White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Red blood cells, each unit

Facility

$546.04

Service Code	HCPCS P9021
Hospital Charge Code	990938
Hospital Revenue Code	392
Rate for Payer: Cash Price	$371.31

Red blood cells, each unit

Facility

$546.04

Service Code	HCPCS P9021
Hospital Charge Code	990937
Hospital Revenue Code	381
Rate for Payer: Cash Price	$371.31

red buffer pads

Facility

$12.54

Hospital Charge Code	993302
Hospital Revenue Code	270
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$9.03
Rate for Payer: Amerigroup CHIP/Medicaid	$1.13
Rate for Payer: BCBS of TX Blue Advantage	$3.76
Rate for Payer: BCBS of TX Blue Essentials	$4.51
Rate for Payer: BCBS of TX PPO	$5.02
Rate for Payer: Cash Price	$8.53
Rate for Payer: Cigna Medicaid	$9.03
Rate for Payer: Molina CHIP/Medicaid	$9.03
Rate for Payer: Multiplan Auto	$8.15
Rate for Payer: Multiplan Commercial	$8.15
Rate for Payer: Multiplan Workers Comp	$8.15
Rate for Payer: Parkland Medicaid	$9.03
Rate for Payer: Scott and White EPO/PPO	$6.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.03
Rate for Payer: Superior Health Plan EPO	$1.71

red buffer pads

Facility

$12.54

Hospital Charge Code	993302
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.53

Reduction mammaplasty

Facility

$14,100.07

Service Code	CPT 19318
Hospital Charge Code	36019318
Hospital Revenue Code	360
Min. Negotiated Rate	$1,845.21
Max. Negotiated Rate	$14,100.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1,845.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Amerigroup Medicare	$6,670.43
Rate for Payer: BCBS of TX Blue Advantage	$8,746.27
Rate for Payer: BCBS of TX Blue Essentials	$10,474.58
Rate for Payer: BCBS of TX Medicare	$6,670.43
Rate for Payer: BCBS of TX PPO	$13,197.97
Rate for Payer: Cigna Commercial	$14,100.07
Rate for Payer: Cigna Medicare	$6,670.43
Rate for Payer: Employer Direct Commercial	$6,670.43
Rate for Payer: Humana Medicare/TRICARE	$6,670.43
Rate for Payer: Molina Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Molina Medicare	$6,670.43
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	$11,033.10
Rate for Payer: Scott and White Medicare	$6,670.43
Rate for Payer: Superior Health Plan EPO	$6,670.43
Rate for Payer: Superior Health Plan Medicare	$6,670.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Universal American Medicare	$6,670.43
Rate for Payer: Wellcare Medicare	$6,670.43
Rate for Payer: Wellmed Medicare	$6,670.43

Reduction mammaplasty

Facility

$22,135.76

Service Code	HCPCS 19318
Hospital Charge Code	9900156
Hospital Revenue Code	360
Min. Negotiated Rate	$1,845.21
Max. Negotiated Rate	$15,937.75
Rate for Payer: Amerigroup CHIP/Medicaid	$1,845.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Amerigroup Medicare	$6,670.43
Rate for Payer: BCBS of TX Blue Advantage	$8,746.27
Rate for Payer: BCBS of TX Blue Essentials	$10,474.58
Rate for Payer: BCBS of TX Medicare	$6,670.43
Rate for Payer: BCBS of TX PPO	$13,197.97
Rate for Payer: Cash Price	$15,052.32
Rate for Payer: Cash Price	$15,052.32
Rate for Payer: Cash Price	$15,052.32
Rate for Payer: Cigna Commercial	$14,100.07
Rate for Payer: Cigna Medicaid	$15,937.75
Rate for Payer: Cigna Medicare	$6,670.43
Rate for Payer: Employer Direct Commercial	$6,670.43
Rate for Payer: Humana Medicare/TRICARE	$6,670.43
Rate for Payer: Molina CHIP/Medicaid	$15,937.75
Rate for Payer: Molina Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Molina Medicare	$6,670.43
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	$15,937.75
Rate for Payer: Scott and White EPO/PPO	$11,033.10
Rate for Payer: Scott and White Medicare	$6,670.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,937.75
Rate for Payer: Superior Health Plan EPO	$6,670.43
Rate for Payer: Superior Health Plan Medicare	$6,670.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Universal American Medicare	$6,670.43
Rate for Payer: Wellcare Medicare	$6,670.43
Rate for Payer: Wellmed Medicare	$6,670.43

Reduction mammaplasty

Facility

$22,135.76

Service Code	HCPCS 19318
Hospital Charge Code	9900156
Hospital Revenue Code	360
Rate for Payer: Cash Price	$15,052.32

Reduction of volvulus, intussusception, internal hernia, by laparotomy

Facility

$64,200.00

Service Code	HCPCS 44050
Hospital Charge Code	994080
Hospital Revenue Code	360
Rate for Payer: Cash Price	$43,656.00

Reduction of volvulus, intussusception, internal hernia, by laparotomy

Facility

$64,200.00

Service Code	HCPCS 44050
Hospital Charge Code	994080
Hospital Revenue Code	360
Min. Negotiated Rate	$1,632.22
Max. Negotiated Rate	$46,224.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,778.00
Rate for Payer: BCBS of TX Blue Advantage	$1,632.22
Rate for Payer: BCBS of TX Blue Essentials	$1,954.76
Rate for Payer: BCBS of TX PPO	$2,463.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cigna Medicaid	$46,224.00
Rate for Payer: Molina CHIP/Medicaid	$46,224.00
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	$46,224.00
Rate for Payer: Scott and White EPO/PPO	$32,100.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,224.00
Rate for Payer: Superior Health Plan EPO	$8,731.20

REFERENCE BUFFER CLEAR PH 8.0 16OZ

Facility

$87.71

Hospital Charge Code	993646
Hospital Revenue Code	270
Min. Negotiated Rate	$7.89
Max. Negotiated Rate	$63.15
Rate for Payer: Amerigroup CHIP/Medicaid	$7.89
Rate for Payer: BCBS of TX Blue Advantage	$26.31
Rate for Payer: BCBS of TX Blue Essentials	$31.58
Rate for Payer: BCBS of TX PPO	$35.08
Rate for Payer: Cash Price	$59.64
Rate for Payer: Cigna Medicaid	$63.15
Rate for Payer: Molina CHIP/Medicaid	$63.15
Rate for Payer: Multiplan Auto	$57.01
Rate for Payer: Multiplan Commercial	$57.01
Rate for Payer: Multiplan Workers Comp	$57.01
Rate for Payer: Parkland Medicaid	$63.15
Rate for Payer: Scott and White EPO/PPO	$43.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.15
Rate for Payer: Superior Health Plan EPO	$11.93

REFERENCE BUFFER CLEAR PH 8.0 16OZ

Facility

$87.71

Hospital Charge Code	993646
Hospital Revenue Code	270
Rate for Payer: Cash Price	$59.64

REFILL/MAINT PMP ADM MD BCE

Facility

$1,218.00

Service Code	HCPCS 95991
Hospital Charge Code	3219903
Hospital Revenue Code	940
Min. Negotiated Rate	$48.29
Max. Negotiated Rate	$876.96
Rate for Payer: Amerigroup CHIP/Medicaid	$109.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.35
Rate for Payer: Amerigroup Medicare	$308.35
Rate for Payer: BCBS of TX Blue Advantage	$365.40
Rate for Payer: BCBS of TX Blue Essentials	$438.48
Rate for Payer: BCBS of TX Medicare	$308.35
Rate for Payer: BCBS of TX PPO	$487.20
Rate for Payer: Cash Price	$828.24
Rate for Payer: Cash Price	$828.24
Rate for Payer: Cash Price	$828.24
Rate for Payer: Cigna Commercial	$651.79
Rate for Payer: Cigna Medicaid	$876.96
Rate for Payer: Cigna Medicare	$308.35
Rate for Payer: Employer Direct Commercial	$308.35
Rate for Payer: Humana Medicare/TRICARE	$308.35
Rate for Payer: Molina CHIP/Medicaid	$876.96
Rate for Payer: Molina Dual Medicare/Medicaid	$308.35
Rate for Payer: Molina Medicare	$308.35
Rate for Payer: Multiplan Auto	$791.70
Rate for Payer: Multiplan Commercial	$791.70
Rate for Payer: Multiplan Workers Comp	$791.70
Rate for Payer: Parkland Medicaid	$876.96
Rate for Payer: Scott and White EPO/PPO	$48.29
Rate for Payer: Scott and White Medicare	$308.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$876.96
Rate for Payer: Superior Health Plan EPO	$308.35
Rate for Payer: Superior Health Plan Medicare	$308.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.35
Rate for Payer: Universal American Medicare	$308.35
Rate for Payer: Wellcare Medicare	$308.35
Rate for Payer: Wellmed Medicare	$308.35

REFILL/MAINT PMP ADM MD BCE

Facility

$1,218.00

Service Code	HCPCS 95991
Hospital Charge Code	3219903
Hospital Revenue Code	940
Rate for Payer: Cash Price	$828.24

Ref Lab Antibody Identification

Facility

$466.00

Service Code	HCPCS 86870
Hospital Charge Code	2403061
Hospital Revenue Code	302
Min. Negotiated Rate	$17.83
Max. Negotiated Rate	$761.14
Rate for Payer: Amerigroup CHIP/Medicaid	$17.83
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$360.08
Rate for Payer: Amerigroup Medicare	$360.08
Rate for Payer: BCBS of TX Blue Advantage	$139.80
Rate for Payer: BCBS of TX Blue Essentials	$167.76
Rate for Payer: BCBS of TX Medicare	$360.08
Rate for Payer: BCBS of TX PPO	$186.40
Rate for Payer: Cash Price	$316.88
Rate for Payer: Cash Price	$316.88
Rate for Payer: Cash Price	$316.88
Rate for Payer: Cigna Commercial	$761.14
Rate for Payer: Cigna Medicaid	$335.52
Rate for Payer: Cigna Medicare	$360.08
Rate for Payer: Employer Direct Commercial	$360.08
Rate for Payer: Humana Medicare/TRICARE	$360.08
Rate for Payer: Molina CHIP/Medicaid	$335.52
Rate for Payer: Molina Dual Medicare/Medicaid	$360.08
Rate for Payer: Molina Medicare	$360.08
Rate for Payer: Multiplan Auto	$302.90
Rate for Payer: Multiplan Commercial	$302.90
Rate for Payer: Multiplan Workers Comp	$302.90
Rate for Payer: Parkland Medicaid	$335.52
Rate for Payer: Scott and White EPO/PPO	$493.10
Rate for Payer: Scott and White Medicare	$360.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$335.52
Rate for Payer: Superior Health Plan EPO	$360.08
Rate for Payer: Superior Health Plan Medicare	$360.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$360.08
Rate for Payer: Universal American Medicare	$360.08
Rate for Payer: Wellcare Medicare	$360.08
Rate for Payer: Wellmed Medicare	$360.08

Ref Lab Antibody Identification

Facility

$466.00

Service Code	HCPCS 86870
Hospital Charge Code	2403061
Hospital Revenue Code	302
Rate for Payer: Cash Price	$316.88

Ref Lab Antibody Titer

Facility

$297.00

Service Code	HCPCS 86886
Hospital Charge Code	2403145
Hospital Revenue Code	300
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$361.78
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$89.10
Rate for Payer: BCBS of TX Blue Essentials	$106.92
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$118.80
Rate for Payer: Cash Price	$201.96
Rate for Payer: Cash Price	$201.96
Rate for Payer: Cash Price	$201.96
Rate for Payer: Cigna Commercial	$361.78
Rate for Payer: Cigna Medicaid	$213.84
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$213.84
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$193.05
Rate for Payer: Multiplan Commercial	$193.05
Rate for Payer: Multiplan Workers Comp	$193.05
Rate for Payer: Parkland Medicaid	$213.84
Rate for Payer: Scott and White EPO/PPO	$6.47
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$213.84
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

Ref Lab Antibody Titer

Facility

$297.00

Service Code	HCPCS 86886
Hospital Charge Code	2403145
Hospital Revenue Code	300
Rate for Payer: Cash Price	$201.96

regadenoson 0.4 mg/5 mL IV Soln 5 mL

Facility

$128.00

Service Code	HCPCS J2785
Hospital Charge Code	77792588
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

regadenoson 0.4 mg/5 mL IV Soln 5 mL

Facility

$128.00

Service Code	HCPCS J2785
Hospital Charge Code	77792588
Hospital Revenue Code	636
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$117.23
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$88.07
Rate for Payer: BCBS of TX Blue Essentials	$105.69
Rate for Payer: BCBS of TX PPO	$117.23
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

regenecare wound care gel ha spray

Facility

$64.51

Hospital Charge Code	8656565
Hospital Revenue Code	270
Rate for Payer: Cash Price	$43.87

regenecare wound care gel ha spray

Facility

$64.51

Hospital Charge Code	8656565
Hospital Revenue Code	270
Min. Negotiated Rate	$5.81
Max. Negotiated Rate	$46.45
Rate for Payer: Amerigroup CHIP/Medicaid	$5.81
Rate for Payer: BCBS of TX Blue Advantage	$19.35
Rate for Payer: BCBS of TX Blue Essentials	$23.22
Rate for Payer: BCBS of TX PPO	$25.80
Rate for Payer: Cash Price	$43.87
Rate for Payer: Cigna Medicaid	$46.45
Rate for Payer: Molina CHIP/Medicaid	$46.45
Rate for Payer: Multiplan Auto	$41.93
Rate for Payer: Multiplan Commercial	$41.93
Rate for Payer: Multiplan Workers Comp	$41.93
Rate for Payer: Parkland Medicaid	$46.45
Rate for Payer: Scott and White EPO/PPO	$32.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.45
Rate for Payer: Superior Health Plan EPO	$8.77

Regional Block, per interval cumulative, 15 Minutes

Facility

$2,105.00

Hospital Charge Code	9900040
Hospital Revenue Code	370
Rate for Payer: Cash Price	$1,431.40

Regional Block, per interval cumulative, 15 Minutes

Facility

$2,105.00

Hospital Charge Code	9900040
Hospital Revenue Code	370
Min. Negotiated Rate	$189.45
Max. Negotiated Rate	$1,515.60
Rate for Payer: Amerigroup CHIP/Medicaid	$189.45
Rate for Payer: BCBS of TX Blue Advantage	$631.50
Rate for Payer: BCBS of TX Blue Essentials	$757.80
Rate for Payer: BCBS of TX PPO	$842.00
Rate for Payer: Cash Price	$1,431.40
Rate for Payer: Cigna Medicaid	$1,515.60
Rate for Payer: Molina CHIP/Medicaid	$1,515.60
Rate for Payer: Multiplan Auto	$1,368.25
Rate for Payer: Multiplan Commercial	$1,368.25
Rate for Payer: Multiplan Workers Comp	$1,368.25
Rate for Payer: Parkland Medicaid	$1,515.60
Rate for Payer: Scott and White EPO/PPO	$1,052.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,515.60
Rate for Payer: Superior Health Plan EPO	$286.28

Regional Block, per unit cumulative, 15 Minutes

Facility

$625.00

Hospital Charge Code	9900041
Hospital Revenue Code	370
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$450.00
Rate for Payer: Amerigroup CHIP/Medicaid	$56.25
Rate for Payer: BCBS of TX Blue Advantage	$187.50
Rate for Payer: BCBS of TX Blue Essentials	$225.00
Rate for Payer: BCBS of TX PPO	$250.00
Rate for Payer: Cash Price	$425.00
Rate for Payer: Cigna Medicaid	$450.00
Rate for Payer: Molina CHIP/Medicaid	$450.00
Rate for Payer: Multiplan Auto	$406.25
Rate for Payer: Multiplan Commercial	$406.25
Rate for Payer: Multiplan Workers Comp	$406.25
Rate for Payer: Parkland Medicaid	$450.00
Rate for Payer: Scott and White EPO/PPO	$312.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$450.00
Rate for Payer: Superior Health Plan EPO	$85.00

Regional Block, per unit cumulative, 15 Minutes

Facility

$625.00

Hospital Charge Code	9900041
Hospital Revenue Code	370
Rate for Payer: Cash Price	$425.00

Know your out-of-pocket cost for care.

All Charges