White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ROD RM 2.5X950MM BALL TIP STRL

Facility

$1,466.42

Hospital Charge Code	117557
Hospital Revenue Code	272
Rate for Payer: Cash Price	$997.17

ROLL STAND SNGL

Facility

$760.18

Hospital Charge Code	992960
Hospital Revenue Code	270
Rate for Payer: Cash Price	$516.92

ROLL STAND SNGL

Facility

$760.18

Hospital Charge Code	992960
Hospital Revenue Code	270
Min. Negotiated Rate	$68.42
Max. Negotiated Rate	$547.33
Rate for Payer: Amerigroup CHIP/Medicaid	$68.42
Rate for Payer: BCBS of TX Blue Advantage	$228.05
Rate for Payer: BCBS of TX Blue Essentials	$273.66
Rate for Payer: BCBS of TX PPO	$304.07
Rate for Payer: Cash Price	$516.92
Rate for Payer: Cigna Medicaid	$547.33
Rate for Payer: Molina CHIP/Medicaid	$547.33
Rate for Payer: Multiplan Auto	$494.12
Rate for Payer: Multiplan Commercial	$494.12
Rate for Payer: Multiplan Workers Comp	$494.12
Rate for Payer: Parkland Medicaid	$547.33
Rate for Payer: Scott and White EPO/PPO	$380.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$547.33
Rate for Payer: Superior Health Plan EPO	$103.38

ROOM/BED: CCU

Facility

$9,266.00

Hospital Charge Code	89003
Hospital Revenue Code	210
Min. Negotiated Rate	$2,500.00
Max. Negotiated Rate	$2,500.00
Rate for Payer: Cash Price	$6,300.88
Rate for Payer: Scott and White EPO/PPO	$2,500.00

ROOM/BED: ICU

Facility

$8,000.00

Hospital Charge Code	19000
Hospital Revenue Code	200
Min. Negotiated Rate	$2,500.00
Max. Negotiated Rate	$2,500.00
Rate for Payer: Cash Price	$5,440.00
Rate for Payer: Scott and White EPO/PPO	$2,500.00

ROOM/BED: ICU Intermediate

Facility

$4,590.00

Hospital Charge Code	1008
Hospital Revenue Code	206
Rate for Payer: Cash Price	$3,121.20

ROOM/BED: Observation

Facility

$110.00

Service Code	HCPCS G0378
Hospital Charge Code	100016
Hospital Revenue Code	762
Rate for Payer: Cash Price	$74.80

ROOM/BED: Observation

Facility

$110.00

Service Code	HCPCS G0378
Hospital Charge Code	100016
Hospital Revenue Code	762
Min. Negotiated Rate	$14.96
Max. Negotiated Rate	$3,660.00
Rate for Payer: Amerigroup CHIP/Medicaid	$400.00
Rate for Payer: BCBS of TX Blue Advantage	$2,745.00
Rate for Payer: BCBS of TX Blue Essentials	$3,294.00
Rate for Payer: BCBS of TX PPO	$3,660.00
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cigna Medicaid	$79.20
Rate for Payer: Molina CHIP/Medicaid	$79.20
Rate for Payer: Multiplan Auto	$71.50
Rate for Payer: Multiplan Commercial	$71.50
Rate for Payer: Multiplan Workers Comp	$71.50
Rate for Payer: Parkland Medicaid	$79.20
Rate for Payer: Scott and White EPO/PPO	$55.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$14.96

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
Rate for Payer: Cash Price	$5.44

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

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	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

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

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	$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	$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

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

Know your out-of-pocket cost for care.

All Charges