White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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 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
Rate for Payer: Cash Price	$5.44

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/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
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 75mg Tab

Facility

$7.65

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

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

$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

$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

BURR 4MM ROUND CRSE/ELITE/SABER

Facility

$656.67

Hospital Charge Code	145310
Hospital Revenue Code	272
Min. Negotiated Rate	$59.10
Max. Negotiated Rate	$472.80
Rate for Payer: Amerigroup CHIP/Medicaid	$59.10
Rate for Payer: BCBS of TX Blue Advantage	$197.00
Rate for Payer: BCBS of TX Blue Essentials	$236.40
Rate for Payer: BCBS of TX PPO	$262.67
Rate for Payer: Cash Price	$446.54
Rate for Payer: Cigna Medicaid	$472.80
Rate for Payer: Molina CHIP/Medicaid	$472.80
Rate for Payer: Multiplan Auto	$426.84
Rate for Payer: Multiplan Commercial	$426.84
Rate for Payer: Multiplan Workers Comp	$426.84
Rate for Payer: Parkland Medicaid	$472.80
Rate for Payer: Scott and White EPO/PPO	$328.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$472.80
Rate for Payer: Superior Health Plan EPO	$89.31

BURR BON S -- DHF

Facility

$799.63

Hospital Charge Code	81728453
Hospital Revenue Code	272
Rate for Payer: Cash Price	$543.75

BURR BON S -- DHF

Facility

$799.63

Hospital Charge Code	81728453
Hospital Revenue Code	272
Min. Negotiated Rate	$71.97
Max. Negotiated Rate	$575.73
Rate for Payer: Amerigroup CHIP/Medicaid	$71.97
Rate for Payer: BCBS of TX Blue Advantage	$239.89
Rate for Payer: BCBS of TX Blue Essentials	$287.87
Rate for Payer: BCBS of TX PPO	$319.85
Rate for Payer: Cash Price	$543.75
Rate for Payer: Cigna Medicaid	$575.73
Rate for Payer: Molina CHIP/Medicaid	$575.73
Rate for Payer: Multiplan Auto	$519.76
Rate for Payer: Multiplan Commercial	$519.76
Rate for Payer: Multiplan Workers Comp	$519.76
Rate for Payer: Parkland Medicaid	$575.73
Rate for Payer: Scott and White EPO/PPO	$399.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$575.73
Rate for Payer: Superior Health Plan EPO	$108.75

BURR CARBIDE OVAL -- DHF

Facility

$94.99

Hospital Charge Code	81728560
Hospital Revenue Code	272
Rate for Payer: Cash Price	$64.59

BURR CARBIDE OVAL -- DHF

Facility

$94.99

Hospital Charge Code	81728560
Hospital Revenue Code	272
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$68.39
Rate for Payer: Amerigroup CHIP/Medicaid	$8.55
Rate for Payer: BCBS of TX Blue Advantage	$28.50
Rate for Payer: BCBS of TX Blue Essentials	$34.20
Rate for Payer: BCBS of TX PPO	$38.00
Rate for Payer: Cash Price	$64.59
Rate for Payer: Cigna Medicaid	$68.39
Rate for Payer: Molina CHIP/Medicaid	$68.39
Rate for Payer: Multiplan Auto	$61.74
Rate for Payer: Multiplan Commercial	$61.74
Rate for Payer: Multiplan Workers Comp	$61.74
Rate for Payer: Parkland Medicaid	$68.39
Rate for Payer: Scott and White EPO/PPO	$47.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$68.39
Rate for Payer: Superior Health Plan EPO	$12.92

BURR, CUTTING OVAL STERLING HI SPEED REDUCD HOOD 4M

Facility

$199.76

Hospital Charge Code	140409
Hospital Revenue Code	272
Rate for Payer: Cash Price	$135.84

Know your out-of-pocket cost for care.

All Charges