White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Hektoen Enteric Agar, for the Selective Isolation and differentiation Of Pathogenic Gram Negative Bacteria, 18 mL fill, 15 x 100 mm Plate

Facility

$5.58

Hospital Charge Code	993360
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.79

Hektoen Enteric Agar, for the Selective Isolation and differentiation Of Pathogenic Gram Negative Bacteria, 18 mL fill, 15 x 100 mm Plate

Facility

$5.58

Hospital Charge Code	993360
Hospital Revenue Code	272
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$4.02
Rate for Payer: Amerigroup CHIP/Medicaid	$0.50
Rate for Payer: BCBS of TX Blue Advantage	$1.67
Rate for Payer: BCBS of TX Blue Essentials	$2.01
Rate for Payer: BCBS of TX PPO	$2.23
Rate for Payer: Cash Price	$3.79
Rate for Payer: Cigna Medicaid	$4.02
Rate for Payer: Molina CHIP/Medicaid	$4.02
Rate for Payer: Multiplan Auto	$3.63
Rate for Payer: Multiplan Commercial	$3.63
Rate for Payer: Multiplan Workers Comp	$3.63
Rate for Payer: Parkland Medicaid	$4.02
Rate for Payer: Scott and White EPO/PPO	$2.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.02
Rate for Payer: Superior Health Plan EPO	$0.76

HELIX, TISSUE 165CM X 2.8MM OD -- DHF

Facility

$1,042.68

Hospital Charge Code	80811680
Hospital Revenue Code	272
Min. Negotiated Rate	$93.84
Max. Negotiated Rate	$750.73
Rate for Payer: Amerigroup CHIP/Medicaid	$93.84
Rate for Payer: BCBS of TX Blue Advantage	$312.80
Rate for Payer: BCBS of TX Blue Essentials	$375.36
Rate for Payer: BCBS of TX PPO	$417.07
Rate for Payer: Cash Price	$709.02
Rate for Payer: Cigna Medicaid	$750.73
Rate for Payer: Molina CHIP/Medicaid	$750.73
Rate for Payer: Multiplan Auto	$677.74
Rate for Payer: Multiplan Commercial	$677.74
Rate for Payer: Multiplan Workers Comp	$677.74
Rate for Payer: Parkland Medicaid	$750.73
Rate for Payer: Scott and White EPO/PPO	$521.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$750.73
Rate for Payer: Superior Health Plan EPO	$141.80

HELIX, TISSUE 165CM X 2.8MM OD -- DHF

Facility

$1,042.68

Hospital Charge Code	80811680
Hospital Revenue Code	272
Rate for Payer: Cash Price	$709.02

Helper T-Lymph-CD4 SO

Facility

$169.00

Service Code	HCPCS 86361
Hospital Charge Code	1700319
Hospital Revenue Code	302
Min. Negotiated Rate	$10.44
Max. Negotiated Rate	$121.68
Rate for Payer: Amerigroup CHIP/Medicaid	$10.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.78
Rate for Payer: Amerigroup Medicare	$26.78
Rate for Payer: BCBS of TX Blue Advantage	$50.70
Rate for Payer: BCBS of TX Blue Essentials	$60.84
Rate for Payer: BCBS of TX Medicare	$26.78
Rate for Payer: BCBS of TX PPO	$67.60
Rate for Payer: Cash Price	$114.92
Rate for Payer: Cash Price	$114.92
Rate for Payer: Cigna Medicaid	$121.68
Rate for Payer: Cigna Medicare	$26.78
Rate for Payer: Employer Direct Commercial	$26.78
Rate for Payer: Humana Medicare/TRICARE	$26.78
Rate for Payer: Molina CHIP/Medicaid	$121.68
Rate for Payer: Molina Dual Medicare/Medicaid	$26.78
Rate for Payer: Molina Medicare	$26.78
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	$121.68
Rate for Payer: Scott and White EPO/PPO	$33.48
Rate for Payer: Scott and White Medicare	$26.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$121.68
Rate for Payer: Superior Health Plan EPO	$26.78
Rate for Payer: Superior Health Plan Medicare	$26.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.78
Rate for Payer: Universal American Medicare	$26.78
Rate for Payer: Wellcare Medicare	$26.78
Rate for Payer: Wellmed Medicare	$26.78

Helper T-Lymph-CD4 SO

Facility

$169.00

Service Code	HCPCS 86361
Hospital Charge Code	1700319
Hospital Revenue Code	302
Rate for Payer: Cash Price	$114.92

Hematocrit (POCT)

Facility

$97.00

Service Code	HCPCS 85014 QW
Hospital Charge Code	1690002
Hospital Revenue Code	305
Rate for Payer: Cash Price	$65.96

Hematocrit (POCT)

Facility

$97.00

Service Code	HCPCS 85014 QW
Hospital Charge Code	1690002
Hospital Revenue Code	305
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$69.84
Rate for Payer: Amerigroup CHIP/Medicaid	$0.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.37
Rate for Payer: Amerigroup Medicare	$2.37
Rate for Payer: BCBS of TX Blue Advantage	$29.10
Rate for Payer: BCBS of TX Blue Essentials	$34.92
Rate for Payer: BCBS of TX Medicare	$2.37
Rate for Payer: BCBS of TX PPO	$38.80
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cigna Medicaid	$69.84
Rate for Payer: Cigna Medicare	$2.37
Rate for Payer: Employer Direct Commercial	$2.37
Rate for Payer: Humana Medicare/TRICARE	$2.37
Rate for Payer: Molina CHIP/Medicaid	$69.84
Rate for Payer: Molina Dual Medicare/Medicaid	$2.37
Rate for Payer: Molina Medicare	$2.37
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$69.84
Rate for Payer: Scott and White EPO/PPO	$2.96
Rate for Payer: Scott and White Medicare	$2.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.84
Rate for Payer: Superior Health Plan EPO	$2.37
Rate for Payer: Superior Health Plan Medicare	$2.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.37
Rate for Payer: Universal American Medicare	$2.37
Rate for Payer: Wellcare Medicare	$2.37
Rate for Payer: Wellmed Medicare	$2.37

Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each

Facility

$10,000.00

Service Code	CPT 28160
Hospital Charge Code	36028160
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	$6,080.78
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

Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each

Facility

$9,906.40

Service Code	HCPCS 28160
Hospital Charge Code	9900485
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	$6,736.35
Rate for Payer: Cash Price	$6,736.35
Rate for Payer: Cash Price	$6,736.35
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$7,132.61
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	$7,132.61
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	$7,132.61
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,132.61
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

Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each

Facility

$9,906.40

Service Code	HCPCS 28160
Hospital Charge Code	9900485
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,736.35

Hemoglobin

Facility

$98.00

Service Code	HCPCS 85018 QW
Hospital Charge Code	1600501
Hospital Revenue Code	305
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$70.56
Rate for Payer: Amerigroup CHIP/Medicaid	$0.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.37
Rate for Payer: Amerigroup Medicare	$2.37
Rate for Payer: BCBS of TX Blue Advantage	$29.40
Rate for Payer: BCBS of TX Blue Essentials	$35.28
Rate for Payer: BCBS of TX Medicare	$2.37
Rate for Payer: BCBS of TX PPO	$39.20
Rate for Payer: Cash Price	$66.64
Rate for Payer: Cash Price	$66.64
Rate for Payer: Cigna Medicaid	$70.56
Rate for Payer: Cigna Medicare	$2.37
Rate for Payer: Employer Direct Commercial	$2.37
Rate for Payer: Humana Medicare/TRICARE	$2.37
Rate for Payer: Molina CHIP/Medicaid	$70.56
Rate for Payer: Molina Dual Medicare/Medicaid	$2.37
Rate for Payer: Molina Medicare	$2.37
Rate for Payer: Multiplan Auto	$63.70
Rate for Payer: Multiplan Commercial	$63.70
Rate for Payer: Multiplan Workers Comp	$63.70
Rate for Payer: Parkland Medicaid	$70.56
Rate for Payer: Scott and White EPO/PPO	$2.96
Rate for Payer: Scott and White Medicare	$2.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$70.56
Rate for Payer: Superior Health Plan EPO	$2.37
Rate for Payer: Superior Health Plan Medicare	$2.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.37
Rate for Payer: Universal American Medicare	$2.37
Rate for Payer: Wellcare Medicare	$2.37
Rate for Payer: Wellmed Medicare	$2.37

Hemoglobin

Facility

$98.00

Service Code	HCPCS 85018 QW
Hospital Charge Code	1600501
Hospital Revenue Code	305
Rate for Payer: Cash Price	$66.64

Hemoglobin A1C

Facility

$279.00

Service Code	HCPCS 83036 QW
Hospital Charge Code	1602176
Hospital Revenue Code	301
Rate for Payer: Cash Price	$189.72

Hemoglobin A1C

Facility

$279.00

Service Code	HCPCS 83036 QW
Hospital Charge Code	8140264
Hospital Revenue Code	301
Rate for Payer: Cash Price	$189.72

Hemoglobin A1C

Facility

$279.00

Service Code	HCPCS 83036 QW
Hospital Charge Code	8140264
Hospital Revenue Code	301
Min. Negotiated Rate	$3.79
Max. Negotiated Rate	$200.88
Rate for Payer: Amerigroup CHIP/Medicaid	$3.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.71
Rate for Payer: Amerigroup Medicare	$9.71
Rate for Payer: BCBS of TX Blue Advantage	$83.70
Rate for Payer: BCBS of TX Blue Essentials	$100.44
Rate for Payer: BCBS of TX Medicare	$9.71
Rate for Payer: BCBS of TX PPO	$111.60
Rate for Payer: Cash Price	$189.72
Rate for Payer: Cash Price	$189.72
Rate for Payer: Cigna Medicaid	$200.88
Rate for Payer: Cigna Medicare	$9.71
Rate for Payer: Employer Direct Commercial	$9.71
Rate for Payer: Humana Medicare/TRICARE	$9.71
Rate for Payer: Molina CHIP/Medicaid	$200.88
Rate for Payer: Molina Dual Medicare/Medicaid	$9.71
Rate for Payer: Molina Medicare	$9.71
Rate for Payer: Multiplan Auto	$181.35
Rate for Payer: Multiplan Commercial	$181.35
Rate for Payer: Multiplan Workers Comp	$181.35
Rate for Payer: Parkland Medicaid	$200.88
Rate for Payer: Scott and White EPO/PPO	$12.14
Rate for Payer: Scott and White Medicare	$9.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$200.88
Rate for Payer: Superior Health Plan EPO	$9.71
Rate for Payer: Superior Health Plan Medicare	$9.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.71
Rate for Payer: Universal American Medicare	$9.71
Rate for Payer: Wellcare Medicare	$9.71
Rate for Payer: Wellmed Medicare	$9.71

Hemoglobin A1C

Facility

$279.00

Service Code	HCPCS 83036 QW
Hospital Charge Code	1602176
Hospital Revenue Code	301
Min. Negotiated Rate	$3.79
Max. Negotiated Rate	$200.88
Rate for Payer: Amerigroup CHIP/Medicaid	$3.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.71
Rate for Payer: Amerigroup Medicare	$9.71
Rate for Payer: BCBS of TX Blue Advantage	$83.70
Rate for Payer: BCBS of TX Blue Essentials	$100.44
Rate for Payer: BCBS of TX Medicare	$9.71
Rate for Payer: BCBS of TX PPO	$111.60
Rate for Payer: Cash Price	$189.72
Rate for Payer: Cash Price	$189.72
Rate for Payer: Cigna Medicaid	$200.88
Rate for Payer: Cigna Medicare	$9.71
Rate for Payer: Employer Direct Commercial	$9.71
Rate for Payer: Humana Medicare/TRICARE	$9.71
Rate for Payer: Molina CHIP/Medicaid	$200.88
Rate for Payer: Molina Dual Medicare/Medicaid	$9.71
Rate for Payer: Molina Medicare	$9.71
Rate for Payer: Multiplan Auto	$181.35
Rate for Payer: Multiplan Commercial	$181.35
Rate for Payer: Multiplan Workers Comp	$181.35
Rate for Payer: Parkland Medicaid	$200.88
Rate for Payer: Scott and White EPO/PPO	$12.14
Rate for Payer: Scott and White Medicare	$9.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$200.88
Rate for Payer: Superior Health Plan EPO	$9.71
Rate for Payer: Superior Health Plan Medicare	$9.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.71
Rate for Payer: Universal American Medicare	$9.71
Rate for Payer: Wellcare Medicare	$9.71
Rate for Payer: Wellmed Medicare	$9.71

HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION

Facility

$5,255.00

Service Code	APR-DRG 8103
Min. Negotiated Rate	$4,954.60
Max. Negotiated Rate	$5,255.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4,954.60
Rate for Payer: Cigna Medicaid	$4,954.60
Rate for Payer: Molina CHIP/Medicaid	$4,954.60
Rate for Payer: Parkland Medicaid	$4,954.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,255.00

HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION

Facility

$24,154.05

Service Code	APR-DRG 8104
Min. Negotiated Rate	$22,773.29
Max. Negotiated Rate	$24,154.05
Rate for Payer: Amerigroup CHIP/Medicaid	$22,773.29
Rate for Payer: Cigna Medicaid	$22,773.29
Rate for Payer: Molina CHIP/Medicaid	$22,773.29
Rate for Payer: Parkland Medicaid	$22,773.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,154.05

HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION

Facility

$1,824.84

Service Code	APR-DRG 8101
Min. Negotiated Rate	$1,720.52
Max. Negotiated Rate	$1,824.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1,720.52
Rate for Payer: Cigna Medicaid	$1,720.52
Rate for Payer: Molina CHIP/Medicaid	$1,720.52
Rate for Payer: Parkland Medicaid	$1,720.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,824.84

HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION

Facility

$3,453.92

Service Code	APR-DRG 8102
Min. Negotiated Rate	$3,256.48
Max. Negotiated Rate	$3,453.92
Rate for Payer: Amerigroup CHIP/Medicaid	$3,256.48
Rate for Payer: Cigna Medicaid	$3,256.48
Rate for Payer: Molina CHIP/Medicaid	$3,256.48
Rate for Payer: Parkland Medicaid	$3,256.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,453.92

HEMOSTAT, ABSORBABLE 4' X 4 STERILE -- DHF

Facility

$530.59

Hospital Charge Code	81845000
Hospital Revenue Code	270
Rate for Payer: Cash Price	$360.80

HEMOSTAT, ABSORBABLE 4' X 4 STERILE -- DHF

Facility

$530.59

Hospital Charge Code	81845000
Hospital Revenue Code	270
Min. Negotiated Rate	$47.75
Max. Negotiated Rate	$382.02
Rate for Payer: Amerigroup CHIP/Medicaid	$47.75
Rate for Payer: BCBS of TX Blue Advantage	$159.18
Rate for Payer: BCBS of TX Blue Essentials	$191.01
Rate for Payer: BCBS of TX PPO	$212.24
Rate for Payer: Cash Price	$360.80
Rate for Payer: Cigna Medicaid	$382.02
Rate for Payer: Molina CHIP/Medicaid	$382.02
Rate for Payer: Multiplan Auto	$344.88
Rate for Payer: Multiplan Commercial	$344.88
Rate for Payer: Multiplan Workers Comp	$344.88
Rate for Payer: Parkland Medicaid	$382.02
Rate for Payer: Scott and White EPO/PPO	$265.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$382.02
Rate for Payer: Superior Health Plan EPO	$72.16

HEMOSTAT, ABSORBABLE SURG NON-WOVEN MATERIAL 1'X2 -- DHF

Facility

$209.72

Hospital Charge Code	80324296
Hospital Revenue Code	272
Min. Negotiated Rate	$18.87
Max. Negotiated Rate	$151.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.87
Rate for Payer: BCBS of TX Blue Advantage	$62.92
Rate for Payer: BCBS of TX Blue Essentials	$75.50
Rate for Payer: BCBS of TX PPO	$83.89
Rate for Payer: Cash Price	$142.61
Rate for Payer: Cigna Medicaid	$151.00
Rate for Payer: Molina CHIP/Medicaid	$151.00
Rate for Payer: Multiplan Auto	$136.32
Rate for Payer: Multiplan Commercial	$136.32
Rate for Payer: Multiplan Workers Comp	$136.32
Rate for Payer: Parkland Medicaid	$151.00
Rate for Payer: Scott and White EPO/PPO	$104.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.00
Rate for Payer: Superior Health Plan EPO	$28.52

HEMOSTAT, ABSORBABLE SURG NON-WOVEN MATERIAL 1'X2 -- DHF

Facility

$209.72

Hospital Charge Code	80324296
Hospital Revenue Code	272
Rate for Payer: Cash Price	$142.61

Know your out-of-pocket cost for care.

All Charges