White Rock Medical Center

All Charges

Charge

Type

Setting

Price

allograft zavatrix viable 1cc

Facility

$2,910.00

Service Code	HCPCS C1762
Hospital Charge Code	8708542
Hospital Revenue Code	278
Min. Negotiated Rate	$261.90
Max. Negotiated Rate	$2,095.20
Rate for Payer: Amerigroup CHIP/Medicaid	$261.90
Rate for Payer: BCBS of TX Blue Advantage	$873.00
Rate for Payer: BCBS of TX Blue Essentials	$1,047.60
Rate for Payer: BCBS of TX PPO	$1,164.00
Rate for Payer: Cash Price	$1,978.80
Rate for Payer: Cigna Medicaid	$2,095.20
Rate for Payer: Molina CHIP/Medicaid	$2,095.20
Rate for Payer: Multiplan Auto	$1,455.00
Rate for Payer: Multiplan Commercial	$1,455.00
Rate for Payer: Multiplan Workers Comp	$1,455.00
Rate for Payer: Parkland Medicaid	$2,095.20
Rate for Payer: Scott and White EPO/PPO	$1,455.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,095.20
Rate for Payer: Superior Health Plan EPO	$395.76

allograft zavatrix viable 1cc

Facility

$2,910.00

Service Code	HCPCS C1762
Hospital Charge Code	8708542
Hospital Revenue Code	278
Min. Negotiated Rate	$727.50
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$1,978.80
Rate for Payer: Cigna Commercial	$727.50
Rate for Payer: Multiplan Auto	$1,455.00
Rate for Payer: Multiplan Commercial	$1,455.00
Rate for Payer: Multiplan Workers Comp	$1,455.00
Rate for Payer: Scott and White EPO/PPO	$1,455.00

allograft zavatrix viable 2cc

Facility

$5,723.00

Service Code	HCPCS C1762
Hospital Charge Code	8708543
Hospital Revenue Code	278
Min. Negotiated Rate	$515.07
Max. Negotiated Rate	$4,120.56
Rate for Payer: Amerigroup CHIP/Medicaid	$515.07
Rate for Payer: BCBS of TX Blue Advantage	$1,716.90
Rate for Payer: BCBS of TX Blue Essentials	$2,060.28
Rate for Payer: BCBS of TX PPO	$2,289.20
Rate for Payer: Cash Price	$3,891.64
Rate for Payer: Cigna Medicaid	$4,120.56
Rate for Payer: Molina CHIP/Medicaid	$4,120.56
Rate for Payer: Multiplan Auto	$2,861.50
Rate for Payer: Multiplan Commercial	$2,861.50
Rate for Payer: Multiplan Workers Comp	$2,861.50
Rate for Payer: Parkland Medicaid	$4,120.56
Rate for Payer: Scott and White EPO/PPO	$2,861.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,120.56
Rate for Payer: Superior Health Plan EPO	$778.33

allograft zavatrix viable 2cc

Facility

$5,723.00

Service Code	HCPCS C1762
Hospital Charge Code	8708543
Hospital Revenue Code	278
Min. Negotiated Rate	$1,430.75
Max. Negotiated Rate	$2,861.50
Rate for Payer: Cash Price	$3,891.64
Rate for Payer: Cigna Commercial	$1,430.75
Rate for Payer: Multiplan Auto	$2,861.50
Rate for Payer: Multiplan Commercial	$2,861.50
Rate for Payer: Multiplan Workers Comp	$2,861.50
Rate for Payer: Scott and White EPO/PPO	$2,861.50

allograft zavatrix viable 5cc

Facility

$13,554.00

Service Code	HCPCS C1762
Hospital Charge Code	8708548
Hospital Revenue Code	278
Min. Negotiated Rate	$3,388.50
Max. Negotiated Rate	$6,777.00
Rate for Payer: Cash Price	$9,216.72
Rate for Payer: Cigna Commercial	$3,388.50
Rate for Payer: Multiplan Auto	$6,777.00
Rate for Payer: Multiplan Commercial	$6,777.00
Rate for Payer: Multiplan Workers Comp	$6,777.00
Rate for Payer: Scott and White EPO/PPO	$6,777.00

allograft zavatrix viable 5cc

Facility

$13,554.00

Service Code	HCPCS C1762
Hospital Charge Code	8708548
Hospital Revenue Code	278
Min. Negotiated Rate	$1,219.86
Max. Negotiated Rate	$9,758.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1,219.86
Rate for Payer: BCBS of TX Blue Advantage	$4,066.20
Rate for Payer: BCBS of TX Blue Essentials	$4,879.44
Rate for Payer: BCBS of TX PPO	$5,421.60
Rate for Payer: Cash Price	$9,216.72
Rate for Payer: Cigna Medicaid	$9,758.88
Rate for Payer: Molina CHIP/Medicaid	$9,758.88
Rate for Payer: Multiplan Auto	$6,777.00
Rate for Payer: Multiplan Commercial	$6,777.00
Rate for Payer: Multiplan Workers Comp	$6,777.00
Rate for Payer: Parkland Medicaid	$9,758.88
Rate for Payer: Scott and White EPO/PPO	$6,777.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,758.88
Rate for Payer: Superior Health Plan EPO	$1,843.34

allopurinol 100 mg tablet

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77362325
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

allopurinol 100 mg tablet

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77362325
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

ALL POLY PAT VE 35 MM DIA

Facility

$4,168.07

Service Code	HCPCS C1734
Hospital Charge Code	992105
Hospital Revenue Code	278
Min. Negotiated Rate	$375.13
Max. Negotiated Rate	$3,001.01
Rate for Payer: Amerigroup CHIP/Medicaid	$375.13
Rate for Payer: BCBS of TX Blue Advantage	$1,250.42
Rate for Payer: BCBS of TX Blue Essentials	$1,500.51
Rate for Payer: BCBS of TX PPO	$1,667.23
Rate for Payer: Cash Price	$2,834.29
Rate for Payer: Cigna Medicaid	$3,001.01
Rate for Payer: Molina CHIP/Medicaid	$3,001.01
Rate for Payer: Multiplan Auto	$2,084.03
Rate for Payer: Multiplan Commercial	$2,084.03
Rate for Payer: Multiplan Workers Comp	$2,084.03
Rate for Payer: Parkland Medicaid	$3,001.01
Rate for Payer: Scott and White EPO/PPO	$2,084.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,001.01
Rate for Payer: Superior Health Plan EPO	$566.86

ALL POLY PAT VE 35 MM DIA

Facility

$4,168.07

Service Code	HCPCS C1734
Hospital Charge Code	992105
Hospital Revenue Code	278
Min. Negotiated Rate	$1,042.02
Max. Negotiated Rate	$2,084.03
Rate for Payer: Cash Price	$2,834.29
Rate for Payer: Cigna Commercial	$1,042.02
Rate for Payer: Multiplan Auto	$2,084.03
Rate for Payer: Multiplan Commercial	$2,084.03
Rate for Payer: Multiplan Workers Comp	$2,084.03
Rate for Payer: Scott and White EPO/PPO	$2,084.03

alogliptin 12.5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	9199037
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

alogliptin 12.5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	9199037
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Alpha-1-Antitrypsin, Serum SO

Facility

$134.00

Service Code	HCPCS 82103
Hospital Charge Code	1701176
Hospital Revenue Code	301
Min. Negotiated Rate	$5.24
Max. Negotiated Rate	$96.48
Rate for Payer: Amerigroup CHIP/Medicaid	$5.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.44
Rate for Payer: Amerigroup Medicare	$13.44
Rate for Payer: BCBS of TX Blue Advantage	$40.20
Rate for Payer: BCBS of TX Blue Essentials	$48.24
Rate for Payer: BCBS of TX Medicare	$13.44
Rate for Payer: BCBS of TX PPO	$53.60
Rate for Payer: Cash Price	$91.12
Rate for Payer: Cash Price	$91.12
Rate for Payer: Cigna Medicaid	$96.48
Rate for Payer: Cigna Medicare	$13.44
Rate for Payer: Employer Direct Commercial	$13.44
Rate for Payer: Humana Medicare/TRICARE	$13.44
Rate for Payer: Molina CHIP/Medicaid	$96.48
Rate for Payer: Molina Dual Medicare/Medicaid	$13.44
Rate for Payer: Molina Medicare	$13.44
Rate for Payer: Multiplan Auto	$87.10
Rate for Payer: Multiplan Commercial	$87.10
Rate for Payer: Multiplan Workers Comp	$87.10
Rate for Payer: Parkland Medicaid	$96.48
Rate for Payer: Scott and White EPO/PPO	$16.80
Rate for Payer: Scott and White Medicare	$13.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96.48
Rate for Payer: Superior Health Plan EPO	$13.44
Rate for Payer: Superior Health Plan Medicare	$13.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.44
Rate for Payer: Universal American Medicare	$13.44
Rate for Payer: Wellcare Medicare	$13.44
Rate for Payer: Wellmed Medicare	$13.44

Alpha-1-Antitrypsin, Serum SO

Facility

$134.00

Service Code	HCPCS 82103
Hospital Charge Code	1701176
Hospital Revenue Code	301
Rate for Payer: Cash Price	$91.12

ALPRAZolam 0.25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77365028
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ALPRAZolam 0.25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77365028
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

ALPRAZolam 0.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77365183
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

ALPRAZolam 0.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77365183
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ALPRAZolam 1 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77365338
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ALPRAZolam 1 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77365338
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

Alprazolam (Xanax) SO

Facility

$312.00

Service Code	HCPCS 80346
Hospital Charge Code	1743001
Hospital Revenue Code	301
Rate for Payer: Cash Price	$212.16

Alprazolam (Xanax) SO

Facility

$312.00

Service Code	HCPCS 80346
Hospital Charge Code	1743001
Hospital Revenue Code	301
Min. Negotiated Rate	$6.28
Max. Negotiated Rate	$224.64
Rate for Payer: Amerigroup CHIP/Medicaid	$6.28
Rate for Payer: BCBS of TX Blue Advantage	$93.60
Rate for Payer: BCBS of TX Blue Essentials	$112.32
Rate for Payer: BCBS of TX PPO	$124.80
Rate for Payer: Cash Price	$212.16
Rate for Payer: Cash Price	$212.16
Rate for Payer: Cigna Medicaid	$224.64
Rate for Payer: Molina CHIP/Medicaid	$224.64
Rate for Payer: Multiplan Auto	$202.80
Rate for Payer: Multiplan Commercial	$202.80
Rate for Payer: Multiplan Workers Comp	$202.80
Rate for Payer: Parkland Medicaid	$224.64
Rate for Payer: Scott and White EPO/PPO	$156.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$224.64
Rate for Payer: Superior Health Plan EPO	$42.43

alteplase 2 mg Inj

Facility

$380.00

Service Code	HCPCS J2997
Hospital Charge Code	77366310
Hospital Revenue Code	636
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$273.60
Rate for Payer: Amerigroup CHIP/Medicaid	$34.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$93.83
Rate for Payer: Amerigroup Medicare	$93.83
Rate for Payer: BCBS of TX Blue Advantage	$54.59
Rate for Payer: BCBS of TX Blue Essentials	$65.51
Rate for Payer: BCBS of TX Medicare	$93.83
Rate for Payer: BCBS of TX PPO	$72.66
Rate for Payer: Cash Price	$258.40
Rate for Payer: Cash Price	$258.40
Rate for Payer: Cigna Medicaid	$273.60
Rate for Payer: Cigna Medicare	$93.83
Rate for Payer: Employer Direct Commercial	$93.83
Rate for Payer: Humana Medicare/TRICARE	$93.83
Rate for Payer: Molina CHIP/Medicaid	$273.60
Rate for Payer: Molina Dual Medicare/Medicaid	$93.83
Rate for Payer: Molina Medicare	$93.83
Rate for Payer: Multiplan Auto	$247.00
Rate for Payer: Multiplan Commercial	$247.00
Rate for Payer: Multiplan Workers Comp	$247.00
Rate for Payer: Parkland Medicaid	$273.60
Rate for Payer: Scott and White EPO/PPO	$190.00
Rate for Payer: Scott and White Medicare	$93.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$273.60
Rate for Payer: Superior Health Plan EPO	$93.83
Rate for Payer: Superior Health Plan Medicare	$93.83
Rate for Payer: Universal American Dual Medicare/Medicaid	$93.83
Rate for Payer: Universal American Medicare	$93.83
Rate for Payer: Wellcare Medicare	$93.83
Rate for Payer: Wellmed Medicare	$93.83

alteplase 2 mg Inj

Facility

$380.00

Service Code	HCPCS J2997
Hospital Charge Code	77366310
Hospital Revenue Code	636
Min. Negotiated Rate	$95.00
Max. Negotiated Rate	$190.00
Rate for Payer: Cash Price	$258.40
Rate for Payer: Cigna Commercial	$95.00
Rate for Payer: Scott and White EPO/PPO	$190.00

ALTERATION IN CONSCIOUSNESS

Facility

$4,638.29

Service Code	APR-DRG 0523
Min. Negotiated Rate	$4,373.15
Max. Negotiated Rate	$4,638.29
Rate for Payer: Amerigroup CHIP/Medicaid	$4,373.15
Rate for Payer: Cigna Medicaid	$4,373.15
Rate for Payer: Molina CHIP/Medicaid	$4,373.15
Rate for Payer: Parkland Medicaid	$4,373.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,638.29

Know your out-of-pocket cost for care.

All Charges