White Rock Medical Center

All Charges

Charge

Type

Setting

Price

HYPERTENSIVE ENCEPHALOPATHY W CC

Facility

$11,123.17

Service Code	MSDRG 078
Min. Negotiated Rate	$8,342.86
Max. Negotiated Rate	$11,123.17
Rate for Payer: BCBS of TX Blue Advantage	$8,342.86
Rate for Payer: BCBS of TX Blue Essentials	$10,010.46
Rate for Payer: BCBS of TX PPO	$11,123.17

HYPERTENSIVE ENCEPHALOPATHY W MCC

Facility

$17,795.23

Service Code	MSDRG 077
Min. Negotiated Rate	$13,347.20
Max. Negotiated Rate	$17,795.23
Rate for Payer: BCBS of TX Blue Advantage	$13,347.20
Rate for Payer: BCBS of TX Blue Essentials	$16,015.09
Rate for Payer: BCBS of TX PPO	$17,795.23

HYPERTENSIVE ENCEPHALOPATHY W/O CC/MCC

Facility

$8,559.37

Service Code	MSDRG 079
Min. Negotiated Rate	$6,419.90
Max. Negotiated Rate	$8,559.37
Rate for Payer: BCBS of TX Blue Advantage	$6,419.90
Rate for Payer: BCBS of TX Blue Essentials	$7,703.13
Rate for Payer: BCBS of TX PPO	$8,559.37

HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS

Facility

$1,208.51

Service Code	APR-DRG 4221
Min. Negotiated Rate	$1,139.43
Max. Negotiated Rate	$1,208.51
Rate for Payer: Amerigroup CHIP/Medicaid	$1,139.43
Rate for Payer: Cigna Medicaid	$1,139.43
Rate for Payer: Molina CHIP/Medicaid	$1,139.43
Rate for Payer: Parkland Medicaid	$1,139.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,208.51

HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS

Facility

$9,017.08

Service Code	APR-DRG 4224
Min. Negotiated Rate	$8,501.62
Max. Negotiated Rate	$9,017.08
Rate for Payer: Amerigroup CHIP/Medicaid	$8,501.62
Rate for Payer: Cigna Medicaid	$8,501.62
Rate for Payer: Molina CHIP/Medicaid	$8,501.62
Rate for Payer: Parkland Medicaid	$8,501.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,017.08

HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS

Facility

$3,623.65

Service Code	APR-DRG 4223
Min. Negotiated Rate	$3,416.51
Max. Negotiated Rate	$3,623.65
Rate for Payer: Amerigroup CHIP/Medicaid	$3,416.51
Rate for Payer: Cigna Medicaid	$3,416.51
Rate for Payer: Molina CHIP/Medicaid	$3,416.51
Rate for Payer: Parkland Medicaid	$3,416.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,623.65

HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS

Facility

$2,031.92

Service Code	APR-DRG 4222
Min. Negotiated Rate	$1,915.76
Max. Negotiated Rate	$2,031.92
Rate for Payer: Amerigroup CHIP/Medicaid	$1,915.76
Rate for Payer: Cigna Medicaid	$1,915.76
Rate for Payer: Molina CHIP/Medicaid	$1,915.76
Rate for Payer: Parkland Medicaid	$1,915.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,031.92

IABP INSERTION PERCUTANEOUS

Facility

$7,398.00

Service Code	HCPCS 33967
Hospital Charge Code	2302784
Hospital Revenue Code	481
Min. Negotiated Rate	$455.01
Max. Negotiated Rate	$5,326.56
Rate for Payer: Amerigroup CHIP/Medicaid	$665.82
Rate for Payer: BCBS of TX Blue Advantage	$455.01
Rate for Payer: BCBS of TX Blue Essentials	$544.92
Rate for Payer: BCBS of TX PPO	$686.60
Rate for Payer: Cash Price	$5,030.64
Rate for Payer: Cash Price	$5,030.64
Rate for Payer: Cigna Medicaid	$5,326.56
Rate for Payer: Molina CHIP/Medicaid	$5,326.56
Rate for Payer: Multiplan Auto	$4,808.70
Rate for Payer: Multiplan Commercial	$4,808.70
Rate for Payer: Multiplan Workers Comp	$4,808.70
Rate for Payer: Parkland Medicaid	$5,326.56
Rate for Payer: Scott and White EPO/PPO	$3,699.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,326.56
Rate for Payer: Superior Health Plan EPO	$1,006.13

IABP INSERTION PERCUTANEOUS

Facility

$7,398.00

Service Code	HCPCS 33967
Hospital Charge Code	2302784
Hospital Revenue Code	481
Rate for Payer: Cash Price	$5,030.64

IB200020

Facility

$746.99

Service Code	HCPCS C1713
Hospital Charge Code	991089
Hospital Revenue Code	278
Min. Negotiated Rate	$186.75
Max. Negotiated Rate	$373.50
Rate for Payer: Cash Price	$507.95
Rate for Payer: Cigna Commercial	$186.75
Rate for Payer: Multiplan Auto	$373.50
Rate for Payer: Multiplan Commercial	$373.50
Rate for Payer: Multiplan Workers Comp	$373.50
Rate for Payer: Scott and White EPO/PPO	$373.50

IB200020

Facility

$746.99

Service Code	HCPCS C1713
Hospital Charge Code	991089
Hospital Revenue Code	278
Min. Negotiated Rate	$67.23
Max. Negotiated Rate	$537.83
Rate for Payer: Amerigroup CHIP/Medicaid	$67.23
Rate for Payer: BCBS of TX Blue Advantage	$224.10
Rate for Payer: BCBS of TX Blue Essentials	$268.92
Rate for Payer: BCBS of TX PPO	$298.80
Rate for Payer: Cash Price	$507.95
Rate for Payer: Cigna Medicaid	$537.83
Rate for Payer: Molina CHIP/Medicaid	$537.83
Rate for Payer: Multiplan Auto	$373.50
Rate for Payer: Multiplan Commercial	$373.50
Rate for Payer: Multiplan Workers Comp	$373.50
Rate for Payer: Parkland Medicaid	$537.83
Rate for Payer: Scott and White EPO/PPO	$373.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$537.83
Rate for Payer: Superior Health Plan EPO	$101.59

IB200051

Facility

$1,710.84

Service Code	HCPCS C1713
Hospital Charge Code	991090
Hospital Revenue Code	278
Min. Negotiated Rate	$427.71
Max. Negotiated Rate	$855.42
Rate for Payer: Cash Price	$1,163.37
Rate for Payer: Cigna Commercial	$427.71
Rate for Payer: Multiplan Auto	$855.42
Rate for Payer: Multiplan Commercial	$855.42
Rate for Payer: Multiplan Workers Comp	$855.42
Rate for Payer: Scott and White EPO/PPO	$855.42

IB200051

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Charge Code	991050
Hospital Revenue Code	278
Min. Negotiated Rate	$149.67
Max. Negotiated Rate	$1,197.36
Rate for Payer: Amerigroup CHIP/Medicaid	$149.67
Rate for Payer: BCBS of TX Blue Advantage	$498.90
Rate for Payer: BCBS of TX Blue Essentials	$598.68
Rate for Payer: BCBS of TX PPO	$665.20
Rate for Payer: Cash Price	$1,130.84
Rate for Payer: Cigna Medicaid	$1,197.36
Rate for Payer: Molina CHIP/Medicaid	$1,197.36
Rate for Payer: Multiplan Auto	$831.50
Rate for Payer: Multiplan Commercial	$831.50
Rate for Payer: Multiplan Workers Comp	$831.50
Rate for Payer: Parkland Medicaid	$1,197.36
Rate for Payer: Scott and White EPO/PPO	$831.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,197.36
Rate for Payer: Superior Health Plan EPO	$226.17

IB200051

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Charge Code	991050
Hospital Revenue Code	278
Min. Negotiated Rate	$415.75
Max. Negotiated Rate	$831.50
Rate for Payer: Cash Price	$1,130.84
Rate for Payer: Cigna Commercial	$415.75
Rate for Payer: Multiplan Auto	$831.50
Rate for Payer: Multiplan Commercial	$831.50
Rate for Payer: Multiplan Workers Comp	$831.50
Rate for Payer: Scott and White EPO/PPO	$831.50

IB200051

Facility

$1,710.84

Service Code	HCPCS C1713
Hospital Charge Code	991090
Hospital Revenue Code	278
Min. Negotiated Rate	$153.98
Max. Negotiated Rate	$1,231.80
Rate for Payer: Amerigroup CHIP/Medicaid	$153.98
Rate for Payer: BCBS of TX Blue Advantage	$513.25
Rate for Payer: BCBS of TX Blue Essentials	$615.90
Rate for Payer: BCBS of TX PPO	$684.34
Rate for Payer: Cash Price	$1,163.37
Rate for Payer: Cigna Medicaid	$1,231.80
Rate for Payer: Molina CHIP/Medicaid	$1,231.80
Rate for Payer: Multiplan Auto	$855.42
Rate for Payer: Multiplan Commercial	$855.42
Rate for Payer: Multiplan Workers Comp	$855.42
Rate for Payer: Parkland Medicaid	$1,231.80
Rate for Payer: Scott and White EPO/PPO	$855.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,231.80
Rate for Payer: Superior Health Plan EPO	$232.67

IB KIT, BC, W/ CC FT AND JUMPSTART

Facility

$11,313.68

Service Code	HCPCS C1776
Hospital Charge Code	992612
Hospital Revenue Code	278
Min. Negotiated Rate	$2,828.42
Max. Negotiated Rate	$5,656.84
Rate for Payer: Cash Price	$7,693.30
Rate for Payer: Cigna Commercial	$2,828.42
Rate for Payer: Multiplan Auto	$5,656.84
Rate for Payer: Multiplan Commercial	$5,656.84
Rate for Payer: Multiplan Workers Comp	$5,656.84
Rate for Payer: Scott and White EPO/PPO	$5,656.84

IB KIT, BC, W/ CC FT AND JUMPSTART

Facility

$11,313.68

Service Code	HCPCS C1776
Hospital Charge Code	992612
Hospital Revenue Code	278
Min. Negotiated Rate	$1,018.23
Max. Negotiated Rate	$8,145.85
Rate for Payer: Amerigroup CHIP/Medicaid	$1,018.23
Rate for Payer: BCBS of TX Blue Advantage	$3,394.10
Rate for Payer: BCBS of TX Blue Essentials	$4,072.92
Rate for Payer: BCBS of TX PPO	$4,525.47
Rate for Payer: Cash Price	$7,693.30
Rate for Payer: Cigna Medicaid	$8,145.85
Rate for Payer: Molina CHIP/Medicaid	$8,145.85
Rate for Payer: Multiplan Auto	$5,656.84
Rate for Payer: Multiplan Commercial	$5,656.84
Rate for Payer: Multiplan Workers Comp	$5,656.84
Rate for Payer: Parkland Medicaid	$8,145.85
Rate for Payer: Scott and White EPO/PPO	$5,656.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,145.85
Rate for Payer: Superior Health Plan EPO	$1,538.66

ibuprofen 100 mg/5 mL Oral Susp 480 mL

Facility

$81.95

Service Code	HCPCS J3490
Hospital Charge Code	77627059
Hospital Revenue Code	250
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$59.00
Rate for Payer: Amerigroup CHIP/Medicaid	$7.38
Rate for Payer: BCBS of TX Blue Advantage	$24.59
Rate for Payer: BCBS of TX Blue Essentials	$29.50
Rate for Payer: BCBS of TX PPO	$32.78
Rate for Payer: Cash Price	$55.73
Rate for Payer: Cigna Medicaid	$59.00
Rate for Payer: Molina CHIP/Medicaid	$59.00
Rate for Payer: Multiplan Auto	$53.27
Rate for Payer: Multiplan Commercial	$53.27
Rate for Payer: Multiplan Workers Comp	$53.27
Rate for Payer: Parkland Medicaid	$59.00
Rate for Payer: Scott and White EPO/PPO	$40.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.00
Rate for Payer: Superior Health Plan EPO	$11.15

ibuprofen 100 mg/5 mL Oral Susp 480 mL

Facility

$81.95

Service Code	HCPCS J3490
Hospital Charge Code	77627059
Hospital Revenue Code	250
Rate for Payer: Cash Price	$55.73

ibuprofen 100 mg/5 mL Oral Susp 5 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77627112
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

ibuprofen 100 mg/5 mL Oral Susp 5 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77627112
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ibuprofen 400 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77627436
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

ibuprofen 400 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77627436
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ibuprofen 600 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77627650
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ibuprofen 600 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77627650
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

Know your out-of-pocket cost for care.

All Charges