White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Circumcision

Facility

$10,500.00

Service Code	CPT 54150
Hospital Charge Code	315036
Hospital Revenue Code	723
Min. Negotiated Rate	$33.31
Max. Negotiated Rate	$6,825.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$2,794.14
Rate for Payer: Amerigroup CHIP/Medicaid	$945.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,862.76
Rate for Payer: Amerigroup Medicare	$1,862.76
Rate for Payer: BCBS of TX Blue Advantage	$2,958.49
Rate for Payer: BCBS of TX Blue Essentials	$3,543.10
Rate for Payer: BCBS of TX Medicare	$1,862.76
Rate for Payer: BCBS of TX PPO	$4,464.31
Rate for Payer: Cash Price	$9,240.00
Rate for Payer: Cash Price	$9,240.00
Rate for Payer: Cash Price	$9,240.00
Rate for Payer: Cigna Commercial	$4,219.69
Rate for Payer: Cigna Medicaid	$652.80
Rate for Payer: Cigna Medicare	$1,862.76
Rate for Payer: Employer Direct Commercial	$1,862.76
Rate for Payer: Humana Medicare/TRICARE	$1,862.76
Rate for Payer: Molina CHIP/Medicaid	$652.80
Rate for Payer: Molina Dual Medicare/Medicaid	$1,862.76
Rate for Payer: Molina Medicare	$1,862.76
Rate for Payer: Multiplan Auto	$6,825.00
Rate for Payer: Multiplan Commercial	$6,825.00
Rate for Payer: Multiplan Workers Comp	$6,825.00
Rate for Payer: Parkland Medicaid	$652.80
Rate for Payer: Scott and White EPO/PPO	$33.31
Rate for Payer: Scott and White Medicare	$1,862.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$652.80
Rate for Payer: Superior Health Plan EPO	$1,862.76
Rate for Payer: Superior Health Plan Medicare	$1,862.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,862.76
Rate for Payer: Universal American Medicare	$1,862.76
Rate for Payer: Wellcare Medicare	$1,862.76
Rate for Payer: Wellmed Medicare	$1,862.76

Circumcision

Facility

$10,500.00

Service Code	CPT 54150
Hospital Charge Code	315036
Hospital Revenue Code	723
Rate for Payer: Cash Price	$9,240.00

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC

Facility

$19,589.00

Service Code	MSDRG 433
Min. Negotiated Rate	$7,974.78
Max. Negotiated Rate	$19,589.00
Rate for Payer: Aetna Commercial	$11,598.75
Rate for Payer: Aetna Medicare	$15,318.09
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,212.06
Rate for Payer: Amerigroup Medicare	$10,212.06
Rate for Payer: BCBS of TX Blue Advantage	$7,974.78
Rate for Payer: BCBS of TX Blue Essentials	$10,606.90
Rate for Payer: BCBS of TX Medicare	$10,212.06
Rate for Payer: BCBS of TX PPO	$11,785.90
Rate for Payer: Cigna Commercial	$13,279.28
Rate for Payer: Cigna Medicare	$10,212.06
Rate for Payer: Employer Direct Commercial	$10,212.06
Rate for Payer: Humana Medicare/TRICARE	$10,212.06
Rate for Payer: Molina Dual Medicare/Medicaid	$10,212.06
Rate for Payer: Molina Medicare	$10,212.06
Rate for Payer: Multiplan Auto	$19,589.00
Rate for Payer: Multiplan Commercial	$19,589.00
Rate for Payer: Multiplan Workers Comp	$19,589.00
Rate for Payer: Scott and White EPO/PPO	$9,021.25
Rate for Payer: Scott and White Medicare	$10,212.06
Rate for Payer: Superior Health Plan EPO	$10,212.06
Rate for Payer: Superior Health Plan Medicare	$10,212.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,212.06
Rate for Payer: Universal American Medicare	$10,212.06
Rate for Payer: Wellcare Medicare	$10,212.06
Rate for Payer: Wellmed Medicare	$10,212.06

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC

Facility

$36,404.00

Service Code	MSDRG 432
Min. Negotiated Rate	$14,716.32
Max. Negotiated Rate	$36,404.00
Rate for Payer: Aetna Commercial	$21,555.00
Rate for Payer: Aetna Medicare	$24,791.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,527.48
Rate for Payer: Amerigroup Medicare	$16,527.48
Rate for Payer: BCBS of TX Blue Advantage	$14,716.32
Rate for Payer: BCBS of TX Blue Essentials	$18,842.49
Rate for Payer: BCBS of TX Medicare	$16,527.48
Rate for Payer: BCBS of TX PPO	$20,936.92
Rate for Payer: Cigna Commercial	$24,678.08
Rate for Payer: Cigna Medicare	$16,527.48
Rate for Payer: Employer Direct Commercial	$16,527.48
Rate for Payer: Humana Medicare/TRICARE	$16,527.48
Rate for Payer: Molina Dual Medicare/Medicaid	$16,527.48
Rate for Payer: Molina Medicare	$16,527.48
Rate for Payer: Multiplan Auto	$36,404.00
Rate for Payer: Multiplan Commercial	$36,404.00
Rate for Payer: Multiplan Workers Comp	$36,404.00
Rate for Payer: Scott and White EPO/PPO	$16,765.00
Rate for Payer: Scott and White Medicare	$16,527.48
Rate for Payer: Superior Health Plan EPO	$16,527.48
Rate for Payer: Superior Health Plan Medicare	$16,527.48
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,527.48
Rate for Payer: Universal American Medicare	$16,527.48
Rate for Payer: Wellcare Medicare	$16,527.48
Rate for Payer: Wellmed Medicare	$16,527.48

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$12,720.50

Service Code	MSDRG 434
Min. Negotiated Rate	$5,263.20
Max. Negotiated Rate	$12,720.50
Rate for Payer: Aetna Commercial	$7,531.88
Rate for Payer: Aetna Medicare	$11,448.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,632.38
Rate for Payer: Amerigroup Medicare	$7,632.38
Rate for Payer: BCBS of TX Blue Advantage	$5,263.20
Rate for Payer: BCBS of TX Blue Essentials	$6,718.70
Rate for Payer: BCBS of TX Medicare	$7,632.38
Rate for Payer: BCBS of TX PPO	$7,465.51
Rate for Payer: Cigna Commercial	$8,623.16
Rate for Payer: Cigna Medicare	$7,632.38
Rate for Payer: Employer Direct Commercial	$7,632.38
Rate for Payer: Humana Medicare/TRICARE	$7,632.38
Rate for Payer: Molina Dual Medicare/Medicaid	$7,632.38
Rate for Payer: Molina Medicare	$7,632.38
Rate for Payer: Multiplan Auto	$12,720.50
Rate for Payer: Multiplan Commercial	$12,720.50
Rate for Payer: Multiplan Workers Comp	$12,720.50
Rate for Payer: Scott and White EPO/PPO	$5,858.12
Rate for Payer: Scott and White Medicare	$7,632.38
Rate for Payer: Superior Health Plan EPO	$7,632.38
Rate for Payer: Superior Health Plan Medicare	$7,632.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,632.38
Rate for Payer: Universal American Medicare	$7,632.38
Rate for Payer: Wellcare Medicare	$7,632.38
Rate for Payer: Wellmed Medicare	$7,632.38

cisatracurium 2 mg/mL IV Soln 10 mL

Facility

$128.19

Service Code	HCPCS J3490
Hospital Charge Code	77469679
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.32
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.46
Rate for Payer: BCBS of TX Blue Essentials	$46.15
Rate for Payer: BCBS of TX PPO	$51.28
Rate for Payer: Cash Price	$87.17
Rate for Payer: Multiplan Auto	$83.32
Rate for Payer: Multiplan Commercial	$83.32
Rate for Payer: Multiplan Workers Comp	$83.32
Rate for Payer: Scott and White EPO/PPO	$64.10
Rate for Payer: Superior Health Plan EPO	$17.43

cisatracurium 2 mg/mL IV Soln 10 mL

Facility

$128.19

Service Code	HCPCS J3490
Hospital Charge Code	77469679
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.17

citalopram 10 mg Tab

Facility

$10.55

Service Code	HCPCS J3490
Hospital Charge Code	7.7470015E7
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$6.86
Rate for Payer: Amerigroup CHIP/Medicaid	$0.95
Rate for Payer: BCBS of TX Blue Advantage	$3.16
Rate for Payer: BCBS of TX Blue Essentials	$3.80
Rate for Payer: BCBS of TX PPO	$4.22
Rate for Payer: Cash Price	$7.17
Rate for Payer: Multiplan Auto	$6.86
Rate for Payer: Multiplan Commercial	$6.86
Rate for Payer: Multiplan Workers Comp	$6.86
Rate for Payer: Scott and White EPO/PPO	$5.28
Rate for Payer: Superior Health Plan EPO	$1.43

citalopram 10 mg Tab

Facility

$10.55

Service Code	HCPCS J3490
Hospital Charge Code	7.7470015E7
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.17

citalopram 20 mg Tab

Facility

$11.70

Service Code	HCPCS J3490
Hospital Charge Code	77470178
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.96

citalopram 20 mg Tab

Facility

$11.70

Service Code	HCPCS J3490
Hospital Charge Code	77470178
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$7.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1.05
Rate for Payer: BCBS of TX Blue Advantage	$3.51
Rate for Payer: BCBS of TX Blue Essentials	$4.21
Rate for Payer: BCBS of TX PPO	$4.68
Rate for Payer: Cash Price	$7.96
Rate for Payer: Multiplan Auto	$7.60
Rate for Payer: Multiplan Commercial	$7.60
Rate for Payer: Multiplan Workers Comp	$7.60
Rate for Payer: Scott and White EPO/PPO	$5.85
Rate for Payer: Superior Health Plan EPO	$1.59

CITRATE

Facility

$109.00

Service Code	CPT 82507
Hospital Charge Code	1700050
Hospital Revenue Code	300
Min. Negotiated Rate	$10.84
Max. Negotiated Rate	$70.85
Rate for Payer: Aetna Commercial	$29.19
Rate for Payer: Aetna Medicare	$41.70
Rate for Payer: Amerigroup CHIP/Medicaid	$10.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.80
Rate for Payer: Amerigroup Medicare	$27.80
Rate for Payer: BCBS of TX Blue Advantage	$45.87
Rate for Payer: BCBS of TX Blue Essentials	$55.04
Rate for Payer: BCBS of TX Medicare	$27.80
Rate for Payer: BCBS of TX PPO	$61.44
Rate for Payer: Cash Price	$95.92
Rate for Payer: Cash Price	$95.92
Rate for Payer: Cigna Medicaid	$27.80
Rate for Payer: Cigna Medicare	$27.80
Rate for Payer: Employer Direct Commercial	$27.80
Rate for Payer: Humana Medicare/TRICARE	$27.80
Rate for Payer: Molina CHIP/Medicaid	$27.80
Rate for Payer: Molina Dual Medicare/Medicaid	$27.80
Rate for Payer: Molina Medicare	$27.80
Rate for Payer: Multiplan Auto	$70.85
Rate for Payer: Multiplan Commercial	$70.85
Rate for Payer: Multiplan Workers Comp	$70.85
Rate for Payer: Parkland Medicaid	$27.80
Rate for Payer: Scott and White EPO/PPO	$34.75
Rate for Payer: Scott and White Medicare	$27.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.80
Rate for Payer: Superior Health Plan EPO	$27.80
Rate for Payer: Superior Health Plan Medicare	$27.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.80
Rate for Payer: Universal American Medicare	$27.80
Rate for Payer: Wellcare Medicare	$27.80
Rate for Payer: Wellmed Medicare	$27.80

CITRATE

Facility

$109.00

Service Code	CPT 82507
Hospital Charge Code	1700050
Hospital Revenue Code	300
Rate for Payer: Cash Price	$95.92

CLAMP, VASC OCCLUS FRM PRS ANGLE 45 DGR MIDI DISP -- DHF

Facility

$164.13

Hospital Charge Code	80810658
Hospital Revenue Code	272
Min. Negotiated Rate	$14.77
Max. Negotiated Rate	$106.68
Rate for Payer: Aetna Commercial	$90.27
Rate for Payer: Amerigroup CHIP/Medicaid	$14.77
Rate for Payer: BCBS of TX Blue Advantage	$49.24
Rate for Payer: BCBS of TX Blue Essentials	$59.09
Rate for Payer: BCBS of TX PPO	$65.65
Rate for Payer: Cash Price	$144.43
Rate for Payer: Multiplan Auto	$106.68
Rate for Payer: Multiplan Commercial	$106.68
Rate for Payer: Multiplan Workers Comp	$106.68
Rate for Payer: Scott and White EPO/PPO	$82.06
Rate for Payer: Superior Health Plan EPO	$22.32

CLAMP, VASC OCCLUS FRM PRS ANGLE 45 DGR MIDI DISP -- DHF

Facility

$164.13

Hospital Charge Code	80810658
Hospital Revenue Code	272
Rate for Payer: Cash Price	$144.43

Claviculectomy; partial

Facility

$10,000.00

Service Code	CPT 23120
Hospital Charge Code	36023120
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

CLEARIFY VISUALIZATION SYSTEM

Facility

$166.93

Hospital Charge Code	8430487
Hospital Revenue Code	272
Min. Negotiated Rate	$15.02
Max. Negotiated Rate	$108.50
Rate for Payer: Aetna Commercial	$91.81
Rate for Payer: Amerigroup CHIP/Medicaid	$15.02
Rate for Payer: BCBS of TX Blue Advantage	$50.08
Rate for Payer: BCBS of TX Blue Essentials	$60.09
Rate for Payer: BCBS of TX PPO	$66.77
Rate for Payer: Cash Price	$146.90
Rate for Payer: Multiplan Auto	$108.50
Rate for Payer: Multiplan Commercial	$108.50
Rate for Payer: Multiplan Workers Comp	$108.50
Rate for Payer: Scott and White EPO/PPO	$83.46
Rate for Payer: Superior Health Plan EPO	$22.70

CLEARIFY VISUALIZATION SYSTEM

Facility

$166.93

Hospital Charge Code	8430487
Hospital Revenue Code	272
Rate for Payer: Cash Price	$146.90

CLICKLINE SCISSOR INSERT 34310MS-D

Facility

$177.24

Hospital Charge Code	144481
Hospital Revenue Code	272
Rate for Payer: Cash Price	$155.97

CLICKLINE SCISSOR INSERT 34310MS-D

Facility

$177.24

Hospital Charge Code	144481
Hospital Revenue Code	272
Min. Negotiated Rate	$15.95
Max. Negotiated Rate	$115.21
Rate for Payer: Aetna Commercial	$97.48
Rate for Payer: Amerigroup CHIP/Medicaid	$15.95
Rate for Payer: BCBS of TX Blue Advantage	$53.17
Rate for Payer: BCBS of TX Blue Essentials	$63.81
Rate for Payer: BCBS of TX PPO	$70.90
Rate for Payer: Cash Price	$155.97
Rate for Payer: Multiplan Auto	$115.21
Rate for Payer: Multiplan Commercial	$115.21
Rate for Payer: Multiplan Workers Comp	$115.21
Rate for Payer: Scott and White EPO/PPO	$88.62
Rate for Payer: Superior Health Plan EPO	$24.10

clindamycin 150 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77472566
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

clindamycin 150 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77472566
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

clindamycin 150 mg/mL Inj Soln 4 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7443828
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

clindamycin 150 mg/mL Inj Soln 4 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7443828
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
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

clindamycin 300 mg Cap

Facility

$16.15

Service Code	HCPCS J3490
Hospital Charge Code	77472892
Hospital Revenue Code	250
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$10.50
Rate for Payer: Amerigroup CHIP/Medicaid	$1.45
Rate for Payer: BCBS of TX Blue Advantage	$4.84
Rate for Payer: BCBS of TX Blue Essentials	$5.81
Rate for Payer: BCBS of TX PPO	$6.46
Rate for Payer: Cash Price	$10.98
Rate for Payer: Multiplan Auto	$10.50
Rate for Payer: Multiplan Commercial	$10.50
Rate for Payer: Multiplan Workers Comp	$10.50
Rate for Payer: Scott and White EPO/PPO	$8.08
Rate for Payer: Superior Health Plan EPO	$2.20

Know your out-of-pocket cost for care.

All Charges