White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KYPHON CEMENT WITH MIXER

Facility

$2,222.89

Service Code	HCPCS C1713
Hospital Charge Code	8484501
Hospital Revenue Code	278
Min. Negotiated Rate	$200.06
Max. Negotiated Rate	$1,111.44
Rate for Payer: Aetna Commercial	$666.87
Rate for Payer: Amerigroup CHIP/Medicaid	$200.06
Rate for Payer: BCBS of TX Blue Advantage	$666.87
Rate for Payer: BCBS of TX Blue Essentials	$800.24
Rate for Payer: BCBS of TX PPO	$889.16
Rate for Payer: Cash Price	$1,956.14
Rate for Payer: Multiplan Auto	$1,111.44
Rate for Payer: Multiplan Commercial	$1,111.44
Rate for Payer: Multiplan Workers Comp	$1,111.44
Rate for Payer: Scott and White EPO/PPO	$1,111.44
Rate for Payer: Superior Health Plan EPO	$302.31

KYPHON FIRST FIX KIT

Facility

$21,565.00

Hospital Charge Code	8484496
Hospital Revenue Code	272
Min. Negotiated Rate	$1,940.85
Max. Negotiated Rate	$14,017.25
Rate for Payer: Aetna Commercial	$11,860.75
Rate for Payer: Amerigroup CHIP/Medicaid	$1,940.85
Rate for Payer: BCBS of TX Blue Advantage	$6,469.50
Rate for Payer: BCBS of TX Blue Essentials	$7,763.40
Rate for Payer: BCBS of TX PPO	$8,626.00
Rate for Payer: Cash Price	$18,977.20
Rate for Payer: Multiplan Auto	$14,017.25
Rate for Payer: Multiplan Commercial	$14,017.25
Rate for Payer: Multiplan Workers Comp	$14,017.25
Rate for Payer: Scott and White EPO/PPO	$10,782.50
Rate for Payer: Superior Health Plan EPO	$2,932.84

KYPHON FIRST FIX KIT

Facility

$21,565.00

Hospital Charge Code	8484496
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18,977.20

labetalol 200 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77649925
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

labetalol 200 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77649925
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

labetalol 5 mg/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J1920
Hospital Charge Code	77650245
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

labetalol 5 mg/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J1920
Hospital Charge Code	77650245
Hospital Revenue Code	636
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$83.31
Rate for Payer: Aetna Medicare	$0.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$0.19
Rate for Payer: Amerigroup Medicare	$0.19
Rate for Payer: BCBS of TX Blue Advantage	$0.39
Rate for Payer: BCBS of TX Blue Essentials	$0.47
Rate for Payer: BCBS of TX Medicare	$0.19
Rate for Payer: BCBS of TX PPO	$0.52
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicare	$0.19
Rate for Payer: Employer Direct Commercial	$0.19
Rate for Payer: Humana Medicare/TRICARE	$0.19
Rate for Payer: Molina Dual Medicare/Medicaid	$0.19
Rate for Payer: Molina Medicare	$0.19
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Scott and White Medicare	$0.19
Rate for Payer: Superior Health Plan EPO	$0.19
Rate for Payer: Superior Health Plan Medicare	$0.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$0.19
Rate for Payer: Universal American Medicare	$0.19
Rate for Payer: Wellcare Medicare	$0.19
Rate for Payer: Wellmed Medicare	$0.19

labetalol 5 mg/mL IV Soln 4 mL

Facility

$128.17

Service Code	HCPCS J1920
Hospital Charge Code	77650190
Hospital Revenue Code	636
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$83.31
Rate for Payer: Aetna Medicare	$0.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$0.19
Rate for Payer: Amerigroup Medicare	$0.19
Rate for Payer: BCBS of TX Blue Advantage	$0.39
Rate for Payer: BCBS of TX Blue Essentials	$0.47
Rate for Payer: BCBS of TX Medicare	$0.19
Rate for Payer: BCBS of TX PPO	$0.52
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicare	$0.19
Rate for Payer: Employer Direct Commercial	$0.19
Rate for Payer: Humana Medicare/TRICARE	$0.19
Rate for Payer: Molina Dual Medicare/Medicaid	$0.19
Rate for Payer: Molina Medicare	$0.19
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Scott and White Medicare	$0.19
Rate for Payer: Superior Health Plan EPO	$0.19
Rate for Payer: Superior Health Plan Medicare	$0.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$0.19
Rate for Payer: Universal American Medicare	$0.19
Rate for Payer: Wellcare Medicare	$0.19
Rate for Payer: Wellmed Medicare	$0.19

labetalol 5 mg/mL IV Soln 4 mL

Facility

$128.17

Service Code	HCPCS J1920
Hospital Charge Code	77650190
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

Labor Level Complex 1st Hour

Facility

$2,345.00

Hospital Charge Code	300038
Hospital Revenue Code	720
Min. Negotiated Rate	$211.05
Max. Negotiated Rate	$1,524.25
Rate for Payer: Aetna Commercial	$1,289.75
Rate for Payer: Amerigroup CHIP/Medicaid	$211.05
Rate for Payer: BCBS of TX Blue Advantage	$703.50
Rate for Payer: BCBS of TX Blue Essentials	$844.20
Rate for Payer: BCBS of TX PPO	$938.00
Rate for Payer: Cash Price	$2,063.60
Rate for Payer: Multiplan Auto	$1,524.25
Rate for Payer: Multiplan Commercial	$1,524.25
Rate for Payer: Multiplan Workers Comp	$1,524.25
Rate for Payer: Scott and White EPO/PPO	$1,172.50
Rate for Payer: Superior Health Plan EPO	$318.92

Labor Level Complex 1st Hour BCE

Facility

$2,345.00

Hospital Charge Code	300038
Hospital Revenue Code	720
Rate for Payer: Cash Price	$2,063.60

Labor Level Complex 1st Hour BCE

Facility

$2,345.00

Hospital Charge Code	300038
Hospital Revenue Code	720
Min. Negotiated Rate	$211.05
Max. Negotiated Rate	$1,524.25
Rate for Payer: Aetna Commercial	$1,289.75
Rate for Payer: Amerigroup CHIP/Medicaid	$211.05
Rate for Payer: BCBS of TX Blue Advantage	$703.50
Rate for Payer: BCBS of TX Blue Essentials	$844.20
Rate for Payer: BCBS of TX PPO	$938.00
Rate for Payer: Cash Price	$2,063.60
Rate for Payer: Multiplan Auto	$1,524.25
Rate for Payer: Multiplan Commercial	$1,524.25
Rate for Payer: Multiplan Workers Comp	$1,524.25
Rate for Payer: Scott and White EPO/PPO	$1,172.50
Rate for Payer: Superior Health Plan EPO	$318.92

Labor Level Complex Additonal Hour

Facility

$1,925.00

Hospital Charge Code	300038
Hospital Revenue Code	720
Min. Negotiated Rate	$173.25
Max. Negotiated Rate	$1,251.25
Rate for Payer: Aetna Commercial	$1,058.75
Rate for Payer: Amerigroup CHIP/Medicaid	$173.25
Rate for Payer: BCBS of TX Blue Advantage	$577.50
Rate for Payer: BCBS of TX Blue Essentials	$693.00
Rate for Payer: BCBS of TX PPO	$770.00
Rate for Payer: Cash Price	$1,694.00
Rate for Payer: Multiplan Auto	$1,251.25
Rate for Payer: Multiplan Commercial	$1,251.25
Rate for Payer: Multiplan Workers Comp	$1,251.25
Rate for Payer: Scott and White EPO/PPO	$962.50
Rate for Payer: Superior Health Plan EPO	$261.80

Labor Level Complex Additonal Hour BCE

Facility

$1,925.00

Hospital Charge Code	300038
Hospital Revenue Code	720
Min. Negotiated Rate	$173.25
Max. Negotiated Rate	$1,251.25
Rate for Payer: Aetna Commercial	$1,058.75
Rate for Payer: Amerigroup CHIP/Medicaid	$173.25
Rate for Payer: BCBS of TX Blue Advantage	$577.50
Rate for Payer: BCBS of TX Blue Essentials	$693.00
Rate for Payer: BCBS of TX PPO	$770.00
Rate for Payer: Cash Price	$1,694.00
Rate for Payer: Multiplan Auto	$1,251.25
Rate for Payer: Multiplan Commercial	$1,251.25
Rate for Payer: Multiplan Workers Comp	$1,251.25
Rate for Payer: Scott and White EPO/PPO	$962.50
Rate for Payer: Superior Health Plan EPO	$261.80

Labor Level Complex Additonal Hour BCE

Facility

$1,925.00

Hospital Charge Code	300038
Hospital Revenue Code	720
Rate for Payer: Cash Price	$1,694.00

Labor Level Intermediate 1st Hour

Facility

$1,060.00

Hospital Charge Code	3101206
Hospital Revenue Code	720
Min. Negotiated Rate	$95.40
Max. Negotiated Rate	$689.00
Rate for Payer: Aetna Commercial	$583.00
Rate for Payer: Amerigroup CHIP/Medicaid	$95.40
Rate for Payer: BCBS of TX Blue Advantage	$318.00
Rate for Payer: BCBS of TX Blue Essentials	$381.60
Rate for Payer: BCBS of TX PPO	$424.00
Rate for Payer: Cash Price	$932.80
Rate for Payer: Multiplan Auto	$689.00
Rate for Payer: Multiplan Commercial	$689.00
Rate for Payer: Multiplan Workers Comp	$689.00
Rate for Payer: Scott and White EPO/PPO	$530.00
Rate for Payer: Superior Health Plan EPO	$144.16

Labor Level Intermediate 1st Hour BCE

Facility

$1,060.00

Hospital Charge Code	3101206
Hospital Revenue Code	720
Min. Negotiated Rate	$95.40
Max. Negotiated Rate	$689.00
Rate for Payer: Aetna Commercial	$583.00
Rate for Payer: Amerigroup CHIP/Medicaid	$95.40
Rate for Payer: BCBS of TX Blue Advantage	$318.00
Rate for Payer: BCBS of TX Blue Essentials	$381.60
Rate for Payer: BCBS of TX PPO	$424.00
Rate for Payer: Cash Price	$932.80
Rate for Payer: Multiplan Auto	$689.00
Rate for Payer: Multiplan Commercial	$689.00
Rate for Payer: Multiplan Workers Comp	$689.00
Rate for Payer: Scott and White EPO/PPO	$530.00
Rate for Payer: Superior Health Plan EPO	$144.16

Labor Level Intermediate 1st Hour BCE

Facility

$1,060.00

Hospital Charge Code	3101206
Hospital Revenue Code	720
Rate for Payer: Cash Price	$932.80

Labor Level Intermediate Additonal Hour

Facility

$850.00

Hospital Charge Code	3101207
Hospital Revenue Code	720
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$552.50
Rate for Payer: Aetna Commercial	$467.50
Rate for Payer: Amerigroup CHIP/Medicaid	$76.50
Rate for Payer: BCBS of TX Blue Advantage	$255.00
Rate for Payer: BCBS of TX Blue Essentials	$306.00
Rate for Payer: BCBS of TX PPO	$340.00
Rate for Payer: Cash Price	$748.00
Rate for Payer: Multiplan Auto	$552.50
Rate for Payer: Multiplan Commercial	$552.50
Rate for Payer: Multiplan Workers Comp	$552.50
Rate for Payer: Scott and White EPO/PPO	$425.00
Rate for Payer: Superior Health Plan EPO	$115.60

Labor Level Intermediate Additonal Hour BCE

Facility

$850.00

Hospital Charge Code	3101207
Hospital Revenue Code	720
Rate for Payer: Cash Price	$748.00

Labor Level Intermediate Additonal Hour BCE

Facility

$850.00

Hospital Charge Code	3101207
Hospital Revenue Code	720
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$552.50
Rate for Payer: Aetna Commercial	$467.50
Rate for Payer: Amerigroup CHIP/Medicaid	$76.50
Rate for Payer: BCBS of TX Blue Advantage	$255.00
Rate for Payer: BCBS of TX Blue Essentials	$306.00
Rate for Payer: BCBS of TX PPO	$340.00
Rate for Payer: Cash Price	$748.00
Rate for Payer: Multiplan Auto	$552.50
Rate for Payer: Multiplan Commercial	$552.50
Rate for Payer: Multiplan Workers Comp	$552.50
Rate for Payer: Scott and White EPO/PPO	$425.00
Rate for Payer: Superior Health Plan EPO	$115.60

Labor Level Simple 1st Hour

Facility

$535.00

Hospital Charge Code	300020
Hospital Revenue Code	720
Min. Negotiated Rate	$48.15
Max. Negotiated Rate	$347.75
Rate for Payer: Aetna Commercial	$294.25
Rate for Payer: Amerigroup CHIP/Medicaid	$48.15
Rate for Payer: BCBS of TX Blue Advantage	$160.50
Rate for Payer: BCBS of TX Blue Essentials	$192.60
Rate for Payer: BCBS of TX PPO	$214.00
Rate for Payer: Cash Price	$470.80
Rate for Payer: Multiplan Auto	$347.75
Rate for Payer: Multiplan Commercial	$347.75
Rate for Payer: Multiplan Workers Comp	$347.75
Rate for Payer: Scott and White EPO/PPO	$267.50
Rate for Payer: Superior Health Plan EPO	$72.76

Labor Level Simple 1st Hour BCE

Facility

$535.00

Hospital Charge Code	300020
Hospital Revenue Code	720
Min. Negotiated Rate	$48.15
Max. Negotiated Rate	$347.75
Rate for Payer: Aetna Commercial	$294.25
Rate for Payer: Amerigroup CHIP/Medicaid	$48.15
Rate for Payer: BCBS of TX Blue Advantage	$160.50
Rate for Payer: BCBS of TX Blue Essentials	$192.60
Rate for Payer: BCBS of TX PPO	$214.00
Rate for Payer: Cash Price	$470.80
Rate for Payer: Multiplan Auto	$347.75
Rate for Payer: Multiplan Commercial	$347.75
Rate for Payer: Multiplan Workers Comp	$347.75
Rate for Payer: Scott and White EPO/PPO	$267.50
Rate for Payer: Superior Health Plan EPO	$72.76

Labor Level Simple 1st Hour BCE

Facility

$535.00

Hospital Charge Code	300020
Hospital Revenue Code	720
Rate for Payer: Cash Price	$470.80

Labor Level Simple Additional Hour

Facility

$430.00

Hospital Charge Code	300020
Hospital Revenue Code	720
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$279.50
Rate for Payer: Aetna Commercial	$236.50
Rate for Payer: Amerigroup CHIP/Medicaid	$38.70
Rate for Payer: BCBS of TX Blue Advantage	$129.00
Rate for Payer: BCBS of TX Blue Essentials	$154.80
Rate for Payer: BCBS of TX PPO	$172.00
Rate for Payer: Cash Price	$378.40
Rate for Payer: Multiplan Auto	$279.50
Rate for Payer: Multiplan Commercial	$279.50
Rate for Payer: Multiplan Workers Comp	$279.50
Rate for Payer: Scott and White EPO/PPO	$215.00
Rate for Payer: Superior Health Plan EPO	$58.48

Know your out-of-pocket cost for care.

All Charges