White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Laryngoscopy, flexible diagnostic

Facility

$10,000.00

Service Code	CPT 31575
Hospital Charge Code	36031575
Hospital Revenue Code	360
Min. Negotiated Rate	$68.14
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$68.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$200.52
Rate for Payer: Amerigroup Medicare	$200.52
Rate for Payer: BCBS of TX Blue Advantage	$132.10
Rate for Payer: BCBS of TX Blue Essentials	$158.20
Rate for Payer: BCBS of TX Medicare	$200.52
Rate for Payer: BCBS of TX PPO	$199.33
Rate for Payer: Cigna Commercial	$423.85
Rate for Payer: Cigna Medicare	$200.52
Rate for Payer: Employer Direct Commercial	$200.52
Rate for Payer: Humana Medicare/TRICARE	$200.52
Rate for Payer: Molina Dual Medicare/Medicaid	$200.52
Rate for Payer: Molina Medicare	$200.52
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	$370.96
Rate for Payer: Scott and White Medicare	$200.52
Rate for Payer: Superior Health Plan EPO	$200.52
Rate for Payer: Superior Health Plan Medicare	$200.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$200.52
Rate for Payer: Universal American Medicare	$200.52
Rate for Payer: Wellcare Medicare	$200.52
Rate for Payer: Wellmed Medicare	$200.52

Laryngoscopy, flexible diagnostic

Facility

$1,643.90

Service Code	HCPCS 31575
Hospital Charge Code	9900620
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,117.85

Laryngoscopy, flexible diagnostic

Facility

$1,643.90

Service Code	HCPCS 31575
Hospital Charge Code	9900620
Hospital Revenue Code	360
Min. Negotiated Rate	$68.14
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$68.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$200.52
Rate for Payer: Amerigroup Medicare	$200.52
Rate for Payer: BCBS of TX Blue Advantage	$132.10
Rate for Payer: BCBS of TX Blue Essentials	$158.20
Rate for Payer: BCBS of TX Medicare	$200.52
Rate for Payer: BCBS of TX PPO	$199.33
Rate for Payer: Cash Price	$1,117.85
Rate for Payer: Cash Price	$1,117.85
Rate for Payer: Cash Price	$1,117.85
Rate for Payer: Cigna Commercial	$423.85
Rate for Payer: Cigna Medicaid	$1,183.61
Rate for Payer: Cigna Medicare	$200.52
Rate for Payer: Employer Direct Commercial	$200.52
Rate for Payer: Humana Medicare/TRICARE	$200.52
Rate for Payer: Molina CHIP/Medicaid	$1,183.61
Rate for Payer: Molina Dual Medicare/Medicaid	$200.52
Rate for Payer: Molina Medicare	$200.52
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	$1,183.61
Rate for Payer: Scott and White EPO/PPO	$370.96
Rate for Payer: Scott and White Medicare	$200.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,183.61
Rate for Payer: Superior Health Plan EPO	$200.52
Rate for Payer: Superior Health Plan Medicare	$200.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$200.52
Rate for Payer: Universal American Medicare	$200.52
Rate for Payer: Wellcare Medicare	$200.52
Rate for Payer: Wellmed Medicare	$200.52

latanoprost ophthalmic 0.005%

Facility

$162.00

Service Code	HCPCS J3490
Hospital Charge Code	78403923
Hospital Revenue Code	250
Rate for Payer: Cash Price	$110.16

latanoprost ophthalmic 0.005%

Facility

$162.00

Service Code	HCPCS J3490
Hospital Charge Code	78403923
Hospital Revenue Code	250
Min. Negotiated Rate	$14.58
Max. Negotiated Rate	$116.64
Rate for Payer: Amerigroup CHIP/Medicaid	$14.58
Rate for Payer: BCBS of TX Blue Advantage	$48.60
Rate for Payer: BCBS of TX Blue Essentials	$58.32
Rate for Payer: BCBS of TX PPO	$64.80
Rate for Payer: Cash Price	$110.16
Rate for Payer: Cigna Medicaid	$116.64
Rate for Payer: Molina CHIP/Medicaid	$116.64
Rate for Payer: Multiplan Auto	$105.30
Rate for Payer: Multiplan Commercial	$105.30
Rate for Payer: Multiplan Workers Comp	$105.30
Rate for Payer: Parkland Medicaid	$116.64
Rate for Payer: Scott and White EPO/PPO	$81.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$116.64
Rate for Payer: Superior Health Plan EPO	$22.03

latch assist nipple everter aid

Facility

$28.01

Hospital Charge Code	8630563
Hospital Revenue Code	272
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$20.17
Rate for Payer: Amerigroup CHIP/Medicaid	$2.52
Rate for Payer: BCBS of TX Blue Advantage	$8.40
Rate for Payer: BCBS of TX Blue Essentials	$10.08
Rate for Payer: BCBS of TX PPO	$11.20
Rate for Payer: Cash Price	$19.05
Rate for Payer: Cigna Medicaid	$20.17
Rate for Payer: Molina CHIP/Medicaid	$20.17
Rate for Payer: Multiplan Auto	$18.21
Rate for Payer: Multiplan Commercial	$18.21
Rate for Payer: Multiplan Workers Comp	$18.21
Rate for Payer: Parkland Medicaid	$20.17
Rate for Payer: Scott and White EPO/PPO	$14.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.17
Rate for Payer: Superior Health Plan EPO	$3.81

latch assist nipple everter aid

Facility

$28.01

Hospital Charge Code	8630563
Hospital Revenue Code	272
Rate for Payer: Cash Price	$19.05

LATERAL FIBULA PLATE LT 125MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$13,000.00

Service Code	HCPCS C1734
Hospital Charge Code	992384
Hospital Revenue Code	278
Min. Negotiated Rate	$1,170.00
Max. Negotiated Rate	$9,360.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,170.00
Rate for Payer: BCBS of TX Blue Advantage	$3,900.00
Rate for Payer: BCBS of TX Blue Essentials	$4,680.00
Rate for Payer: BCBS of TX PPO	$5,200.00
Rate for Payer: Cash Price	$8,840.00
Rate for Payer: Cigna Medicaid	$9,360.00
Rate for Payer: Molina CHIP/Medicaid	$9,360.00
Rate for Payer: Multiplan Auto	$6,500.00
Rate for Payer: Multiplan Commercial	$6,500.00
Rate for Payer: Multiplan Workers Comp	$6,500.00
Rate for Payer: Parkland Medicaid	$9,360.00
Rate for Payer: Scott and White EPO/PPO	$6,500.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,360.00
Rate for Payer: Superior Health Plan EPO	$1,768.00

LATERAL FIBULA PLATE LT 125MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$13,000.00

Service Code	HCPCS C1734
Hospital Charge Code	992384
Hospital Revenue Code	278
Min. Negotiated Rate	$3,250.00
Max. Negotiated Rate	$6,500.00
Rate for Payer: Cash Price	$8,840.00
Rate for Payer: Cigna Commercial	$3,250.00
Rate for Payer: Multiplan Auto	$6,500.00
Rate for Payer: Multiplan Commercial	$6,500.00
Rate for Payer: Multiplan Workers Comp	$6,500.00
Rate for Payer: Scott and White EPO/PPO	$6,500.00

LATERAL FIBULA PLATE RT 101MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$13,277.11

Service Code	HCPCS C1734
Hospital Charge Code	992328
Hospital Revenue Code	278
Min. Negotiated Rate	$3,319.28
Max. Negotiated Rate	$6,638.56
Rate for Payer: Cash Price	$9,028.43
Rate for Payer: Cigna Commercial	$3,319.28
Rate for Payer: Multiplan Auto	$6,638.56
Rate for Payer: Multiplan Commercial	$6,638.56
Rate for Payer: Multiplan Workers Comp	$6,638.56
Rate for Payer: Scott and White EPO/PPO	$6,638.56

LATERAL FIBULA PLATE RT 101MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$13,277.11

Service Code	HCPCS C1734
Hospital Charge Code	992328
Hospital Revenue Code	278
Min. Negotiated Rate	$1,194.94
Max. Negotiated Rate	$9,559.52
Rate for Payer: Amerigroup CHIP/Medicaid	$1,194.94
Rate for Payer: BCBS of TX Blue Advantage	$3,983.13
Rate for Payer: BCBS of TX Blue Essentials	$4,779.76
Rate for Payer: BCBS of TX PPO	$5,310.84
Rate for Payer: Cash Price	$9,028.43
Rate for Payer: Cigna Medicaid	$9,559.52
Rate for Payer: Molina CHIP/Medicaid	$9,559.52
Rate for Payer: Multiplan Auto	$6,638.56
Rate for Payer: Multiplan Commercial	$6,638.56
Rate for Payer: Multiplan Workers Comp	$6,638.56
Rate for Payer: Parkland Medicaid	$9,559.52
Rate for Payer: Scott and White EPO/PPO	$6,638.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,559.52
Rate for Payer: Superior Health Plan EPO	$1,805.69

LATERAL FIBULA PLATE RT 113MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$13,572.29

Service Code	HCPCS C1713
Hospital Charge Code	993151
Hospital Revenue Code	278
Min. Negotiated Rate	$1,221.51
Max. Negotiated Rate	$9,772.05
Rate for Payer: Amerigroup CHIP/Medicaid	$1,221.51
Rate for Payer: BCBS of TX Blue Advantage	$4,071.69
Rate for Payer: BCBS of TX Blue Essentials	$4,886.02
Rate for Payer: BCBS of TX PPO	$5,428.92
Rate for Payer: Cash Price	$9,229.16
Rate for Payer: Cigna Medicaid	$9,772.05
Rate for Payer: Molina CHIP/Medicaid	$9,772.05
Rate for Payer: Multiplan Auto	$6,786.15
Rate for Payer: Multiplan Commercial	$6,786.15
Rate for Payer: Multiplan Workers Comp	$6,786.15
Rate for Payer: Parkland Medicaid	$9,772.05
Rate for Payer: Scott and White EPO/PPO	$6,786.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,772.05
Rate for Payer: Superior Health Plan EPO	$1,845.83

LATERAL FIBULA PLATE RT 113MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$13,572.29

Service Code	HCPCS C1713
Hospital Charge Code	993151
Hospital Revenue Code	278
Min. Negotiated Rate	$3,393.07
Max. Negotiated Rate	$6,786.15
Rate for Payer: Cash Price	$9,229.16
Rate for Payer: Cigna Commercial	$3,393.07
Rate for Payer: Multiplan Auto	$6,786.15
Rate for Payer: Multiplan Commercial	$6,786.15
Rate for Payer: Multiplan Workers Comp	$6,786.15
Rate for Payer: Scott and White EPO/PPO	$6,786.15

LAVAGE BACTISURE WOUND

Facility

$3,405.00

Hospital Charge Code	145078
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,315.40

LAVAGE BACTISURE WOUND

Facility

$3,405.00

Hospital Charge Code	145078
Hospital Revenue Code	272
Min. Negotiated Rate	$306.45
Max. Negotiated Rate	$2,451.60
Rate for Payer: Amerigroup CHIP/Medicaid	$306.45
Rate for Payer: BCBS of TX Blue Advantage	$1,021.50
Rate for Payer: BCBS of TX Blue Essentials	$1,225.80
Rate for Payer: BCBS of TX PPO	$1,362.00
Rate for Payer: Cash Price	$2,315.40
Rate for Payer: Cigna Medicaid	$2,451.60
Rate for Payer: Molina CHIP/Medicaid	$2,451.60
Rate for Payer: Multiplan Auto	$2,213.25
Rate for Payer: Multiplan Commercial	$2,213.25
Rate for Payer: Multiplan Workers Comp	$2,213.25
Rate for Payer: Parkland Medicaid	$2,451.60
Rate for Payer: Scott and White EPO/PPO	$1,702.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,451.60
Rate for Payer: Superior Health Plan EPO	$463.08

LC Skin Sub App Face/Nck/HF ad 100sqcm

Facility

$4,073.00

Hospital Charge Code	7150908
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$2,932.56
Rate for Payer: Amerigroup CHIP/Medicaid	$366.57
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$2,769.64
Rate for Payer: Cash Price	$2,769.64
Rate for Payer: Cigna Medicaid	$2,932.56
Rate for Payer: Molina CHIP/Medicaid	$2,932.56
Rate for Payer: Multiplan Auto	$2,647.45
Rate for Payer: Multiplan Commercial	$2,647.45
Rate for Payer: Multiplan Workers Comp	$2,647.45
Rate for Payer: Parkland Medicaid	$2,932.56
Rate for Payer: Scott and White EPO/PPO	$2,036.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,932.56
Rate for Payer: Superior Health Plan EPO	$553.93

LC Skin Sub App Face/Nck/HF ad 100sqcm

Facility

$4,073.00

Hospital Charge Code	7150908
Hospital Revenue Code	761
Rate for Payer: Cash Price	$2,769.64

LC Skin Sub App Face/Nck/HF ad 25 sqcm

Facility

$1,267.00

Hospital Charge Code	7150906
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$912.24
Rate for Payer: Amerigroup CHIP/Medicaid	$114.03
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$861.56
Rate for Payer: Cash Price	$861.56
Rate for Payer: Cigna Medicaid	$912.24
Rate for Payer: Molina CHIP/Medicaid	$912.24
Rate for Payer: Multiplan Auto	$823.55
Rate for Payer: Multiplan Commercial	$823.55
Rate for Payer: Multiplan Workers Comp	$823.55
Rate for Payer: Parkland Medicaid	$912.24
Rate for Payer: Scott and White EPO/PPO	$633.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$912.24
Rate for Payer: Superior Health Plan EPO	$172.31

LC Skin Sub App Face/Nck/HF ad 25 sqcm

Facility

$1,267.00

Hospital Charge Code	7150906
Hospital Revenue Code	761
Rate for Payer: Cash Price	$861.56

LC Skin Sub App Face/Nck/HF to100sqcm

Facility

$5,030.00

Hospital Charge Code	7150907
Hospital Revenue Code	761
Rate for Payer: Cash Price	$3,420.40

LC Skin Sub App Face/Nck/HF to100sqcm

Facility

$5,030.00

Hospital Charge Code	7150907
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$3,621.60
Rate for Payer: Amerigroup CHIP/Medicaid	$452.70
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$3,420.40
Rate for Payer: Cash Price	$3,420.40
Rate for Payer: Cigna Medicaid	$3,621.60
Rate for Payer: Molina CHIP/Medicaid	$3,621.60
Rate for Payer: Multiplan Auto	$3,269.50
Rate for Payer: Multiplan Commercial	$3,269.50
Rate for Payer: Multiplan Workers Comp	$3,269.50
Rate for Payer: Parkland Medicaid	$3,621.60
Rate for Payer: Scott and White EPO/PPO	$2,515.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,621.60
Rate for Payer: Superior Health Plan EPO	$684.08

LC Skin Sub App Face/Nck/HF to 25 sqcm

Facility

$2,804.00

Hospital Charge Code	7150905
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$2,018.88
Rate for Payer: Amerigroup CHIP/Medicaid	$252.36
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$1,906.72
Rate for Payer: Cash Price	$1,906.72
Rate for Payer: Cigna Medicaid	$2,018.88
Rate for Payer: Molina CHIP/Medicaid	$2,018.88
Rate for Payer: Multiplan Auto	$1,822.60
Rate for Payer: Multiplan Commercial	$1,822.60
Rate for Payer: Multiplan Workers Comp	$1,822.60
Rate for Payer: Parkland Medicaid	$2,018.88
Rate for Payer: Scott and White EPO/PPO	$1,402.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,018.88
Rate for Payer: Superior Health Plan EPO	$381.34

LC Skin Sub App Face/Nck/HF to 25 sqcm

Facility

$2,804.00

Hospital Charge Code	7150905
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,906.72

LC Skin Sub App Trnk/Arm/Leg ad 100sqcm

Facility

$1,623.00

Hospital Charge Code	7150904
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,103.64

LC Skin Sub App Trnk/Arm/Leg ad 100sqcm

Facility

$1,623.00

Hospital Charge Code	7150904
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$1,168.56
Rate for Payer: Amerigroup CHIP/Medicaid	$146.07
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$1,103.64
Rate for Payer: Cash Price	$1,103.64
Rate for Payer: Cigna Medicaid	$1,168.56
Rate for Payer: Molina CHIP/Medicaid	$1,168.56
Rate for Payer: Multiplan Auto	$1,054.95
Rate for Payer: Multiplan Commercial	$1,054.95
Rate for Payer: Multiplan Workers Comp	$1,054.95
Rate for Payer: Parkland Medicaid	$1,168.56
Rate for Payer: Scott and White EPO/PPO	$811.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,168.56
Rate for Payer: Superior Health Plan EPO	$220.73

Know your out-of-pocket cost for care.

All Charges