White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OXYGEN PER HOUR Units

Facility

$29.68

Hospital Charge Code	6034600
Hospital Revenue Code	270
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$19.29
Rate for Payer: Aetna Commercial	$16.32
Rate for Payer: Amerigroup CHIP/Medicaid	$2.67
Rate for Payer: BCBS of TX Blue Advantage	$8.90
Rate for Payer: BCBS of TX Blue Essentials	$10.68
Rate for Payer: BCBS of TX PPO	$11.87
Rate for Payer: Cash Price	$26.12
Rate for Payer: Multiplan Auto	$19.29
Rate for Payer: Multiplan Commercial	$19.29
Rate for Payer: Multiplan Workers Comp	$19.29
Rate for Payer: Scott and White EPO/PPO	$14.84
Rate for Payer: Superior Health Plan EPO	$4.04

oxymetazoline 0.05% Nasal Spray 15 mL

Facility

$8.90

Service Code	HCPCS J3490
Hospital Charge Code	77741759
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.05

oxymetazoline 0.05% Nasal Spray 15 mL

Facility

$8.90

Service Code	HCPCS J3490
Hospital Charge Code	77741759
Hospital Revenue Code	250
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$5.78
Rate for Payer: Amerigroup CHIP/Medicaid	$0.80
Rate for Payer: BCBS of TX Blue Advantage	$2.67
Rate for Payer: BCBS of TX Blue Essentials	$3.20
Rate for Payer: BCBS of TX PPO	$3.56
Rate for Payer: Cash Price	$6.05
Rate for Payer: Multiplan Auto	$5.78
Rate for Payer: Multiplan Commercial	$5.78
Rate for Payer: Multiplan Workers Comp	$5.78
Rate for Payer: Scott and White EPO/PPO	$4.45
Rate for Payer: Superior Health Plan EPO	$1.21

Oxytocin Challenge Test

Facility

$878.00

Service Code	CPT 59020
Hospital Charge Code	10140
Hospital Revenue Code	361
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$482.90
Rate for Payer: Aetna Medicare	$273.36
Rate for Payer: Amerigroup CHIP/Medicaid	$27.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$182.24
Rate for Payer: Amerigroup Medicare	$182.24
Rate for Payer: BCBS of TX Blue Advantage	$55.31
Rate for Payer: BCBS of TX Blue Essentials	$66.37
Rate for Payer: BCBS of TX Medicare	$182.24
Rate for Payer: BCBS of TX PPO	$74.08
Rate for Payer: Cash Price	$772.64
Rate for Payer: Cash Price	$772.64
Rate for Payer: Cash Price	$772.64
Rate for Payer: Cigna Commercial	$412.83
Rate for Payer: Cigna Medicaid	$27.13
Rate for Payer: Cigna Medicare	$182.24
Rate for Payer: Employer Direct Commercial	$182.24
Rate for Payer: Humana Medicare/TRICARE	$182.24
Rate for Payer: Molina CHIP/Medicaid	$27.13
Rate for Payer: Molina Dual Medicare/Medicaid	$182.24
Rate for Payer: Molina Medicare	$182.24
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	$27.13
Rate for Payer: Scott and White EPO/PPO	$4.02
Rate for Payer: Scott and White Medicare	$182.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.13
Rate for Payer: Superior Health Plan EPO	$182.24
Rate for Payer: Superior Health Plan Medicare	$182.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$182.24
Rate for Payer: Universal American Medicare	$182.24
Rate for Payer: Wellcare Medicare	$182.24
Rate for Payer: Wellmed Medicare	$182.24

Oxytocin Challenge Test

Facility

$878.00

Service Code	CPT 59020
Hospital Charge Code	10140
Hospital Revenue Code	361
Rate for Payer: Cash Price	$772.64

PACE ADAPTER CBL -- DHF

Facility

$495.28

Hospital Charge Code	81760159
Hospital Revenue Code	270
Min. Negotiated Rate	$44.58
Max. Negotiated Rate	$321.93
Rate for Payer: Aetna Commercial	$272.40
Rate for Payer: Amerigroup CHIP/Medicaid	$44.58
Rate for Payer: BCBS of TX Blue Advantage	$148.58
Rate for Payer: BCBS of TX Blue Essentials	$178.30
Rate for Payer: BCBS of TX PPO	$198.11
Rate for Payer: Cash Price	$435.85
Rate for Payer: Multiplan Auto	$321.93
Rate for Payer: Multiplan Commercial	$321.93
Rate for Payer: Multiplan Workers Comp	$321.93
Rate for Payer: Scott and White EPO/PPO	$247.64
Rate for Payer: Superior Health Plan EPO	$67.36

PACE ADAPTER CBL -- DHF

Facility

$495.28

Hospital Charge Code	81760159
Hospital Revenue Code	270
Rate for Payer: Cash Price	$435.85

PACEMAKER ALLURE RF PM3222

Facility

$31,437.11

Service Code	HCPCS C2621
Hospital Charge Code	109902
Hospital Revenue Code	275
Min. Negotiated Rate	$7,859.28
Max. Negotiated Rate	$15,718.56
Rate for Payer: Aetna Commercial	$9,431.13
Rate for Payer: Cash Price	$27,664.66
Rate for Payer: Cigna Commercial	$7,859.28
Rate for Payer: Multiplan Auto	$15,718.56
Rate for Payer: Multiplan Commercial	$15,718.56
Rate for Payer: Multiplan Workers Comp	$15,718.56
Rate for Payer: Scott and White EPO/PPO	$15,718.56

PACEMAKER ALLURE RF PM3222

Facility

$31,437.11

Service Code	HCPCS C2621
Hospital Charge Code	109902
Hospital Revenue Code	275
Min. Negotiated Rate	$2,829.34
Max. Negotiated Rate	$15,718.56
Rate for Payer: Aetna Commercial	$9,431.13
Rate for Payer: Amerigroup CHIP/Medicaid	$2,829.34
Rate for Payer: BCBS of TX Blue Advantage	$9,431.13
Rate for Payer: BCBS of TX Blue Essentials	$11,317.36
Rate for Payer: BCBS of TX PPO	$12,574.84
Rate for Payer: Cash Price	$27,664.66
Rate for Payer: Multiplan Auto	$15,718.56
Rate for Payer: Multiplan Commercial	$15,718.56
Rate for Payer: Multiplan Workers Comp	$15,718.56
Rate for Payer: Scott and White EPO/PPO	$15,718.56
Rate for Payer: Superior Health Plan EPO	$4,275.45

PACK, ARTHROSCOPY I DRAPES,GOWNS,TOWELS 90''''X121'''' -- DHF

Facility

$127.21

Hospital Charge Code	81650152
Hospital Revenue Code	272
Rate for Payer: Cash Price	$111.94

PACK, ARTHROSCOPY I DRAPES,GOWNS,TOWELS 90''''X121'''' -- DHF

Facility

$127.21

Hospital Charge Code	81650152
Hospital Revenue Code	272
Min. Negotiated Rate	$11.45
Max. Negotiated Rate	$82.69
Rate for Payer: Aetna Commercial	$69.97
Rate for Payer: Amerigroup CHIP/Medicaid	$11.45
Rate for Payer: BCBS of TX Blue Advantage	$38.16
Rate for Payer: BCBS of TX Blue Essentials	$45.80
Rate for Payer: BCBS of TX PPO	$50.88
Rate for Payer: Cash Price	$111.94
Rate for Payer: Multiplan Auto	$82.69
Rate for Payer: Multiplan Commercial	$82.69
Rate for Payer: Multiplan Workers Comp	$82.69
Rate for Payer: Scott and White EPO/PPO	$63.60
Rate for Payer: Superior Health Plan EPO	$17.30

PACK CARDIAC CATH

Facility

$228.68

Hospital Charge Code	131567
Hospital Revenue Code	272
Min. Negotiated Rate	$20.58
Max. Negotiated Rate	$148.64
Rate for Payer: Aetna Commercial	$125.77
Rate for Payer: Amerigroup CHIP/Medicaid	$20.58
Rate for Payer: BCBS of TX Blue Advantage	$68.60
Rate for Payer: BCBS of TX Blue Essentials	$82.32
Rate for Payer: BCBS of TX PPO	$91.47
Rate for Payer: Cash Price	$201.24
Rate for Payer: Multiplan Auto	$148.64
Rate for Payer: Multiplan Commercial	$148.64
Rate for Payer: Multiplan Workers Comp	$148.64
Rate for Payer: Scott and White EPO/PPO	$114.34
Rate for Payer: Superior Health Plan EPO	$31.10

PACK CARDIAC CATH

Facility

$228.68

Hospital Charge Code	131567
Hospital Revenue Code	272
Rate for Payer: Cash Price	$201.24

PACK CPS DIRECT UNIV FINAL

Facility

$1,861.40

Hospital Charge Code	8504478
Hospital Revenue Code	272
Min. Negotiated Rate	$167.53
Max. Negotiated Rate	$1,209.91
Rate for Payer: Aetna Commercial	$1,023.77
Rate for Payer: Amerigroup CHIP/Medicaid	$167.53
Rate for Payer: BCBS of TX Blue Advantage	$558.42
Rate for Payer: BCBS of TX Blue Essentials	$670.10
Rate for Payer: BCBS of TX PPO	$744.56
Rate for Payer: Cash Price	$1,638.03
Rate for Payer: Multiplan Auto	$1,209.91
Rate for Payer: Multiplan Commercial	$1,209.91
Rate for Payer: Multiplan Workers Comp	$1,209.91
Rate for Payer: Scott and White EPO/PPO	$930.70
Rate for Payer: Superior Health Plan EPO	$253.15

PACK CPS DIRECT UNIV FINAL

Facility

$1,861.40

Hospital Charge Code	8504478
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,638.03

PACK DYNACLIP PROCEDURE

Facility

$1,589.00

Hospital Charge Code	145501
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,398.32

PACK DYNACLIP PROCEDURE

Facility

$1,589.00

Hospital Charge Code	145501
Hospital Revenue Code	272
Min. Negotiated Rate	$143.01
Max. Negotiated Rate	$1,032.85
Rate for Payer: Aetna Commercial	$873.95
Rate for Payer: Amerigroup CHIP/Medicaid	$143.01
Rate for Payer: BCBS of TX Blue Advantage	$476.70
Rate for Payer: BCBS of TX Blue Essentials	$572.04
Rate for Payer: BCBS of TX PPO	$635.60
Rate for Payer: Cash Price	$1,398.32
Rate for Payer: Multiplan Auto	$1,032.85
Rate for Payer: Multiplan Commercial	$1,032.85
Rate for Payer: Multiplan Workers Comp	$1,032.85
Rate for Payer: Scott and White EPO/PPO	$794.50
Rate for Payer: Superior Health Plan EPO	$216.10

PACK, LAPAROSCOPY/PELVISCOPY AURORA SUTURE BAG -- DHF

Facility

$730.83

Hospital Charge Code	81651556
Hospital Revenue Code	272
Rate for Payer: Cash Price	$643.13

PACK, LAPAROSCOPY/PELVISCOPY AURORA SUTURE BAG -- DHF

Facility

$730.83

Hospital Charge Code	81651556
Hospital Revenue Code	272
Min. Negotiated Rate	$65.77
Max. Negotiated Rate	$475.04
Rate for Payer: Aetna Commercial	$401.96
Rate for Payer: Amerigroup CHIP/Medicaid	$65.77
Rate for Payer: BCBS of TX Blue Advantage	$219.25
Rate for Payer: BCBS of TX Blue Essentials	$263.10
Rate for Payer: BCBS of TX PPO	$292.33
Rate for Payer: Cash Price	$643.13
Rate for Payer: Multiplan Auto	$475.04
Rate for Payer: Multiplan Commercial	$475.04
Rate for Payer: Multiplan Workers Comp	$475.04
Rate for Payer: Scott and White EPO/PPO	$365.42
Rate for Payer: Superior Health Plan EPO	$99.39

PACK, LITHOTOMY 1 -- DHF

Facility

$87.56

Hospital Charge Code	80836455
Hospital Revenue Code	272
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$56.91
Rate for Payer: Aetna Commercial	$48.16
Rate for Payer: Amerigroup CHIP/Medicaid	$7.88
Rate for Payer: BCBS of TX Blue Advantage	$26.27
Rate for Payer: BCBS of TX Blue Essentials	$31.52
Rate for Payer: BCBS of TX PPO	$35.02
Rate for Payer: Cash Price	$77.05
Rate for Payer: Multiplan Auto	$56.91
Rate for Payer: Multiplan Commercial	$56.91
Rate for Payer: Multiplan Workers Comp	$56.91
Rate for Payer: Scott and White EPO/PPO	$43.78
Rate for Payer: Superior Health Plan EPO	$11.91

PACK, LITHOTOMY 1 -- DHF

Facility

$87.56

Hospital Charge Code	80836455
Hospital Revenue Code	272
Rate for Payer: Cash Price	$77.05

PACK, LITHOTOMY III SIRUS -- DHF

Facility

$501.49

Hospital Charge Code	81651309
Hospital Revenue Code	272
Min. Negotiated Rate	$45.13
Max. Negotiated Rate	$325.97
Rate for Payer: Aetna Commercial	$275.82
Rate for Payer: Amerigroup CHIP/Medicaid	$45.13
Rate for Payer: BCBS of TX Blue Advantage	$150.45
Rate for Payer: BCBS of TX Blue Essentials	$180.54
Rate for Payer: BCBS of TX PPO	$200.60
Rate for Payer: Cash Price	$441.31
Rate for Payer: Multiplan Auto	$325.97
Rate for Payer: Multiplan Commercial	$325.97
Rate for Payer: Multiplan Workers Comp	$325.97
Rate for Payer: Scott and White EPO/PPO	$250.74
Rate for Payer: Superior Health Plan EPO	$68.20

PACK, LITHOTOMY III SIRUS -- DHF

Facility

$501.49

Hospital Charge Code	81651309
Hospital Revenue Code	272
Rate for Payer: Cash Price	$441.31

PACK MAJOR

Facility

$188.50

Hospital Charge Code	8514474
Hospital Revenue Code	272
Rate for Payer: Cash Price	$165.88

PACK MAJOR

Facility

$188.50

Hospital Charge Code	8514474
Hospital Revenue Code	272
Min. Negotiated Rate	$16.96
Max. Negotiated Rate	$122.52
Rate for Payer: Aetna Commercial	$103.68
Rate for Payer: Amerigroup CHIP/Medicaid	$16.96
Rate for Payer: BCBS of TX Blue Advantage	$56.55
Rate for Payer: BCBS of TX Blue Essentials	$67.86
Rate for Payer: BCBS of TX PPO	$75.40
Rate for Payer: Cash Price	$165.88
Rate for Payer: Multiplan Auto	$122.52
Rate for Payer: Multiplan Commercial	$122.52
Rate for Payer: Multiplan Workers Comp	$122.52
Rate for Payer: Scott and White EPO/PPO	$94.25
Rate for Payer: Superior Health Plan EPO	$25.64

Know your out-of-pocket cost for care.

All Charges