White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Manipulation, wrist, under anesthesia

Facility

$3,828.96

Service Code	HCPCS 25259
Hospital Charge Code	9900281
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cash Price	$2,603.69
Rate for Payer: Cash Price	$2,603.69
Rate for Payer: Cash Price	$2,603.69
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$2,756.85
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina CHIP/Medicaid	$2,756.85
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$2,756.85
Rate for Payer: Scott and White EPO/PPO	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,756.85
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

Manipulation, wrist, under anesthesia

Facility

$10,000.00

Service Code	CPT 25259
Hospital Charge Code	36025259
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

MANIPULATOR, ARCH KOH-EFFIC, PLASTIC

Facility

$1,449.20

Hospital Charge Code	992755
Hospital Revenue Code	272
Rate for Payer: Cash Price	$985.46

MANIPULATOR, ARCH KOH-EFFIC, PLASTIC

Facility

$1,449.20

Hospital Charge Code	992755
Hospital Revenue Code	272
Min. Negotiated Rate	$130.43
Max. Negotiated Rate	$1,043.42
Rate for Payer: Amerigroup CHIP/Medicaid	$130.43
Rate for Payer: BCBS of TX Blue Advantage	$434.76
Rate for Payer: BCBS of TX Blue Essentials	$521.71
Rate for Payer: BCBS of TX PPO	$579.68
Rate for Payer: Cash Price	$985.46
Rate for Payer: Cigna Medicaid	$1,043.42
Rate for Payer: Molina CHIP/Medicaid	$1,043.42
Rate for Payer: Multiplan Auto	$941.98
Rate for Payer: Multiplan Commercial	$941.98
Rate for Payer: Multiplan Workers Comp	$941.98
Rate for Payer: Parkland Medicaid	$1,043.42
Rate for Payer: Scott and White EPO/PPO	$724.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,043.42
Rate for Payer: Superior Health Plan EPO	$197.09

MANIPULATOR, UTERINE CERVICAL CUP V-CARE XL 40MM -- DHF

Facility

$471.74

Hospital Charge Code	81778219
Hospital Revenue Code	272
Rate for Payer: Cash Price	$320.78

MANIPULATOR, UTERINE CERVICAL CUP V-CARE XL 40MM -- DHF

Facility

$471.74

Hospital Charge Code	81778219
Hospital Revenue Code	272
Min. Negotiated Rate	$42.46
Max. Negotiated Rate	$339.65
Rate for Payer: Amerigroup CHIP/Medicaid	$42.46
Rate for Payer: BCBS of TX Blue Advantage	$141.52
Rate for Payer: BCBS of TX Blue Essentials	$169.83
Rate for Payer: BCBS of TX PPO	$188.70
Rate for Payer: Cash Price	$320.78
Rate for Payer: Cigna Medicaid	$339.65
Rate for Payer: Molina CHIP/Medicaid	$339.65
Rate for Payer: Multiplan Auto	$306.63
Rate for Payer: Multiplan Commercial	$306.63
Rate for Payer: Multiplan Workers Comp	$306.63
Rate for Payer: Parkland Medicaid	$339.65
Rate for Payer: Scott and White EPO/PPO	$235.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$339.65
Rate for Payer: Superior Health Plan EPO	$64.16

mannitol 25% IV Soln 50 mL

Facility

$128.00

Service Code	HCPCS J2150
Hospital Charge Code	77679541
Hospital Revenue Code	636
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$4.45
Rate for Payer: BCBS of TX Blue Essentials	$5.34
Rate for Payer: BCBS of TX PPO	$5.93
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

mannitol 25% IV Soln 50 mL

Facility

$128.00

Service Code	HCPCS J2150
Hospital Charge Code	77679541
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

MANOMETER DISP -- DHF

Facility

$89.91

Hospital Charge Code	80826019
Hospital Revenue Code	270
Min. Negotiated Rate	$8.09
Max. Negotiated Rate	$64.74
Rate for Payer: Amerigroup CHIP/Medicaid	$8.09
Rate for Payer: BCBS of TX Blue Advantage	$26.97
Rate for Payer: BCBS of TX Blue Essentials	$32.37
Rate for Payer: BCBS of TX PPO	$35.96
Rate for Payer: Cash Price	$61.14
Rate for Payer: Cigna Medicaid	$64.74
Rate for Payer: Molina CHIP/Medicaid	$64.74
Rate for Payer: Multiplan Auto	$58.44
Rate for Payer: Multiplan Commercial	$58.44
Rate for Payer: Multiplan Workers Comp	$58.44
Rate for Payer: Parkland Medicaid	$64.74
Rate for Payer: Scott and White EPO/PPO	$44.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$64.74
Rate for Payer: Superior Health Plan EPO	$12.23

MANOMETER DISP -- DHF

Facility

$89.91

Hospital Charge Code	80826019
Hospital Revenue Code	270
Rate for Payer: Cash Price	$61.14

Manual Differential

Facility

$81.00

Service Code	HCPCS 85007
Hospital Charge Code	1600485
Hospital Revenue Code	305
Rate for Payer: Cash Price	$55.08

Manual Differential

Facility

$81.00

Service Code	HCPCS 85007
Hospital Charge Code	1600485
Hospital Revenue Code	305
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$58.32
Rate for Payer: Amerigroup CHIP/Medicaid	$1.48
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.80
Rate for Payer: Amerigroup Medicare	$3.80
Rate for Payer: BCBS of TX Blue Advantage	$24.30
Rate for Payer: BCBS of TX Blue Essentials	$29.16
Rate for Payer: BCBS of TX Medicare	$3.80
Rate for Payer: BCBS of TX PPO	$32.40
Rate for Payer: Cash Price	$55.08
Rate for Payer: Cash Price	$55.08
Rate for Payer: Cigna Medicaid	$58.32
Rate for Payer: Cigna Medicare	$3.80
Rate for Payer: Employer Direct Commercial	$3.80
Rate for Payer: Humana Medicare/TRICARE	$3.80
Rate for Payer: Molina CHIP/Medicaid	$58.32
Rate for Payer: Molina Dual Medicare/Medicaid	$3.80
Rate for Payer: Molina Medicare	$3.80
Rate for Payer: Multiplan Auto	$52.65
Rate for Payer: Multiplan Commercial	$52.65
Rate for Payer: Multiplan Workers Comp	$52.65
Rate for Payer: Parkland Medicaid	$58.32
Rate for Payer: Scott and White EPO/PPO	$4.75
Rate for Payer: Scott and White Medicare	$3.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$58.32
Rate for Payer: Superior Health Plan EPO	$3.80
Rate for Payer: Superior Health Plan Medicare	$3.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.80
Rate for Payer: Universal American Medicare	$3.80
Rate for Payer: Wellcare Medicare	$3.80
Rate for Payer: Wellmed Medicare	$3.80

MARKER BIOPSY SITE IDENT -- DHF

Facility

$422.05

Hospital Charge Code	81829095
Hospital Revenue Code	272
Min. Negotiated Rate	$37.98
Max. Negotiated Rate	$303.88
Rate for Payer: Amerigroup CHIP/Medicaid	$37.98
Rate for Payer: BCBS of TX Blue Advantage	$126.61
Rate for Payer: BCBS of TX Blue Essentials	$151.94
Rate for Payer: BCBS of TX PPO	$168.82
Rate for Payer: Cash Price	$286.99
Rate for Payer: Cigna Medicaid	$303.88
Rate for Payer: Molina CHIP/Medicaid	$303.88
Rate for Payer: Multiplan Auto	$274.33
Rate for Payer: Multiplan Commercial	$274.33
Rate for Payer: Multiplan Workers Comp	$274.33
Rate for Payer: Parkland Medicaid	$303.88
Rate for Payer: Scott and White EPO/PPO	$211.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$303.88
Rate for Payer: Superior Health Plan EPO	$57.40

MARKER BIOPSY SITE IDENT -- DHF

Facility

$422.05

Hospital Charge Code	81829095
Hospital Revenue Code	272
Rate for Payer: Cash Price	$286.99

MARKER ENDOSCOPIC ENDOLINK

Facility

$111.37

Hospital Charge Code	145333
Hospital Revenue Code	272
Rate for Payer: Cash Price	$75.73

MARKER ENDOSCOPIC ENDOLINK

Facility

$111.37

Hospital Charge Code	145333
Hospital Revenue Code	272
Min. Negotiated Rate	$10.02
Max. Negotiated Rate	$80.19
Rate for Payer: Amerigroup CHIP/Medicaid	$10.02
Rate for Payer: BCBS of TX Blue Advantage	$33.41
Rate for Payer: BCBS of TX Blue Essentials	$40.09
Rate for Payer: BCBS of TX PPO	$44.55
Rate for Payer: Cash Price	$75.73
Rate for Payer: Cigna Medicaid	$80.19
Rate for Payer: Molina CHIP/Medicaid	$80.19
Rate for Payer: Multiplan Auto	$72.39
Rate for Payer: Multiplan Commercial	$72.39
Rate for Payer: Multiplan Workers Comp	$72.39
Rate for Payer: Parkland Medicaid	$80.19
Rate for Payer: Scott and White EPO/PPO	$55.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$80.19
Rate for Payer: Superior Health Plan EPO	$15.15

MARKER, SKIN W/RULER ON CAP DUAL TIP REG & X-FINE -- DHF

Facility

$78.04

Hospital Charge Code	80334857
Hospital Revenue Code	272
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$56.19
Rate for Payer: Amerigroup CHIP/Medicaid	$7.02
Rate for Payer: BCBS of TX Blue Advantage	$23.41
Rate for Payer: BCBS of TX Blue Essentials	$28.09
Rate for Payer: BCBS of TX PPO	$31.22
Rate for Payer: Cash Price	$53.07
Rate for Payer: Cigna Medicaid	$56.19
Rate for Payer: Molina CHIP/Medicaid	$56.19
Rate for Payer: Multiplan Auto	$50.73
Rate for Payer: Multiplan Commercial	$50.73
Rate for Payer: Multiplan Workers Comp	$50.73
Rate for Payer: Parkland Medicaid	$56.19
Rate for Payer: Scott and White EPO/PPO	$39.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56.19
Rate for Payer: Superior Health Plan EPO	$10.61

MARKER, SKIN W/RULER ON CAP DUAL TIP REG & X-FINE -- DHF

Facility

$78.04

Hospital Charge Code	80334857
Hospital Revenue Code	272
Rate for Payer: Cash Price	$53.07

MARKER, SKIN, W/RULER, STERILE

Facility

$2.66

Hospital Charge Code	992816
Hospital Revenue Code	272
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$1.92
Rate for Payer: Amerigroup CHIP/Medicaid	$0.24
Rate for Payer: BCBS of TX Blue Advantage	$0.80
Rate for Payer: BCBS of TX Blue Essentials	$0.96
Rate for Payer: BCBS of TX PPO	$1.06
Rate for Payer: Cash Price	$1.81
Rate for Payer: Cigna Medicaid	$1.92
Rate for Payer: Molina CHIP/Medicaid	$1.92
Rate for Payer: Multiplan Auto	$1.73
Rate for Payer: Multiplan Commercial	$1.73
Rate for Payer: Multiplan Workers Comp	$1.73
Rate for Payer: Parkland Medicaid	$1.92
Rate for Payer: Scott and White EPO/PPO	$1.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.92
Rate for Payer: Superior Health Plan EPO	$0.36

MARKER, SKIN, W/RULER, STERILE

Facility

$2.66

Hospital Charge Code	992816
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1.81

MASK, AEROSOL, UNDER CHIN

Facility

$1.70

Hospital Charge Code	993347
Hospital Revenue Code	270
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$1.22
Rate for Payer: Amerigroup CHIP/Medicaid	$0.15
Rate for Payer: BCBS of TX Blue Advantage	$0.51
Rate for Payer: BCBS of TX Blue Essentials	$0.61
Rate for Payer: BCBS of TX PPO	$0.68
Rate for Payer: Cash Price	$1.16
Rate for Payer: Cigna Medicaid	$1.22
Rate for Payer: Molina CHIP/Medicaid	$1.22
Rate for Payer: Multiplan Auto	$1.10
Rate for Payer: Multiplan Commercial	$1.10
Rate for Payer: Multiplan Workers Comp	$1.10
Rate for Payer: Parkland Medicaid	$1.22
Rate for Payer: Scott and White EPO/PPO	$0.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.22
Rate for Payer: Superior Health Plan EPO	$0.23

MASK, AEROSOL, UNDER CHIN

Facility

$1.70

Hospital Charge Code	993347
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.16

MASK, AEROSOL UNDER CHIN, PED

Facility

$2.05

Hospital Charge Code	993604
Hospital Revenue Code	270
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$1.48
Rate for Payer: Amerigroup CHIP/Medicaid	$0.18
Rate for Payer: BCBS of TX Blue Advantage	$0.62
Rate for Payer: BCBS of TX Blue Essentials	$0.74
Rate for Payer: BCBS of TX PPO	$0.82
Rate for Payer: Cash Price	$1.39
Rate for Payer: Cigna Medicaid	$1.48
Rate for Payer: Molina CHIP/Medicaid	$1.48
Rate for Payer: Multiplan Auto	$1.33
Rate for Payer: Multiplan Commercial	$1.33
Rate for Payer: Multiplan Workers Comp	$1.33
Rate for Payer: Parkland Medicaid	$1.48
Rate for Payer: Scott and White EPO/PPO	$1.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.48
Rate for Payer: Superior Health Plan EPO	$0.28

MASK, AEROSOL UNDER CHIN, PED

Facility

$2.05

Hospital Charge Code	993604
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.39

MASK AERSL ADLT TRCH LRNTMY SWVL CONN

Facility

$2.54

Hospital Charge Code	993603
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.73

Know your out-of-pocket cost for care.

All Charges