White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SEC ART M-THROMBECT ADD-ON

Facility

$11,606.00

Service Code	HCPCS 37186
Hospital Charge Code	2320224
Hospital Revenue Code	481
Min. Negotiated Rate	$288.07
Max. Negotiated Rate	$8,356.32
Rate for Payer: Amerigroup CHIP/Medicaid	$1,044.54
Rate for Payer: BCBS of TX Blue Advantage	$3,481.80
Rate for Payer: BCBS of TX Blue Essentials	$4,178.16
Rate for Payer: BCBS of TX PPO	$4,642.40
Rate for Payer: Cash Price	$7,892.08
Rate for Payer: Cash Price	$7,892.08
Rate for Payer: Cigna Medicaid	$8,356.32
Rate for Payer: Molina CHIP/Medicaid	$8,356.32
Rate for Payer: Multiplan Auto	$7,543.90
Rate for Payer: Multiplan Commercial	$7,543.90
Rate for Payer: Multiplan Workers Comp	$7,543.90
Rate for Payer: Parkland Medicaid	$8,356.32
Rate for Payer: Scott and White EPO/PPO	$288.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,356.32
Rate for Payer: Superior Health Plan EPO	$1,578.42

SEC ART M-THROMBECT ADD-ON

Facility

$11,606.00

Service Code	HCPCS 37186
Hospital Charge Code	2320224
Hospital Revenue Code	481
Rate for Payer: Cash Price	$7,892.08

Sedimentation Rate

Facility

$191.00

Service Code	HCPCS 85652
Hospital Charge Code	1630019
Hospital Revenue Code	305
Rate for Payer: Cash Price	$129.88

Sedimentation Rate

Facility

$191.00

Service Code	HCPCS 85652
Hospital Charge Code	1630019
Hospital Revenue Code	305
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$137.52
Rate for Payer: Amerigroup CHIP/Medicaid	$1.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.70
Rate for Payer: Amerigroup Medicare	$2.70
Rate for Payer: BCBS of TX Blue Advantage	$57.30
Rate for Payer: BCBS of TX Blue Essentials	$68.76
Rate for Payer: BCBS of TX Medicare	$2.70
Rate for Payer: BCBS of TX PPO	$76.40
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cigna Medicaid	$137.52
Rate for Payer: Cigna Medicare	$2.70
Rate for Payer: Employer Direct Commercial	$2.70
Rate for Payer: Humana Medicare/TRICARE	$2.70
Rate for Payer: Molina CHIP/Medicaid	$137.52
Rate for Payer: Molina Dual Medicare/Medicaid	$2.70
Rate for Payer: Molina Medicare	$2.70
Rate for Payer: Multiplan Auto	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Parkland Medicaid	$137.52
Rate for Payer: Scott and White EPO/PPO	$3.38
Rate for Payer: Scott and White Medicare	$2.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$2.70
Rate for Payer: Superior Health Plan Medicare	$2.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.70
Rate for Payer: Universal American Medicare	$2.70
Rate for Payer: Wellcare Medicare	$2.70
Rate for Payer: Wellmed Medicare	$2.70

Sedimentation rate, erythrocyte; non-automated

Facility

$38.72

Service Code	HCPCS 85651
Hospital Charge Code	993989
Hospital Revenue Code	300
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$27.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.27
Rate for Payer: Amerigroup Medicare	$4.27
Rate for Payer: BCBS of TX Blue Advantage	$11.62
Rate for Payer: BCBS of TX Blue Essentials	$13.94
Rate for Payer: BCBS of TX Medicare	$4.27
Rate for Payer: BCBS of TX PPO	$15.49
Rate for Payer: Cash Price	$26.33
Rate for Payer: Cash Price	$26.33
Rate for Payer: Cigna Medicaid	$27.88
Rate for Payer: Cigna Medicare	$4.27
Rate for Payer: Employer Direct Commercial	$4.27
Rate for Payer: Humana Medicare/TRICARE	$4.27
Rate for Payer: Molina CHIP/Medicaid	$27.88
Rate for Payer: Molina Dual Medicare/Medicaid	$4.27
Rate for Payer: Molina Medicare	$4.27
Rate for Payer: Multiplan Auto	$25.17
Rate for Payer: Multiplan Commercial	$25.17
Rate for Payer: Multiplan Workers Comp	$25.17
Rate for Payer: Parkland Medicaid	$27.88
Rate for Payer: Scott and White EPO/PPO	$5.34
Rate for Payer: Scott and White Medicare	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.88
Rate for Payer: Superior Health Plan EPO	$4.27
Rate for Payer: Superior Health Plan Medicare	$4.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.27
Rate for Payer: Universal American Medicare	$4.27
Rate for Payer: Wellcare Medicare	$4.27
Rate for Payer: Wellmed Medicare	$4.27

Sedimentation rate, erythrocyte; non-automated

Facility

$38.72

Service Code	HCPCS 85651
Hospital Charge Code	993989
Hospital Revenue Code	300
Rate for Payer: Cash Price	$26.33

SEE CLEAR LAPARSCOPIC SMOKE EVAC

Facility

$133.93

Hospital Charge Code	117227
Hospital Revenue Code	270
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$96.43
Rate for Payer: Amerigroup CHIP/Medicaid	$12.05
Rate for Payer: BCBS of TX Blue Advantage	$40.18
Rate for Payer: BCBS of TX Blue Essentials	$48.21
Rate for Payer: BCBS of TX PPO	$53.57
Rate for Payer: Cash Price	$91.07
Rate for Payer: Cigna Medicaid	$96.43
Rate for Payer: Molina CHIP/Medicaid	$96.43
Rate for Payer: Multiplan Auto	$87.05
Rate for Payer: Multiplan Commercial	$87.05
Rate for Payer: Multiplan Workers Comp	$87.05
Rate for Payer: Parkland Medicaid	$96.43
Rate for Payer: Scott and White EPO/PPO	$66.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96.43
Rate for Payer: Superior Health Plan EPO	$18.21

SEE CLEAR LAPARSCOPIC SMOKE EVAC

Facility

$133.93

Hospital Charge Code	117227
Hospital Revenue Code	270
Rate for Payer: Cash Price	$91.07

see sharp

Facility

$254.24

Hospital Charge Code	993169
Hospital Revenue Code	270
Rate for Payer: Cash Price	$172.88

see sharp

Facility

$254.24

Hospital Charge Code	993169
Hospital Revenue Code	270
Min. Negotiated Rate	$22.88
Max. Negotiated Rate	$183.05
Rate for Payer: Amerigroup CHIP/Medicaid	$22.88
Rate for Payer: BCBS of TX Blue Advantage	$76.27
Rate for Payer: BCBS of TX Blue Essentials	$91.53
Rate for Payer: BCBS of TX PPO	$101.70
Rate for Payer: Cash Price	$172.88
Rate for Payer: Cigna Medicaid	$183.05
Rate for Payer: Molina CHIP/Medicaid	$183.05
Rate for Payer: Multiplan Auto	$165.26
Rate for Payer: Multiplan Commercial	$165.26
Rate for Payer: Multiplan Workers Comp	$165.26
Rate for Payer: Parkland Medicaid	$183.05
Rate for Payer: Scott and White EPO/PPO	$127.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$183.05
Rate for Payer: Superior Health Plan EPO	$34.58

SEF02401

Facility

$17,746.99

Hospital Charge Code	991003
Hospital Revenue Code	272
Rate for Payer: Cash Price	$12,067.95

SEF02401

Facility

$17,746.99

Hospital Charge Code	991003
Hospital Revenue Code	272
Min. Negotiated Rate	$1,597.23
Max. Negotiated Rate	$12,777.83
Rate for Payer: Amerigroup CHIP/Medicaid	$1,597.23
Rate for Payer: BCBS of TX Blue Advantage	$5,324.10
Rate for Payer: BCBS of TX Blue Essentials	$6,388.92
Rate for Payer: BCBS of TX PPO	$7,098.80
Rate for Payer: Cash Price	$12,067.95
Rate for Payer: Cigna Medicaid	$12,777.83
Rate for Payer: Molina CHIP/Medicaid	$12,777.83
Rate for Payer: Multiplan Auto	$11,535.54
Rate for Payer: Multiplan Commercial	$11,535.54
Rate for Payer: Multiplan Workers Comp	$11,535.54
Rate for Payer: Parkland Medicaid	$12,777.83
Rate for Payer: Scott and White EPO/PPO	$8,873.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,777.83
Rate for Payer: Superior Health Plan EPO	$2,413.59

SEF05160

Facility

$18,530.00

Service Code	HCPCS C1713
Hospital Charge Code	990995
Hospital Revenue Code	278
Min. Negotiated Rate	$1,667.70
Max. Negotiated Rate	$13,341.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1,667.70
Rate for Payer: BCBS of TX Blue Advantage	$5,559.00
Rate for Payer: BCBS of TX Blue Essentials	$6,670.80
Rate for Payer: BCBS of TX PPO	$7,412.00
Rate for Payer: Cash Price	$12,600.40
Rate for Payer: Cigna Medicaid	$13,341.60
Rate for Payer: Molina CHIP/Medicaid	$13,341.60
Rate for Payer: Multiplan Auto	$9,265.00
Rate for Payer: Multiplan Commercial	$9,265.00
Rate for Payer: Multiplan Workers Comp	$9,265.00
Rate for Payer: Parkland Medicaid	$13,341.60
Rate for Payer: Scott and White EPO/PPO	$9,265.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,341.60
Rate for Payer: Superior Health Plan EPO	$2,520.08

SEF05160

Facility

$18,530.00

Service Code	HCPCS C1713
Hospital Charge Code	990995
Hospital Revenue Code	278
Min. Negotiated Rate	$4,632.50
Max. Negotiated Rate	$9,265.00
Rate for Payer: Cash Price	$12,600.40
Rate for Payer: Cigna Commercial	$4,632.50
Rate for Payer: Multiplan Auto	$9,265.00
Rate for Payer: Multiplan Commercial	$9,265.00
Rate for Payer: Multiplan Workers Comp	$9,265.00
Rate for Payer: Scott and White EPO/PPO	$9,265.00

SEF08160

Facility

$10,199.00

Service Code	HCPCS C1713
Hospital Charge Code	990993
Hospital Revenue Code	278
Min. Negotiated Rate	$2,549.75
Max. Negotiated Rate	$5,099.50
Rate for Payer: Cash Price	$6,935.32
Rate for Payer: Cigna Commercial	$2,549.75
Rate for Payer: Multiplan Auto	$5,099.50
Rate for Payer: Multiplan Commercial	$5,099.50
Rate for Payer: Multiplan Workers Comp	$5,099.50
Rate for Payer: Scott and White EPO/PPO	$5,099.50

SEF08160

Facility

$10,199.00

Service Code	HCPCS C1713
Hospital Charge Code	990993
Hospital Revenue Code	278
Min. Negotiated Rate	$917.91
Max. Negotiated Rate	$7,343.28
Rate for Payer: Amerigroup CHIP/Medicaid	$917.91
Rate for Payer: BCBS of TX Blue Advantage	$3,059.70
Rate for Payer: BCBS of TX Blue Essentials	$3,671.64
Rate for Payer: BCBS of TX PPO	$4,079.60
Rate for Payer: Cash Price	$6,935.32
Rate for Payer: Cigna Medicaid	$7,343.28
Rate for Payer: Molina CHIP/Medicaid	$7,343.28
Rate for Payer: Multiplan Auto	$5,099.50
Rate for Payer: Multiplan Commercial	$5,099.50
Rate for Payer: Multiplan Workers Comp	$5,099.50
Rate for Payer: Parkland Medicaid	$7,343.28
Rate for Payer: Scott and White EPO/PPO	$5,099.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,343.28
Rate for Payer: Superior Health Plan EPO	$1,387.06

SEF10011

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Charge Code	990982
Hospital Revenue Code	278
Min. Negotiated Rate	$500.00
Max. Negotiated Rate	$1,000.00
Rate for Payer: Cash Price	$1,360.00
Rate for Payer: Cigna Commercial	$500.00
Rate for Payer: Multiplan Auto	$1,000.00
Rate for Payer: Multiplan Commercial	$1,000.00
Rate for Payer: Multiplan Workers Comp	$1,000.00
Rate for Payer: Scott and White EPO/PPO	$1,000.00

SEF10011

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Charge Code	990982
Hospital Revenue Code	278
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$1,440.00
Rate for Payer: Amerigroup CHIP/Medicaid	$180.00
Rate for Payer: BCBS of TX Blue Advantage	$600.00
Rate for Payer: BCBS of TX Blue Essentials	$720.00
Rate for Payer: BCBS of TX PPO	$800.00
Rate for Payer: Cash Price	$1,360.00
Rate for Payer: Cigna Medicaid	$1,440.00
Rate for Payer: Molina CHIP/Medicaid	$1,440.00
Rate for Payer: Multiplan Auto	$1,000.00
Rate for Payer: Multiplan Commercial	$1,000.00
Rate for Payer: Multiplan Workers Comp	$1,000.00
Rate for Payer: Parkland Medicaid	$1,440.00
Rate for Payer: Scott and White EPO/PPO	$1,000.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,440.00
Rate for Payer: Superior Health Plan EPO	$272.00

SEF11160

Facility

$8,127.00

Service Code	HCPCS C1713
Hospital Charge Code	990996
Hospital Revenue Code	278
Min. Negotiated Rate	$2,031.75
Max. Negotiated Rate	$4,063.50
Rate for Payer: Cash Price	$5,526.36
Rate for Payer: Cigna Commercial	$2,031.75
Rate for Payer: Multiplan Auto	$4,063.50
Rate for Payer: Multiplan Commercial	$4,063.50
Rate for Payer: Multiplan Workers Comp	$4,063.50
Rate for Payer: Scott and White EPO/PPO	$4,063.50

SEF11160

Facility

$8,127.00

Service Code	HCPCS C1713
Hospital Charge Code	990996
Hospital Revenue Code	278
Min. Negotiated Rate	$731.43
Max. Negotiated Rate	$5,851.44
Rate for Payer: Amerigroup CHIP/Medicaid	$731.43
Rate for Payer: BCBS of TX Blue Advantage	$2,438.10
Rate for Payer: BCBS of TX Blue Essentials	$2,925.72
Rate for Payer: BCBS of TX PPO	$3,250.80
Rate for Payer: Cash Price	$5,526.36
Rate for Payer: Cigna Medicaid	$5,851.44
Rate for Payer: Molina CHIP/Medicaid	$5,851.44
Rate for Payer: Multiplan Auto	$4,063.50
Rate for Payer: Multiplan Commercial	$4,063.50
Rate for Payer: Multiplan Workers Comp	$4,063.50
Rate for Payer: Parkland Medicaid	$5,851.44
Rate for Payer: Scott and White EPO/PPO	$4,063.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,851.44
Rate for Payer: Superior Health Plan EPO	$1,105.27

SEF16160

Facility

$11,723.00

Service Code	HCPCS C1713
Hospital Charge Code	990994
Hospital Revenue Code	278
Min. Negotiated Rate	$2,930.75
Max. Negotiated Rate	$5,861.50
Rate for Payer: Cash Price	$7,971.64
Rate for Payer: Cigna Commercial	$2,930.75
Rate for Payer: Multiplan Auto	$5,861.50
Rate for Payer: Multiplan Commercial	$5,861.50
Rate for Payer: Multiplan Workers Comp	$5,861.50
Rate for Payer: Scott and White EPO/PPO	$5,861.50

SEF16160

Facility

$11,723.00

Service Code	HCPCS C1713
Hospital Charge Code	990994
Hospital Revenue Code	278
Min. Negotiated Rate	$1,055.07
Max. Negotiated Rate	$8,440.56
Rate for Payer: Amerigroup CHIP/Medicaid	$1,055.07
Rate for Payer: BCBS of TX Blue Advantage	$3,516.90
Rate for Payer: BCBS of TX Blue Essentials	$4,220.28
Rate for Payer: BCBS of TX PPO	$4,689.20
Rate for Payer: Cash Price	$7,971.64
Rate for Payer: Cigna Medicaid	$8,440.56
Rate for Payer: Molina CHIP/Medicaid	$8,440.56
Rate for Payer: Multiplan Auto	$5,861.50
Rate for Payer: Multiplan Commercial	$5,861.50
Rate for Payer: Multiplan Workers Comp	$5,861.50
Rate for Payer: Parkland Medicaid	$8,440.56
Rate for Payer: Scott and White EPO/PPO	$5,861.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,440.56
Rate for Payer: Superior Health Plan EPO	$1,594.33

SEF33010

Facility

$259.00

Service Code	HCPCS C1713
Hospital Charge Code	990987
Hospital Revenue Code	278
Min. Negotiated Rate	$23.31
Max. Negotiated Rate	$186.48
Rate for Payer: Amerigroup CHIP/Medicaid	$23.31
Rate for Payer: BCBS of TX Blue Advantage	$77.70
Rate for Payer: BCBS of TX Blue Essentials	$93.24
Rate for Payer: BCBS of TX PPO	$103.60
Rate for Payer: Cash Price	$176.12
Rate for Payer: Cigna Medicaid	$186.48
Rate for Payer: Molina CHIP/Medicaid	$186.48
Rate for Payer: Multiplan Auto	$129.50
Rate for Payer: Multiplan Commercial	$129.50
Rate for Payer: Multiplan Workers Comp	$129.50
Rate for Payer: Parkland Medicaid	$186.48
Rate for Payer: Scott and White EPO/PPO	$129.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$186.48
Rate for Payer: Superior Health Plan EPO	$35.22

SEF33010

Facility

$259.00

Service Code	HCPCS C1713
Hospital Charge Code	990987
Hospital Revenue Code	278
Min. Negotiated Rate	$64.75
Max. Negotiated Rate	$129.50
Rate for Payer: Cash Price	$176.12
Rate for Payer: Cigna Commercial	$64.75
Rate for Payer: Multiplan Auto	$129.50
Rate for Payer: Multiplan Commercial	$129.50
Rate for Payer: Multiplan Workers Comp	$129.50
Rate for Payer: Scott and White EPO/PPO	$129.50

SEF33010

Facility

$259.03

Hospital Charge Code	991001
Hospital Revenue Code	272
Min. Negotiated Rate	$23.31
Max. Negotiated Rate	$186.50
Rate for Payer: Amerigroup CHIP/Medicaid	$23.31
Rate for Payer: BCBS of TX Blue Advantage	$77.71
Rate for Payer: BCBS of TX Blue Essentials	$93.25
Rate for Payer: BCBS of TX PPO	$103.61
Rate for Payer: Cash Price	$176.14
Rate for Payer: Cigna Medicaid	$186.50
Rate for Payer: Molina CHIP/Medicaid	$186.50
Rate for Payer: Multiplan Auto	$168.37
Rate for Payer: Multiplan Commercial	$168.37
Rate for Payer: Multiplan Workers Comp	$168.37
Rate for Payer: Parkland Medicaid	$186.50
Rate for Payer: Scott and White EPO/PPO	$129.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$186.50
Rate for Payer: Superior Health Plan EPO	$35.23

Know your out-of-pocket cost for care.

All Charges