White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SENSOR DISP BIS -- DHF

Facility

$117.50

Hospital Charge Code	80340177
Hospital Revenue Code	271
Min. Negotiated Rate	$10.57
Max. Negotiated Rate	$84.60
Rate for Payer: Amerigroup CHIP/Medicaid	$10.57
Rate for Payer: BCBS of TX Blue Advantage	$35.25
Rate for Payer: BCBS of TX Blue Essentials	$42.30
Rate for Payer: BCBS of TX PPO	$47.00
Rate for Payer: Cash Price	$79.90
Rate for Payer: Cigna Medicaid	$84.60
Rate for Payer: Molina CHIP/Medicaid	$84.60
Rate for Payer: Multiplan Auto	$76.38
Rate for Payer: Multiplan Commercial	$76.38
Rate for Payer: Multiplan Workers Comp	$76.38
Rate for Payer: Parkland Medicaid	$84.60
Rate for Payer: Scott and White EPO/PPO	$58.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.60
Rate for Payer: Superior Health Plan EPO	$15.98

SENSOR, FINGER PULSE OXIMETRY ADULT REUSABLE

Facility

$624.20

Hospital Charge Code	993536
Hospital Revenue Code	270
Rate for Payer: Cash Price	$424.46

SENSOR, FINGER PULSE OXIMETRY ADULT REUSABLE

Facility

$624.20

Hospital Charge Code	993536
Hospital Revenue Code	270
Min. Negotiated Rate	$56.18
Max. Negotiated Rate	$449.42
Rate for Payer: Amerigroup CHIP/Medicaid	$56.18
Rate for Payer: BCBS of TX Blue Advantage	$187.26
Rate for Payer: BCBS of TX Blue Essentials	$224.71
Rate for Payer: BCBS of TX PPO	$249.68
Rate for Payer: Cash Price	$424.46
Rate for Payer: Cigna Medicaid	$449.42
Rate for Payer: Molina CHIP/Medicaid	$449.42
Rate for Payer: Multiplan Auto	$405.73
Rate for Payer: Multiplan Commercial	$405.73
Rate for Payer: Multiplan Workers Comp	$405.73
Rate for Payer: Parkland Medicaid	$449.42
Rate for Payer: Scott and White EPO/PPO	$312.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$449.42
Rate for Payer: Superior Health Plan EPO	$84.89

SENSOR, LNCS, ADULT

Facility

$26.15

Hospital Charge Code	993370
Hospital Revenue Code	270
Rate for Payer: Cash Price	$17.78

SENSOR, LNCS, ADULT

Facility

$26.15

Hospital Charge Code	993370
Hospital Revenue Code	270
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$18.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2.35
Rate for Payer: BCBS of TX Blue Advantage	$7.84
Rate for Payer: BCBS of TX Blue Essentials	$9.41
Rate for Payer: BCBS of TX PPO	$10.46
Rate for Payer: Cash Price	$17.78
Rate for Payer: Cigna Medicaid	$18.83
Rate for Payer: Molina CHIP/Medicaid	$18.83
Rate for Payer: Multiplan Auto	$17.00
Rate for Payer: Multiplan Commercial	$17.00
Rate for Payer: Multiplan Workers Comp	$17.00
Rate for Payer: Parkland Medicaid	$18.83
Rate for Payer: Scott and White EPO/PPO	$13.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.83
Rate for Payer: Superior Health Plan EPO	$3.56

SENSOR, LNCS, PEDIATRIC

Facility

$27.83

Hospital Charge Code	993087
Hospital Revenue Code	270
Rate for Payer: Cash Price	$18.92

SENSOR, LNCS, PEDIATRIC

Facility

$27.83

Hospital Charge Code	993087
Hospital Revenue Code	270
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$20.04
Rate for Payer: Amerigroup CHIP/Medicaid	$2.50
Rate for Payer: BCBS of TX Blue Advantage	$8.35
Rate for Payer: BCBS of TX Blue Essentials	$10.02
Rate for Payer: BCBS of TX PPO	$11.13
Rate for Payer: Cash Price	$18.92
Rate for Payer: Cigna Medicaid	$20.04
Rate for Payer: Molina CHIP/Medicaid	$20.04
Rate for Payer: Multiplan Auto	$18.09
Rate for Payer: Multiplan Commercial	$18.09
Rate for Payer: Multiplan Workers Comp	$18.09
Rate for Payer: Parkland Medicaid	$20.04
Rate for Payer: Scott and White EPO/PPO	$13.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.04
Rate for Payer: Superior Health Plan EPO	$3.78

SENSOR MONITOR BRAIN BIS QUATRO

Facility

$105.06

Hospital Charge Code	993002
Hospital Revenue Code	270
Min. Negotiated Rate	$9.46
Max. Negotiated Rate	$75.64
Rate for Payer: Amerigroup CHIP/Medicaid	$9.46
Rate for Payer: BCBS of TX Blue Advantage	$31.52
Rate for Payer: BCBS of TX Blue Essentials	$37.82
Rate for Payer: BCBS of TX PPO	$42.02
Rate for Payer: Cash Price	$71.44
Rate for Payer: Cigna Medicaid	$75.64
Rate for Payer: Molina CHIP/Medicaid	$75.64
Rate for Payer: Multiplan Auto	$68.29
Rate for Payer: Multiplan Commercial	$68.29
Rate for Payer: Multiplan Workers Comp	$68.29
Rate for Payer: Parkland Medicaid	$75.64
Rate for Payer: Scott and White EPO/PPO	$52.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$75.64
Rate for Payer: Superior Health Plan EPO	$14.29

SENSOR MONITOR BRAIN BIS QUATRO

Facility

$105.06

Hospital Charge Code	993002
Hospital Revenue Code	270
Rate for Payer: Cash Price	$71.44

SENSOR, SPO2, SHORT, NELLCOR COMPAT

Facility

$327.06

Hospital Charge Code	993197
Hospital Revenue Code	270
Rate for Payer: Cash Price	$222.40

SENSOR, SPO2, SHORT, NELLCOR COMPAT

Facility

$327.06

Hospital Charge Code	993197
Hospital Revenue Code	270
Min. Negotiated Rate	$29.44
Max. Negotiated Rate	$235.48
Rate for Payer: Amerigroup CHIP/Medicaid	$29.44
Rate for Payer: BCBS of TX Blue Advantage	$98.12
Rate for Payer: BCBS of TX Blue Essentials	$117.74
Rate for Payer: BCBS of TX PPO	$130.82
Rate for Payer: Cash Price	$222.40
Rate for Payer: Cigna Medicaid	$235.48
Rate for Payer: Molina CHIP/Medicaid	$235.48
Rate for Payer: Multiplan Auto	$212.59
Rate for Payer: Multiplan Commercial	$212.59
Rate for Payer: Multiplan Workers Comp	$212.59
Rate for Payer: Parkland Medicaid	$235.48
Rate for Payer: Scott and White EPO/PPO	$163.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$235.48
Rate for Payer: Superior Health Plan EPO	$44.48

SENSOR URETERORENOSCOPE STERILE SINGLE USE

Facility

$6,356.00

Hospital Charge Code	146125
Hospital Revenue Code	272
Min. Negotiated Rate	$572.04
Max. Negotiated Rate	$4,576.32
Rate for Payer: Amerigroup CHIP/Medicaid	$572.04
Rate for Payer: BCBS of TX Blue Advantage	$1,906.80
Rate for Payer: BCBS of TX Blue Essentials	$2,288.16
Rate for Payer: BCBS of TX PPO	$2,542.40
Rate for Payer: Cash Price	$4,322.08
Rate for Payer: Cigna Medicaid	$4,576.32
Rate for Payer: Molina CHIP/Medicaid	$4,576.32
Rate for Payer: Multiplan Auto	$4,131.40
Rate for Payer: Multiplan Commercial	$4,131.40
Rate for Payer: Multiplan Workers Comp	$4,131.40
Rate for Payer: Parkland Medicaid	$4,576.32
Rate for Payer: Scott and White EPO/PPO	$3,178.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,576.32
Rate for Payer: Superior Health Plan EPO	$864.42

SENSOR URETERORENOSCOPE STERILE SINGLE USE

Facility

$6,356.00

Hospital Charge Code	146125
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,322.08

SEPTIC ARTHRITIS W CC

Facility

$22,936.80

Service Code	MSDRG 549
Min. Negotiated Rate	$10,563.00
Max. Negotiated Rate	$22,936.80
Rate for Payer: BCBS of TX Blue Advantage	$10,700.12
Rate for Payer: BCBS of TX Blue Essentials	$12,838.90
Rate for Payer: BCBS of TX PPO	$14,266.00

SEPTIC ARTHRITIS WITH CC

Facility

$22,936.80

Service Code	MSDRG 549
Min. Negotiated Rate	$10,563.00
Max. Negotiated Rate	$22,936.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,607.68
Rate for Payer: Amerigroup Medicare	$13,607.68
Rate for Payer: BCBS of TX Medicare	$13,607.68
Rate for Payer: Cigna Commercial	$15,548.74
Rate for Payer: Cigna Medicare	$13,607.68
Rate for Payer: Employer Direct Commercial	$13,607.68
Rate for Payer: Humana Medicare/TRICARE	$13,607.68
Rate for Payer: Molina Dual Medicare/Medicaid	$13,607.68
Rate for Payer: Molina Medicare	$13,607.68
Rate for Payer: Multiplan Auto	$22,936.80
Rate for Payer: Multiplan Commercial	$22,936.80
Rate for Payer: Multiplan Workers Comp	$22,936.80
Rate for Payer: Scott and White EPO/PPO	$10,563.00
Rate for Payer: Scott and White Medicare	$13,607.68
Rate for Payer: Superior Health Plan EPO	$13,607.68
Rate for Payer: Superior Health Plan Medicare	$13,607.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,607.68
Rate for Payer: Universal American Medicare	$13,607.68
Rate for Payer: Wellcare Medicare	$13,607.68
Rate for Payer: Wellmed Medicare	$13,607.68

SEPTIC ARTHRITIS WITH MCC

Facility

$36,687.10

Service Code	MSDRG 548
Min. Negotiated Rate	$16,895.38
Max. Negotiated Rate	$36,687.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,911.69
Rate for Payer: Amerigroup Medicare	$18,911.69
Rate for Payer: BCBS of TX Medicare	$18,911.69
Rate for Payer: Cigna Commercial	$24,869.99
Rate for Payer: Cigna Medicare	$18,911.69
Rate for Payer: Employer Direct Commercial	$18,911.69
Rate for Payer: Humana Medicare/TRICARE	$18,911.69
Rate for Payer: Molina Dual Medicare/Medicaid	$18,911.69
Rate for Payer: Molina Medicare	$18,911.69
Rate for Payer: Multiplan Auto	$36,687.10
Rate for Payer: Multiplan Commercial	$36,687.10
Rate for Payer: Multiplan Workers Comp	$36,687.10
Rate for Payer: Scott and White EPO/PPO	$16,895.38
Rate for Payer: Scott and White Medicare	$18,911.69
Rate for Payer: Superior Health Plan EPO	$18,911.69
Rate for Payer: Superior Health Plan Medicare	$18,911.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,911.69
Rate for Payer: Universal American Medicare	$18,911.69
Rate for Payer: Wellcare Medicare	$18,911.69
Rate for Payer: Wellmed Medicare	$18,911.69

SEPTIC ARTHRITIS WITHOUT CC/MCC

Facility

$16,607.90

Service Code	MSDRG 550
Min. Negotiated Rate	$7,648.38
Max. Negotiated Rate	$16,607.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,166.38
Rate for Payer: Amerigroup Medicare	$11,166.38
Rate for Payer: BCBS of TX Medicare	$11,166.38
Rate for Payer: Cigna Commercial	$11,258.41
Rate for Payer: Cigna Medicare	$11,166.38
Rate for Payer: Employer Direct Commercial	$11,166.38
Rate for Payer: Humana Medicare/TRICARE	$11,166.38
Rate for Payer: Molina Dual Medicare/Medicaid	$11,166.38
Rate for Payer: Molina Medicare	$11,166.38
Rate for Payer: Multiplan Auto	$16,607.90
Rate for Payer: Multiplan Commercial	$16,607.90
Rate for Payer: Multiplan Workers Comp	$16,607.90
Rate for Payer: Scott and White EPO/PPO	$7,648.38
Rate for Payer: Scott and White Medicare	$11,166.38
Rate for Payer: Superior Health Plan EPO	$11,166.38
Rate for Payer: Superior Health Plan Medicare	$11,166.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,166.38
Rate for Payer: Universal American Medicare	$11,166.38
Rate for Payer: Wellcare Medicare	$11,166.38
Rate for Payer: Wellmed Medicare	$11,166.38

SEPTIC ARTHRITIS W MCC

Facility

$36,687.10

Service Code	MSDRG 548
Min. Negotiated Rate	$16,895.38
Max. Negotiated Rate	$36,687.10
Rate for Payer: BCBS of TX Blue Advantage	$17,777.92
Rate for Payer: BCBS of TX Blue Essentials	$21,331.44
Rate for Payer: BCBS of TX PPO	$23,702.52

SEPTIC ARTHRITIS W/O CC/MCC

Facility

$16,607.90

Service Code	MSDRG 550
Min. Negotiated Rate	$7,648.38
Max. Negotiated Rate	$16,607.90
Rate for Payer: BCBS of TX Blue Advantage	$7,944.68
Rate for Payer: BCBS of TX Blue Essentials	$9,532.69
Rate for Payer: BCBS of TX PPO	$10,592.29

SEPTICEMIA AND DISSEMINATED INFECTIONS

Facility

$2,410.99

Service Code	APR-DRG 7201
Min. Negotiated Rate	$2,273.17
Max. Negotiated Rate	$2,410.99
Rate for Payer: Amerigroup CHIP/Medicaid	$2,273.17
Rate for Payer: Cigna Medicaid	$2,273.17
Rate for Payer: Molina CHIP/Medicaid	$2,273.17
Rate for Payer: Parkland Medicaid	$2,273.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,410.99

SEPTICEMIA AND DISSEMINATED INFECTIONS

Facility

$3,477.31

Service Code	APR-DRG 7202
Min. Negotiated Rate	$3,278.53
Max. Negotiated Rate	$3,477.31
Rate for Payer: Amerigroup CHIP/Medicaid	$3,278.53
Rate for Payer: Cigna Medicaid	$3,278.53
Rate for Payer: Molina CHIP/Medicaid	$3,278.53
Rate for Payer: Parkland Medicaid	$3,278.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,477.31

SEPTICEMIA AND DISSEMINATED INFECTIONS

Facility

$14,135.53

Service Code	APR-DRG 7204
Min. Negotiated Rate	$13,327.48
Max. Negotiated Rate	$14,135.53
Rate for Payer: Amerigroup CHIP/Medicaid	$13,327.48
Rate for Payer: Cigna Medicaid	$13,327.48
Rate for Payer: Molina CHIP/Medicaid	$13,327.48
Rate for Payer: Parkland Medicaid	$13,327.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,135.53

SEPTICEMIA AND DISSEMINATED INFECTIONS

Facility

$5,801.17

Service Code	APR-DRG 7203
Min. Negotiated Rate	$5,469.54
Max. Negotiated Rate	$5,801.17
Rate for Payer: Amerigroup CHIP/Medicaid	$5,469.54
Rate for Payer: Cigna Medicaid	$5,469.54
Rate for Payer: Molina CHIP/Medicaid	$5,469.54
Rate for Payer: Parkland Medicaid	$5,469.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,801.17

SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS

Facility

$131,324.20

Service Code	MSDRG 870
Min. Negotiated Rate	$54,139.58
Max. Negotiated Rate	$131,324.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55,416.85
Rate for Payer: Amerigroup Medicare	$55,416.85
Rate for Payer: BCBS of TX Medicare	$55,416.85
Rate for Payer: Cigna Commercial	$89,023.98
Rate for Payer: Cigna Medicare	$55,416.85
Rate for Payer: Employer Direct Commercial	$55,416.85
Rate for Payer: Humana Medicare/TRICARE	$55,416.85
Rate for Payer: Molina Dual Medicare/Medicaid	$55,416.85
Rate for Payer: Molina Medicare	$55,416.85
Rate for Payer: Multiplan Auto	$131,324.20
Rate for Payer: Multiplan Commercial	$131,324.20
Rate for Payer: Multiplan Workers Comp	$131,324.20
Rate for Payer: Scott and White EPO/PPO	$60,478.25
Rate for Payer: Scott and White Medicare	$55,416.85
Rate for Payer: Superior Health Plan EPO	$55,416.85
Rate for Payer: Superior Health Plan Medicare	$55,416.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$55,416.85
Rate for Payer: Universal American Medicare	$55,416.85
Rate for Payer: Wellcare Medicare	$55,416.85
Rate for Payer: Wellmed Medicare	$55,416.85

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC

Facility

$36,907.50

Service Code	MSDRG 871
Min. Negotiated Rate	$15,965.04
Max. Negotiated Rate	$36,907.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,996.71
Rate for Payer: Amerigroup Medicare	$18,996.71
Rate for Payer: BCBS of TX Medicare	$18,996.71
Rate for Payer: Cigna Commercial	$25,019.40
Rate for Payer: Cigna Medicare	$18,996.71
Rate for Payer: Employer Direct Commercial	$18,996.71
Rate for Payer: Humana Medicare/TRICARE	$18,996.71
Rate for Payer: Molina Dual Medicare/Medicaid	$18,996.71
Rate for Payer: Molina Medicare	$18,996.71
Rate for Payer: Multiplan Auto	$36,907.50
Rate for Payer: Multiplan Commercial	$36,907.50
Rate for Payer: Multiplan Workers Comp	$36,907.50
Rate for Payer: Scott and White EPO/PPO	$16,996.88
Rate for Payer: Scott and White Medicare	$18,996.71
Rate for Payer: Superior Health Plan EPO	$18,996.71
Rate for Payer: Superior Health Plan Medicare	$18,996.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,996.71
Rate for Payer: Universal American Medicare	$18,996.71
Rate for Payer: Wellcare Medicare	$18,996.71
Rate for Payer: Wellmed Medicare	$18,996.71

Know your out-of-pocket cost for care.

All Charges