White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Eye Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107073
Hospital Revenue Code	306
Rate for Payer: Cash Price	$210.12

Eye Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107073
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$222.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$92.70
Rate for Payer: BCBS of TX Blue Essentials	$111.24
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$123.60
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cigna Medicaid	$222.48
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$222.48
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$222.48
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.48
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility

$2,223.53

Service Code	APR-DRG 0821
Min. Negotiated Rate	$2,096.42
Max. Negotiated Rate	$2,223.53
Rate for Payer: Amerigroup CHIP/Medicaid	$2,096.42
Rate for Payer: Cigna Medicaid	$2,096.42
Rate for Payer: Molina CHIP/Medicaid	$2,096.42
Rate for Payer: Parkland Medicaid	$2,096.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,223.53

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility

$7,617.33

Service Code	APR-DRG 0823
Min. Negotiated Rate	$7,181.89
Max. Negotiated Rate	$7,617.33
Rate for Payer: Amerigroup CHIP/Medicaid	$7,181.89
Rate for Payer: Cigna Medicaid	$7,181.89
Rate for Payer: Molina CHIP/Medicaid	$7,181.89
Rate for Payer: Parkland Medicaid	$7,181.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,617.33

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility

$13,236.32

Service Code	APR-DRG 0824
Min. Negotiated Rate	$12,479.66
Max. Negotiated Rate	$13,236.32
Rate for Payer: Amerigroup CHIP/Medicaid	$12,479.66
Rate for Payer: Cigna Medicaid	$12,479.66
Rate for Payer: Molina CHIP/Medicaid	$12,479.66
Rate for Payer: Parkland Medicaid	$12,479.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,236.32

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility

$4,262.61

Service Code	APR-DRG 0822
Min. Negotiated Rate	$4,018.94
Max. Negotiated Rate	$4,262.61
Rate for Payer: Amerigroup CHIP/Medicaid	$4,018.94
Rate for Payer: Cigna Medicaid	$4,018.94
Rate for Payer: Molina CHIP/Medicaid	$4,018.94
Rate for Payer: Parkland Medicaid	$4,018.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,262.61

EZDILATE BALLOON DILATOR 11-12-13

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993920
Hospital Revenue Code	272
Rate for Payer: Cash Price	$763.78

EZDILATE BALLOON DILATOR 11-12-13

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993920
Hospital Revenue Code	272
Min. Negotiated Rate	$101.09
Max. Negotiated Rate	$808.70
Rate for Payer: Amerigroup CHIP/Medicaid	$101.09
Rate for Payer: BCBS of TX Blue Advantage	$336.96
Rate for Payer: BCBS of TX Blue Essentials	$404.35
Rate for Payer: BCBS of TX PPO	$449.28
Rate for Payer: Cash Price	$763.78
Rate for Payer: Cigna Medicaid	$808.70
Rate for Payer: Molina CHIP/Medicaid	$808.70
Rate for Payer: Multiplan Auto	$730.08
Rate for Payer: Multiplan Commercial	$730.08
Rate for Payer: Multiplan Workers Comp	$730.08
Rate for Payer: Parkland Medicaid	$808.70
Rate for Payer: Scott and White EPO/PPO	$561.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$808.70
Rate for Payer: Superior Health Plan EPO	$152.76

EZDILATE BALLOON DILATOR 13.5-14.5

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993922
Hospital Revenue Code	272
Rate for Payer: Cash Price	$763.78

EZDILATE BALLOON DILATOR 13.5-14.5

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993922
Hospital Revenue Code	272
Min. Negotiated Rate	$101.09
Max. Negotiated Rate	$808.70
Rate for Payer: Amerigroup CHIP/Medicaid	$101.09
Rate for Payer: BCBS of TX Blue Advantage	$336.96
Rate for Payer: BCBS of TX Blue Essentials	$404.35
Rate for Payer: BCBS of TX PPO	$449.28
Rate for Payer: Cash Price	$763.78
Rate for Payer: Cigna Medicaid	$808.70
Rate for Payer: Molina CHIP/Medicaid	$808.70
Rate for Payer: Multiplan Auto	$730.08
Rate for Payer: Multiplan Commercial	$730.08
Rate for Payer: Multiplan Workers Comp	$730.08
Rate for Payer: Parkland Medicaid	$808.70
Rate for Payer: Scott and White EPO/PPO	$561.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$808.70
Rate for Payer: Superior Health Plan EPO	$152.76

EZDILATE BALLOON DILATOR 6-7-8

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993912
Hospital Revenue Code	272
Min. Negotiated Rate	$101.09
Max. Negotiated Rate	$808.70
Rate for Payer: Amerigroup CHIP/Medicaid	$101.09
Rate for Payer: BCBS of TX Blue Advantage	$336.96
Rate for Payer: BCBS of TX Blue Essentials	$404.35
Rate for Payer: BCBS of TX PPO	$449.28
Rate for Payer: Cash Price	$763.78
Rate for Payer: Cigna Medicaid	$808.70
Rate for Payer: Molina CHIP/Medicaid	$808.70
Rate for Payer: Multiplan Auto	$730.08
Rate for Payer: Multiplan Commercial	$730.08
Rate for Payer: Multiplan Workers Comp	$730.08
Rate for Payer: Parkland Medicaid	$808.70
Rate for Payer: Scott and White EPO/PPO	$561.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$808.70
Rate for Payer: Superior Health Plan EPO	$152.76

EZDILATE BALLOON DILATOR 6-7-8

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993912
Hospital Revenue Code	272
Rate for Payer: Cash Price	$763.78

EZDILATE BALLOON DILATOR 8.5-9.5-10

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993680
Hospital Revenue Code	272
Rate for Payer: Cash Price	$763.78

EZDILATE BALLOON DILATOR 8.5-9.5-10

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993923
Hospital Revenue Code	272
Min. Negotiated Rate	$101.09
Max. Negotiated Rate	$808.70
Rate for Payer: Amerigroup CHIP/Medicaid	$101.09
Rate for Payer: BCBS of TX Blue Advantage	$336.96
Rate for Payer: BCBS of TX Blue Essentials	$404.35
Rate for Payer: BCBS of TX PPO	$449.28
Rate for Payer: Cash Price	$763.78
Rate for Payer: Cigna Medicaid	$808.70
Rate for Payer: Molina CHIP/Medicaid	$808.70
Rate for Payer: Multiplan Auto	$730.08
Rate for Payer: Multiplan Commercial	$730.08
Rate for Payer: Multiplan Workers Comp	$730.08
Rate for Payer: Parkland Medicaid	$808.70
Rate for Payer: Scott and White EPO/PPO	$561.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$808.70
Rate for Payer: Superior Health Plan EPO	$152.76

EZDILATE BALLOON DILATOR 8.5-9.5-10

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993923
Hospital Revenue Code	272
Rate for Payer: Cash Price	$763.78

EZDILATE BALLOON DILATOR 8.5-9.5-10

Facility

$1,123.20

Service Code	HCPCS C1726
Hospital Charge Code	993680
Hospital Revenue Code	272
Min. Negotiated Rate	$101.09
Max. Negotiated Rate	$808.70
Rate for Payer: Amerigroup CHIP/Medicaid	$101.09
Rate for Payer: BCBS of TX Blue Advantage	$336.96
Rate for Payer: BCBS of TX Blue Essentials	$404.35
Rate for Payer: BCBS of TX PPO	$449.28
Rate for Payer: Cash Price	$763.78
Rate for Payer: Cigna Medicaid	$808.70
Rate for Payer: Molina CHIP/Medicaid	$808.70
Rate for Payer: Multiplan Auto	$730.08
Rate for Payer: Multiplan Commercial	$730.08
Rate for Payer: Multiplan Workers Comp	$730.08
Rate for Payer: Parkland Medicaid	$808.70
Rate for Payer: Scott and White EPO/PPO	$561.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$808.70
Rate for Payer: Superior Health Plan EPO	$152.76

ezetimibe 10 mg Tab

Facility

$9.00

Service Code	HCPCS J3490
Hospital Charge Code	77560850
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$6.48
Rate for Payer: Amerigroup CHIP/Medicaid	$0.81
Rate for Payer: BCBS of TX Blue Advantage	$2.70
Rate for Payer: BCBS of TX Blue Essentials	$3.24
Rate for Payer: BCBS of TX PPO	$3.60
Rate for Payer: Cash Price	$6.12
Rate for Payer: Cigna Medicaid	$6.48
Rate for Payer: Molina CHIP/Medicaid	$6.48
Rate for Payer: Multiplan Auto	$5.85
Rate for Payer: Multiplan Commercial	$5.85
Rate for Payer: Multiplan Workers Comp	$5.85
Rate for Payer: Parkland Medicaid	$6.48
Rate for Payer: Scott and White EPO/PPO	$4.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.48
Rate for Payer: Superior Health Plan EPO	$1.22

ezetimibe 10 mg Tab

Facility

$9.00

Service Code	HCPCS J3490
Hospital Charge Code	77560850
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.12

F3D Straight Ti Interbody 30mm x 10mm x 0deg x 12mm

Facility

$21,084.34

Service Code	HCPCS C1831
Hospital Charge Code	992224
Hospital Revenue Code	278
Min. Negotiated Rate	$5,271.09
Max. Negotiated Rate	$10,542.17
Rate for Payer: Cash Price	$14,337.35
Rate for Payer: Cigna Commercial	$5,271.09
Rate for Payer: Multiplan Auto	$10,542.17
Rate for Payer: Multiplan Commercial	$10,542.17
Rate for Payer: Multiplan Workers Comp	$10,542.17
Rate for Payer: Scott and White EPO/PPO	$10,542.17

F3D Straight Ti Interbody 30mm x 10mm x 0deg x 12mm

Facility

$21,084.34

Service Code	HCPCS C1831
Hospital Charge Code	992224
Hospital Revenue Code	278
Min. Negotiated Rate	$1,897.59
Max. Negotiated Rate	$15,180.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1,897.59
Rate for Payer: Cash Price	$14,337.35
Rate for Payer: Cigna Medicaid	$15,180.72
Rate for Payer: Molina CHIP/Medicaid	$15,180.72
Rate for Payer: Multiplan Auto	$10,542.17
Rate for Payer: Multiplan Commercial	$10,542.17
Rate for Payer: Multiplan Workers Comp	$10,542.17
Rate for Payer: Parkland Medicaid	$15,180.72
Rate for Payer: Scott and White EPO/PPO	$10,542.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,180.72
Rate for Payer: Superior Health Plan EPO	$2,867.47

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$28,776.50

Service Code	APR-DRG 0924
Min. Negotiated Rate	$27,131.50
Max. Negotiated Rate	$28,776.50
Rate for Payer: Amerigroup CHIP/Medicaid	$27,131.50
Rate for Payer: Cigna Medicaid	$27,131.50
Rate for Payer: Molina CHIP/Medicaid	$27,131.50
Rate for Payer: Parkland Medicaid	$27,131.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28,776.50

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$9,005.01

Service Code	APR-DRG 0922
Min. Negotiated Rate	$8,490.24
Max. Negotiated Rate	$9,005.01
Rate for Payer: Amerigroup CHIP/Medicaid	$8,490.24
Rate for Payer: Cigna Medicaid	$8,490.24
Rate for Payer: Molina CHIP/Medicaid	$8,490.24
Rate for Payer: Parkland Medicaid	$8,490.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,005.01

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$7,670.52

Service Code	APR-DRG 0921
Min. Negotiated Rate	$7,232.03
Max. Negotiated Rate	$7,670.52
Rate for Payer: Amerigroup CHIP/Medicaid	$7,232.03
Rate for Payer: Cigna Medicaid	$7,232.03
Rate for Payer: Molina CHIP/Medicaid	$7,232.03
Rate for Payer: Parkland Medicaid	$7,232.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,670.52

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$27,755.83

Service Code	APR-DRG 0923
Min. Negotiated Rate	$26,169.17
Max. Negotiated Rate	$27,755.83
Rate for Payer: Amerigroup CHIP/Medicaid	$26,169.17
Rate for Payer: Cigna Medicaid	$26,169.17
Rate for Payer: Molina CHIP/Medicaid	$26,169.17
Rate for Payer: Parkland Medicaid	$26,169.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,755.83

Facility Eval and Management Level 2 99212

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	7000078
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

Know your out-of-pocket cost for care.

All Charges