White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

calcium gluconate 100 mg/ml 10 ml injection

Facility

$128.00

Service Code	HCPCS J0612
Hospital Charge Code	77435267
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

calcium gluconate 100 mg/ml 10 ml injection

Facility

$128.00

Service Code	HCPCS J0612
Hospital Charge Code	77435267
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
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	$87.04
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

calcium gluconate 100 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J0612
Hospital Charge Code	7443109
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

calcium gluconate 100 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J0612
Hospital Charge Code	7443109
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

Calcium, Ionized, Serum SO

Facility

$360.00

Service Code	HCPCS 82330 QW
Hospital Charge Code	1701291
Hospital Revenue Code	301
Min. Negotiated Rate	$5.34
Max. Negotiated Rate	$259.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.68
Rate for Payer: Amerigroup Medicare	$13.68
Rate for Payer: BCBS of TX Blue Advantage	$108.00
Rate for Payer: BCBS of TX Blue Essentials	$129.60
Rate for Payer: BCBS of TX Medicare	$13.68
Rate for Payer: BCBS of TX PPO	$144.00
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cigna Medicaid	$259.20
Rate for Payer: Cigna Medicare	$13.68
Rate for Payer: Employer Direct Commercial	$13.68
Rate for Payer: Humana Medicare/TRICARE	$13.68
Rate for Payer: Molina CHIP/Medicaid	$259.20
Rate for Payer: Molina Dual Medicare/Medicaid	$13.68
Rate for Payer: Molina Medicare	$13.68
Rate for Payer: Multiplan Auto	$234.00
Rate for Payer: Multiplan Commercial	$234.00
Rate for Payer: Multiplan Workers Comp	$234.00
Rate for Payer: Parkland Medicaid	$259.20
Rate for Payer: Scott and White EPO/PPO	$17.10
Rate for Payer: Scott and White Medicare	$13.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$259.20
Rate for Payer: Superior Health Plan EPO	$13.68
Rate for Payer: Superior Health Plan Medicare	$13.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.68
Rate for Payer: Universal American Medicare	$13.68
Rate for Payer: Wellcare Medicare	$13.68
Rate for Payer: Wellmed Medicare	$13.68

Calcium, Ionized, Serum SO

Facility

$360.00

Service Code	HCPCS 82330 QW
Hospital Charge Code	1701291
Hospital Revenue Code	301
Rate for Payer: Cash Price	$244.80

Calcium Level Total

Facility

$234.00

Service Code	HCPCS 82310 QW
Hospital Charge Code	1601673
Hospital Revenue Code	301
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$168.48
Rate for Payer: Amerigroup CHIP/Medicaid	$2.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.16
Rate for Payer: Amerigroup Medicare	$5.16
Rate for Payer: BCBS of TX Blue Advantage	$70.20
Rate for Payer: BCBS of TX Blue Essentials	$84.24
Rate for Payer: BCBS of TX Medicare	$5.16
Rate for Payer: BCBS of TX PPO	$93.60
Rate for Payer: Cash Price	$159.12
Rate for Payer: Cash Price	$159.12
Rate for Payer: Cigna Medicaid	$168.48
Rate for Payer: Cigna Medicare	$5.16
Rate for Payer: Employer Direct Commercial	$5.16
Rate for Payer: Humana Medicare/TRICARE	$5.16
Rate for Payer: Molina CHIP/Medicaid	$168.48
Rate for Payer: Molina Dual Medicare/Medicaid	$5.16
Rate for Payer: Molina Medicare	$5.16
Rate for Payer: Multiplan Auto	$152.10
Rate for Payer: Multiplan Commercial	$152.10
Rate for Payer: Multiplan Workers Comp	$152.10
Rate for Payer: Parkland Medicaid	$168.48
Rate for Payer: Scott and White EPO/PPO	$6.45
Rate for Payer: Scott and White Medicare	$5.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$168.48
Rate for Payer: Superior Health Plan EPO	$5.16
Rate for Payer: Superior Health Plan Medicare	$5.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.16
Rate for Payer: Universal American Medicare	$5.16
Rate for Payer: Wellcare Medicare	$5.16
Rate for Payer: Wellmed Medicare	$5.16

Calcium Level Total

Facility

$234.00

Service Code	HCPCS 82310 QW
Hospital Charge Code	1601673
Hospital Revenue Code	301
Rate for Payer: Cash Price	$159.12

Calculi, Urinary SO

Facility

$96.00

Service Code	HCPCS 82360
Hospital Charge Code	1630026
Hospital Revenue Code	301
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$69.12
Rate for Payer: Amerigroup CHIP/Medicaid	$5.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.87
Rate for Payer: Amerigroup Medicare	$12.87
Rate for Payer: BCBS of TX Blue Advantage	$28.80
Rate for Payer: BCBS of TX Blue Essentials	$34.56
Rate for Payer: BCBS of TX Medicare	$12.87
Rate for Payer: BCBS of TX PPO	$38.40
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cigna Medicaid	$69.12
Rate for Payer: Cigna Medicare	$12.87
Rate for Payer: Employer Direct Commercial	$12.87
Rate for Payer: Humana Medicare/TRICARE	$12.87
Rate for Payer: Molina CHIP/Medicaid	$69.12
Rate for Payer: Molina Dual Medicare/Medicaid	$12.87
Rate for Payer: Molina Medicare	$12.87
Rate for Payer: Multiplan Auto	$62.40
Rate for Payer: Multiplan Commercial	$62.40
Rate for Payer: Multiplan Workers Comp	$62.40
Rate for Payer: Parkland Medicaid	$69.12
Rate for Payer: Scott and White EPO/PPO	$16.09
Rate for Payer: Scott and White Medicare	$12.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.12
Rate for Payer: Superior Health Plan EPO	$12.87
Rate for Payer: Superior Health Plan Medicare	$12.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.87
Rate for Payer: Universal American Medicare	$12.87
Rate for Payer: Wellcare Medicare	$12.87
Rate for Payer: Wellmed Medicare	$12.87

Calculi, Urinary SO

Facility

$96.00

Service Code	HCPCS 82360
Hospital Charge Code	1630026
Hospital Revenue Code	301
Rate for Payer: Cash Price	$65.28

CALIBRATED INOCULATION LOOP CLEAR 1000/PK

Facility

$1,022.86

Hospital Charge Code	993643
Hospital Revenue Code	270
Min. Negotiated Rate	$92.06
Max. Negotiated Rate	$736.46
Rate for Payer: Amerigroup CHIP/Medicaid	$92.06
Rate for Payer: BCBS of TX Blue Advantage	$306.86
Rate for Payer: BCBS of TX Blue Essentials	$368.23
Rate for Payer: BCBS of TX PPO	$409.14
Rate for Payer: Cash Price	$695.54
Rate for Payer: Cigna Medicaid	$736.46
Rate for Payer: Molina CHIP/Medicaid	$736.46
Rate for Payer: Multiplan Auto	$664.86
Rate for Payer: Multiplan Commercial	$664.86
Rate for Payer: Multiplan Workers Comp	$664.86
Rate for Payer: Parkland Medicaid	$736.46
Rate for Payer: Scott and White EPO/PPO	$511.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$736.46
Rate for Payer: Superior Health Plan EPO	$139.11

CALIBRATED INOCULATION LOOP CLEAR 1000/PK

Facility

$1,022.86

Hospital Charge Code	993643
Hospital Revenue Code	270
Rate for Payer: Cash Price	$695.54

CALIBRATION TUBE

Facility

$853.52

Hospital Charge Code	993960
Hospital Revenue Code	272
Rate for Payer: Cash Price	$580.39

CALIBRATION TUBE

Facility

$853.52

Hospital Charge Code	993960
Hospital Revenue Code	272
Min. Negotiated Rate	$76.82
Max. Negotiated Rate	$614.53
Rate for Payer: Amerigroup CHIP/Medicaid	$76.82
Rate for Payer: BCBS of TX Blue Advantage	$256.06
Rate for Payer: BCBS of TX Blue Essentials	$307.27
Rate for Payer: BCBS of TX PPO	$341.41
Rate for Payer: Cash Price	$580.39
Rate for Payer: Cigna Medicaid	$614.53
Rate for Payer: Molina CHIP/Medicaid	$614.53
Rate for Payer: Multiplan Auto	$554.79
Rate for Payer: Multiplan Commercial	$554.79
Rate for Payer: Multiplan Workers Comp	$554.79
Rate for Payer: Parkland Medicaid	$614.53
Rate for Payer: Scott and White EPO/PPO	$426.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$614.53
Rate for Payer: Superior Health Plan EPO	$116.08

Calprotectin, Fecal SO

Facility

$338.00

Service Code	HCPCS 83993
Hospital Charge Code	1740932
Hospital Revenue Code	301
Rate for Payer: Cash Price	$229.84

Calprotectin, Fecal SO

Facility

$338.00

Service Code	HCPCS 83993
Hospital Charge Code	1740932
Hospital Revenue Code	301
Min. Negotiated Rate	$7.66
Max. Negotiated Rate	$243.36
Rate for Payer: Amerigroup CHIP/Medicaid	$7.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19.63
Rate for Payer: Amerigroup Medicare	$19.63
Rate for Payer: BCBS of TX Blue Advantage	$101.40
Rate for Payer: BCBS of TX Blue Essentials	$121.68
Rate for Payer: BCBS of TX Medicare	$19.63
Rate for Payer: BCBS of TX PPO	$135.20
Rate for Payer: Cash Price	$229.84
Rate for Payer: Cash Price	$229.84
Rate for Payer: Cigna Medicaid	$243.36
Rate for Payer: Cigna Medicare	$19.63
Rate for Payer: Employer Direct Commercial	$19.63
Rate for Payer: Humana Medicare/TRICARE	$19.63
Rate for Payer: Molina CHIP/Medicaid	$243.36
Rate for Payer: Molina Dual Medicare/Medicaid	$19.63
Rate for Payer: Molina Medicare	$19.63
Rate for Payer: Multiplan Auto	$219.70
Rate for Payer: Multiplan Commercial	$219.70
Rate for Payer: Multiplan Workers Comp	$219.70
Rate for Payer: Parkland Medicaid	$243.36
Rate for Payer: Scott and White EPO/PPO	$24.54
Rate for Payer: Scott and White Medicare	$19.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$243.36
Rate for Payer: Superior Health Plan EPO	$19.63
Rate for Payer: Superior Health Plan Medicare	$19.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$19.63
Rate for Payer: Universal American Medicare	$19.63
Rate for Payer: Wellcare Medicare	$19.63
Rate for Payer: Wellmed Medicare	$19.63

Campy Cva Agar With 5% Sheep Blood, For Campylobacter Spp, 15 x 100 mm plate

Facility

$5.76

Hospital Charge Code	993358
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.92

Campy Cva Agar With 5% Sheep Blood, For Campylobacter Spp, 15 x 100 mm plate

Facility

$5.76

Hospital Charge Code	993358
Hospital Revenue Code	272
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$4.15
Rate for Payer: Amerigroup CHIP/Medicaid	$0.52
Rate for Payer: BCBS of TX Blue Advantage	$1.73
Rate for Payer: BCBS of TX Blue Essentials	$2.07
Rate for Payer: BCBS of TX PPO	$2.30
Rate for Payer: Cash Price	$3.92
Rate for Payer: Cigna Medicaid	$4.15
Rate for Payer: Molina CHIP/Medicaid	$4.15
Rate for Payer: Multiplan Auto	$3.74
Rate for Payer: Multiplan Commercial	$3.74
Rate for Payer: Multiplan Workers Comp	$3.74
Rate for Payer: Parkland Medicaid	$4.15
Rate for Payer: Scott and White EPO/PPO	$2.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.15
Rate for Payer: Superior Health Plan EPO	$0.78

CANCELLOUS BONE CHIPS 30CC

Facility

$15,060.00

Service Code	HCPCS C1734
Hospital Charge Code	8394473
Hospital Revenue Code	278
Min. Negotiated Rate	$1,355.40
Max. Negotiated Rate	$10,843.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1,355.40
Rate for Payer: BCBS of TX Blue Advantage	$4,518.00
Rate for Payer: BCBS of TX Blue Essentials	$5,421.60
Rate for Payer: BCBS of TX PPO	$6,024.00
Rate for Payer: Cash Price	$10,240.80
Rate for Payer: Cigna Medicaid	$10,843.20
Rate for Payer: Molina CHIP/Medicaid	$10,843.20
Rate for Payer: Multiplan Auto	$7,530.00
Rate for Payer: Multiplan Commercial	$7,530.00
Rate for Payer: Multiplan Workers Comp	$7,530.00
Rate for Payer: Parkland Medicaid	$10,843.20
Rate for Payer: Scott and White EPO/PPO	$7,530.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,843.20
Rate for Payer: Superior Health Plan EPO	$2,048.16

CANCELLOUS BONE CHIPS 30CC

Facility

$15,060.00

Service Code	HCPCS C1734
Hospital Charge Code	8394473
Hospital Revenue Code	278
Min. Negotiated Rate	$3,765.00
Max. Negotiated Rate	$7,530.00
Rate for Payer: Cash Price	$10,240.80
Rate for Payer: Cigna Commercial	$3,765.00
Rate for Payer: Multiplan Auto	$7,530.00
Rate for Payer: Multiplan Commercial	$7,530.00
Rate for Payer: Multiplan Workers Comp	$7,530.00
Rate for Payer: Scott and White EPO/PPO	$7,530.00

Cancer Antigen (CA) 125 SO

Facility

$449.00

Service Code	HCPCS 86304
Hospital Charge Code	1706274
Hospital Revenue Code	302
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$323.28
Rate for Payer: Amerigroup CHIP/Medicaid	$8.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.81
Rate for Payer: Amerigroup Medicare	$20.81
Rate for Payer: BCBS of TX Blue Advantage	$134.70
Rate for Payer: BCBS of TX Blue Essentials	$161.64
Rate for Payer: BCBS of TX Medicare	$20.81
Rate for Payer: BCBS of TX PPO	$179.60
Rate for Payer: Cash Price	$305.32
Rate for Payer: Cash Price	$305.32
Rate for Payer: Cigna Medicaid	$323.28
Rate for Payer: Cigna Medicare	$20.81
Rate for Payer: Employer Direct Commercial	$20.81
Rate for Payer: Humana Medicare/TRICARE	$20.81
Rate for Payer: Molina CHIP/Medicaid	$323.28
Rate for Payer: Molina Dual Medicare/Medicaid	$20.81
Rate for Payer: Molina Medicare	$20.81
Rate for Payer: Multiplan Auto	$291.85
Rate for Payer: Multiplan Commercial	$291.85
Rate for Payer: Multiplan Workers Comp	$291.85
Rate for Payer: Parkland Medicaid	$323.28
Rate for Payer: Scott and White EPO/PPO	$26.01
Rate for Payer: Scott and White Medicare	$20.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$323.28
Rate for Payer: Superior Health Plan EPO	$20.81
Rate for Payer: Superior Health Plan Medicare	$20.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.81
Rate for Payer: Universal American Medicare	$20.81
Rate for Payer: Wellcare Medicare	$20.81
Rate for Payer: Wellmed Medicare	$20.81

Cancer Antigen (CA) 125 SO

Facility

$449.00

Service Code	HCPCS 86304
Hospital Charge Code	1706274
Hospital Revenue Code	302
Rate for Payer: Cash Price	$305.32

Cancer Antigen (CA) 15-3

Facility

$148.00

Service Code	HCPCS 86300
Hospital Charge Code	1706282
Hospital Revenue Code	302
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$106.56
Rate for Payer: Amerigroup CHIP/Medicaid	$8.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.81
Rate for Payer: Amerigroup Medicare	$20.81
Rate for Payer: BCBS of TX Blue Advantage	$44.40
Rate for Payer: BCBS of TX Blue Essentials	$53.28
Rate for Payer: BCBS of TX Medicare	$20.81
Rate for Payer: BCBS of TX PPO	$59.20
Rate for Payer: Cash Price	$100.64
Rate for Payer: Cash Price	$100.64
Rate for Payer: Cigna Medicaid	$106.56
Rate for Payer: Cigna Medicare	$20.81
Rate for Payer: Employer Direct Commercial	$20.81
Rate for Payer: Humana Medicare/TRICARE	$20.81
Rate for Payer: Molina CHIP/Medicaid	$106.56
Rate for Payer: Molina Dual Medicare/Medicaid	$20.81
Rate for Payer: Molina Medicare	$20.81
Rate for Payer: Multiplan Auto	$96.20
Rate for Payer: Multiplan Commercial	$96.20
Rate for Payer: Multiplan Workers Comp	$96.20
Rate for Payer: Parkland Medicaid	$106.56
Rate for Payer: Scott and White EPO/PPO	$26.01
Rate for Payer: Scott and White Medicare	$20.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$106.56
Rate for Payer: Superior Health Plan EPO	$20.81
Rate for Payer: Superior Health Plan Medicare	$20.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.81
Rate for Payer: Universal American Medicare	$20.81
Rate for Payer: Wellcare Medicare	$20.81
Rate for Payer: Wellmed Medicare	$20.81

Cancer Antigen (CA) 15-3

Facility

$148.00

Service Code	HCPCS 86300
Hospital Charge Code	1706282
Hospital Revenue Code	302
Rate for Payer: Cash Price	$100.64

Know your out-of-pocket cost for care.

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