White Rock Medical Center

All Charges

Charge

Type

Setting

Price

HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC

Facility

$255,988.90

Service Code	MSDRG 002
Min. Negotiated Rate	$87,811.14
Max. Negotiated Rate	$255,988.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$87,811.14
Rate for Payer: Amerigroup Medicare	$87,811.14
Rate for Payer: BCBS of TX Medicare	$87,811.14
Rate for Payer: Cigna Commercial	$145,953.58
Rate for Payer: Cigna Medicare	$87,811.14
Rate for Payer: Employer Direct Commercial	$87,811.14
Rate for Payer: Molina Dual Medicare/Medicaid	$87,811.14
Rate for Payer: Molina Medicare	$87,811.14
Rate for Payer: Multiplan Auto	$255,988.90
Rate for Payer: Multiplan Commercial	$255,988.90
Rate for Payer: Multiplan Workers Comp	$255,988.90
Rate for Payer: Scott and White EPO/PPO	$117,889.62
Rate for Payer: Scott and White Medicare	$87,811.14
Rate for Payer: Superior Health Plan EPO	$87,811.14
Rate for Payer: Superior Health Plan Medicare	$87,811.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$87,811.14
Rate for Payer: Universal American Medicare	$87,811.14
Rate for Payer: Wellcare Medicare	$87,811.14
Rate for Payer: Wellmed Medicare	$87,811.14

HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC

Facility

$534,775.90

Service Code	MSDRG 001
Min. Negotiated Rate	$210,147.98
Max. Negotiated Rate	$534,775.90
Rate for Payer: BCBS of TX Blue Advantage	$227,131.16
Rate for Payer: BCBS of TX Blue Essentials	$272,530.98
Rate for Payer: BCBS of TX PPO	$302,823.94

HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC

Facility

$255,988.90

Service Code	MSDRG 002
Min. Negotiated Rate	$87,811.14
Max. Negotiated Rate	$255,988.90
Rate for Payer: BCBS of TX Blue Advantage	$115,435.22
Rate for Payer: BCBS of TX Blue Essentials	$138,508.84
Rate for Payer: BCBS of TX PPO	$153,904.68

HEEL/ELBW PROTCT -- DHF

Facility

$132.02

Hospital Charge Code	81142952
Hospital Revenue Code	270
Min. Negotiated Rate	$11.88
Max. Negotiated Rate	$95.05
Rate for Payer: Amerigroup CHIP/Medicaid	$11.88
Rate for Payer: BCBS of TX Blue Advantage	$39.61
Rate for Payer: BCBS of TX Blue Essentials	$47.53
Rate for Payer: BCBS of TX PPO	$52.81
Rate for Payer: Cash Price	$89.77
Rate for Payer: Cigna Medicaid	$95.05
Rate for Payer: Molina CHIP/Medicaid	$95.05
Rate for Payer: Multiplan Auto	$85.81
Rate for Payer: Multiplan Commercial	$85.81
Rate for Payer: Multiplan Workers Comp	$85.81
Rate for Payer: Parkland Medicaid	$95.05
Rate for Payer: Scott and White EPO/PPO	$66.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$95.05
Rate for Payer: Superior Health Plan EPO	$17.95

HEEL/ELBW PROTCT -- DHF

Facility

$132.02

Hospital Charge Code	81142952
Hospital Revenue Code	270
Rate for Payer: Cash Price	$89.77

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
Rate for Payer: Cash Price	$114.92

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

Hematocrit (POCT)

Facility

$97.00

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

Hematocrit (POCT)

Facility

$97.00

Service Code	HCPCS 85014
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

$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	$5,476.44
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

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	$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

Hemoglobin

Facility

$98.00

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

Hemoglobin A1C

Facility

$279.00

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

Hemoglobin A1C

Facility

$279.00

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

Hemoglobin A1C

Facility

$279.00

Service Code	HCPCS 83036
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
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

$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

Know your out-of-pocket cost for care.

All Charges