White Rock Medical Center

All Charges

Charge

Type

Setting

Price

RESP VIRUS 6-11 TARGETS BCE

Facility

$563.00

Service Code	HCPCS 87632
Hospital Charge Code	7257632
Hospital Revenue Code	300
Min. Negotiated Rate	$85.04
Max. Negotiated Rate	$405.36
Rate for Payer: Amerigroup CHIP/Medicaid	$85.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$218.06
Rate for Payer: Amerigroup Medicare	$218.06
Rate for Payer: BCBS of TX Blue Advantage	$168.90
Rate for Payer: BCBS of TX Blue Essentials	$202.68
Rate for Payer: BCBS of TX Medicare	$218.06
Rate for Payer: BCBS of TX PPO	$225.20
Rate for Payer: Cash Price	$382.84
Rate for Payer: Cash Price	$382.84
Rate for Payer: Cigna Medicaid	$405.36
Rate for Payer: Cigna Medicare	$218.06
Rate for Payer: Employer Direct Commercial	$218.06
Rate for Payer: Humana Medicare/TRICARE	$218.06
Rate for Payer: Molina CHIP/Medicaid	$405.36
Rate for Payer: Molina Dual Medicare/Medicaid	$218.06
Rate for Payer: Molina Medicare	$218.06
Rate for Payer: Multiplan Auto	$365.95
Rate for Payer: Multiplan Commercial	$365.95
Rate for Payer: Multiplan Workers Comp	$365.95
Rate for Payer: Parkland Medicaid	$405.36
Rate for Payer: Scott and White EPO/PPO	$272.57
Rate for Payer: Scott and White Medicare	$218.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$405.36
Rate for Payer: Superior Health Plan EPO	$218.06
Rate for Payer: Superior Health Plan Medicare	$218.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$218.06
Rate for Payer: Universal American Medicare	$218.06
Rate for Payer: Wellcare Medicare	$218.06
Rate for Payer: Wellmed Medicare	$218.06

RESP VIRUS 6-11 TARGETS BCE

Facility

$563.00

Service Code	HCPCS 87632
Hospital Charge Code	7257632
Hospital Revenue Code	300
Rate for Payer: Cash Price	$382.84

RESTRAINT, HEAD UNIV MULT

Facility

$522.10

Hospital Charge Code	992592
Hospital Revenue Code	270
Min. Negotiated Rate	$46.99
Max. Negotiated Rate	$375.91
Rate for Payer: Amerigroup CHIP/Medicaid	$46.99
Rate for Payer: BCBS of TX Blue Advantage	$156.63
Rate for Payer: BCBS of TX Blue Essentials	$187.96
Rate for Payer: BCBS of TX PPO	$208.84
Rate for Payer: Cash Price	$355.03
Rate for Payer: Cigna Medicaid	$375.91
Rate for Payer: Molina CHIP/Medicaid	$375.91
Rate for Payer: Multiplan Auto	$339.37
Rate for Payer: Multiplan Commercial	$339.37
Rate for Payer: Multiplan Workers Comp	$339.37
Rate for Payer: Parkland Medicaid	$375.91
Rate for Payer: Scott and White EPO/PPO	$261.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$375.91
Rate for Payer: Superior Health Plan EPO	$71.01

RESTRAINT, HEAD UNIV MULT

Facility

$522.10

Hospital Charge Code	992592
Hospital Revenue Code	270
Rate for Payer: Cash Price	$355.03

RESTRAINT, HEAD UNIV MULTIPLE STRAP ADJT WHT/BLACK -- DHF

Facility

$116.64

Hospital Charge Code	81146805
Hospital Revenue Code	270
Rate for Payer: Cash Price	$79.32

RESTRAINT, HEAD UNIV MULTIPLE STRAP ADJT WHT/BLACK -- DHF

Facility

$116.64

Hospital Charge Code	81146805
Hospital Revenue Code	270
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$83.98
Rate for Payer: Amerigroup CHIP/Medicaid	$10.50
Rate for Payer: BCBS of TX Blue Advantage	$34.99
Rate for Payer: BCBS of TX Blue Essentials	$41.99
Rate for Payer: BCBS of TX PPO	$46.66
Rate for Payer: Cash Price	$79.32
Rate for Payer: Cigna Medicaid	$83.98
Rate for Payer: Molina CHIP/Medicaid	$83.98
Rate for Payer: Multiplan Auto	$75.82
Rate for Payer: Multiplan Commercial	$75.82
Rate for Payer: Multiplan Workers Comp	$75.82
Rate for Payer: Parkland Medicaid	$83.98
Rate for Payer: Scott and White EPO/PPO	$58.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83.98
Rate for Payer: Superior Health Plan EPO	$15.86

RESTRAINT, LIMB, FOAM (PAIR)

Facility

$20.52

Hospital Charge Code	993911
Hospital Revenue Code	271
Rate for Payer: Cash Price	$13.95

RESTRAINT, LIMB, FOAM (PAIR)

Facility

$20.52

Hospital Charge Code	993911
Hospital Revenue Code	271
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$14.77
Rate for Payer: Amerigroup CHIP/Medicaid	$1.85
Rate for Payer: BCBS of TX Blue Advantage	$6.16
Rate for Payer: BCBS of TX Blue Essentials	$7.39
Rate for Payer: BCBS of TX PPO	$8.21
Rate for Payer: Cash Price	$13.95
Rate for Payer: Cigna Medicaid	$14.77
Rate for Payer: Molina CHIP/Medicaid	$14.77
Rate for Payer: Multiplan Auto	$13.34
Rate for Payer: Multiplan Commercial	$13.34
Rate for Payer: Multiplan Workers Comp	$13.34
Rate for Payer: Parkland Medicaid	$14.77
Rate for Payer: Scott and White EPO/PPO	$10.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.77
Rate for Payer: Superior Health Plan EPO	$2.79

RESUSCITATOR ADULT SPURII MED MSK SGL USE CO2 DET

Facility

$47.81

Hospital Charge Code	993263
Hospital Revenue Code	270
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$34.42
Rate for Payer: Amerigroup CHIP/Medicaid	$4.30
Rate for Payer: BCBS of TX Blue Advantage	$14.34
Rate for Payer: BCBS of TX Blue Essentials	$17.21
Rate for Payer: BCBS of TX PPO	$19.12
Rate for Payer: Cash Price	$32.51
Rate for Payer: Cigna Medicaid	$34.42
Rate for Payer: Molina CHIP/Medicaid	$34.42
Rate for Payer: Multiplan Auto	$31.08
Rate for Payer: Multiplan Commercial	$31.08
Rate for Payer: Multiplan Workers Comp	$31.08
Rate for Payer: Parkland Medicaid	$34.42
Rate for Payer: Scott and White EPO/PPO	$23.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.42
Rate for Payer: Superior Health Plan EPO	$6.50

RESUSCITATOR ADULT SPURII MED MSK SGL USE CO2 DET

Facility

$47.81

Hospital Charge Code	993263
Hospital Revenue Code	270
Rate for Payer: Cash Price	$32.51

RESUSCITATOR, PEDI W/TODDLER MASK & CO2 DETECTOR

Facility

$100.20

Hospital Charge Code	993618
Hospital Revenue Code	270
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$72.14
Rate for Payer: Amerigroup CHIP/Medicaid	$9.02
Rate for Payer: BCBS of TX Blue Advantage	$30.06
Rate for Payer: BCBS of TX Blue Essentials	$36.07
Rate for Payer: BCBS of TX PPO	$40.08
Rate for Payer: Cash Price	$68.14
Rate for Payer: Cigna Medicaid	$72.14
Rate for Payer: Molina CHIP/Medicaid	$72.14
Rate for Payer: Multiplan Auto	$65.13
Rate for Payer: Multiplan Commercial	$65.13
Rate for Payer: Multiplan Workers Comp	$65.13
Rate for Payer: Parkland Medicaid	$72.14
Rate for Payer: Scott and White EPO/PPO	$50.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$72.14
Rate for Payer: Superior Health Plan EPO	$13.63

RESUSCITATOR, PEDI W/TODDLER MASK & CO2 DETECTOR

Facility

$100.20

Hospital Charge Code	993618
Hospital Revenue Code	270
Rate for Payer: Cash Price	$68.14

RETAINER VISCERA -- DHF

Facility

$777.12

Hospital Charge Code	81848251
Hospital Revenue Code	272
Min. Negotiated Rate	$69.94
Max. Negotiated Rate	$559.53
Rate for Payer: Amerigroup CHIP/Medicaid	$69.94
Rate for Payer: BCBS of TX Blue Advantage	$233.14
Rate for Payer: BCBS of TX Blue Essentials	$279.76
Rate for Payer: BCBS of TX PPO	$310.85
Rate for Payer: Cash Price	$528.44
Rate for Payer: Cigna Medicaid	$559.53
Rate for Payer: Molina CHIP/Medicaid	$559.53
Rate for Payer: Multiplan Auto	$505.13
Rate for Payer: Multiplan Commercial	$505.13
Rate for Payer: Multiplan Workers Comp	$505.13
Rate for Payer: Parkland Medicaid	$559.53
Rate for Payer: Scott and White EPO/PPO	$388.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$559.53
Rate for Payer: Superior Health Plan EPO	$105.69

RETAINER VISCERA -- DHF

Facility

$777.12

Hospital Charge Code	81848251
Hospital Revenue Code	272
Rate for Payer: Cash Price	$528.44

Retic Count Automated

Facility

$171.00

Service Code	HCPCS 85045
Hospital Charge Code	1611862
Hospital Revenue Code	305
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$123.12
Rate for Payer: Amerigroup CHIP/Medicaid	$1.56
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.99
Rate for Payer: Amerigroup Medicare	$3.99
Rate for Payer: BCBS of TX Blue Advantage	$51.30
Rate for Payer: BCBS of TX Blue Essentials	$61.56
Rate for Payer: BCBS of TX Medicare	$3.99
Rate for Payer: BCBS of TX PPO	$68.40
Rate for Payer: Cash Price	$116.28
Rate for Payer: Cash Price	$116.28
Rate for Payer: Cigna Medicaid	$123.12
Rate for Payer: Cigna Medicare	$3.99
Rate for Payer: Employer Direct Commercial	$3.99
Rate for Payer: Humana Medicare/TRICARE	$3.99
Rate for Payer: Molina CHIP/Medicaid	$123.12
Rate for Payer: Molina Dual Medicare/Medicaid	$3.99
Rate for Payer: Molina Medicare	$3.99
Rate for Payer: Multiplan Auto	$111.15
Rate for Payer: Multiplan Commercial	$111.15
Rate for Payer: Multiplan Workers Comp	$111.15
Rate for Payer: Parkland Medicaid	$123.12
Rate for Payer: Scott and White EPO/PPO	$4.99
Rate for Payer: Scott and White Medicare	$3.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$123.12
Rate for Payer: Superior Health Plan EPO	$3.99
Rate for Payer: Superior Health Plan Medicare	$3.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.99
Rate for Payer: Universal American Medicare	$3.99
Rate for Payer: Wellcare Medicare	$3.99
Rate for Payer: Wellmed Medicare	$3.99

Retic Count Automated

Facility

$171.00

Service Code	HCPCS 85045
Hospital Charge Code	1611862
Hospital Revenue Code	305
Rate for Payer: Cash Price	$116.28

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC

Facility

$19,590.90

Service Code	MSDRG 815
Min. Negotiated Rate	$8,408.22
Max. Negotiated Rate	$19,590.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,191.71
Rate for Payer: Amerigroup Medicare	$12,191.71
Rate for Payer: BCBS of TX Medicare	$12,191.71
Rate for Payer: Cigna Commercial	$13,060.32
Rate for Payer: Cigna Medicare	$12,191.71
Rate for Payer: Employer Direct Commercial	$12,191.71
Rate for Payer: Humana Medicare/TRICARE	$12,191.71
Rate for Payer: Molina Dual Medicare/Medicaid	$12,191.71
Rate for Payer: Molina Medicare	$12,191.71
Rate for Payer: Multiplan Auto	$19,590.90
Rate for Payer: Multiplan Commercial	$19,590.90
Rate for Payer: Multiplan Workers Comp	$19,590.90
Rate for Payer: Scott and White EPO/PPO	$9,022.12
Rate for Payer: Scott and White Medicare	$12,191.71
Rate for Payer: Superior Health Plan EPO	$12,191.71
Rate for Payer: Superior Health Plan Medicare	$12,191.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,191.71
Rate for Payer: Universal American Medicare	$12,191.71
Rate for Payer: Wellcare Medicare	$12,191.71
Rate for Payer: Wellmed Medicare	$12,191.71

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC

Facility

$35,702.90

Service Code	MSDRG 814
Min. Negotiated Rate	$14,301.80
Max. Negotiated Rate	$35,702.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,346.73
Rate for Payer: Amerigroup Medicare	$20,346.73
Rate for Payer: BCBS of TX Medicare	$20,346.73
Rate for Payer: Cigna Commercial	$27,391.90
Rate for Payer: Cigna Medicare	$20,346.73
Rate for Payer: Employer Direct Commercial	$20,346.73
Rate for Payer: Humana Medicare/TRICARE	$20,346.73
Rate for Payer: Molina Dual Medicare/Medicaid	$20,346.73
Rate for Payer: Molina Medicare	$20,346.73
Rate for Payer: Multiplan Auto	$35,702.90
Rate for Payer: Multiplan Commercial	$35,702.90
Rate for Payer: Multiplan Workers Comp	$35,702.90
Rate for Payer: Scott and White EPO/PPO	$16,442.12
Rate for Payer: Scott and White Medicare	$20,346.73
Rate for Payer: Superior Health Plan EPO	$20,346.73
Rate for Payer: Superior Health Plan Medicare	$20,346.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,346.73
Rate for Payer: Universal American Medicare	$20,346.73
Rate for Payer: Wellcare Medicare	$20,346.73
Rate for Payer: Wellmed Medicare	$20,346.73

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC

Facility

$13,851.00

Service Code	MSDRG 816
Min. Negotiated Rate	$6,205.76
Max. Negotiated Rate	$13,851.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,392.01
Rate for Payer: Amerigroup Medicare	$9,392.01
Rate for Payer: BCBS of TX Medicare	$9,392.01
Rate for Payer: Cigna Commercial	$8,140.16
Rate for Payer: Cigna Medicare	$9,392.01
Rate for Payer: Employer Direct Commercial	$9,392.01
Rate for Payer: Humana Medicare/TRICARE	$9,392.01
Rate for Payer: Molina Dual Medicare/Medicaid	$9,392.01
Rate for Payer: Molina Medicare	$9,392.01
Rate for Payer: Multiplan Auto	$13,851.00
Rate for Payer: Multiplan Commercial	$13,851.00
Rate for Payer: Multiplan Workers Comp	$13,851.00
Rate for Payer: Scott and White EPO/PPO	$6,378.75
Rate for Payer: Scott and White Medicare	$9,392.01
Rate for Payer: Superior Health Plan EPO	$9,392.01
Rate for Payer: Superior Health Plan Medicare	$9,392.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,392.01
Rate for Payer: Universal American Medicare	$9,392.01
Rate for Payer: Wellcare Medicare	$9,392.01
Rate for Payer: Wellmed Medicare	$9,392.01

RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC

Facility

$19,590.90

Service Code	MSDRG 815
Min. Negotiated Rate	$8,408.22
Max. Negotiated Rate	$19,590.90
Rate for Payer: BCBS of TX Blue Advantage	$8,408.22
Rate for Payer: BCBS of TX Blue Essentials	$10,088.89
Rate for Payer: BCBS of TX PPO	$11,210.31

RETICULOENDOTHELIAL & IMMUNITY DISORDERS W MCC

Facility

$35,702.90

Service Code	MSDRG 814
Min. Negotiated Rate	$14,301.80
Max. Negotiated Rate	$35,702.90
Rate for Payer: BCBS of TX Blue Advantage	$14,301.80
Rate for Payer: BCBS of TX Blue Essentials	$17,160.50
Rate for Payer: BCBS of TX PPO	$19,067.96

RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC

Facility

$13,851.00

Service Code	MSDRG 816
Min. Negotiated Rate	$6,205.76
Max. Negotiated Rate	$13,851.00
Rate for Payer: BCBS of TX Blue Advantage	$6,205.76
Rate for Payer: BCBS of TX Blue Essentials	$7,446.19
Rate for Payer: BCBS of TX PPO	$8,273.87

RETRACTOR ABD DISP -- DHF

Facility

$431.30

Hospital Charge Code	80826613
Hospital Revenue Code	272
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$310.54
Rate for Payer: Amerigroup CHIP/Medicaid	$38.82
Rate for Payer: BCBS of TX Blue Advantage	$129.39
Rate for Payer: BCBS of TX Blue Essentials	$155.27
Rate for Payer: BCBS of TX PPO	$172.52
Rate for Payer: Cash Price	$293.28
Rate for Payer: Cigna Medicaid	$310.54
Rate for Payer: Molina CHIP/Medicaid	$310.54
Rate for Payer: Multiplan Auto	$280.35
Rate for Payer: Multiplan Commercial	$280.35
Rate for Payer: Multiplan Workers Comp	$280.35
Rate for Payer: Parkland Medicaid	$310.54
Rate for Payer: Scott and White EPO/PPO	$215.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$310.54
Rate for Payer: Superior Health Plan EPO	$58.66

RETRACTOR ABD DISP -- DHF

Facility

$431.30

Hospital Charge Code	80826613
Hospital Revenue Code	272
Rate for Payer: Cash Price	$293.28

RETRACTOR DISP -- DHF

Facility

$265.07

Hospital Charge Code	81763062
Hospital Revenue Code	272
Rate for Payer: Cash Price	$180.25

Know your out-of-pocket cost for care.

All Charges