White Rock Medical Center

All Charges

Charge

Type

Setting

Price

.Lyme Western Blot 163601 SO

Facility

$86.00

Service Code	CPT 86617
Hospital Charge Code	1708866
Hospital Revenue Code	300
Rate for Payer: Cash Price	$75.68

.Lyme Western Blot 163601 SO

Facility

$86.00

Service Code	CPT 86617
Hospital Charge Code	1708866
Hospital Revenue Code	300
Min. Negotiated Rate	$6.04
Max. Negotiated Rate	$55.90
Rate for Payer: Aetna Commercial	$16.26
Rate for Payer: Aetna Medicare	$23.23
Rate for Payer: Amerigroup CHIP/Medicaid	$6.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.49
Rate for Payer: Amerigroup Medicare	$15.49
Rate for Payer: BCBS of TX Blue Advantage	$25.56
Rate for Payer: BCBS of TX Blue Essentials	$30.67
Rate for Payer: BCBS of TX Medicare	$15.49
Rate for Payer: BCBS of TX PPO	$34.23
Rate for Payer: Cash Price	$75.68
Rate for Payer: Cash Price	$75.68
Rate for Payer: Cigna Medicaid	$15.49
Rate for Payer: Cigna Medicare	$15.49
Rate for Payer: Employer Direct Commercial	$15.49
Rate for Payer: Humana Medicare/TRICARE	$15.49
Rate for Payer: Molina CHIP/Medicaid	$15.49
Rate for Payer: Molina Dual Medicare/Medicaid	$15.49
Rate for Payer: Molina Medicare	$15.49
Rate for Payer: Multiplan Auto	$55.90
Rate for Payer: Multiplan Commercial	$55.90
Rate for Payer: Multiplan Workers Comp	$55.90
Rate for Payer: Parkland Medicaid	$15.49
Rate for Payer: Scott and White EPO/PPO	$19.36
Rate for Payer: Scott and White Medicare	$15.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.49
Rate for Payer: Superior Health Plan EPO	$15.49
Rate for Payer: Superior Health Plan Medicare	$15.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.49
Rate for Payer: Universal American Medicare	$15.49
Rate for Payer: Wellcare Medicare	$15.49
Rate for Payer: Wellmed Medicare	$15.49

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$28,749.45

Service Code	MSDRG 821
Min. Negotiated Rate	$20,045.74
Max. Negotiated Rate	$28,749.45
Rate for Payer: Aetna Commercial	$25,111.12
Rate for Payer: Aetna Medicare	$28,174.77
Rate for Payer: BCBS of TX Blue Advantage	$20,045.74
Rate for Payer: BCBS of TX Blue Essentials	$24,706.78
Rate for Payer: BCBS of TX PPO	$27,453.04
Rate for Payer: Cigna Commercial	$28,749.45

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$77,881.50

Service Code	MSDRG 820
Min. Negotiated Rate	$50,862.12
Max. Negotiated Rate	$77,881.50
Rate for Payer: Aetna Commercial	$68,025.38
Rate for Payer: Aetna Medicare	$69,006.60
Rate for Payer: BCBS of TX Blue Advantage	$50,862.12
Rate for Payer: BCBS of TX Blue Essentials	$56,173.54
Rate for Payer: BCBS of TX PPO	$62,417.46
Rate for Payer: Cigna Commercial	$77,881.50

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$17,542.38

Service Code	MSDRG 822
Min. Negotiated Rate	$10,435.24
Max. Negotiated Rate	$17,542.38
Rate for Payer: Aetna Commercial	$13,936.50
Rate for Payer: Aetna Medicare	$17,542.38
Rate for Payer: BCBS of TX Blue Advantage	$10,435.24
Rate for Payer: BCBS of TX Blue Essentials	$12,483.93
Rate for Payer: BCBS of TX PPO	$13,871.57
Rate for Payer: Cigna Commercial	$15,955.74

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC

Facility

$21,125.07

Service Code	MSDRG 841
Min. Negotiated Rate	$14,560.66
Max. Negotiated Rate	$21,125.07
Rate for Payer: Aetna Commercial	$17,701.88
Rate for Payer: Aetna Medicare	$21,125.07
Rate for Payer: BCBS of TX Blue Advantage	$14,560.66
Rate for Payer: BCBS of TX Blue Essentials	$16,869.50
Rate for Payer: BCBS of TX PPO	$18,744.62
Rate for Payer: Cigna Commercial	$20,266.68

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC

Facility

$40,252.58

Service Code	MSDRG 840
Min. Negotiated Rate	$26,845.76
Max. Negotiated Rate	$40,252.58
Rate for Payer: Aetna Commercial	$35,158.50
Rate for Payer: Aetna Medicare	$37,734.58
Rate for Payer: BCBS of TX Blue Advantage	$26,845.76
Rate for Payer: BCBS of TX Blue Essentials	$33,979.44
Rate for Payer: BCBS of TX PPO	$37,756.39
Rate for Payer: Cigna Commercial	$40,252.58

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC

Facility

$28,759.75

Service Code	MSDRG 824
Min. Negotiated Rate	$19,405.04
Max. Negotiated Rate	$28,759.75
Rate for Payer: Aetna Commercial	$25,120.12
Rate for Payer: Aetna Medicare	$28,183.33
Rate for Payer: BCBS of TX Blue Advantage	$19,405.04
Rate for Payer: BCBS of TX Blue Essentials	$22,644.01
Rate for Payer: BCBS of TX PPO	$25,160.99
Rate for Payer: Cigna Commercial	$28,759.75

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC

Facility

$57,984.47

Service Code	MSDRG 823
Min. Negotiated Rate	$38,101.44
Max. Negotiated Rate	$57,984.47
Rate for Payer: Aetna Commercial	$50,646.38
Rate for Payer: Aetna Medicare	$52,470.92
Rate for Payer: BCBS of TX Blue Advantage	$38,101.44
Rate for Payer: BCBS of TX Blue Essentials	$46,689.35
Rate for Payer: BCBS of TX PPO	$51,879.06
Rate for Payer: Cigna Commercial	$57,984.47

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$18,105.42

Service Code	MSDRG 825
Min. Negotiated Rate	$11,662.46
Max. Negotiated Rate	$18,105.42
Rate for Payer: Aetna Commercial	$14,528.25
Rate for Payer: Aetna Medicare	$18,105.42
Rate for Payer: BCBS of TX Blue Advantage	$11,662.46
Rate for Payer: BCBS of TX Blue Essentials	$14,023.52
Rate for Payer: BCBS of TX PPO	$15,582.29
Rate for Payer: Cigna Commercial	$16,633.23

LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$15,697.02

Service Code	MSDRG 842
Min. Negotiated Rate	$9,773.90
Max. Negotiated Rate	$15,697.02
Rate for Payer: Aetna Commercial	$11,997.00
Rate for Payer: Aetna Medicare	$15,697.02
Rate for Payer: BCBS of TX Blue Advantage	$9,773.90
Rate for Payer: BCBS of TX Blue Essentials	$11,568.63
Rate for Payer: BCBS of TX PPO	$12,854.53
Rate for Payer: Cigna Commercial	$13,735.23

Lysozyme, Serum SO

Facility

$97.00

Service Code	CPT 85549
Hospital Charge Code	1740018
Hospital Revenue Code	305
Min. Negotiated Rate	$7.31
Max. Negotiated Rate	$63.05
Rate for Payer: Aetna Commercial	$19.69
Rate for Payer: Aetna Medicare	$28.12
Rate for Payer: Amerigroup CHIP/Medicaid	$7.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.75
Rate for Payer: Amerigroup Medicare	$18.75
Rate for Payer: BCBS of TX Blue Advantage	$30.94
Rate for Payer: BCBS of TX Blue Essentials	$37.12
Rate for Payer: BCBS of TX Medicare	$18.75
Rate for Payer: BCBS of TX PPO	$41.44
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cigna Medicaid	$18.75
Rate for Payer: Cigna Medicare	$18.75
Rate for Payer: Employer Direct Commercial	$18.75
Rate for Payer: Humana Medicare/TRICARE	$18.75
Rate for Payer: Molina CHIP/Medicaid	$18.75
Rate for Payer: Molina Dual Medicare/Medicaid	$18.75
Rate for Payer: Molina Medicare	$18.75
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$18.75
Rate for Payer: Scott and White EPO/PPO	$23.44
Rate for Payer: Scott and White Medicare	$18.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.75
Rate for Payer: Superior Health Plan EPO	$18.75
Rate for Payer: Superior Health Plan Medicare	$18.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.75
Rate for Payer: Universal American Medicare	$18.75
Rate for Payer: Wellcare Medicare	$18.75
Rate for Payer: Wellmed Medicare	$18.75

Lysozyme, Serum SO

Facility

$97.00

Service Code	CPT 85549
Hospital Charge Code	1740018
Hospital Revenue Code	305
Rate for Payer: Cash Price	$85.36

M003-IgE Aspergillus fumigatus SO

Facility

$74.00

Service Code	CPT 86003
Hospital Charge Code	1701028
Hospital Revenue Code	302
Rate for Payer: Cash Price	$65.12

M003-IgE Aspergillus fumigatus SO

Facility

$74.00

Service Code	CPT 86003
Hospital Charge Code	1701028
Hospital Revenue Code	302
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$48.10
Rate for Payer: Aetna Commercial	$5.48
Rate for Payer: Aetna Medicare	$7.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.22
Rate for Payer: Amerigroup Medicare	$5.22
Rate for Payer: BCBS of TX Blue Advantage	$8.61
Rate for Payer: BCBS of TX Blue Essentials	$10.34
Rate for Payer: BCBS of TX Medicare	$5.22
Rate for Payer: BCBS of TX PPO	$11.54
Rate for Payer: Cash Price	$65.12
Rate for Payer: Cash Price	$65.12
Rate for Payer: Cigna Medicaid	$5.22
Rate for Payer: Cigna Medicare	$5.22
Rate for Payer: Employer Direct Commercial	$5.22
Rate for Payer: Humana Medicare/TRICARE	$5.22
Rate for Payer: Molina CHIP/Medicaid	$5.22
Rate for Payer: Molina Dual Medicare/Medicaid	$5.22
Rate for Payer: Molina Medicare	$5.22
Rate for Payer: Multiplan Auto	$48.10
Rate for Payer: Multiplan Commercial	$48.10
Rate for Payer: Multiplan Workers Comp	$48.10
Rate for Payer: Parkland Medicaid	$5.22
Rate for Payer: Scott and White EPO/PPO	$6.53
Rate for Payer: Scott and White Medicare	$5.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.22
Rate for Payer: Superior Health Plan EPO	$5.22
Rate for Payer: Superior Health Plan Medicare	$5.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.22
Rate for Payer: Universal American Medicare	$5.22
Rate for Payer: Wellcare Medicare	$5.22
Rate for Payer: Wellmed Medicare	$5.22

.MAC Susceptibility Broth 182835 SO

Facility

$251.00

Service Code	CPT 87186
Hospital Charge Code	1604610
Hospital Revenue Code	306
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$163.15
Rate for Payer: Aetna Commercial	$9.08
Rate for Payer: Aetna Medicare	$12.97
Rate for Payer: Amerigroup CHIP/Medicaid	$3.37
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.65
Rate for Payer: Amerigroup Medicare	$8.65
Rate for Payer: BCBS of TX Blue Advantage	$14.27
Rate for Payer: BCBS of TX Blue Essentials	$17.13
Rate for Payer: BCBS of TX Medicare	$8.65
Rate for Payer: BCBS of TX PPO	$19.12
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cigna Medicaid	$8.65
Rate for Payer: Cigna Medicare	$8.65
Rate for Payer: Employer Direct Commercial	$8.65
Rate for Payer: Humana Medicare/TRICARE	$8.65
Rate for Payer: Molina CHIP/Medicaid	$8.65
Rate for Payer: Molina Dual Medicare/Medicaid	$8.65
Rate for Payer: Molina Medicare	$8.65
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	$8.65
Rate for Payer: Scott and White EPO/PPO	$10.81
Rate for Payer: Scott and White Medicare	$8.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.65
Rate for Payer: Superior Health Plan EPO	$8.65
Rate for Payer: Superior Health Plan Medicare	$8.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.65
Rate for Payer: Universal American Medicare	$8.65
Rate for Payer: Wellcare Medicare	$8.65
Rate for Payer: Wellmed Medicare	$8.65

Magic Mouthwash

Facility

$30.00

Service Code	HCPCS J3490
Hospital Charge Code	79096582
Hospital Revenue Code	250
Rate for Payer: Cash Price	$20.40

Magic Mouthwash

Facility

$30.00

Service Code	HCPCS J3490
Hospital Charge Code	79096582
Hospital Revenue Code	250
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$19.50
Rate for Payer: Amerigroup CHIP/Medicaid	$2.70
Rate for Payer: BCBS of TX Blue Advantage	$9.00
Rate for Payer: BCBS of TX Blue Essentials	$10.80
Rate for Payer: BCBS of TX PPO	$12.00
Rate for Payer: Cash Price	$20.40
Rate for Payer: Multiplan Auto	$19.50
Rate for Payer: Multiplan Commercial	$19.50
Rate for Payer: Multiplan Workers Comp	$19.50
Rate for Payer: Scott and White EPO/PPO	$15.00
Rate for Payer: Superior Health Plan EPO	$4.08

magnesium citrate 1.745 g/30 mL Oral Liquid 300 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77675114
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

magnesium citrate 1.745 g/30 mL Oral Liquid 300 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77675114
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan EPO	$1.04

magnesium hydroxide 8% Oral Susp 30 mL

Facility

$8.43

Service Code	HCPCS J3490
Hospital Charge Code	77675679
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.73

magnesium hydroxide 8% Oral Susp 30 mL

Facility

$8.43

Service Code	HCPCS J3490
Hospital Charge Code	77675679
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$5.48
Rate for Payer: Amerigroup CHIP/Medicaid	$0.76
Rate for Payer: BCBS of TX Blue Advantage	$2.53
Rate for Payer: BCBS of TX Blue Essentials	$3.03
Rate for Payer: BCBS of TX PPO	$3.37
Rate for Payer: Cash Price	$5.73
Rate for Payer: Multiplan Auto	$5.48
Rate for Payer: Multiplan Commercial	$5.48
Rate for Payer: Multiplan Workers Comp	$5.48
Rate for Payer: Scott and White EPO/PPO	$4.21
Rate for Payer: Superior Health Plan EPO	$1.15

Magnesium Level

Facility

$234.00

Service Code	CPT 83735
Hospital Charge Code	1602143
Hospital Revenue Code	301
Rate for Payer: Cash Price	$205.92

Magnesium Level

Facility

$234.00

Service Code	CPT 83735
Hospital Charge Code	1602143
Hospital Revenue Code	301
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$152.10
Rate for Payer: Aetna Commercial	$7.04
Rate for Payer: Aetna Medicare	$10.05
Rate for Payer: Amerigroup CHIP/Medicaid	$2.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.70
Rate for Payer: Amerigroup Medicare	$6.70
Rate for Payer: BCBS of TX Blue Advantage	$11.05
Rate for Payer: BCBS of TX Blue Essentials	$13.27
Rate for Payer: BCBS of TX Medicare	$6.70
Rate for Payer: BCBS of TX PPO	$14.81
Rate for Payer: Cash Price	$205.92
Rate for Payer: Cash Price	$205.92
Rate for Payer: Cigna Medicaid	$6.70
Rate for Payer: Cigna Medicare	$6.70
Rate for Payer: Employer Direct Commercial	$6.70
Rate for Payer: Humana Medicare/TRICARE	$6.70
Rate for Payer: Molina CHIP/Medicaid	$6.70
Rate for Payer: Molina Dual Medicare/Medicaid	$6.70
Rate for Payer: Molina Medicare	$6.70
Rate for Payer: Multiplan Auto	$152.10
Rate for Payer: Multiplan Commercial	$152.10
Rate for Payer: Multiplan Workers Comp	$152.10
Rate for Payer: Parkland Medicaid	$6.70
Rate for Payer: Scott and White EPO/PPO	$8.38
Rate for Payer: Scott and White Medicare	$6.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.70
Rate for Payer: Superior Health Plan EPO	$6.70
Rate for Payer: Superior Health Plan Medicare	$6.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.70
Rate for Payer: Universal American Medicare	$6.70
Rate for Payer: Wellcare Medicare	$6.70
Rate for Payer: Wellmed Medicare	$6.70

magnesium oxide 400 mg (241.3 mg elemental magnesium) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77676264
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan EPO	$1.04

Know your out-of-pocket cost for care.

All Charges