White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ST GASTROSTOMY -- DHF

Facility

$2,295.27

Hospital Charge Code	81772402
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,560.78

ST GASTROSTOMY -- DHF

Facility

$2,295.27

Hospital Charge Code	81772402
Hospital Revenue Code	272
Min. Negotiated Rate	$206.57
Max. Negotiated Rate	$1,652.59
Rate for Payer: Amerigroup CHIP/Medicaid	$206.57
Rate for Payer: BCBS of TX Blue Advantage	$688.58
Rate for Payer: BCBS of TX Blue Essentials	$826.30
Rate for Payer: BCBS of TX PPO	$918.11
Rate for Payer: Cash Price	$1,560.78
Rate for Payer: Cigna Medicaid	$1,652.59
Rate for Payer: Molina CHIP/Medicaid	$1,652.59
Rate for Payer: Multiplan Auto	$1,491.93
Rate for Payer: Multiplan Commercial	$1,491.93
Rate for Payer: Multiplan Workers Comp	$1,491.93
Rate for Payer: Parkland Medicaid	$1,652.59
Rate for Payer: Scott and White EPO/PPO	$1,147.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,652.59
Rate for Payer: Superior Health Plan EPO	$312.16

ST INFUS EXT -- DHF

Facility

$230.22

Hospital Charge Code	80341662
Hospital Revenue Code	270
Min. Negotiated Rate	$20.72
Max. Negotiated Rate	$165.76
Rate for Payer: Amerigroup CHIP/Medicaid	$20.72
Rate for Payer: BCBS of TX Blue Advantage	$69.07
Rate for Payer: BCBS of TX Blue Essentials	$82.88
Rate for Payer: BCBS of TX PPO	$92.09
Rate for Payer: Cash Price	$156.55
Rate for Payer: Cigna Medicaid	$165.76
Rate for Payer: Molina CHIP/Medicaid	$165.76
Rate for Payer: Multiplan Auto	$149.64
Rate for Payer: Multiplan Commercial	$149.64
Rate for Payer: Multiplan Workers Comp	$149.64
Rate for Payer: Parkland Medicaid	$165.76
Rate for Payer: Scott and White EPO/PPO	$115.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$165.76
Rate for Payer: Superior Health Plan EPO	$31.31

ST INFUS EXT -- DHF

Facility

$230.22

Hospital Charge Code	80341662
Hospital Revenue Code	270
Rate for Payer: Cash Price	$156.55

ST INTRO PEEL-AWAY -- DHF

Facility

$224.14

Hospital Charge Code	82485509
Hospital Revenue Code	272
Rate for Payer: Cash Price	$152.42

ST INTRO PEEL-AWAY -- DHF

Facility

$224.14

Hospital Charge Code	82485509
Hospital Revenue Code	272
Min. Negotiated Rate	$20.17
Max. Negotiated Rate	$161.38
Rate for Payer: Amerigroup CHIP/Medicaid	$20.17
Rate for Payer: BCBS of TX Blue Advantage	$67.24
Rate for Payer: BCBS of TX Blue Essentials	$80.69
Rate for Payer: BCBS of TX PPO	$89.66
Rate for Payer: Cash Price	$152.42
Rate for Payer: Cigna Medicaid	$161.38
Rate for Payer: Molina CHIP/Medicaid	$161.38
Rate for Payer: Multiplan Auto	$145.69
Rate for Payer: Multiplan Commercial	$145.69
Rate for Payer: Multiplan Workers Comp	$145.69
Rate for Payer: Parkland Medicaid	$161.38
Rate for Payer: Scott and White EPO/PPO	$112.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$161.38
Rate for Payer: Superior Health Plan EPO	$30.48

ST IRG TUR -- DHF

Facility

$241.69

Hospital Charge Code	54200696
Hospital Revenue Code	270
Rate for Payer: Cash Price	$164.35

ST IRG TUR -- DHF

Facility

$241.69

Hospital Charge Code	54200696
Hospital Revenue Code	270
Min. Negotiated Rate	$21.75
Max. Negotiated Rate	$174.02
Rate for Payer: Amerigroup CHIP/Medicaid	$21.75
Rate for Payer: BCBS of TX Blue Advantage	$72.51
Rate for Payer: BCBS of TX Blue Essentials	$87.01
Rate for Payer: BCBS of TX PPO	$96.68
Rate for Payer: Cash Price	$164.35
Rate for Payer: Cigna Medicaid	$174.02
Rate for Payer: Molina CHIP/Medicaid	$174.02
Rate for Payer: Multiplan Auto	$157.10
Rate for Payer: Multiplan Commercial	$157.10
Rate for Payer: Multiplan Workers Comp	$157.10
Rate for Payer: Parkland Medicaid	$174.02
Rate for Payer: Scott and White EPO/PPO	$120.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$174.02
Rate for Payer: Superior Health Plan EPO	$32.87

ST IV ADD 3 -- DHF

Facility

$110.27

Hospital Charge Code	54200035
Hospital Revenue Code	270
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$79.39
Rate for Payer: Amerigroup CHIP/Medicaid	$9.92
Rate for Payer: BCBS of TX Blue Advantage	$33.08
Rate for Payer: BCBS of TX Blue Essentials	$39.70
Rate for Payer: BCBS of TX PPO	$44.11
Rate for Payer: Cash Price	$74.98
Rate for Payer: Cigna Medicaid	$79.39
Rate for Payer: Molina CHIP/Medicaid	$79.39
Rate for Payer: Multiplan Auto	$71.68
Rate for Payer: Multiplan Commercial	$71.68
Rate for Payer: Multiplan Workers Comp	$71.68
Rate for Payer: Parkland Medicaid	$79.39
Rate for Payer: Scott and White EPO/PPO	$55.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.39
Rate for Payer: Superior Health Plan EPO	$15.00

ST IV ADD 3 -- DHF

Facility

$110.27

Hospital Charge Code	54200035
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.98

ST IV ADM -- DHF

Facility

$89.07

Hospital Charge Code	54200936
Hospital Revenue Code	272
Rate for Payer: Cash Price	$60.57

ST IV ADM -- DHF

Facility

$89.07

Hospital Charge Code	54200936
Hospital Revenue Code	272
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$64.13
Rate for Payer: Amerigroup CHIP/Medicaid	$8.02
Rate for Payer: BCBS of TX Blue Advantage	$26.72
Rate for Payer: BCBS of TX Blue Essentials	$32.07
Rate for Payer: BCBS of TX PPO	$35.63
Rate for Payer: Cash Price	$60.57
Rate for Payer: Cigna Medicaid	$64.13
Rate for Payer: Molina CHIP/Medicaid	$64.13
Rate for Payer: Multiplan Auto	$57.90
Rate for Payer: Multiplan Commercial	$57.90
Rate for Payer: Multiplan Workers Comp	$57.90
Rate for Payer: Parkland Medicaid	$64.13
Rate for Payer: Scott and White EPO/PPO	$44.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$64.13
Rate for Payer: Superior Health Plan EPO	$12.11

ST IV EXT 2 -- DHF

Facility

$69.98

Hospital Charge Code	54200803
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$50.39
Rate for Payer: Amerigroup CHIP/Medicaid	$6.30
Rate for Payer: BCBS of TX Blue Advantage	$20.99
Rate for Payer: BCBS of TX Blue Essentials	$25.19
Rate for Payer: BCBS of TX PPO	$27.99
Rate for Payer: Cash Price	$47.59
Rate for Payer: Cigna Medicaid	$50.39
Rate for Payer: Molina CHIP/Medicaid	$50.39
Rate for Payer: Multiplan Auto	$45.49
Rate for Payer: Multiplan Commercial	$45.49
Rate for Payer: Multiplan Workers Comp	$45.49
Rate for Payer: Parkland Medicaid	$50.39
Rate for Payer: Scott and White EPO/PPO	$34.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50.39
Rate for Payer: Superior Health Plan EPO	$9.52

ST IV EXT 2 -- DHF

Facility

$69.98

Hospital Charge Code	54200803
Hospital Revenue Code	270
Rate for Payer: Cash Price	$47.59

ST IV INF 23X3/4 -- DHF

Facility

$36.06

Hospital Charge Code	54200175
Hospital Revenue Code	270
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$25.96
Rate for Payer: Amerigroup CHIP/Medicaid	$3.25
Rate for Payer: BCBS of TX Blue Advantage	$10.82
Rate for Payer: BCBS of TX Blue Essentials	$12.98
Rate for Payer: BCBS of TX PPO	$14.42
Rate for Payer: Cash Price	$24.52
Rate for Payer: Cigna Medicaid	$25.96
Rate for Payer: Molina CHIP/Medicaid	$25.96
Rate for Payer: Multiplan Auto	$23.44
Rate for Payer: Multiplan Commercial	$23.44
Rate for Payer: Multiplan Workers Comp	$23.44
Rate for Payer: Parkland Medicaid	$25.96
Rate for Payer: Scott and White EPO/PPO	$18.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25.96
Rate for Payer: Superior Health Plan EPO	$4.90

ST IV INF 23X3/4 -- DHF

Facility

$36.06

Hospital Charge Code	54200175
Hospital Revenue Code	270
Rate for Payer: Cash Price	$24.52

ST IV SEC N/V -- DHF

Facility

$343.57

Hospital Charge Code	54200266
Hospital Revenue Code	270
Rate for Payer: Cash Price	$233.63

ST IV SEC N/V -- DHF

Facility

$343.57

Hospital Charge Code	54200266
Hospital Revenue Code	270
Min. Negotiated Rate	$30.92
Max. Negotiated Rate	$247.37
Rate for Payer: Amerigroup CHIP/Medicaid	$30.92
Rate for Payer: BCBS of TX Blue Advantage	$103.07
Rate for Payer: BCBS of TX Blue Essentials	$123.69
Rate for Payer: BCBS of TX PPO	$137.43
Rate for Payer: Cash Price	$233.63
Rate for Payer: Cigna Medicaid	$247.37
Rate for Payer: Molina CHIP/Medicaid	$247.37
Rate for Payer: Multiplan Auto	$223.32
Rate for Payer: Multiplan Commercial	$223.32
Rate for Payer: Multiplan Workers Comp	$223.32
Rate for Payer: Parkland Medicaid	$247.37
Rate for Payer: Scott and White EPO/PPO	$171.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$247.37
Rate for Payer: Superior Health Plan EPO	$46.73

ST IV START -- DHF

Facility

$110.27

Hospital Charge Code	54201017
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.98

ST IV START -- DHF

Facility

$110.27

Hospital Charge Code	54201017
Hospital Revenue Code	270
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$79.39
Rate for Payer: Amerigroup CHIP/Medicaid	$9.92
Rate for Payer: BCBS of TX Blue Advantage	$33.08
Rate for Payer: BCBS of TX Blue Essentials	$39.70
Rate for Payer: BCBS of TX PPO	$44.11
Rate for Payer: Cash Price	$74.98
Rate for Payer: Cigna Medicaid	$79.39
Rate for Payer: Molina CHIP/Medicaid	$79.39
Rate for Payer: Multiplan Auto	$71.68
Rate for Payer: Multiplan Commercial	$71.68
Rate for Payer: Multiplan Workers Comp	$71.68
Rate for Payer: Parkland Medicaid	$79.39
Rate for Payer: Scott and White EPO/PPO	$55.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.39
Rate for Payer: Superior Health Plan EPO	$15.00

ST NDL BX -- DHF

Facility

$176.60

Hospital Charge Code	80827413
Hospital Revenue Code	272
Min. Negotiated Rate	$15.89
Max. Negotiated Rate	$127.15
Rate for Payer: Amerigroup CHIP/Medicaid	$15.89
Rate for Payer: BCBS of TX Blue Advantage	$52.98
Rate for Payer: BCBS of TX Blue Essentials	$63.58
Rate for Payer: BCBS of TX PPO	$70.64
Rate for Payer: Cash Price	$120.09
Rate for Payer: Cigna Medicaid	$127.15
Rate for Payer: Molina CHIP/Medicaid	$127.15
Rate for Payer: Multiplan Auto	$114.79
Rate for Payer: Multiplan Commercial	$114.79
Rate for Payer: Multiplan Workers Comp	$114.79
Rate for Payer: Parkland Medicaid	$127.15
Rate for Payer: Scott and White EPO/PPO	$88.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$127.15
Rate for Payer: Superior Health Plan EPO	$24.02

ST NDL BX -- DHF

Facility

$176.60

Hospital Charge Code	80827413
Hospital Revenue Code	272
Rate for Payer: Cash Price	$120.09

ST NDL INTRAOSS ADLT -- DHF

Facility

$577.49

Hospital Charge Code	81786501
Hospital Revenue Code	272
Min. Negotiated Rate	$51.97
Max. Negotiated Rate	$415.79
Rate for Payer: Amerigroup CHIP/Medicaid	$51.97
Rate for Payer: BCBS of TX Blue Advantage	$173.25
Rate for Payer: BCBS of TX Blue Essentials	$207.90
Rate for Payer: BCBS of TX PPO	$231.00
Rate for Payer: Cash Price	$392.69
Rate for Payer: Cigna Medicaid	$415.79
Rate for Payer: Molina CHIP/Medicaid	$415.79
Rate for Payer: Multiplan Auto	$375.37
Rate for Payer: Multiplan Commercial	$375.37
Rate for Payer: Multiplan Workers Comp	$375.37
Rate for Payer: Parkland Medicaid	$415.79
Rate for Payer: Scott and White EPO/PPO	$288.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$415.79
Rate for Payer: Superior Health Plan EPO	$78.54

ST NDL INTRAOSS ADLT -- DHF

Facility

$577.49

Hospital Charge Code	81786501
Hospital Revenue Code	272
Rate for Payer: Cash Price	$392.69

STNT C XIENCE ALPINE RX -- DHF

Facility

$10,331.00

Service Code	HCPCS C1713
Hospital Charge Code	80622103
Hospital Revenue Code	278
Min. Negotiated Rate	$929.79
Max. Negotiated Rate	$7,438.32
Rate for Payer: Amerigroup CHIP/Medicaid	$929.79
Rate for Payer: BCBS of TX Blue Advantage	$3,099.30
Rate for Payer: BCBS of TX Blue Essentials	$3,719.16
Rate for Payer: BCBS of TX PPO	$4,132.40
Rate for Payer: Cash Price	$7,025.08
Rate for Payer: Cigna Medicaid	$7,438.32
Rate for Payer: Molina CHIP/Medicaid	$7,438.32
Rate for Payer: Multiplan Auto	$5,165.50
Rate for Payer: Multiplan Commercial	$5,165.50
Rate for Payer: Multiplan Workers Comp	$5,165.50
Rate for Payer: Parkland Medicaid	$7,438.32
Rate for Payer: Scott and White EPO/PPO	$5,165.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,438.32
Rate for Payer: Superior Health Plan EPO	$1,405.02

Know your out-of-pocket cost for care.

All Charges