White Rock Medical Center

All Charges

Charge

Type

Setting

Price

89060 AP Bill Synovial Crystals

Facility

$145.00

Service Code	HCPCS 89060
Hospital Charge Code	1600303
Hospital Revenue Code	300
Rate for Payer: Cash Price	$98.60

9000-0042-A

Facility

$84,307.23

Service Code	HCPCS C1776
Hospital Charge Code	991212
Hospital Revenue Code	278
Min. Negotiated Rate	$7,587.65
Max. Negotiated Rate	$60,701.21
Rate for Payer: Amerigroup CHIP/Medicaid	$7,587.65
Rate for Payer: BCBS of TX Blue Advantage	$25,292.17
Rate for Payer: BCBS of TX Blue Essentials	$30,350.60
Rate for Payer: BCBS of TX PPO	$33,722.89
Rate for Payer: Cash Price	$57,328.92
Rate for Payer: Cigna Medicaid	$60,701.21
Rate for Payer: Molina CHIP/Medicaid	$60,701.21
Rate for Payer: Multiplan Auto	$42,153.61
Rate for Payer: Multiplan Commercial	$42,153.61
Rate for Payer: Multiplan Workers Comp	$42,153.61
Rate for Payer: Parkland Medicaid	$60,701.21
Rate for Payer: Scott and White EPO/PPO	$42,153.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60,701.21
Rate for Payer: Superior Health Plan EPO	$11,465.78

9000-0042-A

Facility

$84,307.23

Service Code	HCPCS C1776
Hospital Charge Code	991212
Hospital Revenue Code	278
Min. Negotiated Rate	$21,076.81
Max. Negotiated Rate	$42,153.61
Rate for Payer: Cash Price	$57,328.92
Rate for Payer: Cigna Commercial	$21,076.81
Rate for Payer: Multiplan Auto	$42,153.61
Rate for Payer: Multiplan Commercial	$42,153.61
Rate for Payer: Multiplan Workers Comp	$42,153.61
Rate for Payer: Scott and White EPO/PPO	$42,153.61

90MM, YELLOW, GUEDEL AIRWAY

Facility

$1.42

Hospital Charge Code	993728
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.97

90MM, YELLOW, GUEDEL AIRWAY

Facility

$1.42

Hospital Charge Code	993728
Hospital Revenue Code	272
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$1.02
Rate for Payer: Amerigroup CHIP/Medicaid	$0.13
Rate for Payer: BCBS of TX Blue Advantage	$0.43
Rate for Payer: BCBS of TX Blue Essentials	$0.51
Rate for Payer: BCBS of TX PPO	$0.57
Rate for Payer: Cash Price	$0.97
Rate for Payer: Cigna Medicaid	$1.02
Rate for Payer: Molina CHIP/Medicaid	$1.02
Rate for Payer: Multiplan Auto	$0.92
Rate for Payer: Multiplan Commercial	$0.92
Rate for Payer: Multiplan Workers Comp	$0.92
Rate for Payer: Parkland Medicaid	$1.02
Rate for Payer: Scott and White EPO/PPO	$0.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.02
Rate for Payer: Superior Health Plan EPO	$0.19

96360 - Hydration, first hour

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	5202361
Hospital Revenue Code	260
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$609.84
Rate for Payer: Amerigroup CHIP/Medicaid	$76.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$254.10
Rate for Payer: BCBS of TX Blue Essentials	$304.92
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$338.80
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$609.84
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$609.84
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$550.55
Rate for Payer: Multiplan Commercial	$550.55
Rate for Payer: Multiplan Workers Comp	$550.55
Rate for Payer: Parkland Medicaid	$609.84
Rate for Payer: Scott and White EPO/PPO	$39.95
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$609.84
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

96360 - Hydration, first hour

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	5202361
Hospital Revenue Code	260
Rate for Payer: Cash Price	$575.96

96361- Hydration, each additional hour

Facility

$251.00

Service Code	HCPCS 96361
Hospital Charge Code	6806361
Hospital Revenue Code	260
Rate for Payer: Cash Price	$170.68

96361- Hydration, each additional hour

Facility

$251.00

Service Code	HCPCS 96361
Hospital Charge Code	6806361
Hospital Revenue Code	260
Min. Negotiated Rate	$15.21
Max. Negotiated Rate	$180.72
Rate for Payer: Amerigroup CHIP/Medicaid	$22.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47.04
Rate for Payer: Amerigroup Medicare	$47.04
Rate for Payer: BCBS of TX Blue Advantage	$75.30
Rate for Payer: BCBS of TX Blue Essentials	$90.36
Rate for Payer: BCBS of TX Medicare	$47.04
Rate for Payer: BCBS of TX PPO	$100.40
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cigna Commercial	$99.43
Rate for Payer: Cigna Medicaid	$180.72
Rate for Payer: Cigna Medicare	$47.04
Rate for Payer: Employer Direct Commercial	$47.04
Rate for Payer: Humana Medicare/TRICARE	$47.04
Rate for Payer: Molina CHIP/Medicaid	$180.72
Rate for Payer: Molina Dual Medicare/Medicaid	$47.04
Rate for Payer: Molina Medicare	$47.04
Rate for Payer: Multiplan Auto	$163.15
Rate for Payer: Multiplan Commercial	$163.15
Rate for Payer: Multiplan Workers Comp	$163.15
Rate for Payer: Parkland Medicaid	$180.72
Rate for Payer: Scott and White EPO/PPO	$15.21
Rate for Payer: Scott and White Medicare	$47.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.72
Rate for Payer: Superior Health Plan EPO	$47.04
Rate for Payer: Superior Health Plan Medicare	$47.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$47.04
Rate for Payer: Universal American Medicare	$47.04
Rate for Payer: Wellcare Medicare	$47.04
Rate for Payer: Wellmed Medicare	$47.04

96365- IV tx, first hour

Facility

$300.00

Service Code	HCPCS 96365
Hospital Charge Code	5202387
Hospital Revenue Code	260
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$451.67
Rate for Payer: Amerigroup CHIP/Medicaid	$27.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$90.00
Rate for Payer: BCBS of TX Blue Essentials	$108.00
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$120.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$216.00
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$216.00
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$195.00
Rate for Payer: Multiplan Commercial	$195.00
Rate for Payer: Multiplan Workers Comp	$195.00
Rate for Payer: Parkland Medicaid	$216.00
Rate for Payer: Scott and White EPO/PPO	$77.31
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.00
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

96365- IV tx, first hour

Facility

$300.00

Service Code	HCPCS 96365
Hospital Charge Code	5202387
Hospital Revenue Code	260
Rate for Payer: Cash Price	$204.00

96367- IV tx, sequential infusion

Facility

$175.00

Service Code	HCPCS 96367
Hospital Charge Code	5202403
Hospital Revenue Code	260
Rate for Payer: Cash Price	$119.00

96367- IV tx, sequential infusion

Facility

$175.00

Service Code	HCPCS 96367
Hospital Charge Code	5202403
Hospital Revenue Code	260
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$152.89
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$52.50
Rate for Payer: BCBS of TX Blue Essentials	$63.00
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$70.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$126.00
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$126.00
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Parkland Medicaid	$126.00
Rate for Payer: Scott and White EPO/PPO	$35.01
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.00
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

96368- IV tx, concurrent infusion

Facility

$149.00

Service Code	HCPCS 96368
Hospital Charge Code	5202411
Hospital Revenue Code	260
Min. Negotiated Rate	$13.41
Max. Negotiated Rate	$107.28
Rate for Payer: Amerigroup CHIP/Medicaid	$13.41
Rate for Payer: BCBS of TX Blue Advantage	$44.70
Rate for Payer: BCBS of TX Blue Essentials	$53.64
Rate for Payer: BCBS of TX PPO	$59.60
Rate for Payer: Cash Price	$101.32
Rate for Payer: Cash Price	$101.32
Rate for Payer: Cigna Medicaid	$107.28
Rate for Payer: Molina CHIP/Medicaid	$107.28
Rate for Payer: Multiplan Auto	$96.85
Rate for Payer: Multiplan Commercial	$96.85
Rate for Payer: Multiplan Workers Comp	$96.85
Rate for Payer: Parkland Medicaid	$107.28
Rate for Payer: Scott and White EPO/PPO	$24.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$107.28
Rate for Payer: Superior Health Plan EPO	$20.26

96368- IV tx, concurrent infusion

Facility

$149.00

Service Code	HCPCS 96368
Hospital Charge Code	5202411
Hospital Revenue Code	260
Rate for Payer: Cash Price	$101.32

96372- Subq/IM Injection

Facility

$280.00

Service Code	HCPCS 96372
Hospital Charge Code	5210315
Hospital Revenue Code	260
Rate for Payer: Cash Price	$190.40

96372- Subq/IM Injection

Facility

$280.00

Service Code	HCPCS 96372
Hospital Charge Code	5210315
Hospital Revenue Code	260
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$201.60
Rate for Payer: Amerigroup CHIP/Medicaid	$25.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$84.00
Rate for Payer: BCBS of TX Blue Essentials	$100.80
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$112.00
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$201.60
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$201.60
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
Rate for Payer: Multiplan Auto	$182.00
Rate for Payer: Multiplan Commercial	$182.00
Rate for Payer: Multiplan Workers Comp	$182.00
Rate for Payer: Parkland Medicaid	$201.60
Rate for Payer: Scott and White EPO/PPO	$17.70
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$201.60
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

96373- Intra-Arterial Injection

Facility

$360.00

Service Code	HCPCS 96373
Hospital Charge Code	6100783
Hospital Revenue Code	260
Min. Negotiated Rate	$23.05
Max. Negotiated Rate	$451.67
Rate for Payer: Amerigroup CHIP/Medicaid	$32.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$108.00
Rate for Payer: BCBS of TX Blue Essentials	$129.60
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$144.00
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$259.20
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$259.20
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$234.00
Rate for Payer: Multiplan Commercial	$234.00
Rate for Payer: Multiplan Workers Comp	$234.00
Rate for Payer: Parkland Medicaid	$259.20
Rate for Payer: Scott and White EPO/PPO	$23.05
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$259.20
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

96373- Intra-Arterial Injection

Facility

$360.00

Service Code	HCPCS 96373
Hospital Charge Code	6100783
Hospital Revenue Code	260
Rate for Payer: Cash Price	$244.80

96374- IV Injection, single/initial

Facility

$360.00

Service Code	HCPCS 96374
Hospital Charge Code	5202437
Hospital Revenue Code	260
Min. Negotiated Rate	$32.40
Max. Negotiated Rate	$451.67
Rate for Payer: Amerigroup CHIP/Medicaid	$32.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$108.00
Rate for Payer: BCBS of TX Blue Essentials	$129.60
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$144.00
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$259.20
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$259.20
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$234.00
Rate for Payer: Multiplan Commercial	$234.00
Rate for Payer: Multiplan Workers Comp	$234.00
Rate for Payer: Parkland Medicaid	$259.20
Rate for Payer: Scott and White EPO/PPO	$45.26
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$259.20
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

96374- IV Injection, single/initial

Facility

$360.00

Service Code	HCPCS 96374
Hospital Charge Code	5202437
Hospital Revenue Code	260
Rate for Payer: Cash Price	$244.80

96376- IV Injection, add same drug

Facility

$330.00

Service Code	HCPCS 96376
Hospital Charge Code	8932544
Hospital Revenue Code	260
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$237.60
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: BCBS of TX Blue Advantage	$99.00
Rate for Payer: BCBS of TX Blue Essentials	$118.80
Rate for Payer: BCBS of TX PPO	$132.00
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cigna Medicaid	$237.60
Rate for Payer: Molina CHIP/Medicaid	$237.60
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Parkland Medicaid	$237.60
Rate for Payer: Scott and White EPO/PPO	$165.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$237.60
Rate for Payer: Superior Health Plan EPO	$44.88

96376- IV Injection, add same drug

Facility

$330.00

Service Code	HCPCS 96376
Hospital Charge Code	8932544
Hospital Revenue Code	260
Rate for Payer: Cash Price	$224.40

96376- IV Injection, add same drug

Facility

$330.00

Service Code	HCPCS 96376
Hospital Charge Code	5202452
Hospital Revenue Code	260
Rate for Payer: Cash Price	$224.40

96376- IV Injection, add same drug

Facility

$330.00

Service Code	HCPCS 96376
Hospital Charge Code	5202452
Hospital Revenue Code	260
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$237.60
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: BCBS of TX Blue Advantage	$99.00
Rate for Payer: BCBS of TX Blue Essentials	$118.80
Rate for Payer: BCBS of TX PPO	$132.00
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cigna Medicaid	$237.60
Rate for Payer: Molina CHIP/Medicaid	$237.60
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Parkland Medicaid	$237.60
Rate for Payer: Scott and White EPO/PPO	$165.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$237.60
Rate for Payer: Superior Health Plan EPO	$44.88

Know your out-of-pocket cost for care.

All Charges