White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CIRCUIT, NEONATAL HEATED VENT REMOTE DUAL LINE 18'

Facility

$68.10

Hospital Charge Code	993620
Hospital Revenue Code	270
Rate for Payer: Cash Price	$46.31

CIRCUIT, PATIENT PARAPAC W/PEEP VALVE DISP

Facility

$29.81

Hospital Charge Code	993611
Hospital Revenue Code	270
Rate for Payer: Cash Price	$20.27

CIRCUIT, PATIENT PARAPAC W/PEEP VALVE DISP

Facility

$29.81

Hospital Charge Code	993611
Hospital Revenue Code	270
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$21.46
Rate for Payer: Amerigroup CHIP/Medicaid	$2.68
Rate for Payer: BCBS of TX Blue Advantage	$8.94
Rate for Payer: BCBS of TX Blue Essentials	$10.73
Rate for Payer: BCBS of TX PPO	$11.92
Rate for Payer: Cash Price	$20.27
Rate for Payer: Cigna Medicaid	$21.46
Rate for Payer: Molina CHIP/Medicaid	$21.46
Rate for Payer: Multiplan Auto	$19.38
Rate for Payer: Multiplan Commercial	$19.38
Rate for Payer: Multiplan Workers Comp	$19.38
Rate for Payer: Parkland Medicaid	$21.46
Rate for Payer: Scott and White EPO/PPO	$14.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.46
Rate for Payer: Superior Health Plan EPO	$4.05

CIRCUIT, UNHTD, SL, NIV, UNIV, 72'

Facility

$33.41

Hospital Charge Code	993312
Hospital Revenue Code	270
Rate for Payer: Cash Price	$22.72

CIRCUIT, UNHTD, SL, NIV, UNIV, 72'

Facility

$33.41

Hospital Charge Code	993312
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

CIRCUIT VENT ADLT W/O PEEP DISP

Facility

$65.90

Hospital Charge Code	993615
Hospital Revenue Code	270
Rate for Payer: Cash Price	$44.81

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
Rate for Payer: Cash Price	$37.22

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 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

$40,299.00

Service Code	MSDRG 286
Min. Negotiated Rate	$18,558.75
Max. Negotiated Rate	$40,299.00
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

$20,903.80

Service Code	MSDRG 287
Min. Negotiated Rate	$9,626.75
Max. Negotiated Rate	$20,903.80
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

$40,299.00

Service Code	MSDRG 286
Min. Negotiated Rate	$18,558.75
Max. Negotiated Rate	$40,299.00
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	$40,299.00
Rate for Payer: Multiplan Commercial	$40,299.00
Rate for Payer: Multiplan Workers Comp	$40,299.00
Rate for Payer: Scott and White EPO/PPO	$18,558.75
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

$20,903.80

Service Code	MSDRG 287
Min. Negotiated Rate	$9,626.75
Max. Negotiated Rate	$20,903.80
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	$20,903.80
Rate for Payer: Multiplan Commercial	$20,903.80
Rate for Payer: Multiplan Workers Comp	$20,903.80
Rate for Payer: Scott and White EPO/PPO	$9,626.75
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
Min. Negotiated Rate	$116.50
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	$116.50
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

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

CIRRHOSIS & ALCOHOLIC HEPATITIS W CC

Facility

$19,756.20

Service Code	MSDRG 433
Min. Negotiated Rate	$8,839.94
Max. Negotiated Rate	$19,756.20
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

$35,875.80

Service Code	MSDRG 432
Min. Negotiated Rate	$15,703.60
Max. Negotiated Rate	$35,875.80
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

$11,926.30

Service Code	MSDRG 434
Min. Negotiated Rate	$5,492.38
Max. Negotiated Rate	$11,926.30
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

$19,756.20

Service Code	MSDRG 433
Min. Negotiated Rate	$8,839.94
Max. Negotiated Rate	$19,756.20
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	$19,756.20
Rate for Payer: Multiplan Commercial	$19,756.20
Rate for Payer: Multiplan Workers Comp	$19,756.20
Rate for Payer: Scott and White EPO/PPO	$9,098.25
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

$35,875.80

Service Code	MSDRG 432
Min. Negotiated Rate	$15,703.60
Max. Negotiated Rate	$35,875.80
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	$35,875.80
Rate for Payer: Multiplan Commercial	$35,875.80
Rate for Payer: Multiplan Workers Comp	$35,875.80
Rate for Payer: Scott and White EPO/PPO	$16,521.75
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

$11,926.30

Service Code	MSDRG 434
Min. Negotiated Rate	$5,492.38
Max. Negotiated Rate	$11,926.30
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	$11,926.30
Rate for Payer: Multiplan Commercial	$11,926.30
Rate for Payer: Multiplan Workers Comp	$11,926.30
Rate for Payer: Scott and White EPO/PPO	$5,492.38
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
Rate for Payer: Cash Price	$87.17

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

Know your out-of-pocket cost for care.

All Charges