White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ANCH SUT Y-KNOT -- DHF

Facility

$3,901.00

Service Code	HCPCS C1713
Hospital Charge Code	40199044
Hospital Revenue Code	278
Min. Negotiated Rate	$975.25
Max. Negotiated Rate	$1,950.50
Rate for Payer: Cash Price	$2,652.68
Rate for Payer: Cigna Commercial	$975.25
Rate for Payer: Multiplan Auto	$1,950.50
Rate for Payer: Multiplan Commercial	$1,950.50
Rate for Payer: Multiplan Workers Comp	$1,950.50
Rate for Payer: Scott and White EPO/PPO	$1,950.50

ANCH VERSALOK

Facility

$3,934.00

Service Code	HCPCS C1713
Hospital Charge Code	40107203
Hospital Revenue Code	278
Min. Negotiated Rate	$983.50
Max. Negotiated Rate	$1,967.00
Rate for Payer: Cash Price	$2,675.12
Rate for Payer: Cigna Commercial	$983.50
Rate for Payer: Multiplan Auto	$1,967.00
Rate for Payer: Multiplan Commercial	$1,967.00
Rate for Payer: Multiplan Workers Comp	$1,967.00
Rate for Payer: Scott and White EPO/PPO	$1,967.00

ANCH VERSALOK

Facility

$3,934.00

Service Code	HCPCS C1713
Hospital Charge Code	40107203
Hospital Revenue Code	278
Min. Negotiated Rate	$354.06
Max. Negotiated Rate	$2,832.48
Rate for Payer: Amerigroup CHIP/Medicaid	$354.06
Rate for Payer: BCBS of TX Blue Advantage	$1,180.20
Rate for Payer: BCBS of TX Blue Essentials	$1,416.24
Rate for Payer: BCBS of TX PPO	$1,573.60
Rate for Payer: Cash Price	$2,675.12
Rate for Payer: Cigna Medicaid	$2,832.48
Rate for Payer: Molina CHIP/Medicaid	$2,832.48
Rate for Payer: Multiplan Auto	$1,967.00
Rate for Payer: Multiplan Commercial	$1,967.00
Rate for Payer: Multiplan Workers Comp	$1,967.00
Rate for Payer: Parkland Medicaid	$2,832.48
Rate for Payer: Scott and White EPO/PPO	$1,967.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,832.48
Rate for Payer: Superior Health Plan EPO	$535.02

ANC TEST KIT VTK2 20 CARDS

Facility

$866.23

Hospital Charge Code	992627
Hospital Revenue Code	270
Rate for Payer: Cash Price	$589.04

ANC TEST KIT VTK2 20 CARDS

Facility

$866.23

Hospital Charge Code	992627
Hospital Revenue Code	270
Min. Negotiated Rate	$77.96
Max. Negotiated Rate	$623.69
Rate for Payer: Amerigroup CHIP/Medicaid	$77.96
Rate for Payer: BCBS of TX Blue Advantage	$259.87
Rate for Payer: BCBS of TX Blue Essentials	$311.84
Rate for Payer: BCBS of TX PPO	$346.49
Rate for Payer: Cash Price	$589.04
Rate for Payer: Cigna Medicaid	$623.69
Rate for Payer: Molina CHIP/Medicaid	$623.69
Rate for Payer: Multiplan Auto	$563.05
Rate for Payer: Multiplan Commercial	$563.05
Rate for Payer: Multiplan Workers Comp	$563.05
Rate for Payer: Parkland Medicaid	$623.69
Rate for Payer: Scott and White EPO/PPO	$433.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$623.69
Rate for Payer: Superior Health Plan EPO	$117.81

ANGINA PECTORIS

Facility

$12,693.90

Service Code	MSDRG 311
Min. Negotiated Rate	$5,845.88
Max. Negotiated Rate	$12,693.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,904.32
Rate for Payer: Amerigroup Medicare	$9,904.32
Rate for Payer: BCBS of TX Blue Advantage	$5,909.92
Rate for Payer: BCBS of TX Blue Essentials	$7,091.22
Rate for Payer: BCBS of TX Medicare	$9,904.32
Rate for Payer: BCBS of TX PPO	$7,879.44
Rate for Payer: Cigna Commercial	$9,040.47
Rate for Payer: Cigna Medicare	$9,904.32
Rate for Payer: Employer Direct Commercial	$9,904.32
Rate for Payer: Humana Medicare/TRICARE	$9,904.32
Rate for Payer: Molina Dual Medicare/Medicaid	$9,904.32
Rate for Payer: Molina Medicare	$9,904.32
Rate for Payer: Multiplan Auto	$12,693.90
Rate for Payer: Multiplan Commercial	$12,693.90
Rate for Payer: Multiplan Workers Comp	$12,693.90
Rate for Payer: Scott and White EPO/PPO	$5,845.88
Rate for Payer: Scott and White Medicare	$9,904.32
Rate for Payer: Superior Health Plan EPO	$9,904.32
Rate for Payer: Superior Health Plan Medicare	$9,904.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,904.32
Rate for Payer: Universal American Medicare	$9,904.32
Rate for Payer: Wellcare Medicare	$9,904.32
Rate for Payer: Wellmed Medicare	$9,904.32

ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS

Facility

$2,987.34

Service Code	APR-DRG 1982
Min. Negotiated Rate	$2,816.57
Max. Negotiated Rate	$2,987.34
Rate for Payer: Amerigroup CHIP/Medicaid	$2,816.57
Rate for Payer: Cigna Medicaid	$2,816.57
Rate for Payer: Molina CHIP/Medicaid	$2,816.57
Rate for Payer: Parkland Medicaid	$2,816.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,987.34

ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS

Facility

$3,654.58

Service Code	APR-DRG 1983
Min. Negotiated Rate	$3,445.67
Max. Negotiated Rate	$3,654.58
Rate for Payer: Amerigroup CHIP/Medicaid	$3,445.67
Rate for Payer: Cigna Medicaid	$3,445.67
Rate for Payer: Molina CHIP/Medicaid	$3,445.67
Rate for Payer: Parkland Medicaid	$3,445.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,654.58

ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS

Facility

$6,195.71

Service Code	APR-DRG 1984
Min. Negotiated Rate	$5,841.53
Max. Negotiated Rate	$6,195.71
Rate for Payer: Amerigroup CHIP/Medicaid	$5,841.53
Rate for Payer: Cigna Medicaid	$5,841.53
Rate for Payer: Molina CHIP/Medicaid	$5,841.53
Rate for Payer: Parkland Medicaid	$5,841.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,195.71

ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS

Facility

$2,341.97

Service Code	APR-DRG 1981
Min. Negotiated Rate	$2,208.09
Max. Negotiated Rate	$2,341.97
Rate for Payer: Amerigroup CHIP/Medicaid	$2,208.09
Rate for Payer: Cigna Medicaid	$2,208.09
Rate for Payer: Molina CHIP/Medicaid	$2,208.09
Rate for Payer: Parkland Medicaid	$2,208.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,341.97

ANGIO EXTREMITY UNILATERAL

Facility

$4,768.00

Service Code	HCPCS 75710
Hospital Charge Code	2330022
Hospital Revenue Code	323
Rate for Payer: Cash Price	$3,242.24

ANGIO EXTREMITY UNILATERAL

Facility

$4,768.00

Service Code	HCPCS 75710
Hospital Charge Code	2330022
Hospital Revenue Code	323
Min. Negotiated Rate	$150.36
Max. Negotiated Rate	$6,704.76
Rate for Payer: Amerigroup CHIP/Medicaid	$150.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$3,242.24
Rate for Payer: Cash Price	$3,242.24
Rate for Payer: Cash Price	$3,242.24
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$3,432.96
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$3,432.96
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
Rate for Payer: Multiplan Auto	$3,099.20
Rate for Payer: Multiplan Commercial	$3,099.20
Rate for Payer: Multiplan Workers Comp	$3,099.20
Rate for Payer: Parkland Medicaid	$3,432.96
Rate for Payer: Scott and White EPO/PPO	$184.44
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,432.96
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

ANGIO FOLLOW UP EXISTING CATHETER

Facility

$2,387.00

Service Code	HCPCS 75898
Hospital Charge Code	2320398
Hospital Revenue Code	320
Min. Negotiated Rate	$133.71
Max. Negotiated Rate	$6,704.76
Rate for Payer: Amerigroup CHIP/Medicaid	$133.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$1,804.75
Rate for Payer: BCBS of TX Blue Essentials	$2,165.70
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$2,417.28
Rate for Payer: Cash Price	$1,623.16
Rate for Payer: Cash Price	$1,623.16
Rate for Payer: Cash Price	$1,623.16
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$1,718.64
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$1,718.64
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
Rate for Payer: Multiplan Auto	$1,551.55
Rate for Payer: Multiplan Commercial	$1,551.55
Rate for Payer: Multiplan Workers Comp	$1,551.55
Rate for Payer: Parkland Medicaid	$1,718.64
Rate for Payer: Scott and White EPO/PPO	$1,193.50
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,718.64
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

ANGIO FOLLOW UP EXISTING CATHETER

Facility

$2,387.00

Service Code	HCPCS 75898
Hospital Charge Code	2320398
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,623.16

ANGIOGRAPHY EXTREMITY BILATERAL

Facility

$5,813.00

Service Code	HCPCS 75716
Hospital Charge Code	2303402
Hospital Revenue Code	320
Min. Negotiated Rate	$163.05
Max. Negotiated Rate	$6,704.76
Rate for Payer: Amerigroup CHIP/Medicaid	$163.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$3,952.84
Rate for Payer: Cash Price	$3,952.84
Rate for Payer: Cash Price	$3,952.84
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$4,185.36
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$4,185.36
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
Rate for Payer: Multiplan Auto	$3,778.45
Rate for Payer: Multiplan Commercial	$3,778.45
Rate for Payer: Multiplan Workers Comp	$3,778.45
Rate for Payer: Parkland Medicaid	$4,185.36
Rate for Payer: Scott and White EPO/PPO	$200.24
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,185.36
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

ANGIOGRAPHY EXTREMITY BILATERAL

Facility

$5,813.00

Service Code	HCPCS 75716
Hospital Charge Code	2303402
Hospital Revenue Code	320
Rate for Payer: Cash Price	$3,952.84

ANGIOGRAPHY EXTREMITY UNILAT

Facility

$4,768.00

Service Code	HCPCS 75710
Hospital Charge Code	2312502
Hospital Revenue Code	320
Min. Negotiated Rate	$150.36
Max. Negotiated Rate	$6,704.76
Rate for Payer: Amerigroup CHIP/Medicaid	$150.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$3,242.24
Rate for Payer: Cash Price	$3,242.24
Rate for Payer: Cash Price	$3,242.24
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$3,432.96
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$3,432.96
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
Rate for Payer: Multiplan Auto	$3,099.20
Rate for Payer: Multiplan Commercial	$3,099.20
Rate for Payer: Multiplan Workers Comp	$3,099.20
Rate for Payer: Parkland Medicaid	$3,432.96
Rate for Payer: Scott and White EPO/PPO	$184.44
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,432.96
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

ANGIOGRAPHY EXTREMITY UNILAT

Facility

$4,768.00

Service Code	HCPCS 75710
Hospital Charge Code	2312502
Hospital Revenue Code	320
Rate for Payer: Cash Price	$3,242.24

Angiojet Solent Omi

Facility

$11,785.84

Hospital Charge Code	993924
Hospital Revenue Code	279
Min. Negotiated Rate	$1,060.73
Max. Negotiated Rate	$8,485.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1,060.73
Rate for Payer: BCBS of TX Blue Advantage	$3,535.75
Rate for Payer: BCBS of TX Blue Essentials	$4,242.90
Rate for Payer: BCBS of TX PPO	$4,714.34
Rate for Payer: Cash Price	$8,014.37
Rate for Payer: Cigna Medicaid	$8,485.80
Rate for Payer: Molina CHIP/Medicaid	$8,485.80
Rate for Payer: Multiplan Auto	$7,660.80
Rate for Payer: Multiplan Commercial	$7,660.80
Rate for Payer: Multiplan Workers Comp	$7,660.80
Rate for Payer: Parkland Medicaid	$8,485.80
Rate for Payer: Scott and White EPO/PPO	$5,892.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,485.80
Rate for Payer: Superior Health Plan EPO	$1,602.87

Angiojet Solent Omi

Facility

$11,785.84

Hospital Charge Code	993924
Hospital Revenue Code	279
Rate for Payer: Cash Price	$8,014.37

ANGIO PELVIC ART SELECT

Facility

$7,951.00

Service Code	HCPCS 75736
Hospital Charge Code	2303378
Hospital Revenue Code	320
Rate for Payer: Cash Price	$5,406.68

ANGIO PELVIC ART SELECT

Facility

$7,951.00

Service Code	HCPCS 75736
Hospital Charge Code	2303378
Hospital Revenue Code	320
Min. Negotiated Rate	$143.68
Max. Negotiated Rate	$11,815.91
Rate for Payer: Amerigroup CHIP/Medicaid	$143.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Amerigroup Medicare	$5,589.84
Rate for Payer: BCBS of TX Blue Advantage	$7,583.71
Rate for Payer: BCBS of TX Blue Essentials	$9,100.46
Rate for Payer: BCBS of TX Medicare	$5,589.84
Rate for Payer: BCBS of TX PPO	$10,157.58
Rate for Payer: Cash Price	$5,406.68
Rate for Payer: Cash Price	$5,406.68
Rate for Payer: Cash Price	$5,406.68
Rate for Payer: Cigna Commercial	$11,815.91
Rate for Payer: Cigna Medicaid	$5,724.72
Rate for Payer: Cigna Medicare	$5,589.84
Rate for Payer: Employer Direct Commercial	$5,589.84
Rate for Payer: Humana Medicare/TRICARE	$5,589.84
Rate for Payer: Molina CHIP/Medicaid	$5,724.72
Rate for Payer: Molina Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Molina Medicare	$5,589.84
Rate for Payer: Multiplan Auto	$5,168.15
Rate for Payer: Multiplan Commercial	$5,168.15
Rate for Payer: Multiplan Workers Comp	$5,168.15
Rate for Payer: Parkland Medicaid	$5,724.72
Rate for Payer: Scott and White EPO/PPO	$176.78
Rate for Payer: Scott and White Medicare	$5,589.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,724.72
Rate for Payer: Superior Health Plan EPO	$5,589.84
Rate for Payer: Superior Health Plan Medicare	$5,589.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Universal American Medicare	$5,589.84
Rate for Payer: Wellcare Medicare	$5,589.84
Rate for Payer: Wellmed Medicare	$5,589.84

ANGIOPLASTY+ATHRECTOMY FEMO/POPLTL

Facility

$25,421.00

Service Code	HCPCS 37225
Hospital Charge Code	2320537
Hospital Revenue Code	361
Rate for Payer: Cash Price	$17,286.28

ANGIOPLASTY+ATHRECTOMY FEMO/POPLTL

Facility

$25,421.00

Service Code	HCPCS 37225
Hospital Charge Code	2320537
Hospital Revenue Code	361
Min. Negotiated Rate	$2,287.89
Max. Negotiated Rate	$29,667.86
Rate for Payer: Amerigroup CHIP/Medicaid	$2,287.89
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$17,286.28
Rate for Payer: Cash Price	$17,286.28
Rate for Payer: Cash Price	$17,286.28
Rate for Payer: Cigna Medicaid	$18,303.12
Rate for Payer: Molina CHIP/Medicaid	$18,303.12
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	$18,303.12
Rate for Payer: Scott and White EPO/PPO	$29,667.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,303.12
Rate for Payer: Superior Health Plan EPO	$3,457.26

ANGIOPLASTY EA ADD TIBIAL/PERONEAL

Facility

$9,499.00

Service Code	HCPCS 37232
Hospital Charge Code	2320544
Hospital Revenue Code	480
Min. Negotiated Rate	$234.94
Max. Negotiated Rate	$6,839.28
Rate for Payer: Amerigroup CHIP/Medicaid	$854.91
Rate for Payer: BCBS of TX Blue Advantage	$2,849.70
Rate for Payer: BCBS of TX Blue Essentials	$3,419.64
Rate for Payer: BCBS of TX PPO	$3,799.60
Rate for Payer: Cash Price	$6,459.32
Rate for Payer: Cash Price	$6,459.32
Rate for Payer: Cigna Medicaid	$6,839.28
Rate for Payer: Molina CHIP/Medicaid	$6,839.28
Rate for Payer: Multiplan Auto	$6,174.35
Rate for Payer: Multiplan Commercial	$6,174.35
Rate for Payer: Multiplan Workers Comp	$6,174.35
Rate for Payer: Parkland Medicaid	$6,839.28
Rate for Payer: Scott and White EPO/PPO	$234.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,839.28
Rate for Payer: Superior Health Plan EPO	$1,291.86

Know your out-of-pocket cost for care.

All Charges