White Rock Medical Center

All Charges

Charge

Type

Setting

Price

LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$20,970.30

Service Code	MSDRG 842
Min. Negotiated Rate	$9,641.46
Max. Negotiated Rate	$20,970.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,165.34
Rate for Payer: Amerigroup Medicare	$12,165.34
Rate for Payer: BCBS of TX Medicare	$12,165.34
Rate for Payer: Cigna Commercial	$13,013.95
Rate for Payer: Cigna Medicare	$12,165.34
Rate for Payer: Employer Direct Commercial	$12,165.34
Rate for Payer: Humana Medicare/TRICARE	$12,165.34
Rate for Payer: Molina Dual Medicare/Medicaid	$12,165.34
Rate for Payer: Molina Medicare	$12,165.34
Rate for Payer: Multiplan Auto	$20,970.30
Rate for Payer: Multiplan Commercial	$20,970.30
Rate for Payer: Multiplan Workers Comp	$20,970.30
Rate for Payer: Scott and White EPO/PPO	$9,657.38
Rate for Payer: Scott and White Medicare	$12,165.34
Rate for Payer: Superior Health Plan EPO	$12,165.34
Rate for Payer: Superior Health Plan Medicare	$12,165.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,165.34
Rate for Payer: Universal American Medicare	$12,165.34
Rate for Payer: Wellcare Medicare	$12,165.34
Rate for Payer: Wellmed Medicare	$12,165.34

LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W CC

Facility

$41,085.60

Service Code	MSDRG 821
Min. Negotiated Rate	$18,921.00
Max. Negotiated Rate	$41,085.60
Rate for Payer: BCBS of TX Blue Advantage	$20,590.98
Rate for Payer: BCBS of TX Blue Essentials	$24,706.78
Rate for Payer: BCBS of TX PPO	$27,453.04

LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W MCC

Facility

$101,034.40

Service Code	MSDRG 820
Min. Negotiated Rate	$46,529.00
Max. Negotiated Rate	$101,034.40
Rate for Payer: BCBS of TX Blue Advantage	$46,815.82
Rate for Payer: BCBS of TX Blue Essentials	$56,173.54
Rate for Payer: BCBS of TX PPO	$62,417.46

LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W/O CC/MCC

Facility

$22,895.00

Service Code	MSDRG 822
Min. Negotiated Rate	$10,404.28
Max. Negotiated Rate	$22,895.00
Rate for Payer: BCBS of TX Blue Advantage	$10,404.28
Rate for Payer: BCBS of TX Blue Essentials	$12,483.93
Rate for Payer: BCBS of TX PPO	$13,871.57

LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA

Facility

$7,282.39

Service Code	APR-DRG 6912
Min. Negotiated Rate	$6,866.09
Max. Negotiated Rate	$7,282.39
Rate for Payer: Amerigroup CHIP/Medicaid	$6,866.09
Rate for Payer: Cigna Medicaid	$6,866.09
Rate for Payer: Molina CHIP/Medicaid	$6,866.09
Rate for Payer: Parkland Medicaid	$6,866.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,282.39

LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA

Facility

$5,800.41

Service Code	APR-DRG 6911
Min. Negotiated Rate	$5,468.83
Max. Negotiated Rate	$5,800.41
Rate for Payer: Amerigroup CHIP/Medicaid	$5,468.83
Rate for Payer: Cigna Medicaid	$5,468.83
Rate for Payer: Molina CHIP/Medicaid	$5,468.83
Rate for Payer: Parkland Medicaid	$5,468.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,800.41

LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA

Facility

$15,199.21

Service Code	APR-DRG 6913
Min. Negotiated Rate	$14,330.35
Max. Negotiated Rate	$15,199.21
Rate for Payer: Amerigroup CHIP/Medicaid	$14,330.35
Rate for Payer: Cigna Medicaid	$14,330.35
Rate for Payer: Molina CHIP/Medicaid	$14,330.35
Rate for Payer: Parkland Medicaid	$14,330.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,199.21

LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA

Facility

$29,426.78

Service Code	APR-DRG 6914
Min. Negotiated Rate	$27,744.60
Max. Negotiated Rate	$29,426.78
Rate for Payer: Amerigroup CHIP/Medicaid	$27,744.60
Rate for Payer: Cigna Medicaid	$27,744.60
Rate for Payer: Molina CHIP/Medicaid	$27,744.60
Rate for Payer: Parkland Medicaid	$27,744.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,426.78

LYMPHOMA & NON-ACUTE LEUKEMIA W CC

Facility

$30,301.20

Service Code	MSDRG 841
Min. Negotiated Rate	$13,954.50
Max. Negotiated Rate	$30,301.20
Rate for Payer: BCBS of TX Blue Advantage	$14,059.28
Rate for Payer: BCBS of TX Blue Essentials	$16,869.50
Rate for Payer: BCBS of TX PPO	$18,744.62

LYMPHOMA & NON-ACUTE LEUKEMIA W MCC

Facility

$59,033.00

Service Code	MSDRG 840
Min. Negotiated Rate	$27,186.25
Max. Negotiated Rate	$59,033.00
Rate for Payer: BCBS of TX Blue Advantage	$28,318.94
Rate for Payer: BCBS of TX Blue Essentials	$33,979.44
Rate for Payer: BCBS of TX PPO	$37,756.39

LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC/MCC

Facility

$20,970.30

Service Code	MSDRG 842
Min. Negotiated Rate	$9,641.46
Max. Negotiated Rate	$20,970.30
Rate for Payer: BCBS of TX Blue Advantage	$9,641.46
Rate for Payer: BCBS of TX Blue Essentials	$11,568.63
Rate for Payer: BCBS of TX PPO	$12,854.53

LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W CC

Facility

$43,515.70

Service Code	MSDRG 824
Min. Negotiated Rate	$18,871.84
Max. Negotiated Rate	$43,515.70
Rate for Payer: BCBS of TX Blue Advantage	$18,871.84
Rate for Payer: BCBS of TX Blue Essentials	$22,644.01
Rate for Payer: BCBS of TX PPO	$25,160.99

LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W MCC

Facility

$82,201.60

Service Code	MSDRG 823
Min. Negotiated Rate	$37,856.00
Max. Negotiated Rate	$82,201.60
Rate for Payer: BCBS of TX Blue Advantage	$38,911.56
Rate for Payer: BCBS of TX Blue Essentials	$46,689.35
Rate for Payer: BCBS of TX PPO	$51,879.06

LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W/O CC/MCC

Facility

$25,015.40

Service Code	MSDRG 825
Min. Negotiated Rate	$11,520.25
Max. Negotiated Rate	$25,015.40
Rate for Payer: BCBS of TX Blue Advantage	$11,687.40
Rate for Payer: BCBS of TX Blue Essentials	$14,023.52
Rate for Payer: BCBS of TX PPO	$15,582.29

Lysozyme, Serum SO

Facility

$135.00

Service Code	HCPCS 85549
Hospital Charge Code	1740018
Hospital Revenue Code	305
Min. Negotiated Rate	$7.31
Max. Negotiated Rate	$97.20
Rate for Payer: Amerigroup CHIP/Medicaid	$7.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.75
Rate for Payer: Amerigroup Medicare	$18.75
Rate for Payer: BCBS of TX Blue Advantage	$40.50
Rate for Payer: BCBS of TX Blue Essentials	$48.60
Rate for Payer: BCBS of TX Medicare	$18.75
Rate for Payer: BCBS of TX PPO	$54.00
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna Medicaid	$97.20
Rate for Payer: Cigna Medicare	$18.75
Rate for Payer: Employer Direct Commercial	$18.75
Rate for Payer: Humana Medicare/TRICARE	$18.75
Rate for Payer: Molina CHIP/Medicaid	$97.20
Rate for Payer: Molina Dual Medicare/Medicaid	$18.75
Rate for Payer: Molina Medicare	$18.75
Rate for Payer: Multiplan Auto	$87.75
Rate for Payer: Multiplan Commercial	$87.75
Rate for Payer: Multiplan Workers Comp	$87.75
Rate for Payer: Parkland Medicaid	$97.20
Rate for Payer: Scott and White EPO/PPO	$23.44
Rate for Payer: Scott and White Medicare	$18.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.20
Rate for Payer: Superior Health Plan EPO	$18.75
Rate for Payer: Superior Health Plan Medicare	$18.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.75
Rate for Payer: Universal American Medicare	$18.75
Rate for Payer: Wellcare Medicare	$18.75
Rate for Payer: Wellmed Medicare	$18.75

Lysozyme, Serum SO

Facility

$135.00

Service Code	HCPCS 85549
Hospital Charge Code	1740018
Hospital Revenue Code	305
Rate for Payer: Cash Price	$91.80

M003-IgE Aspergillus fumigatus SO

Facility

$74.00

Service Code	HCPCS 86003
Hospital Charge Code	1701028
Hospital Revenue Code	302
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$53.28
Rate for Payer: Amerigroup CHIP/Medicaid	$2.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.22
Rate for Payer: Amerigroup Medicare	$5.22
Rate for Payer: BCBS of TX Blue Advantage	$22.20
Rate for Payer: BCBS of TX Blue Essentials	$26.64
Rate for Payer: BCBS of TX Medicare	$5.22
Rate for Payer: BCBS of TX PPO	$29.60
Rate for Payer: Cash Price	$50.32
Rate for Payer: Cash Price	$50.32
Rate for Payer: Cigna Medicaid	$53.28
Rate for Payer: Cigna Medicare	$5.22
Rate for Payer: Employer Direct Commercial	$5.22
Rate for Payer: Humana Medicare/TRICARE	$5.22
Rate for Payer: Molina CHIP/Medicaid	$53.28
Rate for Payer: Molina Dual Medicare/Medicaid	$5.22
Rate for Payer: Molina Medicare	$5.22
Rate for Payer: Multiplan Auto	$48.10
Rate for Payer: Multiplan Commercial	$48.10
Rate for Payer: Multiplan Workers Comp	$48.10
Rate for Payer: Parkland Medicaid	$53.28
Rate for Payer: Scott and White EPO/PPO	$6.53
Rate for Payer: Scott and White Medicare	$5.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53.28
Rate for Payer: Superior Health Plan EPO	$5.22
Rate for Payer: Superior Health Plan Medicare	$5.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.22
Rate for Payer: Universal American Medicare	$5.22
Rate for Payer: Wellcare Medicare	$5.22
Rate for Payer: Wellmed Medicare	$5.22

M003-IgE Aspergillus fumigatus SO

Facility

$74.00

Service Code	HCPCS 86003
Hospital Charge Code	1701028
Hospital Revenue Code	302
Rate for Payer: Cash Price	$50.32

Macconkey Agar, 15 x 100 mm Petri Plate

Facility

$3.39

Hospital Charge Code	993334
Hospital Revenue Code	272
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$2.44
Rate for Payer: Amerigroup CHIP/Medicaid	$0.31
Rate for Payer: BCBS of TX Blue Advantage	$1.02
Rate for Payer: BCBS of TX Blue Essentials	$1.22
Rate for Payer: BCBS of TX PPO	$1.36
Rate for Payer: Cash Price	$2.31
Rate for Payer: Cigna Medicaid	$2.44
Rate for Payer: Molina CHIP/Medicaid	$2.44
Rate for Payer: Multiplan Auto	$2.20
Rate for Payer: Multiplan Commercial	$2.20
Rate for Payer: Multiplan Workers Comp	$2.20
Rate for Payer: Parkland Medicaid	$2.44
Rate for Payer: Scott and White EPO/PPO	$1.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.44
Rate for Payer: Superior Health Plan EPO	$0.46

Macconkey Agar, 15 x 100 mm Petri Plate

Facility

$3.39

Hospital Charge Code	993334
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2.31

Magic Mouthwash

Facility

$30.00

Service Code	HCPCS J3490
Hospital Charge Code	79096582
Hospital Revenue Code	250
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$21.60
Rate for Payer: Amerigroup CHIP/Medicaid	$2.70
Rate for Payer: BCBS of TX Blue Advantage	$9.00
Rate for Payer: BCBS of TX Blue Essentials	$10.80
Rate for Payer: BCBS of TX PPO	$12.00
Rate for Payer: Cash Price	$20.40
Rate for Payer: Cigna Medicaid	$21.60
Rate for Payer: Molina CHIP/Medicaid	$21.60
Rate for Payer: Multiplan Auto	$19.50
Rate for Payer: Multiplan Commercial	$19.50
Rate for Payer: Multiplan Workers Comp	$19.50
Rate for Payer: Parkland Medicaid	$21.60
Rate for Payer: Scott and White EPO/PPO	$15.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.60
Rate for Payer: Superior Health Plan EPO	$4.08

Magic Mouthwash

Facility

$30.00

Service Code	HCPCS J3490
Hospital Charge Code	79096582
Hospital Revenue Code	250
Rate for Payer: Cash Price	$20.40

magnesium citrate 1.745 g/30 mL Oral Liquid 300 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77675114
Hospital Revenue Code	250
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

magnesium citrate 1.745 g/30 mL Oral Liquid 300 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77675114
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

magnesium hydroxide 8% Oral Susp 30 mL

Facility

$8.43

Service Code	HCPCS J3490
Hospital Charge Code	77675679
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$6.07
Rate for Payer: Amerigroup CHIP/Medicaid	$0.76
Rate for Payer: BCBS of TX Blue Advantage	$2.53
Rate for Payer: BCBS of TX Blue Essentials	$3.03
Rate for Payer: BCBS of TX PPO	$3.37
Rate for Payer: Cash Price	$5.73
Rate for Payer: Cigna Medicaid	$6.07
Rate for Payer: Molina CHIP/Medicaid	$6.07
Rate for Payer: Multiplan Auto	$5.48
Rate for Payer: Multiplan Commercial	$5.48
Rate for Payer: Multiplan Workers Comp	$5.48
Rate for Payer: Parkland Medicaid	$6.07
Rate for Payer: Scott and White EPO/PPO	$4.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.07
Rate for Payer: Superior Health Plan EPO	$1.15

Know your out-of-pocket cost for care.

All Charges