White Rock Medical Center

All Charges

Charge

Type

Setting

Price

albuterol 2.5 mg/3 mL (0.083%) Inh Soln 3 mL

Facility

$128.17

Service Code	HCPCS J7613
Hospital Charge Code	78403337
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.12
Rate for Payer: BCBS of TX Blue Essentials	$0.14
Rate for Payer: BCBS of TX PPO	$0.15
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

albuterol 5 mg/mL (0.5%) Inh Soln

Facility

$7.65

Service Code	HCPCS J7611
Hospital Charge Code	7441648
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.82
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.82

albuterol 5 mg/mL (0.5%) Inh Soln

Facility

$7.65

Service Code	HCPCS J7611
Hospital Charge Code	7441648
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.15
Rate for Payer: BCBS of TX Blue Essentials	$0.17
Rate for Payer: BCBS of TX PPO	$0.19
Rate for Payer: Cash Price	$5.20
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

albuterol CFC free 90 mcg/inh Aerosol 6.7 g

Facility

$42.00

Service Code	HCPCS J7612
Hospital Charge Code	1212
Hospital Revenue Code	636
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$21.00
Rate for Payer: Cash Price	$28.56
Rate for Payer: Cigna Commercial	$10.50
Rate for Payer: Scott and White EPO/PPO	$21.00

albuterol CFC free 90 mcg/inh Aerosol 6.7 g

Facility

$42.00

Service Code	HCPCS J7612
Hospital Charge Code	1212
Hospital Revenue Code	636
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$27.30
Rate for Payer: Amerigroup CHIP/Medicaid	$3.78
Rate for Payer: BCBS of TX Blue Advantage	$2.23
Rate for Payer: BCBS of TX Blue Essentials	$2.68
Rate for Payer: BCBS of TX PPO	$2.97
Rate for Payer: Cash Price	$28.56
Rate for Payer: Cash Price	$28.56
Rate for Payer: Multiplan Auto	$27.30
Rate for Payer: Multiplan Commercial	$27.30
Rate for Payer: Multiplan Workers Comp	$27.30
Rate for Payer: Scott and White EPO/PPO	$21.00
Rate for Payer: Superior Health Plan EPO	$5.71

albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Inh Soln 3 mL

Facility

$7.65

Service Code	HCPCS J7620
Hospital Charge Code	7441656
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Inh Soln 3 mL

Facility

$7.65

Service Code	HCPCS J7620
Hospital Charge Code	7441656
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.35
Rate for Payer: BCBS of TX Blue Essentials	$0.42
Rate for Payer: BCBS of TX PPO	$0.46
Rate for Payer: Cash Price	$5.20
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

albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Inh Soln 3 mL

Facility

$8.00

Service Code	HCPCS J7620
Hospital Charge Code	77360082
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$0.35
Rate for Payer: BCBS of TX Blue Essentials	$0.42
Rate for Payer: BCBS of TX PPO	$0.46
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Inh Soln 3 mL

Facility

$8.00

Service Code	HCPCS J7620
Hospital Charge Code	77360082
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA

Facility

$10,915.50

Service Code	MSDRG 894
Min. Negotiated Rate	$4,172.72
Max. Negotiated Rate	$10,915.50
Rate for Payer: Aetna Commercial	$6,463.12
Rate for Payer: Aetna Medicare	$10,431.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,954.45
Rate for Payer: Amerigroup Medicare	$6,954.45
Rate for Payer: BCBS of TX Blue Advantage	$4,172.72
Rate for Payer: BCBS of TX Blue Essentials	$5,333.89
Rate for Payer: BCBS of TX Medicare	$6,954.45
Rate for Payer: BCBS of TX PPO	$5,926.78
Rate for Payer: Cigna Commercial	$7,399.56
Rate for Payer: Cigna Medicare	$6,954.45
Rate for Payer: Employer Direct Commercial	$6,954.45
Rate for Payer: Molina Dual Medicare/Medicaid	$6,954.45
Rate for Payer: Molina Medicare	$6,954.45
Rate for Payer: Multiplan Auto	$10,915.50
Rate for Payer: Multiplan Commercial	$10,915.50
Rate for Payer: Multiplan Workers Comp	$10,915.50
Rate for Payer: Scott and White EPO/PPO	$5,026.88
Rate for Payer: Scott and White Medicare	$6,954.45
Rate for Payer: Superior Health Plan EPO	$6,954.45
Rate for Payer: Superior Health Plan Medicare	$6,954.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,954.45
Rate for Payer: Universal American Medicare	$6,954.45
Rate for Payer: Wellcare Medicare	$6,954.45
Rate for Payer: Wellmed Medicare	$6,954.45

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC

Facility

$33,783.90

Service Code	MSDRG 896
Min. Negotiated Rate	$13,844.28
Max. Negotiated Rate	$33,783.90
Rate for Payer: Aetna Commercial	$20,003.62
Rate for Payer: Aetna Medicare	$23,315.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,543.41
Rate for Payer: Amerigroup Medicare	$15,543.41
Rate for Payer: BCBS of TX Blue Advantage	$13,844.28
Rate for Payer: BCBS of TX Blue Essentials	$18,025.23
Rate for Payer: BCBS of TX Medicare	$15,543.41
Rate for Payer: BCBS of TX PPO	$20,028.81
Rate for Payer: Cigna Commercial	$22,901.93
Rate for Payer: Cigna Medicare	$15,543.41
Rate for Payer: Employer Direct Commercial	$15,543.41
Rate for Payer: Molina Dual Medicare/Medicaid	$15,543.41
Rate for Payer: Molina Medicare	$15,543.41
Rate for Payer: Multiplan Auto	$33,783.90
Rate for Payer: Multiplan Commercial	$33,783.90
Rate for Payer: Multiplan Workers Comp	$33,783.90
Rate for Payer: Scott and White EPO/PPO	$15,558.38
Rate for Payer: Scott and White Medicare	$15,543.41
Rate for Payer: Superior Health Plan EPO	$15,543.41
Rate for Payer: Superior Health Plan Medicare	$15,543.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,543.41
Rate for Payer: Universal American Medicare	$15,543.41
Rate for Payer: Wellcare Medicare	$15,543.41
Rate for Payer: Wellmed Medicare	$15,543.41

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC

Facility

$16,256.40

Service Code	MSDRG 897
Min. Negotiated Rate	$6,433.66
Max. Negotiated Rate	$16,256.40
Rate for Payer: Aetna Commercial	$9,625.50
Rate for Payer: Aetna Medicare	$13,440.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,960.40
Rate for Payer: Amerigroup Medicare	$8,960.40
Rate for Payer: BCBS of TX Blue Advantage	$6,433.66
Rate for Payer: BCBS of TX Blue Essentials	$8,469.84
Rate for Payer: BCBS of TX Medicare	$8,960.40
Rate for Payer: BCBS of TX PPO	$9,411.29
Rate for Payer: Cigna Commercial	$11,020.13
Rate for Payer: Cigna Medicare	$8,960.40
Rate for Payer: Employer Direct Commercial	$8,960.40
Rate for Payer: Molina Dual Medicare/Medicaid	$8,960.40
Rate for Payer: Molina Medicare	$8,960.40
Rate for Payer: Multiplan Auto	$16,256.40
Rate for Payer: Multiplan Commercial	$16,256.40
Rate for Payer: Multiplan Workers Comp	$16,256.40
Rate for Payer: Scott and White EPO/PPO	$7,486.50
Rate for Payer: Scott and White Medicare	$8,960.40
Rate for Payer: Superior Health Plan EPO	$8,960.40
Rate for Payer: Superior Health Plan Medicare	$8,960.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,960.40
Rate for Payer: Universal American Medicare	$8,960.40
Rate for Payer: Wellcare Medicare	$8,960.40
Rate for Payer: Wellmed Medicare	$8,960.40

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY

Facility

$30,567.20

Service Code	MSDRG 895
Min. Negotiated Rate	$11,106.04
Max. Negotiated Rate	$30,567.20
Rate for Payer: Aetna Commercial	$18,099.00
Rate for Payer: Aetna Medicare	$21,502.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,335.28
Rate for Payer: Amerigroup Medicare	$14,335.28
Rate for Payer: BCBS of TX Blue Advantage	$11,106.04
Rate for Payer: BCBS of TX Blue Essentials	$14,785.06
Rate for Payer: BCBS of TX Medicare	$14,335.28
Rate for Payer: BCBS of TX PPO	$16,428.48
Rate for Payer: Cigna Commercial	$20,721.34
Rate for Payer: Cigna Medicare	$14,335.28
Rate for Payer: Employer Direct Commercial	$14,335.28
Rate for Payer: Humana Medicare/TRICARE	$14,335.28
Rate for Payer: Molina Dual Medicare/Medicaid	$14,335.28
Rate for Payer: Molina Medicare	$14,335.28
Rate for Payer: Multiplan Auto	$30,567.20
Rate for Payer: Multiplan Commercial	$30,567.20
Rate for Payer: Multiplan Workers Comp	$30,567.20
Rate for Payer: Scott and White EPO/PPO	$14,077.00
Rate for Payer: Scott and White Medicare	$14,335.28
Rate for Payer: Superior Health Plan EPO	$14,335.28
Rate for Payer: Superior Health Plan Medicare	$14,335.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,335.28
Rate for Payer: Universal American Medicare	$14,335.28
Rate for Payer: Wellcare Medicare	$14,335.28
Rate for Payer: Wellmed Medicare	$14,335.28

Alcohol Level

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640107
Hospital Revenue Code	300
Rate for Payer: Cash Price	$278.96

Alcohol Level

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640107
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$206.05
Rate for Payer: Aetna Commercial	$65.24
Rate for Payer: Aetna Medicare	$93.21
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$102.53
Rate for Payer: BCBS of TX Blue Essentials	$123.04
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$137.33
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cigna Medicaid	$62.14
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$62.14
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$62.14
Rate for Payer: Scott and White EPO/PPO	$77.68
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.14
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

Aldolase SO

Facility

$204.00

Service Code	CPT 82085
Hospital Charge Code	1701150
Hospital Revenue Code	301
Rate for Payer: Cash Price	$179.52

Aldolase SO

Facility

$204.00

Service Code	CPT 82085
Hospital Charge Code	1701150
Hospital Revenue Code	301
Min. Negotiated Rate	$3.79
Max. Negotiated Rate	$132.60
Rate for Payer: Aetna Commercial	$10.20
Rate for Payer: Aetna Medicare	$14.56
Rate for Payer: Amerigroup CHIP/Medicaid	$3.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.71
Rate for Payer: Amerigroup Medicare	$9.71
Rate for Payer: BCBS of TX Blue Advantage	$16.02
Rate for Payer: BCBS of TX Blue Essentials	$19.23
Rate for Payer: BCBS of TX Medicare	$9.71
Rate for Payer: BCBS of TX PPO	$21.46
Rate for Payer: Cash Price	$179.52
Rate for Payer: Cash Price	$179.52
Rate for Payer: Cigna Medicaid	$9.71
Rate for Payer: Cigna Medicare	$9.71
Rate for Payer: Employer Direct Commercial	$9.71
Rate for Payer: Humana Medicare/TRICARE	$9.71
Rate for Payer: Molina CHIP/Medicaid	$9.71
Rate for Payer: Molina Dual Medicare/Medicaid	$9.71
Rate for Payer: Molina Medicare	$9.71
Rate for Payer: Multiplan Auto	$132.60
Rate for Payer: Multiplan Commercial	$132.60
Rate for Payer: Multiplan Workers Comp	$132.60
Rate for Payer: Parkland Medicaid	$9.71
Rate for Payer: Scott and White EPO/PPO	$12.14
Rate for Payer: Scott and White Medicare	$9.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.71
Rate for Payer: Superior Health Plan EPO	$9.71
Rate for Payer: Superior Health Plan Medicare	$9.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.71
Rate for Payer: Universal American Medicare	$9.71
Rate for Payer: Wellcare Medicare	$9.71
Rate for Payer: Wellmed Medicare	$9.71

Aldosterone LCMS, Serum SO

Facility

$552.00

Service Code	CPT 82088
Hospital Charge Code	1701168
Hospital Revenue Code	301
Min. Negotiated Rate	$15.89
Max. Negotiated Rate	$358.80
Rate for Payer: Aetna Commercial	$42.79
Rate for Payer: Aetna Medicare	$61.12
Rate for Payer: Amerigroup CHIP/Medicaid	$15.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$40.75
Rate for Payer: Amerigroup Medicare	$40.75
Rate for Payer: BCBS of TX Blue Advantage	$67.24
Rate for Payer: BCBS of TX Blue Essentials	$80.68
Rate for Payer: BCBS of TX Medicare	$40.75
Rate for Payer: BCBS of TX PPO	$90.06
Rate for Payer: Cash Price	$485.76
Rate for Payer: Cash Price	$485.76
Rate for Payer: Cigna Medicaid	$40.75
Rate for Payer: Cigna Medicare	$40.75
Rate for Payer: Employer Direct Commercial	$40.75
Rate for Payer: Humana Medicare/TRICARE	$40.75
Rate for Payer: Molina CHIP/Medicaid	$40.75
Rate for Payer: Molina Dual Medicare/Medicaid	$40.75
Rate for Payer: Molina Medicare	$40.75
Rate for Payer: Multiplan Auto	$358.80
Rate for Payer: Multiplan Commercial	$358.80
Rate for Payer: Multiplan Workers Comp	$358.80
Rate for Payer: Parkland Medicaid	$40.75
Rate for Payer: Scott and White EPO/PPO	$50.94
Rate for Payer: Scott and White Medicare	$40.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.75
Rate for Payer: Superior Health Plan EPO	$40.75
Rate for Payer: Superior Health Plan Medicare	$40.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$40.75
Rate for Payer: Universal American Medicare	$40.75
Rate for Payer: Wellcare Medicare	$40.75
Rate for Payer: Wellmed Medicare	$40.75

Aldosterone LCMS, Serum SO

Facility

$552.00

Service Code	CPT 82088
Hospital Charge Code	1701168
Hospital Revenue Code	301
Rate for Payer: Cash Price	$485.76

alendronate 70 mg Tab

Facility

$147.00

Service Code	HCPCS J3490
Hospital Charge Code	77360934
Hospital Revenue Code	250
Min. Negotiated Rate	$13.23
Max. Negotiated Rate	$95.55
Rate for Payer: Amerigroup CHIP/Medicaid	$13.23
Rate for Payer: BCBS of TX Blue Advantage	$44.10
Rate for Payer: BCBS of TX Blue Essentials	$52.92
Rate for Payer: BCBS of TX PPO	$58.80
Rate for Payer: Cash Price	$99.96
Rate for Payer: Multiplan Auto	$95.55
Rate for Payer: Multiplan Commercial	$95.55
Rate for Payer: Multiplan Workers Comp	$95.55
Rate for Payer: Scott and White EPO/PPO	$73.50
Rate for Payer: Superior Health Plan EPO	$19.99

alendronate 70 mg Tab

Facility

$147.00

Service Code	HCPCS J3490
Hospital Charge Code	77360934
Hospital Revenue Code	250
Rate for Payer: Cash Price	$99.96

alif 27x15 interbody cage

Facility

$26,096.39

Service Code	HCPCS C1713
Hospital Charge Code	8672533
Hospital Revenue Code	278
Min. Negotiated Rate	$6,524.10
Max. Negotiated Rate	$13,048.20
Rate for Payer: Aetna Commercial	$7,828.92
Rate for Payer: Cash Price	$22,964.82
Rate for Payer: Cigna Commercial	$6,524.10
Rate for Payer: Multiplan Auto	$13,048.20
Rate for Payer: Multiplan Commercial	$13,048.20
Rate for Payer: Multiplan Workers Comp	$13,048.20
Rate for Payer: Scott and White EPO/PPO	$13,048.20

alif 27x15 interbody cage

Facility

$26,096.39

Service Code	HCPCS C1713
Hospital Charge Code	8672533
Hospital Revenue Code	278
Min. Negotiated Rate	$2,348.68
Max. Negotiated Rate	$13,048.20
Rate for Payer: Aetna Commercial	$7,828.92
Rate for Payer: Amerigroup CHIP/Medicaid	$2,348.68
Rate for Payer: BCBS of TX Blue Advantage	$7,828.92
Rate for Payer: BCBS of TX Blue Essentials	$9,394.70
Rate for Payer: BCBS of TX PPO	$10,438.56
Rate for Payer: Cash Price	$22,964.82
Rate for Payer: Multiplan Auto	$13,048.20
Rate for Payer: Multiplan Commercial	$13,048.20
Rate for Payer: Multiplan Workers Comp	$13,048.20
Rate for Payer: Scott and White EPO/PPO	$13,048.20
Rate for Payer: Superior Health Plan EPO	$3,549.11

alif 32x24 interbody cage

Facility

$26,096.39

Service Code	HCPCS C1713
Hospital Charge Code	8672537
Hospital Revenue Code	278
Min. Negotiated Rate	$6,524.10
Max. Negotiated Rate	$13,048.20
Rate for Payer: Aetna Commercial	$7,828.92
Rate for Payer: Cash Price	$22,964.82
Rate for Payer: Cigna Commercial	$6,524.10
Rate for Payer: Multiplan Auto	$13,048.20
Rate for Payer: Multiplan Commercial	$13,048.20
Rate for Payer: Multiplan Workers Comp	$13,048.20
Rate for Payer: Scott and White EPO/PPO	$13,048.20

alif 32x24 interbody cage

Facility

$26,096.39

Service Code	HCPCS C1713
Hospital Charge Code	8672537
Hospital Revenue Code	278
Min. Negotiated Rate	$2,348.68
Max. Negotiated Rate	$13,048.20
Rate for Payer: Aetna Commercial	$7,828.92
Rate for Payer: Amerigroup CHIP/Medicaid	$2,348.68
Rate for Payer: BCBS of TX Blue Advantage	$7,828.92
Rate for Payer: BCBS of TX Blue Essentials	$9,394.70
Rate for Payer: BCBS of TX PPO	$10,438.56
Rate for Payer: Cash Price	$22,964.82
Rate for Payer: Multiplan Auto	$13,048.20
Rate for Payer: Multiplan Commercial	$13,048.20
Rate for Payer: Multiplan Workers Comp	$13,048.20
Rate for Payer: Scott and White EPO/PPO	$13,048.20
Rate for Payer: Superior Health Plan EPO	$3,549.11

Know your out-of-pocket cost for care.

All Charges