White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION

Facility

$7,623.37

Service Code	APR-DRG 0453
Min. Negotiated Rate	$7,187.58
Max. Negotiated Rate	$7,623.37
Rate for Payer: Amerigroup CHIP/Medicaid	$7,187.58
Rate for Payer: Cigna Medicaid	$7,187.58
Rate for Payer: Molina CHIP/Medicaid	$7,187.58
Rate for Payer: Parkland Medicaid	$7,187.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,623.37

CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION

Facility

$13,615.77

Service Code	APR-DRG 0454
Min. Negotiated Rate	$12,837.42
Max. Negotiated Rate	$13,615.77
Rate for Payer: Amerigroup CHIP/Medicaid	$12,837.42
Rate for Payer: Cigna Medicaid	$12,837.42
Rate for Payer: Molina CHIP/Medicaid	$12,837.42
Rate for Payer: Parkland Medicaid	$12,837.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,615.77

CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION

Facility

$3,872.98

Service Code	APR-DRG 0451
Min. Negotiated Rate	$3,651.58
Max. Negotiated Rate	$3,872.98
Rate for Payer: Amerigroup CHIP/Medicaid	$3,651.58
Rate for Payer: Cigna Medicaid	$3,651.58
Rate for Payer: Molina CHIP/Medicaid	$3,651.58
Rate for Payer: Parkland Medicaid	$3,651.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,872.98

CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION

Facility

$5,128.26

Service Code	APR-DRG 0452
Min. Negotiated Rate	$4,835.10
Max. Negotiated Rate	$5,128.26
Rate for Payer: Amerigroup CHIP/Medicaid	$4,835.10
Rate for Payer: Cigna Medicaid	$4,835.10
Rate for Payer: Molina CHIP/Medicaid	$4,835.10
Rate for Payer: Parkland Medicaid	$4,835.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,128.26

CV ECG Acquisition

Facility

$700.00

Service Code	HCPCS 93005
Hospital Charge Code	4603000
Hospital Revenue Code	730
Rate for Payer: Cash Price	$476.00

CV ECG Acquisition

Facility

$700.00

Service Code	HCPCS 93005
Hospital Charge Code	4603000
Hospital Revenue Code	730
Min. Negotiated Rate	$7.78
Max. Negotiated Rate	$504.00
Rate for Payer: Amerigroup CHIP/Medicaid	$63.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$210.00
Rate for Payer: BCBS of TX Blue Essentials	$252.00
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$280.00
Rate for Payer: Cash Price	$476.00
Rate for Payer: Cash Price	$476.00
Rate for Payer: Cash Price	$476.00
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$504.00
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$504.00
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
Rate for Payer: Multiplan Auto	$455.00
Rate for Payer: Multiplan Commercial	$455.00
Rate for Payer: Multiplan Workers Comp	$455.00
Rate for Payer: Parkland Medicaid	$504.00
Rate for Payer: Scott and White EPO/PPO	$7.78
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$504.00
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

cyanocobalamin 1000 mcg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77487253
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

cyanocobalamin 1000 mcg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77487253
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

cyanocobalamin 1000 mcg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77487200
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

cyanocobalamin 1000 mcg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77487200
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

cyclobenzaprine 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77487885
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

cyclobenzaprine 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77487885
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Cyclosporine, Blood SO

Facility

$359.00

Service Code	HCPCS 80158
Hospital Charge Code	1706928
Hospital Revenue Code	300
Rate for Payer: Cash Price	$244.12

Cyclosporine, Blood SO

Facility

$359.00

Service Code	HCPCS 80158
Hospital Charge Code	1706928
Hospital Revenue Code	300
Min. Negotiated Rate	$7.04
Max. Negotiated Rate	$258.48
Rate for Payer: Amerigroup CHIP/Medicaid	$7.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.05
Rate for Payer: Amerigroup Medicare	$18.05
Rate for Payer: BCBS of TX Blue Advantage	$107.70
Rate for Payer: BCBS of TX Blue Essentials	$129.24
Rate for Payer: BCBS of TX Medicare	$18.05
Rate for Payer: BCBS of TX PPO	$143.60
Rate for Payer: Cash Price	$244.12
Rate for Payer: Cash Price	$244.12
Rate for Payer: Cigna Medicaid	$258.48
Rate for Payer: Cigna Medicare	$18.05
Rate for Payer: Employer Direct Commercial	$18.05
Rate for Payer: Humana Medicare/TRICARE	$18.05
Rate for Payer: Molina CHIP/Medicaid	$258.48
Rate for Payer: Molina Dual Medicare/Medicaid	$18.05
Rate for Payer: Molina Medicare	$18.05
Rate for Payer: Multiplan Auto	$233.35
Rate for Payer: Multiplan Commercial	$233.35
Rate for Payer: Multiplan Workers Comp	$233.35
Rate for Payer: Parkland Medicaid	$258.48
Rate for Payer: Scott and White EPO/PPO	$22.56
Rate for Payer: Scott and White Medicare	$18.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$258.48
Rate for Payer: Superior Health Plan EPO	$18.05
Rate for Payer: Superior Health Plan Medicare	$18.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.05
Rate for Payer: Universal American Medicare	$18.05
Rate for Payer: Wellcare Medicare	$18.05
Rate for Payer: Wellmed Medicare	$18.05

Cystatin C SO

Facility

$154.11

Service Code	HCPCS 82610
Hospital Charge Code	9074977
Hospital Revenue Code	301
Rate for Payer: Cash Price	$104.79

Cystatin C SO

Facility

$154.11

Service Code	HCPCS 82610
Hospital Charge Code	9074977
Hospital Revenue Code	301
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$110.96
Rate for Payer: Amerigroup CHIP/Medicaid	$7.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.52
Rate for Payer: Amerigroup Medicare	$18.52
Rate for Payer: BCBS of TX Blue Advantage	$46.23
Rate for Payer: BCBS of TX Blue Essentials	$55.48
Rate for Payer: BCBS of TX Medicare	$18.52
Rate for Payer: BCBS of TX PPO	$61.64
Rate for Payer: Cash Price	$104.79
Rate for Payer: Cash Price	$104.79
Rate for Payer: Cigna Medicaid	$110.96
Rate for Payer: Cigna Medicare	$18.52
Rate for Payer: Employer Direct Commercial	$18.52
Rate for Payer: Humana Medicare/TRICARE	$18.52
Rate for Payer: Molina CHIP/Medicaid	$110.96
Rate for Payer: Molina Dual Medicare/Medicaid	$18.52
Rate for Payer: Molina Medicare	$18.52
Rate for Payer: Multiplan Auto	$100.17
Rate for Payer: Multiplan Commercial	$100.17
Rate for Payer: Multiplan Workers Comp	$100.17
Rate for Payer: Parkland Medicaid	$110.96
Rate for Payer: Scott and White EPO/PPO	$23.15
Rate for Payer: Scott and White Medicare	$18.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.96
Rate for Payer: Superior Health Plan EPO	$18.52
Rate for Payer: Superior Health Plan Medicare	$18.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.52
Rate for Payer: Universal American Medicare	$18.52
Rate for Payer: Wellcare Medicare	$18.52
Rate for Payer: Wellmed Medicare	$18.52

Cystic Fibrosis Profile SO

Facility

$157.00

Service Code	HCPCS 81220
Hospital Charge Code	1740969
Hospital Revenue Code	310
Rate for Payer: Cash Price	$106.76

Cystic Fibrosis Profile SO

Facility

$157.00

Service Code	HCPCS 81220
Hospital Charge Code	1740969
Hospital Revenue Code	310
Min. Negotiated Rate	$47.10
Max. Negotiated Rate	$695.75
Rate for Payer: Amerigroup CHIP/Medicaid	$217.07
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$556.60
Rate for Payer: Amerigroup Medicare	$556.60
Rate for Payer: BCBS of TX Blue Advantage	$47.10
Rate for Payer: BCBS of TX Blue Essentials	$56.52
Rate for Payer: BCBS of TX Medicare	$556.60
Rate for Payer: BCBS of TX PPO	$62.80
Rate for Payer: Cash Price	$106.76
Rate for Payer: Cash Price	$106.76
Rate for Payer: Cigna Medicaid	$113.04
Rate for Payer: Cigna Medicare	$556.60
Rate for Payer: Employer Direct Commercial	$556.60
Rate for Payer: Humana Medicare/TRICARE	$556.60
Rate for Payer: Molina CHIP/Medicaid	$113.04
Rate for Payer: Molina Dual Medicare/Medicaid	$556.60
Rate for Payer: Molina Medicare	$556.60
Rate for Payer: Multiplan Auto	$102.05
Rate for Payer: Multiplan Commercial	$102.05
Rate for Payer: Multiplan Workers Comp	$102.05
Rate for Payer: Parkland Medicaid	$113.04
Rate for Payer: Scott and White EPO/PPO	$695.75
Rate for Payer: Scott and White Medicare	$556.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$113.04
Rate for Payer: Superior Health Plan EPO	$556.60
Rate for Payer: Superior Health Plan Medicare	$556.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$556.60
Rate for Payer: Universal American Medicare	$556.60
Rate for Payer: Wellcare Medicare	$556.60
Rate for Payer: Wellmed Medicare	$556.60

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$10,858.52

Service Code	APR-DRG 1312
Min. Negotiated Rate	$10,237.79
Max. Negotiated Rate	$10,858.52
Rate for Payer: Amerigroup CHIP/Medicaid	$10,237.79
Rate for Payer: Cigna Medicaid	$10,237.79
Rate for Payer: Molina CHIP/Medicaid	$10,237.79
Rate for Payer: Parkland Medicaid	$10,237.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,858.52

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$19,729.63

Service Code	APR-DRG 1314
Min. Negotiated Rate	$18,601.78
Max. Negotiated Rate	$19,729.63
Rate for Payer: Amerigroup CHIP/Medicaid	$18,601.78
Rate for Payer: Cigna Medicaid	$18,601.78
Rate for Payer: Molina CHIP/Medicaid	$18,601.78
Rate for Payer: Parkland Medicaid	$18,601.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,729.63

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$6,199.10

Service Code	APR-DRG 1311
Min. Negotiated Rate	$5,844.73
Max. Negotiated Rate	$6,199.10
Rate for Payer: Amerigroup CHIP/Medicaid	$5,844.73
Rate for Payer: Cigna Medicaid	$5,844.73
Rate for Payer: Molina CHIP/Medicaid	$5,844.73
Rate for Payer: Parkland Medicaid	$5,844.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,199.10

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$14,677.18

Service Code	APR-DRG 1313
Min. Negotiated Rate	$13,838.16
Max. Negotiated Rate	$14,677.18
Rate for Payer: Amerigroup CHIP/Medicaid	$13,838.16
Rate for Payer: Cigna Medicaid	$13,838.16
Rate for Payer: Molina CHIP/Medicaid	$13,838.16
Rate for Payer: Parkland Medicaid	$13,838.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,677.18

CYSTOSCOPY PACK II

Facility

$221.33

Hospital Charge Code	146178
Hospital Revenue Code	272
Min. Negotiated Rate	$19.92
Max. Negotiated Rate	$159.36
Rate for Payer: Amerigroup CHIP/Medicaid	$19.92
Rate for Payer: BCBS of TX Blue Advantage	$66.40
Rate for Payer: BCBS of TX Blue Essentials	$79.68
Rate for Payer: BCBS of TX PPO	$88.53
Rate for Payer: Cash Price	$150.50
Rate for Payer: Cigna Medicaid	$159.36
Rate for Payer: Molina CHIP/Medicaid	$159.36
Rate for Payer: Multiplan Auto	$143.86
Rate for Payer: Multiplan Commercial	$143.86
Rate for Payer: Multiplan Workers Comp	$143.86
Rate for Payer: Parkland Medicaid	$159.36
Rate for Payer: Scott and White EPO/PPO	$110.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$159.36
Rate for Payer: Superior Health Plan EPO	$30.10

CYSTOSCOPY PACK II

Facility

$221.33

Hospital Charge Code	146178
Hospital Revenue Code	272
Rate for Payer: Cash Price	$150.50

D142: INOGEN EL ICD DF4 - DR

Facility

$63,124.16

Service Code	HCPCS C1882
Hospital Charge Code	992635
Hospital Revenue Code	278
Min. Negotiated Rate	$15,781.04
Max. Negotiated Rate	$31,562.08
Rate for Payer: Cash Price	$42,924.43
Rate for Payer: Cigna Commercial	$15,781.04
Rate for Payer: Multiplan Auto	$31,562.08
Rate for Payer: Multiplan Commercial	$31,562.08
Rate for Payer: Multiplan Workers Comp	$31,562.08
Rate for Payer: Scott and White EPO/PPO	$31,562.08

Know your out-of-pocket cost for care.

All Charges