White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PREMIX nitroglycerin 50 mg/D5W 250 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78352160
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

PREMIX nitroglycerin 50 mg/D5W 250 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78352160
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

Prenatal Multivitamins with Folic Acid 0.8 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77778214
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
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: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

Prenatal Multivitamins with Folic Acid 0.8 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77778214
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Prenat Infect Dis Ab, IgM, Qn SO

Facility

$37.00

Service Code	CPT 86694
Hospital Charge Code	1702943
Hospital Revenue Code	302
Rate for Payer: Cash Price	$32.56

Prenat Infect Dis Ab, IgM, Qn SO

Facility

$37.00

Service Code	CPT 86694
Hospital Charge Code	1702943
Hospital Revenue Code	302
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$31.80
Rate for Payer: Aetna Commercial	$15.10
Rate for Payer: Aetna Medicare	$21.58
Rate for Payer: Amerigroup CHIP/Medicaid	$5.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.39
Rate for Payer: Amerigroup Medicare	$14.39
Rate for Payer: BCBS of TX Blue Advantage	$23.74
Rate for Payer: BCBS of TX Blue Essentials	$28.49
Rate for Payer: BCBS of TX Medicare	$14.39
Rate for Payer: BCBS of TX PPO	$31.80
Rate for Payer: Cash Price	$32.56
Rate for Payer: Cash Price	$32.56
Rate for Payer: Cigna Medicaid	$14.39
Rate for Payer: Cigna Medicare	$14.39
Rate for Payer: Employer Direct Commercial	$14.39
Rate for Payer: Humana Medicare/TRICARE	$14.39
Rate for Payer: Molina CHIP/Medicaid	$14.39
Rate for Payer: Molina Dual Medicare/Medicaid	$14.39
Rate for Payer: Molina Medicare	$14.39
Rate for Payer: Multiplan Auto	$24.05
Rate for Payer: Multiplan Commercial	$24.05
Rate for Payer: Multiplan Workers Comp	$24.05
Rate for Payer: Parkland Medicaid	$14.39
Rate for Payer: Scott and White EPO/PPO	$17.99
Rate for Payer: Scott and White Medicare	$14.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.39
Rate for Payer: Superior Health Plan EPO	$14.39
Rate for Payer: Superior Health Plan Medicare	$14.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.39
Rate for Payer: Universal American Medicare	$14.39
Rate for Payer: Wellcare Medicare	$14.39
Rate for Payer: Wellmed Medicare	$14.39

PRESS TB -- DHF

Facility

$147.62

Hospital Charge Code	80337355
Hospital Revenue Code	270
Rate for Payer: Cash Price	$129.91

PRESS TB -- DHF

Facility

$147.62

Hospital Charge Code	80337355
Hospital Revenue Code	270
Min. Negotiated Rate	$13.29
Max. Negotiated Rate	$95.95
Rate for Payer: Aetna Commercial	$81.19
Rate for Payer: Amerigroup CHIP/Medicaid	$13.29
Rate for Payer: BCBS of TX Blue Advantage	$44.29
Rate for Payer: BCBS of TX Blue Essentials	$53.14
Rate for Payer: BCBS of TX PPO	$59.05
Rate for Payer: Cash Price	$129.91
Rate for Payer: Multiplan Auto	$95.95
Rate for Payer: Multiplan Commercial	$95.95
Rate for Payer: Multiplan Workers Comp	$95.95
Rate for Payer: Scott and White EPO/PPO	$73.81
Rate for Payer: Superior Health Plan EPO	$20.08

PRESS TRNSDU -- DHF

Facility

$689.34

Hospital Charge Code	80337405
Hospital Revenue Code	270
Rate for Payer: Cash Price	$606.62

PRESS TRNSDU -- DHF

Facility

$689.34

Hospital Charge Code	80337405
Hospital Revenue Code	270
Min. Negotiated Rate	$62.04
Max. Negotiated Rate	$448.07
Rate for Payer: Aetna Commercial	$379.14
Rate for Payer: Amerigroup CHIP/Medicaid	$62.04
Rate for Payer: BCBS of TX Blue Advantage	$206.80
Rate for Payer: BCBS of TX Blue Essentials	$248.16
Rate for Payer: BCBS of TX PPO	$275.74
Rate for Payer: Cash Price	$606.62
Rate for Payer: Multiplan Auto	$448.07
Rate for Payer: Multiplan Commercial	$448.07
Rate for Payer: Multiplan Workers Comp	$448.07
Rate for Payer: Scott and White EPO/PPO	$344.67
Rate for Payer: Superior Health Plan EPO	$93.75

PRIM ART MECH THROMBECTOMY

Facility

$12,192.00

Service Code	CPT 37184
Hospital Charge Code	2320208
Hospital Revenue Code	481
Min. Negotiated Rate	$286.80
Max. Negotiated Rate	$36,327.72
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$24,055.02
Rate for Payer: Amerigroup CHIP/Medicaid	$1,097.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Amerigroup Medicare	$16,036.68
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$16,036.68
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$10,728.96
Rate for Payer: Cash Price	$10,728.96
Rate for Payer: Cash Price	$10,728.96
Rate for Payer: Cigna Commercial	$36,327.72
Rate for Payer: Cigna Medicaid	$5,429.55
Rate for Payer: Cigna Medicare	$16,036.68
Rate for Payer: Employer Direct Commercial	$16,036.68
Rate for Payer: Humana Medicare/TRICARE	$16,036.68
Rate for Payer: Molina CHIP/Medicaid	$5,429.55
Rate for Payer: Molina Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Molina Medicare	$16,036.68
Rate for Payer: Multiplan Auto	$7,924.80
Rate for Payer: Multiplan Commercial	$7,924.80
Rate for Payer: Multiplan Workers Comp	$7,924.80
Rate for Payer: Parkland Medicaid	$5,429.55
Rate for Payer: Scott and White EPO/PPO	$286.80
Rate for Payer: Scott and White Medicare	$16,036.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,429.55
Rate for Payer: Superior Health Plan EPO	$16,036.68
Rate for Payer: Superior Health Plan Medicare	$16,036.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,036.68
Rate for Payer: Universal American Medicare	$16,036.68
Rate for Payer: Wellcare Medicare	$16,036.68
Rate for Payer: Wellmed Medicare	$16,036.68

PRIM ART MECH THROMBECTOMY

Facility

$12,192.00

Service Code	CPT 37184
Hospital Charge Code	2320208
Hospital Revenue Code	481
Rate for Payer: Cash Price	$10,728.96

PROBE, ABLATION SUCTION 90 DEG 3.5MM -- DHF

Facility

$816.48

Hospital Charge Code	81754616
Hospital Revenue Code	272
Min. Negotiated Rate	$73.48
Max. Negotiated Rate	$530.71
Rate for Payer: Aetna Commercial	$449.06
Rate for Payer: Amerigroup CHIP/Medicaid	$73.48
Rate for Payer: BCBS of TX Blue Advantage	$244.94
Rate for Payer: BCBS of TX Blue Essentials	$293.93
Rate for Payer: BCBS of TX PPO	$326.59
Rate for Payer: Cash Price	$718.50
Rate for Payer: Multiplan Auto	$530.71
Rate for Payer: Multiplan Commercial	$530.71
Rate for Payer: Multiplan Workers Comp	$530.71
Rate for Payer: Scott and White EPO/PPO	$408.24
Rate for Payer: Superior Health Plan EPO	$111.04

PROBE ARTHROSCOPIC 180MM RAD FRQ 50 DEGREE

Facility

$1,248.50

Hospital Charge Code	8394466
Hospital Revenue Code	272
Min. Negotiated Rate	$112.36
Max. Negotiated Rate	$811.52
Rate for Payer: Aetna Commercial	$686.68
Rate for Payer: Amerigroup CHIP/Medicaid	$112.36
Rate for Payer: BCBS of TX Blue Advantage	$374.55
Rate for Payer: BCBS of TX Blue Essentials	$449.46
Rate for Payer: BCBS of TX PPO	$499.40
Rate for Payer: Cash Price	$1,098.68
Rate for Payer: Multiplan Auto	$811.52
Rate for Payer: Multiplan Commercial	$811.52
Rate for Payer: Multiplan Workers Comp	$811.52
Rate for Payer: Scott and White EPO/PPO	$624.25
Rate for Payer: Superior Health Plan EPO	$169.80

PROBE ARTHROSCOPIC 180MM RAD FRQ 50 DEGREE

Facility

$1,248.50

Hospital Charge Code	8394466
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,098.68

PROBE, ARTHROSCOPIC CRUISE 90 DEGREE 3.5MM 90-S -- DHF

Facility

$816.48

Hospital Charge Code	81754616
Hospital Revenue Code	272
Min. Negotiated Rate	$73.48
Max. Negotiated Rate	$530.71
Rate for Payer: Aetna Commercial	$449.06
Rate for Payer: Amerigroup CHIP/Medicaid	$73.48
Rate for Payer: BCBS of TX Blue Advantage	$244.94
Rate for Payer: BCBS of TX Blue Essentials	$293.93
Rate for Payer: BCBS of TX PPO	$326.59
Rate for Payer: Cash Price	$718.50
Rate for Payer: Multiplan Auto	$530.71
Rate for Payer: Multiplan Commercial	$530.71
Rate for Payer: Multiplan Workers Comp	$530.71
Rate for Payer: Scott and White EPO/PPO	$408.24
Rate for Payer: Superior Health Plan EPO	$111.04

PROBE, ARTHROSCOPY SERFAS MAX4MM 90S 4.0MM -- DHF

Facility

$816.48

Hospital Charge Code	81754616
Hospital Revenue Code	272
Min. Negotiated Rate	$73.48
Max. Negotiated Rate	$530.71
Rate for Payer: Aetna Commercial	$449.06
Rate for Payer: Amerigroup CHIP/Medicaid	$73.48
Rate for Payer: BCBS of TX Blue Advantage	$244.94
Rate for Payer: BCBS of TX Blue Essentials	$293.93
Rate for Payer: BCBS of TX PPO	$326.59
Rate for Payer: Cash Price	$718.50
Rate for Payer: Multiplan Auto	$530.71
Rate for Payer: Multiplan Commercial	$530.71
Rate for Payer: Multiplan Workers Comp	$530.71
Rate for Payer: Scott and White EPO/PPO	$408.24
Rate for Payer: Superior Health Plan EPO	$111.04

PROBE, ARTHROSCOPY SERFAS MAX4MM 90S 4.0MM -- DHF

Facility

$816.48

Hospital Charge Code	81754616
Hospital Revenue Code	272
Rate for Payer: Cash Price	$718.50

PROBE COVER CRM 6X96

Facility

$202.71

Hospital Charge Code	145068
Hospital Revenue Code	272
Min. Negotiated Rate	$18.24
Max. Negotiated Rate	$131.76
Rate for Payer: Aetna Commercial	$111.49
Rate for Payer: Amerigroup CHIP/Medicaid	$18.24
Rate for Payer: BCBS of TX Blue Advantage	$60.81
Rate for Payer: BCBS of TX Blue Essentials	$72.98
Rate for Payer: BCBS of TX PPO	$81.08
Rate for Payer: Cash Price	$178.38
Rate for Payer: Multiplan Auto	$131.76
Rate for Payer: Multiplan Commercial	$131.76
Rate for Payer: Multiplan Workers Comp	$131.76
Rate for Payer: Scott and White EPO/PPO	$101.36
Rate for Payer: Superior Health Plan EPO	$27.57

PROBE COVER CRM 6X96

Facility

$202.71

Hospital Charge Code	145068
Hospital Revenue Code	272
Rate for Payer: Cash Price	$178.38

probe disposable

Facility

$158.90

Hospital Charge Code	8672530
Hospital Revenue Code	272
Rate for Payer: Cash Price	$139.83

probe disposable

Facility

$158.90

Hospital Charge Code	8672530
Hospital Revenue Code	272
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$103.28
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Amerigroup CHIP/Medicaid	$14.30
Rate for Payer: BCBS of TX Blue Advantage	$47.67
Rate for Payer: BCBS of TX Blue Essentials	$57.20
Rate for Payer: BCBS of TX PPO	$63.56
Rate for Payer: Cash Price	$139.83
Rate for Payer: Multiplan Auto	$103.28
Rate for Payer: Multiplan Commercial	$103.28
Rate for Payer: Multiplan Workers Comp	$103.28
Rate for Payer: Scott and White EPO/PPO	$79.45
Rate for Payer: Superior Health Plan EPO	$21.61

PROBE RADIOFREQUENCY COOLIEF COOLED

Facility

$1,865.94

Hospital Charge Code	8568959
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,642.03

PROBE RADIOFREQUENCY COOLIEF COOLED

Facility

$1,865.94

Hospital Charge Code	8568959
Hospital Revenue Code	272
Min. Negotiated Rate	$167.93
Max. Negotiated Rate	$1,212.86
Rate for Payer: Aetna Commercial	$1,026.27
Rate for Payer: Amerigroup CHIP/Medicaid	$167.93
Rate for Payer: BCBS of TX Blue Advantage	$559.78
Rate for Payer: BCBS of TX Blue Essentials	$671.74
Rate for Payer: BCBS of TX PPO	$746.38
Rate for Payer: Cash Price	$1,642.03
Rate for Payer: Multiplan Auto	$1,212.86
Rate for Payer: Multiplan Commercial	$1,212.86
Rate for Payer: Multiplan Workers Comp	$1,212.86
Rate for Payer: Scott and White EPO/PPO	$932.97
Rate for Payer: Superior Health Plan EPO	$253.77

Procalcitonin

Facility

$341.00

Service Code	CPT 84145
Hospital Charge Code	1740965
Hospital Revenue Code	301
Min. Negotiated Rate	$10.62
Max. Negotiated Rate	$221.65
Rate for Payer: Aetna Commercial	$28.58
Rate for Payer: Aetna Medicare	$40.83
Rate for Payer: Amerigroup CHIP/Medicaid	$10.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.22
Rate for Payer: Amerigroup Medicare	$27.22
Rate for Payer: BCBS of TX Blue Advantage	$44.91
Rate for Payer: BCBS of TX Blue Essentials	$53.90
Rate for Payer: BCBS of TX Medicare	$27.22
Rate for Payer: BCBS of TX PPO	$60.16
Rate for Payer: Cash Price	$300.08
Rate for Payer: Cash Price	$300.08
Rate for Payer: Cigna Medicaid	$27.22
Rate for Payer: Cigna Medicare	$27.22
Rate for Payer: Employer Direct Commercial	$27.22
Rate for Payer: Humana Medicare/TRICARE	$27.22
Rate for Payer: Molina CHIP/Medicaid	$27.22
Rate for Payer: Molina Dual Medicare/Medicaid	$27.22
Rate for Payer: Molina Medicare	$27.22
Rate for Payer: Multiplan Auto	$221.65
Rate for Payer: Multiplan Commercial	$221.65
Rate for Payer: Multiplan Workers Comp	$221.65
Rate for Payer: Parkland Medicaid	$27.22
Rate for Payer: Scott and White EPO/PPO	$34.02
Rate for Payer: Scott and White Medicare	$27.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.22
Rate for Payer: Superior Health Plan EPO	$27.22
Rate for Payer: Superior Health Plan Medicare	$27.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.22
Rate for Payer: Universal American Medicare	$27.22
Rate for Payer: Wellcare Medicare	$27.22
Rate for Payer: Wellmed Medicare	$27.22

Know your out-of-pocket cost for care.

All Charges