White Rock Medical Center

All Charges

Charge

Type

Setting

Price

diphenhydrAMINE 50 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1200
Hospital Charge Code	77518369
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

diphenhydrAMINE 50 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1200
Hospital Charge Code	77518369
Hospital Revenue Code	636
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.00
Rate for Payer: BCBS of TX Blue Essentials	$1.20
Rate for Payer: BCBS of TX PPO	$1.33
Rate for Payer: Cash Price	$87.16
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

Direct Admit to Hospital Obs Care G0379 BCE

Facility

$796.02

Service Code	HCPCS G0379
Hospital Charge Code	100017
Hospital Revenue Code	762
Min. Negotiated Rate	$398.01
Max. Negotiated Rate	$3,660.00
Rate for Payer: Amerigroup CHIP/Medicaid	$400.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$598.24
Rate for Payer: Amerigroup Medicare	$598.24
Rate for Payer: BCBS of TX Blue Advantage	$2,745.00
Rate for Payer: BCBS of TX Blue Essentials	$3,294.00
Rate for Payer: BCBS of TX Medicare	$598.24
Rate for Payer: BCBS of TX PPO	$3,660.00
Rate for Payer: Cash Price	$541.29
Rate for Payer: Cash Price	$541.29
Rate for Payer: Cash Price	$541.29
Rate for Payer: Cigna Commercial	$1,264.58
Rate for Payer: Cigna Medicaid	$573.13
Rate for Payer: Cigna Medicare	$598.24
Rate for Payer: Employer Direct Commercial	$598.24
Rate for Payer: Humana Medicare/TRICARE	$598.24
Rate for Payer: Molina CHIP/Medicaid	$573.13
Rate for Payer: Molina Dual Medicare/Medicaid	$598.24
Rate for Payer: Molina Medicare	$598.24
Rate for Payer: Multiplan Auto	$517.41
Rate for Payer: Multiplan Commercial	$517.41
Rate for Payer: Multiplan Workers Comp	$517.41
Rate for Payer: Parkland Medicaid	$573.13
Rate for Payer: Scott and White EPO/PPO	$398.01
Rate for Payer: Scott and White Medicare	$598.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$573.13
Rate for Payer: Superior Health Plan EPO	$598.24
Rate for Payer: Superior Health Plan Medicare	$598.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$598.24
Rate for Payer: Universal American Medicare	$598.24
Rate for Payer: Wellcare Medicare	$598.24
Rate for Payer: Wellmed Medicare	$598.24

Direct Admit to Hospital Obs Care G0379 BCE

Facility

$796.02

Service Code	HCPCS G0379
Hospital Charge Code	100017
Hospital Revenue Code	762
Rate for Payer: Cash Price	$541.29

Direct repair of aneurysm, pseudoaneurysm, or excision

Facility

$22,740.04

Service Code	HCPCS 35011
Hospital Charge Code	994214
Hospital Revenue Code	360
Rate for Payer: Cash Price	$15,463.23

Direct repair of aneurysm, pseudoaneurysm, or excision

Facility

$22,740.04

Service Code	HCPCS 35011
Hospital Charge Code	994214
Hospital Revenue Code	360
Min. Negotiated Rate	$2,046.60
Max. Negotiated Rate	$16,372.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2,046.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Amerigroup Medicare	$5,589.84
Rate for Payer: BCBS of TX Blue Advantage	$7,675.64
Rate for Payer: BCBS of TX Blue Essentials	$9,192.38
Rate for Payer: BCBS of TX Medicare	$5,589.84
Rate for Payer: BCBS of TX PPO	$11,582.40
Rate for Payer: Cash Price	$15,463.23
Rate for Payer: Cash Price	$15,463.23
Rate for Payer: Cash Price	$15,463.23
Rate for Payer: Cigna Commercial	$11,815.91
Rate for Payer: Cigna Medicaid	$16,372.83
Rate for Payer: Cigna Medicare	$5,589.84
Rate for Payer: Employer Direct Commercial	$5,589.84
Rate for Payer: Humana Medicare/TRICARE	$5,589.84
Rate for Payer: Molina CHIP/Medicaid	$16,372.83
Rate for Payer: Molina Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Molina Medicare	$5,589.84
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	$16,372.83
Rate for Payer: Scott and White EPO/PPO	$10,341.20
Rate for Payer: Scott and White Medicare	$5,589.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,372.83
Rate for Payer: Superior Health Plan EPO	$5,589.84
Rate for Payer: Superior Health Plan Medicare	$5,589.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Universal American Medicare	$5,589.84
Rate for Payer: Wellcare Medicare	$5,589.84
Rate for Payer: Wellmed Medicare	$5,589.84

Discography, lumbar, radiological supervision and interpretation

Facility

$8,966.55

Service Code	HCPCS 72295
Hospital Charge Code	9900899
Hospital Revenue Code	360
Min. Negotiated Rate	$806.99
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$806.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,836.93
Rate for Payer: BCBS of TX Blue Essentials	$3,404.31
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$3,799.76
Rate for Payer: Cash Price	$6,097.25
Rate for Payer: Cash Price	$6,097.25
Rate for Payer: Cash Price	$6,097.25
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$6,455.92
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$6,455.92
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$6,455.92
Rate for Payer: Scott and White EPO/PPO	$4,483.27
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,455.92
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Discography, lumbar, radiological supervision and interpretation

Facility

$8,966.55

Service Code	HCPCS 72295
Hospital Charge Code	9900899
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,097.25

Discography, lumbar, radiological supervision and interpretation

Facility

$10,000.00

Service Code	CPT 72295
Hospital Charge Code	36072295
Hospital Revenue Code	360
Min. Negotiated Rate	$1,961.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,836.93
Rate for Payer: BCBS of TX Blue Essentials	$3,404.31
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$3,799.76
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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 Medicare	$1,961.62
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

DISINFECTION SYS SONEX-HL TROPHON, 80ML

Facility

$10.03

Hospital Charge Code	993601
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.82

DISINFECTION SYS SONEX-HL TROPHON, 80ML

Facility

$10.03

Hospital Charge Code	993601
Hospital Revenue Code	270
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$7.22
Rate for Payer: Amerigroup CHIP/Medicaid	$0.90
Rate for Payer: BCBS of TX Blue Advantage	$3.01
Rate for Payer: BCBS of TX Blue Essentials	$3.61
Rate for Payer: BCBS of TX PPO	$4.01
Rate for Payer: Cash Price	$6.82
Rate for Payer: Cigna Medicaid	$7.22
Rate for Payer: Molina CHIP/Medicaid	$7.22
Rate for Payer: Multiplan Auto	$6.52
Rate for Payer: Multiplan Commercial	$6.52
Rate for Payer: Multiplan Workers Comp	$6.52
Rate for Payer: Parkland Medicaid	$7.22
Rate for Payer: Scott and White EPO/PPO	$5.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.22
Rate for Payer: Superior Health Plan EPO	$1.36

DISORDERS OF GALLBLADDER AND BILIARY TRACT

Facility

$3,200.07

Service Code	APR-DRG 2841
Min. Negotiated Rate	$3,017.14
Max. Negotiated Rate	$3,200.07
Rate for Payer: Amerigroup CHIP/Medicaid	$3,017.14
Rate for Payer: Cigna Medicaid	$3,017.14
Rate for Payer: Molina CHIP/Medicaid	$3,017.14
Rate for Payer: Parkland Medicaid	$3,017.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,200.07

DISORDERS OF GALLBLADDER AND BILIARY TRACT

Facility

$4,249.41

Service Code	APR-DRG 2842
Min. Negotiated Rate	$4,006.49
Max. Negotiated Rate	$4,249.41
Rate for Payer: Amerigroup CHIP/Medicaid	$4,006.49
Rate for Payer: Cigna Medicaid	$4,006.49
Rate for Payer: Molina CHIP/Medicaid	$4,006.49
Rate for Payer: Parkland Medicaid	$4,006.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,249.41

DISORDERS OF GALLBLADDER AND BILIARY TRACT

Facility

$11,993.10

Service Code	APR-DRG 2844
Min. Negotiated Rate	$11,307.52
Max. Negotiated Rate	$11,993.10
Rate for Payer: Amerigroup CHIP/Medicaid	$11,307.52
Rate for Payer: Cigna Medicaid	$11,307.52
Rate for Payer: Molina CHIP/Medicaid	$11,307.52
Rate for Payer: Parkland Medicaid	$11,307.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,993.10

DISORDERS OF GALLBLADDER AND BILIARY TRACT

Facility

$6,373.36

Service Code	APR-DRG 2843
Min. Negotiated Rate	$6,009.03
Max. Negotiated Rate	$6,373.36
Rate for Payer: Amerigroup CHIP/Medicaid	$6,009.03
Rate for Payer: Cigna Medicaid	$6,009.03
Rate for Payer: Molina CHIP/Medicaid	$6,009.03
Rate for Payer: Parkland Medicaid	$6,009.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,373.36

DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC

Facility

$18,340.70

Service Code	MSDRG 442
Min. Negotiated Rate	$8,074.54
Max. Negotiated Rate	$18,340.70
Rate for Payer: BCBS of TX Blue Advantage	$8,074.54
Rate for Payer: BCBS of TX Blue Essentials	$9,688.51
Rate for Payer: BCBS of TX PPO	$10,765.43

DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W MCC

Facility

$34,099.30

Service Code	MSDRG 441
Min. Negotiated Rate	$15,703.62
Max. Negotiated Rate	$34,099.30
Rate for Payer: BCBS of TX Blue Advantage	$15,971.92
Rate for Payer: BCBS of TX Blue Essentials	$19,164.45
Rate for Payer: BCBS of TX PPO	$21,294.66

DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC/MCC

Facility

$13,294.30

Service Code	MSDRG 443
Min. Negotiated Rate	$5,983.88
Max. Negotiated Rate	$13,294.30
Rate for Payer: BCBS of TX Blue Advantage	$5,983.88
Rate for Payer: BCBS of TX Blue Essentials	$7,179.96
Rate for Payer: BCBS of TX PPO	$7,978.04

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC

Facility

$18,340.70

Service Code	MSDRG 442
Min. Negotiated Rate	$8,074.54
Max. Negotiated Rate	$18,340.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,834.79
Rate for Payer: Amerigroup Medicare	$11,834.79
Rate for Payer: BCBS of TX Medicare	$11,834.79
Rate for Payer: Cigna Commercial	$12,433.06
Rate for Payer: Cigna Medicare	$11,834.79
Rate for Payer: Employer Direct Commercial	$11,834.79
Rate for Payer: Humana Medicare/TRICARE	$11,834.79
Rate for Payer: Molina Dual Medicare/Medicaid	$11,834.79
Rate for Payer: Molina Medicare	$11,834.79
Rate for Payer: Multiplan Auto	$18,340.70
Rate for Payer: Multiplan Commercial	$18,340.70
Rate for Payer: Multiplan Workers Comp	$18,340.70
Rate for Payer: Scott and White EPO/PPO	$8,446.38
Rate for Payer: Scott and White Medicare	$11,834.79
Rate for Payer: Superior Health Plan EPO	$11,834.79
Rate for Payer: Superior Health Plan Medicare	$11,834.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,834.79
Rate for Payer: Universal American Medicare	$11,834.79
Rate for Payer: Wellcare Medicare	$11,834.79
Rate for Payer: Wellmed Medicare	$11,834.79

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC

Facility

$34,099.30

Service Code	MSDRG 441
Min. Negotiated Rate	$15,703.62
Max. Negotiated Rate	$34,099.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,913.49
Rate for Payer: Amerigroup Medicare	$17,913.49
Rate for Payer: BCBS of TX Medicare	$17,913.49
Rate for Payer: Cigna Commercial	$23,115.74
Rate for Payer: Cigna Medicare	$17,913.49
Rate for Payer: Employer Direct Commercial	$17,913.49
Rate for Payer: Humana Medicare/TRICARE	$17,913.49
Rate for Payer: Molina Dual Medicare/Medicaid	$17,913.49
Rate for Payer: Molina Medicare	$17,913.49
Rate for Payer: Multiplan Auto	$34,099.30
Rate for Payer: Multiplan Commercial	$34,099.30
Rate for Payer: Multiplan Workers Comp	$34,099.30
Rate for Payer: Scott and White EPO/PPO	$15,703.62
Rate for Payer: Scott and White Medicare	$17,913.49
Rate for Payer: Superior Health Plan EPO	$17,913.49
Rate for Payer: Superior Health Plan Medicare	$17,913.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,913.49
Rate for Payer: Universal American Medicare	$17,913.49
Rate for Payer: Wellcare Medicare	$17,913.49
Rate for Payer: Wellmed Medicare	$17,913.49

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$13,294.30

Service Code	MSDRG 443
Min. Negotiated Rate	$5,983.88
Max. Negotiated Rate	$13,294.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,888.20
Rate for Payer: Amerigroup Medicare	$9,888.20
Rate for Payer: BCBS of TX Medicare	$9,888.20
Rate for Payer: Cigna Commercial	$9,012.14
Rate for Payer: Cigna Medicare	$9,888.20
Rate for Payer: Employer Direct Commercial	$9,888.20
Rate for Payer: Humana Medicare/TRICARE	$9,888.20
Rate for Payer: Molina Dual Medicare/Medicaid	$9,888.20
Rate for Payer: Molina Medicare	$9,888.20
Rate for Payer: Multiplan Auto	$13,294.30
Rate for Payer: Multiplan Commercial	$13,294.30
Rate for Payer: Multiplan Workers Comp	$13,294.30
Rate for Payer: Scott and White EPO/PPO	$6,122.38
Rate for Payer: Scott and White Medicare	$9,888.20
Rate for Payer: Superior Health Plan EPO	$9,888.20
Rate for Payer: Superior Health Plan Medicare	$9,888.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,888.20
Rate for Payer: Universal American Medicare	$9,888.20
Rate for Payer: Wellcare Medicare	$9,888.20
Rate for Payer: Wellmed Medicare	$9,888.20

DISORDERS OF PANCREAS EXCEPT MALIGNANCY

Facility

$2,534.71

Service Code	APR-DRG 2821
Min. Negotiated Rate	$2,389.81
Max. Negotiated Rate	$2,534.71
Rate for Payer: Amerigroup CHIP/Medicaid	$2,389.81
Rate for Payer: Cigna Medicaid	$2,389.81
Rate for Payer: Molina CHIP/Medicaid	$2,389.81
Rate for Payer: Parkland Medicaid	$2,389.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,534.71

DISORDERS OF PANCREAS EXCEPT MALIGNANCY

Facility

$20,959.64

Service Code	APR-DRG 2824
Min. Negotiated Rate	$19,761.48
Max. Negotiated Rate	$20,959.64
Rate for Payer: Amerigroup CHIP/Medicaid	$19,761.48
Rate for Payer: Cigna Medicaid	$19,761.48
Rate for Payer: Molina CHIP/Medicaid	$19,761.48
Rate for Payer: Parkland Medicaid	$19,761.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,959.64

DISORDERS OF PANCREAS EXCEPT MALIGNANCY

Facility

$5,926.77

Service Code	APR-DRG 2823
Min. Negotiated Rate	$5,587.97
Max. Negotiated Rate	$5,926.77
Rate for Payer: Amerigroup CHIP/Medicaid	$5,587.97
Rate for Payer: Cigna Medicaid	$5,587.97
Rate for Payer: Molina CHIP/Medicaid	$5,587.97
Rate for Payer: Parkland Medicaid	$5,587.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,926.77

DISORDERS OF PANCREAS EXCEPT MALIGNANCY

Facility

$3,501.07

Service Code	APR-DRG 2822
Min. Negotiated Rate	$3,300.93
Max. Negotiated Rate	$3,501.07
Rate for Payer: Amerigroup CHIP/Medicaid	$3,300.93
Rate for Payer: Cigna Medicaid	$3,300.93
Rate for Payer: Molina CHIP/Medicaid	$3,300.93
Rate for Payer: Parkland Medicaid	$3,300.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,501.07

Know your out-of-pocket cost for care.

All Charges