White Rock Medical Center

All Charges

Charge

Type

Setting

Price

iohexol 350 mg/mL Inj Soln 100 mL

Facility

$128.00

Service Code	HCPCS Q9967
Hospital Charge Code	77637772
Hospital Revenue Code	255
Rate for Payer: Cash Price	$87.04

iohexol 350 mg/mL Inj Soln 100 mL

Facility

$128.00

Service Code	HCPCS Q9967
Hospital Charge Code	77637772
Hospital Revenue Code	255
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.46
Rate for Payer: BCBS of TX Blue Essentials	$0.56
Rate for Payer: BCBS of TX PPO	$0.62
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

iopamidol 61% Inj Soln 100 mL

Facility

$128.00

Service Code	HCPCS Q9967
Hospital Charge Code	77639119
Hospital Revenue Code	255
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.46
Rate for Payer: BCBS of TX Blue Essentials	$0.56
Rate for Payer: BCBS of TX PPO	$0.62
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

iopamidol 61% Inj Soln 100 mL

Facility

$128.00

Service Code	HCPCS Q9967
Hospital Charge Code	77639119
Hospital Revenue Code	255
Rate for Payer: Cash Price	$87.04

iopamidol 61% Inj Soln 100 mL

Facility

$128.00

Service Code	HCPCS Q9967
Hospital Charge Code	77638244
Hospital Revenue Code	255
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.46
Rate for Payer: BCBS of TX Blue Essentials	$0.56
Rate for Payer: BCBS of TX PPO	$0.62
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

iopamidol 61% Inj Soln 100 mL

Facility

$128.00

Service Code	HCPCS Q9967
Hospital Charge Code	77638244
Hospital Revenue Code	255
Rate for Payer: Cash Price	$87.04

IPG TEMPLATE

Facility

$340.50

Hospital Charge Code	13522726
Hospital Revenue Code	272
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$245.16
Rate for Payer: Amerigroup CHIP/Medicaid	$30.64
Rate for Payer: BCBS of TX Blue Advantage	$102.15
Rate for Payer: BCBS of TX Blue Essentials	$122.58
Rate for Payer: BCBS of TX PPO	$136.20
Rate for Payer: Cash Price	$231.54
Rate for Payer: Cigna Medicaid	$245.16
Rate for Payer: Molina CHIP/Medicaid	$245.16
Rate for Payer: Multiplan Auto	$221.32
Rate for Payer: Multiplan Commercial	$221.32
Rate for Payer: Multiplan Workers Comp	$221.32
Rate for Payer: Parkland Medicaid	$245.16
Rate for Payer: Scott and White EPO/PPO	$170.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$245.16
Rate for Payer: Superior Health Plan EPO	$46.31

IPG TEMPLATE

Facility

$340.50

Hospital Charge Code	13522726
Hospital Revenue Code	272
Rate for Payer: Cash Price	$231.54

IPG W1DR01 AZURE XT DR MRI

Facility

$11,804.00

Service Code	HCPCS C1785
Hospital Charge Code	8628563
Hospital Revenue Code	275
Min. Negotiated Rate	$2,951.00
Max. Negotiated Rate	$5,902.00
Rate for Payer: Cash Price	$8,026.72
Rate for Payer: Cigna Commercial	$2,951.00
Rate for Payer: Multiplan Auto	$5,902.00
Rate for Payer: Multiplan Commercial	$5,902.00
Rate for Payer: Multiplan Workers Comp	$5,902.00
Rate for Payer: Scott and White EPO/PPO	$5,902.00

IPG W1DR01 AZURE XT DR MRI

Facility

$11,804.00

Service Code	HCPCS C1785
Hospital Charge Code	8628563
Hospital Revenue Code	275
Min. Negotiated Rate	$1,062.36
Max. Negotiated Rate	$8,498.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1,062.36
Rate for Payer: BCBS of TX Blue Advantage	$3,541.20
Rate for Payer: BCBS of TX Blue Essentials	$4,249.44
Rate for Payer: BCBS of TX PPO	$4,721.60
Rate for Payer: Cash Price	$8,026.72
Rate for Payer: Cigna Medicaid	$8,498.88
Rate for Payer: Molina CHIP/Medicaid	$8,498.88
Rate for Payer: Multiplan Auto	$5,902.00
Rate for Payer: Multiplan Commercial	$5,902.00
Rate for Payer: Multiplan Workers Comp	$5,902.00
Rate for Payer: Parkland Medicaid	$8,498.88
Rate for Payer: Scott and White EPO/PPO	$5,902.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,498.88
Rate for Payer: Superior Health Plan EPO	$1,605.34

IPG W1DR01 AZURE XT DR MRI

Facility

$11,804.00

Service Code	HCPCS C1785
Hospital Charge Code	992467
Hospital Revenue Code	275
Min. Negotiated Rate	$1,062.36
Max. Negotiated Rate	$8,498.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1,062.36
Rate for Payer: BCBS of TX Blue Advantage	$3,541.20
Rate for Payer: BCBS of TX Blue Essentials	$4,249.44
Rate for Payer: BCBS of TX PPO	$4,721.60
Rate for Payer: Cash Price	$8,026.72
Rate for Payer: Cigna Medicaid	$8,498.88
Rate for Payer: Molina CHIP/Medicaid	$8,498.88
Rate for Payer: Multiplan Auto	$5,902.00
Rate for Payer: Multiplan Commercial	$5,902.00
Rate for Payer: Multiplan Workers Comp	$5,902.00
Rate for Payer: Parkland Medicaid	$8,498.88
Rate for Payer: Scott and White EPO/PPO	$5,902.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,498.88
Rate for Payer: Superior Health Plan EPO	$1,605.34

IPG W1DR01 AZURE XT DR MRI

Facility

$11,804.00

Service Code	HCPCS C1785
Hospital Charge Code	992467
Hospital Revenue Code	275
Min. Negotiated Rate	$2,951.00
Max. Negotiated Rate	$5,902.00
Rate for Payer: Cash Price	$8,026.72
Rate for Payer: Cigna Commercial	$2,951.00
Rate for Payer: Multiplan Auto	$5,902.00
Rate for Payer: Multiplan Commercial	$5,902.00
Rate for Payer: Multiplan Workers Comp	$5,902.00
Rate for Payer: Scott and White EPO/PPO	$5,902.00

ipratropium 500 mcg/2.5 mL Inh Soln 2.5 mL

Facility

$7.65

Service Code	HCPCS J7644
Hospital Charge Code	77643468
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.83

ipratropium 500 mcg/2.5 mL Inh Soln 2.5 mL

Facility

$7.65

Service Code	HCPCS J7644
Hospital Charge Code	77643468
Hospital Revenue Code	636
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	$0.74
Rate for Payer: BCBS of TX Blue Essentials	$0.89
Rate for Payer: BCBS of TX PPO	$0.98
Rate for Payer: Cash Price	$5.20
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

Iron Bind.Cap.(TIBC)

Facility

$317.00

Service Code	HCPCS 83550
Hospital Charge Code	9050982
Hospital Revenue Code	301
Rate for Payer: Cash Price	$215.56

Iron Bind.Cap.(TIBC)

Facility

$317.00

Service Code	HCPCS 83550
Hospital Charge Code	9050982
Hospital Revenue Code	301
Min. Negotiated Rate	$3.41
Max. Negotiated Rate	$228.24
Rate for Payer: Amerigroup CHIP/Medicaid	$3.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.74
Rate for Payer: Amerigroup Medicare	$8.74
Rate for Payer: BCBS of TX Blue Advantage	$95.10
Rate for Payer: BCBS of TX Blue Essentials	$114.12
Rate for Payer: BCBS of TX Medicare	$8.74
Rate for Payer: BCBS of TX PPO	$126.80
Rate for Payer: Cash Price	$215.56
Rate for Payer: Cash Price	$215.56
Rate for Payer: Cigna Medicaid	$228.24
Rate for Payer: Cigna Medicare	$8.74
Rate for Payer: Employer Direct Commercial	$8.74
Rate for Payer: Humana Medicare/TRICARE	$8.74
Rate for Payer: Molina CHIP/Medicaid	$228.24
Rate for Payer: Molina Dual Medicare/Medicaid	$8.74
Rate for Payer: Molina Medicare	$8.74
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$228.24
Rate for Payer: Scott and White EPO/PPO	$10.93
Rate for Payer: Scott and White Medicare	$8.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$228.24
Rate for Payer: Superior Health Plan EPO	$8.74
Rate for Payer: Superior Health Plan Medicare	$8.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.74
Rate for Payer: Universal American Medicare	$8.74
Rate for Payer: Wellcare Medicare	$8.74
Rate for Payer: Wellmed Medicare	$8.74

Iron Level

Facility

$288.00

Service Code	HCPCS 83540
Hospital Charge Code	1602002
Hospital Revenue Code	301
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$207.36
Rate for Payer: Amerigroup CHIP/Medicaid	$2.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.47
Rate for Payer: Amerigroup Medicare	$6.47
Rate for Payer: BCBS of TX Blue Advantage	$86.40
Rate for Payer: BCBS of TX Blue Essentials	$103.68
Rate for Payer: BCBS of TX Medicare	$6.47
Rate for Payer: BCBS of TX PPO	$115.20
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cigna Medicaid	$207.36
Rate for Payer: Cigna Medicare	$6.47
Rate for Payer: Employer Direct Commercial	$6.47
Rate for Payer: Humana Medicare/TRICARE	$6.47
Rate for Payer: Molina CHIP/Medicaid	$207.36
Rate for Payer: Molina Dual Medicare/Medicaid	$6.47
Rate for Payer: Molina Medicare	$6.47
Rate for Payer: Multiplan Auto	$187.20
Rate for Payer: Multiplan Commercial	$187.20
Rate for Payer: Multiplan Workers Comp	$187.20
Rate for Payer: Parkland Medicaid	$207.36
Rate for Payer: Scott and White EPO/PPO	$8.09
Rate for Payer: Scott and White Medicare	$6.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$207.36
Rate for Payer: Superior Health Plan EPO	$6.47
Rate for Payer: Superior Health Plan Medicare	$6.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.47
Rate for Payer: Universal American Medicare	$6.47
Rate for Payer: Wellcare Medicare	$6.47
Rate for Payer: Wellmed Medicare	$6.47

Iron Level

Facility

$288.00

Service Code	HCPCS 83540
Hospital Charge Code	1602002
Hospital Revenue Code	301
Rate for Payer: Cash Price	$195.84

iron sucrose 20 mg/mL IV Soln 10 mL

Facility

$258.75

Service Code	HCPCS J1756
Hospital Charge Code	77644387
Hospital Revenue Code	636
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$186.30
Rate for Payer: Amerigroup CHIP/Medicaid	$23.29
Rate for Payer: BCBS of TX Blue Advantage	$0.51
Rate for Payer: BCBS of TX Blue Essentials	$0.61
Rate for Payer: BCBS of TX PPO	$0.68
Rate for Payer: Cash Price	$175.95
Rate for Payer: Cash Price	$175.95
Rate for Payer: Cigna Medicaid	$186.30
Rate for Payer: Molina CHIP/Medicaid	$186.30
Rate for Payer: Multiplan Auto	$168.19
Rate for Payer: Multiplan Commercial	$168.19
Rate for Payer: Multiplan Workers Comp	$168.19
Rate for Payer: Parkland Medicaid	$186.30
Rate for Payer: Scott and White EPO/PPO	$129.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$186.30
Rate for Payer: Superior Health Plan EPO	$35.19

iron sucrose 20 mg/mL IV Soln 10 mL

Facility

$258.75

Service Code	HCPCS J1756
Hospital Charge Code	77644387
Hospital Revenue Code	636
Min. Negotiated Rate	$64.69
Max. Negotiated Rate	$129.38
Rate for Payer: Cash Price	$175.95
Rate for Payer: Cigna Commercial	$64.69
Rate for Payer: Scott and White EPO/PPO	$129.38

Irrigation nozzle (drill)

Facility

$440.38

Hospital Charge Code	993409
Hospital Revenue Code	272
Min. Negotiated Rate	$39.63
Max. Negotiated Rate	$317.07
Rate for Payer: Amerigroup CHIP/Medicaid	$39.63
Rate for Payer: BCBS of TX Blue Advantage	$132.11
Rate for Payer: BCBS of TX Blue Essentials	$158.54
Rate for Payer: BCBS of TX PPO	$176.15
Rate for Payer: Cash Price	$299.46
Rate for Payer: Cigna Medicaid	$317.07
Rate for Payer: Molina CHIP/Medicaid	$317.07
Rate for Payer: Multiplan Auto	$286.25
Rate for Payer: Multiplan Commercial	$286.25
Rate for Payer: Multiplan Workers Comp	$286.25
Rate for Payer: Parkland Medicaid	$317.07
Rate for Payer: Scott and White EPO/PPO	$220.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$317.07
Rate for Payer: Superior Health Plan EPO	$59.89

Irrigation nozzle (drill)

Facility

$440.38

Hospital Charge Code	993409
Hospital Revenue Code	272
Rate for Payer: Cash Price	$299.46

Irrigation Solution 0.9% Sodium Chloride 1000ml Plastic Injection Bottle Ea, 16 EA / CA

Facility

$20.16

Hospital Charge Code	992703
Hospital Revenue Code	270
Rate for Payer: Cash Price	$13.71

Irrigation Solution 0.9% Sodium Chloride 1000ml Plastic Injection Bottle Ea, 16 EA / CA

Facility

$20.16

Hospital Charge Code	992703
Hospital Revenue Code	270
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$14.52
Rate for Payer: Amerigroup CHIP/Medicaid	$1.81
Rate for Payer: BCBS of TX Blue Advantage	$6.05
Rate for Payer: BCBS of TX Blue Essentials	$7.26
Rate for Payer: BCBS of TX PPO	$8.06
Rate for Payer: Cash Price	$13.71
Rate for Payer: Cigna Medicaid	$14.52
Rate for Payer: Molina CHIP/Medicaid	$14.52
Rate for Payer: Multiplan Auto	$13.10
Rate for Payer: Multiplan Commercial	$13.10
Rate for Payer: Multiplan Workers Comp	$13.10
Rate for Payer: Parkland Medicaid	$14.52
Rate for Payer: Scott and White EPO/PPO	$10.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.52
Rate for Payer: Superior Health Plan EPO	$2.74

Irrigation Solution Sodium Chloride 0.9% 500ml Plastic Injection Container Ea, 16 EA / CA

Facility

$17.21

Hospital Charge Code	992702
Hospital Revenue Code	270
Rate for Payer: Cash Price	$11.70

Know your out-of-pocket cost for care.

All Charges