White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Parvovirus B19, Human, IgG/IgM SO

Facility

$113.00

Service Code	HCPCS 86747
Hospital Charge Code	1703842
Hospital Revenue Code	302
Min. Negotiated Rate	$5.86
Max. Negotiated Rate	$81.36
Rate for Payer: Amerigroup CHIP/Medicaid	$5.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.03
Rate for Payer: Amerigroup Medicare	$15.03
Rate for Payer: BCBS of TX Blue Advantage	$33.90
Rate for Payer: BCBS of TX Blue Essentials	$40.68
Rate for Payer: BCBS of TX Medicare	$15.03
Rate for Payer: BCBS of TX PPO	$45.20
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cigna Medicaid	$81.36
Rate for Payer: Cigna Medicare	$15.03
Rate for Payer: Employer Direct Commercial	$15.03
Rate for Payer: Humana Medicare/TRICARE	$15.03
Rate for Payer: Molina CHIP/Medicaid	$81.36
Rate for Payer: Molina Dual Medicare/Medicaid	$15.03
Rate for Payer: Molina Medicare	$15.03
Rate for Payer: Multiplan Auto	$73.45
Rate for Payer: Multiplan Commercial	$73.45
Rate for Payer: Multiplan Workers Comp	$73.45
Rate for Payer: Parkland Medicaid	$81.36
Rate for Payer: Scott and White EPO/PPO	$18.79
Rate for Payer: Scott and White Medicare	$15.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.36
Rate for Payer: Superior Health Plan EPO	$15.03
Rate for Payer: Superior Health Plan Medicare	$15.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.03
Rate for Payer: Universal American Medicare	$15.03
Rate for Payer: Wellcare Medicare	$15.03
Rate for Payer: Wellmed Medicare	$15.03

PASSER CIRCLAGE STRGHT LG DISP

Facility

$1,702.50

Hospital Charge Code	146433
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,157.70

PASSER CIRCLAGE STRGHT LG DISP

Facility

$1,702.50

Hospital Charge Code	146433
Hospital Revenue Code	272
Min. Negotiated Rate	$153.22
Max. Negotiated Rate	$1,225.80
Rate for Payer: Amerigroup CHIP/Medicaid	$153.22
Rate for Payer: BCBS of TX Blue Advantage	$510.75
Rate for Payer: BCBS of TX Blue Essentials	$612.90
Rate for Payer: BCBS of TX PPO	$681.00
Rate for Payer: Cash Price	$1,157.70
Rate for Payer: Cigna Medicaid	$1,225.80
Rate for Payer: Molina CHIP/Medicaid	$1,225.80
Rate for Payer: Multiplan Auto	$1,106.62
Rate for Payer: Multiplan Commercial	$1,106.62
Rate for Payer: Multiplan Workers Comp	$1,106.62
Rate for Payer: Parkland Medicaid	$1,225.80
Rate for Payer: Scott and White EPO/PPO	$851.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,225.80
Rate for Payer: Superior Health Plan EPO	$231.54

PASSER CIRCLAGE STRGHT LT OFFSET DISP

Facility

$1,702.50

Hospital Charge Code	146434
Hospital Revenue Code	272
Min. Negotiated Rate	$153.22
Max. Negotiated Rate	$1,225.80
Rate for Payer: Amerigroup CHIP/Medicaid	$153.22
Rate for Payer: BCBS of TX Blue Advantage	$510.75
Rate for Payer: BCBS of TX Blue Essentials	$612.90
Rate for Payer: BCBS of TX PPO	$681.00
Rate for Payer: Cash Price	$1,157.70
Rate for Payer: Cigna Medicaid	$1,225.80
Rate for Payer: Molina CHIP/Medicaid	$1,225.80
Rate for Payer: Multiplan Auto	$1,106.62
Rate for Payer: Multiplan Commercial	$1,106.62
Rate for Payer: Multiplan Workers Comp	$1,106.62
Rate for Payer: Parkland Medicaid	$1,225.80
Rate for Payer: Scott and White EPO/PPO	$851.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,225.80
Rate for Payer: Superior Health Plan EPO	$231.54

PASSER CIRCLAGE STRGHT LT OFFSET DISP

Facility

$1,702.50

Hospital Charge Code	146434
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,157.70

PASSER, SUTURE LAPAROSCOP

Facility

$49.49

Hospital Charge Code	993956
Hospital Revenue Code	279
Rate for Payer: Cash Price	$33.65

PASSER, SUTURE LAPAROSCOP

Facility

$49.49

Hospital Charge Code	993956
Hospital Revenue Code	279
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$35.63
Rate for Payer: Amerigroup CHIP/Medicaid	$4.45
Rate for Payer: BCBS of TX Blue Advantage	$14.85
Rate for Payer: BCBS of TX Blue Essentials	$17.82
Rate for Payer: BCBS of TX PPO	$19.80
Rate for Payer: Cash Price	$33.65
Rate for Payer: Cigna Medicaid	$35.63
Rate for Payer: Molina CHIP/Medicaid	$35.63
Rate for Payer: Multiplan Auto	$32.17
Rate for Payer: Multiplan Commercial	$32.17
Rate for Payer: Multiplan Workers Comp	$32.17
Rate for Payer: Parkland Medicaid	$35.63
Rate for Payer: Scott and White EPO/PPO	$24.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.63
Rate for Payer: Superior Health Plan EPO	$6.73

PASSER, SUTURE LAPAROSCOPIC 14G SINGLE USE -- DHF

Facility

$49.49

Hospital Charge Code	80320914
Hospital Revenue Code	272
Rate for Payer: Cash Price	$33.65

PASSER, SUTURE LAPAROSCOPIC 14G SINGLE USE -- DHF

Facility

$49.49

Hospital Charge Code	80320914
Hospital Revenue Code	272
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$35.63
Rate for Payer: Amerigroup CHIP/Medicaid	$4.45
Rate for Payer: BCBS of TX Blue Advantage	$14.85
Rate for Payer: BCBS of TX Blue Essentials	$17.82
Rate for Payer: BCBS of TX PPO	$19.80
Rate for Payer: Cash Price	$33.65
Rate for Payer: Cigna Medicaid	$35.63
Rate for Payer: Molina CHIP/Medicaid	$35.63
Rate for Payer: Multiplan Auto	$32.17
Rate for Payer: Multiplan Commercial	$32.17
Rate for Payer: Multiplan Workers Comp	$32.17
Rate for Payer: Parkland Medicaid	$35.63
Rate for Payer: Scott and White EPO/PPO	$24.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.63
Rate for Payer: Superior Health Plan EPO	$6.73

PASSER, SUTURE SHUTTLE SUPER .91M DIA X 36' LENGTH

Facility

$342.54

Hospital Charge Code	140687
Hospital Revenue Code	272
Min. Negotiated Rate	$30.83
Max. Negotiated Rate	$246.63
Rate for Payer: Amerigroup CHIP/Medicaid	$30.83
Rate for Payer: BCBS of TX Blue Advantage	$102.76
Rate for Payer: BCBS of TX Blue Essentials	$123.31
Rate for Payer: BCBS of TX PPO	$137.02
Rate for Payer: Cash Price	$232.93
Rate for Payer: Cigna Medicaid	$246.63
Rate for Payer: Molina CHIP/Medicaid	$246.63
Rate for Payer: Multiplan Auto	$222.65
Rate for Payer: Multiplan Commercial	$222.65
Rate for Payer: Multiplan Workers Comp	$222.65
Rate for Payer: Parkland Medicaid	$246.63
Rate for Payer: Scott and White EPO/PPO	$171.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$246.63
Rate for Payer: Superior Health Plan EPO	$46.59

PASSER, SUTURE SHUTTLE SUPER .91M DIA X 36' LENGTH

Facility

$342.54

Hospital Charge Code	140687
Hospital Revenue Code	272
Rate for Payer: Cash Price	$232.93

PATCH VENTRAL PARIETEX COMPOSITE 4.6 CM

Facility

$2,669.00

Service Code	HCPCS C1781
Hospital Charge Code	146126
Hospital Revenue Code	272
Min. Negotiated Rate	$240.21
Max. Negotiated Rate	$1,921.68
Rate for Payer: Amerigroup CHIP/Medicaid	$240.21
Rate for Payer: BCBS of TX Blue Advantage	$800.70
Rate for Payer: BCBS of TX Blue Essentials	$960.84
Rate for Payer: BCBS of TX PPO	$1,067.60
Rate for Payer: Cash Price	$1,814.92
Rate for Payer: Cigna Medicaid	$1,921.68
Rate for Payer: Molina CHIP/Medicaid	$1,921.68
Rate for Payer: Multiplan Auto	$1,734.85
Rate for Payer: Multiplan Commercial	$1,734.85
Rate for Payer: Multiplan Workers Comp	$1,734.85
Rate for Payer: Parkland Medicaid	$1,921.68
Rate for Payer: Scott and White EPO/PPO	$1,334.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,921.68
Rate for Payer: Superior Health Plan EPO	$362.98

PATCH VENTRAL PARIETEX COMPOSITE 4.6 CM

Facility

$2,669.00

Service Code	HCPCS C1781
Hospital Charge Code	146126
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,814.92

PATCH VENTRAL PARIETEX COMPOSITE 6.6 CM

Facility

$3,277.00

Service Code	HCPCS C1781
Hospital Charge Code	146127
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,228.36

PATCH VENTRAL PARIETEX COMPOSITE 6.6 CM

Facility

$3,277.00

Service Code	HCPCS C1781
Hospital Charge Code	146127
Hospital Revenue Code	272
Min. Negotiated Rate	$294.93
Max. Negotiated Rate	$2,359.44
Rate for Payer: Amerigroup CHIP/Medicaid	$294.93
Rate for Payer: BCBS of TX Blue Advantage	$983.10
Rate for Payer: BCBS of TX Blue Essentials	$1,179.72
Rate for Payer: BCBS of TX PPO	$1,310.80
Rate for Payer: Cash Price	$2,228.36
Rate for Payer: Cigna Medicaid	$2,359.44
Rate for Payer: Molina CHIP/Medicaid	$2,359.44
Rate for Payer: Multiplan Auto	$2,130.05
Rate for Payer: Multiplan Commercial	$2,130.05
Rate for Payer: Multiplan Workers Comp	$2,130.05
Rate for Payer: Parkland Medicaid	$2,359.44
Rate for Payer: Scott and White EPO/PPO	$1,638.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,359.44
Rate for Payer: Superior Health Plan EPO	$445.67

PATCH VENTRAL PARIETEX COMPOSITE 8.6 CM

Facility

$4,108.00

Service Code	HCPCS C1781
Hospital Charge Code	146128
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,793.44

PATCH VENTRAL PARIETEX COMPOSITE 8.6 CM

Facility

$4,108.00

Service Code	HCPCS C1781
Hospital Charge Code	146128
Hospital Revenue Code	272
Min. Negotiated Rate	$369.72
Max. Negotiated Rate	$2,957.76
Rate for Payer: Amerigroup CHIP/Medicaid	$369.72
Rate for Payer: BCBS of TX Blue Advantage	$1,232.40
Rate for Payer: BCBS of TX Blue Essentials	$1,478.88
Rate for Payer: BCBS of TX PPO	$1,643.20
Rate for Payer: Cash Price	$2,793.44
Rate for Payer: Cigna Medicaid	$2,957.76
Rate for Payer: Molina CHIP/Medicaid	$2,957.76
Rate for Payer: Multiplan Auto	$2,670.20
Rate for Payer: Multiplan Commercial	$2,670.20
Rate for Payer: Multiplan Workers Comp	$2,670.20
Rate for Payer: Parkland Medicaid	$2,957.76
Rate for Payer: Scott and White EPO/PPO	$2,054.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,957.76
Rate for Payer: Superior Health Plan EPO	$558.69

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC

Facility

$20,691.00

Service Code	MSDRG 543
Min. Negotiated Rate	$9,223.50
Max. Negotiated Rate	$20,691.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,294.32
Rate for Payer: Amerigroup Medicare	$12,294.32
Rate for Payer: BCBS of TX Medicare	$12,294.32
Rate for Payer: Cigna Commercial	$13,240.64
Rate for Payer: Cigna Medicare	$12,294.32
Rate for Payer: Employer Direct Commercial	$12,294.32
Rate for Payer: Humana Medicare/TRICARE	$12,294.32
Rate for Payer: Molina Dual Medicare/Medicaid	$12,294.32
Rate for Payer: Molina Medicare	$12,294.32
Rate for Payer: Multiplan Auto	$20,691.00
Rate for Payer: Multiplan Commercial	$20,691.00
Rate for Payer: Multiplan Workers Comp	$20,691.00
Rate for Payer: Scott and White EPO/PPO	$9,528.75
Rate for Payer: Scott and White Medicare	$12,294.32
Rate for Payer: Superior Health Plan EPO	$12,294.32
Rate for Payer: Superior Health Plan Medicare	$12,294.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,294.32
Rate for Payer: Universal American Medicare	$12,294.32
Rate for Payer: Wellcare Medicare	$12,294.32
Rate for Payer: Wellmed Medicare	$12,294.32

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC

Facility

$34,732.00

Service Code	MSDRG 542
Min. Negotiated Rate	$15,697.58
Max. Negotiated Rate	$34,732.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,706.80
Rate for Payer: Amerigroup Medicare	$17,706.80
Rate for Payer: BCBS of TX Medicare	$17,706.80
Rate for Payer: Cigna Commercial	$22,752.52
Rate for Payer: Cigna Medicare	$17,706.80
Rate for Payer: Employer Direct Commercial	$17,706.80
Rate for Payer: Humana Medicare/TRICARE	$17,706.80
Rate for Payer: Molina Dual Medicare/Medicaid	$17,706.80
Rate for Payer: Molina Medicare	$17,706.80
Rate for Payer: Multiplan Auto	$34,732.00
Rate for Payer: Multiplan Commercial	$34,732.00
Rate for Payer: Multiplan Workers Comp	$34,732.00
Rate for Payer: Scott and White EPO/PPO	$15,995.00
Rate for Payer: Scott and White Medicare	$17,706.80
Rate for Payer: Superior Health Plan EPO	$17,706.80
Rate for Payer: Superior Health Plan Medicare	$17,706.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,706.80
Rate for Payer: Universal American Medicare	$17,706.80
Rate for Payer: Wellcare Medicare	$17,706.80
Rate for Payer: Wellmed Medicare	$17,706.80

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC

Facility

$14,783.90

Service Code	MSDRG 544
Min. Negotiated Rate	$6,808.38
Max. Negotiated Rate	$14,783.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,290.56
Rate for Payer: Amerigroup Medicare	$10,290.56
Rate for Payer: BCBS of TX Medicare	$10,290.56
Rate for Payer: Cigna Commercial	$9,719.25
Rate for Payer: Cigna Medicare	$10,290.56
Rate for Payer: Employer Direct Commercial	$10,290.56
Rate for Payer: Humana Medicare/TRICARE	$10,290.56
Rate for Payer: Molina Dual Medicare/Medicaid	$10,290.56
Rate for Payer: Molina Medicare	$10,290.56
Rate for Payer: Multiplan Auto	$14,783.90
Rate for Payer: Multiplan Commercial	$14,783.90
Rate for Payer: Multiplan Workers Comp	$14,783.90
Rate for Payer: Scott and White EPO/PPO	$6,808.38
Rate for Payer: Scott and White Medicare	$10,290.56
Rate for Payer: Superior Health Plan EPO	$10,290.56
Rate for Payer: Superior Health Plan Medicare	$10,290.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,290.56
Rate for Payer: Universal American Medicare	$10,290.56
Rate for Payer: Wellcare Medicare	$10,290.56
Rate for Payer: Wellmed Medicare	$10,290.56

PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC

Facility

$20,691.00

Service Code	MSDRG 543
Min. Negotiated Rate	$9,223.50
Max. Negotiated Rate	$20,691.00
Rate for Payer: BCBS of TX Blue Advantage	$9,223.50
Rate for Payer: BCBS of TX Blue Essentials	$11,067.13
Rate for Payer: BCBS of TX PPO	$12,297.28

PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W MCC

Facility

$34,732.00

Service Code	MSDRG 542
Min. Negotiated Rate	$15,697.58
Max. Negotiated Rate	$34,732.00
Rate for Payer: BCBS of TX Blue Advantage	$15,697.58
Rate for Payer: BCBS of TX Blue Essentials	$18,835.27
Rate for Payer: BCBS of TX PPO	$20,928.89

PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W/O CC/MCC

Facility

$14,783.90

Service Code	MSDRG 544
Min. Negotiated Rate	$6,808.38
Max. Negotiated Rate	$14,783.90
Rate for Payer: BCBS of TX Blue Advantage	$6,866.24
Rate for Payer: BCBS of TX Blue Essentials	$8,238.69
Rate for Payer: BCBS of TX PPO	$9,154.45

Patient Antigen Type Bill Quantity -> 3

Facility

$124.00

Service Code	HCPCS 86905
Hospital Charge Code	2402949
Hospital Revenue Code	300
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$761.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1.49
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.83
Rate for Payer: Amerigroup Medicare	$3.83
Rate for Payer: BCBS of TX Blue Advantage	$37.20
Rate for Payer: BCBS of TX Blue Essentials	$44.64
Rate for Payer: BCBS of TX Medicare	$3.83
Rate for Payer: BCBS of TX PPO	$49.60
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cigna Commercial	$761.14
Rate for Payer: Cigna Medicaid	$89.28
Rate for Payer: Cigna Medicare	$3.83
Rate for Payer: Employer Direct Commercial	$3.83
Rate for Payer: Humana Medicare/TRICARE	$3.83
Rate for Payer: Molina CHIP/Medicaid	$89.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3.83
Rate for Payer: Molina Medicare	$3.83
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Parkland Medicaid	$89.28
Rate for Payer: Scott and White EPO/PPO	$4.79
Rate for Payer: Scott and White Medicare	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.28
Rate for Payer: Superior Health Plan EPO	$3.83
Rate for Payer: Superior Health Plan Medicare	$3.83
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.83
Rate for Payer: Universal American Medicare	$3.83
Rate for Payer: Wellcare Medicare	$3.83
Rate for Payer: Wellmed Medicare	$3.83

Patient Antigen Type Bill Quantity -> 3

Facility

$124.00

Service Code	HCPCS 86905
Hospital Charge Code	2402949
Hospital Revenue Code	300
Rate for Payer: Cash Price	$84.32

Know your out-of-pocket cost for care.

All Charges