White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Diverticulectomy of hypopharynx or esophagus, with or without myotomy cervical approach

Facility

$6,956.78

Service Code	HCPCS 43130
Hospital Charge Code	9900666
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cash Price	$4,730.61
Rate for Payer: Cash Price	$4,730.61
Rate for Payer: Cash Price	$4,730.61
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicaid	$5,008.88
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina CHIP/Medicaid	$5,008.88
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$5,008.88
Rate for Payer: Scott and White EPO/PPO	$11,001.60
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,008.88
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

DIVERTICULITIS AND DIVERTICULOSIS

Facility

$4,527.78

Service Code	APR-DRG 2443
Min. Negotiated Rate	$4,268.95
Max. Negotiated Rate	$4,527.78
Rate for Payer: Amerigroup CHIP/Medicaid	$4,268.95
Rate for Payer: Cigna Medicaid	$4,268.95
Rate for Payer: Molina CHIP/Medicaid	$4,268.95
Rate for Payer: Parkland Medicaid	$4,268.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,527.78

DIVERTICULITIS AND DIVERTICULOSIS

Facility

$15,053.99

Service Code	APR-DRG 2444
Min. Negotiated Rate	$14,193.43
Max. Negotiated Rate	$15,053.99
Rate for Payer: Amerigroup CHIP/Medicaid	$14,193.43
Rate for Payer: Cigna Medicaid	$14,193.43
Rate for Payer: Molina CHIP/Medicaid	$14,193.43
Rate for Payer: Parkland Medicaid	$14,193.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,053.99

DIVERTICULITIS AND DIVERTICULOSIS

Facility

$3,390.55

Service Code	APR-DRG 2442
Min. Negotiated Rate	$3,196.73
Max. Negotiated Rate	$3,390.55
Rate for Payer: Amerigroup CHIP/Medicaid	$3,196.73
Rate for Payer: Cigna Medicaid	$3,196.73
Rate for Payer: Molina CHIP/Medicaid	$3,196.73
Rate for Payer: Parkland Medicaid	$3,196.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,390.55

DIVERTICULITIS AND DIVERTICULOSIS

Facility

$2,687.09

Service Code	APR-DRG 2441
Min. Negotiated Rate	$2,533.49
Max. Negotiated Rate	$2,687.09
Rate for Payer: Amerigroup CHIP/Medicaid	$2,533.49
Rate for Payer: Cigna Medicaid	$2,533.49
Rate for Payer: Molina CHIP/Medicaid	$2,533.49
Rate for Payer: Parkland Medicaid	$2,533.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,687.09

Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure)

Facility

$17,353.68

Service Code	HCPCS 28250
Hospital Charge Code	9900495
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$12,494.65
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$11,800.50
Rate for Payer: Cash Price	$11,800.50
Rate for Payer: Cash Price	$11,800.50
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$12,494.65
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$12,494.65
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$12,494.65
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,494.65
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure)

Facility

$17,353.68

Service Code	HCPCS 28250
Hospital Charge Code	9900495
Hospital Revenue Code	360
Rate for Payer: Cash Price	$11,800.50

Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure)

Facility

$10,000.00

Service Code	CPT 28250
Hospital Charge Code	36028250
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

DM5300 Assert-IQ 3+_ICM_UMRI_U5

Facility

$33,349.40

Service Code	HCPCS C1764
Hospital Charge Code	145057
Hospital Revenue Code	278
Min. Negotiated Rate	$8,337.35
Max. Negotiated Rate	$16,674.70
Rate for Payer: Cash Price	$22,677.59
Rate for Payer: Cigna Commercial	$8,337.35
Rate for Payer: Multiplan Auto	$16,674.70
Rate for Payer: Multiplan Commercial	$16,674.70
Rate for Payer: Multiplan Workers Comp	$16,674.70
Rate for Payer: Scott and White EPO/PPO	$16,674.70

DM5300 Assert-IQ 3+_ICM_UMRI_U5

Facility

$33,349.40

Service Code	HCPCS C1764
Hospital Charge Code	145057
Hospital Revenue Code	278
Min. Negotiated Rate	$3,001.45
Max. Negotiated Rate	$24,011.57
Rate for Payer: Amerigroup CHIP/Medicaid	$3,001.45
Rate for Payer: BCBS of TX Blue Advantage	$10,004.82
Rate for Payer: BCBS of TX Blue Essentials	$12,005.78
Rate for Payer: BCBS of TX PPO	$13,339.76
Rate for Payer: Cash Price	$22,677.59
Rate for Payer: Cigna Medicaid	$24,011.57
Rate for Payer: Molina CHIP/Medicaid	$24,011.57
Rate for Payer: Multiplan Auto	$16,674.70
Rate for Payer: Multiplan Commercial	$16,674.70
Rate for Payer: Multiplan Workers Comp	$16,674.70
Rate for Payer: Parkland Medicaid	$24,011.57
Rate for Payer: Scott and White EPO/PPO	$16,674.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,011.57
Rate for Payer: Superior Health Plan EPO	$4,535.52

DM5300 Assert-IQ 3+_ICM_UMRI_U5

Facility

$33,349.40

Service Code	HCPCS C1764
Hospital Charge Code	991304
Hospital Revenue Code	278
Min. Negotiated Rate	$8,337.35
Max. Negotiated Rate	$16,674.70
Rate for Payer: Cash Price	$22,677.59
Rate for Payer: Cigna Commercial	$8,337.35
Rate for Payer: Multiplan Auto	$16,674.70
Rate for Payer: Multiplan Commercial	$16,674.70
Rate for Payer: Multiplan Workers Comp	$16,674.70
Rate for Payer: Scott and White EPO/PPO	$16,674.70

DM5300 Assert-IQ 3+_ICM_UMRI_U5

Facility

$33,349.40

Service Code	HCPCS C1764
Hospital Charge Code	991304
Hospital Revenue Code	278
Min. Negotiated Rate	$3,001.45
Max. Negotiated Rate	$24,011.57
Rate for Payer: Amerigroup CHIP/Medicaid	$3,001.45
Rate for Payer: BCBS of TX Blue Advantage	$10,004.82
Rate for Payer: BCBS of TX Blue Essentials	$12,005.78
Rate for Payer: BCBS of TX PPO	$13,339.76
Rate for Payer: Cash Price	$22,677.59
Rate for Payer: Cigna Medicaid	$24,011.57
Rate for Payer: Molina CHIP/Medicaid	$24,011.57
Rate for Payer: Multiplan Auto	$16,674.70
Rate for Payer: Multiplan Commercial	$16,674.70
Rate for Payer: Multiplan Workers Comp	$16,674.70
Rate for Payer: Parkland Medicaid	$24,011.57
Rate for Payer: Scott and White EPO/PPO	$16,674.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,011.57
Rate for Payer: Superior Health Plan EPO	$4,535.52

DOBUTamine 250 mg/250 mL-D5W

Facility

$128.17

Service Code	HCPCS J1250
Hospital Charge Code	77521130
Hospital Revenue Code	636
Min. Negotiated Rate	$4.13
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$4.13
Rate for Payer: BCBS of TX Blue Essentials	$4.96
Rate for Payer: BCBS of TX PPO	$5.50
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

DOBUTamine 250 mg/250 mL-D5W

Facility

$128.17

Service Code	HCPCS J1250
Hospital Charge Code	77521130
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

docusate 100 mg capsule

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77526832
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

docusate 100 mg capsule

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77526832
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

docusate sodium 100 mg Cap

Facility

$7.65

Service Code	HCPCS j3490
Hospital Charge Code	77522438
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

docusate sodium 100 mg Cap

Facility

$7.65

Service Code	HCPCS j3490
Hospital Charge Code	77522438
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

donepezil 5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77523612
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

donepezil 5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77523612
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

Donut Positioner McKesson 9 Inch Diameter Foam Freestanding

Facility

$38.20

Hospital Charge Code	993038
Hospital Revenue Code	270
Rate for Payer: Cash Price	$25.98

Donut Positioner McKesson 9 Inch Diameter Foam Freestanding

Facility

$38.20

Hospital Charge Code	993038
Hospital Revenue Code	270
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$27.50
Rate for Payer: Amerigroup CHIP/Medicaid	$3.44
Rate for Payer: BCBS of TX Blue Advantage	$11.46
Rate for Payer: BCBS of TX Blue Essentials	$13.75
Rate for Payer: BCBS of TX PPO	$15.28
Rate for Payer: Cash Price	$25.98
Rate for Payer: Cigna Medicaid	$27.50
Rate for Payer: Molina CHIP/Medicaid	$27.50
Rate for Payer: Multiplan Auto	$24.83
Rate for Payer: Multiplan Commercial	$24.83
Rate for Payer: Multiplan Workers Comp	$24.83
Rate for Payer: Parkland Medicaid	$27.50
Rate for Payer: Scott and White EPO/PPO	$19.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.50
Rate for Payer: Superior Health Plan EPO	$5.20

DOPamine 40 mg/mL IV Soln 10 mL

Facility

$128.00

Service Code	HCPCS J1265
Hospital Charge Code	77523828
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.36
Rate for Payer: BCBS of TX Blue Essentials	$0.44
Rate for Payer: BCBS of TX PPO	$0.48
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

DOPamine 40 mg/mL IV Soln 10 mL

Facility

$128.00

Service Code	HCPCS J1265
Hospital Charge Code	77523828
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

DOPamine 40 mg/mL IV Soln 10 mL

Facility

$128.00

Service Code	HCPCS J1265
Hospital Charge Code	77523883
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.36
Rate for Payer: BCBS of TX Blue Essentials	$0.44
Rate for Payer: BCBS of TX PPO	$0.48
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

Know your out-of-pocket cost for care.

All Charges