White Rock Medical Center

All Charges

Charge

Type

Setting

Price

albuterol CFC free 90 mcg/inh Aerosol 6.7 g

Facility

$42.00

Service Code	HCPCS J7612
Hospital Charge Code	1212
Hospital Revenue Code	636
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$30.24
Rate for Payer: Amerigroup CHIP/Medicaid	$3.78
Rate for Payer: BCBS of TX Blue Advantage	$2.23
Rate for Payer: BCBS of TX Blue Essentials	$2.68
Rate for Payer: BCBS of TX PPO	$2.97
Rate for Payer: Cash Price	$28.56
Rate for Payer: Cash Price	$28.56
Rate for Payer: Cigna Medicaid	$30.24
Rate for Payer: Molina CHIP/Medicaid	$30.24
Rate for Payer: Multiplan Auto	$27.30
Rate for Payer: Multiplan Commercial	$27.30
Rate for Payer: Multiplan Workers Comp	$27.30
Rate for Payer: Parkland Medicaid	$30.24
Rate for Payer: Scott and White EPO/PPO	$21.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.24
Rate for Payer: Superior Health Plan EPO	$5.71

albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Inh Soln 3 mL

Facility

$7.65

Service Code	HCPCS J7620
Hospital Charge Code	7441656
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.35
Rate for Payer: BCBS of TX Blue Essentials	$0.42
Rate for Payer: BCBS of TX PPO	$0.46
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-ipratropium 2.5 mg-0.5 mg/3 mL Inh Soln 3 mL

Facility

$7.65

Service Code	HCPCS J7620
Hospital Charge Code	77360082
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.35
Rate for Payer: BCBS of TX Blue Essentials	$0.42
Rate for Payer: BCBS of TX PPO	$0.46
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-ipratropium 2.5 mg-0.5 mg/3 mL Inh Soln 3 mL

Facility

$7.65

Service Code	HCPCS J7620
Hospital Charge Code	7441656
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Inh Soln 3 mL

Facility

$7.65

Service Code	HCPCS J7620
Hospital Charge Code	77360082
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Alcohol

Facility

$184.00

Service Code	HCPCS 80320
Hospital Charge Code	8486566
Hospital Revenue Code	301
Min. Negotiated Rate	$4.37
Max. Negotiated Rate	$132.48
Rate for Payer: Amerigroup CHIP/Medicaid	$4.37
Rate for Payer: BCBS of TX Blue Advantage	$55.20
Rate for Payer: BCBS of TX Blue Essentials	$66.24
Rate for Payer: BCBS of TX PPO	$73.60
Rate for Payer: Cash Price	$125.12
Rate for Payer: Cash Price	$125.12
Rate for Payer: Cigna Medicaid	$132.48
Rate for Payer: Molina CHIP/Medicaid	$132.48
Rate for Payer: Multiplan Auto	$119.60
Rate for Payer: Multiplan Commercial	$119.60
Rate for Payer: Multiplan Workers Comp	$119.60
Rate for Payer: Parkland Medicaid	$132.48
Rate for Payer: Scott and White EPO/PPO	$92.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.48
Rate for Payer: Superior Health Plan EPO	$25.02

Alcohol

Facility

$184.00

Service Code	HCPCS 80320
Hospital Charge Code	8486566
Hospital Revenue Code	301
Rate for Payer: Cash Price	$125.12

ALCOHOL ABUSE AND DEPENDENCE

Facility

$1,919.51

Service Code	APR-DRG 7751
Min. Negotiated Rate	$1,809.79
Max. Negotiated Rate	$1,919.51
Rate for Payer: Amerigroup CHIP/Medicaid	$1,809.79
Rate for Payer: Cigna Medicaid	$1,809.79
Rate for Payer: Molina CHIP/Medicaid	$1,809.79
Rate for Payer: Parkland Medicaid	$1,809.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,919.51

ALCOHOL ABUSE AND DEPENDENCE

Facility

$2,594.68

Service Code	APR-DRG 7752
Min. Negotiated Rate	$2,446.36
Max. Negotiated Rate	$2,594.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2,446.36
Rate for Payer: Cigna Medicaid	$2,446.36
Rate for Payer: Molina CHIP/Medicaid	$2,446.36
Rate for Payer: Parkland Medicaid	$2,446.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,594.68

ALCOHOL ABUSE AND DEPENDENCE

Facility

$4,565.12

Service Code	APR-DRG 7753
Min. Negotiated Rate	$4,304.15
Max. Negotiated Rate	$4,565.12
Rate for Payer: Amerigroup CHIP/Medicaid	$4,304.15
Rate for Payer: Cigna Medicaid	$4,304.15
Rate for Payer: Molina CHIP/Medicaid	$4,304.15
Rate for Payer: Parkland Medicaid	$4,304.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,565.12

ALCOHOL ABUSE AND DEPENDENCE

Facility

$8,333.99

Service Code	APR-DRG 7754
Min. Negotiated Rate	$7,857.58
Max. Negotiated Rate	$8,333.99
Rate for Payer: Amerigroup CHIP/Medicaid	$7,857.58
Rate for Payer: Cigna Medicaid	$7,857.58
Rate for Payer: Molina CHIP/Medicaid	$7,857.58
Rate for Payer: Parkland Medicaid	$7,857.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,333.99

ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY

Facility

$1,682.64

Service Code	APR-DRG 7722
Min. Negotiated Rate	$1,586.45
Max. Negotiated Rate	$1,682.64
Rate for Payer: Amerigroup CHIP/Medicaid	$1,586.45
Rate for Payer: Cigna Medicaid	$1,586.45
Rate for Payer: Molina CHIP/Medicaid	$1,586.45
Rate for Payer: Parkland Medicaid	$1,586.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,682.64

ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY

Facility

$1,419.74

Service Code	APR-DRG 7721
Min. Negotiated Rate	$1,338.58
Max. Negotiated Rate	$1,419.74
Rate for Payer: Amerigroup CHIP/Medicaid	$1,338.58
Rate for Payer: Cigna Medicaid	$1,338.58
Rate for Payer: Molina CHIP/Medicaid	$1,338.58
Rate for Payer: Parkland Medicaid	$1,338.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,419.74

ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY

Facility

$2,149.98

Service Code	APR-DRG 7723
Min. Negotiated Rate	$2,027.07
Max. Negotiated Rate	$2,149.98
Rate for Payer: Amerigroup CHIP/Medicaid	$2,027.07
Rate for Payer: Cigna Medicaid	$2,027.07
Rate for Payer: Molina CHIP/Medicaid	$2,027.07
Rate for Payer: Parkland Medicaid	$2,027.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,149.98

ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY

Facility

$12,303.91

Service Code	APR-DRG 7724
Min. Negotiated Rate	$11,600.55
Max. Negotiated Rate	$12,303.91
Rate for Payer: Amerigroup CHIP/Medicaid	$11,600.55
Rate for Payer: Cigna Medicaid	$11,600.55
Rate for Payer: Molina CHIP/Medicaid	$11,600.55
Rate for Payer: Parkland Medicaid	$11,600.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,303.91

ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA

Facility

$11,721.10

Service Code	MSDRG 894
Min. Negotiated Rate	$4,445.34
Max. Negotiated Rate	$11,721.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,281.36
Rate for Payer: Amerigroup Medicare	$9,281.36
Rate for Payer: BCBS of TX Medicare	$9,281.36
Rate for Payer: Cigna Commercial	$7,945.67
Rate for Payer: Cigna Medicare	$9,281.36
Rate for Payer: Employer Direct Commercial	$9,281.36
Rate for Payer: Molina Dual Medicare/Medicaid	$9,281.36
Rate for Payer: Molina Medicare	$9,281.36
Rate for Payer: Multiplan Auto	$11,721.10
Rate for Payer: Multiplan Commercial	$11,721.10
Rate for Payer: Multiplan Workers Comp	$11,721.10
Rate for Payer: Scott and White EPO/PPO	$5,397.88
Rate for Payer: Scott and White Medicare	$9,281.36
Rate for Payer: Superior Health Plan EPO	$9,281.36
Rate for Payer: Superior Health Plan Medicare	$9,281.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,281.36
Rate for Payer: Universal American Medicare	$9,281.36
Rate for Payer: Wellcare Medicare	$9,281.36
Rate for Payer: Wellmed Medicare	$9,281.36

ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA

Facility

$11,721.10

Service Code	MSDRG 894
Min. Negotiated Rate	$4,445.34
Max. Negotiated Rate	$11,721.10
Rate for Payer: BCBS of TX Blue Advantage	$4,445.34
Rate for Payer: BCBS of TX Blue Essentials	$5,333.89
Rate for Payer: BCBS of TX PPO	$5,926.78

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC

Facility

$33,156.90

Service Code	MSDRG 896
Min. Negotiated Rate	$15,022.48
Max. Negotiated Rate	$33,156.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,549.96
Rate for Payer: Amerigroup Medicare	$17,549.96
Rate for Payer: BCBS of TX Medicare	$17,549.96
Rate for Payer: Cigna Commercial	$22,476.89
Rate for Payer: Cigna Medicare	$17,549.96
Rate for Payer: Employer Direct Commercial	$17,549.96
Rate for Payer: Molina Dual Medicare/Medicaid	$17,549.96
Rate for Payer: Molina Medicare	$17,549.96
Rate for Payer: Multiplan Auto	$33,156.90
Rate for Payer: Multiplan Commercial	$33,156.90
Rate for Payer: Multiplan Workers Comp	$33,156.90
Rate for Payer: Scott and White EPO/PPO	$15,269.62
Rate for Payer: Scott and White Medicare	$17,549.96
Rate for Payer: Superior Health Plan EPO	$17,549.96
Rate for Payer: Superior Health Plan Medicare	$17,549.96
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,549.96
Rate for Payer: Universal American Medicare	$17,549.96
Rate for Payer: Wellcare Medicare	$17,549.96
Rate for Payer: Wellmed Medicare	$17,549.96

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC

Facility

$16,773.20

Service Code	MSDRG 897
Min. Negotiated Rate	$7,058.88
Max. Negotiated Rate	$16,773.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,230.15
Rate for Payer: Amerigroup Medicare	$11,230.15
Rate for Payer: BCBS of TX Medicare	$11,230.15
Rate for Payer: Cigna Commercial	$11,370.46
Rate for Payer: Cigna Medicare	$11,230.15
Rate for Payer: Employer Direct Commercial	$11,230.15
Rate for Payer: Molina Dual Medicare/Medicaid	$11,230.15
Rate for Payer: Molina Medicare	$11,230.15
Rate for Payer: Multiplan Auto	$16,773.20
Rate for Payer: Multiplan Commercial	$16,773.20
Rate for Payer: Multiplan Workers Comp	$16,773.20
Rate for Payer: Scott and White EPO/PPO	$7,724.50
Rate for Payer: Scott and White Medicare	$11,230.15
Rate for Payer: Superior Health Plan EPO	$11,230.15
Rate for Payer: Superior Health Plan Medicare	$11,230.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,230.15
Rate for Payer: Universal American Medicare	$11,230.15
Rate for Payer: Wellcare Medicare	$11,230.15
Rate for Payer: Wellmed Medicare	$11,230.15

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY

Facility

$26,896.40

Service Code	MSDRG 895
Min. Negotiated Rate	$12,322.08
Max. Negotiated Rate	$26,896.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,135.05
Rate for Payer: Amerigroup Medicare	$15,135.05
Rate for Payer: BCBS of TX Medicare	$15,135.05
Rate for Payer: Cigna Commercial	$18,232.93
Rate for Payer: Cigna Medicare	$15,135.05
Rate for Payer: Employer Direct Commercial	$15,135.05
Rate for Payer: Humana Medicare/TRICARE	$15,135.05
Rate for Payer: Molina Dual Medicare/Medicaid	$15,135.05
Rate for Payer: Molina Medicare	$15,135.05
Rate for Payer: Multiplan Auto	$26,896.40
Rate for Payer: Multiplan Commercial	$26,896.40
Rate for Payer: Multiplan Workers Comp	$26,896.40
Rate for Payer: Scott and White EPO/PPO	$12,386.50
Rate for Payer: Scott and White Medicare	$15,135.05
Rate for Payer: Superior Health Plan EPO	$15,135.05
Rate for Payer: Superior Health Plan Medicare	$15,135.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,135.05
Rate for Payer: Universal American Medicare	$15,135.05
Rate for Payer: Wellcare Medicare	$15,135.05
Rate for Payer: Wellmed Medicare	$15,135.05

ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC

Facility

$33,156.90

Service Code	MSDRG 896
Min. Negotiated Rate	$15,022.48
Max. Negotiated Rate	$33,156.90
Rate for Payer: BCBS of TX Blue Advantage	$15,022.48
Rate for Payer: BCBS of TX Blue Essentials	$18,025.23
Rate for Payer: BCBS of TX PPO	$20,028.81

ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC

Facility

$16,773.20

Service Code	MSDRG 897
Min. Negotiated Rate	$7,058.88
Max. Negotiated Rate	$16,773.20
Rate for Payer: BCBS of TX Blue Advantage	$7,058.88
Rate for Payer: BCBS of TX Blue Essentials	$8,469.84
Rate for Payer: BCBS of TX PPO	$9,411.29

ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY

Facility

$26,896.40

Service Code	MSDRG 895
Min. Negotiated Rate	$12,322.08
Max. Negotiated Rate	$26,896.40
Rate for Payer: BCBS of TX Blue Advantage	$12,322.08
Rate for Payer: BCBS of TX Blue Essentials	$14,785.06
Rate for Payer: BCBS of TX PPO	$16,428.48

Alcohol (ethanol); any specimen except urine and breath, immunoassay

Facility

$150.00

Service Code	HCPCS 82077
Hospital Charge Code	994116
Hospital Revenue Code	301
Min. Negotiated Rate	$6.74
Max. Negotiated Rate	$108.00
Rate for Payer: Amerigroup CHIP/Medicaid	$6.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.27
Rate for Payer: Amerigroup Medicare	$17.27
Rate for Payer: BCBS of TX Blue Advantage	$45.00
Rate for Payer: BCBS of TX Blue Essentials	$54.00
Rate for Payer: BCBS of TX Medicare	$17.27
Rate for Payer: BCBS of TX PPO	$60.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cigna Medicaid	$108.00
Rate for Payer: Cigna Medicare	$17.27
Rate for Payer: Employer Direct Commercial	$17.27
Rate for Payer: Humana Medicare/TRICARE	$17.27
Rate for Payer: Molina CHIP/Medicaid	$108.00
Rate for Payer: Molina Dual Medicare/Medicaid	$17.27
Rate for Payer: Molina Medicare	$17.27
Rate for Payer: Multiplan Auto	$97.50
Rate for Payer: Multiplan Commercial	$97.50
Rate for Payer: Multiplan Workers Comp	$97.50
Rate for Payer: Parkland Medicaid	$108.00
Rate for Payer: Scott and White EPO/PPO	$21.59
Rate for Payer: Scott and White Medicare	$17.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.00
Rate for Payer: Superior Health Plan EPO	$17.27
Rate for Payer: Superior Health Plan Medicare	$17.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.27
Rate for Payer: Universal American Medicare	$17.27
Rate for Payer: Wellcare Medicare	$17.27
Rate for Payer: Wellmed Medicare	$17.27

Alcohol (ethanol); any specimen except urine and breath, immunoassay

Facility

$150.00

Service Code	HCPCS 82077
Hospital Charge Code	994116
Hospital Revenue Code	301
Rate for Payer: Cash Price	$102.00

Know your out-of-pocket cost for care.

All Charges