White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$195.84

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 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
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 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

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

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

irrigator suction endowrist

Facility

$1,203.10

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

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 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

IRRIGATOR SUCTION W/ SPLASH

Facility

$273.08

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

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

Facility

$36,426.80

Service Code	MSDRG 062
Min. Negotiated Rate	$16,715.82
Max. Negotiated Rate	$36,426.80
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	$36,426.80
Rate for Payer: Multiplan Commercial	$36,426.80
Rate for Payer: Multiplan Workers Comp	$36,426.80
Rate for Payer: Scott and White EPO/PPO	$16,775.50
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

$55,719.40

Service Code	MSDRG 061
Min. Negotiated Rate	$24,490.22
Max. Negotiated Rate	$55,719.40
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	$55,719.40
Rate for Payer: Multiplan Commercial	$55,719.40
Rate for Payer: Multiplan Workers Comp	$55,719.40
Rate for Payer: Scott and White EPO/PPO	$25,660.25
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

$30,039.00

Service Code	MSDRG 063
Min. Negotiated Rate	$13,833.75
Max. Negotiated Rate	$30,039.00
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	$30,039.00
Rate for Payer: Multiplan Commercial	$30,039.00
Rate for Payer: Multiplan Workers Comp	$30,039.00
Rate for Payer: Scott and White EPO/PPO	$13,833.75
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

$36,426.80

Service Code	MSDRG 062
Min. Negotiated Rate	$16,715.82
Max. Negotiated Rate	$36,426.80
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

$55,719.40

Service Code	MSDRG 061
Min. Negotiated Rate	$24,490.22
Max. Negotiated Rate	$55,719.40
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

$30,039.00

Service Code	MSDRG 063
Min. Negotiated Rate	$13,833.75
Max. Negotiated Rate	$30,039.00
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

Know your out-of-pocket cost for care.

All Charges