White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ABLATION-AV NODE

Facility

$7,540.00

Service Code	CPT 93650
Hospital Charge Code	4610650
Hospital Revenue Code	480
Rate for Payer: Cash Price	$6,635.20

Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocauter

Facility

$10,000.00

Service Code	CPT 30802
Hospital Charge Code	36030802
Hospital Revenue Code	360
Min. Negotiated Rate	$30.76
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,092.08
Rate for Payer: Amerigroup CHIP/Medicaid	$420.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,394.72
Rate for Payer: Amerigroup Medicare	$1,394.72
Rate for Payer: BCBS of TX Blue Advantage	$2,253.40
Rate for Payer: BCBS of TX Blue Essentials	$2,698.68
Rate for Payer: BCBS of TX Medicare	$1,394.72
Rate for Payer: BCBS of TX PPO	$3,400.34
Rate for Payer: Cigna Commercial	$3,159.45
Rate for Payer: Cigna Medicaid	$420.64
Rate for Payer: Cigna Medicare	$1,394.72
Rate for Payer: Employer Direct Commercial	$1,394.72
Rate for Payer: Humana Medicare/TRICARE	$1,394.72
Rate for Payer: Molina CHIP/Medicaid	$420.64
Rate for Payer: Molina Dual Medicare/Medicaid	$1,394.72
Rate for Payer: Molina Medicare	$1,394.72
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$420.64
Rate for Payer: Scott and White EPO/PPO	$30.76
Rate for Payer: Scott and White Medicare	$1,394.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$420.64
Rate for Payer: Superior Health Plan EPO	$1,394.72
Rate for Payer: Superior Health Plan Medicare	$1,394.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,394.72
Rate for Payer: Universal American Medicare	$1,394.72
Rate for Payer: Wellcare Medicare	$1,394.72
Rate for Payer: Wellmed Medicare	$1,394.72

Ablation Transurethral Prostate

Facility

$19,784.00

Hospital Charge Code	3219901
Hospital Revenue Code	361
Min. Negotiated Rate	$1,780.56
Max. Negotiated Rate	$10,881.20
Rate for Payer: Aetna Commercial	$10,881.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1,780.56
Rate for Payer: BCBS of TX Blue Advantage	$5,935.20
Rate for Payer: BCBS of TX Blue Essentials	$7,122.24
Rate for Payer: BCBS of TX PPO	$7,913.60
Rate for Payer: Cash Price	$17,409.92
Rate for Payer: Cash Price	$17,409.92
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$9,892.00
Rate for Payer: Superior Health Plan EPO	$2,690.62

Ablation Transurethral Prostate

Facility

$19,784.00

Hospital Charge Code	3219901
Hospital Revenue Code	361
Rate for Payer: Cash Price	$17,409.92

ABO/Rh

Facility

$152.00

Service Code	CPT 86900
Hospital Charge Code	2400406
Hospital Revenue Code	302
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$264.63
Rate for Payer: Aetna Commercial	$3.13
Rate for Payer: Aetna Medicare	$175.23
Rate for Payer: Amerigroup CHIP/Medicaid	$1.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$116.82
Rate for Payer: Amerigroup Medicare	$116.82
Rate for Payer: BCBS of TX Blue Advantage	$179.90
Rate for Payer: BCBS of TX Blue Essentials	$215.88
Rate for Payer: BCBS of TX Medicare	$116.82
Rate for Payer: BCBS of TX PPO	$240.96
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cigna Commercial	$264.63
Rate for Payer: Cigna Medicaid	$2.99
Rate for Payer: Cigna Medicare	$116.82
Rate for Payer: Employer Direct Commercial	$116.82
Rate for Payer: Humana Medicare/TRICARE	$116.82
Rate for Payer: Molina CHIP/Medicaid	$2.99
Rate for Payer: Molina Dual Medicare/Medicaid	$116.82
Rate for Payer: Molina Medicare	$116.82
Rate for Payer: Multiplan Auto	$98.80
Rate for Payer: Multiplan Commercial	$98.80
Rate for Payer: Multiplan Workers Comp	$98.80
Rate for Payer: Parkland Medicaid	$2.99
Rate for Payer: Scott and White EPO/PPO	$3.74
Rate for Payer: Scott and White Medicare	$116.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.99
Rate for Payer: Superior Health Plan EPO	$116.82
Rate for Payer: Superior Health Plan Medicare	$116.82
Rate for Payer: Universal American Dual Medicare/Medicaid	$116.82
Rate for Payer: Universal American Medicare	$116.82
Rate for Payer: Wellcare Medicare	$116.82
Rate for Payer: Wellmed Medicare	$116.82

ABO/Rh Echo

Facility

$152.00

Service Code	CPT 86900
Hospital Charge Code	2400406
Hospital Revenue Code	302
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$264.63
Rate for Payer: Aetna Commercial	$3.13
Rate for Payer: Aetna Medicare	$175.23
Rate for Payer: Amerigroup CHIP/Medicaid	$1.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$116.82
Rate for Payer: Amerigroup Medicare	$116.82
Rate for Payer: BCBS of TX Blue Advantage	$179.90
Rate for Payer: BCBS of TX Blue Essentials	$215.88
Rate for Payer: BCBS of TX Medicare	$116.82
Rate for Payer: BCBS of TX PPO	$240.96
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cigna Commercial	$264.63
Rate for Payer: Cigna Medicaid	$2.99
Rate for Payer: Cigna Medicare	$116.82
Rate for Payer: Employer Direct Commercial	$116.82
Rate for Payer: Humana Medicare/TRICARE	$116.82
Rate for Payer: Molina CHIP/Medicaid	$2.99
Rate for Payer: Molina Dual Medicare/Medicaid	$116.82
Rate for Payer: Molina Medicare	$116.82
Rate for Payer: Multiplan Auto	$98.80
Rate for Payer: Multiplan Commercial	$98.80
Rate for Payer: Multiplan Workers Comp	$98.80
Rate for Payer: Parkland Medicaid	$2.99
Rate for Payer: Scott and White EPO/PPO	$3.74
Rate for Payer: Scott and White Medicare	$116.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.99
Rate for Payer: Superior Health Plan EPO	$116.82
Rate for Payer: Superior Health Plan Medicare	$116.82
Rate for Payer: Universal American Dual Medicare/Medicaid	$116.82
Rate for Payer: Universal American Medicare	$116.82
Rate for Payer: Wellcare Medicare	$116.82
Rate for Payer: Wellmed Medicare	$116.82

ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY

Facility

$15,175.30

Service Code	MSDRG 770
Min. Negotiated Rate	$6,988.62
Max. Negotiated Rate	$15,175.30
Rate for Payer: Aetna Commercial	$8,985.38
Rate for Payer: Aetna Medicare	$12,831.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,554.35
Rate for Payer: Amerigroup Medicare	$8,554.35
Rate for Payer: BCBS of TX Blue Advantage	$8,348.02
Rate for Payer: BCBS of TX Blue Essentials	$11,019.66
Rate for Payer: BCBS of TX Medicare	$8,554.35
Rate for Payer: BCBS of TX PPO	$12,244.54
Rate for Payer: Cigna Commercial	$10,287.26
Rate for Payer: Cigna Medicare	$8,554.35
Rate for Payer: Employer Direct Commercial	$8,554.35
Rate for Payer: Humana Medicare/TRICARE	$8,554.35
Rate for Payer: Molina Dual Medicare/Medicaid	$8,554.35
Rate for Payer: Molina Medicare	$8,554.35
Rate for Payer: Multiplan Auto	$15,175.30
Rate for Payer: Multiplan Commercial	$15,175.30
Rate for Payer: Multiplan Workers Comp	$15,175.30
Rate for Payer: Scott and White EPO/PPO	$6,988.62
Rate for Payer: Scott and White Medicare	$8,554.35
Rate for Payer: Superior Health Plan EPO	$8,554.35
Rate for Payer: Superior Health Plan Medicare	$8,554.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,554.35
Rate for Payer: Universal American Medicare	$8,554.35
Rate for Payer: Wellcare Medicare	$8,554.35
Rate for Payer: Wellmed Medicare	$8,554.35

ABORTION WITHOUT D&C

Facility

$18,794.80

Service Code	MSDRG 779
Min. Negotiated Rate	$5,418.00
Max. Negotiated Rate	$18,794.80
Rate for Payer: Aetna Commercial	$11,128.50
Rate for Payer: Aetna Medicare	$14,870.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,913.77
Rate for Payer: Amerigroup Medicare	$9,913.77
Rate for Payer: BCBS of TX Blue Advantage	$5,418.00
Rate for Payer: BCBS of TX Blue Essentials	$7,783.62
Rate for Payer: BCBS of TX Medicare	$9,913.77
Rate for Payer: BCBS of TX PPO	$8,648.80
Rate for Payer: Cigna Commercial	$12,740.90
Rate for Payer: Cigna Medicare	$9,913.77
Rate for Payer: Employer Direct Commercial	$9,913.77
Rate for Payer: Humana Medicare/TRICARE	$9,913.77
Rate for Payer: Molina Dual Medicare/Medicaid	$9,913.77
Rate for Payer: Molina Medicare	$9,913.77
Rate for Payer: Multiplan Auto	$18,794.80
Rate for Payer: Multiplan Commercial	$18,794.80
Rate for Payer: Multiplan Workers Comp	$18,794.80
Rate for Payer: Scott and White EPO/PPO	$8,655.50
Rate for Payer: Scott and White Medicare	$9,913.77
Rate for Payer: Superior Health Plan EPO	$9,913.77
Rate for Payer: Superior Health Plan Medicare	$9,913.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,913.77
Rate for Payer: Universal American Medicare	$9,913.77
Rate for Payer: Wellcare Medicare	$9,913.77
Rate for Payer: Wellmed Medicare	$9,913.77

ACAPELLA DH (GREEN) VIBRATORY PEP SYSTEM

Facility

$193.86

Hospital Charge Code	111966
Hospital Revenue Code	272
Min. Negotiated Rate	$17.45
Max. Negotiated Rate	$126.01
Rate for Payer: Aetna Commercial	$106.62
Rate for Payer: Amerigroup CHIP/Medicaid	$17.45
Rate for Payer: BCBS of TX Blue Advantage	$58.16
Rate for Payer: BCBS of TX Blue Essentials	$69.79
Rate for Payer: BCBS of TX PPO	$77.54
Rate for Payer: Cash Price	$170.60
Rate for Payer: Multiplan Auto	$126.01
Rate for Payer: Multiplan Commercial	$126.01
Rate for Payer: Multiplan Workers Comp	$126.01
Rate for Payer: Scott and White EPO/PPO	$96.93
Rate for Payer: Superior Health Plan EPO	$26.36

ACAPELLA DH (GREEN) VIBRATORY PEP SYSTEM

Facility

$193.86

Hospital Charge Code	111966
Hospital Revenue Code	272
Rate for Payer: Cash Price	$170.60

ACE, CSF SO

Facility

$246.00

Service Code	CPT 82164
Hospital Charge Code	1701648
Hospital Revenue Code	301
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$159.90
Rate for Payer: Aetna Commercial	$15.33
Rate for Payer: Aetna Medicare	$21.90
Rate for Payer: Amerigroup CHIP/Medicaid	$5.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.60
Rate for Payer: Amerigroup Medicare	$14.60
Rate for Payer: BCBS of TX Blue Advantage	$24.09
Rate for Payer: BCBS of TX Blue Essentials	$28.91
Rate for Payer: BCBS of TX Medicare	$14.60
Rate for Payer: BCBS of TX PPO	$32.27
Rate for Payer: Cash Price	$216.48
Rate for Payer: Cash Price	$216.48
Rate for Payer: Cigna Medicaid	$14.60
Rate for Payer: Cigna Medicare	$14.60
Rate for Payer: Employer Direct Commercial	$14.60
Rate for Payer: Humana Medicare/TRICARE	$14.60
Rate for Payer: Molina CHIP/Medicaid	$14.60
Rate for Payer: Molina Dual Medicare/Medicaid	$14.60
Rate for Payer: Molina Medicare	$14.60
Rate for Payer: Multiplan Auto	$159.90
Rate for Payer: Multiplan Commercial	$159.90
Rate for Payer: Multiplan Workers Comp	$159.90
Rate for Payer: Parkland Medicaid	$14.60
Rate for Payer: Scott and White EPO/PPO	$18.25
Rate for Payer: Scott and White Medicare	$14.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.60
Rate for Payer: Superior Health Plan EPO	$14.60
Rate for Payer: Superior Health Plan Medicare	$14.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.60
Rate for Payer: Universal American Medicare	$14.60
Rate for Payer: Wellcare Medicare	$14.60
Rate for Payer: Wellmed Medicare	$14.60

acetaminophen 10 mg/mL IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J0131
Hospital Charge Code	77343156
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.44
Rate for Payer: BCBS of TX Blue Essentials	$0.52
Rate for Payer: BCBS of TX PPO	$0.58
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

acetaminophen 10 mg/mL IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J0131
Hospital Charge Code	77343156
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

acetaminophen 160 mg/5 mL Oral Liquid 20.3 mL

Facility

$21.20

Service Code	HCPCS J3490
Hospital Charge Code	77343423
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.42

acetaminophen 160 mg/5 mL Oral Liquid 20.3 mL

Facility

$21.20

Service Code	HCPCS J3490
Hospital Charge Code	77343423
Hospital Revenue Code	250
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$13.78
Rate for Payer: Amerigroup CHIP/Medicaid	$1.91
Rate for Payer: BCBS of TX Blue Advantage	$6.36
Rate for Payer: BCBS of TX Blue Essentials	$7.63
Rate for Payer: BCBS of TX PPO	$8.48
Rate for Payer: Cash Price	$14.42
Rate for Payer: Multiplan Auto	$13.78
Rate for Payer: Multiplan Commercial	$13.78
Rate for Payer: Multiplan Workers Comp	$13.78
Rate for Payer: Scott and White EPO/PPO	$10.60
Rate for Payer: Superior Health Plan EPO	$2.88

acetaminophen 160 mg/5 mL Oral Liquid 5 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77343584
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

acetaminophen 160 mg/5 mL Oral Liquid 5 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77343584
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

acetaminophen 325 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77343853
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

acetaminophen 325 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77343853
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

acetaminophen 325 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78405332
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

acetaminophen 325 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78405332
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen 500 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77343959
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen 500 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77343959
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

acetaminophen 650 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77344228
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

acetaminophen 650 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77344228
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

Know your out-of-pocket cost for care.

All Charges