White Rock Medical Center

All Charges

Charge

Type

Setting

Price

88334 AP Bill Immediate Smear Touch Prep Add'l

Facility

$165.00

Service Code	CPT 88334
Hospital Charge Code	1802628
Hospital Revenue Code	312
Rate for Payer: Cash Price	$145.20

88341 AP Bill Surg IPX (Add'l Antibody)

Facility

$402.00

Service Code	CPT 88341
Hospital Charge Code	1841001
Hospital Revenue Code	312
Min. Negotiated Rate	$36.73
Max. Negotiated Rate	$261.30
Rate for Payer: Aetna Commercial	$66.36
Rate for Payer: Amerigroup CHIP/Medicaid	$36.73
Rate for Payer: BCBS of TX Blue Advantage	$106.44
Rate for Payer: BCBS of TX Blue Essentials	$127.73
Rate for Payer: BCBS of TX PPO	$142.57
Rate for Payer: Cash Price	$353.76
Rate for Payer: Cash Price	$353.76
Rate for Payer: Multiplan Auto	$261.30
Rate for Payer: Multiplan Commercial	$261.30
Rate for Payer: Multiplan Workers Comp	$261.30
Rate for Payer: Scott and White EPO/PPO	$201.00
Rate for Payer: Superior Health Plan EPO	$54.67

88341 AP Bill Surg IPX (Add'l Antibody)

Facility

$402.00

Service Code	CPT 88341
Hospital Charge Code	1841001
Hospital Revenue Code	312
Rate for Payer: Cash Price	$353.76

88342 AP Bill Surg IPX (First Antibody)

Facility

$561.00

Service Code	CPT 88342
Hospital Charge Code	1800457
Hospital Revenue Code	312
Rate for Payer: Cash Price	$493.68

88342 AP Bill Surg IPX (First Antibody)

Facility

$561.00

Service Code	CPT 88342
Hospital Charge Code	1800457
Hospital Revenue Code	312
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$364.65
Rate for Payer: Aetna Commercial	$72.90
Rate for Payer: Aetna Medicare	$234.32
Rate for Payer: Amerigroup CHIP/Medicaid	$41.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$156.21
Rate for Payer: Amerigroup Medicare	$156.21
Rate for Payer: BCBS of TX Blue Advantage	$236.78
Rate for Payer: BCBS of TX Blue Essentials	$284.13
Rate for Payer: BCBS of TX Medicare	$156.21
Rate for Payer: BCBS of TX PPO	$317.14
Rate for Payer: Cash Price	$493.68
Rate for Payer: Cash Price	$493.68
Rate for Payer: Cash Price	$493.68
Rate for Payer: Cigna Commercial	$353.86
Rate for Payer: Cigna Medicare	$156.21
Rate for Payer: Employer Direct Commercial	$156.21
Rate for Payer: Humana Medicare/TRICARE	$156.21
Rate for Payer: Molina Dual Medicare/Medicaid	$156.21
Rate for Payer: Molina Medicare	$156.21
Rate for Payer: Multiplan Auto	$364.65
Rate for Payer: Multiplan Commercial	$364.65
Rate for Payer: Multiplan Workers Comp	$364.65
Rate for Payer: Scott and White EPO/PPO	$2.79
Rate for Payer: Scott and White Medicare	$156.21
Rate for Payer: Superior Health Plan EPO	$156.21
Rate for Payer: Superior Health Plan Medicare	$156.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$156.21
Rate for Payer: Universal American Medicare	$156.21
Rate for Payer: Wellcare Medicare	$156.21
Rate for Payer: Wellmed Medicare	$156.21

88360 AP Bill Surg Manual Quant IHC

Facility

$501.00

Service Code	CPT 88360
Hospital Charge Code	1802586
Hospital Revenue Code	310
Rate for Payer: Cash Price	$440.88

88360 AP Bill Surg Manual Quant IHC

Facility

$501.00

Service Code	CPT 88360
Hospital Charge Code	1802586
Hospital Revenue Code	310
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$353.86
Rate for Payer: Aetna Commercial	$87.06
Rate for Payer: Aetna Medicare	$234.32
Rate for Payer: Amerigroup CHIP/Medicaid	$49.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$156.21
Rate for Payer: Amerigroup Medicare	$156.21
Rate for Payer: BCBS of TX Blue Advantage	$236.78
Rate for Payer: BCBS of TX Blue Essentials	$284.13
Rate for Payer: BCBS of TX Medicare	$156.21
Rate for Payer: BCBS of TX PPO	$317.14
Rate for Payer: Cash Price	$440.88
Rate for Payer: Cash Price	$440.88
Rate for Payer: Cash Price	$440.88
Rate for Payer: Cigna Commercial	$353.86
Rate for Payer: Cigna Medicare	$156.21
Rate for Payer: Employer Direct Commercial	$156.21
Rate for Payer: Humana Medicare/TRICARE	$156.21
Rate for Payer: Molina Dual Medicare/Medicaid	$156.21
Rate for Payer: Molina Medicare	$156.21
Rate for Payer: Multiplan Auto	$325.65
Rate for Payer: Multiplan Commercial	$325.65
Rate for Payer: Multiplan Workers Comp	$325.65
Rate for Payer: Scott and White EPO/PPO	$2.79
Rate for Payer: Scott and White Medicare	$156.21
Rate for Payer: Superior Health Plan EPO	$156.21
Rate for Payer: Superior Health Plan Medicare	$156.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$156.21
Rate for Payer: Universal American Medicare	$156.21
Rate for Payer: Wellcare Medicare	$156.21
Rate for Payer: Wellmed Medicare	$156.21

88374 AP Bill Morph Analysis Comp Asst Each Probe

Facility

$741.00

Service Code	CPT 88374
Hospital Charge Code	7038374
Hospital Revenue Code	310
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$481.65
Rate for Payer: Aetna Commercial	$310.75
Rate for Payer: Aetna Medicare	$234.32
Rate for Payer: Amerigroup CHIP/Medicaid	$135.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$156.21
Rate for Payer: Amerigroup Medicare	$156.21
Rate for Payer: BCBS of TX Blue Advantage	$236.78
Rate for Payer: BCBS of TX Blue Essentials	$284.13
Rate for Payer: BCBS of TX Medicare	$156.21
Rate for Payer: BCBS of TX PPO	$317.14
Rate for Payer: Cash Price	$652.08
Rate for Payer: Cash Price	$652.08
Rate for Payer: Cash Price	$652.08
Rate for Payer: Cigna Commercial	$353.86
Rate for Payer: Cigna Medicare	$156.21
Rate for Payer: Employer Direct Commercial	$156.21
Rate for Payer: Humana Medicare/TRICARE	$156.21
Rate for Payer: Molina Dual Medicare/Medicaid	$156.21
Rate for Payer: Molina Medicare	$156.21
Rate for Payer: Multiplan Auto	$481.65
Rate for Payer: Multiplan Commercial	$481.65
Rate for Payer: Multiplan Workers Comp	$481.65
Rate for Payer: Scott and White EPO/PPO	$2.79
Rate for Payer: Scott and White Medicare	$156.21
Rate for Payer: Superior Health Plan EPO	$156.21
Rate for Payer: Superior Health Plan Medicare	$156.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$156.21
Rate for Payer: Universal American Medicare	$156.21
Rate for Payer: Wellcare Medicare	$156.21
Rate for Payer: Wellmed Medicare	$156.21

88374 AP Bill Morph Analysis Comp Asst Each Probe

Facility

$741.00

Service Code	CPT 88374
Hospital Charge Code	7038374
Hospital Revenue Code	310
Rate for Payer: Cash Price	$652.08

89060 AP Bill Synovial Crystals

Facility

$145.00

Service Code	CPT 89060
Hospital Charge Code	1600303
Hospital Revenue Code	300
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$94.25
Rate for Payer: Aetna Commercial	$7.70
Rate for Payer: Aetna Medicare	$11.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.33
Rate for Payer: Amerigroup Medicare	$7.33
Rate for Payer: BCBS of TX Blue Advantage	$12.09
Rate for Payer: BCBS of TX Blue Essentials	$14.51
Rate for Payer: BCBS of TX Medicare	$7.33
Rate for Payer: BCBS of TX PPO	$16.20
Rate for Payer: Cash Price	$127.60
Rate for Payer: Cash Price	$127.60
Rate for Payer: Cigna Medicaid	$7.33
Rate for Payer: Cigna Medicare	$7.33
Rate for Payer: Employer Direct Commercial	$7.33
Rate for Payer: Humana Medicare/TRICARE	$7.33
Rate for Payer: Molina CHIP/Medicaid	$7.33
Rate for Payer: Molina Dual Medicare/Medicaid	$7.33
Rate for Payer: Molina Medicare	$7.33
Rate for Payer: Multiplan Auto	$94.25
Rate for Payer: Multiplan Commercial	$94.25
Rate for Payer: Multiplan Workers Comp	$94.25
Rate for Payer: Parkland Medicaid	$7.33
Rate for Payer: Scott and White EPO/PPO	$9.16
Rate for Payer: Scott and White Medicare	$7.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.33
Rate for Payer: Superior Health Plan EPO	$7.33
Rate for Payer: Superior Health Plan Medicare	$7.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.33
Rate for Payer: Universal American Medicare	$7.33
Rate for Payer: Wellcare Medicare	$7.33
Rate for Payer: Wellmed Medicare	$7.33

96360 - Hydration, first hour

Facility

$847.00

Service Code	CPT 96360
Hospital Charge Code	5202361
Hospital Revenue Code	260
Rate for Payer: Cash Price	$745.36

96360 - Hydration, first hour

Facility

$847.00

Service Code	CPT 96360
Hospital Charge Code	5202361
Hospital Revenue Code	260
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$550.55
Rate for Payer: Aetna Commercial	$465.85
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup CHIP/Medicaid	$76.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$67.09
Rate for Payer: BCBS of TX Blue Essentials	$80.20
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$89.46
Rate for Payer: Cash Price	$745.36
Rate for Payer: Cash Price	$745.36
Rate for Payer: Cash Price	$745.36
Rate for Payer: Cigna Commercial	$444.05
Rate for Payer: Cigna Medicare	$196.02
Rate for Payer: Employer Direct Commercial	$196.02
Rate for Payer: Humana Medicare/TRICARE	$196.02
Rate for Payer: Molina Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
Rate for Payer: Multiplan Auto	$550.55
Rate for Payer: Multiplan Commercial	$550.55
Rate for Payer: Multiplan Workers Comp	$550.55
Rate for Payer: Scott and White EPO/PPO	$3.51
Rate for Payer: Scott and White Medicare	$196.02
Rate for Payer: Superior Health Plan EPO	$196.02
Rate for Payer: Superior Health Plan Medicare	$196.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$196.02
Rate for Payer: Universal American Medicare	$196.02
Rate for Payer: Wellcare Medicare	$196.02
Rate for Payer: Wellmed Medicare	$196.02

96361- Hydration, each additional hour

Facility

$251.00

Service Code	CPT 96361
Hospital Charge Code	5202379
Hospital Revenue Code	260
Rate for Payer: Cash Price	$220.88

96361- Hydration, each additional hour

Facility

$251.00

Service Code	CPT 96361
Hospital Charge Code	5202379
Hospital Revenue Code	260
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$163.15
Rate for Payer: Aetna Commercial	$138.05
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$22.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$23.82
Rate for Payer: BCBS of TX Blue Essentials	$28.48
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$31.76
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
Rate for Payer: Multiplan Auto	$163.15
Rate for Payer: Multiplan Commercial	$163.15
Rate for Payer: Multiplan Workers Comp	$163.15
Rate for Payer: Scott and White EPO/PPO	$0.78
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

96365- IV tx, first hour

Facility

$300.00

Service Code	CPT 96365
Hospital Charge Code	5202387
Hospital Revenue Code	260
Rate for Payer: Cash Price	$264.00

96365- IV tx, first hour

Facility

$300.00

Service Code	CPT 96365
Hospital Charge Code	5202387
Hospital Revenue Code	260
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$444.05
Rate for Payer: Aetna Commercial	$165.00
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup CHIP/Medicaid	$27.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$126.67
Rate for Payer: BCBS of TX Blue Essentials	$151.42
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$168.90
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cigna Commercial	$444.05
Rate for Payer: Cigna Medicare	$196.02
Rate for Payer: Employer Direct Commercial	$196.02
Rate for Payer: Humana Medicare/TRICARE	$196.02
Rate for Payer: Molina Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
Rate for Payer: Multiplan Auto	$195.00
Rate for Payer: Multiplan Commercial	$195.00
Rate for Payer: Multiplan Workers Comp	$195.00
Rate for Payer: Scott and White EPO/PPO	$3.51
Rate for Payer: Scott and White Medicare	$196.02
Rate for Payer: Superior Health Plan EPO	$196.02
Rate for Payer: Superior Health Plan Medicare	$196.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$196.02
Rate for Payer: Universal American Medicare	$196.02
Rate for Payer: Wellcare Medicare	$196.02
Rate for Payer: Wellmed Medicare	$196.02

96366- IV tx, each additional hour

Facility

$153.00

Service Code	CPT 96366
Hospital Charge Code	5202395
Hospital Revenue Code	260
Rate for Payer: Cash Price	$134.64

96366- IV tx, each additional hour

Facility

$153.00

Service Code	CPT 96366
Hospital Charge Code	5202395
Hospital Revenue Code	260
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$99.45
Rate for Payer: Aetna Commercial	$84.15
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$38.25
Rate for Payer: BCBS of TX Blue Essentials	$45.72
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$50.99
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Scott and White EPO/PPO	$0.78
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

96367- IV tx, sequential infusion

Facility

$175.00

Service Code	CPT 96367
Hospital Charge Code	5202403
Hospital Revenue Code	260
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$96.25
Rate for Payer: Aetna Medicare	$96.64
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$64.43
Rate for Payer: Amerigroup Medicare	$64.43
Rate for Payer: BCBS of TX Blue Advantage	$55.18
Rate for Payer: BCBS of TX Blue Essentials	$65.96
Rate for Payer: BCBS of TX Medicare	$64.43
Rate for Payer: BCBS of TX PPO	$73.57
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cigna Commercial	$145.94
Rate for Payer: Cigna Medicare	$64.43
Rate for Payer: Employer Direct Commercial	$64.43
Rate for Payer: Humana Medicare/TRICARE	$64.43
Rate for Payer: Molina Dual Medicare/Medicaid	$64.43
Rate for Payer: Molina Medicare	$64.43
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Scott and White EPO/PPO	$1.15
Rate for Payer: Scott and White Medicare	$64.43
Rate for Payer: Superior Health Plan EPO	$64.43
Rate for Payer: Superior Health Plan Medicare	$64.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$64.43
Rate for Payer: Universal American Medicare	$64.43
Rate for Payer: Wellcare Medicare	$64.43
Rate for Payer: Wellmed Medicare	$64.43

96367- IV tx, sequential infusion

Facility

$175.00

Service Code	CPT 96367
Hospital Charge Code	5202403
Hospital Revenue Code	260
Rate for Payer: Cash Price	$154.00

96368- IV tx, concurrent infusion

Facility

$149.00

Service Code	CPT 96368
Hospital Charge Code	5202411
Hospital Revenue Code	260
Rate for Payer: Cash Price	$131.12

96368- IV tx, concurrent infusion

Facility

$149.00

Service Code	CPT 96368
Hospital Charge Code	5202411
Hospital Revenue Code	260
Min. Negotiated Rate	$13.41
Max. Negotiated Rate	$96.85
Rate for Payer: Aetna Commercial	$81.95
Rate for Payer: Amerigroup CHIP/Medicaid	$13.41
Rate for Payer: BCBS of TX Blue Advantage	$36.99
Rate for Payer: BCBS of TX Blue Essentials	$44.22
Rate for Payer: BCBS of TX PPO	$49.32
Rate for Payer: Cash Price	$131.12
Rate for Payer: Cash Price	$131.12
Rate for Payer: Multiplan Auto	$96.85
Rate for Payer: Multiplan Commercial	$96.85
Rate for Payer: Multiplan Workers Comp	$96.85
Rate for Payer: Scott and White EPO/PPO	$74.50
Rate for Payer: Superior Health Plan EPO	$20.26

96372- Subq/IM Injection

Facility

$280.00

Service Code	CPT 96372
Hospital Charge Code	5210315
Hospital Revenue Code	260
Rate for Payer: Cash Price	$246.40

96372- Subq/IM Injection

Facility

$280.00

Service Code	CPT 96372
Hospital Charge Code	5210315
Hospital Revenue Code	260
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$154.00
Rate for Payer: Aetna Medicare	$96.64
Rate for Payer: Amerigroup CHIP/Medicaid	$25.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$64.43
Rate for Payer: Amerigroup Medicare	$64.43
Rate for Payer: BCBS of TX Blue Advantage	$105.22
Rate for Payer: BCBS of TX Blue Essentials	$125.78
Rate for Payer: BCBS of TX Medicare	$64.43
Rate for Payer: BCBS of TX PPO	$140.29
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cigna Commercial	$145.94
Rate for Payer: Cigna Medicaid	$11.23
Rate for Payer: Cigna Medicare	$64.43
Rate for Payer: Employer Direct Commercial	$64.43
Rate for Payer: Humana Medicare/TRICARE	$64.43
Rate for Payer: Molina CHIP/Medicaid	$11.23
Rate for Payer: Molina Dual Medicare/Medicaid	$64.43
Rate for Payer: Molina Medicare	$64.43
Rate for Payer: Multiplan Auto	$182.00
Rate for Payer: Multiplan Commercial	$182.00
Rate for Payer: Multiplan Workers Comp	$182.00
Rate for Payer: Parkland Medicaid	$11.23
Rate for Payer: Scott and White EPO/PPO	$1.15
Rate for Payer: Scott and White Medicare	$64.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.23
Rate for Payer: Superior Health Plan EPO	$64.43
Rate for Payer: Superior Health Plan Medicare	$64.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$64.43
Rate for Payer: Universal American Medicare	$64.43
Rate for Payer: Wellcare Medicare	$64.43
Rate for Payer: Wellmed Medicare	$64.43

96373- Intra-Arterial Injection

Facility

$360.00

Service Code	CPT 96373
Hospital Charge Code	6100783
Hospital Revenue Code	260
Rate for Payer: Cash Price	$316.80

Know your out-of-pocket cost for care.

All Charges