White Rock Medical Center

All Charges

Charge

Type

Setting

Price

bumetanide 1 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77420317
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

bupivacaine 0.25% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442860
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

bupivacaine 0.25% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442860
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine 0.25% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442864
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine 0.25% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442864
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

bupivacaine 0.25% PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442867
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

bupivacaine 0.25% PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442867
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine 0.5 % 50 ml injection

Facility

$128.19

Service Code	HCPCS J3490
Hospital Charge Code	77424013
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.30
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.46
Rate for Payer: BCBS of TX Blue Essentials	$46.15
Rate for Payer: BCBS of TX PPO	$51.28
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cigna Medicaid	$92.30
Rate for Payer: Molina CHIP/Medicaid	$92.30
Rate for Payer: Multiplan Auto	$83.32
Rate for Payer: Multiplan Commercial	$83.32
Rate for Payer: Multiplan Workers Comp	$83.32
Rate for Payer: Parkland Medicaid	$92.30
Rate for Payer: Scott and White EPO/PPO	$64.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.30
Rate for Payer: Superior Health Plan EPO	$17.43

bupivacaine 0.5 % 50 ml injection

Facility

$128.19

Service Code	HCPCS J3490
Hospital Charge Code	77424013
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.17

bupivacaine 0.5% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442893
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine 0.5% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442893
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

bupivacaine 0.5% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442899
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine 0.5% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442899
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

bupivacaine 0.5% PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442902
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

bupivacaine 0.5% PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442902
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	77425079
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	77425079
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

bupivacaine-EPINEPHrine 0.5%-1:200,000 PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77425289
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine-EPINEPHrine 0.5%-1:200,000 PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77425289
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

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	$1.41
Max. Negotiated Rate	$588.96
Rate for Payer: Amerigroup CHIP/Medicaid	$73.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1.41
Rate for Payer: Amerigroup Medicare	$1.41
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	$1.41
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	$1.41
Rate for Payer: Employer Direct Commercial	$1.41
Rate for Payer: Humana Medicare/TRICARE	$1.41
Rate for Payer: Molina CHIP/Medicaid	$588.96
Rate for Payer: Molina Dual Medicare/Medicaid	$1.41
Rate for Payer: Molina Medicare	$1.41
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	$1.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$588.96
Rate for Payer: Superior Health Plan EPO	$1.41
Rate for Payer: Superior Health Plan Medicare	$1.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$1.41
Rate for Payer: Universal American Medicare	$1.41
Rate for Payer: Wellcare Medicare	$1.41
Rate for Payer: Wellmed Medicare	$1.41

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
Rate for Payer: Cash Price	$87.04

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

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 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

Know your out-of-pocket cost for care.

All Charges