White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$52.59
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	$52.59
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

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
Rate for Payer: Cash Price	$6.38

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

fluticasone 50 mcg/inh Nasal Spray 16 g

Facility

$231.10

Service Code	HCPCS J3490
Hospital Charge Code	77581254
Hospital Revenue Code	250
Rate for Payer: Cash Price	$157.15

fluticasone 50 mcg/inh Nasal Spray 16 g

Facility

$231.10

Service Code	HCPCS J3490
Hospital Charge Code	77581254
Hospital Revenue Code	250
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$166.39
Rate for Payer: Amerigroup CHIP/Medicaid	$20.80
Rate for Payer: BCBS of TX Blue Advantage	$69.33
Rate for Payer: BCBS of TX Blue Essentials	$83.20
Rate for Payer: BCBS of TX PPO	$92.44
Rate for Payer: Cash Price	$157.15
Rate for Payer: Cigna Medicaid	$166.39
Rate for Payer: Molina CHIP/Medicaid	$166.39
Rate for Payer: Multiplan Auto	$150.22
Rate for Payer: Multiplan Commercial	$150.22
Rate for Payer: Multiplan Workers Comp	$150.22
Rate for Payer: Parkland Medicaid	$166.39
Rate for Payer: Scott and White EPO/PPO	$115.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$166.39
Rate for Payer: Superior Health Plan EPO	$31.43

Foam armboard positioner, economy 3' x 5' x 24'

Facility

$19.69

Hospital Charge Code	992930
Hospital Revenue Code	270
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$14.18
Rate for Payer: Amerigroup CHIP/Medicaid	$1.77
Rate for Payer: BCBS of TX Blue Advantage	$5.91
Rate for Payer: BCBS of TX Blue Essentials	$7.09
Rate for Payer: BCBS of TX PPO	$7.88
Rate for Payer: Cash Price	$13.39
Rate for Payer: Cigna Medicaid	$14.18
Rate for Payer: Molina CHIP/Medicaid	$14.18
Rate for Payer: Multiplan Auto	$12.80
Rate for Payer: Multiplan Commercial	$12.80
Rate for Payer: Multiplan Workers Comp	$12.80
Rate for Payer: Parkland Medicaid	$14.18
Rate for Payer: Scott and White EPO/PPO	$9.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.18
Rate for Payer: Superior Health Plan EPO	$2.68

Foam armboard positioner, economy 3' x 5' x 24'

Facility

$19.69

Hospital Charge Code	992930
Hospital Revenue Code	270
Rate for Payer: Cash Price	$13.39

Foam needle conter with adhesive, 10-count

Facility

$4.85

Hospital Charge Code	992790
Hospital Revenue Code	272
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$3.49
Rate for Payer: Amerigroup CHIP/Medicaid	$0.44
Rate for Payer: BCBS of TX Blue Advantage	$1.46
Rate for Payer: BCBS of TX Blue Essentials	$1.75
Rate for Payer: BCBS of TX PPO	$1.94
Rate for Payer: Cash Price	$3.30
Rate for Payer: Cigna Medicaid	$3.49
Rate for Payer: Molina CHIP/Medicaid	$3.49
Rate for Payer: Multiplan Auto	$3.15
Rate for Payer: Multiplan Commercial	$3.15
Rate for Payer: Multiplan Workers Comp	$3.15
Rate for Payer: Parkland Medicaid	$3.49
Rate for Payer: Scott and White EPO/PPO	$2.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.49
Rate for Payer: Superior Health Plan EPO	$0.66

Foam needle conter with adhesive, 10-count

Facility

$4.85

Hospital Charge Code	992790
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.30

FOAM, POSITIONING DEVICE (DONUT) 9' O.D. -- DHF

Facility

$119.61

Hospital Charge Code	80319650
Hospital Revenue Code	270
Min. Negotiated Rate	$10.76
Max. Negotiated Rate	$86.12
Rate for Payer: Amerigroup CHIP/Medicaid	$10.76
Rate for Payer: BCBS of TX Blue Advantage	$35.88
Rate for Payer: BCBS of TX Blue Essentials	$43.06
Rate for Payer: BCBS of TX PPO	$47.84
Rate for Payer: Cash Price	$81.33
Rate for Payer: Cigna Medicaid	$86.12
Rate for Payer: Molina CHIP/Medicaid	$86.12
Rate for Payer: Multiplan Auto	$77.75
Rate for Payer: Multiplan Commercial	$77.75
Rate for Payer: Multiplan Workers Comp	$77.75
Rate for Payer: Parkland Medicaid	$86.12
Rate for Payer: Scott and White EPO/PPO	$59.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.12
Rate for Payer: Superior Health Plan EPO	$16.27

FOAM, POSITIONING DEVICE (DONUT) 9' O.D. -- DHF

Facility

$119.61

Hospital Charge Code	80319650
Hospital Revenue Code	270
Rate for Payer: Cash Price	$81.33

Foam Tip Polystyrene

Facility

$2.84

Hospital Charge Code	993330
Hospital Revenue Code	270
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$2.04
Rate for Payer: Amerigroup CHIP/Medicaid	$0.26
Rate for Payer: BCBS of TX Blue Advantage	$0.85
Rate for Payer: BCBS of TX Blue Essentials	$1.02
Rate for Payer: BCBS of TX PPO	$1.14
Rate for Payer: Cash Price	$1.93
Rate for Payer: Cigna Medicaid	$2.04
Rate for Payer: Molina CHIP/Medicaid	$2.04
Rate for Payer: Multiplan Auto	$1.85
Rate for Payer: Multiplan Commercial	$1.85
Rate for Payer: Multiplan Workers Comp	$1.85
Rate for Payer: Parkland Medicaid	$2.04
Rate for Payer: Scott and White EPO/PPO	$1.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.04
Rate for Payer: Superior Health Plan EPO	$0.39

Foam Tip Polystyrene

Facility

$2.84

Hospital Charge Code	993330
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.93

Folate, Hemolysate SO

Facility

$171.04

Service Code	HCPCS 82747
Hospital Charge Code	1601863
Hospital Revenue Code	301
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$123.15
Rate for Payer: Amerigroup CHIP/Medicaid	$6.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.65
Rate for Payer: Amerigroup Medicare	$17.65
Rate for Payer: BCBS of TX Blue Advantage	$51.31
Rate for Payer: BCBS of TX Blue Essentials	$61.57
Rate for Payer: BCBS of TX Medicare	$17.65
Rate for Payer: BCBS of TX PPO	$68.42
Rate for Payer: Cash Price	$116.31
Rate for Payer: Cash Price	$116.31
Rate for Payer: Cigna Medicaid	$123.15
Rate for Payer: Cigna Medicare	$17.65
Rate for Payer: Employer Direct Commercial	$17.65
Rate for Payer: Humana Medicare/TRICARE	$17.65
Rate for Payer: Molina CHIP/Medicaid	$123.15
Rate for Payer: Molina Dual Medicare/Medicaid	$17.65
Rate for Payer: Molina Medicare	$17.65
Rate for Payer: Multiplan Auto	$111.18
Rate for Payer: Multiplan Commercial	$111.18
Rate for Payer: Multiplan Workers Comp	$111.18
Rate for Payer: Parkland Medicaid	$123.15
Rate for Payer: Scott and White EPO/PPO	$22.06
Rate for Payer: Scott and White Medicare	$17.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$123.15
Rate for Payer: Superior Health Plan EPO	$17.65
Rate for Payer: Superior Health Plan Medicare	$17.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.65
Rate for Payer: Universal American Medicare	$17.65
Rate for Payer: Wellcare Medicare	$17.65
Rate for Payer: Wellmed Medicare	$17.65

Folate, Hemolysate SO

Facility

$171.04

Service Code	HCPCS 82747
Hospital Charge Code	1601863
Hospital Revenue Code	301
Rate for Payer: Cash Price	$116.31

Folate Level

Facility

$331.00

Service Code	HCPCS 82746
Hospital Charge Code	1601855
Hospital Revenue Code	301
Min. Negotiated Rate	$5.73
Max. Negotiated Rate	$238.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.70
Rate for Payer: Amerigroup Medicare	$14.70
Rate for Payer: BCBS of TX Blue Advantage	$99.30
Rate for Payer: BCBS of TX Blue Essentials	$119.16
Rate for Payer: BCBS of TX Medicare	$14.70
Rate for Payer: BCBS of TX PPO	$132.40
Rate for Payer: Cash Price	$225.08
Rate for Payer: Cash Price	$225.08
Rate for Payer: Cigna Medicaid	$238.32
Rate for Payer: Cigna Medicare	$14.70
Rate for Payer: Employer Direct Commercial	$14.70
Rate for Payer: Humana Medicare/TRICARE	$14.70
Rate for Payer: Molina CHIP/Medicaid	$238.32
Rate for Payer: Molina Dual Medicare/Medicaid	$14.70
Rate for Payer: Molina Medicare	$14.70
Rate for Payer: Multiplan Auto	$215.15
Rate for Payer: Multiplan Commercial	$215.15
Rate for Payer: Multiplan Workers Comp	$215.15
Rate for Payer: Parkland Medicaid	$238.32
Rate for Payer: Scott and White EPO/PPO	$18.38
Rate for Payer: Scott and White Medicare	$14.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$238.32
Rate for Payer: Superior Health Plan EPO	$14.70
Rate for Payer: Superior Health Plan Medicare	$14.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.70
Rate for Payer: Universal American Medicare	$14.70
Rate for Payer: Wellcare Medicare	$14.70
Rate for Payer: Wellmed Medicare	$14.70

Folate Level

Facility

$331.00

Service Code	HCPCS 82746
Hospital Charge Code	1601855
Hospital Revenue Code	301
Rate for Payer: Cash Price	$225.08

FOLDER PATIENT ADMIT CITY HOSPITAL AT WHITE ROCK

Facility

$0.62

Hospital Charge Code	993529
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.42

FOLDER PATIENT ADMIT CITY HOSPITAL AT WHITE ROCK

Facility

$0.62

Hospital Charge Code	993529
Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.45
Rate for Payer: Amerigroup CHIP/Medicaid	$0.06
Rate for Payer: BCBS of TX Blue Advantage	$0.19
Rate for Payer: BCBS of TX Blue Essentials	$0.22
Rate for Payer: BCBS of TX PPO	$0.25
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cigna Medicaid	$0.45
Rate for Payer: Molina CHIP/Medicaid	$0.45
Rate for Payer: Multiplan Auto	$0.40
Rate for Payer: Multiplan Commercial	$0.40
Rate for Payer: Multiplan Workers Comp	$0.40
Rate for Payer: Parkland Medicaid	$0.45
Rate for Payer: Scott and White EPO/PPO	$0.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.45
Rate for Payer: Superior Health Plan EPO	$0.08

folic acid 1 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77582494
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

folic acid 1 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77582494
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

folic acid 5 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77582549
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Know your out-of-pocket cost for care.

All Charges