White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ALPRAZolam 0.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77365183
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 0.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77365183
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ALPRAZolam 1 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77365338
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ALPRAZolam 1 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77365338
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 (Xanax) SO

Facility

$312.00

Service Code	CPT 80346
Hospital Charge Code	1743001
Hospital Revenue Code	301
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$202.80
Rate for Payer: Aetna Commercial	$0.02
Rate for Payer: Amerigroup CHIP/Medicaid	$6.28
Rate for Payer: Cash Price	$274.56
Rate for Payer: Cash Price	$274.56
Rate for Payer: Cigna Medicaid	$16.11
Rate for Payer: Molina CHIP/Medicaid	$16.11
Rate for Payer: Multiplan Auto	$202.80
Rate for Payer: Multiplan Commercial	$202.80
Rate for Payer: Multiplan Workers Comp	$202.80
Rate for Payer: Parkland Medicaid	$16.11
Rate for Payer: Scott and White EPO/PPO	$156.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.11
Rate for Payer: Superior Health Plan EPO	$42.43

Alprazolam (Xanax) SO

Facility

$312.00

Service Code	CPT 80346
Hospital Charge Code	1743001
Hospital Revenue Code	301
Rate for Payer: Cash Price	$274.56

alteplase 2 mg Inj

Facility

$379.60

Service Code	HCPCS J2997
Hospital Charge Code	77366310
Hospital Revenue Code	636
Min. Negotiated Rate	$94.90
Max. Negotiated Rate	$189.80
Rate for Payer: Cash Price	$258.13
Rate for Payer: Cigna Commercial	$94.90
Rate for Payer: Scott and White EPO/PPO	$189.80

alteplase 2 mg Inj

Facility

$379.60

Service Code	HCPCS J2997
Hospital Charge Code	77366310
Hospital Revenue Code	636
Min. Negotiated Rate	$34.16
Max. Negotiated Rate	$246.74
Rate for Payer: Aetna Medicare	$133.46
Rate for Payer: Amerigroup CHIP/Medicaid	$34.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$88.97
Rate for Payer: Amerigroup Medicare	$88.97
Rate for Payer: BCBS of TX Blue Advantage	$54.59
Rate for Payer: BCBS of TX Blue Essentials	$65.51
Rate for Payer: BCBS of TX Medicare	$88.97
Rate for Payer: BCBS of TX PPO	$72.66
Rate for Payer: Cash Price	$258.13
Rate for Payer: Cash Price	$258.13
Rate for Payer: Cigna Medicare	$88.97
Rate for Payer: Employer Direct Commercial	$88.97
Rate for Payer: Humana Medicare/TRICARE	$88.97
Rate for Payer: Molina Dual Medicare/Medicaid	$88.97
Rate for Payer: Molina Medicare	$88.97
Rate for Payer: Multiplan Auto	$246.74
Rate for Payer: Multiplan Commercial	$246.74
Rate for Payer: Multiplan Workers Comp	$246.74
Rate for Payer: Scott and White EPO/PPO	$189.80
Rate for Payer: Scott and White Medicare	$88.97
Rate for Payer: Superior Health Plan EPO	$88.97
Rate for Payer: Superior Health Plan Medicare	$88.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$88.97
Rate for Payer: Universal American Medicare	$88.97
Rate for Payer: Wellcare Medicare	$88.97
Rate for Payer: Wellmed Medicare	$88.97

aluminum hydroxide/magnesium hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL Oral Susp 30 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77367101
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

aluminum hydroxide/magnesium hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL Oral Susp 30 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77367101
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

amantadine 50 mg/5 mL Oral Syrup 10 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77368481
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

amantadine 50 mg/5 mL Oral Syrup 10 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77368481
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

Amebiasis Antibodies SO

Facility

$86.00

Service Code	CPT 86753
Hospital Charge Code	1702935
Hospital Revenue Code	302
Rate for Payer: Cash Price	$75.68

Amebiasis Antibodies SO

Facility

$86.00

Service Code	CPT 86753
Hospital Charge Code	1702935
Hospital Revenue Code	302
Min. Negotiated Rate	$4.83
Max. Negotiated Rate	$55.90
Rate for Payer: Aetna Commercial	$13.00
Rate for Payer: Aetna Medicare	$18.58
Rate for Payer: Amerigroup CHIP/Medicaid	$4.83
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.39
Rate for Payer: Amerigroup Medicare	$12.39
Rate for Payer: BCBS of TX Blue Advantage	$20.44
Rate for Payer: BCBS of TX Blue Essentials	$24.53
Rate for Payer: BCBS of TX Medicare	$12.39
Rate for Payer: BCBS of TX PPO	$27.38
Rate for Payer: Cash Price	$75.68
Rate for Payer: Cash Price	$75.68
Rate for Payer: Cigna Medicaid	$12.39
Rate for Payer: Cigna Medicare	$12.39
Rate for Payer: Employer Direct Commercial	$12.39
Rate for Payer: Humana Medicare/TRICARE	$12.39
Rate for Payer: Molina CHIP/Medicaid	$12.39
Rate for Payer: Molina Dual Medicare/Medicaid	$12.39
Rate for Payer: Molina Medicare	$12.39
Rate for Payer: Multiplan Auto	$55.90
Rate for Payer: Multiplan Commercial	$55.90
Rate for Payer: Multiplan Workers Comp	$55.90
Rate for Payer: Parkland Medicaid	$12.39
Rate for Payer: Scott and White EPO/PPO	$15.49
Rate for Payer: Scott and White Medicare	$12.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.39
Rate for Payer: Superior Health Plan EPO	$12.39
Rate for Payer: Superior Health Plan Medicare	$12.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.39
Rate for Payer: Universal American Medicare	$12.39
Rate for Payer: Wellcare Medicare	$12.39
Rate for Payer: Wellmed Medicare	$12.39

Amikacin Peak, Serum SO

Facility

$198.00

Service Code	CPT 80150
Hospital Charge Code	1601442
Hospital Revenue Code	300
Min. Negotiated Rate	$5.88
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna Commercial	$15.84
Rate for Payer: Aetna Medicare	$22.62
Rate for Payer: Amerigroup CHIP/Medicaid	$5.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.08
Rate for Payer: Amerigroup Medicare	$15.08
Rate for Payer: BCBS of TX Blue Advantage	$24.88
Rate for Payer: BCBS of TX Blue Essentials	$29.86
Rate for Payer: BCBS of TX Medicare	$15.08
Rate for Payer: BCBS of TX PPO	$33.33
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cigna Medicaid	$15.08
Rate for Payer: Cigna Medicare	$15.08
Rate for Payer: Employer Direct Commercial	$15.08
Rate for Payer: Humana Medicare/TRICARE	$15.08
Rate for Payer: Molina CHIP/Medicaid	$15.08
Rate for Payer: Molina Dual Medicare/Medicaid	$15.08
Rate for Payer: Molina Medicare	$15.08
Rate for Payer: Multiplan Auto	$128.70
Rate for Payer: Multiplan Commercial	$128.70
Rate for Payer: Multiplan Workers Comp	$128.70
Rate for Payer: Parkland Medicaid	$15.08
Rate for Payer: Scott and White EPO/PPO	$18.85
Rate for Payer: Scott and White Medicare	$15.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.08
Rate for Payer: Superior Health Plan EPO	$15.08
Rate for Payer: Superior Health Plan Medicare	$15.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.08
Rate for Payer: Universal American Medicare	$15.08
Rate for Payer: Wellcare Medicare	$15.08
Rate for Payer: Wellmed Medicare	$15.08

Amikacin Random, Serum SO

Facility

$198.00

Service Code	CPT 80150
Hospital Charge Code	1601442
Hospital Revenue Code	300
Min. Negotiated Rate	$5.88
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna Commercial	$15.84
Rate for Payer: Aetna Medicare	$22.62
Rate for Payer: Amerigroup CHIP/Medicaid	$5.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.08
Rate for Payer: Amerigroup Medicare	$15.08
Rate for Payer: BCBS of TX Blue Advantage	$24.88
Rate for Payer: BCBS of TX Blue Essentials	$29.86
Rate for Payer: BCBS of TX Medicare	$15.08
Rate for Payer: BCBS of TX PPO	$33.33
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cigna Medicaid	$15.08
Rate for Payer: Cigna Medicare	$15.08
Rate for Payer: Employer Direct Commercial	$15.08
Rate for Payer: Humana Medicare/TRICARE	$15.08
Rate for Payer: Molina CHIP/Medicaid	$15.08
Rate for Payer: Molina Dual Medicare/Medicaid	$15.08
Rate for Payer: Molina Medicare	$15.08
Rate for Payer: Multiplan Auto	$128.70
Rate for Payer: Multiplan Commercial	$128.70
Rate for Payer: Multiplan Workers Comp	$128.70
Rate for Payer: Parkland Medicaid	$15.08
Rate for Payer: Scott and White EPO/PPO	$18.85
Rate for Payer: Scott and White Medicare	$15.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.08
Rate for Payer: Superior Health Plan EPO	$15.08
Rate for Payer: Superior Health Plan Medicare	$15.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.08
Rate for Payer: Universal American Medicare	$15.08
Rate for Payer: Wellcare Medicare	$15.08
Rate for Payer: Wellmed Medicare	$15.08

Amikacin Trough, Serum SO

Facility

$198.00

Service Code	CPT 80150
Hospital Charge Code	1601442
Hospital Revenue Code	300
Min. Negotiated Rate	$5.88
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna Commercial	$15.84
Rate for Payer: Aetna Medicare	$22.62
Rate for Payer: Amerigroup CHIP/Medicaid	$5.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.08
Rate for Payer: Amerigroup Medicare	$15.08
Rate for Payer: BCBS of TX Blue Advantage	$24.88
Rate for Payer: BCBS of TX Blue Essentials	$29.86
Rate for Payer: BCBS of TX Medicare	$15.08
Rate for Payer: BCBS of TX PPO	$33.33
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cigna Medicaid	$15.08
Rate for Payer: Cigna Medicare	$15.08
Rate for Payer: Employer Direct Commercial	$15.08
Rate for Payer: Humana Medicare/TRICARE	$15.08
Rate for Payer: Molina CHIP/Medicaid	$15.08
Rate for Payer: Molina Dual Medicare/Medicaid	$15.08
Rate for Payer: Molina Medicare	$15.08
Rate for Payer: Multiplan Auto	$128.70
Rate for Payer: Multiplan Commercial	$128.70
Rate for Payer: Multiplan Workers Comp	$128.70
Rate for Payer: Parkland Medicaid	$15.08
Rate for Payer: Scott and White EPO/PPO	$18.85
Rate for Payer: Scott and White Medicare	$15.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.08
Rate for Payer: Superior Health Plan EPO	$15.08
Rate for Payer: Superior Health Plan Medicare	$15.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.08
Rate for Payer: Universal American Medicare	$15.08
Rate for Payer: Wellcare Medicare	$15.08
Rate for Payer: Wellmed Medicare	$15.08

Amikacin Trough, Serum SO

Facility

$198.00

Service Code	CPT 80150
Hospital Charge Code	1601442
Hospital Revenue Code	300
Rate for Payer: Cash Price	$174.24

Amino Acids 4.25% with 5% Dextrose (Clinimix Sulfite-Free) intravenous solution Amino Acids 4.25% wi

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	8694541
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
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: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

Amino Acids 4.25% with 5% Dextrose (Clinimix Sulfite-Free) intravenous solution Amino Acids 4.25% wi

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	8694541
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

AMINO ACIDS SGL QUANT EA SPECIMEN

Facility

$245.00

Service Code	CPT 82131
Hospital Charge Code	1705995
Hospital Revenue Code	301
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$159.25
Rate for Payer: Aetna Commercial	$24.13
Rate for Payer: Aetna Medicare	$34.47
Rate for Payer: Amerigroup CHIP/Medicaid	$8.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22.98
Rate for Payer: Amerigroup Medicare	$22.98
Rate for Payer: BCBS of TX Blue Advantage	$37.92
Rate for Payer: BCBS of TX Blue Essentials	$45.50
Rate for Payer: BCBS of TX Medicare	$22.98
Rate for Payer: BCBS of TX PPO	$50.79
Rate for Payer: Cash Price	$215.60
Rate for Payer: Cash Price	$215.60
Rate for Payer: Cigna Medicaid	$22.98
Rate for Payer: Cigna Medicare	$22.98
Rate for Payer: Employer Direct Commercial	$22.98
Rate for Payer: Humana Medicare/TRICARE	$22.98
Rate for Payer: Molina CHIP/Medicaid	$22.98
Rate for Payer: Molina Dual Medicare/Medicaid	$22.98
Rate for Payer: Molina Medicare	$22.98
Rate for Payer: Multiplan Auto	$159.25
Rate for Payer: Multiplan Commercial	$159.25
Rate for Payer: Multiplan Workers Comp	$159.25
Rate for Payer: Parkland Medicaid	$22.98
Rate for Payer: Scott and White EPO/PPO	$28.72
Rate for Payer: Scott and White Medicare	$22.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.98
Rate for Payer: Superior Health Plan EPO	$22.98
Rate for Payer: Superior Health Plan Medicare	$22.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$22.98
Rate for Payer: Universal American Medicare	$22.98
Rate for Payer: Wellcare Medicare	$22.98
Rate for Payer: Wellmed Medicare	$22.98

AMINO ACIDS SGL QUANT EA SPECIMEN

Facility

$245.00

Service Code	CPT 82131
Hospital Charge Code	1705995
Hospital Revenue Code	301
Rate for Payer: Cash Price	$215.60

amiodarone 200 mg Tab

Facility

$14.45

Service Code	HCPCS J3490
Hospital Charge Code	77369932
Hospital Revenue Code	250
Rate for Payer: Cash Price	$9.83

amiodarone 200 mg Tab

Facility

$14.45

Service Code	HCPCS J3490
Hospital Charge Code	77369932
Hospital Revenue Code	250
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$9.39
Rate for Payer: Amerigroup CHIP/Medicaid	$1.30
Rate for Payer: BCBS of TX Blue Advantage	$4.34
Rate for Payer: BCBS of TX Blue Essentials	$5.20
Rate for Payer: BCBS of TX PPO	$5.78
Rate for Payer: Cash Price	$9.83
Rate for Payer: Multiplan Auto	$9.39
Rate for Payer: Multiplan Commercial	$9.39
Rate for Payer: Multiplan Workers Comp	$9.39
Rate for Payer: Scott and White EPO/PPO	$7.22
Rate for Payer: Superior Health Plan EPO	$1.97

amiodarone 50 mg/mL IV Soln 3 mL

Facility

$128.17

Service Code	HCPCS J0282
Hospital Charge Code	77370199
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.29
Rate for Payer: BCBS of TX Blue Essentials	$0.35
Rate for Payer: BCBS of TX PPO	$0.39
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

Know your out-of-pocket cost for care.

All Charges