White Rock Medical Center

All Charges

Charge

Type

Setting

Price

burr hip prebent

Facility

$754.78

Hospital Charge Code	8692517
Hospital Revenue Code	272
Rate for Payer: Cash Price	$664.21

burr hip prebent

Facility

$754.78

Hospital Charge Code	8692517
Hospital Revenue Code	272
Min. Negotiated Rate	$67.93
Max. Negotiated Rate	$490.61
Rate for Payer: Aetna Commercial	$415.13
Rate for Payer: Amerigroup CHIP/Medicaid	$67.93
Rate for Payer: BCBS of TX Blue Advantage	$226.43
Rate for Payer: BCBS of TX Blue Essentials	$271.72
Rate for Payer: BCBS of TX PPO	$301.91
Rate for Payer: Cash Price	$664.21
Rate for Payer: Multiplan Auto	$490.61
Rate for Payer: Multiplan Commercial	$490.61
Rate for Payer: Multiplan Workers Comp	$490.61
Rate for Payer: Scott and White EPO/PPO	$377.39
Rate for Payer: Superior Health Plan EPO	$102.65

BURR METAL CUTTING WHEEL MC254

Facility

$823.73

Hospital Charge Code	8528500
Hospital Revenue Code	272
Rate for Payer: Cash Price	$724.88

BURR METAL CUTTING WHEEL MC254

Facility

$823.73

Hospital Charge Code	8528500
Hospital Revenue Code	272
Min. Negotiated Rate	$74.14
Max. Negotiated Rate	$535.42
Rate for Payer: Aetna Commercial	$453.05
Rate for Payer: Amerigroup CHIP/Medicaid	$74.14
Rate for Payer: BCBS of TX Blue Advantage	$247.12
Rate for Payer: BCBS of TX Blue Essentials	$296.54
Rate for Payer: BCBS of TX PPO	$329.49
Rate for Payer: Cash Price	$724.88
Rate for Payer: Multiplan Auto	$535.42
Rate for Payer: Multiplan Commercial	$535.42
Rate for Payer: Multiplan Workers Comp	$535.42
Rate for Payer: Scott and White EPO/PPO	$411.86
Rate for Payer: Superior Health Plan EPO	$112.03

burr oval 4.0

Facility

$204.30

Hospital Charge Code	8688551
Hospital Revenue Code	272
Rate for Payer: Cash Price	$179.78

burr oval 4.0

Facility

$204.30

Hospital Charge Code	8688551
Hospital Revenue Code	272
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$132.80
Rate for Payer: Aetna Commercial	$112.36
Rate for Payer: Amerigroup CHIP/Medicaid	$18.39
Rate for Payer: BCBS of TX Blue Advantage	$61.29
Rate for Payer: BCBS of TX Blue Essentials	$73.55
Rate for Payer: BCBS of TX PPO	$81.72
Rate for Payer: Cash Price	$179.78
Rate for Payer: Multiplan Auto	$132.80
Rate for Payer: Multiplan Commercial	$132.80
Rate for Payer: Multiplan Workers Comp	$132.80
Rate for Payer: Scott and White EPO/PPO	$102.15
Rate for Payer: Superior Health Plan EPO	$27.78

BURR STRYKER 4MM

Facility

$480.19

Hospital Charge Code	8470498
Hospital Revenue Code	272
Rate for Payer: Cash Price	$422.57

BURR STRYKER 4MM

Facility

$480.19

Hospital Charge Code	8470498
Hospital Revenue Code	272
Min. Negotiated Rate	$43.22
Max. Negotiated Rate	$312.12
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Amerigroup CHIP/Medicaid	$43.22
Rate for Payer: BCBS of TX Blue Advantage	$144.06
Rate for Payer: BCBS of TX Blue Essentials	$172.87
Rate for Payer: BCBS of TX PPO	$192.08
Rate for Payer: Cash Price	$422.57
Rate for Payer: Multiplan Auto	$312.12
Rate for Payer: Multiplan Commercial	$312.12
Rate for Payer: Multiplan Workers Comp	$312.12
Rate for Payer: Scott and White EPO/PPO	$240.10
Rate for Payer: Superior Health Plan EPO	$65.31

BURR TYPE 2 -- DHF

Facility

$108.86

Hospital Charge Code	81728909
Hospital Revenue Code	272
Rate for Payer: Cash Price	$95.80

BURR TYPE 2 -- DHF

Facility

$108.86

Hospital Charge Code	81728909
Hospital Revenue Code	272
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$70.76
Rate for Payer: Aetna Commercial	$59.87
Rate for Payer: Amerigroup CHIP/Medicaid	$9.80
Rate for Payer: BCBS of TX Blue Advantage	$32.66
Rate for Payer: BCBS of TX Blue Essentials	$39.19
Rate for Payer: BCBS of TX PPO	$43.54
Rate for Payer: Cash Price	$95.80
Rate for Payer: Multiplan Auto	$70.76
Rate for Payer: Multiplan Commercial	$70.76
Rate for Payer: Multiplan Workers Comp	$70.76
Rate for Payer: Scott and White EPO/PPO	$54.43
Rate for Payer: Superior Health Plan EPO	$14.80

busPIRone 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77428802
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

busPIRone 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77428802
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

C1 Esterase Inhibitor, Func SO

Facility

$201.00

Service Code	CPT 86161
Hospital Charge Code	1707041
Hospital Revenue Code	302
Rate for Payer: Cash Price	$176.88

C1 Esterase Inhibitor, Func SO

Facility

$201.00

Service Code	CPT 86161
Hospital Charge Code	1707041
Hospital Revenue Code	302
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$130.65
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.00
Rate for Payer: Amerigroup Medicare	$12.00
Rate for Payer: BCBS of TX Blue Advantage	$19.80
Rate for Payer: BCBS of TX Blue Essentials	$23.76
Rate for Payer: BCBS of TX Medicare	$12.00
Rate for Payer: BCBS of TX PPO	$26.52
Rate for Payer: Cash Price	$176.88
Rate for Payer: Cash Price	$176.88
Rate for Payer: Cigna Medicaid	$12.00
Rate for Payer: Cigna Medicare	$12.00
Rate for Payer: Employer Direct Commercial	$12.00
Rate for Payer: Humana Medicare/TRICARE	$12.00
Rate for Payer: Molina CHIP/Medicaid	$12.00
Rate for Payer: Molina Dual Medicare/Medicaid	$12.00
Rate for Payer: Molina Medicare	$12.00
Rate for Payer: Multiplan Auto	$130.65
Rate for Payer: Multiplan Commercial	$130.65
Rate for Payer: Multiplan Workers Comp	$130.65
Rate for Payer: Parkland Medicaid	$12.00
Rate for Payer: Scott and White EPO/PPO	$15.00
Rate for Payer: Scott and White Medicare	$12.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.00
Rate for Payer: Superior Health Plan EPO	$12.00
Rate for Payer: Superior Health Plan Medicare	$12.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.00
Rate for Payer: Universal American Medicare	$12.00
Rate for Payer: Wellcare Medicare	$12.00
Rate for Payer: Wellmed Medicare	$12.00

C1 Esterase Inhibitor, Serum SO

Facility

$336.00

Service Code	CPT 86160
Hospital Charge Code	1702562
Hospital Revenue Code	302
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$218.40
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.00
Rate for Payer: Amerigroup Medicare	$12.00
Rate for Payer: BCBS of TX Blue Advantage	$19.80
Rate for Payer: BCBS of TX Blue Essentials	$23.76
Rate for Payer: BCBS of TX Medicare	$12.00
Rate for Payer: BCBS of TX PPO	$26.52
Rate for Payer: Cash Price	$295.68
Rate for Payer: Cash Price	$295.68
Rate for Payer: Cigna Medicaid	$12.00
Rate for Payer: Cigna Medicare	$12.00
Rate for Payer: Employer Direct Commercial	$12.00
Rate for Payer: Humana Medicare/TRICARE	$12.00
Rate for Payer: Molina CHIP/Medicaid	$12.00
Rate for Payer: Molina Dual Medicare/Medicaid	$12.00
Rate for Payer: Molina Medicare	$12.00
Rate for Payer: Multiplan Auto	$218.40
Rate for Payer: Multiplan Commercial	$218.40
Rate for Payer: Multiplan Workers Comp	$218.40
Rate for Payer: Parkland Medicaid	$12.00
Rate for Payer: Scott and White EPO/PPO	$15.00
Rate for Payer: Scott and White Medicare	$12.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.00
Rate for Payer: Superior Health Plan EPO	$12.00
Rate for Payer: Superior Health Plan Medicare	$12.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.00
Rate for Payer: Universal American Medicare	$12.00
Rate for Payer: Wellcare Medicare	$12.00
Rate for Payer: Wellmed Medicare	$12.00

CA 19-9 SO

Facility

$300.00

Service Code	CPT 86301
Hospital Charge Code	1706258
Hospital Revenue Code	302
Rate for Payer: Cash Price	$264.00

CA 19-9 SO

Facility

$300.00

Service Code	CPT 86301
Hospital Charge Code	1706258
Hospital Revenue Code	302
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$21.86
Rate for Payer: Aetna Medicare	$31.22
Rate for Payer: Amerigroup CHIP/Medicaid	$8.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.81
Rate for Payer: Amerigroup Medicare	$20.81
Rate for Payer: BCBS of TX Blue Advantage	$34.34
Rate for Payer: BCBS of TX Blue Essentials	$41.20
Rate for Payer: BCBS of TX Medicare	$20.81
Rate for Payer: BCBS of TX PPO	$45.99
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cigna Medicaid	$20.81
Rate for Payer: Cigna Medicare	$20.81
Rate for Payer: Employer Direct Commercial	$20.81
Rate for Payer: Humana Medicare/TRICARE	$20.81
Rate for Payer: Molina CHIP/Medicaid	$20.81
Rate for Payer: Molina Dual Medicare/Medicaid	$20.81
Rate for Payer: Molina Medicare	$20.81
Rate for Payer: Multiplan Auto	$195.00
Rate for Payer: Multiplan Commercial	$195.00
Rate for Payer: Multiplan Workers Comp	$195.00
Rate for Payer: Parkland Medicaid	$20.81
Rate for Payer: Scott and White EPO/PPO	$26.01
Rate for Payer: Scott and White Medicare	$20.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.81
Rate for Payer: Superior Health Plan EPO	$20.81
Rate for Payer: Superior Health Plan Medicare	$20.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.81
Rate for Payer: Universal American Medicare	$20.81
Rate for Payer: Wellcare Medicare	$20.81
Rate for Payer: Wellmed Medicare	$20.81

CA 27.29 SO

Facility

$169.00

Service Code	CPT 86300
Hospital Charge Code	1706282
Hospital Revenue Code	302
Rate for Payer: Cash Price	$148.72

CA 27.29 SO

Facility

$169.00

Service Code	CPT 86300
Hospital Charge Code	1706282
Hospital Revenue Code	302
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$109.85
Rate for Payer: Aetna Commercial	$21.86
Rate for Payer: Aetna Medicare	$31.22
Rate for Payer: Amerigroup CHIP/Medicaid	$8.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.81
Rate for Payer: Amerigroup Medicare	$20.81
Rate for Payer: BCBS of TX Blue Advantage	$34.34
Rate for Payer: BCBS of TX Blue Essentials	$41.20
Rate for Payer: BCBS of TX Medicare	$20.81
Rate for Payer: BCBS of TX PPO	$45.99
Rate for Payer: Cash Price	$148.72
Rate for Payer: Cash Price	$148.72
Rate for Payer: Cigna Medicaid	$20.81
Rate for Payer: Cigna Medicare	$20.81
Rate for Payer: Employer Direct Commercial	$20.81
Rate for Payer: Humana Medicare/TRICARE	$20.81
Rate for Payer: Molina CHIP/Medicaid	$20.81
Rate for Payer: Molina Dual Medicare/Medicaid	$20.81
Rate for Payer: Molina Medicare	$20.81
Rate for Payer: Multiplan Auto	$109.85
Rate for Payer: Multiplan Commercial	$109.85
Rate for Payer: Multiplan Workers Comp	$109.85
Rate for Payer: Parkland Medicaid	$20.81
Rate for Payer: Scott and White EPO/PPO	$26.01
Rate for Payer: Scott and White Medicare	$20.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.81
Rate for Payer: Superior Health Plan EPO	$20.81
Rate for Payer: Superior Health Plan Medicare	$20.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.81
Rate for Payer: Universal American Medicare	$20.81
Rate for Payer: Wellcare Medicare	$20.81
Rate for Payer: Wellmed Medicare	$20.81

CABLE 301-CD

Facility

$202.71

Hospital Charge Code	145067
Hospital Revenue Code	272
Min. Negotiated Rate	$18.24
Max. Negotiated Rate	$131.76
Rate for Payer: Aetna Commercial	$111.49
Rate for Payer: Amerigroup CHIP/Medicaid	$18.24
Rate for Payer: BCBS of TX Blue Advantage	$60.81
Rate for Payer: BCBS of TX Blue Essentials	$72.98
Rate for Payer: BCBS of TX PPO	$81.08
Rate for Payer: Cash Price	$178.38
Rate for Payer: Multiplan Auto	$131.76
Rate for Payer: Multiplan Commercial	$131.76
Rate for Payer: Multiplan Workers Comp	$131.76
Rate for Payer: Scott and White EPO/PPO	$101.36
Rate for Payer: Superior Health Plan EPO	$27.57

CABLE 301-CD

Facility

$202.71

Hospital Charge Code	145067
Hospital Revenue Code	272
Rate for Payer: Cash Price	$178.38

CABLE 5833SL SURGICAL DISP

Facility

$272.40

Hospital Charge Code	110177
Hospital Revenue Code	272
Rate for Payer: Cash Price	$239.71

CABLE 5833SL SURGICAL DISP

Facility

$272.40

Hospital Charge Code	110177
Hospital Revenue Code	272
Min. Negotiated Rate	$24.52
Max. Negotiated Rate	$177.06
Rate for Payer: Aetna Commercial	$149.82
Rate for Payer: Amerigroup CHIP/Medicaid	$24.52
Rate for Payer: BCBS of TX Blue Advantage	$81.72
Rate for Payer: BCBS of TX Blue Essentials	$98.06
Rate for Payer: BCBS of TX PPO	$108.96
Rate for Payer: Cash Price	$239.71
Rate for Payer: Multiplan Auto	$177.06
Rate for Payer: Multiplan Commercial	$177.06
Rate for Payer: Multiplan Workers Comp	$177.06
Rate for Payer: Scott and White EPO/PPO	$136.20
Rate for Payer: Superior Health Plan EPO	$37.05

CABLE PACING

Facility

$136.20

Hospital Charge Code	8414452
Hospital Revenue Code	272
Min. Negotiated Rate	$12.26
Max. Negotiated Rate	$88.53
Rate for Payer: Aetna Commercial	$74.91
Rate for Payer: Amerigroup CHIP/Medicaid	$12.26
Rate for Payer: BCBS of TX Blue Advantage	$40.86
Rate for Payer: BCBS of TX Blue Essentials	$49.03
Rate for Payer: BCBS of TX PPO	$54.48
Rate for Payer: Cash Price	$119.86
Rate for Payer: Multiplan Auto	$88.53
Rate for Payer: Multiplan Commercial	$88.53
Rate for Payer: Multiplan Workers Comp	$88.53
Rate for Payer: Scott and White EPO/PPO	$68.10
Rate for Payer: Superior Health Plan EPO	$18.52

CABLE PACING

Facility

$136.20

Hospital Charge Code	8414452
Hospital Revenue Code	272
Rate for Payer: Cash Price	$119.86

Know your out-of-pocket cost for care.

All Charges