White Rock Medical Center

All Charges

Charge

Type

Setting

Price

promethazine 25mg Tab

Facility

$7.65

Service Code	HCPCS J2550
Hospital Charge Code	78419587
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.83

promethazine 25mg Tab

Facility

$7.65

Service Code	HCPCS Q0169
Hospital Charge Code	1.42078E+11
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.09
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.12
Rate for Payer: Cash Price	$5.20
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

promethazine 25mg Tab

Facility

$7.65

Service Code	HCPCS J2550
Hospital Charge Code	78419587
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.44
Rate for Payer: BCBS of TX Blue Essentials	$0.52
Rate for Payer: BCBS of TX PPO	$0.58
Rate for Payer: Cash Price	$5.20
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

promethazine 25mg Tab

Facility

$7.65

Service Code	HCPCS Q0169
Hospital Charge Code	1.42078E+11
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

promethazine 50 mg/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2550
Hospital Charge Code	7781075
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

promethazine 50 mg/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2550
Hospital Charge Code	7781075
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.44
Rate for Payer: BCBS of TX Blue Essentials	$0.52
Rate for Payer: BCBS of TX PPO	$0.58
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
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: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

promethazine 6.25 mg/5 mL

Facility

$8.00

Service Code	HCPCS Q0169
Hospital Charge Code	79181839
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

promethazine 6.25 mg/5 mL

Facility

$8.00

Service Code	HCPCS Q0169
Hospital Charge Code	79181839
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$0.09
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.12
Rate for Payer: Cash Price	$5.44
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

promethazine 6.25 mg/5 mL Oral Syrup 5 mL

Facility

$8.00

Service Code	HCPCS Q0169
Hospital Charge Code	77781639
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$0.09
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.12
Rate for Payer: Cash Price	$5.44
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

promethazine 6.25 mg/5 mL Oral Syrup 5 mL

Facility

$8.00

Service Code	HCPCS Q0169
Hospital Charge Code	77781639
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

PROPATEN VASC GRAFT SW RR AXBI / 8MMX70CM 8MMX40CM Heparin

Facility

$24,487.95

Service Code	HCPCS C1768
Hospital Charge Code	992216
Hospital Revenue Code	278
Min. Negotiated Rate	$2,203.92
Max. Negotiated Rate	$17,631.32
Rate for Payer: Amerigroup CHIP/Medicaid	$2,203.92
Rate for Payer: BCBS of TX Blue Advantage	$7,346.39
Rate for Payer: BCBS of TX Blue Essentials	$8,815.66
Rate for Payer: BCBS of TX PPO	$9,795.18
Rate for Payer: Cash Price	$16,651.81
Rate for Payer: Cigna Medicaid	$17,631.32
Rate for Payer: Molina CHIP/Medicaid	$17,631.32
Rate for Payer: Multiplan Auto	$12,243.98
Rate for Payer: Multiplan Commercial	$12,243.98
Rate for Payer: Multiplan Workers Comp	$12,243.98
Rate for Payer: Parkland Medicaid	$17,631.32
Rate for Payer: Scott and White EPO/PPO	$12,243.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,631.32
Rate for Payer: Superior Health Plan EPO	$3,330.36

PROPATEN VASC GRAFT SW RR AXBI / 8MMX70CM 8MMX40CM Heparin

Facility

$24,487.95

Service Code	HCPCS C1768
Hospital Charge Code	992216
Hospital Revenue Code	278
Min. Negotiated Rate	$6,121.99
Max. Negotiated Rate	$12,243.98
Rate for Payer: Cash Price	$16,651.81
Rate for Payer: Cigna Commercial	$6,121.99
Rate for Payer: Multiplan Auto	$12,243.98
Rate for Payer: Multiplan Commercial	$12,243.98
Rate for Payer: Multiplan Workers Comp	$12,243.98
Rate for Payer: Scott and White EPO/PPO	$12,243.98

PROPATEN VASCULAR GRAFT TW RR / 6MMX90CM 70CM Heparin

Facility

$19,530.12

Service Code	HCPCS C1768
Hospital Charge Code	992168
Hospital Revenue Code	278
Min. Negotiated Rate	$1,757.71
Max. Negotiated Rate	$14,061.69
Rate for Payer: Amerigroup CHIP/Medicaid	$1,757.71
Rate for Payer: BCBS of TX Blue Advantage	$5,859.04
Rate for Payer: BCBS of TX Blue Essentials	$7,030.84
Rate for Payer: BCBS of TX PPO	$7,812.05
Rate for Payer: Cash Price	$13,280.48
Rate for Payer: Cigna Medicaid	$14,061.69
Rate for Payer: Molina CHIP/Medicaid	$14,061.69
Rate for Payer: Multiplan Auto	$9,765.06
Rate for Payer: Multiplan Commercial	$9,765.06
Rate for Payer: Multiplan Workers Comp	$9,765.06
Rate for Payer: Parkland Medicaid	$14,061.69
Rate for Payer: Scott and White EPO/PPO	$9,765.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,061.69
Rate for Payer: Superior Health Plan EPO	$2,656.10

PROPATEN VASCULAR GRAFT TW RR / 6MMX90CM 70CM Heparin

Facility

$19,530.12

Service Code	HCPCS C1768
Hospital Charge Code	992168
Hospital Revenue Code	278
Min. Negotiated Rate	$4,882.53
Max. Negotiated Rate	$9,765.06
Rate for Payer: Cash Price	$13,280.48
Rate for Payer: Cigna Commercial	$4,882.53
Rate for Payer: Multiplan Auto	$9,765.06
Rate for Payer: Multiplan Commercial	$9,765.06
Rate for Payer: Multiplan Workers Comp	$9,765.06
Rate for Payer: Scott and White EPO/PPO	$9,765.06

Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, tibia

Facility

$28,574.92

Service Code	HCPCS 27745
Hospital Charge Code	991214
Hospital Revenue Code	360
Min. Negotiated Rate	$3,341.38
Max. Negotiated Rate	$20,573.94
Rate for Payer: Amerigroup CHIP/Medicaid	$3,341.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$19,430.95
Rate for Payer: Cash Price	$19,430.95
Rate for Payer: Cash Price	$19,430.95
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$20,573.94
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$20,573.94
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$20,573.94
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,573.94
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, tibia

Facility

$28,574.92

Service Code	HCPCS 27745
Hospital Charge Code	991214
Hospital Revenue Code	360
Rate for Payer: Cash Price	$19,430.95

propofol 10 mg/mL IV Emulsion 20 mL

Facility

$128.17

Service Code	HCPCS J2704
Hospital Charge Code	77782234
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.25
Rate for Payer: BCBS of TX Blue Essentials	$0.30
Rate for Payer: BCBS of TX PPO	$0.33
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

propofol 10 mg/mL IV Emulsion 20 mL

Facility

$128.17

Service Code	HCPCS J2704
Hospital Charge Code	77782234
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

propofol 10 mg/mL IV Emulsion 20 mL

Facility

$128.17

Service Code	HCPCS J2704
Hospital Charge Code	77782580
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

propofol 10 mg/mL IV Emulsion 20 mL

Facility

$128.17

Service Code	HCPCS J2704
Hospital Charge Code	77782580
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.25
Rate for Payer: BCBS of TX Blue Essentials	$0.30
Rate for Payer: BCBS of TX PPO	$0.33
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

propranolol 10 mg Tab

Facility

$7.65

Service Code	HCPCS J2704
Hospital Charge Code	77782175
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.25
Rate for Payer: BCBS of TX Blue Essentials	$0.30
Rate for Payer: BCBS of TX PPO	$0.33
Rate for Payer: Cash Price	$5.20
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

propranolol 10 mg Tab

Facility

$7.65

Service Code	HCPCS J2704
Hospital Charge Code	77782175
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.83

propranolol 40 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77782894
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

propranolol 40 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77782894
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

PROS SIZER BRST IMP 2 -- DHF

Facility

$1,061.13

Hospital Charge Code	81541872
Hospital Revenue Code	272
Min. Negotiated Rate	$95.50
Max. Negotiated Rate	$764.01
Rate for Payer: Amerigroup CHIP/Medicaid	$95.50
Rate for Payer: BCBS of TX Blue Advantage	$318.34
Rate for Payer: BCBS of TX Blue Essentials	$382.01
Rate for Payer: BCBS of TX PPO	$424.45
Rate for Payer: Cash Price	$721.57
Rate for Payer: Cigna Medicaid	$764.01
Rate for Payer: Molina CHIP/Medicaid	$764.01
Rate for Payer: Multiplan Auto	$689.73
Rate for Payer: Multiplan Commercial	$689.73
Rate for Payer: Multiplan Workers Comp	$689.73
Rate for Payer: Parkland Medicaid	$764.01
Rate for Payer: Scott and White EPO/PPO	$530.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$764.01
Rate for Payer: Superior Health Plan EPO	$144.31

Know your out-of-pocket cost for care.

All Charges