White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ALLOGRAFT AMNIOFIX 6X16 APS-5616

Facility

$20,671.69

Service Code	HCPCS C1762
Hospital Charge Code	120840
Hospital Revenue Code	278
Min. Negotiated Rate	$1,860.45
Max. Negotiated Rate	$10,335.84
Rate for Payer: Aetna Commercial	$6,201.51
Rate for Payer: Amerigroup CHIP/Medicaid	$1,860.45
Rate for Payer: BCBS of TX Blue Advantage	$6,201.51
Rate for Payer: BCBS of TX Blue Essentials	$7,441.81
Rate for Payer: BCBS of TX PPO	$8,268.68
Rate for Payer: Cash Price	$18,191.09
Rate for Payer: Multiplan Auto	$10,335.84
Rate for Payer: Multiplan Commercial	$10,335.84
Rate for Payer: Multiplan Workers Comp	$10,335.84
Rate for Payer: Scott and White EPO/PPO	$10,335.84
Rate for Payer: Superior Health Plan EPO	$2,811.35

ALLOGRAFT AMNIOFIX 6X16 APS-5616

Facility

$20,671.69

Service Code	HCPCS C1762
Hospital Charge Code	120840
Hospital Revenue Code	278
Min. Negotiated Rate	$5,167.92
Max. Negotiated Rate	$10,335.84
Rate for Payer: Aetna Commercial	$6,201.51
Rate for Payer: Cash Price	$18,191.09
Rate for Payer: Cigna Commercial	$5,167.92
Rate for Payer: Multiplan Auto	$10,335.84
Rate for Payer: Multiplan Commercial	$10,335.84
Rate for Payer: Multiplan Workers Comp	$10,335.84
Rate for Payer: Scott and White EPO/PPO	$10,335.84

ALLOGRAFT AMNIOFIX 6X4 AAS-5460

Facility

$10,846.39

Service Code	HCPCS C1762
Hospital Charge Code	120838
Hospital Revenue Code	278
Min. Negotiated Rate	$976.18
Max. Negotiated Rate	$5,423.20
Rate for Payer: Aetna Commercial	$3,253.92
Rate for Payer: Amerigroup CHIP/Medicaid	$976.18
Rate for Payer: BCBS of TX Blue Advantage	$3,253.92
Rate for Payer: BCBS of TX Blue Essentials	$3,904.70
Rate for Payer: BCBS of TX PPO	$4,338.56
Rate for Payer: Cash Price	$9,544.82
Rate for Payer: Multiplan Auto	$5,423.20
Rate for Payer: Multiplan Commercial	$5,423.20
Rate for Payer: Multiplan Workers Comp	$5,423.20
Rate for Payer: Scott and White EPO/PPO	$5,423.20
Rate for Payer: Superior Health Plan EPO	$1,475.11

ALLOGRAFT AMNIOFIX 6X4 AAS-5460

Facility

$10,846.39

Service Code	HCPCS C1762
Hospital Charge Code	120838
Hospital Revenue Code	278
Min. Negotiated Rate	$2,711.60
Max. Negotiated Rate	$5,423.20
Rate for Payer: Aetna Commercial	$3,253.92
Rate for Payer: Cash Price	$9,544.82
Rate for Payer: Cigna Commercial	$2,711.60
Rate for Payer: Multiplan Auto	$5,423.20
Rate for Payer: Multiplan Commercial	$5,423.20
Rate for Payer: Multiplan Workers Comp	$5,423.20
Rate for Payer: Scott and White EPO/PPO	$5,423.20

allograft amniotic tissue 4x4

Facility

$8,433.73

Service Code	HCPCS Q4170
Hospital Charge Code	8394479
Hospital Revenue Code	278
Min. Negotiated Rate	$759.04
Max. Negotiated Rate	$4,216.86
Rate for Payer: Aetna Commercial	$2,530.12
Rate for Payer: Amerigroup CHIP/Medicaid	$759.04
Rate for Payer: BCBS of TX Blue Advantage	$2,530.12
Rate for Payer: BCBS of TX Blue Essentials	$3,036.14
Rate for Payer: BCBS of TX PPO	$3,373.49
Rate for Payer: Cash Price	$7,421.68
Rate for Payer: Multiplan Auto	$4,216.86
Rate for Payer: Multiplan Commercial	$4,216.86
Rate for Payer: Multiplan Workers Comp	$4,216.86
Rate for Payer: Scott and White EPO/PPO	$4,216.86
Rate for Payer: Superior Health Plan EPO	$1,146.99

allograft amniotic tissue 4x4

Facility

$8,433.73

Service Code	HCPCS Q4170
Hospital Charge Code	8394479
Hospital Revenue Code	278
Min. Negotiated Rate	$2,108.43
Max. Negotiated Rate	$4,216.86
Rate for Payer: Aetna Commercial	$2,530.12
Rate for Payer: Cash Price	$7,421.68
Rate for Payer: Cigna Commercial	$2,108.43
Rate for Payer: Multiplan Auto	$4,216.86
Rate for Payer: Multiplan Commercial	$4,216.86
Rate for Payer: Multiplan Workers Comp	$4,216.86
Rate for Payer: Scott and White EPO/PPO	$4,216.86

ALLOGRAFT AMNIOTIC TISSUE 4X6

Facility

$13,253.01

Service Code	HCPCS Q4170
Hospital Charge Code	8394477
Hospital Revenue Code	278
Min. Negotiated Rate	$1,192.77
Max. Negotiated Rate	$6,626.50
Rate for Payer: Aetna Commercial	$3,975.90
Rate for Payer: Amerigroup CHIP/Medicaid	$1,192.77
Rate for Payer: BCBS of TX Blue Advantage	$3,975.90
Rate for Payer: BCBS of TX Blue Essentials	$4,771.08
Rate for Payer: BCBS of TX PPO	$5,301.20
Rate for Payer: Cash Price	$11,662.65
Rate for Payer: Multiplan Auto	$6,626.50
Rate for Payer: Multiplan Commercial	$6,626.50
Rate for Payer: Multiplan Workers Comp	$6,626.50
Rate for Payer: Scott and White EPO/PPO	$6,626.50
Rate for Payer: Superior Health Plan EPO	$1,802.41

ALLOGRAFT AMNIOTIC TISSUE 4X6

Facility

$13,253.01

Service Code	HCPCS Q4170
Hospital Charge Code	8394477
Hospital Revenue Code	278
Min. Negotiated Rate	$3,313.25
Max. Negotiated Rate	$6,626.50
Rate for Payer: Aetna Commercial	$3,975.90
Rate for Payer: Cash Price	$11,662.65
Rate for Payer: Cigna Commercial	$3,313.25
Rate for Payer: Multiplan Auto	$6,626.50
Rate for Payer: Multiplan Commercial	$6,626.50
Rate for Payer: Multiplan Workers Comp	$6,626.50
Rate for Payer: Scott and White EPO/PPO	$6,626.50

ALLOGRAFT ZAVATRIX VIABLE 10CC

Facility

$24,096.39

Service Code	HCPCS C9359
Hospital Charge Code	8720609
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$12,048.20
Rate for Payer: Aetna Commercial	$7,228.92
Rate for Payer: Amerigroup CHIP/Medicaid	$2,168.68
Rate for Payer: BCBS of TX Blue Advantage	$7,228.92
Rate for Payer: BCBS of TX Blue Essentials	$8,674.70
Rate for Payer: BCBS of TX PPO	$9,638.56
Rate for Payer: Cash Price	$21,204.82
Rate for Payer: Cash Price	$21,204.82
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$12,048.20
Rate for Payer: Multiplan Commercial	$12,048.20
Rate for Payer: Multiplan Workers Comp	$12,048.20
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$12,048.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$3,277.11

ALLOGRAFT ZAVATRIX VIABLE 10CC

Facility

$24,096.39

Service Code	HCPCS C9359
Hospital Charge Code	8720609
Hospital Revenue Code	278
Min. Negotiated Rate	$6,024.10
Max. Negotiated Rate	$12,048.20
Rate for Payer: Aetna Commercial	$7,228.92
Rate for Payer: Cash Price	$21,204.82
Rate for Payer: Cigna Commercial	$6,024.10
Rate for Payer: Multiplan Auto	$12,048.20
Rate for Payer: Multiplan Commercial	$12,048.20
Rate for Payer: Multiplan Workers Comp	$12,048.20
Rate for Payer: Scott and White EPO/PPO	$12,048.20

ALLOGRAFT ZAVATRIX VIABLE 15CC

Facility

$34,837.35

Service Code	HCPCS C9359
Hospital Charge Code	8720608
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$17,418.68
Rate for Payer: Aetna Commercial	$10,451.20
Rate for Payer: Amerigroup CHIP/Medicaid	$3,135.36
Rate for Payer: BCBS of TX Blue Advantage	$10,451.20
Rate for Payer: BCBS of TX Blue Essentials	$12,541.45
Rate for Payer: BCBS of TX PPO	$13,934.94
Rate for Payer: Cash Price	$30,656.87
Rate for Payer: Cash Price	$30,656.87
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$17,418.68
Rate for Payer: Multiplan Commercial	$17,418.68
Rate for Payer: Multiplan Workers Comp	$17,418.68
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$17,418.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$4,737.88

ALLOGRAFT ZAVATRIX VIABLE 15CC

Facility

$34,837.35

Service Code	HCPCS C9359
Hospital Charge Code	8720608
Hospital Revenue Code	278
Min. Negotiated Rate	$8,709.34
Max. Negotiated Rate	$17,418.68
Rate for Payer: Aetna Commercial	$10,451.20
Rate for Payer: Cash Price	$30,656.87
Rate for Payer: Cigna Commercial	$8,709.34
Rate for Payer: Multiplan Auto	$17,418.68
Rate for Payer: Multiplan Commercial	$17,418.68
Rate for Payer: Multiplan Workers Comp	$17,418.68
Rate for Payer: Scott and White EPO/PPO	$17,418.68

allograft zavatrix viable 1cc

Facility

$2,909.64

Service Code	HCPCS C9359
Hospital Charge Code	8708542
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$1,454.82
Rate for Payer: Aetna Commercial	$872.89
Rate for Payer: Amerigroup CHIP/Medicaid	$261.87
Rate for Payer: BCBS of TX Blue Advantage	$872.89
Rate for Payer: BCBS of TX Blue Essentials	$1,047.47
Rate for Payer: BCBS of TX PPO	$1,163.86
Rate for Payer: Cash Price	$2,560.48
Rate for Payer: Cash Price	$2,560.48
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$1,454.82
Rate for Payer: Multiplan Commercial	$1,454.82
Rate for Payer: Multiplan Workers Comp	$1,454.82
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$1,454.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$395.71

allograft zavatrix viable 1cc

Facility

$2,909.64

Service Code	HCPCS C9359
Hospital Charge Code	8708542
Hospital Revenue Code	278
Min. Negotiated Rate	$727.41
Max. Negotiated Rate	$1,454.82
Rate for Payer: Aetna Commercial	$872.89
Rate for Payer: Cash Price	$2,560.48
Rate for Payer: Cigna Commercial	$727.41
Rate for Payer: Multiplan Auto	$1,454.82
Rate for Payer: Multiplan Commercial	$1,454.82
Rate for Payer: Multiplan Workers Comp	$1,454.82
Rate for Payer: Scott and White EPO/PPO	$1,454.82

allograft zavatrix viable 2cc

Facility

$5,722.89

Service Code	HCPCS C9359
Hospital Charge Code	8708543
Hospital Revenue Code	278
Min. Negotiated Rate	$1,430.72
Max. Negotiated Rate	$2,861.44
Rate for Payer: Aetna Commercial	$1,716.87
Rate for Payer: Cash Price	$5,036.14
Rate for Payer: Cigna Commercial	$1,430.72
Rate for Payer: Multiplan Auto	$2,861.44
Rate for Payer: Multiplan Commercial	$2,861.44
Rate for Payer: Multiplan Workers Comp	$2,861.44
Rate for Payer: Scott and White EPO/PPO	$2,861.44

allograft zavatrix viable 2cc

Facility

$5,722.89

Service Code	HCPCS C9359
Hospital Charge Code	8708543
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$2,861.44
Rate for Payer: Aetna Commercial	$1,716.87
Rate for Payer: Amerigroup CHIP/Medicaid	$515.06
Rate for Payer: BCBS of TX Blue Advantage	$1,716.87
Rate for Payer: BCBS of TX Blue Essentials	$2,060.24
Rate for Payer: BCBS of TX PPO	$2,289.16
Rate for Payer: Cash Price	$5,036.14
Rate for Payer: Cash Price	$5,036.14
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$2,861.44
Rate for Payer: Multiplan Commercial	$2,861.44
Rate for Payer: Multiplan Workers Comp	$2,861.44
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$2,861.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$778.31

allograft zavatrix viable 5cc

Facility

$13,554.22

Service Code	HCPCS C9359
Hospital Charge Code	8708548
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$6,777.11
Rate for Payer: Aetna Commercial	$4,066.27
Rate for Payer: Amerigroup CHIP/Medicaid	$1,219.88
Rate for Payer: BCBS of TX Blue Advantage	$4,066.27
Rate for Payer: BCBS of TX Blue Essentials	$4,879.52
Rate for Payer: BCBS of TX PPO	$5,421.69
Rate for Payer: Cash Price	$11,927.71
Rate for Payer: Cash Price	$11,927.71
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$6,777.11
Rate for Payer: Multiplan Commercial	$6,777.11
Rate for Payer: Multiplan Workers Comp	$6,777.11
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$6,777.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$1,843.37

allograft zavatrix viable 5cc

Facility

$13,554.22

Service Code	HCPCS C9359
Hospital Charge Code	8708548
Hospital Revenue Code	278
Min. Negotiated Rate	$3,388.56
Max. Negotiated Rate	$6,777.11
Rate for Payer: Aetna Commercial	$4,066.27
Rate for Payer: Cash Price	$11,927.71
Rate for Payer: Cigna Commercial	$3,388.56
Rate for Payer: Multiplan Auto	$6,777.11
Rate for Payer: Multiplan Commercial	$6,777.11
Rate for Payer: Multiplan Workers Comp	$6,777.11
Rate for Payer: Scott and White EPO/PPO	$6,777.11

alogliptin 12.5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	9199037
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
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: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

alogliptin 12.5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	9199037
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Alpha-1-Antitrypsin, Serum SO

Facility

$134.00

Service Code	CPT 82103
Hospital Charge Code	1701176
Hospital Revenue Code	301
Rate for Payer: Cash Price	$117.92

Alpha-1-Antitrypsin, Serum SO

Facility

$134.00

Service Code	CPT 82103
Hospital Charge Code	1701176
Hospital Revenue Code	301
Min. Negotiated Rate	$5.24
Max. Negotiated Rate	$87.10
Rate for Payer: Aetna Commercial	$14.10
Rate for Payer: Aetna Medicare	$20.16
Rate for Payer: Amerigroup CHIP/Medicaid	$5.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.44
Rate for Payer: Amerigroup Medicare	$13.44
Rate for Payer: BCBS of TX Blue Advantage	$22.18
Rate for Payer: BCBS of TX Blue Essentials	$26.61
Rate for Payer: BCBS of TX Medicare	$13.44
Rate for Payer: BCBS of TX PPO	$29.70
Rate for Payer: Cash Price	$117.92
Rate for Payer: Cash Price	$117.92
Rate for Payer: Cigna Medicaid	$13.44
Rate for Payer: Cigna Medicare	$13.44
Rate for Payer: Employer Direct Commercial	$13.44
Rate for Payer: Humana Medicare/TRICARE	$13.44
Rate for Payer: Molina CHIP/Medicaid	$13.44
Rate for Payer: Molina Dual Medicare/Medicaid	$13.44
Rate for Payer: Molina Medicare	$13.44
Rate for Payer: Multiplan Auto	$87.10
Rate for Payer: Multiplan Commercial	$87.10
Rate for Payer: Multiplan Workers Comp	$87.10
Rate for Payer: Parkland Medicaid	$13.44
Rate for Payer: Scott and White EPO/PPO	$16.80
Rate for Payer: Scott and White Medicare	$13.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.44
Rate for Payer: Superior Health Plan EPO	$13.44
Rate for Payer: Superior Health Plan Medicare	$13.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.44
Rate for Payer: Universal American Medicare	$13.44
Rate for Payer: Wellcare Medicare	$13.44
Rate for Payer: Wellmed Medicare	$13.44

ALPHA-FETOPROTEIN SERUM

Facility

$243.00

Service Code	CPT 82105
Hospital Charge Code	1603075
Hospital Revenue Code	301
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$157.95
Rate for Payer: Aetna Commercial	$17.60
Rate for Payer: Aetna Medicare	$25.16
Rate for Payer: Amerigroup CHIP/Medicaid	$6.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.77
Rate for Payer: Amerigroup Medicare	$16.77
Rate for Payer: BCBS of TX Blue Advantage	$27.67
Rate for Payer: BCBS of TX Blue Essentials	$33.20
Rate for Payer: BCBS of TX Medicare	$16.77
Rate for Payer: BCBS of TX PPO	$37.06
Rate for Payer: Cash Price	$213.84
Rate for Payer: Cash Price	$213.84
Rate for Payer: Cigna Medicaid	$16.77
Rate for Payer: Cigna Medicare	$16.77
Rate for Payer: Employer Direct Commercial	$16.77
Rate for Payer: Humana Medicare/TRICARE	$16.77
Rate for Payer: Molina CHIP/Medicaid	$16.77
Rate for Payer: Molina Dual Medicare/Medicaid	$16.77
Rate for Payer: Molina Medicare	$16.77
Rate for Payer: Multiplan Auto	$157.95
Rate for Payer: Multiplan Commercial	$157.95
Rate for Payer: Multiplan Workers Comp	$157.95
Rate for Payer: Parkland Medicaid	$16.77
Rate for Payer: Scott and White EPO/PPO	$20.96
Rate for Payer: Scott and White Medicare	$16.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.77
Rate for Payer: Superior Health Plan EPO	$16.77
Rate for Payer: Superior Health Plan Medicare	$16.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.77
Rate for Payer: Universal American Medicare	$16.77
Rate for Payer: Wellcare Medicare	$16.77
Rate for Payer: Wellmed Medicare	$16.77

ALPRAZolam 0.25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77365028
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

ALPRAZolam 0.25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77365028
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Know your out-of-pocket cost for care.

All Charges