White Rock Medical Center

All Charges

Charge

Type

Setting

Price

FLOW CONT VLV CF -- DHF

Facility

$70.37

Hospital Charge Code	81746356
Hospital Revenue Code	272
Min. Negotiated Rate	$6.33
Max. Negotiated Rate	$45.74
Rate for Payer: Aetna Commercial	$38.70
Rate for Payer: Amerigroup CHIP/Medicaid	$6.33
Rate for Payer: BCBS of TX Blue Advantage	$21.11
Rate for Payer: BCBS of TX Blue Essentials	$25.33
Rate for Payer: BCBS of TX PPO	$28.15
Rate for Payer: Cash Price	$61.93
Rate for Payer: Multiplan Auto	$45.74
Rate for Payer: Multiplan Commercial	$45.74
Rate for Payer: Multiplan Workers Comp	$45.74
Rate for Payer: Scott and White EPO/PPO	$35.18
Rate for Payer: Superior Health Plan EPO	$9.57

FLOW CONT VLV CF -- DHF

Facility

$70.37

Hospital Charge Code	81746356
Hospital Revenue Code	272
Rate for Payer: Cash Price	$61.93

Flow volume loop

Facility

$360.00

Service Code	CPT 94375
Hospital Charge Code	4049086
Hospital Revenue Code	460
Rate for Payer: Cash Price	$316.80

Flow volume loop

Facility

$360.00

Service Code	CPT 94375
Hospital Charge Code	4049086
Hospital Revenue Code	460
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$650.28
Rate for Payer: Aetna Commercial	$198.00
Rate for Payer: Aetna Medicare	$430.59
Rate for Payer: Amerigroup CHIP/Medicaid	$32.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$287.06
Rate for Payer: Amerigroup Medicare	$287.06
Rate for Payer: BCBS of TX Blue Advantage	$440.39
Rate for Payer: BCBS of TX Blue Essentials	$526.45
Rate for Payer: BCBS of TX Medicare	$287.06
Rate for Payer: BCBS of TX PPO	$587.19
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$650.28
Rate for Payer: Cigna Medicare	$287.06
Rate for Payer: Employer Direct Commercial	$287.06
Rate for Payer: Humana Medicare/TRICARE	$287.06
Rate for Payer: Molina Dual Medicare/Medicaid	$287.06
Rate for Payer: Molina Medicare	$287.06
Rate for Payer: Multiplan Auto	$234.00
Rate for Payer: Multiplan Commercial	$234.00
Rate for Payer: Multiplan Workers Comp	$234.00
Rate for Payer: Scott and White EPO/PPO	$5.13
Rate for Payer: Scott and White Medicare	$287.06
Rate for Payer: Superior Health Plan EPO	$287.06
Rate for Payer: Superior Health Plan Medicare	$287.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$287.06
Rate for Payer: Universal American Medicare	$287.06
Rate for Payer: Wellcare Medicare	$287.06
Rate for Payer: Wellmed Medicare	$287.06

FLTR TIS ATEC BRST BX -- DHF

Facility

$18.44

Hospital Charge Code	81746828
Hospital Revenue Code	272
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$11.99
Rate for Payer: Aetna Commercial	$10.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1.66
Rate for Payer: BCBS of TX Blue Advantage	$5.53
Rate for Payer: BCBS of TX Blue Essentials	$6.64
Rate for Payer: BCBS of TX PPO	$7.38
Rate for Payer: Cash Price	$16.23
Rate for Payer: Multiplan Auto	$11.99
Rate for Payer: Multiplan Commercial	$11.99
Rate for Payer: Multiplan Workers Comp	$11.99
Rate for Payer: Scott and White EPO/PPO	$9.22
Rate for Payer: Superior Health Plan EPO	$2.51

FLTR TIS ATEC BRST BX -- DHF

Facility

$18.44

Hospital Charge Code	81746828
Hospital Revenue Code	272
Rate for Payer: Cash Price	$16.23

FLTR VC GUNTHER TULIP

Facility

$7,710.84

Service Code	HCPCS C1880
Hospital Charge Code	40210361
Hospital Revenue Code	278
Min. Negotiated Rate	$693.98
Max. Negotiated Rate	$3,855.42
Rate for Payer: Aetna Commercial	$2,313.25
Rate for Payer: Amerigroup CHIP/Medicaid	$693.98
Rate for Payer: BCBS of TX Blue Advantage	$2,313.25
Rate for Payer: BCBS of TX Blue Essentials	$2,775.90
Rate for Payer: BCBS of TX PPO	$3,084.34
Rate for Payer: Cash Price	$6,785.54
Rate for Payer: Multiplan Auto	$3,855.42
Rate for Payer: Multiplan Commercial	$3,855.42
Rate for Payer: Multiplan Workers Comp	$3,855.42
Rate for Payer: Scott and White EPO/PPO	$3,855.42
Rate for Payer: Superior Health Plan EPO	$1,048.67

FLTR VC GUNTHER TULIP

Facility

$7,710.84

Service Code	HCPCS C1880
Hospital Charge Code	40210361
Hospital Revenue Code	278
Min. Negotiated Rate	$1,927.71
Max. Negotiated Rate	$3,855.42
Rate for Payer: Aetna Commercial	$2,313.25
Rate for Payer: Cash Price	$6,785.54
Rate for Payer: Cigna Commercial	$1,927.71
Rate for Payer: Multiplan Auto	$3,855.42
Rate for Payer: Multiplan Commercial	$3,855.42
Rate for Payer: Multiplan Workers Comp	$3,855.42
Rate for Payer: Scott and White EPO/PPO	$3,855.42

Flu A+B NAA SO

Facility

$304.00

Service Code	CPT 87502
Hospital Charge Code	1630030
Hospital Revenue Code	300
Min. Negotiated Rate	$37.36
Max. Negotiated Rate	$211.72
Rate for Payer: Aetna Commercial	$100.59
Rate for Payer: Aetna Medicare	$143.70
Rate for Payer: Amerigroup CHIP/Medicaid	$37.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$95.80
Rate for Payer: Amerigroup Medicare	$95.80
Rate for Payer: BCBS of TX Blue Advantage	$158.07
Rate for Payer: BCBS of TX Blue Essentials	$189.68
Rate for Payer: BCBS of TX Medicare	$95.80
Rate for Payer: BCBS of TX PPO	$211.72
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cigna Medicaid	$95.80
Rate for Payer: Cigna Medicare	$95.80
Rate for Payer: Employer Direct Commercial	$95.80
Rate for Payer: Humana Medicare/TRICARE	$95.80
Rate for Payer: Molina CHIP/Medicaid	$95.80
Rate for Payer: Molina Dual Medicare/Medicaid	$95.80
Rate for Payer: Molina Medicare	$95.80
Rate for Payer: Multiplan Auto	$197.60
Rate for Payer: Multiplan Commercial	$197.60
Rate for Payer: Multiplan Workers Comp	$197.60
Rate for Payer: Parkland Medicaid	$95.80
Rate for Payer: Scott and White EPO/PPO	$119.75
Rate for Payer: Scott and White Medicare	$95.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$95.80
Rate for Payer: Superior Health Plan EPO	$95.80
Rate for Payer: Superior Health Plan Medicare	$95.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$95.80
Rate for Payer: Universal American Medicare	$95.80
Rate for Payer: Wellcare Medicare	$95.80
Rate for Payer: Wellmed Medicare	$95.80

fluconazole 100 mg Tab

Facility

$33.30

Service Code	HCPCS J3490
Hospital Charge Code	77572828
Hospital Revenue Code	250
Rate for Payer: Cash Price	$22.64

fluconazole 100 mg Tab

Facility

$33.30

Service Code	HCPCS J3490
Hospital Charge Code	77572828
Hospital Revenue Code	250
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$21.64
Rate for Payer: Amerigroup CHIP/Medicaid	$3.00
Rate for Payer: BCBS of TX Blue Advantage	$9.99
Rate for Payer: BCBS of TX Blue Essentials	$11.99
Rate for Payer: BCBS of TX PPO	$13.32
Rate for Payer: Cash Price	$22.64
Rate for Payer: Multiplan Auto	$21.64
Rate for Payer: Multiplan Commercial	$21.64
Rate for Payer: Multiplan Workers Comp	$21.64
Rate for Payer: Scott and White EPO/PPO	$16.65
Rate for Payer: Superior Health Plan EPO	$4.53

FLUID MANAGEMENT SUCTION MAT

Facility

$192.95

Hospital Charge Code	145244
Hospital Revenue Code	270
Rate for Payer: Cash Price	$169.80

FLUID MANAGEMENT SUCTION MAT

Facility

$192.95

Hospital Charge Code	145244
Hospital Revenue Code	270
Min. Negotiated Rate	$17.37
Max. Negotiated Rate	$125.42
Rate for Payer: Aetna Commercial	$106.12
Rate for Payer: Amerigroup CHIP/Medicaid	$17.37
Rate for Payer: BCBS of TX Blue Advantage	$57.88
Rate for Payer: BCBS of TX Blue Essentials	$69.46
Rate for Payer: BCBS of TX PPO	$77.18
Rate for Payer: Cash Price	$169.80
Rate for Payer: Multiplan Auto	$125.42
Rate for Payer: Multiplan Commercial	$125.42
Rate for Payer: Multiplan Workers Comp	$125.42
Rate for Payer: Scott and White EPO/PPO	$96.48
Rate for Payer: Superior Health Plan EPO	$26.24

fluorescein 1 mg Ophth Test

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77575552
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

fluorescein 1 mg Ophth Test

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77575552
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

FLUORO BX/ASP/INJ/GUIDE

Facility

$559.00

Service Code	CPT 77002
Hospital Charge Code	4616003
Hospital Revenue Code	320
Rate for Payer: Cash Price	$491.92

FLUORO BX/ASP/INJ/GUIDE

Facility

$559.00

Service Code	CPT 77002
Hospital Charge Code	4616003
Hospital Revenue Code	320
Min. Negotiated Rate	$50.31
Max. Negotiated Rate	$363.35
Rate for Payer: Aetna Commercial	$103.44
Rate for Payer: Amerigroup CHIP/Medicaid	$50.31
Rate for Payer: BCBS of TX Blue Advantage	$123.09
Rate for Payer: BCBS of TX Blue Essentials	$147.71
Rate for Payer: BCBS of TX PPO	$164.87
Rate for Payer: Cash Price	$491.92
Rate for Payer: Cash Price	$491.92
Rate for Payer: Multiplan Auto	$363.35
Rate for Payer: Multiplan Commercial	$363.35
Rate for Payer: Multiplan Workers Comp	$363.35
Rate for Payer: Scott and White EPO/PPO	$279.50
Rate for Payer: Superior Health Plan EPO	$76.02

FLUORO GUIDE SPINE INJ

Facility

$1,020.00

Service Code	CPT 77003
Hospital Charge Code	4616010
Hospital Revenue Code	320
Rate for Payer: Cash Price	$897.60

FLUORO GUIDE SPINE INJ

Facility

$1,020.00

Service Code	CPT 77003
Hospital Charge Code	4616010
Hospital Revenue Code	320
Min. Negotiated Rate	$88.81
Max. Negotiated Rate	$663.00
Rate for Payer: Aetna Commercial	$88.81
Rate for Payer: Amerigroup CHIP/Medicaid	$91.80
Rate for Payer: BCBS of TX Blue Advantage	$113.57
Rate for Payer: BCBS of TX Blue Essentials	$136.28
Rate for Payer: BCBS of TX PPO	$152.11
Rate for Payer: Cash Price	$897.60
Rate for Payer: Cash Price	$897.60
Rate for Payer: Multiplan Auto	$663.00
Rate for Payer: Multiplan Commercial	$663.00
Rate for Payer: Multiplan Workers Comp	$663.00
Rate for Payer: Scott and White EPO/PPO	$510.00
Rate for Payer: Superior Health Plan EPO	$138.72

FLUOROGUID FOR VEIN DVCE

Facility

$619.00

Service Code	CPT 77001
Hospital Charge Code	4615997
Hospital Revenue Code	320
Min. Negotiated Rate	$55.71
Max. Negotiated Rate	$402.35
Rate for Payer: Aetna Commercial	$97.67
Rate for Payer: Amerigroup CHIP/Medicaid	$55.71
Rate for Payer: BCBS of TX Blue Advantage	$120.12
Rate for Payer: BCBS of TX Blue Essentials	$144.14
Rate for Payer: BCBS of TX PPO	$160.89
Rate for Payer: Cash Price	$544.72
Rate for Payer: Cash Price	$544.72
Rate for Payer: Multiplan Auto	$402.35
Rate for Payer: Multiplan Commercial	$402.35
Rate for Payer: Multiplan Workers Comp	$402.35
Rate for Payer: Scott and White EPO/PPO	$309.50
Rate for Payer: Superior Health Plan EPO	$84.18

FLUOROGUID FOR VEIN DVCE

Facility

$619.00

Service Code	CPT 77001
Hospital Charge Code	4615997
Hospital Revenue Code	320
Rate for Payer: Cash Price	$544.72

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic

Facility

$10,000.00

Service Code	CPT 77003
Hospital Charge Code	36077003
Hospital Revenue Code	360
Min. Negotiated Rate	$88.81
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$88.81
Rate for Payer: BCBS of TX Blue Advantage	$113.57
Rate for Payer: BCBS of TX Blue Essentials	$136.28
Rate for Payer: BCBS of TX PPO	$152.11
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

Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

Facility

$10,000.00

Service Code	CPT 77002
Hospital Charge Code	36077002
Hospital Revenue Code	360
Min. Negotiated Rate	$103.44
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$103.44
Rate for Payer: BCBS of TX Blue Advantage	$123.09
Rate for Payer: BCBS of TX Blue Essentials	$147.71
Rate for Payer: BCBS of TX PPO	$164.87
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

FLUOROSCOPY 1 HOUR

Facility

$480.00

Service Code	CPT 76000
Hospital Charge Code	2300085
Hospital Revenue Code	320
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$507.64
Rate for Payer: Aetna Commercial	$31.80
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$43.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$224.10
Rate for Payer: Amerigroup Medicare	$224.10
Rate for Payer: BCBS of TX Blue Advantage	$52.92
Rate for Payer: BCBS of TX Blue Essentials	$63.50
Rate for Payer: BCBS of TX Medicare	$224.10
Rate for Payer: BCBS of TX PPO	$70.87
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$43.44
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Employer Direct Commercial	$224.10
Rate for Payer: Humana Medicare/TRICARE	$224.10
Rate for Payer: Molina CHIP/Medicaid	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$224.10
Rate for Payer: Molina Medicare	$224.10
Rate for Payer: Multiplan Auto	$312.00
Rate for Payer: Multiplan Commercial	$312.00
Rate for Payer: Multiplan Workers Comp	$312.00
Rate for Payer: Parkland Medicaid	$43.44
Rate for Payer: Scott and White EPO/PPO	$4.01
Rate for Payer: Scott and White Medicare	$224.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.44
Rate for Payer: Superior Health Plan EPO	$224.10
Rate for Payer: Superior Health Plan Medicare	$224.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$224.10
Rate for Payer: Universal American Medicare	$224.10
Rate for Payer: Wellcare Medicare	$224.10
Rate for Payer: Wellmed Medicare	$224.10

FLUOROSCOPY 1 HOUR

Facility

$480.00

Service Code	CPT 76000
Hospital Charge Code	2300085
Hospital Revenue Code	320
Rate for Payer: Cash Price	$422.40

Know your out-of-pocket cost for care.

All Charges