White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Misc Supply-71631436

Facility

$2,933.73

Service Code	HCPCS A4649
Hospital Charge Code	994136
Hospital Revenue Code	272
Min. Negotiated Rate	$264.04
Max. Negotiated Rate	$2,112.29
Rate for Payer: Amerigroup CHIP/Medicaid	$264.04
Rate for Payer: BCBS of TX Blue Advantage	$880.12
Rate for Payer: BCBS of TX Blue Essentials	$1,056.14
Rate for Payer: BCBS of TX PPO	$1,173.49
Rate for Payer: Cash Price	$1,994.94
Rate for Payer: Cigna Medicaid	$2,112.29
Rate for Payer: Molina CHIP/Medicaid	$2,112.29
Rate for Payer: Multiplan Auto	$1,906.92
Rate for Payer: Multiplan Commercial	$1,906.92
Rate for Payer: Multiplan Workers Comp	$1,906.92
Rate for Payer: Parkland Medicaid	$2,112.29
Rate for Payer: Scott and White EPO/PPO	$1,466.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,112.29
Rate for Payer: Superior Health Plan EPO	$398.99

Misc Supply-71631436

Facility

$2,933.73

Service Code	HCPCS A4649
Hospital Charge Code	994136
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,994.94

Misc Supply-AR-8916-06

Facility

$189.24

Service Code	HCPCS A4649
Hospital Charge Code	994220
Hospital Revenue Code	272
Rate for Payer: Cash Price	$128.68

Misc Supply-AR-8916-06

Facility

$189.24

Service Code	HCPCS A4649
Hospital Charge Code	994220
Hospital Revenue Code	272
Min. Negotiated Rate	$17.03
Max. Negotiated Rate	$136.25
Rate for Payer: Amerigroup CHIP/Medicaid	$17.03
Rate for Payer: BCBS of TX Blue Advantage	$56.77
Rate for Payer: BCBS of TX Blue Essentials	$68.13
Rate for Payer: BCBS of TX PPO	$75.70
Rate for Payer: Cash Price	$128.68
Rate for Payer: Cigna Medicaid	$136.25
Rate for Payer: Molina CHIP/Medicaid	$136.25
Rate for Payer: Multiplan Auto	$123.01
Rate for Payer: Multiplan Commercial	$123.01
Rate for Payer: Multiplan Workers Comp	$123.01
Rate for Payer: Parkland Medicaid	$136.25
Rate for Payer: Scott and White EPO/PPO	$94.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$136.25
Rate for Payer: Superior Health Plan EPO	$25.74

Misc Supply-AR-8916-14

Facility

$219.12

Service Code	HCPCS A4649
Hospital Charge Code	994221
Hospital Revenue Code	272
Rate for Payer: Cash Price	$149.00

Misc Supply-AR-8916-14

Facility

$219.12

Service Code	HCPCS A4649
Hospital Charge Code	994221
Hospital Revenue Code	272
Min. Negotiated Rate	$19.72
Max. Negotiated Rate	$157.77
Rate for Payer: Amerigroup CHIP/Medicaid	$19.72
Rate for Payer: BCBS of TX Blue Advantage	$65.74
Rate for Payer: BCBS of TX Blue Essentials	$78.88
Rate for Payer: BCBS of TX PPO	$87.65
Rate for Payer: Cash Price	$149.00
Rate for Payer: Cigna Medicaid	$157.77
Rate for Payer: Molina CHIP/Medicaid	$157.77
Rate for Payer: Multiplan Auto	$142.43
Rate for Payer: Multiplan Commercial	$142.43
Rate for Payer: Multiplan Workers Comp	$142.43
Rate for Payer: Parkland Medicaid	$157.77
Rate for Payer: Scott and White EPO/PPO	$109.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$157.77
Rate for Payer: Superior Health Plan EPO	$29.80

MITSUBISHI HD PRINTER PAPER, 110MM X 21M

Facility

$182.51

Hospital Charge Code	993821
Hospital Revenue Code	270
Min. Negotiated Rate	$16.43
Max. Negotiated Rate	$131.41
Rate for Payer: Amerigroup CHIP/Medicaid	$16.43
Rate for Payer: BCBS of TX Blue Advantage	$54.75
Rate for Payer: BCBS of TX Blue Essentials	$65.70
Rate for Payer: BCBS of TX PPO	$73.00
Rate for Payer: Cash Price	$124.11
Rate for Payer: Cigna Medicaid	$131.41
Rate for Payer: Molina CHIP/Medicaid	$131.41
Rate for Payer: Multiplan Auto	$118.63
Rate for Payer: Multiplan Commercial	$118.63
Rate for Payer: Multiplan Workers Comp	$118.63
Rate for Payer: Parkland Medicaid	$131.41
Rate for Payer: Scott and White EPO/PPO	$91.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.41
Rate for Payer: Superior Health Plan EPO	$24.82

MITSUBISHI HD PRINTER PAPER, 110MM X 21M

Facility

$182.51

Hospital Charge Code	993821
Hospital Revenue Code	270
Rate for Payer: Cash Price	$124.11

modafinil 100 mg Tab

Facility

$38.00

Service Code	HCPCS J3490
Hospital Charge Code	77709492
Hospital Revenue Code	250
Min. Negotiated Rate	$3.42
Max. Negotiated Rate	$27.36
Rate for Payer: Amerigroup CHIP/Medicaid	$3.42
Rate for Payer: BCBS of TX Blue Advantage	$11.40
Rate for Payer: BCBS of TX Blue Essentials	$13.68
Rate for Payer: BCBS of TX PPO	$15.20
Rate for Payer: Cash Price	$25.84
Rate for Payer: Cigna Medicaid	$27.36
Rate for Payer: Molina CHIP/Medicaid	$27.36
Rate for Payer: Multiplan Auto	$24.70
Rate for Payer: Multiplan Commercial	$24.70
Rate for Payer: Multiplan Workers Comp	$24.70
Rate for Payer: Parkland Medicaid	$27.36
Rate for Payer: Scott and White EPO/PPO	$19.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.36
Rate for Payer: Superior Health Plan EPO	$5.17

modafinil 100 mg Tab

Facility

$38.00

Service Code	HCPCS J3490
Hospital Charge Code	77709492
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.84

MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$17,402.37

Service Code	APR-DRG 7933
Min. Negotiated Rate	$16,407.56
Max. Negotiated Rate	$17,402.37
Rate for Payer: Amerigroup CHIP/Medicaid	$16,407.56
Rate for Payer: Cigna Medicaid	$16,407.56
Rate for Payer: Molina CHIP/Medicaid	$16,407.56
Rate for Payer: Parkland Medicaid	$16,407.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,402.37

MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$22,758.83

Service Code	APR-DRG 7934
Min. Negotiated Rate	$21,457.82
Max. Negotiated Rate	$22,758.83
Rate for Payer: Amerigroup CHIP/Medicaid	$21,457.82
Rate for Payer: Cigna Medicaid	$21,457.82
Rate for Payer: Molina CHIP/Medicaid	$21,457.82
Rate for Payer: Parkland Medicaid	$21,457.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,758.83

MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$3,725.87

Service Code	APR-DRG 7931
Min. Negotiated Rate	$3,512.88
Max. Negotiated Rate	$3,725.87
Rate for Payer: Amerigroup CHIP/Medicaid	$3,512.88
Rate for Payer: Cigna Medicaid	$3,512.88
Rate for Payer: Molina CHIP/Medicaid	$3,512.88
Rate for Payer: Parkland Medicaid	$3,512.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,725.87

MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$6,939.15

Service Code	APR-DRG 7932
Min. Negotiated Rate	$6,542.47
Max. Negotiated Rate	$6,939.15
Rate for Payer: Amerigroup CHIP/Medicaid	$6,542.47
Rate for Payer: Cigna Medicaid	$6,542.47
Rate for Payer: Molina CHIP/Medicaid	$6,542.47
Rate for Payer: Parkland Medicaid	$6,542.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,939.15

MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$31,069.81

Service Code	APR-DRG 9514
Min. Negotiated Rate	$29,293.71
Max. Negotiated Rate	$31,069.81
Rate for Payer: Amerigroup CHIP/Medicaid	$29,293.71
Rate for Payer: Cigna Medicaid	$29,293.71
Rate for Payer: Molina CHIP/Medicaid	$29,293.71
Rate for Payer: Parkland Medicaid	$29,293.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31,069.81

MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$6,513.68

Service Code	APR-DRG 9512
Min. Negotiated Rate	$6,141.32
Max. Negotiated Rate	$6,513.68
Rate for Payer: Amerigroup CHIP/Medicaid	$6,141.32
Rate for Payer: Cigna Medicaid	$6,141.32
Rate for Payer: Molina CHIP/Medicaid	$6,141.32
Rate for Payer: Parkland Medicaid	$6,141.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,513.68

MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$4,344.46

Service Code	APR-DRG 9511
Min. Negotiated Rate	$4,096.11
Max. Negotiated Rate	$4,344.46
Rate for Payer: Amerigroup CHIP/Medicaid	$4,096.11
Rate for Payer: Cigna Medicaid	$4,096.11
Rate for Payer: Molina CHIP/Medicaid	$4,096.11
Rate for Payer: Parkland Medicaid	$4,096.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,344.46

MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$12,983.60

Service Code	APR-DRG 9513
Min. Negotiated Rate	$12,241.39
Max. Negotiated Rate	$12,983.60
Rate for Payer: Amerigroup CHIP/Medicaid	$12,241.39
Rate for Payer: Cigna Medicaid	$12,241.39
Rate for Payer: Molina CHIP/Medicaid	$12,241.39
Rate for Payer: Parkland Medicaid	$12,241.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,983.60

Moderate Sedation, per interval cumulative, 15 Minutes

Facility

$494.50

Hospital Charge Code	9900036
Hospital Revenue Code	370
Rate for Payer: Cash Price	$336.26

Moderate Sedation, per interval cumulative, 15 Minutes

Facility

$494.50

Hospital Charge Code	9900036
Hospital Revenue Code	370
Min. Negotiated Rate	$44.51
Max. Negotiated Rate	$356.04
Rate for Payer: Amerigroup CHIP/Medicaid	$44.51
Rate for Payer: BCBS of TX Blue Advantage	$148.35
Rate for Payer: BCBS of TX Blue Essentials	$178.02
Rate for Payer: BCBS of TX PPO	$197.80
Rate for Payer: Cash Price	$336.26
Rate for Payer: Cigna Medicaid	$356.04
Rate for Payer: Molina CHIP/Medicaid	$356.04
Rate for Payer: Multiplan Auto	$321.43
Rate for Payer: Multiplan Commercial	$321.43
Rate for Payer: Multiplan Workers Comp	$321.43
Rate for Payer: Parkland Medicaid	$356.04
Rate for Payer: Scott and White EPO/PPO	$247.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$356.04
Rate for Payer: Superior Health Plan EPO	$67.25

Moderate Sedation, per unit cumulative, 15 Minutes

Facility

$206.95

Hospital Charge Code	9900037
Hospital Revenue Code	370
Rate for Payer: Cash Price	$140.73

Moderate Sedation, per unit cumulative, 15 Minutes

Facility

$206.95

Hospital Charge Code	9900037
Hospital Revenue Code	370
Min. Negotiated Rate	$18.63
Max. Negotiated Rate	$149.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.63
Rate for Payer: BCBS of TX Blue Advantage	$62.09
Rate for Payer: BCBS of TX Blue Essentials	$74.50
Rate for Payer: BCBS of TX PPO	$82.78
Rate for Payer: Cash Price	$140.73
Rate for Payer: Cigna Medicaid	$149.00
Rate for Payer: Molina CHIP/Medicaid	$149.00
Rate for Payer: Multiplan Auto	$134.52
Rate for Payer: Multiplan Commercial	$134.52
Rate for Payer: Multiplan Workers Comp	$134.52
Rate for Payer: Parkland Medicaid	$149.00
Rate for Payer: Scott and White EPO/PPO	$103.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$149.00
Rate for Payer: Superior Health Plan EPO	$28.15

MODIFIED MOD SHAFT

Facility

$2,759.04

Service Code	HCPCS C1776
Hospital Charge Code	992137
Hospital Revenue Code	278
Min. Negotiated Rate	$689.76
Max. Negotiated Rate	$1,379.52
Rate for Payer: Cash Price	$1,876.15
Rate for Payer: Cigna Commercial	$689.76
Rate for Payer: Multiplan Auto	$1,379.52
Rate for Payer: Multiplan Commercial	$1,379.52
Rate for Payer: Multiplan Workers Comp	$1,379.52
Rate for Payer: Scott and White EPO/PPO	$1,379.52

MODIFIED MOD SHAFT

Facility

$2,759.04

Service Code	HCPCS C1776
Hospital Charge Code	992137
Hospital Revenue Code	278
Min. Negotiated Rate	$248.31
Max. Negotiated Rate	$1,986.51
Rate for Payer: Amerigroup CHIP/Medicaid	$248.31
Rate for Payer: BCBS of TX Blue Advantage	$827.71
Rate for Payer: BCBS of TX Blue Essentials	$993.25
Rate for Payer: BCBS of TX PPO	$1,103.62
Rate for Payer: Cash Price	$1,876.15
Rate for Payer: Cigna Medicaid	$1,986.51
Rate for Payer: Molina CHIP/Medicaid	$1,986.51
Rate for Payer: Multiplan Auto	$1,379.52
Rate for Payer: Multiplan Commercial	$1,379.52
Rate for Payer: Multiplan Workers Comp	$1,379.52
Rate for Payer: Parkland Medicaid	$1,986.51
Rate for Payer: Scott and White EPO/PPO	$1,379.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,986.51
Rate for Payer: Superior Health Plan EPO	$375.23

MODULE INTBT BLU

Facility

$186.14

Hospital Charge Code	993478
Hospital Revenue Code	270
Min. Negotiated Rate	$16.75
Max. Negotiated Rate	$134.02
Rate for Payer: Amerigroup CHIP/Medicaid	$16.75
Rate for Payer: BCBS of TX Blue Advantage	$55.84
Rate for Payer: BCBS of TX Blue Essentials	$67.01
Rate for Payer: BCBS of TX PPO	$74.46
Rate for Payer: Cash Price	$126.58
Rate for Payer: Cigna Medicaid	$134.02
Rate for Payer: Molina CHIP/Medicaid	$134.02
Rate for Payer: Multiplan Auto	$120.99
Rate for Payer: Multiplan Commercial	$120.99
Rate for Payer: Multiplan Workers Comp	$120.99
Rate for Payer: Parkland Medicaid	$134.02
Rate for Payer: Scott and White EPO/PPO	$93.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.02
Rate for Payer: Superior Health Plan EPO	$25.32

Know your out-of-pocket cost for care.

All Charges