White Rock Medical Center

All Charges

Charge

Type

Setting

Price

FILTER EXTERNAL WATER

Facility

$106.69

Hospital Charge Code	993929
Hospital Revenue Code	272
Rate for Payer: Cash Price	$72.55

FILTER IVC JUG 7FR 65CM CELECT PLTN

Facility

$7,711.00

Service Code	HCPCS C1880
Hospital Charge Code	109361
Hospital Revenue Code	278
Min. Negotiated Rate	$693.99
Max. Negotiated Rate	$5,551.92
Rate for Payer: Amerigroup CHIP/Medicaid	$693.99
Rate for Payer: BCBS of TX Blue Advantage	$2,313.30
Rate for Payer: BCBS of TX Blue Essentials	$2,775.96
Rate for Payer: BCBS of TX PPO	$3,084.40
Rate for Payer: Cash Price	$5,243.48
Rate for Payer: Cigna Medicaid	$5,551.92
Rate for Payer: Molina CHIP/Medicaid	$5,551.92
Rate for Payer: Multiplan Auto	$3,855.50
Rate for Payer: Multiplan Commercial	$3,855.50
Rate for Payer: Multiplan Workers Comp	$3,855.50
Rate for Payer: Parkland Medicaid	$5,551.92
Rate for Payer: Scott and White EPO/PPO	$3,855.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,551.92
Rate for Payer: Superior Health Plan EPO	$1,048.70

FILTER IVC JUG 7FR 65CM CELECT PLTN

Facility

$7,711.00

Service Code	HCPCS C1880
Hospital Charge Code	109361
Hospital Revenue Code	278
Min. Negotiated Rate	$1,927.75
Max. Negotiated Rate	$3,855.50
Rate for Payer: Cash Price	$5,243.48
Rate for Payer: Cigna Commercial	$1,927.75
Rate for Payer: Multiplan Auto	$3,855.50
Rate for Payer: Multiplan Commercial	$3,855.50
Rate for Payer: Multiplan Workers Comp	$3,855.50
Rate for Payer: Scott and White EPO/PPO	$3,855.50

FILTER OER-PRO 0.2 MICRON INTERNAL WATER

Facility

$2,024.84

Hospital Charge Code	993928
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,376.89

FILTER OER-PRO 0.2 MICRON INTERNAL WATER

Facility

$2,024.84

Hospital Charge Code	993928
Hospital Revenue Code	272
Min. Negotiated Rate	$182.24
Max. Negotiated Rate	$1,457.88
Rate for Payer: Amerigroup CHIP/Medicaid	$182.24
Rate for Payer: BCBS of TX Blue Advantage	$607.45
Rate for Payer: BCBS of TX Blue Essentials	$728.94
Rate for Payer: BCBS of TX PPO	$809.94
Rate for Payer: Cash Price	$1,376.89
Rate for Payer: Cigna Medicaid	$1,457.88
Rate for Payer: Molina CHIP/Medicaid	$1,457.88
Rate for Payer: Multiplan Auto	$1,316.15
Rate for Payer: Multiplan Commercial	$1,316.15
Rate for Payer: Multiplan Workers Comp	$1,316.15
Rate for Payer: Parkland Medicaid	$1,457.88
Rate for Payer: Scott and White EPO/PPO	$1,012.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,457.88
Rate for Payer: Superior Health Plan EPO	$275.38

Filter Retrievers

Facility

$6,221.71

Hospital Charge Code	993719
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4,230.76

Filter Retrievers

Facility

$6,221.71

Hospital Charge Code	993719
Hospital Revenue Code	270
Min. Negotiated Rate	$559.95
Max. Negotiated Rate	$4,479.63
Rate for Payer: Amerigroup CHIP/Medicaid	$559.95
Rate for Payer: BCBS of TX Blue Advantage	$1,866.51
Rate for Payer: BCBS of TX Blue Essentials	$2,239.82
Rate for Payer: BCBS of TX PPO	$2,488.68
Rate for Payer: Cash Price	$4,230.76
Rate for Payer: Cigna Medicaid	$4,479.63
Rate for Payer: Molina CHIP/Medicaid	$4,479.63
Rate for Payer: Multiplan Auto	$4,044.11
Rate for Payer: Multiplan Commercial	$4,044.11
Rate for Payer: Multiplan Workers Comp	$4,044.11
Rate for Payer: Parkland Medicaid	$4,479.63
Rate for Payer: Scott and White EPO/PPO	$3,110.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,479.63
Rate for Payer: Superior Health Plan EPO	$846.15

FILTER STRL RND PPR INDCTR DOT 7.5IN

Facility

$24.77

Hospital Charge Code	993504
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.84

FILTER STRL RND PPR INDCTR DOT 7.5IN

Facility

$24.77

Hospital Charge Code	993504
Hospital Revenue Code	270
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$17.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2.23
Rate for Payer: BCBS of TX Blue Advantage	$7.43
Rate for Payer: BCBS of TX Blue Essentials	$8.92
Rate for Payer: BCBS of TX PPO	$9.91
Rate for Payer: Cash Price	$16.84
Rate for Payer: Cigna Medicaid	$17.83
Rate for Payer: Molina CHIP/Medicaid	$17.83
Rate for Payer: Multiplan Auto	$16.10
Rate for Payer: Multiplan Commercial	$16.10
Rate for Payer: Multiplan Workers Comp	$16.10
Rate for Payer: Parkland Medicaid	$17.83
Rate for Payer: Scott and White EPO/PPO	$12.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.83
Rate for Payer: Superior Health Plan EPO	$3.37

FILTER TPN IV -- DHF

Facility

$65.75

Hospital Charge Code	54202601
Hospital Revenue Code	270
Min. Negotiated Rate	$5.92
Max. Negotiated Rate	$47.34
Rate for Payer: Amerigroup CHIP/Medicaid	$5.92
Rate for Payer: BCBS of TX Blue Advantage	$19.73
Rate for Payer: BCBS of TX Blue Essentials	$23.67
Rate for Payer: BCBS of TX PPO	$26.30
Rate for Payer: Cash Price	$44.71
Rate for Payer: Cigna Medicaid	$47.34
Rate for Payer: Molina CHIP/Medicaid	$47.34
Rate for Payer: Multiplan Auto	$42.74
Rate for Payer: Multiplan Commercial	$42.74
Rate for Payer: Multiplan Workers Comp	$42.74
Rate for Payer: Parkland Medicaid	$47.34
Rate for Payer: Scott and White EPO/PPO	$32.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47.34
Rate for Payer: Superior Health Plan EPO	$8.94

FILTER TPN IV -- DHF

Facility

$65.75

Hospital Charge Code	54202601
Hospital Revenue Code	270
Rate for Payer: Cash Price	$44.71

FILTER, UROLOGICAL STRAIN

Facility

$5.08

Hospital Charge Code	993289
Hospital Revenue Code	270
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$3.66
Rate for Payer: Amerigroup CHIP/Medicaid	$0.46
Rate for Payer: BCBS of TX Blue Advantage	$1.52
Rate for Payer: BCBS of TX Blue Essentials	$1.83
Rate for Payer: BCBS of TX PPO	$2.03
Rate for Payer: Cash Price	$3.45
Rate for Payer: Cigna Medicaid	$3.66
Rate for Payer: Molina CHIP/Medicaid	$3.66
Rate for Payer: Multiplan Auto	$3.30
Rate for Payer: Multiplan Commercial	$3.30
Rate for Payer: Multiplan Workers Comp	$3.30
Rate for Payer: Parkland Medicaid	$3.66
Rate for Payer: Scott and White EPO/PPO	$2.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.66
Rate for Payer: Superior Health Plan EPO	$0.69

FILTER, UROLOGICAL STRAIN

Facility

$5.08

Hospital Charge Code	993289
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.45

finasteride 5 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77572100
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

finasteride 5 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77572100
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

FitGuard Touch Powder-Free Nitrile Exam Gloves, Size L

Facility

$0.50

Hospital Charge Code	992934
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.34

FitGuard Touch Powder-Free Nitrile Exam Gloves, Size L

Facility

$0.50

Hospital Charge Code	992934
Hospital Revenue Code	270
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.36
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.15
Rate for Payer: BCBS of TX Blue Essentials	$0.18
Rate for Payer: BCBS of TX PPO	$0.20
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cigna Medicaid	$0.36
Rate for Payer: Molina CHIP/Medicaid	$0.36
Rate for Payer: Multiplan Auto	$0.33
Rate for Payer: Multiplan Commercial	$0.33
Rate for Payer: Multiplan Workers Comp	$0.33
Rate for Payer: Parkland Medicaid	$0.36
Rate for Payer: Scott and White EPO/PPO	$0.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.36
Rate for Payer: Superior Health Plan EPO	$0.07

FitGuard Touch Powder-Free Nitrile Exam Gloves, Size M

Facility

$0.50

Hospital Charge Code	992935
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.34

FitGuard Touch Powder-Free Nitrile Exam Gloves, Size M

Facility

$0.50

Hospital Charge Code	992935
Hospital Revenue Code	270
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.36
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.15
Rate for Payer: BCBS of TX Blue Essentials	$0.18
Rate for Payer: BCBS of TX PPO	$0.20
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cigna Medicaid	$0.36
Rate for Payer: Molina CHIP/Medicaid	$0.36
Rate for Payer: Multiplan Auto	$0.33
Rate for Payer: Multiplan Commercial	$0.33
Rate for Payer: Multiplan Workers Comp	$0.33
Rate for Payer: Parkland Medicaid	$0.36
Rate for Payer: Scott and White EPO/PPO	$0.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.36
Rate for Payer: Superior Health Plan EPO	$0.07

FitGuard Touch Powder-Free Nitrile Exam Gloves, Size S

Facility

$0.50

Hospital Charge Code	992936
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.34

FitGuard Touch Powder-Free Nitrile Exam Gloves, Size S

Facility

$0.50

Hospital Charge Code	992936
Hospital Revenue Code	270
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.36
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.15
Rate for Payer: BCBS of TX Blue Essentials	$0.18
Rate for Payer: BCBS of TX PPO	$0.20
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cigna Medicaid	$0.36
Rate for Payer: Molina CHIP/Medicaid	$0.36
Rate for Payer: Multiplan Auto	$0.33
Rate for Payer: Multiplan Commercial	$0.33
Rate for Payer: Multiplan Workers Comp	$0.33
Rate for Payer: Parkland Medicaid	$0.36
Rate for Payer: Scott and White EPO/PPO	$0.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.36
Rate for Payer: Superior Health Plan EPO	$0.07

FIX FLUTED PIN 3.2 X 150MM

Facility

$392.00

Service Code	HCPCS C1713
Hospital Charge Code	8702508
Hospital Revenue Code	278
Min. Negotiated Rate	$35.28
Max. Negotiated Rate	$282.24
Rate for Payer: Amerigroup CHIP/Medicaid	$35.28
Rate for Payer: BCBS of TX Blue Advantage	$117.60
Rate for Payer: BCBS of TX Blue Essentials	$141.12
Rate for Payer: BCBS of TX PPO	$156.80
Rate for Payer: Cash Price	$266.56
Rate for Payer: Cigna Medicaid	$282.24
Rate for Payer: Molina CHIP/Medicaid	$282.24
Rate for Payer: Multiplan Auto	$196.00
Rate for Payer: Multiplan Commercial	$196.00
Rate for Payer: Multiplan Workers Comp	$196.00
Rate for Payer: Parkland Medicaid	$282.24
Rate for Payer: Scott and White EPO/PPO	$196.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$282.24
Rate for Payer: Superior Health Plan EPO	$53.31

FIX FLUTED PIN 3.2 X 150MM

Facility

$392.00

Service Code	HCPCS C1713
Hospital Charge Code	8702508
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$196.00
Rate for Payer: Cash Price	$266.56
Rate for Payer: Cigna Commercial	$98.00
Rate for Payer: Multiplan Auto	$196.00
Rate for Payer: Multiplan Commercial	$196.00
Rate for Payer: Multiplan Workers Comp	$196.00
Rate for Payer: Scott and White EPO/PPO	$196.00

FIX FLUTE PIN 3.2X 80MM PK/2

Facility

$392.00

Service Code	HCPCS C1713
Hospital Charge Code	8702507
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$196.00
Rate for Payer: Cash Price	$266.56
Rate for Payer: Cigna Commercial	$98.00
Rate for Payer: Multiplan Auto	$196.00
Rate for Payer: Multiplan Commercial	$196.00
Rate for Payer: Multiplan Workers Comp	$196.00
Rate for Payer: Scott and White EPO/PPO	$196.00

FIX FLUTE PIN 3.2X 80MM PK/2

Facility

$392.00

Service Code	HCPCS C1713
Hospital Charge Code	8702507
Hospital Revenue Code	278
Min. Negotiated Rate	$35.28
Max. Negotiated Rate	$282.24
Rate for Payer: Amerigroup CHIP/Medicaid	$35.28
Rate for Payer: BCBS of TX Blue Advantage	$117.60
Rate for Payer: BCBS of TX Blue Essentials	$141.12
Rate for Payer: BCBS of TX PPO	$156.80
Rate for Payer: Cash Price	$266.56
Rate for Payer: Cigna Medicaid	$282.24
Rate for Payer: Molina CHIP/Medicaid	$282.24
Rate for Payer: Multiplan Auto	$196.00
Rate for Payer: Multiplan Commercial	$196.00
Rate for Payer: Multiplan Workers Comp	$196.00
Rate for Payer: Parkland Medicaid	$282.24
Rate for Payer: Scott and White EPO/PPO	$196.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$282.24
Rate for Payer: Superior Health Plan EPO	$53.31

Know your out-of-pocket cost for care.

All Charges