White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Basic Metabolic Panel

Facility

$496.00

Service Code	HCPCS 80048
Hospital Charge Code	1603182
Hospital Revenue Code	301
Rate for Payer: Cash Price	$337.28

Basic metabolic panel with ionized calcium

Facility

$715.00

Service Code	HCPCS 80047
Hospital Charge Code	1690001
Hospital Revenue Code	301
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$514.80
Rate for Payer: Amerigroup CHIP/Medicaid	$5.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.73
Rate for Payer: Amerigroup Medicare	$13.73
Rate for Payer: BCBS of TX Blue Advantage	$214.50
Rate for Payer: BCBS of TX Blue Essentials	$257.40
Rate for Payer: BCBS of TX Medicare	$13.73
Rate for Payer: BCBS of TX PPO	$286.00
Rate for Payer: Cash Price	$486.20
Rate for Payer: Cash Price	$486.20
Rate for Payer: Cigna Medicaid	$514.80
Rate for Payer: Cigna Medicare	$13.73
Rate for Payer: Employer Direct Commercial	$13.73
Rate for Payer: Humana Medicare/TRICARE	$13.73
Rate for Payer: Molina CHIP/Medicaid	$514.80
Rate for Payer: Molina Dual Medicare/Medicaid	$13.73
Rate for Payer: Molina Medicare	$13.73
Rate for Payer: Multiplan Auto	$464.75
Rate for Payer: Multiplan Commercial	$464.75
Rate for Payer: Multiplan Workers Comp	$464.75
Rate for Payer: Parkland Medicaid	$514.80
Rate for Payer: Scott and White EPO/PPO	$17.16
Rate for Payer: Scott and White Medicare	$13.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$514.80
Rate for Payer: Superior Health Plan EPO	$13.73
Rate for Payer: Superior Health Plan Medicare	$13.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.73
Rate for Payer: Universal American Medicare	$13.73
Rate for Payer: Wellcare Medicare	$13.73
Rate for Payer: Wellmed Medicare	$13.73

Basic metabolic panel with ionized calcium

Facility

$715.00

Service Code	HCPCS 80047
Hospital Charge Code	1690001
Hospital Revenue Code	301
Rate for Payer: Cash Price	$486.20

BASIN WASH RECT 7QT GRAY 50/CS 35/PLT

Facility

$1.23

Hospital Charge Code	993586
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.84

BASIN WASH RECT 7QT GRAY 50/CS 35/PLT

Facility

$1.23

Hospital Charge Code	993586
Hospital Revenue Code	270
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.89
Rate for Payer: Amerigroup CHIP/Medicaid	$0.11
Rate for Payer: BCBS of TX Blue Advantage	$0.37
Rate for Payer: BCBS of TX Blue Essentials	$0.44
Rate for Payer: BCBS of TX PPO	$0.49
Rate for Payer: Cash Price	$0.84
Rate for Payer: Cigna Medicaid	$0.89
Rate for Payer: Molina CHIP/Medicaid	$0.89
Rate for Payer: Multiplan Auto	$0.80
Rate for Payer: Multiplan Commercial	$0.80
Rate for Payer: Multiplan Workers Comp	$0.80
Rate for Payer: Parkland Medicaid	$0.89
Rate for Payer: Scott and White EPO/PPO	$0.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.89
Rate for Payer: Superior Health Plan EPO	$0.17

basket special ret 180x4x2cm

Facility

$1,157.70

Hospital Charge Code	116256
Hospital Revenue Code	272
Rate for Payer: Cash Price	$787.24

basket special ret 180x4x2cm

Facility

$1,157.70

Hospital Charge Code	116256
Hospital Revenue Code	272
Min. Negotiated Rate	$104.19
Max. Negotiated Rate	$833.54
Rate for Payer: Amerigroup CHIP/Medicaid	$104.19
Rate for Payer: BCBS of TX Blue Advantage	$347.31
Rate for Payer: BCBS of TX Blue Essentials	$416.77
Rate for Payer: BCBS of TX PPO	$463.08
Rate for Payer: Cash Price	$787.24
Rate for Payer: Cigna Medicaid	$833.54
Rate for Payer: Molina CHIP/Medicaid	$833.54
Rate for Payer: Multiplan Auto	$752.50
Rate for Payer: Multiplan Commercial	$752.50
Rate for Payer: Multiplan Workers Comp	$752.50
Rate for Payer: Parkland Medicaid	$833.54
Rate for Payer: Scott and White EPO/PPO	$578.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$833.54
Rate for Payer: Superior Health Plan EPO	$157.45

basket special ret 180x6x3cm

Facility

$1,157.70

Hospital Charge Code	116257
Hospital Revenue Code	272
Rate for Payer: Cash Price	$787.24

basket special ret 180x6x3cm

Facility

$1,157.70

Hospital Charge Code	116257
Hospital Revenue Code	272
Min. Negotiated Rate	$104.19
Max. Negotiated Rate	$833.54
Rate for Payer: Amerigroup CHIP/Medicaid	$104.19
Rate for Payer: BCBS of TX Blue Advantage	$347.31
Rate for Payer: BCBS of TX Blue Essentials	$416.77
Rate for Payer: BCBS of TX PPO	$463.08
Rate for Payer: Cash Price	$787.24
Rate for Payer: Cigna Medicaid	$833.54
Rate for Payer: Molina CHIP/Medicaid	$833.54
Rate for Payer: Multiplan Auto	$752.50
Rate for Payer: Multiplan Commercial	$752.50
Rate for Payer: Multiplan Workers Comp	$752.50
Rate for Payer: Parkland Medicaid	$833.54
Rate for Payer: Scott and White EPO/PPO	$578.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$833.54
Rate for Payer: Superior Health Plan EPO	$157.45

BASKET STONE FLEX CATCH 1.9FR

Facility

$966.88

Hospital Charge Code	146365
Hospital Revenue Code	272
Rate for Payer: Cash Price	$657.48

BASKET STONE FLEX CATCH 1.9FR

Facility

$966.88

Hospital Charge Code	146365
Hospital Revenue Code	272
Min. Negotiated Rate	$87.02
Max. Negotiated Rate	$696.15
Rate for Payer: Amerigroup CHIP/Medicaid	$87.02
Rate for Payer: BCBS of TX Blue Advantage	$290.06
Rate for Payer: BCBS of TX Blue Essentials	$348.08
Rate for Payer: BCBS of TX PPO	$386.75
Rate for Payer: Cash Price	$657.48
Rate for Payer: Cigna Medicaid	$696.15
Rate for Payer: Molina CHIP/Medicaid	$696.15
Rate for Payer: Multiplan Auto	$628.47
Rate for Payer: Multiplan Commercial	$628.47
Rate for Payer: Multiplan Workers Comp	$628.47
Rate for Payer: Parkland Medicaid	$696.15
Rate for Payer: Scott and White EPO/PPO	$483.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$696.15
Rate for Payer: Superior Health Plan EPO	$131.50

BAT first test

Facility

$120.00

Service Code	HCPCS 82075
Hospital Charge Code	994060
Hospital Revenue Code	305
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$86.40
Rate for Payer: Amerigroup CHIP/Medicaid	$11.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30.00
Rate for Payer: Amerigroup Medicare	$30.00
Rate for Payer: BCBS of TX Blue Advantage	$36.00
Rate for Payer: BCBS of TX Blue Essentials	$43.20
Rate for Payer: BCBS of TX Medicare	$30.00
Rate for Payer: BCBS of TX PPO	$48.00
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna Medicaid	$86.40
Rate for Payer: Cigna Medicare	$30.00
Rate for Payer: Employer Direct Commercial	$30.00
Rate for Payer: Humana Medicare/TRICARE	$30.00
Rate for Payer: Molina CHIP/Medicaid	$86.40
Rate for Payer: Molina Dual Medicare/Medicaid	$30.00
Rate for Payer: Molina Medicare	$30.00
Rate for Payer: Multiplan Auto	$78.00
Rate for Payer: Multiplan Commercial	$78.00
Rate for Payer: Multiplan Workers Comp	$78.00
Rate for Payer: Parkland Medicaid	$86.40
Rate for Payer: Scott and White EPO/PPO	$37.50
Rate for Payer: Scott and White Medicare	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.40
Rate for Payer: Superior Health Plan EPO	$30.00
Rate for Payer: Superior Health Plan Medicare	$30.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$30.00
Rate for Payer: Universal American Medicare	$30.00
Rate for Payer: Wellcare Medicare	$30.00
Rate for Payer: Wellmed Medicare	$30.00

BAT first test

Facility

$120.00

Service Code	HCPCS 82075
Hospital Charge Code	994060
Hospital Revenue Code	305
Rate for Payer: Cash Price	$81.60

BATTERY, ALKALINE, MEDICELL, 1.5V, AAA

Facility

$1.18

Hospital Charge Code	992996
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.80

BATTERY, ALKALINE, MEDICELL, 1.5V, AAA

Facility

$1.18

Hospital Charge Code	992996
Hospital Revenue Code	270
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.85
Rate for Payer: Amerigroup CHIP/Medicaid	$0.11
Rate for Payer: BCBS of TX Blue Advantage	$0.35
Rate for Payer: BCBS of TX Blue Essentials	$0.42
Rate for Payer: BCBS of TX PPO	$0.47
Rate for Payer: Cash Price	$0.80
Rate for Payer: Cigna Medicaid	$0.85
Rate for Payer: Molina CHIP/Medicaid	$0.85
Rate for Payer: Multiplan Auto	$0.77
Rate for Payer: Multiplan Commercial	$0.77
Rate for Payer: Multiplan Workers Comp	$0.77
Rate for Payer: Parkland Medicaid	$0.85
Rate for Payer: Scott and White EPO/PPO	$0.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.85
Rate for Payer: Superior Health Plan EPO	$0.16

BB Bill Antigen Type Unit

Facility

$217.00

Service Code	HCPCS 86902
Hospital Charge Code	2408749
Hospital Revenue Code	302
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$761.14
Rate for Payer: Amerigroup CHIP/Medicaid	$2.48
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.35
Rate for Payer: Amerigroup Medicare	$6.35
Rate for Payer: BCBS of TX Blue Advantage	$65.10
Rate for Payer: BCBS of TX Blue Essentials	$78.12
Rate for Payer: BCBS of TX Medicare	$6.35
Rate for Payer: BCBS of TX PPO	$86.80
Rate for Payer: Cash Price	$147.56
Rate for Payer: Cash Price	$147.56
Rate for Payer: Cash Price	$147.56
Rate for Payer: Cigna Commercial	$761.14
Rate for Payer: Cigna Medicaid	$156.24
Rate for Payer: Cigna Medicare	$6.35
Rate for Payer: Employer Direct Commercial	$6.35
Rate for Payer: Humana Medicare/TRICARE	$6.35
Rate for Payer: Molina CHIP/Medicaid	$156.24
Rate for Payer: Molina Dual Medicare/Medicaid	$6.35
Rate for Payer: Molina Medicare	$6.35
Rate for Payer: Multiplan Auto	$141.05
Rate for Payer: Multiplan Commercial	$141.05
Rate for Payer: Multiplan Workers Comp	$141.05
Rate for Payer: Parkland Medicaid	$156.24
Rate for Payer: Scott and White EPO/PPO	$7.94
Rate for Payer: Scott and White Medicare	$6.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$156.24
Rate for Payer: Superior Health Plan EPO	$6.35
Rate for Payer: Superior Health Plan Medicare	$6.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.35
Rate for Payer: Universal American Medicare	$6.35
Rate for Payer: Wellcare Medicare	$6.35
Rate for Payer: Wellmed Medicare	$6.35

BB Bill Antigen Type Unit

Facility

$217.00

Service Code	HCPCS 86902
Hospital Charge Code	2408749
Hospital Revenue Code	302
Rate for Payer: Cash Price	$147.56

BB Bill Only Cold Agglutinin Titer

Facility

$91.00

Service Code	HCPCS 86157
Hospital Charge Code	2400513
Hospital Revenue Code	302
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$65.52
Rate for Payer: Amerigroup CHIP/Medicaid	$3.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.06
Rate for Payer: Amerigroup Medicare	$8.06
Rate for Payer: BCBS of TX Blue Advantage	$27.30
Rate for Payer: BCBS of TX Blue Essentials	$32.76
Rate for Payer: BCBS of TX Medicare	$8.06
Rate for Payer: BCBS of TX PPO	$36.40
Rate for Payer: Cash Price	$61.88
Rate for Payer: Cash Price	$61.88
Rate for Payer: Cigna Medicaid	$65.52
Rate for Payer: Cigna Medicare	$8.06
Rate for Payer: Employer Direct Commercial	$8.06
Rate for Payer: Humana Medicare/TRICARE	$8.06
Rate for Payer: Molina CHIP/Medicaid	$65.52
Rate for Payer: Molina Dual Medicare/Medicaid	$8.06
Rate for Payer: Molina Medicare	$8.06
Rate for Payer: Multiplan Auto	$59.15
Rate for Payer: Multiplan Commercial	$59.15
Rate for Payer: Multiplan Workers Comp	$59.15
Rate for Payer: Parkland Medicaid	$65.52
Rate for Payer: Scott and White EPO/PPO	$10.07
Rate for Payer: Scott and White Medicare	$8.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.52
Rate for Payer: Superior Health Plan EPO	$8.06
Rate for Payer: Superior Health Plan Medicare	$8.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.06
Rate for Payer: Universal American Medicare	$8.06
Rate for Payer: Wellcare Medicare	$8.06
Rate for Payer: Wellmed Medicare	$8.06

BB Bill Only Cold Agglutinin Titer

Facility

$91.00

Service Code	HCPCS 86157
Hospital Charge Code	2400513
Hospital Revenue Code	302
Rate for Payer: Cash Price	$61.88

BBL GARAM STAIN KIT 250ML 4/BX

Facility

$107.87

Hospital Charge Code	993642
Hospital Revenue Code	270
Min. Negotiated Rate	$9.71
Max. Negotiated Rate	$77.67
Rate for Payer: Amerigroup CHIP/Medicaid	$9.71
Rate for Payer: BCBS of TX Blue Advantage	$32.36
Rate for Payer: BCBS of TX Blue Essentials	$38.83
Rate for Payer: BCBS of TX PPO	$43.15
Rate for Payer: Cash Price	$73.35
Rate for Payer: Cigna Medicaid	$77.67
Rate for Payer: Molina CHIP/Medicaid	$77.67
Rate for Payer: Multiplan Auto	$70.12
Rate for Payer: Multiplan Commercial	$70.12
Rate for Payer: Multiplan Workers Comp	$70.12
Rate for Payer: Parkland Medicaid	$77.67
Rate for Payer: Scott and White EPO/PPO	$53.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$77.67
Rate for Payer: Superior Health Plan EPO	$14.67

BBL GARAM STAIN KIT 250ML 4/BX

Facility

$107.87

Hospital Charge Code	993642
Hospital Revenue Code	270
Rate for Payer: Cash Price	$73.35

BBL GASPAK DRY ANAEROBIC INDICATOR STRIP

Facility

$4.33

Hospital Charge Code	993104
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.94

BBL GASPAK DRY ANAEROBIC INDICATOR STRIP

Facility

$4.33

Hospital Charge Code	993104
Hospital Revenue Code	270
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$3.12
Rate for Payer: Amerigroup CHIP/Medicaid	$0.39
Rate for Payer: BCBS of TX Blue Advantage	$1.30
Rate for Payer: BCBS of TX Blue Essentials	$1.56
Rate for Payer: BCBS of TX PPO	$1.73
Rate for Payer: Cash Price	$2.94
Rate for Payer: Cigna Medicaid	$3.12
Rate for Payer: Molina CHIP/Medicaid	$3.12
Rate for Payer: Multiplan Auto	$2.81
Rate for Payer: Multiplan Commercial	$2.81
Rate for Payer: Multiplan Workers Comp	$2.81
Rate for Payer: Parkland Medicaid	$3.12
Rate for Payer: Scott and White EPO/PPO	$2.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.12
Rate for Payer: Superior Health Plan EPO	$0.59

BBL PREPARED MEDIA MACCONKEYII AGAR PLATE

Facility

$45.56

Hospital Charge Code	993644
Hospital Revenue Code	270
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$32.80
Rate for Payer: Amerigroup CHIP/Medicaid	$4.10
Rate for Payer: BCBS of TX Blue Advantage	$13.67
Rate for Payer: BCBS of TX Blue Essentials	$16.40
Rate for Payer: BCBS of TX PPO	$18.22
Rate for Payer: Cash Price	$30.98
Rate for Payer: Cigna Medicaid	$32.80
Rate for Payer: Molina CHIP/Medicaid	$32.80
Rate for Payer: Multiplan Auto	$29.61
Rate for Payer: Multiplan Commercial	$29.61
Rate for Payer: Multiplan Workers Comp	$29.61
Rate for Payer: Parkland Medicaid	$32.80
Rate for Payer: Scott and White EPO/PPO	$22.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.80
Rate for Payer: Superior Health Plan EPO	$6.20

BBL PREPARED MEDIA MACCONKEYII AGAR PLATE

Facility

$45.56

Hospital Charge Code	993644
Hospital Revenue Code	270
Rate for Payer: Cash Price	$30.98

Know your out-of-pocket cost for care.

All Charges