White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Cholesterol HDL

Facility

$136.00

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

Cholesterol Total

Facility

$154.00

Service Code	HCPCS 82465
Hospital Charge Code	1601723
Hospital Revenue Code	301
Rate for Payer: Cash Price	$104.72

Cholesterol Total

Facility

$154.00

Service Code	HCPCS 82465
Hospital Charge Code	1601723
Hospital Revenue Code	301
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$110.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.35
Rate for Payer: Amerigroup Medicare	$4.35
Rate for Payer: BCBS of TX Blue Advantage	$46.20
Rate for Payer: BCBS of TX Blue Essentials	$55.44
Rate for Payer: BCBS of TX Medicare	$4.35
Rate for Payer: BCBS of TX PPO	$61.60
Rate for Payer: Cash Price	$104.72
Rate for Payer: Cash Price	$104.72
Rate for Payer: Cigna Medicaid	$110.88
Rate for Payer: Cigna Medicare	$4.35
Rate for Payer: Employer Direct Commercial	$4.35
Rate for Payer: Humana Medicare/TRICARE	$4.35
Rate for Payer: Molina CHIP/Medicaid	$110.88
Rate for Payer: Molina Dual Medicare/Medicaid	$4.35
Rate for Payer: Molina Medicare	$4.35
Rate for Payer: Multiplan Auto	$100.10
Rate for Payer: Multiplan Commercial	$100.10
Rate for Payer: Multiplan Workers Comp	$100.10
Rate for Payer: Parkland Medicaid	$110.88
Rate for Payer: Scott and White EPO/PPO	$5.44
Rate for Payer: Scott and White Medicare	$4.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.88
Rate for Payer: Superior Health Plan EPO	$4.35
Rate for Payer: Superior Health Plan Medicare	$4.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.35
Rate for Payer: Universal American Medicare	$4.35
Rate for Payer: Wellcare Medicare	$4.35
Rate for Payer: Wellmed Medicare	$4.35

cholestyramine 4 gram 5.5 gm packet

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77465494
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

cholestyramine 4 gram 5.5 gm packet

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77465494
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

CHRONIC KIDNEY DISEASE

Facility

$8,536.16

Service Code	APR-DRG 4704
Min. Negotiated Rate	$8,048.19
Max. Negotiated Rate	$8,536.16
Rate for Payer: Amerigroup CHIP/Medicaid	$8,048.19
Rate for Payer: Cigna Medicaid	$8,048.19
Rate for Payer: Molina CHIP/Medicaid	$8,048.19
Rate for Payer: Parkland Medicaid	$8,048.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,536.16

CHRONIC KIDNEY DISEASE

Facility

$4,484.02

Service Code	APR-DRG 4702
Min. Negotiated Rate	$4,227.69
Max. Negotiated Rate	$4,484.02
Rate for Payer: Amerigroup CHIP/Medicaid	$4,227.69
Rate for Payer: Cigna Medicaid	$4,227.69
Rate for Payer: Molina CHIP/Medicaid	$4,227.69
Rate for Payer: Parkland Medicaid	$4,227.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,484.02

CHRONIC KIDNEY DISEASE

Facility

$5,460.19

Service Code	APR-DRG 4703
Min. Negotiated Rate	$5,148.06
Max. Negotiated Rate	$5,460.19
Rate for Payer: Amerigroup CHIP/Medicaid	$5,148.06
Rate for Payer: Cigna Medicaid	$5,148.06
Rate for Payer: Molina CHIP/Medicaid	$5,148.06
Rate for Payer: Parkland Medicaid	$5,148.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,460.19

CHRONIC KIDNEY DISEASE

Facility

$3,507.86

Service Code	APR-DRG 4701
Min. Negotiated Rate	$3,307.33
Max. Negotiated Rate	$3,507.86
Rate for Payer: Amerigroup CHIP/Medicaid	$3,307.33
Rate for Payer: Cigna Medicaid	$3,307.33
Rate for Payer: Molina CHIP/Medicaid	$3,307.33
Rate for Payer: Parkland Medicaid	$3,307.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,507.86

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$5,691.78

Service Code	APR-DRG 1404
Min. Negotiated Rate	$5,366.41
Max. Negotiated Rate	$5,691.78
Rate for Payer: Amerigroup CHIP/Medicaid	$5,366.41
Rate for Payer: Cigna Medicaid	$5,366.41
Rate for Payer: Molina CHIP/Medicaid	$5,366.41
Rate for Payer: Parkland Medicaid	$5,366.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,691.78

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$2,852.30

Service Code	APR-DRG 1401
Min. Negotiated Rate	$2,689.25
Max. Negotiated Rate	$2,852.30
Rate for Payer: Amerigroup CHIP/Medicaid	$2,689.25
Rate for Payer: Cigna Medicaid	$2,689.25
Rate for Payer: Molina CHIP/Medicaid	$2,689.25
Rate for Payer: Parkland Medicaid	$2,689.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,852.30

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$3,307.57

Service Code	APR-DRG 1402
Min. Negotiated Rate	$3,118.49
Max. Negotiated Rate	$3,307.57
Rate for Payer: Amerigroup CHIP/Medicaid	$3,118.49
Rate for Payer: Cigna Medicaid	$3,118.49
Rate for Payer: Molina CHIP/Medicaid	$3,118.49
Rate for Payer: Parkland Medicaid	$3,118.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,307.57

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$3,878.63

Service Code	APR-DRG 1403
Min. Negotiated Rate	$3,656.91
Max. Negotiated Rate	$3,878.63
Rate for Payer: Amerigroup CHIP/Medicaid	$3,656.91
Rate for Payer: Cigna Medicaid	$3,656.91
Rate for Payer: Molina CHIP/Medicaid	$3,656.91
Rate for Payer: Parkland Medicaid	$3,656.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,878.63

CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC

Facility

$16,419.80

Service Code	MSDRG 191
Min. Negotiated Rate	$7,561.75
Max. Negotiated Rate	$16,419.80
Rate for Payer: BCBS of TX Blue Advantage	$7,859.54
Rate for Payer: BCBS of TX Blue Essentials	$9,430.53
Rate for Payer: BCBS of TX PPO	$10,478.78

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC

Facility

$16,419.80

Service Code	MSDRG 191
Min. Negotiated Rate	$7,561.75
Max. Negotiated Rate	$16,419.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,938.45
Rate for Payer: Amerigroup Medicare	$10,938.45
Rate for Payer: BCBS of TX Medicare	$10,938.45
Rate for Payer: Cigna Commercial	$10,857.84
Rate for Payer: Cigna Medicare	$10,938.45
Rate for Payer: Employer Direct Commercial	$10,938.45
Rate for Payer: Humana Medicare/TRICARE	$10,938.45
Rate for Payer: Molina Dual Medicare/Medicaid	$10,938.45
Rate for Payer: Molina Medicare	$10,938.45
Rate for Payer: Multiplan Auto	$16,419.80
Rate for Payer: Multiplan Commercial	$16,419.80
Rate for Payer: Multiplan Workers Comp	$16,419.80
Rate for Payer: Scott and White EPO/PPO	$7,561.75
Rate for Payer: Scott and White Medicare	$10,938.45
Rate for Payer: Superior Health Plan EPO	$10,938.45
Rate for Payer: Superior Health Plan Medicare	$10,938.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,938.45
Rate for Payer: Universal American Medicare	$10,938.45
Rate for Payer: Wellcare Medicare	$10,938.45
Rate for Payer: Wellmed Medicare	$10,938.45

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC

Facility

$20,624.50

Service Code	MSDRG 190
Min. Negotiated Rate	$9,498.12
Max. Negotiated Rate	$20,624.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,878.44
Rate for Payer: Amerigroup Medicare	$12,878.44
Rate for Payer: BCBS of TX Medicare	$12,878.44
Rate for Payer: Cigna Commercial	$14,267.18
Rate for Payer: Cigna Medicare	$12,878.44
Rate for Payer: Employer Direct Commercial	$12,878.44
Rate for Payer: Humana Medicare/TRICARE	$12,878.44
Rate for Payer: Molina Dual Medicare/Medicaid	$12,878.44
Rate for Payer: Molina Medicare	$12,878.44
Rate for Payer: Multiplan Auto	$20,624.50
Rate for Payer: Multiplan Commercial	$20,624.50
Rate for Payer: Multiplan Workers Comp	$20,624.50
Rate for Payer: Scott and White EPO/PPO	$9,498.12
Rate for Payer: Scott and White Medicare	$12,878.44
Rate for Payer: Superior Health Plan EPO	$12,878.44
Rate for Payer: Superior Health Plan Medicare	$12,878.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,878.44
Rate for Payer: Universal American Medicare	$12,878.44
Rate for Payer: Wellcare Medicare	$12,878.44
Rate for Payer: Wellmed Medicare	$12,878.44

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC

Facility

$12,389.90

Service Code	MSDRG 192
Min. Negotiated Rate	$5,705.88
Max. Negotiated Rate	$12,389.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,465.32
Rate for Payer: Amerigroup Medicare	$9,465.32
Rate for Payer: BCBS of TX Medicare	$9,465.32
Rate for Payer: Cigna Commercial	$8,268.96
Rate for Payer: Cigna Medicare	$9,465.32
Rate for Payer: Employer Direct Commercial	$9,465.32
Rate for Payer: Humana Medicare/TRICARE	$9,465.32
Rate for Payer: Molina Dual Medicare/Medicaid	$9,465.32
Rate for Payer: Molina Medicare	$9,465.32
Rate for Payer: Multiplan Auto	$12,389.90
Rate for Payer: Multiplan Commercial	$12,389.90
Rate for Payer: Multiplan Workers Comp	$12,389.90
Rate for Payer: Scott and White EPO/PPO	$5,705.88
Rate for Payer: Scott and White Medicare	$9,465.32
Rate for Payer: Superior Health Plan EPO	$9,465.32
Rate for Payer: Superior Health Plan Medicare	$9,465.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,465.32
Rate for Payer: Universal American Medicare	$9,465.32
Rate for Payer: Wellcare Medicare	$9,465.32
Rate for Payer: Wellmed Medicare	$9,465.32

CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC

Facility

$20,624.50

Service Code	MSDRG 190
Min. Negotiated Rate	$9,498.12
Max. Negotiated Rate	$20,624.50
Rate for Payer: BCBS of TX Blue Advantage	$10,240.02
Rate for Payer: BCBS of TX Blue Essentials	$12,286.83
Rate for Payer: BCBS of TX PPO	$13,652.57

CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC

Facility

$12,389.90

Service Code	MSDRG 192
Min. Negotiated Rate	$5,705.88
Max. Negotiated Rate	$12,389.90
Rate for Payer: BCBS of TX Blue Advantage	$6,227.26
Rate for Payer: BCBS of TX Blue Essentials	$7,471.99
Rate for Payer: BCBS of TX PPO	$8,302.53

CHWR 4 X 4's STERILE PACK EACH

Facility

$36.69

Hospital Charge Code	8024515
Hospital Revenue Code	272
Rate for Payer: Cash Price	$24.95

CHWR 4 X 4's STERILE PACK EACH

Facility

$36.69

Hospital Charge Code	8024515
Hospital Revenue Code	272
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$26.42
Rate for Payer: Amerigroup CHIP/Medicaid	$3.30
Rate for Payer: BCBS of TX Blue Advantage	$11.01
Rate for Payer: BCBS of TX Blue Essentials	$13.21
Rate for Payer: BCBS of TX PPO	$14.68
Rate for Payer: Cash Price	$24.95
Rate for Payer: Cigna Medicaid	$26.42
Rate for Payer: Molina CHIP/Medicaid	$26.42
Rate for Payer: Multiplan Auto	$23.85
Rate for Payer: Multiplan Commercial	$23.85
Rate for Payer: Multiplan Workers Comp	$23.85
Rate for Payer: Parkland Medicaid	$26.42
Rate for Payer: Scott and White EPO/PPO	$18.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.42
Rate for Payer: Superior Health Plan EPO	$4.99

CHWR ACHIEVE NEEDLES

Facility

$239.93

Hospital Charge Code	8032770
Hospital Revenue Code	272
Rate for Payer: Cash Price	$163.15

CHWR ACHIEVE NEEDLES

Facility

$239.93

Hospital Charge Code	8032770
Hospital Revenue Code	272
Min. Negotiated Rate	$21.59
Max. Negotiated Rate	$172.75
Rate for Payer: Amerigroup CHIP/Medicaid	$21.59
Rate for Payer: BCBS of TX Blue Advantage	$71.98
Rate for Payer: BCBS of TX Blue Essentials	$86.37
Rate for Payer: BCBS of TX PPO	$95.97
Rate for Payer: Cash Price	$163.15
Rate for Payer: Cigna Medicaid	$172.75
Rate for Payer: Molina CHIP/Medicaid	$172.75
Rate for Payer: Multiplan Auto	$155.95
Rate for Payer: Multiplan Commercial	$155.95
Rate for Payer: Multiplan Workers Comp	$155.95
Rate for Payer: Parkland Medicaid	$172.75
Rate for Payer: Scott and White EPO/PPO	$119.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$172.75
Rate for Payer: Superior Health Plan EPO	$32.63

CHWR ARTHROGRAM TRAY

Facility

$276.94

Hospital Charge Code	8082935
Hospital Revenue Code	272
Min. Negotiated Rate	$24.92
Max. Negotiated Rate	$199.40
Rate for Payer: Amerigroup CHIP/Medicaid	$24.92
Rate for Payer: BCBS of TX Blue Advantage	$83.08
Rate for Payer: BCBS of TX Blue Essentials	$99.70
Rate for Payer: BCBS of TX PPO	$110.78
Rate for Payer: Cash Price	$188.32
Rate for Payer: Cigna Medicaid	$199.40
Rate for Payer: Molina CHIP/Medicaid	$199.40
Rate for Payer: Multiplan Auto	$180.01
Rate for Payer: Multiplan Commercial	$180.01
Rate for Payer: Multiplan Workers Comp	$180.01
Rate for Payer: Parkland Medicaid	$199.40
Rate for Payer: Scott and White EPO/PPO	$138.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$199.40
Rate for Payer: Superior Health Plan EPO	$37.66

CHWR ARTHROGRAM TRAY

Facility

$276.94

Hospital Charge Code	8082935
Hospital Revenue Code	272
Rate for Payer: Cash Price	$188.32

Know your out-of-pocket cost for care.

All Charges