with respect to an ambulatory surgical center located in a rural or underserved area if the Secretary certifies that imposition of such penalty would result in an immediate threat to access to care for individuals in the service area of such surgical center. (II) Limitation on application The Secretary may not elect to waive a penalty under subclause (I) with respect to an ambulatory surgical center more than once in a 6-year period and may not elect to reduce such a penalty with respect to such a surgical center more than once in such a period. Nothing in the preceding sentence shall be construed as prohibiting the Secretary from both waiving and reducing a penalty with respect to an ambulatory surgical center during a 6-year period. (5) Definitions For purposes of this section: (A) Discounted cash price The term discounted cash price means the charge that applies to an individual who pays cash, or cash equivalent, for a item or service furnished by an ambulatory surgical center. (B) Federal health care program The term Federal health care program has the meaning given such term in section 1128B. (C) Gross charge The term gross charge means the charge for an individual item or service that is reflected on an ambulatory surgical center’s chargemaster, absent any discounts. (D) Group health plan