White Rock Medical Center

All Charges

Charge

Type

Setting

Price

pravastatin 40 mg Tab

Facility

$20.85

Service Code	HCPCS A9270
Hospital Charge Code	77773906
Hospital Revenue Code	636
Min. Negotiated Rate	$5.21
Max. Negotiated Rate	$10.42
Rate for Payer: Cash Price	$14.18
Rate for Payer: Cigna Commercial	$5.21
Rate for Payer: Scott and White EPO/PPO	$10.42

PRC ABLTN EXT INIT VN LS

Facility

$11,222.00

Service Code	CPT 36478
Hospital Charge Code	4616478
Hospital Revenue Code	361
Min. Negotiated Rate	$64.30
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Amerigroup Medicare	$2,915.10
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$2,915.10
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$9,875.36
Rate for Payer: Cash Price	$9,875.36
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$1,118.22
Rate for Payer: Cigna Medicare	$2,915.10
Rate for Payer: Employer Direct Commercial	$2,915.10
Rate for Payer: Humana Medicare/TRICARE	$2,915.10
Rate for Payer: Molina CHIP/Medicaid	$1,118.22
Rate for Payer: Molina Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Molina Medicare	$2,915.10
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	$1,118.22
Rate for Payer: Scott and White EPO/PPO	$64.30
Rate for Payer: Scott and White Medicare	$2,915.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,118.22
Rate for Payer: Superior Health Plan EPO	$2,915.10
Rate for Payer: Superior Health Plan Medicare	$2,915.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Universal American Medicare	$2,915.10
Rate for Payer: Wellcare Medicare	$2,915.10
Rate for Payer: Wellmed Medicare	$2,915.10

PRC ABLTN EXT INIT VN LS

Facility

$11,222.00

Service Code	CPT 36478
Hospital Charge Code	4616478
Hospital Revenue Code	361
Rate for Payer: Cash Price	$9,875.36

Prealbumin

Facility

$304.00

Service Code	CPT 84134
Hospital Charge Code	1703750
Hospital Revenue Code	301
Rate for Payer: Cash Price	$267.52

Prealbumin

Facility

$304.00

Service Code	CPT 84134
Hospital Charge Code	1703750
Hospital Revenue Code	301
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$197.60
Rate for Payer: Aetna Commercial	$15.31
Rate for Payer: Aetna Medicare	$21.88
Rate for Payer: Amerigroup CHIP/Medicaid	$5.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.59
Rate for Payer: Amerigroup Medicare	$14.59
Rate for Payer: BCBS of TX Blue Advantage	$24.07
Rate for Payer: BCBS of TX Blue Essentials	$28.89
Rate for Payer: BCBS of TX Medicare	$14.59
Rate for Payer: BCBS of TX PPO	$32.24
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cigna Medicaid	$14.59
Rate for Payer: Cigna Medicare	$14.59
Rate for Payer: Employer Direct Commercial	$14.59
Rate for Payer: Humana Medicare/TRICARE	$14.59
Rate for Payer: Molina CHIP/Medicaid	$14.59
Rate for Payer: Molina Dual Medicare/Medicaid	$14.59
Rate for Payer: Molina Medicare	$14.59
Rate for Payer: Multiplan Auto	$197.60
Rate for Payer: Multiplan Commercial	$197.60
Rate for Payer: Multiplan Workers Comp	$197.60
Rate for Payer: Parkland Medicaid	$14.59
Rate for Payer: Scott and White EPO/PPO	$18.24
Rate for Payer: Scott and White Medicare	$14.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.59
Rate for Payer: Superior Health Plan EPO	$14.59
Rate for Payer: Superior Health Plan Medicare	$14.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.59
Rate for Payer: Universal American Medicare	$14.59
Rate for Payer: Wellcare Medicare	$14.59
Rate for Payer: Wellmed Medicare	$14.59

prednisoLONE 15 mg/5 mL Oral Syrup 5 mL

Facility

$7.65

Service Code	HCPCS J7510
Hospital Charge Code	77775511
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

prednisoLONE 15 mg/5 mL Oral Syrup 5 mL

Facility

$7.65

Service Code	HCPCS J7510
Hospital Charge Code	77775511
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.28
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.37
Rate for Payer: Cash Price	$5.20
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

prednisoLONE (as sodium phosphate) 5 mg/5 mL Oral Liquid 120 mL

Facility

$18.00

Service Code	HCPCS J7510
Hospital Charge Code	77774664
Hospital Revenue Code	636
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$9.00
Rate for Payer: Cash Price	$12.24
Rate for Payer: Cigna Commercial	$4.50
Rate for Payer: Scott and White EPO/PPO	$9.00

prednisoLONE (as sodium phosphate) 5 mg/5 mL Oral Liquid 120 mL

Facility

$18.00

Service Code	HCPCS J7510
Hospital Charge Code	77774664
Hospital Revenue Code	636
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$11.70
Rate for Payer: Amerigroup CHIP/Medicaid	$1.62
Rate for Payer: BCBS of TX Blue Advantage	$0.28
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.37
Rate for Payer: Cash Price	$12.24
Rate for Payer: Cash Price	$12.24
Rate for Payer: Multiplan Auto	$11.70
Rate for Payer: Multiplan Commercial	$11.70
Rate for Payer: Multiplan Workers Comp	$11.70
Rate for Payer: Scott and White EPO/PPO	$9.00
Rate for Payer: Superior Health Plan EPO	$2.45

prednisoLONE sodium phosphate 15 mg/5 mL Oral Liquid 5 mL REPACK

Facility

$7.65

Service Code	HCPCS J7510
Hospital Charge Code	79171020
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.82
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.82

prednisoLONE sodium phosphate 15 mg/5 mL Oral Liquid 5 mL REPACK

Facility

$7.65

Service Code	HCPCS J7510
Hospital Charge Code	79171020
Hospital Revenue Code	636
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.28
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.37
Rate for Payer: Cash Price	$5.20
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

predniSONE 20 mg Tab

Facility

$7.65

Service Code	HCPCS J7512
Hospital Charge Code	77776950
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.82
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.82

predniSONE 20 mg Tab

Facility

$7.65

Service Code	HCPCS J7512
Hospital Charge Code	77776950
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.01
Rate for Payer: BCBS of TX Blue Essentials	$0.02
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$5.20
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

pregabalin 25 mg capsule

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77777700
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

pregabalin 25 mg capsule

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77777700
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

pregabalin 50 mg Cap

Facility

$34.20

Service Code	HCPCS J3490
Hospital Charge Code	77777798
Hospital Revenue Code	250
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$22.23
Rate for Payer: Amerigroup CHIP/Medicaid	$3.08
Rate for Payer: BCBS of TX Blue Advantage	$10.26
Rate for Payer: BCBS of TX Blue Essentials	$12.31
Rate for Payer: BCBS of TX PPO	$13.68
Rate for Payer: Cash Price	$23.26
Rate for Payer: Multiplan Auto	$22.23
Rate for Payer: Multiplan Commercial	$22.23
Rate for Payer: Multiplan Workers Comp	$22.23
Rate for Payer: Scott and White EPO/PPO	$17.10
Rate for Payer: Superior Health Plan EPO	$4.65

pregabalin 50 mg Cap

Facility

$34.20

Service Code	HCPCS J3490
Hospital Charge Code	77777798
Hospital Revenue Code	250
Rate for Payer: Cash Price	$23.26

PREM-25+W35 -- DHF

Facility

$404.00

Hospital Charge Code	81910903
Hospital Revenue Code	272
Min. Negotiated Rate	$36.36
Max. Negotiated Rate	$262.60
Rate for Payer: Aetna Commercial	$222.20
Rate for Payer: Amerigroup CHIP/Medicaid	$36.36
Rate for Payer: BCBS of TX Blue Advantage	$121.20
Rate for Payer: BCBS of TX Blue Essentials	$145.44
Rate for Payer: BCBS of TX PPO	$161.60
Rate for Payer: Cash Price	$355.52
Rate for Payer: Multiplan Auto	$262.60
Rate for Payer: Multiplan Commercial	$262.60
Rate for Payer: Multiplan Workers Comp	$262.60
Rate for Payer: Scott and White EPO/PPO	$202.00
Rate for Payer: Superior Health Plan EPO	$54.94

PREM-25+W35 -- DHF

Facility

$404.00

Hospital Charge Code	81910903
Hospital Revenue Code	272
Rate for Payer: Cash Price	$355.52

PREMATURITY WITH MAJOR PROBLEMS

Facility

$77,856.30

Service Code	MSDRG 791
Min. Negotiated Rate	$30,948.82
Max. Negotiated Rate	$77,856.30
Rate for Payer: Aetna Commercial	$46,099.12
Rate for Payer: Aetna Medicare	$48,144.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$32,096.20
Rate for Payer: Amerigroup Medicare	$32,096.20
Rate for Payer: BCBS of TX Blue Advantage	$30,948.82
Rate for Payer: BCBS of TX Blue Essentials	$38,665.29
Rate for Payer: BCBS of TX Medicare	$32,096.20
Rate for Payer: BCBS of TX PPO	$42,963.10
Rate for Payer: Cigna Commercial	$52,778.38
Rate for Payer: Cigna Medicare	$32,096.20
Rate for Payer: Employer Direct Commercial	$32,096.20
Rate for Payer: Humana Medicare/TRICARE	$32,096.20
Rate for Payer: Molina Dual Medicare/Medicaid	$32,096.20
Rate for Payer: Molina Medicare	$32,096.20
Rate for Payer: Multiplan Auto	$77,856.30
Rate for Payer: Multiplan Commercial	$77,856.30
Rate for Payer: Multiplan Workers Comp	$77,856.30
Rate for Payer: Scott and White EPO/PPO	$35,854.88
Rate for Payer: Scott and White Medicare	$32,096.20
Rate for Payer: Superior Health Plan EPO	$32,096.20
Rate for Payer: Superior Health Plan Medicare	$32,096.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$32,096.20
Rate for Payer: Universal American Medicare	$32,096.20
Rate for Payer: Wellcare Medicare	$32,096.20
Rate for Payer: Wellmed Medicare	$32,096.20

PREMATURITY WITHOUT MAJOR PROBLEMS

Facility

$46,977.50

Service Code	MSDRG 792
Min. Negotiated Rate	$18,673.18
Max. Negotiated Rate	$46,977.50
Rate for Payer: Aetna Commercial	$27,815.62
Rate for Payer: Aetna Medicare	$30,748.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,498.69
Rate for Payer: Amerigroup Medicare	$20,498.69
Rate for Payer: BCBS of TX Blue Advantage	$18,673.18
Rate for Payer: BCBS of TX Blue Essentials	$23,329.20
Rate for Payer: BCBS of TX Medicare	$20,498.69
Rate for Payer: BCBS of TX PPO	$25,922.33
Rate for Payer: Cigna Commercial	$31,845.80
Rate for Payer: Cigna Medicare	$20,498.69
Rate for Payer: Employer Direct Commercial	$20,498.69
Rate for Payer: Humana Medicare/TRICARE	$20,498.69
Rate for Payer: Molina Dual Medicare/Medicaid	$20,498.69
Rate for Payer: Molina Medicare	$20,498.69
Rate for Payer: Multiplan Auto	$46,977.50
Rate for Payer: Multiplan Commercial	$46,977.50
Rate for Payer: Multiplan Workers Comp	$46,977.50
Rate for Payer: Scott and White EPO/PPO	$21,634.38
Rate for Payer: Scott and White Medicare	$20,498.69
Rate for Payer: Superior Health Plan EPO	$20,498.69
Rate for Payer: Superior Health Plan Medicare	$20,498.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,498.69
Rate for Payer: Universal American Medicare	$20,498.69
Rate for Payer: Wellcare Medicare	$20,498.69
Rate for Payer: Wellmed Medicare	$20,498.69

PREMIX midazolam 50 mg in 0.9% NaCl; 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8348674
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

PREMIX midazolam 50 mg in 0.9% NaCl; 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8348674
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

PREMIX niCARdipine 25 mg in D5W; 250 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	8348673
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

PREMIX niCARdipine 25 mg in D5W; 250 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	8348673
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

Know your out-of-pocket cost for care.

All Charges