White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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

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

$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

$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

CHOLECYSTECTOMY

Facility

$4,762.01

Service Code	APR-DRG 2631
Min. Negotiated Rate	$4,489.79
Max. Negotiated Rate	$4,762.01
Rate for Payer: Amerigroup CHIP/Medicaid	$4,489.79
Rate for Payer: Cigna Medicaid	$4,489.79
Rate for Payer: Molina CHIP/Medicaid	$4,489.79
Rate for Payer: Parkland Medicaid	$4,489.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,762.01

CHOLECYSTECTOMY

Facility

$7,539.25

Service Code	APR-DRG 2633
Min. Negotiated Rate	$7,108.27
Max. Negotiated Rate	$7,539.25
Rate for Payer: Amerigroup CHIP/Medicaid	$7,108.27
Rate for Payer: Cigna Medicaid	$7,108.27
Rate for Payer: Molina CHIP/Medicaid	$7,108.27
Rate for Payer: Parkland Medicaid	$7,108.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,539.25

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 Drape, Fenestrated, Sterile, 102' x 76' x 120'

Facility

$95.21

Hospital Charge Code	992796
Hospital Revenue Code	272
Min. Negotiated Rate	$8.57
Max. Negotiated Rate	$68.55
Rate for Payer: Amerigroup CHIP/Medicaid	$8.57
Rate for Payer: BCBS of TX Blue Advantage	$28.56
Rate for Payer: BCBS of TX Blue Essentials	$34.28
Rate for Payer: BCBS of TX PPO	$38.08
Rate for Payer: Cash Price	$64.74
Rate for Payer: Cigna Medicaid	$68.55
Rate for Payer: Molina CHIP/Medicaid	$68.55
Rate for Payer: Multiplan Auto	$61.89
Rate for Payer: Multiplan Commercial	$61.89
Rate for Payer: Multiplan Workers Comp	$61.89
Rate for Payer: Parkland Medicaid	$68.55
Rate for Payer: Scott and White EPO/PPO	$47.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$68.55
Rate for Payer: Superior Health Plan EPO	$12.95

Cholecystectomy Drape, Fenestrated, Sterile, 102' x 76' x 120'

Facility

$95.21

Hospital Charge Code	992796
Hospital Revenue Code	272
Rate for Payer: Cash Price	$64.74

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC

Facility

$38,000.00

Service Code	MSDRG 415
Min. Negotiated Rate	$17,361.68
Max. Negotiated Rate	$38,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,906.98
Rate for Payer: Amerigroup Medicare	$19,906.98
Rate for Payer: BCBS of TX Medicare	$19,906.98
Rate for Payer: Cigna Commercial	$26,619.10
Rate for Payer: Cigna Medicare	$19,906.98
Rate for Payer: Employer Direct Commercial	$19,906.98
Rate for Payer: Humana Medicare/TRICARE	$19,906.98
Rate for Payer: Molina Dual Medicare/Medicaid	$19,906.98
Rate for Payer: Molina Medicare	$19,906.98
Rate for Payer: Multiplan Auto	$38,000.00
Rate for Payer: Multiplan Commercial	$38,000.00
Rate for Payer: Multiplan Workers Comp	$38,000.00
Rate for Payer: Scott and White EPO/PPO	$17,500.00
Rate for Payer: Scott and White Medicare	$19,906.98
Rate for Payer: Superior Health Plan EPO	$19,906.98
Rate for Payer: Superior Health Plan Medicare	$19,906.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,906.98
Rate for Payer: Universal American Medicare	$19,906.98
Rate for Payer: Wellcare Medicare	$19,906.98
Rate for Payer: Wellmed Medicare	$19,906.98

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC

Facility

$67,159.30

Service Code	MSDRG 414
Min. Negotiated Rate	$30,763.92
Max. Negotiated Rate	$67,159.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,870.47
Rate for Payer: Amerigroup Medicare	$30,870.47
Rate for Payer: BCBS of TX Medicare	$30,870.47
Rate for Payer: Cigna Commercial	$45,886.29
Rate for Payer: Cigna Medicare	$30,870.47
Rate for Payer: Employer Direct Commercial	$30,870.47
Rate for Payer: Humana Medicare/TRICARE	$30,870.47
Rate for Payer: Molina Dual Medicare/Medicaid	$30,870.47
Rate for Payer: Molina Medicare	$30,870.47
Rate for Payer: Multiplan Auto	$67,159.30
Rate for Payer: Multiplan Commercial	$67,159.30
Rate for Payer: Multiplan Workers Comp	$67,159.30
Rate for Payer: Scott and White EPO/PPO	$30,928.62
Rate for Payer: Scott and White Medicare	$30,870.47
Rate for Payer: Superior Health Plan EPO	$30,870.47
Rate for Payer: Superior Health Plan Medicare	$30,870.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,870.47
Rate for Payer: Universal American Medicare	$30,870.47
Rate for Payer: Wellcare Medicare	$30,870.47
Rate for Payer: Wellmed Medicare	$30,870.47

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$26,151.60

Service Code	MSDRG 416
Min. Negotiated Rate	$11,980.66
Max. Negotiated Rate	$26,151.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,751.75
Rate for Payer: Amerigroup Medicare	$14,751.75
Rate for Payer: BCBS of TX Medicare	$14,751.75
Rate for Payer: Cigna Commercial	$17,559.30
Rate for Payer: Cigna Medicare	$14,751.75
Rate for Payer: Employer Direct Commercial	$14,751.75
Rate for Payer: Humana Medicare/TRICARE	$14,751.75
Rate for Payer: Molina Dual Medicare/Medicaid	$14,751.75
Rate for Payer: Molina Medicare	$14,751.75
Rate for Payer: Multiplan Auto	$26,151.60
Rate for Payer: Multiplan Commercial	$26,151.60
Rate for Payer: Multiplan Workers Comp	$26,151.60
Rate for Payer: Scott and White EPO/PPO	$12,043.50
Rate for Payer: Scott and White Medicare	$14,751.75
Rate for Payer: Superior Health Plan EPO	$14,751.75
Rate for Payer: Superior Health Plan Medicare	$14,751.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,751.75
Rate for Payer: Universal American Medicare	$14,751.75
Rate for Payer: Wellcare Medicare	$14,751.75
Rate for Payer: Wellmed Medicare	$14,751.75

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC

Facility

$38,000.00

Service Code	MSDRG 415
Min. Negotiated Rate	$17,361.68
Max. Negotiated Rate	$38,000.00
Rate for Payer: BCBS of TX Blue Advantage	$17,361.68
Rate for Payer: BCBS of TX Blue Essentials	$20,832.00
Rate for Payer: BCBS of TX PPO	$23,147.56

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W MCC

Facility

$67,159.30

Service Code	MSDRG 414
Min. Negotiated Rate	$30,763.92
Max. Negotiated Rate	$67,159.30
Rate for Payer: BCBS of TX Blue Advantage	$30,763.92
Rate for Payer: BCBS of TX Blue Essentials	$36,913.13
Rate for Payer: BCBS of TX PPO	$41,016.18

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC

Facility

$26,151.60

Service Code	MSDRG 416
Min. Negotiated Rate	$11,980.66
Max. Negotiated Rate	$26,151.60
Rate for Payer: BCBS of TX Blue Advantage	$11,980.66
Rate for Payer: BCBS of TX Blue Essentials	$14,375.40
Rate for Payer: BCBS of TX PPO	$15,973.28

CHOLECYSTECTOMY W C.D.E. W CC

Facility

$43,618.30

Service Code	MSDRG 412
Min. Negotiated Rate	$20,087.38
Max. Negotiated Rate	$43,618.30
Rate for Payer: BCBS of TX Blue Advantage	$20,484.34
Rate for Payer: BCBS of TX Blue Essentials	$24,578.83
Rate for Payer: BCBS of TX PPO	$27,310.87

CHOLECYSTECTOMY W C.D.E. W MCC

Facility

$64,185.80

Service Code	MSDRG 411
Min. Negotiated Rate	$28,970.06
Max. Negotiated Rate	$64,185.80
Rate for Payer: BCBS of TX Blue Advantage	$34,383.66
Rate for Payer: BCBS of TX Blue Essentials	$41,256.39
Rate for Payer: BCBS of TX PPO	$45,842.21

CHOLECYSTECTOMY W C.D.E. W/O CC/MCC

Facility

$30,787.60

Service Code	MSDRG 413
Min. Negotiated Rate	$14,178.50
Max. Negotiated Rate	$30,787.60
Rate for Payer: BCBS of TX Blue Advantage	$14,501.32
Rate for Payer: BCBS of TX Blue Essentials	$17,399.90
Rate for Payer: BCBS of TX PPO	$19,333.97

CHOLECYSTECTOMY WITH C.D.E. WITH CC

Facility

$43,618.30

Service Code	MSDRG 412
Min. Negotiated Rate	$20,087.38
Max. Negotiated Rate	$43,618.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,169.35
Rate for Payer: Amerigroup Medicare	$20,169.35
Rate for Payer: BCBS of TX Medicare	$20,169.35
Rate for Payer: Cigna Commercial	$27,080.20
Rate for Payer: Cigna Medicare	$20,169.35
Rate for Payer: Employer Direct Commercial	$20,169.35
Rate for Payer: Humana Medicare/TRICARE	$20,169.35
Rate for Payer: Molina Dual Medicare/Medicaid	$20,169.35
Rate for Payer: Molina Medicare	$20,169.35
Rate for Payer: Multiplan Auto	$43,618.30
Rate for Payer: Multiplan Commercial	$43,618.30
Rate for Payer: Multiplan Workers Comp	$43,618.30
Rate for Payer: Scott and White EPO/PPO	$20,087.38
Rate for Payer: Scott and White Medicare	$20,169.35
Rate for Payer: Superior Health Plan EPO	$20,169.35
Rate for Payer: Superior Health Plan Medicare	$20,169.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,169.35
Rate for Payer: Universal American Medicare	$20,169.35
Rate for Payer: Wellcare Medicare	$20,169.35
Rate for Payer: Wellmed Medicare	$20,169.35

CHOLECYSTECTOMY WITH C.D.E. WITH MCC

Facility

$64,185.80

Service Code	MSDRG 411
Min. Negotiated Rate	$28,970.06
Max. Negotiated Rate	$64,185.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,970.06
Rate for Payer: Amerigroup Medicare	$28,970.06
Rate for Payer: BCBS of TX Medicare	$28,970.06
Rate for Payer: Cigna Commercial	$42,546.50
Rate for Payer: Cigna Medicare	$28,970.06
Rate for Payer: Employer Direct Commercial	$28,970.06
Rate for Payer: Humana Medicare/TRICARE	$28,970.06
Rate for Payer: Molina Dual Medicare/Medicaid	$28,970.06
Rate for Payer: Molina Medicare	$28,970.06
Rate for Payer: Multiplan Auto	$64,185.80
Rate for Payer: Multiplan Commercial	$64,185.80
Rate for Payer: Multiplan Workers Comp	$64,185.80
Rate for Payer: Scott and White EPO/PPO	$29,559.25
Rate for Payer: Scott and White Medicare	$28,970.06
Rate for Payer: Superior Health Plan EPO	$28,970.06
Rate for Payer: Superior Health Plan Medicare	$28,970.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,970.06
Rate for Payer: Universal American Medicare	$28,970.06
Rate for Payer: Wellcare Medicare	$28,970.06
Rate for Payer: Wellmed Medicare	$28,970.06

CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC

Facility

$30,787.60

Service Code	MSDRG 413
Min. Negotiated Rate	$14,178.50
Max. Negotiated Rate	$30,787.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,929.93
Rate for Payer: Amerigroup Medicare	$16,929.93
Rate for Payer: BCBS of TX Medicare	$16,929.93
Rate for Payer: Cigna Commercial	$21,387.24
Rate for Payer: Cigna Medicare	$16,929.93
Rate for Payer: Employer Direct Commercial	$16,929.93
Rate for Payer: Humana Medicare/TRICARE	$16,929.93
Rate for Payer: Molina Dual Medicare/Medicaid	$16,929.93
Rate for Payer: Molina Medicare	$16,929.93
Rate for Payer: Multiplan Auto	$30,787.60
Rate for Payer: Multiplan Commercial	$30,787.60
Rate for Payer: Multiplan Workers Comp	$30,787.60
Rate for Payer: Scott and White EPO/PPO	$14,178.50
Rate for Payer: Scott and White Medicare	$16,929.93
Rate for Payer: Superior Health Plan EPO	$16,929.93
Rate for Payer: Superior Health Plan Medicare	$16,929.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,929.93
Rate for Payer: Universal American Medicare	$16,929.93
Rate for Payer: Wellcare Medicare	$16,929.93
Rate for Payer: Wellmed Medicare	$16,929.93

Cholesterol Body Fluid

Facility

$334.00

Service Code	HCPCS 84311
Hospital Charge Code	4104311
Hospital Revenue Code	301
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$240.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.10
Rate for Payer: Amerigroup Medicare	$8.10
Rate for Payer: BCBS of TX Blue Advantage	$100.20
Rate for Payer: BCBS of TX Blue Essentials	$120.24
Rate for Payer: BCBS of TX Medicare	$8.10
Rate for Payer: BCBS of TX PPO	$133.60
Rate for Payer: Cash Price	$227.12
Rate for Payer: Cash Price	$227.12
Rate for Payer: Cigna Medicaid	$240.48
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Employer Direct Commercial	$8.10
Rate for Payer: Humana Medicare/TRICARE	$8.10
Rate for Payer: Molina CHIP/Medicaid	$240.48
Rate for Payer: Molina Dual Medicare/Medicaid	$8.10
Rate for Payer: Molina Medicare	$8.10
Rate for Payer: Multiplan Auto	$217.10
Rate for Payer: Multiplan Commercial	$217.10
Rate for Payer: Multiplan Workers Comp	$217.10
Rate for Payer: Parkland Medicaid	$240.48
Rate for Payer: Scott and White EPO/PPO	$10.12
Rate for Payer: Scott and White Medicare	$8.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$240.48
Rate for Payer: Superior Health Plan EPO	$8.10
Rate for Payer: Superior Health Plan Medicare	$8.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.10
Rate for Payer: Universal American Medicare	$8.10
Rate for Payer: Wellcare Medicare	$8.10
Rate for Payer: Wellmed Medicare	$8.10

Cholesterol Body Fluid

Facility

$334.00

Service Code	HCPCS 84311
Hospital Charge Code	4104311
Hospital Revenue Code	301
Rate for Payer: Cash Price	$227.12

Cholesterol HDL

Facility

$136.00

Service Code	HCPCS 83718
Hospital Charge Code	1602150
Hospital Revenue Code	301
Rate for Payer: Cash Price	$92.48

Know your out-of-pocket cost for care.

All Charges