White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

brace hip abduction custom

Facility

$3,887.15

Service Code	HCPCS L1686
Hospital Charge Code	8672528
Hospital Revenue Code	274
Min. Negotiated Rate	$971.79
Max. Negotiated Rate	$1,943.58
Rate for Payer: Aetna Commercial	$1,166.14
Rate for Payer: Cash Price	$3,420.69
Rate for Payer: Cigna Commercial	$971.79
Rate for Payer: Multiplan Auto	$1,943.58
Rate for Payer: Multiplan Commercial	$1,943.58
Rate for Payer: Multiplan Workers Comp	$1,943.58
Rate for Payer: Scott and White EPO/PPO	$1,943.58

brace hip abduction custom

Facility

$3,887.15

Service Code	HCPCS L1686
Hospital Charge Code	8672528
Hospital Revenue Code	274
Min. Negotiated Rate	$349.84
Max. Negotiated Rate	$1,943.58
Rate for Payer: Aetna Commercial	$1,166.14
Rate for Payer: Amerigroup CHIP/Medicaid	$349.84
Rate for Payer: BCBS of TX Blue Advantage	$1,166.14
Rate for Payer: BCBS of TX Blue Essentials	$1,399.37
Rate for Payer: BCBS of TX PPO	$1,554.86
Rate for Payer: Cash Price	$3,420.69
Rate for Payer: Multiplan Auto	$1,943.58
Rate for Payer: Multiplan Commercial	$1,943.58
Rate for Payer: Multiplan Workers Comp	$1,943.58
Rate for Payer: Scott and White EPO/PPO	$1,943.58
Rate for Payer: Superior Health Plan EPO	$528.65

BRACE TLSO L0464

Facility

$6,736.04

Hospital Charge Code	8528473
Hospital Revenue Code	272
Min. Negotiated Rate	$606.24
Max. Negotiated Rate	$4,378.43
Rate for Payer: Aetna Commercial	$3,704.82
Rate for Payer: Amerigroup CHIP/Medicaid	$606.24
Rate for Payer: BCBS of TX Blue Advantage	$2,020.81
Rate for Payer: BCBS of TX Blue Essentials	$2,424.97
Rate for Payer: BCBS of TX PPO	$2,694.42
Rate for Payer: Cash Price	$5,927.72
Rate for Payer: Multiplan Auto	$4,378.43
Rate for Payer: Multiplan Commercial	$4,378.43
Rate for Payer: Multiplan Workers Comp	$4,378.43
Rate for Payer: Scott and White EPO/PPO	$3,368.02
Rate for Payer: Superior Health Plan EPO	$916.10

BRACE TLSO L0464

Facility

$6,736.04

Hospital Charge Code	8528473
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,927.72

BRCE ANKLE -- DHF

Facility

$206.86

Hospital Charge Code	81140451
Hospital Revenue Code	270
Min. Negotiated Rate	$18.62
Max. Negotiated Rate	$134.46
Rate for Payer: Aetna Commercial	$113.77
Rate for Payer: Amerigroup CHIP/Medicaid	$18.62
Rate for Payer: BCBS of TX Blue Advantage	$62.06
Rate for Payer: BCBS of TX Blue Essentials	$74.47
Rate for Payer: BCBS of TX PPO	$82.74
Rate for Payer: Cash Price	$182.04
Rate for Payer: Multiplan Auto	$134.46
Rate for Payer: Multiplan Commercial	$134.46
Rate for Payer: Multiplan Workers Comp	$134.46
Rate for Payer: Scott and White EPO/PPO	$103.43
Rate for Payer: Superior Health Plan EPO	$28.13

BRCE ANKLE -- DHF

Facility

$206.86

Hospital Charge Code	81140451
Hospital Revenue Code	270
Rate for Payer: Cash Price	$182.04

BRCE ORTHOPEDIC -- DHF

Facility

$3,483.88

Hospital Charge Code	81141053
Hospital Revenue Code	270
Min. Negotiated Rate	$313.55
Max. Negotiated Rate	$2,264.52
Rate for Payer: Aetna Commercial	$1,916.13
Rate for Payer: Amerigroup CHIP/Medicaid	$313.55
Rate for Payer: BCBS of TX Blue Advantage	$1,045.16
Rate for Payer: BCBS of TX Blue Essentials	$1,254.20
Rate for Payer: BCBS of TX PPO	$1,393.55
Rate for Payer: Cash Price	$3,065.81
Rate for Payer: Multiplan Auto	$2,264.52
Rate for Payer: Multiplan Commercial	$2,264.52
Rate for Payer: Multiplan Workers Comp	$2,264.52
Rate for Payer: Scott and White EPO/PPO	$1,741.94
Rate for Payer: Superior Health Plan EPO	$473.81

BRCE ORTHOPEDIC -- DHF

Facility

$3,483.88

Hospital Charge Code	81141053
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3,065.81

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC

Facility

$25,247.21

Service Code	MSDRG 584
Min. Negotiated Rate	$15,438.72
Max. Negotiated Rate	$25,247.21
Rate for Payer: Aetna Commercial	$22,034.25
Rate for Payer: Aetna Medicare	$25,247.21
Rate for Payer: BCBS of TX Blue Advantage	$15,438.72
Rate for Payer: BCBS of TX Blue Essentials	$19,310.98
Rate for Payer: BCBS of TX PPO	$21,457.47
Rate for Payer: Cigna Commercial	$25,226.77

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC

Facility

$22,307.83

Service Code	MSDRG 585
Min. Negotiated Rate	$13,651.64
Max. Negotiated Rate	$22,307.83
Rate for Payer: Aetna Commercial	$18,945.00
Rate for Payer: Aetna Medicare	$22,307.83
Rate for Payer: BCBS of TX Blue Advantage	$13,651.64
Rate for Payer: BCBS of TX Blue Essentials	$16,156.46
Rate for Payer: BCBS of TX PPO	$17,952.32
Rate for Payer: Cigna Commercial	$21,689.92

breast shields personal fit- 1pr

Facility

$21.27

Hospital Charge Code	144475
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18.72

breast shields personal fit- 1pr

Facility

$21.27

Hospital Charge Code	144475
Hospital Revenue Code	272
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$13.83
Rate for Payer: Aetna Commercial	$11.70
Rate for Payer: Amerigroup CHIP/Medicaid	$1.91
Rate for Payer: BCBS of TX Blue Advantage	$6.38
Rate for Payer: BCBS of TX Blue Essentials	$7.66
Rate for Payer: BCBS of TX PPO	$8.51
Rate for Payer: Cash Price	$18.72
Rate for Payer: Multiplan Auto	$13.83
Rate for Payer: Multiplan Commercial	$13.83
Rate for Payer: Multiplan Workers Comp	$13.83
Rate for Payer: Scott and White EPO/PPO	$10.63
Rate for Payer: Superior Health Plan EPO	$2.89

BRONCHITIS AND ASTHMA WITH CC/MCC

Facility

$14,531.33

Service Code	MSDRG 202
Min. Negotiated Rate	$7,662.60
Max. Negotiated Rate	$14,531.33
Rate for Payer: Aetna Commercial	$10,771.88
Rate for Payer: Aetna Medicare	$14,531.33
Rate for Payer: BCBS of TX Blue Advantage	$7,662.60
Rate for Payer: BCBS of TX Blue Essentials	$9,700.89
Rate for Payer: BCBS of TX PPO	$10,779.19
Rate for Payer: Cigna Commercial	$12,332.60

BRONCHITIS AND ASTHMA WITHOUT CC/MCC

Facility

$11,720.44

Service Code	MSDRG 203
Min. Negotiated Rate	$5,772.32
Max. Negotiated Rate	$11,720.44
Rate for Payer: Aetna Commercial	$7,817.62
Rate for Payer: Aetna Medicare	$11,720.44
Rate for Payer: BCBS of TX Blue Advantage	$5,772.32
Rate for Payer: BCBS of TX Blue Essentials	$7,192.34
Rate for Payer: BCBS of TX PPO	$7,991.80
Rate for Payer: Cigna Commercial	$8,950.31

Bronchoscopy

Facility

$2,957.00

Service Code	CPT 31622
Hospital Charge Code	4010008
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,602.16

Bronchoscopy

Facility

$2,957.00

Service Code	CPT 31622
Hospital Charge Code	4010008
Hospital Revenue Code	361
Min. Negotiated Rate	$525.71
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,328.34
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Amerigroup Medicare	$1,552.23
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,552.23
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cash Price	$2,602.16
Rate for Payer: Cash Price	$2,602.16
Rate for Payer: Cigna Commercial	$3,516.25
Rate for Payer: Cigna Medicaid	$525.71
Rate for Payer: Cigna Medicare	$1,552.23
Rate for Payer: Employer Direct Commercial	$1,552.23
Rate for Payer: Humana Medicare/TRICARE	$1,552.23
Rate for Payer: Molina CHIP/Medicaid	$525.71
Rate for Payer: Molina Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Molina Medicare	$1,552.23
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	$525.71
Rate for Payer: Scott and White EPO/PPO	$2,871.63
Rate for Payer: Scott and White Medicare	$1,552.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$525.71
Rate for Payer: Superior Health Plan EPO	$1,552.23
Rate for Payer: Superior Health Plan Medicare	$1,552.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Universal American Medicare	$1,552.23
Rate for Payer: Wellcare Medicare	$1,552.23
Rate for Payer: Wellmed Medicare	$1,552.23

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed diagnostic, with c

Facility

$10,000.00

Service Code	CPT 31622
Hospital Charge Code	36031622
Hospital Revenue Code	360
Min. Negotiated Rate	$525.71
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,328.34
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Amerigroup Medicare	$1,552.23
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,552.23
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cigna Commercial	$3,516.25
Rate for Payer: Cigna Medicaid	$525.71
Rate for Payer: Cigna Medicare	$1,552.23
Rate for Payer: Employer Direct Commercial	$1,552.23
Rate for Payer: Humana Medicare/TRICARE	$1,552.23
Rate for Payer: Molina CHIP/Medicaid	$525.71
Rate for Payer: Molina Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Molina Medicare	$1,552.23
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	$525.71
Rate for Payer: Scott and White EPO/PPO	$2,871.63
Rate for Payer: Scott and White Medicare	$1,552.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$525.71
Rate for Payer: Superior Health Plan EPO	$1,552.23
Rate for Payer: Superior Health Plan Medicare	$1,552.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Universal American Medicare	$1,552.23
Rate for Payer: Wellcare Medicare	$1,552.23
Rate for Payer: Wellmed Medicare	$1,552.23

BRONCHOSCOPY WITH BRUSHINGS

Facility

$2,972.00

Service Code	CPT 31623
Hospital Charge Code	4010018
Hospital Revenue Code	361
Min. Negotiated Rate	$525.71
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,328.34
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Amerigroup Medicare	$1,552.23
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,552.23
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cash Price	$2,615.36
Rate for Payer: Cash Price	$2,615.36
Rate for Payer: Cigna Commercial	$3,516.25
Rate for Payer: Cigna Medicaid	$525.71
Rate for Payer: Cigna Medicare	$1,552.23
Rate for Payer: Employer Direct Commercial	$1,552.23
Rate for Payer: Humana Medicare/TRICARE	$1,552.23
Rate for Payer: Molina CHIP/Medicaid	$525.71
Rate for Payer: Molina Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Molina Medicare	$1,552.23
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	$525.71
Rate for Payer: Scott and White EPO/PPO	$2,871.63
Rate for Payer: Scott and White Medicare	$1,552.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$525.71
Rate for Payer: Superior Health Plan EPO	$1,552.23
Rate for Payer: Superior Health Plan Medicare	$1,552.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Universal American Medicare	$1,552.23
Rate for Payer: Wellcare Medicare	$1,552.23
Rate for Payer: Wellmed Medicare	$1,552.23

BRONCHOSCOPY WITH BRUSHINGS

Facility

$2,972.00

Service Code	CPT 31623
Hospital Charge Code	4010018
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,615.36

BRONCHOSCOPY WITH CYTOLOGY

Facility

$3,076.00

Service Code	CPT 31624
Hospital Charge Code	4010010
Hospital Revenue Code	361
Min. Negotiated Rate	$525.71
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,328.34
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Amerigroup Medicare	$1,552.23
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,552.23
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cash Price	$2,706.88
Rate for Payer: Cash Price	$2,706.88
Rate for Payer: Cigna Commercial	$3,516.25
Rate for Payer: Cigna Medicaid	$525.71
Rate for Payer: Cigna Medicare	$1,552.23
Rate for Payer: Employer Direct Commercial	$1,552.23
Rate for Payer: Humana Medicare/TRICARE	$1,552.23
Rate for Payer: Molina CHIP/Medicaid	$525.71
Rate for Payer: Molina Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Molina Medicare	$1,552.23
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	$525.71
Rate for Payer: Scott and White EPO/PPO	$2,871.63
Rate for Payer: Scott and White Medicare	$1,552.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$525.71
Rate for Payer: Superior Health Plan EPO	$1,552.23
Rate for Payer: Superior Health Plan Medicare	$1,552.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,552.23
Rate for Payer: Universal American Medicare	$1,552.23
Rate for Payer: Wellcare Medicare	$1,552.23
Rate for Payer: Wellmed Medicare	$1,552.23

BRONCHOSCOPY WITH CYTOLOGY

Facility

$3,076.00

Service Code	CPT 31624
Hospital Charge Code	4010010
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,706.88

BRST PMP SNG -- DHF

Facility

$66.97

Hospital Charge Code	80314701
Hospital Revenue Code	271
Min. Negotiated Rate	$6.03
Max. Negotiated Rate	$43.53
Rate for Payer: Aetna Commercial	$36.83
Rate for Payer: Amerigroup CHIP/Medicaid	$6.03
Rate for Payer: BCBS of TX Blue Advantage	$20.09
Rate for Payer: BCBS of TX Blue Essentials	$24.11
Rate for Payer: BCBS of TX PPO	$26.79
Rate for Payer: Cash Price	$58.93
Rate for Payer: Multiplan Auto	$43.53
Rate for Payer: Multiplan Commercial	$43.53
Rate for Payer: Multiplan Workers Comp	$43.53
Rate for Payer: Scott and White EPO/PPO	$33.48
Rate for Payer: Superior Health Plan EPO	$9.11

BRST PMP SNG -- DHF

Facility

$66.97

Hospital Charge Code	80314701
Hospital Revenue Code	271
Rate for Payer: Cash Price	$58.93

BRUCELLA ANTIBODY

Facility

$58.00

Service Code	CPT 86622
Hospital Charge Code	1708874
Hospital Revenue Code	302
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$37.70
Rate for Payer: Aetna Commercial	$9.38
Rate for Payer: Aetna Medicare	$13.39
Rate for Payer: Amerigroup CHIP/Medicaid	$3.48
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.93
Rate for Payer: Amerigroup Medicare	$8.93
Rate for Payer: BCBS of TX Blue Advantage	$14.73
Rate for Payer: BCBS of TX Blue Essentials	$17.68
Rate for Payer: BCBS of TX Medicare	$8.93
Rate for Payer: BCBS of TX PPO	$19.74
Rate for Payer: Cash Price	$51.04
Rate for Payer: Cash Price	$51.04
Rate for Payer: Cigna Medicaid	$8.93
Rate for Payer: Cigna Medicare	$8.93
Rate for Payer: Employer Direct Commercial	$8.93
Rate for Payer: Humana Medicare/TRICARE	$8.93
Rate for Payer: Molina CHIP/Medicaid	$8.93
Rate for Payer: Molina Dual Medicare/Medicaid	$8.93
Rate for Payer: Molina Medicare	$8.93
Rate for Payer: Multiplan Auto	$37.70
Rate for Payer: Multiplan Commercial	$37.70
Rate for Payer: Multiplan Workers Comp	$37.70
Rate for Payer: Parkland Medicaid	$8.93
Rate for Payer: Scott and White EPO/PPO	$11.16
Rate for Payer: Scott and White Medicare	$8.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.93
Rate for Payer: Superior Health Plan EPO	$8.93
Rate for Payer: Superior Health Plan Medicare	$8.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.93
Rate for Payer: Universal American Medicare	$8.93
Rate for Payer: Wellcare Medicare	$8.93
Rate for Payer: Wellmed Medicare	$8.93

Know your out-of-pocket cost for care.

All Charges