White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CIRCUIT VENT ADLT W/O PEEP DISP

Facility

$65.90

Hospital Charge Code	993615
Hospital Revenue Code	270
Min. Negotiated Rate	$5.93
Max. Negotiated Rate	$47.45
Rate for Payer: Amerigroup CHIP/Medicaid	$5.93
Rate for Payer: BCBS of TX Blue Advantage	$19.77
Rate for Payer: BCBS of TX Blue Essentials	$23.72
Rate for Payer: BCBS of TX PPO	$26.36
Rate for Payer: Cash Price	$44.81
Rate for Payer: Cigna Medicaid	$47.45
Rate for Payer: Molina CHIP/Medicaid	$47.45
Rate for Payer: Multiplan Auto	$42.84
Rate for Payer: Multiplan Commercial	$42.84
Rate for Payer: Multiplan Workers Comp	$42.84
Rate for Payer: Parkland Medicaid	$47.45
Rate for Payer: Scott and White EPO/PPO	$32.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47.45
Rate for Payer: Superior Health Plan EPO	$8.96

CIRCUIT, VENT DUAL HEAT W/O PRESSURE LN FOR MR850

Facility

$54.74

Hospital Charge Code	993537
Hospital Revenue Code	270
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$39.41
Rate for Payer: Amerigroup CHIP/Medicaid	$4.93
Rate for Payer: BCBS of TX Blue Advantage	$16.42
Rate for Payer: BCBS of TX Blue Essentials	$19.71
Rate for Payer: BCBS of TX PPO	$21.90
Rate for Payer: Cash Price	$37.22
Rate for Payer: Cigna Medicaid	$39.41
Rate for Payer: Molina CHIP/Medicaid	$39.41
Rate for Payer: Multiplan Auto	$35.58
Rate for Payer: Multiplan Commercial	$35.58
Rate for Payer: Multiplan Workers Comp	$35.58
Rate for Payer: Parkland Medicaid	$39.41
Rate for Payer: Scott and White EPO/PPO	$27.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.41
Rate for Payer: Superior Health Plan EPO	$7.44

CIRCUIT, VENT DUAL HEAT W/O PRESSURE LN FOR MR850

Facility

$54.74

Hospital Charge Code	993537
Hospital Revenue Code	270
Rate for Payer: Cash Price	$37.22

CIRCUIT VENTILATOR O2 ADLT W/O PEEP 22MM D X 15

Facility

$33.41

Hospital Charge Code	993295
Hospital Revenue Code	270
Rate for Payer: Cash Price	$22.72

CIRCUIT VENTILATOR O2 ADLT W/O PEEP 22MM D X 15

Facility

$33.41

Hospital Charge Code	993295
Hospital Revenue Code	270
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$24.06
Rate for Payer: Amerigroup CHIP/Medicaid	$3.01
Rate for Payer: BCBS of TX Blue Advantage	$10.02
Rate for Payer: BCBS of TX Blue Essentials	$12.03
Rate for Payer: BCBS of TX PPO	$13.36
Rate for Payer: Cash Price	$22.72
Rate for Payer: Cigna Medicaid	$24.06
Rate for Payer: Molina CHIP/Medicaid	$24.06
Rate for Payer: Multiplan Auto	$21.72
Rate for Payer: Multiplan Commercial	$21.72
Rate for Payer: Multiplan Workers Comp	$21.72
Rate for Payer: Parkland Medicaid	$24.06
Rate for Payer: Scott and White EPO/PPO	$16.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.06
Rate for Payer: Superior Health Plan EPO	$4.54

CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC

Facility

$42,043.20

Service Code	MSDRG 286
Min. Negotiated Rate	$18,754.88
Max. Negotiated Rate	$42,043.20
Rate for Payer: BCBS of TX Blue Advantage	$18,754.88
Rate for Payer: BCBS of TX Blue Essentials	$22,503.68
Rate for Payer: BCBS of TX PPO	$25,005.05

CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC

Facility

$20,331.90

Service Code	MSDRG 287
Min. Negotiated Rate	$9,363.38
Max. Negotiated Rate	$20,331.90
Rate for Payer: BCBS of TX Blue Advantage	$9,794.54
Rate for Payer: BCBS of TX Blue Essentials	$11,752.31
Rate for Payer: BCBS of TX PPO	$13,058.63

CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC

Facility

$42,043.20

Service Code	MSDRG 286
Min. Negotiated Rate	$18,754.88
Max. Negotiated Rate	$42,043.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,977.75
Rate for Payer: Amerigroup Medicare	$20,977.75
Rate for Payer: BCBS of TX Medicare	$20,977.75
Rate for Payer: Cigna Commercial	$28,500.86
Rate for Payer: Cigna Medicare	$20,977.75
Rate for Payer: Employer Direct Commercial	$20,977.75
Rate for Payer: Humana Medicare/TRICARE	$20,977.75
Rate for Payer: Molina Dual Medicare/Medicaid	$20,977.75
Rate for Payer: Molina Medicare	$20,977.75
Rate for Payer: Multiplan Auto	$42,043.20
Rate for Payer: Multiplan Commercial	$42,043.20
Rate for Payer: Multiplan Workers Comp	$42,043.20
Rate for Payer: Scott and White EPO/PPO	$19,362.00
Rate for Payer: Scott and White Medicare	$20,977.75
Rate for Payer: Superior Health Plan EPO	$20,977.75
Rate for Payer: Superior Health Plan Medicare	$20,977.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,977.75
Rate for Payer: Universal American Medicare	$20,977.75
Rate for Payer: Wellcare Medicare	$20,977.75
Rate for Payer: Wellmed Medicare	$20,977.75

CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC

Facility

$20,331.90

Service Code	MSDRG 287
Min. Negotiated Rate	$9,363.38
Max. Negotiated Rate	$20,331.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,602.88
Rate for Payer: Amerigroup Medicare	$12,602.88
Rate for Payer: BCBS of TX Medicare	$12,602.88
Rate for Payer: Cigna Commercial	$13,782.89
Rate for Payer: Cigna Medicare	$12,602.88
Rate for Payer: Employer Direct Commercial	$12,602.88
Rate for Payer: Humana Medicare/TRICARE	$12,602.88
Rate for Payer: Molina Dual Medicare/Medicaid	$12,602.88
Rate for Payer: Molina Medicare	$12,602.88
Rate for Payer: Multiplan Auto	$20,331.90
Rate for Payer: Multiplan Commercial	$20,331.90
Rate for Payer: Multiplan Workers Comp	$20,331.90
Rate for Payer: Scott and White EPO/PPO	$9,363.38
Rate for Payer: Scott and White Medicare	$12,602.88
Rate for Payer: Superior Health Plan EPO	$12,602.88
Rate for Payer: Superior Health Plan Medicare	$12,602.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,602.88
Rate for Payer: Universal American Medicare	$12,602.88
Rate for Payer: Wellcare Medicare	$12,602.88
Rate for Payer: Wellmed Medicare	$12,602.88

Circumcision

Facility

$10,500.00

Service Code	HCPCS 54150
Hospital Charge Code	315036
Hospital Revenue Code	723
Rate for Payer: Cash Price	$7,140.00

Circumcision

Facility

$10,500.00

Service Code	HCPCS 54150
Hospital Charge Code	315036
Hospital Revenue Code	723
Min. Negotiated Rate	$945.00
Max. Negotiated Rate	$7,560.00
Rate for Payer: Amerigroup CHIP/Medicaid	$945.00
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	$7,140.00
Rate for Payer: Cash Price	$7,140.00
Rate for Payer: Cash Price	$7,140.00
Rate for Payer: Cigna Commercial	$4,438.84
Rate for Payer: Cigna Medicaid	$7,560.00
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	$7,560.00
Rate for Payer: Molina Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Molina Medicare	$2,099.91
Rate for Payer: Multiplan Auto	$6,825.00
Rate for Payer: Multiplan Commercial	$6,825.00
Rate for Payer: Multiplan Workers Comp	$6,825.00
Rate for Payer: Parkland Medicaid	$7,560.00
Rate for Payer: Scott and White EPO/PPO	$5,250.00
Rate for Payer: Scott and White Medicare	$2,099.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,560.00
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

CIRRHOSIS & ALCOHOLIC HEPATITIS W CC

Facility

$20,067.80

Service Code	MSDRG 433
Min. Negotiated Rate	$8,839.94
Max. Negotiated Rate	$20,067.80
Rate for Payer: BCBS of TX Blue Advantage	$8,839.94
Rate for Payer: BCBS of TX Blue Essentials	$10,606.90
Rate for Payer: BCBS of TX PPO	$11,785.90

CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC

Facility

$37,395.80

Service Code	MSDRG 432
Min. Negotiated Rate	$15,703.60
Max. Negotiated Rate	$37,395.80
Rate for Payer: BCBS of TX Blue Advantage	$15,703.60
Rate for Payer: BCBS of TX Blue Essentials	$18,842.49
Rate for Payer: BCBS of TX PPO	$20,936.92

CIRRHOSIS & ALCOHOLIC HEPATITIS W/O CC/MCC

Facility

$13,537.50

Service Code	MSDRG 434
Min. Negotiated Rate	$5,599.46
Max. Negotiated Rate	$13,537.50
Rate for Payer: BCBS of TX Blue Advantage	$5,599.46
Rate for Payer: BCBS of TX Blue Essentials	$6,718.70
Rate for Payer: BCBS of TX PPO	$7,465.51

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC

Facility

$20,067.80

Service Code	MSDRG 433
Min. Negotiated Rate	$8,839.94
Max. Negotiated Rate	$20,067.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,501.00
Rate for Payer: Amerigroup Medicare	$12,501.00
Rate for Payer: BCBS of TX Medicare	$12,501.00
Rate for Payer: Cigna Commercial	$13,603.86
Rate for Payer: Cigna Medicare	$12,501.00
Rate for Payer: Employer Direct Commercial	$12,501.00
Rate for Payer: Humana Medicare/TRICARE	$12,501.00
Rate for Payer: Molina Dual Medicare/Medicaid	$12,501.00
Rate for Payer: Molina Medicare	$12,501.00
Rate for Payer: Multiplan Auto	$20,067.80
Rate for Payer: Multiplan Commercial	$20,067.80
Rate for Payer: Multiplan Workers Comp	$20,067.80
Rate for Payer: Scott and White EPO/PPO	$9,241.75
Rate for Payer: Scott and White Medicare	$12,501.00
Rate for Payer: Superior Health Plan EPO	$12,501.00
Rate for Payer: Superior Health Plan Medicare	$12,501.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,501.00
Rate for Payer: Universal American Medicare	$12,501.00
Rate for Payer: Wellcare Medicare	$12,501.00
Rate for Payer: Wellmed Medicare	$12,501.00

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC

Facility

$37,395.80

Service Code	MSDRG 432
Min. Negotiated Rate	$15,703.60
Max. Negotiated Rate	$37,395.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,185.07
Rate for Payer: Amerigroup Medicare	$19,185.07
Rate for Payer: BCBS of TX Medicare	$19,185.07
Rate for Payer: Cigna Commercial	$25,350.42
Rate for Payer: Cigna Medicare	$19,185.07
Rate for Payer: Employer Direct Commercial	$19,185.07
Rate for Payer: Humana Medicare/TRICARE	$19,185.07
Rate for Payer: Molina Dual Medicare/Medicaid	$19,185.07
Rate for Payer: Molina Medicare	$19,185.07
Rate for Payer: Multiplan Auto	$37,395.80
Rate for Payer: Multiplan Commercial	$37,395.80
Rate for Payer: Multiplan Workers Comp	$37,395.80
Rate for Payer: Scott and White EPO/PPO	$17,221.75
Rate for Payer: Scott and White Medicare	$19,185.07
Rate for Payer: Superior Health Plan EPO	$19,185.07
Rate for Payer: Superior Health Plan Medicare	$19,185.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,185.07
Rate for Payer: Universal American Medicare	$19,185.07
Rate for Payer: Wellcare Medicare	$19,185.07
Rate for Payer: Wellmed Medicare	$19,185.07

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$13,537.50

Service Code	MSDRG 434
Min. Negotiated Rate	$5,599.46
Max. Negotiated Rate	$13,537.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,982.02
Rate for Payer: Amerigroup Medicare	$9,982.02
Rate for Payer: BCBS of TX Medicare	$9,982.02
Rate for Payer: Cigna Commercial	$9,177.00
Rate for Payer: Cigna Medicare	$9,982.02
Rate for Payer: Employer Direct Commercial	$9,982.02
Rate for Payer: Humana Medicare/TRICARE	$9,982.02
Rate for Payer: Molina Dual Medicare/Medicaid	$9,982.02
Rate for Payer: Molina Medicare	$9,982.02
Rate for Payer: Multiplan Auto	$13,537.50
Rate for Payer: Multiplan Commercial	$13,537.50
Rate for Payer: Multiplan Workers Comp	$13,537.50
Rate for Payer: Scott and White EPO/PPO	$6,234.38
Rate for Payer: Scott and White Medicare	$9,982.02
Rate for Payer: Superior Health Plan EPO	$9,982.02
Rate for Payer: Superior Health Plan Medicare	$9,982.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,982.02
Rate for Payer: Universal American Medicare	$9,982.02
Rate for Payer: Wellcare Medicare	$9,982.02
Rate for Payer: Wellmed Medicare	$9,982.02

cisatracurium 2 mg/mL IV Soln 10 mL

Facility

$128.19

Service Code	HCPCS J3490
Hospital Charge Code	77469679
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.30
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.46
Rate for Payer: BCBS of TX Blue Essentials	$46.15
Rate for Payer: BCBS of TX PPO	$51.28
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cigna Medicaid	$92.30
Rate for Payer: Molina CHIP/Medicaid	$92.30
Rate for Payer: Multiplan Auto	$83.32
Rate for Payer: Multiplan Commercial	$83.32
Rate for Payer: Multiplan Workers Comp	$83.32
Rate for Payer: Parkland Medicaid	$92.30
Rate for Payer: Scott and White EPO/PPO	$64.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.30
Rate for Payer: Superior Health Plan EPO	$17.43

cisatracurium 2 mg/mL IV Soln 10 mL

Facility

$128.19

Service Code	HCPCS J3490
Hospital Charge Code	77469679
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.17

citalopram 10 mg Tab

Facility

$10.55

Service Code	HCPCS J3490
Hospital Charge Code	77470015
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.17

citalopram 10 mg Tab

Facility

$10.55

Service Code	HCPCS J3490
Hospital Charge Code	77470015
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$7.60
Rate for Payer: Amerigroup CHIP/Medicaid	$0.95
Rate for Payer: BCBS of TX Blue Advantage	$3.17
Rate for Payer: BCBS of TX Blue Essentials	$3.80
Rate for Payer: BCBS of TX PPO	$4.22
Rate for Payer: Cash Price	$7.17
Rate for Payer: Cigna Medicaid	$7.60
Rate for Payer: Molina CHIP/Medicaid	$7.60
Rate for Payer: Multiplan Auto	$6.86
Rate for Payer: Multiplan Commercial	$6.86
Rate for Payer: Multiplan Workers Comp	$6.86
Rate for Payer: Parkland Medicaid	$7.60
Rate for Payer: Scott and White EPO/PPO	$5.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.60
Rate for Payer: Superior Health Plan EPO	$1.43

citalopram 20 mg Tab

Facility

$11.70

Service Code	HCPCS J3490
Hospital Charge Code	77470178
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.96

citalopram 20 mg Tab

Facility

$11.70

Service Code	HCPCS J3490
Hospital Charge Code	77470178
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$8.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1.05
Rate for Payer: BCBS of TX Blue Advantage	$3.51
Rate for Payer: BCBS of TX Blue Essentials	$4.21
Rate for Payer: BCBS of TX PPO	$4.68
Rate for Payer: Cash Price	$7.96
Rate for Payer: Cigna Medicaid	$8.42
Rate for Payer: Molina CHIP/Medicaid	$8.42
Rate for Payer: Multiplan Auto	$7.61
Rate for Payer: Multiplan Commercial	$7.61
Rate for Payer: Multiplan Workers Comp	$7.61
Rate for Payer: Parkland Medicaid	$8.42
Rate for Payer: Scott and White EPO/PPO	$5.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.42
Rate for Payer: Superior Health Plan EPO	$1.59

CITY HOSPITAL TURNOVER KIT

Facility

$313.78

Hospital Charge Code	993790
Hospital Revenue Code	270
Rate for Payer: Cash Price	$213.37

CITY HOSPITAL TURNOVER KIT

Facility

$313.78

Hospital Charge Code	993790
Hospital Revenue Code	270
Min. Negotiated Rate	$28.24
Max. Negotiated Rate	$225.92
Rate for Payer: Amerigroup CHIP/Medicaid	$28.24
Rate for Payer: BCBS of TX Blue Advantage	$94.13
Rate for Payer: BCBS of TX Blue Essentials	$112.96
Rate for Payer: BCBS of TX PPO	$125.51
Rate for Payer: Cash Price	$213.37
Rate for Payer: Cigna Medicaid	$225.92
Rate for Payer: Molina CHIP/Medicaid	$225.92
Rate for Payer: Multiplan Auto	$203.96
Rate for Payer: Multiplan Commercial	$203.96
Rate for Payer: Multiplan Workers Comp	$203.96
Rate for Payer: Parkland Medicaid	$225.92
Rate for Payer: Scott and White EPO/PPO	$156.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$225.92
Rate for Payer: Superior Health Plan EPO	$42.67

Know your out-of-pocket cost for care.

All Charges