White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC

Facility

$14,785.80

Service Code	MSDRG 641
Min. Negotiated Rate	$6,466.34
Max. Negotiated Rate	$14,785.80
Rate for Payer: BCBS of TX Blue Advantage	$6,466.34
Rate for Payer: BCBS of TX Blue Essentials	$7,758.86
Rate for Payer: BCBS of TX PPO	$8,621.29

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC

Facility

$25,376.40

Service Code	MSDRG 640
Min. Negotiated Rate	$10,235.72
Max. Negotiated Rate	$25,376.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,548.73
Rate for Payer: Amerigroup Medicare	$14,548.73
Rate for Payer: BCBS of TX Medicare	$14,548.73
Rate for Payer: Cigna Commercial	$17,202.53
Rate for Payer: Cigna Medicare	$14,548.73
Rate for Payer: Employer Direct Commercial	$14,548.73
Rate for Payer: Humana Medicare/TRICARE	$14,548.73
Rate for Payer: Molina Dual Medicare/Medicaid	$14,548.73
Rate for Payer: Molina Medicare	$14,548.73
Rate for Payer: Multiplan Auto	$25,376.40
Rate for Payer: Multiplan Commercial	$25,376.40
Rate for Payer: Multiplan Workers Comp	$25,376.40
Rate for Payer: Scott and White EPO/PPO	$11,686.50
Rate for Payer: Scott and White Medicare	$14,548.73
Rate for Payer: Superior Health Plan EPO	$14,548.73
Rate for Payer: Superior Health Plan Medicare	$14,548.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,548.73
Rate for Payer: Universal American Medicare	$14,548.73
Rate for Payer: Wellcare Medicare	$14,548.73
Rate for Payer: Wellmed Medicare	$14,548.73

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC

Facility

$14,785.80

Service Code	MSDRG 641
Min. Negotiated Rate	$6,466.34
Max. Negotiated Rate	$14,785.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,463.53
Rate for Payer: Amerigroup Medicare	$10,463.53
Rate for Payer: BCBS of TX Medicare	$10,463.53
Rate for Payer: Cigna Commercial	$10,023.22
Rate for Payer: Cigna Medicare	$10,463.53
Rate for Payer: Employer Direct Commercial	$10,463.53
Rate for Payer: Humana Medicare/TRICARE	$10,463.53
Rate for Payer: Molina Dual Medicare/Medicaid	$10,463.53
Rate for Payer: Molina Medicare	$10,463.53
Rate for Payer: Multiplan Auto	$14,785.80
Rate for Payer: Multiplan Commercial	$14,785.80
Rate for Payer: Multiplan Workers Comp	$14,785.80
Rate for Payer: Scott and White EPO/PPO	$6,809.25
Rate for Payer: Scott and White Medicare	$10,463.53
Rate for Payer: Superior Health Plan EPO	$10,463.53
Rate for Payer: Superior Health Plan Medicare	$10,463.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,463.53
Rate for Payer: Universal American Medicare	$10,463.53
Rate for Payer: Wellcare Medicare	$10,463.53
Rate for Payer: Wellmed Medicare	$10,463.53

Misc Supply-12BSGEC60A

Facility

$662.65

Service Code	HCPCS A4649
Hospital Charge Code	991068
Hospital Revenue Code	272
Rate for Payer: Cash Price	$450.60

Misc Supply-12BSGEC60A

Facility

$662.65

Service Code	HCPCS A4649
Hospital Charge Code	991068
Hospital Revenue Code	272
Min. Negotiated Rate	$59.64
Max. Negotiated Rate	$477.11
Rate for Payer: Amerigroup CHIP/Medicaid	$59.64
Rate for Payer: BCBS of TX Blue Advantage	$198.79
Rate for Payer: BCBS of TX Blue Essentials	$238.55
Rate for Payer: BCBS of TX PPO	$265.06
Rate for Payer: Cash Price	$450.60
Rate for Payer: Cigna Medicaid	$477.11
Rate for Payer: Molina CHIP/Medicaid	$477.11
Rate for Payer: Multiplan Auto	$430.72
Rate for Payer: Multiplan Commercial	$430.72
Rate for Payer: Multiplan Workers Comp	$430.72
Rate for Payer: Parkland Medicaid	$477.11
Rate for Payer: Scott and White EPO/PPO	$331.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$477.11
Rate for Payer: Superior Health Plan EPO	$90.12

Misc Supply-200138107S200138108S

Facility

$1,198.80

Service Code	HCPCS A4649
Hospital Charge Code	991082
Hospital Revenue Code	272
Rate for Payer: Cash Price	$815.18

Misc Supply-200138107S200138108S

Facility

$1,296.50

Service Code	HCPCS A4649
Hospital Charge Code	991052
Hospital Revenue Code	272
Min. Negotiated Rate	$116.69
Max. Negotiated Rate	$933.48
Rate for Payer: Amerigroup CHIP/Medicaid	$116.69
Rate for Payer: BCBS of TX Blue Advantage	$388.95
Rate for Payer: BCBS of TX Blue Essentials	$466.74
Rate for Payer: BCBS of TX PPO	$518.60
Rate for Payer: Cash Price	$881.62
Rate for Payer: Cigna Medicaid	$933.48
Rate for Payer: Molina CHIP/Medicaid	$933.48
Rate for Payer: Multiplan Auto	$842.73
Rate for Payer: Multiplan Commercial	$842.73
Rate for Payer: Multiplan Workers Comp	$842.73
Rate for Payer: Parkland Medicaid	$933.48
Rate for Payer: Scott and White EPO/PPO	$648.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$933.48
Rate for Payer: Superior Health Plan EPO	$176.32

Misc Supply-200138107S200138108S

Facility

$1,296.50

Service Code	HCPCS A4649
Hospital Charge Code	991052
Hospital Revenue Code	272
Rate for Payer: Cash Price	$881.62

Misc Supply-200138107S200138108S

Facility

$1,198.80

Service Code	HCPCS A4649
Hospital Charge Code	991082
Hospital Revenue Code	272
Min. Negotiated Rate	$107.89
Max. Negotiated Rate	$863.14
Rate for Payer: Amerigroup CHIP/Medicaid	$107.89
Rate for Payer: BCBS of TX Blue Advantage	$359.64
Rate for Payer: BCBS of TX Blue Essentials	$431.57
Rate for Payer: BCBS of TX PPO	$479.52
Rate for Payer: Cash Price	$815.18
Rate for Payer: Cigna Medicaid	$863.14
Rate for Payer: Molina CHIP/Medicaid	$863.14
Rate for Payer: Multiplan Auto	$779.22
Rate for Payer: Multiplan Commercial	$779.22
Rate for Payer: Multiplan Workers Comp	$779.22
Rate for Payer: Parkland Medicaid	$863.14
Rate for Payer: Scott and White EPO/PPO	$599.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$863.14
Rate for Payer: Superior Health Plan EPO	$163.04

Misc Supply-200178003

Facility

$843.37

Service Code	HCPCS A4649
Hospital Charge Code	991083
Hospital Revenue Code	272
Rate for Payer: Cash Price	$573.49

Misc Supply-200178003

Facility

$843.37

Service Code	HCPCS A4649
Hospital Charge Code	991083
Hospital Revenue Code	272
Min. Negotiated Rate	$75.90
Max. Negotiated Rate	$607.23
Rate for Payer: Amerigroup CHIP/Medicaid	$75.90
Rate for Payer: BCBS of TX Blue Advantage	$253.01
Rate for Payer: BCBS of TX Blue Essentials	$303.61
Rate for Payer: BCBS of TX PPO	$337.35
Rate for Payer: Cash Price	$573.49
Rate for Payer: Cigna Medicaid	$607.23
Rate for Payer: Molina CHIP/Medicaid	$607.23
Rate for Payer: Multiplan Auto	$548.19
Rate for Payer: Multiplan Commercial	$548.19
Rate for Payer: Multiplan Workers Comp	$548.19
Rate for Payer: Parkland Medicaid	$607.23
Rate for Payer: Scott and White EPO/PPO	$421.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$607.23
Rate for Payer: Superior Health Plan EPO	$114.70

Misc Supply-200424010

Facility

$1,536.14

Service Code	HCPCS A4649
Hospital Charge Code	991085
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,044.58

Misc Supply-200424010

Facility

$1,536.14

Service Code	HCPCS A4649
Hospital Charge Code	991085
Hospital Revenue Code	272
Min. Negotiated Rate	$138.25
Max. Negotiated Rate	$1,106.02
Rate for Payer: Amerigroup CHIP/Medicaid	$138.25
Rate for Payer: BCBS of TX Blue Advantage	$460.84
Rate for Payer: BCBS of TX Blue Essentials	$553.01
Rate for Payer: BCBS of TX PPO	$614.46
Rate for Payer: Cash Price	$1,044.58
Rate for Payer: Cigna Medicaid	$1,106.02
Rate for Payer: Molina CHIP/Medicaid	$1,106.02
Rate for Payer: Multiplan Auto	$998.49
Rate for Payer: Multiplan Commercial	$998.49
Rate for Payer: Multiplan Workers Comp	$998.49
Rate for Payer: Parkland Medicaid	$1,106.02
Rate for Payer: Scott and White EPO/PPO	$768.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,106.02
Rate for Payer: Superior Health Plan EPO	$208.92

Misc Supply-4933-1-010

Facility

$162.65

Service Code	HCPCS A4649
Hospital Charge Code	991099
Hospital Revenue Code	272
Rate for Payer: Cash Price	$110.60

Misc Supply-4933-1-010

Facility

$162.65

Service Code	HCPCS A4649
Hospital Charge Code	991099
Hospital Revenue Code	272
Min. Negotiated Rate	$14.64
Max. Negotiated Rate	$117.11
Rate for Payer: Amerigroup CHIP/Medicaid	$14.64
Rate for Payer: BCBS of TX Blue Advantage	$48.80
Rate for Payer: BCBS of TX Blue Essentials	$58.55
Rate for Payer: BCBS of TX PPO	$65.06
Rate for Payer: Cash Price	$110.60
Rate for Payer: Cigna Medicaid	$117.11
Rate for Payer: Molina CHIP/Medicaid	$117.11
Rate for Payer: Multiplan Auto	$105.72
Rate for Payer: Multiplan Commercial	$105.72
Rate for Payer: Multiplan Workers Comp	$105.72
Rate for Payer: Parkland Medicaid	$117.11
Rate for Payer: Scott and White EPO/PPO	$81.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$117.11
Rate for Payer: Superior Health Plan EPO	$22.12

Misc Supply-6191-1-001

Facility

$572.59

Service Code	HCPCS A4649
Hospital Charge Code	991110
Hospital Revenue Code	272
Rate for Payer: Cash Price	$389.36

Misc Supply-6191-1-001

Facility

$572.59

Service Code	HCPCS A4649
Hospital Charge Code	991110
Hospital Revenue Code	272
Min. Negotiated Rate	$51.53
Max. Negotiated Rate	$412.26
Rate for Payer: Amerigroup CHIP/Medicaid	$51.53
Rate for Payer: BCBS of TX Blue Advantage	$171.78
Rate for Payer: BCBS of TX Blue Essentials	$206.13
Rate for Payer: BCBS of TX PPO	$229.04
Rate for Payer: Cash Price	$389.36
Rate for Payer: Cigna Medicaid	$412.26
Rate for Payer: Molina CHIP/Medicaid	$412.26
Rate for Payer: Multiplan Auto	$372.18
Rate for Payer: Multiplan Commercial	$372.18
Rate for Payer: Multiplan Workers Comp	$372.18
Rate for Payer: Parkland Medicaid	$412.26
Rate for Payer: Scott and White EPO/PPO	$286.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$412.26
Rate for Payer: Superior Health Plan EPO	$77.87

Misc Supply-703961703694703690

Facility

$1,373.49

Service Code	HCPCS A4649
Hospital Charge Code	994143
Hospital Revenue Code	272
Rate for Payer: Cash Price	$933.97

Misc Supply-703961703694703690

Facility

$1,373.49

Service Code	HCPCS A4649
Hospital Charge Code	994143
Hospital Revenue Code	272
Min. Negotiated Rate	$123.61
Max. Negotiated Rate	$988.91
Rate for Payer: Amerigroup CHIP/Medicaid	$123.61
Rate for Payer: BCBS of TX Blue Advantage	$412.05
Rate for Payer: BCBS of TX Blue Essentials	$494.46
Rate for Payer: BCBS of TX PPO	$549.40
Rate for Payer: Cash Price	$933.97
Rate for Payer: Cigna Medicaid	$988.91
Rate for Payer: Molina CHIP/Medicaid	$988.91
Rate for Payer: Multiplan Auto	$892.77
Rate for Payer: Multiplan Commercial	$892.77
Rate for Payer: Multiplan Workers Comp	$892.77
Rate for Payer: Parkland Medicaid	$988.91
Rate for Payer: Scott and White EPO/PPO	$686.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$988.91
Rate for Payer: Superior Health Plan EPO	$186.79

Misc Supply-703961703694703690

Facility

$14.46

Service Code	HCPCS A4649
Hospital Charge Code	994095
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.83

Misc Supply-703961703694703690

Facility

$14.46

Service Code	HCPCS A4649
Hospital Charge Code	994095
Hospital Revenue Code	272
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$10.41
Rate for Payer: Amerigroup CHIP/Medicaid	$1.30
Rate for Payer: BCBS of TX Blue Advantage	$4.34
Rate for Payer: BCBS of TX Blue Essentials	$5.21
Rate for Payer: BCBS of TX PPO	$5.78
Rate for Payer: Cash Price	$9.83
Rate for Payer: Cigna Medicaid	$10.41
Rate for Payer: Molina CHIP/Medicaid	$10.41
Rate for Payer: Multiplan Auto	$9.40
Rate for Payer: Multiplan Commercial	$9.40
Rate for Payer: Multiplan Workers Comp	$9.40
Rate for Payer: Parkland Medicaid	$10.41
Rate for Payer: Scott and White EPO/PPO	$7.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.41
Rate for Payer: Superior Health Plan EPO	$1.97

Misc Supply-71631121

Facility

$5,012.04

Service Code	HCPCS A4649
Hospital Charge Code	994137
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,408.19

Misc Supply-71631121

Facility

$5,012.04

Service Code	HCPCS A4649
Hospital Charge Code	994137
Hospital Revenue Code	272
Min. Negotiated Rate	$451.08
Max. Negotiated Rate	$3,608.67
Rate for Payer: Amerigroup CHIP/Medicaid	$451.08
Rate for Payer: BCBS of TX Blue Advantage	$1,503.61
Rate for Payer: BCBS of TX Blue Essentials	$1,804.33
Rate for Payer: BCBS of TX PPO	$2,004.82
Rate for Payer: Cash Price	$3,408.19
Rate for Payer: Cigna Medicaid	$3,608.67
Rate for Payer: Molina CHIP/Medicaid	$3,608.67
Rate for Payer: Multiplan Auto	$3,257.83
Rate for Payer: Multiplan Commercial	$3,257.83
Rate for Payer: Multiplan Workers Comp	$3,257.83
Rate for Payer: Parkland Medicaid	$3,608.67
Rate for Payer: Scott and White EPO/PPO	$2,506.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,608.67
Rate for Payer: Superior Health Plan EPO	$681.64

Misc Supply-71631121-2

Facility

$3,632.53

Service Code	HCPCS A4649
Hospital Charge Code	994138
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,470.12

Misc Supply-71631121-2

Facility

$3,632.53

Service Code	HCPCS A4649
Hospital Charge Code	994138
Hospital Revenue Code	272
Min. Negotiated Rate	$326.93
Max. Negotiated Rate	$2,615.42
Rate for Payer: Amerigroup CHIP/Medicaid	$326.93
Rate for Payer: BCBS of TX Blue Advantage	$1,089.76
Rate for Payer: BCBS of TX Blue Essentials	$1,307.71
Rate for Payer: BCBS of TX PPO	$1,453.01
Rate for Payer: Cash Price	$2,470.12
Rate for Payer: Cigna Medicaid	$2,615.42
Rate for Payer: Molina CHIP/Medicaid	$2,615.42
Rate for Payer: Multiplan Auto	$2,361.14
Rate for Payer: Multiplan Commercial	$2,361.14
Rate for Payer: Multiplan Workers Comp	$2,361.14
Rate for Payer: Parkland Medicaid	$2,615.42
Rate for Payer: Scott and White EPO/PPO	$1,816.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,615.42
Rate for Payer: Superior Health Plan EPO	$494.02

Know your out-of-pocket cost for care.

All Charges