White Rock Medical Center

All Charges

Charge

Type

Setting

Price

citalopram 10 mg Tab

Facility

$10.55

Service Code	HCPCS J3490
Hospital Charge Code	77470015
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.17

citalopram 10 mg Tab

Facility

$10.55

Service Code	HCPCS J3490
Hospital Charge Code	77470015
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$7.60
Rate for Payer: Amerigroup CHIP/Medicaid	$0.95
Rate for Payer: BCBS of TX Blue Advantage	$3.17
Rate for Payer: BCBS of TX Blue Essentials	$3.80
Rate for Payer: BCBS of TX PPO	$4.22
Rate for Payer: Cash Price	$7.17
Rate for Payer: Cigna Medicaid	$7.60
Rate for Payer: Molina CHIP/Medicaid	$7.60
Rate for Payer: Multiplan Auto	$6.86
Rate for Payer: Multiplan Commercial	$6.86
Rate for Payer: Multiplan Workers Comp	$6.86
Rate for Payer: Parkland Medicaid	$7.60
Rate for Payer: Scott and White EPO/PPO	$5.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.60
Rate for Payer: Superior Health Plan EPO	$1.43

citalopram 20 mg Tab

Facility

$11.70

Service Code	HCPCS J3490
Hospital Charge Code	77470178
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.96

citalopram 20 mg Tab

Facility

$11.70

Service Code	HCPCS J3490
Hospital Charge Code	77470178
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$8.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1.05
Rate for Payer: BCBS of TX Blue Advantage	$3.51
Rate for Payer: BCBS of TX Blue Essentials	$4.21
Rate for Payer: BCBS of TX PPO	$4.68
Rate for Payer: Cash Price	$7.96
Rate for Payer: Cigna Medicaid	$8.42
Rate for Payer: Molina CHIP/Medicaid	$8.42
Rate for Payer: Multiplan Auto	$7.61
Rate for Payer: Multiplan Commercial	$7.61
Rate for Payer: Multiplan Workers Comp	$7.61
Rate for Payer: Parkland Medicaid	$8.42
Rate for Payer: Scott and White EPO/PPO	$5.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.42
Rate for Payer: Superior Health Plan EPO	$1.59

CITY HOSPITAL TURNOVER KIT

Facility

$313.78

Hospital Charge Code	993790
Hospital Revenue Code	270
Rate for Payer: Cash Price	$213.37

CITY HOSPITAL TURNOVER KIT

Facility

$313.78

Hospital Charge Code	993790
Hospital Revenue Code	270
Min. Negotiated Rate	$28.24
Max. Negotiated Rate	$225.92
Rate for Payer: Amerigroup CHIP/Medicaid	$28.24
Rate for Payer: BCBS of TX Blue Advantage	$94.13
Rate for Payer: BCBS of TX Blue Essentials	$112.96
Rate for Payer: BCBS of TX PPO	$125.51
Rate for Payer: Cash Price	$213.37
Rate for Payer: Cigna Medicaid	$225.92
Rate for Payer: Molina CHIP/Medicaid	$225.92
Rate for Payer: Multiplan Auto	$203.96
Rate for Payer: Multiplan Commercial	$203.96
Rate for Payer: Multiplan Workers Comp	$203.96
Rate for Payer: Parkland Medicaid	$225.92
Rate for Payer: Scott and White EPO/PPO	$156.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$225.92
Rate for Payer: Superior Health Plan EPO	$42.67

CLAMP, VASC OCCLUS FRM PRS ANGLE 45 DGR MIDI DISP -- DHF

Facility

$164.13

Hospital Charge Code	80810658
Hospital Revenue Code	272
Rate for Payer: Cash Price	$111.61

CLAMP, VASC OCCLUS FRM PRS ANGLE 45 DGR MIDI DISP -- DHF

Facility

$164.13

Hospital Charge Code	80810658
Hospital Revenue Code	272
Min. Negotiated Rate	$14.77
Max. Negotiated Rate	$118.17
Rate for Payer: Amerigroup CHIP/Medicaid	$14.77
Rate for Payer: BCBS of TX Blue Advantage	$49.24
Rate for Payer: BCBS of TX Blue Essentials	$59.09
Rate for Payer: BCBS of TX PPO	$65.65
Rate for Payer: Cash Price	$111.61
Rate for Payer: Cigna Medicaid	$118.17
Rate for Payer: Molina CHIP/Medicaid	$118.17
Rate for Payer: Multiplan Auto	$106.68
Rate for Payer: Multiplan Commercial	$106.68
Rate for Payer: Multiplan Workers Comp	$106.68
Rate for Payer: Parkland Medicaid	$118.17
Rate for Payer: Scott and White EPO/PPO	$82.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.17
Rate for Payer: Superior Health Plan EPO	$22.32

clarithromycin 500 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77471562
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

clarithromycin 500 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77471562
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Claviculectomy; partial

Facility

$17,353.68

Service Code	HCPCS 23120
Hospital Charge Code	9900218
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$12,494.65
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$11,800.50
Rate for Payer: Cash Price	$11,800.50
Rate for Payer: Cash Price	$11,800.50
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$12,494.65
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$12,494.65
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$12,494.65
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,494.65
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Claviculectomy; partial

Facility

$17,353.68

Service Code	HCPCS 23120
Hospital Charge Code	9900218
Hospital Revenue Code	360
Rate for Payer: Cash Price	$11,800.50

Claviculectomy; partial

Facility

$10,000.00

Service Code	CPT 23120
Hospital Charge Code	36023120
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

CLEANER, CRME MILD ABRASIVE, 40OZ

Facility

$14.29

Hospital Charge Code	993212
Hospital Revenue Code	270
Rate for Payer: Cash Price	$9.72

CLEANER, CRME MILD ABRASIVE, 40OZ

Facility

$14.29

Hospital Charge Code	993212
Hospital Revenue Code	270
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$10.29
Rate for Payer: Amerigroup CHIP/Medicaid	$1.29
Rate for Payer: BCBS of TX Blue Advantage	$4.29
Rate for Payer: BCBS of TX Blue Essentials	$5.14
Rate for Payer: BCBS of TX PPO	$5.72
Rate for Payer: Cash Price	$9.72
Rate for Payer: Cigna Medicaid	$10.29
Rate for Payer: Molina CHIP/Medicaid	$10.29
Rate for Payer: Multiplan Auto	$9.29
Rate for Payer: Multiplan Commercial	$9.29
Rate for Payer: Multiplan Workers Comp	$9.29
Rate for Payer: Parkland Medicaid	$10.29
Rate for Payer: Scott and White EPO/PPO	$7.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.29
Rate for Payer: Superior Health Plan EPO	$1.94

CLEANER, ENZYMATIC, ULTRA, NETURAL, 2 X 5L

Facility

$1,875.66

Hospital Charge Code	993813
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,275.45

CLEANER, ENZYMATIC, ULTRA, NETURAL, 2 X 5L

Facility

$1,875.66

Hospital Charge Code	993813
Hospital Revenue Code	270
Min. Negotiated Rate	$168.81
Max. Negotiated Rate	$1,350.48
Rate for Payer: Amerigroup CHIP/Medicaid	$168.81
Rate for Payer: BCBS of TX Blue Advantage	$562.70
Rate for Payer: BCBS of TX Blue Essentials	$675.24
Rate for Payer: BCBS of TX PPO	$750.26
Rate for Payer: Cash Price	$1,275.45
Rate for Payer: Cigna Medicaid	$1,350.48
Rate for Payer: Molina CHIP/Medicaid	$1,350.48
Rate for Payer: Multiplan Auto	$1,219.18
Rate for Payer: Multiplan Commercial	$1,219.18
Rate for Payer: Multiplan Workers Comp	$1,219.18
Rate for Payer: Parkland Medicaid	$1,350.48
Rate for Payer: Scott and White EPO/PPO	$937.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,350.48
Rate for Payer: Superior Health Plan EPO	$255.09

CLEANER, ENZYMATIC, ULTRA, PROLYSTICA, 10L

Facility

$1,875.66

Hospital Charge Code	993017
Hospital Revenue Code	272
Min. Negotiated Rate	$168.81
Max. Negotiated Rate	$1,350.48
Rate for Payer: Amerigroup CHIP/Medicaid	$168.81
Rate for Payer: BCBS of TX Blue Advantage	$562.70
Rate for Payer: BCBS of TX Blue Essentials	$675.24
Rate for Payer: BCBS of TX PPO	$750.26
Rate for Payer: Cash Price	$1,275.45
Rate for Payer: Cigna Medicaid	$1,350.48
Rate for Payer: Molina CHIP/Medicaid	$1,350.48
Rate for Payer: Multiplan Auto	$1,219.18
Rate for Payer: Multiplan Commercial	$1,219.18
Rate for Payer: Multiplan Workers Comp	$1,219.18
Rate for Payer: Parkland Medicaid	$1,350.48
Rate for Payer: Scott and White EPO/PPO	$937.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,350.48
Rate for Payer: Superior Health Plan EPO	$255.09

CLEANER, ENZYMATIC, ULTRA, PROLYSTICA, 10L

Facility

$1,875.66

Hospital Charge Code	993017
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,275.45

CLEANER, INSTRUMENT, ENZYME, EMPOWER

Facility

$73.47

Hospital Charge Code	993018
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.96

CLEANER, INSTRUMENT, ENZYME, EMPOWER

Facility

$73.47

Hospital Charge Code	993018
Hospital Revenue Code	270
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$52.90
Rate for Payer: Amerigroup CHIP/Medicaid	$6.61
Rate for Payer: BCBS of TX Blue Advantage	$22.04
Rate for Payer: BCBS of TX Blue Essentials	$26.45
Rate for Payer: BCBS of TX PPO	$29.39
Rate for Payer: Cash Price	$49.96
Rate for Payer: Cigna Medicaid	$52.90
Rate for Payer: Molina CHIP/Medicaid	$52.90
Rate for Payer: Multiplan Auto	$47.76
Rate for Payer: Multiplan Commercial	$47.76
Rate for Payer: Multiplan Workers Comp	$47.76
Rate for Payer: Parkland Medicaid	$52.90
Rate for Payer: Scott and White EPO/PPO	$36.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.90
Rate for Payer: Superior Health Plan EPO	$9.99

CLEANER, NEUTRAL, FLORAL, 2.5L

Facility

$237.33

Hospital Charge Code	993963
Hospital Revenue Code	270
Rate for Payer: Cash Price	$161.38

CLEANER, NEUTRAL, FLORAL, 2.5L

Facility

$237.33

Hospital Charge Code	993963
Hospital Revenue Code	270
Min. Negotiated Rate	$21.36
Max. Negotiated Rate	$170.88
Rate for Payer: Amerigroup CHIP/Medicaid	$21.36
Rate for Payer: BCBS of TX Blue Advantage	$71.20
Rate for Payer: BCBS of TX Blue Essentials	$85.44
Rate for Payer: BCBS of TX PPO	$94.93
Rate for Payer: Cash Price	$161.38
Rate for Payer: Cigna Medicaid	$170.88
Rate for Payer: Molina CHIP/Medicaid	$170.88
Rate for Payer: Multiplan Auto	$154.26
Rate for Payer: Multiplan Commercial	$154.26
Rate for Payer: Multiplan Workers Comp	$154.26
Rate for Payer: Parkland Medicaid	$170.88
Rate for Payer: Scott and White EPO/PPO	$118.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$170.88
Rate for Payer: Superior Health Plan EPO	$32.28

CLEANER, REAGENT DXH 1 X

Facility

$140.29

Hospital Charge Code	993808
Hospital Revenue Code	279
Min. Negotiated Rate	$12.63
Max. Negotiated Rate	$101.01
Rate for Payer: Amerigroup CHIP/Medicaid	$12.63
Rate for Payer: BCBS of TX Blue Advantage	$42.09
Rate for Payer: BCBS of TX Blue Essentials	$50.50
Rate for Payer: BCBS of TX PPO	$56.12
Rate for Payer: Cash Price	$95.40
Rate for Payer: Cigna Medicaid	$101.01
Rate for Payer: Molina CHIP/Medicaid	$101.01
Rate for Payer: Multiplan Auto	$91.19
Rate for Payer: Multiplan Commercial	$91.19
Rate for Payer: Multiplan Workers Comp	$91.19
Rate for Payer: Parkland Medicaid	$101.01
Rate for Payer: Scott and White EPO/PPO	$70.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$101.01
Rate for Payer: Superior Health Plan EPO	$19.08

CLEANER, REAGENT DXH 1 X

Facility

$140.29

Hospital Charge Code	993808
Hospital Revenue Code	279
Rate for Payer: Cash Price	$95.40

Know your out-of-pocket cost for care.

All Charges