White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$801.58

Service Code	HCPCS J1327
Hospital Charge Code	77550190
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

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

equipment cover

Facility

$5.45

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

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 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

ertapenem 1 g Inj

Facility

$240.22

Service Code	HCPCS J1335
Hospital Charge Code	77550728
Hospital Revenue Code	636
Min. Negotiated Rate	$21.62
Max. Negotiated Rate	$172.96
Rate for Payer: Amerigroup CHIP/Medicaid	$21.62
Rate for Payer: BCBS of TX Blue Advantage	$48.89
Rate for Payer: BCBS of TX Blue Essentials	$58.67
Rate for Payer: BCBS of TX PPO	$65.08
Rate for Payer: Cash Price	$163.35
Rate for Payer: Cash Price	$163.35
Rate for Payer: Cigna Medicaid	$172.96
Rate for Payer: Molina CHIP/Medicaid	$172.96
Rate for Payer: Multiplan Auto	$156.14
Rate for Payer: Multiplan Commercial	$156.14
Rate for Payer: Multiplan Workers Comp	$156.14
Rate for Payer: Parkland Medicaid	$172.96
Rate for Payer: Scott and White EPO/PPO	$120.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$172.96
Rate for Payer: Superior Health Plan EPO	$32.67

ertapenem 1 g Inj

Facility

$240.22

Service Code	HCPCS J1335
Hospital Charge Code	77550728
Hospital Revenue Code	636
Min. Negotiated Rate	$60.05
Max. Negotiated Rate	$120.11
Rate for Payer: Cash Price	$163.35
Rate for Payer: Cigna Commercial	$60.05
Rate for Payer: Scott and White EPO/PPO	$120.11

erythromycin 0.5% Ophth Oint 1 g

Facility

$34.26

Service Code	HCPCS J3490
Hospital Charge Code	77550785
Hospital Revenue Code	636
Min. Negotiated Rate	$8.56
Max. Negotiated Rate	$17.13
Rate for Payer: Cash Price	$23.30
Rate for Payer: Cigna Commercial	$8.56
Rate for Payer: Scott and White EPO/PPO	$17.13

erythromycin 0.5% Ophth Oint 1 g

Facility

$34.26

Service Code	HCPCS J3490
Hospital Charge Code	77550785
Hospital Revenue Code	636
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$24.67
Rate for Payer: Amerigroup CHIP/Medicaid	$3.08
Rate for Payer: BCBS of TX Blue Advantage	$10.28
Rate for Payer: BCBS of TX Blue Essentials	$12.33
Rate for Payer: BCBS of TX PPO	$13.70
Rate for Payer: Cash Price	$23.30
Rate for Payer: Cigna Medicaid	$24.67
Rate for Payer: Molina CHIP/Medicaid	$24.67
Rate for Payer: Multiplan Auto	$22.27
Rate for Payer: Multiplan Commercial	$22.27
Rate for Payer: Multiplan Workers Comp	$22.27
Rate for Payer: Parkland Medicaid	$24.67
Rate for Payer: Scott and White EPO/PPO	$17.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.67
Rate for Payer: Superior Health Plan EPO	$4.66

erythromycin 0.5% Ophth Oint 3.5 g

Facility

$44.65

Service Code	HCPCS J3490
Hospital Charge Code	77550834
Hospital Revenue Code	250
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$32.15
Rate for Payer: Amerigroup CHIP/Medicaid	$4.02
Rate for Payer: BCBS of TX Blue Advantage	$13.39
Rate for Payer: BCBS of TX Blue Essentials	$16.07
Rate for Payer: BCBS of TX PPO	$17.86
Rate for Payer: Cash Price	$30.36
Rate for Payer: Cigna Medicaid	$32.15
Rate for Payer: Molina CHIP/Medicaid	$32.15
Rate for Payer: Multiplan Auto	$29.02
Rate for Payer: Multiplan Commercial	$29.02
Rate for Payer: Multiplan Workers Comp	$29.02
Rate for Payer: Parkland Medicaid	$32.15
Rate for Payer: Scott and White EPO/PPO	$22.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.15
Rate for Payer: Superior Health Plan EPO	$6.07

erythromycin 0.5% Ophth Oint 3.5 g

Facility

$44.65

Service Code	HCPCS J3490
Hospital Charge Code	77550834
Hospital Revenue Code	250
Rate for Payer: Cash Price	$30.36

Erythropoietin (EPO), Serum SO

Facility

$306.00

Service Code	HCPCS 82668
Hospital Charge Code	1701937
Hospital Revenue Code	301
Rate for Payer: Cash Price	$208.08

Erythropoietin (EPO), Serum SO

Facility

$306.00

Service Code	HCPCS 82668
Hospital Charge Code	1701937
Hospital Revenue Code	301
Min. Negotiated Rate	$7.33
Max. Negotiated Rate	$220.32
Rate for Payer: Amerigroup CHIP/Medicaid	$7.33
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.79
Rate for Payer: Amerigroup Medicare	$18.79
Rate for Payer: BCBS of TX Blue Advantage	$91.80
Rate for Payer: BCBS of TX Blue Essentials	$110.16
Rate for Payer: BCBS of TX Medicare	$18.79
Rate for Payer: BCBS of TX PPO	$122.40
Rate for Payer: Cash Price	$208.08
Rate for Payer: Cash Price	$208.08
Rate for Payer: Cigna Medicaid	$220.32
Rate for Payer: Cigna Medicare	$18.79
Rate for Payer: Employer Direct Commercial	$18.79
Rate for Payer: Humana Medicare/TRICARE	$18.79
Rate for Payer: Molina CHIP/Medicaid	$220.32
Rate for Payer: Molina Dual Medicare/Medicaid	$18.79
Rate for Payer: Molina Medicare	$18.79
Rate for Payer: Multiplan Auto	$198.90
Rate for Payer: Multiplan Commercial	$198.90
Rate for Payer: Multiplan Workers Comp	$198.90
Rate for Payer: Parkland Medicaid	$220.32
Rate for Payer: Scott and White EPO/PPO	$23.49
Rate for Payer: Scott and White Medicare	$18.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$220.32
Rate for Payer: Superior Health Plan EPO	$18.79
Rate for Payer: Superior Health Plan Medicare	$18.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.79
Rate for Payer: Universal American Medicare	$18.79
Rate for Payer: Wellcare Medicare	$18.79
Rate for Payer: Wellmed Medicare	$18.79

escitalopram 10 mg Tab

Facility

$32.90

Service Code	HCPCS J3490
Hospital Charge Code	77552051
Hospital Revenue Code	250
Min. Negotiated Rate	$2.96
Max. Negotiated Rate	$23.69
Rate for Payer: Amerigroup CHIP/Medicaid	$2.96
Rate for Payer: BCBS of TX Blue Advantage	$9.87
Rate for Payer: BCBS of TX Blue Essentials	$11.84
Rate for Payer: BCBS of TX PPO	$13.16
Rate for Payer: Cash Price	$22.37
Rate for Payer: Cigna Medicaid	$23.69
Rate for Payer: Molina CHIP/Medicaid	$23.69
Rate for Payer: Multiplan Auto	$21.39
Rate for Payer: Multiplan Commercial	$21.39
Rate for Payer: Multiplan Workers Comp	$21.39
Rate for Payer: Parkland Medicaid	$23.69
Rate for Payer: Scott and White EPO/PPO	$16.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.69
Rate for Payer: Superior Health Plan EPO	$4.47

escitalopram 10 mg Tab

Facility

$32.90

Service Code	HCPCS J3490
Hospital Charge Code	77552051
Hospital Revenue Code	250
Rate for Payer: Cash Price	$22.37

esmolol 10 mg/mL IV Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77552459
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

esmolol 10 mg/mL IV Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77552459
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

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC

Facility

$24,396.00

Service Code	MSDRG 391
Min. Negotiated Rate	$10,504.90
Max. Negotiated Rate	$24,396.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,055.49
Rate for Payer: Amerigroup Medicare	$14,055.49
Rate for Payer: BCBS of TX Medicare	$14,055.49
Rate for Payer: Cigna Commercial	$16,335.70
Rate for Payer: Cigna Medicare	$14,055.49
Rate for Payer: Employer Direct Commercial	$14,055.49
Rate for Payer: Humana Medicare/TRICARE	$14,055.49
Rate for Payer: Molina Dual Medicare/Medicaid	$14,055.49
Rate for Payer: Molina Medicare	$14,055.49
Rate for Payer: Multiplan Auto	$24,396.00
Rate for Payer: Multiplan Commercial	$24,396.00
Rate for Payer: Multiplan Workers Comp	$24,396.00
Rate for Payer: Scott and White EPO/PPO	$11,235.00
Rate for Payer: Scott and White Medicare	$14,055.49
Rate for Payer: Superior Health Plan EPO	$14,055.49
Rate for Payer: Superior Health Plan Medicare	$14,055.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,055.49
Rate for Payer: Universal American Medicare	$14,055.49
Rate for Payer: Wellcare Medicare	$14,055.49
Rate for Payer: Wellmed Medicare	$14,055.49

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC

Facility

$14,964.40

Service Code	MSDRG 392
Min. Negotiated Rate	$6,496.44
Max. Negotiated Rate	$14,964.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,473.79
Rate for Payer: Amerigroup Medicare	$10,473.79
Rate for Payer: BCBS of TX Medicare	$10,473.79
Rate for Payer: Cigna Commercial	$10,041.25
Rate for Payer: Cigna Medicare	$10,473.79
Rate for Payer: Employer Direct Commercial	$10,473.79
Rate for Payer: Humana Medicare/TRICARE	$10,473.79
Rate for Payer: Molina Dual Medicare/Medicaid	$10,473.79
Rate for Payer: Molina Medicare	$10,473.79
Rate for Payer: Multiplan Auto	$14,964.40
Rate for Payer: Multiplan Commercial	$14,964.40
Rate for Payer: Multiplan Workers Comp	$14,964.40
Rate for Payer: Scott and White EPO/PPO	$6,891.50
Rate for Payer: Scott and White Medicare	$10,473.79
Rate for Payer: Superior Health Plan EPO	$10,473.79
Rate for Payer: Superior Health Plan Medicare	$10,473.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,473.79
Rate for Payer: Universal American Medicare	$10,473.79
Rate for Payer: Wellcare Medicare	$10,473.79
Rate for Payer: Wellmed Medicare	$10,473.79

ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC

Facility

$24,396.00

Service Code	MSDRG 391
Min. Negotiated Rate	$10,504.90
Max. Negotiated Rate	$24,396.00
Rate for Payer: BCBS of TX Blue Advantage	$10,504.90
Rate for Payer: BCBS of TX Blue Essentials	$12,604.66
Rate for Payer: BCBS of TX PPO	$14,005.72

ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC

Facility

$14,964.40

Service Code	MSDRG 392
Min. Negotiated Rate	$6,496.44
Max. Negotiated Rate	$14,964.40
Rate for Payer: BCBS of TX Blue Advantage	$6,496.44
Rate for Payer: BCBS of TX Blue Essentials	$7,794.97
Rate for Payer: BCBS of TX PPO	$8,661.42

Know your out-of-pocket cost for care.

All Charges