White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CANCELLOUS BONE CHIPS 30CC

Facility

$15,060.24

Service Code	HCPCS C1713
Hospital Charge Code	8394473
Hospital Revenue Code	278
Min. Negotiated Rate	$1,355.42
Max. Negotiated Rate	$7,530.12
Rate for Payer: Aetna Commercial	$4,518.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1,355.42
Rate for Payer: BCBS of TX Blue Advantage	$4,518.07
Rate for Payer: BCBS of TX Blue Essentials	$5,421.69
Rate for Payer: BCBS of TX PPO	$6,024.10
Rate for Payer: Cash Price	$13,253.01
Rate for Payer: Multiplan Auto	$7,530.12
Rate for Payer: Multiplan Commercial	$7,530.12
Rate for Payer: Multiplan Workers Comp	$7,530.12
Rate for Payer: Scott and White EPO/PPO	$7,530.12
Rate for Payer: Superior Health Plan EPO	$2,048.19

Cancer Antigen (CA) 125 SO

Facility

$449.00

Service Code	CPT 86304
Hospital Charge Code	1706274
Hospital Revenue Code	302
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$291.85
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	$395.12
Rate for Payer: Cash Price	$395.12
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	$291.85
Rate for Payer: Multiplan Commercial	$291.85
Rate for Payer: Multiplan Workers Comp	$291.85
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

Cancer Antigen (CA) 125 SO

Facility

$449.00

Service Code	CPT 86304
Hospital Charge Code	1706274
Hospital Revenue Code	302
Rate for Payer: Cash Price	$395.12

CANISTER ASPIRATION ENGINE

Facility

$1,634.40

Hospital Charge Code	8568962
Hospital Revenue Code	272
Min. Negotiated Rate	$147.10
Max. Negotiated Rate	$1,062.36
Rate for Payer: Aetna Commercial	$898.92
Rate for Payer: Amerigroup CHIP/Medicaid	$147.10
Rate for Payer: BCBS of TX Blue Advantage	$490.32
Rate for Payer: BCBS of TX Blue Essentials	$588.38
Rate for Payer: BCBS of TX PPO	$653.76
Rate for Payer: Cash Price	$1,438.27
Rate for Payer: Multiplan Auto	$1,062.36
Rate for Payer: Multiplan Commercial	$1,062.36
Rate for Payer: Multiplan Workers Comp	$1,062.36
Rate for Payer: Scott and White EPO/PPO	$817.20
Rate for Payer: Superior Health Plan EPO	$222.28

CANISTER ASPIRATION ENGINE

Facility

$1,634.40

Hospital Charge Code	8568962
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,438.27

CANISTER, SUCTION GUARDIAN LRG VOL COLLECTION 12L -- DHF

Facility

$170.09

Hospital Charge Code	80342900
Hospital Revenue Code	270
Min. Negotiated Rate	$15.31
Max. Negotiated Rate	$110.56
Rate for Payer: Aetna Commercial	$93.55
Rate for Payer: Amerigroup CHIP/Medicaid	$15.31
Rate for Payer: BCBS of TX Blue Advantage	$51.03
Rate for Payer: BCBS of TX Blue Essentials	$61.23
Rate for Payer: BCBS of TX PPO	$68.04
Rate for Payer: Cash Price	$149.68
Rate for Payer: Multiplan Auto	$110.56
Rate for Payer: Multiplan Commercial	$110.56
Rate for Payer: Multiplan Workers Comp	$110.56
Rate for Payer: Scott and White EPO/PPO	$85.04
Rate for Payer: Superior Health Plan EPO	$23.13

CANISTER, SUCTION W/O GEL 500ML -- DHF

Facility

$127.66

Hospital Charge Code	80315096
Hospital Revenue Code	272
Min. Negotiated Rate	$11.49
Max. Negotiated Rate	$82.98
Rate for Payer: Aetna Commercial	$70.21
Rate for Payer: Amerigroup CHIP/Medicaid	$11.49
Rate for Payer: BCBS of TX Blue Advantage	$38.30
Rate for Payer: BCBS of TX Blue Essentials	$45.96
Rate for Payer: BCBS of TX PPO	$51.06
Rate for Payer: Cash Price	$112.34
Rate for Payer: Multiplan Auto	$82.98
Rate for Payer: Multiplan Commercial	$82.98
Rate for Payer: Multiplan Workers Comp	$82.98
Rate for Payer: Scott and White EPO/PPO	$63.83
Rate for Payer: Superior Health Plan EPO	$17.36

CANISTER, SUCTION W/O GEL 500ML -- DHF

Facility

$127.66

Hospital Charge Code	80315096
Hospital Revenue Code	272
Rate for Payer: Cash Price	$112.34

CANISTER WND VAC 1000ML -- DHF

Facility

$247.82

Hospital Charge Code	80315161
Hospital Revenue Code	272
Min. Negotiated Rate	$22.30
Max. Negotiated Rate	$161.08
Rate for Payer: Aetna Commercial	$136.30
Rate for Payer: Amerigroup CHIP/Medicaid	$22.30
Rate for Payer: BCBS of TX Blue Advantage	$74.35
Rate for Payer: BCBS of TX Blue Essentials	$89.22
Rate for Payer: BCBS of TX PPO	$99.13
Rate for Payer: Cash Price	$218.08
Rate for Payer: Multiplan Auto	$161.08
Rate for Payer: Multiplan Commercial	$161.08
Rate for Payer: Multiplan Workers Comp	$161.08
Rate for Payer: Scott and White EPO/PPO	$123.91
Rate for Payer: Superior Health Plan EPO	$33.70

CANISTER WND VAC 1000ML -- DHF

Facility

$247.82

Hospital Charge Code	80315161
Hospital Revenue Code	272
Rate for Payer: Cash Price	$218.08

Cannaboind Screen Urine

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640115
Hospital Revenue Code	300
Rate for Payer: Cash Price	$278.96

Cannaboind Screen Urine

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640115
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$206.05
Rate for Payer: Aetna Commercial	$65.24
Rate for Payer: Aetna Medicare	$93.21
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$102.53
Rate for Payer: BCBS of TX Blue Essentials	$123.04
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$137.33
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cigna Medicaid	$62.14
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$62.14
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$62.14
Rate for Payer: Scott and White EPO/PPO	$77.68
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.14
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

CANN DISP INER -- DHF

Facility

$224.92

Hospital Charge Code	82020215
Hospital Revenue Code	272
Min. Negotiated Rate	$20.24
Max. Negotiated Rate	$146.20
Rate for Payer: Aetna Commercial	$123.71
Rate for Payer: Amerigroup CHIP/Medicaid	$20.24
Rate for Payer: BCBS of TX Blue Advantage	$67.48
Rate for Payer: BCBS of TX Blue Essentials	$80.97
Rate for Payer: BCBS of TX PPO	$89.97
Rate for Payer: Cash Price	$197.93
Rate for Payer: Multiplan Auto	$146.20
Rate for Payer: Multiplan Commercial	$146.20
Rate for Payer: Multiplan Workers Comp	$146.20
Rate for Payer: Scott and White EPO/PPO	$112.46
Rate for Payer: Superior Health Plan EPO	$30.59

CANN DISP INER -- DHF

Facility

$224.92

Hospital Charge Code	82020215
Hospital Revenue Code	272
Rate for Payer: Cash Price	$197.93

CANNISTER, SUCTION 3000CC -- DHF

Facility

$170.09

Hospital Charge Code	80342900
Hospital Revenue Code	270
Min. Negotiated Rate	$15.31
Max. Negotiated Rate	$110.56
Rate for Payer: Aetna Commercial	$93.55
Rate for Payer: Amerigroup CHIP/Medicaid	$15.31
Rate for Payer: BCBS of TX Blue Advantage	$51.03
Rate for Payer: BCBS of TX Blue Essentials	$61.23
Rate for Payer: BCBS of TX PPO	$68.04
Rate for Payer: Cash Price	$149.68
Rate for Payer: Multiplan Auto	$110.56
Rate for Payer: Multiplan Commercial	$110.56
Rate for Payer: Multiplan Workers Comp	$110.56
Rate for Payer: Scott and White EPO/PPO	$85.04
Rate for Payer: Superior Health Plan EPO	$23.13

CANNISTER, SUCTION 3000CC -- DHF

Facility

$170.09

Hospital Charge Code	80342900
Hospital Revenue Code	270
Rate for Payer: Cash Price	$149.68

CANN NASAL -- DHF

Facility

$96.91

Hospital Charge Code	82020009
Hospital Revenue Code	270
Rate for Payer: Cash Price	$85.28

CANN NASAL -- DHF

Facility

$96.91

Hospital Charge Code	82020009
Hospital Revenue Code	270
Min. Negotiated Rate	$8.72
Max. Negotiated Rate	$62.99
Rate for Payer: Aetna Commercial	$53.30
Rate for Payer: Amerigroup CHIP/Medicaid	$8.72
Rate for Payer: BCBS of TX Blue Advantage	$29.07
Rate for Payer: BCBS of TX Blue Essentials	$34.89
Rate for Payer: BCBS of TX PPO	$38.76
Rate for Payer: Cash Price	$85.28
Rate for Payer: Multiplan Auto	$62.99
Rate for Payer: Multiplan Commercial	$62.99
Rate for Payer: Multiplan Workers Comp	$62.99
Rate for Payer: Scott and White EPO/PPO	$48.46
Rate for Payer: Superior Health Plan EPO	$13.18

CANN ORTHO -- DHF

Facility

$124.76

Hospital Charge Code	80315104
Hospital Revenue Code	270
Rate for Payer: Cash Price	$109.79

CANN ORTHO -- DHF

Facility

$124.76

Hospital Charge Code	80315104
Hospital Revenue Code	270
Min. Negotiated Rate	$11.23
Max. Negotiated Rate	$81.09
Rate for Payer: Aetna Commercial	$68.62
Rate for Payer: Amerigroup CHIP/Medicaid	$11.23
Rate for Payer: BCBS of TX Blue Advantage	$37.43
Rate for Payer: BCBS of TX Blue Essentials	$44.91
Rate for Payer: BCBS of TX PPO	$49.90
Rate for Payer: Cash Price	$109.79
Rate for Payer: Multiplan Auto	$81.09
Rate for Payer: Multiplan Commercial	$81.09
Rate for Payer: Multiplan Workers Comp	$81.09
Rate for Payer: Scott and White EPO/PPO	$62.38
Rate for Payer: Superior Health Plan EPO	$16.97

CANN STIMULAT ECHOGENIC -- DHF

Facility

$77.61

Hospital Charge Code	80315476
Hospital Revenue Code	272
Rate for Payer: Cash Price	$68.30

CANN STIMULAT ECHOGENIC -- DHF

Facility

$77.61

Hospital Charge Code	80315476
Hospital Revenue Code	272
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$50.45
Rate for Payer: Aetna Commercial	$42.69
Rate for Payer: Amerigroup CHIP/Medicaid	$6.98
Rate for Payer: BCBS of TX Blue Advantage	$23.28
Rate for Payer: BCBS of TX Blue Essentials	$27.94
Rate for Payer: BCBS of TX PPO	$31.04
Rate for Payer: Cash Price	$68.30
Rate for Payer: Multiplan Auto	$50.45
Rate for Payer: Multiplan Commercial	$50.45
Rate for Payer: Multiplan Workers Comp	$50.45
Rate for Payer: Scott and White EPO/PPO	$38.80
Rate for Payer: Superior Health Plan EPO	$10.55

CANNULA ARTHROSCOPIC

Facility

$319.84

Hospital Charge Code	8414484
Hospital Revenue Code	272
Min. Negotiated Rate	$28.79
Max. Negotiated Rate	$207.90
Rate for Payer: Aetna Commercial	$175.91
Rate for Payer: Amerigroup CHIP/Medicaid	$28.79
Rate for Payer: BCBS of TX Blue Advantage	$95.95
Rate for Payer: BCBS of TX Blue Essentials	$115.14
Rate for Payer: BCBS of TX PPO	$127.94
Rate for Payer: Cash Price	$281.46
Rate for Payer: Multiplan Auto	$207.90
Rate for Payer: Multiplan Commercial	$207.90
Rate for Payer: Multiplan Workers Comp	$207.90
Rate for Payer: Scott and White EPO/PPO	$159.92
Rate for Payer: Superior Health Plan EPO	$43.50

CANNULA ARTHROSCOPIC

Facility

$319.84

Hospital Charge Code	8414484
Hospital Revenue Code	272
Rate for Payer: Cash Price	$281.46

CANNULA, ARTHROSCOPIC THREADED 7.0MM X 75MM DISP -- DHF

Facility

$190.68

Hospital Charge Code	81730608
Hospital Revenue Code	272
Min. Negotiated Rate	$17.16
Max. Negotiated Rate	$123.94
Rate for Payer: Aetna Commercial	$104.87
Rate for Payer: Amerigroup CHIP/Medicaid	$17.16
Rate for Payer: BCBS of TX Blue Advantage	$57.20
Rate for Payer: BCBS of TX Blue Essentials	$68.64
Rate for Payer: BCBS of TX PPO	$76.27
Rate for Payer: Cash Price	$167.80
Rate for Payer: Multiplan Auto	$123.94
Rate for Payer: Multiplan Commercial	$123.94
Rate for Payer: Multiplan Workers Comp	$123.94
Rate for Payer: Scott and White EPO/PPO	$95.34
Rate for Payer: Superior Health Plan EPO	$25.93

Know your out-of-pocket cost for care.

All Charges