White Rock Medical Center

All Charges

Charge

Type

Setting

Price

nystatin 100,000 units/g Topical Powder 15 g

Facility

$69.50

Service Code	HCPCS J3490
Hospital Charge Code	77730521
Hospital Revenue Code	250
Rate for Payer: Cash Price	$47.26

nystatin 100,000 units/mL Oral Susp 5 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77731047
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

nystatin 100,000 units/mL Oral Susp 5 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77731047
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

O2 CANN ADULT OVER-EAR FLARED 7 TUB, SC

Facility

$2.57

Hospital Charge Code	993192
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.75

O2 CANN ADULT OVER-EAR FLARED 7 TUB, SC

Facility

$2.57

Hospital Charge Code	993192
Hospital Revenue Code	270
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$1.85
Rate for Payer: Amerigroup CHIP/Medicaid	$0.23
Rate for Payer: BCBS of TX Blue Advantage	$0.77
Rate for Payer: BCBS of TX Blue Essentials	$0.93
Rate for Payer: BCBS of TX PPO	$1.03
Rate for Payer: Cash Price	$1.75
Rate for Payer: Cigna Medicaid	$1.85
Rate for Payer: Molina CHIP/Medicaid	$1.85
Rate for Payer: Multiplan Auto	$1.67
Rate for Payer: Multiplan Commercial	$1.67
Rate for Payer: Multiplan Workers Comp	$1.67
Rate for Payer: Parkland Medicaid	$1.85
Rate for Payer: Scott and White EPO/PPO	$1.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.85
Rate for Payer: Superior Health Plan EPO	$0.35

O2 Sat Meas

Facility

$943.00

Service Code	HCPCS 82805
Hospital Charge Code	4000519
Hospital Revenue Code	301
Min. Negotiated Rate	$30.72
Max. Negotiated Rate	$678.96
Rate for Payer: Amerigroup CHIP/Medicaid	$30.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$78.77
Rate for Payer: Amerigroup Medicare	$78.77
Rate for Payer: BCBS of TX Blue Advantage	$282.90
Rate for Payer: BCBS of TX Blue Essentials	$339.48
Rate for Payer: BCBS of TX Medicare	$78.77
Rate for Payer: BCBS of TX PPO	$377.20
Rate for Payer: Cash Price	$641.24
Rate for Payer: Cash Price	$641.24
Rate for Payer: Cigna Medicaid	$678.96
Rate for Payer: Cigna Medicare	$78.77
Rate for Payer: Employer Direct Commercial	$78.77
Rate for Payer: Humana Medicare/TRICARE	$78.77
Rate for Payer: Molina CHIP/Medicaid	$678.96
Rate for Payer: Molina Dual Medicare/Medicaid	$78.77
Rate for Payer: Molina Medicare	$78.77
Rate for Payer: Multiplan Auto	$612.95
Rate for Payer: Multiplan Commercial	$612.95
Rate for Payer: Multiplan Workers Comp	$612.95
Rate for Payer: Parkland Medicaid	$678.96
Rate for Payer: Scott and White EPO/PPO	$98.46
Rate for Payer: Scott and White Medicare	$78.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$678.96
Rate for Payer: Superior Health Plan EPO	$78.77
Rate for Payer: Superior Health Plan Medicare	$78.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$78.77
Rate for Payer: Universal American Medicare	$78.77
Rate for Payer: Wellcare Medicare	$78.77
Rate for Payer: Wellmed Medicare	$78.77

O2 Sat Meas

Facility

$943.00

Service Code	HCPCS 82805
Hospital Charge Code	4000519
Hospital Revenue Code	301
Rate for Payer: Cash Price	$641.24

O2 Sat Meas

Facility

$320.00

Service Code	HCPCS 82810
Hospital Charge Code	4049206
Hospital Revenue Code	301
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$230.40
Rate for Payer: Amerigroup CHIP/Medicaid	$3.81
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.77
Rate for Payer: Amerigroup Medicare	$9.77
Rate for Payer: BCBS of TX Blue Advantage	$96.00
Rate for Payer: BCBS of TX Blue Essentials	$115.20
Rate for Payer: BCBS of TX Medicare	$9.77
Rate for Payer: BCBS of TX PPO	$128.00
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cigna Medicaid	$230.40
Rate for Payer: Cigna Medicare	$9.77
Rate for Payer: Employer Direct Commercial	$9.77
Rate for Payer: Humana Medicare/TRICARE	$9.77
Rate for Payer: Molina CHIP/Medicaid	$230.40
Rate for Payer: Molina Dual Medicare/Medicaid	$9.77
Rate for Payer: Molina Medicare	$9.77
Rate for Payer: Multiplan Auto	$208.00
Rate for Payer: Multiplan Commercial	$208.00
Rate for Payer: Multiplan Workers Comp	$208.00
Rate for Payer: Parkland Medicaid	$230.40
Rate for Payer: Scott and White EPO/PPO	$12.21
Rate for Payer: Scott and White Medicare	$9.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$230.40
Rate for Payer: Superior Health Plan EPO	$9.77
Rate for Payer: Superior Health Plan Medicare	$9.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.77
Rate for Payer: Universal American Medicare	$9.77
Rate for Payer: Wellcare Medicare	$9.77
Rate for Payer: Wellmed Medicare	$9.77

O2 Sat Meas

Facility

$320.00

Service Code	HCPCS 82810
Hospital Charge Code	4049206
Hospital Revenue Code	301
Rate for Payer: Cash Price	$217.60

Oasis ultra tri‑layer wound matrix - per unit/ sq. Cm

Facility

$771.08

Service Code	HCPCS Q4124
Hospital Charge Code	994157
Hospital Revenue Code	278
Min. Negotiated Rate	$69.40
Max. Negotiated Rate	$555.18
Rate for Payer: Amerigroup CHIP/Medicaid	$69.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$231.32
Rate for Payer: BCBS of TX Blue Essentials	$277.59
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$308.43
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$555.18
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$555.18
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$385.54
Rate for Payer: Multiplan Commercial	$385.54
Rate for Payer: Multiplan Workers Comp	$385.54
Rate for Payer: Parkland Medicaid	$555.18
Rate for Payer: Scott and White EPO/PPO	$385.54
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$555.18
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

Oasis ultra tri‑layer wound matrix - per unit/ sq. Cm

Facility

$771.08

Service Code	HCPCS Q4124
Hospital Charge Code	994157
Hospital Revenue Code	278
Min. Negotiated Rate	$192.77
Max. Negotiated Rate	$385.54
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cigna Commercial	$192.77
Rate for Payer: Multiplan Auto	$385.54
Rate for Payer: Multiplan Commercial	$385.54
Rate for Payer: Multiplan Workers Comp	$385.54
Rate for Payer: Scott and White EPO/PPO	$385.54

Oasis wound matrix - per unit/ sq. cm

Facility

$771.08

Service Code	HCPCS Q4102
Hospital Charge Code	994156
Hospital Revenue Code	278
Min. Negotiated Rate	$69.40
Max. Negotiated Rate	$555.18
Rate for Payer: Amerigroup CHIP/Medicaid	$69.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$231.32
Rate for Payer: BCBS of TX Blue Essentials	$277.59
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$308.43
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$555.18
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$555.18
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$385.54
Rate for Payer: Multiplan Commercial	$385.54
Rate for Payer: Multiplan Workers Comp	$385.54
Rate for Payer: Parkland Medicaid	$555.18
Rate for Payer: Scott and White EPO/PPO	$385.54
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$555.18
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

Oasis wound matrix - per unit/ sq. cm

Facility

$771.08

Service Code	HCPCS Q4102
Hospital Charge Code	994156
Hospital Revenue Code	278
Min. Negotiated Rate	$192.77
Max. Negotiated Rate	$385.54
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cigna Commercial	$192.77
Rate for Payer: Multiplan Auto	$385.54
Rate for Payer: Multiplan Commercial	$385.54
Rate for Payer: Multiplan Workers Comp	$385.54
Rate for Payer: Scott and White EPO/PPO	$385.54

OB Procedure Type -> Outborn placenta delivery

Facility

$5,138.00

Service Code	HCPCS 59414
Hospital Charge Code	10090
Hospital Revenue Code	361
Min. Negotiated Rate	$1,063.52
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,063.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,251.88
Rate for Payer: Amerigroup Medicare	$3,251.88
Rate for Payer: BCBS of TX Blue Advantage	$4,171.83
Rate for Payer: BCBS of TX Blue Essentials	$4,996.20
Rate for Payer: BCBS of TX Medicare	$3,251.88
Rate for Payer: BCBS of TX PPO	$6,295.21
Rate for Payer: Cash Price	$3,493.84
Rate for Payer: Cash Price	$3,493.84
Rate for Payer: Cash Price	$3,493.84
Rate for Payer: Cigna Commercial	$6,873.88
Rate for Payer: Cigna Medicaid	$3,699.36
Rate for Payer: Cigna Medicare	$3,251.88
Rate for Payer: Employer Direct Commercial	$3,251.88
Rate for Payer: Humana Medicare/TRICARE	$3,251.88
Rate for Payer: Molina CHIP/Medicaid	$3,699.36
Rate for Payer: Molina Dual Medicare/Medicaid	$3,251.88
Rate for Payer: Molina Medicare	$3,251.88
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	$3,699.36
Rate for Payer: Scott and White EPO/PPO	$6,015.98
Rate for Payer: Scott and White Medicare	$3,251.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,699.36
Rate for Payer: Superior Health Plan EPO	$3,251.88
Rate for Payer: Superior Health Plan Medicare	$3,251.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,251.88
Rate for Payer: Universal American Medicare	$3,251.88
Rate for Payer: Wellcare Medicare	$3,251.88
Rate for Payer: Wellmed Medicare	$3,251.88

OB Procedure Type -> Outborn placenta delivery

Facility

$5,138.00

Service Code	HCPCS 59414
Hospital Charge Code	10090
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,493.84

obtuator bladeless long opticl 8mm

Facility

$136.20

Hospital Charge Code	8692538
Hospital Revenue Code	272
Min. Negotiated Rate	$12.26
Max. Negotiated Rate	$98.06
Rate for Payer: Amerigroup CHIP/Medicaid	$12.26
Rate for Payer: BCBS of TX Blue Advantage	$40.86
Rate for Payer: BCBS of TX Blue Essentials	$49.03
Rate for Payer: BCBS of TX PPO	$54.48
Rate for Payer: Cash Price	$92.62
Rate for Payer: Cigna Medicaid	$98.06
Rate for Payer: Molina CHIP/Medicaid	$98.06
Rate for Payer: Multiplan Auto	$88.53
Rate for Payer: Multiplan Commercial	$88.53
Rate for Payer: Multiplan Workers Comp	$88.53
Rate for Payer: Parkland Medicaid	$98.06
Rate for Payer: Scott and White EPO/PPO	$68.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.06
Rate for Payer: Superior Health Plan EPO	$18.52

obtuator bladeless long opticl 8mm

Facility

$136.20

Hospital Charge Code	8692538
Hospital Revenue Code	272
Rate for Payer: Cash Price	$92.62

OBTURATATOR FLEX Y KNOT

Facility

$81.72

Hospital Charge Code	144849
Hospital Revenue Code	272
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$58.84
Rate for Payer: Amerigroup CHIP/Medicaid	$7.35
Rate for Payer: BCBS of TX Blue Advantage	$24.52
Rate for Payer: BCBS of TX Blue Essentials	$29.42
Rate for Payer: BCBS of TX PPO	$32.69
Rate for Payer: Cash Price	$55.57
Rate for Payer: Cigna Medicaid	$58.84
Rate for Payer: Molina CHIP/Medicaid	$58.84
Rate for Payer: Multiplan Auto	$53.12
Rate for Payer: Multiplan Commercial	$53.12
Rate for Payer: Multiplan Workers Comp	$53.12
Rate for Payer: Parkland Medicaid	$58.84
Rate for Payer: Scott and White EPO/PPO	$40.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$58.84
Rate for Payer: Superior Health Plan EPO	$11.11

OBTURATATOR FLEX Y KNOT

Facility

$81.72

Hospital Charge Code	144849
Hospital Revenue Code	272
Rate for Payer: Cash Price	$55.57

OBTURATOR BLADELESS OPTICL 8MM

Facility

$858.06

Hospital Charge Code	992733
Hospital Revenue Code	270
Rate for Payer: Cash Price	$583.48

OBTURATOR BLADELESS OPTICL 8MM

Facility

$858.06

Hospital Charge Code	992733
Hospital Revenue Code	270
Min. Negotiated Rate	$77.23
Max. Negotiated Rate	$617.80
Rate for Payer: Amerigroup CHIP/Medicaid	$77.23
Rate for Payer: BCBS of TX Blue Advantage	$257.42
Rate for Payer: BCBS of TX Blue Essentials	$308.90
Rate for Payer: BCBS of TX PPO	$343.22
Rate for Payer: Cash Price	$583.48
Rate for Payer: Cigna Medicaid	$617.80
Rate for Payer: Molina CHIP/Medicaid	$617.80
Rate for Payer: Multiplan Auto	$557.74
Rate for Payer: Multiplan Commercial	$557.74
Rate for Payer: Multiplan Workers Comp	$557.74
Rate for Payer: Parkland Medicaid	$617.80
Rate for Payer: Scott and White EPO/PPO	$429.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$617.80
Rate for Payer: Superior Health Plan EPO	$116.70

obturator bladelss opticle 8mm

Facility

$81.72

Hospital Charge Code	8694516
Hospital Revenue Code	272
Rate for Payer: Cash Price	$55.57

obturator bladelss opticle 8mm

Facility

$81.72

Hospital Charge Code	8694516
Hospital Revenue Code	272
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$58.84
Rate for Payer: Amerigroup CHIP/Medicaid	$7.35
Rate for Payer: BCBS of TX Blue Advantage	$24.52
Rate for Payer: BCBS of TX Blue Essentials	$29.42
Rate for Payer: BCBS of TX PPO	$32.69
Rate for Payer: Cash Price	$55.57
Rate for Payer: Cigna Medicaid	$58.84
Rate for Payer: Molina CHIP/Medicaid	$58.84
Rate for Payer: Multiplan Auto	$53.12
Rate for Payer: Multiplan Commercial	$53.12
Rate for Payer: Multiplan Workers Comp	$53.12
Rate for Payer: Parkland Medicaid	$58.84
Rate for Payer: Scott and White EPO/PPO	$40.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$58.84
Rate for Payer: Superior Health Plan EPO	$11.11

OCCLSN/EMBL CATH NON-CNS

Facility

$12,192.00

Service Code	HCPCS 61626
Hospital Charge Code	4617790
Hospital Revenue Code	361
Min. Negotiated Rate	$1,097.28
Max. Negotiated Rate	$24,969.37
Rate for Payer: Amerigroup CHIP/Medicaid	$1,097.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Amerigroup Medicare	$11,596.79
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	$11,596.79
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$8,290.56
Rate for Payer: Cash Price	$8,290.56
Rate for Payer: Cash Price	$8,290.56
Rate for Payer: Cigna Commercial	$24,513.51
Rate for Payer: Cigna Medicaid	$8,778.24
Rate for Payer: Cigna Medicare	$11,596.79
Rate for Payer: Employer Direct Commercial	$11,596.79
Rate for Payer: Humana Medicare/TRICARE	$11,596.79
Rate for Payer: Molina CHIP/Medicaid	$8,778.24
Rate for Payer: Molina Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Molina Medicare	$11,596.79
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	$8,778.24
Rate for Payer: Scott and White EPO/PPO	$21,454.06
Rate for Payer: Scott and White Medicare	$11,596.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,778.24
Rate for Payer: Superior Health Plan EPO	$11,596.79
Rate for Payer: Superior Health Plan Medicare	$11,596.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Universal American Medicare	$11,596.79
Rate for Payer: Wellcare Medicare	$11,596.79
Rate for Payer: Wellmed Medicare	$11,596.79

OCCLSN/EMBL CATH NON-CNS

Facility

$12,192.00

Service Code	HCPCS 61626
Hospital Charge Code	4617790
Hospital Revenue Code	361
Rate for Payer: Cash Price	$8,290.56

Know your out-of-pocket cost for care.

All Charges