White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ACUTE & SUBACUTE ENDOCARDITIS W MCC

Facility

$51,233.50

Service Code	MSDRG 288
Min. Negotiated Rate	$23,169.26
Max. Negotiated Rate	$51,233.50
Rate for Payer: BCBS of TX Blue Advantage	$23,169.26
Rate for Payer: BCBS of TX Blue Essentials	$27,800.42
Rate for Payer: BCBS of TX PPO	$30,890.55

ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC

Facility

$22,908.30

Service Code	MSDRG 290
Min. Negotiated Rate	$8,698.04
Max. Negotiated Rate	$22,908.30
Rate for Payer: BCBS of TX Blue Advantage	$8,698.04
Rate for Payer: BCBS of TX Blue Essentials	$10,436.64
Rate for Payer: BCBS of TX PPO	$11,596.71

acyclovir 200 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77356308
Hospital Revenue Code	636
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

acyclovir 200 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77356308
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.83

acyclovir 50 mg/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J0133
Hospital Charge Code	77356795
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.17
Rate for Payer: BCBS of TX Blue Essentials	$0.21
Rate for Payer: BCBS of TX PPO	$0.23
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

acyclovir 50 mg/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J0133
Hospital Charge Code	77356795
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

acyclovir 5% Topical Oint 15 g

Facility

$681.95

Service Code	HCPCS J3490
Hospital Charge Code	77356575
Hospital Revenue Code	250
Min. Negotiated Rate	$61.38
Max. Negotiated Rate	$491.00
Rate for Payer: Amerigroup CHIP/Medicaid	$61.38
Rate for Payer: BCBS of TX Blue Advantage	$204.59
Rate for Payer: BCBS of TX Blue Essentials	$245.50
Rate for Payer: BCBS of TX PPO	$272.78
Rate for Payer: Cash Price	$463.73
Rate for Payer: Cigna Medicaid	$491.00
Rate for Payer: Molina CHIP/Medicaid	$491.00
Rate for Payer: Multiplan Auto	$443.27
Rate for Payer: Multiplan Commercial	$443.27
Rate for Payer: Multiplan Workers Comp	$443.27
Rate for Payer: Parkland Medicaid	$491.00
Rate for Payer: Scott and White EPO/PPO	$340.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$491.00
Rate for Payer: Superior Health Plan EPO	$92.75

acyclovir 5% Topical Oint 15 g

Facility

$681.95

Service Code	HCPCS J3490
Hospital Charge Code	77356575
Hospital Revenue Code	250
Rate for Payer: Cash Price	$463.73

acyclovir 800 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77356911
Hospital Revenue Code	636
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

acyclovir 800 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77356911
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

ADAMTS13 Activity SO

Facility

$149.00

Service Code	HCPCS 85397
Hospital Charge Code	1709989
Hospital Revenue Code	305
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$107.28
Rate for Payer: Amerigroup CHIP/Medicaid	$12.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30.86
Rate for Payer: Amerigroup Medicare	$30.86
Rate for Payer: BCBS of TX Blue Advantage	$44.70
Rate for Payer: BCBS of TX Blue Essentials	$53.64
Rate for Payer: BCBS of TX Medicare	$30.86
Rate for Payer: BCBS of TX PPO	$59.60
Rate for Payer: Cash Price	$101.32
Rate for Payer: Cash Price	$101.32
Rate for Payer: Cigna Medicaid	$107.28
Rate for Payer: Cigna Medicare	$30.86
Rate for Payer: Employer Direct Commercial	$30.86
Rate for Payer: Humana Medicare/TRICARE	$30.86
Rate for Payer: Molina CHIP/Medicaid	$107.28
Rate for Payer: Molina Dual Medicare/Medicaid	$30.86
Rate for Payer: Molina Medicare	$30.86
Rate for Payer: Multiplan Auto	$96.85
Rate for Payer: Multiplan Commercial	$96.85
Rate for Payer: Multiplan Workers Comp	$96.85
Rate for Payer: Parkland Medicaid	$107.28
Rate for Payer: Scott and White EPO/PPO	$38.58
Rate for Payer: Scott and White Medicare	$30.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$107.28
Rate for Payer: Superior Health Plan EPO	$30.86
Rate for Payer: Superior Health Plan Medicare	$30.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$30.86
Rate for Payer: Universal American Medicare	$30.86
Rate for Payer: Wellcare Medicare	$30.86
Rate for Payer: Wellmed Medicare	$30.86

ADAMTS13 Activity SO

Facility

$149.00

Service Code	HCPCS 85397
Hospital Charge Code	1709989
Hospital Revenue Code	305
Rate for Payer: Cash Price	$101.32

ADAPTER, CUVETTE CO2 ADULT DISPOSABLE

Facility

$9.96

Hospital Charge Code	993547
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.77

ADAPTER, CUVETTE CO2 ADULT DISPOSABLE

Facility

$9.96

Hospital Charge Code	993547
Hospital Revenue Code	270
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$7.17
Rate for Payer: Amerigroup CHIP/Medicaid	$0.90
Rate for Payer: BCBS of TX Blue Advantage	$2.99
Rate for Payer: BCBS of TX Blue Essentials	$3.59
Rate for Payer: BCBS of TX PPO	$3.98
Rate for Payer: Cash Price	$6.77
Rate for Payer: Cigna Medicaid	$7.17
Rate for Payer: Molina CHIP/Medicaid	$7.17
Rate for Payer: Multiplan Auto	$6.47
Rate for Payer: Multiplan Commercial	$6.47
Rate for Payer: Multiplan Workers Comp	$6.47
Rate for Payer: Parkland Medicaid	$7.17
Rate for Payer: Scott and White EPO/PPO	$4.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.17
Rate for Payer: Superior Health Plan EPO	$1.35

ADAPTER TEE 22MM ID X 22MM OD FOR MISTY NEBULIZER

Facility

$6.63

Hospital Charge Code	993211
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.51

ADAPTER TEE 22MM ID X 22MM OD FOR MISTY NEBULIZER

Facility

$6.63

Hospital Charge Code	993211
Hospital Revenue Code	270
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$4.77
Rate for Payer: Amerigroup CHIP/Medicaid	$0.60
Rate for Payer: BCBS of TX Blue Advantage	$1.99
Rate for Payer: BCBS of TX Blue Essentials	$2.39
Rate for Payer: BCBS of TX PPO	$2.65
Rate for Payer: Cash Price	$4.51
Rate for Payer: Cigna Medicaid	$4.77
Rate for Payer: Molina CHIP/Medicaid	$4.77
Rate for Payer: Multiplan Auto	$4.31
Rate for Payer: Multiplan Commercial	$4.31
Rate for Payer: Multiplan Workers Comp	$4.31
Rate for Payer: Parkland Medicaid	$4.77
Rate for Payer: Scott and White EPO/PPO	$3.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.77
Rate for Payer: Superior Health Plan EPO	$0.90

ADAPTER WRLSS CLL AND SRVC

Facility

$2,043.00

Hospital Charge Code	130246
Hospital Revenue Code	270
Min. Negotiated Rate	$183.87
Max. Negotiated Rate	$1,470.96
Rate for Payer: Amerigroup CHIP/Medicaid	$183.87
Rate for Payer: BCBS of TX Blue Advantage	$612.90
Rate for Payer: BCBS of TX Blue Essentials	$735.48
Rate for Payer: BCBS of TX PPO	$817.20
Rate for Payer: Cash Price	$1,389.24
Rate for Payer: Cigna Medicaid	$1,470.96
Rate for Payer: Molina CHIP/Medicaid	$1,470.96
Rate for Payer: Multiplan Auto	$1,327.95
Rate for Payer: Multiplan Commercial	$1,327.95
Rate for Payer: Multiplan Workers Comp	$1,327.95
Rate for Payer: Parkland Medicaid	$1,470.96
Rate for Payer: Scott and White EPO/PPO	$1,021.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,470.96
Rate for Payer: Superior Health Plan EPO	$277.85

ADAPTER WRLSS CLL AND SRVC

Facility

$2,043.00

Hospital Charge Code	130246
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,389.24

ADAPT EZ-SQUEEZE PREM PASTE 2 OZ

Facility

$19.70

Hospital Charge Code	993223
Hospital Revenue Code	270
Rate for Payer: Cash Price	$13.40

ADAPT EZ-SQUEEZE PREM PASTE 2 OZ

Facility

$19.70

Hospital Charge Code	993223
Hospital Revenue Code	270
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$14.18
Rate for Payer: Amerigroup CHIP/Medicaid	$1.77
Rate for Payer: BCBS of TX Blue Advantage	$5.91
Rate for Payer: BCBS of TX Blue Essentials	$7.09
Rate for Payer: BCBS of TX PPO	$7.88
Rate for Payer: Cash Price	$13.40
Rate for Payer: Cigna Medicaid	$14.18
Rate for Payer: Molina CHIP/Medicaid	$14.18
Rate for Payer: Multiplan Auto	$12.80
Rate for Payer: Multiplan Commercial	$12.80
Rate for Payer: Multiplan Workers Comp	$12.80
Rate for Payer: Parkland Medicaid	$14.18
Rate for Payer: Scott and White EPO/PPO	$9.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.18
Rate for Payer: Superior Health Plan EPO	$2.68

Adenoidectomy, primary age 12 or over

Facility

$10,000.00

Service Code	CPT 42831
Hospital Charge Code	36042831
Hospital Revenue Code	360
Min. Negotiated Rate	$886.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Amerigroup Medicare	$3,330.57
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicare	$3,330.57
Rate for Payer: Employer Direct Commercial	$3,330.57
Rate for Payer: Humana Medicare/TRICARE	$3,330.57
Rate for Payer: Molina Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Molina Medicare	$3,330.57
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 EPO/PPO	$5,447.31
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan EPO	$3,330.57
Rate for Payer: Superior Health Plan Medicare	$3,330.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Universal American Medicare	$3,330.57
Rate for Payer: Wellcare Medicare	$3,330.57
Rate for Payer: Wellmed Medicare	$3,330.57

Adenoidectomy, primary age 12 or over

Facility

$9,577.37

Service Code	HCPCS 42831
Hospital Charge Code	9900664
Hospital Revenue Code	360
Min. Negotiated Rate	$886.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Amerigroup Medicare	$3,330.57
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cash Price	$6,512.61
Rate for Payer: Cash Price	$6,512.61
Rate for Payer: Cash Price	$6,512.61
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicaid	$6,895.71
Rate for Payer: Cigna Medicare	$3,330.57
Rate for Payer: Employer Direct Commercial	$3,330.57
Rate for Payer: Humana Medicare/TRICARE	$3,330.57
Rate for Payer: Molina CHIP/Medicaid	$6,895.71
Rate for Payer: Molina Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Molina Medicare	$3,330.57
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	$6,895.71
Rate for Payer: Scott and White EPO/PPO	$5,447.31
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,895.71
Rate for Payer: Superior Health Plan EPO	$3,330.57
Rate for Payer: Superior Health Plan Medicare	$3,330.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Universal American Medicare	$3,330.57
Rate for Payer: Wellcare Medicare	$3,330.57
Rate for Payer: Wellmed Medicare	$3,330.57

Adenoidectomy, primary age 12 or over

Facility

$9,577.37

Service Code	HCPCS 42831
Hospital Charge Code	9900664
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,512.61

adenosine 3 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J0153
Hospital Charge Code	77357431
Hospital Revenue Code	636
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.83
Rate for Payer: BCBS of TX Blue Essentials	$2.19
Rate for Payer: BCBS of TX PPO	$2.43
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

adenosine 3 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J0153
Hospital Charge Code	7602
Hospital Revenue Code	636
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.83
Rate for Payer: BCBS of TX Blue Essentials	$2.19
Rate for Payer: BCBS of TX PPO	$2.43
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

Know your out-of-pocket cost for care.

All Charges