White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Inf for Therapy, Prophylaxis or Dx Each Addl Hour 96366

Facility

$153.00

Service Code	HCPCS 96366
Hospital Charge Code	1500347
Hospital Revenue Code	260
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$110.16
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47.04
Rate for Payer: Amerigroup Medicare	$47.04
Rate for Payer: BCBS of TX Blue Advantage	$45.90
Rate for Payer: BCBS of TX Blue Essentials	$55.08
Rate for Payer: BCBS of TX Medicare	$47.04
Rate for Payer: BCBS of TX PPO	$61.20
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cigna Commercial	$99.43
Rate for Payer: Cigna Medicaid	$110.16
Rate for Payer: Cigna Medicare	$47.04
Rate for Payer: Employer Direct Commercial	$47.04
Rate for Payer: Humana Medicare/TRICARE	$47.04
Rate for Payer: Molina CHIP/Medicaid	$110.16
Rate for Payer: Molina Dual Medicare/Medicaid	$47.04
Rate for Payer: Molina Medicare	$47.04
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Parkland Medicaid	$110.16
Rate for Payer: Scott and White EPO/PPO	$25.11
Rate for Payer: Scott and White Medicare	$47.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.16
Rate for Payer: Superior Health Plan EPO	$47.04
Rate for Payer: Superior Health Plan Medicare	$47.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$47.04
Rate for Payer: Universal American Medicare	$47.04
Rate for Payer: Wellcare Medicare	$47.04
Rate for Payer: Wellmed Medicare	$47.04

Inf for Therapy, Prophylaxis or Dx Each Addl Hour 96366

Facility

$153.00

Service Code	HCPCS 96366
Hospital Charge Code	1500347
Hospital Revenue Code	260
Rate for Payer: Cash Price	$104.04

Inf for Tx Prophylaxis Dx Addl Seq Infusion New Drug 96367

Facility

$175.00

Service Code	HCPCS 96367
Hospital Charge Code	7003627
Hospital Revenue Code	260
Rate for Payer: Cash Price	$119.00

Inf for Tx Prophylaxis Dx Addl Seq Infusion New Drug 96367

Facility

$175.00

Service Code	HCPCS 96367
Hospital Charge Code	7003627
Hospital Revenue Code	260
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$152.89
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$52.50
Rate for Payer: BCBS of TX Blue Essentials	$63.00
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$70.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$126.00
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$126.00
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Parkland Medicaid	$126.00
Rate for Payer: Scott and White EPO/PPO	$35.01
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.00
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

INFINITY AIM MENISCAL REPAIR DEVICE 25 DEGREE CURVED

Facility

$1,702.50

Hospital Charge Code	992647
Hospital Revenue Code	272
Min. Negotiated Rate	$153.22
Max. Negotiated Rate	$1,225.80
Rate for Payer: Amerigroup CHIP/Medicaid	$153.22
Rate for Payer: BCBS of TX Blue Advantage	$510.75
Rate for Payer: BCBS of TX Blue Essentials	$612.90
Rate for Payer: BCBS of TX PPO	$681.00
Rate for Payer: Cash Price	$1,157.70
Rate for Payer: Cigna Medicaid	$1,225.80
Rate for Payer: Molina CHIP/Medicaid	$1,225.80
Rate for Payer: Multiplan Auto	$1,106.62
Rate for Payer: Multiplan Commercial	$1,106.62
Rate for Payer: Multiplan Workers Comp	$1,106.62
Rate for Payer: Parkland Medicaid	$1,225.80
Rate for Payer: Scott and White EPO/PPO	$851.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,225.80
Rate for Payer: Superior Health Plan EPO	$231.54

INFINITY AIM MENISCAL REPAIR DEVICE 25 DEGREE CURVED

Facility

$1,702.50

Hospital Charge Code	992647
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,157.70

INFINITY AIM SUTURE CUTTER AND SKID

Facility

$544.80

Hospital Charge Code	992648
Hospital Revenue Code	272
Min. Negotiated Rate	$49.03
Max. Negotiated Rate	$392.26
Rate for Payer: Amerigroup CHIP/Medicaid	$49.03
Rate for Payer: BCBS of TX Blue Advantage	$163.44
Rate for Payer: BCBS of TX Blue Essentials	$196.13
Rate for Payer: BCBS of TX PPO	$217.92
Rate for Payer: Cash Price	$370.46
Rate for Payer: Cigna Medicaid	$392.26
Rate for Payer: Molina CHIP/Medicaid	$392.26
Rate for Payer: Multiplan Auto	$354.12
Rate for Payer: Multiplan Commercial	$354.12
Rate for Payer: Multiplan Workers Comp	$354.12
Rate for Payer: Parkland Medicaid	$392.26
Rate for Payer: Scott and White EPO/PPO	$272.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$392.26
Rate for Payer: Superior Health Plan EPO	$74.09

INFINITY AIM SUTURE CUTTER AND SKID

Facility

$544.80

Hospital Charge Code	992648
Hospital Revenue Code	272
Rate for Payer: Cash Price	$370.46

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$27,299.20

Service Code	MSDRG 727
Min. Negotiated Rate	$12,366.80
Max. Negotiated Rate	$27,299.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,628.29
Rate for Payer: Amerigroup Medicare	$15,628.29
Rate for Payer: BCBS of TX Medicare	$15,628.29
Rate for Payer: Cigna Commercial	$19,099.75
Rate for Payer: Cigna Medicare	$15,628.29
Rate for Payer: Employer Direct Commercial	$15,628.29
Rate for Payer: Humana Medicare/TRICARE	$15,628.29
Rate for Payer: Molina Dual Medicare/Medicaid	$15,628.29
Rate for Payer: Molina Medicare	$15,628.29
Rate for Payer: Multiplan Auto	$27,299.20
Rate for Payer: Multiplan Commercial	$27,299.20
Rate for Payer: Multiplan Workers Comp	$27,299.20
Rate for Payer: Scott and White EPO/PPO	$12,572.00
Rate for Payer: Scott and White Medicare	$15,628.29
Rate for Payer: Superior Health Plan EPO	$15,628.29
Rate for Payer: Superior Health Plan Medicare	$15,628.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,628.29
Rate for Payer: Universal American Medicare	$15,628.29
Rate for Payer: Wellcare Medicare	$15,628.29
Rate for Payer: Wellmed Medicare	$15,628.29

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC

Facility

$15,612.30

Service Code	MSDRG 728
Min. Negotiated Rate	$6,806.04
Max. Negotiated Rate	$15,612.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,705.38
Rate for Payer: Amerigroup Medicare	$10,705.38
Rate for Payer: BCBS of TX Medicare	$10,705.38
Rate for Payer: Cigna Commercial	$10,448.26
Rate for Payer: Cigna Medicare	$10,705.38
Rate for Payer: Employer Direct Commercial	$10,705.38
Rate for Payer: Humana Medicare/TRICARE	$10,705.38
Rate for Payer: Molina Dual Medicare/Medicaid	$10,705.38
Rate for Payer: Molina Medicare	$10,705.38
Rate for Payer: Multiplan Auto	$15,612.30
Rate for Payer: Multiplan Commercial	$15,612.30
Rate for Payer: Multiplan Workers Comp	$15,612.30
Rate for Payer: Scott and White EPO/PPO	$7,189.88
Rate for Payer: Scott and White Medicare	$10,705.38
Rate for Payer: Superior Health Plan EPO	$10,705.38
Rate for Payer: Superior Health Plan Medicare	$10,705.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,705.38
Rate for Payer: Universal American Medicare	$10,705.38
Rate for Payer: Wellcare Medicare	$10,705.38
Rate for Payer: Wellmed Medicare	$10,705.38

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W MCC

Facility

$27,299.20

Service Code	MSDRG 727
Min. Negotiated Rate	$12,366.80
Max. Negotiated Rate	$27,299.20
Rate for Payer: BCBS of TX Blue Advantage	$12,366.80
Rate for Payer: BCBS of TX Blue Essentials	$14,838.72
Rate for Payer: BCBS of TX PPO	$16,488.11

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC

Facility

$15,612.30

Service Code	MSDRG 728
Min. Negotiated Rate	$6,806.04
Max. Negotiated Rate	$15,612.30
Rate for Payer: BCBS of TX Blue Advantage	$6,806.04
Rate for Payer: BCBS of TX Blue Essentials	$8,166.46
Rate for Payer: BCBS of TX PPO	$9,074.19

INFLAMMATORY BOWEL DISEASE

Facility

$21,529.95

Service Code	APR-DRG 2454
Min. Negotiated Rate	$20,299.19
Max. Negotiated Rate	$21,529.95
Rate for Payer: Amerigroup CHIP/Medicaid	$20,299.19
Rate for Payer: Cigna Medicaid	$20,299.19
Rate for Payer: Molina CHIP/Medicaid	$20,299.19
Rate for Payer: Parkland Medicaid	$20,299.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,529.95

INFLAMMATORY BOWEL DISEASE

Facility

$3,333.22

Service Code	APR-DRG 2451
Min. Negotiated Rate	$3,142.68
Max. Negotiated Rate	$3,333.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,142.68
Rate for Payer: Cigna Medicaid	$3,142.68
Rate for Payer: Molina CHIP/Medicaid	$3,142.68
Rate for Payer: Parkland Medicaid	$3,142.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,333.22

INFLAMMATORY BOWEL DISEASE

Facility

$4,698.27

Service Code	APR-DRG 2452
Min. Negotiated Rate	$4,429.69
Max. Negotiated Rate	$4,698.27
Rate for Payer: Amerigroup CHIP/Medicaid	$4,429.69
Rate for Payer: Cigna Medicaid	$4,429.69
Rate for Payer: Molina CHIP/Medicaid	$4,429.69
Rate for Payer: Parkland Medicaid	$4,429.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,698.27

INFLAMMATORY BOWEL DISEASE

Facility

$6,541.97

Service Code	APR-DRG 2453
Min. Negotiated Rate	$6,167.99
Max. Negotiated Rate	$6,541.97
Rate for Payer: Amerigroup CHIP/Medicaid	$6,167.99
Rate for Payer: Cigna Medicaid	$6,167.99
Rate for Payer: Molina CHIP/Medicaid	$6,167.99
Rate for Payer: Parkland Medicaid	$6,167.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,541.97

INFLAMMATORY BOWEL DISEASE W CC

Facility

$18,806.20

Service Code	MSDRG 386
Min. Negotiated Rate	$8,428.86
Max. Negotiated Rate	$18,806.20
Rate for Payer: BCBS of TX Blue Advantage	$8,428.86
Rate for Payer: BCBS of TX Blue Essentials	$10,113.65
Rate for Payer: BCBS of TX PPO	$11,237.83

INFLAMMATORY BOWEL DISEASE WITH CC

Facility

$18,806.20

Service Code	MSDRG 386
Min. Negotiated Rate	$8,428.86
Max. Negotiated Rate	$18,806.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,915.41
Rate for Payer: Amerigroup Medicare	$11,915.41
Rate for Payer: BCBS of TX Medicare	$11,915.41
Rate for Payer: Cigna Commercial	$12,574.74
Rate for Payer: Cigna Medicare	$11,915.41
Rate for Payer: Employer Direct Commercial	$11,915.41
Rate for Payer: Humana Medicare/TRICARE	$11,915.41
Rate for Payer: Molina Dual Medicare/Medicaid	$11,915.41
Rate for Payer: Molina Medicare	$11,915.41
Rate for Payer: Multiplan Auto	$18,806.20
Rate for Payer: Multiplan Commercial	$18,806.20
Rate for Payer: Multiplan Workers Comp	$18,806.20
Rate for Payer: Scott and White EPO/PPO	$8,660.75
Rate for Payer: Scott and White Medicare	$11,915.41
Rate for Payer: Superior Health Plan EPO	$11,915.41
Rate for Payer: Superior Health Plan Medicare	$11,915.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,915.41
Rate for Payer: Universal American Medicare	$11,915.41
Rate for Payer: Wellcare Medicare	$11,915.41
Rate for Payer: Wellmed Medicare	$11,915.41

INFLAMMATORY BOWEL DISEASE WITH MCC

Facility

$30,945.30

Service Code	MSDRG 385
Min. Negotiated Rate	$14,251.12
Max. Negotiated Rate	$30,945.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,356.79
Rate for Payer: Amerigroup Medicare	$16,356.79
Rate for Payer: BCBS of TX Medicare	$16,356.79
Rate for Payer: Cigna Commercial	$20,380.02
Rate for Payer: Cigna Medicare	$16,356.79
Rate for Payer: Employer Direct Commercial	$16,356.79
Rate for Payer: Humana Medicare/TRICARE	$16,356.79
Rate for Payer: Molina Dual Medicare/Medicaid	$16,356.79
Rate for Payer: Molina Medicare	$16,356.79
Rate for Payer: Multiplan Auto	$30,945.30
Rate for Payer: Multiplan Commercial	$30,945.30
Rate for Payer: Multiplan Workers Comp	$30,945.30
Rate for Payer: Scott and White EPO/PPO	$14,251.12
Rate for Payer: Scott and White Medicare	$16,356.79
Rate for Payer: Superior Health Plan EPO	$16,356.79
Rate for Payer: Superior Health Plan Medicare	$16,356.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,356.79
Rate for Payer: Universal American Medicare	$16,356.79
Rate for Payer: Wellcare Medicare	$16,356.79
Rate for Payer: Wellmed Medicare	$16,356.79

INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC

Facility

$13,140.40

Service Code	MSDRG 387
Min. Negotiated Rate	$5,991.62
Max. Negotiated Rate	$13,140.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,753.35
Rate for Payer: Amerigroup Medicare	$9,753.35
Rate for Payer: BCBS of TX Medicare	$9,753.35
Rate for Payer: Cigna Commercial	$8,775.14
Rate for Payer: Cigna Medicare	$9,753.35
Rate for Payer: Employer Direct Commercial	$9,753.35
Rate for Payer: Humana Medicare/TRICARE	$9,753.35
Rate for Payer: Molina Dual Medicare/Medicaid	$9,753.35
Rate for Payer: Molina Medicare	$9,753.35
Rate for Payer: Multiplan Auto	$13,140.40
Rate for Payer: Multiplan Commercial	$13,140.40
Rate for Payer: Multiplan Workers Comp	$13,140.40
Rate for Payer: Scott and White EPO/PPO	$6,051.50
Rate for Payer: Scott and White Medicare	$9,753.35
Rate for Payer: Superior Health Plan EPO	$9,753.35
Rate for Payer: Superior Health Plan Medicare	$9,753.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,753.35
Rate for Payer: Universal American Medicare	$9,753.35
Rate for Payer: Wellcare Medicare	$9,753.35
Rate for Payer: Wellmed Medicare	$9,753.35

INFLAMMATORY BOWEL DISEASE W MCC

Facility

$30,945.30

Service Code	MSDRG 385
Min. Negotiated Rate	$14,251.12
Max. Negotiated Rate	$30,945.30
Rate for Payer: BCBS of TX Blue Advantage	$14,601.94
Rate for Payer: BCBS of TX Blue Essentials	$17,520.63
Rate for Payer: BCBS of TX PPO	$19,468.12

INFLAMMATORY BOWEL DISEASE W/O CC/MCC

Facility

$13,140.40

Service Code	MSDRG 387
Min. Negotiated Rate	$5,991.62
Max. Negotiated Rate	$13,140.40
Rate for Payer: BCBS of TX Blue Advantage	$5,991.62
Rate for Payer: BCBS of TX Blue Essentials	$7,189.25
Rate for Payer: BCBS of TX PPO	$7,988.36

INFL SYR W/GAUGE -- DHF

Facility

$149.03

Hospital Charge Code	80325111
Hospital Revenue Code	272
Rate for Payer: Cash Price	$101.34

INFL SYR W/GAUGE -- DHF

Facility

$149.03

Hospital Charge Code	80325111
Hospital Revenue Code	272
Min. Negotiated Rate	$13.41
Max. Negotiated Rate	$107.30
Rate for Payer: Amerigroup CHIP/Medicaid	$13.41
Rate for Payer: BCBS of TX Blue Advantage	$44.71
Rate for Payer: BCBS of TX Blue Essentials	$53.65
Rate for Payer: BCBS of TX PPO	$59.61
Rate for Payer: Cash Price	$101.34
Rate for Payer: Cigna Medicaid	$107.30
Rate for Payer: Molina CHIP/Medicaid	$107.30
Rate for Payer: Multiplan Auto	$96.87
Rate for Payer: Multiplan Commercial	$96.87
Rate for Payer: Multiplan Workers Comp	$96.87
Rate for Payer: Parkland Medicaid	$107.30
Rate for Payer: Scott and White EPO/PPO	$74.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$107.30
Rate for Payer: Superior Health Plan EPO	$20.27

Influenza A and B by RNA

Facility

$304.00

Service Code	HCPCS 87502
Hospital Charge Code	1630030
Hospital Revenue Code	300
Min. Negotiated Rate	$37.36
Max. Negotiated Rate	$218.88
Rate for Payer: Amerigroup CHIP/Medicaid	$37.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$95.80
Rate for Payer: Amerigroup Medicare	$95.80
Rate for Payer: BCBS of TX Blue Advantage	$91.20
Rate for Payer: BCBS of TX Blue Essentials	$109.44
Rate for Payer: BCBS of TX Medicare	$95.80
Rate for Payer: BCBS of TX PPO	$121.60
Rate for Payer: Cash Price	$206.72
Rate for Payer: Cash Price	$206.72
Rate for Payer: Cigna Medicaid	$218.88
Rate for Payer: Cigna Medicare	$95.80
Rate for Payer: Employer Direct Commercial	$95.80
Rate for Payer: Humana Medicare/TRICARE	$95.80
Rate for Payer: Molina CHIP/Medicaid	$218.88
Rate for Payer: Molina Dual Medicare/Medicaid	$95.80
Rate for Payer: Molina Medicare	$95.80
Rate for Payer: Multiplan Auto	$197.60
Rate for Payer: Multiplan Commercial	$197.60
Rate for Payer: Multiplan Workers Comp	$197.60
Rate for Payer: Parkland Medicaid	$218.88
Rate for Payer: Scott and White EPO/PPO	$119.75
Rate for Payer: Scott and White Medicare	$95.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$218.88
Rate for Payer: Superior Health Plan EPO	$95.80
Rate for Payer: Superior Health Plan Medicare	$95.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$95.80
Rate for Payer: Universal American Medicare	$95.80
Rate for Payer: Wellcare Medicare	$95.80
Rate for Payer: Wellmed Medicare	$95.80

Know your out-of-pocket cost for care.

All Charges