White Rock Medical Center

All Charges

Charge

Type

Setting

Price

etomidate 2 mg/mL IV Sol 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	81405158
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

etomidate 2 mg/mL IV Sol 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	81405158
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

etomidate 2 mg/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78470396
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

etomidate 2 mg/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78470396
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

ETS Linear Culter, Articulating, Flex, 45 mm

Facility

$882.53

Hospital Charge Code	992860
Hospital Revenue Code	272
Rate for Payer: Cash Price	$600.12

ETS Linear Culter, Articulating, Flex, 45 mm

Facility

$882.53

Hospital Charge Code	992860
Hospital Revenue Code	272
Min. Negotiated Rate	$79.43
Max. Negotiated Rate	$635.42
Rate for Payer: Amerigroup CHIP/Medicaid	$79.43
Rate for Payer: BCBS of TX Blue Advantage	$264.76
Rate for Payer: BCBS of TX Blue Essentials	$317.71
Rate for Payer: BCBS of TX PPO	$353.01
Rate for Payer: Cash Price	$600.12
Rate for Payer: Cigna Medicaid	$635.42
Rate for Payer: Molina CHIP/Medicaid	$635.42
Rate for Payer: Multiplan Auto	$573.64
Rate for Payer: Multiplan Commercial	$573.64
Rate for Payer: Multiplan Workers Comp	$573.64
Rate for Payer: Parkland Medicaid	$635.42
Rate for Payer: Scott and White EPO/PPO	$441.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$635.42
Rate for Payer: Superior Health Plan EPO	$120.02

Eudermic MP Power-Free 12' High-Risk Exam Gloves, Size L

Facility

$0.91

Hospital Charge Code	992983
Hospital Revenue Code	272
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.66
Rate for Payer: Amerigroup CHIP/Medicaid	$0.08
Rate for Payer: BCBS of TX Blue Advantage	$0.27
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.36
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna Medicaid	$0.66
Rate for Payer: Molina CHIP/Medicaid	$0.66
Rate for Payer: Multiplan Auto	$0.59
Rate for Payer: Multiplan Commercial	$0.59
Rate for Payer: Multiplan Workers Comp	$0.59
Rate for Payer: Parkland Medicaid	$0.66
Rate for Payer: Scott and White EPO/PPO	$0.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.66
Rate for Payer: Superior Health Plan EPO	$0.12

Eudermic MP Power-Free 12' High-Risk Exam Gloves, Size L

Facility

$0.91

Hospital Charge Code	992983
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.62

Eudermic MP Power-Free 12' High-Risk Exam Gloves, Size M

Facility

$0.91

Hospital Charge Code	992984
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.62

Eudermic MP Power-Free 12' High-Risk Exam Gloves, Size M

Facility

$0.91

Hospital Charge Code	992984
Hospital Revenue Code	272
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.66
Rate for Payer: Amerigroup CHIP/Medicaid	$0.08
Rate for Payer: BCBS of TX Blue Advantage	$0.27
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.36
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna Medicaid	$0.66
Rate for Payer: Molina CHIP/Medicaid	$0.66
Rate for Payer: Multiplan Auto	$0.59
Rate for Payer: Multiplan Commercial	$0.59
Rate for Payer: Multiplan Workers Comp	$0.59
Rate for Payer: Parkland Medicaid	$0.66
Rate for Payer: Scott and White EPO/PPO	$0.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.66
Rate for Payer: Superior Health Plan EPO	$0.12

euphora balloon

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992568
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

euphora balloon

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992568
Hospital Revenue Code	272
Min. Negotiated Rate	$69.46
Max. Negotiated Rate	$555.70
Rate for Payer: Amerigroup CHIP/Medicaid	$69.46
Rate for Payer: BCBS of TX Blue Advantage	$231.54
Rate for Payer: BCBS of TX Blue Essentials	$277.85
Rate for Payer: BCBS of TX PPO	$308.72
Rate for Payer: Cash Price	$524.82
Rate for Payer: Cigna Medicaid	$555.70
Rate for Payer: Molina CHIP/Medicaid	$555.70
Rate for Payer: Multiplan Auto	$501.67
Rate for Payer: Multiplan Commercial	$501.67
Rate for Payer: Multiplan Workers Comp	$501.67
Rate for Payer: Parkland Medicaid	$555.70
Rate for Payer: Scott and White EPO/PPO	$385.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$555.70
Rate for Payer: Superior Health Plan EPO	$104.96

EVACUATOR, SILICONE, 100CC, STERILE

Facility

$22.48

Hospital Charge Code	992849
Hospital Revenue Code	272
Rate for Payer: Cash Price	$15.29

EVACUATOR, SILICONE, 100CC, STERILE

Facility

$22.48

Hospital Charge Code	992849
Hospital Revenue Code	272
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$16.19
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: BCBS of TX Blue Advantage	$6.74
Rate for Payer: BCBS of TX Blue Essentials	$8.09
Rate for Payer: BCBS of TX PPO	$8.99
Rate for Payer: Cash Price	$15.29
Rate for Payer: Cigna Medicaid	$16.19
Rate for Payer: Molina CHIP/Medicaid	$16.19
Rate for Payer: Multiplan Auto	$14.61
Rate for Payer: Multiplan Commercial	$14.61
Rate for Payer: Multiplan Workers Comp	$14.61
Rate for Payer: Parkland Medicaid	$16.19
Rate for Payer: Scott and White EPO/PPO	$11.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.19
Rate for Payer: Superior Health Plan EPO	$3.06

Evoked Potential Charges -> Auditory (AEP)

Facility

$1,769.00

Service Code	HCPCS 92652
Hospital Charge Code	4802587
Hospital Revenue Code	471
Min. Negotiated Rate	$159.21
Max. Negotiated Rate	$1,273.68
Rate for Payer: Amerigroup CHIP/Medicaid	$159.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$530.70
Rate for Payer: BCBS of TX Blue Essentials	$636.84
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$707.60
Rate for Payer: Cash Price	$1,202.92
Rate for Payer: Cash Price	$1,202.92
Rate for Payer: Cash Price	$1,202.92
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$1,273.68
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$1,273.68
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$1,149.85
Rate for Payer: Multiplan Commercial	$1,149.85
Rate for Payer: Multiplan Workers Comp	$1,149.85
Rate for Payer: Parkland Medicaid	$1,273.68
Rate for Payer: Scott and White EPO/PPO	$884.50
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,273.68
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

Evoked Potential Charges -> Auditory (AEP)

Facility

$1,769.00

Service Code	HCPCS 92652
Hospital Charge Code	4802587
Hospital Revenue Code	471
Rate for Payer: Cash Price	$1,202.92

Evoked Potential Charges -> Visual (VEP) 95930

Facility

$1,247.00

Service Code	HCPCS 95930
Hospital Charge Code	4805871
Hospital Revenue Code	922
Min. Negotiated Rate	$112.23
Max. Negotiated Rate	$897.84
Rate for Payer: Amerigroup CHIP/Medicaid	$112.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$374.10
Rate for Payer: BCBS of TX Blue Essentials	$448.92
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$498.80
Rate for Payer: Cash Price	$847.96
Rate for Payer: Cash Price	$847.96
Rate for Payer: Cash Price	$847.96
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$897.84
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$897.84
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$810.55
Rate for Payer: Multiplan Commercial	$810.55
Rate for Payer: Multiplan Workers Comp	$810.55
Rate for Payer: Parkland Medicaid	$897.84
Rate for Payer: Scott and White EPO/PPO	$623.50
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$897.84
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

Evoked Potential Charges -> Visual (VEP) 95930

Facility

$1,247.00

Service Code	HCPCS 95930
Hospital Charge Code	4805871
Hospital Revenue Code	922
Rate for Payer: Cash Price	$847.96

EXCEL IV INJECTION SOLUTION SODIUM CHLORIDE 0.9% 1000ML

Facility

$266.95

Hospital Charge Code	993705
Hospital Revenue Code	270
Min. Negotiated Rate	$24.03
Max. Negotiated Rate	$192.20
Rate for Payer: Amerigroup CHIP/Medicaid	$24.03
Rate for Payer: BCBS of TX Blue Advantage	$80.08
Rate for Payer: BCBS of TX Blue Essentials	$96.10
Rate for Payer: BCBS of TX PPO	$106.78
Rate for Payer: Cash Price	$181.53
Rate for Payer: Cigna Medicaid	$192.20
Rate for Payer: Molina CHIP/Medicaid	$192.20
Rate for Payer: Multiplan Auto	$173.52
Rate for Payer: Multiplan Commercial	$173.52
Rate for Payer: Multiplan Workers Comp	$173.52
Rate for Payer: Parkland Medicaid	$192.20
Rate for Payer: Scott and White EPO/PPO	$133.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.20
Rate for Payer: Superior Health Plan EPO	$36.31

EXCEL IV INJECTION SOLUTION SODIUM CHLORIDE 0.9% 1000ML

Facility

$266.95

Hospital Charge Code	993705
Hospital Revenue Code	270
Rate for Payer: Cash Price	$181.53

Exchange nephrostomy catheter, percutaeous, including dx nephrostogram and/or ureterogram BCE

Facility

$6,039.50

Service Code	HCPCS 50435
Hospital Charge Code	9307021
Hospital Revenue Code	361
Min. Negotiated Rate	$652.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$652.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Amerigroup Medicare	$2,099.91
Rate for Payer: BCBS of TX Blue Advantage	$2,958.49
Rate for Payer: BCBS of TX Blue Essentials	$3,543.10
Rate for Payer: BCBS of TX Medicare	$2,099.91
Rate for Payer: BCBS of TX PPO	$4,464.31
Rate for Payer: Cash Price	$4,106.86
Rate for Payer: Cash Price	$4,106.86
Rate for Payer: Cash Price	$4,106.86
Rate for Payer: Cigna Commercial	$4,438.84
Rate for Payer: Cigna Medicaid	$4,348.44
Rate for Payer: Cigna Medicare	$2,099.91
Rate for Payer: Employer Direct Commercial	$2,099.91
Rate for Payer: Humana Medicare/TRICARE	$2,099.91
Rate for Payer: Molina CHIP/Medicaid	$4,348.44
Rate for Payer: Molina Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Molina Medicare	$2,099.91
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	$4,348.44
Rate for Payer: Scott and White EPO/PPO	$3,884.83
Rate for Payer: Scott and White Medicare	$2,099.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,348.44
Rate for Payer: Superior Health Plan EPO	$2,099.91
Rate for Payer: Superior Health Plan Medicare	$2,099.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Universal American Medicare	$2,099.91
Rate for Payer: Wellcare Medicare	$2,099.91
Rate for Payer: Wellmed Medicare	$2,099.91

Exchange nephrostomy catheter, percutaeous, including dx nephrostogram and/or ureterogram BCE

Facility

$6,039.50

Service Code	HCPCS 50435
Hospital Charge Code	9307021
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,106.86

Exchange of intraocular lens

Facility

$13,049.99

Service Code	HCPCS 66986
Hospital Charge Code	9900871
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,873.99

Exchange of intraocular lens

Facility

$13,049.99

Service Code	HCPCS 66986
Hospital Charge Code	9900871
Hospital Revenue Code	360
Min. Negotiated Rate	$849.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$849.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Amerigroup Medicare	$2,318.34
Rate for Payer: BCBS of TX Blue Advantage	$3,376.51
Rate for Payer: BCBS of TX Blue Essentials	$4,043.72
Rate for Payer: BCBS of TX Medicare	$2,318.34
Rate for Payer: BCBS of TX PPO	$5,095.09
Rate for Payer: Cash Price	$8,873.99
Rate for Payer: Cash Price	$8,873.99
Rate for Payer: Cash Price	$8,873.99
Rate for Payer: Cigna Commercial	$4,900.56
Rate for Payer: Cigna Medicaid	$9,395.99
Rate for Payer: Cigna Medicare	$2,318.34
Rate for Payer: Employer Direct Commercial	$2,318.34
Rate for Payer: Humana Medicare/TRICARE	$2,318.34
Rate for Payer: Molina CHIP/Medicaid	$9,395.99
Rate for Payer: Molina Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Molina Medicare	$2,318.34
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	$9,395.99
Rate for Payer: Scott and White EPO/PPO	$4,288.93
Rate for Payer: Scott and White Medicare	$2,318.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,395.99
Rate for Payer: Superior Health Plan EPO	$2,318.34
Rate for Payer: Superior Health Plan Medicare	$2,318.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Universal American Medicare	$2,318.34
Rate for Payer: Wellcare Medicare	$2,318.34
Rate for Payer: Wellmed Medicare	$2,318.34

Exchange of intraocular lens

Facility

$10,000.00

Service Code	CPT 66986
Hospital Charge Code	36066986
Hospital Revenue Code	360
Min. Negotiated Rate	$849.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$849.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Amerigroup Medicare	$2,318.34
Rate for Payer: BCBS of TX Blue Advantage	$3,376.51
Rate for Payer: BCBS of TX Blue Essentials	$4,043.72
Rate for Payer: BCBS of TX Medicare	$2,318.34
Rate for Payer: BCBS of TX PPO	$5,095.09
Rate for Payer: Cigna Commercial	$4,900.56
Rate for Payer: Cigna Medicare	$2,318.34
Rate for Payer: Employer Direct Commercial	$2,318.34
Rate for Payer: Humana Medicare/TRICARE	$2,318.34
Rate for Payer: Molina Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Molina Medicare	$2,318.34
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	$4,288.93
Rate for Payer: Scott and White Medicare	$2,318.34
Rate for Payer: Superior Health Plan EPO	$2,318.34
Rate for Payer: Superior Health Plan Medicare	$2,318.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Universal American Medicare	$2,318.34
Rate for Payer: Wellcare Medicare	$2,318.34
Rate for Payer: Wellmed Medicare	$2,318.34

Know your out-of-pocket cost for care.

All Charges