White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed diagnostic, with c

Facility

$3,740.98

Service Code	HCPCS 31622
Hospital Charge Code	4010008
Hospital Revenue Code	360
Min. Negotiated Rate	$525.71
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Amerigroup Medicare	$1,788.01
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,788.01
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cash Price	$2,543.87
Rate for Payer: Cash Price	$2,543.87
Rate for Payer: Cash Price	$2,543.87
Rate for Payer: Cigna Commercial	$3,779.52
Rate for Payer: Cigna Medicaid	$2,693.51
Rate for Payer: Cigna Medicare	$1,788.01
Rate for Payer: Employer Direct Commercial	$1,788.01
Rate for Payer: Humana Medicare/TRICARE	$1,788.01
Rate for Payer: Molina CHIP/Medicaid	$2,693.51
Rate for Payer: Molina Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Molina Medicare	$1,788.01
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	$2,693.51
Rate for Payer: Scott and White EPO/PPO	$3,307.82
Rate for Payer: Scott and White Medicare	$1,788.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,693.51
Rate for Payer: Superior Health Plan EPO	$1,788.01
Rate for Payer: Superior Health Plan Medicare	$1,788.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Universal American Medicare	$1,788.01
Rate for Payer: Wellcare Medicare	$1,788.01
Rate for Payer: Wellmed Medicare	$1,788.01

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed diagnostic, with c

Facility

$10,000.00

Service Code	CPT 31622
Hospital Charge Code	36031622
Hospital Revenue Code	360
Min. Negotiated Rate	$525.71
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Amerigroup Medicare	$1,788.01
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,788.01
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cigna Commercial	$3,779.52
Rate for Payer: Cigna Medicare	$1,788.01
Rate for Payer: Employer Direct Commercial	$1,788.01
Rate for Payer: Humana Medicare/TRICARE	$1,788.01
Rate for Payer: Molina Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Molina Medicare	$1,788.01
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: Scott and White EPO/PPO	$3,307.82
Rate for Payer: Scott and White Medicare	$1,788.01
Rate for Payer: Superior Health Plan EPO	$1,788.01
Rate for Payer: Superior Health Plan Medicare	$1,788.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Universal American Medicare	$1,788.01
Rate for Payer: Wellcare Medicare	$1,788.01
Rate for Payer: Wellmed Medicare	$1,788.01

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed diagnostic, with c

Facility

$3,740.98

Service Code	HCPCS 31622
Hospital Charge Code	4010008
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,543.87

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed diagnostic, with c

Facility

$3,740.98

Service Code	HCPCS 31622
Hospital Charge Code	9900621
Hospital Revenue Code	360
Min. Negotiated Rate	$525.71
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$525.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Amerigroup Medicare	$1,788.01
Rate for Payer: BCBS of TX Blue Advantage	$2,389.12
Rate for Payer: BCBS of TX Blue Essentials	$2,861.22
Rate for Payer: BCBS of TX Medicare	$1,788.01
Rate for Payer: BCBS of TX PPO	$3,605.14
Rate for Payer: Cash Price	$2,543.87
Rate for Payer: Cash Price	$2,543.87
Rate for Payer: Cash Price	$2,543.87
Rate for Payer: Cigna Commercial	$3,779.52
Rate for Payer: Cigna Medicaid	$2,693.51
Rate for Payer: Cigna Medicare	$1,788.01
Rate for Payer: Employer Direct Commercial	$1,788.01
Rate for Payer: Humana Medicare/TRICARE	$1,788.01
Rate for Payer: Molina CHIP/Medicaid	$2,693.51
Rate for Payer: Molina Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Molina Medicare	$1,788.01
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	$2,693.51
Rate for Payer: Scott and White EPO/PPO	$3,307.82
Rate for Payer: Scott and White Medicare	$1,788.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,693.51
Rate for Payer: Superior Health Plan EPO	$1,788.01
Rate for Payer: Superior Health Plan Medicare	$1,788.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,788.01
Rate for Payer: Universal American Medicare	$1,788.01
Rate for Payer: Wellcare Medicare	$1,788.01
Rate for Payer: Wellmed Medicare	$1,788.01

BRST PMP SNG -- DHF

Facility

$66.97

Hospital Charge Code	80314701
Hospital Revenue Code	271
Rate for Payer: Cash Price	$45.54

BRST PMP SNG -- DHF

Facility

$66.97

Hospital Charge Code	80314701
Hospital Revenue Code	271
Min. Negotiated Rate	$6.03
Max. Negotiated Rate	$48.22
Rate for Payer: Amerigroup CHIP/Medicaid	$6.03
Rate for Payer: BCBS of TX Blue Advantage	$20.09
Rate for Payer: BCBS of TX Blue Essentials	$24.11
Rate for Payer: BCBS of TX PPO	$26.79
Rate for Payer: Cash Price	$45.54
Rate for Payer: Cigna Medicaid	$48.22
Rate for Payer: Molina CHIP/Medicaid	$48.22
Rate for Payer: Multiplan Auto	$43.53
Rate for Payer: Multiplan Commercial	$43.53
Rate for Payer: Multiplan Workers Comp	$43.53
Rate for Payer: Parkland Medicaid	$48.22
Rate for Payer: Scott and White EPO/PPO	$33.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$48.22
Rate for Payer: Superior Health Plan EPO	$9.11

Brucella Antibody IgG/IgM SO

Facility

$96.00

Service Code	HCPCS 86622
Hospital Charge Code	1708874
Hospital Revenue Code	302
Rate for Payer: Cash Price	$65.28

Brucella Antibody IgG/IgM SO

Facility

$96.00

Service Code	HCPCS 86622
Hospital Charge Code	1708874
Hospital Revenue Code	302
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$69.12
Rate for Payer: Amerigroup CHIP/Medicaid	$3.48
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.93
Rate for Payer: Amerigroup Medicare	$8.93
Rate for Payer: BCBS of TX Blue Advantage	$28.80
Rate for Payer: BCBS of TX Blue Essentials	$34.56
Rate for Payer: BCBS of TX Medicare	$8.93
Rate for Payer: BCBS of TX PPO	$38.40
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cigna Medicaid	$69.12
Rate for Payer: Cigna Medicare	$8.93
Rate for Payer: Employer Direct Commercial	$8.93
Rate for Payer: Humana Medicare/TRICARE	$8.93
Rate for Payer: Molina CHIP/Medicaid	$69.12
Rate for Payer: Molina Dual Medicare/Medicaid	$8.93
Rate for Payer: Molina Medicare	$8.93
Rate for Payer: Multiplan Auto	$62.40
Rate for Payer: Multiplan Commercial	$62.40
Rate for Payer: Multiplan Workers Comp	$62.40
Rate for Payer: Parkland Medicaid	$69.12
Rate for Payer: Scott and White EPO/PPO	$11.16
Rate for Payer: Scott and White Medicare	$8.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.12
Rate for Payer: Superior Health Plan EPO	$8.93
Rate for Payer: Superior Health Plan Medicare	$8.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.93
Rate for Payer: Universal American Medicare	$8.93
Rate for Payer: Wellcare Medicare	$8.93
Rate for Payer: Wellmed Medicare	$8.93

BRUSH, CLEANING SCOPE XLN BLUE 1.8MMX2CM75CM

Facility

$12.44

Hospital Charge Code	993193
Hospital Revenue Code	270
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$8.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1.12
Rate for Payer: BCBS of TX Blue Advantage	$3.73
Rate for Payer: BCBS of TX Blue Essentials	$4.48
Rate for Payer: BCBS of TX PPO	$4.98
Rate for Payer: Cash Price	$8.46
Rate for Payer: Cigna Medicaid	$8.96
Rate for Payer: Molina CHIP/Medicaid	$8.96
Rate for Payer: Multiplan Auto	$8.09
Rate for Payer: Multiplan Commercial	$8.09
Rate for Payer: Multiplan Workers Comp	$8.09
Rate for Payer: Parkland Medicaid	$8.96
Rate for Payer: Scott and White EPO/PPO	$6.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.96
Rate for Payer: Superior Health Plan EPO	$1.69

BRUSH, CLEANING SCOPE XLN BLUE 1.8MMX2CM75CM

Facility

$12.44

Hospital Charge Code	993193
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.46

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Facility

$45.94

Hospital Charge Code	8640530
Hospital Revenue Code	270
Min. Negotiated Rate	$4.13
Max. Negotiated Rate	$33.08
Rate for Payer: Amerigroup CHIP/Medicaid	$4.13
Rate for Payer: BCBS of TX Blue Advantage	$13.78
Rate for Payer: BCBS of TX Blue Essentials	$16.54
Rate for Payer: BCBS of TX PPO	$18.38
Rate for Payer: Cash Price	$31.24
Rate for Payer: Cigna Medicaid	$33.08
Rate for Payer: Molina CHIP/Medicaid	$33.08
Rate for Payer: Multiplan Auto	$29.86
Rate for Payer: Multiplan Commercial	$29.86
Rate for Payer: Multiplan Workers Comp	$29.86
Rate for Payer: Parkland Medicaid	$33.08
Rate for Payer: Scott and White EPO/PPO	$22.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.08
Rate for Payer: Superior Health Plan EPO	$6.25

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Facility

$45.94

Hospital Charge Code	8640530
Hospital Revenue Code	270
Rate for Payer: Cash Price	$31.24

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Facility

$467.62

Hospital Charge Code	110080
Hospital Revenue Code	272
Min. Negotiated Rate	$42.09
Max. Negotiated Rate	$336.69
Rate for Payer: Amerigroup CHIP/Medicaid	$42.09
Rate for Payer: BCBS of TX Blue Advantage	$140.29
Rate for Payer: BCBS of TX Blue Essentials	$168.34
Rate for Payer: BCBS of TX PPO	$187.05
Rate for Payer: Cash Price	$317.98
Rate for Payer: Cigna Medicaid	$336.69
Rate for Payer: Molina CHIP/Medicaid	$336.69
Rate for Payer: Multiplan Auto	$303.95
Rate for Payer: Multiplan Commercial	$303.95
Rate for Payer: Multiplan Workers Comp	$303.95
Rate for Payer: Parkland Medicaid	$336.69
Rate for Payer: Scott and White EPO/PPO	$233.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$336.69
Rate for Payer: Superior Health Plan EPO	$63.60

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Facility

$467.62

Hospital Charge Code	110080
Hospital Revenue Code	272
Rate for Payer: Cash Price	$317.98

BRUSH, SCRUB, IMPREGNATED, 3% PCMX, BLUE

Facility

$1.86

Hospital Charge Code	992903
Hospital Revenue Code	270
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$1.34
Rate for Payer: Amerigroup CHIP/Medicaid	$0.17
Rate for Payer: BCBS of TX Blue Advantage	$0.56
Rate for Payer: BCBS of TX Blue Essentials	$0.67
Rate for Payer: BCBS of TX PPO	$0.74
Rate for Payer: Cash Price	$1.26
Rate for Payer: Cigna Medicaid	$1.34
Rate for Payer: Molina CHIP/Medicaid	$1.34
Rate for Payer: Multiplan Auto	$1.21
Rate for Payer: Multiplan Commercial	$1.21
Rate for Payer: Multiplan Workers Comp	$1.21
Rate for Payer: Parkland Medicaid	$1.34
Rate for Payer: Scott and White EPO/PPO	$0.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.34
Rate for Payer: Superior Health Plan EPO	$0.25

BRUSH, SCRUB, IMPREGNATED, 3% PCMX, BLUE

Facility

$1.86

Hospital Charge Code	992903
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.26

BRUSH, SCRUB, IMPREGNATED, 4% CHG, RED, LF

Facility

$2.24

Hospital Charge Code	992902
Hospital Revenue Code	270
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$1.61
Rate for Payer: Amerigroup CHIP/Medicaid	$0.20
Rate for Payer: BCBS of TX Blue Advantage	$0.67
Rate for Payer: BCBS of TX Blue Essentials	$0.81
Rate for Payer: BCBS of TX PPO	$0.90
Rate for Payer: Cash Price	$1.52
Rate for Payer: Cigna Medicaid	$1.61
Rate for Payer: Molina CHIP/Medicaid	$1.61
Rate for Payer: Multiplan Auto	$1.46
Rate for Payer: Multiplan Commercial	$1.46
Rate for Payer: Multiplan Workers Comp	$1.46
Rate for Payer: Parkland Medicaid	$1.61
Rate for Payer: Scott and White EPO/PPO	$1.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.61
Rate for Payer: Superior Health Plan EPO	$0.30

BRUSH, SCRUB, IMPREGNATED, 4% CHG, RED, LF

Facility

$2.24

Hospital Charge Code	992902
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.52

BSK RETRV -- DHF

Facility

$1,406.07

Hospital Charge Code	80410756
Hospital Revenue Code	272
Min. Negotiated Rate	$126.55
Max. Negotiated Rate	$1,012.37
Rate for Payer: Amerigroup CHIP/Medicaid	$126.55
Rate for Payer: BCBS of TX Blue Advantage	$421.82
Rate for Payer: BCBS of TX Blue Essentials	$506.19
Rate for Payer: BCBS of TX PPO	$562.43
Rate for Payer: Cash Price	$956.13
Rate for Payer: Cigna Medicaid	$1,012.37
Rate for Payer: Molina CHIP/Medicaid	$1,012.37
Rate for Payer: Multiplan Auto	$913.95
Rate for Payer: Multiplan Commercial	$913.95
Rate for Payer: Multiplan Workers Comp	$913.95
Rate for Payer: Parkland Medicaid	$1,012.37
Rate for Payer: Scott and White EPO/PPO	$703.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,012.37
Rate for Payer: Superior Health Plan EPO	$191.23

BSK RETRV -- DHF

Facility

$1,406.07

Hospital Charge Code	80410756
Hospital Revenue Code	272
Rate for Payer: Cash Price	$956.13

budeosnide 0.5 mg 2 ml nebulizer

Facility

$31.57

Service Code	HCPCS J7633
Hospital Charge Code	77419540
Hospital Revenue Code	636
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$22.73
Rate for Payer: Amerigroup CHIP/Medicaid	$2.84
Rate for Payer: BCBS of TX Blue Advantage	$9.47
Rate for Payer: BCBS of TX Blue Essentials	$11.37
Rate for Payer: BCBS of TX PPO	$12.63
Rate for Payer: Cash Price	$21.47
Rate for Payer: Cigna Medicaid	$22.73
Rate for Payer: Molina CHIP/Medicaid	$22.73
Rate for Payer: Multiplan Auto	$20.52
Rate for Payer: Multiplan Commercial	$20.52
Rate for Payer: Multiplan Workers Comp	$20.52
Rate for Payer: Parkland Medicaid	$22.73
Rate for Payer: Scott and White EPO/PPO	$15.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.73
Rate for Payer: Superior Health Plan EPO	$4.29

budeosnide 0.5 mg 2 ml nebulizer

Facility

$31.57

Service Code	HCPCS J7633
Hospital Charge Code	77419540
Hospital Revenue Code	636
Min. Negotiated Rate	$7.89
Max. Negotiated Rate	$15.79
Rate for Payer: Cash Price	$21.47
Rate for Payer: Cigna Commercial	$7.89
Rate for Payer: Scott and White EPO/PPO	$15.79

budesonide 0.5 mg/2 mL Inh Susp 2 mL

Facility

$31.57

Service Code	HCPCS J7626
Hospital Charge Code	7442804
Hospital Revenue Code	636
Min. Negotiated Rate	$7.89
Max. Negotiated Rate	$15.79
Rate for Payer: Cash Price	$21.47
Rate for Payer: Cigna Commercial	$7.89
Rate for Payer: Scott and White EPO/PPO	$15.79

budesonide 0.5 mg/2 mL Inh Susp 2 mL

Facility

$31.57

Service Code	HCPCS J7626
Hospital Charge Code	7442804
Hospital Revenue Code	636
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$22.73
Rate for Payer: Amerigroup CHIP/Medicaid	$2.84
Rate for Payer: BCBS of TX Blue Advantage	$8.18
Rate for Payer: BCBS of TX Blue Essentials	$9.81
Rate for Payer: BCBS of TX PPO	$10.89
Rate for Payer: Cash Price	$21.47
Rate for Payer: Cash Price	$21.47
Rate for Payer: Cigna Medicaid	$22.73
Rate for Payer: Molina CHIP/Medicaid	$22.73
Rate for Payer: Multiplan Auto	$20.52
Rate for Payer: Multiplan Commercial	$20.52
Rate for Payer: Multiplan Workers Comp	$20.52
Rate for Payer: Parkland Medicaid	$22.73
Rate for Payer: Scott and White EPO/PPO	$15.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.73
Rate for Payer: Superior Health Plan EPO	$4.29

BUFFER SOLUTION PH 3.0 500ML

Facility

$168.21

Hospital Charge Code	993652
Hospital Revenue Code	270
Rate for Payer: Cash Price	$114.38

Know your out-of-pocket cost for care.

All Charges