White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PKG. HOODED ABRASION BUR SMALL JOINT F

Facility

$2,316.27

Hospital Charge Code	993157
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,575.06

PKG Tomcat hc shaver blade -40mm

Facility

$623.21

Hospital Charge Code	993579
Hospital Revenue Code	272
Rate for Payer: Cash Price	$423.78

PKG Tomcat hc shaver blade -40mm

Facility

$623.21

Hospital Charge Code	993579
Hospital Revenue Code	272
Min. Negotiated Rate	$56.09
Max. Negotiated Rate	$448.71
Rate for Payer: Amerigroup CHIP/Medicaid	$56.09
Rate for Payer: BCBS of TX Blue Advantage	$186.96
Rate for Payer: BCBS of TX Blue Essentials	$224.36
Rate for Payer: BCBS of TX PPO	$249.28
Rate for Payer: Cash Price	$423.78
Rate for Payer: Cigna Medicaid	$448.71
Rate for Payer: Molina CHIP/Medicaid	$448.71
Rate for Payer: Multiplan Auto	$405.09
Rate for Payer: Multiplan Commercial	$405.09
Rate for Payer: Multiplan Workers Comp	$405.09
Rate for Payer: Parkland Medicaid	$448.71
Rate for Payer: Scott and White EPO/PPO	$311.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$448.71
Rate for Payer: Superior Health Plan EPO	$84.76

PKG. TOMCAT SHAVER BALDE SMALL JOINT F-S

Facility

$399.15

Hospital Charge Code	993156
Hospital Revenue Code	270
Min. Negotiated Rate	$35.92
Max. Negotiated Rate	$287.39
Rate for Payer: Amerigroup CHIP/Medicaid	$35.92
Rate for Payer: BCBS of TX Blue Advantage	$119.75
Rate for Payer: BCBS of TX Blue Essentials	$143.69
Rate for Payer: BCBS of TX PPO	$159.66
Rate for Payer: Cash Price	$271.42
Rate for Payer: Cigna Medicaid	$287.39
Rate for Payer: Molina CHIP/Medicaid	$287.39
Rate for Payer: Multiplan Auto	$259.45
Rate for Payer: Multiplan Commercial	$259.45
Rate for Payer: Multiplan Workers Comp	$259.45
Rate for Payer: Parkland Medicaid	$287.39
Rate for Payer: Scott and White EPO/PPO	$199.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$287.39
Rate for Payer: Superior Health Plan EPO	$54.28

PKG. TOMCAT SHAVER BALDE SMALL JOINT F-S

Facility

$399.15

Hospital Charge Code	993156
Hospital Revenue Code	270
Rate for Payer: Cash Price	$271.42

PK HEAD+NECK -- DHF

Facility

$753.76

Hospital Charge Code	81651358
Hospital Revenue Code	272
Rate for Payer: Cash Price	$512.56

PK HEAD+NECK -- DHF

Facility

$753.76

Hospital Charge Code	81651358
Hospital Revenue Code	272
Min. Negotiated Rate	$67.84
Max. Negotiated Rate	$542.71
Rate for Payer: Amerigroup CHIP/Medicaid	$67.84
Rate for Payer: BCBS of TX Blue Advantage	$226.13
Rate for Payer: BCBS of TX Blue Essentials	$271.35
Rate for Payer: BCBS of TX PPO	$301.50
Rate for Payer: Cash Price	$512.56
Rate for Payer: Cigna Medicaid	$542.71
Rate for Payer: Molina CHIP/Medicaid	$542.71
Rate for Payer: Multiplan Auto	$489.94
Rate for Payer: Multiplan Commercial	$489.94
Rate for Payer: Multiplan Workers Comp	$489.94
Rate for Payer: Parkland Medicaid	$542.71
Rate for Payer: Scott and White EPO/PPO	$376.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$542.71
Rate for Payer: Superior Health Plan EPO	$102.51

PK OB CEASARA -- DHF

Facility

$2,610.97

Hospital Charge Code	81652000
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,775.46

PK OB CEASARA -- DHF

Facility

$2,610.97

Hospital Charge Code	81652000
Hospital Revenue Code	272
Min. Negotiated Rate	$234.99
Max. Negotiated Rate	$1,879.90
Rate for Payer: Amerigroup CHIP/Medicaid	$234.99
Rate for Payer: BCBS of TX Blue Advantage	$783.29
Rate for Payer: BCBS of TX Blue Essentials	$939.95
Rate for Payer: BCBS of TX PPO	$1,044.39
Rate for Payer: Cash Price	$1,775.46
Rate for Payer: Cigna Medicaid	$1,879.90
Rate for Payer: Molina CHIP/Medicaid	$1,879.90
Rate for Payer: Multiplan Auto	$1,697.13
Rate for Payer: Multiplan Commercial	$1,697.13
Rate for Payer: Multiplan Workers Comp	$1,697.13
Rate for Payer: Parkland Medicaid	$1,879.90
Rate for Payer: Scott and White EPO/PPO	$1,305.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,879.90
Rate for Payer: Superior Health Plan EPO	$355.09

PK OB -- DHF

Facility

$351.20

Hospital Charge Code	81651952
Hospital Revenue Code	272
Rate for Payer: Cash Price	$238.82

PK OB -- DHF

Facility

$351.20

Hospital Charge Code	81651952
Hospital Revenue Code	272
Min. Negotiated Rate	$31.61
Max. Negotiated Rate	$252.86
Rate for Payer: Amerigroup CHIP/Medicaid	$31.61
Rate for Payer: BCBS of TX Blue Advantage	$105.36
Rate for Payer: BCBS of TX Blue Essentials	$126.43
Rate for Payer: BCBS of TX PPO	$140.48
Rate for Payer: Cash Price	$238.82
Rate for Payer: Cigna Medicaid	$252.86
Rate for Payer: Molina CHIP/Medicaid	$252.86
Rate for Payer: Multiplan Auto	$228.28
Rate for Payer: Multiplan Commercial	$228.28
Rate for Payer: Multiplan Workers Comp	$228.28
Rate for Payer: Parkland Medicaid	$252.86
Rate for Payer: Scott and White EPO/PPO	$175.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$252.86
Rate for Payer: Superior Health Plan EPO	$47.76

PK PACEMAKER -- DHF

Facility

$213.94

Hospital Charge Code	81846073
Hospital Revenue Code	272
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$154.04
Rate for Payer: Amerigroup CHIP/Medicaid	$19.25
Rate for Payer: BCBS of TX Blue Advantage	$64.18
Rate for Payer: BCBS of TX Blue Essentials	$77.02
Rate for Payer: BCBS of TX PPO	$85.58
Rate for Payer: Cash Price	$145.48
Rate for Payer: Cigna Medicaid	$154.04
Rate for Payer: Molina CHIP/Medicaid	$154.04
Rate for Payer: Multiplan Auto	$139.06
Rate for Payer: Multiplan Commercial	$139.06
Rate for Payer: Multiplan Workers Comp	$139.06
Rate for Payer: Parkland Medicaid	$154.04
Rate for Payer: Scott and White EPO/PPO	$106.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$154.04
Rate for Payer: Superior Health Plan EPO	$29.10

PK PACEMAKER -- DHF

Facility

$213.94

Hospital Charge Code	81846073
Hospital Revenue Code	272
Rate for Payer: Cash Price	$145.48

PK TOTAL HIP -- DHF

Facility

$198.05

Hospital Charge Code	81653008
Hospital Revenue Code	272
Rate for Payer: Cash Price	$134.67

PK TOTAL HIP -- DHF

Facility

$198.05

Hospital Charge Code	81653008
Hospital Revenue Code	272
Min. Negotiated Rate	$17.82
Max. Negotiated Rate	$142.60
Rate for Payer: Amerigroup CHIP/Medicaid	$17.82
Rate for Payer: BCBS of TX Blue Advantage	$59.41
Rate for Payer: BCBS of TX Blue Essentials	$71.30
Rate for Payer: BCBS of TX PPO	$79.22
Rate for Payer: Cash Price	$134.67
Rate for Payer: Cigna Medicaid	$142.60
Rate for Payer: Molina CHIP/Medicaid	$142.60
Rate for Payer: Multiplan Auto	$128.73
Rate for Payer: Multiplan Commercial	$128.73
Rate for Payer: Multiplan Workers Comp	$128.73
Rate for Payer: Parkland Medicaid	$142.60
Rate for Payer: Scott and White EPO/PPO	$99.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$142.60
Rate for Payer: Superior Health Plan EPO	$26.93

PLACE CATH THOR/BRAC 3RD

Facility

$3,918.00

Service Code	HCPCS 36217
Hospital Charge Code	2301703
Hospital Revenue Code	361
Min. Negotiated Rate	$352.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$352.62
Rate for Payer: BCBS of TX Blue Advantage	$1,175.40
Rate for Payer: BCBS of TX Blue Essentials	$1,410.48
Rate for Payer: BCBS of TX PPO	$1,567.20
Rate for Payer: Cash Price	$2,664.24
Rate for Payer: Cash Price	$2,664.24
Rate for Payer: Cigna Medicaid	$2,820.96
Rate for Payer: Molina CHIP/Medicaid	$2,820.96
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	$2,820.96
Rate for Payer: Scott and White EPO/PPO	$1,959.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,820.96
Rate for Payer: Superior Health Plan EPO	$532.85

PLACE CATH THOR/BRAC 3RD

Facility

$3,918.00

Service Code	HCPCS 36217
Hospital Charge Code	2301703
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,664.24

Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression)

Facility

$3,301.08

Service Code	HCPCS 44300
Hospital Charge Code	994111
Hospital Revenue Code	360
Min. Negotiated Rate	$297.10
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$297.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Amerigroup Medicare	$1,927.65
Rate for Payer: BCBS of TX Blue Advantage	$1,470.94
Rate for Payer: BCBS of TX Blue Essentials	$1,761.60
Rate for Payer: BCBS of TX Medicare	$1,927.65
Rate for Payer: BCBS of TX PPO	$2,219.62
Rate for Payer: Cash Price	$2,244.73
Rate for Payer: Cash Price	$2,244.73
Rate for Payer: Cash Price	$2,244.73
Rate for Payer: Cigna Commercial	$4,074.70
Rate for Payer: Cigna Medicaid	$2,376.78
Rate for Payer: Cigna Medicare	$1,927.65
Rate for Payer: Employer Direct Commercial	$1,927.65
Rate for Payer: Humana Medicare/TRICARE	$1,927.65
Rate for Payer: Molina CHIP/Medicaid	$2,376.78
Rate for Payer: Molina Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Molina Medicare	$1,927.65
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	$2,376.78
Rate for Payer: Scott and White EPO/PPO	$1,650.54
Rate for Payer: Scott and White Medicare	$1,927.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,376.78
Rate for Payer: Superior Health Plan EPO	$1,927.65
Rate for Payer: Superior Health Plan Medicare	$1,927.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Universal American Medicare	$1,927.65
Rate for Payer: Wellcare Medicare	$1,927.65
Rate for Payer: Wellmed Medicare	$1,927.65

Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression)

Facility

$3,301.08

Service Code	HCPCS 44300
Hospital Charge Code	994111
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,244.73

Placement of access through the biliary tree and into small bowel to assist with an endoscopic biliary procedure

Facility

$24,696.00

Service Code	HCPCS 47541
Hospital Charge Code	994164
Hospital Revenue Code	481
Rate for Payer: Cash Price	$16,793.28

Placement of access through the biliary tree and into small bowel to assist with an endoscopic biliary procedure

Facility

$24,696.00

Service Code	HCPCS 47541
Hospital Charge Code	994164
Hospital Revenue Code	481
Min. Negotiated Rate	$398.73
Max. Negotiated Rate	$17,781.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2,222.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Amerigroup Medicare	$6,503.32
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX Medicare	$6,503.32
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cash Price	$16,793.28
Rate for Payer: Cash Price	$16,793.28
Rate for Payer: Cash Price	$16,793.28
Rate for Payer: Cigna Commercial	$13,746.84
Rate for Payer: Cigna Medicaid	$17,781.12
Rate for Payer: Cigna Medicare	$6,503.32
Rate for Payer: Employer Direct Commercial	$6,503.32
Rate for Payer: Humana Medicare/TRICARE	$6,503.32
Rate for Payer: Molina CHIP/Medicaid	$17,781.12
Rate for Payer: Molina Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Molina Medicare	$6,503.32
Rate for Payer: Multiplan Auto	$16,052.40
Rate for Payer: Multiplan Commercial	$16,052.40
Rate for Payer: Multiplan Workers Comp	$16,052.40
Rate for Payer: Parkland Medicaid	$17,781.12
Rate for Payer: Scott and White EPO/PPO	$398.73
Rate for Payer: Scott and White Medicare	$6,503.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,781.12
Rate for Payer: Superior Health Plan EPO	$6,503.32
Rate for Payer: Superior Health Plan Medicare	$6,503.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Universal American Medicare	$6,503.32
Rate for Payer: Wellcare Medicare	$6,503.32
Rate for Payer: Wellmed Medicare	$6,503.32

Placement of amniotic membrane on the ocular surface; single layer, sutured

Facility

$20,260.08

Service Code	HCPCS 65779
Hospital Charge Code	9900859
Hospital Revenue Code	360
Min. Negotiated Rate	$1,823.41
Max. Negotiated Rate	$14,587.26
Rate for Payer: Amerigroup CHIP/Medicaid	$1,823.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Amerigroup Medicare	$3,949.31
Rate for Payer: BCBS of TX Blue Advantage	$5,222.19
Rate for Payer: BCBS of TX Blue Essentials	$6,254.12
Rate for Payer: BCBS of TX Medicare	$3,949.31
Rate for Payer: BCBS of TX PPO	$7,880.19
Rate for Payer: Cash Price	$13,776.85
Rate for Payer: Cash Price	$13,776.85
Rate for Payer: Cash Price	$13,776.85
Rate for Payer: Cigna Commercial	$8,348.12
Rate for Payer: Cigna Medicaid	$14,587.26
Rate for Payer: Cigna Medicare	$3,949.31
Rate for Payer: Employer Direct Commercial	$3,949.31
Rate for Payer: Humana Medicare/TRICARE	$3,949.31
Rate for Payer: Molina CHIP/Medicaid	$14,587.26
Rate for Payer: Molina Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Molina Medicare	$3,949.31
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	$14,587.26
Rate for Payer: Scott and White EPO/PPO	$6,541.58
Rate for Payer: Scott and White Medicare	$3,949.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,587.26
Rate for Payer: Superior Health Plan EPO	$3,949.31
Rate for Payer: Superior Health Plan Medicare	$3,949.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Universal American Medicare	$3,949.31
Rate for Payer: Wellcare Medicare	$3,949.31
Rate for Payer: Wellmed Medicare	$3,949.31

Placement of amniotic membrane on the ocular surface; single layer, sutured

Facility

$20,260.08

Service Code	HCPCS 65779
Hospital Charge Code	9900859
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,776.85

Placement of amniotic membrane on the ocular surface; single layer, sutured

Facility

$10,000.00

Service Code	CPT 65779
Hospital Charge Code	36065779
Hospital Revenue Code	360
Min. Negotiated Rate	$3,949.31
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Amerigroup Medicare	$3,949.31
Rate for Payer: BCBS of TX Blue Advantage	$5,222.19
Rate for Payer: BCBS of TX Blue Essentials	$6,254.12
Rate for Payer: BCBS of TX Medicare	$3,949.31
Rate for Payer: BCBS of TX PPO	$7,880.19
Rate for Payer: Cigna Commercial	$8,348.12
Rate for Payer: Cigna Medicare	$3,949.31
Rate for Payer: Employer Direct Commercial	$3,949.31
Rate for Payer: Humana Medicare/TRICARE	$3,949.31
Rate for Payer: Molina Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Molina Medicare	$3,949.31
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	$6,541.58
Rate for Payer: Scott and White Medicare	$3,949.31
Rate for Payer: Superior Health Plan EPO	$3,949.31
Rate for Payer: Superior Health Plan Medicare	$3,949.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Universal American Medicare	$3,949.31
Rate for Payer: Wellcare Medicare	$3,949.31
Rate for Payer: Wellmed Medicare	$3,949.31

Placement of occlusive device

Facility

$894.00

Service Code	HCPCS G0269
Hospital Charge Code	991019
Hospital Revenue Code	361
Rate for Payer: Cash Price	$607.92

Know your out-of-pocket cost for care.

All Charges