White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more r

Facility

$2,192.01

Service Code	HCPCS 62305
Hospital Charge Code	3181103
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,490.57

MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W CC

Facility

$46,259.30

Service Code	MSDRG 827
Min. Negotiated Rate	$19,364.62
Max. Negotiated Rate	$46,259.30
Rate for Payer: BCBS of TX Blue Advantage	$19,364.62
Rate for Payer: BCBS of TX Blue Essentials	$23,235.29
Rate for Payer: BCBS of TX PPO	$25,817.99

MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W MCC

Facility

$97,696.10

Service Code	MSDRG 826
Min. Negotiated Rate	$39,043.80
Max. Negotiated Rate	$97,696.10
Rate for Payer: BCBS of TX Blue Advantage	$42,551.94
Rate for Payer: BCBS of TX Blue Essentials	$51,057.38
Rate for Payer: BCBS of TX PPO	$56,732.62

MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W/O CC/MCC

Facility

$33,042.90

Service Code	MSDRG 828
Min. Negotiated Rate	$14,064.44
Max. Negotiated Rate	$33,042.90
Rate for Payer: BCBS of TX Blue Advantage	$14,064.44
Rate for Payer: BCBS of TX Blue Essentials	$16,875.69
Rate for Payer: BCBS of TX PPO	$18,751.50

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$46,259.30

Service Code	MSDRG 827
Min. Negotiated Rate	$19,364.62
Max. Negotiated Rate	$46,259.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,698.91
Rate for Payer: Amerigroup Medicare	$21,698.91
Rate for Payer: BCBS of TX Medicare	$21,698.91
Rate for Payer: Cigna Commercial	$29,768.26
Rate for Payer: Cigna Medicare	$21,698.91
Rate for Payer: Employer Direct Commercial	$21,698.91
Rate for Payer: Humana Medicare/TRICARE	$21,698.91
Rate for Payer: Molina Dual Medicare/Medicaid	$21,698.91
Rate for Payer: Molina Medicare	$21,698.91
Rate for Payer: Multiplan Auto	$46,259.30
Rate for Payer: Multiplan Commercial	$46,259.30
Rate for Payer: Multiplan Workers Comp	$46,259.30
Rate for Payer: Scott and White EPO/PPO	$21,303.62
Rate for Payer: Scott and White Medicare	$21,698.91
Rate for Payer: Superior Health Plan EPO	$21,698.91
Rate for Payer: Superior Health Plan Medicare	$21,698.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,698.91
Rate for Payer: Universal American Medicare	$21,698.91
Rate for Payer: Wellcare Medicare	$21,698.91
Rate for Payer: Wellmed Medicare	$21,698.91

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$97,696.10

Service Code	MSDRG 826
Min. Negotiated Rate	$39,043.80
Max. Negotiated Rate	$97,696.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$39,043.80
Rate for Payer: Amerigroup Medicare	$39,043.80
Rate for Payer: BCBS of TX Medicare	$39,043.80
Rate for Payer: Cigna Commercial	$60,250.06
Rate for Payer: Cigna Medicare	$39,043.80
Rate for Payer: Employer Direct Commercial	$39,043.80
Rate for Payer: Humana Medicare/TRICARE	$39,043.80
Rate for Payer: Molina Dual Medicare/Medicaid	$39,043.80
Rate for Payer: Molina Medicare	$39,043.80
Rate for Payer: Multiplan Auto	$97,696.10
Rate for Payer: Multiplan Commercial	$97,696.10
Rate for Payer: Multiplan Workers Comp	$97,696.10
Rate for Payer: Scott and White EPO/PPO	$44,991.62
Rate for Payer: Scott and White Medicare	$39,043.80
Rate for Payer: Superior Health Plan EPO	$39,043.80
Rate for Payer: Superior Health Plan Medicare	$39,043.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$39,043.80
Rate for Payer: Universal American Medicare	$39,043.80
Rate for Payer: Wellcare Medicare	$39,043.80
Rate for Payer: Wellmed Medicare	$39,043.80

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$33,042.90

Service Code	MSDRG 828
Min. Negotiated Rate	$14,064.44
Max. Negotiated Rate	$33,042.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,247.28
Rate for Payer: Amerigroup Medicare	$17,247.28
Rate for Payer: BCBS of TX Medicare	$17,247.28
Rate for Payer: Cigna Commercial	$21,944.94
Rate for Payer: Cigna Medicare	$17,247.28
Rate for Payer: Employer Direct Commercial	$17,247.28
Rate for Payer: Humana Medicare/TRICARE	$17,247.28
Rate for Payer: Molina Dual Medicare/Medicaid	$17,247.28
Rate for Payer: Molina Medicare	$17,247.28
Rate for Payer: Multiplan Auto	$33,042.90
Rate for Payer: Multiplan Commercial	$33,042.90
Rate for Payer: Multiplan Workers Comp	$33,042.90
Rate for Payer: Scott and White EPO/PPO	$15,217.12
Rate for Payer: Scott and White Medicare	$17,247.28
Rate for Payer: Superior Health Plan EPO	$17,247.28
Rate for Payer: Superior Health Plan Medicare	$17,247.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,247.28
Rate for Payer: Universal American Medicare	$17,247.28
Rate for Payer: Wellcare Medicare	$17,247.28
Rate for Payer: Wellmed Medicare	$17,247.28

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC

Facility

$60,129.30

Service Code	MSDRG 829
Min. Negotiated Rate	$26,743.42
Max. Negotiated Rate	$60,129.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27,919.79
Rate for Payer: Amerigroup Medicare	$27,919.79
Rate for Payer: BCBS of TX Medicare	$27,919.79
Rate for Payer: Cigna Commercial	$40,700.80
Rate for Payer: Cigna Medicare	$27,919.79
Rate for Payer: Employer Direct Commercial	$27,919.79
Rate for Payer: Humana Medicare/TRICARE	$27,919.79
Rate for Payer: Molina Dual Medicare/Medicaid	$27,919.79
Rate for Payer: Molina Medicare	$27,919.79
Rate for Payer: Multiplan Auto	$60,129.30
Rate for Payer: Multiplan Commercial	$60,129.30
Rate for Payer: Multiplan Workers Comp	$60,129.30
Rate for Payer: Scott and White EPO/PPO	$27,691.12
Rate for Payer: Scott and White Medicare	$27,919.79
Rate for Payer: Superior Health Plan EPO	$27,919.79
Rate for Payer: Superior Health Plan Medicare	$27,919.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$27,919.79
Rate for Payer: Universal American Medicare	$27,919.79
Rate for Payer: Wellcare Medicare	$27,919.79
Rate for Payer: Wellmed Medicare	$27,919.79

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$27,939.50

Service Code	MSDRG 830
Min. Negotiated Rate	$12,201.68
Max. Negotiated Rate	$27,939.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,790.26
Rate for Payer: Amerigroup Medicare	$15,790.26
Rate for Payer: BCBS of TX Medicare	$15,790.26
Rate for Payer: Cigna Commercial	$19,384.40
Rate for Payer: Cigna Medicare	$15,790.26
Rate for Payer: Employer Direct Commercial	$15,790.26
Rate for Payer: Humana Medicare/TRICARE	$15,790.26
Rate for Payer: Molina Dual Medicare/Medicaid	$15,790.26
Rate for Payer: Molina Medicare	$15,790.26
Rate for Payer: Multiplan Auto	$27,939.50
Rate for Payer: Multiplan Commercial	$27,939.50
Rate for Payer: Multiplan Workers Comp	$27,939.50
Rate for Payer: Scott and White EPO/PPO	$12,866.88
Rate for Payer: Scott and White Medicare	$15,790.26
Rate for Payer: Superior Health Plan EPO	$15,790.26
Rate for Payer: Superior Health Plan Medicare	$15,790.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,790.26
Rate for Payer: Universal American Medicare	$15,790.26
Rate for Payer: Wellcare Medicare	$15,790.26
Rate for Payer: Wellmed Medicare	$15,790.26

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS W OTHER PROCEDURE W CC/MCC

Facility

$60,129.30

Service Code	MSDRG 829
Min. Negotiated Rate	$26,743.42
Max. Negotiated Rate	$60,129.30
Rate for Payer: BCBS of TX Blue Advantage	$26,743.42
Rate for Payer: BCBS of TX Blue Essentials	$32,088.99
Rate for Payer: BCBS of TX PPO	$35,655.82

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS W OTHER PROCEDURE W/O CC/MCC

Facility

$27,939.50

Service Code	MSDRG 830
Min. Negotiated Rate	$12,201.68
Max. Negotiated Rate	$27,939.50
Rate for Payer: BCBS of TX Blue Advantage	$12,201.68
Rate for Payer: BCBS of TX Blue Essentials	$14,640.60
Rate for Payer: BCBS of TX PPO	$16,267.96

Myoglobin

Facility

$184.00

Service Code	HCPCS 83874
Hospital Charge Code	1706035
Hospital Revenue Code	301
Rate for Payer: Cash Price	$125.12

Myoglobin

Facility

$184.00

Service Code	HCPCS 83874
Hospital Charge Code	1706035
Hospital Revenue Code	301
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$132.48
Rate for Payer: Amerigroup CHIP/Medicaid	$5.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.92
Rate for Payer: Amerigroup Medicare	$12.92
Rate for Payer: BCBS of TX Blue Advantage	$55.20
Rate for Payer: BCBS of TX Blue Essentials	$66.24
Rate for Payer: BCBS of TX Medicare	$12.92
Rate for Payer: BCBS of TX PPO	$73.60
Rate for Payer: Cash Price	$125.12
Rate for Payer: Cash Price	$125.12
Rate for Payer: Cigna Medicaid	$132.48
Rate for Payer: Cigna Medicare	$12.92
Rate for Payer: Employer Direct Commercial	$12.92
Rate for Payer: Humana Medicare/TRICARE	$12.92
Rate for Payer: Molina CHIP/Medicaid	$132.48
Rate for Payer: Molina Dual Medicare/Medicaid	$12.92
Rate for Payer: Molina Medicare	$12.92
Rate for Payer: Multiplan Auto	$119.60
Rate for Payer: Multiplan Commercial	$119.60
Rate for Payer: Multiplan Workers Comp	$119.60
Rate for Payer: Parkland Medicaid	$132.48
Rate for Payer: Scott and White EPO/PPO	$16.15
Rate for Payer: Scott and White Medicare	$12.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.48
Rate for Payer: Superior Health Plan EPO	$12.92
Rate for Payer: Superior Health Plan Medicare	$12.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.92
Rate for Payer: Universal American Medicare	$12.92
Rate for Payer: Wellcare Medicare	$12.92
Rate for Payer: Wellmed Medicare	$12.92

MyoMarker 3 Profile (RDL) SO

Facility

$222.00

Service Code	HCPCS 83520
Hospital Charge Code	8654550
Hospital Revenue Code	301
Min. Negotiated Rate	$6.74
Max. Negotiated Rate	$159.84
Rate for Payer: Amerigroup CHIP/Medicaid	$6.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.27
Rate for Payer: Amerigroup Medicare	$17.27
Rate for Payer: BCBS of TX Blue Advantage	$66.60
Rate for Payer: BCBS of TX Blue Essentials	$79.92
Rate for Payer: BCBS of TX Medicare	$17.27
Rate for Payer: BCBS of TX PPO	$88.80
Rate for Payer: Cash Price	$150.96
Rate for Payer: Cash Price	$150.96
Rate for Payer: Cigna Medicaid	$159.84
Rate for Payer: Cigna Medicare	$17.27
Rate for Payer: Employer Direct Commercial	$17.27
Rate for Payer: Humana Medicare/TRICARE	$17.27
Rate for Payer: Molina CHIP/Medicaid	$159.84
Rate for Payer: Molina Dual Medicare/Medicaid	$17.27
Rate for Payer: Molina Medicare	$17.27
Rate for Payer: Multiplan Auto	$144.30
Rate for Payer: Multiplan Commercial	$144.30
Rate for Payer: Multiplan Workers Comp	$144.30
Rate for Payer: Parkland Medicaid	$159.84
Rate for Payer: Scott and White EPO/PPO	$21.59
Rate for Payer: Scott and White Medicare	$17.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$159.84
Rate for Payer: Superior Health Plan EPO	$17.27
Rate for Payer: Superior Health Plan Medicare	$17.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.27
Rate for Payer: Universal American Medicare	$17.27
Rate for Payer: Wellcare Medicare	$17.27
Rate for Payer: Wellmed Medicare	$17.27

MyoMarker 3 Profile (RDL) SO

Facility

$222.00

Service Code	HCPCS 83520
Hospital Charge Code	8654550
Hospital Revenue Code	301
Rate for Payer: Cash Price	$150.96

MYRIAD MATRIX 20X20CM

Facility

$73.00

Service Code	HCPCS C1734
Hospital Charge Code	145556
Hospital Revenue Code	278
Min. Negotiated Rate	$18.25
Max. Negotiated Rate	$36.50
Rate for Payer: Cash Price	$49.64
Rate for Payer: Cigna Commercial	$18.25
Rate for Payer: Multiplan Auto	$36.50
Rate for Payer: Multiplan Commercial	$36.50
Rate for Payer: Multiplan Workers Comp	$36.50
Rate for Payer: Scott and White EPO/PPO	$36.50

MYRIAD MATRIX 20X20CM

Facility

$73.00

Service Code	HCPCS C1734
Hospital Charge Code	145556
Hospital Revenue Code	278
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$52.56
Rate for Payer: Amerigroup CHIP/Medicaid	$6.57
Rate for Payer: BCBS of TX Blue Advantage	$21.90
Rate for Payer: BCBS of TX Blue Essentials	$26.28
Rate for Payer: BCBS of TX PPO	$29.20
Rate for Payer: Cash Price	$49.64
Rate for Payer: Cigna Medicaid	$52.56
Rate for Payer: Molina CHIP/Medicaid	$52.56
Rate for Payer: Multiplan Auto	$36.50
Rate for Payer: Multiplan Commercial	$36.50
Rate for Payer: Multiplan Workers Comp	$36.50
Rate for Payer: Parkland Medicaid	$52.56
Rate for Payer: Scott and White EPO/PPO	$36.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.56
Rate for Payer: Superior Health Plan EPO	$9.93

MYRIAD MATRIX THICK 7X10CM

Facility

$82.00

Service Code	HCPCS C1734
Hospital Charge Code	145555
Hospital Revenue Code	278
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$41.00
Rate for Payer: Cash Price	$55.76
Rate for Payer: Cigna Commercial	$20.50
Rate for Payer: Multiplan Auto	$41.00
Rate for Payer: Multiplan Commercial	$41.00
Rate for Payer: Multiplan Workers Comp	$41.00
Rate for Payer: Scott and White EPO/PPO	$41.00

MYRIAD MATRIX THICK 7X10CM

Facility

$82.00

Service Code	HCPCS C1734
Hospital Charge Code	145555
Hospital Revenue Code	278
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$59.04
Rate for Payer: Amerigroup CHIP/Medicaid	$7.38
Rate for Payer: BCBS of TX Blue Advantage	$24.60
Rate for Payer: BCBS of TX Blue Essentials	$29.52
Rate for Payer: BCBS of TX PPO	$32.80
Rate for Payer: Cash Price	$55.76
Rate for Payer: Cigna Medicaid	$59.04
Rate for Payer: Molina CHIP/Medicaid	$59.04
Rate for Payer: Multiplan Auto	$41.00
Rate for Payer: Multiplan Commercial	$41.00
Rate for Payer: Multiplan Workers Comp	$41.00
Rate for Payer: Parkland Medicaid	$59.04
Rate for Payer: Scott and White EPO/PPO	$41.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.04
Rate for Payer: Superior Health Plan EPO	$11.15

MYRIAD MATRIX THIN 7X10 CM

Facility

$59.00

Service Code	HCPCS C1734
Hospital Charge Code	145554
Hospital Revenue Code	278
Min. Negotiated Rate	$5.31
Max. Negotiated Rate	$42.48
Rate for Payer: Amerigroup CHIP/Medicaid	$5.31
Rate for Payer: BCBS of TX Blue Advantage	$17.70
Rate for Payer: BCBS of TX Blue Essentials	$21.24
Rate for Payer: BCBS of TX PPO	$23.60
Rate for Payer: Cash Price	$40.12
Rate for Payer: Cigna Medicaid	$42.48
Rate for Payer: Molina CHIP/Medicaid	$42.48
Rate for Payer: Multiplan Auto	$29.50
Rate for Payer: Multiplan Commercial	$29.50
Rate for Payer: Multiplan Workers Comp	$29.50
Rate for Payer: Parkland Medicaid	$42.48
Rate for Payer: Scott and White EPO/PPO	$29.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.48
Rate for Payer: Superior Health Plan EPO	$8.02

MYRIAD MATRIX THIN 7X10 CM

Facility

$59.00

Service Code	HCPCS C1734
Hospital Charge Code	145554
Hospital Revenue Code	278
Min. Negotiated Rate	$14.75
Max. Negotiated Rate	$29.50
Rate for Payer: Cash Price	$40.12
Rate for Payer: Cigna Commercial	$14.75
Rate for Payer: Multiplan Auto	$29.50
Rate for Payer: Multiplan Commercial	$29.50
Rate for Payer: Multiplan Workers Comp	$29.50
Rate for Payer: Scott and White EPO/PPO	$29.50

MYRIAD THICK 5X5, 10X10, 10X20

Facility

$76.00

Service Code	HCPCS C1734
Hospital Charge Code	145550
Hospital Revenue Code	278
Min. Negotiated Rate	$6.84
Max. Negotiated Rate	$54.72
Rate for Payer: Amerigroup CHIP/Medicaid	$6.84
Rate for Payer: BCBS of TX Blue Advantage	$22.80
Rate for Payer: BCBS of TX Blue Essentials	$27.36
Rate for Payer: BCBS of TX PPO	$30.40
Rate for Payer: Cash Price	$51.68
Rate for Payer: Cigna Medicaid	$54.72
Rate for Payer: Molina CHIP/Medicaid	$54.72
Rate for Payer: Multiplan Auto	$38.00
Rate for Payer: Multiplan Commercial	$38.00
Rate for Payer: Multiplan Workers Comp	$38.00
Rate for Payer: Parkland Medicaid	$54.72
Rate for Payer: Scott and White EPO/PPO	$38.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$54.72
Rate for Payer: Superior Health Plan EPO	$10.34

MYRIAD THICK 5X5, 10X10, 10X20

Facility

$76.00

Service Code	HCPCS C1734
Hospital Charge Code	145550
Hospital Revenue Code	278
Min. Negotiated Rate	$19.00
Max. Negotiated Rate	$38.00
Rate for Payer: Cash Price	$51.68
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Multiplan Auto	$38.00
Rate for Payer: Multiplan Commercial	$38.00
Rate for Payer: Multiplan Workers Comp	$38.00
Rate for Payer: Scott and White EPO/PPO	$38.00

MYRIAD THIN 5X5, 10X10, 10X20CM

Facility

$55.00

Service Code	HCPCS C1734
Hospital Charge Code	145546
Hospital Revenue Code	278
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$39.60
Rate for Payer: Amerigroup CHIP/Medicaid	$4.95
Rate for Payer: BCBS of TX Blue Advantage	$16.50
Rate for Payer: BCBS of TX Blue Essentials	$19.80
Rate for Payer: BCBS of TX PPO	$22.00
Rate for Payer: Cash Price	$37.40
Rate for Payer: Cigna Medicaid	$39.60
Rate for Payer: Molina CHIP/Medicaid	$39.60
Rate for Payer: Multiplan Auto	$27.50
Rate for Payer: Multiplan Commercial	$27.50
Rate for Payer: Multiplan Workers Comp	$27.50
Rate for Payer: Parkland Medicaid	$39.60
Rate for Payer: Scott and White EPO/PPO	$27.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.60
Rate for Payer: Superior Health Plan EPO	$7.48

MYRIAD THIN 5X5, 10X10, 10X20CM

Facility

$55.00

Service Code	HCPCS C1734
Hospital Charge Code	145546
Hospital Revenue Code	278
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$27.50
Rate for Payer: Cash Price	$37.40
Rate for Payer: Cigna Commercial	$13.75
Rate for Payer: Multiplan Auto	$27.50
Rate for Payer: Multiplan Commercial	$27.50
Rate for Payer: Multiplan Workers Comp	$27.50
Rate for Payer: Scott and White EPO/PPO	$27.50

Know your out-of-pocket cost for care.

All Charges