White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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 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 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 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 T2 SO

Facility

$189.00

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

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 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-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, 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
Rate for Payer: Cash Price	$101.04

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

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

Saw blade stryker univ wide total ankle .500

Facility

$1,915.88

Hospital Charge Code	993322
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,302.80

Saw blade stryker univ wide total ankle .500

Facility

$1,915.88

Hospital Charge Code	993322
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

SC-4230SC-4276

Facility

$54.22

Service Code	HCPCS A9270
Hospital Charge Code	994127
Hospital Revenue Code	272
Min. Negotiated Rate	$4.88
Max. Negotiated Rate	$39.04
Rate for Payer: Amerigroup CHIP/Medicaid	$4.88
Rate for Payer: BCBS of TX Blue Advantage	$16.27
Rate for Payer: BCBS of TX Blue Essentials	$19.52
Rate for Payer: BCBS of TX PPO	$21.69
Rate for Payer: Cash Price	$36.87
Rate for Payer: Cigna Medicaid	$39.04
Rate for Payer: Molina CHIP/Medicaid	$39.04
Rate for Payer: Multiplan Auto	$35.24
Rate for Payer: Multiplan Commercial	$35.24
Rate for Payer: Multiplan Workers Comp	$35.24
Rate for Payer: Parkland Medicaid	$39.04
Rate for Payer: Scott and White EPO/PPO	$27.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.04
Rate for Payer: Superior Health Plan EPO	$7.37

SC-4230SC-4276

Facility

$54.22

Service Code	HCPCS A9270
Hospital Charge Code	994127
Hospital Revenue Code	272
Rate for Payer: Cash Price	$36.87

SC-4230SC-4276

Facility

$54.22

Service Code	HCPCS A9270
Hospital Charge Code	77773906
Hospital Revenue Code	272
Rate for Payer: Cash Price	$36.87

SC-4230SC-4276

Facility

$54.22

Service Code	HCPCS A9270
Hospital Charge Code	77773906
Hospital Revenue Code	272
Min. Negotiated Rate	$4.88
Max. Negotiated Rate	$39.04
Rate for Payer: Amerigroup CHIP/Medicaid	$4.88
Rate for Payer: BCBS of TX Blue Advantage	$16.27
Rate for Payer: BCBS of TX Blue Essentials	$19.52
Rate for Payer: BCBS of TX PPO	$21.69
Rate for Payer: Cash Price	$36.87
Rate for Payer: Cigna Medicaid	$39.04
Rate for Payer: Molina CHIP/Medicaid	$39.04
Rate for Payer: Multiplan Auto	$35.24
Rate for Payer: Multiplan Commercial	$35.24
Rate for Payer: Multiplan Workers Comp	$35.24
Rate for Payer: Parkland Medicaid	$39.04
Rate for Payer: Scott and White EPO/PPO	$27.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.04
Rate for Payer: Superior Health Plan EPO	$7.37

SC-4316

Facility

$1,204.82

Service Code	HCPCS C1713
Hospital Charge Code	994126
Hospital Revenue Code	278
Min. Negotiated Rate	$301.20
Max. Negotiated Rate	$602.41
Rate for Payer: Cash Price	$819.28
Rate for Payer: Cigna Commercial	$301.20
Rate for Payer: Multiplan Auto	$602.41
Rate for Payer: Multiplan Commercial	$602.41
Rate for Payer: Multiplan Workers Comp	$602.41
Rate for Payer: Scott and White EPO/PPO	$602.41

SC-4316

Facility

$1,204.82

Service Code	HCPCS C1713
Hospital Charge Code	994126
Hospital Revenue Code	278
Min. Negotiated Rate	$108.43
Max. Negotiated Rate	$867.47
Rate for Payer: Amerigroup CHIP/Medicaid	$108.43
Rate for Payer: BCBS of TX Blue Advantage	$361.45
Rate for Payer: BCBS of TX Blue Essentials	$433.74
Rate for Payer: BCBS of TX PPO	$481.93
Rate for Payer: Cash Price	$819.28
Rate for Payer: Cigna Medicaid	$867.47
Rate for Payer: Molina CHIP/Medicaid	$867.47
Rate for Payer: Multiplan Auto	$602.41
Rate for Payer: Multiplan Commercial	$602.41
Rate for Payer: Multiplan Workers Comp	$602.41
Rate for Payer: Parkland Medicaid	$867.47
Rate for Payer: Scott and White EPO/PPO	$602.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$867.47
Rate for Payer: Superior Health Plan EPO	$163.86

SC-8336-50SC-5572-1

Facility

$145,783.13

Service Code	HCPCS C1820
Hospital Charge Code	994125
Hospital Revenue Code	278
Min. Negotiated Rate	$36,445.78
Max. Negotiated Rate	$72,891.57
Rate for Payer: Cash Price	$99,132.53
Rate for Payer: Cigna Commercial	$36,445.78
Rate for Payer: Multiplan Auto	$72,891.57
Rate for Payer: Multiplan Commercial	$72,891.57
Rate for Payer: Multiplan Workers Comp	$72,891.57
Rate for Payer: Scott and White EPO/PPO	$72,891.57

SC-8336-50SC-5572-1

Facility

$145,783.13

Service Code	HCPCS C1820
Hospital Charge Code	13522732
Hospital Revenue Code	278
Min. Negotiated Rate	$13,120.48
Max. Negotiated Rate	$104,963.85
Rate for Payer: Amerigroup CHIP/Medicaid	$13,120.48
Rate for Payer: BCBS of TX Blue Advantage	$43,734.94
Rate for Payer: BCBS of TX Blue Essentials	$52,481.93
Rate for Payer: BCBS of TX PPO	$58,313.25
Rate for Payer: Cash Price	$99,132.53
Rate for Payer: Cigna Medicaid	$104,963.85
Rate for Payer: Molina CHIP/Medicaid	$104,963.85
Rate for Payer: Multiplan Auto	$72,891.57
Rate for Payer: Multiplan Commercial	$72,891.57
Rate for Payer: Multiplan Workers Comp	$72,891.57
Rate for Payer: Parkland Medicaid	$104,963.85
Rate for Payer: Scott and White EPO/PPO	$72,891.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$104,963.85
Rate for Payer: Superior Health Plan EPO	$19,826.51

Know your out-of-pocket cost for care.

All Charges