White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CONNECTOR SWIVEL OXYGEN CLEAR NON STERILE

Facility

$9.38

Hospital Charge Code	993523
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.75
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.81
Rate for Payer: BCBS of TX Blue Essentials	$3.38
Rate for Payer: BCBS of TX PPO	$3.75
Rate for Payer: Cash Price	$6.38
Rate for Payer: Cigna Medicaid	$6.75
Rate for Payer: Molina CHIP/Medicaid	$6.75
Rate for Payer: Multiplan Auto	$6.10
Rate for Payer: Multiplan Commercial	$6.10
Rate for Payer: Multiplan Workers Comp	$6.10
Rate for Payer: Parkland Medicaid	$6.75
Rate for Payer: Scott and White EPO/PPO	$4.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.75
Rate for Payer: Superior Health Plan EPO	$1.28

CONSUMABLE, CLINITEX, UF-II, EACH

Facility

$4.60

Hospital Charge Code	993351
Hospital Revenue Code	270
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$3.31
Rate for Payer: Amerigroup CHIP/Medicaid	$0.41
Rate for Payer: BCBS of TX Blue Advantage	$1.38
Rate for Payer: BCBS of TX Blue Essentials	$1.66
Rate for Payer: BCBS of TX PPO	$1.84
Rate for Payer: Cash Price	$3.13
Rate for Payer: Cigna Medicaid	$3.31
Rate for Payer: Molina CHIP/Medicaid	$3.31
Rate for Payer: Multiplan Auto	$2.99
Rate for Payer: Multiplan Commercial	$2.99
Rate for Payer: Multiplan Workers Comp	$2.99
Rate for Payer: Parkland Medicaid	$3.31
Rate for Payer: Scott and White EPO/PPO	$2.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.31
Rate for Payer: Superior Health Plan EPO	$0.63

CONSUMABLE, CLINITEX, UF-II, EACH

Facility

$4.60

Hospital Charge Code	993351
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.13

CONTAINER, SPICEMEN, OR STERILE, 4OZ

Facility

$3.05

Hospital Charge Code	993181
Hospital Revenue Code	270
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$2.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.27
Rate for Payer: BCBS of TX Blue Advantage	$0.92
Rate for Payer: BCBS of TX Blue Essentials	$1.10
Rate for Payer: BCBS of TX PPO	$1.22
Rate for Payer: Cash Price	$2.07
Rate for Payer: Cigna Medicaid	$2.20
Rate for Payer: Molina CHIP/Medicaid	$2.20
Rate for Payer: Multiplan Auto	$1.98
Rate for Payer: Multiplan Commercial	$1.98
Rate for Payer: Multiplan Workers Comp	$1.98
Rate for Payer: Parkland Medicaid	$2.20
Rate for Payer: Scott and White EPO/PPO	$1.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.20
Rate for Payer: Superior Health Plan EPO	$0.41

CONTAINER, SPICEMEN, OR STERILE, 4OZ

Facility

$3.05

Hospital Charge Code	993181
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.07

CONT NEB

Facility

$15.77

Hospital Charge Code	993472
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10.72

CONT NEB

Facility

$15.77

Hospital Charge Code	993472
Hospital Revenue Code	270
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$11.35
Rate for Payer: Amerigroup CHIP/Medicaid	$1.42
Rate for Payer: BCBS of TX Blue Advantage	$4.73
Rate for Payer: BCBS of TX Blue Essentials	$5.68
Rate for Payer: BCBS of TX PPO	$6.31
Rate for Payer: Cash Price	$10.72
Rate for Payer: Cigna Medicaid	$11.35
Rate for Payer: Molina CHIP/Medicaid	$11.35
Rate for Payer: Multiplan Auto	$10.25
Rate for Payer: Multiplan Commercial	$10.25
Rate for Payer: Multiplan Workers Comp	$10.25
Rate for Payer: Parkland Medicaid	$11.35
Rate for Payer: Scott and White EPO/PPO	$7.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.35
Rate for Payer: Superior Health Plan EPO	$2.14

Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube (separate procedure)

Facility

$3,560.00

Service Code	HCPCS 49424
Hospital Charge Code	991330
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,420.80

Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube (separate procedure)

Facility

$3,560.00

Service Code	HCPCS 49424
Hospital Charge Code	991330
Hospital Revenue Code	360
Min. Negotiated Rate	$320.40
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$320.40
Rate for Payer: BCBS of TX Blue Advantage	$1,068.00
Rate for Payer: BCBS of TX Blue Essentials	$1,281.60
Rate for Payer: BCBS of TX PPO	$1,424.00
Rate for Payer: Cash Price	$2,420.80
Rate for Payer: Cash Price	$2,420.80
Rate for Payer: Cigna Medicaid	$2,563.20
Rate for Payer: Molina CHIP/Medicaid	$2,563.20
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	$2,563.20
Rate for Payer: Scott and White EPO/PPO	$1,780.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,563.20
Rate for Payer: Superior Health Plan EPO	$484.16

CONTRAST VENOGRAPHY INJECTION

Facility

$2,682.00

Service Code	HCPCS 36005
Hospital Charge Code	2303576
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,823.76

CONTRAST VENOGRAPHY INJECTION

Facility

$2,682.00

Service Code	HCPCS 36005
Hospital Charge Code	2303576
Hospital Revenue Code	361
Min. Negotiated Rate	$241.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$241.38
Rate for Payer: BCBS of TX Blue Advantage	$804.60
Rate for Payer: BCBS of TX Blue Essentials	$965.52
Rate for Payer: BCBS of TX PPO	$1,072.80
Rate for Payer: Cash Price	$1,823.76
Rate for Payer: Cash Price	$1,823.76
Rate for Payer: Cigna Medicaid	$1,931.04
Rate for Payer: Molina CHIP/Medicaid	$1,931.04
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	$1,931.04
Rate for Payer: Scott and White EPO/PPO	$1,341.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,931.04
Rate for Payer: Superior Health Plan EPO	$364.75

CONTROL, ACCU CHEK, INFORM II, 10EA/CS

Facility

$132.96

Hospital Charge Code	993076
Hospital Revenue Code	270
Rate for Payer: Cash Price	$90.41

CONTROL, ACCU CHEK, INFORM II, 10EA/CS

Facility

$132.96

Hospital Charge Code	993076
Hospital Revenue Code	270
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$95.73
Rate for Payer: Amerigroup CHIP/Medicaid	$11.97
Rate for Payer: BCBS of TX Blue Advantage	$39.89
Rate for Payer: BCBS of TX Blue Essentials	$47.87
Rate for Payer: BCBS of TX PPO	$53.18
Rate for Payer: Cash Price	$90.41
Rate for Payer: Cigna Medicaid	$95.73
Rate for Payer: Molina CHIP/Medicaid	$95.73
Rate for Payer: Multiplan Auto	$86.42
Rate for Payer: Multiplan Commercial	$86.42
Rate for Payer: Multiplan Workers Comp	$86.42
Rate for Payer: Parkland Medicaid	$95.73
Rate for Payer: Scott and White EPO/PPO	$66.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$95.73
Rate for Payer: Superior Health Plan EPO	$18.08

CONTROL, ACT, LEVEL, 1

Facility

$568.50

Hospital Charge Code	993325
Hospital Revenue Code	270
Rate for Payer: Cash Price	$386.58

CONTROL, ACT, LEVEL, 1

Facility

$568.50

Hospital Charge Code	993325
Hospital Revenue Code	270
Min. Negotiated Rate	$51.16
Max. Negotiated Rate	$409.32
Rate for Payer: Amerigroup CHIP/Medicaid	$51.16
Rate for Payer: BCBS of TX Blue Advantage	$170.55
Rate for Payer: BCBS of TX Blue Essentials	$204.66
Rate for Payer: BCBS of TX PPO	$227.40
Rate for Payer: Cash Price	$386.58
Rate for Payer: Cigna Medicaid	$409.32
Rate for Payer: Molina CHIP/Medicaid	$409.32
Rate for Payer: Multiplan Auto	$369.52
Rate for Payer: Multiplan Commercial	$369.52
Rate for Payer: Multiplan Workers Comp	$369.52
Rate for Payer: Parkland Medicaid	$409.32
Rate for Payer: Scott and White EPO/PPO	$284.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$409.32
Rate for Payer: Superior Health Plan EPO	$77.32

CONTROL, ACT, LEVEL, 2

Facility

$570.77

Hospital Charge Code	993326
Hospital Revenue Code	270
Min. Negotiated Rate	$51.37
Max. Negotiated Rate	$410.95
Rate for Payer: Amerigroup CHIP/Medicaid	$51.37
Rate for Payer: BCBS of TX Blue Advantage	$171.23
Rate for Payer: BCBS of TX Blue Essentials	$205.48
Rate for Payer: BCBS of TX PPO	$228.31
Rate for Payer: Cash Price	$388.12
Rate for Payer: Cigna Medicaid	$410.95
Rate for Payer: Molina CHIP/Medicaid	$410.95
Rate for Payer: Multiplan Auto	$371.00
Rate for Payer: Multiplan Commercial	$371.00
Rate for Payer: Multiplan Workers Comp	$371.00
Rate for Payer: Parkland Medicaid	$410.95
Rate for Payer: Scott and White EPO/PPO	$285.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$410.95
Rate for Payer: Superior Health Plan EPO	$77.62

CONTROL, ACT, LEVEL, 2

Facility

$570.77

Hospital Charge Code	993326
Hospital Revenue Code	270
Rate for Payer: Cash Price	$388.12

CONTROL CHM L1 DIAB GLU LQCHK

Facility

$23.36

Hospital Charge Code	993459
Hospital Revenue Code	270
Rate for Payer: Cash Price	$15.88

CONTROL CHM L1 DIAB GLU LQCHK

Facility

$23.36

Hospital Charge Code	993459
Hospital Revenue Code	270
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$16.82
Rate for Payer: Amerigroup CHIP/Medicaid	$2.10
Rate for Payer: BCBS of TX Blue Advantage	$7.01
Rate for Payer: BCBS of TX Blue Essentials	$8.41
Rate for Payer: BCBS of TX PPO	$9.34
Rate for Payer: Cash Price	$15.88
Rate for Payer: Cigna Medicaid	$16.82
Rate for Payer: Molina CHIP/Medicaid	$16.82
Rate for Payer: Multiplan Auto	$15.18
Rate for Payer: Multiplan Commercial	$15.18
Rate for Payer: Multiplan Workers Comp	$15.18
Rate for Payer: Parkland Medicaid	$16.82
Rate for Payer: Scott and White EPO/PPO	$11.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.82
Rate for Payer: Superior Health Plan EPO	$3.18

CONTROL CHM L2 DIAB GLU LQCHK

Facility

$20.95

Hospital Charge Code	993458
Hospital Revenue Code	270
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$15.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1.89
Rate for Payer: BCBS of TX Blue Advantage	$6.29
Rate for Payer: BCBS of TX Blue Essentials	$7.54
Rate for Payer: BCBS of TX PPO	$8.38
Rate for Payer: Cash Price	$14.25
Rate for Payer: Cigna Medicaid	$15.08
Rate for Payer: Molina CHIP/Medicaid	$15.08
Rate for Payer: Multiplan Auto	$13.62
Rate for Payer: Multiplan Commercial	$13.62
Rate for Payer: Multiplan Workers Comp	$13.62
Rate for Payer: Parkland Medicaid	$15.08
Rate for Payer: Scott and White EPO/PPO	$10.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.08
Rate for Payer: Superior Health Plan EPO	$2.85

CONTROL CHM L2 DIAB GLU LQCHK

Facility

$20.95

Hospital Charge Code	993458
Hospital Revenue Code	270
Rate for Payer: Cash Price	$14.25

CONTROL CI-TRL L1 20ML COAG

Facility

$10.67

Hospital Charge Code	993463
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.26

CONTROL CI-TRL L1 20ML COAG

Facility

$10.67

Hospital Charge Code	993463
Hospital Revenue Code	270
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$7.68
Rate for Payer: Amerigroup CHIP/Medicaid	$0.96
Rate for Payer: BCBS of TX Blue Advantage	$3.20
Rate for Payer: BCBS of TX Blue Essentials	$3.84
Rate for Payer: BCBS of TX PPO	$4.27
Rate for Payer: Cash Price	$7.26
Rate for Payer: Cigna Medicaid	$7.68
Rate for Payer: Molina CHIP/Medicaid	$7.68
Rate for Payer: Multiplan Auto	$6.94
Rate for Payer: Multiplan Commercial	$6.94
Rate for Payer: Multiplan Workers Comp	$6.94
Rate for Payer: Parkland Medicaid	$7.68
Rate for Payer: Scott and White EPO/PPO	$5.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.68
Rate for Payer: Superior Health Plan EPO	$1.45

CONTROL CI-TRL L3 1ML COAG

Facility

$10.67

Hospital Charge Code	993464
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.26

CONTROL CI-TRL L3 1ML COAG

Facility

$10.67

Hospital Charge Code	993464
Hospital Revenue Code	270
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$7.68
Rate for Payer: Amerigroup CHIP/Medicaid	$0.96
Rate for Payer: BCBS of TX Blue Advantage	$3.20
Rate for Payer: BCBS of TX Blue Essentials	$3.84
Rate for Payer: BCBS of TX PPO	$4.27
Rate for Payer: Cash Price	$7.26
Rate for Payer: Cigna Medicaid	$7.68
Rate for Payer: Molina CHIP/Medicaid	$7.68
Rate for Payer: Multiplan Auto	$6.94
Rate for Payer: Multiplan Commercial	$6.94
Rate for Payer: Multiplan Workers Comp	$6.94
Rate for Payer: Parkland Medicaid	$7.68
Rate for Payer: Scott and White EPO/PPO	$5.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.68
Rate for Payer: Superior Health Plan EPO	$1.45

Know your out-of-pocket cost for care.

All Charges