White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Intravenous infusion, hydration; initial, 31 minutes to 1 hour

Facility

$10,000.00

Service Code	CPT 96360
Hospital Charge Code	36096360
Hospital Revenue Code	360
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
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	$39.95
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

Intravenous infusion, hydration; initial, 31 minutes to 1 hour

Facility

$626.79

Service Code	HCPCS 96360
Hospital Charge Code	9900910
Hospital Revenue Code	260
Rate for Payer: Cash Price	$426.22

Intravenous infusion, hydration; initial, 31 minutes to 1 hour

Facility

$626.79

Service Code	HCPCS 96360
Hospital Charge Code	8996978
Hospital Revenue Code	260
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$451.67
Rate for Payer: Amerigroup CHIP/Medicaid	$56.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$188.04
Rate for Payer: BCBS of TX Blue Essentials	$225.64
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$250.72
Rate for Payer: Cash Price	$426.22
Rate for Payer: Cash Price	$426.22
Rate for Payer: Cash Price	$426.22
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$451.29
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$451.29
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$407.41
Rate for Payer: Multiplan Commercial	$407.41
Rate for Payer: Multiplan Workers Comp	$407.41
Rate for Payer: Parkland Medicaid	$451.29
Rate for Payer: Scott and White EPO/PPO	$39.95
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$451.29
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

Intravenous infusion, hydration; initial, 31 minutes to 1 hour

Facility

$626.79

Service Code	HCPCS 96360
Hospital Charge Code	9900910
Hospital Revenue Code	260
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$451.67
Rate for Payer: Amerigroup CHIP/Medicaid	$56.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$188.04
Rate for Payer: BCBS of TX Blue Essentials	$225.64
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$250.72
Rate for Payer: Cash Price	$426.22
Rate for Payer: Cash Price	$426.22
Rate for Payer: Cash Price	$426.22
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$451.29
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$451.29
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$407.41
Rate for Payer: Multiplan Commercial	$407.41
Rate for Payer: Multiplan Workers Comp	$407.41
Rate for Payer: Parkland Medicaid	$451.29
Rate for Payer: Scott and White EPO/PPO	$39.95
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$451.29
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft

Facility

$1,518.52

Service Code	HCPCS 15860
Hospital Charge Code	991150
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,032.59

Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft

Facility

$1,518.52

Service Code	HCPCS 15860
Hospital Charge Code	991150
Hospital Revenue Code	360
Min. Negotiated Rate	$136.67
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$136.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$448.76
Rate for Payer: Amerigroup Medicare	$448.76
Rate for Payer: BCBS of TX Blue Advantage	$607.20
Rate for Payer: BCBS of TX Blue Essentials	$727.18
Rate for Payer: BCBS of TX Medicare	$448.76
Rate for Payer: BCBS of TX PPO	$916.25
Rate for Payer: Cash Price	$1,032.59
Rate for Payer: Cash Price	$1,032.59
Rate for Payer: Cash Price	$1,032.59
Rate for Payer: Cigna Commercial	$948.59
Rate for Payer: Cigna Medicaid	$1,093.33
Rate for Payer: Cigna Medicare	$448.76
Rate for Payer: Employer Direct Commercial	$448.76
Rate for Payer: Humana Medicare/TRICARE	$448.76
Rate for Payer: Molina CHIP/Medicaid	$1,093.33
Rate for Payer: Molina Dual Medicare/Medicaid	$448.76
Rate for Payer: Molina Medicare	$448.76
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	$1,093.33
Rate for Payer: Scott and White EPO/PPO	$674.12
Rate for Payer: Scott and White Medicare	$448.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,093.33
Rate for Payer: Superior Health Plan EPO	$448.76
Rate for Payer: Superior Health Plan Medicare	$448.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$448.76
Rate for Payer: Universal American Medicare	$448.76
Rate for Payer: Wellcare Medicare	$448.76
Rate for Payer: Wellmed Medicare	$448.76

INTRCRD EP 3DMAP

Facility

$8,562.00

Service Code	HCPCS 93613
Hospital Charge Code	4613613
Hospital Revenue Code	480
Rate for Payer: Cash Price	$5,822.16

INTRCRD EP 3DMAP

Facility

$8,562.00

Service Code	HCPCS 93613
Hospital Charge Code	4613613
Hospital Revenue Code	480
Min. Negotiated Rate	$345.59
Max. Negotiated Rate	$6,164.64
Rate for Payer: Amerigroup CHIP/Medicaid	$770.58
Rate for Payer: BCBS of TX Blue Advantage	$2,568.60
Rate for Payer: BCBS of TX Blue Essentials	$3,082.32
Rate for Payer: BCBS of TX PPO	$3,424.80
Rate for Payer: Cash Price	$5,822.16
Rate for Payer: Cash Price	$5,822.16
Rate for Payer: Cigna Medicaid	$6,164.64
Rate for Payer: Molina CHIP/Medicaid	$6,164.64
Rate for Payer: Multiplan Auto	$5,565.30
Rate for Payer: Multiplan Commercial	$5,565.30
Rate for Payer: Multiplan Workers Comp	$5,565.30
Rate for Payer: Parkland Medicaid	$6,164.64
Rate for Payer: Scott and White EPO/PPO	$345.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,164.64
Rate for Payer: Superior Health Plan EPO	$1,164.43

INTRO CATH -- DHF

Facility

$267.72

Hospital Charge Code	81826307
Hospital Revenue Code	272
Rate for Payer: Cash Price	$182.05

INTRO CATH -- DHF

Facility

$267.72

Hospital Charge Code	81826307
Hospital Revenue Code	272
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$192.76
Rate for Payer: Amerigroup CHIP/Medicaid	$24.09
Rate for Payer: BCBS of TX Blue Advantage	$80.32
Rate for Payer: BCBS of TX Blue Essentials	$96.38
Rate for Payer: BCBS of TX PPO	$107.09
Rate for Payer: Cash Price	$182.05
Rate for Payer: Cigna Medicaid	$192.76
Rate for Payer: Molina CHIP/Medicaid	$192.76
Rate for Payer: Multiplan Auto	$174.02
Rate for Payer: Multiplan Commercial	$174.02
Rate for Payer: Multiplan Workers Comp	$174.02
Rate for Payer: Parkland Medicaid	$192.76
Rate for Payer: Scott and White EPO/PPO	$133.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.76
Rate for Payer: Superior Health Plan EPO	$36.41

INTRO, CATHETER AORTA

Facility

$2,583.00

Service Code	HCPCS 36200
Hospital Charge Code	2301778
Hospital Revenue Code	360
Min. Negotiated Rate	$232.47
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$232.47
Rate for Payer: BCBS of TX Blue Advantage	$774.90
Rate for Payer: BCBS of TX Blue Essentials	$929.88
Rate for Payer: BCBS of TX PPO	$1,033.20
Rate for Payer: Cash Price	$1,756.44
Rate for Payer: Cash Price	$1,756.44
Rate for Payer: Cigna Medicaid	$1,859.76
Rate for Payer: Molina CHIP/Medicaid	$1,859.76
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	$1,859.76
Rate for Payer: Scott and White EPO/PPO	$1,291.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,859.76
Rate for Payer: Superior Health Plan EPO	$351.29

INTRO, CATHETER AORTA

Facility

$2,583.00

Service Code	HCPCS 36200
Hospital Charge Code	2301778
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,756.44

INTRO CATH/NDL DIAL-CIRC +S&I

Facility

$3,242.00

Service Code	HCPCS 36901
Hospital Charge Code	2351100
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,204.56

INTRO CATH/NDL DIAL-CIRC +S&I

Facility

$3,242.00

Service Code	HCPCS 36901
Hospital Charge Code	2351100
Hospital Revenue Code	360
Min. Negotiated Rate	$446.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$446.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Amerigroup Medicare	$1,581.33
Rate for Payer: BCBS of TX Blue Advantage	$957.68
Rate for Payer: BCBS of TX Blue Essentials	$1,146.92
Rate for Payer: BCBS of TX Medicare	$1,581.33
Rate for Payer: BCBS of TX PPO	$1,445.12
Rate for Payer: Cash Price	$2,204.56
Rate for Payer: Cash Price	$2,204.56
Rate for Payer: Cash Price	$2,204.56
Rate for Payer: Cigna Commercial	$3,342.63
Rate for Payer: Cigna Medicaid	$2,334.24
Rate for Payer: Cigna Medicare	$1,581.33
Rate for Payer: Employer Direct Commercial	$1,581.33
Rate for Payer: Humana Medicare/TRICARE	$1,581.33
Rate for Payer: Molina CHIP/Medicaid	$2,334.24
Rate for Payer: Molina Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Molina Medicare	$1,581.33
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	$2,334.24
Rate for Payer: Scott and White EPO/PPO	$2,709.66
Rate for Payer: Scott and White Medicare	$1,581.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,334.24
Rate for Payer: Superior Health Plan EPO	$1,581.33
Rate for Payer: Superior Health Plan Medicare	$1,581.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Universal American Medicare	$1,581.33
Rate for Payer: Wellcare Medicare	$1,581.33
Rate for Payer: Wellmed Medicare	$1,581.33

INTRO CATHVAS -- DHF

Facility

$772.26

Hospital Charge Code	81826455
Hospital Revenue Code	272
Rate for Payer: Cash Price	$525.14

INTRO CATHVAS -- DHF

Facility

$772.26

Hospital Charge Code	81826455
Hospital Revenue Code	272
Min. Negotiated Rate	$69.50
Max. Negotiated Rate	$556.03
Rate for Payer: Amerigroup CHIP/Medicaid	$69.50
Rate for Payer: BCBS of TX Blue Advantage	$231.68
Rate for Payer: BCBS of TX Blue Essentials	$278.01
Rate for Payer: BCBS of TX PPO	$308.90
Rate for Payer: Cash Price	$525.14
Rate for Payer: Cigna Medicaid	$556.03
Rate for Payer: Molina CHIP/Medicaid	$556.03
Rate for Payer: Multiplan Auto	$501.97
Rate for Payer: Multiplan Commercial	$501.97
Rate for Payer: Multiplan Workers Comp	$501.97
Rate for Payer: Parkland Medicaid	$556.03
Rate for Payer: Scott and White EPO/PPO	$386.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$556.03
Rate for Payer: Superior Health Plan EPO	$105.03

INTRODUCER ACC VALVE

Facility

$227.00

Hospital Charge Code	8414456
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$163.44
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$154.36
Rate for Payer: Cigna Medicaid	$163.44
Rate for Payer: Molina CHIP/Medicaid	$163.44
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Parkland Medicaid	$163.44
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.44
Rate for Payer: Superior Health Plan EPO	$30.87

INTRODUCER ACC VALVE

Facility

$227.00

Hospital Charge Code	8414456
Hospital Revenue Code	272
Rate for Payer: Cash Price	$154.36

INTRODUCER MERIT PRELUDE

Facility

$227.00

Hospital Charge Code	8478524
Hospital Revenue Code	272
Rate for Payer: Cash Price	$154.36

INTRODUCER MERIT PRELUDE

Facility

$227.00

Hospital Charge Code	8478524
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$163.44
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$154.36
Rate for Payer: Cigna Medicaid	$163.44
Rate for Payer: Molina CHIP/Medicaid	$163.44
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Parkland Medicaid	$163.44
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.44
Rate for Payer: Superior Health Plan EPO	$30.87

INTRODUCER SHEATH

Facility

$908.00

Hospital Charge Code	8484503
Hospital Revenue Code	272
Rate for Payer: Cash Price	$617.44

INTRODUCER SHEATH

Facility

$908.00

Hospital Charge Code	8484503
Hospital Revenue Code	272
Min. Negotiated Rate	$81.72
Max. Negotiated Rate	$653.76
Rate for Payer: Amerigroup CHIP/Medicaid	$81.72
Rate for Payer: BCBS of TX Blue Advantage	$272.40
Rate for Payer: BCBS of TX Blue Essentials	$326.88
Rate for Payer: BCBS of TX PPO	$363.20
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cigna Medicaid	$653.76
Rate for Payer: Molina CHIP/Medicaid	$653.76
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$653.76
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$653.76
Rate for Payer: Superior Health Plan EPO	$123.49

introducer sheath peelaway

Facility

$227.00

Hospital Charge Code	80732605
Hospital Revenue Code	272
Rate for Payer: Cash Price	$154.36

introducer sheath peelaway

Facility

$227.00

Hospital Charge Code	80732605
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$163.44
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$154.36
Rate for Payer: Cigna Medicaid	$163.44
Rate for Payer: Molina CHIP/Medicaid	$163.44
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Parkland Medicaid	$163.44
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.44
Rate for Payer: Superior Health Plan EPO	$30.87

INTRODUCER SHEATH PEELAWAY 22FR

Facility

$204.71

Service Code	HCPCS C1766
Hospital Charge Code	992481
Hospital Revenue Code	272
Min. Negotiated Rate	$18.42
Max. Negotiated Rate	$147.39
Rate for Payer: Amerigroup CHIP/Medicaid	$18.42
Rate for Payer: BCBS of TX Blue Advantage	$61.41
Rate for Payer: BCBS of TX Blue Essentials	$73.70
Rate for Payer: BCBS of TX PPO	$81.88
Rate for Payer: Cash Price	$139.20
Rate for Payer: Cigna Medicaid	$147.39
Rate for Payer: Molina CHIP/Medicaid	$147.39
Rate for Payer: Multiplan Auto	$133.06
Rate for Payer: Multiplan Commercial	$133.06
Rate for Payer: Multiplan Workers Comp	$133.06
Rate for Payer: Parkland Medicaid	$147.39
Rate for Payer: Scott and White EPO/PPO	$102.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$147.39
Rate for Payer: Superior Health Plan EPO	$27.84

Know your out-of-pocket cost for care.

All Charges