White Rock Medical Center

All Charges

Charge

Type

Setting

Price

amoxicillin-clavulanate 875 mg-125 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77376699
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan EPO	$1.04

amoxicillin-clavulanate 875 mg-125 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77376699
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Amphetamine Screen Urine

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640104
Hospital Revenue Code	300
Rate for Payer: Cash Price	$278.96

Amphetamine Screen Urine

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640104
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$206.05
Rate for Payer: Aetna Commercial	$65.24
Rate for Payer: Aetna Medicare	$93.21
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$102.53
Rate for Payer: BCBS of TX Blue Essentials	$123.04
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$137.33
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cigna Medicaid	$62.14
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$62.14
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$62.14
Rate for Payer: Scott and White EPO/PPO	$77.67
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.14
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

ampicillin 2 g Inj

Facility

$128.17

Service Code	HCPCS J0290
Hospital Charge Code	77377989
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.48
Rate for Payer: BCBS of TX Blue Essentials	$4.18
Rate for Payer: BCBS of TX PPO	$4.63
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$1.26
Rate for Payer: Superior Health Plan EPO	$17.43

ampicillin 2 g Inj

Facility

$128.17

Service Code	HCPCS J0290
Hospital Charge Code	77377989
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

ampicillin-sulbactam 1 g-0.5 g Inj

Facility

$128.17

Service Code	HCPCS J0295
Hospital Charge Code	77378425
Hospital Revenue Code	250
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$4.55
Rate for Payer: BCBS of TX Blue Essentials	$5.46
Rate for Payer: BCBS of TX PPO	$6.06
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$2.21
Rate for Payer: Superior Health Plan EPO	$17.43

ampicillin-sulbactam 1 g-0.5 g Inj

Facility

$128.17

Service Code	HCPCS J0295
Hospital Charge Code	77378425
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

ampicillin-sulbactam 2 g-1 g Inj

Facility

$128.17

Service Code	HCPCS J0295
Hospital Charge Code	77378527
Hospital Revenue Code	250
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$4.55
Rate for Payer: BCBS of TX Blue Essentials	$5.46
Rate for Payer: BCBS of TX PPO	$6.06
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$2.21
Rate for Payer: Superior Health Plan EPO	$17.43

ampicillin-sulbactam 2 g-1 g Inj

Facility

$128.17

Service Code	HCPCS J0295
Hospital Charge Code	77378527
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

AMPLATZ VAC PLUG

Facility

$3,653.37

Hospital Charge Code	8484497
Hospital Revenue Code	278
Min. Negotiated Rate	$913.34
Max. Negotiated Rate	$1,826.68
Rate for Payer: Aetna Commercial	$1,096.01
Rate for Payer: Cash Price	$3,214.97
Rate for Payer: Cigna Commercial	$913.34
Rate for Payer: Multiplan Auto	$1,826.68
Rate for Payer: Multiplan Commercial	$1,826.68
Rate for Payer: Multiplan Workers Comp	$1,826.68
Rate for Payer: Scott and White EPO/PPO	$1,826.68

AMPLATZ VAC PLUG

Facility

$3,653.37

Hospital Charge Code	8484497
Hospital Revenue Code	278
Min. Negotiated Rate	$328.80
Max. Negotiated Rate	$1,826.68
Rate for Payer: Aetna Commercial	$1,096.01
Rate for Payer: Amerigroup CHIP/Medicaid	$328.80
Rate for Payer: BCBS of TX Blue Advantage	$1,096.01
Rate for Payer: BCBS of TX Blue Essentials	$1,315.21
Rate for Payer: BCBS of TX PPO	$1,461.35
Rate for Payer: Cash Price	$3,214.97
Rate for Payer: Multiplan Auto	$1,826.68
Rate for Payer: Multiplan Commercial	$1,826.68
Rate for Payer: Multiplan Workers Comp	$1,826.68
Rate for Payer: Scott and White EPO/PPO	$1,826.68
Rate for Payer: Superior Health Plan EPO	$496.86

Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectom

Facility

$10,000.00

Service Code	CPT 26952
Hospital Charge Code	36026952
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectom

Facility

$10,000.00

Service Code	CPT 26951
Hospital Charge Code	36026951
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Amputation, foot transmetatarsal

Facility

$10,000.00

Service Code	CPT 28805
Hospital Charge Code	36028805
Hospital Revenue Code	360
Min. Negotiated Rate	$2,960.24
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC

Facility

$36,182.50

Service Code	MSDRG 240
Min. Negotiated Rate	$23,323.20
Max. Negotiated Rate	$36,182.50
Rate for Payer: Aetna Commercial	$31,603.50
Rate for Payer: Aetna Medicare	$34,352.10
Rate for Payer: BCBS of TX Blue Advantage	$23,323.20
Rate for Payer: BCBS of TX Blue Essentials	$28,324.62
Rate for Payer: BCBS of TX PPO	$31,473.02
Rate for Payer: Cigna Commercial	$36,182.50

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC

Facility

$61,911.58

Service Code	MSDRG 239
Min. Negotiated Rate	$41,416.74
Max. Negotiated Rate	$61,911.58
Rate for Payer: Aetna Commercial	$54,076.50
Rate for Payer: Aetna Medicare	$55,734.60
Rate for Payer: BCBS of TX Blue Advantage	$41,416.74
Rate for Payer: BCBS of TX Blue Essentials	$48,595.27
Rate for Payer: BCBS of TX PPO	$53,996.83
Rate for Payer: Cigna Commercial	$61,911.58

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC

Facility

$19,203.69

Service Code	MSDRG 241
Min. Negotiated Rate	$12,453.66
Max. Negotiated Rate	$19,203.69
Rate for Payer: Aetna Commercial	$15,635.25
Rate for Payer: Aetna Medicare	$19,203.69
Rate for Payer: BCBS of TX Blue Advantage	$12,453.66
Rate for Payer: BCBS of TX Blue Essentials	$16,469.12
Rate for Payer: BCBS of TX PPO	$18,299.74
Rate for Payer: Cigna Commercial	$17,900.62

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$27,623.74

Service Code	MSDRG 475
Min. Negotiated Rate	$17,802.86
Max. Negotiated Rate	$27,623.74
Rate for Payer: Aetna Commercial	$24,127.88
Rate for Payer: Aetna Medicare	$27,239.24
Rate for Payer: BCBS of TX Blue Advantage	$17,802.86
Rate for Payer: BCBS of TX Blue Essentials	$22,173.47
Rate for Payer: BCBS of TX PPO	$24,638.14
Rate for Payer: Cigna Commercial	$27,623.74

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$55,420.06

Service Code	MSDRG 474
Min. Negotiated Rate	$32,248.28
Max. Negotiated Rate	$55,420.06
Rate for Payer: Aetna Commercial	$48,406.50
Rate for Payer: Aetna Medicare	$50,339.76
Rate for Payer: BCBS of TX Blue Advantage	$32,248.28
Rate for Payer: BCBS of TX Blue Essentials	$39,161.64
Rate for Payer: BCBS of TX PPO	$43,514.62
Rate for Payer: Cigna Commercial	$55,420.06

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$16,879.80

Service Code	MSDRG 476
Min. Negotiated Rate	$9,263.06
Max. Negotiated Rate	$16,879.80
Rate for Payer: Aetna Commercial	$13,240.12
Rate for Payer: Aetna Medicare	$16,879.80
Rate for Payer: BCBS of TX Blue Advantage	$9,263.06
Rate for Payer: BCBS of TX Blue Essentials	$11,874.07
Rate for Payer: BCBS of TX PPO	$13,193.93
Rate for Payer: Cigna Commercial	$15,158.47

Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous

Facility

$10,000.00

Service Code	CPT 26910
Hospital Charge Code	36026910
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Amputation, metatarsal, with toe, single

Facility

$10,000.00

Service Code	CPT 28810
Hospital Charge Code	36028810
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$25,560.36

Service Code	MSDRG 617
Min. Negotiated Rate	$17,279.12
Max. Negotiated Rate	$25,560.36
Rate for Payer: Aetna Commercial	$22,325.62
Rate for Payer: Aetna Medicare	$25,524.44
Rate for Payer: BCBS of TX Blue Advantage	$17,279.12
Rate for Payer: BCBS of TX Blue Essentials	$21,397.48
Rate for Payer: BCBS of TX PPO	$23,775.90
Rate for Payer: Cigna Commercial	$25,560.36

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$50,975.18

Service Code	MSDRG 616
Min. Negotiated Rate	$35,022.64
Max. Negotiated Rate	$50,975.18
Rate for Payer: Aetna Commercial	$44,524.12
Rate for Payer: Aetna Medicare	$46,645.77
Rate for Payer: BCBS of TX Blue Advantage	$35,022.64
Rate for Payer: BCBS of TX Blue Essentials	$42,671.13
Rate for Payer: BCBS of TX PPO	$47,414.20
Rate for Payer: Cigna Commercial	$50,975.18

Know your out-of-pocket cost for care.

All Charges