White Rock Medical Center

All Charges

Charge

Type

Setting

Price

AS STPL RELD -- DHF

Facility

$1,714.36

Hospital Charge Code	81911075
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,508.64

AS STPL RELD -- DHF

Facility

$1,714.36

Hospital Charge Code	81911075
Hospital Revenue Code	272
Min. Negotiated Rate	$154.29
Max. Negotiated Rate	$1,114.33
Rate for Payer: Aetna Commercial	$942.90
Rate for Payer: Amerigroup CHIP/Medicaid	$154.29
Rate for Payer: BCBS of TX Blue Advantage	$514.31
Rate for Payer: BCBS of TX Blue Essentials	$617.17
Rate for Payer: BCBS of TX PPO	$685.74
Rate for Payer: Cash Price	$1,508.64
Rate for Payer: Multiplan Auto	$1,114.33
Rate for Payer: Multiplan Commercial	$1,114.33
Rate for Payer: Multiplan Workers Comp	$1,114.33
Rate for Payer: Scott and White EPO/PPO	$857.18
Rate for Payer: Superior Health Plan EPO	$233.15

atenolol 50 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77386224
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

atenolol 50 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77386224
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	$2.30
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	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

ATHERCT ILIAC OPEN PERC

Facility

$17,499.00

Service Code	CPT 0238T
Hospital Charge Code	4610146
Hospital Revenue Code	361
Min. Negotiated Rate	$286.80
Max. Negotiated Rate	$40,168.72
Rate for Payer: Aetna Commercial	$8,755.00
Rate for Payer: Aetna Medicare	$24,055.02
Rate for Payer: Amerigroup CHIP/Medicaid	$1,574.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Amerigroup Medicare	$16,036.68
Rate for Payer: BCBS of TX Blue Advantage	$26,619.75
Rate for Payer: BCBS of TX Blue Essentials	$31,879.94
Rate for Payer: BCBS of TX Medicare	$16,036.68
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cash Price	$15,399.12
Rate for Payer: Cash Price	$15,399.12
Rate for Payer: Cash Price	$15,399.12
Rate for Payer: Cigna Commercial	$36,327.72
Rate for Payer: Cigna Medicare	$16,036.68
Rate for Payer: Employer Direct Commercial	$16,036.68
Rate for Payer: Humana Medicare/TRICARE	$16,036.68
Rate for Payer: Molina Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Molina Medicare	$16,036.68
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	$286.80
Rate for Payer: Scott and White Medicare	$16,036.68
Rate for Payer: Superior Health Plan EPO	$16,036.68
Rate for Payer: Superior Health Plan Medicare	$16,036.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Universal American Medicare	$16,036.68
Rate for Payer: Wellcare Medicare	$16,036.68
Rate for Payer: Wellmed Medicare	$16,036.68

ATHERCT ILIAC OPEN PERC

Facility

$17,499.00

Service Code	CPT 0238T
Hospital Charge Code	4610146
Hospital Revenue Code	361
Rate for Payer: Cash Price	$15,399.12

ATHERECT VISC OPEN PERC

Facility

$21,010.00

Service Code	CPT 0235T
Hospital Charge Code	4610141
Hospital Revenue Code	361
Min. Negotiated Rate	$1,805.34
Max. Negotiated Rate	$10,505.00
Rate for Payer: Aetna Commercial	$4,017.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,890.90
Rate for Payer: BCBS of TX Blue Advantage	$1,805.34
Rate for Payer: BCBS of TX Blue Essentials	$2,162.08
Rate for Payer: BCBS of TX PPO	$2,724.22
Rate for Payer: Cash Price	$18,488.80
Rate for Payer: Cash Price	$18,488.80
Rate for Payer: Cash Price	$18,488.80
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	$10,505.00
Rate for Payer: Superior Health Plan EPO	$2,857.36

ATHERECT VISC OPEN PERC

Facility

$21,010.00

Service Code	CPT 0235T
Hospital Charge Code	4610141
Hospital Revenue Code	361
Rate for Payer: Cash Price	$18,488.80

ATHEROSCLEROSIS WITH MCC

Facility

$21,300.90

Service Code	MSDRG 302
Min. Negotiated Rate	$8,950.88
Max. Negotiated Rate	$21,300.90
Rate for Payer: Aetna Commercial	$12,612.38
Rate for Payer: Aetna Medicare	$16,282.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,855.02
Rate for Payer: Amerigroup Medicare	$10,855.02
Rate for Payer: BCBS of TX Blue Advantage	$8,950.88
Rate for Payer: BCBS of TX Blue Essentials	$11,036.17
Rate for Payer: BCBS of TX Medicare	$10,855.02
Rate for Payer: BCBS of TX PPO	$12,262.89
Rate for Payer: Cigna Commercial	$14,439.77
Rate for Payer: Cigna Medicare	$10,855.02
Rate for Payer: Employer Direct Commercial	$10,855.02
Rate for Payer: Humana Medicare/TRICARE	$10,855.02
Rate for Payer: Molina Dual Medicare/Medicaid	$10,855.02
Rate for Payer: Molina Medicare	$10,855.02
Rate for Payer: Multiplan Auto	$21,300.90
Rate for Payer: Multiplan Commercial	$21,300.90
Rate for Payer: Multiplan Workers Comp	$21,300.90
Rate for Payer: Scott and White EPO/PPO	$9,809.62
Rate for Payer: Scott and White Medicare	$10,855.02
Rate for Payer: Superior Health Plan EPO	$10,855.02
Rate for Payer: Superior Health Plan Medicare	$10,855.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,855.02
Rate for Payer: Universal American Medicare	$10,855.02
Rate for Payer: Wellcare Medicare	$10,855.02
Rate for Payer: Wellmed Medicare	$10,855.02

ATHEROSCLEROSIS WITHOUT MCC

Facility

$12,503.90

Service Code	MSDRG 303
Min. Negotiated Rate	$5,528.08
Max. Negotiated Rate	$12,503.90
Rate for Payer: Aetna Commercial	$7,403.62
Rate for Payer: Aetna Medicare	$11,326.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,551.03
Rate for Payer: Amerigroup Medicare	$7,551.03
Rate for Payer: BCBS of TX Blue Advantage	$5,528.08
Rate for Payer: BCBS of TX Blue Essentials	$6,867.29
Rate for Payer: BCBS of TX Medicare	$7,551.03
Rate for Payer: BCBS of TX PPO	$7,630.62
Rate for Payer: Cigna Commercial	$8,476.33
Rate for Payer: Cigna Medicare	$7,551.03
Rate for Payer: Employer Direct Commercial	$7,551.03
Rate for Payer: Humana Medicare/TRICARE	$7,551.03
Rate for Payer: Molina Dual Medicare/Medicaid	$7,551.03
Rate for Payer: Molina Medicare	$7,551.03
Rate for Payer: Multiplan Auto	$12,503.90
Rate for Payer: Multiplan Commercial	$12,503.90
Rate for Payer: Multiplan Workers Comp	$12,503.90
Rate for Payer: Scott and White EPO/PPO	$5,758.38
Rate for Payer: Scott and White Medicare	$7,551.03
Rate for Payer: Superior Health Plan EPO	$7,551.03
Rate for Payer: Superior Health Plan Medicare	$7,551.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,551.03
Rate for Payer: Universal American Medicare	$7,551.03
Rate for Payer: Wellcare Medicare	$7,551.03
Rate for Payer: Wellmed Medicare	$7,551.03

atorvastatin 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77386738
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
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: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

atorvastatin 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77386738
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

atorvastatin 40 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77386846
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
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: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

atorvastatin 40 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77386846
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

atropine 1 mg 10 ml syringe

Facility

$128.17

Service Code	HCPCS J0461
Hospital Charge Code	77387594
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.07
Rate for Payer: BCBS of TX Blue Essentials	$0.09
Rate for Payer: BCBS of TX PPO	$0.10
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

atropine 1 mg 10 ml syringe

Facility

$128.17

Service Code	HCPCS J0461
Hospital Charge Code	77387594
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

atropine 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J0461
Hospital Charge Code	77388095
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.07
Rate for Payer: BCBS of TX Blue Essentials	$0.09
Rate for Payer: BCBS of TX PPO	$0.10
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

atropine 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J0461
Hospital Charge Code	77388095
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

atropine-diphenoxylate 0.025 mg-2.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77388741
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	$2.30
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	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

atropine-diphenoxylate 0.025 mg-2.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77388741
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Auditory (AEP)

Facility

$1,769.00

Service Code	CPT 92652
Hospital Charge Code	4802587
Hospital Revenue Code	471
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$1,149.85
Rate for Payer: Aetna Commercial	$972.95
Rate for Payer: Aetna Medicare	$430.59
Rate for Payer: Amerigroup CHIP/Medicaid	$159.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$287.06
Rate for Payer: Amerigroup Medicare	$287.06
Rate for Payer: BCBS of TX Blue Advantage	$207.54
Rate for Payer: BCBS of TX Blue Essentials	$249.04
Rate for Payer: BCBS of TX Medicare	$287.06
Rate for Payer: BCBS of TX PPO	$277.97
Rate for Payer: Cash Price	$1,556.72
Rate for Payer: Cash Price	$1,556.72
Rate for Payer: Cash Price	$1,556.72
Rate for Payer: Cigna Commercial	$650.28
Rate for Payer: Cigna Medicare	$287.06
Rate for Payer: Employer Direct Commercial	$287.06
Rate for Payer: Humana Medicare/TRICARE	$287.06
Rate for Payer: Molina Dual Medicare/Medicaid	$287.06
Rate for Payer: Molina Medicare	$287.06
Rate for Payer: Multiplan Auto	$1,149.85
Rate for Payer: Multiplan Commercial	$1,149.85
Rate for Payer: Multiplan Workers Comp	$1,149.85
Rate for Payer: Scott and White EPO/PPO	$5.13
Rate for Payer: Scott and White Medicare	$287.06
Rate for Payer: Superior Health Plan EPO	$287.06
Rate for Payer: Superior Health Plan Medicare	$287.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$287.06
Rate for Payer: Universal American Medicare	$287.06
Rate for Payer: Wellcare Medicare	$287.06
Rate for Payer: Wellmed Medicare	$287.06

AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC

Facility

$117,363.00

Service Code	MSDRG 016
Min. Negotiated Rate	$46,934.21
Max. Negotiated Rate	$117,363.00
Rate for Payer: Aetna Commercial	$69,491.25
Rate for Payer: Aetna Medicare	$70,401.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$46,934.21
Rate for Payer: Amerigroup Medicare	$46,934.21
Rate for Payer: BCBS of TX Blue Advantage	$52,503.00
Rate for Payer: BCBS of TX Blue Essentials	$67,480.07
Rate for Payer: BCBS of TX Medicare	$46,934.21
Rate for Payer: BCBS of TX PPO	$74,980.76
Rate for Payer: Cigna Commercial	$79,559.76
Rate for Payer: Cigna Medicare	$46,934.21
Rate for Payer: Employer Direct Commercial	$46,934.21
Rate for Payer: Humana Medicare/TRICARE	$46,934.21
Rate for Payer: Molina Dual Medicare/Medicaid	$46,934.21
Rate for Payer: Molina Medicare	$46,934.21
Rate for Payer: Multiplan Auto	$117,363.00
Rate for Payer: Multiplan Commercial	$117,363.00
Rate for Payer: Multiplan Workers Comp	$117,363.00
Rate for Payer: Scott and White EPO/PPO	$54,048.75
Rate for Payer: Scott and White Medicare	$46,934.21
Rate for Payer: Superior Health Plan EPO	$46,934.21
Rate for Payer: Superior Health Plan Medicare	$46,934.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$46,934.21
Rate for Payer: Universal American Medicare	$46,934.21
Rate for Payer: Wellcare Medicare	$46,934.21
Rate for Payer: Wellmed Medicare	$46,934.21

AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC

Facility

$117,363.00

Service Code	MSDRG 017
Min. Negotiated Rate	$35,002.86
Max. Negotiated Rate	$117,363.00
Rate for Payer: Aetna Commercial	$69,491.25
Rate for Payer: Aetna Medicare	$70,401.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$46,934.21
Rate for Payer: Amerigroup Medicare	$46,934.21
Rate for Payer: BCBS of TX Blue Advantage	$35,002.86
Rate for Payer: BCBS of TX Blue Essentials	$45,208.57
Rate for Payer: BCBS of TX Medicare	$46,934.21
Rate for Payer: BCBS of TX PPO	$50,233.69
Rate for Payer: Cigna Commercial	$79,559.76
Rate for Payer: Cigna Medicare	$46,934.21
Rate for Payer: Employer Direct Commercial	$46,934.21
Rate for Payer: Humana Medicare/TRICARE	$46,934.21
Rate for Payer: Molina Dual Medicare/Medicaid	$46,934.21
Rate for Payer: Molina Medicare	$46,934.21
Rate for Payer: Multiplan Auto	$117,363.00
Rate for Payer: Multiplan Commercial	$117,363.00
Rate for Payer: Multiplan Workers Comp	$117,363.00
Rate for Payer: Scott and White EPO/PPO	$54,048.75
Rate for Payer: Scott and White Medicare	$46,934.21
Rate for Payer: Superior Health Plan EPO	$46,934.21
Rate for Payer: Superior Health Plan Medicare	$46,934.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$46,934.21
Rate for Payer: Universal American Medicare	$46,934.21
Rate for Payer: Wellcare Medicare	$46,934.21
Rate for Payer: Wellmed Medicare	$46,934.21

Avlsn Plte, Smpl, Sngl

Facility

$476.00

Service Code	CPT 11730
Hospital Charge Code	7150776
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$440.32
Rate for Payer: Aetna Commercial	$261.80
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$42.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$418.88
Rate for Payer: Cash Price	$418.88
Rate for Payer: Cash Price	$418.88
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$309.40
Rate for Payer: Multiplan Commercial	$309.40
Rate for Payer: Multiplan Workers Comp	$309.40
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

Avulsion of nail plate, partial or complete, simple; single

Facility

$10,000.00

Service Code	CPT 11730
Hospital Charge Code	36011730
Hospital Revenue Code	360
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
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	$4.04
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

Know your out-of-pocket cost for care.

All Charges