White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Iron Level

Facility

$288.00

Service Code	CPT 83540
Hospital Charge Code	1602002
Hospital Revenue Code	301
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$187.20
Rate for Payer: Aetna Commercial	$6.79
Rate for Payer: Aetna Medicare	$9.71
Rate for Payer: Amerigroup CHIP/Medicaid	$2.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.47
Rate for Payer: Amerigroup Medicare	$6.47
Rate for Payer: BCBS of TX Blue Advantage	$10.68
Rate for Payer: BCBS of TX Blue Essentials	$12.81
Rate for Payer: BCBS of TX Medicare	$6.47
Rate for Payer: BCBS of TX PPO	$14.30
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cigna Medicaid	$6.47
Rate for Payer: Cigna Medicare	$6.47
Rate for Payer: Employer Direct Commercial	$6.47
Rate for Payer: Humana Medicare/TRICARE	$6.47
Rate for Payer: Molina CHIP/Medicaid	$6.47
Rate for Payer: Molina Dual Medicare/Medicaid	$6.47
Rate for Payer: Molina Medicare	$6.47
Rate for Payer: Multiplan Auto	$187.20
Rate for Payer: Multiplan Commercial	$187.20
Rate for Payer: Multiplan Workers Comp	$187.20
Rate for Payer: Parkland Medicaid	$6.47
Rate for Payer: Scott and White EPO/PPO	$8.09
Rate for Payer: Scott and White Medicare	$6.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.47
Rate for Payer: Superior Health Plan EPO	$6.47
Rate for Payer: Superior Health Plan Medicare	$6.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.47
Rate for Payer: Universal American Medicare	$6.47
Rate for Payer: Wellcare Medicare	$6.47
Rate for Payer: Wellmed Medicare	$6.47

Iron Level

Facility

$288.00

Service Code	CPT 83540
Hospital Charge Code	1602002
Hospital Revenue Code	301
Rate for Payer: Cash Price	$253.44

iron sucrose 20 mg/mL IV Soln 20 mL

Facility

$333.00

Service Code	HCPCS J1756
Hospital Charge Code	77644387
Hospital Revenue Code	636
Min. Negotiated Rate	$83.25
Max. Negotiated Rate	$166.50
Rate for Payer: Cash Price	$226.44
Rate for Payer: Cigna Commercial	$83.25
Rate for Payer: Scott and White EPO/PPO	$166.50

iron sucrose 20 mg/mL IV Soln 20 mL

Facility

$333.00

Service Code	HCPCS J1756
Hospital Charge Code	77644387
Hospital Revenue Code	636
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$216.45
Rate for Payer: Amerigroup CHIP/Medicaid	$29.97
Rate for Payer: BCBS of TX Blue Advantage	$0.51
Rate for Payer: BCBS of TX Blue Essentials	$0.61
Rate for Payer: BCBS of TX PPO	$0.68
Rate for Payer: Cash Price	$226.44
Rate for Payer: Cash Price	$226.44
Rate for Payer: Multiplan Auto	$216.45
Rate for Payer: Multiplan Commercial	$216.45
Rate for Payer: Multiplan Workers Comp	$216.45
Rate for Payer: Scott and White EPO/PPO	$166.50
Rate for Payer: Superior Health Plan EPO	$45.29

IRRIGATOR, LAPAROSCOPIC W/TRMPET VLV 5MM/32CM W/HL -- DHF

Facility

$319.81

Hospital Charge Code	81772477
Hospital Revenue Code	270
Min. Negotiated Rate	$28.78
Max. Negotiated Rate	$207.88
Rate for Payer: Aetna Commercial	$175.90
Rate for Payer: Amerigroup CHIP/Medicaid	$28.78
Rate for Payer: BCBS of TX Blue Advantage	$95.94
Rate for Payer: BCBS of TX Blue Essentials	$115.13
Rate for Payer: BCBS of TX PPO	$127.92
Rate for Payer: Cash Price	$281.43
Rate for Payer: Multiplan Auto	$207.88
Rate for Payer: Multiplan Commercial	$207.88
Rate for Payer: Multiplan Workers Comp	$207.88
Rate for Payer: Scott and White EPO/PPO	$159.91
Rate for Payer: Superior Health Plan EPO	$43.49

IRRIGATOR, LAPAROSCOPIC W/TRMPET VLV 5MM/32CM W/HL -- DHF

Facility

$319.81

Hospital Charge Code	81772477
Hospital Revenue Code	270
Rate for Payer: Cash Price	$281.43

irrigator suction endowrist

Facility

$1,203.10

Hospital Charge Code	8690507
Hospital Revenue Code	272
Min. Negotiated Rate	$108.28
Max. Negotiated Rate	$782.01
Rate for Payer: Aetna Commercial	$661.71
Rate for Payer: Amerigroup CHIP/Medicaid	$108.28
Rate for Payer: BCBS of TX Blue Advantage	$360.93
Rate for Payer: BCBS of TX Blue Essentials	$433.12
Rate for Payer: BCBS of TX PPO	$481.24
Rate for Payer: Cash Price	$1,058.73
Rate for Payer: Multiplan Auto	$782.01
Rate for Payer: Multiplan Commercial	$782.01
Rate for Payer: Multiplan Workers Comp	$782.01
Rate for Payer: Scott and White EPO/PPO	$601.55
Rate for Payer: Superior Health Plan EPO	$163.62

irrigator suction endowrist

Facility

$1,203.10

Hospital Charge Code	8690507
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,058.73

IRRIGATOR SUCTION W/ SPLASH

Facility

$273.08

Hospital Charge Code	8490524
Hospital Revenue Code	272
Min. Negotiated Rate	$24.58
Max. Negotiated Rate	$177.50
Rate for Payer: Aetna Commercial	$150.19
Rate for Payer: Amerigroup CHIP/Medicaid	$24.58
Rate for Payer: BCBS of TX Blue Advantage	$81.92
Rate for Payer: BCBS of TX Blue Essentials	$98.31
Rate for Payer: BCBS of TX PPO	$109.23
Rate for Payer: Cash Price	$240.31
Rate for Payer: Multiplan Auto	$177.50
Rate for Payer: Multiplan Commercial	$177.50
Rate for Payer: Multiplan Workers Comp	$177.50
Rate for Payer: Scott and White EPO/PPO	$136.54
Rate for Payer: Superior Health Plan EPO	$37.14

IRRIGATOR SUCTION W/ SPLASH

Facility

$273.08

Hospital Charge Code	8490524
Hospital Revenue Code	272
Rate for Payer: Cash Price	$240.31

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC

Facility

$24,317.03

Service Code	MSDRG 062
Min. Negotiated Rate	$16,224.76
Max. Negotiated Rate	$24,317.03
Rate for Payer: Aetna Commercial	$21,056.62
Rate for Payer: Aetna Medicare	$24,317.03
Rate for Payer: BCBS of TX Blue Advantage	$16,224.76
Rate for Payer: BCBS of TX Blue Essentials	$20,057.04
Rate for Payer: BCBS of TX PPO	$22,286.46
Rate for Payer: Cigna Commercial	$24,107.50

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC

Facility

$36,100.06

Service Code	MSDRG 061
Min. Negotiated Rate	$23,535.62
Max. Negotiated Rate	$36,100.06
Rate for Payer: Aetna Commercial	$31,531.50
Rate for Payer: Aetna Medicare	$34,283.60
Rate for Payer: BCBS of TX Blue Advantage	$23,535.62
Rate for Payer: BCBS of TX Blue Essentials	$29,385.42
Rate for Payer: BCBS of TX PPO	$32,651.73
Rate for Payer: Cigna Commercial	$36,100.06

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC

Facility

$20,197.02

Service Code	MSDRG 063
Min. Negotiated Rate	$13,557.04
Max. Negotiated Rate	$20,197.02
Rate for Payer: Aetna Commercial	$16,726.50
Rate for Payer: Aetna Medicare	$20,197.02
Rate for Payer: BCBS of TX Blue Advantage	$13,557.04
Rate for Payer: BCBS of TX Blue Essentials	$16,799.33
Rate for Payer: BCBS of TX PPO	$18,666.65
Rate for Payer: Cigna Commercial	$19,149.98

isosorbide dinitrate 10 mg Tab

Facility

$16.30

Service Code	HCPCS J3490
Hospital Charge Code	77646002
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.08

isosorbide dinitrate 10 mg Tab

Facility

$16.30

Service Code	HCPCS J3490
Hospital Charge Code	77646002
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$10.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1.47
Rate for Payer: BCBS of TX Blue Advantage	$4.89
Rate for Payer: BCBS of TX Blue Essentials	$5.87
Rate for Payer: BCBS of TX PPO	$6.52
Rate for Payer: Cash Price	$11.08
Rate for Payer: Multiplan Auto	$10.60
Rate for Payer: Multiplan Commercial	$10.60
Rate for Payer: Multiplan Workers Comp	$10.60
Rate for Payer: Scott and White EPO/PPO	$8.15
Rate for Payer: Superior Health Plan EPO	$2.22

isosorbide mononitrate 30 mg ER Tab

Facility

$14.55

Service Code	HCPCS J3490
Hospital Charge Code	78414362
Hospital Revenue Code	250
Rate for Payer: Cash Price	$9.89

isosorbide mononitrate 30 mg ER Tab

Facility

$14.55

Service Code	HCPCS J3490
Hospital Charge Code	78414362
Hospital Revenue Code	250
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$9.46
Rate for Payer: Amerigroup CHIP/Medicaid	$1.31
Rate for Payer: BCBS of TX Blue Advantage	$4.37
Rate for Payer: BCBS of TX Blue Essentials	$5.24
Rate for Payer: BCBS of TX PPO	$5.82
Rate for Payer: Cash Price	$9.89
Rate for Payer: Multiplan Auto	$9.46
Rate for Payer: Multiplan Commercial	$9.46
Rate for Payer: Multiplan Workers Comp	$9.46
Rate for Payer: Scott and White EPO/PPO	$7.28
Rate for Payer: Superior Health Plan EPO	$1.98

Itraconazole and Mtb, S/P SO

Facility

$176.00

Service Code	CPT 80189
Hospital Charge Code	8722541
Hospital Revenue Code	301
Rate for Payer: Cash Price	$154.88

Itraconazole and Mtb, S/P SO

Facility

$176.00

Service Code	CPT 80189
Hospital Charge Code	8722541
Hospital Revenue Code	301
Min. Negotiated Rate	$10.57
Max. Negotiated Rate	$114.40
Rate for Payer: Aetna Commercial	$28.47
Rate for Payer: Aetna Medicare	$40.66
Rate for Payer: Amerigroup CHIP/Medicaid	$10.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.11
Rate for Payer: Amerigroup Medicare	$27.11
Rate for Payer: BCBS of TX Blue Advantage	$44.73
Rate for Payer: BCBS of TX Blue Essentials	$53.68
Rate for Payer: BCBS of TX Medicare	$27.11
Rate for Payer: BCBS of TX PPO	$59.91
Rate for Payer: Cash Price	$154.88
Rate for Payer: Cash Price	$154.88
Rate for Payer: Cigna Medicaid	$27.11
Rate for Payer: Cigna Medicare	$27.11
Rate for Payer: Employer Direct Commercial	$27.11
Rate for Payer: Humana Medicare/TRICARE	$27.11
Rate for Payer: Molina CHIP/Medicaid	$27.11
Rate for Payer: Molina Dual Medicare/Medicaid	$27.11
Rate for Payer: Molina Medicare	$27.11
Rate for Payer: Multiplan Auto	$114.40
Rate for Payer: Multiplan Commercial	$114.40
Rate for Payer: Multiplan Workers Comp	$114.40
Rate for Payer: Parkland Medicaid	$27.11
Rate for Payer: Scott and White EPO/PPO	$33.89
Rate for Payer: Scott and White Medicare	$27.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.11
Rate for Payer: Superior Health Plan EPO	$27.11
Rate for Payer: Superior Health Plan Medicare	$27.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.11
Rate for Payer: Universal American Medicare	$27.11
Rate for Payer: Wellcare Medicare	$27.11
Rate for Payer: Wellmed Medicare	$27.11

IV CATH 16G X 1.25

Facility

$6.95

Hospital Charge Code	8584506
Hospital Revenue Code	272
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$4.52
Rate for Payer: Aetna Commercial	$3.82
Rate for Payer: Amerigroup CHIP/Medicaid	$0.63
Rate for Payer: BCBS of TX Blue Advantage	$2.08
Rate for Payer: BCBS of TX Blue Essentials	$2.50
Rate for Payer: BCBS of TX PPO	$2.78
Rate for Payer: Cash Price	$6.12
Rate for Payer: Multiplan Auto	$4.52
Rate for Payer: Multiplan Commercial	$4.52
Rate for Payer: Multiplan Workers Comp	$4.52
Rate for Payer: Scott and White EPO/PPO	$3.48
Rate for Payer: Superior Health Plan EPO	$0.95

IV CATH 16G X 1.25

Facility

$6.95

Hospital Charge Code	8584506
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6.12

IV CATH 18G X 1.25

Facility

$7.17

Hospital Charge Code	8584507
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6.31

IV CATH 18G X 1.25

Facility

$7.17

Hospital Charge Code	8584507
Hospital Revenue Code	272
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$4.66
Rate for Payer: Aetna Commercial	$3.94
Rate for Payer: Amerigroup CHIP/Medicaid	$0.65
Rate for Payer: BCBS of TX Blue Advantage	$2.15
Rate for Payer: BCBS of TX Blue Essentials	$2.58
Rate for Payer: BCBS of TX PPO	$2.87
Rate for Payer: Cash Price	$6.31
Rate for Payer: Multiplan Auto	$4.66
Rate for Payer: Multiplan Commercial	$4.66
Rate for Payer: Multiplan Workers Comp	$4.66
Rate for Payer: Scott and White EPO/PPO	$3.58
Rate for Payer: Superior Health Plan EPO	$0.98

IV INJECT SITE -- DHF

Facility

$30.32

Hospital Charge Code	80930597
Hospital Revenue Code	270
Rate for Payer: Cash Price	$26.68

IV INJECT SITE -- DHF

Facility

$30.32

Hospital Charge Code	80930597
Hospital Revenue Code	270
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$19.71
Rate for Payer: Aetna Commercial	$16.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2.73
Rate for Payer: BCBS of TX Blue Advantage	$9.10
Rate for Payer: BCBS of TX Blue Essentials	$10.92
Rate for Payer: BCBS of TX PPO	$12.13
Rate for Payer: Cash Price	$26.68
Rate for Payer: Multiplan Auto	$19.71
Rate for Payer: Multiplan Commercial	$19.71
Rate for Payer: Multiplan Workers Comp	$19.71
Rate for Payer: Scott and White EPO/PPO	$15.16
Rate for Payer: Superior Health Plan EPO	$4.12

Know your out-of-pocket cost for care.

All Charges