White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ROOM/BED: Private

Facility

$3,000.00

Hospital Charge Code	21006
Hospital Revenue Code	110
Rate for Payer: Cash Price	$2,040.00

ROOM/BED: Private ISOLATION

Facility

$3,000.00

Hospital Charge Code	31005
Hospital Revenue Code	164
Rate for Payer: Cash Price	$2,040.00

ROOM/BED: Semi Private

Facility

$2,800.00

Hospital Charge Code	11007
Hospital Revenue Code	120
Rate for Payer: Cash Price	$1,904.00

ROOM/BED: Semi Private OB

Facility

$1,015.00

Hospital Charge Code	16006
Hospital Revenue Code	122
Rate for Payer: Cash Price	$690.20

rOPINIRole 1 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77798348
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

rOPINIRole 1 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77798348
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

ropivacaine 0.5% Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J2795
Hospital Charge Code	77800099
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.04
Rate for Payer: BCBS of TX Blue Essentials	$0.05
Rate for Payer: BCBS of TX PPO	$0.06
Rate for Payer: Cash Price	$87.16
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

ropivacaine 0.5% Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J2795
Hospital Charge Code	77801588
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

ropivacaine 0.5% Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J2795
Hospital Charge Code	77800099
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

ropivacaine 0.5% Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J2795
Hospital Charge Code	77801588
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.04
Rate for Payer: BCBS of TX Blue Essentials	$0.05
Rate for Payer: BCBS of TX PPO	$0.06
Rate for Payer: Cash Price	$87.16
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

Rotavirus lab test

Facility

$130.84

Service Code	HCPCS 87425
Hospital Charge Code	993990
Hospital Revenue Code	300
Rate for Payer: Cash Price	$88.97

Rotavirus lab test

Facility

$130.84

Service Code	HCPCS 87425
Hospital Charge Code	993990
Hospital Revenue Code	300
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$94.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.98
Rate for Payer: Amerigroup Medicare	$11.98
Rate for Payer: BCBS of TX Blue Advantage	$39.25
Rate for Payer: BCBS of TX Blue Essentials	$47.10
Rate for Payer: BCBS of TX Medicare	$11.98
Rate for Payer: BCBS of TX PPO	$52.34
Rate for Payer: Cash Price	$88.97
Rate for Payer: Cash Price	$88.97
Rate for Payer: Cigna Medicaid	$94.20
Rate for Payer: Cigna Medicare	$11.98
Rate for Payer: Employer Direct Commercial	$11.98
Rate for Payer: Humana Medicare/TRICARE	$11.98
Rate for Payer: Molina CHIP/Medicaid	$94.20
Rate for Payer: Molina Dual Medicare/Medicaid	$11.98
Rate for Payer: Molina Medicare	$11.98
Rate for Payer: Multiplan Auto	$85.05
Rate for Payer: Multiplan Commercial	$85.05
Rate for Payer: Multiplan Workers Comp	$85.05
Rate for Payer: Parkland Medicaid	$94.20
Rate for Payer: Scott and White EPO/PPO	$14.97
Rate for Payer: Scott and White Medicare	$11.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$94.20
Rate for Payer: Superior Health Plan EPO	$11.98
Rate for Payer: Superior Health Plan Medicare	$11.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.98
Rate for Payer: Universal American Medicare	$11.98
Rate for Payer: Wellcare Medicare	$11.98
Rate for Payer: Wellmed Medicare	$11.98

RR0120TR

Facility

$639.00

Service Code	HCPCS C1713
Hospital Charge Code	990999
Hospital Revenue Code	278
Min. Negotiated Rate	$57.51
Max. Negotiated Rate	$460.08
Rate for Payer: Amerigroup CHIP/Medicaid	$57.51
Rate for Payer: BCBS of TX Blue Advantage	$191.70
Rate for Payer: BCBS of TX Blue Essentials	$230.04
Rate for Payer: BCBS of TX PPO	$255.60
Rate for Payer: Cash Price	$434.52
Rate for Payer: Cigna Medicaid	$460.08
Rate for Payer: Molina CHIP/Medicaid	$460.08
Rate for Payer: Multiplan Auto	$319.50
Rate for Payer: Multiplan Commercial	$319.50
Rate for Payer: Multiplan Workers Comp	$319.50
Rate for Payer: Parkland Medicaid	$460.08
Rate for Payer: Scott and White EPO/PPO	$319.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$460.08
Rate for Payer: Superior Health Plan EPO	$86.90

RR0120TR

Facility

$639.00

Service Code	HCPCS C1713
Hospital Charge Code	990999
Hospital Revenue Code	278
Min. Negotiated Rate	$159.75
Max. Negotiated Rate	$319.50
Rate for Payer: Cash Price	$434.52
Rate for Payer: Cigna Commercial	$159.75
Rate for Payer: Multiplan Auto	$319.50
Rate for Payer: Multiplan Commercial	$319.50
Rate for Payer: Multiplan Workers Comp	$319.50
Rate for Payer: Scott and White EPO/PPO	$319.50

RR0200TR

Facility

$734.00

Service Code	HCPCS C1776
Hospital Charge Code	990983
Hospital Revenue Code	278
Min. Negotiated Rate	$183.50
Max. Negotiated Rate	$367.00
Rate for Payer: Cash Price	$499.12
Rate for Payer: Cigna Commercial	$183.50
Rate for Payer: Multiplan Auto	$367.00
Rate for Payer: Multiplan Commercial	$367.00
Rate for Payer: Multiplan Workers Comp	$367.00
Rate for Payer: Scott and White EPO/PPO	$367.00

RR0200TR

Facility

$734.00

Service Code	HCPCS C1776
Hospital Charge Code	990983
Hospital Revenue Code	278
Min. Negotiated Rate	$66.06
Max. Negotiated Rate	$528.48
Rate for Payer: Amerigroup CHIP/Medicaid	$66.06
Rate for Payer: BCBS of TX Blue Advantage	$220.20
Rate for Payer: BCBS of TX Blue Essentials	$264.24
Rate for Payer: BCBS of TX PPO	$293.60
Rate for Payer: Cash Price	$499.12
Rate for Payer: Cigna Medicaid	$528.48
Rate for Payer: Molina CHIP/Medicaid	$528.48
Rate for Payer: Multiplan Auto	$367.00
Rate for Payer: Multiplan Commercial	$367.00
Rate for Payer: Multiplan Workers Comp	$367.00
Rate for Payer: Parkland Medicaid	$528.48
Rate for Payer: Scott and White EPO/PPO	$367.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$528.48
Rate for Payer: Superior Health Plan EPO	$99.82

RR0200TR

Facility

$735.00

Service Code	HCPCS C1713
Hospital Charge Code	990997
Hospital Revenue Code	278
Min. Negotiated Rate	$183.75
Max. Negotiated Rate	$367.50
Rate for Payer: Cash Price	$499.80
Rate for Payer: Cigna Commercial	$183.75
Rate for Payer: Multiplan Auto	$367.50
Rate for Payer: Multiplan Commercial	$367.50
Rate for Payer: Multiplan Workers Comp	$367.50
Rate for Payer: Scott and White EPO/PPO	$367.50

RR0200TR

Facility

$735.00

Service Code	HCPCS C1713
Hospital Charge Code	990997
Hospital Revenue Code	278
Min. Negotiated Rate	$66.15
Max. Negotiated Rate	$529.20
Rate for Payer: Amerigroup CHIP/Medicaid	$66.15
Rate for Payer: BCBS of TX Blue Advantage	$220.50
Rate for Payer: BCBS of TX Blue Essentials	$264.60
Rate for Payer: BCBS of TX PPO	$294.00
Rate for Payer: Cash Price	$499.80
Rate for Payer: Cigna Medicaid	$529.20
Rate for Payer: Molina CHIP/Medicaid	$529.20
Rate for Payer: Multiplan Auto	$367.50
Rate for Payer: Multiplan Commercial	$367.50
Rate for Payer: Multiplan Workers Comp	$367.50
Rate for Payer: Parkland Medicaid	$529.20
Rate for Payer: Scott and White EPO/PPO	$367.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$529.20
Rate for Payer: Superior Health Plan EPO	$99.96

RR10P

Facility

$1,168.67

Hospital Charge Code	990985
Hospital Revenue Code	272
Min. Negotiated Rate	$105.18
Max. Negotiated Rate	$841.44
Rate for Payer: Amerigroup CHIP/Medicaid	$105.18
Rate for Payer: BCBS of TX Blue Advantage	$350.60
Rate for Payer: BCBS of TX Blue Essentials	$420.72
Rate for Payer: BCBS of TX PPO	$467.47
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Medicaid	$841.44
Rate for Payer: Molina CHIP/Medicaid	$841.44
Rate for Payer: Multiplan Auto	$759.64
Rate for Payer: Multiplan Commercial	$759.64
Rate for Payer: Multiplan Workers Comp	$759.64
Rate for Payer: Parkland Medicaid	$841.44
Rate for Payer: Scott and White EPO/PPO	$584.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$841.44
Rate for Payer: Superior Health Plan EPO	$158.94

RR10P

Facility

$1,168.67

Hospital Charge Code	990985
Hospital Revenue Code	272
Rate for Payer: Cash Price	$794.70

RR1600

Facility

$410.00

Service Code	HCPCS C1713
Hospital Charge Code	991002
Hospital Revenue Code	278
Min. Negotiated Rate	$102.50
Max. Negotiated Rate	$205.00
Rate for Payer: Cash Price	$278.80
Rate for Payer: Cigna Commercial	$102.50
Rate for Payer: Multiplan Auto	$205.00
Rate for Payer: Multiplan Commercial	$205.00
Rate for Payer: Multiplan Workers Comp	$205.00
Rate for Payer: Scott and White EPO/PPO	$205.00

RR1600

Facility

$410.00

Service Code	HCPCS C1713
Hospital Charge Code	991002
Hospital Revenue Code	278
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$295.20
Rate for Payer: Amerigroup CHIP/Medicaid	$36.90
Rate for Payer: BCBS of TX Blue Advantage	$123.00
Rate for Payer: BCBS of TX Blue Essentials	$147.60
Rate for Payer: BCBS of TX PPO	$164.00
Rate for Payer: Cash Price	$278.80
Rate for Payer: Cigna Medicaid	$295.20
Rate for Payer: Molina CHIP/Medicaid	$295.20
Rate for Payer: Multiplan Auto	$205.00
Rate for Payer: Multiplan Commercial	$205.00
Rate for Payer: Multiplan Workers Comp	$205.00
Rate for Payer: Parkland Medicaid	$295.20
Rate for Payer: Scott and White EPO/PPO	$205.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$295.20
Rate for Payer: Superior Health Plan EPO	$55.76

RR180400

Facility

$2,319.00

Service Code	HCPCS C1713
Hospital Charge Code	990990
Hospital Revenue Code	278
Min. Negotiated Rate	$579.75
Max. Negotiated Rate	$1,159.50
Rate for Payer: Cash Price	$1,576.92
Rate for Payer: Cigna Commercial	$579.75
Rate for Payer: Multiplan Auto	$1,159.50
Rate for Payer: Multiplan Commercial	$1,159.50
Rate for Payer: Multiplan Workers Comp	$1,159.50
Rate for Payer: Scott and White EPO/PPO	$1,159.50

RR180400

Facility

$2,319.00

Service Code	HCPCS C1713
Hospital Charge Code	990990
Hospital Revenue Code	278
Min. Negotiated Rate	$208.71
Max. Negotiated Rate	$1,669.68
Rate for Payer: Amerigroup CHIP/Medicaid	$208.71
Rate for Payer: BCBS of TX Blue Advantage	$695.70
Rate for Payer: BCBS of TX Blue Essentials	$834.84
Rate for Payer: BCBS of TX PPO	$927.60
Rate for Payer: Cash Price	$1,576.92
Rate for Payer: Cigna Medicaid	$1,669.68
Rate for Payer: Molina CHIP/Medicaid	$1,669.68
Rate for Payer: Multiplan Auto	$1,159.50
Rate for Payer: Multiplan Commercial	$1,159.50
Rate for Payer: Multiplan Workers Comp	$1,159.50
Rate for Payer: Parkland Medicaid	$1,669.68
Rate for Payer: Scott and White EPO/PPO	$1,159.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,669.68
Rate for Payer: Superior Health Plan EPO	$315.38

RR180400

Facility

$2,319.00

Service Code	HCPCS C1713
Hospital Charge Code	990984
Hospital Revenue Code	278
Min. Negotiated Rate	$208.71
Max. Negotiated Rate	$1,669.68
Rate for Payer: Amerigroup CHIP/Medicaid	$208.71
Rate for Payer: BCBS of TX Blue Advantage	$695.70
Rate for Payer: BCBS of TX Blue Essentials	$834.84
Rate for Payer: BCBS of TX PPO	$927.60
Rate for Payer: Cash Price	$1,576.92
Rate for Payer: Cigna Medicaid	$1,669.68
Rate for Payer: Molina CHIP/Medicaid	$1,669.68
Rate for Payer: Multiplan Auto	$1,159.50
Rate for Payer: Multiplan Commercial	$1,159.50
Rate for Payer: Multiplan Workers Comp	$1,159.50
Rate for Payer: Parkland Medicaid	$1,669.68
Rate for Payer: Scott and White EPO/PPO	$1,159.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,669.68
Rate for Payer: Superior Health Plan EPO	$315.38

Know your out-of-pocket cost for care.

All Charges