White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Procalcitonin

Facility

$341.00

Service Code	CPT 84145
Hospital Charge Code	1740965
Hospital Revenue Code	301
Rate for Payer: Cash Price	$300.08

Procalcitonin SO

Facility

$341.00

Service Code	CPT 84145
Hospital Charge Code	7258374
Hospital Revenue Code	301
Rate for Payer: Cash Price	$300.08

Procalcitonin SO

Facility

$341.00

Service Code	CPT 84145
Hospital Charge Code	7258374
Hospital Revenue Code	301
Min. Negotiated Rate	$10.62
Max. Negotiated Rate	$221.65
Rate for Payer: Aetna Commercial	$28.58
Rate for Payer: Aetna Medicare	$40.83
Rate for Payer: Amerigroup CHIP/Medicaid	$10.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.22
Rate for Payer: Amerigroup Medicare	$27.22
Rate for Payer: BCBS of TX Blue Advantage	$44.91
Rate for Payer: BCBS of TX Blue Essentials	$53.90
Rate for Payer: BCBS of TX Medicare	$27.22
Rate for Payer: BCBS of TX PPO	$60.16
Rate for Payer: Cash Price	$300.08
Rate for Payer: Cash Price	$300.08
Rate for Payer: Cigna Medicaid	$27.22
Rate for Payer: Cigna Medicare	$27.22
Rate for Payer: Employer Direct Commercial	$27.22
Rate for Payer: Humana Medicare/TRICARE	$27.22
Rate for Payer: Molina CHIP/Medicaid	$27.22
Rate for Payer: Molina Dual Medicare/Medicaid	$27.22
Rate for Payer: Molina Medicare	$27.22
Rate for Payer: Multiplan Auto	$221.65
Rate for Payer: Multiplan Commercial	$221.65
Rate for Payer: Multiplan Workers Comp	$221.65
Rate for Payer: Parkland Medicaid	$27.22
Rate for Payer: Scott and White EPO/PPO	$34.02
Rate for Payer: Scott and White Medicare	$27.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.22
Rate for Payer: Superior Health Plan EPO	$27.22
Rate for Payer: Superior Health Plan Medicare	$27.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.22
Rate for Payer: Universal American Medicare	$27.22
Rate for Payer: Wellcare Medicare	$27.22
Rate for Payer: Wellmed Medicare	$27.22

PROCEED GRAFT PATCH

Facility

$3,272.47

Service Code	HCPCS C1781
Hospital Charge Code	8432541
Hospital Revenue Code	278
Min. Negotiated Rate	$294.52
Max. Negotiated Rate	$1,636.24
Rate for Payer: Aetna Commercial	$981.74
Rate for Payer: Amerigroup CHIP/Medicaid	$294.52
Rate for Payer: BCBS of TX Blue Advantage	$981.74
Rate for Payer: BCBS of TX Blue Essentials	$1,178.09
Rate for Payer: BCBS of TX PPO	$1,308.99
Rate for Payer: Cash Price	$2,879.77
Rate for Payer: Multiplan Auto	$1,636.24
Rate for Payer: Multiplan Commercial	$1,636.24
Rate for Payer: Multiplan Workers Comp	$1,636.24
Rate for Payer: Scott and White EPO/PPO	$1,636.24
Rate for Payer: Superior Health Plan EPO	$445.06

PROCEED GRAFT PATCH

Facility

$3,272.47

Service Code	HCPCS C1781
Hospital Charge Code	8432541
Hospital Revenue Code	278
Min. Negotiated Rate	$818.12
Max. Negotiated Rate	$1,636.24
Rate for Payer: Aetna Commercial	$981.74
Rate for Payer: Cash Price	$2,879.77
Rate for Payer: Cigna Commercial	$818.12
Rate for Payer: Multiplan Auto	$1,636.24
Rate for Payer: Multiplan Commercial	$1,636.24
Rate for Payer: Multiplan Workers Comp	$1,636.24
Rate for Payer: Scott and White EPO/PPO	$1,636.24

prochlorperazine 5 mg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J0780
Hospital Charge Code	77779958
Hospital Revenue Code	636
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	$18.04
Rate for Payer: BCBS of TX Blue Essentials	$21.65
Rate for Payer: BCBS of TX PPO	$24.01
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

prochlorperazine 5 mg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J0780
Hospital Charge Code	77779958
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

Progesterone SO

Facility

$54.00

Service Code	CPT 84144
Hospital Charge Code	1704006
Hospital Revenue Code	301
Rate for Payer: Cash Price	$47.52

Progesterone SO

Facility

$54.00

Service Code	CPT 84144
Hospital Charge Code	1704006
Hospital Revenue Code	301
Min. Negotiated Rate	$8.14
Max. Negotiated Rate	$46.10
Rate for Payer: Aetna Commercial	$21.91
Rate for Payer: Aetna Medicare	$31.29
Rate for Payer: Amerigroup CHIP/Medicaid	$8.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.86
Rate for Payer: Amerigroup Medicare	$20.86
Rate for Payer: BCBS of TX Blue Advantage	$34.42
Rate for Payer: BCBS of TX Blue Essentials	$41.30
Rate for Payer: BCBS of TX Medicare	$20.86
Rate for Payer: BCBS of TX PPO	$46.10
Rate for Payer: Cash Price	$47.52
Rate for Payer: Cash Price	$47.52
Rate for Payer: Cigna Medicaid	$20.86
Rate for Payer: Cigna Medicare	$20.86
Rate for Payer: Employer Direct Commercial	$20.86
Rate for Payer: Humana Medicare/TRICARE	$20.86
Rate for Payer: Molina CHIP/Medicaid	$20.86
Rate for Payer: Molina Dual Medicare/Medicaid	$20.86
Rate for Payer: Molina Medicare	$20.86
Rate for Payer: Multiplan Auto	$35.10
Rate for Payer: Multiplan Commercial	$35.10
Rate for Payer: Multiplan Workers Comp	$35.10
Rate for Payer: Parkland Medicaid	$20.86
Rate for Payer: Scott and White EPO/PPO	$26.08
Rate for Payer: Scott and White Medicare	$20.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.86
Rate for Payer: Superior Health Plan EPO	$20.86
Rate for Payer: Superior Health Plan Medicare	$20.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.86
Rate for Payer: Universal American Medicare	$20.86
Rate for Payer: Wellcare Medicare	$20.86
Rate for Payer: Wellmed Medicare	$20.86

Prolactin SO

Facility

$376.00

Service Code	CPT 84146
Hospital Charge Code	1602218
Hospital Revenue Code	301
Rate for Payer: Cash Price	$330.88

Prolactin SO

Facility

$376.00

Service Code	CPT 84146
Hospital Charge Code	1602218
Hospital Revenue Code	301
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$244.40
Rate for Payer: Aetna Commercial	$20.35
Rate for Payer: Aetna Medicare	$29.07
Rate for Payer: Amerigroup CHIP/Medicaid	$7.56
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19.38
Rate for Payer: Amerigroup Medicare	$19.38
Rate for Payer: BCBS of TX Blue Advantage	$31.98
Rate for Payer: BCBS of TX Blue Essentials	$38.37
Rate for Payer: BCBS of TX Medicare	$19.38
Rate for Payer: BCBS of TX PPO	$42.83
Rate for Payer: Cash Price	$330.88
Rate for Payer: Cash Price	$330.88
Rate for Payer: Cigna Medicaid	$19.38
Rate for Payer: Cigna Medicare	$19.38
Rate for Payer: Employer Direct Commercial	$19.38
Rate for Payer: Humana Medicare/TRICARE	$19.38
Rate for Payer: Molina CHIP/Medicaid	$19.38
Rate for Payer: Molina Dual Medicare/Medicaid	$19.38
Rate for Payer: Molina Medicare	$19.38
Rate for Payer: Multiplan Auto	$244.40
Rate for Payer: Multiplan Commercial	$244.40
Rate for Payer: Multiplan Workers Comp	$244.40
Rate for Payer: Parkland Medicaid	$19.38
Rate for Payer: Scott and White EPO/PPO	$24.22
Rate for Payer: Scott and White Medicare	$19.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.38
Rate for Payer: Superior Health Plan EPO	$19.38
Rate for Payer: Superior Health Plan Medicare	$19.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$19.38
Rate for Payer: Universal American Medicare	$19.38
Rate for Payer: Wellcare Medicare	$19.38
Rate for Payer: Wellmed Medicare	$19.38

promethazine 25 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS Q0169
Hospital Charge Code	77780906
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.09
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.12
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

promethazine 25 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS Q0169
Hospital Charge Code	77780906
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

promethazine 25mg Tab

Facility

$7.65

Service Code	HCPCS Q0169
Hospital Charge Code	78419587
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.09
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.12
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

promethazine 25mg Tab

Facility

$7.65

Service Code	HCPCS Q0169
Hospital Charge Code	78419587
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

promethazine 6.25 mg/5 mL Oral Syrup 5 mL

Facility

$8.00

Service Code	HCPCS Q0169
Hospital Charge Code	79181839
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

promethazine 6.25 mg/5 mL Oral Syrup 5 mL

Facility

$8.00

Service Code	HCPCS Q0169
Hospital Charge Code	79181839
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$0.09
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.12
Rate for Payer: Cash Price	$5.44
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

propofol 10 mg/mL IV Emulsion 100 mL

Facility

$128.17

Service Code	HCPCS J2704
Hospital Charge Code	77782175
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

propofol 10 mg/mL IV Emulsion 100 mL

Facility

$128.17

Service Code	HCPCS J2704
Hospital Charge Code	77782175
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.25
Rate for Payer: BCBS of TX Blue Essentials	$0.30
Rate for Payer: BCBS of TX PPO	$0.33
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

propofol 10 mg/mL IV Emulsion 20 mL

Facility

$128.17

Service Code	HCPCS J2704
Hospital Charge Code	77782234
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.25
Rate for Payer: BCBS of TX Blue Essentials	$0.30
Rate for Payer: BCBS of TX PPO	$0.33
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

propofol 10 mg/mL IV Emulsion 20 mL

Facility

$128.17

Service Code	HCPCS J2704
Hospital Charge Code	77782234
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

propranolol 10 mg Tab

Facility

$7.65

Service Code	HCPCS J2704
Hospital Charge Code	77782580
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

propranolol 10 mg Tab

Facility

$7.65

Service Code	HCPCS J2704
Hospital Charge Code	77782580
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.25
Rate for Payer: BCBS of TX Blue Essentials	$0.30
Rate for Payer: BCBS of TX PPO	$0.33
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

propranolol 40 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77782894
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

propranolol 40 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77782894
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Know your out-of-pocket cost for care.

All Charges