White Rock Medical Center

All Charges

Charge

Type

Setting

Price

hook passer cresent

Facility

$796.18

Hospital Charge Code	8646517
Hospital Revenue Code	272
Min. Negotiated Rate	$71.66
Max. Negotiated Rate	$573.25
Rate for Payer: Amerigroup CHIP/Medicaid	$71.66
Rate for Payer: BCBS of TX Blue Advantage	$238.85
Rate for Payer: BCBS of TX Blue Essentials	$286.62
Rate for Payer: BCBS of TX PPO	$318.47
Rate for Payer: Cash Price	$541.40
Rate for Payer: Cigna Medicaid	$573.25
Rate for Payer: Molina CHIP/Medicaid	$573.25
Rate for Payer: Multiplan Auto	$517.52
Rate for Payer: Multiplan Commercial	$517.52
Rate for Payer: Multiplan Workers Comp	$517.52
Rate for Payer: Parkland Medicaid	$573.25
Rate for Payer: Scott and White EPO/PPO	$398.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$573.25
Rate for Payer: Superior Health Plan EPO	$108.28

hook passer cresent

Facility

$796.18

Hospital Charge Code	8646517
Hospital Revenue Code	272
Rate for Payer: Cash Price	$541.40

HOOK, SUTURE CRESCENT MED CURVE 4X20MM TEAL DISP

Facility

$280.80

Hospital Charge Code	140683
Hospital Revenue Code	272
Min. Negotiated Rate	$25.27
Max. Negotiated Rate	$202.18
Rate for Payer: Amerigroup CHIP/Medicaid	$25.27
Rate for Payer: BCBS of TX Blue Advantage	$84.24
Rate for Payer: BCBS of TX Blue Essentials	$101.09
Rate for Payer: BCBS of TX PPO	$112.32
Rate for Payer: Cash Price	$190.94
Rate for Payer: Cigna Medicaid	$202.18
Rate for Payer: Molina CHIP/Medicaid	$202.18
Rate for Payer: Multiplan Auto	$182.52
Rate for Payer: Multiplan Commercial	$182.52
Rate for Payer: Multiplan Workers Comp	$182.52
Rate for Payer: Parkland Medicaid	$202.18
Rate for Payer: Scott and White EPO/PPO	$140.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$202.18
Rate for Payer: Superior Health Plan EPO	$38.19

HOOK, SUTURE CRESCENT MED CURVE 4X20MM TEAL DISP

Facility

$280.80

Hospital Charge Code	140683
Hospital Revenue Code	272
Rate for Payer: Cash Price	$190.94

HOOK SUTURE -- DHF

Facility

$229.08

Hospital Charge Code	81799025
Hospital Revenue Code	272
Rate for Payer: Cash Price	$155.77

HOOK SUTURE -- DHF

Facility

$229.08

Hospital Charge Code	81799025
Hospital Revenue Code	272
Min. Negotiated Rate	$20.62
Max. Negotiated Rate	$164.94
Rate for Payer: Amerigroup CHIP/Medicaid	$20.62
Rate for Payer: BCBS of TX Blue Advantage	$68.72
Rate for Payer: BCBS of TX Blue Essentials	$82.47
Rate for Payer: BCBS of TX PPO	$91.63
Rate for Payer: Cash Price	$155.77
Rate for Payer: Cigna Medicaid	$164.94
Rate for Payer: Molina CHIP/Medicaid	$164.94
Rate for Payer: Multiplan Auto	$148.90
Rate for Payer: Multiplan Commercial	$148.90
Rate for Payer: Multiplan Workers Comp	$148.90
Rate for Payer: Parkland Medicaid	$164.94
Rate for Payer: Scott and White EPO/PPO	$114.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$164.94
Rate for Payer: Superior Health Plan EPO	$31.15

Hospital outpatient clinic visit

Facility

$503.80

Service Code	HCPCS G0463
Hospital Charge Code	990929
Hospital Revenue Code	510
Rate for Payer: Cash Price	$342.58

Hospital outpatient clinic visit

Facility

$503.80

Service Code	HCPCS G0463
Hospital Charge Code	990929
Hospital Revenue Code	510
Min. Negotiated Rate	$45.34
Max. Negotiated Rate	$362.74
Rate for Payer: Amerigroup CHIP/Medicaid	$45.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.74
Rate for Payer: Amerigroup Medicare	$133.74
Rate for Payer: BCBS of TX Blue Advantage	$151.14
Rate for Payer: BCBS of TX Blue Essentials	$181.37
Rate for Payer: BCBS of TX Medicare	$133.74
Rate for Payer: BCBS of TX PPO	$201.52
Rate for Payer: Cash Price	$342.58
Rate for Payer: Cash Price	$342.58
Rate for Payer: Cash Price	$342.58
Rate for Payer: Cigna Commercial	$282.70
Rate for Payer: Cigna Medicaid	$362.74
Rate for Payer: Cigna Medicare	$133.74
Rate for Payer: Employer Direct Commercial	$133.74
Rate for Payer: Humana Medicare/TRICARE	$133.74
Rate for Payer: Molina CHIP/Medicaid	$362.74
Rate for Payer: Molina Dual Medicare/Medicaid	$133.74
Rate for Payer: Molina Medicare	$133.74
Rate for Payer: Multiplan Auto	$327.47
Rate for Payer: Multiplan Commercial	$327.47
Rate for Payer: Multiplan Workers Comp	$327.47
Rate for Payer: Parkland Medicaid	$362.74
Rate for Payer: Scott and White EPO/PPO	$251.90
Rate for Payer: Scott and White Medicare	$133.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$362.74
Rate for Payer: Superior Health Plan EPO	$133.74
Rate for Payer: Superior Health Plan Medicare	$133.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.74
Rate for Payer: Universal American Medicare	$133.74
Rate for Payer: Wellcare Medicare	$133.74
Rate for Payer: Wellmed Medicare	$133.74

HPC TOTAL COUNT SAMPLER, RED

Facility

$132.39

Hospital Charge Code	993107
Hospital Revenue Code	270
Min. Negotiated Rate	$11.92
Max. Negotiated Rate	$95.32
Rate for Payer: Amerigroup CHIP/Medicaid	$11.92
Rate for Payer: BCBS of TX Blue Advantage	$39.72
Rate for Payer: BCBS of TX Blue Essentials	$47.66
Rate for Payer: BCBS of TX PPO	$52.96
Rate for Payer: Cash Price	$90.03
Rate for Payer: Cigna Medicaid	$95.32
Rate for Payer: Molina CHIP/Medicaid	$95.32
Rate for Payer: Multiplan Auto	$86.05
Rate for Payer: Multiplan Commercial	$86.05
Rate for Payer: Multiplan Workers Comp	$86.05
Rate for Payer: Parkland Medicaid	$95.32
Rate for Payer: Scott and White EPO/PPO	$66.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$95.32
Rate for Payer: Superior Health Plan EPO	$18.01

HPC TOTAL COUNT SAMPLER, RED

Facility

$132.39

Hospital Charge Code	993107
Hospital Revenue Code	270
Rate for Payer: Cash Price	$90.03

.HPV E6/E7 QuantaSure 507905 SO

Facility

$647.00

Service Code	HCPCS 88199
Hospital Charge Code	8662516
Hospital Revenue Code	310
Rate for Payer: Cash Price	$439.96

.HPV E6/E7 QuantaSure 507905 SO

Facility

$647.00

Service Code	HCPCS 88199
Hospital Charge Code	8662516
Hospital Revenue Code	310
Min. Negotiated Rate	$52.35
Max. Negotiated Rate	$465.84
Rate for Payer: Amerigroup CHIP/Medicaid	$58.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$52.35
Rate for Payer: Amerigroup Medicare	$52.35
Rate for Payer: BCBS of TX Blue Advantage	$194.10
Rate for Payer: BCBS of TX Blue Essentials	$232.92
Rate for Payer: BCBS of TX Medicare	$52.35
Rate for Payer: BCBS of TX PPO	$258.80
Rate for Payer: Cash Price	$439.96
Rate for Payer: Cash Price	$439.96
Rate for Payer: Cash Price	$439.96
Rate for Payer: Cigna Commercial	$110.66
Rate for Payer: Cigna Medicaid	$465.84
Rate for Payer: Cigna Medicare	$52.35
Rate for Payer: Employer Direct Commercial	$52.35
Rate for Payer: Humana Medicare/TRICARE	$52.35
Rate for Payer: Molina CHIP/Medicaid	$465.84
Rate for Payer: Molina Dual Medicare/Medicaid	$52.35
Rate for Payer: Molina Medicare	$52.35
Rate for Payer: Multiplan Auto	$420.55
Rate for Payer: Multiplan Commercial	$420.55
Rate for Payer: Multiplan Workers Comp	$420.55
Rate for Payer: Parkland Medicaid	$465.84
Rate for Payer: Scott and White EPO/PPO	$323.50
Rate for Payer: Scott and White Medicare	$52.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$465.84
Rate for Payer: Superior Health Plan EPO	$52.35
Rate for Payer: Superior Health Plan Medicare	$52.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$52.35
Rate for Payer: Universal American Medicare	$52.35
Rate for Payer: Wellcare Medicare	$52.35
Rate for Payer: Wellmed Medicare	$52.35

.HPV low vol rfx 507405 SO

Facility

$234.00

Service Code	HCPCS 87624
Hospital Charge Code	8662515
Hospital Revenue Code	306
Rate for Payer: Cash Price	$159.12

.HPV low vol rfx 507405 SO

Facility

$234.00

Service Code	HCPCS 87624
Hospital Charge Code	8662515
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$168.48
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	$70.20
Rate for Payer: BCBS of TX Blue Essentials	$84.24
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$93.60
Rate for Payer: Cash Price	$159.12
Rate for Payer: Cash Price	$159.12
Rate for Payer: Cigna Medicaid	$168.48
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	$168.48
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$152.10
Rate for Payer: Multiplan Commercial	$152.10
Rate for Payer: Multiplan Workers Comp	$152.10
Rate for Payer: Parkland Medicaid	$168.48
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	$168.48
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

.H pylori Breath Test, Peds SO

Facility

$386.00

Service Code	HCPCS 83013
Hospital Charge Code	1740995
Hospital Revenue Code	301
Min. Negotiated Rate	$26.27
Max. Negotiated Rate	$277.92
Rate for Payer: Amerigroup CHIP/Medicaid	$26.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$67.36
Rate for Payer: Amerigroup Medicare	$67.36
Rate for Payer: BCBS of TX Blue Advantage	$115.80
Rate for Payer: BCBS of TX Blue Essentials	$138.96
Rate for Payer: BCBS of TX Medicare	$67.36
Rate for Payer: BCBS of TX PPO	$154.40
Rate for Payer: Cash Price	$262.48
Rate for Payer: Cash Price	$262.48
Rate for Payer: Cigna Medicaid	$277.92
Rate for Payer: Cigna Medicare	$67.36
Rate for Payer: Employer Direct Commercial	$67.36
Rate for Payer: Humana Medicare/TRICARE	$67.36
Rate for Payer: Molina CHIP/Medicaid	$277.92
Rate for Payer: Molina Dual Medicare/Medicaid	$67.36
Rate for Payer: Molina Medicare	$67.36
Rate for Payer: Multiplan Auto	$250.90
Rate for Payer: Multiplan Commercial	$250.90
Rate for Payer: Multiplan Workers Comp	$250.90
Rate for Payer: Parkland Medicaid	$277.92
Rate for Payer: Scott and White EPO/PPO	$84.20
Rate for Payer: Scott and White Medicare	$67.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$277.92
Rate for Payer: Superior Health Plan EPO	$67.36
Rate for Payer: Superior Health Plan Medicare	$67.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$67.36
Rate for Payer: Universal American Medicare	$67.36
Rate for Payer: Wellcare Medicare	$67.36
Rate for Payer: Wellmed Medicare	$67.36

.H pylori Breath Test, Peds SO

Facility

$386.00

Service Code	HCPCS 83013
Hospital Charge Code	1740995
Hospital Revenue Code	301
Rate for Payer: Cash Price	$262.48

H. pylori Stool Ag, EIA SO

Facility

$209.00

Service Code	HCPCS 87338 QW
Hospital Charge Code	1614015
Hospital Revenue Code	300
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$150.48
Rate for Payer: Amerigroup CHIP/Medicaid	$5.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.38
Rate for Payer: Amerigroup Medicare	$14.38
Rate for Payer: BCBS of TX Blue Advantage	$62.70
Rate for Payer: BCBS of TX Blue Essentials	$75.24
Rate for Payer: BCBS of TX Medicare	$14.38
Rate for Payer: BCBS of TX PPO	$83.60
Rate for Payer: Cash Price	$142.12
Rate for Payer: Cash Price	$142.12
Rate for Payer: Cigna Medicaid	$150.48
Rate for Payer: Cigna Medicare	$14.38
Rate for Payer: Employer Direct Commercial	$14.38
Rate for Payer: Humana Medicare/TRICARE	$14.38
Rate for Payer: Molina CHIP/Medicaid	$150.48
Rate for Payer: Molina Dual Medicare/Medicaid	$14.38
Rate for Payer: Molina Medicare	$14.38
Rate for Payer: Multiplan Auto	$135.85
Rate for Payer: Multiplan Commercial	$135.85
Rate for Payer: Multiplan Workers Comp	$135.85
Rate for Payer: Parkland Medicaid	$150.48
Rate for Payer: Scott and White EPO/PPO	$17.98
Rate for Payer: Scott and White Medicare	$14.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.48
Rate for Payer: Superior Health Plan EPO	$14.38
Rate for Payer: Superior Health Plan Medicare	$14.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.38
Rate for Payer: Universal American Medicare	$14.38
Rate for Payer: Wellcare Medicare	$14.38
Rate for Payer: Wellmed Medicare	$14.38

H. pylori Stool Ag, EIA SO

Facility

$209.00

Service Code	HCPCS 87338 QW
Hospital Charge Code	1614015
Hospital Revenue Code	300
Rate for Payer: Cash Price	$142.12

HSV 1/2 PCR, CSF SO

Facility

$573.00

Service Code	HCPCS 87529
Hospital Charge Code	8722542
Hospital Revenue Code	306
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

HSV 1/2 PCR, CSF SO

Facility

$573.00

Service Code	HCPCS 87529
Hospital Charge Code	8722542
Hospital Revenue Code	306
Rate for Payer: Cash Price	$389.64

HSV 1 and 2 Ab, IgG SO

Facility

$160.96

Service Code	HCPCS 86696
Hospital Charge Code	9213053
Hospital Revenue Code	302
Rate for Payer: Cash Price	$109.45

HSV 1 and 2 Ab, IgG SO

Facility

$160.96

Service Code	HCPCS 86696
Hospital Charge Code	9213053
Hospital Revenue Code	302
Min. Negotiated Rate	$7.55
Max. Negotiated Rate	$115.89
Rate for Payer: Amerigroup CHIP/Medicaid	$7.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19.35
Rate for Payer: Amerigroup Medicare	$19.35
Rate for Payer: BCBS of TX Blue Advantage	$48.29
Rate for Payer: BCBS of TX Blue Essentials	$57.95
Rate for Payer: BCBS of TX Medicare	$19.35
Rate for Payer: BCBS of TX PPO	$64.38
Rate for Payer: Cash Price	$109.45
Rate for Payer: Cash Price	$109.45
Rate for Payer: Cigna Medicaid	$115.89
Rate for Payer: Cigna Medicare	$19.35
Rate for Payer: Employer Direct Commercial	$19.35
Rate for Payer: Humana Medicare/TRICARE	$19.35
Rate for Payer: Molina CHIP/Medicaid	$115.89
Rate for Payer: Molina Dual Medicare/Medicaid	$19.35
Rate for Payer: Molina Medicare	$19.35
Rate for Payer: Multiplan Auto	$104.62
Rate for Payer: Multiplan Commercial	$104.62
Rate for Payer: Multiplan Workers Comp	$104.62
Rate for Payer: Parkland Medicaid	$115.89
Rate for Payer: Scott and White EPO/PPO	$24.19
Rate for Payer: Scott and White Medicare	$19.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.89
Rate for Payer: Superior Health Plan EPO	$19.35
Rate for Payer: Superior Health Plan Medicare	$19.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$19.35
Rate for Payer: Universal American Medicare	$19.35
Rate for Payer: Wellcare Medicare	$19.35
Rate for Payer: Wellmed Medicare	$19.35

HSV 1 and 2-Spec Ab, IgG w/Rfx SO

Facility

$120.00

Service Code	HCPCS 86696
Hospital Charge Code	1708882
Hospital Revenue Code	302
Rate for Payer: Cash Price	$81.60

HSV 1 and 2-Spec Ab, IgG w/Rfx SO

Facility

$120.00

Service Code	HCPCS 86696
Hospital Charge Code	1708882
Hospital Revenue Code	302
Min. Negotiated Rate	$7.55
Max. Negotiated Rate	$86.40
Rate for Payer: Amerigroup CHIP/Medicaid	$7.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19.35
Rate for Payer: Amerigroup Medicare	$19.35
Rate for Payer: BCBS of TX Blue Advantage	$36.00
Rate for Payer: BCBS of TX Blue Essentials	$43.20
Rate for Payer: BCBS of TX Medicare	$19.35
Rate for Payer: BCBS of TX PPO	$48.00
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna Medicaid	$86.40
Rate for Payer: Cigna Medicare	$19.35
Rate for Payer: Employer Direct Commercial	$19.35
Rate for Payer: Humana Medicare/TRICARE	$19.35
Rate for Payer: Molina CHIP/Medicaid	$86.40
Rate for Payer: Molina Dual Medicare/Medicaid	$19.35
Rate for Payer: Molina Medicare	$19.35
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: Parkland Medicaid	$86.40
Rate for Payer: Scott and White EPO/PPO	$24.19
Rate for Payer: Scott and White Medicare	$19.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.40
Rate for Payer: Superior Health Plan EPO	$19.35
Rate for Payer: Superior Health Plan Medicare	$19.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$19.35
Rate for Payer: Universal American Medicare	$19.35
Rate for Payer: Wellcare Medicare	$19.35
Rate for Payer: Wellmed Medicare	$19.35

HSV-2 Ab, IgG SO

Facility

$131.05

Service Code	HCPCS 86696
Hospital Charge Code	9213052
Hospital Revenue Code	302
Rate for Payer: Cash Price	$89.11

Know your out-of-pocket cost for care.

All Charges