White Rock Medical Center

All Charges

Charge

Type

Setting

Price

rocuronium 10 mg/mL IV Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77797828
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

rocuronium 10 mg/mL IV Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77797828
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

rocuronium 10 mg/mL IV Soln 5 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77797883
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

rocuronium 10 mg/mL IV Soln 5 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77797883
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

ROD 5.5MM X 60MM

Facility

$6,024.10

Service Code	HCPCS C1713
Hospital Charge Code	8394460
Hospital Revenue Code	278
Min. Negotiated Rate	$1,506.02
Max. Negotiated Rate	$3,012.05
Rate for Payer: Aetna Commercial	$1,807.23
Rate for Payer: Cash Price	$5,301.21
Rate for Payer: Cigna Commercial	$1,506.02
Rate for Payer: Multiplan Auto	$3,012.05
Rate for Payer: Multiplan Commercial	$3,012.05
Rate for Payer: Multiplan Workers Comp	$3,012.05
Rate for Payer: Scott and White EPO/PPO	$3,012.05

ROD 5.5MM X 60MM

Facility

$6,024.10

Service Code	HCPCS C1713
Hospital Charge Code	8394460
Hospital Revenue Code	278
Min. Negotiated Rate	$542.17
Max. Negotiated Rate	$3,012.05
Rate for Payer: Aetna Commercial	$1,807.23
Rate for Payer: Amerigroup CHIP/Medicaid	$542.17
Rate for Payer: BCBS of TX Blue Advantage	$1,807.23
Rate for Payer: BCBS of TX Blue Essentials	$2,168.68
Rate for Payer: BCBS of TX PPO	$2,409.64
Rate for Payer: Cash Price	$5,301.21
Rate for Payer: Multiplan Auto	$3,012.05
Rate for Payer: Multiplan Commercial	$3,012.05
Rate for Payer: Multiplan Workers Comp	$3,012.05
Rate for Payer: Scott and White EPO/PPO	$3,012.05
Rate for Payer: Superior Health Plan EPO	$819.28

rod 5.5 x 80mm

Facility

$1,445.78

Service Code	HCPCS C1713
Hospital Charge Code	8708545
Hospital Revenue Code	278
Min. Negotiated Rate	$130.12
Max. Negotiated Rate	$722.89
Rate for Payer: Aetna Commercial	$433.73
Rate for Payer: Amerigroup CHIP/Medicaid	$130.12
Rate for Payer: BCBS of TX Blue Advantage	$433.73
Rate for Payer: BCBS of TX Blue Essentials	$520.48
Rate for Payer: BCBS of TX PPO	$578.31
Rate for Payer: Cash Price	$1,272.29
Rate for Payer: Multiplan Auto	$722.89
Rate for Payer: Multiplan Commercial	$722.89
Rate for Payer: Multiplan Workers Comp	$722.89
Rate for Payer: Scott and White EPO/PPO	$722.89
Rate for Payer: Superior Health Plan EPO	$196.63

rod 5.5 x 80mm

Facility

$1,445.78

Service Code	HCPCS C1713
Hospital Charge Code	8708545
Hospital Revenue Code	278
Min. Negotiated Rate	$361.44
Max. Negotiated Rate	$722.89
Rate for Payer: Aetna Commercial	$433.73
Rate for Payer: Cash Price	$1,272.29
Rate for Payer: Cigna Commercial	$361.44
Rate for Payer: Multiplan Auto	$722.89
Rate for Payer: Multiplan Commercial	$722.89
Rate for Payer: Multiplan Workers Comp	$722.89
Rate for Payer: Scott and White EPO/PPO	$722.89

ROD FIXED

Facility

$1,385.54

Service Code	HCPCS C1713
Hospital Charge Code	8504490
Hospital Revenue Code	278
Min. Negotiated Rate	$346.38
Max. Negotiated Rate	$692.77
Rate for Payer: Aetna Commercial	$415.66
Rate for Payer: Cash Price	$1,219.28
Rate for Payer: Cigna Commercial	$346.38
Rate for Payer: Multiplan Auto	$692.77
Rate for Payer: Multiplan Commercial	$692.77
Rate for Payer: Multiplan Workers Comp	$692.77
Rate for Payer: Scott and White EPO/PPO	$692.77

ROD FIXED

Facility

$1,385.54

Service Code	HCPCS C1713
Hospital Charge Code	8504490
Hospital Revenue Code	278
Min. Negotiated Rate	$124.70
Max. Negotiated Rate	$692.77
Rate for Payer: Aetna Commercial	$415.66
Rate for Payer: Amerigroup CHIP/Medicaid	$124.70
Rate for Payer: BCBS of TX Blue Advantage	$415.66
Rate for Payer: BCBS of TX Blue Essentials	$498.79
Rate for Payer: BCBS of TX PPO	$554.22
Rate for Payer: Cash Price	$1,219.28
Rate for Payer: Multiplan Auto	$692.77
Rate for Payer: Multiplan Commercial	$692.77
Rate for Payer: Multiplan Workers Comp	$692.77
Rate for Payer: Scott and White EPO/PPO	$692.77
Rate for Payer: Superior Health Plan EPO	$188.43

ROD LUMBAR 65MM

Facility

$1,506.02

Service Code	HCPCS C1713
Hospital Charge Code	145315
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$753.01
Rate for Payer: Aetna Commercial	$451.81
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.81
Rate for Payer: BCBS of TX Blue Essentials	$542.17
Rate for Payer: BCBS of TX PPO	$602.41
Rate for Payer: Cash Price	$1,325.30
Rate for Payer: Multiplan Auto	$753.01
Rate for Payer: Multiplan Commercial	$753.01
Rate for Payer: Multiplan Workers Comp	$753.01
Rate for Payer: Scott and White EPO/PPO	$753.01
Rate for Payer: Superior Health Plan EPO	$204.82

ROD LUMBAR 65MM

Facility

$1,506.02

Service Code	HCPCS C1713
Hospital Charge Code	145315
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.01
Rate for Payer: Aetna Commercial	$451.81
Rate for Payer: Cash Price	$1,325.30
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.01
Rate for Payer: Multiplan Commercial	$753.01
Rate for Payer: Multiplan Workers Comp	$753.01
Rate for Payer: Scott and White EPO/PPO	$753.01

ROD LUMBAR 70MM

Facility

$1,506.02

Service Code	HCPCS C1713
Hospital Charge Code	145368
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$753.01
Rate for Payer: Aetna Commercial	$451.81
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.81
Rate for Payer: BCBS of TX Blue Essentials	$542.17
Rate for Payer: BCBS of TX PPO	$602.41
Rate for Payer: Cash Price	$1,325.30
Rate for Payer: Multiplan Auto	$753.01
Rate for Payer: Multiplan Commercial	$753.01
Rate for Payer: Multiplan Workers Comp	$753.01
Rate for Payer: Scott and White EPO/PPO	$753.01
Rate for Payer: Superior Health Plan EPO	$204.82

ROD LUMBAR 70MM

Facility

$1,506.02

Service Code	HCPCS C1713
Hospital Charge Code	145368
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.01
Rate for Payer: Aetna Commercial	$451.81
Rate for Payer: Cash Price	$1,325.30
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.01
Rate for Payer: Multiplan Commercial	$753.01
Rate for Payer: Multiplan Workers Comp	$753.01
Rate for Payer: Scott and White EPO/PPO	$753.01

ROOM/BED: CCU

Facility

$9,266.00

Hospital Charge Code	89003
Hospital Revenue Code	210
Min. Negotiated Rate	$2,500.00
Max. Negotiated Rate	$2,500.00
Rate for Payer: Cash Price	$8,154.08
Rate for Payer: Scott and White EPO/PPO	$2,500.00

ROOM/BED: ICU

Facility

$8,000.00

Hospital Charge Code	19000
Hospital Revenue Code	200
Min. Negotiated Rate	$2,500.00
Max. Negotiated Rate	$2,500.00
Rate for Payer: Cash Price	$7,040.00
Rate for Payer: Scott and White EPO/PPO	$2,500.00

ROOM/BED: ICU Intermediate

Facility

$4,590.00

Hospital Charge Code	1008
Hospital Revenue Code	206
Rate for Payer: Cash Price	$4,039.20

ROOM/BED: NICU Level 2

Facility

$3,470.00

Hospital Charge Code	25007
Hospital Revenue Code	172
Min. Negotiated Rate	$675.00
Max. Negotiated Rate	$2,407.00
Rate for Payer: BCBS of TX Blue Advantage	$675.00
Rate for Payer: BCBS of TX Blue Essentials	$810.00
Rate for Payer: BCBS of TX PPO	$900.00
Rate for Payer: Cash Price	$3,053.60
Rate for Payer: Cigna Commercial	$2,407.00
Rate for Payer: Scott and White EPO/PPO	$1,950.00

ROOM/BED: Nursery Level 1

Facility

$1,125.00

Hospital Charge Code	15008
Hospital Revenue Code	171
Min. Negotiated Rate	$291.00
Max. Negotiated Rate	$745.00
Rate for Payer: BCBS of TX Blue Advantage	$525.00
Rate for Payer: BCBS of TX Blue Essentials	$630.00
Rate for Payer: BCBS of TX PPO	$700.00
Rate for Payer: Cash Price	$990.00
Rate for Payer: Cigna Commercial	$745.00
Rate for Payer: Scott and White EPO/PPO	$291.00

ROOM/BED: Observation

Facility

$110.00

Service Code	HCPCS G0378
Hospital Charge Code	100016
Hospital Revenue Code	762
Min. Negotiated Rate	$14.96
Max. Negotiated Rate	$4,120.00
Rate for Payer: Aetna Commercial	$4,120.00
Rate for Payer: Amerigroup CHIP/Medicaid	$400.00
Rate for Payer: BCBS of TX Blue Advantage	$221.36
Rate for Payer: BCBS of TX Blue Essentials	$264.62
Rate for Payer: BCBS of TX PPO	$295.15
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Multiplan Auto	$71.50
Rate for Payer: Multiplan Commercial	$71.50
Rate for Payer: Multiplan Workers Comp	$71.50
Rate for Payer: Scott and White EPO/PPO	$55.00
Rate for Payer: Superior Health Plan EPO	$14.96

ROOM/BED: Observation

Facility

$110.00

Service Code	HCPCS G0378
Hospital Charge Code	100016
Hospital Revenue Code	762
Rate for Payer: Cash Price	$96.80

ROOM/BED: Private

Facility

$3,000.00

Hospital Charge Code	21006
Hospital Revenue Code	110
Rate for Payer: Cash Price	$2,640.00

ROOM/BED: Private ISOLATION

Facility

$3,000.00

Hospital Charge Code	31005
Hospital Revenue Code	164
Rate for Payer: Cash Price	$2,640.00

ROOM/BED: Private OB

Facility

$3,000.00

Hospital Charge Code	26005
Hospital Revenue Code	112
Rate for Payer: Cash Price	$2,640.00

ROOM/BED: Semi Private

Facility

$2,800.00

Hospital Charge Code	11007
Hospital Revenue Code	120
Rate for Payer: Cash Price	$2,464.00

Know your out-of-pocket cost for care.

All Charges