White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Incision, bone cortex (eg, osteomyelitis or bone abscess), foot

Facility

$9,906.40

Service Code	HCPCS 28005
Hospital Charge Code	9900456
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,736.35

Incision, extensor tendon sheath, wrist (eg, de Quervains disease)

Facility

$8,354.10

Service Code	HCPCS 25000
Hospital Charge Code	9900263
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,680.79

Incision, extensor tendon sheath, wrist (eg, de Quervains disease)

Facility

$8,354.10

Service Code	HCPCS 25000
Hospital Charge Code	9900263
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cash Price	$5,680.79
Rate for Payer: Cash Price	$5,680.79
Rate for Payer: Cash Price	$5,680.79
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$6,014.95
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina CHIP/Medicaid	$6,014.95
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$6,014.95
Rate for Payer: Scott and White EPO/PPO	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,014.95
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

Incision, extensor tendon sheath, wrist (eg, de Quervains disease)

Facility

$10,000.00

Service Code	CPT 25000
Hospital Charge Code	36025000
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pul

Facility

$73,379.22

Service Code	CPT 64568
Hospital Charge Code	36064568
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$73,379.22
Rate for Payer: Amerigroup CHIP/Medicaid	$19,861.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$44,247.19
Rate for Payer: Amerigroup Medicare	$44,247.19
Rate for Payer: BCBS of TX Blue Advantage	$48,628.30
Rate for Payer: BCBS of TX Blue Essentials	$58,237.48
Rate for Payer: BCBS of TX Medicare	$44,247.19
Rate for Payer: BCBS of TX PPO	$73,379.22
Rate for Payer: Cigna Medicare	$44,247.19
Rate for Payer: Employer Direct Commercial	$44,247.19
Rate for Payer: Humana Medicare/TRICARE	$44,247.19
Rate for Payer: Molina Dual Medicare/Medicaid	$44,247.19
Rate for Payer: Molina Medicare	$44,247.19
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	$52,537.60
Rate for Payer: Scott and White Medicare	$44,247.19
Rate for Payer: Superior Health Plan EPO	$44,247.19
Rate for Payer: Superior Health Plan Medicare	$44,247.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$44,247.19
Rate for Payer: Universal American Medicare	$44,247.19
Rate for Payer: Wellcare Medicare	$44,247.19
Rate for Payer: Wellmed Medicare	$44,247.19

Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pul

Facility

$73,611.30

Service Code	HCPCS 64568
Hospital Charge Code	9900813
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$73,379.22
Rate for Payer: Amerigroup CHIP/Medicaid	$19,861.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$44,247.19
Rate for Payer: Amerigroup Medicare	$44,247.19
Rate for Payer: BCBS of TX Blue Advantage	$48,628.30
Rate for Payer: BCBS of TX Blue Essentials	$58,237.48
Rate for Payer: BCBS of TX Medicare	$44,247.19
Rate for Payer: BCBS of TX PPO	$73,379.22
Rate for Payer: Cash Price	$50,055.68
Rate for Payer: Cash Price	$50,055.68
Rate for Payer: Cash Price	$50,055.68
Rate for Payer: Cigna Medicaid	$53,000.14
Rate for Payer: Cigna Medicare	$44,247.19
Rate for Payer: Employer Direct Commercial	$44,247.19
Rate for Payer: Humana Medicare/TRICARE	$44,247.19
Rate for Payer: Molina CHIP/Medicaid	$53,000.14
Rate for Payer: Molina Dual Medicare/Medicaid	$44,247.19
Rate for Payer: Molina Medicare	$44,247.19
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	$53,000.14
Rate for Payer: Scott and White EPO/PPO	$52,537.60
Rate for Payer: Scott and White Medicare	$44,247.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53,000.14
Rate for Payer: Superior Health Plan EPO	$44,247.19
Rate for Payer: Superior Health Plan Medicare	$44,247.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$44,247.19
Rate for Payer: Universal American Medicare	$44,247.19
Rate for Payer: Wellcare Medicare	$44,247.19
Rate for Payer: Wellmed Medicare	$44,247.19

Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pul

Facility

$73,611.30

Service Code	HCPCS 64568
Hospital Charge Code	9900813
Hospital Revenue Code	360
Rate for Payer: Cash Price	$50,055.68

INDEFLATOR -- DHF

Facility

$1,917.67

Hospital Charge Code	80811854
Hospital Revenue Code	272
Min. Negotiated Rate	$172.59
Max. Negotiated Rate	$1,380.72
Rate for Payer: Amerigroup CHIP/Medicaid	$172.59
Rate for Payer: BCBS of TX Blue Advantage	$575.30
Rate for Payer: BCBS of TX Blue Essentials	$690.36
Rate for Payer: BCBS of TX PPO	$767.07
Rate for Payer: Cash Price	$1,304.02
Rate for Payer: Cigna Medicaid	$1,380.72
Rate for Payer: Molina CHIP/Medicaid	$1,380.72
Rate for Payer: Multiplan Auto	$1,246.49
Rate for Payer: Multiplan Commercial	$1,246.49
Rate for Payer: Multiplan Workers Comp	$1,246.49
Rate for Payer: Parkland Medicaid	$1,380.72
Rate for Payer: Scott and White EPO/PPO	$958.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,380.72
Rate for Payer: Superior Health Plan EPO	$260.80

INDEFLATOR -- DHF

Facility

$1,917.67

Hospital Charge Code	80811854
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,304.02

INDICATOR TEST ACECIDE-C

Facility

$485.78

Hospital Charge Code	993925
Hospital Revenue Code	279
Rate for Payer: Cash Price	$330.33

INDICATOR TEST ACECIDE-C

Facility

$485.78

Hospital Charge Code	993925
Hospital Revenue Code	279
Min. Negotiated Rate	$43.72
Max. Negotiated Rate	$349.76
Rate for Payer: Amerigroup CHIP/Medicaid	$43.72
Rate for Payer: BCBS of TX Blue Advantage	$145.73
Rate for Payer: BCBS of TX Blue Essentials	$174.88
Rate for Payer: BCBS of TX PPO	$194.31
Rate for Payer: Cash Price	$330.33
Rate for Payer: Cigna Medicaid	$349.76
Rate for Payer: Molina CHIP/Medicaid	$349.76
Rate for Payer: Multiplan Auto	$315.76
Rate for Payer: Multiplan Commercial	$315.76
Rate for Payer: Multiplan Workers Comp	$315.76
Rate for Payer: Parkland Medicaid	$349.76
Rate for Payer: Scott and White EPO/PPO	$242.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$349.76
Rate for Payer: Superior Health Plan EPO	$66.07

INDICTR, BIO, A TEST, RPID, 24MIN, F/H202

Facility

$63.68

Hospital Charge Code	993816
Hospital Revenue Code	272
Rate for Payer: Cash Price	$43.30

INDICTR, BIO, A TEST, RPID, 24MIN, F/H202

Facility

$63.68

Hospital Charge Code	993816
Hospital Revenue Code	272
Min. Negotiated Rate	$5.73
Max. Negotiated Rate	$45.85
Rate for Payer: Amerigroup CHIP/Medicaid	$5.73
Rate for Payer: BCBS of TX Blue Advantage	$19.10
Rate for Payer: BCBS of TX Blue Essentials	$22.92
Rate for Payer: BCBS of TX PPO	$25.47
Rate for Payer: Cash Price	$43.30
Rate for Payer: Cigna Medicaid	$45.85
Rate for Payer: Molina CHIP/Medicaid	$45.85
Rate for Payer: Multiplan Auto	$41.39
Rate for Payer: Multiplan Commercial	$41.39
Rate for Payer: Multiplan Workers Comp	$41.39
Rate for Payer: Parkland Medicaid	$45.85
Rate for Payer: Scott and White EPO/PPO	$31.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$45.85
Rate for Payer: Superior Health Plan EPO	$8.66

indocyanine green 25 mg Inj

Facility

$435.51

Service Code	HCPCS J1815
Hospital Charge Code	77634513
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$313.57
Rate for Payer: Amerigroup CHIP/Medicaid	$39.20
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$296.15
Rate for Payer: Cash Price	$296.15
Rate for Payer: Cigna Medicaid	$313.57
Rate for Payer: Molina CHIP/Medicaid	$313.57
Rate for Payer: Multiplan Auto	$283.08
Rate for Payer: Multiplan Commercial	$283.08
Rate for Payer: Multiplan Workers Comp	$283.08
Rate for Payer: Parkland Medicaid	$313.57
Rate for Payer: Scott and White EPO/PPO	$217.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$313.57
Rate for Payer: Superior Health Plan EPO	$59.23

indocyanine green 25 mg Inj

Facility

$435.51

Service Code	HCPCS J1815
Hospital Charge Code	77632274
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$313.57
Rate for Payer: Amerigroup CHIP/Medicaid	$39.20
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$296.15
Rate for Payer: Cash Price	$296.15
Rate for Payer: Cigna Medicaid	$313.57
Rate for Payer: Molina CHIP/Medicaid	$313.57
Rate for Payer: Multiplan Auto	$283.08
Rate for Payer: Multiplan Commercial	$283.08
Rate for Payer: Multiplan Workers Comp	$283.08
Rate for Payer: Parkland Medicaid	$313.57
Rate for Payer: Scott and White EPO/PPO	$217.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$313.57
Rate for Payer: Superior Health Plan EPO	$59.23

indocyanine green 25 mg Inj

Facility

$435.51

Service Code	HCPCS J1815
Hospital Charge Code	77634513
Hospital Revenue Code	636
Min. Negotiated Rate	$108.88
Max. Negotiated Rate	$217.75
Rate for Payer: Cash Price	$296.15
Rate for Payer: Cigna Commercial	$108.88
Rate for Payer: Scott and White EPO/PPO	$217.75

indocyanine green 25 mg Inj

Facility

$435.51

Service Code	HCPCS J1815
Hospital Charge Code	77632274
Hospital Revenue Code	636
Min. Negotiated Rate	$108.88
Max. Negotiated Rate	$217.75
Rate for Payer: Cash Price	$296.15
Rate for Payer: Cigna Commercial	$108.88
Rate for Payer: Scott and White EPO/PPO	$217.75

indomethacin 25 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77632378
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

indomethacin 25 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77632378
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

indomethacin 50 mg Cap

Facility

$19.20

Service Code	HCPCS J3490
Hospital Charge Code	77632484
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$13.82
Rate for Payer: Amerigroup CHIP/Medicaid	$1.73
Rate for Payer: BCBS of TX Blue Advantage	$5.76
Rate for Payer: BCBS of TX Blue Essentials	$6.91
Rate for Payer: BCBS of TX PPO	$7.68
Rate for Payer: Cash Price	$13.06
Rate for Payer: Cigna Medicaid	$13.82
Rate for Payer: Molina CHIP/Medicaid	$13.82
Rate for Payer: Multiplan Auto	$12.48
Rate for Payer: Multiplan Commercial	$12.48
Rate for Payer: Multiplan Workers Comp	$12.48
Rate for Payer: Parkland Medicaid	$13.82
Rate for Payer: Scott and White EPO/PPO	$9.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.82
Rate for Payer: Superior Health Plan EPO	$2.61

indomethacin 50 mg Cap

Facility

$19.20

Service Code	HCPCS J3490
Hospital Charge Code	77632484
Hospital Revenue Code	250
Rate for Payer: Cash Price	$13.06

Inf agent det by nucleic acid, nos, amp prob tech 8

Facility

$10,000.00

Service Code	CPT 87798
Hospital Charge Code	87798
Hospital Revenue Code	360
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Medicare	$35.09
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 Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
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	$43.86
Rate for Payer: Scott and White Medicare	$35.09
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

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W CC

Facility

$18,154.50

Service Code	MSDRG 758
Min. Negotiated Rate	$8,360.62
Max. Negotiated Rate	$18,154.50
Rate for Payer: BCBS of TX Blue Advantage	$8,775.44
Rate for Payer: BCBS of TX Blue Essentials	$10,529.51
Rate for Payer: BCBS of TX PPO	$11,699.91

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC

Facility

$18,154.50

Service Code	MSDRG 758
Min. Negotiated Rate	$8,360.62
Max. Negotiated Rate	$18,154.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,935.19
Rate for Payer: Amerigroup Medicare	$11,935.19
Rate for Payer: BCBS of TX Medicare	$11,935.19
Rate for Payer: Cigna Commercial	$12,609.52
Rate for Payer: Cigna Medicare	$11,935.19
Rate for Payer: Employer Direct Commercial	$11,935.19
Rate for Payer: Humana Medicare/TRICARE	$11,935.19
Rate for Payer: Molina Dual Medicare/Medicaid	$11,935.19
Rate for Payer: Molina Medicare	$11,935.19
Rate for Payer: Multiplan Auto	$18,154.50
Rate for Payer: Multiplan Commercial	$18,154.50
Rate for Payer: Multiplan Workers Comp	$18,154.50
Rate for Payer: Scott and White EPO/PPO	$8,360.62
Rate for Payer: Scott and White Medicare	$11,935.19
Rate for Payer: Superior Health Plan EPO	$11,935.19
Rate for Payer: Superior Health Plan Medicare	$11,935.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,935.19
Rate for Payer: Universal American Medicare	$11,935.19
Rate for Payer: Wellcare Medicare	$11,935.19
Rate for Payer: Wellmed Medicare	$11,935.19

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$26,071.80

Service Code	MSDRG 757
Min. Negotiated Rate	$12,006.75
Max. Negotiated Rate	$26,071.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,254.52
Rate for Payer: Amerigroup Medicare	$15,254.52
Rate for Payer: BCBS of TX Medicare	$15,254.52
Rate for Payer: Cigna Commercial	$18,442.87
Rate for Payer: Cigna Medicare	$15,254.52
Rate for Payer: Employer Direct Commercial	$15,254.52
Rate for Payer: Humana Medicare/TRICARE	$15,254.52
Rate for Payer: Molina Dual Medicare/Medicaid	$15,254.52
Rate for Payer: Molina Medicare	$15,254.52
Rate for Payer: Multiplan Auto	$26,071.80
Rate for Payer: Multiplan Commercial	$26,071.80
Rate for Payer: Multiplan Workers Comp	$26,071.80
Rate for Payer: Scott and White EPO/PPO	$12,006.75
Rate for Payer: Scott and White Medicare	$15,254.52
Rate for Payer: Superior Health Plan EPO	$15,254.52
Rate for Payer: Superior Health Plan Medicare	$15,254.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,254.52
Rate for Payer: Universal American Medicare	$15,254.52
Rate for Payer: Wellcare Medicare	$15,254.52
Rate for Payer: Wellmed Medicare	$15,254.52

Know your out-of-pocket cost for care.

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