White Rock Medical Center

All Charges

Charge

Type

Setting

Price

bupivacaine liposome 1.3% (13.3 mg/mL) Inj Susp 20 mL

Facility

$818.00

Service Code	HCPCS J0666
Hospital Charge Code	77424920
Hospital Revenue Code	636
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$588.96
Rate for Payer: Amerigroup CHIP/Medicaid	$73.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1.43
Rate for Payer: Amerigroup Medicare	$1.43
Rate for Payer: BCBS of TX Blue Advantage	$245.40
Rate for Payer: BCBS of TX Blue Essentials	$294.48
Rate for Payer: BCBS of TX Medicare	$1.43
Rate for Payer: BCBS of TX PPO	$327.20
Rate for Payer: Cash Price	$556.24
Rate for Payer: Cash Price	$556.24
Rate for Payer: Cigna Medicaid	$588.96
Rate for Payer: Cigna Medicare	$1.43
Rate for Payer: Employer Direct Commercial	$1.43
Rate for Payer: Humana Medicare/TRICARE	$1.43
Rate for Payer: Molina CHIP/Medicaid	$588.96
Rate for Payer: Molina Dual Medicare/Medicaid	$1.43
Rate for Payer: Molina Medicare	$1.43
Rate for Payer: Multiplan Auto	$531.70
Rate for Payer: Multiplan Commercial	$531.70
Rate for Payer: Multiplan Workers Comp	$531.70
Rate for Payer: Parkland Medicaid	$588.96
Rate for Payer: Scott and White EPO/PPO	$409.00
Rate for Payer: Scott and White Medicare	$1.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$588.96
Rate for Payer: Superior Health Plan EPO	$1.43
Rate for Payer: Superior Health Plan Medicare	$1.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$1.43
Rate for Payer: Universal American Medicare	$1.43
Rate for Payer: Wellcare Medicare	$1.43
Rate for Payer: Wellmed Medicare	$1.43

bupivacaine liposome 1.3% (13.3 mg/mL) Inj Susp 20 mL

Facility

$818.00

Service Code	HCPCS J0666
Hospital Charge Code	77424920
Hospital Revenue Code	636
Min. Negotiated Rate	$204.50
Max. Negotiated Rate	$409.00
Rate for Payer: Cash Price	$556.24
Rate for Payer: Cigna Commercial	$204.50
Rate for Payer: Scott and White EPO/PPO	$409.00

bupivacaine MPF 0.5 % 10 ml vial

Facility

$128.00

Service Code	HCPCS j3490
Hospital Charge Code	77424331
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

bupivacaine MPF 0.5 % 10 ml vial

Facility

$128.00

Service Code	HCPCS j3490
Hospital Charge Code	77424331
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

buprenorphine 2 mg SL Tab

Facility

$8.00

Service Code	HCPCS J0571
Hospital Charge Code	77427424
Hospital Revenue Code	636
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$1.59
Rate for Payer: BCBS of TX Blue Essentials	$1.91
Rate for Payer: BCBS of TX PPO	$2.12
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

buprenorphine 2 mg SL Tab

Facility

$8.00

Service Code	HCPCS J0571
Hospital Charge Code	77427424
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

buprenorphine 8 mg SL Tab

Facility

$23.61

Service Code	HCPCS J3490
Hospital Charge Code	77427579
Hospital Revenue Code	250
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$17.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2.12
Rate for Payer: BCBS of TX Blue Advantage	$7.08
Rate for Payer: BCBS of TX Blue Essentials	$8.50
Rate for Payer: BCBS of TX PPO	$9.44
Rate for Payer: Cash Price	$16.05
Rate for Payer: Cigna Medicaid	$17.00
Rate for Payer: Molina CHIP/Medicaid	$17.00
Rate for Payer: Multiplan Auto	$15.35
Rate for Payer: Multiplan Commercial	$15.35
Rate for Payer: Multiplan Workers Comp	$15.35
Rate for Payer: Parkland Medicaid	$17.00
Rate for Payer: Scott and White EPO/PPO	$11.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.00
Rate for Payer: Superior Health Plan EPO	$3.21

buprenorphine 8 mg SL Tab

Facility

$23.61

Service Code	HCPCS J3490
Hospital Charge Code	77427579
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.05

buprenorphine-naloxone 2 mg-0.5 mg tab

Facility

$16.24

Service Code	HCPCS J0572
Hospital Charge Code	78434597
Hospital Revenue Code	636
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$11.69
Rate for Payer: Amerigroup CHIP/Medicaid	$1.46
Rate for Payer: BCBS of TX Blue Advantage	$4.10
Rate for Payer: BCBS of TX Blue Essentials	$4.92
Rate for Payer: BCBS of TX PPO	$5.46
Rate for Payer: Cash Price	$11.04
Rate for Payer: Cash Price	$11.04
Rate for Payer: Cigna Medicaid	$11.69
Rate for Payer: Molina CHIP/Medicaid	$11.69
Rate for Payer: Multiplan Auto	$10.56
Rate for Payer: Multiplan Commercial	$10.56
Rate for Payer: Multiplan Workers Comp	$10.56
Rate for Payer: Parkland Medicaid	$11.69
Rate for Payer: Scott and White EPO/PPO	$8.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.69
Rate for Payer: Superior Health Plan EPO	$2.21

buprenorphine-naloxone 2 mg-0.5 mg tab

Facility

$16.24

Service Code	HCPCS J0572
Hospital Charge Code	78434597
Hospital Revenue Code	636
Min. Negotiated Rate	$4.06
Max. Negotiated Rate	$8.12
Rate for Payer: Cash Price	$11.04
Rate for Payer: Cigna Commercial	$4.06
Rate for Payer: Scott and White EPO/PPO	$8.12

buprenorphine-naloxone 8 mg-2 mg tab

Facility

$10.42

Service Code	HCPCS J0574
Hospital Charge Code	78424253
Hospital Revenue Code	636
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$9.79
Rate for Payer: Amerigroup CHIP/Medicaid	$0.94
Rate for Payer: BCBS of TX Blue Advantage	$7.35
Rate for Payer: BCBS of TX Blue Essentials	$8.82
Rate for Payer: BCBS of TX PPO	$9.79
Rate for Payer: Cash Price	$7.09
Rate for Payer: Cash Price	$7.09
Rate for Payer: Cigna Medicaid	$7.50
Rate for Payer: Molina CHIP/Medicaid	$7.50
Rate for Payer: Multiplan Auto	$6.77
Rate for Payer: Multiplan Commercial	$6.77
Rate for Payer: Multiplan Workers Comp	$6.77
Rate for Payer: Parkland Medicaid	$7.50
Rate for Payer: Scott and White EPO/PPO	$5.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.50
Rate for Payer: Superior Health Plan EPO	$1.42

buprenorphine-naloxone 8 mg-2 mg tab

Facility

$10.42

Service Code	HCPCS J0574
Hospital Charge Code	78424253
Hospital Revenue Code	636
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$5.21
Rate for Payer: Cash Price	$7.09
Rate for Payer: Cigna Commercial	$2.60
Rate for Payer: Scott and White EPO/PPO	$5.21

buPROPion 100 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77428064
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

buPROPion 100 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77428064
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

buPROPion 150 mg/12 hours (SR) ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77428172
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
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: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

buPROPion 150 mg/12 hours (SR) ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77428172
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

buPROPion 150 mg/24 hours (XL) ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	7442973
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

buPROPion 150 mg/24 hours (XL) ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	7442973
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
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: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

buPROPion 75mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78414494
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

buPROPion 75mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78414494
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

BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS

Facility

$32,813.93

Service Code	APR-DRG 8424
Min. Negotiated Rate	$30,938.13
Max. Negotiated Rate	$32,813.93
Rate for Payer: Amerigroup CHIP/Medicaid	$30,938.13
Rate for Payer: Cigna Medicaid	$30,938.13
Rate for Payer: Molina CHIP/Medicaid	$30,938.13
Rate for Payer: Parkland Medicaid	$30,938.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32,813.93

BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS

Facility

$5,487.72

Service Code	APR-DRG 8421
Min. Negotiated Rate	$5,174.02
Max. Negotiated Rate	$5,487.72
Rate for Payer: Amerigroup CHIP/Medicaid	$5,174.02
Rate for Payer: Cigna Medicaid	$5,174.02
Rate for Payer: Molina CHIP/Medicaid	$5,174.02
Rate for Payer: Parkland Medicaid	$5,174.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,487.72

BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS

Facility

$8,316.64

Service Code	APR-DRG 8422
Min. Negotiated Rate	$7,841.22
Max. Negotiated Rate	$8,316.64
Rate for Payer: Amerigroup CHIP/Medicaid	$7,841.22
Rate for Payer: Cigna Medicaid	$7,841.22
Rate for Payer: Molina CHIP/Medicaid	$7,841.22
Rate for Payer: Parkland Medicaid	$7,841.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,316.64

BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS

Facility

$15,973.58

Service Code	APR-DRG 8423
Min. Negotiated Rate	$15,060.45
Max. Negotiated Rate	$15,973.58
Rate for Payer: Amerigroup CHIP/Medicaid	$15,060.45
Rate for Payer: Cigna Medicaid	$15,060.45
Rate for Payer: Molina CHIP/Medicaid	$15,060.45
Rate for Payer: Parkland Medicaid	$15,060.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,973.58

BURR 4MM ROUND CRSE/ELITE/SABER

Facility

$656.67

Hospital Charge Code	145310
Hospital Revenue Code	272
Rate for Payer: Cash Price	$446.54

Know your out-of-pocket cost for care.

All Charges