White Rock Medical Center

All Charges

Charge

Type

Setting

Price

clindamycin 300 mg Cap

Facility

$16.15

Service Code	HCPCS J3490
Hospital Charge Code	77472892
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.98

clindamycin 600 mg/50 mL-NaCl 0.9% Sol

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8134766
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

clindamycin 600 mg/50 mL-NaCl 0.9% Sol

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8134766
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

clindamycin 900 mg/50 mL-NaCl 0.9% Sol

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8134767
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

clindamycin 900 mg/50 mL-NaCl 0.9% Sol

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8134767
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

CLIP, ANASTAMOTIC S105 UCLIP REG FLEX REG NDLE 2PK -- DHF

Facility

$899.29

Hospital Charge Code	82020777
Hospital Revenue Code	272
Rate for Payer: Cash Price	$791.38

CLIP, ANASTAMOTIC S105 UCLIP REG FLEX REG NDLE 2PK -- DHF

Facility

$899.29

Hospital Charge Code	82020777
Hospital Revenue Code	272
Min. Negotiated Rate	$80.94
Max. Negotiated Rate	$584.54
Rate for Payer: Aetna Commercial	$494.61
Rate for Payer: Amerigroup CHIP/Medicaid	$80.94
Rate for Payer: BCBS of TX Blue Advantage	$269.79
Rate for Payer: BCBS of TX Blue Essentials	$323.74
Rate for Payer: BCBS of TX PPO	$359.72
Rate for Payer: Cash Price	$791.38
Rate for Payer: Multiplan Auto	$584.54
Rate for Payer: Multiplan Commercial	$584.54
Rate for Payer: Multiplan Workers Comp	$584.54
Rate for Payer: Scott and White EPO/PPO	$449.64
Rate for Payer: Superior Health Plan EPO	$122.30

clip hemolok large 6 purple

Facility

$137.77

Hospital Charge Code	81560302
Hospital Revenue Code	270
Rate for Payer: Cash Price	$121.24

clip hemolok large 6 purple

Facility

$137.77

Hospital Charge Code	81560302
Hospital Revenue Code	270
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$89.55
Rate for Payer: Aetna Commercial	$75.77
Rate for Payer: Amerigroup CHIP/Medicaid	$12.40
Rate for Payer: BCBS of TX Blue Advantage	$41.33
Rate for Payer: BCBS of TX Blue Essentials	$49.60
Rate for Payer: BCBS of TX PPO	$55.11
Rate for Payer: Cash Price	$121.24
Rate for Payer: Multiplan Auto	$89.55
Rate for Payer: Multiplan Commercial	$89.55
Rate for Payer: Multiplan Workers Comp	$89.55
Rate for Payer: Scott and White EPO/PPO	$68.88
Rate for Payer: Superior Health Plan EPO	$18.74

clip hemolok med/large green

Facility

$143.96

Hospital Charge Code	8692546
Hospital Revenue Code	270
Rate for Payer: Cash Price	$126.68

clip hemolok med/large green

Facility

$143.96

Hospital Charge Code	8692546
Hospital Revenue Code	270
Min. Negotiated Rate	$12.96
Max. Negotiated Rate	$93.57
Rate for Payer: Aetna Commercial	$79.18
Rate for Payer: Amerigroup CHIP/Medicaid	$12.96
Rate for Payer: BCBS of TX Blue Advantage	$43.19
Rate for Payer: BCBS of TX Blue Essentials	$51.83
Rate for Payer: BCBS of TX PPO	$57.58
Rate for Payer: Cash Price	$126.68
Rate for Payer: Multiplan Auto	$93.57
Rate for Payer: Multiplan Commercial	$93.57
Rate for Payer: Multiplan Workers Comp	$93.57
Rate for Payer: Scott and White EPO/PPO	$71.98
Rate for Payer: Superior Health Plan EPO	$19.58

CLIP, LIGATING TITANIUM MEDIUM 6/CR -- DHF

Facility

$51.50

Hospital Charge Code	81941155
Hospital Revenue Code	272
Min. Negotiated Rate	$4.64
Max. Negotiated Rate	$33.48
Rate for Payer: Aetna Commercial	$28.32
Rate for Payer: Amerigroup CHIP/Medicaid	$4.64
Rate for Payer: BCBS of TX Blue Advantage	$15.45
Rate for Payer: BCBS of TX Blue Essentials	$18.54
Rate for Payer: BCBS of TX PPO	$20.60
Rate for Payer: Cash Price	$45.32
Rate for Payer: Multiplan Auto	$33.48
Rate for Payer: Multiplan Commercial	$33.48
Rate for Payer: Multiplan Workers Comp	$33.48
Rate for Payer: Scott and White EPO/PPO	$25.75
Rate for Payer: Superior Health Plan EPO	$7.00

CLIP, LIGATING TITANIUM MEDIUM 6/CR -- DHF

Facility

$51.50

Hospital Charge Code	81941155
Hospital Revenue Code	272
Rate for Payer: Cash Price	$45.32

CLIP RESOLUTION 360 ULTRA

Facility

$1,317.42

Hospital Charge Code	144856
Hospital Revenue Code	272
Min. Negotiated Rate	$118.57
Max. Negotiated Rate	$856.32
Rate for Payer: Aetna Commercial	$724.58
Rate for Payer: Amerigroup CHIP/Medicaid	$118.57
Rate for Payer: BCBS of TX Blue Advantage	$395.23
Rate for Payer: BCBS of TX Blue Essentials	$474.27
Rate for Payer: BCBS of TX PPO	$526.97
Rate for Payer: Cash Price	$1,159.33
Rate for Payer: Multiplan Auto	$856.32
Rate for Payer: Multiplan Commercial	$856.32
Rate for Payer: Multiplan Workers Comp	$856.32
Rate for Payer: Scott and White EPO/PPO	$658.71
Rate for Payer: Superior Health Plan EPO	$179.17

CLIP RESOLUTION 360 ULTRA

Facility

$1,317.42

Hospital Charge Code	144856
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,159.33

CLIP, SUTURE ABSORABLE 2-0 3-0 4-0 COATED VICRYL -- DHF

Facility

$340.05

Hospital Charge Code	81926214
Hospital Revenue Code	272
Rate for Payer: Cash Price	$299.24

CLIP, SUTURE ABSORABLE 2-0 3-0 4-0 COATED VICRYL -- DHF

Facility

$340.05

Hospital Charge Code	81926214
Hospital Revenue Code	272
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$221.03
Rate for Payer: Aetna Commercial	$187.03
Rate for Payer: Amerigroup CHIP/Medicaid	$30.60
Rate for Payer: BCBS of TX Blue Advantage	$102.02
Rate for Payer: BCBS of TX Blue Essentials	$122.42
Rate for Payer: BCBS of TX PPO	$136.02
Rate for Payer: Cash Price	$299.24
Rate for Payer: Multiplan Auto	$221.03
Rate for Payer: Multiplan Commercial	$221.03
Rate for Payer: Multiplan Workers Comp	$221.03
Rate for Payer: Scott and White EPO/PPO	$170.02
Rate for Payer: Superior Health Plan EPO	$46.25

CLMP CORD UMBIL -- DHF

Facility

$74.24

Hospital Charge Code	80810559
Hospital Revenue Code	272
Rate for Payer: Cash Price	$65.33

CLMP CORD UMBIL -- DHF

Facility

$74.24

Hospital Charge Code	80810559
Hospital Revenue Code	272
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$48.26
Rate for Payer: Aetna Commercial	$40.83
Rate for Payer: Amerigroup CHIP/Medicaid	$6.68
Rate for Payer: BCBS of TX Blue Advantage	$22.27
Rate for Payer: BCBS of TX Blue Essentials	$26.73
Rate for Payer: BCBS of TX PPO	$29.70
Rate for Payer: Cash Price	$65.33
Rate for Payer: Multiplan Auto	$48.26
Rate for Payer: Multiplan Commercial	$48.26
Rate for Payer: Multiplan Workers Comp	$48.26
Rate for Payer: Scott and White EPO/PPO	$37.12
Rate for Payer: Superior Health Plan EPO	$10.10

CLN WND -- DHF

Facility

$35.55

Hospital Charge Code	80317209
Hospital Revenue Code	270
Rate for Payer: Cash Price	$31.28

CLN WND -- DHF

Facility

$35.55

Hospital Charge Code	80317209
Hospital Revenue Code	270
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$23.11
Rate for Payer: Aetna Commercial	$19.55
Rate for Payer: Amerigroup CHIP/Medicaid	$3.20
Rate for Payer: BCBS of TX Blue Advantage	$10.66
Rate for Payer: BCBS of TX Blue Essentials	$12.80
Rate for Payer: BCBS of TX PPO	$14.22
Rate for Payer: Cash Price	$31.28
Rate for Payer: Multiplan Auto	$23.11
Rate for Payer: Multiplan Commercial	$23.11
Rate for Payer: Multiplan Workers Comp	$23.11
Rate for Payer: Scott and White EPO/PPO	$17.78
Rate for Payer: Superior Health Plan EPO	$4.83

clonazePAM 0.5 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77475449
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
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: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

clonazePAM 0.5 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77475449
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

cloNIDine 0.1 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77475718
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

cloNIDine 0.1 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77475718
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Know your out-of-pocket cost for care.

All Charges