White Rock Medical Center

All Charges

Charge

Type

Setting

Price

insulin isophane 100 units/mL human recombinant Subcut Susp 10 mL

Facility

$128.00

Service Code	HCPCS J1815
Hospital Charge Code	77634055
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

insulin isophane-insulin regular 70 units-30 units/mL human recombinant Subcut Susp 10 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	77634169
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

insulin isophane-insulin regular 70 units-30 units/mL human recombinant Subcut Susp 10 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	77634169
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
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	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

insulin lispro 100 units/mL Subcut Soln 3 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	77634397
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
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	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

insulin lispro 100 units/mL Subcut Soln 3 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	77634397
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

Insulin SO

Facility

$327.00

Service Code	HCPCS 83525
Hospital Charge Code	1709047
Hospital Revenue Code	301
Rate for Payer: Cash Price	$222.36

Insulin SO

Facility

$327.00

Service Code	HCPCS 83525
Hospital Charge Code	1709047
Hospital Revenue Code	301
Min. Negotiated Rate	$4.46
Max. Negotiated Rate	$235.44
Rate for Payer: Amerigroup CHIP/Medicaid	$4.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.43
Rate for Payer: Amerigroup Medicare	$11.43
Rate for Payer: BCBS of TX Blue Advantage	$98.10
Rate for Payer: BCBS of TX Blue Essentials	$117.72
Rate for Payer: BCBS of TX Medicare	$11.43
Rate for Payer: BCBS of TX PPO	$130.80
Rate for Payer: Cash Price	$222.36
Rate for Payer: Cash Price	$222.36
Rate for Payer: Cigna Medicaid	$235.44
Rate for Payer: Cigna Medicare	$11.43
Rate for Payer: Employer Direct Commercial	$11.43
Rate for Payer: Humana Medicare/TRICARE	$11.43
Rate for Payer: Molina CHIP/Medicaid	$235.44
Rate for Payer: Molina Dual Medicare/Medicaid	$11.43
Rate for Payer: Molina Medicare	$11.43
Rate for Payer: Multiplan Auto	$212.55
Rate for Payer: Multiplan Commercial	$212.55
Rate for Payer: Multiplan Workers Comp	$212.55
Rate for Payer: Parkland Medicaid	$235.44
Rate for Payer: Scott and White EPO/PPO	$14.29
Rate for Payer: Scott and White Medicare	$11.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$235.44
Rate for Payer: Superior Health Plan EPO	$11.43
Rate for Payer: Superior Health Plan Medicare	$11.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.43
Rate for Payer: Universal American Medicare	$11.43
Rate for Payer: Wellcare Medicare	$11.43
Rate for Payer: Wellmed Medicare	$11.43

INTEGRATOR, CHEMICAL, STERIGAGE, 500/PK

Facility

$0.37

Hospital Charge Code	992967
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.25

INTEGRATOR, CHEMICAL, STERIGAGE, 500/PK

Facility

$0.37

Hospital Charge Code	992967
Hospital Revenue Code	270
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.27
Rate for Payer: Amerigroup CHIP/Medicaid	$0.03
Rate for Payer: BCBS of TX Blue Advantage	$0.11
Rate for Payer: BCBS of TX Blue Essentials	$0.13
Rate for Payer: BCBS of TX PPO	$0.15
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna Medicaid	$0.27
Rate for Payer: Molina CHIP/Medicaid	$0.27
Rate for Payer: Multiplan Auto	$0.24
Rate for Payer: Multiplan Commercial	$0.24
Rate for Payer: Multiplan Workers Comp	$0.24
Rate for Payer: Parkland Medicaid	$0.27
Rate for Payer: Scott and White EPO/PPO	$0.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.27
Rate for Payer: Superior Health Plan EPO	$0.05

integuseal skin prep

Facility

$204.53

Hospital Charge Code	144771
Hospital Revenue Code	272
Min. Negotiated Rate	$18.41
Max. Negotiated Rate	$147.26
Rate for Payer: Amerigroup CHIP/Medicaid	$18.41
Rate for Payer: BCBS of TX Blue Advantage	$61.36
Rate for Payer: BCBS of TX Blue Essentials	$73.63
Rate for Payer: BCBS of TX PPO	$81.81
Rate for Payer: Cash Price	$139.08
Rate for Payer: Cigna Medicaid	$147.26
Rate for Payer: Molina CHIP/Medicaid	$147.26
Rate for Payer: Multiplan Auto	$132.94
Rate for Payer: Multiplan Commercial	$132.94
Rate for Payer: Multiplan Workers Comp	$132.94
Rate for Payer: Parkland Medicaid	$147.26
Rate for Payer: Scott and White EPO/PPO	$102.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$147.26
Rate for Payer: Superior Health Plan EPO	$27.82

integuseal skin prep

Facility

$204.53

Hospital Charge Code	144771
Hospital Revenue Code	272
Rate for Payer: Cash Price	$139.08

INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE

Facility

$7,894.19

Service Code	APR-DRG 8174
Min. Negotiated Rate	$7,442.92
Max. Negotiated Rate	$7,894.19
Rate for Payer: Amerigroup CHIP/Medicaid	$7,442.92
Rate for Payer: Cigna Medicaid	$7,442.92
Rate for Payer: Molina CHIP/Medicaid	$7,442.92
Rate for Payer: Parkland Medicaid	$7,442.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,894.19

INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE

Facility

$1,854.26

Service Code	APR-DRG 8171
Min. Negotiated Rate	$1,748.26
Max. Negotiated Rate	$1,854.26
Rate for Payer: Amerigroup CHIP/Medicaid	$1,748.26
Rate for Payer: Cigna Medicaid	$1,748.26
Rate for Payer: Molina CHIP/Medicaid	$1,748.26
Rate for Payer: Parkland Medicaid	$1,748.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,854.26

INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE

Facility

$2,324.62

Service Code	APR-DRG 8172
Min. Negotiated Rate	$2,191.73
Max. Negotiated Rate	$2,324.62
Rate for Payer: Amerigroup CHIP/Medicaid	$2,191.73
Rate for Payer: Cigna Medicaid	$2,191.73
Rate for Payer: Molina CHIP/Medicaid	$2,191.73
Rate for Payer: Parkland Medicaid	$2,191.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,324.62

INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE

Facility

$3,635.35

Service Code	APR-DRG 8173
Min. Negotiated Rate	$3,427.53
Max. Negotiated Rate	$3,635.35
Rate for Payer: Amerigroup CHIP/Medicaid	$3,427.53
Rate for Payer: Cigna Medicaid	$3,427.53
Rate for Payer: Molina CHIP/Medicaid	$3,427.53
Rate for Payer: Parkland Medicaid	$3,427.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,635.35

INTERFACE, TRACHEOSTOMY OPTIFLOW POLY LF NS

Facility

$94.88

Hospital Charge Code	993623
Hospital Revenue Code	270
Min. Negotiated Rate	$8.54
Max. Negotiated Rate	$68.31
Rate for Payer: Amerigroup CHIP/Medicaid	$8.54
Rate for Payer: BCBS of TX Blue Advantage	$28.46
Rate for Payer: BCBS of TX Blue Essentials	$34.16
Rate for Payer: BCBS of TX PPO	$37.95
Rate for Payer: Cash Price	$64.52
Rate for Payer: Cigna Medicaid	$68.31
Rate for Payer: Molina CHIP/Medicaid	$68.31
Rate for Payer: Multiplan Auto	$61.67
Rate for Payer: Multiplan Commercial	$61.67
Rate for Payer: Multiplan Workers Comp	$61.67
Rate for Payer: Parkland Medicaid	$68.31
Rate for Payer: Scott and White EPO/PPO	$47.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$68.31
Rate for Payer: Superior Health Plan EPO	$12.90

INTERFACE, TRACHEOSTOMY OPTIFLOW POLY LF NS

Facility

$94.88

Hospital Charge Code	993623
Hospital Revenue Code	270
Rate for Payer: Cash Price	$64.52

INTERSTITIAL AND ALVEOLAR LUNG DISEASES

Facility

$3,185.36

Service Code	APR-DRG 1421
Min. Negotiated Rate	$3,003.27
Max. Negotiated Rate	$3,185.36
Rate for Payer: Amerigroup CHIP/Medicaid	$3,003.27
Rate for Payer: Cigna Medicaid	$3,003.27
Rate for Payer: Molina CHIP/Medicaid	$3,003.27
Rate for Payer: Parkland Medicaid	$3,003.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,185.36

INTERSTITIAL AND ALVEOLAR LUNG DISEASES

Facility

$5,113.17

Service Code	APR-DRG 1423
Min. Negotiated Rate	$4,820.88
Max. Negotiated Rate	$5,113.17
Rate for Payer: Amerigroup CHIP/Medicaid	$4,820.88
Rate for Payer: Cigna Medicaid	$4,820.88
Rate for Payer: Molina CHIP/Medicaid	$4,820.88
Rate for Payer: Parkland Medicaid	$4,820.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,113.17

INTERSTITIAL AND ALVEOLAR LUNG DISEASES

Facility

$5,035.47

Service Code	APR-DRG 1422
Min. Negotiated Rate	$4,747.62
Max. Negotiated Rate	$5,035.47
Rate for Payer: Amerigroup CHIP/Medicaid	$4,747.62
Rate for Payer: Cigna Medicaid	$4,747.62
Rate for Payer: Molina CHIP/Medicaid	$4,747.62
Rate for Payer: Parkland Medicaid	$4,747.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,035.47

INTERSTITIAL AND ALVEOLAR LUNG DISEASES

Facility

$6,421.64

Service Code	APR-DRG 1424
Min. Negotiated Rate	$6,054.55
Max. Negotiated Rate	$6,421.64
Rate for Payer: Amerigroup CHIP/Medicaid	$6,054.55
Rate for Payer: Cigna Medicaid	$6,054.55
Rate for Payer: Molina CHIP/Medicaid	$6,054.55
Rate for Payer: Parkland Medicaid	$6,054.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,421.64

INTERSTITIAL LUNG DISEASE W CC

Facility

$18,032.90

Service Code	MSDRG 197
Min. Negotiated Rate	$8,304.62
Max. Negotiated Rate	$18,032.90
Rate for Payer: BCBS of TX Blue Advantage	$8,614.62
Rate for Payer: BCBS of TX Blue Essentials	$10,336.54
Rate for Payer: BCBS of TX PPO	$11,485.49

INTERSTITIAL LUNG DISEASE WITH CC

Facility

$18,032.90

Service Code	MSDRG 197
Min. Negotiated Rate	$8,304.62
Max. Negotiated Rate	$18,032.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,716.06
Rate for Payer: Amerigroup Medicare	$11,716.06
Rate for Payer: BCBS of TX Medicare	$11,716.06
Rate for Payer: Cigna Commercial	$12,224.41
Rate for Payer: Cigna Medicare	$11,716.06
Rate for Payer: Employer Direct Commercial	$11,716.06
Rate for Payer: Humana Medicare/TRICARE	$11,716.06
Rate for Payer: Molina Dual Medicare/Medicaid	$11,716.06
Rate for Payer: Molina Medicare	$11,716.06
Rate for Payer: Multiplan Auto	$18,032.90
Rate for Payer: Multiplan Commercial	$18,032.90
Rate for Payer: Multiplan Workers Comp	$18,032.90
Rate for Payer: Scott and White EPO/PPO	$8,304.62
Rate for Payer: Scott and White Medicare	$11,716.06
Rate for Payer: Superior Health Plan EPO	$11,716.06
Rate for Payer: Superior Health Plan Medicare	$11,716.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,716.06
Rate for Payer: Universal American Medicare	$11,716.06
Rate for Payer: Wellcare Medicare	$11,716.06
Rate for Payer: Wellmed Medicare	$11,716.06

INTERSTITIAL LUNG DISEASE WITH MCC

Facility

$35,856.80

Service Code	MSDRG 196
Min. Negotiated Rate	$14,087.66
Max. Negotiated Rate	$35,856.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,591.42
Rate for Payer: Amerigroup Medicare	$18,591.42
Rate for Payer: BCBS of TX Medicare	$18,591.42
Rate for Payer: Cigna Commercial	$24,307.14
Rate for Payer: Cigna Medicare	$18,591.42
Rate for Payer: Employer Direct Commercial	$18,591.42
Rate for Payer: Humana Medicare/TRICARE	$18,591.42
Rate for Payer: Molina Dual Medicare/Medicaid	$18,591.42
Rate for Payer: Molina Medicare	$18,591.42
Rate for Payer: Multiplan Auto	$35,856.80
Rate for Payer: Multiplan Commercial	$35,856.80
Rate for Payer: Multiplan Workers Comp	$35,856.80
Rate for Payer: Scott and White EPO/PPO	$16,513.00
Rate for Payer: Scott and White Medicare	$18,591.42
Rate for Payer: Superior Health Plan EPO	$18,591.42
Rate for Payer: Superior Health Plan Medicare	$18,591.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,591.42
Rate for Payer: Universal American Medicare	$18,591.42
Rate for Payer: Wellcare Medicare	$18,591.42
Rate for Payer: Wellmed Medicare	$18,591.42

INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC

Facility

$13,607.80

Service Code	MSDRG 198
Min. Negotiated Rate	$6,266.75
Max. Negotiated Rate	$13,607.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,009.13
Rate for Payer: Amerigroup Medicare	$10,009.13
Rate for Payer: BCBS of TX Medicare	$10,009.13
Rate for Payer: Cigna Commercial	$9,224.66
Rate for Payer: Cigna Medicare	$10,009.13
Rate for Payer: Employer Direct Commercial	$10,009.13
Rate for Payer: Humana Medicare/TRICARE	$10,009.13
Rate for Payer: Molina Dual Medicare/Medicaid	$10,009.13
Rate for Payer: Molina Medicare	$10,009.13
Rate for Payer: Multiplan Auto	$13,607.80
Rate for Payer: Multiplan Commercial	$13,607.80
Rate for Payer: Multiplan Workers Comp	$13,607.80
Rate for Payer: Scott and White EPO/PPO	$6,266.75
Rate for Payer: Scott and White Medicare	$10,009.13
Rate for Payer: Superior Health Plan EPO	$10,009.13
Rate for Payer: Superior Health Plan Medicare	$10,009.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,009.13
Rate for Payer: Universal American Medicare	$10,009.13
Rate for Payer: Wellcare Medicare	$10,009.13
Rate for Payer: Wellmed Medicare	$10,009.13

Know your out-of-pocket cost for care.

All Charges