White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Lamotrigine (Lamictal), Serum SO

Facility

$161.00

Service Code	HCPCS 80175
Hospital Charge Code	1740990
Hospital Revenue Code	301
Rate for Payer: Cash Price	$109.48

Laparo proc abdm/per/oment

Facility

$15,181.32

Service Code	HCPCS 49329
Hospital Charge Code	9900711
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$10,323.30
Rate for Payer: Cash Price	$10,323.30
Rate for Payer: Cash Price	$10,323.30
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$10,930.55
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$10,930.55
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$10,930.55
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,930.55
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Laparo proc abdm/per/oment

Facility

$12,837.39

Service Code	CPT 49329
Hospital Charge Code	36049329
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Laparo proc abdm/per/oment

Facility

$15,181.32

Service Code	HCPCS 49329
Hospital Charge Code	9900711
Hospital Revenue Code	360
Rate for Payer: Cash Price	$10,323.30

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC

Facility

$31,559.00

Service Code	MSDRG 418
Min. Negotiated Rate	$14,312.12
Max. Negotiated Rate	$31,559.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,157.86
Rate for Payer: Amerigroup Medicare	$17,157.86
Rate for Payer: BCBS of TX Medicare	$17,157.86
Rate for Payer: Cigna Commercial	$21,787.81
Rate for Payer: Cigna Medicare	$17,157.86
Rate for Payer: Employer Direct Commercial	$17,157.86
Rate for Payer: Humana Medicare/TRICARE	$17,157.86
Rate for Payer: Molina Dual Medicare/Medicaid	$17,157.86
Rate for Payer: Molina Medicare	$17,157.86
Rate for Payer: Multiplan Auto	$31,559.00
Rate for Payer: Multiplan Commercial	$31,559.00
Rate for Payer: Multiplan Workers Comp	$31,559.00
Rate for Payer: Scott and White EPO/PPO	$14,533.75
Rate for Payer: Scott and White Medicare	$17,157.86
Rate for Payer: Superior Health Plan EPO	$17,157.86
Rate for Payer: Superior Health Plan Medicare	$17,157.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,157.86
Rate for Payer: Universal American Medicare	$17,157.86
Rate for Payer: Wellcare Medicare	$17,157.86
Rate for Payer: Wellmed Medicare	$17,157.86

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC

Facility

$45,176.30

Service Code	MSDRG 417
Min. Negotiated Rate	$20,804.88
Max. Negotiated Rate	$45,176.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,250.07
Rate for Payer: Amerigroup Medicare	$22,250.07
Rate for Payer: BCBS of TX Medicare	$22,250.07
Rate for Payer: Cigna Commercial	$30,736.83
Rate for Payer: Cigna Medicare	$22,250.07
Rate for Payer: Employer Direct Commercial	$22,250.07
Rate for Payer: Humana Medicare/TRICARE	$22,250.07
Rate for Payer: Molina Dual Medicare/Medicaid	$22,250.07
Rate for Payer: Molina Medicare	$22,250.07
Rate for Payer: Multiplan Auto	$45,176.30
Rate for Payer: Multiplan Commercial	$45,176.30
Rate for Payer: Multiplan Workers Comp	$45,176.30
Rate for Payer: Scott and White EPO/PPO	$20,804.88
Rate for Payer: Scott and White Medicare	$22,250.07
Rate for Payer: Superior Health Plan EPO	$22,250.07
Rate for Payer: Superior Health Plan Medicare	$22,250.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,250.07
Rate for Payer: Universal American Medicare	$22,250.07
Rate for Payer: Wellcare Medicare	$22,250.07
Rate for Payer: Wellmed Medicare	$22,250.07

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$24,795.00

Service Code	MSDRG 419
Min. Negotiated Rate	$11,216.12
Max. Negotiated Rate	$24,795.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,770.07
Rate for Payer: Amerigroup Medicare	$14,770.07
Rate for Payer: BCBS of TX Medicare	$14,770.07
Rate for Payer: Cigna Commercial	$17,591.50
Rate for Payer: Cigna Medicare	$14,770.07
Rate for Payer: Employer Direct Commercial	$14,770.07
Rate for Payer: Humana Medicare/TRICARE	$14,770.07
Rate for Payer: Molina Dual Medicare/Medicaid	$14,770.07
Rate for Payer: Molina Medicare	$14,770.07
Rate for Payer: Multiplan Auto	$24,795.00
Rate for Payer: Multiplan Commercial	$24,795.00
Rate for Payer: Multiplan Workers Comp	$24,795.00
Rate for Payer: Scott and White EPO/PPO	$11,418.75
Rate for Payer: Scott and White Medicare	$14,770.07
Rate for Payer: Superior Health Plan EPO	$14,770.07
Rate for Payer: Superior Health Plan Medicare	$14,770.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,770.07
Rate for Payer: Universal American Medicare	$14,770.07
Rate for Payer: Wellcare Medicare	$14,770.07
Rate for Payer: Wellmed Medicare	$14,770.07

LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC

Facility

$31,559.00

Service Code	MSDRG 418
Min. Negotiated Rate	$14,312.12
Max. Negotiated Rate	$31,559.00
Rate for Payer: BCBS of TX Blue Advantage	$14,312.12
Rate for Payer: BCBS of TX Blue Essentials	$17,172.88
Rate for Payer: BCBS of TX PPO	$19,081.72

LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC

Facility

$45,176.30

Service Code	MSDRG 417
Min. Negotiated Rate	$20,804.88
Max. Negotiated Rate	$45,176.30
Rate for Payer: BCBS of TX Blue Advantage	$20,841.24
Rate for Payer: BCBS of TX Blue Essentials	$25,007.06
Rate for Payer: BCBS of TX PPO	$27,786.70

LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC

Facility

$24,795.00

Service Code	MSDRG 419
Min. Negotiated Rate	$11,216.12
Max. Negotiated Rate	$24,795.00
Rate for Payer: BCBS of TX Blue Advantage	$11,216.12
Rate for Payer: BCBS of TX Blue Essentials	$13,458.04
Rate for Payer: BCBS of TX PPO	$14,953.96

Laparoscopic Duodenal Switch

Facility

$20,242.00

Service Code	HCPCS 43659
Hospital Charge Code	99412
Hospital Revenue Code	360
Min. Negotiated Rate	$1,821.78
Max. Negotiated Rate	$14,574.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,821.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$14,574.24
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$14,574.24
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$14,574.24
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,574.24
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Laparoscopic Duodenal Switch

Facility

$20,242.00

Service Code	HCPCS 43659
Hospital Charge Code	99412
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,764.56

Laparoscopic Electrode

Facility

$53.36

Hospital Charge Code	993168
Hospital Revenue Code	270
Rate for Payer: Cash Price	$36.28

Laparoscopic Electrode

Facility

$53.36

Hospital Charge Code	993168
Hospital Revenue Code	270
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$38.42
Rate for Payer: Amerigroup CHIP/Medicaid	$4.80
Rate for Payer: BCBS of TX Blue Advantage	$16.01
Rate for Payer: BCBS of TX Blue Essentials	$19.21
Rate for Payer: BCBS of TX PPO	$21.34
Rate for Payer: Cash Price	$36.28
Rate for Payer: Cigna Medicaid	$38.42
Rate for Payer: Molina CHIP/Medicaid	$38.42
Rate for Payer: Multiplan Auto	$34.68
Rate for Payer: Multiplan Commercial	$34.68
Rate for Payer: Multiplan Workers Comp	$34.68
Rate for Payer: Parkland Medicaid	$38.42
Rate for Payer: Scott and White EPO/PPO	$26.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.42
Rate for Payer: Superior Health Plan EPO	$7.26

Laparoscopic Liver Biopsy

Facility

$11,221.70

Service Code	HCPCS 47379
Hospital Charge Code	9900705
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,630.76

Laparoscopic Liver Biopsy

Facility

$11,221.70

Service Code	HCPCS 47379
Hospital Charge Code	9900705
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$7,630.76
Rate for Payer: Cash Price	$7,630.76
Rate for Payer: Cash Price	$7,630.76
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$8,079.62
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$8,079.62
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$8,079.62
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,079.62
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Laparoscopic Liver Biopsy

Facility

$12,837.39

Service Code	CPT 47379
Hospital Charge Code	36047379
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Laparoscopic Revision Band- removal gastric bypass

Facility

$20,242.00

Service Code	HCPCS 43659
Hospital Charge Code	994119
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,764.56

Laparoscopic Revision Band- removal gastric bypass

Facility

$20,242.00

Service Code	HCPCS 43659
Hospital Charge Code	994119
Hospital Revenue Code	360
Min. Negotiated Rate	$1,821.78
Max. Negotiated Rate	$14,574.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,821.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cash Price	$13,764.56
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$14,574.24
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$14,574.24
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$14,574.24
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,574.24
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Laparoscopic Roux-en-Y Gastric Bypass (Must Include DRG 620/621 and CPT 43644)

Facility

$16,500.00

Service Code	MSDRG 621
Hospital Charge Code	1
Min. Negotiated Rate	$16,500.00
Max. Negotiated Rate	$16,500.00
Rate for Payer: BARInet Commercial	$16,500.00

Laparoscopic Roux-en-Y Gastric Bypass (Must Include DRG 620/621 and CPT 43644)

Facility

$16,500.00

Service Code	MSDRG 620
Hospital Charge Code	1
Min. Negotiated Rate	$16,500.00
Max. Negotiated Rate	$16,500.00
Rate for Payer: BARInet Commercial	$16,500.00

Laparoscopic Roux-en-Y Gastric Bypass (Must Include DRG 620/621 and CPT 43644)

Facility

$16,500.00

Service Code	MSDRG 620
Hospital Charge Code	2
Min. Negotiated Rate	$16,500.00
Max. Negotiated Rate	$16,500.00
Rate for Payer: BARInet Commercial	$16,500.00

Laparoscopic Roux-en-Y Gastric Bypass (Must Include DRG 620/621 and CPT 43644)

Facility

$16,500.00

Service Code	MSDRG 621
Hospital Charge Code	2
Min. Negotiated Rate	$16,500.00
Max. Negotiated Rate	$16,500.00
Rate for Payer: BARInet Commercial	$16,500.00

laparoscopic shears

Facility

$2,224.60

Hospital Charge Code	993972
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,512.73

laparoscopic shears

Facility

$2,224.60

Hospital Charge Code	993972
Hospital Revenue Code	272
Min. Negotiated Rate	$200.21
Max. Negotiated Rate	$1,601.71
Rate for Payer: Amerigroup CHIP/Medicaid	$200.21
Rate for Payer: BCBS of TX Blue Advantage	$667.38
Rate for Payer: BCBS of TX Blue Essentials	$800.86
Rate for Payer: BCBS of TX PPO	$889.84
Rate for Payer: Cash Price	$1,512.73
Rate for Payer: Cigna Medicaid	$1,601.71
Rate for Payer: Molina CHIP/Medicaid	$1,601.71
Rate for Payer: Multiplan Auto	$1,445.99
Rate for Payer: Multiplan Commercial	$1,445.99
Rate for Payer: Multiplan Workers Comp	$1,445.99
Rate for Payer: Parkland Medicaid	$1,601.71
Rate for Payer: Scott and White EPO/PPO	$1,112.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,601.71
Rate for Payer: Superior Health Plan EPO	$302.55

Know your out-of-pocket cost for care.

All Charges