White Rock Medical Center

All Charges

Charge

Type

Setting

Price

acetylcysteine 20% Inh Soln 4 mL

Facility

$49.79

Service Code	HCPCS J7608
Hospital Charge Code	77355711
Hospital Revenue Code	636
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$35.85
Rate for Payer: Amerigroup CHIP/Medicaid	$4.48
Rate for Payer: BCBS of TX Blue Advantage	$2.22
Rate for Payer: BCBS of TX Blue Essentials	$2.66
Rate for Payer: BCBS of TX PPO	$2.95
Rate for Payer: Cash Price	$33.86
Rate for Payer: Cash Price	$33.86
Rate for Payer: Cigna Medicaid	$35.85
Rate for Payer: Molina CHIP/Medicaid	$35.85
Rate for Payer: Multiplan Auto	$32.36
Rate for Payer: Multiplan Commercial	$32.36
Rate for Payer: Multiplan Workers Comp	$32.36
Rate for Payer: Parkland Medicaid	$35.85
Rate for Payer: Scott and White EPO/PPO	$24.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.85
Rate for Payer: Superior Health Plan EPO	$6.77

acetylcysteine 20% IV Soln 30 mL

Facility

$225.00

Service Code	HCPCS J0132
Hospital Charge Code	77355947
Hospital Revenue Code	636
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$162.00
Rate for Payer: Amerigroup CHIP/Medicaid	$20.25
Rate for Payer: BCBS of TX Blue Advantage	$3.15
Rate for Payer: BCBS of TX Blue Essentials	$3.78
Rate for Payer: BCBS of TX PPO	$4.19
Rate for Payer: Cash Price	$153.00
Rate for Payer: Cash Price	$153.00
Rate for Payer: Cigna Medicaid	$162.00
Rate for Payer: Molina CHIP/Medicaid	$162.00
Rate for Payer: Multiplan Auto	$146.25
Rate for Payer: Multiplan Commercial	$146.25
Rate for Payer: Multiplan Workers Comp	$146.25
Rate for Payer: Parkland Medicaid	$162.00
Rate for Payer: Scott and White EPO/PPO	$112.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$162.00
Rate for Payer: Superior Health Plan EPO	$30.60

acetylcysteine 20% IV Soln 30 mL

Facility

$225.00

Service Code	HCPCS J0132
Hospital Charge Code	77355947
Hospital Revenue Code	636
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$112.50
Rate for Payer: Cash Price	$153.00
Rate for Payer: Cigna Commercial	$56.25
Rate for Payer: Scott and White EPO/PPO	$112.50

Acid Fast Smear+Culture W/Rflx SO

Facility

$106.07

Service Code	HCPCS 87116
Hospital Charge Code	1604248
Hospital Revenue Code	306
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$76.37
Rate for Payer: Amerigroup CHIP/Medicaid	$4.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.80
Rate for Payer: Amerigroup Medicare	$10.80
Rate for Payer: BCBS of TX Blue Advantage	$31.82
Rate for Payer: BCBS of TX Blue Essentials	$38.19
Rate for Payer: BCBS of TX Medicare	$10.80
Rate for Payer: BCBS of TX PPO	$42.43
Rate for Payer: Cash Price	$72.13
Rate for Payer: Cash Price	$72.13
Rate for Payer: Cigna Medicaid	$76.37
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Employer Direct Commercial	$10.80
Rate for Payer: Humana Medicare/TRICARE	$10.80
Rate for Payer: Molina CHIP/Medicaid	$76.37
Rate for Payer: Molina Dual Medicare/Medicaid	$10.80
Rate for Payer: Molina Medicare	$10.80
Rate for Payer: Multiplan Auto	$68.95
Rate for Payer: Multiplan Commercial	$68.95
Rate for Payer: Multiplan Workers Comp	$68.95
Rate for Payer: Parkland Medicaid	$76.37
Rate for Payer: Scott and White EPO/PPO	$13.50
Rate for Payer: Scott and White Medicare	$10.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.37
Rate for Payer: Superior Health Plan EPO	$10.80
Rate for Payer: Superior Health Plan Medicare	$10.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.80
Rate for Payer: Universal American Medicare	$10.80
Rate for Payer: Wellcare Medicare	$10.80
Rate for Payer: Wellmed Medicare	$10.80

Acid Fast Smear+Culture W/Rflx SO

Facility

$106.07

Service Code	HCPCS 87116
Hospital Charge Code	1604248
Hospital Revenue Code	306
Rate for Payer: Cash Price	$72.13

ACII CUTAL 2-LAYER 7X10CM

Facility

$5,093.88

Hospital Charge Code	992715
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,463.84

ACII CUTAL 2-LAYER 7X10CM

Facility

$5,093.88

Hospital Charge Code	992715
Hospital Revenue Code	272
Min. Negotiated Rate	$458.45
Max. Negotiated Rate	$3,667.59
Rate for Payer: Amerigroup CHIP/Medicaid	$458.45
Rate for Payer: BCBS of TX Blue Advantage	$1,528.16
Rate for Payer: BCBS of TX Blue Essentials	$1,833.80
Rate for Payer: BCBS of TX PPO	$2,037.55
Rate for Payer: Cash Price	$3,463.84
Rate for Payer: Cigna Medicaid	$3,667.59
Rate for Payer: Molina CHIP/Medicaid	$3,667.59
Rate for Payer: Multiplan Auto	$3,311.02
Rate for Payer: Multiplan Commercial	$3,311.02
Rate for Payer: Multiplan Workers Comp	$3,311.02
Rate for Payer: Parkland Medicaid	$3,667.59
Rate for Payer: Scott and White EPO/PPO	$2,546.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,667.59
Rate for Payer: Superior Health Plan EPO	$692.77

ACL DISPOSABLE KIT

Facility

$1,203.10

Hospital Charge Code	8420459
Hospital Revenue Code	272
Min. Negotiated Rate	$108.28
Max. Negotiated Rate	$866.23
Rate for Payer: Amerigroup CHIP/Medicaid	$108.28
Rate for Payer: BCBS of TX Blue Advantage	$360.93
Rate for Payer: BCBS of TX Blue Essentials	$433.12
Rate for Payer: BCBS of TX PPO	$481.24
Rate for Payer: Cash Price	$818.11
Rate for Payer: Cigna Medicaid	$866.23
Rate for Payer: Molina CHIP/Medicaid	$866.23
Rate for Payer: Multiplan Auto	$782.01
Rate for Payer: Multiplan Commercial	$782.01
Rate for Payer: Multiplan Workers Comp	$782.01
Rate for Payer: Parkland Medicaid	$866.23
Rate for Payer: Scott and White EPO/PPO	$601.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$866.23
Rate for Payer: Superior Health Plan EPO	$163.62

ACL DISPOSABLE KIT

Facility

$1,203.10

Hospital Charge Code	8420459
Hospital Revenue Code	272
Rate for Payer: Cash Price	$818.11

ACL Kit

Facility

$3,309.66

Hospital Charge Code	992670
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,250.57

ACL Kit

Facility

$3,309.66

Hospital Charge Code	992670
Hospital Revenue Code	272
Min. Negotiated Rate	$297.87
Max. Negotiated Rate	$2,382.96
Rate for Payer: Amerigroup CHIP/Medicaid	$297.87
Rate for Payer: BCBS of TX Blue Advantage	$992.90
Rate for Payer: BCBS of TX Blue Essentials	$1,191.48
Rate for Payer: BCBS of TX PPO	$1,323.86
Rate for Payer: Cash Price	$2,250.57
Rate for Payer: Cigna Medicaid	$2,382.96
Rate for Payer: Molina CHIP/Medicaid	$2,382.96
Rate for Payer: Multiplan Auto	$2,151.28
Rate for Payer: Multiplan Commercial	$2,151.28
Rate for Payer: Multiplan Workers Comp	$2,151.28
Rate for Payer: Parkland Medicaid	$2,382.96
Rate for Payer: Scott and White EPO/PPO	$1,654.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,382.96
Rate for Payer: Superior Health Plan EPO	$450.11

ACTH, Plasma SO

Facility

$328.00

Service Code	HCPCS 82024
Hospital Charge Code	1700889
Hospital Revenue Code	301
Rate for Payer: Cash Price	$223.04

ACTH, Plasma SO

Facility

$328.00

Service Code	HCPCS 82024
Hospital Charge Code	1700889
Hospital Revenue Code	301
Min. Negotiated Rate	$15.06
Max. Negotiated Rate	$236.16
Rate for Payer: Amerigroup CHIP/Medicaid	$15.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$38.62
Rate for Payer: Amerigroup Medicare	$38.62
Rate for Payer: BCBS of TX Blue Advantage	$98.40
Rate for Payer: BCBS of TX Blue Essentials	$118.08
Rate for Payer: BCBS of TX Medicare	$38.62
Rate for Payer: BCBS of TX PPO	$131.20
Rate for Payer: Cash Price	$223.04
Rate for Payer: Cash Price	$223.04
Rate for Payer: Cigna Medicaid	$236.16
Rate for Payer: Cigna Medicare	$38.62
Rate for Payer: Employer Direct Commercial	$38.62
Rate for Payer: Humana Medicare/TRICARE	$38.62
Rate for Payer: Molina CHIP/Medicaid	$236.16
Rate for Payer: Molina Dual Medicare/Medicaid	$38.62
Rate for Payer: Molina Medicare	$38.62
Rate for Payer: Multiplan Auto	$213.20
Rate for Payer: Multiplan Commercial	$213.20
Rate for Payer: Multiplan Workers Comp	$213.20
Rate for Payer: Parkland Medicaid	$236.16
Rate for Payer: Scott and White EPO/PPO	$48.27
Rate for Payer: Scott and White Medicare	$38.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$236.16
Rate for Payer: Superior Health Plan EPO	$38.62
Rate for Payer: Superior Health Plan Medicare	$38.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$38.62
Rate for Payer: Universal American Medicare	$38.62
Rate for Payer: Wellcare Medicare	$38.62
Rate for Payer: Wellmed Medicare	$38.62

Actin (Smooth Muscle) Antibody SO

Facility

$195.00

Service Code	HCPCS 86015
Hospital Charge Code	1706019
Hospital Revenue Code	301
Rate for Payer: Cash Price	$132.60

Actin (Smooth Muscle) Antibody SO

Facility

$195.00

Service Code	HCPCS 86015
Hospital Charge Code	1706019
Hospital Revenue Code	301
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$140.40
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.05
Rate for Payer: Amerigroup Medicare	$12.05
Rate for Payer: BCBS of TX Blue Advantage	$58.50
Rate for Payer: BCBS of TX Blue Essentials	$70.20
Rate for Payer: BCBS of TX Medicare	$12.05
Rate for Payer: BCBS of TX PPO	$78.00
Rate for Payer: Cash Price	$132.60
Rate for Payer: Cash Price	$132.60
Rate for Payer: Cigna Medicaid	$140.40
Rate for Payer: Cigna Medicare	$12.05
Rate for Payer: Employer Direct Commercial	$12.05
Rate for Payer: Humana Medicare/TRICARE	$12.05
Rate for Payer: Molina CHIP/Medicaid	$140.40
Rate for Payer: Molina Dual Medicare/Medicaid	$12.05
Rate for Payer: Molina Medicare	$12.05
Rate for Payer: Multiplan Auto	$126.75
Rate for Payer: Multiplan Commercial	$126.75
Rate for Payer: Multiplan Workers Comp	$126.75
Rate for Payer: Parkland Medicaid	$140.40
Rate for Payer: Scott and White EPO/PPO	$15.06
Rate for Payer: Scott and White Medicare	$12.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.40
Rate for Payer: Superior Health Plan EPO	$12.05
Rate for Payer: Superior Health Plan Medicare	$12.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.05
Rate for Payer: Universal American Medicare	$12.05
Rate for Payer: Wellcare Medicare	$12.05
Rate for Payer: Wellmed Medicare	$12.05

ACTISHIELD AMNIOTIC MEMBRANE 4X8CM

Facility

$475.00

Service Code	HCPCS Q4205
Hospital Charge Code	145563
Hospital Revenue Code	278
Min. Negotiated Rate	$118.75
Max. Negotiated Rate	$237.50
Rate for Payer: Cash Price	$323.00
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Multiplan Auto	$237.50
Rate for Payer: Multiplan Commercial	$237.50
Rate for Payer: Multiplan Workers Comp	$237.50
Rate for Payer: Scott and White EPO/PPO	$237.50

ACTISHIELD AMNIOTIC MEMBRANE 4X8CM

Facility

$475.00

Service Code	HCPCS Q4205
Hospital Charge Code	145563
Hospital Revenue Code	278
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$342.00
Rate for Payer: Amerigroup CHIP/Medicaid	$42.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$14.83
Rate for Payer: BCBS of TX Blue Essentials	$17.80
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$19.74
Rate for Payer: Cash Price	$323.00
Rate for Payer: Cash Price	$323.00
Rate for Payer: Cash Price	$323.00
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$342.00
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$342.00
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$237.50
Rate for Payer: Multiplan Commercial	$237.50
Rate for Payer: Multiplan Workers Comp	$237.50
Rate for Payer: Parkland Medicaid	$342.00
Rate for Payer: Scott and White EPO/PPO	$237.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$342.00
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

.Activated Clotting Time (POCT)

Facility

$141.00

Service Code	HCPCS 85347
Hospital Charge Code	4105347
Hospital Revenue Code	305
Rate for Payer: Cash Price	$95.88

.Activated Clotting Time (POCT)

Facility

$141.00

Service Code	HCPCS 85347
Hospital Charge Code	4105347
Hospital Revenue Code	305
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$101.52
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.28
Rate for Payer: Amerigroup Medicare	$4.28
Rate for Payer: BCBS of TX Blue Advantage	$42.30
Rate for Payer: BCBS of TX Blue Essentials	$50.76
Rate for Payer: BCBS of TX Medicare	$4.28
Rate for Payer: BCBS of TX PPO	$56.40
Rate for Payer: Cash Price	$95.88
Rate for Payer: Cash Price	$95.88
Rate for Payer: Cigna Medicaid	$101.52
Rate for Payer: Cigna Medicare	$4.28
Rate for Payer: Employer Direct Commercial	$4.28
Rate for Payer: Humana Medicare/TRICARE	$4.28
Rate for Payer: Molina CHIP/Medicaid	$101.52
Rate for Payer: Molina Dual Medicare/Medicaid	$4.28
Rate for Payer: Molina Medicare	$4.28
Rate for Payer: Multiplan Auto	$91.65
Rate for Payer: Multiplan Commercial	$91.65
Rate for Payer: Multiplan Workers Comp	$91.65
Rate for Payer: Parkland Medicaid	$101.52
Rate for Payer: Scott and White EPO/PPO	$5.35
Rate for Payer: Scott and White Medicare	$4.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$101.52
Rate for Payer: Superior Health Plan EPO	$4.28
Rate for Payer: Superior Health Plan Medicare	$4.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.28
Rate for Payer: Universal American Medicare	$4.28
Rate for Payer: Wellcare Medicare	$4.28
Rate for Payer: Wellmed Medicare	$4.28

ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION

Facility

$17,217.80

Service Code	MSDRG 880
Min. Negotiated Rate	$6,975.46
Max. Negotiated Rate	$17,217.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,797.42
Rate for Payer: Amerigroup Medicare	$11,797.42
Rate for Payer: BCBS of TX Medicare	$11,797.42
Rate for Payer: Cigna Commercial	$12,367.38
Rate for Payer: Cigna Medicare	$11,797.42
Rate for Payer: Employer Direct Commercial	$11,797.42
Rate for Payer: Molina Dual Medicare/Medicaid	$11,797.42
Rate for Payer: Molina Medicare	$11,797.42
Rate for Payer: Multiplan Auto	$17,217.80
Rate for Payer: Multiplan Commercial	$17,217.80
Rate for Payer: Multiplan Workers Comp	$17,217.80
Rate for Payer: Scott and White EPO/PPO	$7,929.25
Rate for Payer: Scott and White Medicare	$11,797.42
Rate for Payer: Superior Health Plan EPO	$11,797.42
Rate for Payer: Superior Health Plan Medicare	$11,797.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,797.42
Rate for Payer: Universal American Medicare	$11,797.42
Rate for Payer: Wellcare Medicare	$11,797.42
Rate for Payer: Wellmed Medicare	$11,797.42

ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION

Facility

$17,217.80

Service Code	MSDRG 880
Min. Negotiated Rate	$6,975.46
Max. Negotiated Rate	$17,217.80
Rate for Payer: BCBS of TX Blue Advantage	$6,975.46
Rate for Payer: BCBS of TX Blue Essentials	$8,369.74
Rate for Payer: BCBS of TX PPO	$9,300.07

ACUTE AND SUBACUTE ENDOCARDITIS

Facility

$10,245.96

Service Code	APR-DRG 1932
Min. Negotiated Rate	$9,660.25
Max. Negotiated Rate	$10,245.96
Rate for Payer: Amerigroup CHIP/Medicaid	$9,660.25
Rate for Payer: Cigna Medicaid	$9,660.25
Rate for Payer: Molina CHIP/Medicaid	$9,660.25
Rate for Payer: Parkland Medicaid	$9,660.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,245.96

ACUTE AND SUBACUTE ENDOCARDITIS

Facility

$7,997.16

Service Code	APR-DRG 1931
Min. Negotiated Rate	$7,540.00
Max. Negotiated Rate	$7,997.16
Rate for Payer: Amerigroup CHIP/Medicaid	$7,540.00
Rate for Payer: Cigna Medicaid	$7,540.00
Rate for Payer: Molina CHIP/Medicaid	$7,540.00
Rate for Payer: Parkland Medicaid	$7,540.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,997.16

ACUTE AND SUBACUTE ENDOCARDITIS

Facility

$17,123.63

Service Code	APR-DRG 1933
Min. Negotiated Rate	$16,144.75
Max. Negotiated Rate	$17,123.63
Rate for Payer: Amerigroup CHIP/Medicaid	$16,144.75
Rate for Payer: Cigna Medicaid	$16,144.75
Rate for Payer: Molina CHIP/Medicaid	$16,144.75
Rate for Payer: Parkland Medicaid	$16,144.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,123.63

ACUTE AND SUBACUTE ENDOCARDITIS

Facility

$20,415.73

Service Code	APR-DRG 1934
Min. Negotiated Rate	$19,248.67
Max. Negotiated Rate	$20,415.73
Rate for Payer: Amerigroup CHIP/Medicaid	$19,248.67
Rate for Payer: Cigna Medicaid	$19,248.67
Rate for Payer: Molina CHIP/Medicaid	$19,248.67
Rate for Payer: Parkland Medicaid	$19,248.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,415.73

Know your out-of-pocket cost for care.

All Charges