White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Hepatitis B Surface Antibody

Facility

$294.00

Service Code	HCPCS 86706
Hospital Charge Code	1603117
Hospital Revenue Code	302
Rate for Payer: Cash Price	$199.92

Hepatitis Panel (4) SO

Facility

$878.00

Service Code	HCPCS 80074
Hospital Charge Code	1603307
Hospital Revenue Code	301
Min. Negotiated Rate	$18.58
Max. Negotiated Rate	$632.16
Rate for Payer: Amerigroup CHIP/Medicaid	$18.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47.63
Rate for Payer: Amerigroup Medicare	$47.63
Rate for Payer: BCBS of TX Blue Advantage	$263.40
Rate for Payer: BCBS of TX Blue Essentials	$316.08
Rate for Payer: BCBS of TX Medicare	$47.63
Rate for Payer: BCBS of TX PPO	$351.20
Rate for Payer: Cash Price	$597.04
Rate for Payer: Cash Price	$597.04
Rate for Payer: Cigna Medicaid	$632.16
Rate for Payer: Cigna Medicare	$47.63
Rate for Payer: Employer Direct Commercial	$47.63
Rate for Payer: Humana Medicare/TRICARE	$47.63
Rate for Payer: Molina CHIP/Medicaid	$632.16
Rate for Payer: Molina Dual Medicare/Medicaid	$47.63
Rate for Payer: Molina Medicare	$47.63
Rate for Payer: Multiplan Auto	$570.70
Rate for Payer: Multiplan Commercial	$570.70
Rate for Payer: Multiplan Workers Comp	$570.70
Rate for Payer: Parkland Medicaid	$632.16
Rate for Payer: Scott and White EPO/PPO	$59.54
Rate for Payer: Scott and White Medicare	$47.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$632.16
Rate for Payer: Superior Health Plan EPO	$47.63
Rate for Payer: Superior Health Plan Medicare	$47.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$47.63
Rate for Payer: Universal American Medicare	$47.63
Rate for Payer: Wellcare Medicare	$47.63
Rate for Payer: Wellmed Medicare	$47.63

Hepatitis Panel (4) SO

Facility

$878.00

Service Code	HCPCS 80074
Hospital Charge Code	1603307
Hospital Revenue Code	301
Rate for Payer: Cash Price	$597.04

HEPATOBILIARY DIAGNOSTIC PROCEDURES W CC

Facility

$34,420.40

Service Code	MSDRG 421
Min. Negotiated Rate	$15,300.26
Max. Negotiated Rate	$34,420.40
Rate for Payer: BCBS of TX Blue Advantage	$15,300.26
Rate for Payer: BCBS of TX Blue Essentials	$18,358.53
Rate for Payer: BCBS of TX PPO	$20,399.16

HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC

Facility

$34,420.40

Service Code	MSDRG 421
Min. Negotiated Rate	$15,300.26
Max. Negotiated Rate	$34,420.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,494.27
Rate for Payer: Amerigroup Medicare	$17,494.27
Rate for Payer: BCBS of TX Medicare	$17,494.27
Rate for Payer: Cigna Commercial	$22,379.00
Rate for Payer: Cigna Medicare	$17,494.27
Rate for Payer: Employer Direct Commercial	$17,494.27
Rate for Payer: Humana Medicare/TRICARE	$17,494.27
Rate for Payer: Molina Dual Medicare/Medicaid	$17,494.27
Rate for Payer: Molina Medicare	$17,494.27
Rate for Payer: Multiplan Auto	$34,420.40
Rate for Payer: Multiplan Commercial	$34,420.40
Rate for Payer: Multiplan Workers Comp	$34,420.40
Rate for Payer: Scott and White EPO/PPO	$15,851.50
Rate for Payer: Scott and White Medicare	$17,494.27
Rate for Payer: Superior Health Plan EPO	$17,494.27
Rate for Payer: Superior Health Plan Medicare	$17,494.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,494.27
Rate for Payer: Universal American Medicare	$17,494.27
Rate for Payer: Wellcare Medicare	$17,494.27
Rate for Payer: Wellmed Medicare	$17,494.27

HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC

Facility

$61,962.80

Service Code	MSDRG 420
Min. Negotiated Rate	$28,535.50
Max. Negotiated Rate	$61,962.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29,730.80
Rate for Payer: Amerigroup Medicare	$29,730.80
Rate for Payer: BCBS of TX Medicare	$29,730.80
Rate for Payer: Cigna Commercial	$43,883.45
Rate for Payer: Cigna Medicare	$29,730.80
Rate for Payer: Employer Direct Commercial	$29,730.80
Rate for Payer: Humana Medicare/TRICARE	$29,730.80
Rate for Payer: Molina Dual Medicare/Medicaid	$29,730.80
Rate for Payer: Molina Medicare	$29,730.80
Rate for Payer: Multiplan Auto	$61,962.80
Rate for Payer: Multiplan Commercial	$61,962.80
Rate for Payer: Multiplan Workers Comp	$61,962.80
Rate for Payer: Scott and White EPO/PPO	$28,535.50
Rate for Payer: Scott and White Medicare	$29,730.80
Rate for Payer: Superior Health Plan EPO	$29,730.80
Rate for Payer: Superior Health Plan Medicare	$29,730.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$29,730.80
Rate for Payer: Universal American Medicare	$29,730.80
Rate for Payer: Wellcare Medicare	$29,730.80
Rate for Payer: Wellmed Medicare	$29,730.80

HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC

Facility

$26,326.40

Service Code	MSDRG 422
Min. Negotiated Rate	$12,124.00
Max. Negotiated Rate	$26,326.40
Rate for Payer: Superior Health Plan EPO	$15,017.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,017.05
Rate for Payer: Amerigroup Medicare	$15,017.05
Rate for Payer: BCBS of TX Medicare	$15,017.05
Rate for Payer: Cigna Commercial	$18,025.56
Rate for Payer: Cigna Medicare	$15,017.05
Rate for Payer: Employer Direct Commercial	$15,017.05
Rate for Payer: Humana Medicare/TRICARE	$15,017.05
Rate for Payer: Molina Dual Medicare/Medicaid	$15,017.05
Rate for Payer: Molina Medicare	$15,017.05
Rate for Payer: Multiplan Auto	$26,326.40
Rate for Payer: Multiplan Commercial	$26,326.40
Rate for Payer: Multiplan Workers Comp	$26,326.40
Rate for Payer: Scott and White EPO/PPO	$12,124.00
Rate for Payer: Scott and White Medicare	$15,017.05
Rate for Payer: Superior Health Plan Medicare	$15,017.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,017.05
Rate for Payer: Universal American Medicare	$15,017.05
Rate for Payer: Wellcare Medicare	$15,017.05
Rate for Payer: Wellmed Medicare	$15,017.05

HEPATOBILIARY DIAGNOSTIC PROCEDURES W MCC

Facility

$61,962.80

Service Code	MSDRG 420
Min. Negotiated Rate	$28,535.50
Max. Negotiated Rate	$61,962.80
Rate for Payer: BCBS of TX Blue Advantage	$30,251.36
Rate for Payer: BCBS of TX Blue Essentials	$36,298.11
Rate for Payer: BCBS of TX PPO	$40,332.80

HEPATOBILIARY DIAGNOSTIC PROCEDURES W/O CC/MCC

Facility

$26,326.40

Service Code	MSDRG 422
Min. Negotiated Rate	$12,124.00
Max. Negotiated Rate	$26,326.40
Rate for Payer: BCBS of TX Blue Advantage	$12,965.36
Rate for Payer: BCBS of TX Blue Essentials	$15,556.92
Rate for Payer: BCBS of TX PPO	$17,286.14

Hep Be Ab SO

Facility

$97.15

Service Code	HCPCS 86707
Hospital Charge Code	1702703
Hospital Revenue Code	302
Rate for Payer: Cash Price	$66.06

Hep Be Ab SO

Facility

$97.15

Service Code	HCPCS 86707
Hospital Charge Code	1702703
Hospital Revenue Code	302
Min. Negotiated Rate	$4.51
Max. Negotiated Rate	$69.95
Rate for Payer: Amerigroup CHIP/Medicaid	$4.51
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.57
Rate for Payer: Amerigroup Medicare	$11.57
Rate for Payer: BCBS of TX Blue Advantage	$29.14
Rate for Payer: BCBS of TX Blue Essentials	$34.97
Rate for Payer: BCBS of TX Medicare	$11.57
Rate for Payer: BCBS of TX PPO	$38.86
Rate for Payer: Cash Price	$66.06
Rate for Payer: Cash Price	$66.06
Rate for Payer: Cigna Medicaid	$69.95
Rate for Payer: Cigna Medicare	$11.57
Rate for Payer: Employer Direct Commercial	$11.57
Rate for Payer: Humana Medicare/TRICARE	$11.57
Rate for Payer: Molina CHIP/Medicaid	$69.95
Rate for Payer: Molina Dual Medicare/Medicaid	$11.57
Rate for Payer: Molina Medicare	$11.57
Rate for Payer: Multiplan Auto	$63.15
Rate for Payer: Multiplan Commercial	$63.15
Rate for Payer: Multiplan Workers Comp	$63.15
Rate for Payer: Parkland Medicaid	$69.95
Rate for Payer: Scott and White EPO/PPO	$14.46
Rate for Payer: Scott and White Medicare	$11.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.95
Rate for Payer: Superior Health Plan EPO	$11.57
Rate for Payer: Superior Health Plan Medicare	$11.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.57
Rate for Payer: Universal American Medicare	$11.57
Rate for Payer: Wellcare Medicare	$11.57
Rate for Payer: Wellmed Medicare	$11.57

Hered.Hemochromatosis, DNA SO

Facility

$372.00

Service Code	HCPCS 81256
Hospital Charge Code	1740952
Hospital Revenue Code	310
Rate for Payer: Cash Price	$252.96

Hered.Hemochromatosis, DNA SO

Facility

$372.00

Service Code	HCPCS 81256
Hospital Charge Code	1740952
Hospital Revenue Code	310
Min. Negotiated Rate	$25.49
Max. Negotiated Rate	$267.84
Rate for Payer: Amerigroup CHIP/Medicaid	$25.49
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$65.36
Rate for Payer: Amerigroup Medicare	$65.36
Rate for Payer: BCBS of TX Blue Advantage	$111.60
Rate for Payer: BCBS of TX Blue Essentials	$133.92
Rate for Payer: BCBS of TX Medicare	$65.36
Rate for Payer: BCBS of TX PPO	$148.80
Rate for Payer: Cash Price	$252.96
Rate for Payer: Cash Price	$252.96
Rate for Payer: Cigna Medicaid	$267.84
Rate for Payer: Cigna Medicare	$65.36
Rate for Payer: Employer Direct Commercial	$65.36
Rate for Payer: Humana Medicare/TRICARE	$65.36
Rate for Payer: Molina CHIP/Medicaid	$267.84
Rate for Payer: Molina Dual Medicare/Medicaid	$65.36
Rate for Payer: Molina Medicare	$65.36
Rate for Payer: Multiplan Auto	$241.80
Rate for Payer: Multiplan Commercial	$241.80
Rate for Payer: Multiplan Workers Comp	$241.80
Rate for Payer: Parkland Medicaid	$267.84
Rate for Payer: Scott and White EPO/PPO	$81.70
Rate for Payer: Scott and White Medicare	$65.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$267.84
Rate for Payer: Superior Health Plan EPO	$65.36
Rate for Payer: Superior Health Plan Medicare	$65.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$65.36
Rate for Payer: Universal American Medicare	$65.36
Rate for Payer: Wellcare Medicare	$65.36
Rate for Payer: Wellmed Medicare	$65.36

HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC

Facility

$33,288.00

Service Code	MSDRG 354
Min. Negotiated Rate	$14,886.60
Max. Negotiated Rate	$33,288.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,090.44
Rate for Payer: Amerigroup Medicare	$17,090.44
Rate for Payer: BCBS of TX Medicare	$17,090.44
Rate for Payer: Cigna Commercial	$21,669.31
Rate for Payer: Cigna Medicare	$17,090.44
Rate for Payer: Employer Direct Commercial	$17,090.44
Rate for Payer: Humana Medicare/TRICARE	$17,090.44
Rate for Payer: Molina Dual Medicare/Medicaid	$17,090.44
Rate for Payer: Molina Medicare	$17,090.44
Rate for Payer: Multiplan Auto	$33,288.00
Rate for Payer: Multiplan Commercial	$33,288.00
Rate for Payer: Multiplan Workers Comp	$33,288.00
Rate for Payer: Scott and White EPO/PPO	$15,330.00
Rate for Payer: Scott and White Medicare	$17,090.44
Rate for Payer: Superior Health Plan EPO	$17,090.44
Rate for Payer: Superior Health Plan Medicare	$17,090.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,090.44
Rate for Payer: Universal American Medicare	$17,090.44
Rate for Payer: Wellcare Medicare	$17,090.44
Rate for Payer: Wellmed Medicare	$17,090.44

HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC

Facility

$54,488.20

Service Code	MSDRG 353
Min. Negotiated Rate	$25,093.25
Max. Negotiated Rate	$54,488.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,028.93
Rate for Payer: Amerigroup Medicare	$26,028.93
Rate for Payer: BCBS of TX Medicare	$26,028.93
Rate for Payer: Cigna Commercial	$37,377.76
Rate for Payer: Cigna Medicare	$26,028.93
Rate for Payer: Employer Direct Commercial	$26,028.93
Rate for Payer: Humana Medicare/TRICARE	$26,028.93
Rate for Payer: Molina Dual Medicare/Medicaid	$26,028.93
Rate for Payer: Molina Medicare	$26,028.93
Rate for Payer: Multiplan Auto	$54,488.20
Rate for Payer: Multiplan Commercial	$54,488.20
Rate for Payer: Multiplan Workers Comp	$54,488.20
Rate for Payer: Scott and White EPO/PPO	$25,093.25
Rate for Payer: Scott and White Medicare	$26,028.93
Rate for Payer: Superior Health Plan EPO	$26,028.93
Rate for Payer: Superior Health Plan Medicare	$26,028.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,028.93
Rate for Payer: Universal American Medicare	$26,028.93
Rate for Payer: Wellcare Medicare	$26,028.93
Rate for Payer: Wellmed Medicare	$26,028.93

HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC

Facility

$26,073.70

Service Code	MSDRG 355
Min. Negotiated Rate	$11,651.28
Max. Negotiated Rate	$26,073.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,617.62
Rate for Payer: Amerigroup Medicare	$14,617.62
Rate for Payer: BCBS of TX Medicare	$14,617.62
Rate for Payer: Cigna Commercial	$17,323.60
Rate for Payer: Cigna Medicare	$14,617.62
Rate for Payer: Employer Direct Commercial	$14,617.62
Rate for Payer: Humana Medicare/TRICARE	$14,617.62
Rate for Payer: Molina Dual Medicare/Medicaid	$14,617.62
Rate for Payer: Molina Medicare	$14,617.62
Rate for Payer: Multiplan Auto	$26,073.70
Rate for Payer: Multiplan Commercial	$26,073.70
Rate for Payer: Multiplan Workers Comp	$26,073.70
Rate for Payer: Scott and White EPO/PPO	$12,007.62
Rate for Payer: Scott and White Medicare	$14,617.62
Rate for Payer: Superior Health Plan EPO	$14,617.62
Rate for Payer: Superior Health Plan Medicare	$14,617.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,617.62
Rate for Payer: Universal American Medicare	$14,617.62
Rate for Payer: Wellcare Medicare	$14,617.62
Rate for Payer: Wellmed Medicare	$14,617.62

HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL

Facility

$7,094.93

Service Code	APR-DRG 2272
Min. Negotiated Rate	$6,689.34
Max. Negotiated Rate	$7,094.93
Rate for Payer: Amerigroup CHIP/Medicaid	$6,689.34
Rate for Payer: Cigna Medicaid	$6,689.34
Rate for Payer: Molina CHIP/Medicaid	$6,689.34
Rate for Payer: Parkland Medicaid	$6,689.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,094.93

HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL

Facility

$5,497.15

Service Code	APR-DRG 2271
Min. Negotiated Rate	$5,182.91
Max. Negotiated Rate	$5,497.15
Rate for Payer: Amerigroup CHIP/Medicaid	$5,182.91
Rate for Payer: Cigna Medicaid	$5,182.91
Rate for Payer: Molina CHIP/Medicaid	$5,182.91
Rate for Payer: Parkland Medicaid	$5,182.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,497.15

HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL

Facility

$32,965.94

Service Code	APR-DRG 2274
Min. Negotiated Rate	$31,081.44
Max. Negotiated Rate	$32,965.94
Rate for Payer: Amerigroup CHIP/Medicaid	$31,081.44
Rate for Payer: Cigna Medicaid	$31,081.44
Rate for Payer: Molina CHIP/Medicaid	$31,081.44
Rate for Payer: Parkland Medicaid	$31,081.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32,965.94

HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL

Facility

$10,454.92

Service Code	APR-DRG 2273
Min. Negotiated Rate	$9,857.27
Max. Negotiated Rate	$10,454.92
Rate for Payer: Amerigroup CHIP/Medicaid	$9,857.27
Rate for Payer: Cigna Medicaid	$9,857.27
Rate for Payer: Molina CHIP/Medicaid	$9,857.27
Rate for Payer: Parkland Medicaid	$9,857.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,454.92

HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC

Facility

$33,288.00

Service Code	MSDRG 354
Min. Negotiated Rate	$14,886.60
Max. Negotiated Rate	$33,288.00
Rate for Payer: BCBS of TX Blue Advantage	$14,886.60
Rate for Payer: BCBS of TX Blue Essentials	$17,862.19
Rate for Payer: BCBS of TX PPO	$19,847.65

HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W MCC

Facility

$54,488.20

Service Code	MSDRG 353
Min. Negotiated Rate	$25,093.25
Max. Negotiated Rate	$54,488.20
Rate for Payer: BCBS of TX Blue Advantage	$25,506.74
Rate for Payer: BCBS of TX Blue Essentials	$30,605.12
Rate for Payer: BCBS of TX PPO	$34,007.01

HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC

Facility

$26,073.70

Service Code	MSDRG 355
Min. Negotiated Rate	$11,651.28
Max. Negotiated Rate	$26,073.70
Rate for Payer: BCBS of TX Blue Advantage	$11,651.28
Rate for Payer: BCBS of TX Blue Essentials	$13,980.18
Rate for Payer: BCBS of TX PPO	$15,534.14

Herpes Simplex Virus by PCR

Facility

$573.00

Service Code	HCPCS 87529
Hospital Charge Code	4107529
Hospital Revenue Code	300
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$412.56
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$171.90
Rate for Payer: BCBS of TX Blue Essentials	$206.28
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$229.20
Rate for Payer: Cash Price	$389.64
Rate for Payer: Cash Price	$389.64
Rate for Payer: Cigna Medicaid	$412.56
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$412.56
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$372.45
Rate for Payer: Multiplan Commercial	$372.45
Rate for Payer: Multiplan Workers Comp	$372.45
Rate for Payer: Parkland Medicaid	$412.56
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$412.56
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

Herpes Simplex Virus by PCR

Facility

$573.00

Service Code	HCPCS 87529
Hospital Charge Code	4107529
Hospital Revenue Code	300
Rate for Payer: Cash Price	$389.64

Know your out-of-pocket cost for care.

All Charges