White Rock Medical Center

All Charges

Charge

Type

Setting

Price

AR-8943T-07

Facility

$2,560.24

Service Code	HCPCS C1734
Hospital Charge Code	991120
Hospital Revenue Code	278
Min. Negotiated Rate	$230.42
Max. Negotiated Rate	$1,843.37
Rate for Payer: Amerigroup CHIP/Medicaid	$230.42
Rate for Payer: BCBS of TX Blue Advantage	$768.07
Rate for Payer: BCBS of TX Blue Essentials	$921.69
Rate for Payer: BCBS of TX PPO	$1,024.10
Rate for Payer: Cash Price	$1,740.96
Rate for Payer: Cigna Medicaid	$1,843.37
Rate for Payer: Molina CHIP/Medicaid	$1,843.37
Rate for Payer: Multiplan Auto	$1,280.12
Rate for Payer: Multiplan Commercial	$1,280.12
Rate for Payer: Multiplan Workers Comp	$1,280.12
Rate for Payer: Parkland Medicaid	$1,843.37
Rate for Payer: Scott and White EPO/PPO	$1,280.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,843.37
Rate for Payer: Superior Health Plan EPO	$348.19

AR-8991

Facility

$5,975.90

Service Code	HCPCS C1776
Hospital Charge Code	991121
Hospital Revenue Code	278
Min. Negotiated Rate	$1,493.97
Max. Negotiated Rate	$2,987.95
Rate for Payer: Cash Price	$4,063.61
Rate for Payer: Cigna Commercial	$1,493.97
Rate for Payer: Multiplan Auto	$2,987.95
Rate for Payer: Multiplan Commercial	$2,987.95
Rate for Payer: Multiplan Workers Comp	$2,987.95
Rate for Payer: Scott and White EPO/PPO	$2,987.95

AR-8991

Facility

$5,975.90

Service Code	HCPCS C1776
Hospital Charge Code	991121
Hospital Revenue Code	278
Min. Negotiated Rate	$537.83
Max. Negotiated Rate	$4,302.65
Rate for Payer: Amerigroup CHIP/Medicaid	$537.83
Rate for Payer: BCBS of TX Blue Advantage	$1,792.77
Rate for Payer: BCBS of TX Blue Essentials	$2,151.32
Rate for Payer: BCBS of TX PPO	$2,390.36
Rate for Payer: Cash Price	$4,063.61
Rate for Payer: Cigna Medicaid	$4,302.65
Rate for Payer: Molina CHIP/Medicaid	$4,302.65
Rate for Payer: Multiplan Auto	$2,987.95
Rate for Payer: Multiplan Commercial	$2,987.95
Rate for Payer: Multiplan Workers Comp	$2,987.95
Rate for Payer: Parkland Medicaid	$4,302.65
Rate for Payer: Scott and White EPO/PPO	$2,987.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,302.65
Rate for Payer: Superior Health Plan EPO	$812.72

AR-8991DS

Facility

$2,765.06

Service Code	HCPCS C1776
Hospital Charge Code	991122
Hospital Revenue Code	278
Min. Negotiated Rate	$248.86
Max. Negotiated Rate	$1,990.84
Rate for Payer: Amerigroup CHIP/Medicaid	$248.86
Rate for Payer: BCBS of TX Blue Advantage	$829.52
Rate for Payer: BCBS of TX Blue Essentials	$995.42
Rate for Payer: BCBS of TX PPO	$1,106.02
Rate for Payer: Cash Price	$1,880.24
Rate for Payer: Cigna Medicaid	$1,990.84
Rate for Payer: Molina CHIP/Medicaid	$1,990.84
Rate for Payer: Multiplan Auto	$1,382.53
Rate for Payer: Multiplan Commercial	$1,382.53
Rate for Payer: Multiplan Workers Comp	$1,382.53
Rate for Payer: Parkland Medicaid	$1,990.84
Rate for Payer: Scott and White EPO/PPO	$1,382.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,990.84
Rate for Payer: Superior Health Plan EPO	$376.05

AR-8991DS

Facility

$2,765.06

Service Code	HCPCS C1776
Hospital Charge Code	991122
Hospital Revenue Code	278
Min. Negotiated Rate	$691.26
Max. Negotiated Rate	$1,382.53
Rate for Payer: Cash Price	$1,880.24
Rate for Payer: Cigna Commercial	$691.26
Rate for Payer: Multiplan Auto	$1,382.53
Rate for Payer: Multiplan Commercial	$1,382.53
Rate for Payer: Multiplan Workers Comp	$1,382.53
Rate for Payer: Scott and White EPO/PPO	$1,382.53

arformoterol 15 mcg/2 mL Inh Soln 2 mL

Facility

$35.00

Service Code	HCPCS J7605
Hospital Charge Code	77381111
Hospital Revenue Code	636
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$33.12
Rate for Payer: Amerigroup CHIP/Medicaid	$3.15
Rate for Payer: BCBS of TX Blue Advantage	$24.88
Rate for Payer: BCBS of TX Blue Essentials	$29.86
Rate for Payer: BCBS of TX PPO	$33.12
Rate for Payer: Cash Price	$23.80
Rate for Payer: Cash Price	$23.80
Rate for Payer: Cigna Medicaid	$25.20
Rate for Payer: Molina CHIP/Medicaid	$25.20
Rate for Payer: Multiplan Auto	$22.75
Rate for Payer: Multiplan Commercial	$22.75
Rate for Payer: Multiplan Workers Comp	$22.75
Rate for Payer: Parkland Medicaid	$25.20
Rate for Payer: Scott and White EPO/PPO	$17.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25.20
Rate for Payer: Superior Health Plan EPO	$4.76

arformoterol 15 mcg/2 mL Inh Soln 2 mL

Facility

$34.65

Service Code	HCPCS J7605
Hospital Charge Code	7442059
Hospital Revenue Code	636
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$17.32
Rate for Payer: Cash Price	$23.56
Rate for Payer: Cigna Commercial	$8.66
Rate for Payer: Scott and White EPO/PPO	$17.32

arformoterol 15 mcg/2 mL Inh Soln 2 mL

Facility

$35.00

Service Code	HCPCS J7605
Hospital Charge Code	77381111
Hospital Revenue Code	636
Min. Negotiated Rate	$8.75
Max. Negotiated Rate	$17.50
Rate for Payer: Cash Price	$23.80
Rate for Payer: Cigna Commercial	$8.75
Rate for Payer: Scott and White EPO/PPO	$17.50

arformoterol 15 mcg/2 mL Inh Soln 2 mL

Facility

$34.65

Service Code	HCPCS J7605
Hospital Charge Code	7442059
Hospital Revenue Code	636
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$33.12
Rate for Payer: Amerigroup CHIP/Medicaid	$3.12
Rate for Payer: BCBS of TX Blue Advantage	$24.88
Rate for Payer: BCBS of TX Blue Essentials	$29.86
Rate for Payer: BCBS of TX PPO	$33.12
Rate for Payer: Cash Price	$23.56
Rate for Payer: Cash Price	$23.56
Rate for Payer: Cigna Medicaid	$24.95
Rate for Payer: Molina CHIP/Medicaid	$24.95
Rate for Payer: Multiplan Auto	$22.52
Rate for Payer: Multiplan Commercial	$22.52
Rate for Payer: Multiplan Workers Comp	$22.52
Rate for Payer: Parkland Medicaid	$24.95
Rate for Payer: Scott and White EPO/PPO	$17.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.95
Rate for Payer: Superior Health Plan EPO	$4.71

AR Guide Catheter

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992451
Hospital Revenue Code	272
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$140.56
Rate for Payer: Amerigroup CHIP/Medicaid	$17.57
Rate for Payer: BCBS of TX Blue Advantage	$58.57
Rate for Payer: BCBS of TX Blue Essentials	$70.28
Rate for Payer: BCBS of TX PPO	$78.09
Rate for Payer: Cash Price	$132.75
Rate for Payer: Cigna Medicaid	$140.56
Rate for Payer: Molina CHIP/Medicaid	$140.56
Rate for Payer: Multiplan Auto	$126.89
Rate for Payer: Multiplan Commercial	$126.89
Rate for Payer: Multiplan Workers Comp	$126.89
Rate for Payer: Parkland Medicaid	$140.56
Rate for Payer: Scott and White EPO/PPO	$97.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.56
Rate for Payer: Superior Health Plan EPO	$26.55

AR Guide Catheter

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992451
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

ARIPiprazole 10 mg Tab

Facility

$54.83

Service Code	HCPCS J3490
Hospital Charge Code	77381627
Hospital Revenue Code	250
Rate for Payer: Cash Price	$37.28

ARIPiprazole 10 mg Tab

Facility

$54.83

Service Code	HCPCS J3490
Hospital Charge Code	77381627
Hospital Revenue Code	250
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$39.48
Rate for Payer: Amerigroup CHIP/Medicaid	$4.93
Rate for Payer: BCBS of TX Blue Advantage	$16.45
Rate for Payer: BCBS of TX Blue Essentials	$19.74
Rate for Payer: BCBS of TX PPO	$21.93
Rate for Payer: Cash Price	$37.28
Rate for Payer: Cigna Medicaid	$39.48
Rate for Payer: Molina CHIP/Medicaid	$39.48
Rate for Payer: Multiplan Auto	$35.64
Rate for Payer: Multiplan Commercial	$35.64
Rate for Payer: Multiplan Workers Comp	$35.64
Rate for Payer: Parkland Medicaid	$39.48
Rate for Payer: Scott and White EPO/PPO	$27.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.48
Rate for Payer: Superior Health Plan EPO	$7.46

ARIPiprazole 5 mg Tab

Facility

$55.00

Service Code	HCPCS J3490
Hospital Charge Code	77382039
Hospital Revenue Code	250
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$39.60
Rate for Payer: Amerigroup CHIP/Medicaid	$4.95
Rate for Payer: BCBS of TX Blue Advantage	$16.50
Rate for Payer: BCBS of TX Blue Essentials	$19.80
Rate for Payer: BCBS of TX PPO	$22.00
Rate for Payer: Cash Price	$37.40
Rate for Payer: Cigna Medicaid	$39.60
Rate for Payer: Molina CHIP/Medicaid	$39.60
Rate for Payer: Multiplan Auto	$35.75
Rate for Payer: Multiplan Commercial	$35.75
Rate for Payer: Multiplan Workers Comp	$35.75
Rate for Payer: Parkland Medicaid	$39.60
Rate for Payer: Scott and White EPO/PPO	$27.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.60
Rate for Payer: Superior Health Plan EPO	$7.48

ARIPiprazole 5 mg Tab

Facility

$55.00

Service Code	HCPCS J3490
Hospital Charge Code	77382039
Hospital Revenue Code	250
Rate for Payer: Cash Price	$37.40

ARMADA 14

Facility

$1,248.50

Hospital Charge Code	993861
Hospital Revenue Code	272
Min. Negotiated Rate	$112.36
Max. Negotiated Rate	$898.92
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	$848.98
Rate for Payer: Cigna Medicaid	$898.92
Rate for Payer: Molina CHIP/Medicaid	$898.92
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: Parkland Medicaid	$898.92
Rate for Payer: Scott and White EPO/PPO	$624.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$898.92
Rate for Payer: Superior Health Plan EPO	$169.80

ARMADA 14

Facility

$1,248.50

Hospital Charge Code	993861
Hospital Revenue Code	272
Rate for Payer: Cash Price	$848.98

ARMADA 35 LL 80CM

Facility

$867.14

Hospital Charge Code	993867
Hospital Revenue Code	279
Min. Negotiated Rate	$78.04
Max. Negotiated Rate	$624.34
Rate for Payer: Amerigroup CHIP/Medicaid	$78.04
Rate for Payer: BCBS of TX Blue Advantage	$260.14
Rate for Payer: BCBS of TX Blue Essentials	$312.17
Rate for Payer: BCBS of TX PPO	$346.86
Rate for Payer: Cash Price	$589.66
Rate for Payer: Cigna Medicaid	$624.34
Rate for Payer: Molina CHIP/Medicaid	$624.34
Rate for Payer: Multiplan Auto	$563.64
Rate for Payer: Multiplan Commercial	$563.64
Rate for Payer: Multiplan Workers Comp	$563.64
Rate for Payer: Parkland Medicaid	$624.34
Rate for Payer: Scott and White EPO/PPO	$433.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$624.34
Rate for Payer: Superior Health Plan EPO	$117.93

ARMADA 35 LL 80CM

Facility

$867.14

Hospital Charge Code	993867
Hospital Revenue Code	279
Rate for Payer: Cash Price	$589.66

ARMADA 35 WH 80CM

Facility

$685.54

Hospital Charge Code	993866
Hospital Revenue Code	279
Min. Negotiated Rate	$61.70
Max. Negotiated Rate	$493.59
Rate for Payer: Amerigroup CHIP/Medicaid	$61.70
Rate for Payer: BCBS of TX Blue Advantage	$205.66
Rate for Payer: BCBS of TX Blue Essentials	$246.79
Rate for Payer: BCBS of TX PPO	$274.22
Rate for Payer: Cash Price	$466.17
Rate for Payer: Cigna Medicaid	$493.59
Rate for Payer: Molina CHIP/Medicaid	$493.59
Rate for Payer: Multiplan Auto	$445.60
Rate for Payer: Multiplan Commercial	$445.60
Rate for Payer: Multiplan Workers Comp	$445.60
Rate for Payer: Parkland Medicaid	$493.59
Rate for Payer: Scott and White EPO/PPO	$342.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$493.59
Rate for Payer: Superior Health Plan EPO	$93.23

ARMADA 35 WH 80CM

Facility

$685.54

Hospital Charge Code	993866
Hospital Revenue Code	279
Rate for Payer: Cash Price	$466.17

Arrow EZ-IO Needle Set - 25 mm

Facility

$620.16

Hospital Charge Code	993859
Hospital Revenue Code	272
Min. Negotiated Rate	$55.81
Max. Negotiated Rate	$446.52
Rate for Payer: Amerigroup CHIP/Medicaid	$55.81
Rate for Payer: BCBS of TX Blue Advantage	$186.05
Rate for Payer: BCBS of TX Blue Essentials	$223.26
Rate for Payer: BCBS of TX PPO	$248.06
Rate for Payer: Cash Price	$421.71
Rate for Payer: Cigna Medicaid	$446.52
Rate for Payer: Molina CHIP/Medicaid	$446.52
Rate for Payer: Multiplan Auto	$403.10
Rate for Payer: Multiplan Commercial	$403.10
Rate for Payer: Multiplan Workers Comp	$403.10
Rate for Payer: Parkland Medicaid	$446.52
Rate for Payer: Scott and White EPO/PPO	$310.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$446.52
Rate for Payer: Superior Health Plan EPO	$84.34

Arrow EZ-IO Needle Set - 25 mm

Facility

$620.16

Hospital Charge Code	993859
Hospital Revenue Code	272
Rate for Payer: Cash Price	$421.71

Arrow EZ-IO Needle Set - 45 mm

Facility

$620.16

Hospital Charge Code	993655
Hospital Revenue Code	272
Rate for Payer: Cash Price	$421.71

Arrow EZ-IO Needle Set - 45 mm

Facility

$620.16

Hospital Charge Code	993655
Hospital Revenue Code	272
Min. Negotiated Rate	$55.81
Max. Negotiated Rate	$446.52
Rate for Payer: Amerigroup CHIP/Medicaid	$55.81
Rate for Payer: BCBS of TX Blue Advantage	$186.05
Rate for Payer: BCBS of TX Blue Essentials	$223.26
Rate for Payer: BCBS of TX PPO	$248.06
Rate for Payer: Cash Price	$421.71
Rate for Payer: Cigna Medicaid	$446.52
Rate for Payer: Molina CHIP/Medicaid	$446.52
Rate for Payer: Multiplan Auto	$403.10
Rate for Payer: Multiplan Commercial	$403.10
Rate for Payer: Multiplan Workers Comp	$403.10
Rate for Payer: Parkland Medicaid	$446.52
Rate for Payer: Scott and White EPO/PPO	$310.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$446.52
Rate for Payer: Superior Health Plan EPO	$84.34

Know your out-of-pocket cost for care.

All Charges