White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Beta-2 Glycoprotein I Ab G A M SO

Facility

$65.00

Service Code	HCPCS 86146
Hospital Charge Code	1708171
Hospital Revenue Code	302
Min. Negotiated Rate	$9.93
Max. Negotiated Rate	$46.80
Rate for Payer: Amerigroup CHIP/Medicaid	$9.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25.45
Rate for Payer: Amerigroup Medicare	$25.45
Rate for Payer: BCBS of TX Blue Advantage	$19.50
Rate for Payer: BCBS of TX Blue Essentials	$23.40
Rate for Payer: BCBS of TX Medicare	$25.45
Rate for Payer: BCBS of TX PPO	$26.00
Rate for Payer: Cash Price	$44.20
Rate for Payer: Cash Price	$44.20
Rate for Payer: Cigna Medicaid	$46.80
Rate for Payer: Cigna Medicare	$25.45
Rate for Payer: Employer Direct Commercial	$25.45
Rate for Payer: Humana Medicare/TRICARE	$25.45
Rate for Payer: Molina CHIP/Medicaid	$46.80
Rate for Payer: Molina Dual Medicare/Medicaid	$25.45
Rate for Payer: Molina Medicare	$25.45
Rate for Payer: Multiplan Auto	$42.25
Rate for Payer: Multiplan Commercial	$42.25
Rate for Payer: Multiplan Workers Comp	$42.25
Rate for Payer: Parkland Medicaid	$46.80
Rate for Payer: Scott and White EPO/PPO	$31.81
Rate for Payer: Scott and White Medicare	$25.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.80
Rate for Payer: Superior Health Plan EPO	$25.45
Rate for Payer: Superior Health Plan Medicare	$25.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$25.45
Rate for Payer: Universal American Medicare	$25.45
Rate for Payer: Wellcare Medicare	$25.45
Rate for Payer: Wellmed Medicare	$25.45

Beta-2 Glycoprotein I Ab G A M SO

Facility

$65.00

Service Code	HCPCS 86146
Hospital Charge Code	1708171
Hospital Revenue Code	302
Rate for Payer: Cash Price	$44.20

Beta-2 Microglobulin, Serum SO

Facility

$126.00

Service Code	HCPCS 82232
Hospital Charge Code	1702265
Hospital Revenue Code	301
Rate for Payer: Cash Price	$85.68

Beta-2 Microglobulin, Serum SO

Facility

$126.00

Service Code	HCPCS 82232
Hospital Charge Code	1702265
Hospital Revenue Code	301
Min. Negotiated Rate	$6.31
Max. Negotiated Rate	$90.72
Rate for Payer: Amerigroup CHIP/Medicaid	$6.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.18
Rate for Payer: Amerigroup Medicare	$16.18
Rate for Payer: BCBS of TX Blue Advantage	$37.80
Rate for Payer: BCBS of TX Blue Essentials	$45.36
Rate for Payer: BCBS of TX Medicare	$16.18
Rate for Payer: BCBS of TX PPO	$50.40
Rate for Payer: Cash Price	$85.68
Rate for Payer: Cash Price	$85.68
Rate for Payer: Cigna Medicaid	$90.72
Rate for Payer: Cigna Medicare	$16.18
Rate for Payer: Employer Direct Commercial	$16.18
Rate for Payer: Humana Medicare/TRICARE	$16.18
Rate for Payer: Molina CHIP/Medicaid	$90.72
Rate for Payer: Molina Dual Medicare/Medicaid	$16.18
Rate for Payer: Molina Medicare	$16.18
Rate for Payer: Multiplan Auto	$81.90
Rate for Payer: Multiplan Commercial	$81.90
Rate for Payer: Multiplan Workers Comp	$81.90
Rate for Payer: Parkland Medicaid	$90.72
Rate for Payer: Scott and White EPO/PPO	$20.23
Rate for Payer: Scott and White Medicare	$16.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.72
Rate for Payer: Superior Health Plan EPO	$16.18
Rate for Payer: Superior Health Plan Medicare	$16.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.18
Rate for Payer: Universal American Medicare	$16.18
Rate for Payer: Wellcare Medicare	$16.18
Rate for Payer: Wellmed Medicare	$16.18

Beta Lactamase

Facility

$114.00

Service Code	HCPCS 87185
Hospital Charge Code	4177036
Hospital Revenue Code	306
Rate for Payer: Cash Price	$77.52

Beta Lactamase

Facility

$114.00

Service Code	HCPCS 87185
Hospital Charge Code	4177036
Hospital Revenue Code	306
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$82.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.75
Rate for Payer: Amerigroup Medicare	$4.75
Rate for Payer: BCBS of TX Blue Advantage	$34.20
Rate for Payer: BCBS of TX Blue Essentials	$41.04
Rate for Payer: BCBS of TX Medicare	$4.75
Rate for Payer: BCBS of TX PPO	$45.60
Rate for Payer: Cash Price	$77.52
Rate for Payer: Cash Price	$77.52
Rate for Payer: Cigna Medicaid	$82.08
Rate for Payer: Cigna Medicare	$4.75
Rate for Payer: Employer Direct Commercial	$4.75
Rate for Payer: Humana Medicare/TRICARE	$4.75
Rate for Payer: Molina CHIP/Medicaid	$82.08
Rate for Payer: Molina Dual Medicare/Medicaid	$4.75
Rate for Payer: Molina Medicare	$4.75
Rate for Payer: Multiplan Auto	$74.10
Rate for Payer: Multiplan Commercial	$74.10
Rate for Payer: Multiplan Workers Comp	$74.10
Rate for Payer: Parkland Medicaid	$82.08
Rate for Payer: Scott and White EPO/PPO	$5.94
Rate for Payer: Scott and White Medicare	$4.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$82.08
Rate for Payer: Superior Health Plan EPO	$4.75
Rate for Payer: Superior Health Plan Medicare	$4.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.75
Rate for Payer: Universal American Medicare	$4.75
Rate for Payer: Wellcare Medicare	$4.75
Rate for Payer: Wellmed Medicare	$4.75

betamethasone-clotrimazole 0.05%-1% Cream 15 g

Facility

$66.26

Service Code	HCPCS J3490
Hospital Charge Code	77410353
Hospital Revenue Code	250
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$47.71
Rate for Payer: Amerigroup CHIP/Medicaid	$5.96
Rate for Payer: BCBS of TX Blue Advantage	$19.88
Rate for Payer: BCBS of TX Blue Essentials	$23.85
Rate for Payer: BCBS of TX PPO	$26.50
Rate for Payer: Cash Price	$45.06
Rate for Payer: Cigna Medicaid	$47.71
Rate for Payer: Molina CHIP/Medicaid	$47.71
Rate for Payer: Multiplan Auto	$43.07
Rate for Payer: Multiplan Commercial	$43.07
Rate for Payer: Multiplan Workers Comp	$43.07
Rate for Payer: Parkland Medicaid	$47.71
Rate for Payer: Scott and White EPO/PPO	$33.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47.71
Rate for Payer: Superior Health Plan EPO	$9.01

betamethasone-clotrimazole 0.05%-1% Cream 15 g

Facility

$66.26

Service Code	HCPCS J3490
Hospital Charge Code	77410353
Hospital Revenue Code	250
Rate for Payer: Cash Price	$45.06

BG AMBU NEO -- DHF

Facility

$67.43

Hospital Charge Code	82015058
Hospital Revenue Code	270
Rate for Payer: Cash Price	$45.85

BG AMBU NEO -- DHF

Facility

$67.43

Hospital Charge Code	82015058
Hospital Revenue Code	270
Min. Negotiated Rate	$6.07
Max. Negotiated Rate	$48.55
Rate for Payer: Amerigroup CHIP/Medicaid	$6.07
Rate for Payer: BCBS of TX Blue Advantage	$20.23
Rate for Payer: BCBS of TX Blue Essentials	$24.27
Rate for Payer: BCBS of TX PPO	$26.97
Rate for Payer: Cash Price	$45.85
Rate for Payer: Cigna Medicaid	$48.55
Rate for Payer: Molina CHIP/Medicaid	$48.55
Rate for Payer: Multiplan Auto	$43.83
Rate for Payer: Multiplan Commercial	$43.83
Rate for Payer: Multiplan Workers Comp	$43.83
Rate for Payer: Parkland Medicaid	$48.55
Rate for Payer: Scott and White EPO/PPO	$33.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$48.55
Rate for Payer: Superior Health Plan EPO	$9.17

BG ICE DISP PL -- DHF

Facility

$26.48

Hospital Charge Code	80312408
Hospital Revenue Code	270
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$19.07
Rate for Payer: Amerigroup CHIP/Medicaid	$2.38
Rate for Payer: BCBS of TX Blue Advantage	$7.94
Rate for Payer: BCBS of TX Blue Essentials	$9.53
Rate for Payer: BCBS of TX PPO	$10.59
Rate for Payer: Cash Price	$18.01
Rate for Payer: Cigna Medicaid	$19.07
Rate for Payer: Molina CHIP/Medicaid	$19.07
Rate for Payer: Multiplan Auto	$17.21
Rate for Payer: Multiplan Commercial	$17.21
Rate for Payer: Multiplan Workers Comp	$17.21
Rate for Payer: Parkland Medicaid	$19.07
Rate for Payer: Scott and White EPO/PPO	$13.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.07
Rate for Payer: Superior Health Plan EPO	$3.60

BG ICE DISP PL -- DHF

Facility

$26.48

Hospital Charge Code	80312408
Hospital Revenue Code	270
Rate for Payer: Cash Price	$18.01

BG INCNT -- DHF

Facility

$134.02

Hospital Charge Code	80312507
Hospital Revenue Code	272
Min. Negotiated Rate	$12.06
Max. Negotiated Rate	$96.49
Rate for Payer: Amerigroup CHIP/Medicaid	$12.06
Rate for Payer: BCBS of TX Blue Advantage	$40.21
Rate for Payer: BCBS of TX Blue Essentials	$48.25
Rate for Payer: BCBS of TX PPO	$53.61
Rate for Payer: Cash Price	$91.13
Rate for Payer: Cigna Medicaid	$96.49
Rate for Payer: Molina CHIP/Medicaid	$96.49
Rate for Payer: Multiplan Auto	$87.11
Rate for Payer: Multiplan Commercial	$87.11
Rate for Payer: Multiplan Workers Comp	$87.11
Rate for Payer: Parkland Medicaid	$96.49
Rate for Payer: Scott and White EPO/PPO	$67.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96.49
Rate for Payer: Superior Health Plan EPO	$18.23

BG INCNT -- DHF

Facility

$134.02

Hospital Charge Code	80312507
Hospital Revenue Code	272
Rate for Payer: Cash Price	$91.13

BG INTESTINE -- DHF

Facility

$593.22

Hospital Charge Code	81720559
Hospital Revenue Code	272
Min. Negotiated Rate	$53.39
Max. Negotiated Rate	$427.12
Rate for Payer: Amerigroup CHIP/Medicaid	$53.39
Rate for Payer: BCBS of TX Blue Advantage	$177.97
Rate for Payer: BCBS of TX Blue Essentials	$213.56
Rate for Payer: BCBS of TX PPO	$237.29
Rate for Payer: Cash Price	$403.39
Rate for Payer: Cigna Medicaid	$427.12
Rate for Payer: Molina CHIP/Medicaid	$427.12
Rate for Payer: Multiplan Auto	$385.59
Rate for Payer: Multiplan Commercial	$385.59
Rate for Payer: Multiplan Workers Comp	$385.59
Rate for Payer: Parkland Medicaid	$427.12
Rate for Payer: Scott and White EPO/PPO	$296.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$427.12
Rate for Payer: Superior Health Plan EPO	$80.68

BG INTESTINE -- DHF

Facility

$593.22

Hospital Charge Code	81720559
Hospital Revenue Code	272
Rate for Payer: Cash Price	$403.39

BG PRESS INFU

Facility

$34.10

Hospital Charge Code	80910250
Hospital Revenue Code	270
Rate for Payer: Cash Price	$23.19

BG PRESS INFU

Facility

$34.10

Hospital Charge Code	80910250
Hospital Revenue Code	270
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$24.55
Rate for Payer: Amerigroup CHIP/Medicaid	$3.07
Rate for Payer: BCBS of TX Blue Advantage	$10.23
Rate for Payer: BCBS of TX Blue Essentials	$12.28
Rate for Payer: BCBS of TX PPO	$13.64
Rate for Payer: Cash Price	$23.19
Rate for Payer: Cigna Medicaid	$24.55
Rate for Payer: Molina CHIP/Medicaid	$24.55
Rate for Payer: Multiplan Auto	$22.16
Rate for Payer: Multiplan Commercial	$22.16
Rate for Payer: Multiplan Workers Comp	$22.16
Rate for Payer: Parkland Medicaid	$24.55
Rate for Payer: Scott and White EPO/PPO	$17.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.55
Rate for Payer: Superior Health Plan EPO	$4.64

BG URINE DRN -- DHF

Facility

$90.80

Hospital Charge Code	80410558
Hospital Revenue Code	272
Rate for Payer: Cash Price	$61.74

BG URINE DRN -- DHF

Facility

$90.80

Hospital Charge Code	80410558
Hospital Revenue Code	272
Min. Negotiated Rate	$8.17
Max. Negotiated Rate	$65.38
Rate for Payer: Amerigroup CHIP/Medicaid	$8.17
Rate for Payer: BCBS of TX Blue Advantage	$27.24
Rate for Payer: BCBS of TX Blue Essentials	$32.69
Rate for Payer: BCBS of TX PPO	$36.32
Rate for Payer: Cash Price	$61.74
Rate for Payer: Cigna Medicaid	$65.38
Rate for Payer: Molina CHIP/Medicaid	$65.38
Rate for Payer: Multiplan Auto	$59.02
Rate for Payer: Multiplan Commercial	$59.02
Rate for Payer: Multiplan Workers Comp	$59.02
Rate for Payer: Parkland Medicaid	$65.38
Rate for Payer: Scott and White EPO/PPO	$45.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.38
Rate for Payer: Superior Health Plan EPO	$12.35

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC

Facility

$121,888.80

Service Code	MSDRG 461
Min. Negotiated Rate	$38,549.50
Max. Negotiated Rate	$121,888.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$45,238.29
Rate for Payer: Amerigroup Medicare	$45,238.29
Rate for Payer: BCBS of TX Medicare	$45,238.29
Rate for Payer: Cigna Commercial	$69,044.53
Rate for Payer: Cigna Medicare	$45,238.29
Rate for Payer: Employer Direct Commercial	$45,238.29
Rate for Payer: Humana Medicare/TRICARE	$45,238.29
Rate for Payer: Molina Dual Medicare/Medicaid	$45,238.29
Rate for Payer: Molina Medicare	$45,238.29
Rate for Payer: Multiplan Auto	$121,888.80
Rate for Payer: Multiplan Commercial	$121,888.80
Rate for Payer: Multiplan Workers Comp	$121,888.80
Rate for Payer: Scott and White EPO/PPO	$56,133.00
Rate for Payer: Scott and White Medicare	$45,238.29
Rate for Payer: Superior Health Plan EPO	$45,238.29
Rate for Payer: Superior Health Plan Medicare	$45,238.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$45,238.29
Rate for Payer: Universal American Medicare	$45,238.29
Rate for Payer: Wellcare Medicare	$45,238.29
Rate for Payer: Wellmed Medicare	$45,238.29

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC

Facility

$56,726.40

Service Code	MSDRG 462
Min. Negotiated Rate	$24,255.29
Max. Negotiated Rate	$56,726.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24,255.29
Rate for Payer: Amerigroup Medicare	$24,255.29
Rate for Payer: BCBS of TX Medicare	$24,255.29
Rate for Payer: Cigna Commercial	$34,260.80
Rate for Payer: Cigna Medicare	$24,255.29
Rate for Payer: Employer Direct Commercial	$24,255.29
Rate for Payer: Humana Medicare/TRICARE	$24,255.29
Rate for Payer: Molina Dual Medicare/Medicaid	$24,255.29
Rate for Payer: Molina Medicare	$24,255.29
Rate for Payer: Multiplan Auto	$56,726.40
Rate for Payer: Multiplan Commercial	$56,726.40
Rate for Payer: Multiplan Workers Comp	$56,726.40
Rate for Payer: Scott and White EPO/PPO	$26,124.00
Rate for Payer: Scott and White Medicare	$24,255.29
Rate for Payer: Superior Health Plan EPO	$24,255.29
Rate for Payer: Superior Health Plan Medicare	$24,255.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$24,255.29
Rate for Payer: Universal American Medicare	$24,255.29
Rate for Payer: Wellcare Medicare	$24,255.29
Rate for Payer: Wellmed Medicare	$24,255.29

BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W MCC

Facility

$121,888.80

Service Code	MSDRG 461
Min. Negotiated Rate	$38,549.50
Max. Negotiated Rate	$121,888.80
Rate for Payer: BCBS of TX Blue Advantage	$38,549.50
Rate for Payer: BCBS of TX Blue Essentials	$46,254.92
Rate for Payer: BCBS of TX PPO	$51,396.35

BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC

Facility

$56,726.40

Service Code	MSDRG 462
Min. Negotiated Rate	$24,255.29
Max. Negotiated Rate	$56,726.40
Rate for Payer: BCBS of TX Blue Advantage	$27,469.26
Rate for Payer: BCBS of TX Blue Essentials	$32,959.92
Rate for Payer: BCBS of TX PPO	$36,623.55

Bile Acids, Fractionated LCMS SO

Facility

$314.00

Service Code	HCPCS 82542
Hospital Charge Code	1708155
Hospital Revenue Code	301
Min. Negotiated Rate	$9.40
Max. Negotiated Rate	$226.08
Rate for Payer: Amerigroup CHIP/Medicaid	$9.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24.09
Rate for Payer: Amerigroup Medicare	$24.09
Rate for Payer: BCBS of TX Blue Advantage	$94.20
Rate for Payer: BCBS of TX Blue Essentials	$113.04
Rate for Payer: BCBS of TX Medicare	$24.09
Rate for Payer: BCBS of TX PPO	$125.60
Rate for Payer: Cash Price	$213.52
Rate for Payer: Cash Price	$213.52
Rate for Payer: Cigna Medicaid	$226.08
Rate for Payer: Cigna Medicare	$24.09
Rate for Payer: Employer Direct Commercial	$24.09
Rate for Payer: Humana Medicare/TRICARE	$24.09
Rate for Payer: Molina CHIP/Medicaid	$226.08
Rate for Payer: Molina Dual Medicare/Medicaid	$24.09
Rate for Payer: Molina Medicare	$24.09
Rate for Payer: Multiplan Auto	$204.10
Rate for Payer: Multiplan Commercial	$204.10
Rate for Payer: Multiplan Workers Comp	$204.10
Rate for Payer: Parkland Medicaid	$226.08
Rate for Payer: Scott and White EPO/PPO	$30.11
Rate for Payer: Scott and White Medicare	$24.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$226.08
Rate for Payer: Superior Health Plan EPO	$24.09
Rate for Payer: Superior Health Plan Medicare	$24.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$24.09
Rate for Payer: Universal American Medicare	$24.09
Rate for Payer: Wellcare Medicare	$24.09
Rate for Payer: Wellmed Medicare	$24.09

Know your out-of-pocket cost for care.

All Charges