White Rock Medical Center

All Charges

Charge

Type

Setting

Price

EPINEPHrine 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J0171
Hospital Charge Code	77547391
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.13
Rate for Payer: BCBS of TX Blue Essentials	$0.16
Rate for Payer: BCBS of TX PPO	$0.17
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

EPINEPHrine 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J0171
Hospital Charge Code	77547391
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

EPINEPHrine-lidocaine 1:100,000-1% Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77548115
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

EPINEPHrine-lidocaine 1:100,000-1% Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77548115
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

EPINEPHrine-lidocaine 1:100,000-2% Inj Soln 20 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77548435
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

EPINEPHrine-lidocaine 1:100,000-2% Inj Soln 20 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77548435
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

EPINEPHrine-lidocaine 1:200,000-0.5% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77548588
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

EPINEPHrine-lidocaine 1:200,000-0.5% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77548588
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

EPINEPHrine-lidocaine 1:200,000-1% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77548639
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

EPINEPHrine-lidocaine 1:200,000-1% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77548639
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

EPINEPHrine-lidocaine 1:200,000-2% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J2004
Hospital Charge Code	77548892
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

EPINEPHrine-lidocaine 1:200,000-2% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J2004
Hospital Charge Code	77548892
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

EPISTAXIS WITH MCC

Facility

$24,975.50

Service Code	MSDRG 150
Min. Negotiated Rate	$11,501.88
Max. Negotiated Rate	$24,975.50
Rate for Payer: Aetna Commercial	$14,788.12
Rate for Payer: Aetna Medicare	$18,352.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,235.13
Rate for Payer: Amerigroup Medicare	$12,235.13
Rate for Payer: BCBS of TX Blue Advantage	$11,518.84
Rate for Payer: BCBS of TX Blue Essentials	$13,698.47
Rate for Payer: BCBS of TX Medicare	$12,235.13
Rate for Payer: BCBS of TX PPO	$15,221.12
Rate for Payer: Cigna Commercial	$16,930.76
Rate for Payer: Cigna Medicare	$12,235.13
Rate for Payer: Employer Direct Commercial	$12,235.13
Rate for Payer: Humana Medicare/TRICARE	$12,235.13
Rate for Payer: Molina Dual Medicare/Medicaid	$12,235.13
Rate for Payer: Molina Medicare	$12,235.13
Rate for Payer: Multiplan Auto	$24,975.50
Rate for Payer: Multiplan Commercial	$24,975.50
Rate for Payer: Multiplan Workers Comp	$24,975.50
Rate for Payer: Scott and White EPO/PPO	$11,501.88
Rate for Payer: Scott and White Medicare	$12,235.13
Rate for Payer: Superior Health Plan EPO	$12,235.13
Rate for Payer: Superior Health Plan Medicare	$12,235.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,235.13
Rate for Payer: Universal American Medicare	$12,235.13
Rate for Payer: Wellcare Medicare	$12,235.13
Rate for Payer: Wellmed Medicare	$12,235.13

EPISTAXIS WITHOUT MCC

Facility

$14,643.30

Service Code	MSDRG 151
Min. Negotiated Rate	$6,098.26
Max. Negotiated Rate	$14,643.30
Rate for Payer: Aetna Commercial	$8,670.38
Rate for Payer: Aetna Medicare	$12,531.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,354.55
Rate for Payer: Amerigroup Medicare	$8,354.55
Rate for Payer: BCBS of TX Blue Advantage	$6,098.26
Rate for Payer: BCBS of TX Blue Essentials	$7,262.51
Rate for Payer: BCBS of TX Medicare	$8,354.55
Rate for Payer: BCBS of TX PPO	$8,069.77
Rate for Payer: Cigna Commercial	$9,926.62
Rate for Payer: Cigna Medicare	$8,354.55
Rate for Payer: Employer Direct Commercial	$8,354.55
Rate for Payer: Humana Medicare/TRICARE	$8,354.55
Rate for Payer: Molina Dual Medicare/Medicaid	$8,354.55
Rate for Payer: Molina Medicare	$8,354.55
Rate for Payer: Multiplan Auto	$14,643.30
Rate for Payer: Multiplan Commercial	$14,643.30
Rate for Payer: Multiplan Workers Comp	$14,643.30
Rate for Payer: Scott and White EPO/PPO	$6,743.62
Rate for Payer: Scott and White Medicare	$8,354.55
Rate for Payer: Superior Health Plan EPO	$8,354.55
Rate for Payer: Superior Health Plan Medicare	$8,354.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,354.55
Rate for Payer: Universal American Medicare	$8,354.55
Rate for Payer: Wellcare Medicare	$8,354.55
Rate for Payer: Wellmed Medicare	$8,354.55

epoetin alfa epbx 10,000 units/mL preservative-free Sol

Facility

$358.70

Service Code	HCPCS Q5106
Hospital Charge Code	78873269
Hospital Revenue Code	250
Min. Negotiated Rate	$7.82
Max. Negotiated Rate	$233.16
Rate for Payer: Aetna Medicare	$11.74
Rate for Payer: Amerigroup CHIP/Medicaid	$32.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.82
Rate for Payer: Amerigroup Medicare	$7.82
Rate for Payer: BCBS of TX Blue Advantage	$15.54
Rate for Payer: BCBS of TX Blue Essentials	$18.65
Rate for Payer: BCBS of TX Medicare	$7.82
Rate for Payer: BCBS of TX PPO	$20.69
Rate for Payer: Cash Price	$243.92
Rate for Payer: Cash Price	$243.92
Rate for Payer: Cigna Medicare	$7.82
Rate for Payer: Employer Direct Commercial	$7.82
Rate for Payer: Humana Medicare/TRICARE	$7.82
Rate for Payer: Molina Dual Medicare/Medicaid	$7.82
Rate for Payer: Molina Medicare	$7.82
Rate for Payer: Multiplan Auto	$233.16
Rate for Payer: Multiplan Commercial	$233.16
Rate for Payer: Multiplan Workers Comp	$233.16
Rate for Payer: Scott and White EPO/PPO	$179.35
Rate for Payer: Scott and White Medicare	$7.82
Rate for Payer: Superior Health Plan EPO	$7.82
Rate for Payer: Superior Health Plan Medicare	$7.82
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.82
Rate for Payer: Universal American Medicare	$7.82
Rate for Payer: Wellcare Medicare	$7.82
Rate for Payer: Wellmed Medicare	$7.82

epoetin alfa epbx 10,000 units/mL preservative-free Sol

Facility

$358.70

Service Code	HCPCS Q5106
Hospital Charge Code	78873269
Hospital Revenue Code	250
Rate for Payer: Cash Price	$243.92

EP POST DRUG INFUSION

Facility

$1,877.00

Service Code	CPT 93623
Hospital Charge Code	4610631
Hospital Revenue Code	480
Rate for Payer: Cash Price	$1,651.76

EP POST DRUG INFUSION

Facility

$1,877.00

Service Code	CPT 93623
Hospital Charge Code	4610631
Hospital Revenue Code	480
Min. Negotiated Rate	$168.93
Max. Negotiated Rate	$1,220.05
Rate for Payer: Aetna Commercial	$1,032.35
Rate for Payer: Amerigroup CHIP/Medicaid	$168.93
Rate for Payer: BCBS of TX Blue Advantage	$289.08
Rate for Payer: BCBS of TX Blue Essentials	$345.57
Rate for Payer: BCBS of TX PPO	$385.44
Rate for Payer: Cash Price	$1,651.76
Rate for Payer: Cash Price	$1,651.76
Rate for Payer: Multiplan Auto	$1,220.05
Rate for Payer: Multiplan Commercial	$1,220.05
Rate for Payer: Multiplan Workers Comp	$1,220.05
Rate for Payer: Scott and White EPO/PPO	$938.50
Rate for Payer: Superior Health Plan EPO	$255.27

Epstein-Barr DNA Quant, PCR SO

Facility

$647.00

Service Code	CPT 87799
Hospital Charge Code	1709963
Hospital Revenue Code	306
Rate for Payer: Cash Price	$569.36

Epstein-Barr DNA Quant, PCR SO

Facility

$647.00

Service Code	CPT 87799
Hospital Charge Code	1709963
Hospital Revenue Code	306
Min. Negotiated Rate	$16.71
Max. Negotiated Rate	$420.55
Rate for Payer: Aetna Commercial	$44.98
Rate for Payer: Aetna Medicare	$64.26
Rate for Payer: Amerigroup CHIP/Medicaid	$16.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.84
Rate for Payer: Amerigroup Medicare	$42.84
Rate for Payer: BCBS of TX Blue Advantage	$70.69
Rate for Payer: BCBS of TX Blue Essentials	$84.82
Rate for Payer: BCBS of TX Medicare	$42.84
Rate for Payer: BCBS of TX PPO	$94.68
Rate for Payer: Cash Price	$569.36
Rate for Payer: Cash Price	$569.36
Rate for Payer: Cigna Medicaid	$42.84
Rate for Payer: Cigna Medicare	$42.84
Rate for Payer: Employer Direct Commercial	$42.84
Rate for Payer: Humana Medicare/TRICARE	$42.84
Rate for Payer: Molina CHIP/Medicaid	$42.84
Rate for Payer: Molina Dual Medicare/Medicaid	$42.84
Rate for Payer: Molina Medicare	$42.84
Rate for Payer: Multiplan Auto	$420.55
Rate for Payer: Multiplan Commercial	$420.55
Rate for Payer: Multiplan Workers Comp	$420.55
Rate for Payer: Parkland Medicaid	$42.84
Rate for Payer: Scott and White EPO/PPO	$53.55
Rate for Payer: Scott and White Medicare	$42.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.84
Rate for Payer: Superior Health Plan EPO	$42.84
Rate for Payer: Superior Health Plan Medicare	$42.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.84
Rate for Payer: Universal American Medicare	$42.84
Rate for Payer: Wellcare Medicare	$42.84
Rate for Payer: Wellmed Medicare	$42.84

EP TEST AICD LEAD & GEN

Facility

$3,586.00

Service Code	CPT 93641
Hospital Charge Code	4610635
Hospital Revenue Code	480
Rate for Payer: Cash Price	$3,155.68

EP TEST AICD LEAD & GEN

Facility

$3,586.00

Service Code	CPT 93641
Hospital Charge Code	4610635
Hospital Revenue Code	480
Min. Negotiated Rate	$322.74
Max. Negotiated Rate	$2,330.90
Rate for Payer: Aetna Commercial	$1,972.30
Rate for Payer: Amerigroup CHIP/Medicaid	$322.74
Rate for Payer: BCBS of TX Blue Advantage	$570.65
Rate for Payer: BCBS of TX Blue Essentials	$682.16
Rate for Payer: BCBS of TX PPO	$760.87
Rate for Payer: Cash Price	$3,155.68
Rate for Payer: Cash Price	$3,155.68
Rate for Payer: Multiplan Auto	$2,330.90
Rate for Payer: Multiplan Commercial	$2,330.90
Rate for Payer: Multiplan Workers Comp	$2,330.90
Rate for Payer: Scott and White EPO/PPO	$1,793.00
Rate for Payer: Superior Health Plan EPO	$487.70

eptifibatide 0.75 mg/mL IV Soln 100 mL Premix

Facility

$801.58

Service Code	HCPCS J1327
Hospital Charge Code	77550133
Hospital Revenue Code	636
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$521.03
Rate for Payer: Aetna Medicare	$5.02
Rate for Payer: Amerigroup CHIP/Medicaid	$72.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.35
Rate for Payer: Amerigroup Medicare	$3.35
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 Medicare	$3.35
Rate for Payer: BCBS of TX PPO	$29.34
Rate for Payer: Cash Price	$545.07
Rate for Payer: Cash Price	$545.07
Rate for Payer: Cigna Medicare	$3.35
Rate for Payer: Employer Direct Commercial	$3.35
Rate for Payer: Humana Medicare/TRICARE	$3.35
Rate for Payer: Molina Dual Medicare/Medicaid	$3.35
Rate for Payer: Molina Medicare	$3.35
Rate for Payer: Multiplan Auto	$521.03
Rate for Payer: Multiplan Commercial	$521.03
Rate for Payer: Multiplan Workers Comp	$521.03
Rate for Payer: Scott and White EPO/PPO	$400.79
Rate for Payer: Scott and White Medicare	$3.35
Rate for Payer: Superior Health Plan EPO	$3.35
Rate for Payer: Superior Health Plan Medicare	$3.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.35
Rate for Payer: Universal American Medicare	$3.35
Rate for Payer: Wellcare Medicare	$3.35
Rate for Payer: Wellmed Medicare	$3.35

eptifibatide 0.75 mg/mL IV Soln 100 mL Premix

Facility

$801.58

Service Code	HCPCS J1327
Hospital Charge Code	77550133
Hospital Revenue Code	636
Min. Negotiated Rate	$200.40
Max. Negotiated Rate	$400.79
Rate for Payer: Cash Price	$545.07
Rate for Payer: Cigna Commercial	$200.40
Rate for Payer: Scott and White EPO/PPO	$400.79

eptifibatide 2 mg/mL IV Soln 10 mL

Facility

$260.33

Service Code	HCPCS J1327
Hospital Charge Code	77550190
Hospital Revenue Code	636
Min. Negotiated Rate	$65.08
Max. Negotiated Rate	$130.16
Rate for Payer: Cash Price	$177.02
Rate for Payer: Cigna Commercial	$65.08
Rate for Payer: Scott and White EPO/PPO	$130.16

Know your out-of-pocket cost for care.

All Charges