White Rock Medical Center

All Charges

Charge

Type

Setting

Price

RESPIRATORY THERAPY - GROUP SESS Units

Facility

$87.00

Service Code	HCPCS G0239
Hospital Charge Code	6030415
Hospital Revenue Code	460
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$83.09
Rate for Payer: Aetna Commercial	$47.85
Rate for Payer: Aetna Medicare	$55.02
Rate for Payer: Amerigroup CHIP/Medicaid	$7.83
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$36.68
Rate for Payer: Amerigroup Medicare	$36.68
Rate for Payer: BCBS of TX Blue Advantage	$21.94
Rate for Payer: BCBS of TX Blue Essentials	$26.23
Rate for Payer: BCBS of TX Medicare	$36.68
Rate for Payer: BCBS of TX PPO	$29.26
Rate for Payer: Cash Price	$76.56
Rate for Payer: Cash Price	$76.56
Rate for Payer: Cash Price	$76.56
Rate for Payer: Cigna Commercial	$83.09
Rate for Payer: Cigna Medicare	$36.68
Rate for Payer: Employer Direct Commercial	$36.68
Rate for Payer: Humana Medicare/TRICARE	$36.68
Rate for Payer: Molina Dual Medicare/Medicaid	$36.68
Rate for Payer: Molina Medicare	$36.68
Rate for Payer: Multiplan Auto	$56.55
Rate for Payer: Multiplan Commercial	$56.55
Rate for Payer: Multiplan Workers Comp	$56.55
Rate for Payer: Scott and White EPO/PPO	$0.66
Rate for Payer: Scott and White Medicare	$36.68
Rate for Payer: Superior Health Plan EPO	$36.68
Rate for Payer: Superior Health Plan Medicare	$36.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$36.68
Rate for Payer: Universal American Medicare	$36.68
Rate for Payer: Wellcare Medicare	$36.68
Rate for Payer: Wellmed Medicare	$36.68

RESPIRATORY THERAPY - GROUP SESS Units

Facility

$87.00

Service Code	HCPCS G0239
Hospital Charge Code	6030415
Hospital Revenue Code	460
Rate for Payer: Cash Price	$76.56

Respiratory Therapy - Group Sess Units BCE

Facility

$53.00

Hospital Charge Code	6030415
Hospital Revenue Code	460
Rate for Payer: Cash Price	$46.64

Respiratory Therapy - Group Sess Units BCE

Facility

$53.00

Hospital Charge Code	6030415
Hospital Revenue Code	460
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$34.45
Rate for Payer: Aetna Commercial	$29.15
Rate for Payer: Amerigroup CHIP/Medicaid	$4.77
Rate for Payer: BCBS of TX Blue Advantage	$15.90
Rate for Payer: BCBS of TX Blue Essentials	$19.08
Rate for Payer: BCBS of TX PPO	$21.20
Rate for Payer: Cash Price	$46.64
Rate for Payer: Multiplan Auto	$34.45
Rate for Payer: Multiplan Commercial	$34.45
Rate for Payer: Multiplan Workers Comp	$34.45
Rate for Payer: Scott and White EPO/PPO	$26.50
Rate for Payer: Superior Health Plan EPO	$7.21

RESP VIRUS 6-11 TARGETS BCE

Facility

$563.00

Service Code	CPT 87632
Hospital Charge Code	7257632
Hospital Revenue Code	300
Rate for Payer: Cash Price	$495.44

RESP VIRUS 6-11 TARGETS BCE

Facility

$563.00

Service Code	CPT 87632
Hospital Charge Code	7257632
Hospital Revenue Code	300
Min. Negotiated Rate	$85.04
Max. Negotiated Rate	$481.91
Rate for Payer: Aetna Commercial	$228.97
Rate for Payer: Aetna Medicare	$327.09
Rate for Payer: Amerigroup CHIP/Medicaid	$85.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$218.06
Rate for Payer: Amerigroup Medicare	$218.06
Rate for Payer: BCBS of TX Blue Advantage	$359.80
Rate for Payer: BCBS of TX Blue Essentials	$431.76
Rate for Payer: BCBS of TX Medicare	$218.06
Rate for Payer: BCBS of TX PPO	$481.91
Rate for Payer: Cash Price	$495.44
Rate for Payer: Cash Price	$495.44
Rate for Payer: Cigna Medicaid	$218.06
Rate for Payer: Cigna Medicare	$218.06
Rate for Payer: Employer Direct Commercial	$218.06
Rate for Payer: Humana Medicare/TRICARE	$218.06
Rate for Payer: Molina CHIP/Medicaid	$218.06
Rate for Payer: Molina Dual Medicare/Medicaid	$218.06
Rate for Payer: Molina Medicare	$218.06
Rate for Payer: Multiplan Auto	$365.95
Rate for Payer: Multiplan Commercial	$365.95
Rate for Payer: Multiplan Workers Comp	$365.95
Rate for Payer: Parkland Medicaid	$218.06
Rate for Payer: Scott and White EPO/PPO	$272.58
Rate for Payer: Scott and White Medicare	$218.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$218.06
Rate for Payer: Superior Health Plan EPO	$218.06
Rate for Payer: Superior Health Plan Medicare	$218.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$218.06
Rate for Payer: Universal American Medicare	$218.06
Rate for Payer: Wellcare Medicare	$218.06
Rate for Payer: Wellmed Medicare	$218.06

RESTRAINT, HEAD UNIV MULTIPLE STRAP ADJT WHT/BLACK -- DHF

Facility

$116.64

Hospital Charge Code	81146805
Hospital Revenue Code	270
Rate for Payer: Cash Price	$102.64

RESTRAINT, HEAD UNIV MULTIPLE STRAP ADJT WHT/BLACK -- DHF

Facility

$116.64

Hospital Charge Code	81146805
Hospital Revenue Code	270
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$75.82
Rate for Payer: Aetna Commercial	$64.15
Rate for Payer: Amerigroup CHIP/Medicaid	$10.50
Rate for Payer: BCBS of TX Blue Advantage	$34.99
Rate for Payer: BCBS of TX Blue Essentials	$41.99
Rate for Payer: BCBS of TX PPO	$46.66
Rate for Payer: Cash Price	$102.64
Rate for Payer: Multiplan Auto	$75.82
Rate for Payer: Multiplan Commercial	$75.82
Rate for Payer: Multiplan Workers Comp	$75.82
Rate for Payer: Scott and White EPO/PPO	$58.32
Rate for Payer: Superior Health Plan EPO	$15.86

RETAINER VISCERA -- DHF

Facility

$777.12

Hospital Charge Code	81848251
Hospital Revenue Code	272
Min. Negotiated Rate	$69.94
Max. Negotiated Rate	$505.13
Rate for Payer: Aetna Commercial	$427.42
Rate for Payer: Amerigroup CHIP/Medicaid	$69.94
Rate for Payer: BCBS of TX Blue Advantage	$233.14
Rate for Payer: BCBS of TX Blue Essentials	$279.76
Rate for Payer: BCBS of TX PPO	$310.85
Rate for Payer: Cash Price	$683.87
Rate for Payer: Multiplan Auto	$505.13
Rate for Payer: Multiplan Commercial	$505.13
Rate for Payer: Multiplan Workers Comp	$505.13
Rate for Payer: Scott and White EPO/PPO	$388.56
Rate for Payer: Superior Health Plan EPO	$105.69

RETAINER VISCERA -- DHF

Facility

$777.12

Hospital Charge Code	81848251
Hospital Revenue Code	272
Rate for Payer: Cash Price	$683.87

Retic Count Automated

Facility

$171.00

Service Code	CPT 85045
Hospital Charge Code	1611862
Hospital Revenue Code	305
Rate for Payer: Cash Price	$150.48

Retic Count Automated

Facility

$171.00

Service Code	CPT 85045
Hospital Charge Code	1611862
Hospital Revenue Code	305
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$111.15
Rate for Payer: Aetna Commercial	$4.18
Rate for Payer: Aetna Medicare	$5.98
Rate for Payer: Amerigroup CHIP/Medicaid	$1.56
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.99
Rate for Payer: Amerigroup Medicare	$3.99
Rate for Payer: BCBS of TX Blue Advantage	$6.58
Rate for Payer: BCBS of TX Blue Essentials	$7.90
Rate for Payer: BCBS of TX Medicare	$3.99
Rate for Payer: BCBS of TX PPO	$8.82
Rate for Payer: Cash Price	$150.48
Rate for Payer: Cash Price	$150.48
Rate for Payer: Cigna Medicaid	$3.99
Rate for Payer: Cigna Medicare	$3.99
Rate for Payer: Employer Direct Commercial	$3.99
Rate for Payer: Humana Medicare/TRICARE	$3.99
Rate for Payer: Molina CHIP/Medicaid	$3.99
Rate for Payer: Molina Dual Medicare/Medicaid	$3.99
Rate for Payer: Molina Medicare	$3.99
Rate for Payer: Multiplan Auto	$111.15
Rate for Payer: Multiplan Commercial	$111.15
Rate for Payer: Multiplan Workers Comp	$111.15
Rate for Payer: Parkland Medicaid	$3.99
Rate for Payer: Scott and White EPO/PPO	$4.99
Rate for Payer: Scott and White Medicare	$3.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.99
Rate for Payer: Superior Health Plan EPO	$3.99
Rate for Payer: Superior Health Plan Medicare	$3.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.99
Rate for Payer: Universal American Medicare	$3.99
Rate for Payer: Wellcare Medicare	$3.99
Rate for Payer: Wellmed Medicare	$3.99

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC

Facility

$18,889.80

Service Code	MSDRG 815
Min. Negotiated Rate	$8,280.94
Max. Negotiated Rate	$18,889.80
Rate for Payer: Aetna Commercial	$11,184.75
Rate for Payer: Aetna Medicare	$14,924.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,949.44
Rate for Payer: Amerigroup Medicare	$9,949.44
Rate for Payer: BCBS of TX Blue Advantage	$8,280.94
Rate for Payer: BCBS of TX Blue Essentials	$10,088.89
Rate for Payer: BCBS of TX Medicare	$9,949.44
Rate for Payer: BCBS of TX PPO	$11,210.31
Rate for Payer: Cigna Commercial	$12,805.30
Rate for Payer: Cigna Medicare	$9,949.44
Rate for Payer: Employer Direct Commercial	$9,949.44
Rate for Payer: Humana Medicare/TRICARE	$9,949.44
Rate for Payer: Molina Dual Medicare/Medicaid	$9,949.44
Rate for Payer: Molina Medicare	$9,949.44
Rate for Payer: Multiplan Auto	$18,889.80
Rate for Payer: Multiplan Commercial	$18,889.80
Rate for Payer: Multiplan Workers Comp	$18,889.80
Rate for Payer: Scott and White EPO/PPO	$8,699.25
Rate for Payer: Scott and White Medicare	$9,949.44
Rate for Payer: Superior Health Plan EPO	$9,949.44
Rate for Payer: Superior Health Plan Medicare	$9,949.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,949.44
Rate for Payer: Universal American Medicare	$9,949.44
Rate for Payer: Wellcare Medicare	$9,949.44
Rate for Payer: Wellmed Medicare	$9,949.44

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC

Facility

$40,433.90

Service Code	MSDRG 814
Min. Negotiated Rate	$14,648.38
Max. Negotiated Rate	$40,433.90
Rate for Payer: Aetna Commercial	$23,941.12
Rate for Payer: Aetna Medicare	$27,061.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,041.03
Rate for Payer: Amerigroup Medicare	$18,041.03
Rate for Payer: BCBS of TX Blue Advantage	$14,648.38
Rate for Payer: BCBS of TX Blue Essentials	$17,160.50
Rate for Payer: BCBS of TX Medicare	$18,041.03
Rate for Payer: BCBS of TX PPO	$19,067.96
Rate for Payer: Cigna Commercial	$27,409.93
Rate for Payer: Cigna Medicare	$18,041.03
Rate for Payer: Employer Direct Commercial	$18,041.03
Rate for Payer: Humana Medicare/TRICARE	$18,041.03
Rate for Payer: Molina Dual Medicare/Medicaid	$18,041.03
Rate for Payer: Molina Medicare	$18,041.03
Rate for Payer: Multiplan Auto	$40,433.90
Rate for Payer: Multiplan Commercial	$40,433.90
Rate for Payer: Multiplan Workers Comp	$40,433.90
Rate for Payer: Scott and White EPO/PPO	$18,620.88
Rate for Payer: Scott and White Medicare	$18,041.03
Rate for Payer: Superior Health Plan EPO	$18,041.03
Rate for Payer: Superior Health Plan Medicare	$18,041.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,041.03
Rate for Payer: Universal American Medicare	$18,041.03
Rate for Payer: Wellcare Medicare	$18,041.03
Rate for Payer: Wellmed Medicare	$18,041.03

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC

Facility

$13,493.80

Service Code	MSDRG 816
Min. Negotiated Rate	$6,214.25
Max. Negotiated Rate	$13,493.80
Rate for Payer: Aetna Commercial	$7,989.75
Rate for Payer: Aetna Medicare	$11,884.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,922.82
Rate for Payer: Amerigroup Medicare	$7,922.82
Rate for Payer: BCBS of TX Blue Advantage	$6,327.88
Rate for Payer: BCBS of TX Blue Essentials	$7,446.19
Rate for Payer: BCBS of TX Medicare	$7,922.82
Rate for Payer: BCBS of TX PPO	$8,273.87
Rate for Payer: Cigna Commercial	$9,147.38
Rate for Payer: Cigna Medicare	$7,922.82
Rate for Payer: Employer Direct Commercial	$7,922.82
Rate for Payer: Humana Medicare/TRICARE	$7,922.82
Rate for Payer: Molina Dual Medicare/Medicaid	$7,922.82
Rate for Payer: Molina Medicare	$7,922.82
Rate for Payer: Multiplan Auto	$13,493.80
Rate for Payer: Multiplan Commercial	$13,493.80
Rate for Payer: Multiplan Workers Comp	$13,493.80
Rate for Payer: Scott and White EPO/PPO	$6,214.25
Rate for Payer: Scott and White Medicare	$7,922.82
Rate for Payer: Superior Health Plan EPO	$7,922.82
Rate for Payer: Superior Health Plan Medicare	$7,922.82
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,922.82
Rate for Payer: Universal American Medicare	$7,922.82
Rate for Payer: Wellcare Medicare	$7,922.82
Rate for Payer: Wellmed Medicare	$7,922.82

RETRACTOR ABD DISP -- DHF

Facility

$431.30

Hospital Charge Code	80826613
Hospital Revenue Code	272
Rate for Payer: Cash Price	$379.54

RETRACTOR ABD DISP -- DHF

Facility

$431.30

Hospital Charge Code	80826613
Hospital Revenue Code	272
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$280.34
Rate for Payer: Aetna Commercial	$237.22
Rate for Payer: Amerigroup CHIP/Medicaid	$38.82
Rate for Payer: BCBS of TX Blue Advantage	$129.39
Rate for Payer: BCBS of TX Blue Essentials	$155.27
Rate for Payer: BCBS of TX PPO	$172.52
Rate for Payer: Cash Price	$379.54
Rate for Payer: Multiplan Auto	$280.34
Rate for Payer: Multiplan Commercial	$280.34
Rate for Payer: Multiplan Workers Comp	$280.34
Rate for Payer: Scott and White EPO/PPO	$215.65
Rate for Payer: Superior Health Plan EPO	$58.66

RETRACTOR DISP -- DHF

Facility

$265.07

Hospital Charge Code	81763062
Hospital Revenue Code	272
Rate for Payer: Cash Price	$233.26

RETRACTOR DISP -- DHF

Facility

$265.07

Hospital Charge Code	81763062
Hospital Revenue Code	272
Min. Negotiated Rate	$23.86
Max. Negotiated Rate	$172.30
Rate for Payer: Aetna Commercial	$145.79
Rate for Payer: Amerigroup CHIP/Medicaid	$23.86
Rate for Payer: BCBS of TX Blue Advantage	$79.52
Rate for Payer: BCBS of TX Blue Essentials	$95.43
Rate for Payer: BCBS of TX PPO	$106.03
Rate for Payer: Cash Price	$233.26
Rate for Payer: Multiplan Auto	$172.30
Rate for Payer: Multiplan Commercial	$172.30
Rate for Payer: Multiplan Workers Comp	$172.30
Rate for Payer: Scott and White EPO/PPO	$132.54
Rate for Payer: Superior Health Plan EPO	$36.05

RETRACTOR POSTERIOR

Facility

$5,448.00

Hospital Charge Code	8504493
Hospital Revenue Code	272
Min. Negotiated Rate	$490.32
Max. Negotiated Rate	$3,541.20
Rate for Payer: Aetna Commercial	$2,996.40
Rate for Payer: Amerigroup CHIP/Medicaid	$490.32
Rate for Payer: BCBS of TX Blue Advantage	$1,634.40
Rate for Payer: BCBS of TX Blue Essentials	$1,961.28
Rate for Payer: BCBS of TX PPO	$2,179.20
Rate for Payer: Cash Price	$4,794.24
Rate for Payer: Multiplan Auto	$3,541.20
Rate for Payer: Multiplan Commercial	$3,541.20
Rate for Payer: Multiplan Workers Comp	$3,541.20
Rate for Payer: Scott and White EPO/PPO	$2,724.00
Rate for Payer: Superior Health Plan EPO	$740.93

RETRACTOR POSTERIOR

Facility

$5,448.00

Hospital Charge Code	8504493
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,794.24

RETRACTOR WND MEDIUM -- DHF

Facility

$192.50

Hospital Charge Code	81763138
Hospital Revenue Code	272
Rate for Payer: Cash Price	$169.40

RETRACTOR WND MEDIUM -- DHF

Facility

$192.50

Hospital Charge Code	81763138
Hospital Revenue Code	272
Min. Negotiated Rate	$17.32
Max. Negotiated Rate	$125.12
Rate for Payer: Aetna Commercial	$105.88
Rate for Payer: Amerigroup CHIP/Medicaid	$17.32
Rate for Payer: BCBS of TX Blue Advantage	$57.75
Rate for Payer: BCBS of TX Blue Essentials	$69.30
Rate for Payer: BCBS of TX PPO	$77.00
Rate for Payer: Cash Price	$169.40
Rate for Payer: Multiplan Auto	$125.12
Rate for Payer: Multiplan Commercial	$125.12
Rate for Payer: Multiplan Workers Comp	$125.12
Rate for Payer: Scott and White EPO/PPO	$96.25
Rate for Payer: Superior Health Plan EPO	$26.18

RETRIEVER, SUTURE S/S SHAFT NYLON LOOP HDL DISP -- DHF

Facility

$260.27

Hospital Charge Code	81774101
Hospital Revenue Code	272
Min. Negotiated Rate	$23.42
Max. Negotiated Rate	$169.18
Rate for Payer: Aetna Commercial	$143.15
Rate for Payer: Amerigroup CHIP/Medicaid	$23.42
Rate for Payer: BCBS of TX Blue Advantage	$78.08
Rate for Payer: BCBS of TX Blue Essentials	$93.70
Rate for Payer: BCBS of TX PPO	$104.11
Rate for Payer: Cash Price	$229.04
Rate for Payer: Multiplan Auto	$169.18
Rate for Payer: Multiplan Commercial	$169.18
Rate for Payer: Multiplan Workers Comp	$169.18
Rate for Payer: Scott and White EPO/PPO	$130.14
Rate for Payer: Superior Health Plan EPO	$35.40

RETRIEVER, SUTURE S/S SHAFT NYLON LOOP HDL DISP -- DHF

Facility

$260.27

Hospital Charge Code	81774101
Hospital Revenue Code	272
Rate for Payer: Cash Price	$229.04

Know your out-of-pocket cost for care.

All Charges