White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SIGNS AND SYMPTOMS WITH MCC

Facility

$24,118.60

Service Code	MSDRG 947
Min. Negotiated Rate	$10,368.16
Max. Negotiated Rate	$24,118.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,063.55
Rate for Payer: Amerigroup Medicare	$14,063.55
Rate for Payer: BCBS of TX Medicare	$14,063.55
Rate for Payer: Cigna Commercial	$16,349.87
Rate for Payer: Cigna Medicare	$14,063.55
Rate for Payer: Employer Direct Commercial	$14,063.55
Rate for Payer: Humana Medicare/TRICARE	$14,063.55
Rate for Payer: Molina Dual Medicare/Medicaid	$14,063.55
Rate for Payer: Molina Medicare	$14,063.55
Rate for Payer: Multiplan Auto	$24,118.60
Rate for Payer: Multiplan Commercial	$24,118.60
Rate for Payer: Multiplan Workers Comp	$24,118.60
Rate for Payer: Scott and White EPO/PPO	$11,107.25
Rate for Payer: Scott and White Medicare	$14,063.55
Rate for Payer: Superior Health Plan EPO	$14,063.55
Rate for Payer: Superior Health Plan Medicare	$14,063.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,063.55
Rate for Payer: Universal American Medicare	$14,063.55
Rate for Payer: Wellcare Medicare	$14,063.55
Rate for Payer: Wellmed Medicare	$14,063.55

SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$15,209.50

Service Code	MSDRG 948
Min. Negotiated Rate	$6,709.72
Max. Negotiated Rate	$15,209.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,626.98
Rate for Payer: Amerigroup Medicare	$10,626.98
Rate for Payer: BCBS of TX Medicare	$10,626.98
Rate for Payer: Cigna Commercial	$10,310.44
Rate for Payer: Cigna Medicare	$10,626.98
Rate for Payer: Employer Direct Commercial	$10,626.98
Rate for Payer: Humana Medicare/TRICARE	$10,626.98
Rate for Payer: Molina Dual Medicare/Medicaid	$10,626.98
Rate for Payer: Molina Medicare	$10,626.98
Rate for Payer: Multiplan Auto	$15,209.50
Rate for Payer: Multiplan Commercial	$15,209.50
Rate for Payer: Multiplan Workers Comp	$15,209.50
Rate for Payer: Scott and White EPO/PPO	$7,004.38
Rate for Payer: Scott and White Medicare	$10,626.98
Rate for Payer: Superior Health Plan EPO	$10,626.98
Rate for Payer: Superior Health Plan Medicare	$10,626.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,626.98
Rate for Payer: Universal American Medicare	$10,626.98
Rate for Payer: Wellcare Medicare	$10,626.98
Rate for Payer: Wellmed Medicare	$10,626.98

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$1,918.38

Service Code	APR-DRG 8611
Min. Negotiated Rate	$1,808.72
Max. Negotiated Rate	$1,918.38
Rate for Payer: Amerigroup CHIP/Medicaid	$1,808.72
Rate for Payer: Cigna Medicaid	$1,808.72
Rate for Payer: Molina CHIP/Medicaid	$1,808.72
Rate for Payer: Parkland Medicaid	$1,808.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,918.38

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$3,090.69

Service Code	APR-DRG 8612
Min. Negotiated Rate	$2,914.01
Max. Negotiated Rate	$3,090.69
Rate for Payer: Amerigroup CHIP/Medicaid	$2,914.01
Rate for Payer: Cigna Medicaid	$2,914.01
Rate for Payer: Molina CHIP/Medicaid	$2,914.01
Rate for Payer: Parkland Medicaid	$2,914.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,090.69

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$5,871.32

Service Code	APR-DRG 8613
Min. Negotiated Rate	$5,535.69
Max. Negotiated Rate	$5,871.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5,535.69
Rate for Payer: Cigna Medicaid	$5,535.69
Rate for Payer: Molina CHIP/Medicaid	$5,535.69
Rate for Payer: Parkland Medicaid	$5,535.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,871.32

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$11,963.30

Service Code	APR-DRG 8614
Min. Negotiated Rate	$11,279.42
Max. Negotiated Rate	$11,963.30
Rate for Payer: Amerigroup CHIP/Medicaid	$11,279.42
Rate for Payer: Cigna Medicaid	$11,279.42
Rate for Payer: Molina CHIP/Medicaid	$11,279.42
Rate for Payer: Parkland Medicaid	$11,279.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,963.30

SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W MCC

Facility

$25,114.20

Service Code	MSDRG 555
Min. Negotiated Rate	$11,001.12
Max. Negotiated Rate	$25,114.20
Rate for Payer: BCBS of TX Blue Advantage	$11,001.12
Rate for Payer: BCBS of TX Blue Essentials	$13,200.06
Rate for Payer: BCBS of TX PPO	$14,667.31

SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC

Facility

$15,781.40

Service Code	MSDRG 556
Min. Negotiated Rate	$6,602.22
Max. Negotiated Rate	$15,781.40
Rate for Payer: BCBS of TX Blue Advantage	$6,602.22
Rate for Payer: BCBS of TX Blue Essentials	$7,921.90
Rate for Payer: BCBS of TX PPO	$8,802.45

SIGNS & SYMPTOMS W MCC

Facility

$24,118.60

Service Code	MSDRG 947
Min. Negotiated Rate	$10,368.16
Max. Negotiated Rate	$24,118.60
Rate for Payer: BCBS of TX Blue Advantage	$10,368.16
Rate for Payer: BCBS of TX Blue Essentials	$12,440.59
Rate for Payer: BCBS of TX PPO	$13,823.41

SIGNS & SYMPTOMS W/O MCC

Facility

$15,209.50

Service Code	MSDRG 948
Min. Negotiated Rate	$6,709.72
Max. Negotiated Rate	$15,209.50
Rate for Payer: BCBS of TX Blue Advantage	$6,709.72
Rate for Payer: BCBS of TX Blue Essentials	$8,050.88
Rate for Payer: BCBS of TX PPO	$8,945.77

SILTEX® Breast Tissue Expander with Suture Tabs

Facility

$8,535.20

Service Code	HCPCS L8699
Hospital Charge Code	993862
Hospital Revenue Code	278
Min. Negotiated Rate	$768.17
Max. Negotiated Rate	$6,145.34
Rate for Payer: Amerigroup CHIP/Medicaid	$768.17
Rate for Payer: BCBS of TX Blue Advantage	$2,560.56
Rate for Payer: BCBS of TX Blue Essentials	$3,072.67
Rate for Payer: BCBS of TX PPO	$3,414.08
Rate for Payer: Cash Price	$5,803.94
Rate for Payer: Cigna Medicaid	$6,145.34
Rate for Payer: Molina CHIP/Medicaid	$6,145.34
Rate for Payer: Multiplan Auto	$4,267.60
Rate for Payer: Multiplan Commercial	$4,267.60
Rate for Payer: Multiplan Workers Comp	$4,267.60
Rate for Payer: Parkland Medicaid	$6,145.34
Rate for Payer: Scott and White EPO/PPO	$4,267.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,145.34
Rate for Payer: Superior Health Plan EPO	$1,160.79

SILTEX® Breast Tissue Expander with Suture Tabs

Facility

$8,535.20

Service Code	HCPCS L8699
Hospital Charge Code	993862
Hospital Revenue Code	278
Min. Negotiated Rate	$2,133.80
Max. Negotiated Rate	$4,267.60
Rate for Payer: Cash Price	$5,803.94
Rate for Payer: Cigna Commercial	$2,133.80
Rate for Payer: Multiplan Auto	$4,267.60
Rate for Payer: Multiplan Commercial	$4,267.60
Rate for Payer: Multiplan Workers Comp	$4,267.60
Rate for Payer: Scott and White EPO/PPO	$4,267.60

silver nitrate Stick

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77812333
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

silver nitrate Stick

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77812333
Hospital Revenue Code	636
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

SILVERSOAKER, ON-Q,5 IN, 270ML X DUAL

Facility

$828.48

Hospital Charge Code	992762
Hospital Revenue Code	272
Rate for Payer: Cash Price	$563.37

SILVERSOAKER, ON-Q,5 IN, 270ML X DUAL

Facility

$828.48

Hospital Charge Code	992762
Hospital Revenue Code	272
Min. Negotiated Rate	$74.56
Max. Negotiated Rate	$596.51
Rate for Payer: Amerigroup CHIP/Medicaid	$74.56
Rate for Payer: BCBS of TX Blue Advantage	$248.54
Rate for Payer: BCBS of TX Blue Essentials	$298.25
Rate for Payer: BCBS of TX PPO	$331.39
Rate for Payer: Cash Price	$563.37
Rate for Payer: Cigna Medicaid	$596.51
Rate for Payer: Molina CHIP/Medicaid	$596.51
Rate for Payer: Multiplan Auto	$538.51
Rate for Payer: Multiplan Commercial	$538.51
Rate for Payer: Multiplan Workers Comp	$538.51
Rate for Payer: Parkland Medicaid	$596.51
Rate for Payer: Scott and White EPO/PPO	$414.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$596.51
Rate for Payer: Superior Health Plan EPO	$112.67

silver sulfADIAZINE 1% Cream 50 g

Facility

$29.00

Service Code	HCPCS J3490
Hospital Charge Code	77812704
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.72

silver sulfADIAZINE 1% Cream 50 g

Facility

$29.00

Service Code	HCPCS J3490
Hospital Charge Code	77812704
Hospital Revenue Code	250
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$20.88
Rate for Payer: Amerigroup CHIP/Medicaid	$2.61
Rate for Payer: BCBS of TX Blue Advantage	$8.70
Rate for Payer: BCBS of TX Blue Essentials	$10.44
Rate for Payer: BCBS of TX PPO	$11.60
Rate for Payer: Cash Price	$19.72
Rate for Payer: Cigna Medicaid	$20.88
Rate for Payer: Molina CHIP/Medicaid	$20.88
Rate for Payer: Multiplan Auto	$18.85
Rate for Payer: Multiplan Commercial	$18.85
Rate for Payer: Multiplan Workers Comp	$18.85
Rate for Payer: Parkland Medicaid	$20.88
Rate for Payer: Scott and White EPO/PPO	$14.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.88
Rate for Payer: Superior Health Plan EPO	$3.94

simethicone 125mg/ml 1.9ml drops

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	9898989
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

simethicone 125mg/ml 1.9ml drops

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	9898989
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

simethicone 40 mg/0.6 mL Oral Liquid 30 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77813459
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

simethicone 40 mg/0.6 mL Oral Liquid 30 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77813459
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

simethicone 80 mg Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77813565
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

simethicone 80 mg Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77813565
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$15,312.10

Service Code	MSDRG 194
Min. Negotiated Rate	$7,051.62
Max. Negotiated Rate	$15,312.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,666.55
Rate for Payer: Amerigroup Medicare	$10,666.55
Rate for Payer: BCBS of TX Medicare	$10,666.55
Rate for Payer: Cigna Commercial	$10,379.99
Rate for Payer: Cigna Medicare	$10,666.55
Rate for Payer: Employer Direct Commercial	$10,666.55
Rate for Payer: Humana Medicare/TRICARE	$10,666.55
Rate for Payer: Molina Dual Medicare/Medicaid	$10,666.55
Rate for Payer: Molina Medicare	$10,666.55
Rate for Payer: Multiplan Auto	$15,312.10
Rate for Payer: Multiplan Commercial	$15,312.10
Rate for Payer: Multiplan Workers Comp	$15,312.10
Rate for Payer: Scott and White EPO/PPO	$7,051.62
Rate for Payer: Scott and White Medicare	$10,666.55
Rate for Payer: Superior Health Plan EPO	$10,666.55
Rate for Payer: Superior Health Plan Medicare	$10,666.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,666.55
Rate for Payer: Universal American Medicare	$10,666.55
Rate for Payer: Wellcare Medicare	$10,666.55
Rate for Payer: Wellmed Medicare	$10,666.55

Know your out-of-pocket cost for care.

All Charges