White Rock Medical Center

All Charges

Charge

Type

Setting

Price

diphenhydrAMINE 25 mg Cap

Facility

$7.65

Service Code	HCPCS C9399
Hospital Charge Code	77518039
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.83

diphenhydrAMINE 25 mg Cap

Facility

$7.65

Service Code	HCPCS C9399
Hospital Charge Code	77518039
Hospital Revenue Code	636
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Aetna Commercial	$4.21
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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	$3.83
Rate for Payer: Superior Health Plan EPO	$1.04

diphenhydrAMINE 50 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1200
Hospital Charge Code	77518369
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

diphenhydrAMINE 50 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1200
Hospital Charge Code	77518369
Hospital Revenue Code	636
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.00
Rate for Payer: BCBS of TX Blue Essentials	$1.20
Rate for Payer: BCBS of TX PPO	$1.33
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

Direct Antiglobulin Test

Facility

$142.00

Service Code	CPT 86880
Hospital Charge Code	2403103
Hospital Revenue Code	302
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$126.71
Rate for Payer: Aetna Commercial	$5.65
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$2.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.39
Rate for Payer: Amerigroup Medicare	$5.39
Rate for Payer: BCBS of TX Blue Advantage	$55.16
Rate for Payer: BCBS of TX Blue Essentials	$66.19
Rate for Payer: BCBS of TX Medicare	$5.39
Rate for Payer: BCBS of TX PPO	$73.88
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicaid	$5.39
Rate for Payer: Cigna Medicare	$5.39
Rate for Payer: Employer Direct Commercial	$5.39
Rate for Payer: Humana Medicare/TRICARE	$5.39
Rate for Payer: Molina CHIP/Medicaid	$5.39
Rate for Payer: Molina Dual Medicare/Medicaid	$5.39
Rate for Payer: Molina Medicare	$5.39
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: Parkland Medicaid	$5.39
Rate for Payer: Scott and White EPO/PPO	$6.74
Rate for Payer: Scott and White Medicare	$5.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.39
Rate for Payer: Superior Health Plan EPO	$5.39
Rate for Payer: Superior Health Plan Medicare	$5.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.39
Rate for Payer: Universal American Medicare	$5.39
Rate for Payer: Wellcare Medicare	$5.39
Rate for Payer: Wellmed Medicare	$5.39

Discography, lumbar, radiological supervision and interpretation

Facility

$10,000.00

Service Code	CPT 72295
Hospital Charge Code	36072295
Hospital Revenue Code	360
Min. Negotiated Rate	$83.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$83.42
Rate for Payer: Aetna Medicare	$2,648.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,765.79
Rate for Payer: Amerigroup Medicare	$1,765.79
Rate for Payer: BCBS of TX Blue Advantage	$2,836.93
Rate for Payer: BCBS of TX Blue Essentials	$3,404.31
Rate for Payer: BCBS of TX Medicare	$1,765.79
Rate for Payer: BCBS of TX PPO	$3,799.76
Rate for Payer: Cigna Commercial	$4,000.01
Rate for Payer: Cigna Medicaid	$111.26
Rate for Payer: Cigna Medicare	$1,765.79
Rate for Payer: Employer Direct Commercial	$1,765.79
Rate for Payer: Humana Medicare/TRICARE	$1,765.79
Rate for Payer: Molina CHIP/Medicaid	$111.26
Rate for Payer: Molina Dual Medicare/Medicaid	$1,765.79
Rate for Payer: Molina Medicare	$1,765.79
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	$111.26
Rate for Payer: Scott and White EPO/PPO	$137.54
Rate for Payer: Scott and White Medicare	$1,765.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111.26
Rate for Payer: Superior Health Plan EPO	$1,765.79
Rate for Payer: Superior Health Plan Medicare	$1,765.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,765.79
Rate for Payer: Universal American Medicare	$1,765.79
Rate for Payer: Wellcare Medicare	$1,765.79
Rate for Payer: Wellmed Medicare	$1,765.79

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC

Facility

$14,467.11

Service Code	MSDRG 442
Min. Negotiated Rate	$7,845.78
Max. Negotiated Rate	$14,467.11
Rate for Payer: Aetna Commercial	$10,704.38
Rate for Payer: Aetna Medicare	$14,467.11
Rate for Payer: BCBS of TX Blue Advantage	$7,845.78
Rate for Payer: BCBS of TX Blue Essentials	$9,688.51
Rate for Payer: BCBS of TX PPO	$10,765.43
Rate for Payer: Cigna Commercial	$12,255.32

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC

Facility

$23,851.38

Service Code	MSDRG 441
Min. Negotiated Rate	$16,262.60
Max. Negotiated Rate	$23,851.38
Rate for Payer: Aetna Commercial	$20,567.25
Rate for Payer: Aetna Medicare	$23,851.38
Rate for Payer: BCBS of TX Blue Advantage	$16,262.60
Rate for Payer: BCBS of TX Blue Essentials	$19,164.45
Rate for Payer: BCBS of TX PPO	$21,294.66
Rate for Payer: Cigna Commercial	$23,547.22

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$11,932.38

Service Code	MSDRG 443
Min. Negotiated Rate	$5,713.84
Max. Negotiated Rate	$11,932.38
Rate for Payer: Aetna Commercial	$8,040.38
Rate for Payer: Aetna Medicare	$11,932.38
Rate for Payer: BCBS of TX Blue Advantage	$5,713.84
Rate for Payer: BCBS of TX Blue Essentials	$7,179.96
Rate for Payer: BCBS of TX PPO	$7,978.04
Rate for Payer: Cigna Commercial	$9,205.34

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC

Facility

$13,436.28

Service Code	MSDRG 439
Min. Negotiated Rate	$7,484.58
Max. Negotiated Rate	$13,436.28
Rate for Payer: Aetna Commercial	$9,621.00
Rate for Payer: Aetna Medicare	$13,436.28
Rate for Payer: BCBS of TX Blue Advantage	$7,484.58
Rate for Payer: BCBS of TX Blue Essentials	$8,898.07
Rate for Payer: BCBS of TX PPO	$9,887.13
Rate for Payer: Cigna Commercial	$11,014.98

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC

Facility

$22,145.13

Service Code	MSDRG 438
Min. Negotiated Rate	$14,262.24
Max. Negotiated Rate	$22,145.13
Rate for Payer: Aetna Commercial	$18,774.00
Rate for Payer: Aetna Medicare	$22,145.13
Rate for Payer: BCBS of TX Blue Advantage	$14,262.24
Rate for Payer: BCBS of TX Blue Essentials	$16,904.59
Rate for Payer: BCBS of TX PPO	$18,783.60
Rate for Payer: Cigna Commercial	$21,494.14

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC

Facility

$10,871.59

Service Code	MSDRG 440
Min. Negotiated Rate	$5,400.80
Max. Negotiated Rate	$10,871.59
Rate for Payer: Aetna Commercial	$6,925.50
Rate for Payer: Aetna Medicare	$10,871.59
Rate for Payer: BCBS of TX Blue Advantage	$5,400.80
Rate for Payer: BCBS of TX Blue Essentials	$6,411.19
Rate for Payer: BCBS of TX PPO	$7,123.83
Rate for Payer: Cigna Commercial	$7,928.93

DISORDERS OF PERSONALITY AND IMPULSE CONTROL

Facility

$24,356.62

Service Code	MSDRG 883
Min. Negotiated Rate	$11,051.86
Max. Negotiated Rate	$24,356.62
Rate for Payer: Aetna Commercial	$21,098.25
Rate for Payer: Aetna Medicare	$24,356.62
Rate for Payer: BCBS of TX Blue Advantage	$11,051.86
Rate for Payer: BCBS of TX Blue Essentials	$13,620.05
Rate for Payer: BCBS of TX PPO	$15,133.97
Rate for Payer: Cigna Commercial	$24,155.15

DISORDERS OF THE BILIARY TRACT WITH CC

Facility

$15,915.38

Service Code	MSDRG 445
Min. Negotiated Rate	$8,877.78
Max. Negotiated Rate	$15,915.38
Rate for Payer: Aetna Commercial	$12,226.50
Rate for Payer: Aetna Medicare	$15,915.38
Rate for Payer: BCBS of TX Blue Advantage	$8,877.78
Rate for Payer: BCBS of TX Blue Essentials	$11,016.56
Rate for Payer: BCBS of TX PPO	$12,241.10
Rate for Payer: Cigna Commercial	$13,997.98

DISORDERS OF THE BILIARY TRACT WITH MCC

Facility

$21,764.08

Service Code	MSDRG 444
Min. Negotiated Rate	$13,737.64
Max. Negotiated Rate	$21,764.08
Rate for Payer: Aetna Commercial	$18,373.50
Rate for Payer: Aetna Medicare	$21,764.08
Rate for Payer: BCBS of TX Blue Advantage	$13,737.64
Rate for Payer: BCBS of TX Blue Essentials	$16,622.88
Rate for Payer: BCBS of TX PPO	$18,470.58
Rate for Payer: Cigna Commercial	$21,035.62

DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC

Facility

$12,861.50

Service Code	MSDRG 446
Min. Negotiated Rate	$6,571.26
Max. Negotiated Rate	$12,861.50
Rate for Payer: Aetna Commercial	$9,016.88
Rate for Payer: Aetna Medicare	$12,861.50
Rate for Payer: BCBS of TX Blue Advantage	$6,571.26
Rate for Payer: BCBS of TX Blue Essentials	$8,203.60
Rate for Payer: BCBS of TX PPO	$9,115.47
Rate for Payer: Cigna Commercial	$10,323.32

DISTAL REPAIR KIT

Facility

$5,120.48

Service Code	HCPCS C1713
Hospital Charge Code	8420457
Hospital Revenue Code	278
Min. Negotiated Rate	$1,280.12
Max. Negotiated Rate	$2,560.24
Rate for Payer: Aetna Commercial	$1,536.14
Rate for Payer: Cash Price	$4,506.02
Rate for Payer: Cigna Commercial	$1,280.12
Rate for Payer: Multiplan Auto	$2,560.24
Rate for Payer: Multiplan Commercial	$2,560.24
Rate for Payer: Multiplan Workers Comp	$2,560.24
Rate for Payer: Scott and White EPO/PPO	$2,560.24

DISTAL REPAIR KIT

Facility

$5,120.48

Service Code	HCPCS C1713
Hospital Charge Code	8420457
Hospital Revenue Code	278
Min. Negotiated Rate	$460.84
Max. Negotiated Rate	$2,560.24
Rate for Payer: Aetna Commercial	$1,536.14
Rate for Payer: Amerigroup CHIP/Medicaid	$460.84
Rate for Payer: BCBS of TX Blue Advantage	$1,536.14
Rate for Payer: BCBS of TX Blue Essentials	$1,843.37
Rate for Payer: BCBS of TX PPO	$2,048.19
Rate for Payer: Cash Price	$4,506.02
Rate for Payer: Multiplan Auto	$2,560.24
Rate for Payer: Multiplan Commercial	$2,560.24
Rate for Payer: Multiplan Workers Comp	$2,560.24
Rate for Payer: Scott and White EPO/PPO	$2,560.24
Rate for Payer: Superior Health Plan EPO	$696.39

DISTRACTOR LINEAR TELESCOPIC

Facility

$2,275.31

Hospital Charge Code	138444
Hospital Revenue Code	272
Min. Negotiated Rate	$204.78
Max. Negotiated Rate	$1,478.95
Rate for Payer: Aetna Commercial	$1,251.42
Rate for Payer: Amerigroup CHIP/Medicaid	$204.78
Rate for Payer: BCBS of TX Blue Advantage	$682.59
Rate for Payer: BCBS of TX Blue Essentials	$819.11
Rate for Payer: BCBS of TX PPO	$910.12
Rate for Payer: Cash Price	$2,002.27
Rate for Payer: Multiplan Auto	$1,478.95
Rate for Payer: Multiplan Commercial	$1,478.95
Rate for Payer: Multiplan Workers Comp	$1,478.95
Rate for Payer: Scott and White EPO/PPO	$1,137.65
Rate for Payer: Superior Health Plan EPO	$309.44

DISTRACTOR LINEAR TELESCOPIC

Facility

$2,275.31

Hospital Charge Code	138444
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,002.27

divalproex sodium 250 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77520916
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	$2.29
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	$3.83
Rate for Payer: Superior Health Plan EPO	$1.04

divalproex sodium 250 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77520916
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Diverticulectomy of hypopharynx or esophagus, with or without myotomy cervical approach

Facility

$12,223.34

Service Code	CPT 43130
Hospital Charge Code	36043130
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,223.34
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$8,033.61
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Amerigroup Medicare	$5,355.74
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,355.74
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,132.30
Rate for Payer: Cigna Medicaid	$1,954.22
Rate for Payer: Cigna Medicare	$5,355.74
Rate for Payer: Employer Direct Commercial	$5,355.74
Rate for Payer: Humana Medicare/TRICARE	$5,355.74
Rate for Payer: Molina CHIP/Medicaid	$1,954.22
Rate for Payer: Molina Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Molina Medicare	$5,355.74
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	$1,954.22
Rate for Payer: Scott and White EPO/PPO	$9,908.12
Rate for Payer: Scott and White Medicare	$5,355.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.22
Rate for Payer: Superior Health Plan EPO	$5,355.74
Rate for Payer: Superior Health Plan Medicare	$5,355.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Universal American Medicare	$5,355.74
Rate for Payer: Wellcare Medicare	$5,355.74
Rate for Payer: Wellmed Medicare	$5,355.74

Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure)

Facility

$10,000.00

Service Code	CPT 28250
Hospital Charge Code	36028250
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
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	$5,476.44
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

DOBUTamine 250 mg/250 mL-D5W

Facility

$128.17

Service Code	HCPCS J1250
Hospital Charge Code	77521130
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

Know your out-of-pocket cost for care.

All Charges