White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Occult Blood Gastric

Facility

$78.00

Service Code	HCPCS 82271 QW
Hospital Charge Code	1630025
Hospital Revenue Code	301
Rate for Payer: Cash Price	$53.04

Occult Blood Gastric

Facility

$78.00

Service Code	HCPCS 82271 QW
Hospital Charge Code	1630025
Hospital Revenue Code	301
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$56.16
Rate for Payer: Amerigroup CHIP/Medicaid	$2.07
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.32
Rate for Payer: Amerigroup Medicare	$5.32
Rate for Payer: BCBS of TX Blue Advantage	$23.40
Rate for Payer: BCBS of TX Blue Essentials	$28.08
Rate for Payer: BCBS of TX Medicare	$5.32
Rate for Payer: BCBS of TX PPO	$31.20
Rate for Payer: Cash Price	$53.04
Rate for Payer: Cash Price	$53.04
Rate for Payer: Cigna Medicaid	$56.16
Rate for Payer: Cigna Medicare	$5.32
Rate for Payer: Employer Direct Commercial	$5.32
Rate for Payer: Humana Medicare/TRICARE	$5.32
Rate for Payer: Molina CHIP/Medicaid	$56.16
Rate for Payer: Molina Dual Medicare/Medicaid	$5.32
Rate for Payer: Molina Medicare	$5.32
Rate for Payer: Multiplan Auto	$50.70
Rate for Payer: Multiplan Commercial	$50.70
Rate for Payer: Multiplan Workers Comp	$50.70
Rate for Payer: Parkland Medicaid	$56.16
Rate for Payer: Scott and White EPO/PPO	$6.65
Rate for Payer: Scott and White Medicare	$5.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56.16
Rate for Payer: Superior Health Plan EPO	$5.32
Rate for Payer: Superior Health Plan Medicare	$5.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.32
Rate for Payer: Universal American Medicare	$5.32
Rate for Payer: Wellcare Medicare	$5.32
Rate for Payer: Wellmed Medicare	$5.32

octreotide 1000 mcg/mL Inj Soln 5mL

Facility

$203.00

Service Code	HCPCS J2354
Hospital Charge Code	77732009
Hospital Revenue Code	636
Min. Negotiated Rate	$50.75
Max. Negotiated Rate	$101.50
Rate for Payer: Cash Price	$138.04
Rate for Payer: Cigna Commercial	$50.75
Rate for Payer: Scott and White EPO/PPO	$101.50

octreotide 1000 mcg/mL Inj Soln 5mL

Facility

$203.00

Service Code	HCPCS J2354
Hospital Charge Code	77732009
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$146.16
Rate for Payer: Amerigroup CHIP/Medicaid	$18.27
Rate for Payer: BCBS of TX Blue Advantage	$0.90
Rate for Payer: BCBS of TX Blue Essentials	$1.08
Rate for Payer: BCBS of TX PPO	$1.20
Rate for Payer: Cash Price	$138.04
Rate for Payer: Cash Price	$138.04
Rate for Payer: Cigna Medicaid	$146.16
Rate for Payer: Molina CHIP/Medicaid	$146.16
Rate for Payer: Multiplan Auto	$131.95
Rate for Payer: Multiplan Commercial	$131.95
Rate for Payer: Multiplan Workers Comp	$131.95
Rate for Payer: Parkland Medicaid	$146.16
Rate for Payer: Scott and White EPO/PPO	$101.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$146.16
Rate for Payer: Superior Health Plan EPO	$27.61

octreotide 50 mcg/mL Inj Soln 1 mL

Facility

$203.00

Service Code	HCPCS J2354
Hospital Charge Code	77732066
Hospital Revenue Code	636
Min. Negotiated Rate	$50.75
Max. Negotiated Rate	$101.50
Rate for Payer: Cash Price	$138.04
Rate for Payer: Cigna Commercial	$50.75
Rate for Payer: Scott and White EPO/PPO	$101.50

octreotide 50 mcg/mL Inj Soln 1 mL

Facility

$203.00

Service Code	HCPCS J2354
Hospital Charge Code	77732066
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$146.16
Rate for Payer: Amerigroup CHIP/Medicaid	$18.27
Rate for Payer: BCBS of TX Blue Advantage	$0.90
Rate for Payer: BCBS of TX Blue Essentials	$1.08
Rate for Payer: BCBS of TX PPO	$1.20
Rate for Payer: Cash Price	$138.04
Rate for Payer: Cash Price	$138.04
Rate for Payer: Cigna Medicaid	$146.16
Rate for Payer: Molina CHIP/Medicaid	$146.16
Rate for Payer: Multiplan Auto	$131.95
Rate for Payer: Multiplan Commercial	$131.95
Rate for Payer: Multiplan Workers Comp	$131.95
Rate for Payer: Parkland Medicaid	$146.16
Rate for Payer: Scott and White EPO/PPO	$101.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$146.16
Rate for Payer: Superior Health Plan EPO	$27.61

ocular lubricant preserved Ophth Soln 15 mL

Facility

$29.00

Service Code	HCPCS J3490
Hospital Charge Code	77732973
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.72

ocular lubricant preserved Ophth Soln 15 mL

Facility

$29.00

Service Code	HCPCS J3490
Hospital Charge Code	77732973
Hospital Revenue Code	250
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$20.88
Rate for Payer: Amerigroup CHIP/Medicaid	$2.61
Rate for Payer: BCBS of TX Blue Advantage	$8.70
Rate for Payer: BCBS of TX Blue Essentials	$10.44
Rate for Payer: BCBS of TX PPO	$11.60
Rate for Payer: Cash Price	$19.72
Rate for Payer: Cigna Medicaid	$20.88
Rate for Payer: Molina CHIP/Medicaid	$20.88
Rate for Payer: Multiplan Auto	$18.85
Rate for Payer: Multiplan Commercial	$18.85
Rate for Payer: Multiplan Workers Comp	$18.85
Rate for Payer: Parkland Medicaid	$20.88
Rate for Payer: Scott and White EPO/PPO	$14.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.88
Rate for Payer: Superior Health Plan EPO	$3.94

Ocular surface reconstruction amniotic membrane transplantation, multiple layers

Facility

$9,916.35

Service Code	HCPCS 65780
Hospital Charge Code	9900860
Hospital Revenue Code	360
Min. Negotiated Rate	$1,427.68
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,427.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Amerigroup Medicare	$3,949.31
Rate for Payer: BCBS of TX Blue Advantage	$5,222.19
Rate for Payer: BCBS of TX Blue Essentials	$6,254.12
Rate for Payer: BCBS of TX Medicare	$3,949.31
Rate for Payer: BCBS of TX PPO	$7,880.19
Rate for Payer: Cash Price	$6,743.12
Rate for Payer: Cash Price	$6,743.12
Rate for Payer: Cash Price	$6,743.12
Rate for Payer: Cigna Commercial	$8,348.12
Rate for Payer: Cigna Medicaid	$7,139.77
Rate for Payer: Cigna Medicare	$3,949.31
Rate for Payer: Employer Direct Commercial	$3,949.31
Rate for Payer: Humana Medicare/TRICARE	$3,949.31
Rate for Payer: Molina CHIP/Medicaid	$7,139.77
Rate for Payer: Molina Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Molina Medicare	$3,949.31
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	$7,139.77
Rate for Payer: Scott and White EPO/PPO	$7,306.22
Rate for Payer: Scott and White Medicare	$3,949.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,139.77
Rate for Payer: Superior Health Plan EPO	$3,949.31
Rate for Payer: Superior Health Plan Medicare	$3,949.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Universal American Medicare	$3,949.31
Rate for Payer: Wellcare Medicare	$3,949.31
Rate for Payer: Wellmed Medicare	$3,949.31

Ocular surface reconstruction amniotic membrane transplantation, multiple layers

Facility

$10,000.00

Service Code	CPT 65780
Hospital Charge Code	36065780
Hospital Revenue Code	360
Min. Negotiated Rate	$1,427.68
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,427.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Amerigroup Medicare	$3,949.31
Rate for Payer: BCBS of TX Blue Advantage	$5,222.19
Rate for Payer: BCBS of TX Blue Essentials	$6,254.12
Rate for Payer: BCBS of TX Medicare	$3,949.31
Rate for Payer: BCBS of TX PPO	$7,880.19
Rate for Payer: Cigna Commercial	$8,348.12
Rate for Payer: Cigna Medicare	$3,949.31
Rate for Payer: Employer Direct Commercial	$3,949.31
Rate for Payer: Humana Medicare/TRICARE	$3,949.31
Rate for Payer: Molina Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Molina Medicare	$3,949.31
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	$7,306.22
Rate for Payer: Scott and White Medicare	$3,949.31
Rate for Payer: Superior Health Plan EPO	$3,949.31
Rate for Payer: Superior Health Plan Medicare	$3,949.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Universal American Medicare	$3,949.31
Rate for Payer: Wellcare Medicare	$3,949.31
Rate for Payer: Wellmed Medicare	$3,949.31

Ocular surface reconstruction amniotic membrane transplantation, multiple layers

Facility

$9,916.35

Service Code	HCPCS 65780
Hospital Charge Code	9900860
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,743.12

ofloxacin 0.3% Ophth Soln 5 mL

Facility

$268.00

Service Code	HCPCS J3490
Hospital Charge Code	77733456
Hospital Revenue Code	250
Rate for Payer: Cash Price	$182.24

ofloxacin 0.3% Ophth Soln 5 mL

Facility

$268.00

Service Code	HCPCS J3490
Hospital Charge Code	77733456
Hospital Revenue Code	250
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$192.96
Rate for Payer: Amerigroup CHIP/Medicaid	$24.12
Rate for Payer: BCBS of TX Blue Advantage	$80.40
Rate for Payer: BCBS of TX Blue Essentials	$96.48
Rate for Payer: BCBS of TX PPO	$107.20
Rate for Payer: Cash Price	$182.24
Rate for Payer: Cigna Medicaid	$192.96
Rate for Payer: Molina CHIP/Medicaid	$192.96
Rate for Payer: Multiplan Auto	$174.20
Rate for Payer: Multiplan Commercial	$174.20
Rate for Payer: Multiplan Workers Comp	$174.20
Rate for Payer: Parkland Medicaid	$192.96
Rate for Payer: Scott and White EPO/PPO	$134.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.96
Rate for Payer: Superior Health Plan EPO	$36.45

OH CATH B AORTIC -- DHF

Facility

$4,234.73

Hospital Charge Code	81758401
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,879.62

OH CATH B AORTIC -- DHF

Facility

$4,234.73

Hospital Charge Code	81758401
Hospital Revenue Code	272
Min. Negotiated Rate	$381.13
Max. Negotiated Rate	$3,049.01
Rate for Payer: Amerigroup CHIP/Medicaid	$381.13
Rate for Payer: BCBS of TX Blue Advantage	$1,270.42
Rate for Payer: BCBS of TX Blue Essentials	$1,524.50
Rate for Payer: BCBS of TX PPO	$1,693.89
Rate for Payer: Cash Price	$2,879.62
Rate for Payer: Cigna Medicaid	$3,049.01
Rate for Payer: Molina CHIP/Medicaid	$3,049.01
Rate for Payer: Multiplan Auto	$2,752.57
Rate for Payer: Multiplan Commercial	$2,752.57
Rate for Payer: Multiplan Workers Comp	$2,752.57
Rate for Payer: Parkland Medicaid	$3,049.01
Rate for Payer: Scott and White EPO/PPO	$2,117.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,049.01
Rate for Payer: Superior Health Plan EPO	$575.92

OH NDL CARDIO -- DHF

Facility

$276.09

Hospital Charge Code	81758906
Hospital Revenue Code	272
Min. Negotiated Rate	$24.85
Max. Negotiated Rate	$198.78
Rate for Payer: Amerigroup CHIP/Medicaid	$24.85
Rate for Payer: BCBS of TX Blue Advantage	$82.83
Rate for Payer: BCBS of TX Blue Essentials	$99.39
Rate for Payer: BCBS of TX PPO	$110.44
Rate for Payer: Cash Price	$187.74
Rate for Payer: Cigna Medicaid	$198.78
Rate for Payer: Molina CHIP/Medicaid	$198.78
Rate for Payer: Multiplan Auto	$179.46
Rate for Payer: Multiplan Commercial	$179.46
Rate for Payer: Multiplan Workers Comp	$179.46
Rate for Payer: Parkland Medicaid	$198.78
Rate for Payer: Scott and White EPO/PPO	$138.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$198.78
Rate for Payer: Superior Health Plan EPO	$37.55

OH NDL CARDIO -- DHF

Facility

$276.09

Hospital Charge Code	81758906
Hospital Revenue Code	272
Rate for Payer: Cash Price	$187.74

OH TUBING PUMP -- DHF

Facility

$473.26

Hospital Charge Code	81759250
Hospital Revenue Code	272
Rate for Payer: Cash Price	$321.82

OH TUBING PUMP -- DHF

Facility

$473.26

Hospital Charge Code	81759250
Hospital Revenue Code	272
Min. Negotiated Rate	$42.59
Max. Negotiated Rate	$340.75
Rate for Payer: Amerigroup CHIP/Medicaid	$42.59
Rate for Payer: BCBS of TX Blue Advantage	$141.98
Rate for Payer: BCBS of TX Blue Essentials	$170.37
Rate for Payer: BCBS of TX PPO	$189.30
Rate for Payer: Cash Price	$321.82
Rate for Payer: Cigna Medicaid	$340.75
Rate for Payer: Molina CHIP/Medicaid	$340.75
Rate for Payer: Multiplan Auto	$307.62
Rate for Payer: Multiplan Commercial	$307.62
Rate for Payer: Multiplan Workers Comp	$307.62
Rate for Payer: Parkland Medicaid	$340.75
Rate for Payer: Scott and White EPO/PPO	$236.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$340.75
Rate for Payer: Superior Health Plan EPO	$64.36

OLANZapine 10 mg IM Inj

Facility

$81.00

Service Code	HCPCS J3490
Hospital Charge Code	77733827
Hospital Revenue Code	250
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$58.32
Rate for Payer: Amerigroup CHIP/Medicaid	$7.29
Rate for Payer: BCBS of TX Blue Advantage	$24.30
Rate for Payer: BCBS of TX Blue Essentials	$29.16
Rate for Payer: BCBS of TX PPO	$32.40
Rate for Payer: Cash Price	$55.08
Rate for Payer: Cigna Medicaid	$58.32
Rate for Payer: Molina CHIP/Medicaid	$58.32
Rate for Payer: Multiplan Auto	$52.65
Rate for Payer: Multiplan Commercial	$52.65
Rate for Payer: Multiplan Workers Comp	$52.65
Rate for Payer: Parkland Medicaid	$58.32
Rate for Payer: Scott and White EPO/PPO	$40.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$58.32
Rate for Payer: Superior Health Plan EPO	$11.02

OLANZapine 10 mg IM Inj

Facility

$81.00

Service Code	HCPCS J3490
Hospital Charge Code	77733827
Hospital Revenue Code	250
Rate for Payer: Cash Price	$55.08

OLANZapine 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78432803
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
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: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

OLANZapine 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78432803
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

OLANZapine 5 mg Tab

Facility

$30.78

Service Code	HCPCS J3490
Hospital Charge Code	77734410
Hospital Revenue Code	250
Rate for Payer: Cash Price	$20.93

OLANZapine 5 mg Tab

Facility

$30.78

Service Code	HCPCS J3490
Hospital Charge Code	77734410
Hospital Revenue Code	250
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$22.16
Rate for Payer: Amerigroup CHIP/Medicaid	$2.77
Rate for Payer: BCBS of TX Blue Advantage	$9.23
Rate for Payer: BCBS of TX Blue Essentials	$11.08
Rate for Payer: BCBS of TX PPO	$12.31
Rate for Payer: Cash Price	$20.93
Rate for Payer: Cigna Medicaid	$22.16
Rate for Payer: Molina CHIP/Medicaid	$22.16
Rate for Payer: Multiplan Auto	$20.01
Rate for Payer: Multiplan Commercial	$20.01
Rate for Payer: Multiplan Workers Comp	$20.01
Rate for Payer: Parkland Medicaid	$22.16
Rate for Payer: Scott and White EPO/PPO	$15.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.16
Rate for Payer: Superior Health Plan EPO	$4.19

Know your out-of-pocket cost for care.

All Charges