White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC

Facility

$45,299.80

Service Code	MSDRG 095
Min. Negotiated Rate	$19,868.58
Max. Negotiated Rate	$45,299.80
Rate for Payer: Aetna Commercial	$26,822.25
Rate for Payer: Aetna Medicare	$29,802.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,868.58
Rate for Payer: Amerigroup Medicare	$19,868.58
Rate for Payer: BCBS of TX Blue Advantage	$20,468.86
Rate for Payer: BCBS of TX Blue Essentials	$24,568.51
Rate for Payer: BCBS of TX Medicare	$19,868.58
Rate for Payer: BCBS of TX PPO	$27,299.40
Rate for Payer: Cigna Commercial	$30,708.50
Rate for Payer: Cigna Medicare	$19,868.58
Rate for Payer: Employer Direct Commercial	$19,868.58
Rate for Payer: Humana Medicare/TRICARE	$19,868.58
Rate for Payer: Molina Dual Medicare/Medicaid	$19,868.58
Rate for Payer: Molina Medicare	$19,868.58
Rate for Payer: Multiplan Auto	$45,299.80
Rate for Payer: Multiplan Commercial	$45,299.80
Rate for Payer: Multiplan Workers Comp	$45,299.80
Rate for Payer: Scott and White EPO/PPO	$20,861.75
Rate for Payer: Scott and White Medicare	$19,868.58
Rate for Payer: Superior Health Plan EPO	$19,868.58
Rate for Payer: Superior Health Plan Medicare	$19,868.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,868.58
Rate for Payer: Universal American Medicare	$19,868.58
Rate for Payer: Wellcare Medicare	$19,868.58
Rate for Payer: Wellmed Medicare	$19,868.58

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC

Facility

$68,831.30

Service Code	MSDRG 094
Min. Negotiated Rate	$28,706.58
Max. Negotiated Rate	$68,831.30
Rate for Payer: Aetna Commercial	$40,755.38
Rate for Payer: Aetna Medicare	$43,059.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,706.58
Rate for Payer: Amerigroup Medicare	$28,706.58
Rate for Payer: BCBS of TX Blue Advantage	$29,945.20
Rate for Payer: BCBS of TX Blue Essentials	$37,952.25
Rate for Payer: BCBS of TX Medicare	$28,706.58
Rate for Payer: BCBS of TX PPO	$42,170.80
Rate for Payer: Cigna Commercial	$46,660.38
Rate for Payer: Cigna Medicare	$28,706.58
Rate for Payer: Employer Direct Commercial	$28,706.58
Rate for Payer: Humana Medicare/TRICARE	$28,706.58
Rate for Payer: Molina Dual Medicare/Medicaid	$28,706.58
Rate for Payer: Molina Medicare	$28,706.58
Rate for Payer: Multiplan Auto	$68,831.30
Rate for Payer: Multiplan Commercial	$68,831.30
Rate for Payer: Multiplan Workers Comp	$68,831.30
Rate for Payer: Scott and White EPO/PPO	$31,698.62
Rate for Payer: Scott and White Medicare	$28,706.58
Rate for Payer: Superior Health Plan EPO	$28,706.58
Rate for Payer: Superior Health Plan Medicare	$28,706.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,706.58
Rate for Payer: Universal American Medicare	$28,706.58
Rate for Payer: Wellcare Medicare	$28,706.58
Rate for Payer: Wellmed Medicare	$28,706.58

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC

Facility

$41,414.30

Service Code	MSDRG 096
Min. Negotiated Rate	$18,409.25
Max. Negotiated Rate	$41,414.30
Rate for Payer: Aetna Commercial	$24,521.62
Rate for Payer: Aetna Medicare	$27,613.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,409.25
Rate for Payer: Amerigroup Medicare	$18,409.25
Rate for Payer: BCBS of TX Blue Advantage	$18,419.48
Rate for Payer: BCBS of TX Blue Essentials	$21,783.41
Rate for Payer: BCBS of TX Medicare	$18,409.25
Rate for Payer: BCBS of TX PPO	$24,204.73
Rate for Payer: Cigna Commercial	$28,074.54
Rate for Payer: Cigna Medicare	$18,409.25
Rate for Payer: Employer Direct Commercial	$18,409.25
Rate for Payer: Humana Medicare/TRICARE	$18,409.25
Rate for Payer: Molina Dual Medicare/Medicaid	$18,409.25
Rate for Payer: Molina Medicare	$18,409.25
Rate for Payer: Multiplan Auto	$41,414.30
Rate for Payer: Multiplan Commercial	$41,414.30
Rate for Payer: Multiplan Workers Comp	$41,414.30
Rate for Payer: Scott and White EPO/PPO	$19,072.38
Rate for Payer: Scott and White Medicare	$18,409.25
Rate for Payer: Superior Health Plan EPO	$18,409.25
Rate for Payer: Superior Health Plan Medicare	$18,409.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,409.25
Rate for Payer: Universal American Medicare	$18,409.25
Rate for Payer: Wellcare Medicare	$18,409.25
Rate for Payer: Wellmed Medicare	$18,409.25

BAG, RETREIVAL ANCHOR TISSUE 5.51'''' DIA 10MM 235ML -- DHF

Facility

$340.50

Hospital Charge Code	80816978
Hospital Revenue Code	272
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$221.32
Rate for Payer: Aetna Commercial	$187.28
Rate for Payer: Amerigroup CHIP/Medicaid	$30.64
Rate for Payer: BCBS of TX Blue Advantage	$102.15
Rate for Payer: BCBS of TX Blue Essentials	$122.58
Rate for Payer: BCBS of TX PPO	$136.20
Rate for Payer: Cash Price	$299.64
Rate for Payer: Multiplan Auto	$221.32
Rate for Payer: Multiplan Commercial	$221.32
Rate for Payer: Multiplan Workers Comp	$221.32
Rate for Payer: Scott and White EPO/PPO	$170.25
Rate for Payer: Superior Health Plan EPO	$46.31

BAG, SPECIMEN RETRIEVAL MED 7.3CMX17CMX10MM, 240ML -- DHF

Facility

$340.50

Hospital Charge Code	80816978
Hospital Revenue Code	272
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$221.32
Rate for Payer: Aetna Commercial	$187.28
Rate for Payer: Amerigroup CHIP/Medicaid	$30.64
Rate for Payer: BCBS of TX Blue Advantage	$102.15
Rate for Payer: BCBS of TX Blue Essentials	$122.58
Rate for Payer: BCBS of TX PPO	$136.20
Rate for Payer: Cash Price	$299.64
Rate for Payer: Multiplan Auto	$221.32
Rate for Payer: Multiplan Commercial	$221.32
Rate for Payer: Multiplan Workers Comp	$221.32
Rate for Payer: Scott and White EPO/PPO	$170.25
Rate for Payer: Superior Health Plan EPO	$46.31

BALO ANGIOP CTR DIALYSIS SEG

Facility

$8,145.00

Service Code	CPT 36907
Hospital Charge Code	2351106
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,167.60

BALO ANGIOP CTR DIALYSIS SEG

Facility

$8,145.00

Service Code	CPT 36907
Hospital Charge Code	2351106
Hospital Revenue Code	360
Min. Negotiated Rate	$733.05
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,479.75
Rate for Payer: Amerigroup CHIP/Medicaid	$733.05
Rate for Payer: Cash Price	$7,167.60
Rate for Payer: Cash Price	$7,167.60
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	$4,072.50
Rate for Payer: Superior Health Plan EPO	$1,107.72

BANANA SUTURE LASSO

Facility

$844.44

Hospital Charge Code	114792
Hospital Revenue Code	272
Min. Negotiated Rate	$76.00
Max. Negotiated Rate	$548.89
Rate for Payer: Aetna Commercial	$464.44
Rate for Payer: Amerigroup CHIP/Medicaid	$76.00
Rate for Payer: BCBS of TX Blue Advantage	$253.33
Rate for Payer: BCBS of TX Blue Essentials	$304.00
Rate for Payer: BCBS of TX PPO	$337.78
Rate for Payer: Cash Price	$743.11
Rate for Payer: Multiplan Auto	$548.89
Rate for Payer: Multiplan Commercial	$548.89
Rate for Payer: Multiplan Workers Comp	$548.89
Rate for Payer: Scott and White EPO/PPO	$422.22
Rate for Payer: Superior Health Plan EPO	$114.84

BANANA SUTURE LASSO

Facility

$844.44

Hospital Charge Code	114792
Hospital Revenue Code	272
Rate for Payer: Cash Price	$743.11

BANDAGE, CONFORMING GAUZE 3-PLY 4''''X 4.1 YD STERILE -- DHF

Facility

$78.04

Hospital Charge Code	80241102
Hospital Revenue Code	270
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$50.73
Rate for Payer: Aetna Commercial	$42.92
Rate for Payer: Amerigroup CHIP/Medicaid	$7.02
Rate for Payer: BCBS of TX Blue Advantage	$23.41
Rate for Payer: BCBS of TX Blue Essentials	$28.09
Rate for Payer: BCBS of TX PPO	$31.22
Rate for Payer: Cash Price	$68.68
Rate for Payer: Multiplan Auto	$50.73
Rate for Payer: Multiplan Commercial	$50.73
Rate for Payer: Multiplan Workers Comp	$50.73
Rate for Payer: Scott and White EPO/PPO	$39.02
Rate for Payer: Superior Health Plan EPO	$10.61

BANDAGE, CONFORMING GAUZE 3-PLY 4''''X 4.1 YD STERILE -- DHF

Facility

$78.04

Hospital Charge Code	80241102
Hospital Revenue Code	270
Rate for Payer: Cash Price	$68.68

BANDAGE, ELASTIC LTX FREE W/VELCRO CLOS STR 3''''X5YD -- DHF

Facility

$48.15

Hospital Charge Code	80240419
Hospital Revenue Code	270
Min. Negotiated Rate	$4.33
Max. Negotiated Rate	$31.30
Rate for Payer: Aetna Commercial	$26.48
Rate for Payer: Amerigroup CHIP/Medicaid	$4.33
Rate for Payer: BCBS of TX Blue Advantage	$14.44
Rate for Payer: BCBS of TX Blue Essentials	$17.33
Rate for Payer: BCBS of TX PPO	$19.26
Rate for Payer: Cash Price	$42.37
Rate for Payer: Multiplan Auto	$31.30
Rate for Payer: Multiplan Commercial	$31.30
Rate for Payer: Multiplan Workers Comp	$31.30
Rate for Payer: Scott and White EPO/PPO	$24.08
Rate for Payer: Superior Health Plan EPO	$6.55

BANDAGE, ELASTIC LTX FREE W/VELCRO CLOS STR 4''''X5YD -- DHF

Facility

$48.15

Hospital Charge Code	80240419
Hospital Revenue Code	270
Min. Negotiated Rate	$4.33
Max. Negotiated Rate	$31.30
Rate for Payer: Aetna Commercial	$26.48
Rate for Payer: Amerigroup CHIP/Medicaid	$4.33
Rate for Payer: BCBS of TX Blue Advantage	$14.44
Rate for Payer: BCBS of TX Blue Essentials	$17.33
Rate for Payer: BCBS of TX PPO	$19.26
Rate for Payer: Cash Price	$42.37
Rate for Payer: Multiplan Auto	$31.30
Rate for Payer: Multiplan Commercial	$31.30
Rate for Payer: Multiplan Workers Comp	$31.30
Rate for Payer: Scott and White EPO/PPO	$24.08
Rate for Payer: Superior Health Plan EPO	$6.55

BANDAGE, ELASTIC LTX FREE W/VELCRO CLOS STR 6''''X5YD -- DHF

Facility

$48.15

Hospital Charge Code	80240419
Hospital Revenue Code	270
Min. Negotiated Rate	$4.33
Max. Negotiated Rate	$31.30
Rate for Payer: Aetna Commercial	$26.48
Rate for Payer: Amerigroup CHIP/Medicaid	$4.33
Rate for Payer: BCBS of TX Blue Advantage	$14.44
Rate for Payer: BCBS of TX Blue Essentials	$17.33
Rate for Payer: BCBS of TX PPO	$19.26
Rate for Payer: Cash Price	$42.37
Rate for Payer: Multiplan Auto	$31.30
Rate for Payer: Multiplan Commercial	$31.30
Rate for Payer: Multiplan Workers Comp	$31.30
Rate for Payer: Scott and White EPO/PPO	$24.08
Rate for Payer: Superior Health Plan EPO	$6.55

BANDAGE, ELASTIC LTX FREE W/VELCRO CLOS STR 6''''X5YD -- DHF

Facility

$48.15

Hospital Charge Code	80240419
Hospital Revenue Code	270
Rate for Payer: Cash Price	$42.37

BANDAGE, GAUZE ROLL 4 1/2'''' X 147'''' STERILE -- DHF

Facility

$82.27

Hospital Charge Code	80240955
Hospital Revenue Code	270
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$53.48
Rate for Payer: Aetna Commercial	$45.25
Rate for Payer: Amerigroup CHIP/Medicaid	$7.40
Rate for Payer: BCBS of TX Blue Advantage	$24.68
Rate for Payer: BCBS of TX Blue Essentials	$29.62
Rate for Payer: BCBS of TX PPO	$32.91
Rate for Payer: Cash Price	$72.40
Rate for Payer: Multiplan Auto	$53.48
Rate for Payer: Multiplan Commercial	$53.48
Rate for Payer: Multiplan Workers Comp	$53.48
Rate for Payer: Scott and White EPO/PPO	$41.14
Rate for Payer: Superior Health Plan EPO	$11.19

BANDAGE, GAUZE ROLL 4 1/2'''' X 147'''' STERILE -- DHF

Facility

$82.27

Hospital Charge Code	80240955
Hospital Revenue Code	270
Rate for Payer: Cash Price	$72.40

BANDAGE, SELF-ADHERENT ELASTIC WRAP LF 4''''X5YD STRL -- DHF

Facility

$45.82

Hospital Charge Code	80240310
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$29.78
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$40.32
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan EPO	$6.23

BANDAGE, SELF-ADHERENT WRAP LTX-FRE TAN 6''''X5YD STL -- DHF

Facility

$45.82

Hospital Charge Code	80240310
Hospital Revenue Code	270
Rate for Payer: Cash Price	$40.32

BANDAGE, SELF-ADHERENT WRAP LTX-FRE TAN 6''''X5YD STL -- DHF

Facility

$45.82

Hospital Charge Code	80240310
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$29.78
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$40.32
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan EPO	$6.23

Barbiturates Screen Urine

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640109
Hospital Revenue Code	300
Rate for Payer: Cash Price	$278.96

Barbiturates Screen Urine

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640109
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$206.05
Rate for Payer: Aetna Commercial	$65.24
Rate for Payer: Aetna Medicare	$93.21
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$102.53
Rate for Payer: BCBS of TX Blue Essentials	$123.04
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$137.33
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cigna Medicaid	$62.14
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$62.14
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$62.14
Rate for Payer: Scott and White EPO/PPO	$77.68
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.14
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

BARIATRIC BEHAVIOR COUNSEL OBESITY 15MIN BCE

Facility

$150.00

Service Code	HCPCS G0447
Hospital Charge Code	8582484
Hospital Revenue Code	510
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$184.66
Rate for Payer: Aetna Commercial	$82.50
Rate for Payer: Aetna Medicare	$122.28
Rate for Payer: Amerigroup CHIP/Medicaid	$13.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$81.52
Rate for Payer: Amerigroup Medicare	$81.52
Rate for Payer: BCBS of TX Blue Advantage	$45.00
Rate for Payer: BCBS of TX Blue Essentials	$54.00
Rate for Payer: BCBS of TX Medicare	$81.52
Rate for Payer: BCBS of TX PPO	$60.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cigna Commercial	$184.66
Rate for Payer: Cigna Medicare	$81.52
Rate for Payer: Employer Direct Commercial	$81.52
Rate for Payer: Humana Medicare/TRICARE	$81.52
Rate for Payer: Molina Dual Medicare/Medicaid	$81.52
Rate for Payer: Molina Medicare	$81.52
Rate for Payer: Multiplan Auto	$97.50
Rate for Payer: Multiplan Commercial	$97.50
Rate for Payer: Multiplan Workers Comp	$97.50
Rate for Payer: Scott and White EPO/PPO	$1.46
Rate for Payer: Scott and White Medicare	$81.52
Rate for Payer: Superior Health Plan EPO	$81.52
Rate for Payer: Superior Health Plan Medicare	$81.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$81.52
Rate for Payer: Universal American Medicare	$81.52
Rate for Payer: Wellcare Medicare	$81.52
Rate for Payer: Wellmed Medicare	$81.52

BARIATRIC BEHAVIOR COUNSEL OBESITY 15MIN BCE

Facility

$150.00

Service Code	HCPCS G0447
Hospital Charge Code	8582484
Hospital Revenue Code	510
Rate for Payer: Cash Price	$132.00

BARIATRIC E&M-EST. PATIENT-LVL I BCE

Facility

$113.00

Service Code	CPT 99211
Hospital Charge Code	6809211
Hospital Revenue Code	510
Rate for Payer: Cash Price	$99.44

Know your out-of-pocket cost for care.

All Charges