White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHLORDIAZEPOXIDE HCL 25 MG CAP

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77454801
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

chlorhexidine Top 0.12% Liquid 15ml

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78349656
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

chlorhexidine Top 0.12% Liquid 15ml

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78349656
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

Chloride, Fecal SO

Facility

$7.00

Service Code	HCPCS 82438
Hospital Charge Code	1602432
Hospital Revenue Code	301
Rate for Payer: Cash Price	$4.76

Chloride, Fecal SO

Facility

$7.00

Service Code	HCPCS 82438
Hospital Charge Code	1602432
Hospital Revenue Code	301
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$6.25
Rate for Payer: Amerigroup CHIP/Medicaid	$1.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.00
Rate for Payer: Amerigroup Medicare	$5.00
Rate for Payer: BCBS of TX Blue Advantage	$2.10
Rate for Payer: BCBS of TX Blue Essentials	$2.52
Rate for Payer: BCBS of TX Medicare	$5.00
Rate for Payer: BCBS of TX PPO	$2.80
Rate for Payer: Cash Price	$4.76
Rate for Payer: Cash Price	$4.76
Rate for Payer: Cigna Medicaid	$5.04
Rate for Payer: Cigna Medicare	$5.00
Rate for Payer: Employer Direct Commercial	$5.00
Rate for Payer: Humana Medicare/TRICARE	$5.00
Rate for Payer: Molina CHIP/Medicaid	$5.04
Rate for Payer: Molina Dual Medicare/Medicaid	$5.00
Rate for Payer: Molina Medicare	$5.00
Rate for Payer: Multiplan Auto	$4.55
Rate for Payer: Multiplan Commercial	$4.55
Rate for Payer: Multiplan Workers Comp	$4.55
Rate for Payer: Parkland Medicaid	$5.04
Rate for Payer: Scott and White EPO/PPO	$6.25
Rate for Payer: Scott and White Medicare	$5.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.04
Rate for Payer: Superior Health Plan EPO	$5.00
Rate for Payer: Superior Health Plan Medicare	$5.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.00
Rate for Payer: Universal American Medicare	$5.00
Rate for Payer: Wellcare Medicare	$5.00
Rate for Payer: Wellmed Medicare	$5.00

Chloride Level

Facility

$111.00

Service Code	HCPCS 82435 QW
Hospital Charge Code	1601715
Hospital Revenue Code	301
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$79.92
Rate for Payer: Amerigroup CHIP/Medicaid	$1.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.60
Rate for Payer: Amerigroup Medicare	$4.60
Rate for Payer: BCBS of TX Blue Advantage	$33.30
Rate for Payer: BCBS of TX Blue Essentials	$39.96
Rate for Payer: BCBS of TX Medicare	$4.60
Rate for Payer: BCBS of TX PPO	$44.40
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cigna Medicaid	$79.92
Rate for Payer: Cigna Medicare	$4.60
Rate for Payer: Employer Direct Commercial	$4.60
Rate for Payer: Humana Medicare/TRICARE	$4.60
Rate for Payer: Molina CHIP/Medicaid	$79.92
Rate for Payer: Molina Dual Medicare/Medicaid	$4.60
Rate for Payer: Molina Medicare	$4.60
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Parkland Medicaid	$79.92
Rate for Payer: Scott and White EPO/PPO	$5.75
Rate for Payer: Scott and White Medicare	$4.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.92
Rate for Payer: Superior Health Plan EPO	$4.60
Rate for Payer: Superior Health Plan Medicare	$4.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.60
Rate for Payer: Universal American Medicare	$4.60
Rate for Payer: Wellcare Medicare	$4.60
Rate for Payer: Wellmed Medicare	$4.60

Chloride Level

Facility

$111.00

Service Code	HCPCS 82435 QW
Hospital Charge Code	1601715
Hospital Revenue Code	301
Rate for Payer: Cash Price	$75.48

Chloride Level 24 Hour Urine

Facility

$144.00

Service Code	HCPCS 82436
Hospital Charge Code	1602473
Hospital Revenue Code	301
Rate for Payer: Cash Price	$97.92

Chloride Level 24 Hour Urine

Facility

$144.00

Service Code	HCPCS 82436
Hospital Charge Code	1602473
Hospital Revenue Code	301
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$103.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.75
Rate for Payer: Amerigroup Medicare	$5.75
Rate for Payer: BCBS of TX Blue Advantage	$43.20
Rate for Payer: BCBS of TX Blue Essentials	$51.84
Rate for Payer: BCBS of TX Medicare	$5.75
Rate for Payer: BCBS of TX PPO	$57.60
Rate for Payer: Cash Price	$97.92
Rate for Payer: Cash Price	$97.92
Rate for Payer: Cigna Medicaid	$103.68
Rate for Payer: Cigna Medicare	$5.75
Rate for Payer: Employer Direct Commercial	$5.75
Rate for Payer: Humana Medicare/TRICARE	$5.75
Rate for Payer: Molina CHIP/Medicaid	$103.68
Rate for Payer: Molina Dual Medicare/Medicaid	$5.75
Rate for Payer: Molina Medicare	$5.75
Rate for Payer: Multiplan Auto	$93.60
Rate for Payer: Multiplan Commercial	$93.60
Rate for Payer: Multiplan Workers Comp	$93.60
Rate for Payer: Parkland Medicaid	$103.68
Rate for Payer: Scott and White EPO/PPO	$7.19
Rate for Payer: Scott and White Medicare	$5.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$103.68
Rate for Payer: Superior Health Plan EPO	$5.75
Rate for Payer: Superior Health Plan Medicare	$5.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.75
Rate for Payer: Universal American Medicare	$5.75
Rate for Payer: Wellcare Medicare	$5.75
Rate for Payer: Wellmed Medicare	$5.75

chlorproMAZINE 25 mg Tab

Facility

$8.00

Service Code	HCPCS Q0161
Hospital Charge Code	77463456
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
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	$5.44
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

chlorproMAZINE 25 mg Tab

Facility

$8.00

Service Code	HCPCS Q0161
Hospital Charge Code	77463456
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

CHNG EXT/INT URETR STENT

Facility

$3,529.00

Service Code	HCPCS 50387
Hospital Charge Code	4614483
Hospital Revenue Code	361
Min. Negotiated Rate	$652.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$652.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Amerigroup Medicare	$2,099.91
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	$2,099.91
Rate for Payer: BCBS of TX PPO	$4,464.31
Rate for Payer: Cash Price	$2,399.72
Rate for Payer: Cash Price	$2,399.72
Rate for Payer: Cash Price	$2,399.72
Rate for Payer: Cigna Commercial	$4,438.84
Rate for Payer: Cigna Medicaid	$2,540.88
Rate for Payer: Cigna Medicare	$2,099.91
Rate for Payer: Employer Direct Commercial	$2,099.91
Rate for Payer: Humana Medicare/TRICARE	$2,099.91
Rate for Payer: Molina CHIP/Medicaid	$2,540.88
Rate for Payer: Molina Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Molina Medicare	$2,099.91
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	$2,540.88
Rate for Payer: Scott and White EPO/PPO	$3,884.83
Rate for Payer: Scott and White Medicare	$2,099.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,540.88
Rate for Payer: Superior Health Plan EPO	$2,099.91
Rate for Payer: Superior Health Plan Medicare	$2,099.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Universal American Medicare	$2,099.91
Rate for Payer: Wellcare Medicare	$2,099.91
Rate for Payer: Wellmed Medicare	$2,099.91

CHNG EXT/INT URETR STENT

Facility

$3,529.00

Service Code	HCPCS 50387
Hospital Charge Code	4614483
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,399.72

Chocolate Agar, (Gc Agar Base With 1% Bovine Hemoglobin Andkoenzyme Supplement), For Faslidious Bacteria, 15 x 100 mm plate

Facility

$4.56

Hospital Charge Code	993333
Hospital Revenue Code	272
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$3.28
Rate for Payer: Amerigroup CHIP/Medicaid	$0.41
Rate for Payer: BCBS of TX Blue Advantage	$1.37
Rate for Payer: BCBS of TX Blue Essentials	$1.64
Rate for Payer: BCBS of TX PPO	$1.82
Rate for Payer: Cash Price	$3.10
Rate for Payer: Cigna Medicaid	$3.28
Rate for Payer: Molina CHIP/Medicaid	$3.28
Rate for Payer: Multiplan Auto	$2.96
Rate for Payer: Multiplan Commercial	$2.96
Rate for Payer: Multiplan Workers Comp	$2.96
Rate for Payer: Parkland Medicaid	$3.28
Rate for Payer: Scott and White EPO/PPO	$2.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.28
Rate for Payer: Superior Health Plan EPO	$0.62

Chocolate Agar, (Gc Agar Base With 1% Bovine Hemoglobin Andkoenzyme Supplement), For Faslidious Bacteria, 15 x 100 mm plate

Facility

$4.56

Hospital Charge Code	993333
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.10

CHOLANGIO+INJ EXIST CTH

Facility

$14,632.00

Service Code	HCPCS 47531
Hospital Charge Code	4617531
Hospital Revenue Code	360
Min. Negotiated Rate	$1,316.88
Max. Negotiated Rate	$10,535.04
Rate for Payer: Amerigroup CHIP/Medicaid	$1,316.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Amerigroup Medicare	$3,596.72
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX Medicare	$3,596.72
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cash Price	$9,949.76
Rate for Payer: Cash Price	$9,949.76
Rate for Payer: Cash Price	$9,949.76
Rate for Payer: Cigna Commercial	$7,602.81
Rate for Payer: Cigna Medicaid	$10,535.04
Rate for Payer: Cigna Medicare	$3,596.72
Rate for Payer: Employer Direct Commercial	$3,596.72
Rate for Payer: Humana Medicare/TRICARE	$3,596.72
Rate for Payer: Molina CHIP/Medicaid	$10,535.04
Rate for Payer: Molina Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Molina Medicare	$3,596.72
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	$10,535.04
Rate for Payer: Scott and White EPO/PPO	$6,653.93
Rate for Payer: Scott and White Medicare	$3,596.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,535.04
Rate for Payer: Superior Health Plan EPO	$3,596.72
Rate for Payer: Superior Health Plan Medicare	$3,596.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Universal American Medicare	$3,596.72
Rate for Payer: Wellcare Medicare	$3,596.72
Rate for Payer: Wellmed Medicare	$3,596.72

CHOLANGIO+INJ EXIST CTH

Facility

$14,632.00

Service Code	HCPCS 47531
Hospital Charge Code	4617531
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,949.76

CHOLANGIO+INJ NEW

Facility

$14,632.00

Service Code	HCPCS 47532
Hospital Charge Code	4617532
Hospital Revenue Code	360
Min. Negotiated Rate	$1,316.88
Max. Negotiated Rate	$10,535.04
Rate for Payer: Amerigroup CHIP/Medicaid	$1,316.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Amerigroup Medicare	$3,596.72
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX Medicare	$3,596.72
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cash Price	$9,949.76
Rate for Payer: Cash Price	$9,949.76
Rate for Payer: Cash Price	$9,949.76
Rate for Payer: Cigna Commercial	$7,602.81
Rate for Payer: Cigna Medicaid	$10,535.04
Rate for Payer: Cigna Medicare	$3,596.72
Rate for Payer: Employer Direct Commercial	$3,596.72
Rate for Payer: Humana Medicare/TRICARE	$3,596.72
Rate for Payer: Molina CHIP/Medicaid	$10,535.04
Rate for Payer: Molina Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Molina Medicare	$3,596.72
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	$10,535.04
Rate for Payer: Scott and White EPO/PPO	$6,653.93
Rate for Payer: Scott and White Medicare	$3,596.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,535.04
Rate for Payer: Superior Health Plan EPO	$3,596.72
Rate for Payer: Superior Health Plan Medicare	$3,596.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Universal American Medicare	$3,596.72
Rate for Payer: Wellcare Medicare	$3,596.72
Rate for Payer: Wellmed Medicare	$3,596.72

CHOLANGIO+INJ NEW

Facility

$14,632.00

Service Code	HCPCS 47532
Hospital Charge Code	4617532
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,949.76

cholecalciferol 1,000 intl units Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77464294
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

cholecalciferol 1,000 intl units Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77464294
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Cholecystectomy

Facility

$46,200.00

Service Code	HCPCS 47600
Hospital Charge Code	994152
Hospital Revenue Code	360
Min. Negotiated Rate	$1,863.94
Max. Negotiated Rate	$33,264.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4,158.00
Rate for Payer: BCBS of TX Blue Advantage	$1,863.94
Rate for Payer: BCBS of TX Blue Essentials	$2,232.26
Rate for Payer: BCBS of TX PPO	$2,812.65
Rate for Payer: Cash Price	$31,416.00
Rate for Payer: Cash Price	$31,416.00
Rate for Payer: Cash Price	$31,416.00
Rate for Payer: Cigna Medicaid	$33,264.00
Rate for Payer: Molina CHIP/Medicaid	$33,264.00
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	$33,264.00
Rate for Payer: Scott and White EPO/PPO	$23,100.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33,264.00
Rate for Payer: Superior Health Plan EPO	$6,283.20

Cholecystectomy

Facility

$46,200.00

Service Code	HCPCS 47600
Hospital Charge Code	994152
Hospital Revenue Code	360
Rate for Payer: Cash Price	$31,416.00

CHOLECYSTECTOMY

Facility

$5,913.19

Service Code	APR-DRG 2632
Min. Negotiated Rate	$5,575.16
Max. Negotiated Rate	$5,913.19
Rate for Payer: Amerigroup CHIP/Medicaid	$5,575.16
Rate for Payer: Cigna Medicaid	$5,575.16
Rate for Payer: Molina CHIP/Medicaid	$5,575.16
Rate for Payer: Parkland Medicaid	$5,575.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,913.19

CHOLECYSTECTOMY

Facility

$20,834.03

Service Code	APR-DRG 2634
Min. Negotiated Rate	$19,643.06
Max. Negotiated Rate	$20,834.03
Rate for Payer: Amerigroup CHIP/Medicaid	$19,643.06
Rate for Payer: Cigna Medicaid	$19,643.06
Rate for Payer: Molina CHIP/Medicaid	$19,643.06
Rate for Payer: Parkland Medicaid	$19,643.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,834.03

Know your out-of-pocket cost for care.

All Charges