White Rock Medical Center

All Charges

Charge

Type

Setting

Price

.Hex Phase Phospholipid 117020 SO

Facility

$121.00

Service Code	HCPCS 85598
Hospital Charge Code	1740994
Hospital Revenue Code	305
Min. Negotiated Rate	$7.01
Max. Negotiated Rate	$87.12
Rate for Payer: Amerigroup CHIP/Medicaid	$7.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.98
Rate for Payer: Amerigroup Medicare	$17.98
Rate for Payer: BCBS of TX Blue Advantage	$36.30
Rate for Payer: BCBS of TX Blue Essentials	$43.56
Rate for Payer: BCBS of TX Medicare	$17.98
Rate for Payer: BCBS of TX PPO	$48.40
Rate for Payer: Cash Price	$82.28
Rate for Payer: Cash Price	$82.28
Rate for Payer: Cigna Medicaid	$87.12
Rate for Payer: Cigna Medicare	$17.98
Rate for Payer: Employer Direct Commercial	$17.98
Rate for Payer: Humana Medicare/TRICARE	$17.98
Rate for Payer: Molina CHIP/Medicaid	$87.12
Rate for Payer: Molina Dual Medicare/Medicaid	$17.98
Rate for Payer: Molina Medicare	$17.98
Rate for Payer: Multiplan Auto	$78.65
Rate for Payer: Multiplan Commercial	$78.65
Rate for Payer: Multiplan Workers Comp	$78.65
Rate for Payer: Parkland Medicaid	$87.12
Rate for Payer: Scott and White EPO/PPO	$22.48
Rate for Payer: Scott and White Medicare	$17.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$87.12
Rate for Payer: Superior Health Plan EPO	$17.98
Rate for Payer: Superior Health Plan Medicare	$17.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.98
Rate for Payer: Universal American Medicare	$17.98
Rate for Payer: Wellcare Medicare	$17.98
Rate for Payer: Wellmed Medicare	$17.98

.Hex Phase Phospholipid 117020 SO

Facility

$121.00

Service Code	HCPCS 85598
Hospital Charge Code	1740994
Hospital Revenue Code	305
Rate for Payer: Cash Price	$82.28

Hgb Fractionation Cascade SO

Facility

$199.00

Service Code	HCPCS 83020
Hospital Charge Code	8546509
Hospital Revenue Code	301
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$143.28
Rate for Payer: Amerigroup CHIP/Medicaid	$5.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.87
Rate for Payer: Amerigroup Medicare	$12.87
Rate for Payer: BCBS of TX Blue Advantage	$59.70
Rate for Payer: BCBS of TX Blue Essentials	$71.64
Rate for Payer: BCBS of TX Medicare	$12.87
Rate for Payer: BCBS of TX PPO	$79.60
Rate for Payer: Cash Price	$135.32
Rate for Payer: Cash Price	$135.32
Rate for Payer: Cigna Medicaid	$143.28
Rate for Payer: Cigna Medicare	$12.87
Rate for Payer: Employer Direct Commercial	$12.87
Rate for Payer: Humana Medicare/TRICARE	$12.87
Rate for Payer: Molina CHIP/Medicaid	$143.28
Rate for Payer: Molina Dual Medicare/Medicaid	$12.87
Rate for Payer: Molina Medicare	$12.87
Rate for Payer: Multiplan Auto	$129.35
Rate for Payer: Multiplan Commercial	$129.35
Rate for Payer: Multiplan Workers Comp	$129.35
Rate for Payer: Parkland Medicaid	$143.28
Rate for Payer: Scott and White EPO/PPO	$16.09
Rate for Payer: Scott and White Medicare	$12.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$143.28
Rate for Payer: Superior Health Plan EPO	$12.87
Rate for Payer: Superior Health Plan Medicare	$12.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.87
Rate for Payer: Universal American Medicare	$12.87
Rate for Payer: Wellcare Medicare	$12.87
Rate for Payer: Wellmed Medicare	$12.87

Hgb Fractionation Cascade SO

Facility

$199.00

Service Code	HCPCS 83020
Hospital Charge Code	8546509
Hospital Revenue Code	301
Rate for Payer: Cash Price	$135.32

HIBICLENS, LIQUID, FLIP-TOP 4OZ

Facility

$9.24

Hospital Charge Code	993367
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.28

HIBICLENS, LIQUID, FLIP-TOP 4OZ

Facility

$9.24

Hospital Charge Code	993367
Hospital Revenue Code	270
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$6.65
Rate for Payer: Amerigroup CHIP/Medicaid	$0.83
Rate for Payer: BCBS of TX Blue Advantage	$2.77
Rate for Payer: BCBS of TX Blue Essentials	$3.33
Rate for Payer: BCBS of TX PPO	$3.70
Rate for Payer: Cash Price	$6.28
Rate for Payer: Cigna Medicaid	$6.65
Rate for Payer: Molina CHIP/Medicaid	$6.65
Rate for Payer: Multiplan Auto	$6.01
Rate for Payer: Multiplan Commercial	$6.01
Rate for Payer: Multiplan Workers Comp	$6.01
Rate for Payer: Parkland Medicaid	$6.65
Rate for Payer: Scott and White EPO/PPO	$4.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.65
Rate for Payer: Superior Health Plan EPO	$1.26

High-Flow Humidifier Kit with 14' Standard Cannula, Up to 15

Facility

$39.32

Hospital Charge Code	993378
Hospital Revenue Code	270
Rate for Payer: Cash Price	$26.74

High-Flow Humidifier Kit with 14' Standard Cannula, Up to 15

Facility

$39.32

Hospital Charge Code	993378
Hospital Revenue Code	270
Min. Negotiated Rate	$3.54
Max. Negotiated Rate	$28.31
Rate for Payer: Amerigroup CHIP/Medicaid	$3.54
Rate for Payer: BCBS of TX Blue Advantage	$11.80
Rate for Payer: BCBS of TX Blue Essentials	$14.16
Rate for Payer: BCBS of TX PPO	$15.73
Rate for Payer: Cash Price	$26.74
Rate for Payer: Cigna Medicaid	$28.31
Rate for Payer: Molina CHIP/Medicaid	$28.31
Rate for Payer: Multiplan Auto	$25.56
Rate for Payer: Multiplan Commercial	$25.56
Rate for Payer: Multiplan Workers Comp	$25.56
Rate for Payer: Parkland Medicaid	$28.31
Rate for Payer: Scott and White EPO/PPO	$19.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.31
Rate for Payer: Superior Health Plan EPO	$5.35

HINGE BOLT - MEDIUM

Facility

$408.60

Hospital Charge Code	993431
Hospital Revenue Code	272
Min. Negotiated Rate	$36.77
Max. Negotiated Rate	$294.19
Rate for Payer: Amerigroup CHIP/Medicaid	$36.77
Rate for Payer: BCBS of TX Blue Advantage	$122.58
Rate for Payer: BCBS of TX Blue Essentials	$147.10
Rate for Payer: BCBS of TX PPO	$163.44
Rate for Payer: Cash Price	$277.85
Rate for Payer: Cigna Medicaid	$294.19
Rate for Payer: Molina CHIP/Medicaid	$294.19
Rate for Payer: Multiplan Auto	$265.59
Rate for Payer: Multiplan Commercial	$265.59
Rate for Payer: Multiplan Workers Comp	$265.59
Rate for Payer: Parkland Medicaid	$294.19
Rate for Payer: Scott and White EPO/PPO	$204.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$294.19
Rate for Payer: Superior Health Plan EPO	$55.57

HINGE BOLT - MEDIUM

Facility

$408.60

Hospital Charge Code	993431
Hospital Revenue Code	272
Rate for Payer: Cash Price	$277.85

Hintermann Large

Facility

$3,632.91

Hospital Charge Code	992927
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2,470.38

Hintermann Large

Facility

$3,632.91

Hospital Charge Code	992927
Hospital Revenue Code	270
Min. Negotiated Rate	$326.96
Max. Negotiated Rate	$2,615.70
Rate for Payer: Amerigroup CHIP/Medicaid	$326.96
Rate for Payer: BCBS of TX Blue Advantage	$1,089.87
Rate for Payer: BCBS of TX Blue Essentials	$1,307.85
Rate for Payer: BCBS of TX PPO	$1,453.16
Rate for Payer: Cash Price	$2,470.38
Rate for Payer: Cigna Medicaid	$2,615.70
Rate for Payer: Molina CHIP/Medicaid	$2,615.70
Rate for Payer: Multiplan Auto	$2,361.39
Rate for Payer: Multiplan Commercial	$2,361.39
Rate for Payer: Multiplan Workers Comp	$2,361.39
Rate for Payer: Parkland Medicaid	$2,615.70
Rate for Payer: Scott and White EPO/PPO	$1,816.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,615.70
Rate for Payer: Superior Health Plan EPO	$494.08

Hintermann Small

Facility

$5,147.04

Hospital Charge Code	992928
Hospital Revenue Code	270
Min. Negotiated Rate	$463.23
Max. Negotiated Rate	$3,705.87
Rate for Payer: Amerigroup CHIP/Medicaid	$463.23
Rate for Payer: BCBS of TX Blue Advantage	$1,544.11
Rate for Payer: BCBS of TX Blue Essentials	$1,852.93
Rate for Payer: BCBS of TX PPO	$2,058.82
Rate for Payer: Cash Price	$3,499.99
Rate for Payer: Cigna Medicaid	$3,705.87
Rate for Payer: Molina CHIP/Medicaid	$3,705.87
Rate for Payer: Multiplan Auto	$3,345.58
Rate for Payer: Multiplan Commercial	$3,345.58
Rate for Payer: Multiplan Workers Comp	$3,345.58
Rate for Payer: Parkland Medicaid	$3,705.87
Rate for Payer: Scott and White EPO/PPO	$2,573.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,705.87
Rate for Payer: Superior Health Plan EPO	$700.00

Hintermann Small

Facility

$5,147.04

Hospital Charge Code	992928
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3,499.99

HIP AND FEMUR FRACTURE REPAIR

Facility

$22,612.10

Service Code	APR-DRG 3084
Min. Negotiated Rate	$21,319.48
Max. Negotiated Rate	$22,612.10
Rate for Payer: Amerigroup CHIP/Medicaid	$21,319.48
Rate for Payer: Cigna Medicaid	$21,319.48
Rate for Payer: Molina CHIP/Medicaid	$21,319.48
Rate for Payer: Parkland Medicaid	$21,319.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,612.10

HIP AND FEMUR FRACTURE REPAIR

Facility

$10,816.65

Service Code	APR-DRG 3083
Min. Negotiated Rate	$10,198.32
Max. Negotiated Rate	$10,816.65
Rate for Payer: Amerigroup CHIP/Medicaid	$10,198.32
Rate for Payer: Cigna Medicaid	$10,198.32
Rate for Payer: Molina CHIP/Medicaid	$10,198.32
Rate for Payer: Parkland Medicaid	$10,198.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,816.65

HIP AND FEMUR FRACTURE REPAIR

Facility

$7,651.66

Service Code	APR-DRG 3082
Min. Negotiated Rate	$7,214.25
Max. Negotiated Rate	$7,651.66
Rate for Payer: Amerigroup CHIP/Medicaid	$7,214.25
Rate for Payer: Cigna Medicaid	$7,214.25
Rate for Payer: Molina CHIP/Medicaid	$7,214.25
Rate for Payer: Parkland Medicaid	$7,214.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,651.66

HIP AND FEMUR FRACTURE REPAIR

Facility

$6,171.94

Service Code	APR-DRG 3081
Min. Negotiated Rate	$5,819.12
Max. Negotiated Rate	$6,171.94
Rate for Payer: Amerigroup CHIP/Medicaid	$5,819.12
Rate for Payer: Cigna Medicaid	$5,819.12
Rate for Payer: Molina CHIP/Medicaid	$5,819.12
Rate for Payer: Parkland Medicaid	$5,819.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,171.94

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC

Facility

$40,135.60

Service Code	MSDRG 481
Min. Negotiated Rate	$17,735.78
Max. Negotiated Rate	$40,135.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,110.71
Rate for Payer: Amerigroup Medicare	$20,110.71
Rate for Payer: BCBS of TX Medicare	$20,110.71
Rate for Payer: Cigna Commercial	$26,977.16
Rate for Payer: Cigna Medicare	$20,110.71
Rate for Payer: Employer Direct Commercial	$20,110.71
Rate for Payer: Humana Medicare/TRICARE	$20,110.71
Rate for Payer: Molina Dual Medicare/Medicaid	$20,110.71
Rate for Payer: Molina Medicare	$20,110.71
Rate for Payer: Multiplan Auto	$40,135.60
Rate for Payer: Multiplan Commercial	$40,135.60
Rate for Payer: Multiplan Workers Comp	$40,135.60
Rate for Payer: Scott and White EPO/PPO	$18,483.50
Rate for Payer: Scott and White Medicare	$20,110.71
Rate for Payer: Superior Health Plan EPO	$20,110.71
Rate for Payer: Superior Health Plan Medicare	$20,110.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,110.71
Rate for Payer: Universal American Medicare	$20,110.71
Rate for Payer: Wellcare Medicare	$20,110.71
Rate for Payer: Wellmed Medicare	$20,110.71

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC

Facility

$56,354.00

Service Code	MSDRG 480
Min. Negotiated Rate	$25,952.50
Max. Negotiated Rate	$56,354.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,104.41
Rate for Payer: Amerigroup Medicare	$26,104.41
Rate for Payer: BCBS of TX Medicare	$26,104.41
Rate for Payer: Cigna Commercial	$37,510.42
Rate for Payer: Cigna Medicare	$26,104.41
Rate for Payer: Employer Direct Commercial	$26,104.41
Rate for Payer: Humana Medicare/TRICARE	$26,104.41
Rate for Payer: Molina Dual Medicare/Medicaid	$26,104.41
Rate for Payer: Molina Medicare	$26,104.41
Rate for Payer: Multiplan Auto	$56,354.00
Rate for Payer: Multiplan Commercial	$56,354.00
Rate for Payer: Multiplan Workers Comp	$56,354.00
Rate for Payer: Scott and White EPO/PPO	$25,952.50
Rate for Payer: Scott and White Medicare	$26,104.41
Rate for Payer: Superior Health Plan EPO	$26,104.41
Rate for Payer: Superior Health Plan Medicare	$26,104.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,104.41
Rate for Payer: Universal American Medicare	$26,104.41
Rate for Payer: Wellcare Medicare	$26,104.41
Rate for Payer: Wellmed Medicare	$26,104.41

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC

Facility

$31,275.90

Service Code	MSDRG 482
Min. Negotiated Rate	$14,314.70
Max. Negotiated Rate	$31,275.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,713.73
Rate for Payer: Amerigroup Medicare	$16,713.73
Rate for Payer: BCBS of TX Medicare	$16,713.73
Rate for Payer: Cigna Commercial	$21,007.28
Rate for Payer: Cigna Medicare	$16,713.73
Rate for Payer: Employer Direct Commercial	$16,713.73
Rate for Payer: Humana Medicare/TRICARE	$16,713.73
Rate for Payer: Molina Dual Medicare/Medicaid	$16,713.73
Rate for Payer: Molina Medicare	$16,713.73
Rate for Payer: Multiplan Auto	$31,275.90
Rate for Payer: Multiplan Commercial	$31,275.90
Rate for Payer: Multiplan Workers Comp	$31,275.90
Rate for Payer: Scott and White EPO/PPO	$14,403.38
Rate for Payer: Scott and White Medicare	$16,713.73
Rate for Payer: Superior Health Plan EPO	$16,713.73
Rate for Payer: Superior Health Plan Medicare	$16,713.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,713.73
Rate for Payer: Universal American Medicare	$16,713.73
Rate for Payer: Wellcare Medicare	$16,713.73
Rate for Payer: Wellmed Medicare	$16,713.73

Hip Arthro w/Labral Repair

Facility

$64,435.00

Service Code	HCPCS 29916
Hospital Charge Code	9900589
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$46,393.20
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$43,815.80
Rate for Payer: Cash Price	$43,815.80
Rate for Payer: Cash Price	$43,815.80
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$46,393.20
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$46,393.20
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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: Parkland Medicaid	$46,393.20
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,393.20
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Hip Arthro w/Labral Repair

Facility

$15,408.22

Service Code	CPT 29916
Hospital Charge Code	36029916
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Hip Arthro w/Labral Repair

Facility

$64,435.00

Service Code	HCPCS 29916
Hospital Charge Code	9900589
Hospital Revenue Code	360
Rate for Payer: Cash Price	$43,815.80

HIP BLADE

Facility

$1,638.94

Hospital Charge Code	992665
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,114.48

Know your out-of-pocket cost for care.

All Charges