White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Revision or repair of operative wound of anterior segment, any type, early or late, major or minor p

Facility

$8,174.80

Service Code	HCPCS 66250
Hospital Charge Code	9900865
Hospital Revenue Code	360
Min. Negotiated Rate	$698.30
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$698.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,388.32
Rate for Payer: Amerigroup Medicare	$2,388.32
Rate for Payer: BCBS of TX Blue Advantage	$3,231.78
Rate for Payer: BCBS of TX Blue Essentials	$3,870.40
Rate for Payer: BCBS of TX Medicare	$2,388.32
Rate for Payer: BCBS of TX PPO	$4,876.70
Rate for Payer: Cash Price	$5,558.86
Rate for Payer: Cash Price	$5,558.86
Rate for Payer: Cash Price	$5,558.86
Rate for Payer: Cigna Commercial	$5,048.47
Rate for Payer: Cigna Medicaid	$5,885.86
Rate for Payer: Cigna Medicare	$2,388.32
Rate for Payer: Employer Direct Commercial	$2,388.32
Rate for Payer: Humana Medicare/TRICARE	$2,388.32
Rate for Payer: Molina CHIP/Medicaid	$5,885.86
Rate for Payer: Molina Dual Medicare/Medicaid	$2,388.32
Rate for Payer: Molina Medicare	$2,388.32
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$5,885.86
Rate for Payer: Scott and White EPO/PPO	$3,953.65
Rate for Payer: Scott and White Medicare	$2,388.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,885.86
Rate for Payer: Superior Health Plan EPO	$2,388.32
Rate for Payer: Superior Health Plan Medicare	$2,388.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,388.32
Rate for Payer: Universal American Medicare	$2,388.32
Rate for Payer: Wellcare Medicare	$2,388.32
Rate for Payer: Wellmed Medicare	$2,388.32

Revision or repair of operative wound of anterior segment, any type, early or late, major or minor p

Facility

$8,174.80

Service Code	HCPCS 66250
Hospital Charge Code	9900865
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,558.86

Revision or repair of operative wound of anterior segment, any type, early or late, major or minor p

Facility

$10,000.00

Service Code	CPT 66250
Hospital Charge Code	36066250
Hospital Revenue Code	360
Min. Negotiated Rate	$698.30
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$698.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,388.32
Rate for Payer: Amerigroup Medicare	$2,388.32
Rate for Payer: BCBS of TX Blue Advantage	$3,231.78
Rate for Payer: BCBS of TX Blue Essentials	$3,870.40
Rate for Payer: BCBS of TX Medicare	$2,388.32
Rate for Payer: BCBS of TX PPO	$4,876.70
Rate for Payer: Cigna Commercial	$5,048.47
Rate for Payer: Cigna Medicare	$2,388.32
Rate for Payer: Employer Direct Commercial	$2,388.32
Rate for Payer: Humana Medicare/TRICARE	$2,388.32
Rate for Payer: Molina Dual Medicare/Medicaid	$2,388.32
Rate for Payer: Molina Medicare	$2,388.32
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$3,953.65
Rate for Payer: Scott and White Medicare	$2,388.32
Rate for Payer: Superior Health Plan EPO	$2,388.32
Rate for Payer: Superior Health Plan Medicare	$2,388.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,388.32
Rate for Payer: Universal American Medicare	$2,388.32
Rate for Payer: Wellcare Medicare	$2,388.32
Rate for Payer: Wellmed Medicare	$2,388.32

REV SKIN POCKET SNGL/DUAL AICD

Facility

$4,566.00

Service Code	HCPCS 33223
Hospital Charge Code	2302347
Hospital Revenue Code	481
Rate for Payer: Cash Price	$3,104.88

REV SKIN POCKET SNGL/DUAL AICD

Facility

$4,566.00

Service Code	HCPCS 33223
Hospital Charge Code	2302347
Hospital Revenue Code	481
Min. Negotiated Rate	$410.94
Max. Negotiated Rate	$4,381.27
Rate for Payer: Amerigroup CHIP/Medicaid	$410.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$3,104.88
Rate for Payer: Cash Price	$3,104.88
Rate for Payer: Cash Price	$3,104.88
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$3,287.52
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$3,287.52
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
Rate for Payer: Multiplan Auto	$2,967.90
Rate for Payer: Multiplan Commercial	$2,967.90
Rate for Payer: Multiplan Workers Comp	$2,967.90
Rate for Payer: Parkland Medicaid	$3,287.52
Rate for Payer: Scott and White EPO/PPO	$491.62
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,287.52
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

RFE356

Facility

$1,325.00

Service Code	HCPCS C1713
Hospital Charge Code	991008
Hospital Revenue Code	278
Min. Negotiated Rate	$119.25
Max. Negotiated Rate	$954.00
Rate for Payer: Amerigroup CHIP/Medicaid	$119.25
Rate for Payer: BCBS of TX Blue Advantage	$397.50
Rate for Payer: BCBS of TX Blue Essentials	$477.00
Rate for Payer: BCBS of TX PPO	$530.00
Rate for Payer: Cash Price	$901.00
Rate for Payer: Cigna Medicaid	$954.00
Rate for Payer: Molina CHIP/Medicaid	$954.00
Rate for Payer: Multiplan Auto	$662.50
Rate for Payer: Multiplan Commercial	$662.50
Rate for Payer: Multiplan Workers Comp	$662.50
Rate for Payer: Parkland Medicaid	$954.00
Rate for Payer: Scott and White EPO/PPO	$662.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$954.00
Rate for Payer: Superior Health Plan EPO	$180.20

RFE356

Facility

$1,325.00

Service Code	HCPCS C1713
Hospital Charge Code	991008
Hospital Revenue Code	278
Min. Negotiated Rate	$331.25
Max. Negotiated Rate	$662.50
Rate for Payer: Cash Price	$901.00
Rate for Payer: Cigna Commercial	$331.25
Rate for Payer: Multiplan Auto	$662.50
Rate for Payer: Multiplan Commercial	$662.50
Rate for Payer: Multiplan Workers Comp	$662.50
Rate for Payer: Scott and White EPO/PPO	$662.50

Rheumatoid Factor

Facility

$227.00

Service Code	HCPCS 86431
Hospital Charge Code	1603398
Hospital Revenue Code	302
Rate for Payer: Cash Price	$154.36

Rheumatoid Factor

Facility

$227.00

Service Code	HCPCS 86431
Hospital Charge Code	1603398
Hospital Revenue Code	302
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$163.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.67
Rate for Payer: Amerigroup Medicare	$5.67
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX Medicare	$5.67
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$154.36
Rate for Payer: Cash Price	$154.36
Rate for Payer: Cigna Medicaid	$163.44
Rate for Payer: Cigna Medicare	$5.67
Rate for Payer: Employer Direct Commercial	$5.67
Rate for Payer: Humana Medicare/TRICARE	$5.67
Rate for Payer: Molina CHIP/Medicaid	$163.44
Rate for Payer: Molina Dual Medicare/Medicaid	$5.67
Rate for Payer: Molina Medicare	$5.67
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Parkland Medicaid	$163.44
Rate for Payer: Scott and White EPO/PPO	$7.09
Rate for Payer: Scott and White Medicare	$5.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.44
Rate for Payer: Superior Health Plan EPO	$5.67
Rate for Payer: Superior Health Plan Medicare	$5.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.67
Rate for Payer: Universal American Medicare	$5.67
Rate for Payer: Wellcare Medicare	$5.67
Rate for Payer: Wellmed Medicare	$5.67

RHo (D) immune globulin 1500 intl units IM Soln

Facility

$141.93

Service Code	HCPCS J2790
Hospital Charge Code	77793734
Hospital Revenue Code	636
Min. Negotiated Rate	$12.77
Max. Negotiated Rate	$145.75
Rate for Payer: Amerigroup CHIP/Medicaid	$12.77
Rate for Payer: BCBS of TX Blue Advantage	$109.50
Rate for Payer: BCBS of TX Blue Essentials	$131.40
Rate for Payer: BCBS of TX PPO	$145.75
Rate for Payer: Cash Price	$96.51
Rate for Payer: Cash Price	$96.51
Rate for Payer: Cigna Medicaid	$102.19
Rate for Payer: Molina CHIP/Medicaid	$102.19
Rate for Payer: Multiplan Auto	$92.25
Rate for Payer: Multiplan Commercial	$92.25
Rate for Payer: Multiplan Workers Comp	$92.25
Rate for Payer: Parkland Medicaid	$102.19
Rate for Payer: Scott and White EPO/PPO	$70.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.19
Rate for Payer: Superior Health Plan EPO	$19.30

RHo (D) immune globulin 1500 intl units IM Soln

Facility

$141.93

Service Code	HCPCS J2790
Hospital Charge Code	77793734
Hospital Revenue Code	636
Min. Negotiated Rate	$35.48
Max. Negotiated Rate	$70.97
Rate for Payer: Cash Price	$96.51
Rate for Payer: Cigna Commercial	$35.48
Rate for Payer: Scott and White EPO/PPO	$70.97

rifAXIMin 550 mg Tab

Facility

$118.44

Service Code	HCPCS J3490
Hospital Charge Code	77795169
Hospital Revenue Code	250
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$85.28
Rate for Payer: Amerigroup CHIP/Medicaid	$10.66
Rate for Payer: BCBS of TX Blue Advantage	$35.53
Rate for Payer: BCBS of TX Blue Essentials	$42.64
Rate for Payer: BCBS of TX PPO	$47.38
Rate for Payer: Cash Price	$80.54
Rate for Payer: Cigna Medicaid	$85.28
Rate for Payer: Molina CHIP/Medicaid	$85.28
Rate for Payer: Multiplan Auto	$76.99
Rate for Payer: Multiplan Commercial	$76.99
Rate for Payer: Multiplan Workers Comp	$76.99
Rate for Payer: Parkland Medicaid	$85.28
Rate for Payer: Scott and White EPO/PPO	$59.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$85.28
Rate for Payer: Superior Health Plan EPO	$16.11

rifAXIMin 550 mg Tab

Facility

$118.44

Service Code	HCPCS J3490
Hospital Charge Code	77795169
Hospital Revenue Code	250
Rate for Payer: Cash Price	$80.54

Rigidfix ST Kit

Facility

$2,832.96

Service Code	HCPCS C1776
Hospital Charge Code	992671
Hospital Revenue Code	278
Min. Negotiated Rate	$708.24
Max. Negotiated Rate	$1,416.48
Rate for Payer: Cash Price	$1,926.41
Rate for Payer: Cigna Commercial	$708.24
Rate for Payer: Multiplan Auto	$1,416.48
Rate for Payer: Multiplan Commercial	$1,416.48
Rate for Payer: Multiplan Workers Comp	$1,416.48
Rate for Payer: Scott and White EPO/PPO	$1,416.48

Rigidfix ST Kit

Facility

$2,832.96

Service Code	HCPCS C1776
Hospital Charge Code	992671
Hospital Revenue Code	278
Min. Negotiated Rate	$254.97
Max. Negotiated Rate	$2,039.73
Rate for Payer: Amerigroup CHIP/Medicaid	$254.97
Rate for Payer: BCBS of TX Blue Advantage	$849.89
Rate for Payer: BCBS of TX Blue Essentials	$1,019.87
Rate for Payer: BCBS of TX PPO	$1,133.18
Rate for Payer: Cash Price	$1,926.41
Rate for Payer: Cigna Medicaid	$2,039.73
Rate for Payer: Molina CHIP/Medicaid	$2,039.73
Rate for Payer: Multiplan Auto	$1,416.48
Rate for Payer: Multiplan Commercial	$1,416.48
Rate for Payer: Multiplan Workers Comp	$1,416.48
Rate for Payer: Parkland Medicaid	$2,039.73
Rate for Payer: Scott and White EPO/PPO	$1,416.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,039.73
Rate for Payer: Superior Health Plan EPO	$385.28

risperiDONE 1 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77796415
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

risperiDONE 1 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77796415
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

rivaroxaban 10 mg Tab

Facility

$40.90

Service Code	HCPCS j3490
Hospital Charge Code	77797108
Hospital Revenue Code	250
Rate for Payer: Cash Price	$27.81

rivaroxaban 10 mg Tab

Facility

$40.90

Service Code	HCPCS j3490
Hospital Charge Code	77797108
Hospital Revenue Code	250
Min. Negotiated Rate	$3.68
Max. Negotiated Rate	$29.45
Rate for Payer: Amerigroup CHIP/Medicaid	$3.68
Rate for Payer: BCBS of TX Blue Advantage	$12.27
Rate for Payer: BCBS of TX Blue Essentials	$14.72
Rate for Payer: BCBS of TX PPO	$16.36
Rate for Payer: Cash Price	$27.81
Rate for Payer: Cigna Medicaid	$29.45
Rate for Payer: Molina CHIP/Medicaid	$29.45
Rate for Payer: Multiplan Auto	$26.59
Rate for Payer: Multiplan Commercial	$26.59
Rate for Payer: Multiplan Workers Comp	$26.59
Rate for Payer: Parkland Medicaid	$29.45
Rate for Payer: Scott and White EPO/PPO	$20.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.45
Rate for Payer: Superior Health Plan EPO	$5.56

RMV TUNLD CVAD W SQ PORT

Facility

$2,334.00

Service Code	HCPCS 36590
Hospital Charge Code	4616590
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,587.12

RMV TUNLD CVAD W SQ PORT

Facility

$2,334.00

Service Code	HCPCS 36590
Hospital Charge Code	4616590
Hospital Revenue Code	360
Min. Negotiated Rate	$446.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$446.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Amerigroup Medicare	$1,581.33
Rate for Payer: BCBS of TX Blue Advantage	$1,052.95
Rate for Payer: BCBS of TX Blue Essentials	$1,261.02
Rate for Payer: BCBS of TX Medicare	$1,581.33
Rate for Payer: BCBS of TX PPO	$1,588.89
Rate for Payer: Cash Price	$1,587.12
Rate for Payer: Cash Price	$1,587.12
Rate for Payer: Cash Price	$1,587.12
Rate for Payer: Cigna Commercial	$3,342.63
Rate for Payer: Cigna Medicaid	$1,680.48
Rate for Payer: Cigna Medicare	$1,581.33
Rate for Payer: Employer Direct Commercial	$1,581.33
Rate for Payer: Humana Medicare/TRICARE	$1,581.33
Rate for Payer: Molina CHIP/Medicaid	$1,680.48
Rate for Payer: Molina Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Molina Medicare	$1,581.33
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,680.48
Rate for Payer: Scott and White EPO/PPO	$2,709.66
Rate for Payer: Scott and White Medicare	$1,581.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,680.48
Rate for Payer: Superior Health Plan EPO	$1,581.33
Rate for Payer: Superior Health Plan Medicare	$1,581.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Universal American Medicare	$1,581.33
Rate for Payer: Wellcare Medicare	$1,581.33
Rate for Payer: Wellmed Medicare	$1,581.33

RNA, Real Time PCR (Non-Graph) SO

Facility

$441.00

Service Code	HCPCS 87536
Hospital Charge Code	1701069
Hospital Revenue Code	306
Min. Negotiated Rate	$33.19
Max. Negotiated Rate	$317.52
Rate for Payer: Amerigroup CHIP/Medicaid	$33.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$85.10
Rate for Payer: Amerigroup Medicare	$85.10
Rate for Payer: BCBS of TX Blue Advantage	$132.30
Rate for Payer: BCBS of TX Blue Essentials	$158.76
Rate for Payer: BCBS of TX Medicare	$85.10
Rate for Payer: BCBS of TX PPO	$176.40
Rate for Payer: Cash Price	$299.88
Rate for Payer: Cash Price	$299.88
Rate for Payer: Cigna Medicaid	$317.52
Rate for Payer: Cigna Medicare	$85.10
Rate for Payer: Employer Direct Commercial	$85.10
Rate for Payer: Humana Medicare/TRICARE	$85.10
Rate for Payer: Molina CHIP/Medicaid	$317.52
Rate for Payer: Molina Dual Medicare/Medicaid	$85.10
Rate for Payer: Molina Medicare	$85.10
Rate for Payer: Multiplan Auto	$286.65
Rate for Payer: Multiplan Commercial	$286.65
Rate for Payer: Multiplan Workers Comp	$286.65
Rate for Payer: Parkland Medicaid	$317.52
Rate for Payer: Scott and White EPO/PPO	$106.38
Rate for Payer: Scott and White Medicare	$85.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$317.52
Rate for Payer: Superior Health Plan EPO	$85.10
Rate for Payer: Superior Health Plan Medicare	$85.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$85.10
Rate for Payer: Universal American Medicare	$85.10
Rate for Payer: Wellcare Medicare	$85.10
Rate for Payer: Wellmed Medicare	$85.10

RNA, Real Time PCR (Non-Graph) SO

Facility

$441.00

Service Code	HCPCS 87536
Hospital Charge Code	1701069
Hospital Revenue Code	306
Rate for Payer: Cash Price	$299.88

rocuronium 10 mg/mL IV Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77797828
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

rocuronium 10 mg/mL IV Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77797828
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Know your out-of-pocket cost for care.

All Charges