White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ondansetron 4 mg Tab

Facility

$7.65

Service Code	HCPCS Q0162
Hospital Charge Code	77736698
Hospital Revenue Code	636
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.33
Rate for Payer: BCBS of TX Blue Essentials	$0.40
Rate for Payer: BCBS of TX PPO	$0.44
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

ondansetron 4 mg Tab

Facility

$7.65

Service Code	HCPCS Q0162
Hospital Charge Code	77736810
Hospital Revenue Code	636
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.33
Rate for Payer: BCBS of TX Blue Essentials	$0.40
Rate for Payer: BCBS of TX PPO	$0.44
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

ONE STEP CONICAL REAMER

Facility

$4,540.00

Hospital Charge Code	993247
Hospital Revenue Code	272
Min. Negotiated Rate	$408.60
Max. Negotiated Rate	$3,268.80
Rate for Payer: Amerigroup CHIP/Medicaid	$408.60
Rate for Payer: BCBS of TX Blue Advantage	$1,362.00
Rate for Payer: BCBS of TX Blue Essentials	$1,634.40
Rate for Payer: BCBS of TX PPO	$1,816.00
Rate for Payer: Cash Price	$3,087.20
Rate for Payer: Cigna Medicaid	$3,268.80
Rate for Payer: Molina CHIP/Medicaid	$3,268.80
Rate for Payer: Multiplan Auto	$2,951.00
Rate for Payer: Multiplan Commercial	$2,951.00
Rate for Payer: Multiplan Workers Comp	$2,951.00
Rate for Payer: Parkland Medicaid	$3,268.80
Rate for Payer: Scott and White EPO/PPO	$2,270.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,268.80
Rate for Payer: Superior Health Plan EPO	$617.44

ONE STEP CONICAL REAMER

Facility

$4,540.00

Hospital Charge Code	993247
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,087.20

OneStep+ Ultra Flu A&B Test Kit CLIA Waived

Facility

$277.31

Hospital Charge Code	992711
Hospital Revenue Code	270
Rate for Payer: Cash Price	$188.57

OneStep+ Ultra Flu A&B Test Kit CLIA Waived

Facility

$277.31

Hospital Charge Code	992711
Hospital Revenue Code	270
Min. Negotiated Rate	$24.96
Max. Negotiated Rate	$199.66
Rate for Payer: Amerigroup CHIP/Medicaid	$24.96
Rate for Payer: BCBS of TX Blue Advantage	$83.19
Rate for Payer: BCBS of TX Blue Essentials	$99.83
Rate for Payer: BCBS of TX PPO	$110.92
Rate for Payer: Cash Price	$188.57
Rate for Payer: Cigna Medicaid	$199.66
Rate for Payer: Molina CHIP/Medicaid	$199.66
Rate for Payer: Multiplan Auto	$180.25
Rate for Payer: Multiplan Commercial	$180.25
Rate for Payer: Multiplan Workers Comp	$180.25
Rate for Payer: Parkland Medicaid	$199.66
Rate for Payer: Scott and White EPO/PPO	$138.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$199.66
Rate for Payer: Superior Health Plan EPO	$37.71

ON-Q' Pain Relief System with SELECT-A-

Facility

$5,107.50

Hospital Charge Code	992614
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,473.10

ON-Q' Pain Relief System with SELECT-A-

Facility

$5,107.50

Hospital Charge Code	992614
Hospital Revenue Code	272
Min. Negotiated Rate	$459.68
Max. Negotiated Rate	$3,677.40
Rate for Payer: Amerigroup CHIP/Medicaid	$459.68
Rate for Payer: BCBS of TX Blue Advantage	$1,532.25
Rate for Payer: BCBS of TX Blue Essentials	$1,838.70
Rate for Payer: BCBS of TX PPO	$2,043.00
Rate for Payer: Cash Price	$3,473.10
Rate for Payer: Cigna Medicaid	$3,677.40
Rate for Payer: Molina CHIP/Medicaid	$3,677.40
Rate for Payer: Multiplan Auto	$3,319.88
Rate for Payer: Multiplan Commercial	$3,319.88
Rate for Payer: Multiplan Workers Comp	$3,319.88
Rate for Payer: Parkland Medicaid	$3,677.40
Rate for Payer: Scott and White EPO/PPO	$2,553.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,677.40
Rate for Payer: Superior Health Plan EPO	$694.62

onyx frontier stents

Facility

$6,219.80

Service Code	HCPCS C1874
Hospital Charge Code	8504481
Hospital Revenue Code	278
Min. Negotiated Rate	$1,554.95
Max. Negotiated Rate	$3,109.90
Rate for Payer: Cash Price	$4,229.46
Rate for Payer: Cigna Commercial	$1,554.95
Rate for Payer: Multiplan Auto	$3,109.90
Rate for Payer: Multiplan Commercial	$3,109.90
Rate for Payer: Multiplan Workers Comp	$3,109.90
Rate for Payer: Scott and White EPO/PPO	$3,109.90

onyx frontier stents

Facility

$6,219.80

Service Code	HCPCS C1874
Hospital Charge Code	992464
Hospital Revenue Code	278
Min. Negotiated Rate	$559.78
Max. Negotiated Rate	$4,478.26
Rate for Payer: Amerigroup CHIP/Medicaid	$559.78
Rate for Payer: BCBS of TX Blue Advantage	$1,865.94
Rate for Payer: BCBS of TX Blue Essentials	$2,239.13
Rate for Payer: BCBS of TX PPO	$2,487.92
Rate for Payer: Cash Price	$4,229.46
Rate for Payer: Cigna Medicaid	$4,478.26
Rate for Payer: Molina CHIP/Medicaid	$4,478.26
Rate for Payer: Multiplan Auto	$3,109.90
Rate for Payer: Multiplan Commercial	$3,109.90
Rate for Payer: Multiplan Workers Comp	$3,109.90
Rate for Payer: Parkland Medicaid	$4,478.26
Rate for Payer: Scott and White EPO/PPO	$3,109.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,478.26
Rate for Payer: Superior Health Plan EPO	$845.89

onyx frontier stents

Facility

$6,219.80

Service Code	HCPCS C1874
Hospital Charge Code	8504481
Hospital Revenue Code	278
Min. Negotiated Rate	$559.78
Max. Negotiated Rate	$4,478.26
Rate for Payer: Amerigroup CHIP/Medicaid	$559.78
Rate for Payer: BCBS of TX Blue Advantage	$1,865.94
Rate for Payer: BCBS of TX Blue Essentials	$2,239.13
Rate for Payer: BCBS of TX PPO	$2,487.92
Rate for Payer: Cash Price	$4,229.46
Rate for Payer: Cigna Medicaid	$4,478.26
Rate for Payer: Molina CHIP/Medicaid	$4,478.26
Rate for Payer: Multiplan Auto	$3,109.90
Rate for Payer: Multiplan Commercial	$3,109.90
Rate for Payer: Multiplan Workers Comp	$3,109.90
Rate for Payer: Parkland Medicaid	$4,478.26
Rate for Payer: Scott and White EPO/PPO	$3,109.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,478.26
Rate for Payer: Superior Health Plan EPO	$845.89

onyx frontier stents

Facility

$6,219.80

Service Code	HCPCS C1874
Hospital Charge Code	992464
Hospital Revenue Code	278
Min. Negotiated Rate	$1,554.95
Max. Negotiated Rate	$3,109.90
Rate for Payer: Cash Price	$4,229.46
Rate for Payer: Cigna Commercial	$1,554.95
Rate for Payer: Multiplan Auto	$3,109.90
Rate for Payer: Multiplan Commercial	$3,109.90
Rate for Payer: Multiplan Workers Comp	$3,109.90
Rate for Payer: Scott and White EPO/PPO	$3,109.90

OPEN CRANIOTOMY EXCEPT TRAUMA

Facility

$40,020.13

Service Code	APR-DRG 0214
Min. Negotiated Rate	$37,732.38
Max. Negotiated Rate	$40,020.13
Rate for Payer: Amerigroup CHIP/Medicaid	$37,732.38
Rate for Payer: Cigna Medicaid	$37,732.38
Rate for Payer: Molina CHIP/Medicaid	$37,732.38
Rate for Payer: Parkland Medicaid	$37,732.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40,020.13

OPEN CRANIOTOMY EXCEPT TRAUMA

Facility

$14,556.86

Service Code	APR-DRG 0212
Min. Negotiated Rate	$13,724.71
Max. Negotiated Rate	$14,556.86
Rate for Payer: Amerigroup CHIP/Medicaid	$13,724.71
Rate for Payer: Cigna Medicaid	$13,724.71
Rate for Payer: Molina CHIP/Medicaid	$13,724.71
Rate for Payer: Parkland Medicaid	$13,724.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,556.86

OPEN CRANIOTOMY EXCEPT TRAUMA

Facility

$10,714.05

Service Code	APR-DRG 0211
Min. Negotiated Rate	$10,101.58
Max. Negotiated Rate	$10,714.05
Rate for Payer: Amerigroup CHIP/Medicaid	$10,101.58
Rate for Payer: Cigna Medicaid	$10,101.58
Rate for Payer: Molina CHIP/Medicaid	$10,101.58
Rate for Payer: Parkland Medicaid	$10,101.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,714.05

OPEN CRANIOTOMY EXCEPT TRAUMA

Facility

$22,904.42

Service Code	APR-DRG 0213
Min. Negotiated Rate	$21,595.09
Max. Negotiated Rate	$22,904.42
Rate for Payer: Amerigroup CHIP/Medicaid	$21,595.09
Rate for Payer: Cigna Medicaid	$21,595.09
Rate for Payer: Molina CHIP/Medicaid	$21,595.09
Rate for Payer: Parkland Medicaid	$21,595.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,904.42

OPEN CRANIOTOMY FOR TRAUMA

Facility

$21,135.41

Service Code	APR-DRG 0203
Min. Negotiated Rate	$19,927.20
Max. Negotiated Rate	$21,135.41
Rate for Payer: Amerigroup CHIP/Medicaid	$19,927.20
Rate for Payer: Cigna Medicaid	$19,927.20
Rate for Payer: Molina CHIP/Medicaid	$19,927.20
Rate for Payer: Parkland Medicaid	$19,927.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,135.41

OPEN CRANIOTOMY FOR TRAUMA

Facility

$33,617.72

Service Code	APR-DRG 0204
Min. Negotiated Rate	$31,695.97
Max. Negotiated Rate	$33,617.72
Rate for Payer: Amerigroup CHIP/Medicaid	$31,695.97
Rate for Payer: Cigna Medicaid	$31,695.97
Rate for Payer: Molina CHIP/Medicaid	$31,695.97
Rate for Payer: Parkland Medicaid	$31,695.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33,617.72

OPEN CRANIOTOMY FOR TRAUMA

Facility

$11,857.69

Service Code	APR-DRG 0202
Min. Negotiated Rate	$11,179.85
Max. Negotiated Rate	$11,857.69
Rate for Payer: Amerigroup CHIP/Medicaid	$11,179.85
Rate for Payer: Cigna Medicaid	$11,179.85
Rate for Payer: Molina CHIP/Medicaid	$11,179.85
Rate for Payer: Parkland Medicaid	$11,179.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,857.69

OPEN CRANIOTOMY FOR TRAUMA

Facility

$9,925.35

Service Code	APR-DRG 0201
Min. Negotiated Rate	$9,357.97
Max. Negotiated Rate	$9,925.35
Rate for Payer: Amerigroup CHIP/Medicaid	$9,357.97
Rate for Payer: Cigna Medicaid	$9,357.97
Rate for Payer: Molina CHIP/Medicaid	$9,357.97
Rate for Payer: Parkland Medicaid	$9,357.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,925.35

OPEN EXTRACRANIAL VASCULAR PROCEDURES

Facility

$22,704.89

Service Code	APR-DRG 0244
Min. Negotiated Rate	$21,406.97
Max. Negotiated Rate	$22,704.89
Rate for Payer: Amerigroup CHIP/Medicaid	$21,406.97
Rate for Payer: Cigna Medicaid	$21,406.97
Rate for Payer: Molina CHIP/Medicaid	$21,406.97
Rate for Payer: Parkland Medicaid	$21,406.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,704.89

OPEN EXTRACRANIAL VASCULAR PROCEDURES

Facility

$4,328.62

Service Code	APR-DRG 0241
Min. Negotiated Rate	$4,081.18
Max. Negotiated Rate	$4,328.62
Rate for Payer: Amerigroup CHIP/Medicaid	$4,081.18
Rate for Payer: Cigna Medicaid	$4,081.18
Rate for Payer: Molina CHIP/Medicaid	$4,081.18
Rate for Payer: Parkland Medicaid	$4,081.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,328.62

OPEN EXTRACRANIAL VASCULAR PROCEDURES

Facility

$6,592.13

Service Code	APR-DRG 0242
Min. Negotiated Rate	$6,215.29
Max. Negotiated Rate	$6,592.13
Rate for Payer: Amerigroup CHIP/Medicaid	$6,215.29
Rate for Payer: Cigna Medicaid	$6,215.29
Rate for Payer: Molina CHIP/Medicaid	$6,215.29
Rate for Payer: Parkland Medicaid	$6,215.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,592.13

OPEN EXTRACRANIAL VASCULAR PROCEDURES

Facility

$11,800.36

Service Code	APR-DRG 0243
Min. Negotiated Rate	$11,125.79
Max. Negotiated Rate	$11,800.36
Rate for Payer: Amerigroup CHIP/Medicaid	$11,125.79
Rate for Payer: Cigna Medicaid	$11,125.79
Rate for Payer: Molina CHIP/Medicaid	$11,125.79
Rate for Payer: Parkland Medicaid	$11,125.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,800.36

Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respirator

Facility

$180,380.88

Service Code	HCPCS 64582
Hospital Charge Code	9900815
Hospital Revenue Code	360
Rate for Payer: Cash Price	$122,659.00

Know your out-of-pocket cost for care.

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