White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Range Bearing Implant, Size 0/1, left, 7mm

Facility

$8,042.17

Service Code	HCPCS C1713
Hospital Charge Code	993128
Hospital Revenue Code	278
Min. Negotiated Rate	$2,010.54
Max. Negotiated Rate	$4,021.09
Rate for Payer: Cash Price	$5,468.68
Rate for Payer: Cigna Commercial	$2,010.54
Rate for Payer: Multiplan Auto	$4,021.09
Rate for Payer: Multiplan Commercial	$4,021.09
Rate for Payer: Multiplan Workers Comp	$4,021.09
Rate for Payer: Scott and White EPO/PPO	$4,021.09

Range Bearing Implant, Size 0/1, left, 7mm

Facility

$8,042.17

Service Code	HCPCS C1713
Hospital Charge Code	993128
Hospital Revenue Code	278
Min. Negotiated Rate	$723.80
Max. Negotiated Rate	$5,790.36
Rate for Payer: Amerigroup CHIP/Medicaid	$723.80
Rate for Payer: BCBS of TX Blue Advantage	$2,412.65
Rate for Payer: BCBS of TX Blue Essentials	$2,895.18
Rate for Payer: BCBS of TX PPO	$3,216.87
Rate for Payer: Cash Price	$5,468.68
Rate for Payer: Cigna Medicaid	$5,790.36
Rate for Payer: Molina CHIP/Medicaid	$5,790.36
Rate for Payer: Multiplan Auto	$4,021.09
Rate for Payer: Multiplan Commercial	$4,021.09
Rate for Payer: Multiplan Workers Comp	$4,021.09
Rate for Payer: Parkland Medicaid	$5,790.36
Rate for Payer: Scott and White EPO/PPO	$4,021.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,790.36
Rate for Payer: Superior Health Plan EPO	$1,093.74

ranolazine 500 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77792227
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

ranolazine 500 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77792227
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Rapid Rhino5.5 cm Anterior Airway

Facility

$308.51

Service Code	HCPCS A4649
Hospital Charge Code	991140
Hospital Revenue Code	272
Rate for Payer: Cash Price	$209.79

Rapid Rhino5.5 cm Anterior Airway

Facility

$308.51

Service Code	HCPCS A4649
Hospital Charge Code	991140
Hospital Revenue Code	272
Min. Negotiated Rate	$27.77
Max. Negotiated Rate	$222.13
Rate for Payer: Amerigroup CHIP/Medicaid	$27.77
Rate for Payer: BCBS of TX Blue Advantage	$92.55
Rate for Payer: BCBS of TX Blue Essentials	$111.06
Rate for Payer: BCBS of TX PPO	$123.40
Rate for Payer: Cash Price	$209.79
Rate for Payer: Cigna Medicaid	$222.13
Rate for Payer: Molina CHIP/Medicaid	$222.13
Rate for Payer: Multiplan Auto	$200.53
Rate for Payer: Multiplan Commercial	$200.53
Rate for Payer: Multiplan Workers Comp	$200.53
Rate for Payer: Parkland Medicaid	$222.13
Rate for Payer: Scott and White EPO/PPO	$154.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.13
Rate for Payer: Superior Health Plan EPO	$41.96

Rapid Strep A Antigen

Facility

$384.00

Service Code	HCPCS 87880
Hospital Charge Code	1603778
Hospital Revenue Code	306
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$276.48
Rate for Payer: Amerigroup CHIP/Medicaid	$6.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.53
Rate for Payer: Amerigroup Medicare	$16.53
Rate for Payer: BCBS of TX Blue Advantage	$115.20
Rate for Payer: BCBS of TX Blue Essentials	$138.24
Rate for Payer: BCBS of TX Medicare	$16.53
Rate for Payer: BCBS of TX PPO	$153.60
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cigna Medicaid	$276.48
Rate for Payer: Cigna Medicare	$16.53
Rate for Payer: Employer Direct Commercial	$16.53
Rate for Payer: Humana Medicare/TRICARE	$16.53
Rate for Payer: Molina CHIP/Medicaid	$276.48
Rate for Payer: Molina Dual Medicare/Medicaid	$16.53
Rate for Payer: Molina Medicare	$16.53
Rate for Payer: Multiplan Auto	$249.60
Rate for Payer: Multiplan Commercial	$249.60
Rate for Payer: Multiplan Workers Comp	$249.60
Rate for Payer: Parkland Medicaid	$276.48
Rate for Payer: Scott and White EPO/PPO	$20.66
Rate for Payer: Scott and White Medicare	$16.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$276.48
Rate for Payer: Superior Health Plan EPO	$16.53
Rate for Payer: Superior Health Plan Medicare	$16.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.53
Rate for Payer: Universal American Medicare	$16.53
Rate for Payer: Wellcare Medicare	$16.53
Rate for Payer: Wellmed Medicare	$16.53

Rapid Strep A Antigen

Facility

$384.00

Service Code	HCPCS 87880
Hospital Charge Code	1603778
Hospital Revenue Code	306
Rate for Payer: Cash Price	$261.12

RASP HELIOCOIDAL 5820080021

Facility

$480.19

Hospital Charge Code	8532469
Hospital Revenue Code	272
Min. Negotiated Rate	$43.22
Max. Negotiated Rate	$345.74
Rate for Payer: Amerigroup CHIP/Medicaid	$43.22
Rate for Payer: BCBS of TX Blue Advantage	$144.06
Rate for Payer: BCBS of TX Blue Essentials	$172.87
Rate for Payer: BCBS of TX PPO	$192.08
Rate for Payer: Cash Price	$326.53
Rate for Payer: Cigna Medicaid	$345.74
Rate for Payer: Molina CHIP/Medicaid	$345.74
Rate for Payer: Multiplan Auto	$312.12
Rate for Payer: Multiplan Commercial	$312.12
Rate for Payer: Multiplan Workers Comp	$312.12
Rate for Payer: Parkland Medicaid	$345.74
Rate for Payer: Scott and White EPO/PPO	$240.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$345.74
Rate for Payer: Superior Health Plan EPO	$65.31

RASP HELIOCOIDAL 5820080021

Facility

$480.19

Hospital Charge Code	8532469
Hospital Revenue Code	272
Rate for Payer: Cash Price	$326.53

ready bath

Facility

$2.94

Hospital Charge Code	993585
Hospital Revenue Code	270
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$2.12
Rate for Payer: Amerigroup CHIP/Medicaid	$0.26
Rate for Payer: BCBS of TX Blue Advantage	$0.88
Rate for Payer: BCBS of TX Blue Essentials	$1.06
Rate for Payer: BCBS of TX PPO	$1.18
Rate for Payer: Cash Price	$2.00
Rate for Payer: Cigna Medicaid	$2.12
Rate for Payer: Molina CHIP/Medicaid	$2.12
Rate for Payer: Multiplan Auto	$1.91
Rate for Payer: Multiplan Commercial	$1.91
Rate for Payer: Multiplan Workers Comp	$1.91
Rate for Payer: Parkland Medicaid	$2.12
Rate for Payer: Scott and White EPO/PPO	$1.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.12
Rate for Payer: Superior Health Plan EPO	$0.40

ready bath

Facility

$2.94

Hospital Charge Code	993585
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.00

REAGENT ACT PTT DADE ACN FSL 10ML COAG

Facility

$40.62

Hospital Charge Code	993460
Hospital Revenue Code	270
Rate for Payer: Cash Price	$27.62

REAGENT ACT PTT DADE ACN FSL 10ML COAG

Facility

$40.62

Hospital Charge Code	993460
Hospital Revenue Code	270
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$29.25
Rate for Payer: Amerigroup CHIP/Medicaid	$3.66
Rate for Payer: BCBS of TX Blue Advantage	$12.19
Rate for Payer: BCBS of TX Blue Essentials	$14.62
Rate for Payer: BCBS of TX PPO	$16.25
Rate for Payer: Cash Price	$27.62
Rate for Payer: Cigna Medicaid	$29.25
Rate for Payer: Molina CHIP/Medicaid	$29.25
Rate for Payer: Multiplan Auto	$26.40
Rate for Payer: Multiplan Commercial	$26.40
Rate for Payer: Multiplan Workers Comp	$26.40
Rate for Payer: Parkland Medicaid	$29.25
Rate for Payer: Scott and White EPO/PPO	$20.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.25
Rate for Payer: Superior Health Plan EPO	$5.52

REAGENT COAG INVN 10X10ML HUM TIS

Facility

$67.88

Hospital Charge Code	993462
Hospital Revenue Code	270
Min. Negotiated Rate	$6.11
Max. Negotiated Rate	$48.87
Rate for Payer: Amerigroup CHIP/Medicaid	$6.11
Rate for Payer: BCBS of TX Blue Advantage	$20.36
Rate for Payer: BCBS of TX Blue Essentials	$24.44
Rate for Payer: BCBS of TX PPO	$27.15
Rate for Payer: Cash Price	$46.16
Rate for Payer: Cigna Medicaid	$48.87
Rate for Payer: Molina CHIP/Medicaid	$48.87
Rate for Payer: Multiplan Auto	$44.12
Rate for Payer: Multiplan Commercial	$44.12
Rate for Payer: Multiplan Workers Comp	$44.12
Rate for Payer: Parkland Medicaid	$48.87
Rate for Payer: Scott and White EPO/PPO	$33.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$48.87
Rate for Payer: Superior Health Plan EPO	$9.23

REAGENT COAG INVN 10X10ML HUM TIS

Facility

$67.88

Hospital Charge Code	993462
Hospital Revenue Code	270
Rate for Payer: Cash Price	$46.16

REAGENT, DIFFERENTIAL PAC

Facility

$570.50

Hospital Charge Code	993807
Hospital Revenue Code	279
Min. Negotiated Rate	$51.34
Max. Negotiated Rate	$410.76
Rate for Payer: Amerigroup CHIP/Medicaid	$51.34
Rate for Payer: BCBS of TX Blue Advantage	$171.15
Rate for Payer: BCBS of TX Blue Essentials	$205.38
Rate for Payer: BCBS of TX PPO	$228.20
Rate for Payer: Cash Price	$387.94
Rate for Payer: Cigna Medicaid	$410.76
Rate for Payer: Molina CHIP/Medicaid	$410.76
Rate for Payer: Multiplan Auto	$370.82
Rate for Payer: Multiplan Commercial	$370.82
Rate for Payer: Multiplan Workers Comp	$370.82
Rate for Payer: Parkland Medicaid	$410.76
Rate for Payer: Scott and White EPO/PPO	$285.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$410.76
Rate for Payer: Superior Health Plan EPO	$77.59

REAGENT, DIFFERENTIAL PAC

Facility

$570.50

Hospital Charge Code	993807
Hospital Revenue Code	279
Rate for Payer: Cash Price	$387.94

REAGENT, DILUENT DXH 1 X

Facility

$52.39

Hospital Charge Code	993805
Hospital Revenue Code	279
Rate for Payer: Cash Price	$35.63

REAGENT, DILUENT DXH 1 X

Facility

$52.39

Hospital Charge Code	993805
Hospital Revenue Code	279
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$37.72
Rate for Payer: Amerigroup CHIP/Medicaid	$4.72
Rate for Payer: BCBS of TX Blue Advantage	$15.72
Rate for Payer: BCBS of TX Blue Essentials	$18.86
Rate for Payer: BCBS of TX PPO	$20.96
Rate for Payer: Cash Price	$35.63
Rate for Payer: Cigna Medicaid	$37.72
Rate for Payer: Molina CHIP/Medicaid	$37.72
Rate for Payer: Multiplan Auto	$34.05
Rate for Payer: Multiplan Commercial	$34.05
Rate for Payer: Multiplan Workers Comp	$34.05
Rate for Payer: Parkland Medicaid	$37.72
Rate for Payer: Scott and White EPO/PPO	$26.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.72
Rate for Payer: Superior Health Plan EPO	$7.13

REAGENT DXH 380ML RTCPK ANLYZ HMTL

Facility

$1,589.91

Hospital Charge Code	993788
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,081.14

REAGENT DXH 380ML RTCPK ANLYZ HMTL

Facility

$1,589.91

Hospital Charge Code	993788
Hospital Revenue Code	270
Min. Negotiated Rate	$143.09
Max. Negotiated Rate	$1,144.74
Rate for Payer: Amerigroup CHIP/Medicaid	$143.09
Rate for Payer: BCBS of TX Blue Advantage	$476.97
Rate for Payer: BCBS of TX Blue Essentials	$572.37
Rate for Payer: BCBS of TX PPO	$635.96
Rate for Payer: Cash Price	$1,081.14
Rate for Payer: Cigna Medicaid	$1,144.74
Rate for Payer: Molina CHIP/Medicaid	$1,144.74
Rate for Payer: Multiplan Auto	$1,033.44
Rate for Payer: Multiplan Commercial	$1,033.44
Rate for Payer: Multiplan Workers Comp	$1,033.44
Rate for Payer: Parkland Medicaid	$1,144.74
Rate for Payer: Scott and White EPO/PPO	$794.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,144.74
Rate for Payer: Superior Health Plan EPO	$216.23

REAGENT, LYSE CELL DXH 1

Facility

$1,356.10

Hospital Charge Code	993806
Hospital Revenue Code	279
Min. Negotiated Rate	$122.05
Max. Negotiated Rate	$976.39
Rate for Payer: Amerigroup CHIP/Medicaid	$122.05
Rate for Payer: BCBS of TX Blue Advantage	$406.83
Rate for Payer: BCBS of TX Blue Essentials	$488.20
Rate for Payer: BCBS of TX PPO	$542.44
Rate for Payer: Cash Price	$922.15
Rate for Payer: Cigna Medicaid	$976.39
Rate for Payer: Molina CHIP/Medicaid	$976.39
Rate for Payer: Multiplan Auto	$881.47
Rate for Payer: Multiplan Commercial	$881.47
Rate for Payer: Multiplan Workers Comp	$881.47
Rate for Payer: Parkland Medicaid	$976.39
Rate for Payer: Scott and White EPO/PPO	$678.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$976.39
Rate for Payer: Superior Health Plan EPO	$184.43

REAGENT, LYSE CELL DXH 1

Facility

$1,356.10

Hospital Charge Code	993806
Hospital Revenue Code	279
Rate for Payer: Cash Price	$922.15

REAGENT THRMB 10X5ML COAG

Facility

$217.49

Hospital Charge Code	993461
Hospital Revenue Code	270
Rate for Payer: Cash Price	$147.89

Know your out-of-pocket cost for care.

All Charges