White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Electrolyte Panel

Facility

$272.00

Service Code	HCPCS 80051 QW
Hospital Charge Code	1602804
Hospital Revenue Code	301
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$195.84
Rate for Payer: Amerigroup CHIP/Medicaid	$2.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.01
Rate for Payer: Amerigroup Medicare	$7.01
Rate for Payer: BCBS of TX Blue Advantage	$81.60
Rate for Payer: BCBS of TX Blue Essentials	$97.92
Rate for Payer: BCBS of TX Medicare	$7.01
Rate for Payer: BCBS of TX PPO	$108.80
Rate for Payer: Cash Price	$184.96
Rate for Payer: Cash Price	$184.96
Rate for Payer: Cigna Medicaid	$195.84
Rate for Payer: Cigna Medicare	$7.01
Rate for Payer: Employer Direct Commercial	$7.01
Rate for Payer: Humana Medicare/TRICARE	$7.01
Rate for Payer: Molina CHIP/Medicaid	$195.84
Rate for Payer: Molina Dual Medicare/Medicaid	$7.01
Rate for Payer: Molina Medicare	$7.01
Rate for Payer: Multiplan Auto	$176.80
Rate for Payer: Multiplan Commercial	$176.80
Rate for Payer: Multiplan Workers Comp	$176.80
Rate for Payer: Parkland Medicaid	$195.84
Rate for Payer: Scott and White EPO/PPO	$8.76
Rate for Payer: Scott and White Medicare	$7.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.84
Rate for Payer: Superior Health Plan EPO	$7.01
Rate for Payer: Superior Health Plan Medicare	$7.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.01
Rate for Payer: Universal American Medicare	$7.01
Rate for Payer: Wellcare Medicare	$7.01
Rate for Payer: Wellmed Medicare	$7.01

Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s],

Facility

$10,000.00

Service Code	CPT 95972
Hospital Charge Code	36095972
Hospital Revenue Code	360
Min. Negotiated Rate	$95.50
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$95.50
Rate for Payer: Amerigroup Medicare	$95.50
Rate for Payer: BCBS of TX Medicare	$95.50
Rate for Payer: Cigna Commercial	$201.88
Rate for Payer: Cigna Medicare	$95.50
Rate for Payer: Employer Direct Commercial	$95.50
Rate for Payer: Humana Medicare/TRICARE	$95.50
Rate for Payer: Molina Dual Medicare/Medicaid	$95.50
Rate for Payer: Molina Medicare	$95.50
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 Medicare	$95.50
Rate for Payer: Superior Health Plan EPO	$95.50
Rate for Payer: Superior Health Plan Medicare	$95.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$95.50
Rate for Payer: Universal American Medicare	$95.50
Rate for Payer: Wellcare Medicare	$95.50
Rate for Payer: Wellmed Medicare	$95.50

Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s],

Facility

$601.86

Service Code	HCPCS 95972
Hospital Charge Code	9900909
Hospital Revenue Code	360
Min. Negotiated Rate	$54.17
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$54.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$95.50
Rate for Payer: Amerigroup Medicare	$95.50
Rate for Payer: BCBS of TX Blue Advantage	$180.56
Rate for Payer: BCBS of TX Blue Essentials	$216.67
Rate for Payer: BCBS of TX Medicare	$95.50
Rate for Payer: BCBS of TX PPO	$240.74
Rate for Payer: Cash Price	$409.26
Rate for Payer: Cash Price	$409.26
Rate for Payer: Cash Price	$409.26
Rate for Payer: Cigna Commercial	$201.88
Rate for Payer: Cigna Medicaid	$433.34
Rate for Payer: Cigna Medicare	$95.50
Rate for Payer: Employer Direct Commercial	$95.50
Rate for Payer: Humana Medicare/TRICARE	$95.50
Rate for Payer: Molina CHIP/Medicaid	$433.34
Rate for Payer: Molina Dual Medicare/Medicaid	$95.50
Rate for Payer: Molina Medicare	$95.50
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	$433.34
Rate for Payer: Scott and White EPO/PPO	$300.93
Rate for Payer: Scott and White Medicare	$95.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$433.34
Rate for Payer: Superior Health Plan EPO	$95.50
Rate for Payer: Superior Health Plan Medicare	$95.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$95.50
Rate for Payer: Universal American Medicare	$95.50
Rate for Payer: Wellcare Medicare	$95.50
Rate for Payer: Wellmed Medicare	$95.50

Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s],

Facility

$601.86

Service Code	HCPCS 95972
Hospital Charge Code	9900909
Hospital Revenue Code	360
Rate for Payer: Cash Price	$409.26

Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (inclu

Facility

$10,000.00

Service Code	CPT 62370
Hospital Charge Code	36062370
Hospital Revenue Code	360
Min. Negotiated Rate	$110.89
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.54
Rate for Payer: Amerigroup Medicare	$308.54
Rate for Payer: BCBS of TX Blue Advantage	$110.89
Rate for Payer: BCBS of TX Blue Essentials	$132.80
Rate for Payer: BCBS of TX Medicare	$308.54
Rate for Payer: BCBS of TX PPO	$167.33
Rate for Payer: Cigna Commercial	$652.19
Rate for Payer: Cigna Medicare	$308.54
Rate for Payer: Employer Direct Commercial	$308.54
Rate for Payer: Humana Medicare/TRICARE	$308.54
Rate for Payer: Molina Dual Medicare/Medicaid	$308.54
Rate for Payer: Molina Medicare	$308.54
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	$570.80
Rate for Payer: Scott and White Medicare	$308.54
Rate for Payer: Superior Health Plan EPO	$308.54
Rate for Payer: Superior Health Plan Medicare	$308.54
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.54
Rate for Payer: Universal American Medicare	$308.54
Rate for Payer: Wellcare Medicare	$308.54
Rate for Payer: Wellmed Medicare	$308.54

Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (inclu

Facility

$1,089.88

Service Code	HCPCS 62370
Hospital Charge Code	9900758
Hospital Revenue Code	360
Min. Negotiated Rate	$98.09
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$98.09
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$308.54
Rate for Payer: Amerigroup Medicare	$308.54
Rate for Payer: BCBS of TX Blue Advantage	$110.89
Rate for Payer: BCBS of TX Blue Essentials	$132.80
Rate for Payer: BCBS of TX Medicare	$308.54
Rate for Payer: BCBS of TX PPO	$167.33
Rate for Payer: Cash Price	$741.12
Rate for Payer: Cash Price	$741.12
Rate for Payer: Cash Price	$741.12
Rate for Payer: Cigna Commercial	$652.19
Rate for Payer: Cigna Medicaid	$784.71
Rate for Payer: Cigna Medicare	$308.54
Rate for Payer: Employer Direct Commercial	$308.54
Rate for Payer: Humana Medicare/TRICARE	$308.54
Rate for Payer: Molina CHIP/Medicaid	$784.71
Rate for Payer: Molina Dual Medicare/Medicaid	$308.54
Rate for Payer: Molina Medicare	$308.54
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	$784.71
Rate for Payer: Scott and White EPO/PPO	$570.80
Rate for Payer: Scott and White Medicare	$308.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$784.71
Rate for Payer: Superior Health Plan EPO	$308.54
Rate for Payer: Superior Health Plan Medicare	$308.54
Rate for Payer: Universal American Dual Medicare/Medicaid	$308.54
Rate for Payer: Universal American Medicare	$308.54
Rate for Payer: Wellcare Medicare	$308.54
Rate for Payer: Wellmed Medicare	$308.54

Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (inclu

Facility

$1,089.88

Service Code	HCPCS 62370
Hospital Charge Code	9900758
Hospital Revenue Code	360
Rate for Payer: Cash Price	$741.12

Ellipse DR_ICD_UMRI_PR

Facility

$106,546.20

Service Code	HCPCS C1721
Hospital Charge Code	110256
Hospital Revenue Code	278
Min. Negotiated Rate	$26,636.55
Max. Negotiated Rate	$53,273.10
Rate for Payer: Cash Price	$72,451.42
Rate for Payer: Cigna Commercial	$26,636.55
Rate for Payer: Multiplan Auto	$53,273.10
Rate for Payer: Multiplan Commercial	$53,273.10
Rate for Payer: Multiplan Workers Comp	$53,273.10
Rate for Payer: Scott and White EPO/PPO	$53,273.10

Ellipse DR_ICD_UMRI_PR

Facility

$106,546.20

Service Code	HCPCS C1721
Hospital Charge Code	110256
Hospital Revenue Code	278
Min. Negotiated Rate	$9,589.16
Max. Negotiated Rate	$76,713.26
Rate for Payer: Amerigroup CHIP/Medicaid	$9,589.16
Rate for Payer: BCBS of TX Blue Advantage	$31,963.86
Rate for Payer: BCBS of TX Blue Essentials	$38,356.63
Rate for Payer: BCBS of TX PPO	$42,618.48
Rate for Payer: Cash Price	$72,451.42
Rate for Payer: Cigna Medicaid	$76,713.26
Rate for Payer: Molina CHIP/Medicaid	$76,713.26
Rate for Payer: Multiplan Auto	$53,273.10
Rate for Payer: Multiplan Commercial	$53,273.10
Rate for Payer: Multiplan Workers Comp	$53,273.10
Rate for Payer: Parkland Medicaid	$76,713.26
Rate for Payer: Scott and White EPO/PPO	$53,273.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76,713.26
Rate for Payer: Superior Health Plan EPO	$14,490.28

Ellipse DR_ICD_UMRI_PR

Facility

$106,546.20

Service Code	HCPCS C1721
Hospital Charge Code	991302
Hospital Revenue Code	278
Min. Negotiated Rate	$26,636.55
Max. Negotiated Rate	$53,273.10
Rate for Payer: Cash Price	$72,451.42
Rate for Payer: Cigna Commercial	$26,636.55
Rate for Payer: Multiplan Auto	$53,273.10
Rate for Payer: Multiplan Commercial	$53,273.10
Rate for Payer: Multiplan Workers Comp	$53,273.10
Rate for Payer: Scott and White EPO/PPO	$53,273.10

Ellipse DR_ICD_UMRI_PR

Facility

$106,546.20

Service Code	HCPCS C1721
Hospital Charge Code	991302
Hospital Revenue Code	278
Min. Negotiated Rate	$9,589.16
Max. Negotiated Rate	$76,713.26
Rate for Payer: Amerigroup CHIP/Medicaid	$9,589.16
Rate for Payer: BCBS of TX Blue Advantage	$31,963.86
Rate for Payer: BCBS of TX Blue Essentials	$38,356.63
Rate for Payer: BCBS of TX PPO	$42,618.48
Rate for Payer: Cash Price	$72,451.42
Rate for Payer: Cigna Medicaid	$76,713.26
Rate for Payer: Molina CHIP/Medicaid	$76,713.26
Rate for Payer: Multiplan Auto	$53,273.10
Rate for Payer: Multiplan Commercial	$53,273.10
Rate for Payer: Multiplan Workers Comp	$53,273.10
Rate for Payer: Parkland Medicaid	$76,713.26
Rate for Payer: Scott and White EPO/PPO	$53,273.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76,713.26
Rate for Payer: Superior Health Plan EPO	$14,490.28

EMBOSHIELD SYSTEM

Facility

$6,583.00

Hospital Charge Code	8450467
Hospital Revenue Code	272
Min. Negotiated Rate	$592.47
Max. Negotiated Rate	$4,739.76
Rate for Payer: Amerigroup CHIP/Medicaid	$592.47
Rate for Payer: BCBS of TX Blue Advantage	$1,974.90
Rate for Payer: BCBS of TX Blue Essentials	$2,369.88
Rate for Payer: BCBS of TX PPO	$2,633.20
Rate for Payer: Cash Price	$4,476.44
Rate for Payer: Cigna Medicaid	$4,739.76
Rate for Payer: Molina CHIP/Medicaid	$4,739.76
Rate for Payer: Multiplan Auto	$4,278.95
Rate for Payer: Multiplan Commercial	$4,278.95
Rate for Payer: Multiplan Workers Comp	$4,278.95
Rate for Payer: Parkland Medicaid	$4,739.76
Rate for Payer: Scott and White EPO/PPO	$3,291.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,739.76
Rate for Payer: Superior Health Plan EPO	$895.29

EMBOSHIELD SYSTEM

Facility

$6,583.00

Hospital Charge Code	8450467
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,476.44

emerel plus mutisurface cream cleanser

Facility

$15.00

Hospital Charge Code	993299
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10.20

emerel plus mutisurface cream cleanser

Facility

$15.00

Hospital Charge Code	993299
Hospital Revenue Code	270
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$10.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1.35
Rate for Payer: BCBS of TX Blue Advantage	$4.50
Rate for Payer: BCBS of TX Blue Essentials	$5.40
Rate for Payer: BCBS of TX PPO	$6.00
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cigna Medicaid	$10.80
Rate for Payer: Molina CHIP/Medicaid	$10.80
Rate for Payer: Multiplan Auto	$9.75
Rate for Payer: Multiplan Commercial	$9.75
Rate for Payer: Multiplan Workers Comp	$9.75
Rate for Payer: Parkland Medicaid	$10.80
Rate for Payer: Scott and White EPO/PPO	$7.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.80
Rate for Payer: Superior Health Plan EPO	$2.04

EMERGENCY BIRTH

Facility

$160.97

Hospital Charge Code	993308
Hospital Revenue Code	270
Min. Negotiated Rate	$14.49
Max. Negotiated Rate	$115.90
Rate for Payer: Amerigroup CHIP/Medicaid	$14.49
Rate for Payer: BCBS of TX Blue Advantage	$48.29
Rate for Payer: BCBS of TX Blue Essentials	$57.95
Rate for Payer: BCBS of TX PPO	$64.39
Rate for Payer: Cash Price	$109.46
Rate for Payer: Cigna Medicaid	$115.90
Rate for Payer: Molina CHIP/Medicaid	$115.90
Rate for Payer: Multiplan Auto	$104.63
Rate for Payer: Multiplan Commercial	$104.63
Rate for Payer: Multiplan Workers Comp	$104.63
Rate for Payer: Parkland Medicaid	$115.90
Rate for Payer: Scott and White EPO/PPO	$80.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.90
Rate for Payer: Superior Health Plan EPO	$21.89

EMERGENCY BIRTH

Facility

$160.97

Hospital Charge Code	993308
Hospital Revenue Code	270
Rate for Payer: Cash Price	$109.46

Emesis Bag 5.5x7.5' Blue Top Ring Plastic 24 / Pk, 6 PK / CA

Facility

$60.29

Hospital Charge Code	993835
Hospital Revenue Code	271
Rate for Payer: Cash Price	$41.00

Emesis Bag 5.5x7.5' Blue Top Ring Plastic 24 / Pk, 6 PK / CA

Facility

$60.29

Hospital Charge Code	993835
Hospital Revenue Code	271
Min. Negotiated Rate	$5.43
Max. Negotiated Rate	$43.41
Rate for Payer: Amerigroup CHIP/Medicaid	$5.43
Rate for Payer: BCBS of TX Blue Advantage	$18.09
Rate for Payer: BCBS of TX Blue Essentials	$21.70
Rate for Payer: BCBS of TX PPO	$24.12
Rate for Payer: Cash Price	$41.00
Rate for Payer: Cigna Medicaid	$43.41
Rate for Payer: Molina CHIP/Medicaid	$43.41
Rate for Payer: Multiplan Auto	$39.19
Rate for Payer: Multiplan Commercial	$39.19
Rate for Payer: Multiplan Workers Comp	$39.19
Rate for Payer: Parkland Medicaid	$43.41
Rate for Payer: Scott and White EPO/PPO	$30.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.41
Rate for Payer: Superior Health Plan EPO	$8.20

empagliflozin 10mg tab

Facility

$23.94

Service Code	HCPCS J3490
Hospital Charge Code	78364595
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.28

empagliflozin 10mg tab

Facility

$23.94

Service Code	HCPCS J3490
Hospital Charge Code	78364595
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$17.24
Rate for Payer: Amerigroup CHIP/Medicaid	$2.15
Rate for Payer: BCBS of TX Blue Advantage	$7.18
Rate for Payer: BCBS of TX Blue Essentials	$8.62
Rate for Payer: BCBS of TX PPO	$9.58
Rate for Payer: Cash Price	$16.28
Rate for Payer: Cigna Medicaid	$17.24
Rate for Payer: Molina CHIP/Medicaid	$17.24
Rate for Payer: Multiplan Auto	$15.56
Rate for Payer: Multiplan Commercial	$15.56
Rate for Payer: Multiplan Workers Comp	$15.56
Rate for Payer: Parkland Medicaid	$17.24
Rate for Payer: Scott and White EPO/PPO	$11.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.24
Rate for Payer: Superior Health Plan EPO	$3.26

empagliflozin 25mg

Facility

$23.94

Service Code	HCPCS j3490
Hospital Charge Code	78364591
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.28

empagliflozin 25mg

Facility

$23.94

Service Code	HCPCS j3490
Hospital Charge Code	78364591
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$17.24
Rate for Payer: Amerigroup CHIP/Medicaid	$2.15
Rate for Payer: BCBS of TX Blue Advantage	$7.18
Rate for Payer: BCBS of TX Blue Essentials	$8.62
Rate for Payer: BCBS of TX PPO	$9.58
Rate for Payer: Cash Price	$16.28
Rate for Payer: Cigna Medicaid	$17.24
Rate for Payer: Molina CHIP/Medicaid	$17.24
Rate for Payer: Multiplan Auto	$15.56
Rate for Payer: Multiplan Commercial	$15.56
Rate for Payer: Multiplan Workers Comp	$15.56
Rate for Payer: Parkland Medicaid	$17.24
Rate for Payer: Scott and White EPO/PPO	$11.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.24
Rate for Payer: Superior Health Plan EPO	$3.26

empagliflozin ORAL TABLET 10 MG

Facility

$23.94

Service Code	HCPCS J3490
Hospital Charge Code	78364594
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$17.24
Rate for Payer: Amerigroup CHIP/Medicaid	$2.15
Rate for Payer: BCBS of TX Blue Advantage	$7.18
Rate for Payer: BCBS of TX Blue Essentials	$8.62
Rate for Payer: BCBS of TX PPO	$9.58
Rate for Payer: Cash Price	$16.28
Rate for Payer: Cigna Medicaid	$17.24
Rate for Payer: Molina CHIP/Medicaid	$17.24
Rate for Payer: Multiplan Auto	$15.56
Rate for Payer: Multiplan Commercial	$15.56
Rate for Payer: Multiplan Workers Comp	$15.56
Rate for Payer: Parkland Medicaid	$17.24
Rate for Payer: Scott and White EPO/PPO	$11.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.24
Rate for Payer: Superior Health Plan EPO	$3.26

empagliflozin ORAL TABLET 10 MG

Facility

$23.94

Service Code	HCPCS J3490
Hospital Charge Code	78364594
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.28

Know your out-of-pocket cost for care.

All Charges