White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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

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

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
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

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

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

$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

$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

$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

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

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	$5,681.17
Max. Negotiated Rate	$45,449.40
Rate for Payer: Amerigroup CHIP/Medicaid	$5,681.17
Rate for Payer: BCBS of TX Blue Advantage	$18,937.25
Rate for Payer: BCBS of TX Blue Essentials	$22,724.70
Rate for Payer: BCBS of TX PPO	$25,249.66
Rate for Payer: Cash Price	$42,924.43
Rate for Payer: Cigna Medicaid	$45,449.40
Rate for Payer: Molina CHIP/Medicaid	$45,449.40
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: Parkland Medicaid	$45,449.40
Rate for Payer: Scott and White EPO/PPO	$31,562.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$45,449.40
Rate for Payer: Superior Health Plan EPO	$8,584.89

D142: INOGEN EL ICD DF4 - DR

Facility

$63,124.16

Service Code	HCPCS C1882
Hospital Charge Code	991303
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

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

D142: INOGEN EL ICD DF4 - DR

Facility

$63,124.16

Service Code	HCPCS C1882
Hospital Charge Code	991303
Hospital Revenue Code	278
Min. Negotiated Rate	$5,681.17
Max. Negotiated Rate	$45,449.40
Rate for Payer: Amerigroup CHIP/Medicaid	$5,681.17
Rate for Payer: BCBS of TX Blue Advantage	$18,937.25
Rate for Payer: BCBS of TX Blue Essentials	$22,724.70
Rate for Payer: BCBS of TX PPO	$25,249.66
Rate for Payer: Cash Price	$42,924.43
Rate for Payer: Cigna Medicaid	$45,449.40
Rate for Payer: Molina CHIP/Medicaid	$45,449.40
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: Parkland Medicaid	$45,449.40
Rate for Payer: Scott and White EPO/PPO	$31,562.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$45,449.40
Rate for Payer: Superior Health Plan EPO	$8,584.89

D1N20012S

Facility

$1,188.27

Service Code	HCPCS C1713
Hospital Charge Code	991225
Hospital Revenue Code	278
Min. Negotiated Rate	$106.94
Max. Negotiated Rate	$855.55
Rate for Payer: Amerigroup CHIP/Medicaid	$106.94
Rate for Payer: BCBS of TX Blue Advantage	$356.48
Rate for Payer: BCBS of TX Blue Essentials	$427.78
Rate for Payer: BCBS of TX PPO	$475.31
Rate for Payer: Cash Price	$808.02
Rate for Payer: Cigna Medicaid	$855.55
Rate for Payer: Molina CHIP/Medicaid	$855.55
Rate for Payer: Multiplan Auto	$594.13
Rate for Payer: Multiplan Commercial	$594.13
Rate for Payer: Multiplan Workers Comp	$594.13
Rate for Payer: Parkland Medicaid	$855.55
Rate for Payer: Scott and White EPO/PPO	$594.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$855.55
Rate for Payer: Superior Health Plan EPO	$161.60

D1N20012S

Facility

$1,188.27

Service Code	HCPCS C1713
Hospital Charge Code	991225
Hospital Revenue Code	278
Min. Negotiated Rate	$297.07
Max. Negotiated Rate	$594.13
Rate for Payer: Cash Price	$808.02
Rate for Payer: Cigna Commercial	$297.07
Rate for Payer: Multiplan Auto	$594.13
Rate for Payer: Multiplan Commercial	$594.13
Rate for Payer: Multiplan Workers Comp	$594.13
Rate for Payer: Scott and White EPO/PPO	$594.13

D1N30022SD1N30034SD1N30036S

Facility

$1,199.39

Service Code	HCPCS C1713
Hospital Charge Code	991171
Hospital Revenue Code	278
Min. Negotiated Rate	$299.85
Max. Negotiated Rate	$599.70
Rate for Payer: Cash Price	$815.59
Rate for Payer: Cigna Commercial	$299.85
Rate for Payer: Multiplan Auto	$599.70
Rate for Payer: Multiplan Commercial	$599.70
Rate for Payer: Multiplan Workers Comp	$599.70
Rate for Payer: Scott and White EPO/PPO	$599.70

D1N30022SD1N30034SD1N30036S

Facility

$1,199.39

Service Code	HCPCS C1713
Hospital Charge Code	991171
Hospital Revenue Code	278
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$863.56
Rate for Payer: Amerigroup CHIP/Medicaid	$107.95
Rate for Payer: BCBS of TX Blue Advantage	$359.82
Rate for Payer: BCBS of TX Blue Essentials	$431.78
Rate for Payer: BCBS of TX PPO	$479.76
Rate for Payer: Cash Price	$815.59
Rate for Payer: Cigna Medicaid	$863.56
Rate for Payer: Molina CHIP/Medicaid	$863.56
Rate for Payer: Multiplan Auto	$599.70
Rate for Payer: Multiplan Commercial	$599.70
Rate for Payer: Multiplan Workers Comp	$599.70
Rate for Payer: Parkland Medicaid	$863.56
Rate for Payer: Scott and White EPO/PPO	$599.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$863.56
Rate for Payer: Superior Health Plan EPO	$163.12

D2N25024

Facility

$1,636.42

Service Code	HCPCS C1713
Hospital Charge Code	991226
Hospital Revenue Code	278
Min. Negotiated Rate	$409.11
Max. Negotiated Rate	$818.21
Rate for Payer: Cash Price	$1,112.77
Rate for Payer: Cigna Commercial	$409.11
Rate for Payer: Multiplan Auto	$818.21
Rate for Payer: Multiplan Commercial	$818.21
Rate for Payer: Multiplan Workers Comp	$818.21
Rate for Payer: Scott and White EPO/PPO	$818.21

D2N25024

Facility

$1,636.42

Service Code	HCPCS C1713
Hospital Charge Code	991226
Hospital Revenue Code	278
Min. Negotiated Rate	$147.28
Max. Negotiated Rate	$1,178.22
Rate for Payer: Amerigroup CHIP/Medicaid	$147.28
Rate for Payer: BCBS of TX Blue Advantage	$490.93
Rate for Payer: BCBS of TX Blue Essentials	$589.11
Rate for Payer: BCBS of TX PPO	$654.57
Rate for Payer: Cash Price	$1,112.77
Rate for Payer: Cigna Medicaid	$1,178.22
Rate for Payer: Molina CHIP/Medicaid	$1,178.22
Rate for Payer: Multiplan Auto	$818.21
Rate for Payer: Multiplan Commercial	$818.21
Rate for Payer: Multiplan Workers Comp	$818.21
Rate for Payer: Parkland Medicaid	$1,178.22
Rate for Payer: Scott and White EPO/PPO	$818.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,178.22
Rate for Payer: Superior Health Plan EPO	$222.55

Know your out-of-pocket cost for care.

All Charges