White Rock Medical Center

All Charges

Charge

Type

Setting

Price

furosemide 10 mg/mL Inj Soln 4 mL

Facility

$128.17

Service Code	HCPCS J1941
Hospital Charge Code	77585248
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

furosemide 20 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585407
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

furosemide 20 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585407
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

furosemide 40 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585462
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

furosemide 40 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585462
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Fusion/Graft of Finger Joint

Facility

$25,038.00

Service Code	HCPCS 26862
Hospital Charge Code	9900374
Hospital Revenue Code	360
Rate for Payer: Cash Price	$17,025.84

Fusion/Graft of Finger Joint

Facility

$10,000.00

Service Code	CPT 26862
Hospital Charge Code	36026862
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Fusion/Graft of Finger Joint

Facility

$25,038.00

Service Code	HCPCS 26862
Hospital Charge Code	9900374
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$18,027.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$17,025.84
Rate for Payer: Cash Price	$17,025.84
Rate for Payer: Cash Price	$17,025.84
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$18,027.36
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$18,027.36
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$18,027.36
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,027.36
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W MCC

Facility

$27,793.20

Service Code	MSDRG 562
Min. Negotiated Rate	$12,109.66
Max. Negotiated Rate	$27,793.20
Rate for Payer: BCBS of TX Blue Advantage	$12,109.66
Rate for Payer: BCBS of TX Blue Essentials	$14,530.18
Rate for Payer: BCBS of TX PPO	$16,145.27

FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC

Facility

$16,362.80

Service Code	MSDRG 563
Min. Negotiated Rate	$7,207.66
Max. Negotiated Rate	$16,362.80
Rate for Payer: BCBS of TX Blue Advantage	$7,207.66
Rate for Payer: BCBS of TX Blue Essentials	$8,648.35
Rate for Payer: BCBS of TX PPO	$9,609.65

G-6-PD, Quant, Blood and RBC SO

Facility

$115.86

Service Code	HCPCS 82955
Hospital Charge Code	1701390
Hospital Revenue Code	301
Rate for Payer: Cash Price	$78.78

G-6-PD, Quant, Blood and RBC SO

Facility

$115.86

Service Code	HCPCS 82955
Hospital Charge Code	1701390
Hospital Revenue Code	301
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$83.42
Rate for Payer: Amerigroup CHIP/Medicaid	$3.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.70
Rate for Payer: Amerigroup Medicare	$9.70
Rate for Payer: BCBS of TX Blue Advantage	$34.76
Rate for Payer: BCBS of TX Blue Essentials	$41.71
Rate for Payer: BCBS of TX Medicare	$9.70
Rate for Payer: BCBS of TX PPO	$46.34
Rate for Payer: Cash Price	$78.78
Rate for Payer: Cash Price	$78.78
Rate for Payer: Cigna Medicaid	$83.42
Rate for Payer: Cigna Medicare	$9.70
Rate for Payer: Employer Direct Commercial	$9.70
Rate for Payer: Humana Medicare/TRICARE	$9.70
Rate for Payer: Molina CHIP/Medicaid	$83.42
Rate for Payer: Molina Dual Medicare/Medicaid	$9.70
Rate for Payer: Molina Medicare	$9.70
Rate for Payer: Multiplan Auto	$75.31
Rate for Payer: Multiplan Commercial	$75.31
Rate for Payer: Multiplan Workers Comp	$75.31
Rate for Payer: Parkland Medicaid	$83.42
Rate for Payer: Scott and White EPO/PPO	$12.12
Rate for Payer: Scott and White Medicare	$9.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83.42
Rate for Payer: Superior Health Plan EPO	$9.70
Rate for Payer: Superior Health Plan Medicare	$9.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.70
Rate for Payer: Universal American Medicare	$9.70
Rate for Payer: Wellcare Medicare	$9.70
Rate for Payer: Wellmed Medicare	$9.70

G7 OSSEOTI 3 HOLE SHELL 50MM D PROSTHESIS HIP

Facility

$13,640.96

Service Code	HCPCS C1734
Hospital Charge Code	992147
Hospital Revenue Code	278
Min. Negotiated Rate	$1,227.69
Max. Negotiated Rate	$9,821.49
Rate for Payer: Amerigroup CHIP/Medicaid	$1,227.69
Rate for Payer: BCBS of TX Blue Advantage	$4,092.29
Rate for Payer: BCBS of TX Blue Essentials	$4,910.75
Rate for Payer: BCBS of TX PPO	$5,456.38
Rate for Payer: Cash Price	$9,275.85
Rate for Payer: Cigna Medicaid	$9,821.49
Rate for Payer: Molina CHIP/Medicaid	$9,821.49
Rate for Payer: Multiplan Auto	$6,820.48
Rate for Payer: Multiplan Commercial	$6,820.48
Rate for Payer: Multiplan Workers Comp	$6,820.48
Rate for Payer: Parkland Medicaid	$9,821.49
Rate for Payer: Scott and White EPO/PPO	$6,820.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,821.49
Rate for Payer: Superior Health Plan EPO	$1,855.17

G7 OSSEOTI 3 HOLE SHELL 50MM D PROSTHESIS HIP

Facility

$13,640.96

Service Code	HCPCS C1734
Hospital Charge Code	992147
Hospital Revenue Code	278
Min. Negotiated Rate	$3,410.24
Max. Negotiated Rate	$6,820.48
Rate for Payer: Cash Price	$9,275.85
Rate for Payer: Cigna Commercial	$3,410.24
Rate for Payer: Multiplan Auto	$6,820.48
Rate for Payer: Multiplan Commercial	$6,820.48
Rate for Payer: Multiplan Workers Comp	$6,820.48
Rate for Payer: Scott and White EPO/PPO	$6,820.48

G7 OSSEOTI 3 HOLE SHELL 52MM

Facility

$13,978.00

Service Code	HCPCS C1776
Hospital Charge Code	145982
Hospital Revenue Code	278
Min. Negotiated Rate	$1,258.02
Max. Negotiated Rate	$10,064.16
Rate for Payer: Amerigroup CHIP/Medicaid	$1,258.02
Rate for Payer: BCBS of TX Blue Advantage	$4,193.40
Rate for Payer: BCBS of TX Blue Essentials	$5,032.08
Rate for Payer: BCBS of TX PPO	$5,591.20
Rate for Payer: Cash Price	$9,505.04
Rate for Payer: Cigna Medicaid	$10,064.16
Rate for Payer: Molina CHIP/Medicaid	$10,064.16
Rate for Payer: Multiplan Auto	$6,989.00
Rate for Payer: Multiplan Commercial	$6,989.00
Rate for Payer: Multiplan Workers Comp	$6,989.00
Rate for Payer: Parkland Medicaid	$10,064.16
Rate for Payer: Scott and White EPO/PPO	$6,989.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,064.16
Rate for Payer: Superior Health Plan EPO	$1,901.01

G7 OSSEOTI 3 HOLE SHELL 52MM

Facility

$13,978.00

Service Code	HCPCS C1776
Hospital Charge Code	145982
Hospital Revenue Code	278
Min. Negotiated Rate	$3,494.50
Max. Negotiated Rate	$6,989.00
Rate for Payer: Cash Price	$9,505.04
Rate for Payer: Cigna Commercial	$3,494.50
Rate for Payer: Multiplan Auto	$6,989.00
Rate for Payer: Multiplan Commercial	$6,989.00
Rate for Payer: Multiplan Workers Comp	$6,989.00
Rate for Payer: Scott and White EPO/PPO	$6,989.00

G7 OSSEOTI 3 HOLE SHELL 52MM E

Facility

$13,640.96

Service Code	HCPCS C1734
Hospital Charge Code	992298
Hospital Revenue Code	278
Min. Negotiated Rate	$1,227.69
Max. Negotiated Rate	$9,821.49
Rate for Payer: Amerigroup CHIP/Medicaid	$1,227.69
Rate for Payer: BCBS of TX Blue Advantage	$4,092.29
Rate for Payer: BCBS of TX Blue Essentials	$4,910.75
Rate for Payer: BCBS of TX PPO	$5,456.38
Rate for Payer: Cash Price	$9,275.85
Rate for Payer: Cigna Medicaid	$9,821.49
Rate for Payer: Molina CHIP/Medicaid	$9,821.49
Rate for Payer: Multiplan Auto	$6,820.48
Rate for Payer: Multiplan Commercial	$6,820.48
Rate for Payer: Multiplan Workers Comp	$6,820.48
Rate for Payer: Parkland Medicaid	$9,821.49
Rate for Payer: Scott and White EPO/PPO	$6,820.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,821.49
Rate for Payer: Superior Health Plan EPO	$1,855.17

G7 OSSEOTI 3 HOLE SHELL 52MM E

Facility

$13,640.96

Service Code	HCPCS C1734
Hospital Charge Code	992298
Hospital Revenue Code	278
Min. Negotiated Rate	$3,410.24
Max. Negotiated Rate	$6,820.48
Rate for Payer: Cash Price	$9,275.85
Rate for Payer: Cigna Commercial	$3,410.24
Rate for Payer: Multiplan Auto	$6,820.48
Rate for Payer: Multiplan Commercial	$6,820.48
Rate for Payer: Multiplan Workers Comp	$6,820.48
Rate for Payer: Scott and White EPO/PPO	$6,820.48

G7 Osseoti 3 Hole Shell 52MM E Prosthesis Hip

Facility

$12,861.00

Service Code	HCPCS C1776
Hospital Charge Code	145777
Hospital Revenue Code	278
Min. Negotiated Rate	$3,215.25
Max. Negotiated Rate	$6,430.50
Rate for Payer: Cash Price	$8,745.48
Rate for Payer: Cigna Commercial	$3,215.25
Rate for Payer: Multiplan Auto	$6,430.50
Rate for Payer: Multiplan Commercial	$6,430.50
Rate for Payer: Multiplan Workers Comp	$6,430.50
Rate for Payer: Scott and White EPO/PPO	$6,430.50

G7 Osseoti 3 Hole Shell 52MM E Prosthesis Hip

Facility

$12,861.00

Service Code	HCPCS C1776
Hospital Charge Code	145777
Hospital Revenue Code	278
Min. Negotiated Rate	$1,157.49
Max. Negotiated Rate	$9,259.92
Rate for Payer: Amerigroup CHIP/Medicaid	$1,157.49
Rate for Payer: BCBS of TX Blue Advantage	$3,858.30
Rate for Payer: BCBS of TX Blue Essentials	$4,629.96
Rate for Payer: BCBS of TX PPO	$5,144.40
Rate for Payer: Cash Price	$8,745.48
Rate for Payer: Cigna Medicaid	$9,259.92
Rate for Payer: Molina CHIP/Medicaid	$9,259.92
Rate for Payer: Multiplan Auto	$6,430.50
Rate for Payer: Multiplan Commercial	$6,430.50
Rate for Payer: Multiplan Workers Comp	$6,430.50
Rate for Payer: Parkland Medicaid	$9,259.92
Rate for Payer: Scott and White EPO/PPO	$6,430.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,259.92
Rate for Payer: Superior Health Plan EPO	$1,749.10

G7 OSSEOTI 4 HOLE SHELL 62MM

Facility

$15,165.00

Service Code	HCPCS C1776
Hospital Charge Code	9275005
Hospital Revenue Code	278
Min. Negotiated Rate	$3,791.25
Max. Negotiated Rate	$7,582.50
Rate for Payer: Cash Price	$10,312.20
Rate for Payer: Cigna Commercial	$3,791.25
Rate for Payer: Multiplan Auto	$7,582.50
Rate for Payer: Multiplan Commercial	$7,582.50
Rate for Payer: Multiplan Workers Comp	$7,582.50
Rate for Payer: Scott and White EPO/PPO	$7,582.50

G7 OSSEOTI 4 HOLE SHELL 62MM

Facility

$15,165.00

Service Code	HCPCS C1776
Hospital Charge Code	9275005
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.85
Max. Negotiated Rate	$10,918.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1,364.85
Rate for Payer: BCBS of TX Blue Advantage	$4,549.50
Rate for Payer: BCBS of TX Blue Essentials	$5,459.40
Rate for Payer: BCBS of TX PPO	$6,066.00
Rate for Payer: Cash Price	$10,312.20
Rate for Payer: Cigna Medicaid	$10,918.80
Rate for Payer: Molina CHIP/Medicaid	$10,918.80
Rate for Payer: Multiplan Auto	$7,582.50
Rate for Payer: Multiplan Commercial	$7,582.50
Rate for Payer: Multiplan Workers Comp	$7,582.50
Rate for Payer: Parkland Medicaid	$10,918.80
Rate for Payer: Scott and White EPO/PPO	$7,582.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,918.80
Rate for Payer: Superior Health Plan EPO	$2,062.44

gabapentin 100 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585676
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

gabapentin 100 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585676
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

gabapentin 300 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585945
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Know your out-of-pocket cost for care.

All Charges