White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	77548892
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 1:200,000-2% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	77548892
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

EPISTAXIS WITH MCC

Facility

$25,298.50

Service Code	MSDRG 150
Min. Negotiated Rate	$11,416.50
Max. Negotiated Rate	$25,298.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,518.68
Rate for Payer: Amerigroup Medicare	$14,518.68
Rate for Payer: BCBS of TX Medicare	$14,518.68
Rate for Payer: Cigna Commercial	$17,149.72
Rate for Payer: Cigna Medicare	$14,518.68
Rate for Payer: Employer Direct Commercial	$14,518.68
Rate for Payer: Humana Medicare/TRICARE	$14,518.68
Rate for Payer: Molina Dual Medicare/Medicaid	$14,518.68
Rate for Payer: Molina Medicare	$14,518.68
Rate for Payer: Multiplan Auto	$25,298.50
Rate for Payer: Multiplan Commercial	$25,298.50
Rate for Payer: Multiplan Workers Comp	$25,298.50
Rate for Payer: Scott and White EPO/PPO	$11,650.62
Rate for Payer: Scott and White Medicare	$14,518.68
Rate for Payer: Superior Health Plan EPO	$14,518.68
Rate for Payer: Superior Health Plan Medicare	$14,518.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,518.68
Rate for Payer: Universal American Medicare	$14,518.68
Rate for Payer: Wellcare Medicare	$14,518.68
Rate for Payer: Wellmed Medicare	$14,518.68

EPISTAXIS WITHOUT MCC

Facility

$13,946.00

Service Code	MSDRG 151
Min. Negotiated Rate	$6,052.68
Max. Negotiated Rate	$13,946.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,139.59
Rate for Payer: Amerigroup Medicare	$10,139.59
Rate for Payer: BCBS of TX Medicare	$10,139.59
Rate for Payer: Cigna Commercial	$9,453.92
Rate for Payer: Cigna Medicare	$10,139.59
Rate for Payer: Employer Direct Commercial	$10,139.59
Rate for Payer: Humana Medicare/TRICARE	$10,139.59
Rate for Payer: Molina Dual Medicare/Medicaid	$10,139.59
Rate for Payer: Molina Medicare	$10,139.59
Rate for Payer: Multiplan Auto	$13,946.00
Rate for Payer: Multiplan Commercial	$13,946.00
Rate for Payer: Multiplan Workers Comp	$13,946.00
Rate for Payer: Scott and White EPO/PPO	$6,422.50
Rate for Payer: Scott and White Medicare	$10,139.59
Rate for Payer: Superior Health Plan EPO	$10,139.59
Rate for Payer: Superior Health Plan Medicare	$10,139.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,139.59
Rate for Payer: Universal American Medicare	$10,139.59
Rate for Payer: Wellcare Medicare	$10,139.59
Rate for Payer: Wellmed Medicare	$10,139.59

EPISTAXIS W MCC

Facility

$25,298.50

Service Code	MSDRG 150
Min. Negotiated Rate	$11,416.50
Max. Negotiated Rate	$25,298.50
Rate for Payer: BCBS of TX Blue Advantage	$11,416.50
Rate for Payer: BCBS of TX Blue Essentials	$13,698.47
Rate for Payer: BCBS of TX PPO	$15,221.11

EPISTAXIS W/O MCC

Facility

$13,946.00

Service Code	MSDRG 151
Min. Negotiated Rate	$6,052.68
Max. Negotiated Rate	$13,946.00
Rate for Payer: BCBS of TX Blue Advantage	$6,052.68
Rate for Payer: BCBS of TX Blue Essentials	$7,262.51
Rate for Payer: BCBS of TX PPO	$8,069.77

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	$7.97
Max. Negotiated Rate	$258.26
Rate for Payer: Amerigroup CHIP/Medicaid	$32.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.97
Rate for Payer: Amerigroup Medicare	$7.97
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	$7.97
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 Medicaid	$258.26
Rate for Payer: Cigna Medicare	$7.97
Rate for Payer: Employer Direct Commercial	$7.97
Rate for Payer: Humana Medicare/TRICARE	$7.97
Rate for Payer: Molina CHIP/Medicaid	$258.26
Rate for Payer: Molina Dual Medicare/Medicaid	$7.97
Rate for Payer: Molina Medicare	$7.97
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: Parkland Medicaid	$258.26
Rate for Payer: Scott and White EPO/PPO	$179.35
Rate for Payer: Scott and White Medicare	$7.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$258.26
Rate for Payer: Superior Health Plan EPO	$7.97
Rate for Payer: Superior Health Plan Medicare	$7.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.97
Rate for Payer: Universal American Medicare	$7.97
Rate for Payer: Wellcare Medicare	$7.97
Rate for Payer: Wellmed Medicare	$7.97

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	HCPCS 93623
Hospital Charge Code	4610631
Hospital Revenue Code	480
Min. Negotiated Rate	$168.93
Max. Negotiated Rate	$1,351.44
Rate for Payer: Amerigroup CHIP/Medicaid	$168.93
Rate for Payer: BCBS of TX Blue Advantage	$563.10
Rate for Payer: BCBS of TX Blue Essentials	$675.72
Rate for Payer: BCBS of TX PPO	$750.80
Rate for Payer: Cash Price	$1,276.36
Rate for Payer: Cigna Medicaid	$1,351.44
Rate for Payer: Molina CHIP/Medicaid	$1,351.44
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: Parkland Medicaid	$1,351.44
Rate for Payer: Scott and White EPO/PPO	$938.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,351.44
Rate for Payer: Superior Health Plan EPO	$255.27

EP POST DRUG INFUSION

Facility

$1,877.00

Service Code	HCPCS 93623
Hospital Charge Code	4610631
Hospital Revenue Code	480
Rate for Payer: Cash Price	$1,276.36

EP TEST AICD LEAD & GEN

Facility

$3,586.00

Service Code	HCPCS 93641
Hospital Charge Code	4610635
Hospital Revenue Code	480
Rate for Payer: Cash Price	$2,438.48

EP TEST AICD LEAD & GEN

Facility

$3,586.00

Service Code	HCPCS 93641
Hospital Charge Code	4610635
Hospital Revenue Code	480
Min. Negotiated Rate	$322.74
Max. Negotiated Rate	$2,581.92
Rate for Payer: Amerigroup CHIP/Medicaid	$322.74
Rate for Payer: BCBS of TX Blue Advantage	$1,075.80
Rate for Payer: BCBS of TX Blue Essentials	$1,290.96
Rate for Payer: BCBS of TX PPO	$1,434.40
Rate for Payer: Cash Price	$2,438.48
Rate for Payer: Cigna Medicaid	$2,581.92
Rate for Payer: Molina CHIP/Medicaid	$2,581.92
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: Parkland Medicaid	$2,581.92
Rate for Payer: Scott and White EPO/PPO	$1,793.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,581.92
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	$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 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	$3.87
Max. Negotiated Rate	$577.14
Rate for Payer: Amerigroup CHIP/Medicaid	$72.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.87
Rate for Payer: Amerigroup Medicare	$3.87
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	$3.87
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 Medicaid	$577.14
Rate for Payer: Cigna Medicare	$3.87
Rate for Payer: Employer Direct Commercial	$3.87
Rate for Payer: Humana Medicare/TRICARE	$3.87
Rate for Payer: Molina CHIP/Medicaid	$577.14
Rate for Payer: Molina Dual Medicare/Medicaid	$3.87
Rate for Payer: Molina Medicare	$3.87
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: Parkland Medicaid	$577.14
Rate for Payer: Scott and White EPO/PPO	$400.79
Rate for Payer: Scott and White Medicare	$3.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$577.14
Rate for Payer: Superior Health Plan EPO	$3.87
Rate for Payer: Superior Health Plan Medicare	$3.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.87
Rate for Payer: Universal American Medicare	$3.87
Rate for Payer: Wellcare Medicare	$3.87
Rate for Payer: Wellmed Medicare	$3.87

eptifibatide 2 mg/mL IV Soln 10 mL

Facility

$801.58

Service Code	HCPCS J1327
Hospital Charge Code	77550190
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

$801.58

Service Code	HCPCS J1327
Hospital Charge Code	77550190
Hospital Revenue Code	636
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$577.14
Rate for Payer: Amerigroup CHIP/Medicaid	$72.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.87
Rate for Payer: Amerigroup Medicare	$3.87
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	$3.87
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 Medicaid	$577.14
Rate for Payer: Cigna Medicare	$3.87
Rate for Payer: Employer Direct Commercial	$3.87
Rate for Payer: Humana Medicare/TRICARE	$3.87
Rate for Payer: Molina CHIP/Medicaid	$577.14
Rate for Payer: Molina Dual Medicare/Medicaid	$3.87
Rate for Payer: Molina Medicare	$3.87
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: Parkland Medicaid	$577.14
Rate for Payer: Scott and White EPO/PPO	$400.79
Rate for Payer: Scott and White Medicare	$3.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$577.14
Rate for Payer: Superior Health Plan EPO	$3.87
Rate for Payer: Superior Health Plan Medicare	$3.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.87
Rate for Payer: Universal American Medicare	$3.87
Rate for Payer: Wellcare Medicare	$3.87
Rate for Payer: Wellmed Medicare	$3.87

equipment cover

Facility

$5.45

Hospital Charge Code	993272
Hospital Revenue Code	270
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$3.92
Rate for Payer: Amerigroup CHIP/Medicaid	$0.49
Rate for Payer: BCBS of TX Blue Advantage	$1.64
Rate for Payer: BCBS of TX Blue Essentials	$1.96
Rate for Payer: BCBS of TX PPO	$2.18
Rate for Payer: Cash Price	$3.71
Rate for Payer: Cigna Medicaid	$3.92
Rate for Payer: Molina CHIP/Medicaid	$3.92
Rate for Payer: Multiplan Auto	$3.54
Rate for Payer: Multiplan Commercial	$3.54
Rate for Payer: Multiplan Workers Comp	$3.54
Rate for Payer: Parkland Medicaid	$3.92
Rate for Payer: Scott and White EPO/PPO	$2.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.92
Rate for Payer: Superior Health Plan EPO	$0.74

equipment cover

Facility

$5.45

Hospital Charge Code	993272
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.71

EQUIPMENT COVER 28 X 22 X 56

Facility

$250.65

Hospital Charge Code	993632
Hospital Revenue Code	270
Min. Negotiated Rate	$22.56
Max. Negotiated Rate	$180.47
Rate for Payer: Amerigroup CHIP/Medicaid	$22.56
Rate for Payer: BCBS of TX Blue Advantage	$75.19
Rate for Payer: BCBS of TX Blue Essentials	$90.23
Rate for Payer: BCBS of TX PPO	$100.26
Rate for Payer: Cash Price	$170.44
Rate for Payer: Cigna Medicaid	$180.47
Rate for Payer: Molina CHIP/Medicaid	$180.47
Rate for Payer: Multiplan Auto	$162.92
Rate for Payer: Multiplan Commercial	$162.92
Rate for Payer: Multiplan Workers Comp	$162.92
Rate for Payer: Parkland Medicaid	$180.47
Rate for Payer: Scott and White EPO/PPO	$125.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.47
Rate for Payer: Superior Health Plan EPO	$34.09

EQUIPMENT COVER 28 X 22 X 56

Facility

$250.65

Hospital Charge Code	993632
Hospital Revenue Code	270
Rate for Payer: Cash Price	$170.44

ergocalciferol 50,000 intl units (1.25 mg) Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77550304
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ergocalciferol 50,000 intl units (1.25 mg) Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77550304
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

Know your out-of-pocket cost for care.

All Charges