White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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

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

IV CATH 18G X 1.25

Facility

$7.17

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

IV CATH 18G X 1.25

Facility

$7.17

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

IV INJECTION SOLUTION LACTATED RINGERS 1000ML

Facility

$134.84

Hospital Charge Code	993704
Hospital Revenue Code	270
Min. Negotiated Rate	$12.14
Max. Negotiated Rate	$97.08
Rate for Payer: Amerigroup CHIP/Medicaid	$12.14
Rate for Payer: BCBS of TX Blue Advantage	$40.45
Rate for Payer: BCBS of TX Blue Essentials	$48.54
Rate for Payer: BCBS of TX PPO	$53.94
Rate for Payer: Cash Price	$91.69
Rate for Payer: Cigna Medicaid	$97.08
Rate for Payer: Molina CHIP/Medicaid	$97.08
Rate for Payer: Multiplan Auto	$87.65
Rate for Payer: Multiplan Commercial	$87.65
Rate for Payer: Multiplan Workers Comp	$87.65
Rate for Payer: Parkland Medicaid	$97.08
Rate for Payer: Scott and White EPO/PPO	$67.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.08
Rate for Payer: Superior Health Plan EPO	$18.34

IV INJECTION SOLUTION LACTATED RINGERS 1000ML

Facility

$134.84

Hospital Charge Code	993704
Hospital Revenue Code	270
Rate for Payer: Cash Price	$91.69

IV INJECT SITE -- DHF

Facility

$30.32

Hospital Charge Code	80930597
Hospital Revenue Code	270
Rate for Payer: Cash Price	$20.62

IV INJECT SITE -- DHF

Facility

$30.32

Hospital Charge Code	80930597
Hospital Revenue Code	270
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$21.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2.73
Rate for Payer: BCBS of TX Blue Advantage	$9.10
Rate for Payer: BCBS of TX Blue Essentials	$10.92
Rate for Payer: BCBS of TX PPO	$12.13
Rate for Payer: Cash Price	$20.62
Rate for Payer: Cigna Medicaid	$21.83
Rate for Payer: Molina CHIP/Medicaid	$21.83
Rate for Payer: Multiplan Auto	$19.71
Rate for Payer: Multiplan Commercial	$19.71
Rate for Payer: Multiplan Workers Comp	$19.71
Rate for Payer: Parkland Medicaid	$21.83
Rate for Payer: Scott and White EPO/PPO	$15.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.83
Rate for Payer: Superior Health Plan EPO	$4.12

IV Sodium chloride

Facility

$13.36

Hospital Charge Code	992700
Hospital Revenue Code	270
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$9.62
Rate for Payer: Amerigroup CHIP/Medicaid	$1.20
Rate for Payer: BCBS of TX Blue Advantage	$4.01
Rate for Payer: BCBS of TX Blue Essentials	$4.81
Rate for Payer: BCBS of TX PPO	$5.34
Rate for Payer: Cash Price	$9.08
Rate for Payer: Cigna Medicaid	$9.62
Rate for Payer: Molina CHIP/Medicaid	$9.62
Rate for Payer: Multiplan Auto	$8.68
Rate for Payer: Multiplan Commercial	$8.68
Rate for Payer: Multiplan Workers Comp	$8.68
Rate for Payer: Parkland Medicaid	$9.62
Rate for Payer: Scott and White EPO/PPO	$6.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.62
Rate for Payer: Superior Health Plan EPO	$1.82

IV Sodium chloride

Facility

$13.36

Hospital Charge Code	992700
Hospital Revenue Code	270
Rate for Payer: Cash Price	$9.08

IVUS ADDITIONAL VESSEL

Facility

$2,578.00

Service Code	HCPCS 92979
Hospital Charge Code	2302222
Hospital Revenue Code	481
Rate for Payer: Cash Price	$1,753.04

IVUS ADDITIONAL VESSEL

Facility

$2,578.00

Service Code	HCPCS 92979
Hospital Charge Code	2302222
Hospital Revenue Code	481
Min. Negotiated Rate	$232.02
Max. Negotiated Rate	$1,856.16
Rate for Payer: Amerigroup CHIP/Medicaid	$232.02
Rate for Payer: BCBS of TX Blue Advantage	$773.40
Rate for Payer: BCBS of TX Blue Essentials	$928.08
Rate for Payer: BCBS of TX PPO	$1,031.20
Rate for Payer: Cash Price	$1,753.04
Rate for Payer: Cigna Medicaid	$1,856.16
Rate for Payer: Molina CHIP/Medicaid	$1,856.16
Rate for Payer: Multiplan Auto	$1,675.70
Rate for Payer: Multiplan Commercial	$1,675.70
Rate for Payer: Multiplan Workers Comp	$1,675.70
Rate for Payer: Parkland Medicaid	$1,856.16
Rate for Payer: Scott and White EPO/PPO	$1,289.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,856.16
Rate for Payer: Superior Health Plan EPO	$350.61

IVUS NON CORON ADDL VESL

Facility

$3,815.00

Service Code	HCPCS 37253
Hospital Charge Code	4617251
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,594.20

IVUS NON CORON ADDL VESL

Facility

$3,815.00

Service Code	HCPCS 37253
Hospital Charge Code	4617251
Hospital Revenue Code	360
Min. Negotiated Rate	$343.35
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$343.35
Rate for Payer: BCBS of TX Blue Advantage	$1,144.50
Rate for Payer: BCBS of TX Blue Essentials	$1,373.40
Rate for Payer: BCBS of TX PPO	$1,526.00
Rate for Payer: Cash Price	$2,594.20
Rate for Payer: Cash Price	$2,594.20
Rate for Payer: Cigna Medicaid	$2,746.80
Rate for Payer: Molina CHIP/Medicaid	$2,746.80
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	$2,746.80
Rate for Payer: Scott and White EPO/PPO	$1,907.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,746.80
Rate for Payer: Superior Health Plan EPO	$518.84

IVUS NON CORONARY INITL

Facility

$8,555.10

Service Code	HCPCS 37252
Hospital Charge Code	4615944
Hospital Revenue Code	361
Rate for Payer: Cash Price	$5,817.47

IVUS NON CORONARY INITL

Facility

$8,555.10

Service Code	HCPCS 37252
Hospital Charge Code	4615944
Hospital Revenue Code	361
Min. Negotiated Rate	$769.96
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$769.96
Rate for Payer: BCBS of TX Blue Advantage	$2,566.53
Rate for Payer: BCBS of TX Blue Essentials	$3,079.84
Rate for Payer: BCBS of TX PPO	$3,422.04
Rate for Payer: Cash Price	$5,817.47
Rate for Payer: Cash Price	$5,817.47
Rate for Payer: Cigna Medicaid	$6,159.67
Rate for Payer: Molina CHIP/Medicaid	$6,159.67
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	$6,159.67
Rate for Payer: Scott and White EPO/PPO	$4,277.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,159.67
Rate for Payer: Superior Health Plan EPO	$1,163.49

JAK2 Exons 12-15 SO

Facility

$734.00

Service Code	HCPCS 81279
Hospital Charge Code	8993055
Hospital Revenue Code	310
Min. Negotiated Rate	$72.23
Max. Negotiated Rate	$528.48
Rate for Payer: Amerigroup CHIP/Medicaid	$72.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$185.20
Rate for Payer: Amerigroup Medicare	$185.20
Rate for Payer: BCBS of TX Blue Advantage	$220.20
Rate for Payer: BCBS of TX Blue Essentials	$264.24
Rate for Payer: BCBS of TX Medicare	$185.20
Rate for Payer: BCBS of TX PPO	$293.60
Rate for Payer: Cash Price	$499.12
Rate for Payer: Cash Price	$499.12
Rate for Payer: Cigna Medicaid	$528.48
Rate for Payer: Cigna Medicare	$185.20
Rate for Payer: Employer Direct Commercial	$185.20
Rate for Payer: Humana Medicare/TRICARE	$185.20
Rate for Payer: Molina CHIP/Medicaid	$528.48
Rate for Payer: Molina Dual Medicare/Medicaid	$185.20
Rate for Payer: Molina Medicare	$185.20
Rate for Payer: Multiplan Auto	$477.10
Rate for Payer: Multiplan Commercial	$477.10
Rate for Payer: Multiplan Workers Comp	$477.10
Rate for Payer: Parkland Medicaid	$528.48
Rate for Payer: Scott and White EPO/PPO	$231.50
Rate for Payer: Scott and White Medicare	$185.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$528.48
Rate for Payer: Superior Health Plan EPO	$185.20
Rate for Payer: Superior Health Plan Medicare	$185.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$185.20
Rate for Payer: Universal American Medicare	$185.20
Rate for Payer: Wellcare Medicare	$185.20
Rate for Payer: Wellmed Medicare	$185.20

JAK2 Exons 12-15 SO

Facility

$734.00

Service Code	HCPCS 81279
Hospital Charge Code	8993055
Hospital Revenue Code	310
Rate for Payer: Cash Price	$499.12

Jam Shidi Needle/Bone Marrow Aspitation

Facility

$454.00

Service Code	HCPCS C1830
Hospital Charge Code	993664
Hospital Revenue Code	272
Min. Negotiated Rate	$40.86
Max. Negotiated Rate	$326.88
Rate for Payer: Amerigroup CHIP/Medicaid	$40.86
Rate for Payer: BCBS of TX Blue Advantage	$136.20
Rate for Payer: BCBS of TX Blue Essentials	$163.44
Rate for Payer: BCBS of TX PPO	$181.60
Rate for Payer: Cash Price	$308.72
Rate for Payer: Cigna Medicaid	$326.88
Rate for Payer: Molina CHIP/Medicaid	$326.88
Rate for Payer: Multiplan Auto	$295.10
Rate for Payer: Multiplan Commercial	$295.10
Rate for Payer: Multiplan Workers Comp	$295.10
Rate for Payer: Parkland Medicaid	$326.88
Rate for Payer: Scott and White EPO/PPO	$227.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$326.88
Rate for Payer: Superior Health Plan EPO	$61.74

Know your out-of-pocket cost for care.

All Charges