White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SCRW LCK TIT -- DHF

Facility

$845.37

Service Code	HCPCS C1713
Hospital Charge Code	81361941
Hospital Revenue Code	278
Min. Negotiated Rate	$211.34
Max. Negotiated Rate	$422.68
Rate for Payer: Aetna Commercial	$253.61
Rate for Payer: Cash Price	$743.93
Rate for Payer: Cigna Commercial	$211.34
Rate for Payer: Multiplan Auto	$422.68
Rate for Payer: Multiplan Commercial	$422.68
Rate for Payer: Multiplan Workers Comp	$422.68
Rate for Payer: Scott and White EPO/PPO	$422.68

SCRW LOCKING -- DHF

Facility

$802.10

Service Code	HCPCS C1713
Hospital Charge Code	81361966
Hospital Revenue Code	278
Min. Negotiated Rate	$200.52
Max. Negotiated Rate	$401.05
Rate for Payer: Aetna Commercial	$240.63
Rate for Payer: Cash Price	$705.85
Rate for Payer: Cigna Commercial	$200.52
Rate for Payer: Multiplan Auto	$401.05
Rate for Payer: Multiplan Commercial	$401.05
Rate for Payer: Multiplan Workers Comp	$401.05
Rate for Payer: Scott and White EPO/PPO	$401.05

SCRW LOCKING -- DHF

Facility

$802.10

Service Code	HCPCS C1713
Hospital Charge Code	81361966
Hospital Revenue Code	278
Min. Negotiated Rate	$72.19
Max. Negotiated Rate	$401.05
Rate for Payer: Aetna Commercial	$240.63
Rate for Payer: Amerigroup CHIP/Medicaid	$72.19
Rate for Payer: BCBS of TX Blue Advantage	$240.63
Rate for Payer: BCBS of TX Blue Essentials	$288.76
Rate for Payer: BCBS of TX PPO	$320.84
Rate for Payer: Cash Price	$705.85
Rate for Payer: Multiplan Auto	$401.05
Rate for Payer: Multiplan Commercial	$401.05
Rate for Payer: Multiplan Workers Comp	$401.05
Rate for Payer: Scott and White EPO/PPO	$401.05
Rate for Payer: Superior Health Plan EPO	$109.09

SCRW SOLID 81362600 -- DHF

Facility

$6,435.06

Service Code	HCPCS C1713
Hospital Charge Code	81362600
Hospital Revenue Code	278
Min. Negotiated Rate	$1,608.76
Max. Negotiated Rate	$3,217.53
Rate for Payer: Aetna Commercial	$1,930.52
Rate for Payer: Cash Price	$5,662.85
Rate for Payer: Cigna Commercial	$1,608.76
Rate for Payer: Multiplan Auto	$3,217.53
Rate for Payer: Multiplan Commercial	$3,217.53
Rate for Payer: Multiplan Workers Comp	$3,217.53
Rate for Payer: Scott and White EPO/PPO	$3,217.53

SCRW SOLID 81362600 -- DHF

Facility

$6,435.06

Service Code	HCPCS C1713
Hospital Charge Code	81362600
Hospital Revenue Code	278
Min. Negotiated Rate	$579.16
Max. Negotiated Rate	$3,217.53
Rate for Payer: Aetna Commercial	$1,930.52
Rate for Payer: Amerigroup CHIP/Medicaid	$579.16
Rate for Payer: BCBS of TX Blue Advantage	$1,930.52
Rate for Payer: BCBS of TX Blue Essentials	$2,316.62
Rate for Payer: BCBS of TX PPO	$2,574.02
Rate for Payer: Cash Price	$5,662.85
Rate for Payer: Multiplan Auto	$3,217.53
Rate for Payer: Multiplan Commercial	$3,217.53
Rate for Payer: Multiplan Workers Comp	$3,217.53
Rate for Payer: Scott and White EPO/PPO	$3,217.53
Rate for Payer: Superior Health Plan EPO	$875.17

SCRW SOLID 81362659 -- DHF

Facility

$383.56

Service Code	HCPCS C1713
Hospital Charge Code	81362659
Hospital Revenue Code	278
Min. Negotiated Rate	$34.52
Max. Negotiated Rate	$191.78
Rate for Payer: Aetna Commercial	$115.07
Rate for Payer: Amerigroup CHIP/Medicaid	$34.52
Rate for Payer: BCBS of TX Blue Advantage	$115.07
Rate for Payer: BCBS of TX Blue Essentials	$138.08
Rate for Payer: BCBS of TX PPO	$153.42
Rate for Payer: Cash Price	$337.53
Rate for Payer: Multiplan Auto	$191.78
Rate for Payer: Multiplan Commercial	$191.78
Rate for Payer: Multiplan Workers Comp	$191.78
Rate for Payer: Scott and White EPO/PPO	$191.78
Rate for Payer: Superior Health Plan EPO	$52.16

SCRW SOLID 81362659 -- DHF

Facility

$383.56

Service Code	HCPCS C1713
Hospital Charge Code	81362659
Hospital Revenue Code	278
Min. Negotiated Rate	$95.89
Max. Negotiated Rate	$191.78
Rate for Payer: Aetna Commercial	$115.07
Rate for Payer: Cash Price	$337.53
Rate for Payer: Cigna Commercial	$95.89
Rate for Payer: Multiplan Auto	$191.78
Rate for Payer: Multiplan Commercial	$191.78
Rate for Payer: Multiplan Workers Comp	$191.78
Rate for Payer: Scott and White EPO/PPO	$191.78

SCRW WOODRUF -- DHF

Facility

$479.30

Service Code	HCPCS C1713
Hospital Charge Code	81362956
Hospital Revenue Code	278
Min. Negotiated Rate	$43.14
Max. Negotiated Rate	$239.65
Rate for Payer: Aetna Commercial	$143.79
Rate for Payer: Amerigroup CHIP/Medicaid	$43.14
Rate for Payer: BCBS of TX Blue Advantage	$143.79
Rate for Payer: BCBS of TX Blue Essentials	$172.55
Rate for Payer: BCBS of TX PPO	$191.72
Rate for Payer: Cash Price	$421.78
Rate for Payer: Multiplan Auto	$239.65
Rate for Payer: Multiplan Commercial	$239.65
Rate for Payer: Multiplan Workers Comp	$239.65
Rate for Payer: Scott and White EPO/PPO	$239.65
Rate for Payer: Superior Health Plan EPO	$65.18

SCRW WOODRUF -- DHF

Facility

$479.30

Service Code	HCPCS C1713
Hospital Charge Code	81362956
Hospital Revenue Code	278
Min. Negotiated Rate	$119.82
Max. Negotiated Rate	$239.65
Rate for Payer: Aetna Commercial	$143.79
Rate for Payer: Cash Price	$421.78
Rate for Payer: Cigna Commercial	$119.82
Rate for Payer: Multiplan Auto	$239.65
Rate for Payer: Multiplan Commercial	$239.65
Rate for Payer: Multiplan Workers Comp	$239.65
Rate for Payer: Scott and White EPO/PPO	$239.65

SDS Facility Eval, Management Level 1 99211 BCE

Facility

$113.00

Service Code	CPT 99211
Hospital Charge Code	3603079
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$73.45
Rate for Payer: Aetna Commercial	$62.15
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$16.30
Rate for Payer: BCBS of TX Blue Essentials	$19.49
Rate for Payer: BCBS of TX PPO	$21.74
Rate for Payer: Cash Price	$99.44
Rate for Payer: Cash Price	$99.44
Rate for Payer: Cigna Medicaid	$12.41
Rate for Payer: Molina CHIP/Medicaid	$12.41
Rate for Payer: Multiplan Auto	$73.45
Rate for Payer: Multiplan Commercial	$73.45
Rate for Payer: Multiplan Workers Comp	$73.45
Rate for Payer: Parkland Medicaid	$12.41
Rate for Payer: Scott and White EPO/PPO	$56.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.41

SDS Facility Eval, Management Level 1 99211 BCE

Facility

$113.00

Service Code	CPT 99211
Hospital Charge Code	3603079
Hospital Revenue Code	510
Rate for Payer: Cash Price	$99.44

SDS Inf Hydration Each Addl Hr 96361 BCE

Facility

$251.00

Service Code	CPT 96361
Hospital Charge Code	610010
Hospital Revenue Code	260
Rate for Payer: Cash Price	$220.88

SDS Inf Hydration Each Addl Hr 96361 BCE

Facility

$251.00

Service Code	CPT 96361
Hospital Charge Code	610010
Hospital Revenue Code	260
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$163.15
Rate for Payer: Aetna Commercial	$138.05
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$22.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$23.82
Rate for Payer: BCBS of TX Blue Essentials	$28.48
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$31.76
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
Rate for Payer: Multiplan Auto	$163.15
Rate for Payer: Multiplan Commercial	$163.15
Rate for Payer: Multiplan Workers Comp	$163.15
Rate for Payer: Scott and White EPO/PPO	$0.78
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

SDS Inf Hydration Initial 31 to 60 Min 96360 BCE

Facility

$847.00

Service Code	CPT 96360
Hospital Charge Code	610009
Hospital Revenue Code	260
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$550.55
Rate for Payer: Aetna Commercial	$465.85
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup CHIP/Medicaid	$76.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$67.09
Rate for Payer: BCBS of TX Blue Essentials	$80.20
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$89.46
Rate for Payer: Cash Price	$745.36
Rate for Payer: Cash Price	$745.36
Rate for Payer: Cash Price	$745.36
Rate for Payer: Cigna Commercial	$444.05
Rate for Payer: Cigna Medicare	$196.02
Rate for Payer: Employer Direct Commercial	$196.02
Rate for Payer: Humana Medicare/TRICARE	$196.02
Rate for Payer: Molina Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
Rate for Payer: Multiplan Auto	$550.55
Rate for Payer: Multiplan Commercial	$550.55
Rate for Payer: Multiplan Workers Comp	$550.55
Rate for Payer: Scott and White EPO/PPO	$3.51
Rate for Payer: Scott and White Medicare	$196.02
Rate for Payer: Superior Health Plan EPO	$196.02
Rate for Payer: Superior Health Plan Medicare	$196.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$196.02
Rate for Payer: Universal American Medicare	$196.02
Rate for Payer: Wellcare Medicare	$196.02
Rate for Payer: Wellmed Medicare	$196.02

SDS Inf Hydration Initial 31 to 60 Min 96360 BCE

Facility

$847.00

Service Code	CPT 96360
Hospital Charge Code	610009
Hospital Revenue Code	260
Rate for Payer: Cash Price	$745.36

SDS Inf Ther Proph Dx Each Addl Hr 96366 BCE

Facility

$153.00

Service Code	CPT 96366
Hospital Charge Code	600569
Hospital Revenue Code	260
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$99.45
Rate for Payer: Aetna Commercial	$84.15
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$38.25
Rate for Payer: BCBS of TX Blue Essentials	$45.72
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$50.99
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Scott and White EPO/PPO	$0.78
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

SDS Inf Ther Proph Dx Each Addl Hr 96366 BCE

Facility

$153.00

Service Code	CPT 96366
Hospital Charge Code	600569
Hospital Revenue Code	260
Rate for Payer: Cash Price	$134.64

SDS Inf Tx Prophylaxis Dx up to 1 Hour 96365 BCE

Facility

$300.00

Service Code	CPT 96365
Hospital Charge Code	600551
Hospital Revenue Code	260
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$444.05
Rate for Payer: Aetna Commercial	$165.00
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup CHIP/Medicaid	$27.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$126.67
Rate for Payer: BCBS of TX Blue Essentials	$151.42
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$168.90
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cigna Commercial	$444.05
Rate for Payer: Cigna Medicare	$196.02
Rate for Payer: Employer Direct Commercial	$196.02
Rate for Payer: Humana Medicare/TRICARE	$196.02
Rate for Payer: Molina Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
Rate for Payer: Multiplan Auto	$195.00
Rate for Payer: Multiplan Commercial	$195.00
Rate for Payer: Multiplan Workers Comp	$195.00
Rate for Payer: Scott and White EPO/PPO	$3.51
Rate for Payer: Scott and White Medicare	$196.02
Rate for Payer: Superior Health Plan EPO	$196.02
Rate for Payer: Superior Health Plan Medicare	$196.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$196.02
Rate for Payer: Universal American Medicare	$196.02
Rate for Payer: Wellcare Medicare	$196.02
Rate for Payer: Wellmed Medicare	$196.02

SDS Inf Tx Prophylaxis Dx up to 1 Hour 96365 BCE

Facility

$300.00

Service Code	CPT 96365
Hospital Charge Code	600551
Hospital Revenue Code	260
Rate for Payer: Cash Price	$264.00

SDS Tx Proph Diag Ea Addl IVP Drug 96375 BCE

Facility

$330.00

Service Code	CPT 96375
Hospital Charge Code	610014
Hospital Revenue Code	260
Rate for Payer: Cash Price	$290.40

SDS Tx Proph Diag Ea Addl IVP Drug 96375 BCE

Facility

$330.00

Service Code	CPT 96375
Hospital Charge Code	610014
Hospital Revenue Code	260
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$214.50
Rate for Payer: Aetna Commercial	$181.50
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$29.48
Rate for Payer: BCBS of TX Blue Essentials	$35.24
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$39.30
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Scott and White EPO/PPO	$0.78
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

SDS Tx Proph Diag Injection SQ or IM 96372 BCE

Facility

$280.00

Service Code	CPT 96372
Hospital Charge Code	600577
Hospital Revenue Code	260
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$154.00
Rate for Payer: Aetna Medicare	$96.64
Rate for Payer: Amerigroup CHIP/Medicaid	$25.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$64.43
Rate for Payer: Amerigroup Medicare	$64.43
Rate for Payer: BCBS of TX Blue Advantage	$105.22
Rate for Payer: BCBS of TX Blue Essentials	$125.78
Rate for Payer: BCBS of TX Medicare	$64.43
Rate for Payer: BCBS of TX PPO	$140.29
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cigna Commercial	$145.94
Rate for Payer: Cigna Medicaid	$11.23
Rate for Payer: Cigna Medicare	$64.43
Rate for Payer: Employer Direct Commercial	$64.43
Rate for Payer: Humana Medicare/TRICARE	$64.43
Rate for Payer: Molina CHIP/Medicaid	$11.23
Rate for Payer: Molina Dual Medicare/Medicaid	$64.43
Rate for Payer: Molina Medicare	$64.43
Rate for Payer: Multiplan Auto	$182.00
Rate for Payer: Multiplan Commercial	$182.00
Rate for Payer: Multiplan Workers Comp	$182.00
Rate for Payer: Parkland Medicaid	$11.23
Rate for Payer: Scott and White EPO/PPO	$1.15
Rate for Payer: Scott and White Medicare	$64.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.23
Rate for Payer: Superior Health Plan EPO	$64.43
Rate for Payer: Superior Health Plan Medicare	$64.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$64.43
Rate for Payer: Universal American Medicare	$64.43
Rate for Payer: Wellcare Medicare	$64.43
Rate for Payer: Wellmed Medicare	$64.43

SDS Tx Proph Diag Injection SQ or IM 96372 BCE

Facility

$280.00

Service Code	CPT 96372
Hospital Charge Code	600577
Hospital Revenue Code	260
Rate for Payer: Cash Price	$246.40

SDS Tx Prophylactic Diag IVP Drug 96374 BCE

Facility

$360.00

Service Code	CPT 96374
Hospital Charge Code	610013
Hospital Revenue Code	260
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$444.05
Rate for Payer: Aetna Commercial	$198.00
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup CHIP/Medicaid	$32.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$68.97
Rate for Payer: BCBS of TX Blue Essentials	$82.45
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$91.96
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$444.05
Rate for Payer: Cigna Medicare	$196.02
Rate for Payer: Employer Direct Commercial	$196.02
Rate for Payer: Humana Medicare/TRICARE	$196.02
Rate for Payer: Molina Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
Rate for Payer: Multiplan Auto	$234.00
Rate for Payer: Multiplan Commercial	$234.00
Rate for Payer: Multiplan Workers Comp	$234.00
Rate for Payer: Scott and White EPO/PPO	$3.51
Rate for Payer: Scott and White Medicare	$196.02
Rate for Payer: Superior Health Plan EPO	$196.02
Rate for Payer: Superior Health Plan Medicare	$196.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$196.02
Rate for Payer: Universal American Medicare	$196.02
Rate for Payer: Wellcare Medicare	$196.02
Rate for Payer: Wellmed Medicare	$196.02

SDS Tx Prophylactic Diag IVP Drug 96374 BCE

Facility

$360.00

Service Code	CPT 96374
Hospital Charge Code	610013
Hospital Revenue Code	260
Rate for Payer: Cash Price	$316.80

Know your out-of-pocket cost for care.

All Charges