White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CCHD Screen Result, Initial -> Fail

Facility

$26.64

Service Code	HCPCS 94760
Hospital Charge Code	10108
Hospital Revenue Code	410
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$19.18
Rate for Payer: Amerigroup CHIP/Medicaid	$2.40
Rate for Payer: BCBS of TX Blue Advantage	$7.99
Rate for Payer: BCBS of TX Blue Essentials	$9.59
Rate for Payer: BCBS of TX PPO	$10.66
Rate for Payer: Cash Price	$18.12
Rate for Payer: Cash Price	$18.12
Rate for Payer: Cigna Medicaid	$19.18
Rate for Payer: Molina CHIP/Medicaid	$19.18
Rate for Payer: Multiplan Auto	$17.32
Rate for Payer: Multiplan Commercial	$17.32
Rate for Payer: Multiplan Workers Comp	$17.32
Rate for Payer: Parkland Medicaid	$19.18
Rate for Payer: Scott and White EPO/PPO	$3.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.18
Rate for Payer: Superior Health Plan EPO	$3.62

CCP Antibodies IgG/IgA SO

Facility

$137.24

Service Code	HCPCS 86200
Hospital Charge Code	1740356
Hospital Revenue Code	302
Rate for Payer: Cash Price	$93.32

CCP Antibodies IgG/IgA SO

Facility

$137.24

Service Code	HCPCS 86200
Hospital Charge Code	1740356
Hospital Revenue Code	302
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$98.81
Rate for Payer: Amerigroup CHIP/Medicaid	$5.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.95
Rate for Payer: Amerigroup Medicare	$12.95
Rate for Payer: BCBS of TX Blue Advantage	$41.17
Rate for Payer: BCBS of TX Blue Essentials	$49.41
Rate for Payer: BCBS of TX Medicare	$12.95
Rate for Payer: BCBS of TX PPO	$54.90
Rate for Payer: Cash Price	$93.32
Rate for Payer: Cash Price	$93.32
Rate for Payer: Cigna Medicaid	$98.81
Rate for Payer: Cigna Medicare	$12.95
Rate for Payer: Employer Direct Commercial	$12.95
Rate for Payer: Humana Medicare/TRICARE	$12.95
Rate for Payer: Molina CHIP/Medicaid	$98.81
Rate for Payer: Molina Dual Medicare/Medicaid	$12.95
Rate for Payer: Molina Medicare	$12.95
Rate for Payer: Multiplan Auto	$89.21
Rate for Payer: Multiplan Commercial	$89.21
Rate for Payer: Multiplan Workers Comp	$89.21
Rate for Payer: Parkland Medicaid	$98.81
Rate for Payer: Scott and White EPO/PPO	$16.19
Rate for Payer: Scott and White Medicare	$12.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.81
Rate for Payer: Superior Health Plan EPO	$12.95
Rate for Payer: Superior Health Plan Medicare	$12.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.95
Rate for Payer: Universal American Medicare	$12.95
Rate for Payer: Wellcare Medicare	$12.95
Rate for Payer: Wellmed Medicare	$12.95

CD1411-36Q Ellipse VR_ICU_UMRI_PR

Facility

$96,952.29

Service Code	HCPCS C1722
Hospital Charge Code	40082976
Hospital Revenue Code	278
Min. Negotiated Rate	$8,725.71
Max. Negotiated Rate	$69,805.65
Rate for Payer: Amerigroup CHIP/Medicaid	$8,725.71
Rate for Payer: BCBS of TX Blue Advantage	$29,085.69
Rate for Payer: BCBS of TX Blue Essentials	$34,902.82
Rate for Payer: BCBS of TX PPO	$38,780.92
Rate for Payer: Cash Price	$65,927.56
Rate for Payer: Cigna Medicaid	$69,805.65
Rate for Payer: Molina CHIP/Medicaid	$69,805.65
Rate for Payer: Multiplan Auto	$48,476.14
Rate for Payer: Multiplan Commercial	$48,476.14
Rate for Payer: Multiplan Workers Comp	$48,476.14
Rate for Payer: Parkland Medicaid	$69,805.65
Rate for Payer: Scott and White EPO/PPO	$48,476.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69,805.65
Rate for Payer: Superior Health Plan EPO	$13,185.51

CD1411-36Q Ellipse VR_ICU_UMRI_PR

Facility

$96,952.29

Service Code	HCPCS C1722
Hospital Charge Code	40082976
Hospital Revenue Code	278
Min. Negotiated Rate	$24,238.07
Max. Negotiated Rate	$48,476.14
Rate for Payer: Cash Price	$65,927.56
Rate for Payer: Cigna Commercial	$24,238.07
Rate for Payer: Multiplan Auto	$48,476.14
Rate for Payer: Multiplan Commercial	$48,476.14
Rate for Payer: Multiplan Workers Comp	$48,476.14
Rate for Payer: Scott and White EPO/PPO	$48,476.14

CEA, Fluid SO

Facility

$405.00

Service Code	HCPCS 82378
Hospital Charge Code	1700145
Hospital Revenue Code	301
Min. Negotiated Rate	$7.39
Max. Negotiated Rate	$291.60
Rate for Payer: Amerigroup CHIP/Medicaid	$7.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.96
Rate for Payer: Amerigroup Medicare	$18.96
Rate for Payer: BCBS of TX Blue Advantage	$121.50
Rate for Payer: BCBS of TX Blue Essentials	$145.80
Rate for Payer: BCBS of TX Medicare	$18.96
Rate for Payer: BCBS of TX PPO	$162.00
Rate for Payer: Cash Price	$275.40
Rate for Payer: Cash Price	$275.40
Rate for Payer: Cigna Medicaid	$291.60
Rate for Payer: Cigna Medicare	$18.96
Rate for Payer: Employer Direct Commercial	$18.96
Rate for Payer: Humana Medicare/TRICARE	$18.96
Rate for Payer: Molina CHIP/Medicaid	$291.60
Rate for Payer: Molina Dual Medicare/Medicaid	$18.96
Rate for Payer: Molina Medicare	$18.96
Rate for Payer: Multiplan Auto	$263.25
Rate for Payer: Multiplan Commercial	$263.25
Rate for Payer: Multiplan Workers Comp	$263.25
Rate for Payer: Parkland Medicaid	$291.60
Rate for Payer: Scott and White EPO/PPO	$23.70
Rate for Payer: Scott and White Medicare	$18.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$291.60
Rate for Payer: Superior Health Plan EPO	$18.96
Rate for Payer: Superior Health Plan Medicare	$18.96
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.96
Rate for Payer: Universal American Medicare	$18.96
Rate for Payer: Wellcare Medicare	$18.96
Rate for Payer: Wellmed Medicare	$18.96

CEA, Fluid SO

Facility

$405.00

Service Code	HCPCS 82378
Hospital Charge Code	1700145
Hospital Revenue Code	301
Rate for Payer: Cash Price	$275.40

ceFAZolin 1 g and D5W; 50 mL connect

Facility

$128.17

Service Code	HCPCS J0690
Hospital Charge Code	77446122
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.55
Rate for Payer: BCBS of TX Blue Essentials	$0.66
Rate for Payer: BCBS of TX PPO	$0.73
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

ceFAZolin 1 g and D5W; 50 mL connect

Facility

$128.17

Service Code	HCPCS J0690
Hospital Charge Code	77446122
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

ceFAZolin 1 g and D5W; 50 mL connect

Facility

$128.17

Service Code	HCPCS J0690
Hospital Charge Code	79498093
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.55
Rate for Payer: BCBS of TX Blue Essentials	$0.66
Rate for Payer: BCBS of TX PPO	$0.73
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

ceFAZolin 1 g and D5W; 50 mL connect

Facility

$128.17

Service Code	HCPCS J0690
Hospital Charge Code	79498093
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

ceFAZolin 1 g Pow

Facility

$128.17

Service Code	HCPCS J0690
Hospital Charge Code	78872080
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.55
Rate for Payer: BCBS of TX Blue Essentials	$0.66
Rate for Payer: BCBS of TX PPO	$0.73
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

ceFAZolin 1 g Pow

Facility

$128.17

Service Code	HCPCS J0690
Hospital Charge Code	78872080
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

cefdinir 300 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77446721
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

cefdinir 300 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77446721
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

cefepime 1 g Inj

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77447098
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

cefepime 1 g Inj

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77447098
Hospital Revenue Code	636
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.49
Rate for Payer: BCBS of TX Blue Essentials	$2.99
Rate for Payer: BCBS of TX PPO	$3.32
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

cefepime 2 g/50 mL Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77446988
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

cefepime 2 g/50 mL Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77446933
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

cefepime 2 g/50 mL Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77446988
Hospital Revenue Code	636
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.49
Rate for Payer: BCBS of TX Blue Essentials	$2.99
Rate for Payer: BCBS of TX PPO	$3.32
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

cefepime 2 g/50 mL Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77446933
Hospital Revenue Code	636
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.49
Rate for Payer: BCBS of TX Blue Essentials	$2.99
Rate for Payer: BCBS of TX PPO	$3.32
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

cefepime 2 g Inj

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77446878
Hospital Revenue Code	636
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.49
Rate for Payer: BCBS of TX Blue Essentials	$2.99
Rate for Payer: BCBS of TX PPO	$3.32
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

cefepime 2 g Inj

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77446878
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

cefOXitin 2 g Inj

Facility

$128.17

Service Code	HCPCS J0694
Hospital Charge Code	77448372
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

cefOXitin 2 g Inj

Facility

$128.17

Service Code	HCPCS J0694
Hospital Charge Code	77448372
Hospital Revenue Code	636
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$6.39
Rate for Payer: BCBS of TX Blue Essentials	$7.67
Rate for Payer: BCBS of TX PPO	$8.51
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