White Rock Medical Center

All Charges

Charge

Type

Setting

Price

EP EVAL AICD LEADS INIT

Facility

$1,882.00

Service Code	HCPCS 93640
Hospital Charge Code	4610640
Hospital Revenue Code	480
Rate for Payer: Cash Price	$1,279.76

ePHEDrine 50 mg/ml 1 ml vial

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78406597
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

ePHEDrine 50 mg/ml 1 ml vial

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78406597
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

Epidermal Autograft Face/Neck/Hf/G First 100 Sq cm

Facility

$5,070.00

Service Code	HCPCS 15115
Hospital Charge Code	7150914
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,447.60

Epidermal Autograft Face/Neck/Hf/G First 100 Sq cm

Facility

$5,070.00

Service Code	HCPCS 15115
Hospital Charge Code	7150914
Hospital Revenue Code	361
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$3,447.60
Rate for Payer: Cash Price	$3,447.60
Rate for Payer: Cash Price	$3,447.60
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$3,650.40
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$3,650.40
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$3,650.40
Rate for Payer: Scott and White EPO/PPO	$3,834.46
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,650.40
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Epidermal Autograft Trnk/Arms/Legs First 100 Sq cm

Facility

$5,206.00

Service Code	HCPCS 15110
Hospital Charge Code	7150912
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,540.08

Epidermal Autograft Trnk/Arms/Legs First 100 Sq cm

Facility

$5,206.00

Service Code	HCPCS 15110
Hospital Charge Code	7150912
Hospital Revenue Code	361
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$3,540.08
Rate for Payer: Cash Price	$3,540.08
Rate for Payer: Cash Price	$3,540.08
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$3,748.32
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$3,748.32
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$3,748.32
Rate for Payer: Scott and White EPO/PPO	$3,834.46
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,748.32
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Epidural Ea Addl 15 Min BCE

Facility

$625.00

Hospital Charge Code	320020
Hospital Revenue Code	370
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$450.00
Rate for Payer: Amerigroup CHIP/Medicaid	$56.25
Rate for Payer: BCBS of TX Blue Advantage	$187.50
Rate for Payer: BCBS of TX Blue Essentials	$225.00
Rate for Payer: BCBS of TX PPO	$250.00
Rate for Payer: Cash Price	$425.00
Rate for Payer: Cigna Medicaid	$450.00
Rate for Payer: Molina CHIP/Medicaid	$450.00
Rate for Payer: Multiplan Auto	$406.25
Rate for Payer: Multiplan Commercial	$406.25
Rate for Payer: Multiplan Workers Comp	$406.25
Rate for Payer: Parkland Medicaid	$450.00
Rate for Payer: Scott and White EPO/PPO	$312.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$450.00
Rate for Payer: Superior Health Plan EPO	$85.00

Epidural Ea Addl 15 Min BCE

Facility

$625.00

Hospital Charge Code	320020
Hospital Revenue Code	370
Rate for Payer: Cash Price	$425.00

Epidural First 60 Min BCE

Facility

$4,210.00

Hospital Charge Code	320019
Hospital Revenue Code	370
Min. Negotiated Rate	$378.90
Max. Negotiated Rate	$3,031.20
Rate for Payer: Amerigroup CHIP/Medicaid	$378.90
Rate for Payer: BCBS of TX Blue Advantage	$1,263.00
Rate for Payer: BCBS of TX Blue Essentials	$1,515.60
Rate for Payer: BCBS of TX PPO	$1,684.00
Rate for Payer: Cash Price	$2,862.80
Rate for Payer: Cigna Medicaid	$3,031.20
Rate for Payer: Molina CHIP/Medicaid	$3,031.20
Rate for Payer: Multiplan Auto	$2,736.50
Rate for Payer: Multiplan Commercial	$2,736.50
Rate for Payer: Multiplan Workers Comp	$2,736.50
Rate for Payer: Parkland Medicaid	$3,031.20
Rate for Payer: Scott and White EPO/PPO	$2,105.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,031.20
Rate for Payer: Superior Health Plan EPO	$572.56

Epidural First 60 Min BCE

Facility

$4,210.00

Hospital Charge Code	320019
Hospital Revenue Code	370
Rate for Payer: Cash Price	$2,862.80

Epidurography, radiological supervision and interpretation

Facility

$3,540.00

Service Code	HCPCS 72275
Hospital Charge Code	9900898
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,407.20

Epidurography, radiological supervision and interpretation

Facility

$10,000.00

Service Code	CPT 72275
Hospital Charge Code	36072275
Hospital Revenue Code	360
Min. Negotiated Rate	$140.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$140.93
Rate for Payer: BCBS of TX Blue Essentials	$169.11
Rate for Payer: BCBS of TX PPO	$188.76
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

Epidurography, radiological supervision and interpretation

Facility

$3,540.00

Service Code	HCPCS 72275
Hospital Charge Code	9900898
Hospital Revenue Code	360
Min. Negotiated Rate	$140.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$318.60
Rate for Payer: BCBS of TX Blue Advantage	$140.93
Rate for Payer: BCBS of TX Blue Essentials	$169.11
Rate for Payer: BCBS of TX PPO	$188.76
Rate for Payer: Cash Price	$2,407.20
Rate for Payer: Cash Price	$2,407.20
Rate for Payer: Cash Price	$2,407.20
Rate for Payer: Cigna Medicaid	$2,548.80
Rate for Payer: Molina CHIP/Medicaid	$2,548.80
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	$2,548.80
Rate for Payer: Scott and White EPO/PPO	$1,770.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,548.80
Rate for Payer: Superior Health Plan EPO	$481.44

EPINEPHrine 0.1 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J0169
Hospital Charge Code	78435731
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 0.1 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J0169
Hospital Charge Code	78435731
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

EPINEPHrine 1 mg/ml 10 mg vial

Facility

$191.00

Service Code	HCPCS J3490
Hospital Charge Code	77547503
Hospital Revenue Code	250
Min. Negotiated Rate	$17.19
Max. Negotiated Rate	$137.52
Rate for Payer: Amerigroup CHIP/Medicaid	$17.19
Rate for Payer: BCBS of TX Blue Advantage	$57.30
Rate for Payer: BCBS of TX Blue Essentials	$68.76
Rate for Payer: BCBS of TX PPO	$76.40
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cigna Medicaid	$137.52
Rate for Payer: Molina CHIP/Medicaid	$137.52
Rate for Payer: Multiplan Auto	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Parkland Medicaid	$137.52
Rate for Payer: Scott and White EPO/PPO	$95.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$25.98

EPINEPHrine 1 mg/ml 10 mg vial

Facility

$191.00

Service Code	HCPCS J3490
Hospital Charge Code	77547503
Hospital Revenue Code	250
Rate for Payer: Cash Price	$129.88

EPINEPHrine 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS j0165
Hospital Charge Code	77547391
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

EPINEPHrine 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS j0165
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
Rate for Payer: Cash Price	$87.16

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	$92.28
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: 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

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	$92.28
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: 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

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 1:200,000-0.5% 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

Know your out-of-pocket cost for care.

All Charges