White Rock Medical Center

All Charges

Charge

Type

Setting

Price

bupivacaine 0.5 % 50 ml injection

Facility

$128.19

Service Code	HCPCS J3490
Hospital Charge Code	77424013
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.32
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.46
Rate for Payer: BCBS of TX Blue Essentials	$46.15
Rate for Payer: BCBS of TX PPO	$51.28
Rate for Payer: Cash Price	$87.17
Rate for Payer: Multiplan Auto	$83.32
Rate for Payer: Multiplan Commercial	$83.32
Rate for Payer: Multiplan Workers Comp	$83.32
Rate for Payer: Scott and White EPO/PPO	$64.10
Rate for Payer: Superior Health Plan EPO	$17.43

bupivacaine 0.5% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442893
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 0.5% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442893
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine 0.5% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442899
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine 0.5% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442899
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 0.5% PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442902
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

bupivacaine 0.5% PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	7442902
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 liposome 1.3% (13.3 mg/mL) Inj Susp 20 mL

Facility

$772.00

Service Code	HCPCS C9290
Hospital Charge Code	77424920
Hospital Revenue Code	636
Min. Negotiated Rate	$69.48
Max. Negotiated Rate	$501.80
Rate for Payer: Aetna Commercial	$424.60
Rate for Payer: Amerigroup CHIP/Medicaid	$69.48
Rate for Payer: BCBS of TX Blue Advantage	$231.60
Rate for Payer: BCBS of TX Blue Essentials	$277.92
Rate for Payer: BCBS of TX PPO	$308.80
Rate for Payer: Cash Price	$524.96
Rate for Payer: Multiplan Auto	$501.80
Rate for Payer: Multiplan Commercial	$501.80
Rate for Payer: Multiplan Workers Comp	$501.80
Rate for Payer: Scott and White EPO/PPO	$386.00
Rate for Payer: Superior Health Plan EPO	$104.99

bupivacaine liposome 1.3% (13.3 mg/mL) Inj Susp 20 mL

Facility

$772.00

Service Code	HCPCS C9290
Hospital Charge Code	77424920
Hospital Revenue Code	636
Min. Negotiated Rate	$193.00
Max. Negotiated Rate	$386.00
Rate for Payer: Cash Price	$524.96
Rate for Payer: Cigna Commercial	$193.00
Rate for Payer: Scott and White EPO/PPO	$386.00

bupivacaine MPF 0.5 % 10 ml vial

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	77424331
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

bupivacaine MPF 0.5 % 10 ml vial

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	77424331
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

buPROPion 100 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77428064
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

buPROPion 100 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77428064
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

buPROPion 150 mg/24 hours (XL) ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	7442973
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

buPROPion 150 mg/24 hours (XL) ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	7442973
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

buPROPion 75mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78414494
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

buPROPion 75mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78414494
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

BURR 4MM ROUND CRSE/ELITE/SABER

Facility

$656.67

Hospital Charge Code	145310
Hospital Revenue Code	272
Rate for Payer: Cash Price	$577.87

BURR 4MM ROUND CRSE/ELITE/SABER

Facility

$656.67

Hospital Charge Code	145310
Hospital Revenue Code	272
Min. Negotiated Rate	$59.10
Max. Negotiated Rate	$426.84
Rate for Payer: Aetna Commercial	$361.17
Rate for Payer: Amerigroup CHIP/Medicaid	$59.10
Rate for Payer: BCBS of TX Blue Advantage	$197.00
Rate for Payer: BCBS of TX Blue Essentials	$236.40
Rate for Payer: BCBS of TX PPO	$262.67
Rate for Payer: Cash Price	$577.87
Rate for Payer: Multiplan Auto	$426.84
Rate for Payer: Multiplan Commercial	$426.84
Rate for Payer: Multiplan Workers Comp	$426.84
Rate for Payer: Scott and White EPO/PPO	$328.34
Rate for Payer: Superior Health Plan EPO	$89.31

burr 5.0mm standard

Facility

$249.70

Hospital Charge Code	144830
Hospital Revenue Code	272
Rate for Payer: Cash Price	$219.74

burr 5.0mm standard

Facility

$249.70

Hospital Charge Code	144830
Hospital Revenue Code	272
Min. Negotiated Rate	$22.47
Max. Negotiated Rate	$162.30
Rate for Payer: Aetna Commercial	$137.34
Rate for Payer: Amerigroup CHIP/Medicaid	$22.47
Rate for Payer: BCBS of TX Blue Advantage	$74.91
Rate for Payer: BCBS of TX Blue Essentials	$89.89
Rate for Payer: BCBS of TX PPO	$99.88
Rate for Payer: Cash Price	$219.74
Rate for Payer: Multiplan Auto	$162.30
Rate for Payer: Multiplan Commercial	$162.30
Rate for Payer: Multiplan Workers Comp	$162.30
Rate for Payer: Scott and White EPO/PPO	$124.85
Rate for Payer: Superior Health Plan EPO	$33.96

BURR BON S -- DHF

Facility

$799.63

Hospital Charge Code	81728453
Hospital Revenue Code	272
Rate for Payer: Cash Price	$703.67

BURR BON S -- DHF

Facility

$799.63

Hospital Charge Code	81728453
Hospital Revenue Code	272
Min. Negotiated Rate	$71.97
Max. Negotiated Rate	$519.76
Rate for Payer: Aetna Commercial	$439.80
Rate for Payer: Amerigroup CHIP/Medicaid	$71.97
Rate for Payer: BCBS of TX Blue Advantage	$239.89
Rate for Payer: BCBS of TX Blue Essentials	$287.87
Rate for Payer: BCBS of TX PPO	$319.85
Rate for Payer: Cash Price	$703.67
Rate for Payer: Multiplan Auto	$519.76
Rate for Payer: Multiplan Commercial	$519.76
Rate for Payer: Multiplan Workers Comp	$519.76
Rate for Payer: Scott and White EPO/PPO	$399.82
Rate for Payer: Superior Health Plan EPO	$108.75

BURR CARBIDE OVAL -- DHF

Facility

$94.99

Hospital Charge Code	81728560
Hospital Revenue Code	272
Rate for Payer: Cash Price	$83.59

BURR CARBIDE OVAL -- DHF

Facility

$94.99

Hospital Charge Code	81728560
Hospital Revenue Code	272
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$61.74
Rate for Payer: Aetna Commercial	$52.24
Rate for Payer: Amerigroup CHIP/Medicaid	$8.55
Rate for Payer: BCBS of TX Blue Advantage	$28.50
Rate for Payer: BCBS of TX Blue Essentials	$34.20
Rate for Payer: BCBS of TX PPO	$38.00
Rate for Payer: Cash Price	$83.59
Rate for Payer: Multiplan Auto	$61.74
Rate for Payer: Multiplan Commercial	$61.74
Rate for Payer: Multiplan Workers Comp	$61.74
Rate for Payer: Scott and White EPO/PPO	$47.50
Rate for Payer: Superior Health Plan EPO	$12.92

Know your out-of-pocket cost for care.

All Charges