White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BONE VITOSS 5ML

Facility

$13,043.67

Service Code	HCPCS C1713
Hospital Charge Code	8666519
Hospital Revenue Code	278
Min. Negotiated Rate	$3,260.92
Max. Negotiated Rate	$6,521.84
Rate for Payer: Aetna Commercial	$3,913.10
Rate for Payer: Cash Price	$11,478.43
Rate for Payer: Cigna Commercial	$3,260.92
Rate for Payer: Multiplan Auto	$6,521.84
Rate for Payer: Multiplan Commercial	$6,521.84
Rate for Payer: Multiplan Workers Comp	$6,521.84
Rate for Payer: Scott and White EPO/PPO	$6,521.84

Booster Dose 2 Moderna 0094A

Facility

$40.00

Service Code	CPT 0064A
Hospital Charge Code	8828629
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$22.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$35.20
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan EPO	$5.44

Booster Dose 2 Moderna 0094A

Facility

$40.00

Service Code	CPT 0064A
Hospital Charge Code	8828629
Hospital Revenue Code	771
Rate for Payer: Cash Price	$35.20

Booster Dose 2 Pfizer 0004A

Facility

$40.00

Service Code	CPT 0004A
Hospital Charge Code	8832580
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$22.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$35.20
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan EPO	$5.44

Booster Dose 2 Pfizer 0004A

Facility

$40.00

Service Code	CPT 0004A
Hospital Charge Code	8832580
Hospital Revenue Code	771
Rate for Payer: Cash Price	$35.20

Booster Dose Janssen 0034A

Facility

$60.00

Service Code	CPT 0034A
Hospital Charge Code	8740575
Hospital Revenue Code	771
Rate for Payer: Cash Price	$52.80

Booster Dose Janssen 0034A

Facility

$60.00

Service Code	CPT 0034A
Hospital Charge Code	8740575
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$33.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan EPO	$8.16

Booster Dose Moderna 0064A

Facility

$60.00

Service Code	CPT 0064A
Hospital Charge Code	8734592
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$33.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan EPO	$8.16

Booster Dose Moderna 0064A

Facility

$60.00

Service Code	CPT 0064A
Hospital Charge Code	8734592
Hospital Revenue Code	771
Rate for Payer: Cash Price	$52.80

Booster Dose Pfizer 0004A

Facility

$60.00

Service Code	CPT 0004A
Hospital Charge Code	8734593
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$33.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan EPO	$8.16

Booster Dose Pfizer 0004A

Facility

$60.00

Service Code	CPT 0004A
Hospital Charge Code	8734593
Hospital Revenue Code	771
Rate for Payer: Cash Price	$52.80

BOOT BUNNY -- DHF

Facility

$915.61

Hospital Charge Code	80313851
Hospital Revenue Code	270
Min. Negotiated Rate	$82.40
Max. Negotiated Rate	$595.15
Rate for Payer: Aetna Commercial	$503.59
Rate for Payer: Amerigroup CHIP/Medicaid	$82.40
Rate for Payer: BCBS of TX Blue Advantage	$274.68
Rate for Payer: BCBS of TX Blue Essentials	$329.62
Rate for Payer: BCBS of TX PPO	$366.24
Rate for Payer: Cash Price	$805.74
Rate for Payer: Multiplan Auto	$595.15
Rate for Payer: Multiplan Commercial	$595.15
Rate for Payer: Multiplan Workers Comp	$595.15
Rate for Payer: Scott and White EPO/PPO	$457.80
Rate for Payer: Superior Health Plan EPO	$124.52

BOOT BUNNY -- DHF

Facility

$915.61

Hospital Charge Code	80313851
Hospital Revenue Code	270
Rate for Payer: Cash Price	$805.74

BOOT EQUALIZER -- DHF

Facility

$928.84

Hospital Charge Code	80313968
Hospital Revenue Code	270
Min. Negotiated Rate	$83.60
Max. Negotiated Rate	$603.75
Rate for Payer: Aetna Commercial	$510.86
Rate for Payer: Amerigroup CHIP/Medicaid	$83.60
Rate for Payer: BCBS of TX Blue Advantage	$278.65
Rate for Payer: BCBS of TX Blue Essentials	$334.38
Rate for Payer: BCBS of TX PPO	$371.54
Rate for Payer: Cash Price	$817.38
Rate for Payer: Multiplan Auto	$603.75
Rate for Payer: Multiplan Commercial	$603.75
Rate for Payer: Multiplan Workers Comp	$603.75
Rate for Payer: Scott and White EPO/PPO	$464.42
Rate for Payer: Superior Health Plan EPO	$126.32

BOOT EQUALIZER -- DHF

Facility

$928.84

Hospital Charge Code	80313968
Hospital Revenue Code	270
Rate for Payer: Cash Price	$817.38

BOOT HI GRD REG FULL -- DHF

Facility

$300.35

Hospital Charge Code	80313984
Hospital Revenue Code	270
Rate for Payer: Cash Price	$264.31

BOOT HI GRD REG FULL -- DHF

Facility

$300.35

Hospital Charge Code	80313984
Hospital Revenue Code	270
Min. Negotiated Rate	$27.03
Max. Negotiated Rate	$195.23
Rate for Payer: Aetna Commercial	$165.19
Rate for Payer: Amerigroup CHIP/Medicaid	$27.03
Rate for Payer: BCBS of TX Blue Advantage	$90.10
Rate for Payer: BCBS of TX Blue Essentials	$108.13
Rate for Payer: BCBS of TX PPO	$120.14
Rate for Payer: Cash Price	$264.31
Rate for Payer: Multiplan Auto	$195.23
Rate for Payer: Multiplan Commercial	$195.23
Rate for Payer: Multiplan Workers Comp	$195.23
Rate for Payer: Scott and White EPO/PPO	$150.18
Rate for Payer: Superior Health Plan EPO	$40.85

BOTL CLEANSING -- DHF

Facility

$267.13

Hospital Charge Code	80314057
Hospital Revenue Code	270
Min. Negotiated Rate	$24.04
Max. Negotiated Rate	$173.63
Rate for Payer: Aetna Commercial	$146.92
Rate for Payer: Amerigroup CHIP/Medicaid	$24.04
Rate for Payer: BCBS of TX Blue Advantage	$80.14
Rate for Payer: BCBS of TX Blue Essentials	$96.17
Rate for Payer: BCBS of TX PPO	$106.85
Rate for Payer: Cash Price	$235.07
Rate for Payer: Multiplan Auto	$173.63
Rate for Payer: Multiplan Commercial	$173.63
Rate for Payer: Multiplan Workers Comp	$173.63
Rate for Payer: Scott and White EPO/PPO	$133.56
Rate for Payer: Superior Health Plan EPO	$36.33

BOTL CLEANSING -- DHF

Facility

$267.13

Hospital Charge Code	80314057
Hospital Revenue Code	270
Rate for Payer: Cash Price	$235.07

BOTTLE, COLLECTION SECONDARY W/SEALING CAPS -- DHF

Facility

$38.82

Hospital Charge Code	80343007
Hospital Revenue Code	270
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$25.23
Rate for Payer: Aetna Commercial	$21.35
Rate for Payer: Amerigroup CHIP/Medicaid	$3.49
Rate for Payer: BCBS of TX Blue Advantage	$11.65
Rate for Payer: BCBS of TX Blue Essentials	$13.98
Rate for Payer: BCBS of TX PPO	$15.53
Rate for Payer: Cash Price	$34.16
Rate for Payer: Multiplan Auto	$25.23
Rate for Payer: Multiplan Commercial	$25.23
Rate for Payer: Multiplan Workers Comp	$25.23
Rate for Payer: Scott and White EPO/PPO	$19.41
Rate for Payer: Superior Health Plan EPO	$5.28

BOTTLE, COLLECTION SECONDARY W/SEALING CAPS -- DHF

Facility

$38.82

Hospital Charge Code	80343007
Hospital Revenue Code	270
Rate for Payer: Cash Price	$34.16

BOTTLE, ENDOSCOPIC WATER W/CO2 LENS CLEANING -- DHF

Facility

$46.80

Hospital Charge Code	81777054
Hospital Revenue Code	270
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$30.42
Rate for Payer: Aetna Commercial	$25.74
Rate for Payer: Amerigroup CHIP/Medicaid	$4.21
Rate for Payer: BCBS of TX Blue Advantage	$14.04
Rate for Payer: BCBS of TX Blue Essentials	$16.85
Rate for Payer: BCBS of TX PPO	$18.72
Rate for Payer: Cash Price	$41.18
Rate for Payer: Multiplan Auto	$30.42
Rate for Payer: Multiplan Commercial	$30.42
Rate for Payer: Multiplan Workers Comp	$30.42
Rate for Payer: Scott and White EPO/PPO	$23.40
Rate for Payer: Superior Health Plan EPO	$6.36

bowl mixing quick-vac single

Facility

$431.30

Hospital Charge Code	144807
Hospital Revenue Code	270
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$280.34
Rate for Payer: Aetna Commercial	$237.22
Rate for Payer: Amerigroup CHIP/Medicaid	$38.82
Rate for Payer: BCBS of TX Blue Advantage	$129.39
Rate for Payer: BCBS of TX Blue Essentials	$155.27
Rate for Payer: BCBS of TX PPO	$172.52
Rate for Payer: Cash Price	$379.54
Rate for Payer: Multiplan Auto	$280.34
Rate for Payer: Multiplan Commercial	$280.34
Rate for Payer: Multiplan Workers Comp	$280.34
Rate for Payer: Scott and White EPO/PPO	$215.65
Rate for Payer: Superior Health Plan EPO	$58.66

bowl mixing quick-vac single

Facility

$431.30

Hospital Charge Code	144807
Hospital Revenue Code	270
Rate for Payer: Cash Price	$379.54

BRACE BACK LSO L0631

Facility

$4,652.27

Service Code	HCPCS L0631
Hospital Charge Code	137832
Hospital Revenue Code	274
Min. Negotiated Rate	$1,163.07
Max. Negotiated Rate	$2,326.14
Rate for Payer: Aetna Commercial	$1,395.68
Rate for Payer: Cash Price	$4,094.00
Rate for Payer: Cigna Commercial	$1,163.07
Rate for Payer: Multiplan Auto	$2,326.14
Rate for Payer: Multiplan Commercial	$2,326.14
Rate for Payer: Multiplan Workers Comp	$2,326.14
Rate for Payer: Scott and White EPO/PPO	$2,326.14

Know your out-of-pocket cost for care.

All Charges