White Rock Medical Center

All Charges

Charge

Type

Setting

Price

pantoprazole 40 mg iv

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78414989
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

pantoprazole 40 mg iv

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78414989
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

pantoprazole 40 mg IV Inj

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8037080
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

pantoprazole 40 mg IV Inj

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8037080
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

PAPER AND INK CRTDG SEPC 110

Facility

$1,471.91

Hospital Charge Code	993201
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,000.90

PAPER AND INK CRTDG SEPC 110

Facility

$1,471.91

Hospital Charge Code	993201
Hospital Revenue Code	270
Min. Negotiated Rate	$132.47
Max. Negotiated Rate	$1,059.78
Rate for Payer: Amerigroup CHIP/Medicaid	$132.47
Rate for Payer: BCBS of TX Blue Advantage	$441.57
Rate for Payer: BCBS of TX Blue Essentials	$529.89
Rate for Payer: BCBS of TX PPO	$588.76
Rate for Payer: Cash Price	$1,000.90
Rate for Payer: Cigna Medicaid	$1,059.78
Rate for Payer: Molina CHIP/Medicaid	$1,059.78
Rate for Payer: Multiplan Auto	$956.74
Rate for Payer: Multiplan Commercial	$956.74
Rate for Payer: Multiplan Workers Comp	$956.74
Rate for Payer: Parkland Medicaid	$1,059.78
Rate for Payer: Scott and White EPO/PPO	$735.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,059.78
Rate for Payer: Superior Health Plan EPO	$200.18

PAPER, AUTOCLAVE

Facility

$318.98

Hospital Charge Code	992944
Hospital Revenue Code	270
Min. Negotiated Rate	$28.71
Max. Negotiated Rate	$229.67
Rate for Payer: Amerigroup CHIP/Medicaid	$28.71
Rate for Payer: BCBS of TX Blue Advantage	$95.69
Rate for Payer: BCBS of TX Blue Essentials	$114.83
Rate for Payer: BCBS of TX PPO	$127.59
Rate for Payer: Cash Price	$216.91
Rate for Payer: Cigna Medicaid	$229.67
Rate for Payer: Molina CHIP/Medicaid	$229.67
Rate for Payer: Multiplan Auto	$207.34
Rate for Payer: Multiplan Commercial	$207.34
Rate for Payer: Multiplan Workers Comp	$207.34
Rate for Payer: Parkland Medicaid	$229.67
Rate for Payer: Scott and White EPO/PPO	$159.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$229.67
Rate for Payer: Superior Health Plan EPO	$43.38

PAPER, AUTOCLAVE

Facility

$318.98

Hospital Charge Code	992944
Hospital Revenue Code	270
Rate for Payer: Cash Price	$216.91

Paper CD / DVD Sleeves, White

Facility

$1.10

Hospital Charge Code	993323
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.75

Paper CD / DVD Sleeves, White

Facility

$1.10

Hospital Charge Code	993323
Hospital Revenue Code	270
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.79
Rate for Payer: Amerigroup CHIP/Medicaid	$0.10
Rate for Payer: BCBS of TX Blue Advantage	$0.33
Rate for Payer: BCBS of TX Blue Essentials	$0.40
Rate for Payer: BCBS of TX PPO	$0.44
Rate for Payer: Cash Price	$0.75
Rate for Payer: Cigna Medicaid	$0.79
Rate for Payer: Molina CHIP/Medicaid	$0.79
Rate for Payer: Multiplan Auto	$0.72
Rate for Payer: Multiplan Commercial	$0.72
Rate for Payer: Multiplan Workers Comp	$0.72
Rate for Payer: Parkland Medicaid	$0.79
Rate for Payer: Scott and White EPO/PPO	$0.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.79
Rate for Payer: Superior Health Plan EPO	$0.15

PAPER CHART RCRD ECG Z FOLD 8.5X11 ELI-250/350

Facility

$99.48

Hospital Charge Code	993535
Hospital Revenue Code	270
Min. Negotiated Rate	$8.95
Max. Negotiated Rate	$71.63
Rate for Payer: Amerigroup CHIP/Medicaid	$8.95
Rate for Payer: BCBS of TX Blue Advantage	$29.84
Rate for Payer: BCBS of TX Blue Essentials	$35.81
Rate for Payer: BCBS of TX PPO	$39.79
Rate for Payer: Cash Price	$67.65
Rate for Payer: Cigna Medicaid	$71.63
Rate for Payer: Molina CHIP/Medicaid	$71.63
Rate for Payer: Multiplan Auto	$64.66
Rate for Payer: Multiplan Commercial	$64.66
Rate for Payer: Multiplan Workers Comp	$64.66
Rate for Payer: Parkland Medicaid	$71.63
Rate for Payer: Scott and White EPO/PPO	$49.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$71.63
Rate for Payer: Superior Health Plan EPO	$13.53

PAPER CHART RCRD ECG Z FOLD 8.5X11 ELI-250/350

Facility

$99.48

Hospital Charge Code	993535
Hospital Revenue Code	270
Rate for Payer: Cash Price	$67.65

PAPER, ECG, MORTARA EL250

Facility

$64.10

Hospital Charge Code	992978
Hospital Revenue Code	270
Rate for Payer: Cash Price	$43.59

PAPER, ECG, MORTARA EL250

Facility

$64.10

Hospital Charge Code	992978
Hospital Revenue Code	270
Min. Negotiated Rate	$5.77
Max. Negotiated Rate	$46.15
Rate for Payer: Amerigroup CHIP/Medicaid	$5.77
Rate for Payer: BCBS of TX Blue Advantage	$19.23
Rate for Payer: BCBS of TX Blue Essentials	$23.08
Rate for Payer: BCBS of TX PPO	$25.64
Rate for Payer: Cash Price	$43.59
Rate for Payer: Cigna Medicaid	$46.15
Rate for Payer: Molina CHIP/Medicaid	$46.15
Rate for Payer: Multiplan Auto	$41.66
Rate for Payer: Multiplan Commercial	$41.66
Rate for Payer: Multiplan Workers Comp	$41.66
Rate for Payer: Parkland Medicaid	$46.15
Rate for Payer: Scott and White EPO/PPO	$32.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.15
Rate for Payer: Superior Health Plan EPO	$8.72

PAPER, LINER, TRAP, 20' X 25

Facility

$1.04

Hospital Charge Code	992946
Hospital Revenue Code	270
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.75
Rate for Payer: Amerigroup CHIP/Medicaid	$0.09
Rate for Payer: BCBS of TX Blue Advantage	$0.31
Rate for Payer: BCBS of TX Blue Essentials	$0.37
Rate for Payer: BCBS of TX PPO	$0.42
Rate for Payer: Cash Price	$0.71
Rate for Payer: Cigna Medicaid	$0.75
Rate for Payer: Molina CHIP/Medicaid	$0.75
Rate for Payer: Multiplan Auto	$0.68
Rate for Payer: Multiplan Commercial	$0.68
Rate for Payer: Multiplan Workers Comp	$0.68
Rate for Payer: Parkland Medicaid	$0.75
Rate for Payer: Scott and White EPO/PPO	$0.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.75
Rate for Payer: Superior Health Plan EPO	$0.14

PAPER, LINER, TRAP, 20' X 25

Facility

$1.04

Hospital Charge Code	992946
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.71

PAPER PRINTER FOR GEM PREMIER

Facility

$9.48

Hospital Charge Code	993534
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.45

PAPER PRINTER FOR GEM PREMIER

Facility

$9.48

Hospital Charge Code	993534
Hospital Revenue Code	270
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$6.83
Rate for Payer: Amerigroup CHIP/Medicaid	$0.85
Rate for Payer: BCBS of TX Blue Advantage	$2.84
Rate for Payer: BCBS of TX Blue Essentials	$3.41
Rate for Payer: BCBS of TX PPO	$3.79
Rate for Payer: Cash Price	$6.45
Rate for Payer: Cigna Medicaid	$6.83
Rate for Payer: Molina CHIP/Medicaid	$6.83
Rate for Payer: Multiplan Auto	$6.16
Rate for Payer: Multiplan Commercial	$6.16
Rate for Payer: Multiplan Workers Comp	$6.16
Rate for Payer: Parkland Medicaid	$6.83
Rate for Payer: Scott and White EPO/PPO	$4.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.83
Rate for Payer: Superior Health Plan EPO	$1.29

PAPER, TOILET ST CVR, 1/2FO, REFILL, 5000CS

Facility

$0.04

Hospital Charge Code	993970
Hospital Revenue Code	270
Max. Negotiated Rate	$0.03
Rate for Payer: Amerigroup CHIP/Medicaid	$0.00
Rate for Payer: BCBS of TX Blue Advantage	$0.01
Rate for Payer: BCBS of TX Blue Essentials	$0.01
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna Medicaid	$0.03
Rate for Payer: Molina CHIP/Medicaid	$0.03
Rate for Payer: Multiplan Auto	$0.03
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: Multiplan Workers Comp	$0.03
Rate for Payer: Parkland Medicaid	$0.03
Rate for Payer: Scott and White EPO/PPO	$0.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.03
Rate for Payer: Superior Health Plan EPO	$0.01

PAPER, TOILET ST CVR, 1/2FO, REFILL, 5000CS

Facility

$0.04

Hospital Charge Code	993970
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.03

paper towels

Facility

$27.33

Hospital Charge Code	993344
Hospital Revenue Code	270
Rate for Payer: Cash Price	$18.58

paper towels

Facility

$27.33

Hospital Charge Code	993344
Hospital Revenue Code	270
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$19.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2.46
Rate for Payer: BCBS of TX Blue Advantage	$8.20
Rate for Payer: BCBS of TX Blue Essentials	$9.84
Rate for Payer: BCBS of TX PPO	$10.93
Rate for Payer: Cash Price	$18.58
Rate for Payer: Cigna Medicaid	$19.68
Rate for Payer: Molina CHIP/Medicaid	$19.68
Rate for Payer: Multiplan Auto	$17.76
Rate for Payer: Multiplan Commercial	$17.76
Rate for Payer: Multiplan Workers Comp	$17.76
Rate for Payer: Parkland Medicaid	$19.68
Rate for Payer: Scott and White EPO/PPO	$13.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.68
Rate for Payer: Superior Health Plan EPO	$3.72

Pap IG (Image Guided) SO

Facility

$169.00

Service Code	HCPCS 88175
Hospital Charge Code	8662511
Hospital Revenue Code	311
Rate for Payer: Cash Price	$114.92

Pap IG (Image Guided) SO

Facility

$169.00

Service Code	HCPCS 88175
Hospital Charge Code	8662511
Hospital Revenue Code	311
Min. Negotiated Rate	$10.38
Max. Negotiated Rate	$121.68
Rate for Payer: Amerigroup CHIP/Medicaid	$10.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.61
Rate for Payer: Amerigroup Medicare	$26.61
Rate for Payer: BCBS of TX Blue Advantage	$50.70
Rate for Payer: BCBS of TX Blue Essentials	$60.84
Rate for Payer: BCBS of TX Medicare	$26.61
Rate for Payer: BCBS of TX PPO	$67.60
Rate for Payer: Cash Price	$114.92
Rate for Payer: Cash Price	$114.92
Rate for Payer: Cigna Medicaid	$121.68
Rate for Payer: Cigna Medicare	$26.61
Rate for Payer: Employer Direct Commercial	$26.61
Rate for Payer: Humana Medicare/TRICARE	$26.61
Rate for Payer: Molina CHIP/Medicaid	$121.68
Rate for Payer: Molina Dual Medicare/Medicaid	$26.61
Rate for Payer: Molina Medicare	$26.61
Rate for Payer: Multiplan Auto	$109.85
Rate for Payer: Multiplan Commercial	$109.85
Rate for Payer: Multiplan Workers Comp	$109.85
Rate for Payer: Parkland Medicaid	$121.68
Rate for Payer: Scott and White EPO/PPO	$33.26
Rate for Payer: Scott and White Medicare	$26.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$121.68
Rate for Payer: Superior Health Plan EPO	$26.61
Rate for Payer: Superior Health Plan Medicare	$26.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.61
Rate for Payer: Universal American Medicare	$26.61
Rate for Payer: Wellcare Medicare	$26.61
Rate for Payer: Wellmed Medicare	$26.61

Parathyroid Hormone Intact Intraoperative/Post Operative

Facility

$302.00

Service Code	HCPCS 83970
Hospital Charge Code	1707926
Hospital Revenue Code	301
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$217.44
Rate for Payer: Amerigroup CHIP/Medicaid	$16.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$41.28
Rate for Payer: Amerigroup Medicare	$41.28
Rate for Payer: BCBS of TX Blue Advantage	$90.60
Rate for Payer: BCBS of TX Blue Essentials	$108.72
Rate for Payer: BCBS of TX Medicare	$41.28
Rate for Payer: BCBS of TX PPO	$120.80
Rate for Payer: Cash Price	$205.36
Rate for Payer: Cash Price	$205.36
Rate for Payer: Cigna Medicaid	$217.44
Rate for Payer: Cigna Medicare	$41.28
Rate for Payer: Employer Direct Commercial	$41.28
Rate for Payer: Humana Medicare/TRICARE	$41.28
Rate for Payer: Molina CHIP/Medicaid	$217.44
Rate for Payer: Molina Dual Medicare/Medicaid	$41.28
Rate for Payer: Molina Medicare	$41.28
Rate for Payer: Multiplan Auto	$196.30
Rate for Payer: Multiplan Commercial	$196.30
Rate for Payer: Multiplan Workers Comp	$196.30
Rate for Payer: Parkland Medicaid	$217.44
Rate for Payer: Scott and White EPO/PPO	$51.60
Rate for Payer: Scott and White Medicare	$41.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$217.44
Rate for Payer: Superior Health Plan EPO	$41.28
Rate for Payer: Superior Health Plan Medicare	$41.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$41.28
Rate for Payer: Universal American Medicare	$41.28
Rate for Payer: Wellcare Medicare	$41.28
Rate for Payer: Wellmed Medicare	$41.28

Know your out-of-pocket cost for care.

All Charges