White Rock Medical Center

All Charges

Charge

Type

Setting

Price

IB KIT, BC, W/ CC FT AND JUMPSTART

Facility

$11,313.68

Service Code	HCPCS C1776
Hospital Charge Code	992612
Hospital Revenue Code	278
Min. Negotiated Rate	$1,018.23
Max. Negotiated Rate	$8,145.85
Rate for Payer: Amerigroup CHIP/Medicaid	$1,018.23
Rate for Payer: BCBS of TX Blue Advantage	$3,394.10
Rate for Payer: BCBS of TX Blue Essentials	$4,072.92
Rate for Payer: BCBS of TX PPO	$4,525.47
Rate for Payer: Cash Price	$7,693.30
Rate for Payer: Cigna Medicaid	$8,145.85
Rate for Payer: Molina CHIP/Medicaid	$8,145.85
Rate for Payer: Multiplan Auto	$5,656.84
Rate for Payer: Multiplan Commercial	$5,656.84
Rate for Payer: Multiplan Workers Comp	$5,656.84
Rate for Payer: Parkland Medicaid	$8,145.85
Rate for Payer: Scott and White EPO/PPO	$5,656.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,145.85
Rate for Payer: Superior Health Plan EPO	$1,538.66

IB KIT, BC, W/ CC FT AND JUMPSTART

Facility

$11,313.68

Service Code	HCPCS C1776
Hospital Charge Code	992612
Hospital Revenue Code	278
Min. Negotiated Rate	$2,828.42
Max. Negotiated Rate	$5,656.84
Rate for Payer: Cash Price	$7,693.30
Rate for Payer: Cigna Commercial	$2,828.42
Rate for Payer: Multiplan Auto	$5,656.84
Rate for Payer: Multiplan Commercial	$5,656.84
Rate for Payer: Multiplan Workers Comp	$5,656.84
Rate for Payer: Scott and White EPO/PPO	$5,656.84

ibuprofen 100 mg/5 mL Oral Susp 480 mL

Facility

$81.95

Service Code	HCPCS J3490
Hospital Charge Code	77627059
Hospital Revenue Code	250
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$59.00
Rate for Payer: Amerigroup CHIP/Medicaid	$7.38
Rate for Payer: BCBS of TX Blue Advantage	$24.59
Rate for Payer: BCBS of TX Blue Essentials	$29.50
Rate for Payer: BCBS of TX PPO	$32.78
Rate for Payer: Cash Price	$55.73
Rate for Payer: Cigna Medicaid	$59.00
Rate for Payer: Molina CHIP/Medicaid	$59.00
Rate for Payer: Multiplan Auto	$53.27
Rate for Payer: Multiplan Commercial	$53.27
Rate for Payer: Multiplan Workers Comp	$53.27
Rate for Payer: Parkland Medicaid	$59.00
Rate for Payer: Scott and White EPO/PPO	$40.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.00
Rate for Payer: Superior Health Plan EPO	$11.15

ibuprofen 100 mg/5 mL Oral Susp 480 mL

Facility

$81.95

Service Code	HCPCS J3490
Hospital Charge Code	77627059
Hospital Revenue Code	250
Rate for Payer: Cash Price	$55.73

ibuprofen 100 mg/5 mL Oral Susp 5 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77627112
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ibuprofen 100 mg/5 mL Oral Susp 5 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77627112
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

ibuprofen 400 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77627436
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

ibuprofen 400 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77627436
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ibuprofen 600 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77627650
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ibuprofen 600 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77627650
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

ibuprofen 800 mg / 200 mL

Facility

$128.17

Service Code	HCPCS J1741
Hospital Charge Code	79495460
Hospital Revenue Code	636
Min. Negotiated Rate	$2.91
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.91
Rate for Payer: BCBS of TX Blue Essentials	$3.50
Rate for Payer: BCBS of TX PPO	$3.88
Rate for Payer: Cash Price	$87.16
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

ibuprofen 800 mg / 200 mL

Facility

$128.17

Service Code	HCPCS J1741
Hospital Charge Code	79495460
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

IGF-1 SO

Facility

$200.22

Service Code	HCPCS 84305
Hospital Charge Code	1707140
Hospital Revenue Code	301
Rate for Payer: Cash Price	$136.15

IGF-1 SO

Facility

$200.22

Service Code	HCPCS 84305
Hospital Charge Code	1707140
Hospital Revenue Code	301
Min. Negotiated Rate	$8.29
Max. Negotiated Rate	$144.16
Rate for Payer: Amerigroup CHIP/Medicaid	$8.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.26
Rate for Payer: Amerigroup Medicare	$21.26
Rate for Payer: BCBS of TX Blue Advantage	$60.07
Rate for Payer: BCBS of TX Blue Essentials	$72.08
Rate for Payer: BCBS of TX Medicare	$21.26
Rate for Payer: BCBS of TX PPO	$80.09
Rate for Payer: Cash Price	$136.15
Rate for Payer: Cash Price	$136.15
Rate for Payer: Cigna Medicaid	$144.16
Rate for Payer: Cigna Medicare	$21.26
Rate for Payer: Employer Direct Commercial	$21.26
Rate for Payer: Humana Medicare/TRICARE	$21.26
Rate for Payer: Molina CHIP/Medicaid	$144.16
Rate for Payer: Molina Dual Medicare/Medicaid	$21.26
Rate for Payer: Molina Medicare	$21.26
Rate for Payer: Multiplan Auto	$130.14
Rate for Payer: Multiplan Commercial	$130.14
Rate for Payer: Multiplan Workers Comp	$130.14
Rate for Payer: Parkland Medicaid	$144.16
Rate for Payer: Scott and White EPO/PPO	$26.57
Rate for Payer: Scott and White Medicare	$21.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$144.16
Rate for Payer: Superior Health Plan EPO	$21.26
Rate for Payer: Superior Health Plan Medicare	$21.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.26
Rate for Payer: Universal American Medicare	$21.26
Rate for Payer: Wellcare Medicare	$21.26
Rate for Payer: Wellmed Medicare	$21.26

illuminator surg 60mm

Facility

$4,199.50

Hospital Charge Code	8672529
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,855.66

illuminator surg 60mm

Facility

$4,199.50

Hospital Charge Code	8672529
Hospital Revenue Code	272
Min. Negotiated Rate	$377.95
Max. Negotiated Rate	$3,023.64
Rate for Payer: Amerigroup CHIP/Medicaid	$377.95
Rate for Payer: BCBS of TX Blue Advantage	$1,259.85
Rate for Payer: BCBS of TX Blue Essentials	$1,511.82
Rate for Payer: BCBS of TX PPO	$1,679.80
Rate for Payer: Cash Price	$2,855.66
Rate for Payer: Cigna Medicaid	$3,023.64
Rate for Payer: Molina CHIP/Medicaid	$3,023.64
Rate for Payer: Multiplan Auto	$2,729.68
Rate for Payer: Multiplan Commercial	$2,729.68
Rate for Payer: Multiplan Workers Comp	$2,729.68
Rate for Payer: Parkland Medicaid	$3,023.64
Rate for Payer: Scott and White EPO/PPO	$2,099.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,023.64
Rate for Payer: Superior Health Plan EPO	$571.13

Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

Facility

$19,555.95

Service Code	HCPCS 19340
Hospital Charge Code	9900160
Hospital Revenue Code	360
Min. Negotiated Rate	$1,845.21
Max. Negotiated Rate	$17,355.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1,845.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,210.63
Rate for Payer: Amerigroup Medicare	$8,210.63
Rate for Payer: BCBS of TX Blue Advantage	$8,746.27
Rate for Payer: BCBS of TX Blue Essentials	$10,474.58
Rate for Payer: BCBS of TX Medicare	$8,210.63
Rate for Payer: BCBS of TX PPO	$13,197.97
Rate for Payer: Cash Price	$13,298.05
Rate for Payer: Cash Price	$13,298.05
Rate for Payer: Cash Price	$13,298.05
Rate for Payer: Cigna Commercial	$17,355.80
Rate for Payer: Cigna Medicaid	$14,080.28
Rate for Payer: Cigna Medicare	$8,210.63
Rate for Payer: Employer Direct Commercial	$8,210.63
Rate for Payer: Humana Medicare/TRICARE	$8,210.63
Rate for Payer: Molina CHIP/Medicaid	$14,080.28
Rate for Payer: Molina Dual Medicare/Medicaid	$8,210.63
Rate for Payer: Molina Medicare	$8,210.63
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	$14,080.28
Rate for Payer: Scott and White EPO/PPO	$11,033.10
Rate for Payer: Scott and White Medicare	$8,210.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,080.28
Rate for Payer: Superior Health Plan EPO	$8,210.63
Rate for Payer: Superior Health Plan Medicare	$8,210.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,210.63
Rate for Payer: Universal American Medicare	$8,210.63
Rate for Payer: Wellcare Medicare	$8,210.63
Rate for Payer: Wellmed Medicare	$8,210.63

Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

Facility

$19,555.95

Service Code	HCPCS 19340
Hospital Charge Code	9900160
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,298.05

Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

Facility

$17,355.80

Service Code	CPT 19340
Hospital Charge Code	36019340
Hospital Revenue Code	360
Min. Negotiated Rate	$1,845.21
Max. Negotiated Rate	$17,355.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1,845.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,210.63
Rate for Payer: Amerigroup Medicare	$8,210.63
Rate for Payer: BCBS of TX Blue Advantage	$8,746.27
Rate for Payer: BCBS of TX Blue Essentials	$10,474.58
Rate for Payer: BCBS of TX Medicare	$8,210.63
Rate for Payer: BCBS of TX PPO	$13,197.97
Rate for Payer: Cigna Commercial	$17,355.80
Rate for Payer: Cigna Medicare	$8,210.63
Rate for Payer: Employer Direct Commercial	$8,210.63
Rate for Payer: Humana Medicare/TRICARE	$8,210.63
Rate for Payer: Molina Dual Medicare/Medicaid	$8,210.63
Rate for Payer: Molina Medicare	$8,210.63
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 EPO/PPO	$11,033.10
Rate for Payer: Scott and White Medicare	$8,210.63
Rate for Payer: Superior Health Plan EPO	$8,210.63
Rate for Payer: Superior Health Plan Medicare	$8,210.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,210.63
Rate for Payer: Universal American Medicare	$8,210.63
Rate for Payer: Wellcare Medicare	$8,210.63
Rate for Payer: Wellmed Medicare	$8,210.63

IMMOBILIZER SHOULDER KAHUNA MINI

Facility

$352.76

Hospital Charge Code	144898
Hospital Revenue Code	270
Rate for Payer: Cash Price	$239.88

IMMOBILIZER SHOULDER KAHUNA MINI

Facility

$352.76

Hospital Charge Code	144898
Hospital Revenue Code	270
Min. Negotiated Rate	$31.75
Max. Negotiated Rate	$253.99
Rate for Payer: Amerigroup CHIP/Medicaid	$31.75
Rate for Payer: BCBS of TX Blue Advantage	$105.83
Rate for Payer: BCBS of TX Blue Essentials	$126.99
Rate for Payer: BCBS of TX PPO	$141.10
Rate for Payer: Cash Price	$239.88
Rate for Payer: Cigna Medicaid	$253.99
Rate for Payer: Molina CHIP/Medicaid	$253.99
Rate for Payer: Multiplan Auto	$229.29
Rate for Payer: Multiplan Commercial	$229.29
Rate for Payer: Multiplan Workers Comp	$229.29
Rate for Payer: Parkland Medicaid	$253.99
Rate for Payer: Scott and White EPO/PPO	$176.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$253.99
Rate for Payer: Superior Health Plan EPO	$47.98

.Immunofixation Elect 001686 SO

Facility

$417.00

Service Code	HCPCS 86334
Hospital Charge Code	1602044
Hospital Revenue Code	302
Rate for Payer: Cash Price	$283.56

.Immunofixation Elect 001686 SO

Facility

$417.00

Service Code	HCPCS 86334
Hospital Charge Code	1602044
Hospital Revenue Code	302
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$300.24
Rate for Payer: Amerigroup CHIP/Medicaid	$8.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22.34
Rate for Payer: Amerigroup Medicare	$22.34
Rate for Payer: BCBS of TX Blue Advantage	$125.10
Rate for Payer: BCBS of TX Blue Essentials	$150.12
Rate for Payer: BCBS of TX Medicare	$22.34
Rate for Payer: BCBS of TX PPO	$166.80
Rate for Payer: Cash Price	$283.56
Rate for Payer: Cash Price	$283.56
Rate for Payer: Cigna Medicaid	$300.24
Rate for Payer: Cigna Medicare	$22.34
Rate for Payer: Employer Direct Commercial	$22.34
Rate for Payer: Humana Medicare/TRICARE	$22.34
Rate for Payer: Molina CHIP/Medicaid	$300.24
Rate for Payer: Molina Dual Medicare/Medicaid	$22.34
Rate for Payer: Molina Medicare	$22.34
Rate for Payer: Multiplan Auto	$271.05
Rate for Payer: Multiplan Commercial	$271.05
Rate for Payer: Multiplan Workers Comp	$271.05
Rate for Payer: Parkland Medicaid	$300.24
Rate for Payer: Scott and White EPO/PPO	$27.93
Rate for Payer: Scott and White Medicare	$22.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$300.24
Rate for Payer: Superior Health Plan EPO	$22.34
Rate for Payer: Superior Health Plan Medicare	$22.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$22.34
Rate for Payer: Universal American Medicare	$22.34
Rate for Payer: Wellcare Medicare	$22.34
Rate for Payer: Wellmed Medicare	$22.34

Immunoglobulin G,Syn Rate,CSF SO

Facility

$180.00

Service Code	HCPCS 82040
Hospital Charge Code	1601491
Hospital Revenue Code	301
Rate for Payer: Cash Price	$122.40

Immunoglobulin G,Syn Rate,CSF SO

Facility

$180.00

Service Code	HCPCS 82040
Hospital Charge Code	1601491
Hospital Revenue Code	301
Min. Negotiated Rate	$1.93
Max. Negotiated Rate	$129.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.95
Rate for Payer: Amerigroup Medicare	$4.95
Rate for Payer: BCBS of TX Blue Advantage	$54.00
Rate for Payer: BCBS of TX Blue Essentials	$64.80
Rate for Payer: BCBS of TX Medicare	$4.95
Rate for Payer: BCBS of TX PPO	$72.00
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cigna Medicaid	$129.60
Rate for Payer: Cigna Medicare	$4.95
Rate for Payer: Employer Direct Commercial	$4.95
Rate for Payer: Humana Medicare/TRICARE	$4.95
Rate for Payer: Molina CHIP/Medicaid	$129.60
Rate for Payer: Molina Dual Medicare/Medicaid	$4.95
Rate for Payer: Molina Medicare	$4.95
Rate for Payer: Multiplan Auto	$117.00
Rate for Payer: Multiplan Commercial	$117.00
Rate for Payer: Multiplan Workers Comp	$117.00
Rate for Payer: Parkland Medicaid	$129.60
Rate for Payer: Scott and White EPO/PPO	$6.19
Rate for Payer: Scott and White Medicare	$4.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$129.60
Rate for Payer: Superior Health Plan EPO	$4.95
Rate for Payer: Superior Health Plan Medicare	$4.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.95
Rate for Payer: Universal American Medicare	$4.95
Rate for Payer: Wellcare Medicare	$4.95
Rate for Payer: Wellmed Medicare	$4.95

Know your out-of-pocket cost for care.

All Charges