White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SARS-CoV-2

Facility

$165.52

Service Code	HCPCS 87811
Hospital Charge Code	994062
Hospital Revenue Code	301
Rate for Payer: Cash Price	$112.55

SARS-CoV-2 Ab, Nucleocapsid SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8660505
Hospital Revenue Code	302
Rate for Payer: Cash Price	$72.08

SARS-CoV-2 Ab, Nucleocapsid SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8660505
Hospital Revenue Code	302
Min. Negotiated Rate	$31.80
Max. Negotiated Rate	$76.32
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$31.80
Rate for Payer: BCBS of TX Blue Essentials	$38.16
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$42.40
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cigna Medicaid	$76.32
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$76.32
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$76.32
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.32
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV-2 Antibody, IgG SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8628549
Hospital Revenue Code	302
Min. Negotiated Rate	$31.80
Max. Negotiated Rate	$76.32
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$31.80
Rate for Payer: BCBS of TX Blue Essentials	$38.16
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$42.40
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cigna Medicaid	$76.32
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$76.32
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$76.32
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.32
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV-2 Antibody, IgG SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8628549
Hospital Revenue Code	302
Rate for Payer: Cash Price	$72.08

SARS-CoV-2 Antibody, IgM SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8660506
Hospital Revenue Code	302
Rate for Payer: Cash Price	$72.08

SARS-CoV-2 Antibody, IgM SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8660506
Hospital Revenue Code	302
Min. Negotiated Rate	$31.80
Max. Negotiated Rate	$76.32
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$31.80
Rate for Payer: BCBS of TX Blue Essentials	$38.16
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$42.40
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cigna Medicaid	$76.32
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$76.32
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$76.32
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.32
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV-2/Flu/RSV PCR

Facility

$282.00

Service Code	HCPCS 0241U
Hospital Charge Code	8484529
Hospital Revenue Code	300
Rate for Payer: Cash Price	$191.76

SARS-CoV-2/Flu/RSV PCR

Facility

$282.00

Service Code	HCPCS 0241U
Hospital Charge Code	8484529
Hospital Revenue Code	300
Min. Negotiated Rate	$38.35
Max. Negotiated Rate	$203.04
Rate for Payer: Amerigroup CHIP/Medicaid	$142.63
Rate for Payer: BCBS of TX Blue Advantage	$84.60
Rate for Payer: BCBS of TX Blue Essentials	$101.52
Rate for Payer: BCBS of TX PPO	$112.80
Rate for Payer: Cash Price	$191.76
Rate for Payer: Cash Price	$191.76
Rate for Payer: Cigna Medicaid	$203.04
Rate for Payer: Molina CHIP/Medicaid	$203.04
Rate for Payer: Multiplan Auto	$183.30
Rate for Payer: Multiplan Commercial	$183.30
Rate for Payer: Multiplan Workers Comp	$183.30
Rate for Payer: Parkland Medicaid	$203.04
Rate for Payer: Scott and White EPO/PPO	$141.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$203.04
Rate for Payer: Superior Health Plan EPO	$38.35

SARS-CoV-2, NAA SO

Facility

$189.00

Hospital Charge Code	1700027
Hospital Revenue Code	300
Rate for Payer: Cash Price	$128.52

SARS-CoV-2, NAA SO

Facility

$189.00

Hospital Charge Code	1700027
Hospital Revenue Code	300
Min. Negotiated Rate	$17.01
Max. Negotiated Rate	$136.08
Rate for Payer: Amerigroup CHIP/Medicaid	$17.01
Rate for Payer: BCBS of TX Blue Advantage	$56.70
Rate for Payer: BCBS of TX Blue Essentials	$68.04
Rate for Payer: BCBS of TX PPO	$75.60
Rate for Payer: Cash Price	$128.52
Rate for Payer: Cigna Medicaid	$136.08
Rate for Payer: Molina CHIP/Medicaid	$136.08
Rate for Payer: Multiplan Auto	$122.85
Rate for Payer: Multiplan Commercial	$122.85
Rate for Payer: Multiplan Workers Comp	$122.85
Rate for Payer: Parkland Medicaid	$136.08
Rate for Payer: Scott and White EPO/PPO	$94.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$136.08
Rate for Payer: Superior Health Plan EPO	$25.70

SARS-CoV-2 PCR

Facility

$157.00

Service Code	HCPCS 87635
Hospital Charge Code	1600005
Hospital Revenue Code	300
Rate for Payer: Cash Price	$106.76

SARS-CoV-2 PCR

Facility

$157.00

Service Code	HCPCS 87635
Hospital Charge Code	1600005
Hospital Revenue Code	300
Min. Negotiated Rate	$47.10
Max. Negotiated Rate	$113.04
Rate for Payer: Amerigroup CHIP/Medicaid	$51.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$51.31
Rate for Payer: Amerigroup Medicare	$51.31
Rate for Payer: BCBS of TX Blue Advantage	$47.10
Rate for Payer: BCBS of TX Blue Essentials	$56.52
Rate for Payer: BCBS of TX Medicare	$51.31
Rate for Payer: BCBS of TX PPO	$62.80
Rate for Payer: Cash Price	$106.76
Rate for Payer: Cash Price	$106.76
Rate for Payer: Cigna Medicaid	$113.04
Rate for Payer: Cigna Medicare	$51.31
Rate for Payer: Employer Direct Commercial	$51.31
Rate for Payer: Humana Medicare/TRICARE	$51.31
Rate for Payer: Molina CHIP/Medicaid	$113.04
Rate for Payer: Molina Dual Medicare/Medicaid	$51.31
Rate for Payer: Molina Medicare	$51.31
Rate for Payer: Multiplan Auto	$102.05
Rate for Payer: Multiplan Commercial	$102.05
Rate for Payer: Multiplan Workers Comp	$102.05
Rate for Payer: Parkland Medicaid	$113.04
Rate for Payer: Scott and White EPO/PPO	$64.14
Rate for Payer: Scott and White Medicare	$51.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$113.04
Rate for Payer: Superior Health Plan EPO	$51.31
Rate for Payer: Superior Health Plan Medicare	$51.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$51.31
Rate for Payer: Universal American Medicare	$51.31
Rate for Payer: Wellcare Medicare	$51.31
Rate for Payer: Wellmed Medicare	$51.31

SARS-CoV-2 Semi-Quant Total Ab SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8628548
Hospital Revenue Code	302
Rate for Payer: Cash Price	$72.08

SARS-CoV-2 Semi-Quant Total Ab SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8628548
Hospital Revenue Code	302
Min. Negotiated Rate	$31.80
Max. Negotiated Rate	$76.32
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$31.80
Rate for Payer: BCBS of TX Blue Essentials	$38.16
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$42.40
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cigna Medicaid	$76.32
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$76.32
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$76.32
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.32
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV-2 T2 SO

Facility

$189.00

Hospital Charge Code	8698536
Hospital Revenue Code	300
Min. Negotiated Rate	$17.01
Max. Negotiated Rate	$136.08
Rate for Payer: Amerigroup CHIP/Medicaid	$17.01
Rate for Payer: BCBS of TX Blue Advantage	$56.70
Rate for Payer: BCBS of TX Blue Essentials	$68.04
Rate for Payer: BCBS of TX PPO	$75.60
Rate for Payer: Cash Price	$128.52
Rate for Payer: Cigna Medicaid	$136.08
Rate for Payer: Molina CHIP/Medicaid	$136.08
Rate for Payer: Multiplan Auto	$122.85
Rate for Payer: Multiplan Commercial	$122.85
Rate for Payer: Multiplan Workers Comp	$122.85
Rate for Payer: Parkland Medicaid	$136.08
Rate for Payer: Scott and White EPO/PPO	$94.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$136.08
Rate for Payer: Superior Health Plan EPO	$25.70

SARS-CoV-2 T2 SO

Facility

$189.00

Hospital Charge Code	8698536
Hospital Revenue Code	300
Rate for Payer: Cash Price	$128.52

SARS-CoV-2 Total Antibody

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	4106522
Hospital Revenue Code	300
Rate for Payer: Cash Price	$72.08

SARS-CoV-2 Total Antibody

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	4106522
Hospital Revenue Code	300
Min. Negotiated Rate	$31.80
Max. Negotiated Rate	$76.32
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$31.80
Rate for Payer: BCBS of TX Blue Essentials	$38.16
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$42.40
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cigna Medicaid	$76.32
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$76.32
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$76.32
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.32
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B

Facility

$281.16

Service Code	HCPCS 87428
Hospital Charge Code	994103
Hospital Revenue Code	306
Rate for Payer: Cash Price	$191.19

SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B

Facility

$281.16

Service Code	HCPCS 87428
Hospital Charge Code	994103
Hospital Revenue Code	306
Min. Negotiated Rate	$25.30
Max. Negotiated Rate	$202.44
Rate for Payer: Amerigroup CHIP/Medicaid	$25.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$70.29
Rate for Payer: Amerigroup Medicare	$70.29
Rate for Payer: BCBS of TX Blue Advantage	$84.35
Rate for Payer: BCBS of TX Blue Essentials	$101.22
Rate for Payer: BCBS of TX Medicare	$70.29
Rate for Payer: BCBS of TX PPO	$112.46
Rate for Payer: Cash Price	$191.19
Rate for Payer: Cash Price	$191.19
Rate for Payer: Cigna Medicaid	$202.44
Rate for Payer: Cigna Medicare	$70.29
Rate for Payer: Employer Direct Commercial	$70.29
Rate for Payer: Humana Medicare/TRICARE	$70.29
Rate for Payer: Molina CHIP/Medicaid	$202.44
Rate for Payer: Molina Dual Medicare/Medicaid	$70.29
Rate for Payer: Molina Medicare	$70.29
Rate for Payer: Multiplan Auto	$182.75
Rate for Payer: Multiplan Commercial	$182.75
Rate for Payer: Multiplan Workers Comp	$182.75
Rate for Payer: Parkland Medicaid	$202.44
Rate for Payer: Scott and White EPO/PPO	$87.86
Rate for Payer: Scott and White Medicare	$70.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$202.44
Rate for Payer: Superior Health Plan EPO	$70.29
Rate for Payer: Superior Health Plan Medicare	$70.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$70.29
Rate for Payer: Universal American Medicare	$70.29
Rate for Payer: Wellcare Medicare	$70.29
Rate for Payer: Wellmed Medicare	$70.29

S. AUREUS, ATCC 25923, KWIK-S,2/PK

Facility

$148.59

Hospital Charge Code	993015
Hospital Revenue Code	270
Min. Negotiated Rate	$13.37
Max. Negotiated Rate	$106.98
Rate for Payer: Amerigroup CHIP/Medicaid	$13.37
Rate for Payer: BCBS of TX Blue Advantage	$44.58
Rate for Payer: BCBS of TX Blue Essentials	$53.49
Rate for Payer: BCBS of TX PPO	$59.44
Rate for Payer: Cash Price	$101.04
Rate for Payer: Cigna Medicaid	$106.98
Rate for Payer: Molina CHIP/Medicaid	$106.98
Rate for Payer: Multiplan Auto	$96.58
Rate for Payer: Multiplan Commercial	$96.58
Rate for Payer: Multiplan Workers Comp	$96.58
Rate for Payer: Parkland Medicaid	$106.98
Rate for Payer: Scott and White EPO/PPO	$74.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$106.98
Rate for Payer: Superior Health Plan EPO	$20.21

S. AUREUS, ATCC 25923, KWIK-S,2/PK

Facility

$148.59

Hospital Charge Code	993015
Hospital Revenue Code	270
Rate for Payer: Cash Price	$101.04

Saw blade stryker univ narrow total ankle .315 in

Facility

$1,915.88

Hospital Charge Code	993320
Hospital Revenue Code	272
Min. Negotiated Rate	$172.43
Max. Negotiated Rate	$1,379.43
Rate for Payer: Amerigroup CHIP/Medicaid	$172.43
Rate for Payer: BCBS of TX Blue Advantage	$574.76
Rate for Payer: BCBS of TX Blue Essentials	$689.72
Rate for Payer: BCBS of TX PPO	$766.35
Rate for Payer: Cash Price	$1,302.80
Rate for Payer: Cigna Medicaid	$1,379.43
Rate for Payer: Molina CHIP/Medicaid	$1,379.43
Rate for Payer: Multiplan Auto	$1,245.32
Rate for Payer: Multiplan Commercial	$1,245.32
Rate for Payer: Multiplan Workers Comp	$1,245.32
Rate for Payer: Parkland Medicaid	$1,379.43
Rate for Payer: Scott and White EPO/PPO	$957.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,379.43
Rate for Payer: Superior Health Plan EPO	$260.56

Saw blade stryker univ narrow total ankle .315 in

Facility

$1,915.88

Hospital Charge Code	993320
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,302.80

Know your out-of-pocket cost for care.

All Charges