White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$24,973.60

Service Code	MSDRG 193
Min. Negotiated Rate	$11,323.62
Max. Negotiated Rate	$24,973.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,393.35
Rate for Payer: Amerigroup Medicare	$14,393.35
Rate for Payer: BCBS of TX Medicare	$14,393.35
Rate for Payer: Cigna Commercial	$16,929.47
Rate for Payer: Cigna Medicare	$14,393.35
Rate for Payer: Employer Direct Commercial	$14,393.35
Rate for Payer: Humana Medicare/TRICARE	$14,393.35
Rate for Payer: Molina Dual Medicare/Medicaid	$14,393.35
Rate for Payer: Molina Medicare	$14,393.35
Rate for Payer: Multiplan Auto	$24,973.60
Rate for Payer: Multiplan Commercial	$24,973.60
Rate for Payer: Multiplan Workers Comp	$24,973.60
Rate for Payer: Scott and White EPO/PPO	$11,501.00
Rate for Payer: Scott and White Medicare	$14,393.35
Rate for Payer: Superior Health Plan EPO	$14,393.35
Rate for Payer: Superior Health Plan Medicare	$14,393.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,393.35
Rate for Payer: Universal American Medicare	$14,393.35
Rate for Payer: Wellcare Medicare	$14,393.35
Rate for Payer: Wellmed Medicare	$14,393.35

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$11,941.50

Service Code	MSDRG 195
Min. Negotiated Rate	$5,499.38
Max. Negotiated Rate	$11,941.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,366.37
Rate for Payer: Amerigroup Medicare	$9,366.37
Rate for Payer: BCBS of TX Medicare	$9,366.37
Rate for Payer: Cigna Commercial	$8,095.08
Rate for Payer: Cigna Medicare	$9,366.37
Rate for Payer: Employer Direct Commercial	$9,366.37
Rate for Payer: Humana Medicare/TRICARE	$9,366.37
Rate for Payer: Molina Dual Medicare/Medicaid	$9,366.37
Rate for Payer: Molina Medicare	$9,366.37
Rate for Payer: Multiplan Auto	$11,941.50
Rate for Payer: Multiplan Commercial	$11,941.50
Rate for Payer: Multiplan Workers Comp	$11,941.50
Rate for Payer: Scott and White EPO/PPO	$5,499.38
Rate for Payer: Scott and White Medicare	$9,366.37
Rate for Payer: Superior Health Plan EPO	$9,366.37
Rate for Payer: Superior Health Plan Medicare	$9,366.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,366.37
Rate for Payer: Universal American Medicare	$9,366.37
Rate for Payer: Wellcare Medicare	$9,366.37
Rate for Payer: Wellmed Medicare	$9,366.37

SIMPLE PNEUMONIA & PLEURISY W CC

Facility

$15,312.10

Service Code	MSDRG 194
Min. Negotiated Rate	$7,051.62
Max. Negotiated Rate	$15,312.10
Rate for Payer: BCBS of TX Blue Advantage	$7,741.72
Rate for Payer: BCBS of TX Blue Essentials	$9,289.16
Rate for Payer: BCBS of TX PPO	$10,321.69

SIMPLE PNEUMONIA & PLEURISY W MCC

Facility

$24,973.60

Service Code	MSDRG 193
Min. Negotiated Rate	$11,323.62
Max. Negotiated Rate	$24,973.60
Rate for Payer: BCBS of TX Blue Advantage	$11,323.62
Rate for Payer: BCBS of TX Blue Essentials	$13,587.03
Rate for Payer: BCBS of TX PPO	$15,097.28

SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC

Facility

$11,941.50

Service Code	MSDRG 195
Min. Negotiated Rate	$5,499.38
Max. Negotiated Rate	$11,941.50
Rate for Payer: BCBS of TX Blue Advantage	$5,906.48
Rate for Payer: BCBS of TX Blue Essentials	$7,087.09
Rate for Payer: BCBS of TX PPO	$7,874.85

SIMPLEX P FULL DOSE 1 PACK

Facility

$431.53

Hospital Charge Code	993435
Hospital Revenue Code	272
Rate for Payer: Cash Price	$293.44

SIMPLEX P FULL DOSE 1 PACK

Facility

$431.53

Hospital Charge Code	993435
Hospital Revenue Code	272
Min. Negotiated Rate	$38.84
Max. Negotiated Rate	$310.70
Rate for Payer: Amerigroup CHIP/Medicaid	$38.84
Rate for Payer: BCBS of TX Blue Advantage	$129.46
Rate for Payer: BCBS of TX Blue Essentials	$155.35
Rate for Payer: BCBS of TX PPO	$172.61
Rate for Payer: Cash Price	$293.44
Rate for Payer: Cigna Medicaid	$310.70
Rate for Payer: Molina CHIP/Medicaid	$310.70
Rate for Payer: Multiplan Auto	$280.49
Rate for Payer: Multiplan Commercial	$280.49
Rate for Payer: Multiplan Workers Comp	$280.49
Rate for Payer: Parkland Medicaid	$310.70
Rate for Payer: Scott and White EPO/PPO	$215.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$310.70
Rate for Payer: Superior Health Plan EPO	$58.69

SIMPLEX P WITH TOBRAMYCIN 1 PACK

Facility

$2,152.05

Service Code	HCPCS C1734
Hospital Charge Code	992283
Hospital Revenue Code	278
Min. Negotiated Rate	$193.68
Max. Negotiated Rate	$1,549.48
Rate for Payer: Amerigroup CHIP/Medicaid	$193.68
Rate for Payer: BCBS of TX Blue Advantage	$645.62
Rate for Payer: BCBS of TX Blue Essentials	$774.74
Rate for Payer: BCBS of TX PPO	$860.82
Rate for Payer: Cash Price	$1,463.39
Rate for Payer: Cigna Medicaid	$1,549.48
Rate for Payer: Molina CHIP/Medicaid	$1,549.48
Rate for Payer: Multiplan Auto	$1,076.03
Rate for Payer: Multiplan Commercial	$1,076.03
Rate for Payer: Multiplan Workers Comp	$1,076.03
Rate for Payer: Parkland Medicaid	$1,549.48
Rate for Payer: Scott and White EPO/PPO	$1,076.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,549.48
Rate for Payer: Superior Health Plan EPO	$292.68

SIMPLEX P WITH TOBRAMYCIN 1 PACK

Facility

$2,152.05

Service Code	HCPCS C1734
Hospital Charge Code	992283
Hospital Revenue Code	278
Min. Negotiated Rate	$538.01
Max. Negotiated Rate	$1,076.03
Rate for Payer: Cash Price	$1,463.39
Rate for Payer: Cigna Commercial	$538.01
Rate for Payer: Multiplan Auto	$1,076.03
Rate for Payer: Multiplan Commercial	$1,076.03
Rate for Payer: Multiplan Workers Comp	$1,076.03
Rate for Payer: Scott and White EPO/PPO	$1,076.03

SIMPULSE SOLO SYSTEM W/ ULTREXSPLASH

Facility

$420.86

Hospital Charge Code	992900
Hospital Revenue Code	270
Rate for Payer: Cash Price	$286.18

SIMPULSE SOLO SYSTEM W/ ULTREXSPLASH

Facility

$420.86

Hospital Charge Code	992900
Hospital Revenue Code	270
Min. Negotiated Rate	$37.88
Max. Negotiated Rate	$303.02
Rate for Payer: Amerigroup CHIP/Medicaid	$37.88
Rate for Payer: BCBS of TX Blue Advantage	$126.26
Rate for Payer: BCBS of TX Blue Essentials	$151.51
Rate for Payer: BCBS of TX PPO	$168.34
Rate for Payer: Cash Price	$286.18
Rate for Payer: Cigna Medicaid	$303.02
Rate for Payer: Molina CHIP/Medicaid	$303.02
Rate for Payer: Multiplan Auto	$273.56
Rate for Payer: Multiplan Commercial	$273.56
Rate for Payer: Multiplan Workers Comp	$273.56
Rate for Payer: Parkland Medicaid	$303.02
Rate for Payer: Scott and White EPO/PPO	$210.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$303.02
Rate for Payer: Superior Health Plan EPO	$57.24

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$106,487.40

Service Code	MSDRG 008
Min. Negotiated Rate	$45,141.40
Max. Negotiated Rate	$106,487.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$45,836.34
Rate for Payer: Amerigroup Medicare	$45,836.34
Rate for Payer: BCBS of TX Medicare	$45,836.34
Rate for Payer: Cigna Commercial	$72,187.25
Rate for Payer: Cigna Medicare	$45,836.34
Rate for Payer: Employer Direct Commercial	$45,836.34
Rate for Payer: Molina Dual Medicare/Medicaid	$45,836.34
Rate for Payer: Molina Medicare	$45,836.34
Rate for Payer: Multiplan Auto	$106,487.40
Rate for Payer: Multiplan Commercial	$106,487.40
Rate for Payer: Multiplan Workers Comp	$106,487.40
Rate for Payer: Scott and White EPO/PPO	$49,040.25
Rate for Payer: Scott and White Medicare	$45,836.34
Rate for Payer: Superior Health Plan EPO	$45,836.34
Rate for Payer: Superior Health Plan Medicare	$45,836.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$45,836.34
Rate for Payer: Universal American Medicare	$45,836.34
Rate for Payer: Wellcare Medicare	$45,836.34
Rate for Payer: Wellmed Medicare	$45,836.34

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS

Facility

$125,916.80

Service Code	MSDRG 019
Min. Negotiated Rate	$57,049.76
Max. Negotiated Rate	$125,916.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$57,049.76
Rate for Payer: Amerigroup Medicare	$57,049.76
Rate for Payer: BCBS of TX Medicare	$57,049.76
Rate for Payer: Cigna Commercial	$85,358.34
Rate for Payer: Cigna Medicare	$57,049.76
Rate for Payer: Employer Direct Commercial	$57,049.76
Rate for Payer: Humana Medicare/TRICARE	$57,049.76
Rate for Payer: Molina Dual Medicare/Medicaid	$57,049.76
Rate for Payer: Molina Medicare	$57,049.76
Rate for Payer: Multiplan Auto	$125,916.80
Rate for Payer: Multiplan Commercial	$125,916.80
Rate for Payer: Multiplan Workers Comp	$125,916.80
Rate for Payer: Scott and White EPO/PPO	$57,988.00
Rate for Payer: Scott and White Medicare	$57,049.76
Rate for Payer: Superior Health Plan EPO	$57,049.76
Rate for Payer: Superior Health Plan Medicare	$57,049.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$57,049.76
Rate for Payer: Universal American Medicare	$57,049.76
Rate for Payer: Wellcare Medicare	$57,049.76
Rate for Payer: Wellmed Medicare	$57,049.76

SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT

Facility

$106,487.40

Service Code	MSDRG 008
Min. Negotiated Rate	$45,141.40
Max. Negotiated Rate	$106,487.40
Rate for Payer: BCBS of TX Blue Advantage	$45,141.40
Rate for Payer: BCBS of TX Blue Essentials	$54,164.43
Rate for Payer: BCBS of TX PPO	$60,185.03

SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$76,389.50

Service Code	MSDRG 402
Min. Negotiated Rate	$34,226.43
Max. Negotiated Rate	$76,389.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$34,226.43
Rate for Payer: Amerigroup Medicare	$34,226.43
Rate for Payer: BCBS of TX Medicare	$34,226.43
Rate for Payer: Cigna Commercial	$51,784.04
Rate for Payer: Cigna Medicare	$34,226.43
Rate for Payer: Employer Direct Commercial	$34,226.43
Rate for Payer: Humana Medicare/TRICARE	$34,226.43
Rate for Payer: Molina Dual Medicare/Medicaid	$34,226.43
Rate for Payer: Molina Medicare	$34,226.43
Rate for Payer: Multiplan Auto	$76,389.50
Rate for Payer: Multiplan Commercial	$76,389.50
Rate for Payer: Multiplan Workers Comp	$76,389.50
Rate for Payer: Scott and White EPO/PPO	$35,179.38
Rate for Payer: Scott and White Medicare	$34,226.43
Rate for Payer: Superior Health Plan EPO	$34,226.43
Rate for Payer: Superior Health Plan Medicare	$34,226.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$34,226.43
Rate for Payer: Universal American Medicare	$34,226.43
Rate for Payer: Wellcare Medicare	$34,226.43
Rate for Payer: Wellmed Medicare	$34,226.43

SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$101,262.40

Service Code	MSDRG 450
Min. Negotiated Rate	$43,820.85
Max. Negotiated Rate	$101,262.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43,820.85
Rate for Payer: Amerigroup Medicare	$43,820.85
Rate for Payer: BCBS of TX Medicare	$43,820.85
Rate for Payer: Cigna Commercial	$68,645.25
Rate for Payer: Cigna Medicare	$43,820.85
Rate for Payer: Employer Direct Commercial	$43,820.85
Rate for Payer: Humana Medicare/TRICARE	$43,820.85
Rate for Payer: Molina Dual Medicare/Medicaid	$43,820.85
Rate for Payer: Molina Medicare	$43,820.85
Rate for Payer: Multiplan Auto	$101,262.40
Rate for Payer: Multiplan Commercial	$101,262.40
Rate for Payer: Multiplan Workers Comp	$101,262.40
Rate for Payer: Scott and White EPO/PPO	$46,634.00
Rate for Payer: Scott and White Medicare	$43,820.85
Rate for Payer: Superior Health Plan EPO	$43,820.85
Rate for Payer: Superior Health Plan Medicare	$43,820.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$43,820.85
Rate for Payer: Universal American Medicare	$43,820.85
Rate for Payer: Wellcare Medicare	$43,820.85
Rate for Payer: Wellmed Medicare	$43,820.85

SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$61,377.60

Service Code	MSDRG 451
Min. Negotiated Rate	$28,266.00
Max. Negotiated Rate	$61,377.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,435.77
Rate for Payer: Amerigroup Medicare	$28,435.77
Rate for Payer: BCBS of TX Medicare	$28,435.77
Rate for Payer: Cigna Commercial	$41,607.55
Rate for Payer: Cigna Medicare	$28,435.77
Rate for Payer: Employer Direct Commercial	$28,435.77
Rate for Payer: Humana Medicare/TRICARE	$28,435.77
Rate for Payer: Molina Dual Medicare/Medicaid	$28,435.77
Rate for Payer: Molina Medicare	$28,435.77
Rate for Payer: Multiplan Auto	$61,377.60
Rate for Payer: Multiplan Commercial	$61,377.60
Rate for Payer: Multiplan Workers Comp	$61,377.60
Rate for Payer: Scott and White EPO/PPO	$28,266.00
Rate for Payer: Scott and White Medicare	$28,435.77
Rate for Payer: Superior Health Plan EPO	$28,435.77
Rate for Payer: Superior Health Plan Medicare	$28,435.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,435.77
Rate for Payer: Universal American Medicare	$28,435.77
Rate for Payer: Wellcare Medicare	$28,435.77
Rate for Payer: Wellmed Medicare	$28,435.77

Single-tread patient slippers, blue, one size fits most

Facility

$3.67

Hospital Charge Code	993319
Hospital Revenue Code	270
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$2.64
Rate for Payer: Amerigroup CHIP/Medicaid	$0.33
Rate for Payer: BCBS of TX Blue Advantage	$1.10
Rate for Payer: BCBS of TX Blue Essentials	$1.32
Rate for Payer: BCBS of TX PPO	$1.47
Rate for Payer: Cash Price	$2.50
Rate for Payer: Cigna Medicaid	$2.64
Rate for Payer: Molina CHIP/Medicaid	$2.64
Rate for Payer: Multiplan Auto	$2.39
Rate for Payer: Multiplan Commercial	$2.39
Rate for Payer: Multiplan Workers Comp	$2.39
Rate for Payer: Parkland Medicaid	$2.64
Rate for Payer: Scott and White EPO/PPO	$1.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.64
Rate for Payer: Superior Health Plan EPO	$0.50

Single-tread patient slippers, blue, one size fits most

Facility

$3.67

Hospital Charge Code	993319
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.50

SINGLE TROCAR WIRE 1.0X150MM CHARLOTTE F&A SYSTEM

Facility

$234.94

Hospital Charge Code	992292
Hospital Revenue Code	272
Min. Negotiated Rate	$21.14
Max. Negotiated Rate	$169.16
Rate for Payer: Amerigroup CHIP/Medicaid	$21.14
Rate for Payer: BCBS of TX Blue Advantage	$70.48
Rate for Payer: BCBS of TX Blue Essentials	$84.58
Rate for Payer: BCBS of TX PPO	$93.98
Rate for Payer: Cash Price	$159.76
Rate for Payer: Cigna Medicaid	$169.16
Rate for Payer: Molina CHIP/Medicaid	$169.16
Rate for Payer: Multiplan Auto	$152.71
Rate for Payer: Multiplan Commercial	$152.71
Rate for Payer: Multiplan Workers Comp	$152.71
Rate for Payer: Parkland Medicaid	$169.16
Rate for Payer: Scott and White EPO/PPO	$117.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$169.16
Rate for Payer: Superior Health Plan EPO	$31.95

SINGLE TROCAR WIRE 1.0X150MM CHARLOTTE F&A SYSTEM

Facility

$234.94

Hospital Charge Code	992292
Hospital Revenue Code	272
Rate for Payer: Cash Price	$159.76

SINGLE TROCAR WIRE 1.6X150MM CHARLOTTE F&A SYSTEM

Facility

$172.52

Hospital Charge Code	993164
Hospital Revenue Code	272
Min. Negotiated Rate	$15.53
Max. Negotiated Rate	$124.21
Rate for Payer: Amerigroup CHIP/Medicaid	$15.53
Rate for Payer: BCBS of TX Blue Advantage	$51.76
Rate for Payer: BCBS of TX Blue Essentials	$62.11
Rate for Payer: BCBS of TX PPO	$69.01
Rate for Payer: Cash Price	$117.31
Rate for Payer: Cigna Medicaid	$124.21
Rate for Payer: Molina CHIP/Medicaid	$124.21
Rate for Payer: Multiplan Auto	$112.14
Rate for Payer: Multiplan Commercial	$112.14
Rate for Payer: Multiplan Workers Comp	$112.14
Rate for Payer: Parkland Medicaid	$124.21
Rate for Payer: Scott and White EPO/PPO	$86.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$124.21
Rate for Payer: Superior Health Plan EPO	$23.46

SINGLE TROCAR WIRE 1.6X150MM CHARLOTTE F&A SYSTEM

Facility

$172.52

Hospital Charge Code	993164
Hospital Revenue Code	272
Rate for Payer: Cash Price	$117.31

Single-Use, Skin-Friendly Arthroscopic Knee Positioner

Facility

$126.74

Hospital Charge Code	993170
Hospital Revenue Code	270
Rate for Payer: Cash Price	$86.18

Single-Use, Skin-Friendly Arthroscopic Knee Positioner

Facility

$126.74

Hospital Charge Code	993170
Hospital Revenue Code	270
Min. Negotiated Rate	$11.41
Max. Negotiated Rate	$91.25
Rate for Payer: Amerigroup CHIP/Medicaid	$11.41
Rate for Payer: BCBS of TX Blue Advantage	$38.02
Rate for Payer: BCBS of TX Blue Essentials	$45.63
Rate for Payer: BCBS of TX PPO	$50.70
Rate for Payer: Cash Price	$86.18
Rate for Payer: Cigna Medicaid	$91.25
Rate for Payer: Molina CHIP/Medicaid	$91.25
Rate for Payer: Multiplan Auto	$82.38
Rate for Payer: Multiplan Commercial	$82.38
Rate for Payer: Multiplan Workers Comp	$82.38
Rate for Payer: Parkland Medicaid	$91.25
Rate for Payer: Scott and White EPO/PPO	$63.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.25
Rate for Payer: Superior Health Plan EPO	$17.24

Know your out-of-pocket cost for care.

All Charges