White Rock Medical Center

All Charges

Charge

Type

Setting

Price

AS STPL RELD -- DHF

Facility

$1,714.36

Hospital Charge Code	81911075
Hospital Revenue Code	272
Min. Negotiated Rate	$154.29
Max. Negotiated Rate	$1,234.34
Rate for Payer: Amerigroup CHIP/Medicaid	$154.29
Rate for Payer: BCBS of TX Blue Advantage	$514.31
Rate for Payer: BCBS of TX Blue Essentials	$617.17
Rate for Payer: BCBS of TX PPO	$685.74
Rate for Payer: Cash Price	$1,165.76
Rate for Payer: Cigna Medicaid	$1,234.34
Rate for Payer: Molina CHIP/Medicaid	$1,234.34
Rate for Payer: Multiplan Auto	$1,114.33
Rate for Payer: Multiplan Commercial	$1,114.33
Rate for Payer: Multiplan Workers Comp	$1,114.33
Rate for Payer: Parkland Medicaid	$1,234.34
Rate for Payer: Scott and White EPO/PPO	$857.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,234.34
Rate for Payer: Superior Health Plan EPO	$233.15

Assurity MRI_Pacemaker_UMRI_PR

Facility

$11,800.37

Hospital Charge Code	993252
Hospital Revenue Code	275
Min. Negotiated Rate	$1,062.03
Max. Negotiated Rate	$8,496.27
Rate for Payer: Amerigroup CHIP/Medicaid	$1,062.03
Rate for Payer: BCBS of TX Blue Advantage	$3,540.11
Rate for Payer: BCBS of TX Blue Essentials	$4,248.13
Rate for Payer: BCBS of TX PPO	$4,720.15
Rate for Payer: Cash Price	$8,024.25
Rate for Payer: Cigna Medicaid	$8,496.27
Rate for Payer: Molina CHIP/Medicaid	$8,496.27
Rate for Payer: Multiplan Auto	$5,900.19
Rate for Payer: Multiplan Commercial	$5,900.19
Rate for Payer: Multiplan Workers Comp	$5,900.19
Rate for Payer: Parkland Medicaid	$8,496.27
Rate for Payer: Scott and White EPO/PPO	$5,900.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,496.27
Rate for Payer: Superior Health Plan EPO	$1,604.85

Assurity MRI_Pacemaker_UMRI_PR

Facility

$11,800.37

Hospital Charge Code	993252
Hospital Revenue Code	275
Min. Negotiated Rate	$2,950.09
Max. Negotiated Rate	$5,900.19
Rate for Payer: Cash Price	$8,024.25
Rate for Payer: Cigna Commercial	$2,950.09
Rate for Payer: Multiplan Auto	$5,900.19
Rate for Payer: Multiplan Commercial	$5,900.19
Rate for Payer: Multiplan Workers Comp	$5,900.19
Rate for Payer: Scott and White EPO/PPO	$5,900.19

AST-GP67 TEST KIT 20 CARDS

Facility

$439.88

Hospital Charge Code	992628
Hospital Revenue Code	270
Rate for Payer: Cash Price	$299.12

AST-GP67 TEST KIT 20 CARDS

Facility

$439.88

Hospital Charge Code	992628
Hospital Revenue Code	270
Min. Negotiated Rate	$39.59
Max. Negotiated Rate	$316.71
Rate for Payer: Amerigroup CHIP/Medicaid	$39.59
Rate for Payer: BCBS of TX Blue Advantage	$131.96
Rate for Payer: BCBS of TX Blue Essentials	$158.36
Rate for Payer: BCBS of TX PPO	$175.95
Rate for Payer: Cash Price	$299.12
Rate for Payer: Cigna Medicaid	$316.71
Rate for Payer: Molina CHIP/Medicaid	$316.71
Rate for Payer: Multiplan Auto	$285.92
Rate for Payer: Multiplan Commercial	$285.92
Rate for Payer: Multiplan Workers Comp	$285.92
Rate for Payer: Parkland Medicaid	$316.71
Rate for Payer: Scott and White EPO/PPO	$219.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$316.71
Rate for Payer: Superior Health Plan EPO	$59.82

ASTHMA

Facility

$3,342.27

Service Code	APR-DRG 1413
Min. Negotiated Rate	$3,151.21
Max. Negotiated Rate	$3,342.27
Rate for Payer: Amerigroup CHIP/Medicaid	$3,151.21
Rate for Payer: Cigna Medicaid	$3,151.21
Rate for Payer: Molina CHIP/Medicaid	$3,151.21
Rate for Payer: Parkland Medicaid	$3,151.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,342.27

ASTHMA

Facility

$6,816.18

Service Code	APR-DRG 1414
Min. Negotiated Rate	$6,426.54
Max. Negotiated Rate	$6,816.18
Rate for Payer: Amerigroup CHIP/Medicaid	$6,426.54
Rate for Payer: Cigna Medicaid	$6,426.54
Rate for Payer: Molina CHIP/Medicaid	$6,426.54
Rate for Payer: Parkland Medicaid	$6,426.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,816.18

ASTHMA

Facility

$2,637.68

Service Code	APR-DRG 1412
Min. Negotiated Rate	$2,486.90
Max. Negotiated Rate	$2,637.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2,486.90
Rate for Payer: Cigna Medicaid	$2,486.90
Rate for Payer: Molina CHIP/Medicaid	$2,486.90
Rate for Payer: Parkland Medicaid	$2,486.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,637.68

ASTHMA

Facility

$1,804.85

Service Code	APR-DRG 1411
Min. Negotiated Rate	$1,701.68
Max. Negotiated Rate	$1,804.85
Rate for Payer: Amerigroup CHIP/Medicaid	$1,701.68
Rate for Payer: Cigna Medicaid	$1,701.68
Rate for Payer: Molina CHIP/Medicaid	$1,701.68
Rate for Payer: Parkland Medicaid	$1,701.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,804.85

AST-STO2 TEST KIT 20 CARDS

Facility

$360.25

Hospital Charge Code	992632
Hospital Revenue Code	270
Rate for Payer: Cash Price	$244.97

AST-STO2 TEST KIT 20 CARDS

Facility

$360.25

Hospital Charge Code	992632
Hospital Revenue Code	270
Min. Negotiated Rate	$32.42
Max. Negotiated Rate	$259.38
Rate for Payer: Amerigroup CHIP/Medicaid	$32.42
Rate for Payer: BCBS of TX Blue Advantage	$108.08
Rate for Payer: BCBS of TX Blue Essentials	$129.69
Rate for Payer: BCBS of TX PPO	$144.10
Rate for Payer: Cash Price	$244.97
Rate for Payer: Cigna Medicaid	$259.38
Rate for Payer: Molina CHIP/Medicaid	$259.38
Rate for Payer: Multiplan Auto	$234.16
Rate for Payer: Multiplan Commercial	$234.16
Rate for Payer: Multiplan Workers Comp	$234.16
Rate for Payer: Parkland Medicaid	$259.38
Rate for Payer: Scott and White EPO/PPO	$180.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$259.38
Rate for Payer: Superior Health Plan EPO	$48.99

atenolol 50 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77386224
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

atenolol 50 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77386224
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

ATHERCT ILIAC OPEN PERC

Facility

$17,499.00

Service Code	HCPCS 0238T
Hospital Charge Code	4610146
Hospital Revenue Code	361
Min. Negotiated Rate	$1,574.91
Max. Negotiated Rate	$40,168.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1,574.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,415.17
Rate for Payer: Amerigroup Medicare	$18,415.17
Rate for Payer: BCBS of TX Blue Advantage	$26,619.75
Rate for Payer: BCBS of TX Blue Essentials	$31,879.94
Rate for Payer: BCBS of TX Medicare	$18,415.17
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cash Price	$11,899.32
Rate for Payer: Cash Price	$11,899.32
Rate for Payer: Cash Price	$11,899.32
Rate for Payer: Cigna Commercial	$38,926.35
Rate for Payer: Cigna Medicaid	$12,599.28
Rate for Payer: Cigna Medicare	$18,415.17
Rate for Payer: Employer Direct Commercial	$18,415.17
Rate for Payer: Humana Medicare/TRICARE	$18,415.17
Rate for Payer: Molina CHIP/Medicaid	$12,599.28
Rate for Payer: Molina Dual Medicare/Medicaid	$18,415.17
Rate for Payer: Molina Medicare	$18,415.17
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$12,599.28
Rate for Payer: Scott and White EPO/PPO	$8,749.50
Rate for Payer: Scott and White Medicare	$18,415.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,599.28
Rate for Payer: Superior Health Plan EPO	$18,415.17
Rate for Payer: Superior Health Plan Medicare	$18,415.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,415.17
Rate for Payer: Universal American Medicare	$18,415.17
Rate for Payer: Wellcare Medicare	$18,415.17
Rate for Payer: Wellmed Medicare	$18,415.17

ATHERCT ILIAC OPEN PERC

Facility

$17,499.00

Service Code	HCPCS 0238T
Hospital Charge Code	4610146
Hospital Revenue Code	361
Rate for Payer: Cash Price	$11,899.32

ATHERECT VISC OPEN PERC

Facility

$21,010.00

Service Code	HCPCS 0235T
Hospital Charge Code	4610141
Hospital Revenue Code	361
Min. Negotiated Rate	$1,805.34
Max. Negotiated Rate	$15,127.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1,890.90
Rate for Payer: BCBS of TX Blue Advantage	$1,805.34
Rate for Payer: BCBS of TX Blue Essentials	$2,162.08
Rate for Payer: BCBS of TX PPO	$2,724.22
Rate for Payer: Cash Price	$14,286.80
Rate for Payer: Cash Price	$14,286.80
Rate for Payer: Cash Price	$14,286.80
Rate for Payer: Cigna Medicaid	$15,127.20
Rate for Payer: Molina CHIP/Medicaid	$15,127.20
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$15,127.20
Rate for Payer: Scott and White EPO/PPO	$10,505.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,127.20
Rate for Payer: Superior Health Plan EPO	$2,857.36

ATHERECT VISC OPEN PERC

Facility

$21,010.00

Service Code	HCPCS 0235T
Hospital Charge Code	4610141
Hospital Revenue Code	361
Rate for Payer: Cash Price	$14,286.80

ATHEROSCLEROSIS WITH MCC

Facility

$22,910.20

Service Code	MSDRG 302
Min. Negotiated Rate	$9,197.70
Max. Negotiated Rate	$22,910.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,529.99
Rate for Payer: Amerigroup Medicare	$13,529.99
Rate for Payer: BCBS of TX Medicare	$13,529.99
Rate for Payer: Cigna Commercial	$15,412.21
Rate for Payer: Cigna Medicare	$13,529.99
Rate for Payer: Employer Direct Commercial	$13,529.99
Rate for Payer: Humana Medicare/TRICARE	$13,529.99
Rate for Payer: Molina Dual Medicare/Medicaid	$13,529.99
Rate for Payer: Molina Medicare	$13,529.99
Rate for Payer: Multiplan Auto	$22,910.20
Rate for Payer: Multiplan Commercial	$22,910.20
Rate for Payer: Multiplan Workers Comp	$22,910.20
Rate for Payer: Scott and White EPO/PPO	$10,550.75
Rate for Payer: Scott and White Medicare	$13,529.99
Rate for Payer: Superior Health Plan EPO	$13,529.99
Rate for Payer: Superior Health Plan Medicare	$13,529.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,529.99
Rate for Payer: Universal American Medicare	$13,529.99
Rate for Payer: Wellcare Medicare	$13,529.99
Rate for Payer: Wellmed Medicare	$13,529.99

ATHEROSCLEROSIS WITHOUT MCC

Facility

$12,845.90

Service Code	MSDRG 303
Min. Negotiated Rate	$5,723.30
Max. Negotiated Rate	$12,845.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,693.99
Rate for Payer: Amerigroup Medicare	$9,693.99
Rate for Payer: BCBS of TX Medicare	$9,693.99
Rate for Payer: Cigna Commercial	$8,670.82
Rate for Payer: Cigna Medicare	$9,693.99
Rate for Payer: Employer Direct Commercial	$9,693.99
Rate for Payer: Humana Medicare/TRICARE	$9,693.99
Rate for Payer: Molina Dual Medicare/Medicaid	$9,693.99
Rate for Payer: Molina Medicare	$9,693.99
Rate for Payer: Multiplan Auto	$12,845.90
Rate for Payer: Multiplan Commercial	$12,845.90
Rate for Payer: Multiplan Workers Comp	$12,845.90
Rate for Payer: Scott and White EPO/PPO	$5,915.88
Rate for Payer: Scott and White Medicare	$9,693.99
Rate for Payer: Superior Health Plan EPO	$9,693.99
Rate for Payer: Superior Health Plan Medicare	$9,693.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,693.99
Rate for Payer: Universal American Medicare	$9,693.99
Rate for Payer: Wellcare Medicare	$9,693.99
Rate for Payer: Wellmed Medicare	$9,693.99

ATHEROSCLEROSIS W MCC

Facility

$22,910.20

Service Code	MSDRG 302
Min. Negotiated Rate	$9,197.70
Max. Negotiated Rate	$22,910.20
Rate for Payer: BCBS of TX Blue Advantage	$9,197.70
Rate for Payer: BCBS of TX Blue Essentials	$11,036.17
Rate for Payer: BCBS of TX PPO	$12,262.89

ATHEROSCLEROSIS W/O MCC

Facility

$12,845.90

Service Code	MSDRG 303
Min. Negotiated Rate	$5,723.30
Max. Negotiated Rate	$12,845.90
Rate for Payer: BCBS of TX Blue Advantage	$5,723.30
Rate for Payer: BCBS of TX Blue Essentials	$6,867.29
Rate for Payer: BCBS of TX PPO	$7,630.62

ATOMIZER, MUCOSAL ATMZR DEVICE, NO SY

Facility

$34.07

Hospital Charge Code	993309
Hospital Revenue Code	270
Rate for Payer: Cash Price	$23.17

ATOMIZER, MUCOSAL ATMZR DEVICE, NO SY

Facility

$34.07

Hospital Charge Code	993309
Hospital Revenue Code	270
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$24.53
Rate for Payer: Amerigroup CHIP/Medicaid	$3.07
Rate for Payer: BCBS of TX Blue Advantage	$10.22
Rate for Payer: BCBS of TX Blue Essentials	$12.27
Rate for Payer: BCBS of TX PPO	$13.63
Rate for Payer: Cash Price	$23.17
Rate for Payer: Cigna Medicaid	$24.53
Rate for Payer: Molina CHIP/Medicaid	$24.53
Rate for Payer: Multiplan Auto	$22.15
Rate for Payer: Multiplan Commercial	$22.15
Rate for Payer: Multiplan Workers Comp	$22.15
Rate for Payer: Parkland Medicaid	$24.53
Rate for Payer: Scott and White EPO/PPO	$17.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.53
Rate for Payer: Superior Health Plan EPO	$4.63

atorvastatin 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77386738
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

atorvastatin 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77386738
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Know your out-of-pocket cost for care.

All Charges