White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ascorbic acid 500 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77383232
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

AS DISP INST -- DHF

Facility

$3,692.44

Hospital Charge Code	81910259
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,249.35

AS DISP INST -- DHF

Facility

$3,692.44

Hospital Charge Code	81910259
Hospital Revenue Code	272
Min. Negotiated Rate	$332.32
Max. Negotiated Rate	$2,400.09
Rate for Payer: Aetna Commercial	$2,030.84
Rate for Payer: Amerigroup CHIP/Medicaid	$332.32
Rate for Payer: BCBS of TX Blue Advantage	$1,107.73
Rate for Payer: BCBS of TX Blue Essentials	$1,329.28
Rate for Payer: BCBS of TX PPO	$1,476.98
Rate for Payer: Cash Price	$3,249.35
Rate for Payer: Multiplan Auto	$2,400.09
Rate for Payer: Multiplan Commercial	$2,400.09
Rate for Payer: Multiplan Workers Comp	$2,400.09
Rate for Payer: Scott and White EPO/PPO	$1,846.22
Rate for Payer: Superior Health Plan EPO	$502.17

AS GIA A/T -- DHF

Facility

$1,823.77

Hospital Charge Code	81910507
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,604.92

AS GIA A/T -- DHF

Facility

$1,823.77

Hospital Charge Code	81910507
Hospital Revenue Code	272
Min. Negotiated Rate	$164.14
Max. Negotiated Rate	$1,185.45
Rate for Payer: Aetna Commercial	$1,003.07
Rate for Payer: Amerigroup CHIP/Medicaid	$164.14
Rate for Payer: BCBS of TX Blue Advantage	$547.13
Rate for Payer: BCBS of TX Blue Essentials	$656.56
Rate for Payer: BCBS of TX PPO	$729.51
Rate for Payer: Cash Price	$1,604.92
Rate for Payer: Multiplan Auto	$1,185.45
Rate for Payer: Multiplan Commercial	$1,185.45
Rate for Payer: Multiplan Workers Comp	$1,185.45
Rate for Payer: Scott and White EPO/PPO	$911.88
Rate for Payer: Superior Health Plan EPO	$248.03

Aspartate Aminotransferase

Facility

$236.00

Service Code	CPT 84450
Hospital Charge Code	1602333
Hospital Revenue Code	301
Rate for Payer: Cash Price	$207.68

Aspartate Aminotransferase

Facility

$236.00

Service Code	CPT 84450
Hospital Charge Code	1602333
Hospital Revenue Code	301
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$153.40
Rate for Payer: Aetna Commercial	$5.44
Rate for Payer: Aetna Medicare	$7.77
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$8.55
Rate for Payer: BCBS of TX Blue Essentials	$10.26
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$11.45
Rate for Payer: Cash Price	$207.68
Rate for Payer: Cash Price	$207.68
Rate for Payer: Cigna Medicaid	$5.18
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$5.18
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$153.40
Rate for Payer: Multiplan Commercial	$153.40
Rate for Payer: Multiplan Workers Comp	$153.40
Rate for Payer: Parkland Medicaid	$5.18
Rate for Payer: Scott and White EPO/PPO	$6.48
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.18
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

Aspergillus Ab, Qn, DID SO

Facility

$203.00

Service Code	CPT 86606
Hospital Charge Code	1706894
Hospital Revenue Code	302
Rate for Payer: Cash Price	$178.64

Aspergillus Ab, Qn, DID SO

Facility

$203.00

Service Code	CPT 86606
Hospital Charge Code	1706894
Hospital Revenue Code	302
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$131.95
Rate for Payer: Aetna Commercial	$15.80
Rate for Payer: Aetna Medicare	$22.58
Rate for Payer: Amerigroup CHIP/Medicaid	$5.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.05
Rate for Payer: Amerigroup Medicare	$15.05
Rate for Payer: BCBS of TX Blue Advantage	$24.83
Rate for Payer: BCBS of TX Blue Essentials	$29.80
Rate for Payer: BCBS of TX Medicare	$15.05
Rate for Payer: BCBS of TX PPO	$33.26
Rate for Payer: Cash Price	$178.64
Rate for Payer: Cash Price	$178.64
Rate for Payer: Cigna Medicaid	$15.05
Rate for Payer: Cigna Medicare	$15.05
Rate for Payer: Employer Direct Commercial	$15.05
Rate for Payer: Humana Medicare/TRICARE	$15.05
Rate for Payer: Molina CHIP/Medicaid	$15.05
Rate for Payer: Molina Dual Medicare/Medicaid	$15.05
Rate for Payer: Molina Medicare	$15.05
Rate for Payer: Multiplan Auto	$131.95
Rate for Payer: Multiplan Commercial	$131.95
Rate for Payer: Multiplan Workers Comp	$131.95
Rate for Payer: Parkland Medicaid	$15.05
Rate for Payer: Scott and White EPO/PPO	$18.81
Rate for Payer: Scott and White Medicare	$15.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.05
Rate for Payer: Superior Health Plan EPO	$15.05
Rate for Payer: Superior Health Plan Medicare	$15.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.05
Rate for Payer: Universal American Medicare	$15.05
Rate for Payer: Wellcare Medicare	$15.05
Rate for Payer: Wellmed Medicare	$15.05

ASP/INJ RENL CYST/PELVIS

Facility

$2,001.00

Service Code	CPT 50390
Hospital Charge Code	4610390
Hospital Revenue Code	360
Min. Negotiated Rate	$14.19
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$965.18
Rate for Payer: Amerigroup CHIP/Medicaid	$257.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$643.45
Rate for Payer: Amerigroup Medicare	$643.45
Rate for Payer: BCBS of TX Blue Advantage	$1,018.72
Rate for Payer: BCBS of TX Blue Essentials	$1,220.02
Rate for Payer: BCBS of TX Medicare	$643.45
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$1,760.88
Rate for Payer: Cash Price	$1,760.88
Rate for Payer: Cigna Commercial	$1,457.60
Rate for Payer: Cigna Medicaid	$257.60
Rate for Payer: Cigna Medicare	$643.45
Rate for Payer: Employer Direct Commercial	$643.45
Rate for Payer: Humana Medicare/TRICARE	$643.45
Rate for Payer: Molina CHIP/Medicaid	$257.60
Rate for Payer: Molina Dual Medicare/Medicaid	$643.45
Rate for Payer: Molina Medicare	$643.45
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	$257.60
Rate for Payer: Scott and White EPO/PPO	$14.19
Rate for Payer: Scott and White Medicare	$643.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$257.60
Rate for Payer: Superior Health Plan EPO	$643.45
Rate for Payer: Superior Health Plan Medicare	$643.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$643.45
Rate for Payer: Universal American Medicare	$643.45
Rate for Payer: Wellcare Medicare	$643.45
Rate for Payer: Wellmed Medicare	$643.45

ASP/INJ RENL CYST/PELVIS

Facility

$2,001.00

Service Code	CPT 50390
Hospital Charge Code	4610390
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,760.88

ASPIR BLADDR W/INS CATH

Facility

$4,177.00

Service Code	CPT 51102
Hospital Charge Code	4617460
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,675.76

ASPIR BLADDR W/INS CATH

Facility

$4,177.00

Service Code	CPT 51102
Hospital Charge Code	4617460
Hospital Revenue Code	360
Min. Negotiated Rate	$41.09
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$2,794.14
Rate for Payer: Amerigroup CHIP/Medicaid	$652.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,862.76
Rate for Payer: Amerigroup Medicare	$1,862.76
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	$1,862.76
Rate for Payer: BCBS of TX PPO	$4,464.31
Rate for Payer: Cash Price	$3,675.76
Rate for Payer: Cash Price	$3,675.76
Rate for Payer: Cigna Commercial	$4,219.69
Rate for Payer: Cigna Medicaid	$652.80
Rate for Payer: Cigna Medicare	$1,862.76
Rate for Payer: Employer Direct Commercial	$1,862.76
Rate for Payer: Humana Medicare/TRICARE	$1,862.76
Rate for Payer: Molina CHIP/Medicaid	$652.80
Rate for Payer: Molina Dual Medicare/Medicaid	$1,862.76
Rate for Payer: Molina Medicare	$1,862.76
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	$652.80
Rate for Payer: Scott and White EPO/PPO	$41.09
Rate for Payer: Scott and White Medicare	$1,862.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$652.80
Rate for Payer: Superior Health Plan EPO	$1,862.76
Rate for Payer: Superior Health Plan Medicare	$1,862.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,862.76
Rate for Payer: Universal American Medicare	$1,862.76
Rate for Payer: Wellcare Medicare	$1,862.76
Rate for Payer: Wellmed Medicare	$1,862.76

aspirin 325 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77384117
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

aspirin 325 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77384117
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

aspirin 325 mg Tab

Facility

$2.55

Service Code	HCPCS J3490
Hospital Charge Code	77384172
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$1.66
Rate for Payer: Amerigroup CHIP/Medicaid	$0.23
Rate for Payer: BCBS of TX Blue Advantage	$0.77
Rate for Payer: BCBS of TX Blue Essentials	$0.92
Rate for Payer: BCBS of TX PPO	$1.02
Rate for Payer: Cash Price	$1.73
Rate for Payer: Multiplan Auto	$1.66
Rate for Payer: Multiplan Commercial	$1.66
Rate for Payer: Multiplan Workers Comp	$1.66
Rate for Payer: Scott and White EPO/PPO	$1.28
Rate for Payer: Superior Health Plan EPO	$0.35

aspirin 325 mg Tab

Facility

$2.55

Service Code	HCPCS J3490
Hospital Charge Code	77384172
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1.73

aspirin 81 mg Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77384435
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

aspirin 81 mg Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77384435
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

aspirin 81 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77384539
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

aspirin 81 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77384539
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ASSEMBLY, BLADE CARPAL TUNNEL RELEASE SYSTEM DISP -- DHF

Facility

$845.49

Hospital Charge Code	81722852
Hospital Revenue Code	272
Min. Negotiated Rate	$76.09
Max. Negotiated Rate	$549.57
Rate for Payer: Aetna Commercial	$465.02
Rate for Payer: Amerigroup CHIP/Medicaid	$76.09
Rate for Payer: BCBS of TX Blue Advantage	$253.65
Rate for Payer: BCBS of TX Blue Essentials	$304.38
Rate for Payer: BCBS of TX PPO	$338.20
Rate for Payer: Cash Price	$744.03
Rate for Payer: Multiplan Auto	$549.57
Rate for Payer: Multiplan Commercial	$549.57
Rate for Payer: Multiplan Workers Comp	$549.57
Rate for Payer: Scott and White EPO/PPO	$422.74
Rate for Payer: Superior Health Plan EPO	$114.99

ASSEMBLY, BLADE CARPAL TUNNEL RELEASE SYSTEM DISP -- DHF

Facility

$845.49

Hospital Charge Code	81722852
Hospital Revenue Code	272
Rate for Payer: Cash Price	$744.03

ASSEMBLY, PUMP&HNDPIECE SUCT/IRR 10' TBE STRYKER 2 -- 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	$159.90
Rate for Payer: Superior Health Plan EPO	$43.49

ASSEMBLY, PUMP&HNDPIECE SUCT/IRR 10' W/TIPS DISP -- 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	$159.90
Rate for Payer: Superior Health Plan EPO	$43.49

Know your out-of-pocket cost for care.

All Charges