White Rock Medical Center

All Charges

Charge

Type

Setting

Price

oxymetazoline 0.05% Nasal Spray 15 mL

Facility

$8.90

Service Code	HCPCS J3490
Hospital Charge Code	77741759
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.05

oxytocin 10 units/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	77742832
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

oxytocin 10 units/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	77742832
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

Oxytocin Challenge Test

Facility

$878.00

Service Code	HCPCS 59020
Hospital Charge Code	10140
Hospital Revenue Code	361
Rate for Payer: Cash Price	$597.04

Oxytocin Challenge Test

Facility

$878.00

Service Code	HCPCS 59020
Hospital Charge Code	10140
Hospital Revenue Code	361
Min. Negotiated Rate	$27.13
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$27.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$203.09
Rate for Payer: Amerigroup Medicare	$203.09
Rate for Payer: BCBS of TX Blue Advantage	$263.40
Rate for Payer: BCBS of TX Blue Essentials	$316.08
Rate for Payer: BCBS of TX Medicare	$203.09
Rate for Payer: BCBS of TX PPO	$351.20
Rate for Payer: Cash Price	$597.04
Rate for Payer: Cash Price	$597.04
Rate for Payer: Cash Price	$597.04
Rate for Payer: Cigna Commercial	$429.31
Rate for Payer: Cigna Medicaid	$632.16
Rate for Payer: Cigna Medicare	$203.09
Rate for Payer: Employer Direct Commercial	$203.09
Rate for Payer: Humana Medicare/TRICARE	$203.09
Rate for Payer: Molina CHIP/Medicaid	$632.16
Rate for Payer: Molina Dual Medicare/Medicaid	$203.09
Rate for Payer: Molina Medicare	$203.09
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	$632.16
Rate for Payer: Scott and White EPO/PPO	$337.14
Rate for Payer: Scott and White Medicare	$203.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$632.16
Rate for Payer: Superior Health Plan EPO	$203.09
Rate for Payer: Superior Health Plan Medicare	$203.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$203.09
Rate for Payer: Universal American Medicare	$203.09
Rate for Payer: Wellcare Medicare	$203.09
Rate for Payer: Wellmed Medicare	$203.09

P06N0332P06N0341

Facility

$295.18

Service Code	HCPCS C1769
Hospital Charge Code	991208
Hospital Revenue Code	272
Rate for Payer: Cash Price	$200.72

P06N0332P06N0341

Facility

$295.18

Service Code	HCPCS C1769
Hospital Charge Code	991208
Hospital Revenue Code	272
Min. Negotiated Rate	$26.57
Max. Negotiated Rate	$212.53
Rate for Payer: Amerigroup CHIP/Medicaid	$26.57
Rate for Payer: BCBS of TX Blue Advantage	$88.55
Rate for Payer: BCBS of TX Blue Essentials	$106.26
Rate for Payer: BCBS of TX PPO	$118.07
Rate for Payer: Cash Price	$200.72
Rate for Payer: Cigna Medicaid	$212.53
Rate for Payer: Molina CHIP/Medicaid	$212.53
Rate for Payer: Multiplan Auto	$191.87
Rate for Payer: Multiplan Commercial	$191.87
Rate for Payer: Multiplan Workers Comp	$191.87
Rate for Payer: Parkland Medicaid	$212.53
Rate for Payer: Scott and White EPO/PPO	$147.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$212.53
Rate for Payer: Superior Health Plan EPO	$40.14

P06N0461P06N0562

Facility

$1,343.37

Service Code	HCPCS C1713
Hospital Charge Code	991209
Hospital Revenue Code	278
Min. Negotiated Rate	$335.84
Max. Negotiated Rate	$671.68
Rate for Payer: Cash Price	$913.49
Rate for Payer: Cigna Commercial	$335.84
Rate for Payer: Multiplan Auto	$671.68
Rate for Payer: Multiplan Commercial	$671.68
Rate for Payer: Multiplan Workers Comp	$671.68
Rate for Payer: Scott and White EPO/PPO	$671.68

P06N0461P06N0562

Facility

$1,343.37

Service Code	HCPCS C1713
Hospital Charge Code	991209
Hospital Revenue Code	278
Min. Negotiated Rate	$120.90
Max. Negotiated Rate	$967.23
Rate for Payer: Amerigroup CHIP/Medicaid	$120.90
Rate for Payer: BCBS of TX Blue Advantage	$403.01
Rate for Payer: BCBS of TX Blue Essentials	$483.61
Rate for Payer: BCBS of TX PPO	$537.35
Rate for Payer: Cash Price	$913.49
Rate for Payer: Cigna Medicaid	$967.23
Rate for Payer: Molina CHIP/Medicaid	$967.23
Rate for Payer: Multiplan Auto	$671.68
Rate for Payer: Multiplan Commercial	$671.68
Rate for Payer: Multiplan Workers Comp	$671.68
Rate for Payer: Parkland Medicaid	$967.23
Rate for Payer: Scott and White EPO/PPO	$671.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$967.23
Rate for Payer: Superior Health Plan EPO	$182.70

P65 ST567

Facility

$4,308.64

Service Code	HCPCS C1713
Hospital Charge Code	991218
Hospital Revenue Code	278
Min. Negotiated Rate	$387.78
Max. Negotiated Rate	$3,102.22
Rate for Payer: Amerigroup CHIP/Medicaid	$387.78
Rate for Payer: BCBS of TX Blue Advantage	$1,292.59
Rate for Payer: BCBS of TX Blue Essentials	$1,551.11
Rate for Payer: BCBS of TX PPO	$1,723.46
Rate for Payer: Cash Price	$2,929.88
Rate for Payer: Cigna Medicaid	$3,102.22
Rate for Payer: Molina CHIP/Medicaid	$3,102.22
Rate for Payer: Multiplan Auto	$2,154.32
Rate for Payer: Multiplan Commercial	$2,154.32
Rate for Payer: Multiplan Workers Comp	$2,154.32
Rate for Payer: Parkland Medicaid	$3,102.22
Rate for Payer: Scott and White EPO/PPO	$2,154.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,102.22
Rate for Payer: Superior Health Plan EPO	$585.98

P65 ST567

Facility

$4,308.64

Service Code	HCPCS C1713
Hospital Charge Code	991218
Hospital Revenue Code	278
Min. Negotiated Rate	$1,077.16
Max. Negotiated Rate	$2,154.32
Rate for Payer: Cash Price	$2,929.88
Rate for Payer: Cigna Commercial	$1,077.16
Rate for Payer: Multiplan Auto	$2,154.32
Rate for Payer: Multiplan Commercial	$2,154.32
Rate for Payer: Multiplan Workers Comp	$2,154.32
Rate for Payer: Scott and White EPO/PPO	$2,154.32

P65 ST650

Facility

$5,543.00

Service Code	HCPCS C1713
Hospital Charge Code	991217
Hospital Revenue Code	278
Min. Negotiated Rate	$498.87
Max. Negotiated Rate	$3,990.96
Rate for Payer: Amerigroup CHIP/Medicaid	$498.87
Rate for Payer: BCBS of TX Blue Advantage	$1,662.90
Rate for Payer: BCBS of TX Blue Essentials	$1,995.48
Rate for Payer: BCBS of TX PPO	$2,217.20
Rate for Payer: Cash Price	$3,769.24
Rate for Payer: Cigna Medicaid	$3,990.96
Rate for Payer: Molina CHIP/Medicaid	$3,990.96
Rate for Payer: Multiplan Auto	$2,771.50
Rate for Payer: Multiplan Commercial	$2,771.50
Rate for Payer: Multiplan Workers Comp	$2,771.50
Rate for Payer: Parkland Medicaid	$3,990.96
Rate for Payer: Scott and White EPO/PPO	$2,771.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,990.96
Rate for Payer: Superior Health Plan EPO	$753.85

P65 ST650

Facility

$5,543.00

Service Code	HCPCS C1713
Hospital Charge Code	991217
Hospital Revenue Code	278
Min. Negotiated Rate	$1,385.75
Max. Negotiated Rate	$2,771.50
Rate for Payer: Cash Price	$3,769.24
Rate for Payer: Cigna Commercial	$1,385.75
Rate for Payer: Multiplan Auto	$2,771.50
Rate for Payer: Multiplan Commercial	$2,771.50
Rate for Payer: Multiplan Workers Comp	$2,771.50
Rate for Payer: Scott and White EPO/PPO	$2,771.50

P65ST650P65ST567

Facility

$5,409.63

Service Code	HCPCS C1734
Hospital Charge Code	991210
Hospital Revenue Code	278
Min. Negotiated Rate	$1,352.41
Max. Negotiated Rate	$2,704.82
Rate for Payer: Cash Price	$3,678.55
Rate for Payer: Cigna Commercial	$1,352.41
Rate for Payer: Multiplan Auto	$2,704.82
Rate for Payer: Multiplan Commercial	$2,704.82
Rate for Payer: Multiplan Workers Comp	$2,704.82
Rate for Payer: Scott and White EPO/PPO	$2,704.82

P65ST650P65ST567

Facility

$5,409.63

Service Code	HCPCS C1734
Hospital Charge Code	991210
Hospital Revenue Code	278
Min. Negotiated Rate	$486.87
Max. Negotiated Rate	$3,894.93
Rate for Payer: Amerigroup CHIP/Medicaid	$486.87
Rate for Payer: BCBS of TX Blue Advantage	$1,622.89
Rate for Payer: BCBS of TX Blue Essentials	$1,947.47
Rate for Payer: BCBS of TX PPO	$2,163.85
Rate for Payer: Cash Price	$3,678.55
Rate for Payer: Cigna Medicaid	$3,894.93
Rate for Payer: Molina CHIP/Medicaid	$3,894.93
Rate for Payer: Multiplan Auto	$2,704.82
Rate for Payer: Multiplan Commercial	$2,704.82
Rate for Payer: Multiplan Workers Comp	$2,704.82
Rate for Payer: Parkland Medicaid	$3,894.93
Rate for Payer: Scott and White EPO/PPO	$2,704.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,894.93
Rate for Payer: Superior Health Plan EPO	$735.71

PACE ADAPTER CBL -- DHF

Facility

$495.28

Hospital Charge Code	81760159
Hospital Revenue Code	270
Min. Negotiated Rate	$44.58
Max. Negotiated Rate	$356.60
Rate for Payer: Amerigroup CHIP/Medicaid	$44.58
Rate for Payer: BCBS of TX Blue Advantage	$148.58
Rate for Payer: BCBS of TX Blue Essentials	$178.30
Rate for Payer: BCBS of TX PPO	$198.11
Rate for Payer: Cash Price	$336.79
Rate for Payer: Cigna Medicaid	$356.60
Rate for Payer: Molina CHIP/Medicaid	$356.60
Rate for Payer: Multiplan Auto	$321.93
Rate for Payer: Multiplan Commercial	$321.93
Rate for Payer: Multiplan Workers Comp	$321.93
Rate for Payer: Parkland Medicaid	$356.60
Rate for Payer: Scott and White EPO/PPO	$247.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$356.60
Rate for Payer: Superior Health Plan EPO	$67.36

PACE ADAPTER CBL -- DHF

Facility

$495.28

Hospital Charge Code	81760159
Hospital Revenue Code	270
Rate for Payer: Cash Price	$336.79

Pacemaker, dual chamber, rate-responsive (implantable)

Facility

$22,559.76

Service Code	HCPCS C1785
Hospital Charge Code	990936
Hospital Revenue Code	275
Min. Negotiated Rate	$5,639.94
Max. Negotiated Rate	$11,279.88
Rate for Payer: Cash Price	$15,340.64
Rate for Payer: Cigna Commercial	$5,639.94
Rate for Payer: Multiplan Auto	$11,279.88
Rate for Payer: Multiplan Commercial	$11,279.88
Rate for Payer: Multiplan Workers Comp	$11,279.88
Rate for Payer: Scott and White EPO/PPO	$11,279.88

Pacemaker, dual chamber, rate-responsive (implantable)

Facility

$22,559.76

Service Code	HCPCS C1785
Hospital Charge Code	990936
Hospital Revenue Code	275
Min. Negotiated Rate	$2,030.38
Max. Negotiated Rate	$16,243.03
Rate for Payer: Amerigroup CHIP/Medicaid	$2,030.38
Rate for Payer: BCBS of TX Blue Advantage	$6,767.93
Rate for Payer: BCBS of TX Blue Essentials	$8,121.51
Rate for Payer: BCBS of TX PPO	$9,023.90
Rate for Payer: Cash Price	$15,340.64
Rate for Payer: Cigna Medicaid	$16,243.03
Rate for Payer: Molina CHIP/Medicaid	$16,243.03
Rate for Payer: Multiplan Auto	$11,279.88
Rate for Payer: Multiplan Commercial	$11,279.88
Rate for Payer: Multiplan Workers Comp	$11,279.88
Rate for Payer: Parkland Medicaid	$16,243.03
Rate for Payer: Scott and White EPO/PPO	$11,279.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,243.03
Rate for Payer: Superior Health Plan EPO	$3,068.13

Package 3.2mm x 330mm Steinmann Pin Threaded

Facility

$1,275.74

Hospital Charge Code	993905
Hospital Revenue Code	272
Rate for Payer: Cash Price	$867.50

Package 3.2mm x 330mm Steinmann Pin Threaded

Facility

$1,275.74

Hospital Charge Code	993905
Hospital Revenue Code	272
Min. Negotiated Rate	$114.82
Max. Negotiated Rate	$918.53
Rate for Payer: Amerigroup CHIP/Medicaid	$114.82
Rate for Payer: BCBS of TX Blue Advantage	$382.72
Rate for Payer: BCBS of TX Blue Essentials	$459.27
Rate for Payer: BCBS of TX PPO	$510.30
Rate for Payer: Cash Price	$867.50
Rate for Payer: Cigna Medicaid	$918.53
Rate for Payer: Molina CHIP/Medicaid	$918.53
Rate for Payer: Multiplan Auto	$829.23
Rate for Payer: Multiplan Commercial	$829.23
Rate for Payer: Multiplan Workers Comp	$829.23
Rate for Payer: Parkland Medicaid	$918.53
Rate for Payer: Scott and White EPO/PPO	$637.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$918.53
Rate for Payer: Superior Health Plan EPO	$173.50

PACKAGED 4.3MM DRILL BIT FULLY THREADED, ANKLE SA

Facility

$1,552.68

Hospital Charge Code	993897
Hospital Revenue Code	272
Min. Negotiated Rate	$139.74
Max. Negotiated Rate	$1,117.93
Rate for Payer: Amerigroup CHIP/Medicaid	$139.74
Rate for Payer: BCBS of TX Blue Advantage	$465.80
Rate for Payer: BCBS of TX Blue Essentials	$558.96
Rate for Payer: BCBS of TX PPO	$621.07
Rate for Payer: Cash Price	$1,055.82
Rate for Payer: Cigna Medicaid	$1,117.93
Rate for Payer: Molina CHIP/Medicaid	$1,117.93
Rate for Payer: Multiplan Auto	$1,009.24
Rate for Payer: Multiplan Commercial	$1,009.24
Rate for Payer: Multiplan Workers Comp	$1,009.24
Rate for Payer: Parkland Medicaid	$1,117.93
Rate for Payer: Scott and White EPO/PPO	$776.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,117.93
Rate for Payer: Superior Health Plan EPO	$211.16

PACKAGED 4.3MM DRILL BIT FULLY THREADED, ANKLE SA

Facility

$1,552.68

Hospital Charge Code	993897
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,055.82

PACKAGED 5.0MM STEP DRILL BIT, ANKLE SALVAGE

Facility

$1,983.98

Hospital Charge Code	993900
Hospital Revenue Code	272
Min. Negotiated Rate	$178.56
Max. Negotiated Rate	$1,428.47
Rate for Payer: Amerigroup CHIP/Medicaid	$178.56
Rate for Payer: BCBS of TX Blue Advantage	$595.19
Rate for Payer: BCBS of TX Blue Essentials	$714.23
Rate for Payer: BCBS of TX PPO	$793.59
Rate for Payer: Cash Price	$1,349.11
Rate for Payer: Cigna Medicaid	$1,428.47
Rate for Payer: Molina CHIP/Medicaid	$1,428.47
Rate for Payer: Multiplan Auto	$1,289.59
Rate for Payer: Multiplan Commercial	$1,289.59
Rate for Payer: Multiplan Workers Comp	$1,289.59
Rate for Payer: Parkland Medicaid	$1,428.47
Rate for Payer: Scott and White EPO/PPO	$991.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,428.47
Rate for Payer: Superior Health Plan EPO	$269.82

PACKAGED 5.0MM STEP DRILL BIT, ANKLE SALVAGE

Facility

$1,983.98

Hospital Charge Code	993900
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,349.11

Know your out-of-pocket cost for care.

All Charges