White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ASNIS III SS CANN SCR 5X75MM

Facility

$1,692.77

Service Code	HCPCS C1713
Hospital Charge Code	992180
Hospital Revenue Code	278
Min. Negotiated Rate	$423.19
Max. Negotiated Rate	$846.38
Rate for Payer: Cash Price	$1,151.08
Rate for Payer: Cigna Commercial	$423.19
Rate for Payer: Multiplan Auto	$846.38
Rate for Payer: Multiplan Commercial	$846.38
Rate for Payer: Multiplan Workers Comp	$846.38
Rate for Payer: Scott and White EPO/PPO	$846.38

ASNIS III SS CANN SCR 5X75MM

Facility

$1,692.77

Service Code	HCPCS C1713
Hospital Charge Code	992180
Hospital Revenue Code	278
Min. Negotiated Rate	$152.35
Max. Negotiated Rate	$1,218.79
Rate for Payer: Amerigroup CHIP/Medicaid	$152.35
Rate for Payer: BCBS of TX Blue Advantage	$507.83
Rate for Payer: BCBS of TX Blue Essentials	$609.40
Rate for Payer: BCBS of TX PPO	$677.11
Rate for Payer: Cash Price	$1,151.08
Rate for Payer: Cigna Medicaid	$1,218.79
Rate for Payer: Molina CHIP/Medicaid	$1,218.79
Rate for Payer: Multiplan Auto	$846.38
Rate for Payer: Multiplan Commercial	$846.38
Rate for Payer: Multiplan Workers Comp	$846.38
Rate for Payer: Parkland Medicaid	$1,218.79
Rate for Payer: Scott and White EPO/PPO	$846.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,218.79
Rate for Payer: Superior Health Plan EPO	$230.22

ASNIS III SS CANN SCR 5X80MM

Facility

$1,692.77

Service Code	HCPCS C1713
Hospital Charge Code	992181
Hospital Revenue Code	278
Min. Negotiated Rate	$152.35
Max. Negotiated Rate	$1,218.79
Rate for Payer: Amerigroup CHIP/Medicaid	$152.35
Rate for Payer: BCBS of TX Blue Advantage	$507.83
Rate for Payer: BCBS of TX Blue Essentials	$609.40
Rate for Payer: BCBS of TX PPO	$677.11
Rate for Payer: Cash Price	$1,151.08
Rate for Payer: Cigna Medicaid	$1,218.79
Rate for Payer: Molina CHIP/Medicaid	$1,218.79
Rate for Payer: Multiplan Auto	$846.38
Rate for Payer: Multiplan Commercial	$846.38
Rate for Payer: Multiplan Workers Comp	$846.38
Rate for Payer: Parkland Medicaid	$1,218.79
Rate for Payer: Scott and White EPO/PPO	$846.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,218.79
Rate for Payer: Superior Health Plan EPO	$230.22

ASNIS III SS CANN SCR 5X80MM

Facility

$1,692.77

Service Code	HCPCS C1713
Hospital Charge Code	992181
Hospital Revenue Code	278
Min. Negotiated Rate	$423.19
Max. Negotiated Rate	$846.38
Rate for Payer: Cash Price	$1,151.08
Rate for Payer: Cigna Commercial	$423.19
Rate for Payer: Multiplan Auto	$846.38
Rate for Payer: Multiplan Commercial	$846.38
Rate for Payer: Multiplan Workers Comp	$846.38
Rate for Payer: Scott and White EPO/PPO	$846.38

Aspartate Aminotransferase

Facility

$236.00

Service Code	HCPCS 84450
Hospital Charge Code	1602333
Hospital Revenue Code	301
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$169.92
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$70.80
Rate for Payer: BCBS of TX Blue Essentials	$84.96
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$94.40
Rate for Payer: Cash Price	$160.48
Rate for Payer: Cash Price	$160.48
Rate for Payer: Cigna Medicaid	$169.92
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$169.92
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$153.40
Rate for Payer: Multiplan Commercial	$153.40
Rate for Payer: Multiplan Workers Comp	$153.40
Rate for Payer: Parkland Medicaid	$169.92
Rate for Payer: Scott and White EPO/PPO	$6.47
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$169.92
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

Aspartate Aminotransferase

Facility

$236.00

Service Code	HCPCS 84450
Hospital Charge Code	1602333
Hospital Revenue Code	301
Rate for Payer: Cash Price	$160.48

ASP/INJ RENL CYST/PELVIS

Facility

$2,001.00

Service Code	HCPCS 50390
Hospital Charge Code	4610390
Hospital Revenue Code	360
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$257.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$711.36
Rate for Payer: Amerigroup Medicare	$711.36
Rate for Payer: BCBS of TX Blue Advantage	$1,018.72
Rate for Payer: BCBS of TX Blue Essentials	$1,220.02
Rate for Payer: BCBS of TX Medicare	$711.36
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$1,360.68
Rate for Payer: Cash Price	$1,360.68
Rate for Payer: Cash Price	$1,360.68
Rate for Payer: Cigna Commercial	$1,503.68
Rate for Payer: Cigna Medicaid	$1,440.72
Rate for Payer: Cigna Medicare	$711.36
Rate for Payer: Employer Direct Commercial	$711.36
Rate for Payer: Humana Medicare/TRICARE	$711.36
Rate for Payer: Molina CHIP/Medicaid	$1,440.72
Rate for Payer: Molina Dual Medicare/Medicaid	$711.36
Rate for Payer: Molina Medicare	$711.36
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	$1,440.72
Rate for Payer: Scott and White EPO/PPO	$1,190.38
Rate for Payer: Scott and White Medicare	$711.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,440.72
Rate for Payer: Superior Health Plan EPO	$711.36
Rate for Payer: Superior Health Plan Medicare	$711.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$711.36
Rate for Payer: Universal American Medicare	$711.36
Rate for Payer: Wellcare Medicare	$711.36
Rate for Payer: Wellmed Medicare	$711.36

ASP/INJ RENL CYST/PELVIS

Facility

$2,001.00

Service Code	HCPCS 50390
Hospital Charge Code	4610390
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,360.68

ASPIR BLADDR W/INS CATH

Facility

$4,177.00

Service Code	HCPCS 51102
Hospital Charge Code	4617460
Hospital Revenue Code	360
Min. Negotiated Rate	$652.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$652.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Amerigroup Medicare	$2,099.91
Rate for Payer: BCBS of TX Blue Advantage	$2,958.49
Rate for Payer: BCBS of TX Blue Essentials	$3,543.10
Rate for Payer: BCBS of TX Medicare	$2,099.91
Rate for Payer: BCBS of TX PPO	$4,464.31
Rate for Payer: Cash Price	$2,840.36
Rate for Payer: Cash Price	$2,840.36
Rate for Payer: Cash Price	$2,840.36
Rate for Payer: Cigna Commercial	$4,438.84
Rate for Payer: Cigna Medicaid	$3,007.44
Rate for Payer: Cigna Medicare	$2,099.91
Rate for Payer: Employer Direct Commercial	$2,099.91
Rate for Payer: Humana Medicare/TRICARE	$2,099.91
Rate for Payer: Molina CHIP/Medicaid	$3,007.44
Rate for Payer: Molina Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Molina Medicare	$2,099.91
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	$3,007.44
Rate for Payer: Scott and White EPO/PPO	$3,446.11
Rate for Payer: Scott and White Medicare	$2,099.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,007.44
Rate for Payer: Superior Health Plan EPO	$2,099.91
Rate for Payer: Superior Health Plan Medicare	$2,099.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Universal American Medicare	$2,099.91
Rate for Payer: Wellcare Medicare	$2,099.91
Rate for Payer: Wellmed Medicare	$2,099.91

ASPIR BLADDR W/INS CATH

Facility

$4,177.00

Service Code	HCPCS 51102
Hospital Charge Code	4617460
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,840.36

aspirin 325 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77384117
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

aspirin 325 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77384117
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

aspirin 325 mg Tab

Facility

$2.55

Service Code	HCPCS J3490
Hospital Charge Code	77384172
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1.73

aspirin 325 mg Tab

Facility

$2.55

Service Code	HCPCS J3490
Hospital Charge Code	77384172
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$1.84
Rate for Payer: Amerigroup CHIP/Medicaid	$0.23
Rate for Payer: BCBS of TX Blue Advantage	$0.77
Rate for Payer: BCBS of TX Blue Essentials	$0.92
Rate for Payer: BCBS of TX PPO	$1.02
Rate for Payer: Cash Price	$1.73
Rate for Payer: Cigna Medicaid	$1.84
Rate for Payer: Molina CHIP/Medicaid	$1.84
Rate for Payer: Multiplan Auto	$1.66
Rate for Payer: Multiplan Commercial	$1.66
Rate for Payer: Multiplan Workers Comp	$1.66
Rate for Payer: Parkland Medicaid	$1.84
Rate for Payer: Scott and White EPO/PPO	$1.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.84
Rate for Payer: Superior Health Plan EPO	$0.35

aspirin 81 mg Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77384435
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

aspirin 81 mg Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77384435
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

aspirin 81 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77384539
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

aspirin 81 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77384539
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

ASSEMBLY, BLADE CARPAL TUNNEL RELEASE SYSTEM DISP -- DHF

Facility

$845.49

Hospital Charge Code	81722852
Hospital Revenue Code	272
Min. Negotiated Rate	$76.09
Max. Negotiated Rate	$608.75
Rate for Payer: Amerigroup CHIP/Medicaid	$76.09
Rate for Payer: BCBS of TX Blue Advantage	$253.65
Rate for Payer: BCBS of TX Blue Essentials	$304.38
Rate for Payer: BCBS of TX PPO	$338.20
Rate for Payer: Cash Price	$574.93
Rate for Payer: Cigna Medicaid	$608.75
Rate for Payer: Molina CHIP/Medicaid	$608.75
Rate for Payer: Multiplan Auto	$549.57
Rate for Payer: Multiplan Commercial	$549.57
Rate for Payer: Multiplan Workers Comp	$549.57
Rate for Payer: Parkland Medicaid	$608.75
Rate for Payer: Scott and White EPO/PPO	$422.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$608.75
Rate for Payer: Superior Health Plan EPO	$114.99

ASSEMBLY, BLADE CARPAL TUNNEL RELEASE SYSTEM DISP -- DHF

Facility

$845.49

Hospital Charge Code	81722852
Hospital Revenue Code	272
Rate for Payer: Cash Price	$574.93

ASSEMBLY, BULB & BLADDER

Facility

$125.22

Hospital Charge Code	993282
Hospital Revenue Code	270
Min. Negotiated Rate	$11.27
Max. Negotiated Rate	$90.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.27
Rate for Payer: BCBS of TX Blue Advantage	$37.57
Rate for Payer: BCBS of TX Blue Essentials	$45.08
Rate for Payer: BCBS of TX PPO	$50.09
Rate for Payer: Cash Price	$85.15
Rate for Payer: Cigna Medicaid	$90.16
Rate for Payer: Molina CHIP/Medicaid	$90.16
Rate for Payer: Multiplan Auto	$81.39
Rate for Payer: Multiplan Commercial	$81.39
Rate for Payer: Multiplan Workers Comp	$81.39
Rate for Payer: Parkland Medicaid	$90.16
Rate for Payer: Scott and White EPO/PPO	$62.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.16
Rate for Payer: Superior Health Plan EPO	$17.03

ASSEMBLY, BULB & BLADDER

Facility

$125.22

Hospital Charge Code	993282
Hospital Revenue Code	270
Rate for Payer: Cash Price	$85.15

ASSEMBLY, PUMP&HNDPIECE SUCT/IRR 10' TBE STRYKER 2 -- DHF

Facility

$319.81

Hospital Charge Code	81772477
Hospital Revenue Code	270
Min. Negotiated Rate	$28.78
Max. Negotiated Rate	$230.26
Rate for Payer: Amerigroup CHIP/Medicaid	$28.78
Rate for Payer: BCBS of TX Blue Advantage	$95.94
Rate for Payer: BCBS of TX Blue Essentials	$115.13
Rate for Payer: BCBS of TX PPO	$127.92
Rate for Payer: Cash Price	$217.47
Rate for Payer: Cigna Medicaid	$230.26
Rate for Payer: Molina CHIP/Medicaid	$230.26
Rate for Payer: Multiplan Auto	$207.88
Rate for Payer: Multiplan Commercial	$207.88
Rate for Payer: Multiplan Workers Comp	$207.88
Rate for Payer: Parkland Medicaid	$230.26
Rate for Payer: Scott and White EPO/PPO	$159.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$230.26
Rate for Payer: Superior Health Plan EPO	$43.49

ASSEMBLY, PUMP&HNDPIECE SUCT/IRR 10' TBE STRYKER 2 -- DHF

Facility

$319.81

Hospital Charge Code	81772477
Hospital Revenue Code	270
Rate for Payer: Cash Price	$217.47

AS STPL RELD -- DHF

Facility

$1,714.36

Hospital Charge Code	81911075
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,165.76

Know your out-of-pocket cost for care.

All Charges