White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Brucella Antibody IgG/IgM SO

Facility

$58.00

Service Code	CPT 86622
Hospital Charge Code	1708874
Hospital Revenue Code	302
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$37.70
Rate for Payer: Aetna Commercial	$9.38
Rate for Payer: Aetna Medicare	$13.40
Rate for Payer: Amerigroup CHIP/Medicaid	$3.48
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.93
Rate for Payer: Amerigroup Medicare	$8.93
Rate for Payer: BCBS of TX Blue Advantage	$14.73
Rate for Payer: BCBS of TX Blue Essentials	$17.68
Rate for Payer: BCBS of TX Medicare	$8.93
Rate for Payer: BCBS of TX PPO	$19.74
Rate for Payer: Cash Price	$51.04
Rate for Payer: Cash Price	$51.04
Rate for Payer: Cigna Medicaid	$8.93
Rate for Payer: Cigna Medicare	$8.93
Rate for Payer: Employer Direct Commercial	$8.93
Rate for Payer: Humana Medicare/TRICARE	$8.93
Rate for Payer: Molina CHIP/Medicaid	$8.93
Rate for Payer: Molina Dual Medicare/Medicaid	$8.93
Rate for Payer: Molina Medicare	$8.93
Rate for Payer: Multiplan Auto	$37.70
Rate for Payer: Multiplan Commercial	$37.70
Rate for Payer: Multiplan Workers Comp	$37.70
Rate for Payer: Parkland Medicaid	$8.93
Rate for Payer: Scott and White EPO/PPO	$11.16
Rate for Payer: Scott and White Medicare	$8.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.93
Rate for Payer: Superior Health Plan EPO	$8.93
Rate for Payer: Superior Health Plan Medicare	$8.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.93
Rate for Payer: Universal American Medicare	$8.93
Rate for Payer: Wellcare Medicare	$8.93
Rate for Payer: Wellmed Medicare	$8.93

Brucella Antibody IgG/IgM SO

Facility

$58.00

Service Code	CPT 86622
Hospital Charge Code	1708874
Hospital Revenue Code	302
Rate for Payer: Cash Price	$51.04

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Facility

$45.94

Hospital Charge Code	8640530
Hospital Revenue Code	270
Min. Negotiated Rate	$4.13
Max. Negotiated Rate	$29.86
Rate for Payer: Aetna Commercial	$25.27
Rate for Payer: Amerigroup CHIP/Medicaid	$4.13
Rate for Payer: BCBS of TX Blue Advantage	$13.78
Rate for Payer: BCBS of TX Blue Essentials	$16.54
Rate for Payer: BCBS of TX PPO	$18.38
Rate for Payer: Cash Price	$40.43
Rate for Payer: Multiplan Auto	$29.86
Rate for Payer: Multiplan Commercial	$29.86
Rate for Payer: Multiplan Workers Comp	$29.86
Rate for Payer: Scott and White EPO/PPO	$22.97
Rate for Payer: Superior Health Plan EPO	$6.25

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Facility

$45.94

Hospital Charge Code	8640530
Hospital Revenue Code	270
Rate for Payer: Cash Price	$40.43

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Facility

$467.62

Hospital Charge Code	110080
Hospital Revenue Code	272
Min. Negotiated Rate	$42.09
Max. Negotiated Rate	$303.95
Rate for Payer: Aetna Commercial	$257.19
Rate for Payer: Amerigroup CHIP/Medicaid	$42.09
Rate for Payer: BCBS of TX Blue Advantage	$140.29
Rate for Payer: BCBS of TX Blue Essentials	$168.34
Rate for Payer: BCBS of TX PPO	$187.05
Rate for Payer: Cash Price	$411.51
Rate for Payer: Multiplan Auto	$303.95
Rate for Payer: Multiplan Commercial	$303.95
Rate for Payer: Multiplan Workers Comp	$303.95
Rate for Payer: Scott and White EPO/PPO	$233.81
Rate for Payer: Superior Health Plan EPO	$63.60

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Facility

$467.62

Hospital Charge Code	110080
Hospital Revenue Code	272
Rate for Payer: Cash Price	$411.51

BSK RETRV -- DHF

Facility

$1,406.07

Hospital Charge Code	80410756
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,237.34

BSK RETRV -- DHF

Facility

$1,406.07

Hospital Charge Code	80410756
Hospital Revenue Code	272
Min. Negotiated Rate	$126.55
Max. Negotiated Rate	$913.95
Rate for Payer: Aetna Commercial	$773.34
Rate for Payer: Amerigroup CHIP/Medicaid	$126.55
Rate for Payer: BCBS of TX Blue Advantage	$421.82
Rate for Payer: BCBS of TX Blue Essentials	$506.19
Rate for Payer: BCBS of TX PPO	$562.43
Rate for Payer: Cash Price	$1,237.34
Rate for Payer: Multiplan Auto	$913.95
Rate for Payer: Multiplan Commercial	$913.95
Rate for Payer: Multiplan Workers Comp	$913.95
Rate for Payer: Scott and White EPO/PPO	$703.04
Rate for Payer: Superior Health Plan EPO	$191.23

B-Type Natriuretic Peptide

Facility

$499.00

Service Code	CPT 83880
Hospital Charge Code	1605807
Hospital Revenue Code	301
Min. Negotiated Rate	$15.31
Max. Negotiated Rate	$324.35
Rate for Payer: Aetna Commercial	$41.23
Rate for Payer: Aetna Medicare	$58.89
Rate for Payer: Amerigroup CHIP/Medicaid	$15.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$39.26
Rate for Payer: Amerigroup Medicare	$39.26
Rate for Payer: BCBS of TX Blue Advantage	$64.78
Rate for Payer: BCBS of TX Blue Essentials	$77.73
Rate for Payer: BCBS of TX Medicare	$39.26
Rate for Payer: BCBS of TX PPO	$86.76
Rate for Payer: Cash Price	$439.12
Rate for Payer: Cash Price	$439.12
Rate for Payer: Cigna Medicaid	$39.26
Rate for Payer: Cigna Medicare	$39.26
Rate for Payer: Employer Direct Commercial	$39.26
Rate for Payer: Humana Medicare/TRICARE	$39.26
Rate for Payer: Molina CHIP/Medicaid	$39.26
Rate for Payer: Molina Dual Medicare/Medicaid	$39.26
Rate for Payer: Molina Medicare	$39.26
Rate for Payer: Multiplan Auto	$324.35
Rate for Payer: Multiplan Commercial	$324.35
Rate for Payer: Multiplan Workers Comp	$324.35
Rate for Payer: Parkland Medicaid	$39.26
Rate for Payer: Scott and White EPO/PPO	$49.08
Rate for Payer: Scott and White Medicare	$39.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.26
Rate for Payer: Superior Health Plan EPO	$39.26
Rate for Payer: Superior Health Plan Medicare	$39.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$39.26
Rate for Payer: Universal American Medicare	$39.26
Rate for Payer: Wellcare Medicare	$39.26
Rate for Payer: Wellmed Medicare	$39.26

B-Type Natriuretic Peptide

Facility

$499.00

Service Code	CPT 83880
Hospital Charge Code	1605807
Hospital Revenue Code	301
Rate for Payer: Cash Price	$439.12

budesonide 0.5 mg/2 mL Inh Susp 2 mL

Facility

$22.80

Service Code	HCPCS J7633
Hospital Charge Code	7442804
Hospital Revenue Code	636
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$14.82
Rate for Payer: Amerigroup CHIP/Medicaid	$2.05
Rate for Payer: BCBS of TX Blue Advantage	$6.84
Rate for Payer: BCBS of TX Blue Essentials	$8.21
Rate for Payer: BCBS of TX PPO	$9.12
Rate for Payer: Cash Price	$15.50
Rate for Payer: Multiplan Auto	$14.82
Rate for Payer: Multiplan Commercial	$14.82
Rate for Payer: Multiplan Workers Comp	$14.82
Rate for Payer: Scott and White EPO/PPO	$11.40
Rate for Payer: Superior Health Plan EPO	$3.10

budesonide 0.5 mg/2 mL Inh Susp 2 mL

Facility

$22.80

Service Code	HCPCS J7633
Hospital Charge Code	7442804
Hospital Revenue Code	636
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$11.40
Rate for Payer: Cash Price	$15.50
Rate for Payer: Cigna Commercial	$5.70
Rate for Payer: Scott and White EPO/PPO	$11.40

bumetanide 0.25 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442815
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

bumetanide 0.25 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442815
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bumetanide 0.25 mg/mL Inj Soln 4 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442817
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

bumetanide 0.25 mg/mL Inj Soln 4 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442817
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bumetanide 1 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77420317
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

bumetanide 1 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77420317
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

bupivacaine 0.25% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442860
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

bupivacaine 0.25% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442860
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine 0.25% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442864
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

bupivacaine 0.25% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442864
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine 0.25% PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442867
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

bupivacaine 0.25% PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442867
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine 0.5 % 50 ml injection

Facility

$128.19

Service Code	HCPCS J3490
Hospital Charge Code	77424013
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.17

Know your out-of-pocket cost for care.

All Charges