White Rock Medical Center

All Charges

Charge

Type

Setting

Price

cefTRIAXone 1 g

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	78398414
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

cefTRIAXone 1 g

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	78398414
Hospital Revenue Code	636
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.67
Rate for Payer: BCBS of TX Blue Essentials	$4.40
Rate for Payer: BCBS of TX PPO	$4.88
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

cefTRIAXone 1 g and NS; 50 mL connect

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	79364329
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

cefTRIAXone 1 g and NS; 50 mL connect

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	79364329
Hospital Revenue Code	636
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.67
Rate for Payer: BCBS of TX Blue Essentials	$4.40
Rate for Payer: BCBS of TX PPO	$4.88
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

cefTRIAXone 250 mg Inj

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	77450277
Hospital Revenue Code	636
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.67
Rate for Payer: BCBS of TX Blue Essentials	$4.40
Rate for Payer: BCBS of TX PPO	$4.88
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

cefTRIAXone 250 mg Inj

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	77450277
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

cefTRIAXone 2 g and NS; 50 mL connect

Facility

$128.17

Service Code	HCPCS J7999
Hospital Charge Code	79364444
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

cefTRIAXone 2 g and NS; 50 mL connect

Facility

$128.17

Service Code	HCPCS J7999
Hospital Charge Code	79364444
Hospital Revenue Code	636
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

cefTRIAXone 2 g Inj

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	77450163
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

cefTRIAXone 2 g Inj

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	77450163
Hospital Revenue Code	636
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.67
Rate for Payer: BCBS of TX Blue Essentials	$4.40
Rate for Payer: BCBS of TX PPO	$4.88
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

cefTRIAXone 500 mg Inj

Facility

$128.00

Service Code	HCPCS J0696
Hospital Charge Code	78398456
Hospital Revenue Code	636
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$3.67
Rate for Payer: BCBS of TX Blue Essentials	$4.40
Rate for Payer: BCBS of TX PPO	$4.88
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

cefTRIAXone 500 mg Inj

Facility

$128.00

Service Code	HCPCS J0696
Hospital Charge Code	78398456
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

cefuroxime 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77450660
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

cefuroxime 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77450660
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

celecoxib 100 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77451090
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

celecoxib 100 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77451090
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

Celiac Disease Comprehensive SO

Facility

$372.00

Service Code	HCPCS 86364
Hospital Charge Code	1707074
Hospital Revenue Code	302
Rate for Payer: Cash Price	$252.96

Celiac Disease Comprehensive SO

Facility

$372.00

Service Code	HCPCS 86364
Hospital Charge Code	1707074
Hospital Revenue Code	302
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$267.84
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.53
Rate for Payer: Amerigroup Medicare	$11.53
Rate for Payer: BCBS of TX Blue Advantage	$111.60
Rate for Payer: BCBS of TX Blue Essentials	$133.92
Rate for Payer: BCBS of TX Medicare	$11.53
Rate for Payer: BCBS of TX PPO	$148.80
Rate for Payer: Cash Price	$252.96
Rate for Payer: Cash Price	$252.96
Rate for Payer: Cigna Medicaid	$267.84
Rate for Payer: Cigna Medicare	$11.53
Rate for Payer: Employer Direct Commercial	$11.53
Rate for Payer: Humana Medicare/TRICARE	$11.53
Rate for Payer: Molina CHIP/Medicaid	$267.84
Rate for Payer: Molina Dual Medicare/Medicaid	$11.53
Rate for Payer: Molina Medicare	$11.53
Rate for Payer: Multiplan Auto	$241.80
Rate for Payer: Multiplan Commercial	$241.80
Rate for Payer: Multiplan Workers Comp	$241.80
Rate for Payer: Parkland Medicaid	$267.84
Rate for Payer: Scott and White EPO/PPO	$14.41
Rate for Payer: Scott and White Medicare	$11.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$267.84
Rate for Payer: Superior Health Plan EPO	$11.53
Rate for Payer: Superior Health Plan Medicare	$11.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.53
Rate for Payer: Universal American Medicare	$11.53
Rate for Payer: Wellcare Medicare	$11.53
Rate for Payer: Wellmed Medicare	$11.53

Cell Lyse f/DXH 5Lt

Facility

$2,902.74

Hospital Charge Code	993847
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,973.86

Cell Lyse f/DXH 5Lt

Facility

$2,902.74

Hospital Charge Code	993847
Hospital Revenue Code	272
Min. Negotiated Rate	$261.25
Max. Negotiated Rate	$2,089.97
Rate for Payer: Amerigroup CHIP/Medicaid	$261.25
Rate for Payer: BCBS of TX Blue Advantage	$870.82
Rate for Payer: BCBS of TX Blue Essentials	$1,044.99
Rate for Payer: BCBS of TX PPO	$1,161.10
Rate for Payer: Cash Price	$1,973.86
Rate for Payer: Cigna Medicaid	$2,089.97
Rate for Payer: Molina CHIP/Medicaid	$2,089.97
Rate for Payer: Multiplan Auto	$1,886.78
Rate for Payer: Multiplan Commercial	$1,886.78
Rate for Payer: Multiplan Workers Comp	$1,886.78
Rate for Payer: Parkland Medicaid	$2,089.97
Rate for Payer: Scott and White EPO/PPO	$1,451.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,089.97
Rate for Payer: Superior Health Plan EPO	$394.77

CELLULITIS AND OTHER SKIN INFECTIONS

Facility

$2,959.42

Service Code	APR-DRG 3832
Min. Negotiated Rate	$2,790.25
Max. Negotiated Rate	$2,959.42
Rate for Payer: Amerigroup CHIP/Medicaid	$2,790.25
Rate for Payer: Cigna Medicaid	$2,790.25
Rate for Payer: Molina CHIP/Medicaid	$2,790.25
Rate for Payer: Parkland Medicaid	$2,790.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,959.42

CELLULITIS AND OTHER SKIN INFECTIONS

Facility

$1,939.51

Service Code	APR-DRG 3831
Min. Negotiated Rate	$1,828.63
Max. Negotiated Rate	$1,939.51
Rate for Payer: Amerigroup CHIP/Medicaid	$1,828.63
Rate for Payer: Cigna Medicaid	$1,828.63
Rate for Payer: Molina CHIP/Medicaid	$1,828.63
Rate for Payer: Parkland Medicaid	$1,828.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,939.51

CELLULITIS AND OTHER SKIN INFECTIONS

Facility

$12,938.71

Service Code	APR-DRG 3834
Min. Negotiated Rate	$12,199.07
Max. Negotiated Rate	$12,938.71
Rate for Payer: Amerigroup CHIP/Medicaid	$12,199.07
Rate for Payer: Cigna Medicaid	$12,199.07
Rate for Payer: Molina CHIP/Medicaid	$12,199.07
Rate for Payer: Parkland Medicaid	$12,199.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,938.71

CELLULITIS AND OTHER SKIN INFECTIONS

Facility

$4,655.64

Service Code	APR-DRG 3833
Min. Negotiated Rate	$4,389.50
Max. Negotiated Rate	$4,655.64
Rate for Payer: Amerigroup CHIP/Medicaid	$4,389.50
Rate for Payer: Cigna Medicaid	$4,389.50
Rate for Payer: Molina CHIP/Medicaid	$4,389.50
Rate for Payer: Parkland Medicaid	$4,389.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,655.64

CELLULITIS WITH MCC

Facility

$27,382.80

Service Code	MSDRG 602
Min. Negotiated Rate	$12,418.40
Max. Negotiated Rate	$27,382.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,176.84
Rate for Payer: Amerigroup Medicare	$15,176.84
Rate for Payer: BCBS of TX Medicare	$15,176.84
Rate for Payer: Cigna Commercial	$18,306.34
Rate for Payer: Cigna Medicare	$15,176.84
Rate for Payer: Employer Direct Commercial	$15,176.84
Rate for Payer: Humana Medicare/TRICARE	$15,176.84
Rate for Payer: Molina Dual Medicare/Medicaid	$15,176.84
Rate for Payer: Molina Medicare	$15,176.84
Rate for Payer: Multiplan Auto	$27,382.80
Rate for Payer: Multiplan Commercial	$27,382.80
Rate for Payer: Multiplan Workers Comp	$27,382.80
Rate for Payer: Scott and White EPO/PPO	$12,610.50
Rate for Payer: Scott and White Medicare	$15,176.84
Rate for Payer: Superior Health Plan EPO	$15,176.84
Rate for Payer: Superior Health Plan Medicare	$15,176.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,176.84
Rate for Payer: Universal American Medicare	$15,176.84
Rate for Payer: Wellcare Medicare	$15,176.84
Rate for Payer: Wellmed Medicare	$15,176.84

Know your out-of-pocket cost for care.

All Charges