White Rock Medical Center

All Charges

Charge

Type

Setting

Price

sterile water Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS A4216
Hospital Charge Code	77827157
Hospital Revenue Code	270
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.64
Rate for Payer: BCBS of TX Blue Essentials	$0.77
Rate for Payer: BCBS of TX PPO	$0.85
Rate for Payer: Cash Price	$87.16
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

STERRAD 100NX CASSETTE, SC

Facility

$1,016.78

Hospital Charge Code	992511
Hospital Revenue Code	270
Rate for Payer: Cash Price	$691.41

STERRAD 100NX CASSETTE, SC

Facility

$1,016.78

Hospital Charge Code	992511
Hospital Revenue Code	270
Min. Negotiated Rate	$91.51
Max. Negotiated Rate	$732.08
Rate for Payer: Amerigroup CHIP/Medicaid	$91.51
Rate for Payer: BCBS of TX Blue Advantage	$305.03
Rate for Payer: BCBS of TX Blue Essentials	$366.04
Rate for Payer: BCBS of TX PPO	$406.71
Rate for Payer: Cash Price	$691.41
Rate for Payer: Cigna Medicaid	$732.08
Rate for Payer: Molina CHIP/Medicaid	$732.08
Rate for Payer: Multiplan Auto	$660.91
Rate for Payer: Multiplan Commercial	$660.91
Rate for Payer: Multiplan Workers Comp	$660.91
Rate for Payer: Parkland Medicaid	$732.08
Rate for Payer: Scott and White EPO/PPO	$508.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$732.08
Rate for Payer: Superior Health Plan EPO	$138.28

STERRAD SEALSURE CHEMICAL

Facility

$2.76

Hospital Charge Code	992580
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1.88

STERRAD SEALSURE CHEMICAL

Facility

$2.76

Hospital Charge Code	992580
Hospital Revenue Code	272
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$1.99
Rate for Payer: Amerigroup CHIP/Medicaid	$0.25
Rate for Payer: BCBS of TX Blue Advantage	$0.83
Rate for Payer: BCBS of TX Blue Essentials	$0.99
Rate for Payer: BCBS of TX PPO	$1.10
Rate for Payer: Cash Price	$1.88
Rate for Payer: Cigna Medicaid	$1.99
Rate for Payer: Molina CHIP/Medicaid	$1.99
Rate for Payer: Multiplan Auto	$1.79
Rate for Payer: Multiplan Commercial	$1.79
Rate for Payer: Multiplan Workers Comp	$1.79
Rate for Payer: Parkland Medicaid	$1.99
Rate for Payer: Scott and White EPO/PPO	$1.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.99
Rate for Payer: Superior Health Plan EPO	$0.38

STETHOSCOPE, SINGLE-HEAD, BLACK

Facility

$19.29

Hospital Charge Code	993977
Hospital Revenue Code	271
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$13.89
Rate for Payer: Amerigroup CHIP/Medicaid	$1.74
Rate for Payer: BCBS of TX Blue Advantage	$5.79
Rate for Payer: BCBS of TX Blue Essentials	$6.94
Rate for Payer: BCBS of TX PPO	$7.72
Rate for Payer: Cash Price	$13.12
Rate for Payer: Cigna Medicaid	$13.89
Rate for Payer: Molina CHIP/Medicaid	$13.89
Rate for Payer: Multiplan Auto	$12.54
Rate for Payer: Multiplan Commercial	$12.54
Rate for Payer: Multiplan Workers Comp	$12.54
Rate for Payer: Parkland Medicaid	$13.89
Rate for Payer: Scott and White EPO/PPO	$9.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.89
Rate for Payer: Superior Health Plan EPO	$2.62

STETHOSCOPE, SINGLE-HEAD, BLACK

Facility

$19.29

Hospital Charge Code	993977
Hospital Revenue Code	271
Rate for Payer: Cash Price	$13.12

ST GASTROSTOMY -- DHF

Facility

$2,295.27

Hospital Charge Code	81772402
Hospital Revenue Code	272
Min. Negotiated Rate	$206.57
Max. Negotiated Rate	$1,652.59
Rate for Payer: Amerigroup CHIP/Medicaid	$206.57
Rate for Payer: BCBS of TX Blue Advantage	$688.58
Rate for Payer: BCBS of TX Blue Essentials	$826.30
Rate for Payer: BCBS of TX PPO	$918.11
Rate for Payer: Cash Price	$1,560.78
Rate for Payer: Cigna Medicaid	$1,652.59
Rate for Payer: Molina CHIP/Medicaid	$1,652.59
Rate for Payer: Multiplan Auto	$1,491.93
Rate for Payer: Multiplan Commercial	$1,491.93
Rate for Payer: Multiplan Workers Comp	$1,491.93
Rate for Payer: Parkland Medicaid	$1,652.59
Rate for Payer: Scott and White EPO/PPO	$1,147.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,652.59
Rate for Payer: Superior Health Plan EPO	$312.16

ST GASTROSTOMY -- DHF

Facility

$2,295.27

Hospital Charge Code	81772402
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,560.78

ST INFUS EXT -- DHF

Facility

$230.22

Hospital Charge Code	80341662
Hospital Revenue Code	270
Min. Negotiated Rate	$20.72
Max. Negotiated Rate	$165.76
Rate for Payer: Amerigroup CHIP/Medicaid	$20.72
Rate for Payer: BCBS of TX Blue Advantage	$69.07
Rate for Payer: BCBS of TX Blue Essentials	$82.88
Rate for Payer: BCBS of TX PPO	$92.09
Rate for Payer: Cash Price	$156.55
Rate for Payer: Cigna Medicaid	$165.76
Rate for Payer: Molina CHIP/Medicaid	$165.76
Rate for Payer: Multiplan Auto	$149.64
Rate for Payer: Multiplan Commercial	$149.64
Rate for Payer: Multiplan Workers Comp	$149.64
Rate for Payer: Parkland Medicaid	$165.76
Rate for Payer: Scott and White EPO/PPO	$115.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$165.76
Rate for Payer: Superior Health Plan EPO	$31.31

ST INFUS EXT -- DHF

Facility

$230.22

Hospital Charge Code	80341662
Hospital Revenue Code	270
Rate for Payer: Cash Price	$156.55

ST INTRO PEEL-AWAY -- DHF

Facility

$224.14

Hospital Charge Code	82485509
Hospital Revenue Code	272
Min. Negotiated Rate	$20.17
Max. Negotiated Rate	$161.38
Rate for Payer: Amerigroup CHIP/Medicaid	$20.17
Rate for Payer: BCBS of TX Blue Advantage	$67.24
Rate for Payer: BCBS of TX Blue Essentials	$80.69
Rate for Payer: BCBS of TX PPO	$89.66
Rate for Payer: Cash Price	$152.42
Rate for Payer: Cigna Medicaid	$161.38
Rate for Payer: Molina CHIP/Medicaid	$161.38
Rate for Payer: Multiplan Auto	$145.69
Rate for Payer: Multiplan Commercial	$145.69
Rate for Payer: Multiplan Workers Comp	$145.69
Rate for Payer: Parkland Medicaid	$161.38
Rate for Payer: Scott and White EPO/PPO	$112.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$161.38
Rate for Payer: Superior Health Plan EPO	$30.48

ST INTRO PEEL-AWAY -- DHF

Facility

$224.14

Hospital Charge Code	82485509
Hospital Revenue Code	272
Rate for Payer: Cash Price	$152.42

ST IRG TUR -- DHF

Facility

$241.69

Hospital Charge Code	54200696
Hospital Revenue Code	270
Min. Negotiated Rate	$21.75
Max. Negotiated Rate	$174.02
Rate for Payer: Amerigroup CHIP/Medicaid	$21.75
Rate for Payer: BCBS of TX Blue Advantage	$72.51
Rate for Payer: BCBS of TX Blue Essentials	$87.01
Rate for Payer: BCBS of TX PPO	$96.68
Rate for Payer: Cash Price	$164.35
Rate for Payer: Cigna Medicaid	$174.02
Rate for Payer: Molina CHIP/Medicaid	$174.02
Rate for Payer: Multiplan Auto	$157.10
Rate for Payer: Multiplan Commercial	$157.10
Rate for Payer: Multiplan Workers Comp	$157.10
Rate for Payer: Parkland Medicaid	$174.02
Rate for Payer: Scott and White EPO/PPO	$120.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$174.02
Rate for Payer: Superior Health Plan EPO	$32.87

ST IRG TUR -- DHF

Facility

$241.69

Hospital Charge Code	54200696
Hospital Revenue Code	270
Rate for Payer: Cash Price	$164.35

ST IV ADD 3 -- DHF

Facility

$110.27

Hospital Charge Code	54200035
Hospital Revenue Code	270
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$79.39
Rate for Payer: Amerigroup CHIP/Medicaid	$9.92
Rate for Payer: BCBS of TX Blue Advantage	$33.08
Rate for Payer: BCBS of TX Blue Essentials	$39.70
Rate for Payer: BCBS of TX PPO	$44.11
Rate for Payer: Cash Price	$74.98
Rate for Payer: Cigna Medicaid	$79.39
Rate for Payer: Molina CHIP/Medicaid	$79.39
Rate for Payer: Multiplan Auto	$71.68
Rate for Payer: Multiplan Commercial	$71.68
Rate for Payer: Multiplan Workers Comp	$71.68
Rate for Payer: Parkland Medicaid	$79.39
Rate for Payer: Scott and White EPO/PPO	$55.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.39
Rate for Payer: Superior Health Plan EPO	$15.00

ST IV ADD 3 -- DHF

Facility

$110.27

Hospital Charge Code	54200035
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.98

ST IV ADM -- DHF

Facility

$89.07

Hospital Charge Code	54200936
Hospital Revenue Code	272
Rate for Payer: Cash Price	$60.57

ST IV ADM -- DHF

Facility

$89.07

Hospital Charge Code	54200936
Hospital Revenue Code	272
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$64.13
Rate for Payer: Amerigroup CHIP/Medicaid	$8.02
Rate for Payer: BCBS of TX Blue Advantage	$26.72
Rate for Payer: BCBS of TX Blue Essentials	$32.07
Rate for Payer: BCBS of TX PPO	$35.63
Rate for Payer: Cash Price	$60.57
Rate for Payer: Cigna Medicaid	$64.13
Rate for Payer: Molina CHIP/Medicaid	$64.13
Rate for Payer: Multiplan Auto	$57.90
Rate for Payer: Multiplan Commercial	$57.90
Rate for Payer: Multiplan Workers Comp	$57.90
Rate for Payer: Parkland Medicaid	$64.13
Rate for Payer: Scott and White EPO/PPO	$44.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$64.13
Rate for Payer: Superior Health Plan EPO	$12.11

ST IV EXT 2 -- DHF

Facility

$69.98

Hospital Charge Code	54200803
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$50.39
Rate for Payer: Amerigroup CHIP/Medicaid	$6.30
Rate for Payer: BCBS of TX Blue Advantage	$20.99
Rate for Payer: BCBS of TX Blue Essentials	$25.19
Rate for Payer: BCBS of TX PPO	$27.99
Rate for Payer: Cash Price	$47.59
Rate for Payer: Cigna Medicaid	$50.39
Rate for Payer: Molina CHIP/Medicaid	$50.39
Rate for Payer: Multiplan Auto	$45.49
Rate for Payer: Multiplan Commercial	$45.49
Rate for Payer: Multiplan Workers Comp	$45.49
Rate for Payer: Parkland Medicaid	$50.39
Rate for Payer: Scott and White EPO/PPO	$34.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50.39
Rate for Payer: Superior Health Plan EPO	$9.52

ST IV EXT 2 -- DHF

Facility

$69.98

Hospital Charge Code	54200803
Hospital Revenue Code	270
Rate for Payer: Cash Price	$47.59

ST IV INF 23X3/4 -- DHF

Facility

$36.06

Hospital Charge Code	54200175
Hospital Revenue Code	270
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$25.96
Rate for Payer: Amerigroup CHIP/Medicaid	$3.25
Rate for Payer: BCBS of TX Blue Advantage	$10.82
Rate for Payer: BCBS of TX Blue Essentials	$12.98
Rate for Payer: BCBS of TX PPO	$14.42
Rate for Payer: Cash Price	$24.52
Rate for Payer: Cigna Medicaid	$25.96
Rate for Payer: Molina CHIP/Medicaid	$25.96
Rate for Payer: Multiplan Auto	$23.44
Rate for Payer: Multiplan Commercial	$23.44
Rate for Payer: Multiplan Workers Comp	$23.44
Rate for Payer: Parkland Medicaid	$25.96
Rate for Payer: Scott and White EPO/PPO	$18.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25.96
Rate for Payer: Superior Health Plan EPO	$4.90

ST IV INF 23X3/4 -- DHF

Facility

$36.06

Hospital Charge Code	54200175
Hospital Revenue Code	270
Rate for Payer: Cash Price	$24.52

ST IV SEC N/V -- DHF

Facility

$343.57

Hospital Charge Code	54200266
Hospital Revenue Code	270
Min. Negotiated Rate	$30.92
Max. Negotiated Rate	$247.37
Rate for Payer: Amerigroup CHIP/Medicaid	$30.92
Rate for Payer: BCBS of TX Blue Advantage	$103.07
Rate for Payer: BCBS of TX Blue Essentials	$123.69
Rate for Payer: BCBS of TX PPO	$137.43
Rate for Payer: Cash Price	$233.63
Rate for Payer: Cigna Medicaid	$247.37
Rate for Payer: Molina CHIP/Medicaid	$247.37
Rate for Payer: Multiplan Auto	$223.32
Rate for Payer: Multiplan Commercial	$223.32
Rate for Payer: Multiplan Workers Comp	$223.32
Rate for Payer: Parkland Medicaid	$247.37
Rate for Payer: Scott and White EPO/PPO	$171.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$247.37
Rate for Payer: Superior Health Plan EPO	$46.73

ST IV SEC N/V -- DHF

Facility

$343.57

Hospital Charge Code	54200266
Hospital Revenue Code	270
Rate for Payer: Cash Price	$233.63

Know your out-of-pocket cost for care.

All Charges