White Rock Medical Center

All Charges

Charge

Type

Setting

Price

potassium phosphate 3 mmol/mL IV Soln 15 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77769934
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

potassium phosphate-sodium phosphate 250 mg-280 mg-160 mg Oral Powder-Recon

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77770295
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

potassium phosphate-sodium phosphate 250 mg-280 mg-160 mg Oral Powder-Recon

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77770295
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

POUCH

Facility

$180.24

Hospital Charge Code	992681
Hospital Revenue Code	272
Min. Negotiated Rate	$16.22
Max. Negotiated Rate	$129.77
Rate for Payer: Amerigroup CHIP/Medicaid	$16.22
Rate for Payer: BCBS of TX Blue Advantage	$54.07
Rate for Payer: BCBS of TX Blue Essentials	$64.89
Rate for Payer: BCBS of TX PPO	$72.10
Rate for Payer: Cash Price	$122.56
Rate for Payer: Cigna Medicaid	$129.77
Rate for Payer: Molina CHIP/Medicaid	$129.77
Rate for Payer: Multiplan Auto	$117.16
Rate for Payer: Multiplan Commercial	$117.16
Rate for Payer: Multiplan Workers Comp	$117.16
Rate for Payer: Parkland Medicaid	$129.77
Rate for Payer: Scott and White EPO/PPO	$90.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$129.77
Rate for Payer: Superior Health Plan EPO	$24.51

POUCH

Facility

$180.24

Hospital Charge Code	992681
Hospital Revenue Code	272
Rate for Payer: Cash Price	$122.56

POUCH 15MM ECTCH 2 SPEC RET

Facility

$147.42

Hospital Charge Code	993741
Hospital Revenue Code	272
Min. Negotiated Rate	$13.27
Max. Negotiated Rate	$106.14
Rate for Payer: Amerigroup CHIP/Medicaid	$13.27
Rate for Payer: BCBS of TX Blue Advantage	$44.23
Rate for Payer: BCBS of TX Blue Essentials	$53.07
Rate for Payer: BCBS of TX PPO	$58.97
Rate for Payer: Cash Price	$100.25
Rate for Payer: Cigna Medicaid	$106.14
Rate for Payer: Molina CHIP/Medicaid	$106.14
Rate for Payer: Multiplan Auto	$95.82
Rate for Payer: Multiplan Commercial	$95.82
Rate for Payer: Multiplan Workers Comp	$95.82
Rate for Payer: Parkland Medicaid	$106.14
Rate for Payer: Scott and White EPO/PPO	$73.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$106.14
Rate for Payer: Superior Health Plan EPO	$20.05

POUCH 15MM ECTCH 2 SPEC RET

Facility

$147.42

Hospital Charge Code	993741
Hospital Revenue Code	272
Rate for Payer: Cash Price	$100.25

POUCH, DRNBL, PREMIER, TRANS, CTF 2.5',1PC

Facility

$7.87

Hospital Charge Code	993215
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.35

POUCH, DRNBL, PREMIER, TRANS, CTF 2.5',1PC

Facility

$7.87

Hospital Charge Code	993215
Hospital Revenue Code	270
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$5.67
Rate for Payer: Amerigroup CHIP/Medicaid	$0.71
Rate for Payer: BCBS of TX Blue Advantage	$2.36
Rate for Payer: BCBS of TX Blue Essentials	$2.83
Rate for Payer: BCBS of TX PPO	$3.15
Rate for Payer: Cash Price	$5.35
Rate for Payer: Cigna Medicaid	$5.67
Rate for Payer: Molina CHIP/Medicaid	$5.67
Rate for Payer: Multiplan Auto	$5.12
Rate for Payer: Multiplan Commercial	$5.12
Rate for Payer: Multiplan Workers Comp	$5.12
Rate for Payer: Parkland Medicaid	$5.67
Rate for Payer: Scott and White EPO/PPO	$3.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.67
Rate for Payer: Superior Health Plan EPO	$1.07

POUCH, NI DRNBL, FILTR TRNS 1 3/4' FLANGE

Facility

$5.41

Hospital Charge Code	992873
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.68

POUCH, NI DRNBL, FILTR TRNS 1 3/4' FLANGE

Facility

$5.41

Hospital Charge Code	992873
Hospital Revenue Code	272
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$3.90
Rate for Payer: Amerigroup CHIP/Medicaid	$0.49
Rate for Payer: BCBS of TX Blue Advantage	$1.62
Rate for Payer: BCBS of TX Blue Essentials	$1.95
Rate for Payer: BCBS of TX PPO	$2.16
Rate for Payer: Cash Price	$3.68
Rate for Payer: Cigna Medicaid	$3.90
Rate for Payer: Molina CHIP/Medicaid	$3.90
Rate for Payer: Multiplan Auto	$3.52
Rate for Payer: Multiplan Commercial	$3.52
Rate for Payer: Multiplan Workers Comp	$3.52
Rate for Payer: Parkland Medicaid	$3.90
Rate for Payer: Scott and White EPO/PPO	$2.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.90
Rate for Payer: Superior Health Plan EPO	$0.74

POUCH, NI DRNBL, FILTR TRNS 2 1/4' FLANGE

Facility

$5.41

Hospital Charge Code	993006
Hospital Revenue Code	270
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$3.90
Rate for Payer: Amerigroup CHIP/Medicaid	$0.49
Rate for Payer: BCBS of TX Blue Advantage	$1.62
Rate for Payer: BCBS of TX Blue Essentials	$1.95
Rate for Payer: BCBS of TX PPO	$2.16
Rate for Payer: Cash Price	$3.68
Rate for Payer: Cigna Medicaid	$3.90
Rate for Payer: Molina CHIP/Medicaid	$3.90
Rate for Payer: Multiplan Auto	$3.52
Rate for Payer: Multiplan Commercial	$3.52
Rate for Payer: Multiplan Workers Comp	$3.52
Rate for Payer: Parkland Medicaid	$3.90
Rate for Payer: Scott and White EPO/PPO	$2.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.90
Rate for Payer: Superior Health Plan EPO	$0.74

POUCH, NI DRNBL, FILTR TRNS 2 1/4' FLANGE

Facility

$5.41

Hospital Charge Code	993006
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.68

POUCH, NI DRNBL, FILTR TRNS 2 3/4' FLANGE

Facility

$5.41

Hospital Charge Code	993007
Hospital Revenue Code	270
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$3.90
Rate for Payer: Amerigroup CHIP/Medicaid	$0.49
Rate for Payer: BCBS of TX Blue Advantage	$1.62
Rate for Payer: BCBS of TX Blue Essentials	$1.95
Rate for Payer: BCBS of TX PPO	$2.16
Rate for Payer: Cash Price	$3.68
Rate for Payer: Cigna Medicaid	$3.90
Rate for Payer: Molina CHIP/Medicaid	$3.90
Rate for Payer: Multiplan Auto	$3.52
Rate for Payer: Multiplan Commercial	$3.52
Rate for Payer: Multiplan Workers Comp	$3.52
Rate for Payer: Parkland Medicaid	$3.90
Rate for Payer: Scott and White EPO/PPO	$2.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.90
Rate for Payer: Superior Health Plan EPO	$0.74

POUCH, NI DRNBL, FILTR TRNS 2 3/4' FLANGE

Facility

$5.41

Hospital Charge Code	993007
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.68

POUCH, NI HIGH OUTPUT 2PC DRNBL 2.75'

Facility

$10.92

Hospital Charge Code	993008
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.43

POUCH, NI HIGH OUTPUT 2PC DRNBL 2.75'

Facility

$10.92

Hospital Charge Code	993008
Hospital Revenue Code	270
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$7.86
Rate for Payer: Amerigroup CHIP/Medicaid	$0.98
Rate for Payer: BCBS of TX Blue Advantage	$3.28
Rate for Payer: BCBS of TX Blue Essentials	$3.93
Rate for Payer: BCBS of TX PPO	$4.37
Rate for Payer: Cash Price	$7.43
Rate for Payer: Cigna Medicaid	$7.86
Rate for Payer: Molina CHIP/Medicaid	$7.86
Rate for Payer: Multiplan Auto	$7.10
Rate for Payer: Multiplan Commercial	$7.10
Rate for Payer: Multiplan Workers Comp	$7.10
Rate for Payer: Parkland Medicaid	$7.86
Rate for Payer: Scott and White EPO/PPO	$5.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.86
Rate for Payer: Superior Health Plan EPO	$1.49

POUCH ONE PIECE HI-OUTPUT

Facility

$17.25

Hospital Charge Code	145058
Hospital Revenue Code	270
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$12.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1.55
Rate for Payer: BCBS of TX Blue Advantage	$5.17
Rate for Payer: BCBS of TX Blue Essentials	$6.21
Rate for Payer: BCBS of TX PPO	$6.90
Rate for Payer: Cash Price	$11.73
Rate for Payer: Cigna Medicaid	$12.42
Rate for Payer: Molina CHIP/Medicaid	$12.42
Rate for Payer: Multiplan Auto	$11.21
Rate for Payer: Multiplan Commercial	$11.21
Rate for Payer: Multiplan Workers Comp	$11.21
Rate for Payer: Parkland Medicaid	$12.42
Rate for Payer: Scott and White EPO/PPO	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.42
Rate for Payer: Superior Health Plan EPO	$2.35

POUCH ONE PIECE HI-OUTPUT

Facility

$17.25

Hospital Charge Code	145058
Hospital Revenue Code	270
Rate for Payer: Cash Price	$11.73

POUCH, STERIDRAPE, INSTRUMENT, 7'X11'

Facility

$6.67

Hospital Charge Code	992808
Hospital Revenue Code	272
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$4.80
Rate for Payer: Amerigroup CHIP/Medicaid	$0.60
Rate for Payer: BCBS of TX Blue Advantage	$2.00
Rate for Payer: BCBS of TX Blue Essentials	$2.40
Rate for Payer: BCBS of TX PPO	$2.67
Rate for Payer: Cash Price	$4.54
Rate for Payer: Cigna Medicaid	$4.80
Rate for Payer: Molina CHIP/Medicaid	$4.80
Rate for Payer: Multiplan Auto	$4.34
Rate for Payer: Multiplan Commercial	$4.34
Rate for Payer: Multiplan Workers Comp	$4.34
Rate for Payer: Parkland Medicaid	$4.80
Rate for Payer: Scott and White EPO/PPO	$3.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.80
Rate for Payer: Superior Health Plan EPO	$0.91

POUCH, STERIDRAPE, INSTRUMENT, 7'X11'

Facility

$6.67

Hospital Charge Code	992808
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.54

POUCH, STERILIZATION, SELF-SEAL, 3.5 X 9

Facility

$0.22

Hospital Charge Code	993023
Hospital Revenue Code	272
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.16
Rate for Payer: Amerigroup CHIP/Medicaid	$0.02
Rate for Payer: BCBS of TX Blue Advantage	$0.07
Rate for Payer: BCBS of TX Blue Essentials	$0.08
Rate for Payer: BCBS of TX PPO	$0.09
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna Medicaid	$0.16
Rate for Payer: Molina CHIP/Medicaid	$0.16
Rate for Payer: Multiplan Auto	$0.14
Rate for Payer: Multiplan Commercial	$0.14
Rate for Payer: Multiplan Workers Comp	$0.14
Rate for Payer: Parkland Medicaid	$0.16
Rate for Payer: Scott and White EPO/PPO	$0.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.16
Rate for Payer: Superior Health Plan EPO	$0.03

POUCH, STERILIZATION, SELF-SEAL, 3.5 X 9

Facility

$0.22

Hospital Charge Code	993023
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.15

POUCH, STERILIZATION, SELF-SEAL, 5.25 X 10

Facility

$0.30

Hospital Charge Code	993024
Hospital Revenue Code	270
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.22
Rate for Payer: Amerigroup CHIP/Medicaid	$0.03
Rate for Payer: BCBS of TX Blue Advantage	$0.09
Rate for Payer: BCBS of TX Blue Essentials	$0.11
Rate for Payer: BCBS of TX PPO	$0.12
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna Medicaid	$0.22
Rate for Payer: Molina CHIP/Medicaid	$0.22
Rate for Payer: Multiplan Auto	$0.20
Rate for Payer: Multiplan Commercial	$0.20
Rate for Payer: Multiplan Workers Comp	$0.20
Rate for Payer: Parkland Medicaid	$0.22
Rate for Payer: Scott and White EPO/PPO	$0.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.22
Rate for Payer: Superior Health Plan EPO	$0.04

POUCH, STERILIZATION, SELF-SEAL, 5.25 X 10

Facility

$0.30

Hospital Charge Code	993024
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.20

Know your out-of-pocket cost for care.

All Charges