White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

ALCOHOLIC LIVER DISEASE

Facility

$4,817.84

Service Code	APR-DRG 2803
Min. Negotiated Rate	$4,542.42
Max. Negotiated Rate	$4,817.84
Rate for Payer: Amerigroup CHIP/Medicaid	$4,542.42
Rate for Payer: Cigna Medicaid	$4,542.42
Rate for Payer: Molina CHIP/Medicaid	$4,542.42
Rate for Payer: Parkland Medicaid	$4,542.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,817.84

ALCOHOLIC LIVER DISEASE

Facility

$2,335.18

Service Code	APR-DRG 2801
Min. Negotiated Rate	$2,201.69
Max. Negotiated Rate	$2,335.18
Rate for Payer: Amerigroup CHIP/Medicaid	$2,201.69
Rate for Payer: Cigna Medicaid	$2,201.69
Rate for Payer: Molina CHIP/Medicaid	$2,201.69
Rate for Payer: Parkland Medicaid	$2,201.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,335.18

ALCOHOLIC LIVER DISEASE

Facility

$12,265.05

Service Code	APR-DRG 2804
Min. Negotiated Rate	$11,563.92
Max. Negotiated Rate	$12,265.05
Rate for Payer: Amerigroup CHIP/Medicaid	$11,563.92
Rate for Payer: Cigna Medicaid	$11,563.92
Rate for Payer: Molina CHIP/Medicaid	$11,563.92
Rate for Payer: Parkland Medicaid	$11,563.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,265.05

ALCOHOLIC LIVER DISEASE

Facility

$3,092.95

Service Code	APR-DRG 2802
Min. Negotiated Rate	$2,916.14
Max. Negotiated Rate	$3,092.95
Rate for Payer: Amerigroup CHIP/Medicaid	$2,916.14
Rate for Payer: Cigna Medicaid	$2,916.14
Rate for Payer: Molina CHIP/Medicaid	$2,916.14
Rate for Payer: Parkland Medicaid	$2,916.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,092.95

ALCOHOL, RUBBING, 70PERCENT ISOPROPYL, I-OZ

Facility

$5.01

Hospital Charge Code	992989
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.41

ALCOHOL, RUBBING, 70PERCENT ISOPROPYL, I-OZ

Facility

$5.01

Hospital Charge Code	992989
Hospital Revenue Code	270
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$3.61
Rate for Payer: Amerigroup CHIP/Medicaid	$0.45
Rate for Payer: BCBS of TX Blue Advantage	$1.50
Rate for Payer: BCBS of TX Blue Essentials	$1.80
Rate for Payer: BCBS of TX PPO	$2.00
Rate for Payer: Cash Price	$3.41
Rate for Payer: Cigna Medicaid	$3.61
Rate for Payer: Molina CHIP/Medicaid	$3.61
Rate for Payer: Multiplan Auto	$3.26
Rate for Payer: Multiplan Commercial	$3.26
Rate for Payer: Multiplan Workers Comp	$3.26
Rate for Payer: Parkland Medicaid	$3.61
Rate for Payer: Scott and White EPO/PPO	$2.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.61
Rate for Payer: Superior Health Plan EPO	$0.68

Aldolase SO

Facility

$204.00

Service Code	HCPCS 82085
Hospital Charge Code	1701150
Hospital Revenue Code	301
Min. Negotiated Rate	$3.79
Max. Negotiated Rate	$146.88
Rate for Payer: Amerigroup CHIP/Medicaid	$3.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.71
Rate for Payer: Amerigroup Medicare	$9.71
Rate for Payer: BCBS of TX Blue Advantage	$61.20
Rate for Payer: BCBS of TX Blue Essentials	$73.44
Rate for Payer: BCBS of TX Medicare	$9.71
Rate for Payer: BCBS of TX PPO	$81.60
Rate for Payer: Cash Price	$138.72
Rate for Payer: Cash Price	$138.72
Rate for Payer: Cigna Medicaid	$146.88
Rate for Payer: Cigna Medicare	$9.71
Rate for Payer: Employer Direct Commercial	$9.71
Rate for Payer: Humana Medicare/TRICARE	$9.71
Rate for Payer: Molina CHIP/Medicaid	$146.88
Rate for Payer: Molina Dual Medicare/Medicaid	$9.71
Rate for Payer: Molina Medicare	$9.71
Rate for Payer: Multiplan Auto	$132.60
Rate for Payer: Multiplan Commercial	$132.60
Rate for Payer: Multiplan Workers Comp	$132.60
Rate for Payer: Parkland Medicaid	$146.88
Rate for Payer: Scott and White EPO/PPO	$12.14
Rate for Payer: Scott and White Medicare	$9.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$146.88
Rate for Payer: Superior Health Plan EPO	$9.71
Rate for Payer: Superior Health Plan Medicare	$9.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.71
Rate for Payer: Universal American Medicare	$9.71
Rate for Payer: Wellcare Medicare	$9.71
Rate for Payer: Wellmed Medicare	$9.71

Aldolase SO

Facility

$204.00

Service Code	HCPCS 82085
Hospital Charge Code	1701150
Hospital Revenue Code	301
Rate for Payer: Cash Price	$138.72

Aldosterone LCMS, Serum SO

Facility

$552.00

Service Code	HCPCS 82088
Hospital Charge Code	1701168
Hospital Revenue Code	301
Min. Negotiated Rate	$15.89
Max. Negotiated Rate	$397.44
Rate for Payer: Amerigroup CHIP/Medicaid	$15.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$40.75
Rate for Payer: Amerigroup Medicare	$40.75
Rate for Payer: BCBS of TX Blue Advantage	$165.60
Rate for Payer: BCBS of TX Blue Essentials	$198.72
Rate for Payer: BCBS of TX Medicare	$40.75
Rate for Payer: BCBS of TX PPO	$220.80
Rate for Payer: Cash Price	$375.36
Rate for Payer: Cash Price	$375.36
Rate for Payer: Cigna Medicaid	$397.44
Rate for Payer: Cigna Medicare	$40.75
Rate for Payer: Employer Direct Commercial	$40.75
Rate for Payer: Humana Medicare/TRICARE	$40.75
Rate for Payer: Molina CHIP/Medicaid	$397.44
Rate for Payer: Molina Dual Medicare/Medicaid	$40.75
Rate for Payer: Molina Medicare	$40.75
Rate for Payer: Multiplan Auto	$358.80
Rate for Payer: Multiplan Commercial	$358.80
Rate for Payer: Multiplan Workers Comp	$358.80
Rate for Payer: Parkland Medicaid	$397.44
Rate for Payer: Scott and White EPO/PPO	$50.94
Rate for Payer: Scott and White Medicare	$40.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$397.44
Rate for Payer: Superior Health Plan EPO	$40.75
Rate for Payer: Superior Health Plan Medicare	$40.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$40.75
Rate for Payer: Universal American Medicare	$40.75
Rate for Payer: Wellcare Medicare	$40.75
Rate for Payer: Wellmed Medicare	$40.75

Aldosterone LCMS, Serum SO

Facility

$552.00

Service Code	HCPCS 82088
Hospital Charge Code	1701168
Hospital Revenue Code	301
Rate for Payer: Cash Price	$375.36

alendronate 70 mg Tab

Facility

$147.00

Service Code	HCPCS J3490
Hospital Charge Code	77360934
Hospital Revenue Code	250
Rate for Payer: Cash Price	$99.96

alendronate 70 mg Tab

Facility

$147.00

Service Code	HCPCS J3490
Hospital Charge Code	77360934
Hospital Revenue Code	250
Min. Negotiated Rate	$13.23
Max. Negotiated Rate	$105.84
Rate for Payer: Amerigroup CHIP/Medicaid	$13.23
Rate for Payer: BCBS of TX Blue Advantage	$44.10
Rate for Payer: BCBS of TX Blue Essentials	$52.92
Rate for Payer: BCBS of TX PPO	$58.80
Rate for Payer: Cash Price	$99.96
Rate for Payer: Cigna Medicaid	$105.84
Rate for Payer: Molina CHIP/Medicaid	$105.84
Rate for Payer: Multiplan Auto	$95.55
Rate for Payer: Multiplan Commercial	$95.55
Rate for Payer: Multiplan Workers Comp	$95.55
Rate for Payer: Parkland Medicaid	$105.84
Rate for Payer: Scott and White EPO/PPO	$73.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$105.84
Rate for Payer: Superior Health Plan EPO	$19.99

alif 27x15 interbody cage

Facility

$26,096.00

Service Code	HCPCS C1831
Hospital Charge Code	8672533
Hospital Revenue Code	278
Min. Negotiated Rate	$2,348.64
Max. Negotiated Rate	$18,789.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2,348.64
Rate for Payer: Cash Price	$17,745.28
Rate for Payer: Cigna Medicaid	$18,789.12
Rate for Payer: Molina CHIP/Medicaid	$18,789.12
Rate for Payer: Multiplan Auto	$13,048.00
Rate for Payer: Multiplan Commercial	$13,048.00
Rate for Payer: Multiplan Workers Comp	$13,048.00
Rate for Payer: Parkland Medicaid	$18,789.12
Rate for Payer: Scott and White EPO/PPO	$13,048.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,789.12
Rate for Payer: Superior Health Plan EPO	$3,549.06

alif 27x15 interbody cage

Facility

$26,096.00

Service Code	HCPCS C1831
Hospital Charge Code	8672533
Hospital Revenue Code	278
Min. Negotiated Rate	$6,524.00
Max. Negotiated Rate	$13,048.00
Rate for Payer: Cash Price	$17,745.28
Rate for Payer: Cigna Commercial	$6,524.00
Rate for Payer: Multiplan Auto	$13,048.00
Rate for Payer: Multiplan Commercial	$13,048.00
Rate for Payer: Multiplan Workers Comp	$13,048.00
Rate for Payer: Scott and White EPO/PPO	$13,048.00

alif 32x24 interbody cage

Facility

$26,096.00

Service Code	HCPCS C1831
Hospital Charge Code	8672537
Hospital Revenue Code	278
Min. Negotiated Rate	$2,348.64
Max. Negotiated Rate	$18,789.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2,348.64
Rate for Payer: Cash Price	$17,745.28
Rate for Payer: Cigna Medicaid	$18,789.12
Rate for Payer: Molina CHIP/Medicaid	$18,789.12
Rate for Payer: Multiplan Auto	$13,048.00
Rate for Payer: Multiplan Commercial	$13,048.00
Rate for Payer: Multiplan Workers Comp	$13,048.00
Rate for Payer: Parkland Medicaid	$18,789.12
Rate for Payer: Scott and White EPO/PPO	$13,048.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,789.12
Rate for Payer: Superior Health Plan EPO	$3,549.06

alif 32x24 interbody cage

Facility

$26,096.00

Service Code	HCPCS C1831
Hospital Charge Code	8672537
Hospital Revenue Code	278
Min. Negotiated Rate	$6,524.00
Max. Negotiated Rate	$13,048.00
Rate for Payer: Cash Price	$17,745.28
Rate for Payer: Cigna Commercial	$6,524.00
Rate for Payer: Multiplan Auto	$13,048.00
Rate for Payer: Multiplan Commercial	$13,048.00
Rate for Payer: Multiplan Workers Comp	$13,048.00
Rate for Payer: Scott and White EPO/PPO	$13,048.00

Alk Phos Isoenzyme SO

Facility

$186.00

Service Code	HCPCS 84075
Hospital Charge Code	1601608
Hospital Revenue Code	301
Rate for Payer: Cash Price	$126.48

Alk Phos Isoenzyme SO

Facility

$186.00

Service Code	HCPCS 84075
Hospital Charge Code	1601608
Hospital Revenue Code	301
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$133.92
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$55.80
Rate for Payer: BCBS of TX Blue Essentials	$66.96
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$74.40
Rate for Payer: Cash Price	$126.48
Rate for Payer: Cash Price	$126.48
Rate for Payer: Cigna Medicaid	$133.92
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$133.92
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$120.90
Rate for Payer: Multiplan Commercial	$120.90
Rate for Payer: Multiplan Workers Comp	$120.90
Rate for Payer: Parkland Medicaid	$133.92
Rate for Payer: Scott and White EPO/PPO	$6.47
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$133.92
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

Alk Phosphatase, Bone Specific SO

Facility

$95.85

Service Code	HCPCS 84080
Hospital Charge Code	1701549
Hospital Revenue Code	301
Rate for Payer: Cash Price	$65.18

Alk Phosphatase, Bone Specific SO

Facility

$95.85

Service Code	HCPCS 84080
Hospital Charge Code	1701549
Hospital Revenue Code	301
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$69.01
Rate for Payer: Amerigroup CHIP/Medicaid	$5.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.78
Rate for Payer: Amerigroup Medicare	$14.78
Rate for Payer: BCBS of TX Blue Advantage	$28.75
Rate for Payer: BCBS of TX Blue Essentials	$34.51
Rate for Payer: BCBS of TX Medicare	$14.78
Rate for Payer: BCBS of TX PPO	$38.34
Rate for Payer: Cash Price	$65.18
Rate for Payer: Cash Price	$65.18
Rate for Payer: Cigna Medicaid	$69.01
Rate for Payer: Cigna Medicare	$14.78
Rate for Payer: Employer Direct Commercial	$14.78
Rate for Payer: Humana Medicare/TRICARE	$14.78
Rate for Payer: Molina CHIP/Medicaid	$69.01
Rate for Payer: Molina Dual Medicare/Medicaid	$14.78
Rate for Payer: Molina Medicare	$14.78
Rate for Payer: Multiplan Auto	$62.30
Rate for Payer: Multiplan Commercial	$62.30
Rate for Payer: Multiplan Workers Comp	$62.30
Rate for Payer: Parkland Medicaid	$69.01
Rate for Payer: Scott and White EPO/PPO	$18.48
Rate for Payer: Scott and White Medicare	$14.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.01
Rate for Payer: Superior Health Plan EPO	$14.78
Rate for Payer: Superior Health Plan Medicare	$14.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.78
Rate for Payer: Universal American Medicare	$14.78
Rate for Payer: Wellcare Medicare	$14.78
Rate for Payer: Wellmed Medicare	$14.78

ALLERGIC REACTIONS

Facility

$8,284.96

Service Code	APR-DRG 8114
Min. Negotiated Rate	$7,811.35
Max. Negotiated Rate	$8,284.96
Rate for Payer: Amerigroup CHIP/Medicaid	$7,811.35
Rate for Payer: Cigna Medicaid	$7,811.35
Rate for Payer: Molina CHIP/Medicaid	$7,811.35
Rate for Payer: Parkland Medicaid	$7,811.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,284.96

ALLERGIC REACTIONS

Facility

$1,453.31

Service Code	APR-DRG 8111
Min. Negotiated Rate	$1,370.23
Max. Negotiated Rate	$1,453.31
Rate for Payer: Amerigroup CHIP/Medicaid	$1,370.23
Rate for Payer: Cigna Medicaid	$1,370.23
Rate for Payer: Molina CHIP/Medicaid	$1,370.23
Rate for Payer: Parkland Medicaid	$1,370.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,453.31

ALLERGIC REACTIONS

Facility

$4,925.71

Service Code	APR-DRG 8113
Min. Negotiated Rate	$4,644.13
Max. Negotiated Rate	$4,925.71
Rate for Payer: Amerigroup CHIP/Medicaid	$4,644.13
Rate for Payer: Cigna Medicaid	$4,644.13
Rate for Payer: Molina CHIP/Medicaid	$4,644.13
Rate for Payer: Parkland Medicaid	$4,644.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,925.71

Know your out-of-pocket cost for care.

All Charges