White Rock Medical Center

All Charges

Charge

Type

Setting

Price

kerecis omega3 7x20 (ea) per sq cm

Facility

$323.25

Service Code	HCPCS C1781
Hospital Charge Code	8630552
Hospital Revenue Code	278
Min. Negotiated Rate	$29.09
Max. Negotiated Rate	$161.62
Rate for Payer: Aetna Commercial	$96.97
Rate for Payer: Amerigroup CHIP/Medicaid	$29.09
Rate for Payer: BCBS of TX Blue Advantage	$96.97
Rate for Payer: BCBS of TX Blue Essentials	$116.37
Rate for Payer: BCBS of TX PPO	$129.30
Rate for Payer: Cash Price	$284.46
Rate for Payer: Multiplan Auto	$161.62
Rate for Payer: Multiplan Commercial	$161.62
Rate for Payer: Multiplan Workers Comp	$161.62
Rate for Payer: Scott and White EPO/PPO	$161.62
Rate for Payer: Superior Health Plan EPO	$43.96

kerecis omega 3 7x7(bx) 50200s04b2d sq cm

Facility

$183.19

Service Code	HCPCS Q4158
Hospital Charge Code	8688548
Hospital Revenue Code	278
Min. Negotiated Rate	$45.80
Max. Negotiated Rate	$91.59
Rate for Payer: Aetna Commercial	$54.96
Rate for Payer: Cash Price	$161.21
Rate for Payer: Cigna Commercial	$45.80
Rate for Payer: Multiplan Auto	$91.59
Rate for Payer: Multiplan Commercial	$91.59
Rate for Payer: Multiplan Workers Comp	$91.59
Rate for Payer: Scott and White EPO/PPO	$91.59

kerecis omega 3 7x7(bx) 50200s04b2d sq cm

Facility

$183.19

Service Code	HCPCS Q4158
Hospital Charge Code	8688548
Hospital Revenue Code	278
Min. Negotiated Rate	$16.49
Max. Negotiated Rate	$91.59
Rate for Payer: Aetna Commercial	$54.96
Rate for Payer: Amerigroup CHIP/Medicaid	$16.49
Rate for Payer: BCBS of TX Blue Advantage	$54.96
Rate for Payer: BCBS of TX Blue Essentials	$65.95
Rate for Payer: BCBS of TX PPO	$73.28
Rate for Payer: Cash Price	$161.21
Rate for Payer: Multiplan Auto	$91.59
Rate for Payer: Multiplan Commercial	$91.59
Rate for Payer: Multiplan Workers Comp	$91.59
Rate for Payer: Scott and White EPO/PPO	$91.59
Rate for Payer: Superior Health Plan EPO	$24.91

kerecis omega3 7x7cm 50200s04b0d sq cm

Facility

$201.74

Service Code	HCPCS Q4158
Hospital Charge Code	8638507
Hospital Revenue Code	278
Min. Negotiated Rate	$18.16
Max. Negotiated Rate	$100.87
Rate for Payer: Aetna Commercial	$60.52
Rate for Payer: Amerigroup CHIP/Medicaid	$18.16
Rate for Payer: BCBS of TX Blue Advantage	$60.52
Rate for Payer: BCBS of TX Blue Essentials	$72.63
Rate for Payer: BCBS of TX PPO	$80.70
Rate for Payer: Cash Price	$177.53
Rate for Payer: Multiplan Auto	$100.87
Rate for Payer: Multiplan Commercial	$100.87
Rate for Payer: Multiplan Workers Comp	$100.87
Rate for Payer: Scott and White EPO/PPO	$100.87
Rate for Payer: Superior Health Plan EPO	$27.44

kerecis omega3 7x7cm 50200s04b0d sq cm

Facility

$201.74

Service Code	HCPCS Q4158
Hospital Charge Code	8638507
Hospital Revenue Code	278
Min. Negotiated Rate	$50.44
Max. Negotiated Rate	$100.87
Rate for Payer: Aetna Commercial	$60.52
Rate for Payer: Cash Price	$177.53
Rate for Payer: Cigna Commercial	$50.44
Rate for Payer: Multiplan Auto	$100.87
Rate for Payer: Multiplan Commercial	$100.87
Rate for Payer: Multiplan Workers Comp	$100.87
Rate for Payer: Scott and White EPO/PPO	$100.87

KERECIS OMEGA3 PER SQ CM

Facility

$252.41

Service Code	HCPCS Q4158
Hospital Charge Code	40299018
Hospital Revenue Code	278
Min. Negotiated Rate	$22.72
Max. Negotiated Rate	$126.20
Rate for Payer: Aetna Commercial	$75.72
Rate for Payer: Amerigroup CHIP/Medicaid	$22.72
Rate for Payer: BCBS of TX Blue Advantage	$75.72
Rate for Payer: BCBS of TX Blue Essentials	$90.87
Rate for Payer: BCBS of TX PPO	$100.96
Rate for Payer: Cash Price	$222.12
Rate for Payer: Multiplan Auto	$126.20
Rate for Payer: Multiplan Commercial	$126.20
Rate for Payer: Multiplan Workers Comp	$126.20
Rate for Payer: Scott and White EPO/PPO	$126.20
Rate for Payer: Superior Health Plan EPO	$34.33

KERECIS OMEGA3 PER SQ CM

Facility

$252.41

Service Code	HCPCS Q4158
Hospital Charge Code	40299018
Hospital Revenue Code	278
Min. Negotiated Rate	$63.10
Max. Negotiated Rate	$126.20
Rate for Payer: Aetna Commercial	$75.72
Rate for Payer: Cash Price	$222.12
Rate for Payer: Cigna Commercial	$63.10
Rate for Payer: Multiplan Auto	$126.20
Rate for Payer: Multiplan Commercial	$126.20
Rate for Payer: Multiplan Workers Comp	$126.20
Rate for Payer: Scott and White EPO/PPO	$126.20

ketamine 50 mg/ml Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	79732735
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

ketamine 50 mg/ml Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	79732735
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

ketorolac 30 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1885
Hospital Charge Code	78470543
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

ketorolac 30 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1885
Hospital Charge Code	78470543
Hospital Revenue Code	636
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.26
Rate for Payer: BCBS of TX Blue Essentials	$0.31
Rate for Payer: BCBS of TX PPO	$0.35
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC

Facility

$24,022.67

Service Code	MSDRG 657
Min. Negotiated Rate	$17,318.68
Max. Negotiated Rate	$24,022.67
Rate for Payer: Aetna Commercial	$20,747.25
Rate for Payer: Aetna Medicare	$24,022.67
Rate for Payer: BCBS of TX Blue Advantage	$17,318.68
Rate for Payer: BCBS of TX Blue Essentials	$20,095.22
Rate for Payer: BCBS of TX PPO	$22,328.89
Rate for Payer: Cigna Commercial	$23,753.30

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC

Facility

$40,412.29

Service Code	MSDRG 656
Min. Negotiated Rate	$29,627.86
Max. Negotiated Rate	$40,412.29
Rate for Payer: Aetna Commercial	$35,298.00
Rate for Payer: Aetna Medicare	$37,867.32
Rate for Payer: BCBS of TX Blue Advantage	$29,627.86
Rate for Payer: BCBS of TX Blue Essentials	$34,337.50
Rate for Payer: BCBS of TX PPO	$38,154.26
Rate for Payer: Cigna Commercial	$40,412.29

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC

Facility

$20,128.50

Service Code	MSDRG 658
Min. Negotiated Rate	$13,187.24
Max. Negotiated Rate	$20,128.50
Rate for Payer: Aetna Commercial	$16,654.50
Rate for Payer: Aetna Medicare	$20,128.50
Rate for Payer: BCBS of TX Blue Advantage	$13,187.24
Rate for Payer: BCBS of TX Blue Essentials	$16,163.68
Rate for Payer: BCBS of TX PPO	$17,960.34
Rate for Payer: Cigna Commercial	$19,067.55

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC

Facility

$18,688.80

Service Code	MSDRG 660
Min. Negotiated Rate	$14,937.78
Max. Negotiated Rate	$18,688.80
Rate for Payer: Aetna Commercial	$15,141.38
Rate for Payer: Aetna Medicare	$18,688.80
Rate for Payer: BCBS of TX Blue Advantage	$16,222.18
Rate for Payer: BCBS of TX Blue Essentials	$14,937.78
Rate for Payer: BCBS of TX PPO	$16,598.18
Rate for Payer: Cigna Commercial	$17,335.19

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC

Facility

$33,345.03

Service Code	MSDRG 659
Min. Negotiated Rate	$28,140.94
Max. Negotiated Rate	$33,345.03
Rate for Payer: Aetna Commercial	$29,125.12
Rate for Payer: Aetna Medicare	$31,994.01
Rate for Payer: BCBS of TX Blue Advantage	$28,873.64
Rate for Payer: BCBS of TX Blue Essentials	$28,140.94
Rate for Payer: BCBS of TX PPO	$31,268.93
Rate for Payer: Cigna Commercial	$33,345.03

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC

Facility

$15,504.34

Service Code	MSDRG 661
Min. Negotiated Rate	$11,070.22
Max. Negotiated Rate	$15,504.34
Rate for Payer: Aetna Commercial	$11,794.50
Rate for Payer: Aetna Medicare	$15,504.34
Rate for Payer: BCBS of TX Blue Advantage	$12,245.54
Rate for Payer: BCBS of TX Blue Essentials	$11,070.22
Rate for Payer: BCBS of TX PPO	$12,300.72
Rate for Payer: Cigna Commercial	$13,503.39

KIDNEY AND URINARY TRACT INFECTIONS WITH MCC

Facility

$16,853.04

Service Code	MSDRG 689
Min. Negotiated Rate	$9,158.14
Max. Negotiated Rate	$16,853.04
Rate for Payer: Aetna Commercial	$13,212.00
Rate for Payer: Aetna Medicare	$16,853.04
Rate for Payer: BCBS of TX Blue Advantage	$9,158.14
Rate for Payer: BCBS of TX Blue Essentials	$11,470.60
Rate for Payer: BCBS of TX PPO	$12,745.61
Rate for Payer: Cigna Commercial	$15,126.27

KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC

Facility

$12,919.31

Service Code	MSDRG 690
Min. Negotiated Rate	$6,688.22
Max. Negotiated Rate	$12,919.31
Rate for Payer: Aetna Commercial	$9,077.62
Rate for Payer: Aetna Medicare	$12,919.31
Rate for Payer: BCBS of TX Blue Advantage	$6,688.22
Rate for Payer: BCBS of TX Blue Essentials	$8,194.32
Rate for Payer: BCBS of TX PPO	$9,105.15
Rate for Payer: Cigna Commercial	$10,392.87

KIDNEY AND URINARY TRACT NEOPLASMS WITH CC

Facility

$15,471.15

Service Code	MSDRG 687
Min. Negotiated Rate	$9,122.02
Max. Negotiated Rate	$15,471.15
Rate for Payer: Aetna Commercial	$11,759.62
Rate for Payer: Aetna Medicare	$15,471.15
Rate for Payer: BCBS of TX Blue Advantage	$9,122.02
Rate for Payer: BCBS of TX Blue Essentials	$10,873.13
Rate for Payer: BCBS of TX PPO	$12,081.72
Rate for Payer: Cigna Commercial	$13,463.46

KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC

Facility

$23,971.28

Service Code	MSDRG 686
Min. Negotiated Rate	$14,370.60
Max. Negotiated Rate	$23,971.28
Rate for Payer: Aetna Commercial	$20,693.25
Rate for Payer: Aetna Medicare	$23,971.28
Rate for Payer: BCBS of TX Blue Advantage	$14,370.60
Rate for Payer: BCBS of TX Blue Essentials	$17,723.91
Rate for Payer: BCBS of TX PPO	$19,694.00
Rate for Payer: Cigna Commercial	$23,691.47

KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC

Facility

$12,640.98

Service Code	MSDRG 688
Min. Negotiated Rate	$5,926.26
Max. Negotiated Rate	$12,640.98
Rate for Payer: Aetna Commercial	$8,785.12
Rate for Payer: Aetna Medicare	$12,640.98
Rate for Payer: BCBS of TX Blue Advantage	$5,926.26
Rate for Payer: BCBS of TX Blue Essentials	$8,161.30
Rate for Payer: BCBS of TX PPO	$9,068.46
Rate for Payer: Cigna Commercial	$10,057.99

KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC

Facility

$17,084.26

Service Code	MSDRG 695
Min. Negotiated Rate	$10,471.36
Max. Negotiated Rate	$17,084.26
Rate for Payer: Aetna Commercial	$13,455.00
Rate for Payer: Aetna Medicare	$17,084.26
Rate for Payer: BCBS of TX Blue Advantage	$10,471.36
Rate for Payer: BCBS of TX Blue Essentials	$11,853.44
Rate for Payer: BCBS of TX PPO	$13,170.99
Rate for Payer: Cigna Commercial	$15,404.48

KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$11,690.48

Service Code	MSDRG 696
Min. Negotiated Rate	$5,966.68
Max. Negotiated Rate	$11,690.48
Rate for Payer: Aetna Commercial	$7,786.12
Rate for Payer: Aetna Medicare	$11,690.48
Rate for Payer: BCBS of TX Blue Advantage	$5,966.68
Rate for Payer: BCBS of TX Blue Essentials	$7,105.66
Rate for Payer: BCBS of TX PPO	$7,895.49
Rate for Payer: Cigna Commercial	$8,914.25

Kidney Stone, Urine/Saturation SO

Facility

$122.00

Service Code	CPT 81003
Hospital Charge Code	1605211
Hospital Revenue Code	307
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$79.30
Rate for Payer: Aetna Commercial	$2.36
Rate for Payer: Aetna Medicare	$3.38
Rate for Payer: Amerigroup CHIP/Medicaid	$0.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.25
Rate for Payer: Amerigroup Medicare	$2.25
Rate for Payer: BCBS of TX Blue Advantage	$3.71
Rate for Payer: BCBS of TX Blue Essentials	$4.46
Rate for Payer: BCBS of TX Medicare	$2.25
Rate for Payer: BCBS of TX PPO	$4.97
Rate for Payer: Cash Price	$107.36
Rate for Payer: Cash Price	$107.36
Rate for Payer: Cigna Medicaid	$2.25
Rate for Payer: Cigna Medicare	$2.25
Rate for Payer: Employer Direct Commercial	$2.25
Rate for Payer: Humana Medicare/TRICARE	$2.25
Rate for Payer: Molina CHIP/Medicaid	$2.25
Rate for Payer: Molina Dual Medicare/Medicaid	$2.25
Rate for Payer: Molina Medicare	$2.25
Rate for Payer: Multiplan Auto	$79.30
Rate for Payer: Multiplan Commercial	$79.30
Rate for Payer: Multiplan Workers Comp	$79.30
Rate for Payer: Parkland Medicaid	$2.25
Rate for Payer: Scott and White EPO/PPO	$2.81
Rate for Payer: Scott and White Medicare	$2.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.25
Rate for Payer: Superior Health Plan EPO	$2.25
Rate for Payer: Superior Health Plan Medicare	$2.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.25
Rate for Payer: Universal American Medicare	$2.25
Rate for Payer: Wellcare Medicare	$2.25
Rate for Payer: Wellmed Medicare	$2.25

Know your out-of-pocket cost for care.

All Charges