White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Admin Vaccine Charge - Pfizer-BioNTech Biv Boost -> Pfizer-BioNTech Bivalent Booster (12 years and older) - 0124A

Facility

$60.00

Service Code	HCPCS 0124A
Hospital Charge Code	8962549
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

Admin Vaccine Charge - Pfizer-BioNTech Biv Boost -> Pfizer-BioNTech Bivalent Booster (5-11 years old) - 0154A

Facility

$60.00

Service Code	HCPCS 0154A
Hospital Charge Code	8962550
Hospital Revenue Code	771
Rate for Payer: Cash Price	$40.80

Admin Vaccine Charge - Pfizer-BioNTech Biv Boost -> Pfizer-BioNTech Bivalent Booster (5-11 years old) - 0154A

Facility

$60.00

Service Code	HCPCS 0154A
Hospital Charge Code	8962550
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

ADPT CATH -- DHF

Facility

$56.17

Hospital Charge Code	80550007
Hospital Revenue Code	272
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$40.44
Rate for Payer: Amerigroup CHIP/Medicaid	$5.06
Rate for Payer: BCBS of TX Blue Advantage	$16.85
Rate for Payer: BCBS of TX Blue Essentials	$20.22
Rate for Payer: BCBS of TX PPO	$22.47
Rate for Payer: Cash Price	$38.20
Rate for Payer: Cigna Medicaid	$40.44
Rate for Payer: Molina CHIP/Medicaid	$40.44
Rate for Payer: Multiplan Auto	$36.51
Rate for Payer: Multiplan Commercial	$36.51
Rate for Payer: Multiplan Workers Comp	$36.51
Rate for Payer: Parkland Medicaid	$40.44
Rate for Payer: Scott and White EPO/PPO	$28.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.44
Rate for Payer: Superior Health Plan EPO	$7.64

ADPT CATH -- DHF

Facility

$56.17

Hospital Charge Code	80550007
Hospital Revenue Code	272
Rate for Payer: Cash Price	$38.20

ADPT CATH WLL -- DHF

Facility

$87.80

Hospital Charge Code	80410103
Hospital Revenue Code	272
Rate for Payer: Cash Price	$59.70

ADPT CATH WLL -- DHF

Facility

$87.80

Hospital Charge Code	80410103
Hospital Revenue Code	272
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$63.22
Rate for Payer: Amerigroup CHIP/Medicaid	$7.90
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.61
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$59.70
Rate for Payer: Cigna Medicaid	$63.22
Rate for Payer: Molina CHIP/Medicaid	$63.22
Rate for Payer: Multiplan Auto	$57.07
Rate for Payer: Multiplan Commercial	$57.07
Rate for Payer: Multiplan Workers Comp	$57.07
Rate for Payer: Parkland Medicaid	$63.22
Rate for Payer: Scott and White EPO/PPO	$43.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.22
Rate for Payer: Superior Health Plan EPO	$11.94

ADPT LL -- DHF

Facility

$239.05

Hospital Charge Code	80310089
Hospital Revenue Code	272
Rate for Payer: Cash Price	$162.55

ADPT LL -- DHF

Facility

$239.05

Hospital Charge Code	80310089
Hospital Revenue Code	272
Min. Negotiated Rate	$21.51
Max. Negotiated Rate	$172.12
Rate for Payer: Amerigroup CHIP/Medicaid	$21.51
Rate for Payer: BCBS of TX Blue Advantage	$71.72
Rate for Payer: BCBS of TX Blue Essentials	$86.06
Rate for Payer: BCBS of TX PPO	$95.62
Rate for Payer: Cash Price	$162.55
Rate for Payer: Cigna Medicaid	$172.12
Rate for Payer: Molina CHIP/Medicaid	$172.12
Rate for Payer: Multiplan Auto	$155.38
Rate for Payer: Multiplan Commercial	$155.38
Rate for Payer: Multiplan Workers Comp	$155.38
Rate for Payer: Parkland Medicaid	$172.12
Rate for Payer: Scott and White EPO/PPO	$119.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$172.12
Rate for Payer: Superior Health Plan EPO	$32.51

ADPT PORTS -- DHF

Facility

$533.65

Hospital Charge Code	80310105
Hospital Revenue Code	270
Rate for Payer: Cash Price	$362.88

ADPT PORTS -- DHF

Facility

$533.65

Hospital Charge Code	80310105
Hospital Revenue Code	270
Min. Negotiated Rate	$48.03
Max. Negotiated Rate	$384.23
Rate for Payer: Amerigroup CHIP/Medicaid	$48.03
Rate for Payer: BCBS of TX Blue Advantage	$160.09
Rate for Payer: BCBS of TX Blue Essentials	$192.11
Rate for Payer: BCBS of TX PPO	$213.46
Rate for Payer: Cash Price	$362.88
Rate for Payer: Cigna Medicaid	$384.23
Rate for Payer: Molina CHIP/Medicaid	$384.23
Rate for Payer: Multiplan Auto	$346.87
Rate for Payer: Multiplan Commercial	$346.87
Rate for Payer: Multiplan Workers Comp	$346.87
Rate for Payer: Parkland Medicaid	$384.23
Rate for Payer: Scott and White EPO/PPO	$266.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$384.23
Rate for Payer: Superior Health Plan EPO	$72.58

ADPT VENT -- DHF

Facility

$55.15

Hospital Charge Code	82010208
Hospital Revenue Code	270
Rate for Payer: Cash Price	$37.50

ADPT VENT -- DHF

Facility

$55.15

Hospital Charge Code	82010208
Hospital Revenue Code	270
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$39.71
Rate for Payer: Amerigroup CHIP/Medicaid	$4.96
Rate for Payer: BCBS of TX Blue Advantage	$16.55
Rate for Payer: BCBS of TX Blue Essentials	$19.85
Rate for Payer: BCBS of TX PPO	$22.06
Rate for Payer: Cash Price	$37.50
Rate for Payer: Cigna Medicaid	$39.71
Rate for Payer: Molina CHIP/Medicaid	$39.71
Rate for Payer: Multiplan Auto	$35.85
Rate for Payer: Multiplan Commercial	$35.85
Rate for Payer: Multiplan Workers Comp	$35.85
Rate for Payer: Parkland Medicaid	$39.71
Rate for Payer: Scott and White EPO/PPO	$27.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.71
Rate for Payer: Superior Health Plan EPO	$7.50

ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC

Facility

$44,648.10

Service Code	MSDRG 614
Min. Negotiated Rate	$20,326.96
Max. Negotiated Rate	$44,648.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,823.84
Rate for Payer: Amerigroup Medicare	$20,823.84
Rate for Payer: BCBS of TX Medicare	$20,823.84
Rate for Payer: Cigna Commercial	$28,230.38
Rate for Payer: Cigna Medicare	$20,823.84
Rate for Payer: Employer Direct Commercial	$20,823.84
Rate for Payer: Humana Medicare/TRICARE	$20,823.84
Rate for Payer: Molina Dual Medicare/Medicaid	$20,823.84
Rate for Payer: Molina Medicare	$20,823.84
Rate for Payer: Multiplan Auto	$44,648.10
Rate for Payer: Multiplan Commercial	$44,648.10
Rate for Payer: Multiplan Workers Comp	$44,648.10
Rate for Payer: Scott and White EPO/PPO	$20,561.62
Rate for Payer: Scott and White Medicare	$20,823.84
Rate for Payer: Superior Health Plan EPO	$20,823.84
Rate for Payer: Superior Health Plan Medicare	$20,823.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,823.84
Rate for Payer: Universal American Medicare	$20,823.84
Rate for Payer: Wellcare Medicare	$20,823.84
Rate for Payer: Wellmed Medicare	$20,823.84

ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC

Facility

$28,040.20

Service Code	MSDRG 615
Min. Negotiated Rate	$12,738.32
Max. Negotiated Rate	$28,040.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,015.59
Rate for Payer: Amerigroup Medicare	$15,015.59
Rate for Payer: BCBS of TX Medicare	$15,015.59
Rate for Payer: Cigna Commercial	$18,022.98
Rate for Payer: Cigna Medicare	$15,015.59
Rate for Payer: Employer Direct Commercial	$15,015.59
Rate for Payer: Humana Medicare/TRICARE	$15,015.59
Rate for Payer: Molina Dual Medicare/Medicaid	$15,015.59
Rate for Payer: Molina Medicare	$15,015.59
Rate for Payer: Multiplan Auto	$28,040.20
Rate for Payer: Multiplan Commercial	$28,040.20
Rate for Payer: Multiplan Workers Comp	$28,040.20
Rate for Payer: Scott and White EPO/PPO	$12,913.25
Rate for Payer: Scott and White Medicare	$15,015.59
Rate for Payer: Superior Health Plan EPO	$15,015.59
Rate for Payer: Superior Health Plan Medicare	$15,015.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,015.59
Rate for Payer: Universal American Medicare	$15,015.59
Rate for Payer: Wellcare Medicare	$15,015.59
Rate for Payer: Wellmed Medicare	$15,015.59

ADRENALIN 4 MG BAG 250ml

Facility

$128.00

Service Code	HCPCS J1951
Hospital Charge Code	8666508
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$274.47
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$139.88
Rate for Payer: Amerigroup Medicare	$139.88
Rate for Payer: BCBS of TX Blue Advantage	$206.20
Rate for Payer: BCBS of TX Blue Essentials	$247.45
Rate for Payer: BCBS of TX Medicare	$139.88
Rate for Payer: BCBS of TX PPO	$274.47
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Cigna Medicare	$139.88
Rate for Payer: Employer Direct Commercial	$139.88
Rate for Payer: Humana Medicare/TRICARE	$139.88
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Molina Dual Medicare/Medicaid	$139.88
Rate for Payer: Molina Medicare	$139.88
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$164.78
Rate for Payer: Scott and White Medicare	$139.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$139.88
Rate for Payer: Superior Health Plan Medicare	$139.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$139.88
Rate for Payer: Universal American Medicare	$139.88
Rate for Payer: Wellcare Medicare	$139.88
Rate for Payer: Wellmed Medicare	$139.88

ADRENALIN 4 MG BAG 250ml

Facility

$128.00

Service Code	HCPCS J1951
Hospital Charge Code	77646691
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

ADRENALIN 4 MG BAG 250ml

Facility

$128.00

Service Code	HCPCS J1951
Hospital Charge Code	8666508
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

ADRENALIN 4 MG BAG 250ml

Facility

$128.00

Service Code	HCPCS J1951
Hospital Charge Code	77646691
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$274.47
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$139.88
Rate for Payer: Amerigroup Medicare	$139.88
Rate for Payer: BCBS of TX Blue Advantage	$206.20
Rate for Payer: BCBS of TX Blue Essentials	$247.45
Rate for Payer: BCBS of TX Medicare	$139.88
Rate for Payer: BCBS of TX PPO	$274.47
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Cigna Medicare	$139.88
Rate for Payer: Employer Direct Commercial	$139.88
Rate for Payer: Humana Medicare/TRICARE	$139.88
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Molina Dual Medicare/Medicaid	$139.88
Rate for Payer: Molina Medicare	$139.88
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$164.78
Rate for Payer: Scott and White Medicare	$139.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$139.88
Rate for Payer: Superior Health Plan Medicare	$139.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$139.88
Rate for Payer: Universal American Medicare	$139.88
Rate for Payer: Wellcare Medicare	$139.88
Rate for Payer: Wellmed Medicare	$139.88

ADRENAL & PITUITARY PROCEDURES W CC/MCC

Facility

$44,648.10

Service Code	MSDRG 614
Min. Negotiated Rate	$20,326.96
Max. Negotiated Rate	$44,648.10
Rate for Payer: BCBS of TX Blue Advantage	$20,326.96
Rate for Payer: BCBS of TX Blue Essentials	$24,389.99
Rate for Payer: BCBS of TX PPO	$27,101.04

ADRENAL & PITUITARY PROCEDURES W/O CC/MCC

Facility

$28,040.20

Service Code	MSDRG 615
Min. Negotiated Rate	$12,738.32
Max. Negotiated Rate	$28,040.20
Rate for Payer: BCBS of TX Blue Advantage	$12,738.32
Rate for Payer: BCBS of TX Blue Essentials	$15,284.50
Rate for Payer: BCBS of TX PPO	$16,983.44

ADRENAL PROCEDURES

Facility

$26,167.86

Service Code	APR-DRG 4013
Min. Negotiated Rate	$24,671.98
Max. Negotiated Rate	$26,167.86
Rate for Payer: Amerigroup CHIP/Medicaid	$24,671.98
Rate for Payer: Cigna Medicaid	$24,671.98
Rate for Payer: Molina CHIP/Medicaid	$24,671.98
Rate for Payer: Parkland Medicaid	$24,671.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26,167.86

ADRENAL PROCEDURES

Facility

$23,400.43

Service Code	APR-DRG 4014
Min. Negotiated Rate	$22,062.74
Max. Negotiated Rate	$23,400.43
Rate for Payer: Amerigroup CHIP/Medicaid	$22,062.74
Rate for Payer: Cigna Medicaid	$22,062.74
Rate for Payer: Molina CHIP/Medicaid	$22,062.74
Rate for Payer: Parkland Medicaid	$22,062.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,400.43

ADRENAL PROCEDURES

Facility

$7,467.97

Service Code	APR-DRG 4011
Min. Negotiated Rate	$7,041.06
Max. Negotiated Rate	$7,467.97
Rate for Payer: Amerigroup CHIP/Medicaid	$7,041.06
Rate for Payer: Cigna Medicaid	$7,041.06
Rate for Payer: Molina CHIP/Medicaid	$7,041.06
Rate for Payer: Parkland Medicaid	$7,041.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,467.97

ADRENAL PROCEDURES

Facility

$22,299.04

Service Code	APR-DRG 4012
Min. Negotiated Rate	$21,024.31
Max. Negotiated Rate	$22,299.04
Rate for Payer: Amerigroup CHIP/Medicaid	$21,024.31
Rate for Payer: Cigna Medicaid	$21,024.31
Rate for Payer: Molina CHIP/Medicaid	$21,024.31
Rate for Payer: Parkland Medicaid	$21,024.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,299.04

Know your out-of-pocket cost for care.

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