White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DIABETES WITH CC

Facility

$17,088.60

Service Code	MSDRG 638
Min. Negotiated Rate	$7,208.52
Max. Negotiated Rate	$17,088.60
Rate for Payer: Aetna Commercial	$10,118.25
Rate for Payer: Aetna Medicare	$13,909.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,272.95
Rate for Payer: Amerigroup Medicare	$9,272.95
Rate for Payer: BCBS of TX Blue Advantage	$7,208.52
Rate for Payer: BCBS of TX Blue Essentials	$9,000.23
Rate for Payer: BCBS of TX Medicare	$9,272.95
Rate for Payer: BCBS of TX PPO	$10,000.65
Rate for Payer: Cigna Commercial	$11,584.27
Rate for Payer: Cigna Medicare	$9,272.95
Rate for Payer: Employer Direct Commercial	$9,272.95
Rate for Payer: Humana Medicare/TRICARE	$9,272.95
Rate for Payer: Molina Dual Medicare/Medicaid	$9,272.95
Rate for Payer: Molina Medicare	$9,272.95
Rate for Payer: Multiplan Auto	$17,088.60
Rate for Payer: Multiplan Commercial	$17,088.60
Rate for Payer: Multiplan Workers Comp	$17,088.60
Rate for Payer: Scott and White EPO/PPO	$7,869.75
Rate for Payer: Scott and White Medicare	$9,272.95
Rate for Payer: Superior Health Plan EPO	$9,272.95
Rate for Payer: Superior Health Plan Medicare	$9,272.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,272.95
Rate for Payer: Universal American Medicare	$9,272.95
Rate for Payer: Wellcare Medicare	$9,272.95
Rate for Payer: Wellmed Medicare	$9,272.95

DIABETES WITH MCC

Facility

$27,536.70

Service Code	MSDRG 637
Min. Negotiated Rate	$11,667.62
Max. Negotiated Rate	$27,536.70
Rate for Payer: Aetna Commercial	$16,304.62
Rate for Payer: Aetna Medicare	$19,795.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,197.06
Rate for Payer: Amerigroup Medicare	$13,197.06
Rate for Payer: BCBS of TX Blue Advantage	$11,667.62
Rate for Payer: BCBS of TX Blue Essentials	$14,253.63
Rate for Payer: BCBS of TX Medicare	$13,197.06
Rate for Payer: BCBS of TX PPO	$15,837.99
Rate for Payer: Cigna Commercial	$18,666.98
Rate for Payer: Cigna Medicare	$13,197.06
Rate for Payer: Employer Direct Commercial	$13,197.06
Rate for Payer: Humana Medicare/TRICARE	$13,197.06
Rate for Payer: Molina Dual Medicare/Medicaid	$13,197.06
Rate for Payer: Molina Medicare	$13,197.06
Rate for Payer: Multiplan Auto	$27,536.70
Rate for Payer: Multiplan Commercial	$27,536.70
Rate for Payer: Multiplan Workers Comp	$27,536.70
Rate for Payer: Scott and White EPO/PPO	$12,681.38
Rate for Payer: Scott and White Medicare	$13,197.06
Rate for Payer: Superior Health Plan EPO	$13,197.06
Rate for Payer: Superior Health Plan Medicare	$13,197.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,197.06
Rate for Payer: Universal American Medicare	$13,197.06
Rate for Payer: Wellcare Medicare	$13,197.06
Rate for Payer: Wellmed Medicare	$13,197.06

DIABETES WITHOUT CC/MCC

Facility

$11,827.50

Service Code	MSDRG 639
Min. Negotiated Rate	$5,135.92
Max. Negotiated Rate	$11,827.50
Rate for Payer: Aetna Commercial	$7,003.12
Rate for Payer: Aetna Medicare	$10,945.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,296.98
Rate for Payer: Amerigroup Medicare	$7,296.98
Rate for Payer: BCBS of TX Blue Advantage	$5,135.92
Rate for Payer: BCBS of TX Blue Essentials	$6,520.58
Rate for Payer: BCBS of TX Medicare	$7,296.98
Rate for Payer: BCBS of TX PPO	$7,245.37
Rate for Payer: Cigna Commercial	$8,017.80
Rate for Payer: Cigna Medicare	$7,296.98
Rate for Payer: Employer Direct Commercial	$7,296.98
Rate for Payer: Humana Medicare/TRICARE	$7,296.98
Rate for Payer: Molina Dual Medicare/Medicaid	$7,296.98
Rate for Payer: Molina Medicare	$7,296.98
Rate for Payer: Multiplan Auto	$11,827.50
Rate for Payer: Multiplan Commercial	$11,827.50
Rate for Payer: Multiplan Workers Comp	$11,827.50
Rate for Payer: Scott and White EPO/PPO	$5,446.88
Rate for Payer: Scott and White Medicare	$7,296.98
Rate for Payer: Superior Health Plan EPO	$7,296.98
Rate for Payer: Superior Health Plan Medicare	$7,296.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,296.98
Rate for Payer: Universal American Medicare	$7,296.98
Rate for Payer: Wellcare Medicare	$7,296.98
Rate for Payer: Wellmed Medicare	$7,296.98

Diagnostic bone marrow aspiration(s)

Facility

$10,000.00

Service Code	CPT 38220
Hospital Charge Code	36038220
Hospital Revenue Code	360
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$92.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
Rate for Payer: BCBS of TX Blue Advantage	$204.31
Rate for Payer: BCBS of TX Blue Essentials	$244.68
Rate for Payer: BCBS of TX Medicare	$1,482.74
Rate for Payer: BCBS of TX PPO	$308.30
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$92.74
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$92.74
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
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	$92.74
Rate for Payer: Scott and White EPO/PPO	$32.70
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.74
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

DIALYSIS CIRCUIT EMBOLJ

Facility

$10,870.00

Service Code	CPT 36909
Hospital Charge Code	2351108
Hospital Revenue Code	360
Min. Negotiated Rate	$978.30
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$5,978.50
Rate for Payer: Amerigroup CHIP/Medicaid	$978.30
Rate for Payer: Cash Price	$9,565.60
Rate for Payer: Cash Price	$9,565.60
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	$5,435.00
Rate for Payer: Superior Health Plan EPO	$1,478.32

DIALYSIS CIRCUIT EMBOLJ

Facility

$10,870.00

Service Code	CPT 36909
Hospital Charge Code	2351108
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,565.60

Dialysis Treatment Complete BCE

Facility

$5,866.00

Service Code	CPT 90945
Hospital Charge Code	810001
Hospital Revenue Code	804
Min. Negotiated Rate	$7.24
Max. Negotiated Rate	$3,812.90
Rate for Payer: Aetna Commercial	$3,226.30
Rate for Payer: Aetna Medicare	$607.59
Rate for Payer: Amerigroup CHIP/Medicaid	$527.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$405.06
Rate for Payer: Amerigroup Medicare	$405.06
Rate for Payer: BCBS of TX Blue Advantage	$1,759.80
Rate for Payer: BCBS of TX Blue Essentials	$2,111.76
Rate for Payer: BCBS of TX Medicare	$405.06
Rate for Payer: BCBS of TX PPO	$2,346.40
Rate for Payer: Cash Price	$5,162.08
Rate for Payer: Cash Price	$5,162.08
Rate for Payer: Cash Price	$5,162.08
Rate for Payer: Cigna Commercial	$917.59
Rate for Payer: Cigna Medicare	$405.06
Rate for Payer: Employer Direct Commercial	$405.06
Rate for Payer: Humana Medicare/TRICARE	$405.06
Rate for Payer: Molina Dual Medicare/Medicaid	$405.06
Rate for Payer: Molina Medicare	$405.06
Rate for Payer: Multiplan Auto	$3,812.90
Rate for Payer: Multiplan Commercial	$3,812.90
Rate for Payer: Multiplan Workers Comp	$3,812.90
Rate for Payer: Scott and White EPO/PPO	$7.24
Rate for Payer: Scott and White Medicare	$405.06
Rate for Payer: Superior Health Plan EPO	$405.06
Rate for Payer: Superior Health Plan Medicare	$405.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$405.06
Rate for Payer: Universal American Medicare	$405.06
Rate for Payer: Wellcare Medicare	$405.06
Rate for Payer: Wellmed Medicare	$405.06

DIAMOND BACK CARTRIDGE CLASSIC DBP-CART-150CLA145

Facility

$11,350.00

Service Code	HCPCS C1724
Hospital Charge Code	144469
Hospital Revenue Code	272
Min. Negotiated Rate	$1,021.50
Max. Negotiated Rate	$7,377.50
Rate for Payer: Aetna Commercial	$6,242.50
Rate for Payer: Amerigroup CHIP/Medicaid	$1,021.50
Rate for Payer: BCBS of TX Blue Advantage	$3,405.00
Rate for Payer: BCBS of TX Blue Essentials	$4,086.00
Rate for Payer: BCBS of TX PPO	$4,540.00
Rate for Payer: Cash Price	$9,988.00
Rate for Payer: Multiplan Auto	$7,377.50
Rate for Payer: Multiplan Commercial	$7,377.50
Rate for Payer: Multiplan Workers Comp	$7,377.50
Rate for Payer: Scott and White EPO/PPO	$5,675.00
Rate for Payer: Superior Health Plan EPO	$1,543.60

DIAMOND BACK CARTRIDGE CLASSIC DBP-CART-150CLA145

Facility

$11,350.00

Service Code	HCPCS C1724
Hospital Charge Code	144469
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9,988.00

DIAMOND BACK CARTRIDGE MICRO DBP-CART-125MIC145

Facility

$11,350.00

Service Code	HCPCS C1724
Hospital Charge Code	144468
Hospital Revenue Code	272
Min. Negotiated Rate	$1,021.50
Max. Negotiated Rate	$7,377.50
Rate for Payer: Aetna Commercial	$6,242.50
Rate for Payer: Amerigroup CHIP/Medicaid	$1,021.50
Rate for Payer: BCBS of TX Blue Advantage	$3,405.00
Rate for Payer: BCBS of TX Blue Essentials	$4,086.00
Rate for Payer: BCBS of TX PPO	$4,540.00
Rate for Payer: Cash Price	$9,988.00
Rate for Payer: Multiplan Auto	$7,377.50
Rate for Payer: Multiplan Commercial	$7,377.50
Rate for Payer: Multiplan Workers Comp	$7,377.50
Rate for Payer: Scott and White EPO/PPO	$5,675.00
Rate for Payer: Superior Health Plan EPO	$1,543.60

DIAMOND BACK CARTRIDGE MICRO DBP-CART-125MIC145

Facility

$11,350.00

Service Code	HCPCS C1724
Hospital Charge Code	144468
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9,988.00

Diaphragmatic Hernia Repair with Mesh

Facility

$12,180.95

Service Code	CPT 49659
Hospital Charge Code	36049659
Hospital Revenue Code	360
Min. Negotiated Rate	$116.39
Max. Negotiated Rate	$12,180.95
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$7,915.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Amerigroup Medicare	$5,276.92
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$5,276.92
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$11,953.74
Rate for Payer: Cigna Medicare	$5,276.92
Rate for Payer: Employer Direct Commercial	$5,276.92
Rate for Payer: Humana Medicare/TRICARE	$5,276.92
Rate for Payer: Molina Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Molina Medicare	$5,276.92
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	$116.39
Rate for Payer: Scott and White Medicare	$5,276.92
Rate for Payer: Superior Health Plan EPO	$5,276.92
Rate for Payer: Superior Health Plan Medicare	$5,276.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,276.92
Rate for Payer: Universal American Medicare	$5,276.92
Rate for Payer: Wellcare Medicare	$5,276.92
Rate for Payer: Wellmed Medicare	$5,276.92

diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

Facility

$142.00

Service Code	HCPCS Q9963
Hospital Charge Code	77510372
Hospital Revenue Code	255
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$92.30
Rate for Payer: Amerigroup CHIP/Medicaid	$12.78
Rate for Payer: BCBS of TX Blue Advantage	$0.28
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.37
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cash Price	$96.56
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Scott and White EPO/PPO	$71.00
Rate for Payer: Superior Health Plan EPO	$19.31

diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

Facility

$142.00

Service Code	HCPCS Q9963
Hospital Charge Code	77510372
Hospital Revenue Code	255
Rate for Payer: Cash Price	$96.56

diazepam 2 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77510651
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

diazepam 2 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77510651
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

diazepam 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77510806
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

diazepam 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77510806
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

diclofenac 1% Topical Gel 100 g

Facility

$89.98

Service Code	HCPCS J3490
Hospital Charge Code	77511495
Hospital Revenue Code	250
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$58.49
Rate for Payer: Amerigroup CHIP/Medicaid	$8.10
Rate for Payer: BCBS of TX Blue Advantage	$26.99
Rate for Payer: BCBS of TX Blue Essentials	$32.39
Rate for Payer: BCBS of TX PPO	$35.99
Rate for Payer: Cash Price	$61.19
Rate for Payer: Multiplan Auto	$58.49
Rate for Payer: Multiplan Commercial	$58.49
Rate for Payer: Multiplan Workers Comp	$58.49
Rate for Payer: Scott and White EPO/PPO	$44.99
Rate for Payer: Superior Health Plan EPO	$12.24

diclofenac 1% Topical Gel 100 g

Facility

$89.98

Service Code	HCPCS J3490
Hospital Charge Code	77511495
Hospital Revenue Code	250
Rate for Payer: Cash Price	$61.19

dicyclomine 10 mg Cap

Facility

$7.65

Service Code	HCPCS J0500
Hospital Charge Code	77512411
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

dicyclomine 10 mg Cap

Facility

$7.65

Service Code	HCPCS J0500
Hospital Charge Code	77512411
Hospital Revenue Code	636
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$54.19
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$40.72
Rate for Payer: BCBS of TX Blue Essentials	$48.86
Rate for Payer: BCBS of TX PPO	$54.19
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

Diffusion (DLCO)

Facility

$491.00

Service Code	CPT 94729
Hospital Charge Code	4049204
Hospital Revenue Code	460
Min. Negotiated Rate	$44.19
Max. Negotiated Rate	$319.15
Rate for Payer: Aetna Commercial	$270.05
Rate for Payer: Amerigroup CHIP/Medicaid	$44.19
Rate for Payer: BCBS of TX Blue Advantage	$81.52
Rate for Payer: BCBS of TX Blue Essentials	$97.45
Rate for Payer: BCBS of TX PPO	$108.69
Rate for Payer: Cash Price	$432.08
Rate for Payer: Cash Price	$432.08
Rate for Payer: Multiplan Auto	$319.15
Rate for Payer: Multiplan Commercial	$319.15
Rate for Payer: Multiplan Workers Comp	$319.15
Rate for Payer: Scott and White EPO/PPO	$245.50
Rate for Payer: Superior Health Plan EPO	$66.78

Diffusion (DLCO)

Facility

$491.00

Service Code	CPT 94729
Hospital Charge Code	4049204
Hospital Revenue Code	460
Rate for Payer: Cash Price	$432.08

DIGESTIVE MALIGNANCY WITH CC

Facility

$22,767.70

Service Code	MSDRG 375
Min. Negotiated Rate	$10,485.12
Max. Negotiated Rate	$22,767.70
Rate for Payer: Aetna Commercial	$13,480.88
Rate for Payer: Aetna Medicare	$17,108.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,405.92
Rate for Payer: Amerigroup Medicare	$11,405.92
Rate for Payer: BCBS of TX Blue Advantage	$10,531.56
Rate for Payer: BCBS of TX Blue Essentials	$12,451.94
Rate for Payer: BCBS of TX Medicare	$11,405.92
Rate for Payer: BCBS of TX PPO	$13,836.02
Rate for Payer: Cigna Commercial	$15,434.10
Rate for Payer: Cigna Medicare	$11,405.92
Rate for Payer: Employer Direct Commercial	$11,405.92
Rate for Payer: Humana Medicare/TRICARE	$11,405.92
Rate for Payer: Molina Dual Medicare/Medicaid	$11,405.92
Rate for Payer: Molina Medicare	$11,405.92
Rate for Payer: Multiplan Auto	$22,767.70
Rate for Payer: Multiplan Commercial	$22,767.70
Rate for Payer: Multiplan Workers Comp	$22,767.70
Rate for Payer: Scott and White EPO/PPO	$10,485.12
Rate for Payer: Scott and White Medicare	$11,405.92
Rate for Payer: Superior Health Plan EPO	$11,405.92
Rate for Payer: Superior Health Plan Medicare	$11,405.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,405.92
Rate for Payer: Universal American Medicare	$11,405.92
Rate for Payer: Wellcare Medicare	$11,405.92
Rate for Payer: Wellmed Medicare	$11,405.92

Know your out-of-pocket cost for care.

All Charges