White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHWR XR INJ SI JT ARTHROGRAM BCE

Facility

$2,500.00

Service Code	CPT 27096
Hospital Charge Code	4907096
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,200.00

CHWR XR INJ SINUS TRACT DX

Facility

$354.00

Service Code	CPT 20501
Hospital Charge Code	4907705
Hospital Revenue Code	361
Min. Negotiated Rate	$31.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$194.70
Rate for Payer: Amerigroup CHIP/Medicaid	$31.86
Rate for Payer: Cash Price	$311.52
Rate for Payer: Cash Price	$311.52
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	$177.00
Rate for Payer: Superior Health Plan EPO	$48.14

CHWR XR INJ SINUS TRACT DX BCE

Facility

$354.00

Service Code	CPT 20501
Hospital Charge Code	4907705
Hospital Revenue Code	361
Rate for Payer: Cash Price	$311.52

CHWR XR INJ SINUS TRACT DX BCE

Facility

$354.00

Service Code	CPT 20501
Hospital Charge Code	4907705
Hospital Revenue Code	361
Min. Negotiated Rate	$31.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$194.70
Rate for Payer: Amerigroup CHIP/Medicaid	$31.86
Rate for Payer: Cash Price	$311.52
Rate for Payer: Cash Price	$311.52
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	$177.00
Rate for Payer: Superior Health Plan EPO	$48.14

CHWR XR INJ WRIST ARTHRO

Facility

$430.00

Service Code	CPT 25246
Hospital Charge Code	4907745
Hospital Revenue Code	361
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$236.50
Rate for Payer: Amerigroup CHIP/Medicaid	$38.70
Rate for Payer: Cash Price	$378.40
Rate for Payer: Cash Price	$378.40
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	$215.00
Rate for Payer: Superior Health Plan EPO	$58.48

CHWR XR INJ WRIST ARTHRO BCE

Facility

$430.00

Service Code	CPT 25246
Hospital Charge Code	4907745
Hospital Revenue Code	361
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$236.50
Rate for Payer: Amerigroup CHIP/Medicaid	$38.70
Rate for Payer: Cash Price	$378.40
Rate for Payer: Cash Price	$378.40
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	$215.00
Rate for Payer: Superior Health Plan EPO	$58.48

CHWR XR INJ WRIST ARTHRO BCE

Facility

$430.00

Service Code	CPT 25246
Hospital Charge Code	4907745
Hospital Revenue Code	361
Rate for Payer: Cash Price	$378.40

CHWR YUEH NEEDLE

Facility

$134.49

Hospital Charge Code	8178171
Hospital Revenue Code	272
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$87.42
Rate for Payer: Aetna Commercial	$73.97
Rate for Payer: Amerigroup CHIP/Medicaid	$12.10
Rate for Payer: BCBS of TX Blue Advantage	$40.35
Rate for Payer: BCBS of TX Blue Essentials	$48.42
Rate for Payer: BCBS of TX PPO	$53.80
Rate for Payer: Cash Price	$118.35
Rate for Payer: Multiplan Auto	$87.42
Rate for Payer: Multiplan Commercial	$87.42
Rate for Payer: Multiplan Workers Comp	$87.42
Rate for Payer: Scott and White EPO/PPO	$67.24
Rate for Payer: Superior Health Plan EPO	$18.29

CHWR YUEH NEEDLE BCE

Facility

$134.49

Hospital Charge Code	8178171
Hospital Revenue Code	272
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$87.42
Rate for Payer: Aetna Commercial	$73.97
Rate for Payer: Amerigroup CHIP/Medicaid	$12.10
Rate for Payer: BCBS of TX Blue Advantage	$40.35
Rate for Payer: BCBS of TX Blue Essentials	$48.42
Rate for Payer: BCBS of TX PPO	$53.80
Rate for Payer: Cash Price	$118.35
Rate for Payer: Multiplan Auto	$87.42
Rate for Payer: Multiplan Commercial	$87.42
Rate for Payer: Multiplan Workers Comp	$87.42
Rate for Payer: Scott and White EPO/PPO	$67.24
Rate for Payer: Superior Health Plan EPO	$18.29

CHWR YUEH NEEDLE BCE

Facility

$134.49

Hospital Charge Code	8178171
Hospital Revenue Code	272
Rate for Payer: Cash Price	$118.35

CHYLMD TRACH DNA AMP PROBE

Facility

$298.00

Service Code	CPT 87491
Hospital Charge Code	1709682
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$193.70
Rate for Payer: Aetna Commercial	$36.84
Rate for Payer: Aetna Medicare	$52.64
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$57.90
Rate for Payer: BCBS of TX Blue Essentials	$69.48
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$77.55
Rate for Payer: Cash Price	$262.24
Rate for Payer: Cash Price	$262.24
Rate for Payer: Cigna Medicaid	$35.09
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$35.09
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$193.70
Rate for Payer: Multiplan Commercial	$193.70
Rate for Payer: Multiplan Workers Comp	$193.70
Rate for Payer: Parkland Medicaid	$35.09
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.09
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

cinacalcet 30 mg Tab

Facility

$52.38

Service Code	HCPCS J3490
Hospital Charge Code	78432238
Hospital Revenue Code	250
Rate for Payer: Cash Price	$35.62

cinacalcet 30 mg Tab

Facility

$52.38

Service Code	HCPCS J3490
Hospital Charge Code	78432238
Hospital Revenue Code	250
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$34.05
Rate for Payer: Amerigroup CHIP/Medicaid	$4.71
Rate for Payer: BCBS of TX Blue Advantage	$15.71
Rate for Payer: BCBS of TX Blue Essentials	$18.86
Rate for Payer: BCBS of TX PPO	$20.95
Rate for Payer: Cash Price	$35.62
Rate for Payer: Multiplan Auto	$34.05
Rate for Payer: Multiplan Commercial	$34.05
Rate for Payer: Multiplan Workers Comp	$34.05
Rate for Payer: Scott and White EPO/PPO	$26.19
Rate for Payer: Superior Health Plan EPO	$7.12

ciprofloxacin 0.3% Ophth Oint 3.5 g

Facility

$557.00

Service Code	HCPCS J3490
Hospital Charge Code	77468658
Hospital Revenue Code	250
Rate for Payer: Cash Price	$378.76

ciprofloxacin 0.3% Ophth Oint 3.5 g

Facility

$557.00

Service Code	HCPCS J3490
Hospital Charge Code	77468658
Hospital Revenue Code	250
Min. Negotiated Rate	$50.13
Max. Negotiated Rate	$362.05
Rate for Payer: Amerigroup CHIP/Medicaid	$50.13
Rate for Payer: BCBS of TX Blue Advantage	$167.10
Rate for Payer: BCBS of TX Blue Essentials	$200.52
Rate for Payer: BCBS of TX PPO	$222.80
Rate for Payer: Cash Price	$378.76
Rate for Payer: Multiplan Auto	$362.05
Rate for Payer: Multiplan Commercial	$362.05
Rate for Payer: Multiplan Workers Comp	$362.05
Rate for Payer: Scott and White EPO/PPO	$278.50
Rate for Payer: Superior Health Plan EPO	$75.75

ciprofloxacin 0.3% Ophth Soln 5 mL

Facility

$80.90

Service Code	HCPCS J3490
Hospital Charge Code	77468817
Hospital Revenue Code	250
Min. Negotiated Rate	$7.28
Max. Negotiated Rate	$52.58
Rate for Payer: Amerigroup CHIP/Medicaid	$7.28
Rate for Payer: BCBS of TX Blue Advantage	$24.27
Rate for Payer: BCBS of TX Blue Essentials	$29.12
Rate for Payer: BCBS of TX PPO	$32.36
Rate for Payer: Cash Price	$55.01
Rate for Payer: Multiplan Auto	$52.58
Rate for Payer: Multiplan Commercial	$52.58
Rate for Payer: Multiplan Workers Comp	$52.58
Rate for Payer: Scott and White EPO/PPO	$40.45
Rate for Payer: Superior Health Plan EPO	$11.00

ciprofloxacin 0.3% Ophth Soln 5 mL

Facility

$80.90

Service Code	HCPCS J3490
Hospital Charge Code	77468817
Hospital Revenue Code	250
Rate for Payer: Cash Price	$55.01

ciprofloxacin 400 mg/D5W 200 mL

Facility

$128.17

Service Code	HCPCS J0744
Hospital Charge Code	77469251
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

ciprofloxacin 400 mg/D5W 200 mL

Facility

$128.17

Service Code	HCPCS J0744
Hospital Charge Code	77469251
Hospital Revenue Code	636
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.28
Rate for Payer: BCBS of TX Blue Essentials	$2.73
Rate for Payer: BCBS of TX PPO	$3.03
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

ciprofloxacin 500 mg Tab

Facility

$13.80

Service Code	HCPCS J3490
Hospital Charge Code	77469363
Hospital Revenue Code	250
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$8.97
Rate for Payer: Amerigroup CHIP/Medicaid	$1.24
Rate for Payer: BCBS of TX Blue Advantage	$4.14
Rate for Payer: BCBS of TX Blue Essentials	$4.97
Rate for Payer: BCBS of TX PPO	$5.52
Rate for Payer: Cash Price	$9.38
Rate for Payer: Multiplan Auto	$8.97
Rate for Payer: Multiplan Commercial	$8.97
Rate for Payer: Multiplan Workers Comp	$8.97
Rate for Payer: Scott and White EPO/PPO	$6.90
Rate for Payer: Superior Health Plan EPO	$1.88

ciprofloxacin 500 mg Tab

Facility

$13.80

Service Code	HCPCS J3490
Hospital Charge Code	77469363
Hospital Revenue Code	250
Rate for Payer: Cash Price	$9.38

CIRC BREATH ANES -- DHF

Facility

$36.37

Hospital Charge Code	81711251
Hospital Revenue Code	271
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$23.64
Rate for Payer: Aetna Commercial	$20.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.27
Rate for Payer: BCBS of TX Blue Advantage	$10.91
Rate for Payer: BCBS of TX Blue Essentials	$13.09
Rate for Payer: BCBS of TX PPO	$14.55
Rate for Payer: Cash Price	$32.01
Rate for Payer: Multiplan Auto	$23.64
Rate for Payer: Multiplan Commercial	$23.64
Rate for Payer: Multiplan Workers Comp	$23.64
Rate for Payer: Scott and White EPO/PPO	$18.18
Rate for Payer: Superior Health Plan EPO	$4.95

CIRC BREATH ANES -- DHF

Facility

$36.37

Hospital Charge Code	81711251
Hospital Revenue Code	271
Rate for Payer: Cash Price	$32.01

CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC

Facility

$40,956.40

Service Code	MSDRG 286
Min. Negotiated Rate	$18,237.28
Max. Negotiated Rate	$40,956.40
Rate for Payer: Aetna Commercial	$24,250.50
Rate for Payer: Aetna Medicare	$27,355.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,237.28
Rate for Payer: Amerigroup Medicare	$18,237.28
Rate for Payer: BCBS of TX Blue Advantage	$18,943.22
Rate for Payer: BCBS of TX Blue Essentials	$22,503.68
Rate for Payer: BCBS of TX Medicare	$18,237.28
Rate for Payer: BCBS of TX PPO	$25,005.05
Rate for Payer: Cigna Commercial	$27,764.13
Rate for Payer: Cigna Medicare	$18,237.28
Rate for Payer: Employer Direct Commercial	$18,237.28
Rate for Payer: Humana Medicare/TRICARE	$18,237.28
Rate for Payer: Molina Dual Medicare/Medicaid	$18,237.28
Rate for Payer: Molina Medicare	$18,237.28
Rate for Payer: Multiplan Auto	$40,956.40
Rate for Payer: Multiplan Commercial	$40,956.40
Rate for Payer: Multiplan Workers Comp	$40,956.40
Rate for Payer: Scott and White EPO/PPO	$18,861.50
Rate for Payer: Scott and White Medicare	$18,237.28
Rate for Payer: Superior Health Plan EPO	$18,237.28
Rate for Payer: Superior Health Plan Medicare	$18,237.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,237.28
Rate for Payer: Universal American Medicare	$18,237.28
Rate for Payer: Wellcare Medicare	$18,237.28
Rate for Payer: Wellmed Medicare	$18,237.28

CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC

Facility

$20,550.40

Service Code	MSDRG 287
Min. Negotiated Rate	$9,464.00
Max. Negotiated Rate	$20,550.40
Rate for Payer: Aetna Commercial	$12,168.00
Rate for Payer: Aetna Medicare	$15,859.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,573.14
Rate for Payer: Amerigroup Medicare	$10,573.14
Rate for Payer: BCBS of TX Blue Advantage	$10,055.98
Rate for Payer: BCBS of TX Blue Essentials	$11,752.31
Rate for Payer: BCBS of TX Medicare	$10,573.14
Rate for Payer: BCBS of TX PPO	$13,058.63
Rate for Payer: Cigna Commercial	$13,931.01
Rate for Payer: Cigna Medicare	$10,573.14
Rate for Payer: Employer Direct Commercial	$10,573.14
Rate for Payer: Humana Medicare/TRICARE	$10,573.14
Rate for Payer: Molina Dual Medicare/Medicaid	$10,573.14
Rate for Payer: Molina Medicare	$10,573.14
Rate for Payer: Multiplan Auto	$20,550.40
Rate for Payer: Multiplan Commercial	$20,550.40
Rate for Payer: Multiplan Workers Comp	$20,550.40
Rate for Payer: Scott and White EPO/PPO	$9,464.00
Rate for Payer: Scott and White Medicare	$10,573.14
Rate for Payer: Superior Health Plan EPO	$10,573.14
Rate for Payer: Superior Health Plan Medicare	$10,573.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,573.14
Rate for Payer: Universal American Medicare	$10,573.14
Rate for Payer: Wellcare Medicare	$10,573.14
Rate for Payer: Wellmed Medicare	$10,573.14

Know your out-of-pocket cost for care.

All Charges