White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W CC/MCC

Facility

$40,673.30

Service Code	MSDRG 584
Min. Negotiated Rate	$16,094.04
Max. Negotiated Rate	$40,673.30
Rate for Payer: BCBS of TX Blue Advantage	$16,094.04
Rate for Payer: BCBS of TX Blue Essentials	$19,310.98
Rate for Payer: BCBS of TX PPO	$21,457.47

BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC

Facility

$36,652.90

Service Code	MSDRG 585
Min. Negotiated Rate	$13,465.02
Max. Negotiated Rate	$36,652.90
Rate for Payer: BCBS of TX Blue Advantage	$13,465.02
Rate for Payer: BCBS of TX Blue Essentials	$16,156.46
Rate for Payer: BCBS of TX PPO	$17,952.32

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$12,743.71

Service Code	APR-DRG 3633
Min. Negotiated Rate	$12,015.21
Max. Negotiated Rate	$12,743.71
Rate for Payer: Amerigroup CHIP/Medicaid	$12,015.21
Rate for Payer: Cigna Medicaid	$12,015.21
Rate for Payer: Molina CHIP/Medicaid	$12,015.21
Rate for Payer: Parkland Medicaid	$12,015.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,743.71

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$8,774.17

Service Code	APR-DRG 3632
Min. Negotiated Rate	$8,272.60
Max. Negotiated Rate	$8,774.17
Rate for Payer: Amerigroup CHIP/Medicaid	$8,272.60
Rate for Payer: Cigna Medicaid	$8,272.60
Rate for Payer: Molina CHIP/Medicaid	$8,272.60
Rate for Payer: Parkland Medicaid	$8,272.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,774.17

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$4,487.42

Service Code	APR-DRG 3631
Min. Negotiated Rate	$4,230.89
Max. Negotiated Rate	$4,487.42
Rate for Payer: Amerigroup CHIP/Medicaid	$4,230.89
Rate for Payer: Cigna Medicaid	$4,230.89
Rate for Payer: Molina CHIP/Medicaid	$4,230.89
Rate for Payer: Parkland Medicaid	$4,230.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,487.42

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$17,232.26

Service Code	APR-DRG 3634
Min. Negotiated Rate	$16,247.18
Max. Negotiated Rate	$17,232.26
Rate for Payer: Amerigroup CHIP/Medicaid	$16,247.18
Rate for Payer: Cigna Medicaid	$16,247.18
Rate for Payer: Molina CHIP/Medicaid	$16,247.18
Rate for Payer: Parkland Medicaid	$16,247.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,232.26

breast shields personal fit- 1pr

Facility

$21.27

Hospital Charge Code	144475
Hospital Revenue Code	272
Rate for Payer: Cash Price	$14.46

breast shields personal fit- 1pr

Facility

$21.27

Hospital Charge Code	144475
Hospital Revenue Code	272
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$15.31
Rate for Payer: Amerigroup CHIP/Medicaid	$1.91
Rate for Payer: BCBS of TX Blue Advantage	$6.38
Rate for Payer: BCBS of TX Blue Essentials	$7.66
Rate for Payer: BCBS of TX PPO	$8.51
Rate for Payer: Cash Price	$14.46
Rate for Payer: Cigna Medicaid	$15.31
Rate for Payer: Molina CHIP/Medicaid	$15.31
Rate for Payer: Multiplan Auto	$13.83
Rate for Payer: Multiplan Commercial	$13.83
Rate for Payer: Multiplan Workers Comp	$13.83
Rate for Payer: Parkland Medicaid	$15.31
Rate for Payer: Scott and White EPO/PPO	$10.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.31
Rate for Payer: Superior Health Plan EPO	$2.89

breather

Facility

$5.59

Hospital Charge Code	993280
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.80

breather

Facility

$5.59

Hospital Charge Code	993280
Hospital Revenue Code	270
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$4.02
Rate for Payer: Amerigroup CHIP/Medicaid	$0.50
Rate for Payer: BCBS of TX Blue Advantage	$1.68
Rate for Payer: BCBS of TX Blue Essentials	$2.01
Rate for Payer: BCBS of TX PPO	$2.24
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cigna Medicaid	$4.02
Rate for Payer: Molina CHIP/Medicaid	$4.02
Rate for Payer: Multiplan Auto	$3.63
Rate for Payer: Multiplan Commercial	$3.63
Rate for Payer: Multiplan Workers Comp	$3.63
Rate for Payer: Parkland Medicaid	$4.02
Rate for Payer: Scott and White EPO/PPO	$2.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.02
Rate for Payer: Superior Health Plan EPO	$0.76

BREEZA, 160Z,F/ USE WITH CONTRAST

Facility

$20.48

Hospital Charge Code	993237
Hospital Revenue Code	270
Rate for Payer: Cash Price	$13.93

BREEZA, 160Z,F/ USE WITH CONTRAST

Facility

$20.48

Hospital Charge Code	993237
Hospital Revenue Code	270
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$14.75
Rate for Payer: Amerigroup CHIP/Medicaid	$1.84
Rate for Payer: BCBS of TX Blue Advantage	$6.14
Rate for Payer: BCBS of TX Blue Essentials	$7.37
Rate for Payer: BCBS of TX PPO	$8.19
Rate for Payer: Cash Price	$13.93
Rate for Payer: Cigna Medicaid	$14.75
Rate for Payer: Molina CHIP/Medicaid	$14.75
Rate for Payer: Multiplan Auto	$13.31
Rate for Payer: Multiplan Commercial	$13.31
Rate for Payer: Multiplan Workers Comp	$13.31
Rate for Payer: Parkland Medicaid	$14.75
Rate for Payer: Scott and White EPO/PPO	$10.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.75
Rate for Payer: Superior Health Plan EPO	$2.79

BRIEF ADULT FITRIGHT XTRA INCONTINEN.LARGE

Facility

$16.92

Hospital Charge Code	993266
Hospital Revenue Code	270
Rate for Payer: Cash Price	$11.51

BRIEF ADULT FITRIGHT XTRA INCONTINEN.LARGE

Facility

$16.92

Hospital Charge Code	993266
Hospital Revenue Code	270
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$12.18
Rate for Payer: Amerigroup CHIP/Medicaid	$1.52
Rate for Payer: BCBS of TX Blue Advantage	$5.08
Rate for Payer: BCBS of TX Blue Essentials	$6.09
Rate for Payer: BCBS of TX PPO	$6.77
Rate for Payer: Cash Price	$11.51
Rate for Payer: Cigna Medicaid	$12.18
Rate for Payer: Molina CHIP/Medicaid	$12.18
Rate for Payer: Multiplan Auto	$11.00
Rate for Payer: Multiplan Commercial	$11.00
Rate for Payer: Multiplan Workers Comp	$11.00
Rate for Payer: Parkland Medicaid	$12.18
Rate for Payer: Scott and White EPO/PPO	$8.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.18
Rate for Payer: Superior Health Plan EPO	$2.30

brimonidine 0.1% Ophth Soln 5 mL

Facility

$332.49

Service Code	HCPCS J3490
Hospital Charge Code	77414960
Hospital Revenue Code	250
Rate for Payer: Cash Price	$226.09

brimonidine 0.1% Ophth Soln 5 mL

Facility

$332.49

Service Code	HCPCS J3490
Hospital Charge Code	77414960
Hospital Revenue Code	250
Min. Negotiated Rate	$29.92
Max. Negotiated Rate	$239.39
Rate for Payer: Amerigroup CHIP/Medicaid	$29.92
Rate for Payer: BCBS of TX Blue Advantage	$99.75
Rate for Payer: BCBS of TX Blue Essentials	$119.70
Rate for Payer: BCBS of TX PPO	$133.00
Rate for Payer: Cash Price	$226.09
Rate for Payer: Cigna Medicaid	$239.39
Rate for Payer: Molina CHIP/Medicaid	$239.39
Rate for Payer: Multiplan Auto	$216.12
Rate for Payer: Multiplan Commercial	$216.12
Rate for Payer: Multiplan Workers Comp	$216.12
Rate for Payer: Parkland Medicaid	$239.39
Rate for Payer: Scott and White EPO/PPO	$166.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$239.39
Rate for Payer: Superior Health Plan EPO	$45.22

BRONCHIOLITIS AND RSV PNEUMONIA

Facility

$3,709.65

Service Code	APR-DRG 1383
Min. Negotiated Rate	$3,497.59
Max. Negotiated Rate	$3,709.65
Rate for Payer: Amerigroup CHIP/Medicaid	$3,497.59
Rate for Payer: Cigna Medicaid	$3,497.59
Rate for Payer: Molina CHIP/Medicaid	$3,497.59
Rate for Payer: Parkland Medicaid	$3,497.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,709.65

BRONCHIOLITIS AND RSV PNEUMONIA

Facility

$1,557.79

Service Code	APR-DRG 1381
Min. Negotiated Rate	$1,468.74
Max. Negotiated Rate	$1,557.79
Rate for Payer: Amerigroup CHIP/Medicaid	$1,468.74
Rate for Payer: Cigna Medicaid	$1,468.74
Rate for Payer: Molina CHIP/Medicaid	$1,468.74
Rate for Payer: Parkland Medicaid	$1,468.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,557.79

BRONCHIOLITIS AND RSV PNEUMONIA

Facility

$2,171.85

Service Code	APR-DRG 1382
Min. Negotiated Rate	$2,047.70
Max. Negotiated Rate	$2,171.85
Rate for Payer: Amerigroup CHIP/Medicaid	$2,047.70
Rate for Payer: Cigna Medicaid	$2,047.70
Rate for Payer: Molina CHIP/Medicaid	$2,047.70
Rate for Payer: Parkland Medicaid	$2,047.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,171.85

BRONCHIOLITIS AND RSV PNEUMONIA

Facility

$8,292.12

Service Code	APR-DRG 1384
Min. Negotiated Rate	$7,818.10
Max. Negotiated Rate	$8,292.12
Rate for Payer: Amerigroup CHIP/Medicaid	$7,818.10
Rate for Payer: Cigna Medicaid	$7,818.10
Rate for Payer: Molina CHIP/Medicaid	$7,818.10
Rate for Payer: Parkland Medicaid	$7,818.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,292.12

BRONCHITIS AND ASTHMA WITH CC/MCC

Facility

$18,452.80

Service Code	MSDRG 202
Min. Negotiated Rate	$8,084.86
Max. Negotiated Rate	$18,452.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,878.04
Rate for Payer: Amerigroup Medicare	$11,878.04
Rate for Payer: BCBS of TX Medicare	$11,878.04
Rate for Payer: Cigna Commercial	$12,509.06
Rate for Payer: Cigna Medicare	$11,878.04
Rate for Payer: Employer Direct Commercial	$11,878.04
Rate for Payer: Humana Medicare/TRICARE	$11,878.04
Rate for Payer: Molina Dual Medicare/Medicaid	$11,878.04
Rate for Payer: Molina Medicare	$11,878.04
Rate for Payer: Multiplan Auto	$18,452.80
Rate for Payer: Multiplan Commercial	$18,452.80
Rate for Payer: Multiplan Workers Comp	$18,452.80
Rate for Payer: Scott and White EPO/PPO	$8,498.00
Rate for Payer: Scott and White Medicare	$11,878.04
Rate for Payer: Superior Health Plan EPO	$11,878.04
Rate for Payer: Superior Health Plan Medicare	$11,878.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,878.04
Rate for Payer: Universal American Medicare	$11,878.04
Rate for Payer: Wellcare Medicare	$11,878.04
Rate for Payer: Wellmed Medicare	$11,878.04

BRONCHITIS AND ASTHMA WITHOUT CC/MCC

Facility

$12,730.00

Service Code	MSDRG 203
Min. Negotiated Rate	$5,862.50
Max. Negotiated Rate	$12,730.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,670.52
Rate for Payer: Amerigroup Medicare	$9,670.52
Rate for Payer: BCBS of TX Medicare	$9,670.52
Rate for Payer: Cigna Commercial	$8,629.60
Rate for Payer: Cigna Medicare	$9,670.52
Rate for Payer: Employer Direct Commercial	$9,670.52
Rate for Payer: Humana Medicare/TRICARE	$9,670.52
Rate for Payer: Molina Dual Medicare/Medicaid	$9,670.52
Rate for Payer: Molina Medicare	$9,670.52
Rate for Payer: Multiplan Auto	$12,730.00
Rate for Payer: Multiplan Commercial	$12,730.00
Rate for Payer: Multiplan Workers Comp	$12,730.00
Rate for Payer: Scott and White EPO/PPO	$5,862.50
Rate for Payer: Scott and White Medicare	$9,670.52
Rate for Payer: Superior Health Plan EPO	$9,670.52
Rate for Payer: Superior Health Plan Medicare	$9,670.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,670.52
Rate for Payer: Universal American Medicare	$9,670.52
Rate for Payer: Wellcare Medicare	$9,670.52
Rate for Payer: Wellmed Medicare	$9,670.52

BRONCHITIS & ASTHMA W CC/MCC

Facility

$18,452.80

Service Code	MSDRG 202
Min. Negotiated Rate	$8,084.86
Max. Negotiated Rate	$18,452.80
Rate for Payer: BCBS of TX Blue Advantage	$8,084.86
Rate for Payer: BCBS of TX Blue Essentials	$9,700.89
Rate for Payer: BCBS of TX PPO	$10,779.19

BRONCHITIS & ASTHMA W/O CC/MCC

Facility

$12,730.00

Service Code	MSDRG 203
Min. Negotiated Rate	$5,862.50
Max. Negotiated Rate	$12,730.00
Rate for Payer: BCBS of TX Blue Advantage	$5,994.20
Rate for Payer: BCBS of TX Blue Essentials	$7,192.34
Rate for Payer: BCBS of TX PPO	$7,991.80

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed diagnostic, with c

Facility

$3,740.98

Service Code	HCPCS 31622
Hospital Charge Code	9900621
Hospital Revenue Code	360
Min. Negotiated Rate	$525.71
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Amerigroup Medicare	$1,788.01
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,788.01
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cash Price	$2,543.87
Rate for Payer: Cash Price	$2,543.87
Rate for Payer: Cash Price	$2,543.87
Rate for Payer: Cigna Commercial	$3,779.52
Rate for Payer: Cigna Medicaid	$2,693.51
Rate for Payer: Cigna Medicare	$1,788.01
Rate for Payer: Employer Direct Commercial	$1,788.01
Rate for Payer: Humana Medicare/TRICARE	$1,788.01
Rate for Payer: Molina CHIP/Medicaid	$2,693.51
Rate for Payer: Molina Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Molina Medicare	$1,788.01
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	$2,693.51
Rate for Payer: Scott and White EPO/PPO	$3,307.82
Rate for Payer: Scott and White Medicare	$1,788.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,693.51
Rate for Payer: Superior Health Plan EPO	$1,788.01
Rate for Payer: Superior Health Plan Medicare	$1,788.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Universal American Medicare	$1,788.01
Rate for Payer: Wellcare Medicare	$1,788.01
Rate for Payer: Wellmed Medicare	$1,788.01

Know your out-of-pocket cost for care.

All Charges