White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CALCFX PERCPLT,STD ANT PROC/POST TUBER,R

Facility

$8,285.50

Service Code	HCPCS C1734
Hospital Charge Code	992596
Hospital Revenue Code	278
Min. Negotiated Rate	$2,071.38
Max. Negotiated Rate	$4,142.75
Rate for Payer: Cash Price	$5,634.14
Rate for Payer: Cigna Commercial	$2,071.38
Rate for Payer: Multiplan Auto	$4,142.75
Rate for Payer: Multiplan Commercial	$4,142.75
Rate for Payer: Multiplan Workers Comp	$4,142.75
Rate for Payer: Scott and White EPO/PPO	$4,142.75

CALCFX PERCPLT,STD ANT PROC/POST TUBER,R

Facility

$8,285.50

Service Code	HCPCS C1734
Hospital Charge Code	992596
Hospital Revenue Code	278
Min. Negotiated Rate	$745.70
Max. Negotiated Rate	$5,965.56
Rate for Payer: Amerigroup CHIP/Medicaid	$745.70
Rate for Payer: BCBS of TX Blue Advantage	$2,485.65
Rate for Payer: BCBS of TX Blue Essentials	$2,982.78
Rate for Payer: BCBS of TX PPO	$3,314.20
Rate for Payer: Cash Price	$5,634.14
Rate for Payer: Cigna Medicaid	$5,965.56
Rate for Payer: Molina CHIP/Medicaid	$5,965.56
Rate for Payer: Multiplan Auto	$4,142.75
Rate for Payer: Multiplan Commercial	$4,142.75
Rate for Payer: Multiplan Workers Comp	$4,142.75
Rate for Payer: Parkland Medicaid	$5,965.56
Rate for Payer: Scott and White EPO/PPO	$4,142.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,965.56
Rate for Payer: Superior Health Plan EPO	$1,126.83

calcitonin-salmon

Facility

$1,641.60

Service Code	HCPCS J0630
Hospital Charge Code	78435496
Hospital Revenue Code	636
Min. Negotiated Rate	$147.74
Max. Negotiated Rate	$5,216.93
Rate for Payer: Amerigroup CHIP/Medicaid	$147.74
Rate for Payer: BCBS of TX Blue Advantage	$3,919.45
Rate for Payer: BCBS of TX Blue Essentials	$4,703.34
Rate for Payer: BCBS of TX PPO	$5,216.93
Rate for Payer: Cash Price	$1,116.29
Rate for Payer: Cash Price	$1,116.29
Rate for Payer: Cigna Medicaid	$1,181.95
Rate for Payer: Molina CHIP/Medicaid	$1,181.95
Rate for Payer: Multiplan Auto	$1,067.04
Rate for Payer: Multiplan Commercial	$1,067.04
Rate for Payer: Multiplan Workers Comp	$1,067.04
Rate for Payer: Parkland Medicaid	$1,181.95
Rate for Payer: Scott and White EPO/PPO	$820.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,181.95
Rate for Payer: Superior Health Plan EPO	$223.26

calcitonin-salmon

Facility

$1,641.60

Service Code	HCPCS J0630
Hospital Charge Code	78435496
Hospital Revenue Code	636
Min. Negotiated Rate	$410.40
Max. Negotiated Rate	$820.80
Rate for Payer: Cash Price	$1,116.29
Rate for Payer: Cigna Commercial	$410.40
Rate for Payer: Scott and White EPO/PPO	$820.80

Calcitonin, Serum SO

Facility

$419.00

Service Code	HCPCS 82308
Hospital Charge Code	1701564
Hospital Revenue Code	301
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$301.68
Rate for Payer: Amerigroup CHIP/Medicaid	$10.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.79
Rate for Payer: Amerigroup Medicare	$26.79
Rate for Payer: BCBS of TX Blue Advantage	$125.70
Rate for Payer: BCBS of TX Blue Essentials	$150.84
Rate for Payer: BCBS of TX Medicare	$26.79
Rate for Payer: BCBS of TX PPO	$167.60
Rate for Payer: Cash Price	$284.92
Rate for Payer: Cash Price	$284.92
Rate for Payer: Cigna Medicaid	$301.68
Rate for Payer: Cigna Medicare	$26.79
Rate for Payer: Employer Direct Commercial	$26.79
Rate for Payer: Humana Medicare/TRICARE	$26.79
Rate for Payer: Molina CHIP/Medicaid	$301.68
Rate for Payer: Molina Dual Medicare/Medicaid	$26.79
Rate for Payer: Molina Medicare	$26.79
Rate for Payer: Multiplan Auto	$272.35
Rate for Payer: Multiplan Commercial	$272.35
Rate for Payer: Multiplan Workers Comp	$272.35
Rate for Payer: Parkland Medicaid	$301.68
Rate for Payer: Scott and White EPO/PPO	$33.49
Rate for Payer: Scott and White Medicare	$26.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$301.68
Rate for Payer: Superior Health Plan EPO	$26.79
Rate for Payer: Superior Health Plan Medicare	$26.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.79
Rate for Payer: Universal American Medicare	$26.79
Rate for Payer: Wellcare Medicare	$26.79
Rate for Payer: Wellmed Medicare	$26.79

Calcitonin, Serum SO

Facility

$419.00

Service Code	HCPCS 82308
Hospital Charge Code	1701564
Hospital Revenue Code	301
Rate for Payer: Cash Price	$284.92

calcitriol 0.25 mcg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77431842
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

calcitriol 0.25 mcg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77431842
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Calcitriol(1,25 di-OH Vit D) SO

Facility

$454.00

Service Code	HCPCS 82652
Hospital Charge Code	1706910
Hospital Revenue Code	301
Min. Negotiated Rate	$15.02
Max. Negotiated Rate	$326.88
Rate for Payer: Amerigroup CHIP/Medicaid	$15.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$38.50
Rate for Payer: Amerigroup Medicare	$38.50
Rate for Payer: BCBS of TX Blue Advantage	$136.20
Rate for Payer: BCBS of TX Blue Essentials	$163.44
Rate for Payer: BCBS of TX Medicare	$38.50
Rate for Payer: BCBS of TX PPO	$181.60
Rate for Payer: Cash Price	$308.72
Rate for Payer: Cash Price	$308.72
Rate for Payer: Cigna Medicaid	$326.88
Rate for Payer: Cigna Medicare	$38.50
Rate for Payer: Employer Direct Commercial	$38.50
Rate for Payer: Humana Medicare/TRICARE	$38.50
Rate for Payer: Molina CHIP/Medicaid	$326.88
Rate for Payer: Molina Dual Medicare/Medicaid	$38.50
Rate for Payer: Molina Medicare	$38.50
Rate for Payer: Multiplan Auto	$295.10
Rate for Payer: Multiplan Commercial	$295.10
Rate for Payer: Multiplan Workers Comp	$295.10
Rate for Payer: Parkland Medicaid	$326.88
Rate for Payer: Scott and White EPO/PPO	$48.12
Rate for Payer: Scott and White Medicare	$38.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$326.88
Rate for Payer: Superior Health Plan EPO	$38.50
Rate for Payer: Superior Health Plan Medicare	$38.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$38.50
Rate for Payer: Universal American Medicare	$38.50
Rate for Payer: Wellcare Medicare	$38.50
Rate for Payer: Wellmed Medicare	$38.50

Calcitriol(1,25 di-OH Vit D) SO

Facility

$454.00

Service Code	HCPCS 82652
Hospital Charge Code	1706910
Hospital Revenue Code	301
Rate for Payer: Cash Price	$308.72

calcium acetate 667 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77433217
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

calcium acetate 667 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77433217
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

calcium acetate 667 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77433268
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

calcium acetate 667 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77433268
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

calcium (as carbonate) 600 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77432319
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

calcium (as carbonate) 600 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77432319
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

calcium (as carbonnate)-vitamin D 250 mg-125 intl units Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78419911
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

calcium (as carbonnate)-vitamin D 250 mg-125 intl units Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78419911
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

calcium carbonate 500 mg (200 mg elemental calcium) Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77433943
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

calcium carbonate 500 mg (200 mg elemental calcium) Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77433943
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

calcium chloride 100 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77434912
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

calcium chloride 100 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77434912
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

calcium chloride solution

Facility

$6.23

Hospital Charge Code	993564
Hospital Revenue Code	270
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$4.49
Rate for Payer: Amerigroup CHIP/Medicaid	$0.56
Rate for Payer: BCBS of TX Blue Advantage	$1.87
Rate for Payer: BCBS of TX Blue Essentials	$2.24
Rate for Payer: BCBS of TX PPO	$2.49
Rate for Payer: Cash Price	$4.24
Rate for Payer: Cigna Medicaid	$4.49
Rate for Payer: Molina CHIP/Medicaid	$4.49
Rate for Payer: Multiplan Auto	$4.05
Rate for Payer: Multiplan Commercial	$4.05
Rate for Payer: Multiplan Workers Comp	$4.05
Rate for Payer: Parkland Medicaid	$4.49
Rate for Payer: Scott and White EPO/PPO	$3.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.49
Rate for Payer: Superior Health Plan EPO	$0.85

calcium chloride solution

Facility

$6.23

Hospital Charge Code	993564
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.24

calcium gluconate 1000 mg/50 mL-NaCl - IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J0612
Hospital Charge Code	79364704
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.07
Rate for Payer: BCBS of TX Blue Essentials	$0.09
Rate for Payer: BCBS of TX PPO	$0.10
Rate for Payer: Cash Price	$87.16
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

Know your out-of-pocket cost for care.

All Charges