White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Medline frame headrest positioner, 6' high with 10.75 x 9.75 base

Facility

$53.64

Hospital Charge Code	992932
Hospital Revenue Code	270
Rate for Payer: Cash Price	$36.48

Med Nutrition Therapy Re-Eval per 15 Min

Facility

$102.00

Service Code	HCPCS 97803
Hospital Charge Code	8994982
Hospital Revenue Code	942
Min. Negotiated Rate	$9.18
Max. Negotiated Rate	$73.44
Rate for Payer: Amerigroup CHIP/Medicaid	$9.18
Rate for Payer: BCBS of TX Blue Advantage	$30.60
Rate for Payer: BCBS of TX Blue Essentials	$36.72
Rate for Payer: BCBS of TX PPO	$40.80
Rate for Payer: Cash Price	$69.36
Rate for Payer: Cash Price	$69.36
Rate for Payer: Cigna Medicaid	$73.44
Rate for Payer: Molina CHIP/Medicaid	$73.44
Rate for Payer: Multiplan Auto	$66.30
Rate for Payer: Multiplan Commercial	$66.30
Rate for Payer: Multiplan Workers Comp	$66.30
Rate for Payer: Parkland Medicaid	$73.44
Rate for Payer: Scott and White EPO/PPO	$33.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$73.44
Rate for Payer: Superior Health Plan EPO	$13.87

Med Nutrition Therapy Re-Eval per 15 Min

Facility

$102.00

Service Code	HCPCS 97803
Hospital Charge Code	8582486
Hospital Revenue Code	942
Min. Negotiated Rate	$9.18
Max. Negotiated Rate	$73.44
Rate for Payer: Amerigroup CHIP/Medicaid	$9.18
Rate for Payer: BCBS of TX Blue Advantage	$30.60
Rate for Payer: BCBS of TX Blue Essentials	$36.72
Rate for Payer: BCBS of TX PPO	$40.80
Rate for Payer: Cash Price	$69.36
Rate for Payer: Cash Price	$69.36
Rate for Payer: Cigna Medicaid	$73.44
Rate for Payer: Molina CHIP/Medicaid	$73.44
Rate for Payer: Multiplan Auto	$66.30
Rate for Payer: Multiplan Commercial	$66.30
Rate for Payer: Multiplan Workers Comp	$66.30
Rate for Payer: Parkland Medicaid	$73.44
Rate for Payer: Scott and White EPO/PPO	$33.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$73.44
Rate for Payer: Superior Health Plan EPO	$13.87

Med Nutrition Therapy Re-Eval per 15 Min

Facility

$102.00

Service Code	HCPCS 97803
Hospital Charge Code	8582486
Hospital Revenue Code	942
Rate for Payer: Cash Price	$69.36

Med Nutrition Therapy Re-Eval per 15 Min

Facility

$102.00

Service Code	HCPCS 97803
Hospital Charge Code	8994982
Hospital Revenue Code	942
Rate for Payer: Cash Price	$69.36

MEDTRONIC ENDURANT II AAA 16X10

Facility

$29,669.00

Service Code	HCPCS C1874
Hospital Charge Code	8484499
Hospital Revenue Code	278
Min. Negotiated Rate	$7,417.25
Max. Negotiated Rate	$14,834.50
Rate for Payer: Cash Price	$20,174.92
Rate for Payer: Cigna Commercial	$7,417.25
Rate for Payer: Multiplan Auto	$14,834.50
Rate for Payer: Multiplan Commercial	$14,834.50
Rate for Payer: Multiplan Workers Comp	$14,834.50
Rate for Payer: Scott and White EPO/PPO	$14,834.50

MEDTRONIC ENDURANT II AAA 16X10

Facility

$29,669.00

Service Code	HCPCS C1874
Hospital Charge Code	8484499
Hospital Revenue Code	278
Min. Negotiated Rate	$2,670.21
Max. Negotiated Rate	$21,361.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2,670.21
Rate for Payer: BCBS of TX Blue Advantage	$8,900.70
Rate for Payer: BCBS of TX Blue Essentials	$10,680.84
Rate for Payer: BCBS of TX PPO	$11,867.60
Rate for Payer: Cash Price	$20,174.92
Rate for Payer: Cigna Medicaid	$21,361.68
Rate for Payer: Molina CHIP/Medicaid	$21,361.68
Rate for Payer: Multiplan Auto	$14,834.50
Rate for Payer: Multiplan Commercial	$14,834.50
Rate for Payer: Multiplan Workers Comp	$14,834.50
Rate for Payer: Parkland Medicaid	$21,361.68
Rate for Payer: Scott and White EPO/PPO	$14,834.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,361.68
Rate for Payer: Superior Health Plan EPO	$4,034.98

MEDTRONIC ENDURANT II AAA 16X16

Facility

$28,012.00

Service Code	HCPCS C1874
Hospital Charge Code	8484504
Hospital Revenue Code	278
Min. Negotiated Rate	$2,521.08
Max. Negotiated Rate	$20,168.64
Rate for Payer: Amerigroup CHIP/Medicaid	$2,521.08
Rate for Payer: BCBS of TX Blue Advantage	$8,403.60
Rate for Payer: BCBS of TX Blue Essentials	$10,084.32
Rate for Payer: BCBS of TX PPO	$11,204.80
Rate for Payer: Cash Price	$19,048.16
Rate for Payer: Cigna Medicaid	$20,168.64
Rate for Payer: Molina CHIP/Medicaid	$20,168.64
Rate for Payer: Multiplan Auto	$14,006.00
Rate for Payer: Multiplan Commercial	$14,006.00
Rate for Payer: Multiplan Workers Comp	$14,006.00
Rate for Payer: Parkland Medicaid	$20,168.64
Rate for Payer: Scott and White EPO/PPO	$14,006.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,168.64
Rate for Payer: Superior Health Plan EPO	$3,809.63

MEDTRONIC ENDURANT II AAA 16X16

Facility

$28,012.00

Service Code	HCPCS C1874
Hospital Charge Code	8484504
Hospital Revenue Code	278
Min. Negotiated Rate	$7,003.00
Max. Negotiated Rate	$14,006.00
Rate for Payer: Cash Price	$19,048.16
Rate for Payer: Cigna Commercial	$7,003.00
Rate for Payer: Multiplan Auto	$14,006.00
Rate for Payer: Multiplan Commercial	$14,006.00
Rate for Payer: Multiplan Workers Comp	$14,006.00
Rate for Payer: Scott and White EPO/PPO	$14,006.00

MEDTRONIC ENDURANT II AAA 16X24

Facility

$29,669.00

Service Code	HCPCS C1874
Hospital Charge Code	8484494
Hospital Revenue Code	278
Min. Negotiated Rate	$2,670.21
Max. Negotiated Rate	$21,361.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2,670.21
Rate for Payer: BCBS of TX Blue Advantage	$8,900.70
Rate for Payer: BCBS of TX Blue Essentials	$10,680.84
Rate for Payer: BCBS of TX PPO	$11,867.60
Rate for Payer: Cash Price	$20,174.92
Rate for Payer: Cigna Medicaid	$21,361.68
Rate for Payer: Molina CHIP/Medicaid	$21,361.68
Rate for Payer: Multiplan Auto	$14,834.50
Rate for Payer: Multiplan Commercial	$14,834.50
Rate for Payer: Multiplan Workers Comp	$14,834.50
Rate for Payer: Parkland Medicaid	$21,361.68
Rate for Payer: Scott and White EPO/PPO	$14,834.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,361.68
Rate for Payer: Superior Health Plan EPO	$4,034.98

MEDTRONIC ENDURANT II AAA 16X24

Facility

$29,669.00

Service Code	HCPCS C1874
Hospital Charge Code	8484494
Hospital Revenue Code	278
Min. Negotiated Rate	$7,417.25
Max. Negotiated Rate	$14,834.50
Rate for Payer: Cash Price	$20,174.92
Rate for Payer: Cigna Commercial	$7,417.25
Rate for Payer: Multiplan Auto	$14,834.50
Rate for Payer: Multiplan Commercial	$14,834.50
Rate for Payer: Multiplan Workers Comp	$14,834.50
Rate for Payer: Scott and White EPO/PPO	$14,834.50

MEDTRONIC ENDURANT II ILIAC GRAFT 28X14

Facility

$60,090.00

Service Code	HCPCS C1874
Hospital Charge Code	8484500
Hospital Revenue Code	278
Min. Negotiated Rate	$15,022.50
Max. Negotiated Rate	$30,045.00
Rate for Payer: Cash Price	$40,861.20
Rate for Payer: Cigna Commercial	$15,022.50
Rate for Payer: Multiplan Auto	$30,045.00
Rate for Payer: Multiplan Commercial	$30,045.00
Rate for Payer: Multiplan Workers Comp	$30,045.00
Rate for Payer: Scott and White EPO/PPO	$30,045.00

MEDTRONIC ENDURANT II ILIAC GRAFT 28X14

Facility

$60,090.00

Service Code	HCPCS C1874
Hospital Charge Code	8484500
Hospital Revenue Code	278
Min. Negotiated Rate	$5,408.10
Max. Negotiated Rate	$43,264.80
Rate for Payer: Amerigroup CHIP/Medicaid	$5,408.10
Rate for Payer: BCBS of TX Blue Advantage	$18,027.00
Rate for Payer: BCBS of TX Blue Essentials	$21,632.40
Rate for Payer: BCBS of TX PPO	$24,036.00
Rate for Payer: Cash Price	$40,861.20
Rate for Payer: Cigna Medicaid	$43,264.80
Rate for Payer: Molina CHIP/Medicaid	$43,264.80
Rate for Payer: Multiplan Auto	$30,045.00
Rate for Payer: Multiplan Commercial	$30,045.00
Rate for Payer: Multiplan Workers Comp	$30,045.00
Rate for Payer: Parkland Medicaid	$43,264.80
Rate for Payer: Scott and White EPO/PPO	$30,045.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43,264.80
Rate for Payer: Superior Health Plan EPO	$8,172.24

megestrol 40 mg/mL Oral Susp 10 mL

Facility

$25.09

Service Code	HCPCS j3490
Hospital Charge Code	77681482
Hospital Revenue Code	250
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$18.06
Rate for Payer: Amerigroup CHIP/Medicaid	$2.26
Rate for Payer: BCBS of TX Blue Advantage	$7.53
Rate for Payer: BCBS of TX Blue Essentials	$9.03
Rate for Payer: BCBS of TX PPO	$10.04
Rate for Payer: Cash Price	$17.06
Rate for Payer: Cigna Medicaid	$18.06
Rate for Payer: Molina CHIP/Medicaid	$18.06
Rate for Payer: Multiplan Auto	$16.31
Rate for Payer: Multiplan Commercial	$16.31
Rate for Payer: Multiplan Workers Comp	$16.31
Rate for Payer: Parkland Medicaid	$18.06
Rate for Payer: Scott and White EPO/PPO	$12.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.06
Rate for Payer: Superior Health Plan EPO	$3.41

megestrol 40 mg/mL Oral Susp 10 mL

Facility

$25.09

Service Code	HCPCS j3490
Hospital Charge Code	77681482
Hospital Revenue Code	250
Rate for Payer: Cash Price	$17.06

melatonin 3 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77682000
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

melatonin 3 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77682000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

meloxicam 7.5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77682253
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

meloxicam 7.5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77682253
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

memantine 5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77887503
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

memantine 5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77887503
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

MEMBRANE AMNIOTIC 4X4FUSECHOICE

Facility

$8,133.00

Service Code	HCPCS Q4205
Hospital Charge Code	145508
Hospital Revenue Code	278
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$5,855.76
Rate for Payer: Amerigroup CHIP/Medicaid	$731.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$14.83
Rate for Payer: BCBS of TX Blue Essentials	$17.80
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$19.74
Rate for Payer: Cash Price	$5,530.44
Rate for Payer: Cash Price	$5,530.44
Rate for Payer: Cash Price	$5,530.44
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$5,855.76
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$5,855.76
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$4,066.50
Rate for Payer: Multiplan Commercial	$4,066.50
Rate for Payer: Multiplan Workers Comp	$4,066.50
Rate for Payer: Parkland Medicaid	$5,855.76
Rate for Payer: Scott and White EPO/PPO	$4,066.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,855.76
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

MEMBRANE AMNIOTIC 4X4FUSECHOICE

Facility

$8,133.00

Service Code	HCPCS Q4205
Hospital Charge Code	145508
Hospital Revenue Code	278
Min. Negotiated Rate	$2,033.25
Max. Negotiated Rate	$4,066.50
Rate for Payer: Cash Price	$5,530.44
Rate for Payer: Cigna Commercial	$2,033.25
Rate for Payer: Multiplan Auto	$4,066.50
Rate for Payer: Multiplan Commercial	$4,066.50
Rate for Payer: Multiplan Workers Comp	$4,066.50
Rate for Payer: Scott and White EPO/PPO	$4,066.50

Membrane graft or membrane wrap - per unit/ sq. cm

Facility

$771.08

Service Code	HCPCS Q4205
Hospital Charge Code	99154
Hospital Revenue Code	278
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$555.18
Rate for Payer: Amerigroup CHIP/Medicaid	$69.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$14.83
Rate for Payer: BCBS of TX Blue Essentials	$17.80
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$19.74
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$555.18
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$555.18
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$385.54
Rate for Payer: Multiplan Commercial	$385.54
Rate for Payer: Multiplan Workers Comp	$385.54
Rate for Payer: Parkland Medicaid	$555.18
Rate for Payer: Scott and White EPO/PPO	$385.54
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$555.18
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

Membrane graft or membrane wrap - per unit/ sq. cm

Facility

$771.08

Service Code	HCPCS Q4205
Hospital Charge Code	99154
Hospital Revenue Code	278
Min. Negotiated Rate	$192.77
Max. Negotiated Rate	$385.54
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cigna Commercial	$192.77
Rate for Payer: Multiplan Auto	$385.54
Rate for Payer: Multiplan Commercial	$385.54
Rate for Payer: Multiplan Workers Comp	$385.54
Rate for Payer: Scott and White EPO/PPO	$385.54

Know your out-of-pocket cost for care.

All Charges