White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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

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

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

RR180400

Facility

$2,319.00

Service Code	HCPCS C1713
Hospital Charge Code	990984
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	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

RR18400

Facility

$1,747.00

Service Code	HCPCS C1713
Hospital Charge Code	990991
Hospital Revenue Code	278
Min. Negotiated Rate	$436.75
Max. Negotiated Rate	$873.50
Rate for Payer: Cash Price	$1,187.96
Rate for Payer: Cigna Commercial	$436.75
Rate for Payer: Multiplan Auto	$873.50
Rate for Payer: Multiplan Commercial	$873.50
Rate for Payer: Multiplan Workers Comp	$873.50
Rate for Payer: Scott and White EPO/PPO	$873.50

RR18400

Facility

$1,746.99

Service Code	HCPCS C1769
Hospital Charge Code	990981
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,187.95

RR18400

Facility

$1,747.00

Service Code	HCPCS C1713
Hospital Charge Code	990991
Hospital Revenue Code	278
Min. Negotiated Rate	$157.23
Max. Negotiated Rate	$1,257.84
Rate for Payer: Amerigroup CHIP/Medicaid	$157.23
Rate for Payer: BCBS of TX Blue Advantage	$524.10
Rate for Payer: BCBS of TX Blue Essentials	$628.92
Rate for Payer: BCBS of TX PPO	$698.80
Rate for Payer: Cash Price	$1,187.96
Rate for Payer: Cigna Medicaid	$1,257.84
Rate for Payer: Molina CHIP/Medicaid	$1,257.84
Rate for Payer: Multiplan Auto	$873.50
Rate for Payer: Multiplan Commercial	$873.50
Rate for Payer: Multiplan Workers Comp	$873.50
Rate for Payer: Parkland Medicaid	$1,257.84
Rate for Payer: Scott and White EPO/PPO	$873.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,257.84
Rate for Payer: Superior Health Plan EPO	$237.59

RR18400

Facility

$1,746.99

Service Code	HCPCS C1769
Hospital Charge Code	990981
Hospital Revenue Code	272
Min. Negotiated Rate	$157.23
Max. Negotiated Rate	$1,257.83
Rate for Payer: Amerigroup CHIP/Medicaid	$157.23
Rate for Payer: BCBS of TX Blue Advantage	$524.10
Rate for Payer: BCBS of TX Blue Essentials	$628.92
Rate for Payer: BCBS of TX PPO	$698.80
Rate for Payer: Cash Price	$1,187.95
Rate for Payer: Cigna Medicaid	$1,257.83
Rate for Payer: Molina CHIP/Medicaid	$1,257.83
Rate for Payer: Multiplan Auto	$1,135.54
Rate for Payer: Multiplan Commercial	$1,135.54
Rate for Payer: Multiplan Workers Comp	$1,135.54
Rate for Payer: Parkland Medicaid	$1,257.83
Rate for Payer: Scott and White EPO/PPO	$873.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,257.83
Rate for Payer: Superior Health Plan EPO	$237.59

RR20P

Facility

$1,168.67

Hospital Charge Code	990986
Hospital Revenue Code	272
Rate for Payer: Cash Price	$794.70

RR20P

Facility

$1,168.67

Hospital Charge Code	990986
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

RSV, NAA SO

Facility

$142.00

Service Code	HCPCS 87634
Hospital Charge Code	9130980
Hospital Revenue Code	306
Min. Negotiated Rate	$27.38
Max. Negotiated Rate	$102.24
Rate for Payer: Amerigroup CHIP/Medicaid	$27.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$70.20
Rate for Payer: Amerigroup Medicare	$70.20
Rate for Payer: BCBS of TX Blue Advantage	$42.60
Rate for Payer: BCBS of TX Blue Essentials	$51.12
Rate for Payer: BCBS of TX Medicare	$70.20
Rate for Payer: BCBS of TX PPO	$56.80
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cigna Medicaid	$102.24
Rate for Payer: Cigna Medicare	$70.20
Rate for Payer: Employer Direct Commercial	$70.20
Rate for Payer: Humana Medicare/TRICARE	$70.20
Rate for Payer: Molina CHIP/Medicaid	$102.24
Rate for Payer: Molina Dual Medicare/Medicaid	$70.20
Rate for Payer: Molina Medicare	$70.20
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Parkland Medicaid	$102.24
Rate for Payer: Scott and White EPO/PPO	$87.75
Rate for Payer: Scott and White Medicare	$70.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.24
Rate for Payer: Superior Health Plan EPO	$70.20
Rate for Payer: Superior Health Plan Medicare	$70.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$70.20
Rate for Payer: Universal American Medicare	$70.20
Rate for Payer: Wellcare Medicare	$70.20
Rate for Payer: Wellmed Medicare	$70.20

RSV, NAA SO

Facility

$142.00

Service Code	HCPCS 87634
Hospital Charge Code	9130980
Hospital Revenue Code	306
Rate for Payer: Cash Price	$96.56

RT CHARGE Aerosol Demo/Eval -> Yes

Facility

$42.00

Service Code	HCPCS 94664
Hospital Charge Code	4000048
Hospital Revenue Code	410
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$464.99
Rate for Payer: Amerigroup CHIP/Medicaid	$3.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$219.97
Rate for Payer: Amerigroup Medicare	$219.97
Rate for Payer: BCBS of TX Blue Advantage	$12.60
Rate for Payer: BCBS of TX Blue Essentials	$15.12
Rate for Payer: BCBS of TX Medicare	$219.97
Rate for Payer: BCBS of TX PPO	$16.80
Rate for Payer: Cash Price	$28.56
Rate for Payer: Cash Price	$28.56
Rate for Payer: Cash Price	$28.56
Rate for Payer: Cigna Commercial	$464.99
Rate for Payer: Cigna Medicaid	$30.24
Rate for Payer: Cigna Medicare	$219.97
Rate for Payer: Employer Direct Commercial	$219.97
Rate for Payer: Humana Medicare/TRICARE	$219.97
Rate for Payer: Molina CHIP/Medicaid	$30.24
Rate for Payer: Molina Dual Medicare/Medicaid	$219.97
Rate for Payer: Molina Medicare	$219.97
Rate for Payer: Multiplan Auto	$27.30
Rate for Payer: Multiplan Commercial	$27.30
Rate for Payer: Multiplan Workers Comp	$27.30
Rate for Payer: Parkland Medicaid	$30.24
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Scott and White Medicare	$219.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.24
Rate for Payer: Superior Health Plan EPO	$219.97
Rate for Payer: Superior Health Plan Medicare	$219.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$219.97
Rate for Payer: Universal American Medicare	$219.97
Rate for Payer: Wellcare Medicare	$219.97
Rate for Payer: Wellmed Medicare	$219.97

RT CHARGE Aerosol Demo/Eval -> Yes

Facility

$42.00

Service Code	HCPCS 94664
Hospital Charge Code	4000048
Hospital Revenue Code	410
Rate for Payer: Cash Price	$28.56

RT CHARGE Aerosol Therapy -> Subsequent

Facility

$170.00

Service Code	HCPCS 94640
Hospital Charge Code	4049144
Hospital Revenue Code	410
Rate for Payer: Cash Price	$115.60

RT CHARGE Aerosol Therapy -> Subsequent

Facility

$170.00

Service Code	HCPCS 94640
Hospital Charge Code	4049144
Hospital Revenue Code	410
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$464.99
Rate for Payer: Amerigroup CHIP/Medicaid	$15.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$219.97
Rate for Payer: Amerigroup Medicare	$219.97
Rate for Payer: BCBS of TX Blue Advantage	$51.00
Rate for Payer: BCBS of TX Blue Essentials	$61.20
Rate for Payer: BCBS of TX Medicare	$219.97
Rate for Payer: BCBS of TX PPO	$68.00
Rate for Payer: Cash Price	$115.60
Rate for Payer: Cash Price	$115.60
Rate for Payer: Cash Price	$115.60
Rate for Payer: Cigna Commercial	$464.99
Rate for Payer: Cigna Medicaid	$122.40
Rate for Payer: Cigna Medicare	$219.97
Rate for Payer: Employer Direct Commercial	$219.97
Rate for Payer: Humana Medicare/TRICARE	$219.97
Rate for Payer: Molina CHIP/Medicaid	$122.40
Rate for Payer: Molina Dual Medicare/Medicaid	$219.97
Rate for Payer: Molina Medicare	$219.97
Rate for Payer: Multiplan Auto	$110.50
Rate for Payer: Multiplan Commercial	$110.50
Rate for Payer: Multiplan Workers Comp	$110.50
Rate for Payer: Parkland Medicaid	$122.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Scott and White Medicare	$219.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$122.40
Rate for Payer: Superior Health Plan EPO	$219.97
Rate for Payer: Superior Health Plan Medicare	$219.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$219.97
Rate for Payer: Universal American Medicare	$219.97
Rate for Payer: Wellcare Medicare	$219.97
Rate for Payer: Wellmed Medicare	$219.97

RT CHARGE BiPAP -> Initial

Facility

$699.00

Service Code	HCPCS 94660
Hospital Charge Code	5501857
Hospital Revenue Code	410
Rate for Payer: Cash Price	$475.32

RT CHARGE BiPAP -> Initial

Facility

$699.00

Service Code	HCPCS 94660
Hospital Charge Code	5501857
Hospital Revenue Code	410
Min. Negotiated Rate	$62.91
Max. Negotiated Rate	$503.28
Rate for Payer: Amerigroup CHIP/Medicaid	$62.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$219.97
Rate for Payer: Amerigroup Medicare	$219.97
Rate for Payer: BCBS of TX Blue Advantage	$209.70
Rate for Payer: BCBS of TX Blue Essentials	$251.64
Rate for Payer: BCBS of TX Medicare	$219.97
Rate for Payer: BCBS of TX PPO	$279.60
Rate for Payer: Cash Price	$475.32
Rate for Payer: Cash Price	$475.32
Rate for Payer: Cash Price	$475.32
Rate for Payer: Cigna Commercial	$464.99
Rate for Payer: Cigna Medicaid	$503.28
Rate for Payer: Cigna Medicare	$219.97
Rate for Payer: Employer Direct Commercial	$219.97
Rate for Payer: Humana Medicare/TRICARE	$219.97
Rate for Payer: Molina CHIP/Medicaid	$503.28
Rate for Payer: Molina Dual Medicare/Medicaid	$219.97
Rate for Payer: Molina Medicare	$219.97
Rate for Payer: Multiplan Auto	$454.35
Rate for Payer: Multiplan Commercial	$454.35
Rate for Payer: Multiplan Workers Comp	$454.35
Rate for Payer: Parkland Medicaid	$503.28
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Scott and White Medicare	$219.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$503.28
Rate for Payer: Superior Health Plan EPO	$219.97
Rate for Payer: Superior Health Plan Medicare	$219.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$219.97
Rate for Payer: Universal American Medicare	$219.97
Rate for Payer: Wellcare Medicare	$219.97
Rate for Payer: Wellmed Medicare	$219.97

RT CHARGE BiPAP -> Subsequent

Facility

$699.00

Service Code	HCPCS 94660
Hospital Charge Code	5504662
Hospital Revenue Code	410
Rate for Payer: Cash Price	$475.32

RT CHARGE BiPAP -> Subsequent

Facility

$699.00

Service Code	HCPCS 94660
Hospital Charge Code	5504662
Hospital Revenue Code	410
Min. Negotiated Rate	$62.91
Max. Negotiated Rate	$503.28
Rate for Payer: Amerigroup CHIP/Medicaid	$62.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$219.97
Rate for Payer: Amerigroup Medicare	$219.97
Rate for Payer: BCBS of TX Blue Advantage	$209.70
Rate for Payer: BCBS of TX Blue Essentials	$251.64
Rate for Payer: BCBS of TX Medicare	$219.97
Rate for Payer: BCBS of TX PPO	$279.60
Rate for Payer: Cash Price	$475.32
Rate for Payer: Cash Price	$475.32
Rate for Payer: Cash Price	$475.32
Rate for Payer: Cigna Commercial	$464.99
Rate for Payer: Cigna Medicaid	$503.28
Rate for Payer: Cigna Medicare	$219.97
Rate for Payer: Employer Direct Commercial	$219.97
Rate for Payer: Humana Medicare/TRICARE	$219.97
Rate for Payer: Molina CHIP/Medicaid	$503.28
Rate for Payer: Molina Dual Medicare/Medicaid	$219.97
Rate for Payer: Molina Medicare	$219.97
Rate for Payer: Multiplan Auto	$454.35
Rate for Payer: Multiplan Commercial	$454.35
Rate for Payer: Multiplan Workers Comp	$454.35
Rate for Payer: Parkland Medicaid	$503.28
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Scott and White Medicare	$219.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$503.28
Rate for Payer: Superior Health Plan EPO	$219.97
Rate for Payer: Superior Health Plan Medicare	$219.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$219.97
Rate for Payer: Universal American Medicare	$219.97
Rate for Payer: Wellcare Medicare	$219.97
Rate for Payer: Wellmed Medicare	$219.97

Know your out-of-pocket cost for care.

All Charges