White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

fluorescein 1 mg Ophth Test

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77575552
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

fluorescein 1 mg Ophth Test

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77575552
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

FLUORO BX/ASP/INJ/GUIDE

Facility

$559.00

Service Code	HCPCS 77002
Hospital Charge Code	4616003
Hospital Revenue Code	320
Min. Negotiated Rate	$50.31
Max. Negotiated Rate	$402.48
Rate for Payer: Amerigroup CHIP/Medicaid	$50.31
Rate for Payer: BCBS of TX Blue Advantage	$123.09
Rate for Payer: BCBS of TX Blue Essentials	$147.71
Rate for Payer: BCBS of TX PPO	$164.87
Rate for Payer: Cash Price	$380.12
Rate for Payer: Cash Price	$380.12
Rate for Payer: Cigna Medicaid	$402.48
Rate for Payer: Molina CHIP/Medicaid	$402.48
Rate for Payer: Multiplan Auto	$363.35
Rate for Payer: Multiplan Commercial	$363.35
Rate for Payer: Multiplan Workers Comp	$363.35
Rate for Payer: Parkland Medicaid	$402.48
Rate for Payer: Scott and White EPO/PPO	$279.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$402.48
Rate for Payer: Superior Health Plan EPO	$76.02

FLUORO BX/ASP/INJ/GUIDE

Facility

$559.00

Service Code	HCPCS 77002
Hospital Charge Code	4616003
Hospital Revenue Code	320
Rate for Payer: Cash Price	$380.12

FLUORO GUIDE SPINE INJ

Facility

$1,020.00

Service Code	HCPCS 77003
Hospital Charge Code	4616010
Hospital Revenue Code	320
Rate for Payer: Cash Price	$693.60

FLUORO GUIDE SPINE INJ

Facility

$1,020.00

Service Code	HCPCS 77003
Hospital Charge Code	4616010
Hospital Revenue Code	320
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$734.40
Rate for Payer: Amerigroup CHIP/Medicaid	$91.80
Rate for Payer: BCBS of TX Blue Advantage	$113.57
Rate for Payer: BCBS of TX Blue Essentials	$136.28
Rate for Payer: BCBS of TX PPO	$152.11
Rate for Payer: Cash Price	$693.60
Rate for Payer: Cash Price	$693.60
Rate for Payer: Cigna Medicaid	$734.40
Rate for Payer: Molina CHIP/Medicaid	$734.40
Rate for Payer: Multiplan Auto	$663.00
Rate for Payer: Multiplan Commercial	$663.00
Rate for Payer: Multiplan Workers Comp	$663.00
Rate for Payer: Parkland Medicaid	$734.40
Rate for Payer: Scott and White EPO/PPO	$510.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$734.40
Rate for Payer: Superior Health Plan EPO	$138.72

FLUOROGUID FOR VEIN DVCE

Facility

$619.00

Service Code	HCPCS 77001
Hospital Charge Code	4615997
Hospital Revenue Code	320
Min. Negotiated Rate	$55.71
Max. Negotiated Rate	$445.68
Rate for Payer: Amerigroup CHIP/Medicaid	$55.71
Rate for Payer: BCBS of TX Blue Advantage	$120.12
Rate for Payer: BCBS of TX Blue Essentials	$144.14
Rate for Payer: BCBS of TX PPO	$160.89
Rate for Payer: Cash Price	$420.92
Rate for Payer: Cash Price	$420.92
Rate for Payer: Cigna Medicaid	$445.68
Rate for Payer: Molina CHIP/Medicaid	$445.68
Rate for Payer: Multiplan Auto	$402.35
Rate for Payer: Multiplan Commercial	$402.35
Rate for Payer: Multiplan Workers Comp	$402.35
Rate for Payer: Parkland Medicaid	$445.68
Rate for Payer: Scott and White EPO/PPO	$309.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$445.68
Rate for Payer: Superior Health Plan EPO	$84.18

FLUOROGUID FOR VEIN DVCE

Facility

$619.00

Service Code	HCPCS 77001
Hospital Charge Code	4615997
Hospital Revenue Code	320
Rate for Payer: Cash Price	$420.92

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic

Facility

$6,465.00

Service Code	HCPCS 77003
Hospital Charge Code	9900904
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,396.20

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic

Facility

$6,465.00

Service Code	HCPCS 77003
Hospital Charge Code	9900904
Hospital Revenue Code	360
Min. Negotiated Rate	$113.57
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$581.85
Rate for Payer: BCBS of TX Blue Advantage	$113.57
Rate for Payer: BCBS of TX Blue Essentials	$136.28
Rate for Payer: BCBS of TX PPO	$152.11
Rate for Payer: Cash Price	$4,396.20
Rate for Payer: Cash Price	$4,396.20
Rate for Payer: Cash Price	$4,396.20
Rate for Payer: Cigna Medicaid	$4,654.80
Rate for Payer: Molina CHIP/Medicaid	$4,654.80
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	$4,654.80
Rate for Payer: Scott and White EPO/PPO	$3,232.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,654.80
Rate for Payer: Superior Health Plan EPO	$879.24

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic

Facility

$6,465.00

Service Code	HCPCS 77003
Hospital Charge Code	3120029
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,396.20

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic

Facility

$6,465.00

Service Code	HCPCS 77003
Hospital Charge Code	3120029
Hospital Revenue Code	360
Min. Negotiated Rate	$113.57
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$581.85
Rate for Payer: BCBS of TX Blue Advantage	$113.57
Rate for Payer: BCBS of TX Blue Essentials	$136.28
Rate for Payer: BCBS of TX PPO	$152.11
Rate for Payer: Cash Price	$4,396.20
Rate for Payer: Cash Price	$4,396.20
Rate for Payer: Cash Price	$4,396.20
Rate for Payer: Cigna Medicaid	$4,654.80
Rate for Payer: Molina CHIP/Medicaid	$4,654.80
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	$4,654.80
Rate for Payer: Scott and White EPO/PPO	$3,232.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,654.80
Rate for Payer: Superior Health Plan EPO	$879.24

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic

Facility

$10,000.00

Service Code	CPT 77003
Hospital Charge Code	36077003
Hospital Revenue Code	360
Min. Negotiated Rate	$113.57
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$113.57
Rate for Payer: BCBS of TX Blue Essentials	$136.28
Rate for Payer: BCBS of TX PPO	$152.11
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

Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

Facility

$10,000.00

Service Code	CPT 77002
Hospital Charge Code	36077002
Hospital Revenue Code	360
Min. Negotiated Rate	$123.09
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$123.09
Rate for Payer: BCBS of TX Blue Essentials	$147.71
Rate for Payer: BCBS of TX PPO	$164.87
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

Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

Facility

$6,465.00

Service Code	HCPCS 77002
Hospital Charge Code	9900903
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,396.20

Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

Facility

$6,465.00

Service Code	HCPCS 77002
Hospital Charge Code	9900903
Hospital Revenue Code	360
Min. Negotiated Rate	$123.09
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$581.85
Rate for Payer: BCBS of TX Blue Advantage	$123.09
Rate for Payer: BCBS of TX Blue Essentials	$147.71
Rate for Payer: BCBS of TX PPO	$164.87
Rate for Payer: Cash Price	$4,396.20
Rate for Payer: Cash Price	$4,396.20
Rate for Payer: Cash Price	$4,396.20
Rate for Payer: Cigna Medicaid	$4,654.80
Rate for Payer: Molina CHIP/Medicaid	$4,654.80
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	$4,654.80
Rate for Payer: Scott and White EPO/PPO	$3,232.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,654.80
Rate for Payer: Superior Health Plan EPO	$879.24

FLUOROSCOPY 1 HOUR

Facility

$480.00

Service Code	HCPCS 76000
Hospital Charge Code	2300085
Hospital Revenue Code	320
Rate for Payer: Cash Price	$326.40

FLUOROSCOPY 1 HOUR

Facility

$480.00

Service Code	HCPCS 76000
Hospital Charge Code	2300085
Hospital Revenue Code	320
Min. Negotiated Rate	$42.78
Max. Negotiated Rate	$506.65
Rate for Payer: Amerigroup CHIP/Medicaid	$42.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$52.92
Rate for Payer: BCBS of TX Blue Essentials	$63.50
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$70.87
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$345.60
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$345.60
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$312.00
Rate for Payer: Multiplan Commercial	$312.00
Rate for Payer: Multiplan Workers Comp	$312.00
Rate for Payer: Parkland Medicaid	$345.60
Rate for Payer: Scott and White EPO/PPO	$359.54
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$345.60
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional

Facility

$1,034.00

Service Code	HCPCS 76000
Hospital Charge Code	9900902
Hospital Revenue Code	360
Min. Negotiated Rate	$52.92
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$93.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$52.92
Rate for Payer: BCBS of TX Blue Essentials	$63.50
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$70.87
Rate for Payer: Cash Price	$703.12
Rate for Payer: Cash Price	$703.12
Rate for Payer: Cash Price	$703.12
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$744.48
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$744.48
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
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	$744.48
Rate for Payer: Scott and White EPO/PPO	$517.00
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$744.48
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional

Facility

$1,034.00

Service Code	HCPCS 76000
Hospital Charge Code	9900902
Hospital Revenue Code	360
Rate for Payer: Cash Price	$703.12

Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional

Facility

$10,000.00

Service Code	CPT 76000
Hospital Charge Code	36076000
Hospital Revenue Code	360
Min. Negotiated Rate	$52.92
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$52.92
Rate for Payer: BCBS of TX Blue Essentials	$63.50
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$70.87
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
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 Medicare	$239.69
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

FLUoxetine 10 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77578684
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

FLUoxetine 10 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77578684
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

FLUoxetine 20 mg Cap

Facility

$9.38

Service Code	HCPCS J3490
Hospital Charge Code	77578790
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.75
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.81
Rate for Payer: BCBS of TX Blue Essentials	$3.38
Rate for Payer: BCBS of TX PPO	$3.75
Rate for Payer: Cash Price	$6.38
Rate for Payer: Cigna Medicaid	$6.75
Rate for Payer: Molina CHIP/Medicaid	$6.75
Rate for Payer: Multiplan Auto	$6.10
Rate for Payer: Multiplan Commercial	$6.10
Rate for Payer: Multiplan Workers Comp	$6.10
Rate for Payer: Parkland Medicaid	$6.75
Rate for Payer: Scott and White EPO/PPO	$4.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.75
Rate for Payer: Superior Health Plan EPO	$1.28

Know your out-of-pocket cost for care.

All Charges