White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Streptococcus pneumoniae Ag SO

Facility

$138.00

Service Code	CPT 87899
Hospital Charge Code	1605872
Hospital Revenue Code	306
Rate for Payer: Cash Price	$121.44

Streptococcus Pneumoniae Antigen Urine

Facility

$117.00

Service Code	CPT 87899
Hospital Charge Code	4107893
Hospital Revenue Code	306
Rate for Payer: Cash Price	$102.96

Streptococcus Pneumoniae Antigen Urine

Facility

$117.00

Service Code	CPT 87899
Hospital Charge Code	4107893
Hospital Revenue Code	306
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$76.05
Rate for Payer: Aetna Commercial	$16.87
Rate for Payer: Aetna Medicare	$24.10
Rate for Payer: Amerigroup CHIP/Medicaid	$6.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.07
Rate for Payer: Amerigroup Medicare	$16.07
Rate for Payer: BCBS of TX Blue Advantage	$26.52
Rate for Payer: BCBS of TX Blue Essentials	$31.82
Rate for Payer: BCBS of TX Medicare	$16.07
Rate for Payer: BCBS of TX PPO	$35.51
Rate for Payer: Cash Price	$102.96
Rate for Payer: Cash Price	$102.96
Rate for Payer: Cigna Medicaid	$16.07
Rate for Payer: Cigna Medicare	$16.07
Rate for Payer: Employer Direct Commercial	$16.07
Rate for Payer: Humana Medicare/TRICARE	$16.07
Rate for Payer: Molina CHIP/Medicaid	$16.07
Rate for Payer: Molina Dual Medicare/Medicaid	$16.07
Rate for Payer: Molina Medicare	$16.07
Rate for Payer: Multiplan Auto	$76.05
Rate for Payer: Multiplan Commercial	$76.05
Rate for Payer: Multiplan Workers Comp	$76.05
Rate for Payer: Parkland Medicaid	$16.07
Rate for Payer: Scott and White EPO/PPO	$20.09
Rate for Payer: Scott and White Medicare	$16.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.07
Rate for Payer: Superior Health Plan EPO	$16.07
Rate for Payer: Superior Health Plan Medicare	$16.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.07
Rate for Payer: Universal American Medicare	$16.07
Rate for Payer: Wellcare Medicare	$16.07
Rate for Payer: Wellmed Medicare	$16.07

Stress Echo w/ Dobutamine 93350

Facility

$2,782.00

Service Code	CPT 93350
Hospital Charge Code	2800555
Hospital Revenue Code	480
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$1,808.30
Rate for Payer: Aetna Commercial	$206.63
Rate for Payer: Aetna Medicare	$756.80
Rate for Payer: Amerigroup CHIP/Medicaid	$250.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$504.53
Rate for Payer: Amerigroup Medicare	$504.53
Rate for Payer: BCBS of TX Blue Advantage	$206.31
Rate for Payer: BCBS of TX Blue Essentials	$246.63
Rate for Payer: BCBS of TX Medicare	$504.53
Rate for Payer: BCBS of TX PPO	$275.08
Rate for Payer: Cash Price	$2,448.16
Rate for Payer: Cash Price	$2,448.16
Rate for Payer: Cash Price	$2,448.16
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicaid	$185.11
Rate for Payer: Cigna Medicare	$504.53
Rate for Payer: Employer Direct Commercial	$504.53
Rate for Payer: Humana Medicare/TRICARE	$504.53
Rate for Payer: Molina CHIP/Medicaid	$185.11
Rate for Payer: Molina Dual Medicare/Medicaid	$504.53
Rate for Payer: Molina Medicare	$504.53
Rate for Payer: Multiplan Auto	$1,808.30
Rate for Payer: Multiplan Commercial	$1,808.30
Rate for Payer: Multiplan Workers Comp	$1,808.30
Rate for Payer: Parkland Medicaid	$185.11
Rate for Payer: Scott and White EPO/PPO	$9.02
Rate for Payer: Scott and White Medicare	$504.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$185.11
Rate for Payer: Superior Health Plan EPO	$504.53
Rate for Payer: Superior Health Plan Medicare	$504.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$504.53
Rate for Payer: Universal American Medicare	$504.53
Rate for Payer: Wellcare Medicare	$504.53
Rate for Payer: Wellmed Medicare	$504.53

Stress Echo w/ Dobutamine 93350 BCE

Facility

$2,782.00

Service Code	CPT 93350
Hospital Charge Code	2800555
Hospital Revenue Code	480
Rate for Payer: Cash Price	$2,448.16

Stress Echo w/ Dobutamine 93350 BCE

Facility

$2,782.00

Service Code	CPT 93350
Hospital Charge Code	2800555
Hospital Revenue Code	480
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$1,808.30
Rate for Payer: Aetna Commercial	$206.63
Rate for Payer: Aetna Medicare	$756.80
Rate for Payer: Amerigroup CHIP/Medicaid	$250.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$504.53
Rate for Payer: Amerigroup Medicare	$504.53
Rate for Payer: BCBS of TX Blue Advantage	$206.31
Rate for Payer: BCBS of TX Blue Essentials	$246.63
Rate for Payer: BCBS of TX Medicare	$504.53
Rate for Payer: BCBS of TX PPO	$275.08
Rate for Payer: Cash Price	$2,448.16
Rate for Payer: Cash Price	$2,448.16
Rate for Payer: Cash Price	$2,448.16
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicaid	$185.11
Rate for Payer: Cigna Medicare	$504.53
Rate for Payer: Employer Direct Commercial	$504.53
Rate for Payer: Humana Medicare/TRICARE	$504.53
Rate for Payer: Molina CHIP/Medicaid	$185.11
Rate for Payer: Molina Dual Medicare/Medicaid	$504.53
Rate for Payer: Molina Medicare	$504.53
Rate for Payer: Multiplan Auto	$1,808.30
Rate for Payer: Multiplan Commercial	$1,808.30
Rate for Payer: Multiplan Workers Comp	$1,808.30
Rate for Payer: Parkland Medicaid	$185.11
Rate for Payer: Scott and White EPO/PPO	$9.02
Rate for Payer: Scott and White Medicare	$504.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$185.11
Rate for Payer: Superior Health Plan EPO	$504.53
Rate for Payer: Superior Health Plan Medicare	$504.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$504.53
Rate for Payer: Universal American Medicare	$504.53
Rate for Payer: Wellcare Medicare	$504.53
Rate for Payer: Wellmed Medicare	$504.53

Stresss TTE Complete 93351

Facility

$2,991.00

Service Code	CPT 93351
Hospital Charge Code	2810003
Hospital Revenue Code	483
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$1,944.15
Rate for Payer: Aetna Commercial	$260.94
Rate for Payer: Aetna Medicare	$756.80
Rate for Payer: Amerigroup CHIP/Medicaid	$269.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$504.53
Rate for Payer: Amerigroup Medicare	$504.53
Rate for Payer: BCBS of TX Blue Advantage	$260.23
Rate for Payer: BCBS of TX Blue Essentials	$311.08
Rate for Payer: BCBS of TX Medicare	$504.53
Rate for Payer: BCBS of TX PPO	$346.98
Rate for Payer: Cash Price	$2,632.08
Rate for Payer: Cash Price	$2,632.08
Rate for Payer: Cash Price	$2,632.08
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicare	$504.53
Rate for Payer: Employer Direct Commercial	$504.53
Rate for Payer: Humana Medicare/TRICARE	$504.53
Rate for Payer: Molina Dual Medicare/Medicaid	$504.53
Rate for Payer: Molina Medicare	$504.53
Rate for Payer: Multiplan Auto	$1,944.15
Rate for Payer: Multiplan Commercial	$1,944.15
Rate for Payer: Multiplan Workers Comp	$1,944.15
Rate for Payer: Scott and White EPO/PPO	$9.02
Rate for Payer: Scott and White Medicare	$504.53
Rate for Payer: Superior Health Plan EPO	$504.53
Rate for Payer: Superior Health Plan Medicare	$504.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$504.53
Rate for Payer: Universal American Medicare	$504.53
Rate for Payer: Wellcare Medicare	$504.53
Rate for Payer: Wellmed Medicare	$504.53

Stresss TTE Complete 93351 BCE

Facility

$2,991.00

Service Code	CPT 93351
Hospital Charge Code	2810003
Hospital Revenue Code	483
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$1,944.15
Rate for Payer: Aetna Commercial	$260.94
Rate for Payer: Aetna Medicare	$756.80
Rate for Payer: Amerigroup CHIP/Medicaid	$269.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$504.53
Rate for Payer: Amerigroup Medicare	$504.53
Rate for Payer: BCBS of TX Blue Advantage	$260.23
Rate for Payer: BCBS of TX Blue Essentials	$311.08
Rate for Payer: BCBS of TX Medicare	$504.53
Rate for Payer: BCBS of TX PPO	$346.98
Rate for Payer: Cash Price	$2,632.08
Rate for Payer: Cash Price	$2,632.08
Rate for Payer: Cash Price	$2,632.08
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicare	$504.53
Rate for Payer: Employer Direct Commercial	$504.53
Rate for Payer: Humana Medicare/TRICARE	$504.53
Rate for Payer: Molina Dual Medicare/Medicaid	$504.53
Rate for Payer: Molina Medicare	$504.53
Rate for Payer: Multiplan Auto	$1,944.15
Rate for Payer: Multiplan Commercial	$1,944.15
Rate for Payer: Multiplan Workers Comp	$1,944.15
Rate for Payer: Scott and White EPO/PPO	$9.02
Rate for Payer: Scott and White Medicare	$504.53
Rate for Payer: Superior Health Plan EPO	$504.53
Rate for Payer: Superior Health Plan Medicare	$504.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$504.53
Rate for Payer: Universal American Medicare	$504.53
Rate for Payer: Wellcare Medicare	$504.53
Rate for Payer: Wellmed Medicare	$504.53

Stresss TTE Complete 93351 BCE

Facility

$2,991.00

Service Code	CPT 93351
Hospital Charge Code	2810003
Hospital Revenue Code	483
Rate for Payer: Cash Price	$2,632.08

STRIP, BOVINE PERICARDIUM DRY PROXI NEW GEN 21MM -- DHF

Facility

$2,715.43

Service Code	HCPCS C1713
Hospital Charge Code	81853418
Hospital Revenue Code	278
Min. Negotiated Rate	$244.39
Max. Negotiated Rate	$1,357.72
Rate for Payer: Aetna Commercial	$814.63
Rate for Payer: Amerigroup CHIP/Medicaid	$244.39
Rate for Payer: BCBS of TX Blue Advantage	$814.63
Rate for Payer: BCBS of TX Blue Essentials	$977.55
Rate for Payer: BCBS of TX PPO	$1,086.17
Rate for Payer: Cash Price	$2,389.58
Rate for Payer: Multiplan Auto	$1,357.72
Rate for Payer: Multiplan Commercial	$1,357.72
Rate for Payer: Multiplan Workers Comp	$1,357.72
Rate for Payer: Scott and White EPO/PPO	$1,357.72
Rate for Payer: Superior Health Plan EPO	$369.30

STRIP, BOVINE PERICARDIUM DRY PROXI NEW GEN 21MM -- DHF

Facility

$2,715.43

Service Code	HCPCS C1713
Hospital Charge Code	81853418
Hospital Revenue Code	278
Min. Negotiated Rate	$678.86
Max. Negotiated Rate	$1,357.72
Rate for Payer: Aetna Commercial	$814.63
Rate for Payer: Cash Price	$2,389.58
Rate for Payer: Cigna Commercial	$678.86
Rate for Payer: Multiplan Auto	$1,357.72
Rate for Payer: Multiplan Commercial	$1,357.72
Rate for Payer: Multiplan Workers Comp	$1,357.72
Rate for Payer: Scott and White EPO/PPO	$1,357.72

STRIP, BOVINE PERICARDIUM DRY VERITAS ECHELON 60 -- DHF

Facility

$1,408.61

Service Code	HCPCS C1713
Hospital Charge Code	81851388
Hospital Revenue Code	278
Min. Negotiated Rate	$352.15
Max. Negotiated Rate	$704.30
Rate for Payer: Aetna Commercial	$422.58
Rate for Payer: Cash Price	$1,239.58
Rate for Payer: Cigna Commercial	$352.15
Rate for Payer: Multiplan Auto	$704.30
Rate for Payer: Multiplan Commercial	$704.30
Rate for Payer: Multiplan Workers Comp	$704.30
Rate for Payer: Scott and White EPO/PPO	$704.30

STRIP, BOVINE PERICARDIUM DRY VERITAS ECHELON 60 -- DHF

Facility

$1,408.61

Service Code	HCPCS C1713
Hospital Charge Code	81851388
Hospital Revenue Code	278
Min. Negotiated Rate	$126.77
Max. Negotiated Rate	$704.30
Rate for Payer: Aetna Commercial	$422.58
Rate for Payer: Amerigroup CHIP/Medicaid	$126.77
Rate for Payer: BCBS of TX Blue Advantage	$422.58
Rate for Payer: BCBS of TX Blue Essentials	$507.10
Rate for Payer: BCBS of TX PPO	$563.44
Rate for Payer: Cash Price	$1,239.58
Rate for Payer: Multiplan Auto	$704.30
Rate for Payer: Multiplan Commercial	$704.30
Rate for Payer: Multiplan Workers Comp	$704.30
Rate for Payer: Scott and White EPO/PPO	$704.30
Rate for Payer: Superior Health Plan EPO	$191.57

ST THROMB ZELANTE DVT -- DHF

Facility

$23,204.82

Service Code	HCPCS C1757
Hospital Charge Code	80585003
Hospital Revenue Code	278
Min. Negotiated Rate	$2,088.43
Max. Negotiated Rate	$11,602.41
Rate for Payer: Aetna Commercial	$6,961.45
Rate for Payer: Amerigroup CHIP/Medicaid	$2,088.43
Rate for Payer: BCBS of TX Blue Advantage	$6,961.45
Rate for Payer: BCBS of TX Blue Essentials	$8,353.74
Rate for Payer: BCBS of TX PPO	$9,281.93
Rate for Payer: Cash Price	$20,420.24
Rate for Payer: Multiplan Auto	$11,602.41
Rate for Payer: Multiplan Commercial	$11,602.41
Rate for Payer: Multiplan Workers Comp	$11,602.41
Rate for Payer: Scott and White EPO/PPO	$11,602.41
Rate for Payer: Superior Health Plan EPO	$3,155.86

ST THROMB ZELANTE DVT -- DHF

Facility

$23,204.82

Service Code	HCPCS C1757
Hospital Charge Code	80585003
Hospital Revenue Code	278
Min. Negotiated Rate	$5,801.20
Max. Negotiated Rate	$11,602.41
Rate for Payer: Aetna Commercial	$6,961.45
Rate for Payer: Cash Price	$20,420.24
Rate for Payer: Cigna Commercial	$5,801.20
Rate for Payer: Multiplan Auto	$11,602.41
Rate for Payer: Multiplan Commercial	$11,602.41
Rate for Payer: Multiplan Workers Comp	$11,602.41
Rate for Payer: Scott and White EPO/PPO	$11,602.41

ST TSR IMP -- DHF

Facility

$170.92

Hospital Charge Code	80827785
Hospital Revenue Code	270
Min. Negotiated Rate	$15.38
Max. Negotiated Rate	$111.10
Rate for Payer: Aetna Commercial	$94.01
Rate for Payer: Amerigroup CHIP/Medicaid	$15.38
Rate for Payer: BCBS of TX Blue Advantage	$51.28
Rate for Payer: BCBS of TX Blue Essentials	$61.53
Rate for Payer: BCBS of TX PPO	$68.37
Rate for Payer: Cash Price	$150.41
Rate for Payer: Multiplan Auto	$111.10
Rate for Payer: Multiplan Commercial	$111.10
Rate for Payer: Multiplan Workers Comp	$111.10
Rate for Payer: Scott and White EPO/PPO	$85.46
Rate for Payer: Superior Health Plan EPO	$23.25

ST TSR IMP -- DHF

Facility

$170.92

Hospital Charge Code	80827785
Hospital Revenue Code	270
Rate for Payer: Cash Price	$150.41

ST TUBING REFIL -- DHF

Facility

$82.27

Hospital Charge Code	81853103
Hospital Revenue Code	270
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$53.48
Rate for Payer: Aetna Commercial	$45.25
Rate for Payer: Amerigroup CHIP/Medicaid	$7.40
Rate for Payer: BCBS of TX Blue Advantage	$24.68
Rate for Payer: BCBS of TX Blue Essentials	$29.62
Rate for Payer: BCBS of TX PPO	$32.91
Rate for Payer: Cash Price	$72.40
Rate for Payer: Multiplan Auto	$53.48
Rate for Payer: Multiplan Commercial	$53.48
Rate for Payer: Multiplan Workers Comp	$53.48
Rate for Payer: Scott and White EPO/PPO	$41.14
Rate for Payer: Superior Health Plan EPO	$11.19

ST TUBING REFIL -- DHF

Facility

$82.27

Hospital Charge Code	81853103
Hospital Revenue Code	270
Rate for Payer: Cash Price	$72.40

STYLET PERITONEAL CATHETER

Facility

$227.00

Service Code	HCPCS C1729
Hospital Charge Code	8484502
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$147.55
Rate for Payer: Aetna Commercial	$124.85
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$199.76
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan EPO	$30.87

STYLET PERITONEAL CATHETER

Facility

$227.00

Service Code	HCPCS C1729
Hospital Charge Code	8484502
Hospital Revenue Code	272
Rate for Payer: Cash Price	$199.76

STYLET RT RGD GLIDESCOPE

Facility

$174.79

Hospital Charge Code	115522
Hospital Revenue Code	272
Min. Negotiated Rate	$15.73
Max. Negotiated Rate	$113.61
Rate for Payer: Aetna Commercial	$96.13
Rate for Payer: Amerigroup CHIP/Medicaid	$15.73
Rate for Payer: BCBS of TX Blue Advantage	$52.44
Rate for Payer: BCBS of TX Blue Essentials	$62.92
Rate for Payer: BCBS of TX PPO	$69.92
Rate for Payer: Cash Price	$153.82
Rate for Payer: Multiplan Auto	$113.61
Rate for Payer: Multiplan Commercial	$113.61
Rate for Payer: Multiplan Workers Comp	$113.61
Rate for Payer: Scott and White EPO/PPO	$87.40
Rate for Payer: Superior Health Plan EPO	$23.77

STYLET RT RGD GLIDESCOPE

Facility

$174.79

Hospital Charge Code	115522
Hospital Revenue Code	272
Rate for Payer: Cash Price	$153.82

Submucous resection inferior turbinate, partial or complete, any method

Facility

$10,000.00

Service Code	CPT 30140
Hospital Charge Code	36030140
Hospital Revenue Code	360
Min. Negotiated Rate	$64.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,416.74
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,944.49
Rate for Payer: Amerigroup Medicare	$2,944.49
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$2,944.49
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cigna Commercial	$6,670.12
Rate for Payer: Cigna Medicaid	$886.62
Rate for Payer: Cigna Medicare	$2,944.49
Rate for Payer: Employer Direct Commercial	$2,944.49
Rate for Payer: Humana Medicare/TRICARE	$2,944.49
Rate for Payer: Molina CHIP/Medicaid	$886.62
Rate for Payer: Molina Dual Medicare/Medicaid	$2,944.49
Rate for Payer: Molina Medicare	$2,944.49
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	$886.62
Rate for Payer: Scott and White EPO/PPO	$64.95
Rate for Payer: Scott and White Medicare	$2,944.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$886.62
Rate for Payer: Superior Health Plan EPO	$2,944.49
Rate for Payer: Superior Health Plan Medicare	$2,944.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,944.49
Rate for Payer: Universal American Medicare	$2,944.49
Rate for Payer: Wellcare Medicare	$2,944.49
Rate for Payer: Wellmed Medicare	$2,944.49

succinylcholine 20 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J0330
Hospital Charge Code	77828712
Hospital Revenue Code	636
Min. Negotiated Rate	$1.93
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.93
Rate for Payer: BCBS of TX Blue Essentials	$2.31
Rate for Payer: BCBS of TX PPO	$2.57
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

Know your out-of-pocket cost for care.

All Charges