White Rock Medical Center

All Charges

Charge

Type

Setting

Price

LD PM TENDRIL STS 2088TC

Facility

$3,409.00

Service Code	HCPCS C1898
Hospital Charge Code	40087421
Hospital Revenue Code	278
Min. Negotiated Rate	$306.81
Max. Negotiated Rate	$2,454.48
Rate for Payer: Amerigroup CHIP/Medicaid	$306.81
Rate for Payer: BCBS of TX Blue Advantage	$1,022.70
Rate for Payer: BCBS of TX Blue Essentials	$1,227.24
Rate for Payer: BCBS of TX PPO	$1,363.60
Rate for Payer: Cash Price	$2,318.12
Rate for Payer: Cigna Medicaid	$2,454.48
Rate for Payer: Molina CHIP/Medicaid	$2,454.48
Rate for Payer: Multiplan Auto	$1,704.50
Rate for Payer: Multiplan Commercial	$1,704.50
Rate for Payer: Multiplan Workers Comp	$1,704.50
Rate for Payer: Parkland Medicaid	$2,454.48
Rate for Payer: Scott and White EPO/PPO	$1,704.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,454.48
Rate for Payer: Superior Health Plan EPO	$463.62

LD PM TENDRIL STS 2088TC

Facility

$3,409.00

Service Code	HCPCS C1898
Hospital Charge Code	82402280
Hospital Revenue Code	278
Min. Negotiated Rate	$852.25
Max. Negotiated Rate	$1,704.50
Rate for Payer: Cash Price	$2,318.12
Rate for Payer: Cigna Commercial	$852.25
Rate for Payer: Multiplan Auto	$1,704.50
Rate for Payer: Multiplan Commercial	$1,704.50
Rate for Payer: Multiplan Workers Comp	$1,704.50
Rate for Payer: Scott and White EPO/PPO	$1,704.50

LD PM TENDRIL STS 2088TC

Facility

$3,409.00

Service Code	HCPCS C1898
Hospital Charge Code	40087421
Hospital Revenue Code	278
Min. Negotiated Rate	$852.25
Max. Negotiated Rate	$1,704.50
Rate for Payer: Cash Price	$2,318.12
Rate for Payer: Cigna Commercial	$852.25
Rate for Payer: Multiplan Auto	$1,704.50
Rate for Payer: Multiplan Commercial	$1,704.50
Rate for Payer: Multiplan Workers Comp	$1,704.50
Rate for Payer: Scott and White EPO/PPO	$1,704.50

LD WIRE EKG -- DHF

Facility

$75.74

Hospital Charge Code	80326150
Hospital Revenue Code	270
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$54.53
Rate for Payer: Amerigroup CHIP/Medicaid	$6.82
Rate for Payer: BCBS of TX Blue Advantage	$22.72
Rate for Payer: BCBS of TX Blue Essentials	$27.27
Rate for Payer: BCBS of TX PPO	$30.30
Rate for Payer: Cash Price	$51.50
Rate for Payer: Cigna Medicaid	$54.53
Rate for Payer: Molina CHIP/Medicaid	$54.53
Rate for Payer: Multiplan Auto	$49.23
Rate for Payer: Multiplan Commercial	$49.23
Rate for Payer: Multiplan Workers Comp	$49.23
Rate for Payer: Parkland Medicaid	$54.53
Rate for Payer: Scott and White EPO/PPO	$37.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$54.53
Rate for Payer: Superior Health Plan EPO	$10.30

LD WIRE EKG -- DHF

Facility

$75.74

Hospital Charge Code	80326150
Hospital Revenue Code	270
Rate for Payer: Cash Price	$51.50

Lead, Blood (Adult) SO

Facility

$96.73

Service Code	HCPCS 83655
Hospital Charge Code	1601228
Hospital Revenue Code	301
Rate for Payer: Cash Price	$65.78

Lead, Blood (Adult) SO

Facility

$96.73

Service Code	HCPCS 83655
Hospital Charge Code	1601228
Hospital Revenue Code	301
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$69.65
Rate for Payer: Amerigroup CHIP/Medicaid	$4.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.11
Rate for Payer: Amerigroup Medicare	$12.11
Rate for Payer: BCBS of TX Blue Advantage	$29.02
Rate for Payer: BCBS of TX Blue Essentials	$34.82
Rate for Payer: BCBS of TX Medicare	$12.11
Rate for Payer: BCBS of TX PPO	$38.69
Rate for Payer: Cash Price	$65.78
Rate for Payer: Cash Price	$65.78
Rate for Payer: Cigna Medicaid	$69.65
Rate for Payer: Cigna Medicare	$12.11
Rate for Payer: Employer Direct Commercial	$12.11
Rate for Payer: Humana Medicare/TRICARE	$12.11
Rate for Payer: Molina CHIP/Medicaid	$69.65
Rate for Payer: Molina Dual Medicare/Medicaid	$12.11
Rate for Payer: Molina Medicare	$12.11
Rate for Payer: Multiplan Auto	$62.87
Rate for Payer: Multiplan Commercial	$62.87
Rate for Payer: Multiplan Workers Comp	$62.87
Rate for Payer: Parkland Medicaid	$69.65
Rate for Payer: Scott and White EPO/PPO	$15.14
Rate for Payer: Scott and White Medicare	$12.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.65
Rate for Payer: Superior Health Plan EPO	$12.11
Rate for Payer: Superior Health Plan Medicare	$12.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.11
Rate for Payer: Universal American Medicare	$12.11
Rate for Payer: Wellcare Medicare	$12.11
Rate for Payer: Wellmed Medicare	$12.11

LEAD ICD PLEXA PROMRIS 65

Facility

$26,125.00

Service Code	HCPCS C1882
Hospital Charge Code	110044
Hospital Revenue Code	278
Min. Negotiated Rate	$6,531.25
Max. Negotiated Rate	$13,062.50
Rate for Payer: Cash Price	$17,765.00
Rate for Payer: Cigna Commercial	$6,531.25
Rate for Payer: Multiplan Auto	$13,062.50
Rate for Payer: Multiplan Commercial	$13,062.50
Rate for Payer: Multiplan Workers Comp	$13,062.50
Rate for Payer: Scott and White EPO/PPO	$13,062.50

LEAD ICD PLEXA PROMRIS 65

Facility

$26,125.00

Service Code	HCPCS C1882
Hospital Charge Code	110044
Hospital Revenue Code	278
Min. Negotiated Rate	$2,351.25
Max. Negotiated Rate	$18,810.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2,351.25
Rate for Payer: BCBS of TX Blue Advantage	$7,837.50
Rate for Payer: BCBS of TX Blue Essentials	$9,405.00
Rate for Payer: BCBS of TX PPO	$10,450.00
Rate for Payer: Cash Price	$17,765.00
Rate for Payer: Cigna Medicaid	$18,810.00
Rate for Payer: Molina CHIP/Medicaid	$18,810.00
Rate for Payer: Multiplan Auto	$13,062.50
Rate for Payer: Multiplan Commercial	$13,062.50
Rate for Payer: Multiplan Workers Comp	$13,062.50
Rate for Payer: Parkland Medicaid	$18,810.00
Rate for Payer: Scott and White EPO/PPO	$13,062.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,810.00
Rate for Payer: Superior Health Plan EPO	$3,553.00

LEAD PACING CPSR

Facility

$3,488.00

Service Code	HCPCS C1898
Hospital Charge Code	8420456
Hospital Revenue Code	278
Min. Negotiated Rate	$872.00
Max. Negotiated Rate	$1,744.00
Rate for Payer: Cash Price	$2,371.84
Rate for Payer: Cigna Commercial	$872.00
Rate for Payer: Multiplan Auto	$1,744.00
Rate for Payer: Multiplan Commercial	$1,744.00
Rate for Payer: Multiplan Workers Comp	$1,744.00
Rate for Payer: Scott and White EPO/PPO	$1,744.00

LEAD PACING CPSR

Facility

$3,488.00

Service Code	HCPCS C1898
Hospital Charge Code	8420456
Hospital Revenue Code	278
Min. Negotiated Rate	$313.92
Max. Negotiated Rate	$2,511.36
Rate for Payer: Amerigroup CHIP/Medicaid	$313.92
Rate for Payer: BCBS of TX Blue Advantage	$1,046.40
Rate for Payer: BCBS of TX Blue Essentials	$1,255.68
Rate for Payer: BCBS of TX PPO	$1,395.20
Rate for Payer: Cash Price	$2,371.84
Rate for Payer: Cigna Medicaid	$2,511.36
Rate for Payer: Molina CHIP/Medicaid	$2,511.36
Rate for Payer: Multiplan Auto	$1,744.00
Rate for Payer: Multiplan Commercial	$1,744.00
Rate for Payer: Multiplan Workers Comp	$1,744.00
Rate for Payer: Parkland Medicaid	$2,511.36
Rate for Payer: Scott and White EPO/PPO	$1,744.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,511.36
Rate for Payer: Superior Health Plan EPO	$474.37

LEADWIRE 33135BT

Facility

$227.00

Hospital Charge Code	145282
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

LEADWIRE 33135BT

Facility

$227.00

Hospital Charge Code	145282
Hospital Revenue Code	272
Rate for Payer: Cash Price	$154.36

LEADWIRE 33136BT

Facility

$380.95

Hospital Charge Code	145281
Hospital Revenue Code	272
Rate for Payer: Cash Price	$259.05

LEADWIRE 33136BT

Facility

$380.95

Hospital Charge Code	145281
Hospital Revenue Code	272
Min. Negotiated Rate	$34.29
Max. Negotiated Rate	$274.28
Rate for Payer: Amerigroup CHIP/Medicaid	$34.29
Rate for Payer: BCBS of TX Blue Advantage	$114.28
Rate for Payer: BCBS of TX Blue Essentials	$137.14
Rate for Payer: BCBS of TX PPO	$152.38
Rate for Payer: Cash Price	$259.05
Rate for Payer: Cigna Medicaid	$274.28
Rate for Payer: Molina CHIP/Medicaid	$274.28
Rate for Payer: Multiplan Auto	$247.62
Rate for Payer: Multiplan Commercial	$247.62
Rate for Payer: Multiplan Workers Comp	$247.62
Rate for Payer: Parkland Medicaid	$274.28
Rate for Payer: Scott and White EPO/PPO	$190.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$274.28
Rate for Payer: Superior Health Plan EPO	$51.81

LEADWIRE SYSTEM CABLE DISP

Facility

$42.31

Hospital Charge Code	144399
Hospital Revenue Code	272
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$30.46
Rate for Payer: Amerigroup CHIP/Medicaid	$3.81
Rate for Payer: BCBS of TX Blue Advantage	$12.69
Rate for Payer: BCBS of TX Blue Essentials	$15.23
Rate for Payer: BCBS of TX PPO	$16.92
Rate for Payer: Cash Price	$28.77
Rate for Payer: Cigna Medicaid	$30.46
Rate for Payer: Molina CHIP/Medicaid	$30.46
Rate for Payer: Multiplan Auto	$27.50
Rate for Payer: Multiplan Commercial	$27.50
Rate for Payer: Multiplan Workers Comp	$27.50
Rate for Payer: Parkland Medicaid	$30.46
Rate for Payer: Scott and White EPO/PPO	$21.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.46
Rate for Payer: Superior Health Plan EPO	$5.75

LEADWIRE SYSTEM CABLE DISP

Facility

$42.31

Hospital Charge Code	144399
Hospital Revenue Code	272
Rate for Payer: Cash Price	$28.77

Left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone, normal or abnormal native connections

Facility

$12,418.92

Service Code	HCPCS 93595
Hospital Charge Code	991137
Hospital Revenue Code	481
Rate for Payer: Cash Price	$8,444.87

Left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone, normal or abnormal native connections

Facility

$12,418.92

Service Code	HCPCS 93595
Hospital Charge Code	991137
Hospital Revenue Code	481
Min. Negotiated Rate	$1,117.70
Max. Negotiated Rate	$8,941.62
Rate for Payer: Amerigroup CHIP/Medicaid	$1,117.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,256.70
Rate for Payer: Amerigroup Medicare	$3,256.70
Rate for Payer: BCBS of TX Blue Advantage	$4,945.74
Rate for Payer: BCBS of TX Blue Essentials	$5,923.04
Rate for Payer: BCBS of TX Medicare	$3,256.70
Rate for Payer: BCBS of TX PPO	$7,463.03
Rate for Payer: Cash Price	$8,444.87
Rate for Payer: Cash Price	$8,444.87
Rate for Payer: Cash Price	$8,444.87
Rate for Payer: Cigna Commercial	$6,884.08
Rate for Payer: Cigna Medicaid	$8,941.62
Rate for Payer: Cigna Medicare	$3,256.70
Rate for Payer: Employer Direct Commercial	$3,256.70
Rate for Payer: Humana Medicare/TRICARE	$3,256.70
Rate for Payer: Molina CHIP/Medicaid	$8,941.62
Rate for Payer: Molina Dual Medicare/Medicaid	$3,256.70
Rate for Payer: Molina Medicare	$3,256.70
Rate for Payer: Multiplan Auto	$8,072.30
Rate for Payer: Multiplan Commercial	$8,072.30
Rate for Payer: Multiplan Workers Comp	$8,072.30
Rate for Payer: Parkland Medicaid	$8,941.62
Rate for Payer: Scott and White EPO/PPO	$6,209.46
Rate for Payer: Scott and White Medicare	$3,256.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,941.62
Rate for Payer: Superior Health Plan EPO	$3,256.70
Rate for Payer: Superior Health Plan Medicare	$3,256.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,256.70
Rate for Payer: Universal American Medicare	$3,256.70
Rate for Payer: Wellcare Medicare	$3,256.70
Rate for Payer: Wellmed Medicare	$3,256.70

Left Tibio - Talo-Calcaneal Truss Implant

Facility

$96,385.54

Service Code	HCPCS C1734
Hospital Charge Code	992263
Hospital Revenue Code	278
Min. Negotiated Rate	$24,096.38
Max. Negotiated Rate	$48,192.77
Rate for Payer: Cash Price	$65,542.17
Rate for Payer: Cigna Commercial	$24,096.38
Rate for Payer: Multiplan Auto	$48,192.77
Rate for Payer: Multiplan Commercial	$48,192.77
Rate for Payer: Multiplan Workers Comp	$48,192.77
Rate for Payer: Scott and White EPO/PPO	$48,192.77

Left Tibio - Talo-Calcaneal Truss Implant

Facility

$96,385.54

Service Code	HCPCS C1734
Hospital Charge Code	992263
Hospital Revenue Code	278
Min. Negotiated Rate	$8,674.70
Max. Negotiated Rate	$69,397.59
Rate for Payer: Amerigroup CHIP/Medicaid	$8,674.70
Rate for Payer: BCBS of TX Blue Advantage	$28,915.66
Rate for Payer: BCBS of TX Blue Essentials	$34,698.79
Rate for Payer: BCBS of TX PPO	$38,554.22
Rate for Payer: Cash Price	$65,542.17
Rate for Payer: Cigna Medicaid	$69,397.59
Rate for Payer: Molina CHIP/Medicaid	$69,397.59
Rate for Payer: Multiplan Auto	$48,192.77
Rate for Payer: Multiplan Commercial	$48,192.77
Rate for Payer: Multiplan Workers Comp	$48,192.77
Rate for Payer: Parkland Medicaid	$69,397.59
Rate for Payer: Scott and White EPO/PPO	$48,192.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69,397.59
Rate for Payer: Superior Health Plan EPO	$13,108.43

Left total tatar replacement w/sz 3 wright done mapping

Facility

$90,361.45

Service Code	HCPCS C1776
Hospital Charge Code	992169
Hospital Revenue Code	278
Min. Negotiated Rate	$8,132.53
Max. Negotiated Rate	$65,060.24
Rate for Payer: Amerigroup CHIP/Medicaid	$8,132.53
Rate for Payer: BCBS of TX Blue Advantage	$27,108.44
Rate for Payer: BCBS of TX Blue Essentials	$32,530.12
Rate for Payer: BCBS of TX PPO	$36,144.58
Rate for Payer: Cash Price	$61,445.79
Rate for Payer: Cigna Medicaid	$65,060.24
Rate for Payer: Molina CHIP/Medicaid	$65,060.24
Rate for Payer: Multiplan Auto	$45,180.72
Rate for Payer: Multiplan Commercial	$45,180.72
Rate for Payer: Multiplan Workers Comp	$45,180.72
Rate for Payer: Parkland Medicaid	$65,060.24
Rate for Payer: Scott and White EPO/PPO	$45,180.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65,060.24
Rate for Payer: Superior Health Plan EPO	$12,289.16

Left total tatar replacement w/sz 3 wright done mapping

Facility

$90,361.45

Service Code	HCPCS C1776
Hospital Charge Code	992169
Hospital Revenue Code	278
Min. Negotiated Rate	$22,590.36
Max. Negotiated Rate	$45,180.72
Rate for Payer: Cash Price	$61,445.79
Rate for Payer: Cigna Commercial	$22,590.36
Rate for Payer: Multiplan Auto	$45,180.72
Rate for Payer: Multiplan Commercial	$45,180.72
Rate for Payer: Multiplan Workers Comp	$45,180.72
Rate for Payer: Scott and White EPO/PPO	$45,180.72

Legionella Culture

Facility

$229.00

Service Code	HCPCS 87081
Hospital Charge Code	4108701
Hospital Revenue Code	306
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$164.88
Rate for Payer: Amerigroup CHIP/Medicaid	$2.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.63
Rate for Payer: Amerigroup Medicare	$6.63
Rate for Payer: BCBS of TX Blue Advantage	$68.70
Rate for Payer: BCBS of TX Blue Essentials	$82.44
Rate for Payer: BCBS of TX Medicare	$6.63
Rate for Payer: BCBS of TX PPO	$91.60
Rate for Payer: Cash Price	$155.72
Rate for Payer: Cash Price	$155.72
Rate for Payer: Cigna Medicaid	$164.88
Rate for Payer: Cigna Medicare	$6.63
Rate for Payer: Employer Direct Commercial	$6.63
Rate for Payer: Humana Medicare/TRICARE	$6.63
Rate for Payer: Molina CHIP/Medicaid	$164.88
Rate for Payer: Molina Dual Medicare/Medicaid	$6.63
Rate for Payer: Molina Medicare	$6.63
Rate for Payer: Multiplan Auto	$148.85
Rate for Payer: Multiplan Commercial	$148.85
Rate for Payer: Multiplan Workers Comp	$148.85
Rate for Payer: Parkland Medicaid	$164.88
Rate for Payer: Scott and White EPO/PPO	$8.29
Rate for Payer: Scott and White Medicare	$6.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$164.88
Rate for Payer: Superior Health Plan EPO	$6.63
Rate for Payer: Superior Health Plan Medicare	$6.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.63
Rate for Payer: Universal American Medicare	$6.63
Rate for Payer: Wellcare Medicare	$6.63
Rate for Payer: Wellmed Medicare	$6.63

Legionella Culture

Facility

$229.00

Service Code	HCPCS 87081
Hospital Charge Code	4108701
Hospital Revenue Code	306
Rate for Payer: Cash Price	$155.72

Know your out-of-pocket cost for care.

All Charges