White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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 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
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 1:100,000-1% 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	$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 1:200,000-0.5% 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	$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 1:200,000-1% 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 1:200,000-2% 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

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

EPISTAXIS WITH MCC

Facility

$26,206.70

Service Code	MSDRG 150
Min. Negotiated Rate	$11,416.50
Max. Negotiated Rate	$26,206.70
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	$26,206.70
Rate for Payer: Multiplan Commercial	$26,206.70
Rate for Payer: Multiplan Workers Comp	$26,206.70
Rate for Payer: Scott and White EPO/PPO	$12,068.88
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

$14,649.00

Service Code	MSDRG 151
Min. Negotiated Rate	$6,052.68
Max. Negotiated Rate	$14,649.00
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	$14,649.00
Rate for Payer: Multiplan Commercial	$14,649.00
Rate for Payer: Multiplan Workers Comp	$14,649.00
Rate for Payer: Scott and White EPO/PPO	$6,746.25
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

$26,206.70

Service Code	MSDRG 150
Min. Negotiated Rate	$11,416.50
Max. Negotiated Rate	$26,206.70
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

$14,649.00

Service Code	MSDRG 151
Min. Negotiated Rate	$6,052.68
Max. Negotiated Rate	$14,649.00
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	$7.57
Max. Negotiated Rate	$258.26
Rate for Payer: Amerigroup CHIP/Medicaid	$32.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.57
Rate for Payer: Amerigroup Medicare	$7.57
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	$7.57
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	$7.57
Rate for Payer: Employer Direct Commercial	$7.57
Rate for Payer: Humana Medicare/TRICARE	$7.57
Rate for Payer: Molina CHIP/Medicaid	$258.26
Rate for Payer: Molina Dual Medicare/Medicaid	$7.57
Rate for Payer: Molina Medicare	$7.57
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	$9.78
Rate for Payer: Scott and White Medicare	$7.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$258.26
Rate for Payer: Superior Health Plan EPO	$7.57
Rate for Payer: Superior Health Plan Medicare	$7.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.57
Rate for Payer: Universal American Medicare	$7.57
Rate for Payer: Wellcare Medicare	$7.57
Rate for Payer: Wellmed Medicare	$7.57

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
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

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

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	$3.52
Max. Negotiated Rate	$577.14
Rate for Payer: Amerigroup CHIP/Medicaid	$72.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.52
Rate for Payer: Amerigroup Medicare	$3.52
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	$3.52
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	$3.52
Rate for Payer: Employer Direct Commercial	$3.52
Rate for Payer: Humana Medicare/TRICARE	$3.52
Rate for Payer: Molina CHIP/Medicaid	$577.14
Rate for Payer: Molina Dual Medicare/Medicaid	$3.52
Rate for Payer: Molina Medicare	$3.52
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	$3.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$577.14
Rate for Payer: Superior Health Plan EPO	$3.52
Rate for Payer: Superior Health Plan Medicare	$3.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.52
Rate for Payer: Universal American Medicare	$3.52
Rate for Payer: Wellcare Medicare	$3.52
Rate for Payer: Wellmed Medicare	$3.52

Know your out-of-pocket cost for care.

All Charges