White Rock Medical Center

All Charges

Charge

Type

Setting

Price

flecainide 50 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77572620
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

flecainide 50 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77572620
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

FLEXIBLE INOCULATION LOOP LIGHT BLUE 1000/BX

Facility

$0.83

Hospital Charge Code	993648
Hospital Revenue Code	270
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.60
Rate for Payer: Amerigroup CHIP/Medicaid	$0.07
Rate for Payer: BCBS of TX Blue Advantage	$0.25
Rate for Payer: BCBS of TX Blue Essentials	$0.30
Rate for Payer: BCBS of TX PPO	$0.33
Rate for Payer: Cash Price	$0.56
Rate for Payer: Cigna Medicaid	$0.60
Rate for Payer: Molina CHIP/Medicaid	$0.60
Rate for Payer: Multiplan Auto	$0.54
Rate for Payer: Multiplan Commercial	$0.54
Rate for Payer: Multiplan Workers Comp	$0.54
Rate for Payer: Parkland Medicaid	$0.60
Rate for Payer: Scott and White EPO/PPO	$0.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.60
Rate for Payer: Superior Health Plan EPO	$0.11

FLEXIBLE INOCULATION LOOP LIGHT BLUE 1000/BX

Facility

$0.83

Hospital Charge Code	993648
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.56

FLIM SONY B&W

Facility

$94.90

Hospital Charge Code	993824
Hospital Revenue Code	270
Min. Negotiated Rate	$8.54
Max. Negotiated Rate	$68.33
Rate for Payer: Amerigroup CHIP/Medicaid	$8.54
Rate for Payer: BCBS of TX Blue Advantage	$28.47
Rate for Payer: BCBS of TX Blue Essentials	$34.16
Rate for Payer: BCBS of TX PPO	$37.96
Rate for Payer: Cash Price	$64.53
Rate for Payer: Cigna Medicaid	$68.33
Rate for Payer: Molina CHIP/Medicaid	$68.33
Rate for Payer: Multiplan Auto	$61.69
Rate for Payer: Multiplan Commercial	$61.69
Rate for Payer: Multiplan Workers Comp	$61.69
Rate for Payer: Parkland Medicaid	$68.33
Rate for Payer: Scott and White EPO/PPO	$47.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$68.33
Rate for Payer: Superior Health Plan EPO	$12.91

FLIM SONY B&W

Facility

$94.90

Hospital Charge Code	993824
Hospital Revenue Code	270
Rate for Payer: Cash Price	$64.53

FLOSEAL APPLICATOR

Facility

$149.82

Hospital Charge Code	992693
Hospital Revenue Code	272
Min. Negotiated Rate	$13.48
Max. Negotiated Rate	$107.87
Rate for Payer: Amerigroup CHIP/Medicaid	$13.48
Rate for Payer: BCBS of TX Blue Advantage	$44.95
Rate for Payer: BCBS of TX Blue Essentials	$53.94
Rate for Payer: BCBS of TX PPO	$59.93
Rate for Payer: Cash Price	$101.88
Rate for Payer: Cigna Medicaid	$107.87
Rate for Payer: Molina CHIP/Medicaid	$107.87
Rate for Payer: Multiplan Auto	$97.38
Rate for Payer: Multiplan Commercial	$97.38
Rate for Payer: Multiplan Workers Comp	$97.38
Rate for Payer: Parkland Medicaid	$107.87
Rate for Payer: Scott and White EPO/PPO	$74.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$107.87
Rate for Payer: Superior Health Plan EPO	$20.38

FLOSEAL APPLICATOR

Facility

$149.82

Hospital Charge Code	992693
Hospital Revenue Code	272
Rate for Payer: Cash Price	$101.88

FLOW CONT VLV CF -- DHF

Facility

$70.37

Hospital Charge Code	81746356
Hospital Revenue Code	272
Rate for Payer: Cash Price	$47.85

FLOW CONT VLV CF -- DHF

Facility

$70.37

Hospital Charge Code	81746356
Hospital Revenue Code	272
Min. Negotiated Rate	$6.33
Max. Negotiated Rate	$50.67
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	$47.85
Rate for Payer: Cigna Medicaid	$50.67
Rate for Payer: Molina CHIP/Medicaid	$50.67
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: Parkland Medicaid	$50.67
Rate for Payer: Scott and White EPO/PPO	$35.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50.67
Rate for Payer: Superior Health Plan EPO	$9.57

FLOWMETER O2 PK W 3-ZONE ASTH MGMT ZN

Facility

$8.54

Hospital Charge Code	993608
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.81

FLOWMETER O2 PK W 3-ZONE ASTH MGMT ZN

Facility

$8.54

Hospital Charge Code	993608
Hospital Revenue Code	270
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$6.15
Rate for Payer: Amerigroup CHIP/Medicaid	$0.77
Rate for Payer: BCBS of TX Blue Advantage	$2.56
Rate for Payer: BCBS of TX Blue Essentials	$3.07
Rate for Payer: BCBS of TX PPO	$3.42
Rate for Payer: Cash Price	$5.81
Rate for Payer: Cigna Medicaid	$6.15
Rate for Payer: Molina CHIP/Medicaid	$6.15
Rate for Payer: Multiplan Auto	$5.55
Rate for Payer: Multiplan Commercial	$5.55
Rate for Payer: Multiplan Workers Comp	$5.55
Rate for Payer: Parkland Medicaid	$6.15
Rate for Payer: Scott and White EPO/PPO	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.15
Rate for Payer: Superior Health Plan EPO	$1.16

FLTR TIS ATEC BRST BX -- DHF

Facility

$18.44

Hospital Charge Code	81746828
Hospital Revenue Code	272
Rate for Payer: Cash Price	$12.54

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	$13.28
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	$12.54
Rate for Payer: Cigna Medicaid	$13.28
Rate for Payer: Molina CHIP/Medicaid	$13.28
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: Parkland Medicaid	$13.28
Rate for Payer: Scott and White EPO/PPO	$9.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.28
Rate for Payer: Superior Health Plan EPO	$2.51

fluconazole 100 mg Tab

Facility

$24.51

Service Code	HCPCS J3490
Hospital Charge Code	77572828
Hospital Revenue Code	250
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$17.65
Rate for Payer: Amerigroup CHIP/Medicaid	$2.21
Rate for Payer: BCBS of TX Blue Advantage	$7.35
Rate for Payer: BCBS of TX Blue Essentials	$8.82
Rate for Payer: BCBS of TX PPO	$9.80
Rate for Payer: Cash Price	$16.67
Rate for Payer: Cigna Medicaid	$17.65
Rate for Payer: Molina CHIP/Medicaid	$17.65
Rate for Payer: Multiplan Auto	$15.93
Rate for Payer: Multiplan Commercial	$15.93
Rate for Payer: Multiplan Workers Comp	$15.93
Rate for Payer: Parkland Medicaid	$17.65
Rate for Payer: Scott and White EPO/PPO	$12.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.65
Rate for Payer: Superior Health Plan EPO	$3.33

fluconazole 100 mg Tab

Facility

$24.51

Service Code	HCPCS J3490
Hospital Charge Code	77572828
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.67

fluconazole 200 mg/NaCl 0.9% 100 mL

Facility

$128.00

Service Code	HCPCS J1450
Hospital Charge Code	77572985
Hospital Revenue Code	636
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$9.15
Rate for Payer: BCBS of TX Blue Essentials	$10.98
Rate for Payer: BCBS of TX PPO	$12.18
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

fluconazole 200 mg/NaCl 0.9% 100 mL

Facility

$128.00

Service Code	HCPCS J1450
Hospital Charge Code	77572985
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

fluconazole 200 mg/NaCl 0.9% 100 mL

Facility

$128.00

Service Code	HCPCS J1450
Hospital Charge Code	78430765
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

fluconazole 200 mg/NaCl 0.9% 100 mL

Facility

$128.00

Service Code	HCPCS J1450
Hospital Charge Code	78430765
Hospital Revenue Code	636
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$9.15
Rate for Payer: BCBS of TX Blue Essentials	$10.98
Rate for Payer: BCBS of TX PPO	$12.18
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

FLUID MANAGEMENT SUCTION MAT

Facility

$192.95

Hospital Charge Code	145244
Hospital Revenue Code	270
Rate for Payer: Cash Price	$131.21

FLUID MANAGEMENT SUCTION MAT

Facility

$192.95

Hospital Charge Code	145244
Hospital Revenue Code	270
Min. Negotiated Rate	$17.37
Max. Negotiated Rate	$138.92
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	$131.21
Rate for Payer: Cigna Medicaid	$138.92
Rate for Payer: Molina CHIP/Medicaid	$138.92
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: Parkland Medicaid	$138.92
Rate for Payer: Scott and White EPO/PPO	$96.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$138.92
Rate for Payer: Superior Health Plan EPO	$26.24

FLUID THIOGLYCOLLATE, WITH INDICATOR, USP, 10 ML

Facility

$149.61

Hospital Charge Code	993100
Hospital Revenue Code	270
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$107.72
Rate for Payer: Amerigroup CHIP/Medicaid	$13.46
Rate for Payer: BCBS of TX Blue Advantage	$44.88
Rate for Payer: BCBS of TX Blue Essentials	$53.86
Rate for Payer: BCBS of TX PPO	$59.84
Rate for Payer: Cash Price	$101.73
Rate for Payer: Cigna Medicaid	$107.72
Rate for Payer: Molina CHIP/Medicaid	$107.72
Rate for Payer: Multiplan Auto	$97.25
Rate for Payer: Multiplan Commercial	$97.25
Rate for Payer: Multiplan Workers Comp	$97.25
Rate for Payer: Parkland Medicaid	$107.72
Rate for Payer: Scott and White EPO/PPO	$74.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$107.72
Rate for Payer: Superior Health Plan EPO	$20.35

FLUID THIOGLYCOLLATE, WITH INDICATOR, USP, 10 ML

Facility

$149.61

Hospital Charge Code	993100
Hospital Revenue Code	270
Rate for Payer: Cash Price	$101.73

flumazenil 0.1 mg/mL IV Soln 5 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	78438552
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

Know your out-of-pocket cost for care.

All Charges