White Rock Medical Center

All Charges

Charge

Type

Setting

Price

cetirizine 10 mg Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77452444
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

cetirizine 10 mg Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77452444
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

CHAMBER HMDF STRL H2O 1650ML CNCH

Facility

$10.85

Hospital Charge Code	993610
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.38

CHAMBER HMDF STRL H2O 1650ML CNCH

Facility

$10.85

Hospital Charge Code	993610
Hospital Revenue Code	270
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$7.81
Rate for Payer: Amerigroup CHIP/Medicaid	$0.98
Rate for Payer: BCBS of TX Blue Advantage	$3.25
Rate for Payer: BCBS of TX Blue Essentials	$3.91
Rate for Payer: BCBS of TX PPO	$4.34
Rate for Payer: Cash Price	$7.38
Rate for Payer: Cigna Medicaid	$7.81
Rate for Payer: Molina CHIP/Medicaid	$7.81
Rate for Payer: Multiplan Auto	$7.05
Rate for Payer: Multiplan Commercial	$7.05
Rate for Payer: Multiplan Workers Comp	$7.05
Rate for Payer: Parkland Medicaid	$7.81
Rate for Payer: Scott and White EPO/PPO	$5.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.81
Rate for Payer: Superior Health Plan EPO	$1.48

Chamfered screw 5.5 X 35,mm

Facility

$10,337.35

Service Code	HCPCS C1713
Hospital Charge Code	992211
Hospital Revenue Code	278
Min. Negotiated Rate	$930.36
Max. Negotiated Rate	$7,442.89
Rate for Payer: Amerigroup CHIP/Medicaid	$930.36
Rate for Payer: BCBS of TX Blue Advantage	$3,101.20
Rate for Payer: BCBS of TX Blue Essentials	$3,721.45
Rate for Payer: BCBS of TX PPO	$4,134.94
Rate for Payer: Cash Price	$7,029.40
Rate for Payer: Cigna Medicaid	$7,442.89
Rate for Payer: Molina CHIP/Medicaid	$7,442.89
Rate for Payer: Multiplan Auto	$5,168.68
Rate for Payer: Multiplan Commercial	$5,168.68
Rate for Payer: Multiplan Workers Comp	$5,168.68
Rate for Payer: Parkland Medicaid	$7,442.89
Rate for Payer: Scott and White EPO/PPO	$5,168.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,442.89
Rate for Payer: Superior Health Plan EPO	$1,405.88

Chamfered screw 5.5 X 35,mm

Facility

$10,337.35

Service Code	HCPCS C1713
Hospital Charge Code	992211
Hospital Revenue Code	278
Min. Negotiated Rate	$2,584.34
Max. Negotiated Rate	$5,168.68
Rate for Payer: Cash Price	$7,029.40
Rate for Payer: Cigna Commercial	$2,584.34
Rate for Payer: Multiplan Auto	$5,168.68
Rate for Payer: Multiplan Commercial	$5,168.68
Rate for Payer: Multiplan Workers Comp	$5,168.68
Rate for Payer: Scott and White EPO/PPO	$5,168.68

Chamfered screw 5.5 X 40,mm

Facility

$10,337.35

Service Code	HCPCS C1713
Hospital Charge Code	992212
Hospital Revenue Code	278
Min. Negotiated Rate	$930.36
Max. Negotiated Rate	$7,442.89
Rate for Payer: Amerigroup CHIP/Medicaid	$930.36
Rate for Payer: BCBS of TX Blue Advantage	$3,101.20
Rate for Payer: BCBS of TX Blue Essentials	$3,721.45
Rate for Payer: BCBS of TX PPO	$4,134.94
Rate for Payer: Cash Price	$7,029.40
Rate for Payer: Cigna Medicaid	$7,442.89
Rate for Payer: Molina CHIP/Medicaid	$7,442.89
Rate for Payer: Multiplan Auto	$5,168.68
Rate for Payer: Multiplan Commercial	$5,168.68
Rate for Payer: Multiplan Workers Comp	$5,168.68
Rate for Payer: Parkland Medicaid	$7,442.89
Rate for Payer: Scott and White EPO/PPO	$5,168.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,442.89
Rate for Payer: Superior Health Plan EPO	$1,405.88

Chamfered screw 5.5 X 40,mm

Facility

$10,337.35

Service Code	HCPCS C1713
Hospital Charge Code	992212
Hospital Revenue Code	278
Min. Negotiated Rate	$2,584.34
Max. Negotiated Rate	$5,168.68
Rate for Payer: Cash Price	$7,029.40
Rate for Payer: Cigna Commercial	$2,584.34
Rate for Payer: Multiplan Auto	$5,168.68
Rate for Payer: Multiplan Commercial	$5,168.68
Rate for Payer: Multiplan Workers Comp	$5,168.68
Rate for Payer: Scott and White EPO/PPO	$5,168.68

.Change IG Pap to LB Pap 192555 SO

Facility

$156.00

Service Code	HCPCS 88142
Hospital Charge Code	8662512
Hospital Revenue Code	311
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$112.32
Rate for Payer: Amerigroup CHIP/Medicaid	$7.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.26
Rate for Payer: Amerigroup Medicare	$20.26
Rate for Payer: BCBS of TX Blue Advantage	$46.80
Rate for Payer: BCBS of TX Blue Essentials	$56.16
Rate for Payer: BCBS of TX Medicare	$20.26
Rate for Payer: BCBS of TX PPO	$62.40
Rate for Payer: Cash Price	$106.08
Rate for Payer: Cash Price	$106.08
Rate for Payer: Cigna Medicaid	$112.32
Rate for Payer: Cigna Medicare	$20.26
Rate for Payer: Employer Direct Commercial	$20.26
Rate for Payer: Humana Medicare/TRICARE	$20.26
Rate for Payer: Molina CHIP/Medicaid	$112.32
Rate for Payer: Molina Dual Medicare/Medicaid	$20.26
Rate for Payer: Molina Medicare	$20.26
Rate for Payer: Multiplan Auto	$101.40
Rate for Payer: Multiplan Commercial	$101.40
Rate for Payer: Multiplan Workers Comp	$101.40
Rate for Payer: Parkland Medicaid	$112.32
Rate for Payer: Scott and White EPO/PPO	$25.32
Rate for Payer: Scott and White Medicare	$20.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$112.32
Rate for Payer: Superior Health Plan EPO	$20.26
Rate for Payer: Superior Health Plan Medicare	$20.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.26
Rate for Payer: Universal American Medicare	$20.26
Rate for Payer: Wellcare Medicare	$20.26
Rate for Payer: Wellmed Medicare	$20.26

.Change IG Pap to LB Pap 192555 SO

Facility

$156.00

Service Code	HCPCS 88142
Hospital Charge Code	8662512
Hospital Revenue Code	311
Rate for Payer: Cash Price	$106.08

Change of Gastrostomy Tube, percutaneous, without imaging or endoscopic guidance BCE

Facility

$1,397.25

Service Code	HCPCS 43762
Hospital Charge Code	9303000
Hospital Revenue Code	361
Rate for Payer: Cash Price	$950.13

Change of Gastrostomy Tube, percutaneous, without imaging or endoscopic guidance BCE

Facility

$1,397.25

Service Code	HCPCS 43762
Hospital Charge Code	9303000
Hospital Revenue Code	361
Min. Negotiated Rate	$110.15
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$110.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$250.99
Rate for Payer: Amerigroup Medicare	$250.99
Rate for Payer: BCBS of TX Blue Advantage	$392.28
Rate for Payer: BCBS of TX Blue Essentials	$469.80
Rate for Payer: BCBS of TX Medicare	$250.99
Rate for Payer: BCBS of TX PPO	$591.95
Rate for Payer: Cash Price	$950.13
Rate for Payer: Cash Price	$950.13
Rate for Payer: Cash Price	$950.13
Rate for Payer: Cigna Commercial	$530.54
Rate for Payer: Cigna Medicaid	$1,006.02
Rate for Payer: Cigna Medicare	$250.99
Rate for Payer: Employer Direct Commercial	$250.99
Rate for Payer: Humana Medicare/TRICARE	$250.99
Rate for Payer: Molina CHIP/Medicaid	$1,006.02
Rate for Payer: Molina Dual Medicare/Medicaid	$250.99
Rate for Payer: Molina Medicare	$250.99
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	$1,006.02
Rate for Payer: Scott and White EPO/PPO	$418.16
Rate for Payer: Scott and White Medicare	$250.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,006.02
Rate for Payer: Superior Health Plan EPO	$250.99
Rate for Payer: Superior Health Plan Medicare	$250.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$250.99
Rate for Payer: Universal American Medicare	$250.99
Rate for Payer: Wellcare Medicare	$250.99
Rate for Payer: Wellmed Medicare	$250.99

CHANGE PERC DRAIN CATH

Facility

$815.00

Service Code	HCPCS 75984
Hospital Charge Code	5055984
Hospital Revenue Code	320
Rate for Payer: Cash Price	$554.20

CHANGE PERC DRAIN CATH

Facility

$815.00

Service Code	HCPCS 75984
Hospital Charge Code	5055984
Hospital Revenue Code	320
Min. Negotiated Rate	$73.35
Max. Negotiated Rate	$586.80
Rate for Payer: Amerigroup CHIP/Medicaid	$73.35
Rate for Payer: BCBS of TX Blue Advantage	$112.98
Rate for Payer: BCBS of TX Blue Essentials	$135.57
Rate for Payer: BCBS of TX PPO	$151.32
Rate for Payer: Cash Price	$554.20
Rate for Payer: Cash Price	$554.20
Rate for Payer: Cigna Medicaid	$586.80
Rate for Payer: Molina CHIP/Medicaid	$586.80
Rate for Payer: Multiplan Auto	$529.75
Rate for Payer: Multiplan Commercial	$529.75
Rate for Payer: Multiplan Workers Comp	$529.75
Rate for Payer: Parkland Medicaid	$586.80
Rate for Payer: Scott and White EPO/PPO	$117.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$586.80
Rate for Payer: Superior Health Plan EPO	$110.84

charcoal 25 g Oral Susp 120 mL

Facility

$28.55

Service Code	HCPCS J3490
Hospital Charge Code	77453072
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.41

charcoal 25 g Oral Susp 120 mL

Facility

$28.55

Service Code	HCPCS J3490
Hospital Charge Code	77453072
Hospital Revenue Code	250
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$20.56
Rate for Payer: Amerigroup CHIP/Medicaid	$2.57
Rate for Payer: BCBS of TX Blue Advantage	$8.56
Rate for Payer: BCBS of TX Blue Essentials	$10.28
Rate for Payer: BCBS of TX PPO	$11.42
Rate for Payer: Cash Price	$19.41
Rate for Payer: Cigna Medicaid	$20.56
Rate for Payer: Molina CHIP/Medicaid	$20.56
Rate for Payer: Multiplan Auto	$18.56
Rate for Payer: Multiplan Commercial	$18.56
Rate for Payer: Multiplan Workers Comp	$18.56
Rate for Payer: Parkland Medicaid	$20.56
Rate for Payer: Scott and White EPO/PPO	$14.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.56
Rate for Payer: Superior Health Plan EPO	$3.88

CHARGER, CLIPPER, F/9661L, STAND MODEL

Facility

$218.56

Hospital Charge Code	992980
Hospital Revenue Code	270
Min. Negotiated Rate	$19.67
Max. Negotiated Rate	$157.36
Rate for Payer: Amerigroup CHIP/Medicaid	$19.67
Rate for Payer: BCBS of TX Blue Advantage	$65.57
Rate for Payer: BCBS of TX Blue Essentials	$78.68
Rate for Payer: BCBS of TX PPO	$87.42
Rate for Payer: Cash Price	$148.62
Rate for Payer: Cigna Medicaid	$157.36
Rate for Payer: Molina CHIP/Medicaid	$157.36
Rate for Payer: Multiplan Auto	$142.06
Rate for Payer: Multiplan Commercial	$142.06
Rate for Payer: Multiplan Workers Comp	$142.06
Rate for Payer: Parkland Medicaid	$157.36
Rate for Payer: Scott and White EPO/PPO	$109.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$157.36
Rate for Payer: Superior Health Plan EPO	$29.72

CHARGER, CLIPPER, F/9661L, STAND MODEL

Facility

$218.56

Hospital Charge Code	992980
Hospital Revenue Code	270
Rate for Payer: Cash Price	$148.62

CHED 96360 - Hydration, first hour BCE

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	8928542
Hospital Revenue Code	260
Rate for Payer: Cash Price	$575.96

CHED 96360 - Hydration, first hour BCE

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	8928542
Hospital Revenue Code	260
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$609.84
Rate for Payer: Amerigroup CHIP/Medicaid	$76.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$254.10
Rate for Payer: BCBS of TX Blue Essentials	$304.92
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$338.80
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$609.84
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$609.84
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$550.55
Rate for Payer: Multiplan Commercial	$550.55
Rate for Payer: Multiplan Workers Comp	$550.55
Rate for Payer: Parkland Medicaid	$609.84
Rate for Payer: Scott and White EPO/PPO	$39.95
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$609.84
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

CHED 96361- Hydration, each additional hour BCE

Facility

$251.00

Service Code	HCPCS 96361
Hospital Charge Code	8996979
Hospital Revenue Code	260
Rate for Payer: Cash Price	$170.68

CHED 96361- Hydration, each additional hour BCE

Facility

$251.00

Service Code	HCPCS 96361
Hospital Charge Code	8996979
Hospital Revenue Code	260
Min. Negotiated Rate	$15.21
Max. Negotiated Rate	$180.72
Rate for Payer: Amerigroup CHIP/Medicaid	$22.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47.04
Rate for Payer: Amerigroup Medicare	$47.04
Rate for Payer: BCBS of TX Blue Advantage	$75.30
Rate for Payer: BCBS of TX Blue Essentials	$90.36
Rate for Payer: BCBS of TX Medicare	$47.04
Rate for Payer: BCBS of TX PPO	$100.40
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cigna Commercial	$99.43
Rate for Payer: Cigna Medicaid	$180.72
Rate for Payer: Cigna Medicare	$47.04
Rate for Payer: Employer Direct Commercial	$47.04
Rate for Payer: Humana Medicare/TRICARE	$47.04
Rate for Payer: Molina CHIP/Medicaid	$180.72
Rate for Payer: Molina Dual Medicare/Medicaid	$47.04
Rate for Payer: Molina Medicare	$47.04
Rate for Payer: Multiplan Auto	$163.15
Rate for Payer: Multiplan Commercial	$163.15
Rate for Payer: Multiplan Workers Comp	$163.15
Rate for Payer: Parkland Medicaid	$180.72
Rate for Payer: Scott and White EPO/PPO	$15.21
Rate for Payer: Scott and White Medicare	$47.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.72
Rate for Payer: Superior Health Plan EPO	$47.04
Rate for Payer: Superior Health Plan Medicare	$47.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$47.04
Rate for Payer: Universal American Medicare	$47.04
Rate for Payer: Wellcare Medicare	$47.04
Rate for Payer: Wellmed Medicare	$47.04

CHED 96365- IV tx, first hour BCE

Facility

$300.00

Service Code	HCPCS 96365
Hospital Charge Code	8928543
Hospital Revenue Code	260
Rate for Payer: Cash Price	$204.00

CHED 96365- IV tx, first hour BCE

Facility

$300.00

Service Code	HCPCS 96365
Hospital Charge Code	600551
Hospital Revenue Code	260
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$451.67
Rate for Payer: Amerigroup CHIP/Medicaid	$27.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$90.00
Rate for Payer: BCBS of TX Blue Essentials	$108.00
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$120.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$216.00
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$216.00
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$195.00
Rate for Payer: Multiplan Commercial	$195.00
Rate for Payer: Multiplan Workers Comp	$195.00
Rate for Payer: Parkland Medicaid	$216.00
Rate for Payer: Scott and White EPO/PPO	$77.31
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.00
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

CHED 96365- IV tx, first hour BCE

Facility

$300.00

Service Code	HCPCS 96365
Hospital Charge Code	8928543
Hospital Revenue Code	260
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$451.67
Rate for Payer: Amerigroup CHIP/Medicaid	$27.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$90.00
Rate for Payer: BCBS of TX Blue Essentials	$108.00
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$120.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$216.00
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$216.00
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$195.00
Rate for Payer: Multiplan Commercial	$195.00
Rate for Payer: Multiplan Workers Comp	$195.00
Rate for Payer: Parkland Medicaid	$216.00
Rate for Payer: Scott and White EPO/PPO	$77.31
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.00
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

Know your out-of-pocket cost for care.

All Charges