White Rock Medical Center

All Charges

Charge

Type

Setting

Price

AW LARYNGEAL MSK 2 -- DHF

Facility

$70.84

Hospital Charge Code	82011099
Hospital Revenue Code	272
Min. Negotiated Rate	$6.38
Max. Negotiated Rate	$46.05
Rate for Payer: Aetna Commercial	$38.96
Rate for Payer: Amerigroup CHIP/Medicaid	$6.38
Rate for Payer: BCBS of TX Blue Advantage	$21.25
Rate for Payer: BCBS of TX Blue Essentials	$25.50
Rate for Payer: BCBS of TX PPO	$28.34
Rate for Payer: Cash Price	$62.34
Rate for Payer: Multiplan Auto	$46.05
Rate for Payer: Multiplan Commercial	$46.05
Rate for Payer: Multiplan Workers Comp	$46.05
Rate for Payer: Scott and White EPO/PPO	$35.42
Rate for Payer: Superior Health Plan EPO	$9.63

AW LARYNGEAL MSK 2 -- DHF

Facility

$70.84

Hospital Charge Code	82011099
Hospital Revenue Code	272
Rate for Payer: Cash Price	$62.34

AW NASO-PHARYNGL -- DHF

Facility

$66.15

Hospital Charge Code	82011156
Hospital Revenue Code	270
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$36.38
Rate for Payer: Amerigroup CHIP/Medicaid	$5.95
Rate for Payer: BCBS of TX Blue Advantage	$19.84
Rate for Payer: BCBS of TX Blue Essentials	$23.81
Rate for Payer: BCBS of TX PPO	$26.46
Rate for Payer: Cash Price	$58.21
Rate for Payer: Multiplan Auto	$43.00
Rate for Payer: Multiplan Commercial	$43.00
Rate for Payer: Multiplan Workers Comp	$43.00
Rate for Payer: Scott and White EPO/PPO	$33.08
Rate for Payer: Superior Health Plan EPO	$9.00

AW NASO-PHARYNGL -- DHF

Facility

$66.15

Hospital Charge Code	82011156
Hospital Revenue Code	270
Rate for Payer: Cash Price	$58.21

azithromycin 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77390617
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

azithromycin 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77390617
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

azithromycin 500 mg in NS; 250 mL connect

Facility

$128.17

Service Code	HCPCS J0456
Hospital Charge Code	79477098
Hospital Revenue Code	636
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$6.02
Rate for Payer: BCBS of TX Blue Essentials	$7.22
Rate for Payer: BCBS of TX PPO	$8.01
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Superior Health Plan EPO	$17.43

azithromycin 500 mg in NS; 250 mL connect

Facility

$128.17

Service Code	HCPCS J0456
Hospital Charge Code	79477098
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

azithromycin 500 mg IV Inj

Facility

$128.17

Service Code	HCPCS J0456
Hospital Charge Code	77390668
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

azithromycin 500 mg IV Inj

Facility

$128.17

Service Code	HCPCS J0456
Hospital Charge Code	77390668
Hospital Revenue Code	636
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$6.02
Rate for Payer: BCBS of TX Blue Essentials	$7.22
Rate for Payer: BCBS of TX PPO	$8.01
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Superior Health Plan EPO	$17.43

azithromycin 500 mg Tab

Facility

$36.50

Service Code	HCPCS J3490
Hospital Charge Code	77390723
Hospital Revenue Code	250
Rate for Payer: Cash Price	$24.82

azithromycin 500 mg Tab

Facility

$36.50

Service Code	HCPCS J3490
Hospital Charge Code	77390723
Hospital Revenue Code	250
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$23.72
Rate for Payer: Amerigroup CHIP/Medicaid	$3.28
Rate for Payer: BCBS of TX Blue Advantage	$10.95
Rate for Payer: BCBS of TX Blue Essentials	$13.14
Rate for Payer: BCBS of TX PPO	$14.60
Rate for Payer: Cash Price	$24.82
Rate for Payer: Multiplan Auto	$23.72
Rate for Payer: Multiplan Commercial	$23.72
Rate for Payer: Multiplan Workers Comp	$23.72
Rate for Payer: Scott and White EPO/PPO	$18.25
Rate for Payer: Superior Health Plan EPO	$4.96

bacitracin 500 units/g Topical Oint

Facility

$56.43

Service Code	HCPCS J3490
Hospital Charge Code	77391251
Hospital Revenue Code	250
Rate for Payer: Cash Price	$38.37

bacitracin 500 units/g Topical Oint

Facility

$56.43

Service Code	HCPCS J3490
Hospital Charge Code	77391251
Hospital Revenue Code	250
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$36.68
Rate for Payer: Amerigroup CHIP/Medicaid	$5.08
Rate for Payer: BCBS of TX Blue Advantage	$16.93
Rate for Payer: BCBS of TX Blue Essentials	$20.31
Rate for Payer: BCBS of TX PPO	$22.57
Rate for Payer: Cash Price	$38.37
Rate for Payer: Multiplan Auto	$36.68
Rate for Payer: Multiplan Commercial	$36.68
Rate for Payer: Multiplan Workers Comp	$36.68
Rate for Payer: Scott and White EPO/PPO	$28.22
Rate for Payer: Superior Health Plan EPO	$7.67

bacitracin 500 units/g Topical Oint 30 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77391514
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

bacitracin 500 units/g Topical Oint 30 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77391514
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin UD

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78747386
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin UD

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78747386
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

bacitracin zinc 500 units/g Topical Oint

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77391673
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

bacitracin zinc 500 units/g Topical Oint

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77391673
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC

Facility

$37,403.40

Service Code	MSDRG 519
Min. Negotiated Rate	$14,761.90
Max. Negotiated Rate	$37,403.40
Rate for Payer: Aetna Commercial	$22,146.75
Rate for Payer: Aetna Medicare	$25,354.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,902.81
Rate for Payer: Amerigroup Medicare	$16,902.81
Rate for Payer: BCBS of TX Blue Advantage	$14,761.90
Rate for Payer: BCBS of TX Blue Essentials	$19,213.98
Rate for Payer: BCBS of TX Medicare	$16,902.81
Rate for Payer: BCBS of TX PPO	$21,349.69
Rate for Payer: Cigna Commercial	$25,355.57
Rate for Payer: Cigna Medicare	$16,902.81
Rate for Payer: Employer Direct Commercial	$16,902.81
Rate for Payer: Humana Medicare/TRICARE	$16,902.81
Rate for Payer: Molina Dual Medicare/Medicaid	$16,902.81
Rate for Payer: Molina Medicare	$16,902.81
Rate for Payer: Multiplan Auto	$37,403.40
Rate for Payer: Multiplan Commercial	$37,403.40
Rate for Payer: Multiplan Workers Comp	$37,403.40
Rate for Payer: Scott and White EPO/PPO	$17,225.25
Rate for Payer: Scott and White Medicare	$16,902.81
Rate for Payer: Superior Health Plan EPO	$16,902.81
Rate for Payer: Superior Health Plan Medicare	$16,902.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,902.81
Rate for Payer: Universal American Medicare	$16,902.81
Rate for Payer: Wellcare Medicare	$16,902.81
Rate for Payer: Wellmed Medicare	$16,902.81

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR

Facility

$69,384.20

Service Code	MSDRG 518
Min. Negotiated Rate	$24,881.52
Max. Negotiated Rate	$69,384.20
Rate for Payer: Aetna Commercial	$41,082.75
Rate for Payer: Aetna Medicare	$43,371.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,914.24
Rate for Payer: Amerigroup Medicare	$28,914.24
Rate for Payer: BCBS of TX Blue Advantage	$24,881.52
Rate for Payer: BCBS of TX Blue Essentials	$31,990.96
Rate for Payer: BCBS of TX Medicare	$28,914.24
Rate for Payer: BCBS of TX PPO	$35,546.89
Rate for Payer: Cigna Commercial	$47,035.18
Rate for Payer: Cigna Medicare	$28,914.24
Rate for Payer: Employer Direct Commercial	$28,914.24
Rate for Payer: Humana Medicare/TRICARE	$28,914.24
Rate for Payer: Molina Dual Medicare/Medicaid	$28,914.24
Rate for Payer: Molina Medicare	$28,914.24
Rate for Payer: Multiplan Auto	$69,384.20
Rate for Payer: Multiplan Commercial	$69,384.20
Rate for Payer: Multiplan Workers Comp	$69,384.20
Rate for Payer: Scott and White EPO/PPO	$31,953.25
Rate for Payer: Scott and White Medicare	$28,914.24
Rate for Payer: Superior Health Plan EPO	$28,914.24
Rate for Payer: Superior Health Plan Medicare	$28,914.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,914.24
Rate for Payer: Universal American Medicare	$28,914.24
Rate for Payer: Wellcare Medicare	$28,914.24
Rate for Payer: Wellmed Medicare	$28,914.24

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC

Facility

$27,198.50

Service Code	MSDRG 520
Min. Negotiated Rate	$10,598.64
Max. Negotiated Rate	$27,198.50
Rate for Payer: Aetna Commercial	$16,104.38
Rate for Payer: Aetna Medicare	$19,605.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,070.05
Rate for Payer: Amerigroup Medicare	$13,070.05
Rate for Payer: BCBS of TX Blue Advantage	$10,598.64
Rate for Payer: BCBS of TX Blue Essentials	$13,560.20
Rate for Payer: BCBS of TX Medicare	$13,070.05
Rate for Payer: BCBS of TX PPO	$15,067.47
Rate for Payer: Cigna Commercial	$18,437.72
Rate for Payer: Cigna Medicare	$13,070.05
Rate for Payer: Employer Direct Commercial	$13,070.05
Rate for Payer: Humana Medicare/TRICARE	$13,070.05
Rate for Payer: Molina Dual Medicare/Medicaid	$13,070.05
Rate for Payer: Molina Medicare	$13,070.05
Rate for Payer: Multiplan Auto	$27,198.50
Rate for Payer: Multiplan Commercial	$27,198.50
Rate for Payer: Multiplan Workers Comp	$27,198.50
Rate for Payer: Scott and White EPO/PPO	$12,525.62
Rate for Payer: Scott and White Medicare	$13,070.05
Rate for Payer: Superior Health Plan EPO	$13,070.05
Rate for Payer: Superior Health Plan Medicare	$13,070.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,070.05
Rate for Payer: Universal American Medicare	$13,070.05
Rate for Payer: Wellcare Medicare	$13,070.05
Rate for Payer: Wellmed Medicare	$13,070.05

baclofen 10 mg Tab

Facility

$10.75

Service Code	HCPCS J3490
Hospital Charge Code	77393400
Hospital Revenue Code	250
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$6.99
Rate for Payer: Amerigroup CHIP/Medicaid	$0.97
Rate for Payer: BCBS of TX Blue Advantage	$3.22
Rate for Payer: BCBS of TX Blue Essentials	$3.87
Rate for Payer: BCBS of TX PPO	$4.30
Rate for Payer: Cash Price	$7.31
Rate for Payer: Multiplan Auto	$6.99
Rate for Payer: Multiplan Commercial	$6.99
Rate for Payer: Multiplan Workers Comp	$6.99
Rate for Payer: Scott and White EPO/PPO	$5.38
Rate for Payer: Superior Health Plan EPO	$1.46

baclofen 10 mg Tab

Facility

$10.75

Service Code	HCPCS J3490
Hospital Charge Code	77393400
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.31

Know your out-of-pocket cost for care.

All Charges