White Rock Medical Center

All Charges

Charge

Type

Setting

Price

INDICATOR TEST ACECIDE-C

Facility

$485.78

Hospital Charge Code	993925
Hospital Revenue Code	279
Min. Negotiated Rate	$43.72
Max. Negotiated Rate	$349.76
Rate for Payer: Amerigroup CHIP/Medicaid	$43.72
Rate for Payer: BCBS of TX Blue Advantage	$145.73
Rate for Payer: BCBS of TX Blue Essentials	$174.88
Rate for Payer: BCBS of TX PPO	$194.31
Rate for Payer: Cash Price	$330.33
Rate for Payer: Cigna Medicaid	$349.76
Rate for Payer: Molina CHIP/Medicaid	$349.76
Rate for Payer: Multiplan Auto	$315.76
Rate for Payer: Multiplan Commercial	$315.76
Rate for Payer: Multiplan Workers Comp	$315.76
Rate for Payer: Parkland Medicaid	$349.76
Rate for Payer: Scott and White EPO/PPO	$242.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$349.76
Rate for Payer: Superior Health Plan EPO	$66.07

INDICTR, BIO, A TEST, RPID, 24MIN, F/H202

Facility

$63.68

Hospital Charge Code	993816
Hospital Revenue Code	272
Rate for Payer: Cash Price	$43.30

INDICTR, BIO, A TEST, RPID, 24MIN, F/H202

Facility

$63.68

Hospital Charge Code	993816
Hospital Revenue Code	272
Min. Negotiated Rate	$5.73
Max. Negotiated Rate	$45.85
Rate for Payer: Amerigroup CHIP/Medicaid	$5.73
Rate for Payer: BCBS of TX Blue Advantage	$19.10
Rate for Payer: BCBS of TX Blue Essentials	$22.92
Rate for Payer: BCBS of TX PPO	$25.47
Rate for Payer: Cash Price	$43.30
Rate for Payer: Cigna Medicaid	$45.85
Rate for Payer: Molina CHIP/Medicaid	$45.85
Rate for Payer: Multiplan Auto	$41.39
Rate for Payer: Multiplan Commercial	$41.39
Rate for Payer: Multiplan Workers Comp	$41.39
Rate for Payer: Parkland Medicaid	$45.85
Rate for Payer: Scott and White EPO/PPO	$31.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$45.85
Rate for Payer: Superior Health Plan EPO	$8.66

indocyanine green 25 mg Inj

Facility

$435.51

Service Code	HCPCS J1815
Hospital Charge Code	77634513
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$313.57
Rate for Payer: Amerigroup CHIP/Medicaid	$39.20
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$296.15
Rate for Payer: Cash Price	$296.15
Rate for Payer: Cigna Medicaid	$313.57
Rate for Payer: Molina CHIP/Medicaid	$313.57
Rate for Payer: Multiplan Auto	$283.08
Rate for Payer: Multiplan Commercial	$283.08
Rate for Payer: Multiplan Workers Comp	$283.08
Rate for Payer: Parkland Medicaid	$313.57
Rate for Payer: Scott and White EPO/PPO	$217.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$313.57
Rate for Payer: Superior Health Plan EPO	$59.23

indocyanine green 25 mg Inj

Facility

$435.51

Service Code	HCPCS J1815
Hospital Charge Code	77632274
Hospital Revenue Code	636
Min. Negotiated Rate	$108.88
Max. Negotiated Rate	$217.75
Rate for Payer: Cash Price	$296.15
Rate for Payer: Cigna Commercial	$108.88
Rate for Payer: Scott and White EPO/PPO	$217.75

indocyanine green 25 mg Inj

Facility

$435.51

Service Code	HCPCS J1815
Hospital Charge Code	77632274
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$313.57
Rate for Payer: Amerigroup CHIP/Medicaid	$39.20
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$296.15
Rate for Payer: Cash Price	$296.15
Rate for Payer: Cigna Medicaid	$313.57
Rate for Payer: Molina CHIP/Medicaid	$313.57
Rate for Payer: Multiplan Auto	$283.08
Rate for Payer: Multiplan Commercial	$283.08
Rate for Payer: Multiplan Workers Comp	$283.08
Rate for Payer: Parkland Medicaid	$313.57
Rate for Payer: Scott and White EPO/PPO	$217.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$313.57
Rate for Payer: Superior Health Plan EPO	$59.23

indocyanine green 25 mg Inj

Facility

$435.51

Service Code	HCPCS J1815
Hospital Charge Code	77634513
Hospital Revenue Code	636
Min. Negotiated Rate	$108.88
Max. Negotiated Rate	$217.75
Rate for Payer: Cash Price	$296.15
Rate for Payer: Cigna Commercial	$108.88
Rate for Payer: Scott and White EPO/PPO	$217.75

indomethacin 25 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77632378
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

indomethacin 25 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77632378
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
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: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

indomethacin 50 mg Cap

Facility

$19.20

Service Code	HCPCS J3490
Hospital Charge Code	77632484
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$13.82
Rate for Payer: Amerigroup CHIP/Medicaid	$1.73
Rate for Payer: BCBS of TX Blue Advantage	$5.76
Rate for Payer: BCBS of TX Blue Essentials	$6.91
Rate for Payer: BCBS of TX PPO	$7.68
Rate for Payer: Cash Price	$13.06
Rate for Payer: Cigna Medicaid	$13.82
Rate for Payer: Molina CHIP/Medicaid	$13.82
Rate for Payer: Multiplan Auto	$12.48
Rate for Payer: Multiplan Commercial	$12.48
Rate for Payer: Multiplan Workers Comp	$12.48
Rate for Payer: Parkland Medicaid	$13.82
Rate for Payer: Scott and White EPO/PPO	$9.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.82
Rate for Payer: Superior Health Plan EPO	$2.61

indomethacin 50 mg Cap

Facility

$19.20

Service Code	HCPCS J3490
Hospital Charge Code	77632484
Hospital Revenue Code	250
Rate for Payer: Cash Price	$13.06

Inf agent det by nucleic acid, nos, amp prob tech 8

Facility

$10,000.00

Service Code	CPT 87798
Hospital Charge Code	87798
Hospital Revenue Code	360
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
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 Medicare	$35.09
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W CC

Facility

$18,601.00

Service Code	MSDRG 758
Min. Negotiated Rate	$8,566.25
Max. Negotiated Rate	$18,601.00
Rate for Payer: BCBS of TX Blue Advantage	$8,775.44
Rate for Payer: BCBS of TX Blue Essentials	$10,529.51
Rate for Payer: BCBS of TX PPO	$11,699.91

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC

Facility

$18,601.00

Service Code	MSDRG 758
Min. Negotiated Rate	$8,566.25
Max. Negotiated Rate	$18,601.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,935.19
Rate for Payer: Amerigroup Medicare	$11,935.19
Rate for Payer: BCBS of TX Medicare	$11,935.19
Rate for Payer: Cigna Commercial	$12,609.52
Rate for Payer: Cigna Medicare	$11,935.19
Rate for Payer: Employer Direct Commercial	$11,935.19
Rate for Payer: Humana Medicare/TRICARE	$11,935.19
Rate for Payer: Molina Dual Medicare/Medicaid	$11,935.19
Rate for Payer: Molina Medicare	$11,935.19
Rate for Payer: Multiplan Auto	$18,601.00
Rate for Payer: Multiplan Commercial	$18,601.00
Rate for Payer: Multiplan Workers Comp	$18,601.00
Rate for Payer: Scott and White EPO/PPO	$8,566.25
Rate for Payer: Scott and White Medicare	$11,935.19
Rate for Payer: Superior Health Plan EPO	$11,935.19
Rate for Payer: Superior Health Plan Medicare	$11,935.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,935.19
Rate for Payer: Universal American Medicare	$11,935.19
Rate for Payer: Wellcare Medicare	$11,935.19
Rate for Payer: Wellmed Medicare	$11,935.19

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$27,206.10

Service Code	MSDRG 757
Min. Negotiated Rate	$12,391.74
Max. Negotiated Rate	$27,206.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,254.52
Rate for Payer: Amerigroup Medicare	$15,254.52
Rate for Payer: BCBS of TX Medicare	$15,254.52
Rate for Payer: Cigna Commercial	$18,442.87
Rate for Payer: Cigna Medicare	$15,254.52
Rate for Payer: Employer Direct Commercial	$15,254.52
Rate for Payer: Humana Medicare/TRICARE	$15,254.52
Rate for Payer: Molina Dual Medicare/Medicaid	$15,254.52
Rate for Payer: Molina Medicare	$15,254.52
Rate for Payer: Multiplan Auto	$27,206.10
Rate for Payer: Multiplan Commercial	$27,206.10
Rate for Payer: Multiplan Workers Comp	$27,206.10
Rate for Payer: Scott and White EPO/PPO	$12,529.12
Rate for Payer: Scott and White Medicare	$15,254.52
Rate for Payer: Superior Health Plan EPO	$15,254.52
Rate for Payer: Superior Health Plan Medicare	$15,254.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,254.52
Rate for Payer: Universal American Medicare	$15,254.52
Rate for Payer: Wellcare Medicare	$15,254.52
Rate for Payer: Wellmed Medicare	$15,254.52

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC

Facility

$12,608.40

Service Code	MSDRG 759
Min. Negotiated Rate	$5,806.50
Max. Negotiated Rate	$12,608.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,623.62
Rate for Payer: Amerigroup Medicare	$9,623.62
Rate for Payer: BCBS of TX Medicare	$9,623.62
Rate for Payer: Cigna Commercial	$8,547.17
Rate for Payer: Cigna Medicare	$9,623.62
Rate for Payer: Employer Direct Commercial	$9,623.62
Rate for Payer: Humana Medicare/TRICARE	$9,623.62
Rate for Payer: Molina Dual Medicare/Medicaid	$9,623.62
Rate for Payer: Molina Medicare	$9,623.62
Rate for Payer: Multiplan Auto	$12,608.40
Rate for Payer: Multiplan Commercial	$12,608.40
Rate for Payer: Multiplan Workers Comp	$12,608.40
Rate for Payer: Scott and White EPO/PPO	$5,806.50
Rate for Payer: Scott and White Medicare	$9,623.62
Rate for Payer: Superior Health Plan EPO	$9,623.62
Rate for Payer: Superior Health Plan Medicare	$9,623.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,623.62
Rate for Payer: Universal American Medicare	$9,623.62
Rate for Payer: Wellcare Medicare	$9,623.62
Rate for Payer: Wellmed Medicare	$9,623.62

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W MCC

Facility

$27,206.10

Service Code	MSDRG 757
Min. Negotiated Rate	$12,391.74
Max. Negotiated Rate	$27,206.10
Rate for Payer: BCBS of TX Blue Advantage	$12,391.74
Rate for Payer: BCBS of TX Blue Essentials	$14,868.65
Rate for Payer: BCBS of TX PPO	$16,521.36

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC

Facility

$12,608.40

Service Code	MSDRG 759
Min. Negotiated Rate	$5,806.50
Max. Negotiated Rate	$12,608.40
Rate for Payer: BCBS of TX Blue Advantage	$6,112.02
Rate for Payer: BCBS of TX Blue Essentials	$7,333.71
Rate for Payer: BCBS of TX PPO	$8,148.89

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$10,499.06

Service Code	APR-DRG 1134
Min. Negotiated Rate	$9,898.88
Max. Negotiated Rate	$10,499.06
Rate for Payer: Amerigroup CHIP/Medicaid	$9,898.88
Rate for Payer: Cigna Medicaid	$9,898.88
Rate for Payer: Molina CHIP/Medicaid	$9,898.88
Rate for Payer: Parkland Medicaid	$9,898.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,499.06

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$1,438.22

Service Code	APR-DRG 1131
Min. Negotiated Rate	$1,356.01
Max. Negotiated Rate	$1,438.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,356.01
Rate for Payer: Cigna Medicaid	$1,356.01
Rate for Payer: Molina CHIP/Medicaid	$1,356.01
Rate for Payer: Parkland Medicaid	$1,356.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,438.22

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$2,180.53

Service Code	APR-DRG 1132
Min. Negotiated Rate	$2,055.88
Max. Negotiated Rate	$2,180.53
Rate for Payer: Amerigroup CHIP/Medicaid	$2,055.88
Rate for Payer: Cigna Medicaid	$2,055.88
Rate for Payer: Molina CHIP/Medicaid	$2,055.88
Rate for Payer: Parkland Medicaid	$2,055.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,180.53

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$6,493.31

Service Code	APR-DRG 1133
Min. Negotiated Rate	$6,122.12
Max. Negotiated Rate	$6,493.31
Rate for Payer: Amerigroup CHIP/Medicaid	$6,122.12
Rate for Payer: Cigna Medicaid	$6,122.12
Rate for Payer: Molina CHIP/Medicaid	$6,122.12
Rate for Payer: Parkland Medicaid	$6,122.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,493.31

Infectious agent antigen detection by immunoassay technique qualitative or semiquantitative; Shiga-like toxin

Facility

$182.00

Service Code	HCPCS 87427
Hospital Charge Code	8239741
Hospital Revenue Code	301
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$131.04
Rate for Payer: Amerigroup CHIP/Medicaid	$4.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.98
Rate for Payer: Amerigroup Medicare	$11.98
Rate for Payer: BCBS of TX Blue Advantage	$54.60
Rate for Payer: BCBS of TX Blue Essentials	$65.52
Rate for Payer: BCBS of TX Medicare	$11.98
Rate for Payer: BCBS of TX PPO	$72.80
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cigna Medicaid	$131.04
Rate for Payer: Cigna Medicare	$11.98
Rate for Payer: Employer Direct Commercial	$11.98
Rate for Payer: Humana Medicare/TRICARE	$11.98
Rate for Payer: Molina CHIP/Medicaid	$131.04
Rate for Payer: Molina Dual Medicare/Medicaid	$11.98
Rate for Payer: Molina Medicare	$11.98
Rate for Payer: Multiplan Auto	$118.30
Rate for Payer: Multiplan Commercial	$118.30
Rate for Payer: Multiplan Workers Comp	$118.30
Rate for Payer: Parkland Medicaid	$131.04
Rate for Payer: Scott and White EPO/PPO	$14.97
Rate for Payer: Scott and White Medicare	$11.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.04
Rate for Payer: Superior Health Plan EPO	$11.98
Rate for Payer: Superior Health Plan Medicare	$11.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.98
Rate for Payer: Universal American Medicare	$11.98
Rate for Payer: Wellcare Medicare	$11.98
Rate for Payer: Wellmed Medicare	$11.98

Infectious agent antigen detection by immunoassay technique qualitative or semiquantitative; Shiga-like toxin

Facility

$182.00

Service Code	HCPCS 87427
Hospital Charge Code	8239741
Hospital Revenue Code	301
Rate for Payer: Cash Price	$123.76

INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE

Facility

$12,519.66

Service Code	APR-DRG 7103
Min. Negotiated Rate	$11,803.97
Max. Negotiated Rate	$12,519.66
Rate for Payer: Amerigroup CHIP/Medicaid	$11,803.97
Rate for Payer: Cigna Medicaid	$11,803.97
Rate for Payer: Molina CHIP/Medicaid	$11,803.97
Rate for Payer: Parkland Medicaid	$11,803.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,519.66

Know your out-of-pocket cost for care.

All Charges