White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Biopsy, soft tissue of thigh or knee area; deep (subfascial or intramuscular)

Facility

$10,000.00

Service Code	CPT 27324
Hospital Charge Code	36027324
Hospital Revenue Code	360
Min. Negotiated Rate	$57.32
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$3,898.02
Rate for Payer: Amerigroup CHIP/Medicaid	$815.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,598.68
Rate for Payer: Amerigroup Medicare	$2,598.68
Rate for Payer: BCBS of TX Blue Advantage	$3,872.55
Rate for Payer: BCBS of TX Blue Essentials	$4,637.78
Rate for Payer: BCBS of TX Medicare	$2,598.68
Rate for Payer: BCBS of TX PPO	$5,843.60
Rate for Payer: Cigna Commercial	$5,886.75
Rate for Payer: Cigna Medicaid	$815.20
Rate for Payer: Cigna Medicare	$2,598.68
Rate for Payer: Employer Direct Commercial	$2,598.68
Rate for Payer: Humana Medicare/TRICARE	$2,598.68
Rate for Payer: Molina CHIP/Medicaid	$815.20
Rate for Payer: Molina Dual Medicare/Medicaid	$2,598.68
Rate for Payer: Molina Medicare	$2,598.68
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	$815.20
Rate for Payer: Scott and White EPO/PPO	$57.32
Rate for Payer: Scott and White Medicare	$2,598.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$815.20
Rate for Payer: Superior Health Plan EPO	$2,598.68
Rate for Payer: Superior Health Plan Medicare	$2,598.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,598.68
Rate for Payer: Universal American Medicare	$2,598.68
Rate for Payer: Wellcare Medicare	$2,598.68
Rate for Payer: Wellmed Medicare	$2,598.68

bisacodyl 10 mg Rectal Supp

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77412297
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

bisacodyl 10 mg Rectal Supp

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77412297
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

bisacodyl 5 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77412350
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

bisacodyl 5 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77412350
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

BIT, DRILL 2.5MM X 110MM--DHF

Facility

$581.03

Hospital Charge Code	80911472
Hospital Revenue Code	272
Rate for Payer: Cash Price	$511.31

BIT, DRILL 2.5MM X 110MM--DHF

Facility

$581.03

Hospital Charge Code	80911472
Hospital Revenue Code	272
Min. Negotiated Rate	$52.29
Max. Negotiated Rate	$377.67
Rate for Payer: Aetna Commercial	$319.57
Rate for Payer: Amerigroup CHIP/Medicaid	$52.29
Rate for Payer: BCBS of TX Blue Advantage	$174.31
Rate for Payer: BCBS of TX Blue Essentials	$209.17
Rate for Payer: BCBS of TX PPO	$232.41
Rate for Payer: Cash Price	$511.31
Rate for Payer: Multiplan Auto	$377.67
Rate for Payer: Multiplan Commercial	$377.67
Rate for Payer: Multiplan Workers Comp	$377.67
Rate for Payer: Scott and White EPO/PPO	$290.52
Rate for Payer: Superior Health Plan EPO	$79.02

BK Quant PCR (Plasma/Serum) SO

Facility

$647.00

Service Code	CPT 87799
Hospital Charge Code	1709963
Hospital Revenue Code	306
Min. Negotiated Rate	$16.71
Max. Negotiated Rate	$420.55
Rate for Payer: Aetna Commercial	$44.98
Rate for Payer: Aetna Medicare	$64.26
Rate for Payer: Amerigroup CHIP/Medicaid	$16.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.84
Rate for Payer: Amerigroup Medicare	$42.84
Rate for Payer: BCBS of TX Blue Advantage	$70.69
Rate for Payer: BCBS of TX Blue Essentials	$84.82
Rate for Payer: BCBS of TX Medicare	$42.84
Rate for Payer: BCBS of TX PPO	$94.68
Rate for Payer: Cash Price	$569.36
Rate for Payer: Cash Price	$569.36
Rate for Payer: Cigna Medicaid	$42.84
Rate for Payer: Cigna Medicare	$42.84
Rate for Payer: Employer Direct Commercial	$42.84
Rate for Payer: Humana Medicare/TRICARE	$42.84
Rate for Payer: Molina CHIP/Medicaid	$42.84
Rate for Payer: Molina Dual Medicare/Medicaid	$42.84
Rate for Payer: Molina Medicare	$42.84
Rate for Payer: Multiplan Auto	$420.55
Rate for Payer: Multiplan Commercial	$420.55
Rate for Payer: Multiplan Workers Comp	$420.55
Rate for Payer: Parkland Medicaid	$42.84
Rate for Payer: Scott and White EPO/PPO	$53.55
Rate for Payer: Scott and White Medicare	$42.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.84
Rate for Payer: Superior Health Plan EPO	$42.84
Rate for Payer: Superior Health Plan Medicare	$42.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.84
Rate for Payer: Universal American Medicare	$42.84
Rate for Payer: Wellcare Medicare	$42.84
Rate for Payer: Wellmed Medicare	$42.84

BLADE ARTHROSCOPY BNS

Facility

$877.53

Hospital Charge Code	8414483
Hospital Revenue Code	272
Min. Negotiated Rate	$78.98
Max. Negotiated Rate	$570.39
Rate for Payer: Aetna Commercial	$482.64
Rate for Payer: Amerigroup CHIP/Medicaid	$78.98
Rate for Payer: BCBS of TX Blue Advantage	$263.26
Rate for Payer: BCBS of TX Blue Essentials	$315.91
Rate for Payer: BCBS of TX PPO	$351.01
Rate for Payer: Cash Price	$772.23
Rate for Payer: Multiplan Auto	$570.39
Rate for Payer: Multiplan Commercial	$570.39
Rate for Payer: Multiplan Workers Comp	$570.39
Rate for Payer: Scott and White EPO/PPO	$438.76
Rate for Payer: Superior Health Plan EPO	$119.34

BLADE ARTHROSCOPY BNS

Facility

$877.53

Hospital Charge Code	8414483
Hospital Revenue Code	272
Rate for Payer: Cash Price	$772.23

blade great white shaver

Facility

$754.78

Hospital Charge Code	8688554
Hospital Revenue Code	272
Min. Negotiated Rate	$67.93
Max. Negotiated Rate	$490.61
Rate for Payer: Aetna Commercial	$415.13
Rate for Payer: Amerigroup CHIP/Medicaid	$67.93
Rate for Payer: BCBS of TX Blue Advantage	$226.43
Rate for Payer: BCBS of TX Blue Essentials	$271.72
Rate for Payer: BCBS of TX PPO	$301.91
Rate for Payer: Cash Price	$664.21
Rate for Payer: Multiplan Auto	$490.61
Rate for Payer: Multiplan Commercial	$490.61
Rate for Payer: Multiplan Workers Comp	$490.61
Rate for Payer: Scott and White EPO/PPO	$377.39
Rate for Payer: Superior Health Plan EPO	$102.65

blade great white shaver

Facility

$754.78

Hospital Charge Code	8688554
Hospital Revenue Code	272
Rate for Payer: Cash Price	$664.21

BLADE HIP

Facility

$1,725.20

Hospital Charge Code	8528466
Hospital Revenue Code	272
Min. Negotiated Rate	$155.27
Max. Negotiated Rate	$1,121.38
Rate for Payer: Aetna Commercial	$948.86
Rate for Payer: Amerigroup CHIP/Medicaid	$155.27
Rate for Payer: BCBS of TX Blue Advantage	$517.56
Rate for Payer: BCBS of TX Blue Essentials	$621.07
Rate for Payer: BCBS of TX PPO	$690.08
Rate for Payer: Cash Price	$1,518.18
Rate for Payer: Multiplan Auto	$1,121.38
Rate for Payer: Multiplan Commercial	$1,121.38
Rate for Payer: Multiplan Workers Comp	$1,121.38
Rate for Payer: Scott and White EPO/PPO	$862.60
Rate for Payer: Superior Health Plan EPO	$234.63

BLADE HIP

Facility

$1,725.20

Hospital Charge Code	8528466
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,518.18

BLADE, INCISOR PLUS 2.9 X 357MM DISPOSABLE -- DHF

Facility

$3,496.43

Hospital Charge Code	81723124
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,076.86

BLADE, INCISOR PLUS 2.9 X 357MM DISPOSABLE -- DHF

Facility

$3,496.43

Hospital Charge Code	81723124
Hospital Revenue Code	272
Min. Negotiated Rate	$314.68
Max. Negotiated Rate	$2,272.68
Rate for Payer: Aetna Commercial	$1,923.04
Rate for Payer: Amerigroup CHIP/Medicaid	$314.68
Rate for Payer: BCBS of TX Blue Advantage	$1,048.93
Rate for Payer: BCBS of TX Blue Essentials	$1,258.71
Rate for Payer: BCBS of TX PPO	$1,398.57
Rate for Payer: Cash Price	$3,076.86
Rate for Payer: Multiplan Auto	$2,272.68
Rate for Payer: Multiplan Commercial	$2,272.68
Rate for Payer: Multiplan Workers Comp	$2,272.68
Rate for Payer: Scott and White EPO/PPO	$1,748.22
Rate for Payer: Superior Health Plan EPO	$475.51

BLADE LONG MED 31X9X0.38

Facility

$147.55

Hospital Charge Code	114231
Hospital Revenue Code	272
Min. Negotiated Rate	$13.28
Max. Negotiated Rate	$95.91
Rate for Payer: Aetna Commercial	$81.15
Rate for Payer: Amerigroup CHIP/Medicaid	$13.28
Rate for Payer: BCBS of TX Blue Advantage	$44.26
Rate for Payer: BCBS of TX Blue Essentials	$53.12
Rate for Payer: BCBS of TX PPO	$59.02
Rate for Payer: Cash Price	$129.84
Rate for Payer: Multiplan Auto	$95.91
Rate for Payer: Multiplan Commercial	$95.91
Rate for Payer: Multiplan Workers Comp	$95.91
Rate for Payer: Scott and White EPO/PPO	$73.78
Rate for Payer: Superior Health Plan EPO	$20.07

BLADE LONG MED 31X9X0.38

Facility

$147.55

Hospital Charge Code	114231
Hospital Revenue Code	272
Rate for Payer: Cash Price	$129.84

BLADE, MINIATURE EDGED STAINLESS STEEL #69 -- DHF

Facility

$30.81

Hospital Charge Code	81722407
Hospital Revenue Code	272
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$20.03
Rate for Payer: Aetna Commercial	$16.95
Rate for Payer: Amerigroup CHIP/Medicaid	$2.77
Rate for Payer: BCBS of TX Blue Advantage	$9.24
Rate for Payer: BCBS of TX Blue Essentials	$11.09
Rate for Payer: BCBS of TX PPO	$12.32
Rate for Payer: Cash Price	$27.11
Rate for Payer: Multiplan Auto	$20.03
Rate for Payer: Multiplan Commercial	$20.03
Rate for Payer: Multiplan Workers Comp	$20.03
Rate for Payer: Scott and White EPO/PPO	$15.40
Rate for Payer: Superior Health Plan EPO	$4.19

BLADE, MINIATURE EDGED STAINLESS STEEL #69 -- DHF

Facility

$30.81

Hospital Charge Code	81722407
Hospital Revenue Code	272
Rate for Payer: Cash Price	$27.11

BLADE PRECISION THIN 5.5X0.38X18

Facility

$147.55

Hospital Charge Code	133016
Hospital Revenue Code	272
Rate for Payer: Cash Price	$129.84

BLADE PRECISION THIN 5.5X0.38X18

Facility

$147.55

Hospital Charge Code	133016
Hospital Revenue Code	272
Min. Negotiated Rate	$13.28
Max. Negotiated Rate	$95.91
Rate for Payer: Aetna Commercial	$81.15
Rate for Payer: Amerigroup CHIP/Medicaid	$13.28
Rate for Payer: BCBS of TX Blue Advantage	$44.26
Rate for Payer: BCBS of TX Blue Essentials	$53.12
Rate for Payer: BCBS of TX PPO	$59.02
Rate for Payer: Cash Price	$129.84
Rate for Payer: Multiplan Auto	$95.91
Rate for Payer: Multiplan Commercial	$95.91
Rate for Payer: Multiplan Workers Comp	$95.91
Rate for Payer: Scott and White EPO/PPO	$73.78
Rate for Payer: Superior Health Plan EPO	$20.07

blade reciproc dbl side 0277096275

Facility

$136.20

Hospital Charge Code	8610562
Hospital Revenue Code	272
Min. Negotiated Rate	$12.26
Max. Negotiated Rate	$88.53
Rate for Payer: Aetna Commercial	$74.91
Rate for Payer: Amerigroup CHIP/Medicaid	$12.26
Rate for Payer: BCBS of TX Blue Advantage	$40.86
Rate for Payer: BCBS of TX Blue Essentials	$49.03
Rate for Payer: BCBS of TX PPO	$54.48
Rate for Payer: Cash Price	$119.86
Rate for Payer: Multiplan Auto	$88.53
Rate for Payer: Multiplan Commercial	$88.53
Rate for Payer: Multiplan Workers Comp	$88.53
Rate for Payer: Scott and White EPO/PPO	$68.10
Rate for Payer: Superior Health Plan EPO	$18.52

blade reciproc dbl side 0277096275

Facility

$136.20

Hospital Charge Code	8610562
Hospital Revenue Code	272
Rate for Payer: Cash Price	$119.86

BLADE RETRACTABLE BANANA

Facility

$2,805.72

Hospital Charge Code	8428487
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,469.03

Know your out-of-pocket cost for care.

All Charges