White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Stereotactic computer-assisted (navigational) procedure; cranial, extradural

Facility

$10,000.00

Service Code	CPT 61782
Hospital Charge Code	36061782
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$10,000.00
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

sterile water Inj Soln 1000 mL

Facility

$128.17

Service Code	HCPCS A4217
Hospital Charge Code	77827275
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

sterile water Inj Soln 1000 mL

Facility

$128.17

Service Code	HCPCS A4217
Hospital Charge Code	77827275
Hospital Revenue Code	258
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$83.31
Rate for Payer: Aetna Commercial	$70.49
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$5.28
Rate for Payer: BCBS of TX Blue Essentials	$6.33
Rate for Payer: BCBS of TX PPO	$7.03
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

ST GASTROSTOMY -- DHF

Facility

$2,295.27

Hospital Charge Code	81772402
Hospital Revenue Code	272
Min. Negotiated Rate	$206.57
Max. Negotiated Rate	$1,491.93
Rate for Payer: Aetna Commercial	$1,262.40
Rate for Payer: Amerigroup CHIP/Medicaid	$206.57
Rate for Payer: BCBS of TX Blue Advantage	$688.58
Rate for Payer: BCBS of TX Blue Essentials	$826.30
Rate for Payer: BCBS of TX PPO	$918.11
Rate for Payer: Cash Price	$2,019.84
Rate for Payer: Multiplan Auto	$1,491.93
Rate for Payer: Multiplan Commercial	$1,491.93
Rate for Payer: Multiplan Workers Comp	$1,491.93
Rate for Payer: Scott and White EPO/PPO	$1,147.64
Rate for Payer: Superior Health Plan EPO	$312.16

ST GASTROSTOMY -- DHF

Facility

$2,295.27

Hospital Charge Code	81772402
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,019.84

ST INFUS EXT -- DHF

Facility

$230.22

Hospital Charge Code	80341662
Hospital Revenue Code	270
Min. Negotiated Rate	$20.72
Max. Negotiated Rate	$149.64
Rate for Payer: Aetna Commercial	$126.62
Rate for Payer: Amerigroup CHIP/Medicaid	$20.72
Rate for Payer: BCBS of TX Blue Advantage	$69.07
Rate for Payer: BCBS of TX Blue Essentials	$82.88
Rate for Payer: BCBS of TX PPO	$92.09
Rate for Payer: Cash Price	$202.59
Rate for Payer: Multiplan Auto	$149.64
Rate for Payer: Multiplan Commercial	$149.64
Rate for Payer: Multiplan Workers Comp	$149.64
Rate for Payer: Scott and White EPO/PPO	$115.11
Rate for Payer: Superior Health Plan EPO	$31.31

ST INFUS EXT -- DHF

Facility

$230.22

Hospital Charge Code	80341662
Hospital Revenue Code	270
Rate for Payer: Cash Price	$202.59

ST INTRO PEEL-AWAY -- DHF

Facility

$224.14

Service Code	HCPCS C1892
Hospital Charge Code	82485509
Hospital Revenue Code	272
Min. Negotiated Rate	$20.17
Max. Negotiated Rate	$145.69
Rate for Payer: Aetna Commercial	$123.28
Rate for Payer: Amerigroup CHIP/Medicaid	$20.17
Rate for Payer: BCBS of TX Blue Advantage	$67.24
Rate for Payer: BCBS of TX Blue Essentials	$80.69
Rate for Payer: BCBS of TX PPO	$89.66
Rate for Payer: Cash Price	$197.24
Rate for Payer: Multiplan Auto	$145.69
Rate for Payer: Multiplan Commercial	$145.69
Rate for Payer: Multiplan Workers Comp	$145.69
Rate for Payer: Scott and White EPO/PPO	$112.07
Rate for Payer: Superior Health Plan EPO	$30.48

ST INTRO PEEL-AWAY -- DHF

Facility

$224.14

Service Code	HCPCS C1892
Hospital Charge Code	82485509
Hospital Revenue Code	272
Rate for Payer: Cash Price	$197.24

ST IRG TUR -- DHF

Facility

$241.69

Hospital Charge Code	54200696
Hospital Revenue Code	270
Min. Negotiated Rate	$21.75
Max. Negotiated Rate	$157.10
Rate for Payer: Aetna Commercial	$132.93
Rate for Payer: Amerigroup CHIP/Medicaid	$21.75
Rate for Payer: BCBS of TX Blue Advantage	$72.51
Rate for Payer: BCBS of TX Blue Essentials	$87.01
Rate for Payer: BCBS of TX PPO	$96.68
Rate for Payer: Cash Price	$212.69
Rate for Payer: Multiplan Auto	$157.10
Rate for Payer: Multiplan Commercial	$157.10
Rate for Payer: Multiplan Workers Comp	$157.10
Rate for Payer: Scott and White EPO/PPO	$120.84
Rate for Payer: Superior Health Plan EPO	$32.87

ST IRG TUR -- DHF

Facility

$241.69

Hospital Charge Code	54200696
Hospital Revenue Code	270
Rate for Payer: Cash Price	$212.69

ST IV ADD 3 -- DHF

Facility

$110.27

Hospital Charge Code	54200035
Hospital Revenue Code	270
Rate for Payer: Cash Price	$97.04

ST IV ADD 3 -- DHF

Facility

$110.27

Hospital Charge Code	54200035
Hospital Revenue Code	270
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$71.68
Rate for Payer: Aetna Commercial	$60.65
Rate for Payer: Amerigroup CHIP/Medicaid	$9.92
Rate for Payer: BCBS of TX Blue Advantage	$33.08
Rate for Payer: BCBS of TX Blue Essentials	$39.70
Rate for Payer: BCBS of TX PPO	$44.11
Rate for Payer: Cash Price	$97.04
Rate for Payer: Multiplan Auto	$71.68
Rate for Payer: Multiplan Commercial	$71.68
Rate for Payer: Multiplan Workers Comp	$71.68
Rate for Payer: Scott and White EPO/PPO	$55.14
Rate for Payer: Superior Health Plan EPO	$15.00

ST IV ADM -- DHF

Facility

$89.07

Hospital Charge Code	54200936
Hospital Revenue Code	272
Rate for Payer: Cash Price	$78.38

ST IV ADM -- DHF

Facility

$89.07

Hospital Charge Code	54200936
Hospital Revenue Code	272
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$57.90
Rate for Payer: Aetna Commercial	$48.99
Rate for Payer: Amerigroup CHIP/Medicaid	$8.02
Rate for Payer: BCBS of TX Blue Advantage	$26.72
Rate for Payer: BCBS of TX Blue Essentials	$32.07
Rate for Payer: BCBS of TX PPO	$35.63
Rate for Payer: Cash Price	$78.38
Rate for Payer: Multiplan Auto	$57.90
Rate for Payer: Multiplan Commercial	$57.90
Rate for Payer: Multiplan Workers Comp	$57.90
Rate for Payer: Scott and White EPO/PPO	$44.54
Rate for Payer: Superior Health Plan EPO	$12.11

ST IV EXT 2 -- DHF

Facility

$69.98

Hospital Charge Code	54200803
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$45.49
Rate for Payer: Aetna Commercial	$38.49
Rate for Payer: Amerigroup CHIP/Medicaid	$6.30
Rate for Payer: BCBS of TX Blue Advantage	$20.99
Rate for Payer: BCBS of TX Blue Essentials	$25.19
Rate for Payer: BCBS of TX PPO	$27.99
Rate for Payer: Cash Price	$61.58
Rate for Payer: Multiplan Auto	$45.49
Rate for Payer: Multiplan Commercial	$45.49
Rate for Payer: Multiplan Workers Comp	$45.49
Rate for Payer: Scott and White EPO/PPO	$34.99
Rate for Payer: Superior Health Plan EPO	$9.52

ST IV EXT 2 -- DHF

Facility

$69.98

Hospital Charge Code	54200803
Hospital Revenue Code	270
Rate for Payer: Cash Price	$61.58

ST IV INF 23X3/4 -- DHF

Facility

$36.06

Hospital Charge Code	54200175
Hospital Revenue Code	270
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$23.44
Rate for Payer: Aetna Commercial	$19.83
Rate for Payer: Amerigroup CHIP/Medicaid	$3.25
Rate for Payer: BCBS of TX Blue Advantage	$10.82
Rate for Payer: BCBS of TX Blue Essentials	$12.98
Rate for Payer: BCBS of TX PPO	$14.42
Rate for Payer: Cash Price	$31.73
Rate for Payer: Multiplan Auto	$23.44
Rate for Payer: Multiplan Commercial	$23.44
Rate for Payer: Multiplan Workers Comp	$23.44
Rate for Payer: Scott and White EPO/PPO	$18.03
Rate for Payer: Superior Health Plan EPO	$4.90

ST IV INF 23X3/4 -- DHF

Facility

$36.06

Hospital Charge Code	54200175
Hospital Revenue Code	270
Rate for Payer: Cash Price	$31.73

ST IV SEC N/V -- DHF

Facility

$343.57

Hospital Charge Code	54200266
Hospital Revenue Code	270
Rate for Payer: Cash Price	$302.34

ST IV SEC N/V -- DHF

Facility

$343.57

Hospital Charge Code	54200266
Hospital Revenue Code	270
Min. Negotiated Rate	$30.92
Max. Negotiated Rate	$223.32
Rate for Payer: Aetna Commercial	$188.96
Rate for Payer: Amerigroup CHIP/Medicaid	$30.92
Rate for Payer: BCBS of TX Blue Advantage	$103.07
Rate for Payer: BCBS of TX Blue Essentials	$123.69
Rate for Payer: BCBS of TX PPO	$137.43
Rate for Payer: Cash Price	$302.34
Rate for Payer: Multiplan Auto	$223.32
Rate for Payer: Multiplan Commercial	$223.32
Rate for Payer: Multiplan Workers Comp	$223.32
Rate for Payer: Scott and White EPO/PPO	$171.78
Rate for Payer: Superior Health Plan EPO	$46.73

ST IV START -- DHF

Facility

$110.27

Hospital Charge Code	54201017
Hospital Revenue Code	270
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$71.68
Rate for Payer: Aetna Commercial	$60.65
Rate for Payer: Amerigroup CHIP/Medicaid	$9.92
Rate for Payer: BCBS of TX Blue Advantage	$33.08
Rate for Payer: BCBS of TX Blue Essentials	$39.70
Rate for Payer: BCBS of TX PPO	$44.11
Rate for Payer: Cash Price	$97.04
Rate for Payer: Multiplan Auto	$71.68
Rate for Payer: Multiplan Commercial	$71.68
Rate for Payer: Multiplan Workers Comp	$71.68
Rate for Payer: Scott and White EPO/PPO	$55.14
Rate for Payer: Superior Health Plan EPO	$15.00

ST IV START -- DHF

Facility

$110.27

Hospital Charge Code	54201017
Hospital Revenue Code	270
Rate for Payer: Cash Price	$97.04

ST NDL BX -- DHF

Facility

$176.60

Hospital Charge Code	80827413
Hospital Revenue Code	272
Min. Negotiated Rate	$15.89
Max. Negotiated Rate	$114.79
Rate for Payer: Aetna Commercial	$97.13
Rate for Payer: Amerigroup CHIP/Medicaid	$15.89
Rate for Payer: BCBS of TX Blue Advantage	$52.98
Rate for Payer: BCBS of TX Blue Essentials	$63.58
Rate for Payer: BCBS of TX PPO	$70.64
Rate for Payer: Cash Price	$155.41
Rate for Payer: Multiplan Auto	$114.79
Rate for Payer: Multiplan Commercial	$114.79
Rate for Payer: Multiplan Workers Comp	$114.79
Rate for Payer: Scott and White EPO/PPO	$88.30
Rate for Payer: Superior Health Plan EPO	$24.02

ST NDL BX -- DHF

Facility

$176.60

Hospital Charge Code	80827413
Hospital Revenue Code	272
Rate for Payer: Cash Price	$155.41

Know your out-of-pocket cost for care.

All Charges