comp	$14,834.34
Rate for Payer: Scott and White EPO/PPO	$14,834.34
Rate for Payer: Superior Health Plan EPO	$4,034.94

MEDTRONIC ENDURANT II AAA 16X24

Facility

$29,668.67

Hospital Charge Code	8484494
Hospital Revenue Code	278
Min. Negotiated Rate	$7,417.17
Max. Negotiated Rate	$14,834.34
Rate for Payer: Aetna Commercial	$8,900.60
Rate for Payer: Cash Price	$26,108.43
Rate for Payer: Cigna Commercial	$7,417.17
Rate for Payer: Multiplan Auto	$14,834.34
Rate for Payer: Multiplan Commercial	$14,834.34
Rate for Payer: Multiplan Workers Comp	$14,834.34
Rate for Payer: Scott and White EPO/PPO	$14,834.34

MEDTRONIC ENDURANT II ILIAC GRAFT 28X14

Facility

$60,090.36

Hospital Charge Code	8484500
Hospital Revenue Code	278
Min. Negotiated Rate	$5,408.13
Max. Negotiated Rate	$30,045.18
Rate for Payer: Aetna Commercial	$18,027.11
Rate for Payer: Amerigroup CHIP/Medicaid	$5,408.13
Rate for Payer: BCBS of TX Blue Advantage	$18,027.11
Rate for Payer: BCBS of TX Blue Essentials	$21,632.53
Rate for Payer: BCBS of TX PPO	$24,036.14
Rate for Payer: Cash Price	$52,879.52
Rate for Payer: Multiplan Auto	$30,045.18
Rate for Payer: Multiplan Commercial	$30,045.18
Rate for Payer: Multiplan Workers Comp	$30,045.18
Rate for Payer: Scott and White EPO/PPO	$30,045.18
Rate for Payer: Superior Health Plan EPO	$8,172.29

MEDTRONIC ENDURANT II ILIAC GRAFT 28X14

Facility

$60,090.36

Hospital Charge Code	8484500
Hospital Revenue Code	278
Min. Negotiated Rate	$15,022.59
Max. Negotiated Rate	$30,045.18
Rate for Payer: Aetna Commercial	$18,027.11
Rate for Payer: Cash Price	$52,879.52
Rate for Payer: Cigna Commercial	$15,022.59
Rate for Payer: Multiplan Auto	$30,045.18
Rate for Payer: Multiplan Commercial	$30,045.18
Rate for Payer: Multiplan Workers Comp	$30,045.18
Rate for Payer: Scott and White EPO/PPO	$30,045.18

melatonin 3 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77682000
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

melatonin 3 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77682000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

memantine 5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77887503
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

memantine 5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77887503
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

MEMBRANE AMNIOTIC 4X4FUSECHOICE

Facility

$8,132.53

Service Code	HCPCS Q4139
Hospital Charge Code	145508
Hospital Revenue Code	278
Min. Negotiated Rate	$731.93
Max. Negotiated Rate	$4,066.26
Rate for Payer: Aetna Commercial	$2,439.76
Rate for Payer: Amerigroup CHIP/Medicaid	$731.93
Rate for Payer: BCBS of TX Blue Advantage	$2,439.76
Rate for Payer: BCBS of TX Blue Essentials	$2,927.71
Rate for Payer: BCBS of TX PPO	$3,253.01
Rate for Payer: Cash Price	$7,156.63
Rate for Payer: Multiplan Auto	$4,066.26
Rate for Payer: Multiplan Commercial	$4,066.26
Rate for Payer: Multiplan Workers Comp	$4,066.26
Rate for Payer: Scott and White EPO/PPO	$4,066.26
Rate for Payer: Superior Health Plan EPO	$1,106.02

MEMBRANE AMNIOTIC 4X4FUSECHOICE

Facility

$8,132.53

Service Code	HCPCS Q4139
Hospital Charge Code	145508
Hospital Revenue Code	278
Min. Negotiated Rate	$2,033.13
Max. Negotiated Rate	$4,066.26
Rate for Payer: Aetna Commercial	$2,439.76
Rate for Payer: Cash Price	$7,156.63
Rate for Payer: Cigna Commercial	$2,033.13
Rate for Payer: Multiplan Auto	$4,066.26
Rate for Payer: Multiplan Commercial	$4,066.26
Rate for Payer: Multiplan Workers Comp	$4,066.26
Rate for Payer: Scott and White EPO/PPO	$4,066.26

MENISCUS CUTTER -- DHF

Facility

$274.09

Hospital Charge Code	81753105
Hospital Revenue Code	272
Min. Negotiated Rate	$24.67
Max. Negotiated Rate	$178.16
Rate for Payer: Aetna Commercial	$150.75
Rate for Payer: Amerigroup CHIP/Medicaid	$24.67
Rate for Payer: BCBS of TX Blue Advantage	$82.23
Rate for Payer: BCBS of TX Blue Essentials	$98.67
Rate for Payer: BCBS of TX PPO	$109.64
Rate for Payer: Cash Price	$241.20
Rate for Payer: Multiplan Auto	$178.16
Rate for Payer: Multiplan Commercial	$178.16
Rate for Payer: Multiplan Workers Comp	$178.16
Rate for Payer: Scott and White EPO/PPO	$137.04
Rate for Payer: Superior Health Plan EPO	$37.28

Know your out-of-pocket cost for care.

All Charges