White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Influenza A and B by RNA

Facility

$304.00

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

Influenza A Antigen

Facility

$172.00

Service Code	HCPCS 87804
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
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
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
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
Rate for Payer: Cash Price	$224.40

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	$18.93
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	$18.93
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

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	$15.21
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	$15.21
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 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 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

Infusion for Hydration Initial 31 to 60 Minutes 96360

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	7003585
Hospital Revenue Code	260
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$609.84
Rate for Payer: Amerigroup CHIP/Medicaid	$76.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$254.10
Rate for Payer: BCBS of TX Blue Essentials	$304.92
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$338.80
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$609.84
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$609.84
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$550.55
Rate for Payer: Multiplan Commercial	$550.55
Rate for Payer: Multiplan Workers Comp	$550.55
Rate for Payer: Parkland Medicaid	$609.84
Rate for Payer: Scott and White EPO/PPO	$39.95
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$609.84
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

Infusion pump, programmable (implantable)

Facility

$67,127.00

Service Code	HCPCS C1772
Hospital Charge Code	990932
Hospital Revenue Code	278
Min. Negotiated Rate	$6,041.43
Max. Negotiated Rate	$48,331.44
Rate for Payer: Amerigroup CHIP/Medicaid	$6,041.43
Rate for Payer: BCBS of TX Blue Advantage	$20,138.10
Rate for Payer: BCBS of TX Blue Essentials	$24,165.72
Rate for Payer: BCBS of TX PPO	$26,850.80
Rate for Payer: Cash Price	$45,646.36
Rate for Payer: Cigna Medicaid	$48,331.44
Rate for Payer: Molina CHIP/Medicaid	$48,331.44
Rate for Payer: Multiplan Auto	$33,563.50
Rate for Payer: Multiplan Commercial	$33,563.50
Rate for Payer: Multiplan Workers Comp	$33,563.50
Rate for Payer: Parkland Medicaid	$48,331.44
Rate for Payer: Scott and White EPO/PPO	$33,563.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$48,331.44
Rate for Payer: Superior Health Plan EPO	$9,129.27

Infusion pump, programmable (implantable)

Facility

$67,127.00

Service Code	HCPCS C1772
Hospital Charge Code	990932
Hospital Revenue Code	278
Min. Negotiated Rate	$16,781.75
Max. Negotiated Rate	$33,563.50
Rate for Payer: Cash Price	$45,646.36
Rate for Payer: Cigna Commercial	$16,781.75
Rate for Payer: Multiplan Auto	$33,563.50
Rate for Payer: Multiplan Commercial	$33,563.50
Rate for Payer: Multiplan Workers Comp	$33,563.50
Rate for Payer: Scott and White EPO/PPO	$33,563.50

INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC

Facility

$27,933.80

Service Code	MSDRG 351
Min. Negotiated Rate	$12,864.25
Max. Negotiated Rate	$27,933.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,933.19
Rate for Payer: Amerigroup Medicare	$15,933.19
Rate for Payer: BCBS of TX Medicare	$15,933.19
Rate for Payer: Cigna Commercial	$19,635.56
Rate for Payer: Cigna Medicare	$15,933.19
Rate for Payer: Employer Direct Commercial	$15,933.19
Rate for Payer: Humana Medicare/TRICARE	$15,933.19
Rate for Payer: Molina Dual Medicare/Medicaid	$15,933.19
Rate for Payer: Molina Medicare	$15,933.19
Rate for Payer: Multiplan Auto	$27,933.80
Rate for Payer: Multiplan Commercial	$27,933.80
Rate for Payer: Multiplan Workers Comp	$27,933.80
Rate for Payer: Scott and White EPO/PPO	$12,864.25
Rate for Payer: Scott and White Medicare	$15,933.19
Rate for Payer: Superior Health Plan EPO	$15,933.19
Rate for Payer: Superior Health Plan Medicare	$15,933.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,933.19
Rate for Payer: Universal American Medicare	$15,933.19
Rate for Payer: Wellcare Medicare	$15,933.19
Rate for Payer: Wellmed Medicare	$15,933.19

INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC

Facility

$44,783.00

Service Code	MSDRG 350
Min. Negotiated Rate	$20,623.75
Max. Negotiated Rate	$44,783.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,023.29
Rate for Payer: Amerigroup Medicare	$23,023.29
Rate for Payer: BCBS of TX Medicare	$23,023.29
Rate for Payer: Cigna Commercial	$32,095.67
Rate for Payer: Cigna Medicare	$23,023.29
Rate for Payer: Employer Direct Commercial	$23,023.29
Rate for Payer: Humana Medicare/TRICARE	$23,023.29
Rate for Payer: Molina Dual Medicare/Medicaid	$23,023.29
Rate for Payer: Molina Medicare	$23,023.29
Rate for Payer: Multiplan Auto	$44,783.00
Rate for Payer: Multiplan Commercial	$44,783.00
Rate for Payer: Multiplan Workers Comp	$44,783.00
Rate for Payer: Scott and White EPO/PPO	$20,623.75
Rate for Payer: Scott and White Medicare	$23,023.29
Rate for Payer: Superior Health Plan EPO	$23,023.29
Rate for Payer: Superior Health Plan Medicare	$23,023.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,023.29
Rate for Payer: Universal American Medicare	$23,023.29
Rate for Payer: Wellcare Medicare	$23,023.29
Rate for Payer: Wellmed Medicare	$23,023.29

INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC

Facility

$20,939.90

Service Code	MSDRG 352
Min. Negotiated Rate	$9,060.10
Max. Negotiated Rate	$20,939.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,318.92
Rate for Payer: Amerigroup Medicare	$13,318.92
Rate for Payer: BCBS of TX Medicare	$13,318.92
Rate for Payer: Cigna Commercial	$15,041.26
Rate for Payer: Cigna Medicare	$13,318.92
Rate for Payer: Employer Direct Commercial	$13,318.92
Rate for Payer: Humana Medicare/TRICARE	$13,318.92
Rate for Payer: Molina Dual Medicare/Medicaid	$13,318.92
Rate for Payer: Molina Medicare	$13,318.92
Rate for Payer: Multiplan Auto	$20,939.90
Rate for Payer: Multiplan Commercial	$20,939.90
Rate for Payer: Multiplan Workers Comp	$20,939.90
Rate for Payer: Scott and White EPO/PPO	$9,643.38
Rate for Payer: Scott and White Medicare	$13,318.92
Rate for Payer: Superior Health Plan EPO	$13,318.92
Rate for Payer: Superior Health Plan Medicare	$13,318.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,318.92
Rate for Payer: Universal American Medicare	$13,318.92
Rate for Payer: Wellcare Medicare	$13,318.92
Rate for Payer: Wellmed Medicare	$13,318.92

INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES

Facility

$5,211.24

Service Code	APR-DRG 2282
Min. Negotiated Rate	$4,913.34
Max. Negotiated Rate	$5,211.24
Rate for Payer: Amerigroup CHIP/Medicaid	$4,913.34
Rate for Payer: Cigna Medicaid	$4,913.34
Rate for Payer: Molina CHIP/Medicaid	$4,913.34
Rate for Payer: Parkland Medicaid	$4,913.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,211.24

INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES

Facility

$16,611.40

Service Code	APR-DRG 2284
Min. Negotiated Rate	$15,661.81
Max. Negotiated Rate	$16,611.40
Rate for Payer: Amerigroup CHIP/Medicaid	$15,661.81
Rate for Payer: Cigna Medicaid	$15,661.81
Rate for Payer: Molina CHIP/Medicaid	$15,661.81
Rate for Payer: Parkland Medicaid	$15,661.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,611.40

INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES

Facility

$3,860.15

Service Code	APR-DRG 2281
Min. Negotiated Rate	$3,639.49
Max. Negotiated Rate	$3,860.15
Rate for Payer: Amerigroup CHIP/Medicaid	$3,639.49
Rate for Payer: Cigna Medicaid	$3,639.49
Rate for Payer: Molina CHIP/Medicaid	$3,639.49
Rate for Payer: Parkland Medicaid	$3,639.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,860.15

INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES

Facility

$8,638.76

Service Code	APR-DRG 2283
Min. Negotiated Rate	$8,144.93
Max. Negotiated Rate	$8,638.76
Rate for Payer: Amerigroup CHIP/Medicaid	$8,144.93
Rate for Payer: Cigna Medicaid	$8,144.93
Rate for Payer: Molina CHIP/Medicaid	$8,144.93
Rate for Payer: Parkland Medicaid	$8,144.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,638.76

INGUINAL & FEMORAL HERNIA PROCEDURES W CC

Facility

$27,933.80

Service Code	MSDRG 351
Min. Negotiated Rate	$12,864.25
Max. Negotiated Rate	$27,933.80
Rate for Payer: BCBS of TX Blue Advantage	$12,900.86
Rate for Payer: BCBS of TX Blue Essentials	$15,479.53
Rate for Payer: BCBS of TX PPO	$17,200.15

INGUINAL & FEMORAL HERNIA PROCEDURES W MCC

Facility

$44,783.00

Service Code	MSDRG 350
Min. Negotiated Rate	$20,623.75
Max. Negotiated Rate	$44,783.00
Rate for Payer: BCBS of TX Blue Advantage	$21,039.90
Rate for Payer: BCBS of TX Blue Essentials	$25,245.43
Rate for Payer: BCBS of TX PPO	$28,051.57

INGUINAL & FEMORAL HERNIA PROCEDURES W/O CC/MCC

Facility

$20,939.90

Service Code	MSDRG 352
Min. Negotiated Rate	$9,060.10
Max. Negotiated Rate	$20,939.90
Rate for Payer: BCBS of TX Blue Advantage	$9,060.10
Rate for Payer: BCBS of TX Blue Essentials	$10,871.07
Rate for Payer: BCBS of TX PPO	$12,079.43

Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure)

Facility

$12,960.81

Service Code	HCPCS 38760
Hospital Charge Code	9900638
Hospital Revenue Code	360
Min. Negotiated Rate	$1,845.21
Max. Negotiated Rate	$14,100.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1,845.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Amerigroup Medicare	$6,670.43
Rate for Payer: BCBS of TX Blue Advantage	$8,746.27
Rate for Payer: BCBS of TX Blue Essentials	$10,474.58
Rate for Payer: BCBS of TX Medicare	$6,670.43
Rate for Payer: BCBS of TX PPO	$13,197.97
Rate for Payer: Cash Price	$8,813.35
Rate for Payer: Cash Price	$8,813.35
Rate for Payer: Cash Price	$8,813.35
Rate for Payer: Cigna Commercial	$14,100.07
Rate for Payer: Cigna Medicaid	$9,331.78
Rate for Payer: Cigna Medicare	$6,670.43
Rate for Payer: Employer Direct Commercial	$6,670.43
Rate for Payer: Humana Medicare/TRICARE	$6,670.43
Rate for Payer: Molina CHIP/Medicaid	$9,331.78
Rate for Payer: Molina Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Molina Medicare	$6,670.43
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: Parkland Medicaid	$9,331.78
Rate for Payer: Scott and White EPO/PPO	$11,033.10
Rate for Payer: Scott and White Medicare	$6,670.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,331.78
Rate for Payer: Superior Health Plan EPO	$6,670.43
Rate for Payer: Superior Health Plan Medicare	$6,670.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,670.43
Rate for Payer: Universal American Medicare	$6,670.43
Rate for Payer: Wellcare Medicare	$6,670.43
Rate for Payer: Wellmed Medicare	$6,670.43

Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure)

Facility

$12,960.81

Service Code	HCPCS 38760
Hospital Charge Code	9900638
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,813.35

Know your out-of-pocket cost for care.

All Charges