White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SARS-CoV-2 Ab, Nucleocapsid SO

Facility

$106.00

Service Code	CPT 86769
Hospital Charge Code	8660505
Hospital Revenue Code	302
Rate for Payer: Cash Price	$93.28

SARS-CoV-2 Ab, Nucleocapsid SO

Facility

$106.00

Service Code	CPT 86769
Hospital Charge Code	8660505
Hospital Revenue Code	302
Min. Negotiated Rate	$42.13
Max. Negotiated Rate	$93.11
Rate for Payer: Aetna Commercial	$73.73
Rate for Payer: Aetna Medicare	$63.20
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$69.51
Rate for Payer: BCBS of TX Blue Essentials	$83.42
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$93.11
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cigna Medicaid	$42.13
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$42.13
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$42.13
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.13
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV-2 Antibody, IgG SO

Facility

$106.00

Service Code	CPT 86769
Hospital Charge Code	8628549
Hospital Revenue Code	302
Rate for Payer: Cash Price	$93.28

SARS-CoV-2 Antibody, IgG SO

Facility

$106.00

Service Code	CPT 86769
Hospital Charge Code	8628549
Hospital Revenue Code	302
Min. Negotiated Rate	$42.13
Max. Negotiated Rate	$93.11
Rate for Payer: Aetna Commercial	$73.73
Rate for Payer: Aetna Medicare	$63.20
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$69.51
Rate for Payer: BCBS of TX Blue Essentials	$83.42
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$93.11
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cigna Medicaid	$42.13
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$42.13
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$42.13
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.13
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV-2 Antibody, IgM SO

Facility

$106.00

Service Code	CPT 86769
Hospital Charge Code	8660506
Hospital Revenue Code	302
Rate for Payer: Cash Price	$93.28

SARS-CoV-2 Antibody, IgM SO

Facility

$106.00

Service Code	CPT 86769
Hospital Charge Code	8660506
Hospital Revenue Code	302
Min. Negotiated Rate	$42.13
Max. Negotiated Rate	$93.11
Rate for Payer: Aetna Commercial	$73.73
Rate for Payer: Aetna Medicare	$63.20
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$69.51
Rate for Payer: BCBS of TX Blue Essentials	$83.42
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$93.11
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cigna Medicaid	$42.13
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$42.13
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$42.13
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.13
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV-2/Flu/RSV PCR

Facility

$282.00

Service Code	CPT 0241U
Hospital Charge Code	8484529
Hospital Revenue Code	300
Min. Negotiated Rate	$142.63
Max. Negotiated Rate	$315.21
Rate for Payer: Aetna Commercial	$155.10
Rate for Payer: Aetna Medicare	$213.94
Rate for Payer: Amerigroup CHIP/Medicaid	$142.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$142.63
Rate for Payer: Amerigroup Medicare	$142.63
Rate for Payer: BCBS of TX Blue Advantage	$235.34
Rate for Payer: BCBS of TX Blue Essentials	$282.41
Rate for Payer: BCBS of TX Medicare	$142.63
Rate for Payer: BCBS of TX PPO	$315.21
Rate for Payer: Cash Price	$248.16
Rate for Payer: Cash Price	$248.16
Rate for Payer: Cigna Medicare	$142.63
Rate for Payer: Employer Direct Commercial	$142.63
Rate for Payer: Humana Medicare/TRICARE	$142.63
Rate for Payer: Molina Dual Medicare/Medicaid	$142.63
Rate for Payer: Molina Medicare	$142.63
Rate for Payer: Multiplan Auto	$183.30
Rate for Payer: Multiplan Commercial	$183.30
Rate for Payer: Multiplan Workers Comp	$183.30
Rate for Payer: Scott and White EPO/PPO	$178.29
Rate for Payer: Scott and White Medicare	$142.63
Rate for Payer: Superior Health Plan EPO	$142.63
Rate for Payer: Superior Health Plan Medicare	$142.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$142.63
Rate for Payer: Universal American Medicare	$142.63
Rate for Payer: Wellcare Medicare	$142.63
Rate for Payer: Wellmed Medicare	$142.63

SARS-CoV-2/Flu/RSV PCR

Facility

$282.00

Service Code	CPT 0241U
Hospital Charge Code	8484529
Hospital Revenue Code	300
Rate for Payer: Cash Price	$248.16

SARS CoV2 IgG Ab

Facility

$106.00

Service Code	CPT 86769
Hospital Charge Code	4106522
Hospital Revenue Code	300
Min. Negotiated Rate	$42.13
Max. Negotiated Rate	$93.11
Rate for Payer: Aetna Commercial	$73.73
Rate for Payer: Aetna Medicare	$63.20
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$69.51
Rate for Payer: BCBS of TX Blue Essentials	$83.42
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$93.11
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cigna Medicaid	$42.13
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$42.13
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$42.13
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.13
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV-2, NAA SO

Facility

$189.00

Service Code	HCPCS U0003
Hospital Charge Code	1700027
Hospital Revenue Code	300
Rate for Payer: Cash Price	$166.32

SARS-CoV-2, NAA SO

Facility

$189.00

Service Code	HCPCS U0003
Hospital Charge Code	1700027
Hospital Revenue Code	300
Min. Negotiated Rate	$25.70
Max. Negotiated Rate	$122.85
Rate for Payer: Aetna Commercial	$103.95
Rate for Payer: Amerigroup CHIP/Medicaid	$75.00
Rate for Payer: BCBS of TX Blue Advantage	$56.70
Rate for Payer: BCBS of TX Blue Essentials	$68.04
Rate for Payer: BCBS of TX PPO	$75.60
Rate for Payer: Cash Price	$166.32
Rate for Payer: Cash Price	$166.32
Rate for Payer: Multiplan Auto	$122.85
Rate for Payer: Multiplan Commercial	$122.85
Rate for Payer: Multiplan Workers Comp	$122.85
Rate for Payer: Scott and White EPO/PPO	$94.50
Rate for Payer: Superior Health Plan EPO	$25.70

SARS-CoV-2 PCR

Facility

$157.00

Service Code	CPT 87635
Hospital Charge Code	1600005
Hospital Revenue Code	300
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$113.40
Rate for Payer: Aetna Commercial	$89.79
Rate for Payer: Aetna Medicare	$76.96
Rate for Payer: Amerigroup CHIP/Medicaid	$51.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$51.31
Rate for Payer: Amerigroup Medicare	$51.31
Rate for Payer: BCBS of TX Blue Advantage	$84.66
Rate for Payer: BCBS of TX Blue Essentials	$101.59
Rate for Payer: BCBS of TX Medicare	$51.31
Rate for Payer: BCBS of TX PPO	$113.40
Rate for Payer: Cash Price	$138.16
Rate for Payer: Cash Price	$138.16
Rate for Payer: Cigna Medicaid	$51.31
Rate for Payer: Cigna Medicare	$51.31
Rate for Payer: Employer Direct Commercial	$51.31
Rate for Payer: Humana Medicare/TRICARE	$51.31
Rate for Payer: Molina CHIP/Medicaid	$51.31
Rate for Payer: Molina Dual Medicare/Medicaid	$51.31
Rate for Payer: Molina Medicare	$51.31
Rate for Payer: Multiplan Auto	$102.05
Rate for Payer: Multiplan Commercial	$102.05
Rate for Payer: Multiplan Workers Comp	$102.05
Rate for Payer: Parkland Medicaid	$51.31
Rate for Payer: Scott and White EPO/PPO	$64.14
Rate for Payer: Scott and White Medicare	$51.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.31
Rate for Payer: Superior Health Plan EPO	$51.31
Rate for Payer: Superior Health Plan Medicare	$51.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$51.31
Rate for Payer: Universal American Medicare	$51.31
Rate for Payer: Wellcare Medicare	$51.31
Rate for Payer: Wellmed Medicare	$51.31

SARS-CoV-2 PCR

Facility

$157.00

Service Code	CPT 87635
Hospital Charge Code	1600005
Hospital Revenue Code	300
Rate for Payer: Cash Price	$138.16

SARS-CoV-2 Semi-Quant Total Ab SO

Facility

$106.00

Service Code	CPT 86769
Hospital Charge Code	8628548
Hospital Revenue Code	302
Rate for Payer: Cash Price	$93.28

SARS-CoV-2 Semi-Quant Total Ab SO

Facility

$106.00

Service Code	CPT 86769
Hospital Charge Code	8628548
Hospital Revenue Code	302
Min. Negotiated Rate	$42.13
Max. Negotiated Rate	$93.11
Rate for Payer: Aetna Commercial	$73.73
Rate for Payer: Aetna Medicare	$63.20
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$69.51
Rate for Payer: BCBS of TX Blue Essentials	$83.42
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$93.11
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cigna Medicaid	$42.13
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$42.13
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$42.13
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.13
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV-2 T2 SO

Facility

$189.00

Service Code	HCPCS U0004
Hospital Charge Code	8698536
Hospital Revenue Code	300
Rate for Payer: Cash Price	$166.32

SARS-CoV-2 T2 SO

Facility

$189.00

Service Code	HCPCS U0004
Hospital Charge Code	8698536
Hospital Revenue Code	300
Min. Negotiated Rate	$25.70
Max. Negotiated Rate	$122.85
Rate for Payer: Aetna Commercial	$103.95
Rate for Payer: Amerigroup CHIP/Medicaid	$75.00
Rate for Payer: BCBS of TX Blue Advantage	$56.70
Rate for Payer: BCBS of TX Blue Essentials	$68.04
Rate for Payer: BCBS of TX PPO	$75.60
Rate for Payer: Cash Price	$166.32
Rate for Payer: Cash Price	$166.32
Rate for Payer: Multiplan Auto	$122.85
Rate for Payer: Multiplan Commercial	$122.85
Rate for Payer: Multiplan Workers Comp	$122.85
Rate for Payer: Scott and White EPO/PPO	$94.50
Rate for Payer: Superior Health Plan EPO	$25.70

SARS CoV2 Tot Ab

Facility

$106.00

Service Code	CPT 86769
Hospital Charge Code	4106522
Hospital Revenue Code	300
Rate for Payer: Cash Price	$93.28

SARS CoV2 Tot Ab

Facility

$106.00

Service Code	CPT 86769
Hospital Charge Code	4106522
Hospital Revenue Code	300
Min. Negotiated Rate	$42.13
Max. Negotiated Rate	$93.11
Rate for Payer: Aetna Commercial	$73.73
Rate for Payer: Aetna Medicare	$63.20
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$69.51
Rate for Payer: BCBS of TX Blue Essentials	$83.42
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$93.11
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cigna Medicaid	$42.13
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$42.13
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$42.13
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.13
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SCALPEL HARMONIC FOCUS HAR9F

Facility

$1,631.99

Hospital Charge Code	134451
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,436.15

SCALPEL HARMONIC FOCUS HAR9F

Facility

$1,631.99

Hospital Charge Code	134451
Hospital Revenue Code	272
Min. Negotiated Rate	$146.88
Max. Negotiated Rate	$1,060.79
Rate for Payer: Aetna Commercial	$897.59
Rate for Payer: Amerigroup CHIP/Medicaid	$146.88
Rate for Payer: BCBS of TX Blue Advantage	$489.60
Rate for Payer: BCBS of TX Blue Essentials	$587.52
Rate for Payer: BCBS of TX PPO	$652.80
Rate for Payer: Cash Price	$1,436.15
Rate for Payer: Multiplan Auto	$1,060.79
Rate for Payer: Multiplan Commercial	$1,060.79
Rate for Payer: Multiplan Workers Comp	$1,060.79
Rate for Payer: Scott and White EPO/PPO	$816.00
Rate for Payer: Superior Health Plan EPO	$221.95

SCISSOR DISP. LAP 45CM

Facility

$172.52

Hospital Charge Code	145301
Hospital Revenue Code	270
Min. Negotiated Rate	$15.53
Max. Negotiated Rate	$112.14
Rate for Payer: Aetna Commercial	$94.89
Rate for Payer: Amerigroup CHIP/Medicaid	$15.53
Rate for Payer: BCBS of TX Blue Advantage	$51.76
Rate for Payer: BCBS of TX Blue Essentials	$62.11
Rate for Payer: BCBS of TX PPO	$69.01
Rate for Payer: Cash Price	$151.82
Rate for Payer: Multiplan Auto	$112.14
Rate for Payer: Multiplan Commercial	$112.14
Rate for Payer: Multiplan Workers Comp	$112.14
Rate for Payer: Scott and White EPO/PPO	$86.26
Rate for Payer: Superior Health Plan EPO	$23.46

SCISSOR DISP. LAP 45CM

Facility

$172.52

Hospital Charge Code	145301
Hospital Revenue Code	270
Rate for Payer: Cash Price	$151.82

scopolamine 1.3 mg TD Film, ER

Facility

$62.35

Service Code	HCPCS J3490
Hospital Charge Code	78876081
Hospital Revenue Code	250
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$40.53
Rate for Payer: Amerigroup CHIP/Medicaid	$5.61
Rate for Payer: BCBS of TX Blue Advantage	$18.70
Rate for Payer: BCBS of TX Blue Essentials	$22.45
Rate for Payer: BCBS of TX PPO	$24.94
Rate for Payer: Cash Price	$42.40
Rate for Payer: Multiplan Auto	$40.53
Rate for Payer: Multiplan Commercial	$40.53
Rate for Payer: Multiplan Workers Comp	$40.53
Rate for Payer: Scott and White EPO/PPO	$31.18
Rate for Payer: Superior Health Plan EPO	$8.48

scopolamine 1.3 mg TD Film, ER

Facility

$62.35

Service Code	HCPCS J3490
Hospital Charge Code	78876081
Hospital Revenue Code	250
Rate for Payer: Cash Price	$42.40

Know your out-of-pocket cost for care.

All Charges