White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OPMI Microscope drape, sterile, 48' x 118'

Facility

$197.14

Hospital Charge Code	993733
Hospital Revenue Code	272
Rate for Payer: Cash Price	$134.06

OPTICHAMBER DIAMOND

Facility

$306.90

Hospital Charge Code	993377
Hospital Revenue Code	270
Rate for Payer: Cash Price	$208.69

OPTICHAMBER DIAMOND

Facility

$306.90

Hospital Charge Code	993377
Hospital Revenue Code	270
Min. Negotiated Rate	$27.62
Max. Negotiated Rate	$220.97
Rate for Payer: Amerigroup CHIP/Medicaid	$27.62
Rate for Payer: BCBS of TX Blue Advantage	$92.07
Rate for Payer: BCBS of TX Blue Essentials	$110.48
Rate for Payer: BCBS of TX PPO	$122.76
Rate for Payer: Cash Price	$208.69
Rate for Payer: Cigna Medicaid	$220.97
Rate for Payer: Molina CHIP/Medicaid	$220.97
Rate for Payer: Multiplan Auto	$199.49
Rate for Payer: Multiplan Commercial	$199.49
Rate for Payer: Multiplan Workers Comp	$199.49
Rate for Payer: Parkland Medicaid	$220.97
Rate for Payer: Scott and White EPO/PPO	$153.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$220.97
Rate for Payer: Superior Health Plan EPO	$41.74

OPTIFLOW HASAL CANNULA LG

Facility

$94.43

Hospital Charge Code	993628
Hospital Revenue Code	270
Rate for Payer: Cash Price	$64.21

OPTIFLOW HASAL CANNULA LG

Facility

$94.43

Hospital Charge Code	993628
Hospital Revenue Code	270
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$67.99
Rate for Payer: Amerigroup CHIP/Medicaid	$8.50
Rate for Payer: BCBS of TX Blue Advantage	$28.33
Rate for Payer: BCBS of TX Blue Essentials	$33.99
Rate for Payer: BCBS of TX PPO	$37.77
Rate for Payer: Cash Price	$64.21
Rate for Payer: Cigna Medicaid	$67.99
Rate for Payer: Molina CHIP/Medicaid	$67.99
Rate for Payer: Multiplan Auto	$61.38
Rate for Payer: Multiplan Commercial	$61.38
Rate for Payer: Multiplan Workers Comp	$61.38
Rate for Payer: Parkland Medicaid	$67.99
Rate for Payer: Scott and White EPO/PPO	$47.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$67.99
Rate for Payer: Superior Health Plan EPO	$12.84

OptiSeal 6F, 13cm_Univ_US

Facility

$263.32

Hospital Charge Code	993884
Hospital Revenue Code	272
Min. Negotiated Rate	$23.70
Max. Negotiated Rate	$189.59
Rate for Payer: Amerigroup CHIP/Medicaid	$23.70
Rate for Payer: BCBS of TX Blue Advantage	$79.00
Rate for Payer: BCBS of TX Blue Essentials	$94.80
Rate for Payer: BCBS of TX PPO	$105.33
Rate for Payer: Cash Price	$179.06
Rate for Payer: Cigna Medicaid	$189.59
Rate for Payer: Molina CHIP/Medicaid	$189.59
Rate for Payer: Multiplan Auto	$171.16
Rate for Payer: Multiplan Commercial	$171.16
Rate for Payer: Multiplan Workers Comp	$171.16
Rate for Payer: Parkland Medicaid	$189.59
Rate for Payer: Scott and White EPO/PPO	$131.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$189.59
Rate for Payer: Superior Health Plan EPO	$35.81

OptiSeal 6F, 13cm_Univ_US

Facility

$263.32

Hospital Charge Code	993884
Hospital Revenue Code	272
Rate for Payer: Cash Price	$179.06

OptiSeal 7F, 13cm_Univ_US

Facility

$263.32

Hospital Charge Code	993885
Hospital Revenue Code	272
Min. Negotiated Rate	$23.70
Max. Negotiated Rate	$189.59
Rate for Payer: Amerigroup CHIP/Medicaid	$23.70
Rate for Payer: BCBS of TX Blue Advantage	$79.00
Rate for Payer: BCBS of TX Blue Essentials	$94.80
Rate for Payer: BCBS of TX PPO	$105.33
Rate for Payer: Cash Price	$179.06
Rate for Payer: Cigna Medicaid	$189.59
Rate for Payer: Molina CHIP/Medicaid	$189.59
Rate for Payer: Multiplan Auto	$171.16
Rate for Payer: Multiplan Commercial	$171.16
Rate for Payer: Multiplan Workers Comp	$171.16
Rate for Payer: Parkland Medicaid	$189.59
Rate for Payer: Scott and White EPO/PPO	$131.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$189.59
Rate for Payer: Superior Health Plan EPO	$35.81

OptiSeal 7F, 13cm_Univ_US

Facility

$263.32

Hospital Charge Code	993885
Hospital Revenue Code	272
Rate for Payer: Cash Price	$179.06

OPTISEAL EXTENSION 6FR 13CM

Facility

$263.32

Hospital Charge Code	145518
Hospital Revenue Code	272
Min. Negotiated Rate	$23.70
Max. Negotiated Rate	$189.59
Rate for Payer: Amerigroup CHIP/Medicaid	$23.70
Rate for Payer: BCBS of TX Blue Advantage	$79.00
Rate for Payer: BCBS of TX Blue Essentials	$94.80
Rate for Payer: BCBS of TX PPO	$105.33
Rate for Payer: Cash Price	$179.06
Rate for Payer: Cigna Medicaid	$189.59
Rate for Payer: Molina CHIP/Medicaid	$189.59
Rate for Payer: Multiplan Auto	$171.16
Rate for Payer: Multiplan Commercial	$171.16
Rate for Payer: Multiplan Workers Comp	$171.16
Rate for Payer: Parkland Medicaid	$189.59
Rate for Payer: Scott and White EPO/PPO	$131.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$189.59
Rate for Payer: Superior Health Plan EPO	$35.81

OPTISEAL EXTENSION 6FR 13CM

Facility

$263.32

Hospital Charge Code	145518
Hospital Revenue Code	272
Rate for Payer: Cash Price	$179.06

OPWC Apply Rigid Leg Cast Lt BCE

Facility

$874.00

Service Code	HCPCS 29445
Hospital Charge Code	8910540
Hospital Revenue Code	761
Min. Negotiated Rate	$78.66
Max. Negotiated Rate	$629.28
Rate for Payer: Amerigroup CHIP/Medicaid	$78.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$103.66
Rate for Payer: BCBS of TX Blue Essentials	$124.14
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$156.42
Rate for Payer: Cash Price	$594.32
Rate for Payer: Cash Price	$594.32
Rate for Payer: Cash Price	$594.32
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$629.28
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$629.28
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
Rate for Payer: Multiplan Auto	$568.10
Rate for Payer: Multiplan Commercial	$568.10
Rate for Payer: Multiplan Workers Comp	$568.10
Rate for Payer: Parkland Medicaid	$629.28
Rate for Payer: Scott and White EPO/PPO	$120.81
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$629.28
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

OPWC Apply Rigid Leg Cast Lt BCE

Facility

$874.00

Service Code	HCPCS 29445
Hospital Charge Code	8910540
Hospital Revenue Code	761
Rate for Payer: Cash Price	$594.32

OPWC Apply Rigid Leg Cast Rt BCE

Facility

$874.00

Service Code	HCPCS 29445
Hospital Charge Code	8910541
Hospital Revenue Code	761
Min. Negotiated Rate	$78.66
Max. Negotiated Rate	$629.28
Rate for Payer: Amerigroup CHIP/Medicaid	$78.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$103.66
Rate for Payer: BCBS of TX Blue Essentials	$124.14
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$156.42
Rate for Payer: Cash Price	$594.32
Rate for Payer: Cash Price	$594.32
Rate for Payer: Cash Price	$594.32
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$629.28
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$629.28
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
Rate for Payer: Multiplan Auto	$568.10
Rate for Payer: Multiplan Commercial	$568.10
Rate for Payer: Multiplan Workers Comp	$568.10
Rate for Payer: Parkland Medicaid	$629.28
Rate for Payer: Scott and White EPO/PPO	$120.81
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$629.28
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

OPWC Apply Rigid Leg Cast Rt BCE

Facility

$874.00

Service Code	HCPCS 29445
Hospital Charge Code	8910541
Hospital Revenue Code	761
Rate for Payer: Cash Price	$594.32

OPWC Avlsn Plte, Smpl, Sngl BCE

Facility

$993.50

Service Code	HCPCS 11730
Hospital Charge Code	8912540
Hospital Revenue Code	361
Min. Negotiated Rate	$89.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$89.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
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	$715.32
Rate for Payer: Scott and White EPO/PPO	$338.72
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

OPWC Avlsn Plte, Smpl, Sngl BCE

Facility

$993.50

Service Code	HCPCS 11730
Hospital Charge Code	8912540
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

OPWC Biopsy Bone Open BCE

Facility

$4,752.00

Service Code	HCPCS 20240
Hospital Charge Code	7150911
Hospital Revenue Code	361
Min. Negotiated Rate	$815.20
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$815.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Amerigroup Medicare	$2,917.95
Rate for Payer: BCBS of TX Blue Advantage	$3,872.55
Rate for Payer: BCBS of TX Blue Essentials	$4,637.78
Rate for Payer: BCBS of TX Medicare	$2,917.95
Rate for Payer: BCBS of TX PPO	$5,843.60
Rate for Payer: Cash Price	$3,231.36
Rate for Payer: Cash Price	$3,231.36
Rate for Payer: Cash Price	$3,231.36
Rate for Payer: Cigna Commercial	$6,168.03
Rate for Payer: Cigna Medicaid	$3,421.44
Rate for Payer: Cigna Medicare	$2,917.95
Rate for Payer: Employer Direct Commercial	$2,917.95
Rate for Payer: Humana Medicare/TRICARE	$2,917.95
Rate for Payer: Molina CHIP/Medicaid	$3,421.44
Rate for Payer: Molina Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Molina Medicare	$2,917.95
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	$3,421.44
Rate for Payer: Scott and White EPO/PPO	$4,807.56
Rate for Payer: Scott and White Medicare	$2,917.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,421.44
Rate for Payer: Superior Health Plan EPO	$2,917.95
Rate for Payer: Superior Health Plan Medicare	$2,917.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Universal American Medicare	$2,917.95
Rate for Payer: Wellcare Medicare	$2,917.95
Rate for Payer: Wellmed Medicare	$2,917.95

OPWC Biopsy Bone Open BCE

Facility

$4,752.00

Service Code	HCPCS 20240
Hospital Charge Code	7150911
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,231.36

OPWC Biopsy Bone Open BCE

Facility

$4,752.00

Service Code	HCPCS 20240
Hospital Charge Code	8910542
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,231.36

OPWC Biopsy Bone Open BCE

Facility

$4,752.00

Service Code	HCPCS 20240
Hospital Charge Code	8910542
Hospital Revenue Code	361
Min. Negotiated Rate	$815.20
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$815.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Amerigroup Medicare	$2,917.95
Rate for Payer: BCBS of TX Blue Advantage	$3,872.55
Rate for Payer: BCBS of TX Blue Essentials	$4,637.78
Rate for Payer: BCBS of TX Medicare	$2,917.95
Rate for Payer: BCBS of TX PPO	$5,843.60
Rate for Payer: Cash Price	$3,231.36
Rate for Payer: Cash Price	$3,231.36
Rate for Payer: Cash Price	$3,231.36
Rate for Payer: Cigna Commercial	$6,168.03
Rate for Payer: Cigna Medicaid	$3,421.44
Rate for Payer: Cigna Medicare	$2,917.95
Rate for Payer: Employer Direct Commercial	$2,917.95
Rate for Payer: Humana Medicare/TRICARE	$2,917.95
Rate for Payer: Molina CHIP/Medicaid	$3,421.44
Rate for Payer: Molina Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Molina Medicare	$2,917.95
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	$3,421.44
Rate for Payer: Scott and White EPO/PPO	$4,807.56
Rate for Payer: Scott and White Medicare	$2,917.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,421.44
Rate for Payer: Superior Health Plan EPO	$2,917.95
Rate for Payer: Superior Health Plan Medicare	$2,917.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Universal American Medicare	$2,917.95
Rate for Payer: Wellcare Medicare	$2,917.95
Rate for Payer: Wellmed Medicare	$2,917.95

OPWC BONE BIOPSY NEEDLE/TROCAR DEEP BCE

Facility

$2,948.00

Service Code	HCPCS 20225
Hospital Charge Code	8912541
Hospital Revenue Code	761
Min. Negotiated Rate	$156.11
Max. Negotiated Rate	$3,507.10
Rate for Payer: Amerigroup CHIP/Medicaid	$265.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$2,004.64
Rate for Payer: Cash Price	$2,004.64
Rate for Payer: Cash Price	$2,004.64
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$2,122.56
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$2,122.56
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
Rate for Payer: Multiplan Auto	$1,916.20
Rate for Payer: Multiplan Commercial	$1,916.20
Rate for Payer: Multiplan Workers Comp	$1,916.20
Rate for Payer: Parkland Medicaid	$2,122.56
Rate for Payer: Scott and White EPO/PPO	$156.11
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,122.56
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

OPWC BONE BIOPSY NEEDLE/TROCAR DEEP BCE

Facility

$2,948.00

Service Code	HCPCS 20225
Hospital Charge Code	8912541
Hospital Revenue Code	761
Rate for Payer: Cash Price	$2,004.64

OPWC Bone Biopsy Needle/Trocar, Superficial BCE

Facility

$2,714.00

Service Code	HCPCS 20220
Hospital Charge Code	8912542
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,845.52

OPWC Bone Biopsy Needle/Trocar, Superficial BCE

Facility

$2,714.00

Service Code	HCPCS 20220
Hospital Charge Code	8912542
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$1,954.08
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$1,954.08
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$1,954.08
Rate for Payer: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.08
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

Know your out-of-pocket cost for care.

All Charges