White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BACT/ALERT FA PLUS (PLASTIC) 100 BTLS

Facility

$11.80

Hospital Charge Code	993843
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8.02

BACT/ALERT FA PLUS (PLASTIC) 100 BTLS

Facility

$11.80

Hospital Charge Code	993843
Hospital Revenue Code	272
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$8.50
Rate for Payer: Amerigroup CHIP/Medicaid	$1.06
Rate for Payer: BCBS of TX Blue Advantage	$3.54
Rate for Payer: BCBS of TX Blue Essentials	$4.25
Rate for Payer: BCBS of TX PPO	$4.72
Rate for Payer: Cash Price	$8.02
Rate for Payer: Cigna Medicaid	$8.50
Rate for Payer: Molina CHIP/Medicaid	$8.50
Rate for Payer: Multiplan Auto	$7.67
Rate for Payer: Multiplan Commercial	$7.67
Rate for Payer: Multiplan Workers Comp	$7.67
Rate for Payer: Parkland Medicaid	$8.50
Rate for Payer: Scott and White EPO/PPO	$5.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.50
Rate for Payer: Superior Health Plan EPO	$1.60

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM

Facility

$23,867.77

Service Code	APR-DRG 0494
Min. Negotiated Rate	$22,503.37
Max. Negotiated Rate	$23,867.77
Rate for Payer: Amerigroup CHIP/Medicaid	$22,503.37
Rate for Payer: Cigna Medicaid	$22,503.37
Rate for Payer: Molina CHIP/Medicaid	$22,503.37
Rate for Payer: Parkland Medicaid	$22,503.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,867.77

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM

Facility

$11,059.18

Service Code	APR-DRG 0492
Min. Negotiated Rate	$10,426.98
Max. Negotiated Rate	$11,059.18
Rate for Payer: Amerigroup CHIP/Medicaid	$10,426.98
Rate for Payer: Cigna Medicaid	$10,426.98
Rate for Payer: Molina CHIP/Medicaid	$10,426.98
Rate for Payer: Parkland Medicaid	$10,426.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,059.18

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM

Facility

$11,692.10

Service Code	APR-DRG 0493
Min. Negotiated Rate	$11,023.73
Max. Negotiated Rate	$11,692.10
Rate for Payer: Amerigroup CHIP/Medicaid	$11,023.73
Rate for Payer: Cigna Medicaid	$11,023.73
Rate for Payer: Molina CHIP/Medicaid	$11,023.73
Rate for Payer: Parkland Medicaid	$11,023.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,692.10

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM

Facility

$5,509.22

Service Code	APR-DRG 0491
Min. Negotiated Rate	$5,194.29
Max. Negotiated Rate	$5,509.22
Rate for Payer: Amerigroup CHIP/Medicaid	$5,194.29
Rate for Payer: Cigna Medicaid	$5,194.29
Rate for Payer: Molina CHIP/Medicaid	$5,194.29
Rate for Payer: Parkland Medicaid	$5,194.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,509.22

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC

Facility

$48,579.20

Service Code	MSDRG 095
Min. Negotiated Rate	$20,475.74
Max. Negotiated Rate	$48,579.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,663.10
Rate for Payer: Amerigroup Medicare	$23,663.10
Rate for Payer: BCBS of TX Medicare	$23,663.10
Rate for Payer: Cigna Commercial	$33,220.10
Rate for Payer: Cigna Medicare	$23,663.10
Rate for Payer: Employer Direct Commercial	$23,663.10
Rate for Payer: Humana Medicare/TRICARE	$23,663.10
Rate for Payer: Molina Dual Medicare/Medicaid	$23,663.10
Rate for Payer: Molina Medicare	$23,663.10
Rate for Payer: Multiplan Auto	$48,579.20
Rate for Payer: Multiplan Commercial	$48,579.20
Rate for Payer: Multiplan Workers Comp	$48,579.20
Rate for Payer: Scott and White EPO/PPO	$22,372.00
Rate for Payer: Scott and White Medicare	$23,663.10
Rate for Payer: Superior Health Plan EPO	$23,663.10
Rate for Payer: Superior Health Plan Medicare	$23,663.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,663.10
Rate for Payer: Universal American Medicare	$23,663.10
Rate for Payer: Wellcare Medicare	$23,663.10
Rate for Payer: Wellmed Medicare	$23,663.10

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC

Facility

$67,896.50

Service Code	MSDRG 094
Min. Negotiated Rate	$30,553.85
Max. Negotiated Rate	$67,896.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,553.85
Rate for Payer: Amerigroup Medicare	$30,553.85
Rate for Payer: BCBS of TX Medicare	$30,553.85
Rate for Payer: Cigna Commercial	$45,329.87
Rate for Payer: Cigna Medicare	$30,553.85
Rate for Payer: Employer Direct Commercial	$30,553.85
Rate for Payer: Humana Medicare/TRICARE	$30,553.85
Rate for Payer: Molina Dual Medicare/Medicaid	$30,553.85
Rate for Payer: Molina Medicare	$30,553.85
Rate for Payer: Multiplan Auto	$67,896.50
Rate for Payer: Multiplan Commercial	$67,896.50
Rate for Payer: Multiplan Workers Comp	$67,896.50
Rate for Payer: Scott and White EPO/PPO	$31,268.12
Rate for Payer: Scott and White Medicare	$30,553.85
Rate for Payer: Superior Health Plan EPO	$30,553.85
Rate for Payer: Superior Health Plan Medicare	$30,553.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,553.85
Rate for Payer: Universal American Medicare	$30,553.85
Rate for Payer: Wellcare Medicare	$30,553.85
Rate for Payer: Wellmed Medicare	$30,553.85

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC

Facility

$43,401.70

Service Code	MSDRG 096
Min. Negotiated Rate	$18,154.60
Max. Negotiated Rate	$43,401.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,663.10
Rate for Payer: Amerigroup Medicare	$23,663.10
Rate for Payer: BCBS of TX Medicare	$23,663.10
Rate for Payer: Cigna Commercial	$33,220.10
Rate for Payer: Cigna Medicare	$23,663.10
Rate for Payer: Employer Direct Commercial	$23,663.10
Rate for Payer: Humana Medicare/TRICARE	$23,663.10
Rate for Payer: Molina Dual Medicare/Medicaid	$23,663.10
Rate for Payer: Molina Medicare	$23,663.10
Rate for Payer: Multiplan Auto	$43,401.70
Rate for Payer: Multiplan Commercial	$43,401.70
Rate for Payer: Multiplan Workers Comp	$43,401.70
Rate for Payer: Scott and White EPO/PPO	$19,987.62
Rate for Payer: Scott and White Medicare	$23,663.10
Rate for Payer: Superior Health Plan EPO	$23,663.10
Rate for Payer: Superior Health Plan Medicare	$23,663.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,663.10
Rate for Payer: Universal American Medicare	$23,663.10
Rate for Payer: Wellcare Medicare	$23,663.10
Rate for Payer: Wellmed Medicare	$23,663.10

BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W CC

Facility

$48,579.20

Service Code	MSDRG 095
Min. Negotiated Rate	$20,475.74
Max. Negotiated Rate	$48,579.20
Rate for Payer: BCBS of TX Blue Advantage	$20,475.74
Rate for Payer: BCBS of TX Blue Essentials	$24,568.51
Rate for Payer: BCBS of TX PPO	$27,299.40

BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W MCC

Facility

$67,896.50

Service Code	MSDRG 094
Min. Negotiated Rate	$30,553.85
Max. Negotiated Rate	$67,896.50
Rate for Payer: BCBS of TX Blue Advantage	$31,629.94
Rate for Payer: BCBS of TX Blue Essentials	$37,952.25
Rate for Payer: BCBS of TX PPO	$42,170.80

BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W/O CC/MCC

Facility

$43,401.70

Service Code	MSDRG 096
Min. Negotiated Rate	$18,154.60
Max. Negotiated Rate	$43,401.70
Rate for Payer: BCBS of TX Blue Advantage	$18,154.60
Rate for Payer: BCBS of TX Blue Essentials	$21,783.41
Rate for Payer: BCBS of TX PPO	$24,204.73

BAG 2L STERILE H2O

Facility

$24.16

Hospital Charge Code	993513
Hospital Revenue Code	270
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$17.40
Rate for Payer: Amerigroup CHIP/Medicaid	$2.17
Rate for Payer: BCBS of TX Blue Advantage	$7.25
Rate for Payer: BCBS of TX Blue Essentials	$8.70
Rate for Payer: BCBS of TX PPO	$9.66
Rate for Payer: Cash Price	$16.43
Rate for Payer: Cigna Medicaid	$17.40
Rate for Payer: Molina CHIP/Medicaid	$17.40
Rate for Payer: Multiplan Auto	$15.70
Rate for Payer: Multiplan Commercial	$15.70
Rate for Payer: Multiplan Workers Comp	$15.70
Rate for Payer: Parkland Medicaid	$17.40
Rate for Payer: Scott and White EPO/PPO	$12.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.40
Rate for Payer: Superior Health Plan EPO	$3.29

BAG 2L STERILE H2O

Facility

$24.16

Hospital Charge Code	993513
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.43

BAG, DRAIN, URLGY, ANTIREFLUX, 2000ML, LF

Facility

$10.96

Hospital Charge Code	992993
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.45

BAG, DRAIN, URLGY, ANTIREFLUX, 2000ML, LF

Facility

$10.96

Hospital Charge Code	992993
Hospital Revenue Code	270
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$7.89
Rate for Payer: Amerigroup CHIP/Medicaid	$0.99
Rate for Payer: BCBS of TX Blue Advantage	$3.29
Rate for Payer: BCBS of TX Blue Essentials	$3.95
Rate for Payer: BCBS of TX PPO	$4.38
Rate for Payer: Cash Price	$7.45
Rate for Payer: Cigna Medicaid	$7.89
Rate for Payer: Molina CHIP/Medicaid	$7.89
Rate for Payer: Multiplan Auto	$7.12
Rate for Payer: Multiplan Commercial	$7.12
Rate for Payer: Multiplan Workers Comp	$7.12
Rate for Payer: Parkland Medicaid	$7.89
Rate for Payer: Scott and White EPO/PPO	$5.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.89
Rate for Payer: Superior Health Plan EPO	$1.49

BAG DRN 750ML AERSL WYE ADPT SLF LCK

Facility

$3.54

Hospital Charge Code	993607
Hospital Revenue Code	270
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$2.55
Rate for Payer: Amerigroup CHIP/Medicaid	$0.32
Rate for Payer: BCBS of TX Blue Advantage	$1.06
Rate for Payer: BCBS of TX Blue Essentials	$1.27
Rate for Payer: BCBS of TX PPO	$1.42
Rate for Payer: Cash Price	$2.41
Rate for Payer: Cigna Medicaid	$2.55
Rate for Payer: Molina CHIP/Medicaid	$2.55
Rate for Payer: Multiplan Auto	$2.30
Rate for Payer: Multiplan Commercial	$2.30
Rate for Payer: Multiplan Workers Comp	$2.30
Rate for Payer: Parkland Medicaid	$2.55
Rate for Payer: Scott and White EPO/PPO	$1.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.55
Rate for Payer: Superior Health Plan EPO	$0.48

BAG DRN 750ML AERSL WYE ADPT SLF LCK

Facility

$3.54

Hospital Charge Code	993607
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.41

BAG: EMESIS 6.5x15 1.35ML PR 100/CS

Facility

$4.47

Hospital Charge Code	993256
Hospital Revenue Code	270
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$3.22
Rate for Payer: Amerigroup CHIP/Medicaid	$0.40
Rate for Payer: BCBS of TX Blue Advantage	$1.34
Rate for Payer: BCBS of TX Blue Essentials	$1.61
Rate for Payer: BCBS of TX PPO	$1.79
Rate for Payer: Cash Price	$3.04
Rate for Payer: Cigna Medicaid	$3.22
Rate for Payer: Molina CHIP/Medicaid	$3.22
Rate for Payer: Multiplan Auto	$2.91
Rate for Payer: Multiplan Commercial	$2.91
Rate for Payer: Multiplan Workers Comp	$2.91
Rate for Payer: Parkland Medicaid	$3.22
Rate for Payer: Scott and White EPO/PPO	$2.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.22
Rate for Payer: Superior Health Plan EPO	$0.61

BAG: EMESIS 6.5x15 1.35ML PR 100/CS

Facility

$4.47

Hospital Charge Code	993256
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.04

BAG, EMESIS, BLUE, LDPE

Facility

$2.33

Hospital Charge Code	993083
Hospital Revenue Code	271
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$1.68
Rate for Payer: Amerigroup CHIP/Medicaid	$0.21
Rate for Payer: BCBS of TX Blue Advantage	$0.70
Rate for Payer: BCBS of TX Blue Essentials	$0.84
Rate for Payer: BCBS of TX PPO	$0.93
Rate for Payer: Cash Price	$1.58
Rate for Payer: Cigna Medicaid	$1.68
Rate for Payer: Molina CHIP/Medicaid	$1.68
Rate for Payer: Multiplan Auto	$1.51
Rate for Payer: Multiplan Commercial	$1.51
Rate for Payer: Multiplan Workers Comp	$1.51
Rate for Payer: Parkland Medicaid	$1.68
Rate for Payer: Scott and White EPO/PPO	$1.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.68
Rate for Payer: Superior Health Plan EPO	$0.32

BAG, EMESIS, BLUE, LDPE

Facility

$2.33

Hospital Charge Code	993083
Hospital Revenue Code	271
Rate for Payer: Cash Price	$1.58

BAG EMESIS PLASTIC

Facility

$1.36

Hospital Charge Code	993961
Hospital Revenue Code	271
Rate for Payer: Cash Price	$0.92

BAG EMESIS PLASTIC

Facility

$1.36

Hospital Charge Code	993961
Hospital Revenue Code	271
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.98
Rate for Payer: Amerigroup CHIP/Medicaid	$0.12
Rate for Payer: BCBS of TX Blue Advantage	$0.41
Rate for Payer: BCBS of TX Blue Essentials	$0.49
Rate for Payer: BCBS of TX PPO	$0.54
Rate for Payer: Cash Price	$0.92
Rate for Payer: Cigna Medicaid	$0.98
Rate for Payer: Molina CHIP/Medicaid	$0.98
Rate for Payer: Multiplan Auto	$0.88
Rate for Payer: Multiplan Commercial	$0.88
Rate for Payer: Multiplan Workers Comp	$0.88
Rate for Payer: Parkland Medicaid	$0.98
Rate for Payer: Scott and White EPO/PPO	$0.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.98
Rate for Payer: Superior Health Plan EPO	$0.18

BAG, ICE, CLAMP-CLOSE, 4TIES, WHITE, 6.5X14

Facility

$5.68

Hospital Charge Code	993982
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.86

Know your out-of-pocket cost for care.

All Charges