White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomye

Facility

$10,000.00

Service Code	CPT 28120
Hospital Charge Code	36028120
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomye

Facility

$14,152.00

Service Code	HCPCS 28120
Hospital Charge Code	9900481
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,623.36

Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomye

Facility

$10,000.00

Service Code	CPT 28122
Hospital Charge Code	36028122
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomye

Facility

$10,000.00

Service Code	CPT 28124
Hospital Charge Code	36028124
Hospital Revenue Code	360
Min. Negotiated Rate	$238.37
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$238.37
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$503.86
Rate for Payer: BCBS of TX Blue Essentials	$603.42
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$760.31
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomye

Facility

$12,312.24

Service Code	HCPCS 28122
Hospital Charge Code	9900482
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,372.32

Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomye

Facility

$14,152.00

Service Code	HCPCS 28120
Hospital Charge Code	9900481
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,189.44
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$9,623.36
Rate for Payer: Cash Price	$9,623.36
Rate for Payer: Cash Price	$9,623.36
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$10,189.44
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$10,189.44
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$10,189.44
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,189.44
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomye

Facility

$12,312.24

Service Code	HCPCS 28122
Hospital Charge Code	9900482
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$8,372.32
Rate for Payer: Cash Price	$8,372.32
Rate for Payer: Cash Price	$8,372.32
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$8,864.81
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$8,864.81
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$8,864.81
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,864.81
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT

Facility

$3,252.88

Service Code	APR-DRG 8442
Min. Negotiated Rate	$3,066.93
Max. Negotiated Rate	$3,252.88
Rate for Payer: Amerigroup CHIP/Medicaid	$3,066.93
Rate for Payer: Cigna Medicaid	$3,066.93
Rate for Payer: Molina CHIP/Medicaid	$3,066.93
Rate for Payer: Parkland Medicaid	$3,066.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,252.88

PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT

Facility

$15,471.92

Service Code	APR-DRG 8444
Min. Negotiated Rate	$14,587.46
Max. Negotiated Rate	$15,471.92
Rate for Payer: Amerigroup CHIP/Medicaid	$14,587.46
Rate for Payer: Cigna Medicaid	$14,587.46
Rate for Payer: Molina CHIP/Medicaid	$14,587.46
Rate for Payer: Parkland Medicaid	$14,587.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,471.92

PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT

Facility

$5,386.64

Service Code	APR-DRG 8443
Min. Negotiated Rate	$5,078.71
Max. Negotiated Rate	$5,386.64
Rate for Payer: Amerigroup CHIP/Medicaid	$5,078.71
Rate for Payer: Cigna Medicaid	$5,078.71
Rate for Payer: Molina CHIP/Medicaid	$5,078.71
Rate for Payer: Parkland Medicaid	$5,078.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,386.64

PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT

Facility

$2,189.96

Service Code	APR-DRG 8441
Min. Negotiated Rate	$2,064.77
Max. Negotiated Rate	$2,189.96
Rate for Payer: Amerigroup CHIP/Medicaid	$2,064.77
Rate for Payer: Cigna Medicaid	$2,064.77
Rate for Payer: Molina CHIP/Medicaid	$2,064.77
Rate for Payer: Parkland Medicaid	$2,064.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,189.96

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

Parvovirus B19, Human, IgG/IgM SO

Facility

$113.00

Service Code	HCPCS 86747
Hospital Charge Code	1703842
Hospital Revenue Code	302
Rate for Payer: Cash Price	$76.84

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
Rate for Payer: Cash Price	$1,157.70

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, 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 LAPAROSCOP

Facility

$49.49

Hospital Charge Code	993956
Hospital Revenue Code	279
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 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 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
Rate for Payer: Cash Price	$1,814.92

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

Know your out-of-pocket cost for care.

All Charges