White Rock Medical Center

All Charges

Charge

Type

Setting

Price

AFTERCARE W CC/MCC

Facility

$22,648.00

Service Code	MSDRG 949
Min. Negotiated Rate	$9,857.32
Max. Negotiated Rate	$22,648.00
Rate for Payer: BCBS of TX Blue Advantage	$9,857.32
Rate for Payer: BCBS of TX Blue Essentials	$11,827.64
Rate for Payer: BCBS of TX PPO	$13,142.33

AFTERCARE WITH CC/MCC

Facility

$22,648.00

Service Code	MSDRG 949
Min. Negotiated Rate	$9,857.32
Max. Negotiated Rate	$22,648.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,479.43
Rate for Payer: Amerigroup Medicare	$13,479.43
Rate for Payer: BCBS of TX Medicare	$13,479.43
Rate for Payer: Cigna Commercial	$15,323.34
Rate for Payer: Cigna Medicare	$13,479.43
Rate for Payer: Employer Direct Commercial	$13,479.43
Rate for Payer: Humana Medicare/TRICARE	$13,479.43
Rate for Payer: Molina Dual Medicare/Medicaid	$13,479.43
Rate for Payer: Molina Medicare	$13,479.43
Rate for Payer: Multiplan Auto	$22,648.00
Rate for Payer: Multiplan Commercial	$22,648.00
Rate for Payer: Multiplan Workers Comp	$22,648.00
Rate for Payer: Scott and White EPO/PPO	$10,430.00
Rate for Payer: Scott and White Medicare	$13,479.43
Rate for Payer: Superior Health Plan EPO	$13,479.43
Rate for Payer: Superior Health Plan Medicare	$13,479.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,479.43
Rate for Payer: Universal American Medicare	$13,479.43
Rate for Payer: Wellcare Medicare	$13,479.43
Rate for Payer: Wellmed Medicare	$13,479.43

AFTERCARE WITHOUT CC/MCC

Facility

$13,480.50

Service Code	MSDRG 950
Min. Negotiated Rate	$6,208.12
Max. Negotiated Rate	$13,480.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,360.52
Rate for Payer: Amerigroup Medicare	$9,360.52
Rate for Payer: BCBS of TX Medicare	$9,360.52
Rate for Payer: Cigna Commercial	$8,084.78
Rate for Payer: Cigna Medicare	$9,360.52
Rate for Payer: Employer Direct Commercial	$9,360.52
Rate for Payer: Humana Medicare/TRICARE	$9,360.52
Rate for Payer: Molina Dual Medicare/Medicaid	$9,360.52
Rate for Payer: Molina Medicare	$9,360.52
Rate for Payer: Multiplan Auto	$13,480.50
Rate for Payer: Multiplan Commercial	$13,480.50
Rate for Payer: Multiplan Workers Comp	$13,480.50
Rate for Payer: Scott and White EPO/PPO	$6,208.12
Rate for Payer: Scott and White Medicare	$9,360.52
Rate for Payer: Superior Health Plan EPO	$9,360.52
Rate for Payer: Superior Health Plan Medicare	$9,360.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,360.52
Rate for Payer: Universal American Medicare	$9,360.52
Rate for Payer: Wellcare Medicare	$9,360.52
Rate for Payer: Wellmed Medicare	$9,360.52

AFTERCARE W/O CC/MCC

Facility

$13,480.50

Service Code	MSDRG 950
Min. Negotiated Rate	$6,208.12
Max. Negotiated Rate	$13,480.50
Rate for Payer: BCBS of TX Blue Advantage	$6,406.14
Rate for Payer: BCBS of TX Blue Essentials	$7,686.62
Rate for Payer: BCBS of TX PPO	$8,541.02

AICD GENERATOR PROCEDURES

Facility

$92,644.00

Service Code	MSDRG 245
Min. Negotiated Rate	$38,198.03
Max. Negotiated Rate	$92,644.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$38,198.03
Rate for Payer: Amerigroup Medicare	$38,198.03
Rate for Payer: BCBS of TX Blue Advantage	$43,104.06
Rate for Payer: BCBS of TX Blue Essentials	$51,719.86
Rate for Payer: BCBS of TX Medicare	$38,198.03
Rate for Payer: BCBS of TX PPO	$57,468.74
Rate for Payer: Cigna Commercial	$58,763.71
Rate for Payer: Cigna Medicare	$38,198.03
Rate for Payer: Employer Direct Commercial	$38,198.03
Rate for Payer: Humana Medicare/TRICARE	$38,198.03
Rate for Payer: Molina Dual Medicare/Medicaid	$38,198.03
Rate for Payer: Molina Medicare	$38,198.03
Rate for Payer: Multiplan Auto	$92,644.00
Rate for Payer: Multiplan Commercial	$92,644.00
Rate for Payer: Multiplan Workers Comp	$92,644.00
Rate for Payer: Scott and White EPO/PPO	$42,665.00
Rate for Payer: Scott and White Medicare	$38,198.03
Rate for Payer: Superior Health Plan EPO	$38,198.03
Rate for Payer: Superior Health Plan Medicare	$38,198.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$38,198.03
Rate for Payer: Universal American Medicare	$38,198.03
Rate for Payer: Wellcare Medicare	$38,198.03
Rate for Payer: Wellmed Medicare	$38,198.03

AICD LEAD PROCEDURES

Facility

$64,259.90

Service Code	MSDRG 265
Min. Negotiated Rate	$26,803.62
Max. Negotiated Rate	$64,259.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$31,277.97
Rate for Payer: Amerigroup Medicare	$31,277.97
Rate for Payer: BCBS of TX Blue Advantage	$26,803.62
Rate for Payer: BCBS of TX Blue Essentials	$32,161.23
Rate for Payer: BCBS of TX Medicare	$31,277.97
Rate for Payer: BCBS of TX PPO	$35,736.08
Rate for Payer: Cigna Commercial	$46,602.42
Rate for Payer: Cigna Medicare	$31,277.97
Rate for Payer: Employer Direct Commercial	$31,277.97
Rate for Payer: Humana Medicare/TRICARE	$31,277.97
Rate for Payer: Molina Dual Medicare/Medicaid	$31,277.97
Rate for Payer: Molina Medicare	$31,277.97
Rate for Payer: Multiplan Auto	$64,259.90
Rate for Payer: Multiplan Commercial	$64,259.90
Rate for Payer: Multiplan Workers Comp	$64,259.90
Rate for Payer: Scott and White EPO/PPO	$29,593.38
Rate for Payer: Scott and White Medicare	$31,277.97
Rate for Payer: Superior Health Plan EPO	$31,277.97
Rate for Payer: Superior Health Plan Medicare	$31,277.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$31,277.97
Rate for Payer: Universal American Medicare	$31,277.97
Rate for Payer: Wellcare Medicare	$31,277.97
Rate for Payer: Wellmed Medicare	$31,277.97

AirLife Misty Max 10 Small Volume Disposable Nebulizer with Patient 'Y' Mouthpiece, 7' Oxygen Tubing with Rigid Blue Tip, 6' Flextube, and Bacteria Filter

Facility

$15.44

Hospital Charge Code	993337
Hospital Revenue Code	270
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$11.12
Rate for Payer: Amerigroup CHIP/Medicaid	$1.39
Rate for Payer: BCBS of TX Blue Advantage	$4.63
Rate for Payer: BCBS of TX Blue Essentials	$5.56
Rate for Payer: BCBS of TX PPO	$6.18
Rate for Payer: Cash Price	$10.50
Rate for Payer: Cigna Medicaid	$11.12
Rate for Payer: Molina CHIP/Medicaid	$11.12
Rate for Payer: Multiplan Auto	$10.04
Rate for Payer: Multiplan Commercial	$10.04
Rate for Payer: Multiplan Workers Comp	$10.04
Rate for Payer: Parkland Medicaid	$11.12
Rate for Payer: Scott and White EPO/PPO	$7.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.12
Rate for Payer: Superior Health Plan EPO	$2.10

AirLife Misty Max 10 Small Volume Disposable Nebulizer with Patient 'Y' Mouthpiece, 7' Oxygen Tubing with Rigid Blue Tip, 6' Flextube, and Bacteria Filter

Facility

$15.44

Hospital Charge Code	993337
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10.50

AIRVO TUBE CHMB 10PK

Facility

$223.52

Hospital Charge Code	993569
Hospital Revenue Code	270
Rate for Payer: Cash Price	$151.99

AIRVO TUBE CHMB 10PK

Facility

$223.52

Hospital Charge Code	993569
Hospital Revenue Code	270
Min. Negotiated Rate	$20.12
Max. Negotiated Rate	$160.93
Rate for Payer: Amerigroup CHIP/Medicaid	$20.12
Rate for Payer: BCBS of TX Blue Advantage	$67.06
Rate for Payer: BCBS of TX Blue Essentials	$80.47
Rate for Payer: BCBS of TX PPO	$89.41
Rate for Payer: Cash Price	$151.99
Rate for Payer: Cigna Medicaid	$160.93
Rate for Payer: Molina CHIP/Medicaid	$160.93
Rate for Payer: Multiplan Auto	$145.29
Rate for Payer: Multiplan Commercial	$145.29
Rate for Payer: Multiplan Workers Comp	$145.29
Rate for Payer: Parkland Medicaid	$160.93
Rate for Payer: Scott and White EPO/PPO	$111.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$160.93
Rate for Payer: Superior Health Plan EPO	$30.40

AIRWAY ESPH 4 SPRM LRYNG MSK CUF

Facility

$102.65

Hospital Charge Code	112228
Hospital Revenue Code	272
Rate for Payer: Cash Price	$69.80

AIRWAY ESPH 4 SPRM LRYNG MSK CUF

Facility

$102.65

Hospital Charge Code	112228
Hospital Revenue Code	272
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$73.91
Rate for Payer: Amerigroup CHIP/Medicaid	$9.24
Rate for Payer: BCBS of TX Blue Advantage	$30.80
Rate for Payer: BCBS of TX Blue Essentials	$36.95
Rate for Payer: BCBS of TX PPO	$41.06
Rate for Payer: Cash Price	$69.80
Rate for Payer: Cigna Medicaid	$73.91
Rate for Payer: Molina CHIP/Medicaid	$73.91
Rate for Payer: Multiplan Auto	$66.72
Rate for Payer: Multiplan Commercial	$66.72
Rate for Payer: Multiplan Workers Comp	$66.72
Rate for Payer: Parkland Medicaid	$73.91
Rate for Payer: Scott and White EPO/PPO	$51.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$73.91
Rate for Payer: Superior Health Plan EPO	$13.96

AIRWAY, SIL, CUFF,PILOT BALLON, SZ 5

Facility

$90.04

Hospital Charge Code	992988
Hospital Revenue Code	270
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$64.83
Rate for Payer: Amerigroup CHIP/Medicaid	$8.10
Rate for Payer: BCBS of TX Blue Advantage	$27.01
Rate for Payer: BCBS of TX Blue Essentials	$32.41
Rate for Payer: BCBS of TX PPO	$36.02
Rate for Payer: Cash Price	$61.23
Rate for Payer: Cigna Medicaid	$64.83
Rate for Payer: Molina CHIP/Medicaid	$64.83
Rate for Payer: Multiplan Auto	$58.53
Rate for Payer: Multiplan Commercial	$58.53
Rate for Payer: Multiplan Workers Comp	$58.53
Rate for Payer: Parkland Medicaid	$64.83
Rate for Payer: Scott and White EPO/PPO	$45.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$64.83
Rate for Payer: Superior Health Plan EPO	$12.25

AIRWAY, SIL, CUFF,PILOT BALLON, SZ 5

Facility

$90.04

Hospital Charge Code	992988
Hospital Revenue Code	270
Rate for Payer: Cash Price	$61.23

Alanine Aminotransferase

Facility

$225.00

Service Code	HCPCS 84460
Hospital Charge Code	1602341
Hospital Revenue Code	301
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$162.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2.07
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.30
Rate for Payer: Amerigroup Medicare	$5.30
Rate for Payer: BCBS of TX Blue Advantage	$67.50
Rate for Payer: BCBS of TX Blue Essentials	$81.00
Rate for Payer: BCBS of TX Medicare	$5.30
Rate for Payer: BCBS of TX PPO	$90.00
Rate for Payer: Cash Price	$153.00
Rate for Payer: Cash Price	$153.00
Rate for Payer: Cigna Medicaid	$162.00
Rate for Payer: Cigna Medicare	$5.30
Rate for Payer: Employer Direct Commercial	$5.30
Rate for Payer: Humana Medicare/TRICARE	$5.30
Rate for Payer: Molina CHIP/Medicaid	$162.00
Rate for Payer: Molina Dual Medicare/Medicaid	$5.30
Rate for Payer: Molina Medicare	$5.30
Rate for Payer: Multiplan Auto	$146.25
Rate for Payer: Multiplan Commercial	$146.25
Rate for Payer: Multiplan Workers Comp	$146.25
Rate for Payer: Parkland Medicaid	$162.00
Rate for Payer: Scott and White EPO/PPO	$6.62
Rate for Payer: Scott and White Medicare	$5.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$162.00
Rate for Payer: Superior Health Plan EPO	$5.30
Rate for Payer: Superior Health Plan Medicare	$5.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.30
Rate for Payer: Universal American Medicare	$5.30
Rate for Payer: Wellcare Medicare	$5.30
Rate for Payer: Wellmed Medicare	$5.30

Alanine Aminotransferase

Facility

$225.00

Service Code	HCPCS 84460
Hospital Charge Code	1602341
Hospital Revenue Code	301
Rate for Payer: Cash Price	$153.00

Albumin/Creatinine Ratio,Ur SO

Facility

$226.00

Service Code	HCPCS 82043
Hospital Charge Code	4152044
Hospital Revenue Code	301
Rate for Payer: Cash Price	$153.68

Albumin/Creatinine Ratio,Ur SO

Facility

$226.00

Service Code	HCPCS 82043
Hospital Charge Code	4152044
Hospital Revenue Code	301
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$162.72
Rate for Payer: Amerigroup CHIP/Medicaid	$2.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.78
Rate for Payer: Amerigroup Medicare	$5.78
Rate for Payer: BCBS of TX Blue Advantage	$67.80
Rate for Payer: BCBS of TX Blue Essentials	$81.36
Rate for Payer: BCBS of TX Medicare	$5.78
Rate for Payer: BCBS of TX PPO	$90.40
Rate for Payer: Cash Price	$153.68
Rate for Payer: Cash Price	$153.68
Rate for Payer: Cigna Medicaid	$162.72
Rate for Payer: Cigna Medicare	$5.78
Rate for Payer: Employer Direct Commercial	$5.78
Rate for Payer: Humana Medicare/TRICARE	$5.78
Rate for Payer: Molina CHIP/Medicaid	$162.72
Rate for Payer: Molina Dual Medicare/Medicaid	$5.78
Rate for Payer: Molina Medicare	$5.78
Rate for Payer: Multiplan Auto	$146.90
Rate for Payer: Multiplan Commercial	$146.90
Rate for Payer: Multiplan Workers Comp	$146.90
Rate for Payer: Parkland Medicaid	$162.72
Rate for Payer: Scott and White EPO/PPO	$7.22
Rate for Payer: Scott and White Medicare	$5.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$162.72
Rate for Payer: Superior Health Plan EPO	$5.78
Rate for Payer: Superior Health Plan Medicare	$5.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.78
Rate for Payer: Universal American Medicare	$5.78
Rate for Payer: Wellcare Medicare	$5.78
Rate for Payer: Wellmed Medicare	$5.78

albumin human 25% IV Soln 50 mL

Facility

$128.00

Service Code	HCPCS P9046
Hospital Charge Code	77358389
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

albumin human 25% IV Soln 50 mL

Facility

$128.00

Service Code	HCPCS P9046
Hospital Charge Code	77358389
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.23
Rate for Payer: Amerigroup Medicare	$21.23
Rate for Payer: BCBS of TX Blue Advantage	$36.08
Rate for Payer: BCBS of TX Blue Essentials	$43.29
Rate for Payer: BCBS of TX Medicare	$21.23
Rate for Payer: BCBS of TX PPO	$48.02
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	$21.23
Rate for Payer: Employer Direct Commercial	$21.23
Rate for Payer: Humana Medicare/TRICARE	$21.23
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Molina Dual Medicare/Medicaid	$21.23
Rate for Payer: Molina Medicare	$21.23
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	$26.54
Rate for Payer: Scott and White Medicare	$21.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$21.23
Rate for Payer: Superior Health Plan Medicare	$21.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.23
Rate for Payer: Universal American Medicare	$21.23
Rate for Payer: Wellcare Medicare	$21.23
Rate for Payer: Wellmed Medicare	$21.23

albumin human 5% IV Soln 250 mL

Facility

$128.17

Service Code	HCPCS P9045
Hospital Charge Code	77358503
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

albumin human 5% IV Soln 250 mL

Facility

$128.17

Service Code	HCPCS P9045
Hospital Charge Code	77358503
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$120.07
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$53.08
Rate for Payer: Amerigroup Medicare	$53.08
Rate for Payer: BCBS of TX Blue Advantage	$90.20
Rate for Payer: BCBS of TX Blue Essentials	$108.25
Rate for Payer: BCBS of TX Medicare	$53.08
Rate for Payer: BCBS of TX PPO	$120.07
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Cigna Medicare	$53.08
Rate for Payer: Employer Direct Commercial	$53.08
Rate for Payer: Humana Medicare/TRICARE	$53.08
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Molina Dual Medicare/Medicaid	$53.08
Rate for Payer: Molina Medicare	$53.08
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	$66.35
Rate for Payer: Scott and White Medicare	$53.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$53.08
Rate for Payer: Superior Health Plan Medicare	$53.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$53.08
Rate for Payer: Universal American Medicare	$53.08
Rate for Payer: Wellcare Medicare	$53.08
Rate for Payer: Wellmed Medicare	$53.08

albuterol 2.5 mg/3 mL (0.083%) Inh Soln 3 mL

Facility

$7.65

Service Code	HCPCS J7613
Hospital Charge Code	78403337
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.12
Rate for Payer: BCBS of TX Blue Essentials	$0.14
Rate for Payer: BCBS of TX PPO	$0.15
Rate for Payer: Cash Price	$5.20
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

albuterol 2.5 mg/3 mL (0.083%) Inh Soln 3 mL

Facility

$7.65

Service Code	HCPCS J7613
Hospital Charge Code	78403337
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

albuterol 5 mg/mL (0.5%) Inh Soln

Facility

$7.65

Service Code	HCPCS J7611
Hospital Charge Code	7441648
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

Know your out-of-pocket cost for care.

All Charges