White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MASK, OXYGEN ETCO2 LL CAPF CO2 SMPL LN RBGP 7FT-10 -- DHF

Facility

$43.13

Hospital Charge Code	82057050
Hospital Revenue Code	270
Rate for Payer: Cash Price	$29.33

MASK, OXYGEN ETCO2 LL CAPF CO2 SMPL LN RBGP 7FT-10 -- DHF

Facility

$43.13

Hospital Charge Code	82057050
Hospital Revenue Code	270
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$31.05
Rate for Payer: Amerigroup CHIP/Medicaid	$3.88
Rate for Payer: BCBS of TX Blue Advantage	$12.94
Rate for Payer: BCBS of TX Blue Essentials	$15.53
Rate for Payer: BCBS of TX PPO	$17.25
Rate for Payer: Cash Price	$29.33
Rate for Payer: Cigna Medicaid	$31.05
Rate for Payer: Molina CHIP/Medicaid	$31.05
Rate for Payer: Multiplan Auto	$28.03
Rate for Payer: Multiplan Commercial	$28.03
Rate for Payer: Multiplan Workers Comp	$28.03
Rate for Payer: Parkland Medicaid	$31.05
Rate for Payer: Scott and White EPO/PPO	$21.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.05
Rate for Payer: Superior Health Plan EPO	$5.87

MASK, OXY, NONREBREATHING, ADLT, 7', UC

Facility

$5.15

Hospital Charge Code	993315
Hospital Revenue Code	270
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$3.71
Rate for Payer: Amerigroup CHIP/Medicaid	$0.46
Rate for Payer: BCBS of TX Blue Advantage	$1.54
Rate for Payer: BCBS of TX Blue Essentials	$1.85
Rate for Payer: BCBS of TX PPO	$2.06
Rate for Payer: Cash Price	$3.50
Rate for Payer: Cigna Medicaid	$3.71
Rate for Payer: Molina CHIP/Medicaid	$3.71
Rate for Payer: Multiplan Auto	$3.35
Rate for Payer: Multiplan Commercial	$3.35
Rate for Payer: Multiplan Workers Comp	$3.35
Rate for Payer: Parkland Medicaid	$3.71
Rate for Payer: Scott and White EPO/PPO	$2.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.71
Rate for Payer: Superior Health Plan EPO	$0.70

MASK, OXY, NONREBREATHING, ADLT, 7', UC

Facility

$5.15

Hospital Charge Code	993315
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.50

MASK, SURGICAL, ANTIFOG ADHESIVE

Facility

$1.55

Hospital Charge Code	993775
Hospital Revenue Code	271
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$1.12
Rate for Payer: Amerigroup CHIP/Medicaid	$0.14
Rate for Payer: BCBS of TX Blue Advantage	$0.47
Rate for Payer: BCBS of TX Blue Essentials	$0.56
Rate for Payer: BCBS of TX PPO	$0.62
Rate for Payer: Cash Price	$1.05
Rate for Payer: Cigna Medicaid	$1.12
Rate for Payer: Molina CHIP/Medicaid	$1.12
Rate for Payer: Multiplan Auto	$1.01
Rate for Payer: Multiplan Commercial	$1.01
Rate for Payer: Multiplan Workers Comp	$1.01
Rate for Payer: Parkland Medicaid	$1.12
Rate for Payer: Scott and White EPO/PPO	$0.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.12
Rate for Payer: Superior Health Plan EPO	$0.21

MASK, SURGICAL, ANTIFOG ADHESIVE

Facility

$1.55

Hospital Charge Code	993775
Hospital Revenue Code	271
Rate for Payer: Cash Price	$1.05

MASK, SURGICAL, INSTA GARD, POLY

Facility

$0.57

Hospital Charge Code	993725
Hospital Revenue Code	271
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.41
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.17
Rate for Payer: BCBS of TX Blue Essentials	$0.21
Rate for Payer: BCBS of TX PPO	$0.23
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna Medicaid	$0.41
Rate for Payer: Molina CHIP/Medicaid	$0.41
Rate for Payer: Multiplan Auto	$0.37
Rate for Payer: Multiplan Commercial	$0.37
Rate for Payer: Multiplan Workers Comp	$0.37
Rate for Payer: Parkland Medicaid	$0.41
Rate for Payer: Scott and White EPO/PPO	$0.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.41
Rate for Payer: Superior Health Plan EPO	$0.08

MASK, SURGICAL, INSTA GARD, POLY

Facility

$0.57

Hospital Charge Code	993725
Hospital Revenue Code	271
Rate for Payer: Cash Price	$0.39

MASK, SURGICAL, LEVEL, 1, TIES, BLUE

Facility

$0.57

Hospital Charge Code	993724
Hospital Revenue Code	271
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.41
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.17
Rate for Payer: BCBS of TX Blue Essentials	$0.21
Rate for Payer: BCBS of TX PPO	$0.23
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna Medicaid	$0.41
Rate for Payer: Molina CHIP/Medicaid	$0.41
Rate for Payer: Multiplan Auto	$0.37
Rate for Payer: Multiplan Commercial	$0.37
Rate for Payer: Multiplan Workers Comp	$0.37
Rate for Payer: Parkland Medicaid	$0.41
Rate for Payer: Scott and White EPO/PPO	$0.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.41
Rate for Payer: Superior Health Plan EPO	$0.08

MASK, SURGICAL, LEVEL, 1, TIES, BLUE

Facility

$0.57

Hospital Charge Code	993724
Hospital Revenue Code	271
Rate for Payer: Cash Price	$0.39

MASK SURG PLTD LVL 1 TIES BLU

Facility

$0.90

Hospital Charge Code	993055
Hospital Revenue Code	270
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.65
Rate for Payer: Amerigroup CHIP/Medicaid	$0.08
Rate for Payer: BCBS of TX Blue Advantage	$0.27
Rate for Payer: BCBS of TX Blue Essentials	$0.32
Rate for Payer: BCBS of TX PPO	$0.36
Rate for Payer: Cash Price	$0.61
Rate for Payer: Cigna Medicaid	$0.65
Rate for Payer: Molina CHIP/Medicaid	$0.65
Rate for Payer: Multiplan Auto	$0.59
Rate for Payer: Multiplan Commercial	$0.59
Rate for Payer: Multiplan Workers Comp	$0.59
Rate for Payer: Parkland Medicaid	$0.65
Rate for Payer: Scott and White EPO/PPO	$0.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.65
Rate for Payer: Superior Health Plan EPO	$0.12

MASK SURG PLTD LVL 1 TIES BLU

Facility

$0.90

Hospital Charge Code	993055
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.61

MASK SURG PLTD LVL 1 TIES GRN

Facility

$1.48

Hospital Charge Code	993058
Hospital Revenue Code	270
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$1.07
Rate for Payer: Amerigroup CHIP/Medicaid	$0.13
Rate for Payer: BCBS of TX Blue Advantage	$0.44
Rate for Payer: BCBS of TX Blue Essentials	$0.53
Rate for Payer: BCBS of TX PPO	$0.59
Rate for Payer: Cash Price	$1.01
Rate for Payer: Cigna Medicaid	$1.07
Rate for Payer: Molina CHIP/Medicaid	$1.07
Rate for Payer: Multiplan Auto	$0.96
Rate for Payer: Multiplan Commercial	$0.96
Rate for Payer: Multiplan Workers Comp	$0.96
Rate for Payer: Parkland Medicaid	$1.07
Rate for Payer: Scott and White EPO/PPO	$0.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.07
Rate for Payer: Superior Health Plan EPO	$0.20

MASK SURG PLTD LVL 1 TIES GRN

Facility

$1.48

Hospital Charge Code	993058
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.01

MASK, TIE, SURGICAL, INSTGARD, FLUID RES

Facility

$2.54

Hospital Charge Code	992968
Hospital Revenue Code	270
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$1.83
Rate for Payer: Amerigroup CHIP/Medicaid	$0.23
Rate for Payer: BCBS of TX Blue Advantage	$0.76
Rate for Payer: BCBS of TX Blue Essentials	$0.91
Rate for Payer: BCBS of TX PPO	$1.02
Rate for Payer: Cash Price	$1.73
Rate for Payer: Cigna Medicaid	$1.83
Rate for Payer: Molina CHIP/Medicaid	$1.83
Rate for Payer: Multiplan Auto	$1.65
Rate for Payer: Multiplan Commercial	$1.65
Rate for Payer: Multiplan Workers Comp	$1.65
Rate for Payer: Parkland Medicaid	$1.83
Rate for Payer: Scott and White EPO/PPO	$1.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.83
Rate for Payer: Superior Health Plan EPO	$0.35

MASK, TIE, SURGICAL, INSTGARD, FLUID RES

Facility

$2.54

Hospital Charge Code	992968
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.73

Mastectomy for gynecomastia

Facility

$10,000.00

Service Code	CPT 19300
Hospital Charge Code	36019300
Hospital Revenue Code	360
Min. Negotiated Rate	$963.66
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$963.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Amerigroup Medicare	$3,933.28
Rate for Payer: BCBS of TX Blue Advantage	$5,059.35
Rate for Payer: BCBS of TX Blue Essentials	$6,059.10
Rate for Payer: BCBS of TX Medicare	$3,933.28
Rate for Payer: BCBS of TX PPO	$7,634.47
Rate for Payer: Cigna Commercial	$8,314.23
Rate for Payer: Cigna Medicare	$3,933.28
Rate for Payer: Employer Direct Commercial	$3,933.28
Rate for Payer: Humana Medicare/TRICARE	$3,933.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Molina Medicare	$3,933.28
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	$7,276.57
Rate for Payer: Scott and White Medicare	$3,933.28
Rate for Payer: Superior Health Plan EPO	$3,933.28
Rate for Payer: Superior Health Plan Medicare	$3,933.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Universal American Medicare	$3,933.28
Rate for Payer: Wellcare Medicare	$3,933.28
Rate for Payer: Wellmed Medicare	$3,933.28

Mastectomy for gynecomastia

Facility

$12,745.43

Service Code	HCPCS 19300
Hospital Charge Code	9900153
Hospital Revenue Code	360
Min. Negotiated Rate	$963.66
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$963.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Amerigroup Medicare	$3,933.28
Rate for Payer: BCBS of TX Blue Advantage	$5,059.35
Rate for Payer: BCBS of TX Blue Essentials	$6,059.10
Rate for Payer: BCBS of TX Medicare	$3,933.28
Rate for Payer: BCBS of TX PPO	$7,634.47
Rate for Payer: Cash Price	$8,666.89
Rate for Payer: Cash Price	$8,666.89
Rate for Payer: Cash Price	$8,666.89
Rate for Payer: Cigna Commercial	$8,314.23
Rate for Payer: Cigna Medicaid	$9,176.71
Rate for Payer: Cigna Medicare	$3,933.28
Rate for Payer: Employer Direct Commercial	$3,933.28
Rate for Payer: Humana Medicare/TRICARE	$3,933.28
Rate for Payer: Molina CHIP/Medicaid	$9,176.71
Rate for Payer: Molina Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Molina Medicare	$3,933.28
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	$9,176.71
Rate for Payer: Scott and White EPO/PPO	$7,276.57
Rate for Payer: Scott and White Medicare	$3,933.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,176.71
Rate for Payer: Superior Health Plan EPO	$3,933.28
Rate for Payer: Superior Health Plan Medicare	$3,933.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Universal American Medicare	$3,933.28
Rate for Payer: Wellcare Medicare	$3,933.28
Rate for Payer: Wellmed Medicare	$3,933.28

Mastectomy for gynecomastia

Facility

$12,745.43

Service Code	HCPCS 19300
Hospital Charge Code	9900153
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,666.89

MASTECTOMY FOR MALIGNANCY W CC/MCC

Facility

$36,605.40

Service Code	MSDRG 582
Min. Negotiated Rate	$13,497.70
Max. Negotiated Rate	$36,605.40
Rate for Payer: BCBS of TX Blue Advantage	$13,497.70
Rate for Payer: BCBS of TX Blue Essentials	$16,195.67
Rate for Payer: BCBS of TX PPO	$17,995.89

MASTECTOMY FOR MALIGNANCY WITH CC/MCC

Facility

$36,605.40

Service Code	MSDRG 582
Min. Negotiated Rate	$13,497.70
Max. Negotiated Rate	$36,605.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,880.20
Rate for Payer: Amerigroup Medicare	$18,880.20
Rate for Payer: BCBS of TX Medicare	$18,880.20
Rate for Payer: Cigna Commercial	$24,814.61
Rate for Payer: Cigna Medicare	$18,880.20
Rate for Payer: Employer Direct Commercial	$18,880.20
Rate for Payer: Humana Medicare/TRICARE	$18,880.20
Rate for Payer: Molina Dual Medicare/Medicaid	$18,880.20
Rate for Payer: Molina Medicare	$18,880.20
Rate for Payer: Multiplan Auto	$36,605.40
Rate for Payer: Multiplan Commercial	$36,605.40
Rate for Payer: Multiplan Workers Comp	$36,605.40
Rate for Payer: Scott and White EPO/PPO	$16,857.75
Rate for Payer: Scott and White Medicare	$18,880.20
Rate for Payer: Superior Health Plan EPO	$18,880.20
Rate for Payer: Superior Health Plan Medicare	$18,880.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,880.20
Rate for Payer: Universal American Medicare	$18,880.20
Rate for Payer: Wellcare Medicare	$18,880.20
Rate for Payer: Wellmed Medicare	$18,880.20

MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC

Facility

$32,763.60

Service Code	MSDRG 583
Min. Negotiated Rate	$11,851.66
Max. Negotiated Rate	$32,763.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,398.25
Rate for Payer: Amerigroup Medicare	$17,398.25
Rate for Payer: BCBS of TX Medicare	$17,398.25
Rate for Payer: Cigna Commercial	$22,210.27
Rate for Payer: Cigna Medicare	$17,398.25
Rate for Payer: Employer Direct Commercial	$17,398.25
Rate for Payer: Humana Medicare/TRICARE	$17,398.25
Rate for Payer: Molina Dual Medicare/Medicaid	$17,398.25
Rate for Payer: Molina Medicare	$17,398.25
Rate for Payer: Multiplan Auto	$32,763.60
Rate for Payer: Multiplan Commercial	$32,763.60
Rate for Payer: Multiplan Workers Comp	$32,763.60
Rate for Payer: Scott and White EPO/PPO	$15,088.50
Rate for Payer: Scott and White Medicare	$17,398.25
Rate for Payer: Superior Health Plan EPO	$17,398.25
Rate for Payer: Superior Health Plan Medicare	$17,398.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,398.25
Rate for Payer: Universal American Medicare	$17,398.25
Rate for Payer: Wellcare Medicare	$17,398.25
Rate for Payer: Wellmed Medicare	$17,398.25

MASTECTOMY FOR MALIGNANCY W/O CC/MCC

Facility

$32,763.60

Service Code	MSDRG 583
Min. Negotiated Rate	$11,851.66
Max. Negotiated Rate	$32,763.60
Rate for Payer: BCBS of TX Blue Advantage	$11,851.66
Rate for Payer: BCBS of TX Blue Essentials	$14,220.61
Rate for Payer: BCBS of TX PPO	$15,801.29

Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)

Facility

$13,655.82

Service Code	HCPCS 19301
Hospital Charge Code	9900154
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,285.96

Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)

Facility

$10,000.00

Service Code	CPT 19301
Hospital Charge Code	36019301
Hospital Revenue Code	360
Min. Negotiated Rate	$963.66
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$963.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Amerigroup Medicare	$3,933.28
Rate for Payer: BCBS of TX Blue Advantage	$5,059.35
Rate for Payer: BCBS of TX Blue Essentials	$6,059.10
Rate for Payer: BCBS of TX Medicare	$3,933.28
Rate for Payer: BCBS of TX PPO	$7,634.47
Rate for Payer: Cigna Commercial	$8,314.23
Rate for Payer: Cigna Medicare	$3,933.28
Rate for Payer: Employer Direct Commercial	$3,933.28
Rate for Payer: Humana Medicare/TRICARE	$3,933.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Molina Medicare	$3,933.28
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	$7,276.57
Rate for Payer: Scott and White Medicare	$3,933.28
Rate for Payer: Superior Health Plan EPO	$3,933.28
Rate for Payer: Superior Health Plan Medicare	$3,933.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Universal American Medicare	$3,933.28
Rate for Payer: Wellcare Medicare	$3,933.28
Rate for Payer: Wellmed Medicare	$3,933.28

Know your out-of-pocket cost for care.

All Charges