White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BLANKET WARMING FULL BODY

Facility

$104.05

Hospital Charge Code	8538531
Hospital Revenue Code	272
Min. Negotiated Rate	$9.36
Max. Negotiated Rate	$67.63
Rate for Payer: Aetna Commercial	$57.23
Rate for Payer: Amerigroup CHIP/Medicaid	$9.36
Rate for Payer: BCBS of TX Blue Advantage	$31.22
Rate for Payer: BCBS of TX Blue Essentials	$37.46
Rate for Payer: BCBS of TX PPO	$41.62
Rate for Payer: Cash Price	$91.56
Rate for Payer: Multiplan Auto	$67.63
Rate for Payer: Multiplan Commercial	$67.63
Rate for Payer: Multiplan Workers Comp	$67.63
Rate for Payer: Scott and White EPO/PPO	$52.02
Rate for Payer: Superior Health Plan EPO	$14.15

BLANKET WARMING FULL BODY

Facility

$104.05

Hospital Charge Code	8538531
Hospital Revenue Code	272
Rate for Payer: Cash Price	$91.56

BLANKET WARMING HALF BODY

Facility

$23.24

Hospital Charge Code	8538532
Hospital Revenue Code	272
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$15.11
Rate for Payer: Aetna Commercial	$12.78
Rate for Payer: Amerigroup CHIP/Medicaid	$2.09
Rate for Payer: BCBS of TX Blue Advantage	$6.97
Rate for Payer: BCBS of TX Blue Essentials	$8.37
Rate for Payer: BCBS of TX PPO	$9.30
Rate for Payer: Cash Price	$20.45
Rate for Payer: Multiplan Auto	$15.11
Rate for Payer: Multiplan Commercial	$15.11
Rate for Payer: Multiplan Workers Comp	$15.11
Rate for Payer: Scott and White EPO/PPO	$11.62
Rate for Payer: Superior Health Plan EPO	$3.16

BLANKET WARMING HALF BODY

Facility

$23.24

Hospital Charge Code	8538532
Hospital Revenue Code	272
Rate for Payer: Cash Price	$20.45

BLANKET, WARMING MULTI POSITION UPPER BODY 24X78'''' -- DHF

Facility

$45.82

Hospital Charge Code	80334659
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$29.78
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$40.32
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan EPO	$6.23

BLD ARTHRO -- DHF

Facility

$681.00

Hospital Charge Code	81713505
Hospital Revenue Code	272
Min. Negotiated Rate	$61.29
Max. Negotiated Rate	$442.65
Rate for Payer: Aetna Commercial	$374.55
Rate for Payer: Amerigroup CHIP/Medicaid	$61.29
Rate for Payer: BCBS of TX Blue Advantage	$204.30
Rate for Payer: BCBS of TX Blue Essentials	$245.16
Rate for Payer: BCBS of TX PPO	$272.40
Rate for Payer: Cash Price	$599.28
Rate for Payer: Multiplan Auto	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
Rate for Payer: Scott and White EPO/PPO	$340.50
Rate for Payer: Superior Health Plan EPO	$92.62

BLD ARTHRO -- DHF

Facility

$681.00

Hospital Charge Code	81713505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$599.28

BLD BONE GRAFT -- DHF

Facility

$680.11

Hospital Charge Code	81722555
Hospital Revenue Code	272
Min. Negotiated Rate	$61.21
Max. Negotiated Rate	$442.07
Rate for Payer: Aetna Commercial	$374.06
Rate for Payer: Amerigroup CHIP/Medicaid	$61.21
Rate for Payer: BCBS of TX Blue Advantage	$204.03
Rate for Payer: BCBS of TX Blue Essentials	$244.84
Rate for Payer: BCBS of TX PPO	$272.04
Rate for Payer: Cash Price	$598.50
Rate for Payer: Multiplan Auto	$442.07
Rate for Payer: Multiplan Commercial	$442.07
Rate for Payer: Multiplan Workers Comp	$442.07
Rate for Payer: Scott and White EPO/PPO	$340.06
Rate for Payer: Superior Health Plan EPO	$92.49

BLD BONE GRAFT -- DHF

Facility

$680.11

Hospital Charge Code	81722555
Hospital Revenue Code	272
Rate for Payer: Cash Price	$598.50

BLD BONE LG HA -- DHF

Facility

$1,282.55

Hospital Charge Code	81722605
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,128.64

BLD BONE LG HA -- DHF

Facility

$1,282.55

Hospital Charge Code	81722605
Hospital Revenue Code	272
Min. Negotiated Rate	$115.43
Max. Negotiated Rate	$833.66
Rate for Payer: Aetna Commercial	$705.40
Rate for Payer: Amerigroup CHIP/Medicaid	$115.43
Rate for Payer: BCBS of TX Blue Advantage	$384.76
Rate for Payer: BCBS of TX Blue Essentials	$461.72
Rate for Payer: BCBS of TX PPO	$513.02
Rate for Payer: Cash Price	$1,128.64
Rate for Payer: Multiplan Auto	$833.66
Rate for Payer: Multiplan Commercial	$833.66
Rate for Payer: Multiplan Workers Comp	$833.66
Rate for Payer: Scott and White EPO/PPO	$641.28
Rate for Payer: Superior Health Plan EPO	$174.43

BLD OTOLARYNGOLOY DISP -- DHF

Facility

$967.14

Hospital Charge Code	81723249
Hospital Revenue Code	272
Min. Negotiated Rate	$87.04
Max. Negotiated Rate	$628.64
Rate for Payer: Aetna Commercial	$531.93
Rate for Payer: Amerigroup CHIP/Medicaid	$87.04
Rate for Payer: BCBS of TX Blue Advantage	$290.14
Rate for Payer: BCBS of TX Blue Essentials	$348.17
Rate for Payer: BCBS of TX PPO	$386.86
Rate for Payer: Cash Price	$851.08
Rate for Payer: Multiplan Auto	$628.64
Rate for Payer: Multiplan Commercial	$628.64
Rate for Payer: Multiplan Workers Comp	$628.64
Rate for Payer: Scott and White EPO/PPO	$483.57
Rate for Payer: Superior Health Plan EPO	$131.53

BLD OTOLARYNGOLOY DISP -- DHF

Facility

$967.14

Hospital Charge Code	81723249
Hospital Revenue Code	272
Rate for Payer: Cash Price	$851.08

BLD PLASMA -- DHF

Facility

$2,601.42

Hospital Charge Code	81812349
Hospital Revenue Code	272
Min. Negotiated Rate	$234.13
Max. Negotiated Rate	$1,690.92
Rate for Payer: Aetna Commercial	$1,430.78
Rate for Payer: Amerigroup CHIP/Medicaid	$234.13
Rate for Payer: BCBS of TX Blue Advantage	$780.43
Rate for Payer: BCBS of TX Blue Essentials	$936.51
Rate for Payer: BCBS of TX PPO	$1,040.57
Rate for Payer: Cash Price	$2,289.25
Rate for Payer: Multiplan Auto	$1,690.92
Rate for Payer: Multiplan Commercial	$1,690.92
Rate for Payer: Multiplan Workers Comp	$1,690.92
Rate for Payer: Scott and White EPO/PPO	$1,300.71
Rate for Payer: Superior Health Plan EPO	$353.79

BLD PLASMA -- DHF

Facility

$2,601.42

Hospital Charge Code	81812349
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,289.25

BLD SINUS RADICAL DISP -- DHF

Facility

$790.48

Hospital Charge Code	81723660
Hospital Revenue Code	272
Min. Negotiated Rate	$71.14
Max. Negotiated Rate	$513.81
Rate for Payer: Aetna Commercial	$434.76
Rate for Payer: Amerigroup CHIP/Medicaid	$71.14
Rate for Payer: BCBS of TX Blue Advantage	$237.14
Rate for Payer: BCBS of TX Blue Essentials	$284.57
Rate for Payer: BCBS of TX PPO	$316.19
Rate for Payer: Cash Price	$695.62
Rate for Payer: Multiplan Auto	$513.81
Rate for Payer: Multiplan Commercial	$513.81
Rate for Payer: Multiplan Workers Comp	$513.81
Rate for Payer: Scott and White EPO/PPO	$395.24
Rate for Payer: Superior Health Plan EPO	$107.51

BLD SINUS RADICAL DISP -- DHF

Facility

$790.48

Hospital Charge Code	81723660
Hospital Revenue Code	272
Rate for Payer: Cash Price	$695.62

Blepharoplasty, upper eyelid

Facility

$10,000.00

Service Code	CPT 15822
Hospital Charge Code	36015822
Hospital Revenue Code	360
Min. Negotiated Rate	$36.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,501.68
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Amerigroup Medicare	$1,667.79
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$1,667.79
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$3,778.02
Rate for Payer: Cigna Medicaid	$709.01
Rate for Payer: Cigna Medicare	$1,667.79
Rate for Payer: Employer Direct Commercial	$1,667.79
Rate for Payer: Humana Medicare/TRICARE	$1,667.79
Rate for Payer: Molina CHIP/Medicaid	$709.01
Rate for Payer: Molina Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Molina Medicare	$1,667.79
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	$709.01
Rate for Payer: Scott and White EPO/PPO	$36.79
Rate for Payer: Scott and White Medicare	$1,667.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$709.01
Rate for Payer: Superior Health Plan EPO	$1,667.79
Rate for Payer: Superior Health Plan Medicare	$1,667.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Universal American Medicare	$1,667.79
Rate for Payer: Wellcare Medicare	$1,667.79
Rate for Payer: Wellmed Medicare	$1,667.79

Blepharoplasty, upper eyelid; with excessive skin weighting down lid

Facility

$10,000.00

Service Code	CPT 15823
Hospital Charge Code	36015823
Hospital Revenue Code	360
Min. Negotiated Rate	$36.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,501.68
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Amerigroup Medicare	$1,667.79
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$1,667.79
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$3,778.02
Rate for Payer: Cigna Medicaid	$709.01
Rate for Payer: Cigna Medicare	$1,667.79
Rate for Payer: Employer Direct Commercial	$1,667.79
Rate for Payer: Humana Medicare/TRICARE	$1,667.79
Rate for Payer: Molina CHIP/Medicaid	$709.01
Rate for Payer: Molina Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Molina Medicare	$1,667.79
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	$709.01
Rate for Payer: Scott and White EPO/PPO	$36.79
Rate for Payer: Scott and White Medicare	$1,667.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$709.01
Rate for Payer: Superior Health Plan EPO	$1,667.79
Rate for Payer: Superior Health Plan Medicare	$1,667.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Universal American Medicare	$1,667.79
Rate for Payer: Wellcare Medicare	$1,667.79
Rate for Payer: Wellmed Medicare	$1,667.79

BLOCKER ENDOBRONCHIAL RUSCH EZ-BLOCK

Facility

$894.38

Hospital Charge Code	145525
Hospital Revenue Code	272
Min. Negotiated Rate	$80.49
Max. Negotiated Rate	$581.35
Rate for Payer: Aetna Commercial	$491.91
Rate for Payer: Amerigroup CHIP/Medicaid	$80.49
Rate for Payer: BCBS of TX Blue Advantage	$268.31
Rate for Payer: BCBS of TX Blue Essentials	$321.98
Rate for Payer: BCBS of TX PPO	$357.75
Rate for Payer: Cash Price	$787.05
Rate for Payer: Multiplan Auto	$581.35
Rate for Payer: Multiplan Commercial	$581.35
Rate for Payer: Multiplan Workers Comp	$581.35
Rate for Payer: Scott and White EPO/PPO	$447.19
Rate for Payer: Superior Health Plan EPO	$121.64

BLOCKER ENDOBRONCHIAL RUSCH EZ-BLOCK

Facility

$894.38

Hospital Charge Code	145525
Hospital Revenue Code	272
Rate for Payer: Cash Price	$787.05

Blood Administration Complete

Facility

$2,059.00

Service Code	CPT 36430
Hospital Charge Code	2408664
Hospital Revenue Code	391
Rate for Payer: Cash Price	$1,811.92

Blood Administration Complete

Facility

$2,059.00

Service Code	CPT 36430
Hospital Charge Code	2408664
Hospital Revenue Code	391
Min. Negotiated Rate	$7.10
Max. Negotiated Rate	$1,338.35
Rate for Payer: Aetna Commercial	$1,132.45
Rate for Payer: Aetna Medicare	$595.52
Rate for Payer: Amerigroup CHIP/Medicaid	$185.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$397.01
Rate for Payer: Amerigroup Medicare	$397.01
Rate for Payer: BCBS of TX Blue Advantage	$58.47
Rate for Payer: BCBS of TX Blue Essentials	$70.02
Rate for Payer: BCBS of TX Medicare	$397.01
Rate for Payer: BCBS of TX PPO	$88.23
Rate for Payer: Cash Price	$1,811.92
Rate for Payer: Cash Price	$1,811.92
Rate for Payer: Cash Price	$1,811.92
Rate for Payer: Cigna Commercial	$899.35
Rate for Payer: Cigna Medicaid	$30.73
Rate for Payer: Cigna Medicare	$397.01
Rate for Payer: Employer Direct Commercial	$397.01
Rate for Payer: Humana Medicare/TRICARE	$397.01
Rate for Payer: Molina CHIP/Medicaid	$30.73
Rate for Payer: Molina Dual Medicare/Medicaid	$397.01
Rate for Payer: Molina Medicare	$397.01
Rate for Payer: Multiplan Auto	$1,338.35
Rate for Payer: Multiplan Commercial	$1,338.35
Rate for Payer: Multiplan Workers Comp	$1,338.35
Rate for Payer: Parkland Medicaid	$30.73
Rate for Payer: Scott and White EPO/PPO	$7.10
Rate for Payer: Scott and White Medicare	$397.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.73
Rate for Payer: Superior Health Plan EPO	$397.01
Rate for Payer: Superior Health Plan Medicare	$397.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$397.01
Rate for Payer: Universal American Medicare	$397.01
Rate for Payer: Wellcare Medicare	$397.01
Rate for Payer: Wellmed Medicare	$397.01

Blood Administration Complete Blood Bank BCE

Facility

$2,059.00

Service Code	CPT 36430
Hospital Charge Code	2408664
Hospital Revenue Code	391
Min. Negotiated Rate	$7.10
Max. Negotiated Rate	$1,338.35
Rate for Payer: Aetna Commercial	$1,132.45
Rate for Payer: Aetna Medicare	$595.52
Rate for Payer: Amerigroup CHIP/Medicaid	$185.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$397.01
Rate for Payer: Amerigroup Medicare	$397.01
Rate for Payer: BCBS of TX Blue Advantage	$58.47
Rate for Payer: BCBS of TX Blue Essentials	$70.02
Rate for Payer: BCBS of TX Medicare	$397.01
Rate for Payer: BCBS of TX PPO	$88.23
Rate for Payer: Cash Price	$1,811.92
Rate for Payer: Cash Price	$1,811.92
Rate for Payer: Cash Price	$1,811.92
Rate for Payer: Cigna Commercial	$899.35
Rate for Payer: Cigna Medicaid	$30.73
Rate for Payer: Cigna Medicare	$397.01
Rate for Payer: Employer Direct Commercial	$397.01
Rate for Payer: Humana Medicare/TRICARE	$397.01
Rate for Payer: Molina CHIP/Medicaid	$30.73
Rate for Payer: Molina Dual Medicare/Medicaid	$397.01
Rate for Payer: Molina Medicare	$397.01
Rate for Payer: Multiplan Auto	$1,338.35
Rate for Payer: Multiplan Commercial	$1,338.35
Rate for Payer: Multiplan Workers Comp	$1,338.35
Rate for Payer: Parkland Medicaid	$30.73
Rate for Payer: Scott and White EPO/PPO	$7.10
Rate for Payer: Scott and White Medicare	$397.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.73
Rate for Payer: Superior Health Plan EPO	$397.01
Rate for Payer: Superior Health Plan Medicare	$397.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$397.01
Rate for Payer: Universal American Medicare	$397.01
Rate for Payer: Wellcare Medicare	$397.01
Rate for Payer: Wellmed Medicare	$397.01

BLOOD ADMIN SET KENTEC 039600F

Facility

$65.96

Hospital Charge Code	8568497
Hospital Revenue Code	272
Rate for Payer: Cash Price	$58.04

Know your out-of-pocket cost for care.

All Charges