White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$12.39
Rate for Payer: Amerigroup CHIP/Medicaid	$1.55
Rate for Payer: BCBS of TX Blue Advantage	$5.16
Rate for Payer: BCBS of TX Blue Essentials	$6.20
Rate for Payer: BCBS of TX PPO	$6.88
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Medicaid	$12.39
Rate for Payer: Molina CHIP/Medicaid	$12.39
Rate for Payer: Multiplan Auto	$11.19
Rate for Payer: Multiplan Commercial	$11.19
Rate for Payer: Multiplan Workers Comp	$11.19
Rate for Payer: Parkland Medicaid	$12.39
Rate for Payer: Scott and White EPO/PPO	$8.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.39
Rate for Payer: Superior Health Plan EPO	$2.34

Irrigation Solution Water 1000ml Plastic Injection Container Ea, 16 EA / CA

Facility

$18.48

Hospital Charge Code	992701
Hospital Revenue Code	270
Rate for Payer: Cash Price	$12.57

Irrigation Solution Water 1000ml Plastic Injection Container Ea, 16 EA / CA

Facility

$18.48

Hospital Charge Code	992701
Hospital Revenue Code	270
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$13.31
Rate for Payer: Amerigroup CHIP/Medicaid	$1.66
Rate for Payer: BCBS of TX Blue Advantage	$5.54
Rate for Payer: BCBS of TX Blue Essentials	$6.65
Rate for Payer: BCBS of TX PPO	$7.39
Rate for Payer: Cash Price	$12.57
Rate for Payer: Cigna Medicaid	$13.31
Rate for Payer: Molina CHIP/Medicaid	$13.31
Rate for Payer: Multiplan Auto	$12.01
Rate for Payer: Multiplan Commercial	$12.01
Rate for Payer: Multiplan Workers Comp	$12.01
Rate for Payer: Parkland Medicaid	$13.31
Rate for Payer: Scott and White EPO/PPO	$9.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.31
Rate for Payer: Superior Health Plan EPO	$2.51

irrigator suction endowrist

Facility

$1,203.10

Hospital Charge Code	8690507
Hospital Revenue Code	272
Min. Negotiated Rate	$108.28
Max. Negotiated Rate	$866.23
Rate for Payer: Amerigroup CHIP/Medicaid	$108.28
Rate for Payer: BCBS of TX Blue Advantage	$360.93
Rate for Payer: BCBS of TX Blue Essentials	$433.12
Rate for Payer: BCBS of TX PPO	$481.24
Rate for Payer: Cash Price	$818.11
Rate for Payer: Cigna Medicaid	$866.23
Rate for Payer: Molina CHIP/Medicaid	$866.23
Rate for Payer: Multiplan Auto	$782.01
Rate for Payer: Multiplan Commercial	$782.01
Rate for Payer: Multiplan Workers Comp	$782.01
Rate for Payer: Parkland Medicaid	$866.23
Rate for Payer: Scott and White EPO/PPO	$601.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$866.23
Rate for Payer: Superior Health Plan EPO	$163.62

irrigator suction endowrist

Facility

$1,203.10

Hospital Charge Code	8690507
Hospital Revenue Code	272
Rate for Payer: Cash Price	$818.11

IRRIGATOR SUCTION W/ SPLASH

Facility

$273.08

Hospital Charge Code	8490524
Hospital Revenue Code	272
Rate for Payer: Cash Price	$185.69

IRRIGATOR SUCTION W/ SPLASH

Facility

$273.08

Hospital Charge Code	8490524
Hospital Revenue Code	272
Min. Negotiated Rate	$24.58
Max. Negotiated Rate	$196.62
Rate for Payer: Amerigroup CHIP/Medicaid	$24.58
Rate for Payer: BCBS of TX Blue Advantage	$81.92
Rate for Payer: BCBS of TX Blue Essentials	$98.31
Rate for Payer: BCBS of TX PPO	$109.23
Rate for Payer: Cash Price	$185.69
Rate for Payer: Cigna Medicaid	$196.62
Rate for Payer: Molina CHIP/Medicaid	$196.62
Rate for Payer: Multiplan Auto	$177.50
Rate for Payer: Multiplan Commercial	$177.50
Rate for Payer: Multiplan Workers Comp	$177.50
Rate for Payer: Parkland Medicaid	$196.62
Rate for Payer: Scott and White EPO/PPO	$136.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$196.62
Rate for Payer: Superior Health Plan EPO	$37.14

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC

Facility

$33,386.80

Service Code	MSDRG 062
Min. Negotiated Rate	$15,375.50
Max. Negotiated Rate	$33,386.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,638.65
Rate for Payer: Amerigroup Medicare	$17,638.65
Rate for Payer: BCBS of TX Medicare	$17,638.65
Rate for Payer: Cigna Commercial	$22,632.74
Rate for Payer: Cigna Medicare	$17,638.65
Rate for Payer: Employer Direct Commercial	$17,638.65
Rate for Payer: Humana Medicare/TRICARE	$17,638.65
Rate for Payer: Molina Dual Medicare/Medicaid	$17,638.65
Rate for Payer: Molina Medicare	$17,638.65
Rate for Payer: Multiplan Auto	$33,386.80
Rate for Payer: Multiplan Commercial	$33,386.80
Rate for Payer: Multiplan Workers Comp	$33,386.80
Rate for Payer: Scott and White EPO/PPO	$15,375.50
Rate for Payer: Scott and White Medicare	$17,638.65
Rate for Payer: Superior Health Plan EPO	$17,638.65
Rate for Payer: Superior Health Plan Medicare	$17,638.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,638.65
Rate for Payer: Universal American Medicare	$17,638.65
Rate for Payer: Wellcare Medicare	$17,638.65
Rate for Payer: Wellmed Medicare	$17,638.65

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC

Facility

$52,384.90

Service Code	MSDRG 061
Min. Negotiated Rate	$24,124.62
Max. Negotiated Rate	$52,384.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24,966.94
Rate for Payer: Amerigroup Medicare	$24,966.94
Rate for Payer: BCBS of TX Medicare	$24,966.94
Rate for Payer: Cigna Commercial	$35,511.45
Rate for Payer: Cigna Medicare	$24,966.94
Rate for Payer: Employer Direct Commercial	$24,966.94
Rate for Payer: Humana Medicare/TRICARE	$24,966.94
Rate for Payer: Molina Dual Medicare/Medicaid	$24,966.94
Rate for Payer: Molina Medicare	$24,966.94
Rate for Payer: Multiplan Auto	$52,384.90
Rate for Payer: Multiplan Commercial	$52,384.90
Rate for Payer: Multiplan Workers Comp	$52,384.90
Rate for Payer: Scott and White EPO/PPO	$24,124.62
Rate for Payer: Scott and White Medicare	$24,966.94
Rate for Payer: Superior Health Plan EPO	$24,966.94
Rate for Payer: Superior Health Plan Medicare	$24,966.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$24,966.94
Rate for Payer: Universal American Medicare	$24,966.94
Rate for Payer: Wellcare Medicare	$24,966.94
Rate for Payer: Wellmed Medicare	$24,966.94

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC

Facility

$26,672.20

Service Code	MSDRG 063
Min. Negotiated Rate	$12,283.25
Max. Negotiated Rate	$26,672.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,048.57
Rate for Payer: Amerigroup Medicare	$15,048.57
Rate for Payer: BCBS of TX Medicare	$15,048.57
Rate for Payer: Cigna Commercial	$18,080.94
Rate for Payer: Cigna Medicare	$15,048.57
Rate for Payer: Employer Direct Commercial	$15,048.57
Rate for Payer: Humana Medicare/TRICARE	$15,048.57
Rate for Payer: Molina Dual Medicare/Medicaid	$15,048.57
Rate for Payer: Molina Medicare	$15,048.57
Rate for Payer: Multiplan Auto	$26,672.20
Rate for Payer: Multiplan Commercial	$26,672.20
Rate for Payer: Multiplan Workers Comp	$26,672.20
Rate for Payer: Scott and White EPO/PPO	$12,283.25
Rate for Payer: Scott and White Medicare	$15,048.57
Rate for Payer: Superior Health Plan EPO	$15,048.57
Rate for Payer: Superior Health Plan Medicare	$15,048.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,048.57
Rate for Payer: Universal American Medicare	$15,048.57
Rate for Payer: Wellcare Medicare	$15,048.57
Rate for Payer: Wellmed Medicare	$15,048.57

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W CC

Facility

$33,386.80

Service Code	MSDRG 062
Min. Negotiated Rate	$15,375.50
Max. Negotiated Rate	$33,386.80
Rate for Payer: BCBS of TX Blue Advantage	$16,715.82
Rate for Payer: BCBS of TX Blue Essentials	$20,057.04
Rate for Payer: BCBS of TX PPO	$22,286.46

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W MCC

Facility

$52,384.90

Service Code	MSDRG 061
Min. Negotiated Rate	$24,124.62
Max. Negotiated Rate	$52,384.90
Rate for Payer: BCBS of TX Blue Advantage	$24,490.22
Rate for Payer: BCBS of TX Blue Essentials	$29,385.42
Rate for Payer: BCBS of TX PPO	$32,651.73

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W/O CC/MCC

Facility

$26,672.20

Service Code	MSDRG 063
Min. Negotiated Rate	$12,283.25
Max. Negotiated Rate	$26,672.20
Rate for Payer: BCBS of TX Blue Advantage	$14,000.80
Rate for Payer: BCBS of TX Blue Essentials	$16,799.33
Rate for Payer: BCBS of TX PPO	$18,666.65

isosorbide dinitrate 10 mg Tab

Facility

$16.30

Service Code	HCPCS J3490
Hospital Charge Code	77646002
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.08

isosorbide dinitrate 10 mg Tab

Facility

$16.30

Service Code	HCPCS J3490
Hospital Charge Code	77646002
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$11.74
Rate for Payer: Amerigroup CHIP/Medicaid	$1.47
Rate for Payer: BCBS of TX Blue Advantage	$4.89
Rate for Payer: BCBS of TX Blue Essentials	$5.87
Rate for Payer: BCBS of TX PPO	$6.52
Rate for Payer: Cash Price	$11.08
Rate for Payer: Cigna Medicaid	$11.74
Rate for Payer: Molina CHIP/Medicaid	$11.74
Rate for Payer: Multiplan Auto	$10.60
Rate for Payer: Multiplan Commercial	$10.60
Rate for Payer: Multiplan Workers Comp	$10.60
Rate for Payer: Parkland Medicaid	$11.74
Rate for Payer: Scott and White EPO/PPO	$8.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.74
Rate for Payer: Superior Health Plan EPO	$2.22

isosorbide mononitrate 30 mg ER Tab

Facility

$14.55

Service Code	HCPCS J3490
Hospital Charge Code	78414362
Hospital Revenue Code	250
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$10.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1.31
Rate for Payer: BCBS of TX Blue Advantage	$4.37
Rate for Payer: BCBS of TX Blue Essentials	$5.24
Rate for Payer: BCBS of TX PPO	$5.82
Rate for Payer: Cash Price	$9.89
Rate for Payer: Cigna Medicaid	$10.48
Rate for Payer: Molina CHIP/Medicaid	$10.48
Rate for Payer: Multiplan Auto	$9.46
Rate for Payer: Multiplan Commercial	$9.46
Rate for Payer: Multiplan Workers Comp	$9.46
Rate for Payer: Parkland Medicaid	$10.48
Rate for Payer: Scott and White EPO/PPO	$7.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.48
Rate for Payer: Superior Health Plan EPO	$1.98

isosorbide mononitrate 30 mg ER Tab

Facility

$14.55

Service Code	HCPCS J3490
Hospital Charge Code	78414362
Hospital Revenue Code	250
Rate for Payer: Cash Price	$9.89

Itraconazole and Mtb, S/P SO

Facility

$176.00

Service Code	HCPCS 80189
Hospital Charge Code	8722541
Hospital Revenue Code	301
Min. Negotiated Rate	$10.57
Max. Negotiated Rate	$126.72
Rate for Payer: Amerigroup CHIP/Medicaid	$10.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.11
Rate for Payer: Amerigroup Medicare	$27.11
Rate for Payer: BCBS of TX Blue Advantage	$52.80
Rate for Payer: BCBS of TX Blue Essentials	$63.36
Rate for Payer: BCBS of TX Medicare	$27.11
Rate for Payer: BCBS of TX PPO	$70.40
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cigna Medicaid	$126.72
Rate for Payer: Cigna Medicare	$27.11
Rate for Payer: Employer Direct Commercial	$27.11
Rate for Payer: Humana Medicare/TRICARE	$27.11
Rate for Payer: Molina CHIP/Medicaid	$126.72
Rate for Payer: Molina Dual Medicare/Medicaid	$27.11
Rate for Payer: Molina Medicare	$27.11
Rate for Payer: Multiplan Auto	$114.40
Rate for Payer: Multiplan Commercial	$114.40
Rate for Payer: Multiplan Workers Comp	$114.40
Rate for Payer: Parkland Medicaid	$126.72
Rate for Payer: Scott and White EPO/PPO	$33.89
Rate for Payer: Scott and White Medicare	$27.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.72
Rate for Payer: Superior Health Plan EPO	$27.11
Rate for Payer: Superior Health Plan Medicare	$27.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.11
Rate for Payer: Universal American Medicare	$27.11
Rate for Payer: Wellcare Medicare	$27.11
Rate for Payer: Wellmed Medicare	$27.11

Itraconazole and Mtb, S/P SO

Facility

$176.00

Service Code	HCPCS 80189
Hospital Charge Code	8722541
Hospital Revenue Code	301
Rate for Payer: Cash Price	$119.68

IV CATH 16G X 1.25

Facility

$6.95

Service Code	HCPCS A4649
Hospital Charge Code	8584506
Hospital Revenue Code	272
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$5.00
Rate for Payer: Amerigroup CHIP/Medicaid	$0.63
Rate for Payer: BCBS of TX Blue Advantage	$2.08
Rate for Payer: BCBS of TX Blue Essentials	$2.50
Rate for Payer: BCBS of TX PPO	$2.78
Rate for Payer: Cash Price	$4.73
Rate for Payer: Cigna Medicaid	$5.00
Rate for Payer: Molina CHIP/Medicaid	$5.00
Rate for Payer: Multiplan Auto	$4.52
Rate for Payer: Multiplan Commercial	$4.52
Rate for Payer: Multiplan Workers Comp	$4.52
Rate for Payer: Parkland Medicaid	$5.00
Rate for Payer: Scott and White EPO/PPO	$3.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.00
Rate for Payer: Superior Health Plan EPO	$0.95

IV CATH 16G X 1.25

Facility

$6.95

Service Code	HCPCS A4649
Hospital Charge Code	8584506
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.73

IV CATH 18G X 1.25

Facility

$7.17

Service Code	HCPCS A4649
Hospital Charge Code	8584507
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.88

IV CATH 18G X 1.25

Facility

$7.17

Service Code	HCPCS A4649
Hospital Charge Code	8584507
Hospital Revenue Code	272
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$5.16
Rate for Payer: Amerigroup CHIP/Medicaid	$0.65
Rate for Payer: BCBS of TX Blue Advantage	$2.15
Rate for Payer: BCBS of TX Blue Essentials	$2.58
Rate for Payer: BCBS of TX PPO	$2.87
Rate for Payer: Cash Price	$4.88
Rate for Payer: Cigna Medicaid	$5.16
Rate for Payer: Molina CHIP/Medicaid	$5.16
Rate for Payer: Multiplan Auto	$4.66
Rate for Payer: Multiplan Commercial	$4.66
Rate for Payer: Multiplan Workers Comp	$4.66
Rate for Payer: Parkland Medicaid	$5.16
Rate for Payer: Scott and White EPO/PPO	$3.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.16
Rate for Payer: Superior Health Plan EPO	$0.98

IV EXT SET, 6'ULTRASITE, STD BORE, LF

Facility

$8.11

Hospital Charge Code	993188
Hospital Revenue Code	270
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$5.84
Rate for Payer: Amerigroup CHIP/Medicaid	$0.73
Rate for Payer: BCBS of TX Blue Advantage	$2.43
Rate for Payer: BCBS of TX Blue Essentials	$2.92
Rate for Payer: BCBS of TX PPO	$3.24
Rate for Payer: Cash Price	$5.51
Rate for Payer: Cigna Medicaid	$5.84
Rate for Payer: Molina CHIP/Medicaid	$5.84
Rate for Payer: Multiplan Auto	$5.27
Rate for Payer: Multiplan Commercial	$5.27
Rate for Payer: Multiplan Workers Comp	$5.27
Rate for Payer: Parkland Medicaid	$5.84
Rate for Payer: Scott and White EPO/PPO	$4.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.84
Rate for Payer: Superior Health Plan EPO	$1.10

IV EXT SET, 6'ULTRASITE, STD BORE, LF

Facility

$8.11

Hospital Charge Code	993188
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.51

Know your out-of-pocket cost for care.

All Charges