White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BCE Booster Dose Moderna 0064A

Facility

$40.00

Service Code	HCPCS 0064A
Hospital Charge Code	8828629
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$28.80
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna Medicaid	$28.80
Rate for Payer: Molina CHIP/Medicaid	$28.80
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Parkland Medicaid	$28.80
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.80
Rate for Payer: Superior Health Plan EPO	$5.44

BCE Booster Dose Moderna 0064A

Facility

$40.00

Service Code	HCPCS 0064A
Hospital Charge Code	8828629
Hospital Revenue Code	771
Rate for Payer: Cash Price	$27.20

BCE Booster Dose Pfizer 0004A

Facility

$60.00

Service Code	HCPCS 0004A
Hospital Charge Code	8752545
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

BCE Booster Dose Pfizer 0004A

Facility

$60.00

Service Code	HCPCS 0004A
Hospital Charge Code	8752545
Hospital Revenue Code	771
Rate for Payer: Cash Price	$40.80

BCE First Dose Moderna 0011A

Facility

$40.00

Service Code	HCPCS 0011A
Hospital Charge Code	8812544
Hospital Revenue Code	771
Rate for Payer: Cash Price	$27.20

BCE First Dose Moderna 0011A

Facility

$40.00

Service Code	HCPCS 0011A
Hospital Charge Code	8812544
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$28.80
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna Medicaid	$28.80
Rate for Payer: Molina CHIP/Medicaid	$28.80
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Parkland Medicaid	$28.80
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.80
Rate for Payer: Superior Health Plan EPO	$5.44

BCE First Dose Pfizer 0001A

Facility

$40.00

Service Code	HCPCS 0001A
Hospital Charge Code	8814541
Hospital Revenue Code	771
Rate for Payer: Cash Price	$27.20

BCE First Dose Pfizer 0001A

Facility

$40.00

Service Code	HCPCS 0001A
Hospital Charge Code	8814541
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$28.80
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna Medicaid	$28.80
Rate for Payer: Molina CHIP/Medicaid	$28.80
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Parkland Medicaid	$28.80
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.80
Rate for Payer: Superior Health Plan EPO	$5.44

BCE OP Peritoneal Dialysis Treatment Complete

Facility

$2,495.91

Service Code	HCPCS 90945
Hospital Charge Code	8862568
Hospital Revenue Code	830
Min. Negotiated Rate	$104.41
Max. Negotiated Rate	$1,797.06
Rate for Payer: Amerigroup CHIP/Medicaid	$224.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$419.16
Rate for Payer: Amerigroup Medicare	$419.16
Rate for Payer: BCBS of TX Blue Advantage	$748.77
Rate for Payer: BCBS of TX Blue Essentials	$898.53
Rate for Payer: BCBS of TX Medicare	$419.16
Rate for Payer: BCBS of TX PPO	$998.36
Rate for Payer: Cash Price	$1,697.22
Rate for Payer: Cash Price	$1,697.22
Rate for Payer: Cash Price	$1,697.22
Rate for Payer: Cigna Commercial	$886.05
Rate for Payer: Cigna Medicaid	$1,797.06
Rate for Payer: Cigna Medicare	$419.16
Rate for Payer: Employer Direct Commercial	$419.16
Rate for Payer: Humana Medicare/TRICARE	$419.16
Rate for Payer: Molina CHIP/Medicaid	$1,797.06
Rate for Payer: Molina Dual Medicare/Medicaid	$419.16
Rate for Payer: Molina Medicare	$419.16
Rate for Payer: Multiplan Auto	$1,622.34
Rate for Payer: Multiplan Commercial	$1,622.34
Rate for Payer: Multiplan Workers Comp	$1,622.34
Rate for Payer: Parkland Medicaid	$1,797.06
Rate for Payer: Scott and White EPO/PPO	$104.41
Rate for Payer: Scott and White Medicare	$419.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,797.06
Rate for Payer: Superior Health Plan EPO	$419.16
Rate for Payer: Superior Health Plan Medicare	$419.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$419.16
Rate for Payer: Universal American Medicare	$419.16
Rate for Payer: Wellcare Medicare	$419.16
Rate for Payer: Wellmed Medicare	$419.16

BCE OP Peritoneal Dialysis Treatment Complete

Facility

$2,495.91

Service Code	HCPCS 90945
Hospital Charge Code	8862568
Hospital Revenue Code	830
Rate for Payer: Cash Price	$1,697.22

BCE Third Dose Moderna 0013A

Facility

$40.00

Service Code	HCPCS 0013A
Hospital Charge Code	8812542
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$28.80
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna Medicaid	$28.80
Rate for Payer: Molina CHIP/Medicaid	$28.80
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Parkland Medicaid	$28.80
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.80
Rate for Payer: Superior Health Plan EPO	$5.44

BCE Third Dose Moderna 0013A

Facility

$40.00

Service Code	HCPCS 0013A
Hospital Charge Code	8812542
Hospital Revenue Code	771
Rate for Payer: Cash Price	$27.20

BD BBL Cefinese Paper Disc, 1/4', impregnated with Nitrocefin

Facility

$264.27

Hospital Charge Code	993331
Hospital Revenue Code	270
Rate for Payer: Cash Price	$179.70

BD BBL Cefinese Paper Disc, 1/4', impregnated with Nitrocefin

Facility

$264.27

Hospital Charge Code	993331
Hospital Revenue Code	270
Min. Negotiated Rate	$23.78
Max. Negotiated Rate	$190.27
Rate for Payer: Amerigroup CHIP/Medicaid	$23.78
Rate for Payer: BCBS of TX Blue Advantage	$79.28
Rate for Payer: BCBS of TX Blue Essentials	$95.14
Rate for Payer: BCBS of TX PPO	$105.71
Rate for Payer: Cash Price	$179.70
Rate for Payer: Cigna Medicaid	$190.27
Rate for Payer: Molina CHIP/Medicaid	$190.27
Rate for Payer: Multiplan Auto	$171.78
Rate for Payer: Multiplan Commercial	$171.78
Rate for Payer: Multiplan Workers Comp	$171.78
Rate for Payer: Parkland Medicaid	$190.27
Rate for Payer: Scott and White EPO/PPO	$132.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$190.27
Rate for Payer: Superior Health Plan EPO	$35.94

BD Bone Density DEXA App Skeleton

Facility

$274.00

Service Code	HCPCS 77081
Hospital Charge Code	3620143
Hospital Revenue Code	320
Rate for Payer: Cash Price	$186.32

BD Bone Density DEXA App Skeleton

Facility

$274.00

Service Code	HCPCS 77081
Hospital Charge Code	3620143
Hospital Revenue Code	320
Min. Negotiated Rate	$31.74
Max. Negotiated Rate	$197.28
Rate for Payer: Amerigroup CHIP/Medicaid	$31.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$87.42
Rate for Payer: Amerigroup Medicare	$87.42
Rate for Payer: BCBS of TX Blue Advantage	$38.66
Rate for Payer: BCBS of TX Blue Essentials	$46.39
Rate for Payer: BCBS of TX Medicare	$87.42
Rate for Payer: BCBS of TX PPO	$51.78
Rate for Payer: Cash Price	$186.32
Rate for Payer: Cash Price	$186.32
Rate for Payer: Cash Price	$186.32
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$197.28
Rate for Payer: Cigna Medicare	$87.42
Rate for Payer: Employer Direct Commercial	$87.42
Rate for Payer: Humana Medicare/TRICARE	$87.42
Rate for Payer: Molina CHIP/Medicaid	$197.28
Rate for Payer: Molina Dual Medicare/Medicaid	$87.42
Rate for Payer: Molina Medicare	$87.42
Rate for Payer: Multiplan Auto	$178.10
Rate for Payer: Multiplan Commercial	$178.10
Rate for Payer: Multiplan Workers Comp	$178.10
Rate for Payer: Parkland Medicaid	$197.28
Rate for Payer: Scott and White EPO/PPO	$39.09
Rate for Payer: Scott and White Medicare	$87.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$197.28
Rate for Payer: Superior Health Plan EPO	$87.42
Rate for Payer: Superior Health Plan Medicare	$87.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$87.42
Rate for Payer: Universal American Medicare	$87.42
Rate for Payer: Wellcare Medicare	$87.42
Rate for Payer: Wellmed Medicare	$87.42

BD Bone Density DEXA Axial Skeleton

Facility

$510.00

Service Code	HCPCS 77080
Hospital Charge Code	3620135
Hospital Revenue Code	320
Min. Negotiated Rate	$39.09
Max. Negotiated Rate	$367.20
Rate for Payer: Amerigroup CHIP/Medicaid	$39.09
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$50.54
Rate for Payer: BCBS of TX Blue Essentials	$60.65
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$67.69
Rate for Payer: Cash Price	$346.80
Rate for Payer: Cash Price	$346.80
Rate for Payer: Cash Price	$346.80
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$367.20
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$367.20
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$331.50
Rate for Payer: Multiplan Commercial	$331.50
Rate for Payer: Multiplan Workers Comp	$331.50
Rate for Payer: Parkland Medicaid	$367.20
Rate for Payer: Scott and White EPO/PPO	$48.15
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$367.20
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

BD Bone Density DEXA Axial Skeleton

Facility

$510.00

Service Code	HCPCS 77080
Hospital Charge Code	3620135
Hospital Revenue Code	320
Rate for Payer: Cash Price	$346.80

BD Bone Density Vertebral FX 1+ Sites

Facility

$538.00

Service Code	HCPCS 77085
Hospital Charge Code	5017085
Hospital Revenue Code	320
Min. Negotiated Rate	$53.46
Max. Negotiated Rate	$387.36
Rate for Payer: Amerigroup CHIP/Medicaid	$53.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$365.84
Rate for Payer: Cash Price	$365.84
Rate for Payer: Cash Price	$365.84
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$387.36
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$387.36
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$349.70
Rate for Payer: Multiplan Commercial	$349.70
Rate for Payer: Multiplan Workers Comp	$349.70
Rate for Payer: Parkland Medicaid	$387.36
Rate for Payer: Scott and White EPO/PPO	$65.84
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$387.36
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

BD Bone Density Vertebral FX 1+ Sites

Facility

$538.00

Service Code	HCPCS 77085
Hospital Charge Code	5017085
Hospital Revenue Code	320
Rate for Payer: Cash Price	$365.84

BD Chloraprep hi-lite orange 26 ml skin prep applicator with sterile solution

Facility

$27.94

Hospital Charge Code	992784
Hospital Revenue Code	272
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$20.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2.51
Rate for Payer: BCBS of TX Blue Advantage	$8.38
Rate for Payer: BCBS of TX Blue Essentials	$10.06
Rate for Payer: BCBS of TX PPO	$11.18
Rate for Payer: Cash Price	$19.00
Rate for Payer: Cigna Medicaid	$20.12
Rate for Payer: Molina CHIP/Medicaid	$20.12
Rate for Payer: Multiplan Auto	$18.16
Rate for Payer: Multiplan Commercial	$18.16
Rate for Payer: Multiplan Workers Comp	$18.16
Rate for Payer: Parkland Medicaid	$20.12
Rate for Payer: Scott and White EPO/PPO	$13.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.12
Rate for Payer: Superior Health Plan EPO	$3.80

BD Chloraprep hi-lite orange 26 ml skin prep applicator with sterile solution

Facility

$27.94

Hospital Charge Code	992784
Hospital Revenue Code	272
Rate for Payer: Cash Price	$19.00

bean bag positioner, with cutout, xlarge, 36'wx40'l

Facility

$2,339.24

Hospital Charge Code	992591
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,590.68

bean bag positioner, with cutout, xlarge, 36'wx40'l

Facility

$2,339.24

Hospital Charge Code	992591
Hospital Revenue Code	270
Min. Negotiated Rate	$210.53
Max. Negotiated Rate	$1,684.25
Rate for Payer: Amerigroup CHIP/Medicaid	$210.53
Rate for Payer: BCBS of TX Blue Advantage	$701.77
Rate for Payer: BCBS of TX Blue Essentials	$842.13
Rate for Payer: BCBS of TX PPO	$935.70
Rate for Payer: Cash Price	$1,590.68
Rate for Payer: Cigna Medicaid	$1,684.25
Rate for Payer: Molina CHIP/Medicaid	$1,684.25
Rate for Payer: Multiplan Auto	$1,520.51
Rate for Payer: Multiplan Commercial	$1,520.51
Rate for Payer: Multiplan Workers Comp	$1,520.51
Rate for Payer: Parkland Medicaid	$1,684.25
Rate for Payer: Scott and White EPO/PPO	$1,169.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,684.25
Rate for Payer: Superior Health Plan EPO	$318.14

BEARING TIBIAL STABLE VANGUARD POSTERIOR

Facility

$10,118.00

Service Code	HCPCS C1776
Hospital Charge Code	146430
Hospital Revenue Code	278
Min. Negotiated Rate	$910.62
Max. Negotiated Rate	$7,284.96
Rate for Payer: Amerigroup CHIP/Medicaid	$910.62
Rate for Payer: BCBS of TX Blue Advantage	$3,035.40
Rate for Payer: BCBS of TX Blue Essentials	$3,642.48
Rate for Payer: BCBS of TX PPO	$4,047.20
Rate for Payer: Cash Price	$6,880.24
Rate for Payer: Cigna Medicaid	$7,284.96
Rate for Payer: Molina CHIP/Medicaid	$7,284.96
Rate for Payer: Multiplan Auto	$5,059.00
Rate for Payer: Multiplan Commercial	$5,059.00
Rate for Payer: Multiplan Workers Comp	$5,059.00
Rate for Payer: Parkland Medicaid	$7,284.96
Rate for Payer: Scott and White EPO/PPO	$5,059.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,284.96
Rate for Payer: Superior Health Plan EPO	$1,376.05

Know your out-of-pocket cost for care.

All Charges