White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ciprofloxacin 200 mg/D5W 100 mL

Facility

$128.17

Service Code	HCPCS J0744
Hospital Charge Code	77469251
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

ciprofloxacin 200 mg/D5W 100 mL

Facility

$128.17

Service Code	HCPCS J0744
Hospital Charge Code	77469251
Hospital Revenue Code	636
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.28
Rate for Payer: BCBS of TX Blue Essentials	$2.73
Rate for Payer: BCBS of TX PPO	$3.03
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

ciprofloxacin 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77469147
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

ciprofloxacin 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77469147
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

ciprofloxacin 400 mg/D5W 200 mL

Facility

$128.17

Service Code	HCPCS J0744
Hospital Charge Code	77469088
Hospital Revenue Code	636
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.28
Rate for Payer: BCBS of TX Blue Essentials	$2.73
Rate for Payer: BCBS of TX PPO	$3.03
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

ciprofloxacin 400 mg/D5W 200 mL

Facility

$128.17

Service Code	HCPCS J0744
Hospital Charge Code	77469088
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

ciprofloxacin 500 mg Tab

Facility

$13.80

Service Code	HCPCS J3490
Hospital Charge Code	77469363
Hospital Revenue Code	250
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$9.94
Rate for Payer: Amerigroup CHIP/Medicaid	$1.24
Rate for Payer: BCBS of TX Blue Advantage	$4.14
Rate for Payer: BCBS of TX Blue Essentials	$4.97
Rate for Payer: BCBS of TX PPO	$5.52
Rate for Payer: Cash Price	$9.38
Rate for Payer: Cigna Medicaid	$9.94
Rate for Payer: Molina CHIP/Medicaid	$9.94
Rate for Payer: Multiplan Auto	$8.97
Rate for Payer: Multiplan Commercial	$8.97
Rate for Payer: Multiplan Workers Comp	$8.97
Rate for Payer: Parkland Medicaid	$9.94
Rate for Payer: Scott and White EPO/PPO	$6.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.94
Rate for Payer: Superior Health Plan EPO	$1.88

ciprofloxacin 500 mg Tab

Facility

$13.80

Service Code	HCPCS J3490
Hospital Charge Code	77469363
Hospital Revenue Code	250
Rate for Payer: Cash Price	$9.38

CIRC BREATH ANES -- DHF

Facility

$36.37

Hospital Charge Code	81711251
Hospital Revenue Code	271
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$26.19
Rate for Payer: Amerigroup CHIP/Medicaid	$3.27
Rate for Payer: BCBS of TX Blue Advantage	$10.91
Rate for Payer: BCBS of TX Blue Essentials	$13.09
Rate for Payer: BCBS of TX PPO	$14.55
Rate for Payer: Cash Price	$24.73
Rate for Payer: Cigna Medicaid	$26.19
Rate for Payer: Molina CHIP/Medicaid	$26.19
Rate for Payer: Multiplan Auto	$23.64
Rate for Payer: Multiplan Commercial	$23.64
Rate for Payer: Multiplan Workers Comp	$23.64
Rate for Payer: Parkland Medicaid	$26.19
Rate for Payer: Scott and White EPO/PPO	$18.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.19
Rate for Payer: Superior Health Plan EPO	$4.95

CIRC BREATH ANES -- DHF

Facility

$36.37

Hospital Charge Code	81711251
Hospital Revenue Code	271
Rate for Payer: Cash Price	$24.73

CIRCUIT, ADLT, EVAQUA 2, DUAL HTD BREAT

Facility

$143.21

Hospital Charge Code	993827
Hospital Revenue Code	279
Min. Negotiated Rate	$12.89
Max. Negotiated Rate	$103.11
Rate for Payer: Amerigroup CHIP/Medicaid	$12.89
Rate for Payer: BCBS of TX Blue Advantage	$42.96
Rate for Payer: BCBS of TX Blue Essentials	$51.56
Rate for Payer: BCBS of TX PPO	$57.28
Rate for Payer: Cash Price	$97.38
Rate for Payer: Cigna Medicaid	$103.11
Rate for Payer: Molina CHIP/Medicaid	$103.11
Rate for Payer: Multiplan Auto	$93.09
Rate for Payer: Multiplan Commercial	$93.09
Rate for Payer: Multiplan Workers Comp	$93.09
Rate for Payer: Parkland Medicaid	$103.11
Rate for Payer: Scott and White EPO/PPO	$71.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$103.11
Rate for Payer: Superior Health Plan EPO	$19.48

CIRCUIT, ADLT, EVAQUA 2, DUAL HTD BREAT

Facility

$143.21

Hospital Charge Code	993827
Hospital Revenue Code	279
Rate for Payer: Cash Price	$97.38

CIRCUIT BREATHING COAX 180 VENTSTAR

Facility

$25.79

Hospital Charge Code	993518
Hospital Revenue Code	270
Rate for Payer: Cash Price	$17.54

CIRCUIT BREATHING COAX 180 VENTSTAR

Facility

$25.79

Hospital Charge Code	993518
Hospital Revenue Code	270
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$18.57
Rate for Payer: Amerigroup CHIP/Medicaid	$2.32
Rate for Payer: BCBS of TX Blue Advantage	$7.74
Rate for Payer: BCBS of TX Blue Essentials	$9.28
Rate for Payer: BCBS of TX PPO	$10.32
Rate for Payer: Cash Price	$17.54
Rate for Payer: Cigna Medicaid	$18.57
Rate for Payer: Molina CHIP/Medicaid	$18.57
Rate for Payer: Multiplan Auto	$16.76
Rate for Payer: Multiplan Commercial	$16.76
Rate for Payer: Multiplan Workers Comp	$16.76
Rate for Payer: Parkland Medicaid	$18.57
Rate for Payer: Scott and White EPO/PPO	$12.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.57
Rate for Payer: Superior Health Plan EPO	$3.51

CIRCUIT, F2, 70 IN, FILTER, LF, BAG

Facility

$19.75

Hospital Charge Code	992973
Hospital Revenue Code	270
Rate for Payer: Cash Price	$13.43

CIRCUIT, F2, 70 IN, FILTER, LF, BAG

Facility

$19.75

Hospital Charge Code	992973
Hospital Revenue Code	270
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$14.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1.78
Rate for Payer: BCBS of TX Blue Advantage	$5.92
Rate for Payer: BCBS of TX Blue Essentials	$7.11
Rate for Payer: BCBS of TX PPO	$7.90
Rate for Payer: Cash Price	$13.43
Rate for Payer: Cigna Medicaid	$14.22
Rate for Payer: Molina CHIP/Medicaid	$14.22
Rate for Payer: Multiplan Auto	$12.84
Rate for Payer: Multiplan Commercial	$12.84
Rate for Payer: Multiplan Workers Comp	$12.84
Rate for Payer: Parkland Medicaid	$14.22
Rate for Payer: Scott and White EPO/PPO	$9.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.22
Rate for Payer: Superior Health Plan EPO	$2.69

CIRCUIT, KIT VENT ADULT CONCERA SMART

Facility

$8.54

Hospital Charge Code	993287
Hospital Revenue Code	270
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$6.15
Rate for Payer: Amerigroup CHIP/Medicaid	$0.77
Rate for Payer: BCBS of TX Blue Advantage	$2.56
Rate for Payer: BCBS of TX Blue Essentials	$3.07
Rate for Payer: BCBS of TX PPO	$3.42
Rate for Payer: Cash Price	$5.81
Rate for Payer: Cigna Medicaid	$6.15
Rate for Payer: Molina CHIP/Medicaid	$6.15
Rate for Payer: Multiplan Auto	$5.55
Rate for Payer: Multiplan Commercial	$5.55
Rate for Payer: Multiplan Workers Comp	$5.55
Rate for Payer: Parkland Medicaid	$6.15
Rate for Payer: Scott and White EPO/PPO	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.15
Rate for Payer: Superior Health Plan EPO	$1.16

CIRCUIT, KIT VENT ADULT CONCERA SMART

Facility

$8.54

Hospital Charge Code	993287
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.81

CIRCUIT, NEONATAL HEATED VENT REMOTE DUAL LINE 18'

Facility

$68.10

Hospital Charge Code	993620
Hospital Revenue Code	270
Min. Negotiated Rate	$6.13
Max. Negotiated Rate	$49.03
Rate for Payer: Amerigroup CHIP/Medicaid	$6.13
Rate for Payer: BCBS of TX Blue Advantage	$20.43
Rate for Payer: BCBS of TX Blue Essentials	$24.52
Rate for Payer: BCBS of TX PPO	$27.24
Rate for Payer: Cash Price	$46.31
Rate for Payer: Cigna Medicaid	$49.03
Rate for Payer: Molina CHIP/Medicaid	$49.03
Rate for Payer: Multiplan Auto	$44.27
Rate for Payer: Multiplan Commercial	$44.27
Rate for Payer: Multiplan Workers Comp	$44.27
Rate for Payer: Parkland Medicaid	$49.03
Rate for Payer: Scott and White EPO/PPO	$34.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.03
Rate for Payer: Superior Health Plan EPO	$9.26

CIRCUIT, NEONATAL HEATED VENT REMOTE DUAL LINE 18'

Facility

$68.10

Hospital Charge Code	993620
Hospital Revenue Code	270
Rate for Payer: Cash Price	$46.31

CIRCUIT, PATIENT PARAPAC W/PEEP VALVE DISP

Facility

$29.81

Hospital Charge Code	993611
Hospital Revenue Code	270
Rate for Payer: Cash Price	$20.27

CIRCUIT, PATIENT PARAPAC W/PEEP VALVE DISP

Facility

$29.81

Hospital Charge Code	993611
Hospital Revenue Code	270
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$21.46
Rate for Payer: Amerigroup CHIP/Medicaid	$2.68
Rate for Payer: BCBS of TX Blue Advantage	$8.94
Rate for Payer: BCBS of TX Blue Essentials	$10.73
Rate for Payer: BCBS of TX PPO	$11.92
Rate for Payer: Cash Price	$20.27
Rate for Payer: Cigna Medicaid	$21.46
Rate for Payer: Molina CHIP/Medicaid	$21.46
Rate for Payer: Multiplan Auto	$19.38
Rate for Payer: Multiplan Commercial	$19.38
Rate for Payer: Multiplan Workers Comp	$19.38
Rate for Payer: Parkland Medicaid	$21.46
Rate for Payer: Scott and White EPO/PPO	$14.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.46
Rate for Payer: Superior Health Plan EPO	$4.05

CIRCUIT, UNHTD, SL, NIV, UNIV, 72'

Facility

$33.41

Hospital Charge Code	993312
Hospital Revenue Code	270
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$24.06
Rate for Payer: Amerigroup CHIP/Medicaid	$3.01
Rate for Payer: BCBS of TX Blue Advantage	$10.02
Rate for Payer: BCBS of TX Blue Essentials	$12.03
Rate for Payer: BCBS of TX PPO	$13.36
Rate for Payer: Cash Price	$22.72
Rate for Payer: Cigna Medicaid	$24.06
Rate for Payer: Molina CHIP/Medicaid	$24.06
Rate for Payer: Multiplan Auto	$21.72
Rate for Payer: Multiplan Commercial	$21.72
Rate for Payer: Multiplan Workers Comp	$21.72
Rate for Payer: Parkland Medicaid	$24.06
Rate for Payer: Scott and White EPO/PPO	$16.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.06
Rate for Payer: Superior Health Plan EPO	$4.54

CIRCUIT, UNHTD, SL, NIV, UNIV, 72'

Facility

$33.41

Hospital Charge Code	993312
Hospital Revenue Code	270
Rate for Payer: Cash Price	$22.72

CIRCUIT VENT ADLT W/O PEEP DISP

Facility

$65.90

Hospital Charge Code	993615
Hospital Revenue Code	270
Min. Negotiated Rate	$5.93
Max. Negotiated Rate	$47.45
Rate for Payer: Amerigroup CHIP/Medicaid	$5.93
Rate for Payer: BCBS of TX Blue Advantage	$19.77
Rate for Payer: BCBS of TX Blue Essentials	$23.72
Rate for Payer: BCBS of TX PPO	$26.36
Rate for Payer: Cash Price	$44.81
Rate for Payer: Cigna Medicaid	$47.45
Rate for Payer: Molina CHIP/Medicaid	$47.45
Rate for Payer: Multiplan Auto	$42.84
Rate for Payer: Multiplan Commercial	$42.84
Rate for Payer: Multiplan Workers Comp	$42.84
Rate for Payer: Parkland Medicaid	$47.45
Rate for Payer: Scott and White EPO/PPO	$32.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47.45
Rate for Payer: Superior Health Plan EPO	$8.96

Know your out-of-pocket cost for care.

All Charges