White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$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

$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, 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 & NON-ACUTE LEUKEMIA W CC

Facility

$30,996.60

Service Code	MSDRG 841
Min. Negotiated Rate	$14,059.28
Max. Negotiated Rate	$30,996.60
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

$61,463.10

Service Code	MSDRG 840
Min. Negotiated Rate	$28,305.38
Max. Negotiated Rate	$61,463.10
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

$19,197.60

Service Code	MSDRG 842
Min. Negotiated Rate	$8,841.00
Max. Negotiated Rate	$19,197.60
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

$43,046.40

Service Code	MSDRG 824
Min. Negotiated Rate	$18,871.84
Max. Negotiated Rate	$43,046.40
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

$87,111.20

Service Code	MSDRG 823
Min. Negotiated Rate	$38,362.20
Max. Negotiated Rate	$87,111.20
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

$25,638.60

Service Code	MSDRG 825
Min. Negotiated Rate	$11,687.40
Max. Negotiated Rate	$25,638.60
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
Rate for Payer: Cash Price	$91.80

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

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
Rate for Payer: Cash Price	$2.31

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

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
Rate for Payer: Cash Price	$5.73

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

Magnesium Level SO

Facility

$55.12

Service Code	HCPCS 83735
Hospital Charge Code	1148254
Hospital Revenue Code	301
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$39.69
Rate for Payer: Amerigroup CHIP/Medicaid	$2.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.70
Rate for Payer: Amerigroup Medicare	$6.70
Rate for Payer: BCBS of TX Blue Advantage	$16.54
Rate for Payer: BCBS of TX Blue Essentials	$19.84
Rate for Payer: BCBS of TX Medicare	$6.70
Rate for Payer: BCBS of TX PPO	$22.05
Rate for Payer: Cash Price	$37.48
Rate for Payer: Cash Price	$37.48
Rate for Payer: Cigna Medicaid	$39.69
Rate for Payer: Cigna Medicare	$6.70
Rate for Payer: Employer Direct Commercial	$6.70
Rate for Payer: Humana Medicare/TRICARE	$6.70
Rate for Payer: Molina CHIP/Medicaid	$39.69
Rate for Payer: Molina Dual Medicare/Medicaid	$6.70
Rate for Payer: Molina Medicare	$6.70
Rate for Payer: Multiplan Auto	$35.83
Rate for Payer: Multiplan Commercial	$35.83
Rate for Payer: Multiplan Workers Comp	$35.83
Rate for Payer: Parkland Medicaid	$39.69
Rate for Payer: Scott and White EPO/PPO	$8.38
Rate for Payer: Scott and White Medicare	$6.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.69
Rate for Payer: Superior Health Plan EPO	$6.70
Rate for Payer: Superior Health Plan Medicare	$6.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.70
Rate for Payer: Universal American Medicare	$6.70
Rate for Payer: Wellcare Medicare	$6.70
Rate for Payer: Wellmed Medicare	$6.70

Magnesium Level SO

Facility

$55.12

Service Code	HCPCS 83735
Hospital Charge Code	1148254
Hospital Revenue Code	301
Rate for Payer: Cash Price	$37.48

magnesium oxide 400 mg (241.3 mg elemental magnesium) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77676264
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Know your out-of-pocket cost for care.

All Charges