White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Adult anesthesia circuit with 90 expandable tubing

Facility

$34.12

Hospital Charge Code	992929
Hospital Revenue Code	270
Rate for Payer: Cash Price	$23.20

Adult anesthesia circuit with 90 expandable tubing

Facility

$34.12

Hospital Charge Code	992929
Hospital Revenue Code	270
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$24.57
Rate for Payer: Amerigroup CHIP/Medicaid	$3.07
Rate for Payer: BCBS of TX Blue Advantage	$10.24
Rate for Payer: BCBS of TX Blue Essentials	$12.28
Rate for Payer: BCBS of TX PPO	$13.65
Rate for Payer: Cash Price	$23.20
Rate for Payer: Cigna Medicaid	$24.57
Rate for Payer: Molina CHIP/Medicaid	$24.57
Rate for Payer: Multiplan Auto	$22.18
Rate for Payer: Multiplan Commercial	$22.18
Rate for Payer: Multiplan Workers Comp	$22.18
Rate for Payer: Parkland Medicaid	$24.57
Rate for Payer: Scott and White EPO/PPO	$17.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.57
Rate for Payer: Superior Health Plan EPO	$4.64

Adult oxygen mask, non rebreather, medium concentration, 7 tubing

Facility

$4.01

Hospital Charge Code	993931
Hospital Revenue Code	271
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$2.89
Rate for Payer: Amerigroup CHIP/Medicaid	$0.36
Rate for Payer: BCBS of TX Blue Advantage	$1.20
Rate for Payer: BCBS of TX Blue Essentials	$1.44
Rate for Payer: BCBS of TX PPO	$1.60
Rate for Payer: Cash Price	$2.73
Rate for Payer: Cigna Medicaid	$2.89
Rate for Payer: Molina CHIP/Medicaid	$2.89
Rate for Payer: Multiplan Auto	$2.61
Rate for Payer: Multiplan Commercial	$2.61
Rate for Payer: Multiplan Workers Comp	$2.61
Rate for Payer: Parkland Medicaid	$2.89
Rate for Payer: Scott and White EPO/PPO	$2.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.89
Rate for Payer: Superior Health Plan EPO	$0.55

Adult oxygen mask, non rebreather, medium concentration, 7 tubing

Facility

$4.01

Hospital Charge Code	993931
Hospital Revenue Code	271
Rate for Payer: Cash Price	$2.73

AEQUALIS PERFORM + GUIDE WIRE D2.5 X 220 MM

Facility

$703.70

Service Code	HCPCS C1769
Hospital Charge Code	993660
Hospital Revenue Code	272
Min. Negotiated Rate	$63.33
Max. Negotiated Rate	$506.66
Rate for Payer: Amerigroup CHIP/Medicaid	$63.33
Rate for Payer: BCBS of TX Blue Advantage	$211.11
Rate for Payer: BCBS of TX Blue Essentials	$253.33
Rate for Payer: BCBS of TX PPO	$281.48
Rate for Payer: Cash Price	$478.52
Rate for Payer: Cigna Medicaid	$506.66
Rate for Payer: Molina CHIP/Medicaid	$506.66
Rate for Payer: Multiplan Auto	$457.40
Rate for Payer: Multiplan Commercial	$457.40
Rate for Payer: Multiplan Workers Comp	$457.40
Rate for Payer: Parkland Medicaid	$506.66
Rate for Payer: Scott and White EPO/PPO	$351.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$506.66
Rate for Payer: Superior Health Plan EPO	$95.70

AEQUALIS PERFORM + GUIDE WIRE D2.5 X 220 MM

Facility

$703.70

Service Code	HCPCS C1769
Hospital Charge Code	993660
Hospital Revenue Code	272
Rate for Payer: Cash Price	$478.52

.Aerobic Bact ID by Seq 183269 SO

Facility

$300.00

Service Code	HCPCS 87153
Hospital Charge Code	1700032
Hospital Revenue Code	300
Min. Negotiated Rate	$44.99
Max. Negotiated Rate	$216.00
Rate for Payer: Amerigroup CHIP/Medicaid	$44.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$115.36
Rate for Payer: Amerigroup Medicare	$115.36
Rate for Payer: BCBS of TX Blue Advantage	$90.00
Rate for Payer: BCBS of TX Blue Essentials	$108.00
Rate for Payer: BCBS of TX Medicare	$115.36
Rate for Payer: BCBS of TX PPO	$120.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cigna Medicaid	$216.00
Rate for Payer: Cigna Medicare	$115.36
Rate for Payer: Employer Direct Commercial	$115.36
Rate for Payer: Humana Medicare/TRICARE	$115.36
Rate for Payer: Molina CHIP/Medicaid	$216.00
Rate for Payer: Molina Dual Medicare/Medicaid	$115.36
Rate for Payer: Molina Medicare	$115.36
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: Parkland Medicaid	$216.00
Rate for Payer: Scott and White EPO/PPO	$144.20
Rate for Payer: Scott and White Medicare	$115.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.00
Rate for Payer: Superior Health Plan EPO	$115.36
Rate for Payer: Superior Health Plan Medicare	$115.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$115.36
Rate for Payer: Universal American Medicare	$115.36
Rate for Payer: Wellcare Medicare	$115.36
Rate for Payer: Wellmed Medicare	$115.36

.Aerobic Bact ID by Seq 183269 SO

Facility

$300.00

Service Code	HCPCS 87153
Hospital Charge Code	1700032
Hospital Revenue Code	300
Rate for Payer: Cash Price	$204.00

.Aerobic ID by MALDI 183404 SO

Facility

$33.75

Service Code	HCPCS 87077
Hospital Charge Code	9058998
Hospital Revenue Code	306
Rate for Payer: Cash Price	$22.95

.Aerobic ID by MALDI 183404 SO

Facility

$33.75

Service Code	HCPCS 87077
Hospital Charge Code	9058998
Hospital Revenue Code	306
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$24.30
Rate for Payer: Amerigroup CHIP/Medicaid	$3.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.08
Rate for Payer: Amerigroup Medicare	$8.08
Rate for Payer: BCBS of TX Blue Advantage	$10.12
Rate for Payer: BCBS of TX Blue Essentials	$12.15
Rate for Payer: BCBS of TX Medicare	$8.08
Rate for Payer: BCBS of TX PPO	$13.50
Rate for Payer: Cash Price	$22.95
Rate for Payer: Cash Price	$22.95
Rate for Payer: Cigna Medicaid	$24.30
Rate for Payer: Cigna Medicare	$8.08
Rate for Payer: Employer Direct Commercial	$8.08
Rate for Payer: Humana Medicare/TRICARE	$8.08
Rate for Payer: Molina CHIP/Medicaid	$24.30
Rate for Payer: Molina Dual Medicare/Medicaid	$8.08
Rate for Payer: Molina Medicare	$8.08
Rate for Payer: Multiplan Auto	$21.94
Rate for Payer: Multiplan Commercial	$21.94
Rate for Payer: Multiplan Workers Comp	$21.94
Rate for Payer: Parkland Medicaid	$24.30
Rate for Payer: Scott and White EPO/PPO	$10.10
Rate for Payer: Scott and White Medicare	$8.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.30
Rate for Payer: Superior Health Plan EPO	$8.08
Rate for Payer: Superior Health Plan Medicare	$8.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.08
Rate for Payer: Universal American Medicare	$8.08
Rate for Payer: Wellcare Medicare	$8.08
Rate for Payer: Wellmed Medicare	$8.08

Aerosol Mask, Short, Pediatric

Facility

$2.49

Hospital Charge Code	993373
Hospital Revenue Code	270
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$1.79
Rate for Payer: Amerigroup CHIP/Medicaid	$0.22
Rate for Payer: BCBS of TX Blue Advantage	$0.75
Rate for Payer: BCBS of TX Blue Essentials	$0.90
Rate for Payer: BCBS of TX PPO	$1.00
Rate for Payer: Cash Price	$1.69
Rate for Payer: Cigna Medicaid	$1.79
Rate for Payer: Molina CHIP/Medicaid	$1.79
Rate for Payer: Multiplan Auto	$1.62
Rate for Payer: Multiplan Commercial	$1.62
Rate for Payer: Multiplan Workers Comp	$1.62
Rate for Payer: Parkland Medicaid	$1.79
Rate for Payer: Scott and White EPO/PPO	$1.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.79
Rate for Payer: Superior Health Plan EPO	$0.34

Aerosol Mask, Short, Pediatric

Facility

$2.49

Hospital Charge Code	993373
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.69

AES 90 PROBE

Facility

$804.31

Hospital Charge Code	992645
Hospital Revenue Code	272
Min. Negotiated Rate	$72.39
Max. Negotiated Rate	$579.10
Rate for Payer: Amerigroup CHIP/Medicaid	$72.39
Rate for Payer: BCBS of TX Blue Advantage	$241.29
Rate for Payer: BCBS of TX Blue Essentials	$289.55
Rate for Payer: BCBS of TX PPO	$321.72
Rate for Payer: Cash Price	$546.93
Rate for Payer: Cigna Medicaid	$579.10
Rate for Payer: Molina CHIP/Medicaid	$579.10
Rate for Payer: Multiplan Auto	$522.80
Rate for Payer: Multiplan Commercial	$522.80
Rate for Payer: Multiplan Workers Comp	$522.80
Rate for Payer: Parkland Medicaid	$579.10
Rate for Payer: Scott and White EPO/PPO	$402.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$579.10
Rate for Payer: Superior Health Plan EPO	$109.39

AES 90 PROBE

Facility

$804.31

Hospital Charge Code	992645
Hospital Revenue Code	272
Rate for Payer: Cash Price	$546.93

.AFB ID by DNA Probe Rflx AST 008694 SO

Facility

$224.00

Service Code	HCPCS 87149
Hospital Charge Code	1605062
Hospital Revenue Code	306
Rate for Payer: Cash Price	$152.32

.AFB ID by DNA Probe Rflx AST 008694 SO

Facility

$224.00

Service Code	HCPCS 87149
Hospital Charge Code	1605062
Hospital Revenue Code	306
Min. Negotiated Rate	$7.82
Max. Negotiated Rate	$161.28
Rate for Payer: Amerigroup CHIP/Medicaid	$7.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.05
Rate for Payer: Amerigroup Medicare	$20.05
Rate for Payer: BCBS of TX Blue Advantage	$67.20
Rate for Payer: BCBS of TX Blue Essentials	$80.64
Rate for Payer: BCBS of TX Medicare	$20.05
Rate for Payer: BCBS of TX PPO	$89.60
Rate for Payer: Cash Price	$152.32
Rate for Payer: Cash Price	$152.32
Rate for Payer: Cigna Medicaid	$161.28
Rate for Payer: Cigna Medicare	$20.05
Rate for Payer: Employer Direct Commercial	$20.05
Rate for Payer: Humana Medicare/TRICARE	$20.05
Rate for Payer: Molina CHIP/Medicaid	$161.28
Rate for Payer: Molina Dual Medicare/Medicaid	$20.05
Rate for Payer: Molina Medicare	$20.05
Rate for Payer: Multiplan Auto	$145.60
Rate for Payer: Multiplan Commercial	$145.60
Rate for Payer: Multiplan Workers Comp	$145.60
Rate for Payer: Parkland Medicaid	$161.28
Rate for Payer: Scott and White EPO/PPO	$25.06
Rate for Payer: Scott and White Medicare	$20.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$161.28
Rate for Payer: Superior Health Plan EPO	$20.05
Rate for Payer: Superior Health Plan Medicare	$20.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.05
Rate for Payer: Universal American Medicare	$20.05
Rate for Payer: Wellcare Medicare	$20.05
Rate for Payer: Wellmed Medicare	$20.05

After 9.1.2020 / Injection, anesthetic agent sphenopalatine ganglion

Facility

$10,000.00

Service Code	CPT 64505
Hospital Charge Code	36064505
Hospital Revenue Code	360
Min. Negotiated Rate	$70.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$70.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.35
Rate for Payer: Amerigroup Medicare	$308.35
Rate for Payer: BCBS of TX Blue Advantage	$119.34
Rate for Payer: BCBS of TX Blue Essentials	$142.92
Rate for Payer: BCBS of TX Medicare	$308.35
Rate for Payer: BCBS of TX PPO	$180.08
Rate for Payer: Cigna Commercial	$651.79
Rate for Payer: Cigna Medicare	$308.35
Rate for Payer: Employer Direct Commercial	$308.35
Rate for Payer: Humana Medicare/TRICARE	$308.35
Rate for Payer: Molina Dual Medicare/Medicaid	$308.35
Rate for Payer: Molina Medicare	$308.35
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	$501.11
Rate for Payer: Scott and White Medicare	$308.35
Rate for Payer: Superior Health Plan EPO	$308.35
Rate for Payer: Superior Health Plan Medicare	$308.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.35
Rate for Payer: Universal American Medicare	$308.35
Rate for Payer: Wellcare Medicare	$308.35
Rate for Payer: Wellmed Medicare	$308.35

After 9.1.2020 / Injection, anesthetic agent sphenopalatine ganglion

Facility

$2,089.36

Service Code	HCPCS 64505
Hospital Charge Code	9900806
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,420.76

After 9.1.2020 / Injection, anesthetic agent sphenopalatine ganglion

Facility

$2,089.36

Service Code	HCPCS 64505
Hospital Charge Code	9900806
Hospital Revenue Code	360
Min. Negotiated Rate	$70.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$70.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.35
Rate for Payer: Amerigroup Medicare	$308.35
Rate for Payer: BCBS of TX Blue Advantage	$119.34
Rate for Payer: BCBS of TX Blue Essentials	$142.92
Rate for Payer: BCBS of TX Medicare	$308.35
Rate for Payer: BCBS of TX PPO	$180.08
Rate for Payer: Cash Price	$1,420.76
Rate for Payer: Cash Price	$1,420.76
Rate for Payer: Cash Price	$1,420.76
Rate for Payer: Cigna Commercial	$651.79
Rate for Payer: Cigna Medicaid	$1,504.34
Rate for Payer: Cigna Medicare	$308.35
Rate for Payer: Employer Direct Commercial	$308.35
Rate for Payer: Humana Medicare/TRICARE	$308.35
Rate for Payer: Molina CHIP/Medicaid	$1,504.34
Rate for Payer: Molina Dual Medicare/Medicaid	$308.35
Rate for Payer: Molina Medicare	$308.35
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	$1,504.34
Rate for Payer: Scott and White EPO/PPO	$501.11
Rate for Payer: Scott and White Medicare	$308.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,504.34
Rate for Payer: Superior Health Plan EPO	$308.35
Rate for Payer: Superior Health Plan Medicare	$308.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.35
Rate for Payer: Universal American Medicare	$308.35
Rate for Payer: Wellcare Medicare	$308.35
Rate for Payer: Wellmed Medicare	$308.35

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC

Facility

$20,816.40

Service Code	MSDRG 560
Min. Negotiated Rate	$8,786.62
Max. Negotiated Rate	$20,816.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,013.30
Rate for Payer: Amerigroup Medicare	$13,013.30
Rate for Payer: BCBS of TX Medicare	$13,013.30
Rate for Payer: Cigna Commercial	$14,504.17
Rate for Payer: Cigna Medicare	$13,013.30
Rate for Payer: Employer Direct Commercial	$13,013.30
Rate for Payer: Humana Medicare/TRICARE	$13,013.30
Rate for Payer: Molina Dual Medicare/Medicaid	$13,013.30
Rate for Payer: Molina Medicare	$13,013.30
Rate for Payer: Multiplan Auto	$20,816.40
Rate for Payer: Multiplan Commercial	$20,816.40
Rate for Payer: Multiplan Workers Comp	$20,816.40
Rate for Payer: Scott and White EPO/PPO	$9,586.50
Rate for Payer: Scott and White Medicare	$13,013.30
Rate for Payer: Superior Health Plan EPO	$13,013.30
Rate for Payer: Superior Health Plan Medicare	$13,013.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,013.30
Rate for Payer: Universal American Medicare	$13,013.30
Rate for Payer: Wellcare Medicare	$13,013.30
Rate for Payer: Wellmed Medicare	$13,013.30

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$33,915.00

Service Code	MSDRG 559
Min. Negotiated Rate	$15,468.82
Max. Negotiated Rate	$33,915.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,427.98
Rate for Payer: Amerigroup Medicare	$18,427.98
Rate for Payer: BCBS of TX Medicare	$18,427.98
Rate for Payer: Cigna Commercial	$24,019.91
Rate for Payer: Cigna Medicare	$18,427.98
Rate for Payer: Employer Direct Commercial	$18,427.98
Rate for Payer: Humana Medicare/TRICARE	$18,427.98
Rate for Payer: Molina Dual Medicare/Medicaid	$18,427.98
Rate for Payer: Molina Medicare	$18,427.98
Rate for Payer: Multiplan Auto	$33,915.00
Rate for Payer: Multiplan Commercial	$33,915.00
Rate for Payer: Multiplan Workers Comp	$33,915.00
Rate for Payer: Scott and White EPO/PPO	$15,618.75
Rate for Payer: Scott and White Medicare	$18,427.98
Rate for Payer: Superior Health Plan EPO	$18,427.98
Rate for Payer: Superior Health Plan Medicare	$18,427.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,427.98
Rate for Payer: Universal American Medicare	$18,427.98
Rate for Payer: Wellcare Medicare	$18,427.98
Rate for Payer: Wellmed Medicare	$18,427.98

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC

Facility

$15,013.80

Service Code	MSDRG 561
Min. Negotiated Rate	$6,502.46
Max. Negotiated Rate	$15,013.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,651.89
Rate for Payer: Amerigroup Medicare	$10,651.89
Rate for Payer: BCBS of TX Medicare	$10,651.89
Rate for Payer: Cigna Commercial	$10,354.23
Rate for Payer: Cigna Medicare	$10,651.89
Rate for Payer: Employer Direct Commercial	$10,651.89
Rate for Payer: Humana Medicare/TRICARE	$10,651.89
Rate for Payer: Molina Dual Medicare/Medicaid	$10,651.89
Rate for Payer: Molina Medicare	$10,651.89
Rate for Payer: Multiplan Auto	$15,013.80
Rate for Payer: Multiplan Commercial	$15,013.80
Rate for Payer: Multiplan Workers Comp	$15,013.80
Rate for Payer: Scott and White EPO/PPO	$6,914.25
Rate for Payer: Scott and White Medicare	$10,651.89
Rate for Payer: Superior Health Plan EPO	$10,651.89
Rate for Payer: Superior Health Plan Medicare	$10,651.89
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,651.89
Rate for Payer: Universal American Medicare	$10,651.89
Rate for Payer: Wellcare Medicare	$10,651.89
Rate for Payer: Wellmed Medicare	$10,651.89

AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC

Facility

$20,816.40

Service Code	MSDRG 560
Min. Negotiated Rate	$8,786.62
Max. Negotiated Rate	$20,816.40
Rate for Payer: BCBS of TX Blue Advantage	$8,786.62
Rate for Payer: BCBS of TX Blue Essentials	$10,542.92
Rate for Payer: BCBS of TX PPO	$11,714.81

AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC

Facility

$33,915.00

Service Code	MSDRG 559
Min. Negotiated Rate	$15,468.82
Max. Negotiated Rate	$33,915.00
Rate for Payer: BCBS of TX Blue Advantage	$15,468.82
Rate for Payer: BCBS of TX Blue Essentials	$18,560.79
Rate for Payer: BCBS of TX PPO	$20,623.89

AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC

Facility

$15,013.80

Service Code	MSDRG 561
Min. Negotiated Rate	$6,502.46
Max. Negotiated Rate	$15,013.80
Rate for Payer: BCBS of TX Blue Advantage	$6,502.46
Rate for Payer: BCBS of TX Blue Essentials	$7,802.20
Rate for Payer: BCBS of TX PPO	$8,669.44

Know your out-of-pocket cost for care.

All Charges