White Rock Medical Center

All Charges

Charge

Type

Setting

Price

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W MCC

Facility

$28,175.10

Service Code	MSDRG 727
Min. Negotiated Rate	$12,366.80
Max. Negotiated Rate	$28,175.10
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

$15,412.80

Service Code	MSDRG 728
Min. Negotiated Rate	$6,806.04
Max. Negotiated Rate	$15,412.80
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

$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

$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

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

$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 W CC

Facility

$18,549.70

Service Code	MSDRG 386
Min. Negotiated Rate	$8,428.86
Max. Negotiated Rate	$18,549.70
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

$18,549.70

Service Code	MSDRG 386
Min. Negotiated Rate	$8,428.86
Max. Negotiated Rate	$18,549.70
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	$18,549.70
Rate for Payer: Multiplan Commercial	$18,549.70
Rate for Payer: Multiplan Workers Comp	$18,549.70
Rate for Payer: Scott and White EPO/PPO	$8,542.62
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

$30,063.70

Service Code	MSDRG 385
Min. Negotiated Rate	$13,845.12
Max. Negotiated Rate	$30,063.70
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	$30,063.70
Rate for Payer: Multiplan Commercial	$30,063.70
Rate for Payer: Multiplan Workers Comp	$30,063.70
Rate for Payer: Scott and White EPO/PPO	$13,845.12
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

$12,944.70

Service Code	MSDRG 387
Min. Negotiated Rate	$5,961.38
Max. Negotiated Rate	$12,944.70
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	$12,944.70
Rate for Payer: Multiplan Commercial	$12,944.70
Rate for Payer: Multiplan Workers Comp	$12,944.70
Rate for Payer: Scott and White EPO/PPO	$5,961.38
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

$30,063.70

Service Code	MSDRG 385
Min. Negotiated Rate	$13,845.12
Max. Negotiated Rate	$30,063.70
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

$12,944.70

Service Code	MSDRG 387
Min. Negotiated Rate	$5,961.38
Max. Negotiated Rate	$12,944.70
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
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

INFL SYR W/GAUGE -- DHF

Facility

$149.03

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

Influenza A and B by RNA

Facility

$304.00

Service Code	HCPCS 87502 QW
Hospital Charge Code	1630030
Hospital Revenue Code	300
Rate for Payer: Cash Price	$206.72

Influenza A and B by RNA

Facility

$304.00

Service Code	HCPCS 87502 QW
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

Influenza A Antigen

Facility

$172.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	1640072
Hospital Revenue Code	306
Rate for Payer: Cash Price	$116.96

Influenza A Antigen

Facility

$172.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	1640072
Hospital Revenue Code	306
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$123.84
Rate for Payer: Amerigroup CHIP/Medicaid	$6.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.55
Rate for Payer: Amerigroup Medicare	$16.55
Rate for Payer: BCBS of TX Blue Advantage	$51.60
Rate for Payer: BCBS of TX Blue Essentials	$61.92
Rate for Payer: BCBS of TX Medicare	$16.55
Rate for Payer: BCBS of TX PPO	$68.80
Rate for Payer: Cash Price	$116.96
Rate for Payer: Cash Price	$116.96
Rate for Payer: Cigna Medicaid	$123.84
Rate for Payer: Cigna Medicare	$16.55
Rate for Payer: Employer Direct Commercial	$16.55
Rate for Payer: Humana Medicare/TRICARE	$16.55
Rate for Payer: Molina CHIP/Medicaid	$123.84
Rate for Payer: Molina Dual Medicare/Medicaid	$16.55
Rate for Payer: Molina Medicare	$16.55
Rate for Payer: Multiplan Auto	$111.80
Rate for Payer: Multiplan Commercial	$111.80
Rate for Payer: Multiplan Workers Comp	$111.80
Rate for Payer: Parkland Medicaid	$123.84
Rate for Payer: Scott and White EPO/PPO	$20.69
Rate for Payer: Scott and White Medicare	$16.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$123.84
Rate for Payer: Superior Health Plan EPO	$16.55
Rate for Payer: Superior Health Plan Medicare	$16.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.55
Rate for Payer: Universal American Medicare	$16.55
Rate for Payer: Wellcare Medicare	$16.55
Rate for Payer: Wellmed Medicare	$16.55

Influenza B Antigen

Facility

$172.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8142123
Hospital Revenue Code	306
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$123.84
Rate for Payer: Amerigroup CHIP/Medicaid	$6.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.55
Rate for Payer: Amerigroup Medicare	$16.55
Rate for Payer: BCBS of TX Blue Advantage	$51.60
Rate for Payer: BCBS of TX Blue Essentials	$61.92
Rate for Payer: BCBS of TX Medicare	$16.55
Rate for Payer: BCBS of TX PPO	$68.80
Rate for Payer: Cash Price	$116.96
Rate for Payer: Cash Price	$116.96
Rate for Payer: Cigna Medicaid	$123.84
Rate for Payer: Cigna Medicare	$16.55
Rate for Payer: Employer Direct Commercial	$16.55
Rate for Payer: Humana Medicare/TRICARE	$16.55
Rate for Payer: Molina CHIP/Medicaid	$123.84
Rate for Payer: Molina Dual Medicare/Medicaid	$16.55
Rate for Payer: Molina Medicare	$16.55
Rate for Payer: Multiplan Auto	$111.80
Rate for Payer: Multiplan Commercial	$111.80
Rate for Payer: Multiplan Workers Comp	$111.80
Rate for Payer: Parkland Medicaid	$123.84
Rate for Payer: Scott and White EPO/PPO	$20.69
Rate for Payer: Scott and White Medicare	$16.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$123.84
Rate for Payer: Superior Health Plan EPO	$16.55
Rate for Payer: Superior Health Plan Medicare	$16.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.55
Rate for Payer: Universal American Medicare	$16.55
Rate for Payer: Wellcare Medicare	$16.55
Rate for Payer: Wellmed Medicare	$16.55

Influenza B Antigen

Facility

$172.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8142123
Hospital Revenue Code	306
Rate for Payer: Cash Price	$116.96

Inf Tx Proph Diag Ea Addl IVP Drug 96375 BCE

Facility

$330.00

Service Code	HCPCS 96375
Hospital Charge Code	6290775
Hospital Revenue Code	260
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$237.60
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47.04
Rate for Payer: Amerigroup Medicare	$47.04
Rate for Payer: BCBS of TX Blue Advantage	$99.00
Rate for Payer: BCBS of TX Blue Essentials	$118.80
Rate for Payer: BCBS of TX Medicare	$47.04
Rate for Payer: BCBS of TX PPO	$132.00
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cigna Commercial	$99.43
Rate for Payer: Cigna Medicaid	$237.60
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	$237.60
Rate for Payer: Molina Dual Medicare/Medicaid	$47.04
Rate for Payer: Molina Medicare	$47.04
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Parkland Medicaid	$237.60
Rate for Payer: Scott and White EPO/PPO	$165.00
Rate for Payer: Scott and White Medicare	$47.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$237.60
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 Tx Proph Diag Ea Addl IVP Drug 96375 BCE

Facility

$330.00

Service Code	HCPCS 96375
Hospital Charge Code	6290775
Hospital Revenue Code	260
Rate for Payer: Cash Price	$224.40

Infusion for Hydration Each Additional Hour 96361

Facility

$251.00

Service Code	HCPCS 96361
Hospital Charge Code	9900911
Hospital Revenue Code	260
Rate for Payer: Cash Price	$170.68

Infusion for Hydration Each Additional Hour 96361

Facility

$251.00

Service Code	HCPCS 96361
Hospital Charge Code	9900911
Hospital Revenue Code	260
Min. Negotiated Rate	$22.59
Max. Negotiated Rate	$180.72
Rate for Payer: Amerigroup CHIP/Medicaid	$22.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47.04
Rate for Payer: Amerigroup Medicare	$47.04
Rate for Payer: BCBS of TX Blue Advantage	$75.30
Rate for Payer: BCBS of TX Blue Essentials	$90.36
Rate for Payer: BCBS of TX Medicare	$47.04
Rate for Payer: BCBS of TX PPO	$100.40
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cigna Commercial	$99.43
Rate for Payer: Cigna Medicaid	$180.72
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	$180.72
Rate for Payer: Molina Dual Medicare/Medicaid	$47.04
Rate for Payer: Molina Medicare	$47.04
Rate for Payer: Multiplan Auto	$163.15
Rate for Payer: Multiplan Commercial	$163.15
Rate for Payer: Multiplan Workers Comp	$163.15
Rate for Payer: Parkland Medicaid	$180.72
Rate for Payer: Scott and White EPO/PPO	$125.50
Rate for Payer: Scott and White Medicare	$47.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.72
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

Infusion for Hydration Initial 31 to 60 Minutes 96360

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	7003585
Hospital Revenue Code	260
Rate for Payer: Cash Price	$575.96

Know your out-of-pocket cost for care.

All Charges