White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Dialysis Treatment Charge -> TPE Complete

Facility

$3,926.00

Service Code	HCPCS 36514
Hospital Charge Code	810005
Hospital Revenue Code	940
Rate for Payer: Cash Price	$2,669.68

Dialysis Treatment Charge -> Unscheduled Dial ESR PT

Facility

$2,811.00

Hospital Charge Code	5600257
Hospital Revenue Code	820
Min. Negotiated Rate	$252.99
Max. Negotiated Rate	$2,023.92
Rate for Payer: Amerigroup CHIP/Medicaid	$252.99
Rate for Payer: BCBS of TX Blue Advantage	$843.30
Rate for Payer: BCBS of TX Blue Essentials	$1,011.96
Rate for Payer: BCBS of TX PPO	$1,124.40
Rate for Payer: Cash Price	$1,911.48
Rate for Payer: Cigna Medicaid	$2,023.92
Rate for Payer: Molina CHIP/Medicaid	$2,023.92
Rate for Payer: Multiplan Auto	$1,827.15
Rate for Payer: Multiplan Commercial	$1,827.15
Rate for Payer: Multiplan Workers Comp	$1,827.15
Rate for Payer: Parkland Medicaid	$2,023.92
Rate for Payer: Scott and White EPO/PPO	$1,405.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,023.92
Rate for Payer: Superior Health Plan EPO	$382.30

Dialysis Treatment Charge -> Unscheduled Dial ESR PT

Facility

$2,811.00

Hospital Charge Code	5600257
Hospital Revenue Code	820
Rate for Payer: Cash Price	$1,911.48

DIAMOND BACK CARTRIDGE CLASSIC DBP-CART-150CLA145

Facility

$11,350.00

Hospital Charge Code	144469
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7,718.00

DIAMOND BACK CARTRIDGE CLASSIC DBP-CART-150CLA145

Facility

$11,350.00

Hospital Charge Code	144469
Hospital Revenue Code	272
Min. Negotiated Rate	$1,021.50
Max. Negotiated Rate	$8,172.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,021.50
Rate for Payer: BCBS of TX Blue Advantage	$3,405.00
Rate for Payer: BCBS of TX Blue Essentials	$4,086.00
Rate for Payer: BCBS of TX PPO	$4,540.00
Rate for Payer: Cash Price	$7,718.00
Rate for Payer: Cigna Medicaid	$8,172.00
Rate for Payer: Molina CHIP/Medicaid	$8,172.00
Rate for Payer: Multiplan Auto	$7,377.50
Rate for Payer: Multiplan Commercial	$7,377.50
Rate for Payer: Multiplan Workers Comp	$7,377.50
Rate for Payer: Parkland Medicaid	$8,172.00
Rate for Payer: Scott and White EPO/PPO	$5,675.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,172.00
Rate for Payer: Superior Health Plan EPO	$1,543.60

DIAMOND BACK CARTRIDGE MICRO DBP-CART-125MIC145

Facility

$11,350.00

Hospital Charge Code	144468
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7,718.00

DIAMOND BACK CARTRIDGE MICRO DBP-CART-125MIC145

Facility

$11,350.00

Hospital Charge Code	144468
Hospital Revenue Code	272
Min. Negotiated Rate	$1,021.50
Max. Negotiated Rate	$8,172.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,021.50
Rate for Payer: BCBS of TX Blue Advantage	$3,405.00
Rate for Payer: BCBS of TX Blue Essentials	$4,086.00
Rate for Payer: BCBS of TX PPO	$4,540.00
Rate for Payer: Cash Price	$7,718.00
Rate for Payer: Cigna Medicaid	$8,172.00
Rate for Payer: Molina CHIP/Medicaid	$8,172.00
Rate for Payer: Multiplan Auto	$7,377.50
Rate for Payer: Multiplan Commercial	$7,377.50
Rate for Payer: Multiplan Workers Comp	$7,377.50
Rate for Payer: Parkland Medicaid	$8,172.00
Rate for Payer: Scott and White EPO/PPO	$5,675.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,172.00
Rate for Payer: Superior Health Plan EPO	$1,543.60

Diaphragmatic Hernia Repair with Mesh

Facility

$10,327.10

Service Code	HCPCS 49659
Hospital Charge Code	9900729
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$7,022.43
Rate for Payer: Cash Price	$7,022.43
Rate for Payer: Cash Price	$7,022.43
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$7,435.51
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$7,435.51
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$7,435.51
Rate for Payer: Scott and White EPO/PPO	$11,235.20
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,435.51
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Diaphragmatic Hernia Repair with Mesh

Facility

$12,837.39

Service Code	CPT 49659
Hospital Charge Code	36049659
Hospital Revenue Code	360
Min. Negotiated Rate	$6,073.08
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$11,235.20
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Diaphragmatic Hernia Repair with Mesh

Facility

$10,327.10

Service Code	HCPCS 49659
Hospital Charge Code	9900729
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,022.43

diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

Facility

$142.00

Service Code	HCPCS Q9963
Hospital Charge Code	77510372
Hospital Revenue Code	255
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$102.24
Rate for Payer: Amerigroup CHIP/Medicaid	$12.78
Rate for Payer: BCBS of TX Blue Advantage	$0.28
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.37
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cigna Medicaid	$102.24
Rate for Payer: Molina CHIP/Medicaid	$102.24
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Parkland Medicaid	$102.24
Rate for Payer: Scott and White EPO/PPO	$71.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.24
Rate for Payer: Superior Health Plan EPO	$19.31

diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

Facility

$142.00

Service Code	HCPCS Q9963
Hospital Charge Code	77510372
Hospital Revenue Code	255
Rate for Payer: Cash Price	$96.56

DIAZEPAM 10 MG

Facility

$128.00

Service Code	HCPCS J3360
Hospital Charge Code	79282810
Hospital Revenue Code	636
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$8.99
Rate for Payer: BCBS of TX Blue Essentials	$10.79
Rate for Payer: BCBS of TX PPO	$11.97
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

DIAZEPAM 10 MG

Facility

$128.00

Service Code	HCPCS J3360
Hospital Charge Code	79282810
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

diazepam 2 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77510651
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

diazepam 2 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77510651
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

diazepam 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77510806
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

diazepam 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77510806
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

diclofenac 1% Topical Gel 100 g

Facility

$89.98

Service Code	HCPCS J3490
Hospital Charge Code	77511495
Hospital Revenue Code	250
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$64.79
Rate for Payer: Amerigroup CHIP/Medicaid	$8.10
Rate for Payer: BCBS of TX Blue Advantage	$26.99
Rate for Payer: BCBS of TX Blue Essentials	$32.39
Rate for Payer: BCBS of TX PPO	$35.99
Rate for Payer: Cash Price	$61.19
Rate for Payer: Cigna Medicaid	$64.79
Rate for Payer: Molina CHIP/Medicaid	$64.79
Rate for Payer: Multiplan Auto	$58.49
Rate for Payer: Multiplan Commercial	$58.49
Rate for Payer: Multiplan Workers Comp	$58.49
Rate for Payer: Parkland Medicaid	$64.79
Rate for Payer: Scott and White EPO/PPO	$44.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$64.79
Rate for Payer: Superior Health Plan EPO	$12.24

diclofenac 1% Topical Gel 100 g

Facility

$89.98

Service Code	HCPCS J3490
Hospital Charge Code	77511495
Hospital Revenue Code	250
Rate for Payer: Cash Price	$61.19

dicyclomine 10 mg Cap

Facility

$7.65

Service Code	HCPCS J0500
Hospital Charge Code	77512411
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.83

dicyclomine 10 mg Cap

Facility

$7.65

Service Code	HCPCS J0500
Hospital Charge Code	77512411
Hospital Revenue Code	636
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$54.19
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$40.72
Rate for Payer: BCBS of TX Blue Essentials	$48.86
Rate for Payer: BCBS of TX PPO	$54.19
Rate for Payer: Cash Price	$5.20
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

dicyclomine HCl ORAL TABLET 20 MG

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77512412
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

dicyclomine HCl ORAL TABLET 20 MG

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77512412
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

DIGESTIVE MALIGNANCY

Facility

$10,672.19

Service Code	APR-DRG 2404
Min. Negotiated Rate	$10,062.11
Max. Negotiated Rate	$10,672.19
Rate for Payer: Amerigroup CHIP/Medicaid	$10,062.11
Rate for Payer: Cigna Medicaid	$10,062.11
Rate for Payer: Molina CHIP/Medicaid	$10,062.11
Rate for Payer: Parkland Medicaid	$10,062.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,672.19

Know your out-of-pocket cost for care.

All Charges