White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BEARING TIBIAL STABLE VANGUARD POSTERIOR

Facility

$10,118.00

Service Code	HCPCS C1776
Hospital Charge Code	146430
Hospital Revenue Code	278
Min. Negotiated Rate	$910.62
Max. Negotiated Rate	$7,284.96
Rate for Payer: Amerigroup CHIP/Medicaid	$910.62
Rate for Payer: BCBS of TX Blue Advantage	$3,035.40
Rate for Payer: BCBS of TX Blue Essentials	$3,642.48
Rate for Payer: BCBS of TX PPO	$4,047.20
Rate for Payer: Cash Price	$6,880.24
Rate for Payer: Cigna Medicaid	$7,284.96
Rate for Payer: Molina CHIP/Medicaid	$7,284.96
Rate for Payer: Multiplan Auto	$5,059.00
Rate for Payer: Multiplan Commercial	$5,059.00
Rate for Payer: Multiplan Workers Comp	$5,059.00
Rate for Payer: Parkland Medicaid	$7,284.96
Rate for Payer: Scott and White EPO/PPO	$5,059.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,284.96
Rate for Payer: Superior Health Plan EPO	$1,376.05

BEHAVIORAL AND DEVELOPMENTAL DISORDERS

Facility

$26,729.86

Service Code	MSDRG 886
Min. Negotiated Rate	$8,502.82
Max. Negotiated Rate	$26,729.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,970.00
Rate for Payer: Amerigroup Medicare	$19,970.00
Rate for Payer: BCBS of TX Medicare	$19,970.00
Rate for Payer: Cigna Commercial	$26,729.86
Rate for Payer: Cigna Medicare	$19,970.00
Rate for Payer: Employer Direct Commercial	$19,970.00
Rate for Payer: Molina Dual Medicare/Medicaid	$19,970.00
Rate for Payer: Molina Medicare	$19,970.00
Rate for Payer: Multiplan Auto	$25,935.00
Rate for Payer: Multiplan Commercial	$25,935.00
Rate for Payer: Multiplan Workers Comp	$25,935.00
Rate for Payer: Scott and White EPO/PPO	$11,943.75
Rate for Payer: Scott and White Medicare	$19,970.00
Rate for Payer: Superior Health Plan EPO	$19,970.00
Rate for Payer: Superior Health Plan Medicare	$19,970.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,970.00
Rate for Payer: Universal American Medicare	$19,970.00
Rate for Payer: Wellcare Medicare	$19,970.00
Rate for Payer: Wellmed Medicare	$19,970.00

BEHAVIORAL & DEVELOPMENTAL DISORDERS

Facility

$26,729.86

Service Code	MSDRG 886
Min. Negotiated Rate	$8,502.82
Max. Negotiated Rate	$26,729.86
Rate for Payer: BCBS of TX Blue Advantage	$8,502.82
Rate for Payer: BCBS of TX Blue Essentials	$10,202.40
Rate for Payer: BCBS of TX PPO	$11,336.43

BEHAVIORAL DISORDERS

Facility

$1,813.90

Service Code	APR-DRG 7582
Min. Negotiated Rate	$1,710.21
Max. Negotiated Rate	$1,813.90
Rate for Payer: Amerigroup CHIP/Medicaid	$1,710.21
Rate for Payer: Cigna Medicaid	$1,710.21
Rate for Payer: Molina CHIP/Medicaid	$1,710.21
Rate for Payer: Parkland Medicaid	$1,710.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,813.90

BEHAVIORAL DISORDERS

Facility

$1,192.67

Service Code	APR-DRG 7581
Min. Negotiated Rate	$1,124.49
Max. Negotiated Rate	$1,192.67
Rate for Payer: Amerigroup CHIP/Medicaid	$1,124.49
Rate for Payer: Cigna Medicaid	$1,124.49
Rate for Payer: Molina CHIP/Medicaid	$1,124.49
Rate for Payer: Parkland Medicaid	$1,124.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,192.67

BEHAVIORAL DISORDERS

Facility

$1,892.36

Service Code	APR-DRG 7583
Min. Negotiated Rate	$1,784.18
Max. Negotiated Rate	$1,892.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,784.18
Rate for Payer: Cigna Medicaid	$1,784.18
Rate for Payer: Molina CHIP/Medicaid	$1,784.18
Rate for Payer: Parkland Medicaid	$1,784.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,892.36

BEHAVIORAL DISORDERS

Facility

$7,759.91

Service Code	APR-DRG 7584
Min. Negotiated Rate	$7,316.31
Max. Negotiated Rate	$7,759.91
Rate for Payer: Amerigroup CHIP/Medicaid	$7,316.31
Rate for Payer: Cigna Medicaid	$7,316.31
Rate for Payer: Molina CHIP/Medicaid	$7,316.31
Rate for Payer: Parkland Medicaid	$7,316.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,759.91

Behavioral, Qualitative Analysis Units

Facility

$521.00

Service Code	HCPCS 92524
Hospital Charge Code	4450056
Hospital Revenue Code	444
Rate for Payer: Cash Price	$354.28

Behavioral, Qualitative Analysis Units

Facility

$521.00

Service Code	HCPCS 92524
Hospital Charge Code	4450056
Hospital Revenue Code	444
Min. Negotiated Rate	$70.86
Max. Negotiated Rate	$375.12
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$156.30
Rate for Payer: BCBS of TX Blue Essentials	$187.56
Rate for Payer: BCBS of TX PPO	$208.40
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$375.12
Rate for Payer: Molina CHIP/Medicaid	$375.12
Rate for Payer: Multiplan Auto	$338.65
Rate for Payer: Multiplan Commercial	$338.65
Rate for Payer: Multiplan Workers Comp	$338.65
Rate for Payer: Parkland Medicaid	$375.12
Rate for Payer: Scott and White EPO/PPO	$135.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$375.12
Rate for Payer: Superior Health Plan EPO	$70.86

BELT GAIT -- DHF

Facility

$49.53

Hospital Charge Code	80313448
Hospital Revenue Code	270
Min. Negotiated Rate	$4.46
Max. Negotiated Rate	$35.66
Rate for Payer: Amerigroup CHIP/Medicaid	$4.46
Rate for Payer: BCBS of TX Blue Advantage	$14.86
Rate for Payer: BCBS of TX Blue Essentials	$17.83
Rate for Payer: BCBS of TX PPO	$19.81
Rate for Payer: Cash Price	$33.68
Rate for Payer: Cigna Medicaid	$35.66
Rate for Payer: Molina CHIP/Medicaid	$35.66
Rate for Payer: Multiplan Auto	$32.19
Rate for Payer: Multiplan Commercial	$32.19
Rate for Payer: Multiplan Workers Comp	$32.19
Rate for Payer: Parkland Medicaid	$35.66
Rate for Payer: Scott and White EPO/PPO	$24.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.66
Rate for Payer: Superior Health Plan EPO	$6.74

BELT GAIT -- DHF

Facility

$49.53

Hospital Charge Code	80313448
Hospital Revenue Code	270
Rate for Payer: Cash Price	$33.68

BELT GAIT ECONOMY

Facility

$17.85

Hospital Charge Code	993285
Hospital Revenue Code	270
Min. Negotiated Rate	$1.61
Max. Negotiated Rate	$12.85
Rate for Payer: Amerigroup CHIP/Medicaid	$1.61
Rate for Payer: BCBS of TX Blue Advantage	$5.36
Rate for Payer: BCBS of TX Blue Essentials	$6.43
Rate for Payer: BCBS of TX PPO	$7.14
Rate for Payer: Cash Price	$12.14
Rate for Payer: Cigna Medicaid	$12.85
Rate for Payer: Molina CHIP/Medicaid	$12.85
Rate for Payer: Multiplan Auto	$11.60
Rate for Payer: Multiplan Commercial	$11.60
Rate for Payer: Multiplan Workers Comp	$11.60
Rate for Payer: Parkland Medicaid	$12.85
Rate for Payer: Scott and White EPO/PPO	$8.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.85
Rate for Payer: Superior Health Plan EPO	$2.43

BELT GAIT ECONOMY

Facility

$17.85

Hospital Charge Code	993285
Hospital Revenue Code	270
Rate for Payer: Cash Price	$12.14

BENIGN PROSTATIC HYPERTROPHY WITH MCC

Facility

$23,736.70

Service Code	MSDRG 725
Min. Negotiated Rate	$10,442.98
Max. Negotiated Rate	$23,736.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,336.50
Rate for Payer: Amerigroup Medicare	$13,336.50
Rate for Payer: BCBS of TX Medicare	$13,336.50
Rate for Payer: Cigna Commercial	$15,072.18
Rate for Payer: Cigna Medicare	$13,336.50
Rate for Payer: Employer Direct Commercial	$13,336.50
Rate for Payer: Humana Medicare/TRICARE	$13,336.50
Rate for Payer: Molina Dual Medicare/Medicaid	$13,336.50
Rate for Payer: Molina Medicare	$13,336.50
Rate for Payer: Multiplan Auto	$23,736.70
Rate for Payer: Multiplan Commercial	$23,736.70
Rate for Payer: Multiplan Workers Comp	$23,736.70
Rate for Payer: Scott and White EPO/PPO	$10,931.38
Rate for Payer: Scott and White Medicare	$13,336.50
Rate for Payer: Superior Health Plan EPO	$13,336.50
Rate for Payer: Superior Health Plan Medicare	$13,336.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,336.50
Rate for Payer: Universal American Medicare	$13,336.50
Rate for Payer: Wellcare Medicare	$13,336.50
Rate for Payer: Wellmed Medicare	$13,336.50

BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC

Facility

$14,660.40

Service Code	MSDRG 726
Min. Negotiated Rate	$6,574.70
Max. Negotiated Rate	$14,660.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,051.64
Rate for Payer: Amerigroup Medicare	$10,051.64
Rate for Payer: BCBS of TX Medicare	$10,051.64
Rate for Payer: Cigna Commercial	$9,299.36
Rate for Payer: Cigna Medicare	$10,051.64
Rate for Payer: Employer Direct Commercial	$10,051.64
Rate for Payer: Humana Medicare/TRICARE	$10,051.64
Rate for Payer: Molina Dual Medicare/Medicaid	$10,051.64
Rate for Payer: Molina Medicare	$10,051.64
Rate for Payer: Multiplan Auto	$14,660.40
Rate for Payer: Multiplan Commercial	$14,660.40
Rate for Payer: Multiplan Workers Comp	$14,660.40
Rate for Payer: Scott and White EPO/PPO	$6,751.50
Rate for Payer: Scott and White Medicare	$10,051.64
Rate for Payer: Superior Health Plan EPO	$10,051.64
Rate for Payer: Superior Health Plan Medicare	$10,051.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,051.64
Rate for Payer: Universal American Medicare	$10,051.64
Rate for Payer: Wellcare Medicare	$10,051.64
Rate for Payer: Wellmed Medicare	$10,051.64

BENIGN PROSTATIC HYPERTROPHY W MCC

Facility

$23,736.70

Service Code	MSDRG 725
Min. Negotiated Rate	$10,442.98
Max. Negotiated Rate	$23,736.70
Rate for Payer: BCBS of TX Blue Advantage	$10,442.98
Rate for Payer: BCBS of TX Blue Essentials	$12,530.36
Rate for Payer: BCBS of TX PPO	$13,923.16

BENIGN PROSTATIC HYPERTROPHY W/O MCC

Facility

$14,660.40

Service Code	MSDRG 726
Min. Negotiated Rate	$6,574.70
Max. Negotiated Rate	$14,660.40
Rate for Payer: BCBS of TX Blue Advantage	$6,574.70
Rate for Payer: BCBS of TX Blue Essentials	$7,888.88
Rate for Payer: BCBS of TX PPO	$8,765.76

benzocaine 20% Mucous Membrane Gel

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	78349269
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

benzocaine 20% Mucous Membrane Gel

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	78349269
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

benzocaine-menthol 15 mg-3.6 mg Lozenge

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77401187
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

benzocaine-menthol 15 mg-3.6 mg Lozenge

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77401187
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

benzocaine-menthol topical 20%-0.5% Topical Spray

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	78871664
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

benzocaine-menthol topical 20%-0.5% Topical Spray

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	78871664
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

benzonatate 100 mg Cap

Facility

$9.52

Service Code	HCPCS J3490
Hospital Charge Code	77402472
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.47

benzonatate 100 mg Cap

Facility

$9.52

Service Code	HCPCS J3490
Hospital Charge Code	77402472
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$6.85
Rate for Payer: Amerigroup CHIP/Medicaid	$0.86
Rate for Payer: BCBS of TX Blue Advantage	$2.86
Rate for Payer: BCBS of TX Blue Essentials	$3.43
Rate for Payer: BCBS of TX PPO	$3.81
Rate for Payer: Cash Price	$6.47
Rate for Payer: Cigna Medicaid	$6.85
Rate for Payer: Molina CHIP/Medicaid	$6.85
Rate for Payer: Multiplan Auto	$6.19
Rate for Payer: Multiplan Commercial	$6.19
Rate for Payer: Multiplan Workers Comp	$6.19
Rate for Payer: Parkland Medicaid	$6.85
Rate for Payer: Scott and White EPO/PPO	$4.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.85
Rate for Payer: Superior Health Plan EPO	$1.29

Know your out-of-pocket cost for care.

All Charges