White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SURG PROC II

Facility

$207.00

Hospital Charge Code	6296001
Hospital Revenue Code	361
Min. Negotiated Rate	$18.63
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$113.85
Rate for Payer: Amerigroup CHIP/Medicaid	$18.63
Rate for Payer: BCBS of TX Blue Advantage	$62.10
Rate for Payer: BCBS of TX Blue Essentials	$74.52
Rate for Payer: BCBS of TX PPO	$82.80
Rate for Payer: Cash Price	$182.16
Rate for Payer: Cash Price	$182.16
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	$103.50
Rate for Payer: Superior Health Plan EPO	$28.15

SURG PROC II

Facility

$207.00

Hospital Charge Code	6296001
Hospital Revenue Code	361
Rate for Payer: Cash Price	$182.16

Surg Proc II Charge BCE

Facility

$207.00

Hospital Charge Code	6296001
Hospital Revenue Code	361
Min. Negotiated Rate	$18.63
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$113.85
Rate for Payer: Amerigroup CHIP/Medicaid	$18.63
Rate for Payer: BCBS of TX Blue Advantage	$62.10
Rate for Payer: BCBS of TX Blue Essentials	$74.52
Rate for Payer: BCBS of TX PPO	$82.80
Rate for Payer: Cash Price	$182.16
Rate for Payer: Cash Price	$182.16
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	$103.50
Rate for Payer: Superior Health Plan EPO	$28.15

SURG PROC III CHARGE

Facility

$315.00

Hospital Charge Code	6296002
Hospital Revenue Code	361
Min. Negotiated Rate	$28.35
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$173.25
Rate for Payer: Amerigroup CHIP/Medicaid	$28.35
Rate for Payer: BCBS of TX Blue Advantage	$94.50
Rate for Payer: BCBS of TX Blue Essentials	$113.40
Rate for Payer: BCBS of TX PPO	$126.00
Rate for Payer: Cash Price	$277.20
Rate for Payer: Cash Price	$277.20
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	$157.50
Rate for Payer: Superior Health Plan EPO	$42.84

SURG PROC III CHARGE

Facility

$315.00

Hospital Charge Code	6296002
Hospital Revenue Code	361
Rate for Payer: Cash Price	$277.20

Surg Proc III Charge BCE

Facility

$315.00

Hospital Charge Code	6296002
Hospital Revenue Code	361
Min. Negotiated Rate	$28.35
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$173.25
Rate for Payer: Amerigroup CHIP/Medicaid	$28.35
Rate for Payer: BCBS of TX Blue Advantage	$94.50
Rate for Payer: BCBS of TX Blue Essentials	$113.40
Rate for Payer: BCBS of TX PPO	$126.00
Rate for Payer: Cash Price	$277.20
Rate for Payer: Cash Price	$277.20
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	$157.50
Rate for Payer: Superior Health Plan EPO	$42.84

Susceptibility, Aer + Anaerob SO

Facility

$251.00

Service Code	CPT 87186
Hospital Charge Code	1604610
Hospital Revenue Code	306
Rate for Payer: Cash Price	$220.88

Susceptibility, Aer + Anaerob SO

Facility

$251.00

Service Code	CPT 87186
Hospital Charge Code	1604610
Hospital Revenue Code	306
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$163.15
Rate for Payer: Aetna Commercial	$9.08
Rate for Payer: Aetna Medicare	$12.98
Rate for Payer: Amerigroup CHIP/Medicaid	$3.37
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.65
Rate for Payer: Amerigroup Medicare	$8.65
Rate for Payer: BCBS of TX Blue Advantage	$14.27
Rate for Payer: BCBS of TX Blue Essentials	$17.13
Rate for Payer: BCBS of TX Medicare	$8.65
Rate for Payer: BCBS of TX PPO	$19.12
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cigna Medicaid	$8.65
Rate for Payer: Cigna Medicare	$8.65
Rate for Payer: Employer Direct Commercial	$8.65
Rate for Payer: Humana Medicare/TRICARE	$8.65
Rate for Payer: Molina CHIP/Medicaid	$8.65
Rate for Payer: Molina Dual Medicare/Medicaid	$8.65
Rate for Payer: Molina Medicare	$8.65
Rate for Payer: Multiplan Auto	$163.15
Rate for Payer: Multiplan Commercial	$163.15
Rate for Payer: Multiplan Workers Comp	$163.15
Rate for Payer: Parkland Medicaid	$8.65
Rate for Payer: Scott and White EPO/PPO	$10.81
Rate for Payer: Scott and White Medicare	$8.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.65
Rate for Payer: Superior Health Plan EPO	$8.65
Rate for Payer: Superior Health Plan Medicare	$8.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.65
Rate for Payer: Universal American Medicare	$8.65
Rate for Payer: Wellcare Medicare	$8.65
Rate for Payer: Wellmed Medicare	$8.65

SUSCEPTIBILITY STDY MYCOBAC PROPORT

Facility

$147.00

Service Code	CPT 87190
Hospital Charge Code	1603794
Hospital Revenue Code	306
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$95.55
Rate for Payer: Aetna Commercial	$7.68
Rate for Payer: Aetna Medicare	$10.96
Rate for Payer: Amerigroup CHIP/Medicaid	$2.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.31
Rate for Payer: Amerigroup Medicare	$7.31
Rate for Payer: BCBS of TX Blue Advantage	$12.06
Rate for Payer: BCBS of TX Blue Essentials	$14.47
Rate for Payer: BCBS of TX Medicare	$7.31
Rate for Payer: BCBS of TX PPO	$16.16
Rate for Payer: Cash Price	$129.36
Rate for Payer: Cash Price	$129.36
Rate for Payer: Cigna Medicaid	$7.31
Rate for Payer: Cigna Medicare	$7.31
Rate for Payer: Employer Direct Commercial	$7.31
Rate for Payer: Humana Medicare/TRICARE	$7.31
Rate for Payer: Molina CHIP/Medicaid	$7.31
Rate for Payer: Molina Dual Medicare/Medicaid	$7.31
Rate for Payer: Molina Medicare	$7.31
Rate for Payer: Multiplan Auto	$95.55
Rate for Payer: Multiplan Commercial	$95.55
Rate for Payer: Multiplan Workers Comp	$95.55
Rate for Payer: Parkland Medicaid	$7.31
Rate for Payer: Scott and White EPO/PPO	$9.14
Rate for Payer: Scott and White Medicare	$7.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.31
Rate for Payer: Superior Health Plan EPO	$7.31
Rate for Payer: Superior Health Plan Medicare	$7.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.31
Rate for Payer: Universal American Medicare	$7.31
Rate for Payer: Wellcare Medicare	$7.31
Rate for Payer: Wellmed Medicare	$7.31

SUSCEPTIBILITY STDY MYCOBAC PROPORT

Facility

$147.00

Service Code	CPT 87190
Hospital Charge Code	1603794
Hospital Revenue Code	306
Rate for Payer: Cash Price	$129.36

SUT CATG I -- DHF

Facility

$245.68

Hospital Charge Code	81940819
Hospital Revenue Code	272
Min. Negotiated Rate	$22.11
Max. Negotiated Rate	$159.69
Rate for Payer: Aetna Commercial	$135.12
Rate for Payer: Amerigroup CHIP/Medicaid	$22.11
Rate for Payer: BCBS of TX Blue Advantage	$73.70
Rate for Payer: BCBS of TX Blue Essentials	$88.44
Rate for Payer: BCBS of TX PPO	$98.27
Rate for Payer: Cash Price	$216.20
Rate for Payer: Multiplan Auto	$159.69
Rate for Payer: Multiplan Commercial	$159.69
Rate for Payer: Multiplan Workers Comp	$159.69
Rate for Payer: Scott and White EPO/PPO	$122.84
Rate for Payer: Superior Health Plan EPO	$33.41

SUT CATG I -- DHF

Facility

$245.68

Hospital Charge Code	81940819
Hospital Revenue Code	272
Rate for Payer: Cash Price	$216.20

SUT CLIP HEMO -- DHF

Facility

$544.80

Hospital Charge Code	81941106
Hospital Revenue Code	272
Rate for Payer: Cash Price	$479.42

SUT CLIP HEMO -- DHF

Facility

$544.80

Hospital Charge Code	81941106
Hospital Revenue Code	272
Min. Negotiated Rate	$49.03
Max. Negotiated Rate	$354.12
Rate for Payer: Aetna Commercial	$299.64
Rate for Payer: Amerigroup CHIP/Medicaid	$49.03
Rate for Payer: BCBS of TX Blue Advantage	$163.44
Rate for Payer: BCBS of TX Blue Essentials	$196.13
Rate for Payer: BCBS of TX PPO	$217.92
Rate for Payer: Cash Price	$479.42
Rate for Payer: Multiplan Auto	$354.12
Rate for Payer: Multiplan Commercial	$354.12
Rate for Payer: Multiplan Workers Comp	$354.12
Rate for Payer: Scott and White EPO/PPO	$272.40
Rate for Payer: Superior Health Plan EPO	$74.09

SUT CLOS SLK -- DHF

Facility

$239.05

Hospital Charge Code	81941650
Hospital Revenue Code	272
Rate for Payer: Cash Price	$210.36

SUT CLOS SLK -- DHF

Facility

$239.05

Hospital Charge Code	81941650
Hospital Revenue Code	272
Min. Negotiated Rate	$21.51
Max. Negotiated Rate	$155.38
Rate for Payer: Aetna Commercial	$131.48
Rate for Payer: Amerigroup CHIP/Medicaid	$21.51
Rate for Payer: BCBS of TX Blue Advantage	$71.72
Rate for Payer: BCBS of TX Blue Essentials	$86.06
Rate for Payer: BCBS of TX PPO	$95.62
Rate for Payer: Cash Price	$210.36
Rate for Payer: Multiplan Auto	$155.38
Rate for Payer: Multiplan Commercial	$155.38
Rate for Payer: Multiplan Workers Comp	$155.38
Rate for Payer: Scott and White EPO/PPO	$119.52
Rate for Payer: Superior Health Plan EPO	$32.51

SUT FIBERTAPE -- DHF

Facility

$490.32

Hospital Charge Code	81943334
Hospital Revenue Code	272
Rate for Payer: Cash Price	$431.48

SUT FIBERTAPE -- DHF

Facility

$490.32

Hospital Charge Code	81943334
Hospital Revenue Code	272
Min. Negotiated Rate	$44.13
Max. Negotiated Rate	$318.71
Rate for Payer: Aetna Commercial	$269.68
Rate for Payer: Amerigroup CHIP/Medicaid	$44.13
Rate for Payer: BCBS of TX Blue Advantage	$147.10
Rate for Payer: BCBS of TX Blue Essentials	$176.52
Rate for Payer: BCBS of TX PPO	$196.13
Rate for Payer: Cash Price	$431.48
Rate for Payer: Multiplan Auto	$318.71
Rate for Payer: Multiplan Commercial	$318.71
Rate for Payer: Multiplan Workers Comp	$318.71
Rate for Payer: Scott and White EPO/PPO	$245.16
Rate for Payer: Superior Health Plan EPO	$66.68

SUT OBGYN MERLN -- DHF

Facility

$138.61

Hospital Charge Code	81944407
Hospital Revenue Code	272
Min. Negotiated Rate	$12.47
Max. Negotiated Rate	$90.10
Rate for Payer: Aetna Commercial	$76.24
Rate for Payer: Amerigroup CHIP/Medicaid	$12.47
Rate for Payer: BCBS of TX Blue Advantage	$41.58
Rate for Payer: BCBS of TX Blue Essentials	$49.90
Rate for Payer: BCBS of TX PPO	$55.44
Rate for Payer: Cash Price	$121.98
Rate for Payer: Multiplan Auto	$90.10
Rate for Payer: Multiplan Commercial	$90.10
Rate for Payer: Multiplan Workers Comp	$90.10
Rate for Payer: Scott and White EPO/PPO	$69.30
Rate for Payer: Superior Health Plan EPO	$18.85

SUT OBGYN MERLN -- DHF

Facility

$138.61

Hospital Charge Code	81944407
Hospital Revenue Code	272
Rate for Payer: Cash Price	$121.98

SUT ORTHOBG GUT -- DHF

Facility

$336.09

Hospital Charge Code	81944753
Hospital Revenue Code	272
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$218.46
Rate for Payer: Aetna Commercial	$184.85
Rate for Payer: Amerigroup CHIP/Medicaid	$30.25
Rate for Payer: BCBS of TX Blue Advantage	$100.83
Rate for Payer: BCBS of TX Blue Essentials	$120.99
Rate for Payer: BCBS of TX PPO	$134.44
Rate for Payer: Cash Price	$295.76
Rate for Payer: Multiplan Auto	$218.46
Rate for Payer: Multiplan Commercial	$218.46
Rate for Payer: Multiplan Workers Comp	$218.46
Rate for Payer: Scott and White EPO/PPO	$168.04
Rate for Payer: Superior Health Plan EPO	$45.71

SUT ORTHOBG GUT -- DHF

Facility

$336.09

Hospital Charge Code	81944753
Hospital Revenue Code	272
Rate for Payer: Cash Price	$295.76

SUT PAK GUT -- DHF

Facility

$138.28

Hospital Charge Code	81944803
Hospital Revenue Code	272
Min. Negotiated Rate	$12.45
Max. Negotiated Rate	$89.88
Rate for Payer: Aetna Commercial	$76.05
Rate for Payer: Amerigroup CHIP/Medicaid	$12.45
Rate for Payer: BCBS of TX Blue Advantage	$41.48
Rate for Payer: BCBS of TX Blue Essentials	$49.78
Rate for Payer: BCBS of TX PPO	$55.31
Rate for Payer: Cash Price	$121.69
Rate for Payer: Multiplan Auto	$89.88
Rate for Payer: Multiplan Commercial	$89.88
Rate for Payer: Multiplan Workers Comp	$89.88
Rate for Payer: Scott and White EPO/PPO	$69.14
Rate for Payer: Superior Health Plan EPO	$18.81

SUT PAK GUT -- DHF

Facility

$138.28

Hospital Charge Code	81944803
Hospital Revenue Code	272
Rate for Payer: Cash Price	$121.69

SUT PASSER -- DHF

Facility

$166.75

Hospital Charge Code	81774010
Hospital Revenue Code	272
Rate for Payer: Cash Price	$146.74

Know your out-of-pocket cost for care.

All Charges