White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MECHE AO - D 2.7 X L 125 MM

Facility

$2,308.43

Service Code	HCPCS C1713
Hospital Charge Code	992406
Hospital Revenue Code	278
Min. Negotiated Rate	$207.76
Max. Negotiated Rate	$1,662.07
Rate for Payer: Amerigroup CHIP/Medicaid	$207.76
Rate for Payer: BCBS of TX Blue Advantage	$692.53
Rate for Payer: BCBS of TX Blue Essentials	$831.03
Rate for Payer: BCBS of TX PPO	$923.37
Rate for Payer: Cash Price	$1,569.73
Rate for Payer: Cigna Medicaid	$1,662.07
Rate for Payer: Molina CHIP/Medicaid	$1,662.07
Rate for Payer: Multiplan Auto	$1,154.21
Rate for Payer: Multiplan Commercial	$1,154.21
Rate for Payer: Multiplan Workers Comp	$1,154.21
Rate for Payer: Parkland Medicaid	$1,662.07
Rate for Payer: Scott and White EPO/PPO	$1,154.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,662.07
Rate for Payer: Superior Health Plan EPO	$313.95

MECHE AO - D 2.7 X L 125 MM

Facility

$2,308.43

Service Code	HCPCS C1713
Hospital Charge Code	992406
Hospital Revenue Code	278
Min. Negotiated Rate	$577.11
Max. Negotiated Rate	$1,154.21
Rate for Payer: Cash Price	$1,569.73
Rate for Payer: Cigna Commercial	$577.11
Rate for Payer: Multiplan Auto	$1,154.21
Rate for Payer: Multiplan Commercial	$1,154.21
Rate for Payer: Multiplan Workers Comp	$1,154.21
Rate for Payer: Scott and White EPO/PPO	$1,154.21

meclizine 12.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77680581
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

meclizine 12.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77680581
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

meclizine 25 mg Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77680634
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

meclizine 25 mg Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77680634
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

MEDIA BLD CULT BTL ANAER

Facility

$39.07

Hospital Charge Code	993457
Hospital Revenue Code	270
Rate for Payer: Cash Price	$26.57

MEDIA BLD CULT BTL ANAER

Facility

$39.07

Hospital Charge Code	993457
Hospital Revenue Code	270
Min. Negotiated Rate	$3.52
Max. Negotiated Rate	$28.13
Rate for Payer: Amerigroup CHIP/Medicaid	$3.52
Rate for Payer: BCBS of TX Blue Advantage	$11.72
Rate for Payer: BCBS of TX Blue Essentials	$14.07
Rate for Payer: BCBS of TX PPO	$15.63
Rate for Payer: Cash Price	$26.57
Rate for Payer: Cigna Medicaid	$28.13
Rate for Payer: Molina CHIP/Medicaid	$28.13
Rate for Payer: Multiplan Auto	$25.40
Rate for Payer: Multiplan Commercial	$25.40
Rate for Payer: Multiplan Workers Comp	$25.40
Rate for Payer: Parkland Medicaid	$28.13
Rate for Payer: Scott and White EPO/PPO	$19.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.13
Rate for Payer: Superior Health Plan EPO	$5.31

MEDIA BLD CULT BTL BC 40ML PLS AERB

Facility

$39.07

Hospital Charge Code	993456
Hospital Revenue Code	270
Min. Negotiated Rate	$3.52
Max. Negotiated Rate	$28.13
Rate for Payer: Amerigroup CHIP/Medicaid	$3.52
Rate for Payer: BCBS of TX Blue Advantage	$11.72
Rate for Payer: BCBS of TX Blue Essentials	$14.07
Rate for Payer: BCBS of TX PPO	$15.63
Rate for Payer: Cash Price	$26.57
Rate for Payer: Cigna Medicaid	$28.13
Rate for Payer: Molina CHIP/Medicaid	$28.13
Rate for Payer: Multiplan Auto	$25.40
Rate for Payer: Multiplan Commercial	$25.40
Rate for Payer: Multiplan Workers Comp	$25.40
Rate for Payer: Parkland Medicaid	$28.13
Rate for Payer: Scott and White EPO/PPO	$19.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.13
Rate for Payer: Superior Health Plan EPO	$5.31

MEDIA BLD CULT BTL BC 40ML PLS AERB

Facility

$39.07

Hospital Charge Code	993456
Hospital Revenue Code	270
Rate for Payer: Cash Price	$26.57

MEDIA MICRO ORGANISM GROWTH BACT/ALERT PF + 30MM

Facility

$29.51

Hospital Charge Code	993551
Hospital Revenue Code	270
Rate for Payer: Cash Price	$20.07

MEDIA MICRO ORGANISM GROWTH BACT/ALERT PF + 30MM

Facility

$29.51

Hospital Charge Code	993551
Hospital Revenue Code	270
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$21.25
Rate for Payer: Amerigroup CHIP/Medicaid	$2.66
Rate for Payer: BCBS of TX Blue Advantage	$8.85
Rate for Payer: BCBS of TX Blue Essentials	$10.62
Rate for Payer: BCBS of TX PPO	$11.80
Rate for Payer: Cash Price	$20.07
Rate for Payer: Cigna Medicaid	$21.25
Rate for Payer: Molina CHIP/Medicaid	$21.25
Rate for Payer: Multiplan Auto	$19.18
Rate for Payer: Multiplan Commercial	$19.18
Rate for Payer: Multiplan Workers Comp	$19.18
Rate for Payer: Parkland Medicaid	$21.25
Rate for Payer: Scott and White EPO/PPO	$14.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.25
Rate for Payer: Superior Health Plan EPO	$4.01

MEDICAL BACK PROBLEMS WITH MCC

Facility

$31,794.60

Service Code	MSDRG 551
Min. Negotiated Rate	$13,687.76
Max. Negotiated Rate	$31,794.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,044.27
Rate for Payer: Amerigroup Medicare	$17,044.27
Rate for Payer: BCBS of TX Medicare	$17,044.27
Rate for Payer: Cigna Commercial	$21,588.17
Rate for Payer: Cigna Medicare	$17,044.27
Rate for Payer: Employer Direct Commercial	$17,044.27
Rate for Payer: Humana Medicare/TRICARE	$17,044.27
Rate for Payer: Molina Dual Medicare/Medicaid	$17,044.27
Rate for Payer: Molina Medicare	$17,044.27
Rate for Payer: Multiplan Auto	$31,794.60
Rate for Payer: Multiplan Commercial	$31,794.60
Rate for Payer: Multiplan Workers Comp	$31,794.60
Rate for Payer: Scott and White EPO/PPO	$14,642.25
Rate for Payer: Scott and White Medicare	$17,044.27
Rate for Payer: Superior Health Plan EPO	$17,044.27
Rate for Payer: Superior Health Plan Medicare	$17,044.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,044.27
Rate for Payer: Universal American Medicare	$17,044.27
Rate for Payer: Wellcare Medicare	$17,044.27
Rate for Payer: Wellmed Medicare	$17,044.27

MEDICAL BACK PROBLEMS WITHOUT MCC

Facility

$18,249.50

Service Code	MSDRG 552
Min. Negotiated Rate	$7,748.60
Max. Negotiated Rate	$18,249.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,805.46
Rate for Payer: Amerigroup Medicare	$11,805.46
Rate for Payer: BCBS of TX Medicare	$11,805.46
Rate for Payer: Cigna Commercial	$12,381.54
Rate for Payer: Cigna Medicare	$11,805.46
Rate for Payer: Employer Direct Commercial	$11,805.46
Rate for Payer: Humana Medicare/TRICARE	$11,805.46
Rate for Payer: Molina Dual Medicare/Medicaid	$11,805.46
Rate for Payer: Molina Medicare	$11,805.46
Rate for Payer: Multiplan Auto	$18,249.50
Rate for Payer: Multiplan Commercial	$18,249.50
Rate for Payer: Multiplan Workers Comp	$18,249.50
Rate for Payer: Scott and White EPO/PPO	$8,404.38
Rate for Payer: Scott and White Medicare	$11,805.46
Rate for Payer: Superior Health Plan EPO	$11,805.46
Rate for Payer: Superior Health Plan Medicare	$11,805.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,805.46
Rate for Payer: Universal American Medicare	$11,805.46
Rate for Payer: Wellcare Medicare	$11,805.46
Rate for Payer: Wellmed Medicare	$11,805.46

MEDICAL BACK PROBLEMS W MCC

Facility

$31,794.60

Service Code	MSDRG 551
Min. Negotiated Rate	$13,687.76
Max. Negotiated Rate	$31,794.60
Rate for Payer: BCBS of TX Blue Advantage	$13,687.76
Rate for Payer: BCBS of TX Blue Essentials	$16,423.72
Rate for Payer: BCBS of TX PPO	$18,249.29

MEDICAL BACK PROBLEMS W/O MCC

Facility

$18,249.50

Service Code	MSDRG 552
Min. Negotiated Rate	$7,748.60
Max. Negotiated Rate	$18,249.50
Rate for Payer: BCBS of TX Blue Advantage	$7,748.60
Rate for Payer: BCBS of TX Blue Essentials	$9,297.42
Rate for Payer: BCBS of TX PPO	$10,330.87

Medical Nutrition Therapy Intl 15 min

Facility

$120.00

Service Code	HCPCS 97802
Hospital Charge Code	8500183
Hospital Revenue Code	942
Rate for Payer: Cash Price	$81.60

Medical Nutrition Therapy Intl 15 min

Facility

$120.00

Service Code	HCPCS 97802
Hospital Charge Code	8500183
Hospital Revenue Code	942
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$86.40
Rate for Payer: Amerigroup CHIP/Medicaid	$10.80
Rate for Payer: BCBS of TX Blue Advantage	$36.00
Rate for Payer: BCBS of TX Blue Essentials	$43.20
Rate for Payer: BCBS of TX PPO	$48.00
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna Medicaid	$86.40
Rate for Payer: Molina CHIP/Medicaid	$86.40
Rate for Payer: Multiplan Auto	$78.00
Rate for Payer: Multiplan Commercial	$78.00
Rate for Payer: Multiplan Workers Comp	$78.00
Rate for Payer: Parkland Medicaid	$86.40
Rate for Payer: Scott and White EPO/PPO	$39.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.40
Rate for Payer: Superior Health Plan EPO	$16.32

Medical/Surgical Supplies and Devices - General Classification

Facility

$14,400.00

Service Code	HCPCS A4649
Hospital Charge Code	994094
Hospital Revenue Code	270
Rate for Payer: Cash Price	$9,792.00

Medical/Surgical Supplies and Devices - General Classification

Facility

$14,400.00

Service Code	HCPCS A4649
Hospital Charge Code	994094
Hospital Revenue Code	270
Min. Negotiated Rate	$1,296.00
Max. Negotiated Rate	$10,368.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,296.00
Rate for Payer: BCBS of TX Blue Advantage	$4,320.00
Rate for Payer: BCBS of TX Blue Essentials	$5,184.00
Rate for Payer: BCBS of TX PPO	$5,760.00
Rate for Payer: Cash Price	$9,792.00
Rate for Payer: Cigna Medicaid	$10,368.00
Rate for Payer: Molina CHIP/Medicaid	$10,368.00
Rate for Payer: Multiplan Auto	$9,360.00
Rate for Payer: Multiplan Commercial	$9,360.00
Rate for Payer: Multiplan Workers Comp	$9,360.00
Rate for Payer: Parkland Medicaid	$10,368.00
Rate for Payer: Scott and White EPO/PPO	$7,200.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,368.00
Rate for Payer: Superior Health Plan EPO	$1,958.40

Medical/Surgical Supplies and Devices - Sterile Supply

Facility

$10,224.40

Service Code	HCPCS A4649
Hospital Charge Code	994093
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6,952.59

Medical/Surgical Supplies and Devices - Sterile Supply

Facility

$10,224.40

Service Code	HCPCS A4649
Hospital Charge Code	994093
Hospital Revenue Code	272
Min. Negotiated Rate	$920.20
Max. Negotiated Rate	$7,361.57
Rate for Payer: Amerigroup CHIP/Medicaid	$920.20
Rate for Payer: BCBS of TX Blue Advantage	$3,067.32
Rate for Payer: BCBS of TX Blue Essentials	$3,680.78
Rate for Payer: BCBS of TX PPO	$4,089.76
Rate for Payer: Cash Price	$6,952.59
Rate for Payer: Cigna Medicaid	$7,361.57
Rate for Payer: Molina CHIP/Medicaid	$7,361.57
Rate for Payer: Multiplan Auto	$6,645.86
Rate for Payer: Multiplan Commercial	$6,645.86
Rate for Payer: Multiplan Workers Comp	$6,645.86
Rate for Payer: Parkland Medicaid	$7,361.57
Rate for Payer: Scott and White EPO/PPO	$5,112.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,361.57
Rate for Payer: Superior Health Plan EPO	$1,390.52

MEDIUM ROCKER SHOE - LOING

Facility

$10,859.68

Hospital Charge Code	993663
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7,384.58

MEDIUM ROCKER SHOE - LOING

Facility

$10,859.68

Hospital Charge Code	993663
Hospital Revenue Code	272
Min. Negotiated Rate	$977.37
Max. Negotiated Rate	$7,818.97
Rate for Payer: Amerigroup CHIP/Medicaid	$977.37
Rate for Payer: BCBS of TX Blue Advantage	$3,257.90
Rate for Payer: BCBS of TX Blue Essentials	$3,909.48
Rate for Payer: BCBS of TX PPO	$4,343.87
Rate for Payer: Cash Price	$7,384.58
Rate for Payer: Cigna Medicaid	$7,818.97
Rate for Payer: Molina CHIP/Medicaid	$7,818.97
Rate for Payer: Multiplan Auto	$7,058.79
Rate for Payer: Multiplan Commercial	$7,058.79
Rate for Payer: Multiplan Workers Comp	$7,058.79
Rate for Payer: Parkland Medicaid	$7,818.97
Rate for Payer: Scott and White EPO/PPO	$5,429.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,818.97
Rate for Payer: Superior Health Plan EPO	$1,476.92

Medline frame headrest positioner, 6' high with 10.75 x 9.75 base

Facility

$53.64

Hospital Charge Code	992932
Hospital Revenue Code	270
Min. Negotiated Rate	$4.83
Max. Negotiated Rate	$38.62
Rate for Payer: Amerigroup CHIP/Medicaid	$4.83
Rate for Payer: BCBS of TX Blue Advantage	$16.09
Rate for Payer: BCBS of TX Blue Essentials	$19.31
Rate for Payer: BCBS of TX PPO	$21.46
Rate for Payer: Cash Price	$36.48
Rate for Payer: Cigna Medicaid	$38.62
Rate for Payer: Molina CHIP/Medicaid	$38.62
Rate for Payer: Multiplan Auto	$34.87
Rate for Payer: Multiplan Commercial	$34.87
Rate for Payer: Multiplan Workers Comp	$34.87
Rate for Payer: Parkland Medicaid	$38.62
Rate for Payer: Scott and White EPO/PPO	$26.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.62
Rate for Payer: Superior Health Plan EPO	$7.30

Know your out-of-pocket cost for care.

All Charges