White Rock Medical Center

All Charges

Charge

Type

Setting

Price

rivaroxaban 10 mg Tab

Facility

$40.90

Service Code	HCPCS j3490
Hospital Charge Code	77797108
Hospital Revenue Code	250
Min. Negotiated Rate	$3.68
Max. Negotiated Rate	$29.45
Rate for Payer: Amerigroup CHIP/Medicaid	$3.68
Rate for Payer: BCBS of TX Blue Advantage	$12.27
Rate for Payer: BCBS of TX Blue Essentials	$14.72
Rate for Payer: BCBS of TX PPO	$16.36
Rate for Payer: Cash Price	$27.81
Rate for Payer: Cigna Medicaid	$29.45
Rate for Payer: Molina CHIP/Medicaid	$29.45
Rate for Payer: Multiplan Auto	$26.59
Rate for Payer: Multiplan Commercial	$26.59
Rate for Payer: Multiplan Workers Comp	$26.59
Rate for Payer: Parkland Medicaid	$29.45
Rate for Payer: Scott and White EPO/PPO	$20.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.45
Rate for Payer: Superior Health Plan EPO	$5.56

rivaroxaban 10 mg Tab

Facility

$40.90

Service Code	HCPCS j3490
Hospital Charge Code	77797108
Hospital Revenue Code	250
Rate for Payer: Cash Price	$27.81

RMV TUNLD CVAD W SQ PORT

Facility

$2,334.00

Service Code	HCPCS 36590
Hospital Charge Code	4616590
Hospital Revenue Code	360
Min. Negotiated Rate	$446.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$446.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Amerigroup Medicare	$1,581.33
Rate for Payer: BCBS of TX Blue Advantage	$1,052.95
Rate for Payer: BCBS of TX Blue Essentials	$1,261.02
Rate for Payer: BCBS of TX Medicare	$1,581.33
Rate for Payer: BCBS of TX PPO	$1,588.89
Rate for Payer: Cash Price	$1,587.12
Rate for Payer: Cash Price	$1,587.12
Rate for Payer: Cash Price	$1,587.12
Rate for Payer: Cigna Commercial	$3,342.63
Rate for Payer: Cigna Medicaid	$1,680.48
Rate for Payer: Cigna Medicare	$1,581.33
Rate for Payer: Employer Direct Commercial	$1,581.33
Rate for Payer: Humana Medicare/TRICARE	$1,581.33
Rate for Payer: Molina CHIP/Medicaid	$1,680.48
Rate for Payer: Molina Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Molina Medicare	$1,581.33
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	$1,680.48
Rate for Payer: Scott and White EPO/PPO	$2,925.46
Rate for Payer: Scott and White Medicare	$1,581.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,680.48
Rate for Payer: Superior Health Plan EPO	$1,581.33
Rate for Payer: Superior Health Plan Medicare	$1,581.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Universal American Medicare	$1,581.33
Rate for Payer: Wellcare Medicare	$1,581.33
Rate for Payer: Wellmed Medicare	$1,581.33

RMV TUNLD CVAD W SQ PORT

Facility

$2,334.00

Service Code	HCPCS 36590
Hospital Charge Code	4616590
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,587.12

RNA, Real Time PCR (Non-Graph) SO

Facility

$441.00

Service Code	HCPCS 87536
Hospital Charge Code	1701069
Hospital Revenue Code	306
Rate for Payer: Cash Price	$299.88

RNA, Real Time PCR (Non-Graph) SO

Facility

$441.00

Service Code	HCPCS 87536
Hospital Charge Code	1701069
Hospital Revenue Code	306
Min. Negotiated Rate	$33.19
Max. Negotiated Rate	$317.52
Rate for Payer: Amerigroup CHIP/Medicaid	$33.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$85.10
Rate for Payer: Amerigroup Medicare	$85.10
Rate for Payer: BCBS of TX Blue Advantage	$132.30
Rate for Payer: BCBS of TX Blue Essentials	$158.76
Rate for Payer: BCBS of TX Medicare	$85.10
Rate for Payer: BCBS of TX PPO	$176.40
Rate for Payer: Cash Price	$299.88
Rate for Payer: Cash Price	$299.88
Rate for Payer: Cigna Medicaid	$317.52
Rate for Payer: Cigna Medicare	$85.10
Rate for Payer: Employer Direct Commercial	$85.10
Rate for Payer: Humana Medicare/TRICARE	$85.10
Rate for Payer: Molina CHIP/Medicaid	$317.52
Rate for Payer: Molina Dual Medicare/Medicaid	$85.10
Rate for Payer: Molina Medicare	$85.10
Rate for Payer: Multiplan Auto	$286.65
Rate for Payer: Multiplan Commercial	$286.65
Rate for Payer: Multiplan Workers Comp	$286.65
Rate for Payer: Parkland Medicaid	$317.52
Rate for Payer: Scott and White EPO/PPO	$106.38
Rate for Payer: Scott and White Medicare	$85.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$317.52
Rate for Payer: Superior Health Plan EPO	$85.10
Rate for Payer: Superior Health Plan Medicare	$85.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$85.10
Rate for Payer: Universal American Medicare	$85.10
Rate for Payer: Wellcare Medicare	$85.10
Rate for Payer: Wellmed Medicare	$85.10

rocuronium 10 mg/mL IV Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77797828
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

rocuronium 10 mg/mL IV Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77797828
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

rocuronium 10 mg/mL IV Soln 5 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77797883
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

rocuronium 10 mg/mL IV Soln 5 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77797883
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

ROD 5.5MM X 60MM

Facility

$6,024.00

Service Code	HCPCS C1776
Hospital Charge Code	8394460
Hospital Revenue Code	278
Min. Negotiated Rate	$542.16
Max. Negotiated Rate	$4,337.28
Rate for Payer: Amerigroup CHIP/Medicaid	$542.16
Rate for Payer: BCBS of TX Blue Advantage	$1,807.20
Rate for Payer: BCBS of TX Blue Essentials	$2,168.64
Rate for Payer: BCBS of TX PPO	$2,409.60
Rate for Payer: Cash Price	$4,096.32
Rate for Payer: Cigna Medicaid	$4,337.28
Rate for Payer: Molina CHIP/Medicaid	$4,337.28
Rate for Payer: Multiplan Auto	$3,012.00
Rate for Payer: Multiplan Commercial	$3,012.00
Rate for Payer: Multiplan Workers Comp	$3,012.00
Rate for Payer: Parkland Medicaid	$4,337.28
Rate for Payer: Scott and White EPO/PPO	$3,012.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,337.28
Rate for Payer: Superior Health Plan EPO	$819.26

ROD 5.5MM X 60MM

Facility

$6,024.00

Service Code	HCPCS C1776
Hospital Charge Code	8394460
Hospital Revenue Code	278
Min. Negotiated Rate	$1,506.00
Max. Negotiated Rate	$3,012.00
Rate for Payer: Cash Price	$4,096.32
Rate for Payer: Cigna Commercial	$1,506.00
Rate for Payer: Multiplan Auto	$3,012.00
Rate for Payer: Multiplan Commercial	$3,012.00
Rate for Payer: Multiplan Workers Comp	$3,012.00
Rate for Payer: Scott and White EPO/PPO	$3,012.00

rod 5.5 x 80mm

Facility

$1,446.00

Service Code	HCPCS C1776
Hospital Charge Code	8708545
Hospital Revenue Code	278
Min. Negotiated Rate	$130.14
Max. Negotiated Rate	$1,041.12
Rate for Payer: Amerigroup CHIP/Medicaid	$130.14
Rate for Payer: BCBS of TX Blue Advantage	$433.80
Rate for Payer: BCBS of TX Blue Essentials	$520.56
Rate for Payer: BCBS of TX PPO	$578.40
Rate for Payer: Cash Price	$983.28
Rate for Payer: Cigna Medicaid	$1,041.12
Rate for Payer: Molina CHIP/Medicaid	$1,041.12
Rate for Payer: Multiplan Auto	$723.00
Rate for Payer: Multiplan Commercial	$723.00
Rate for Payer: Multiplan Workers Comp	$723.00
Rate for Payer: Parkland Medicaid	$1,041.12
Rate for Payer: Scott and White EPO/PPO	$723.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,041.12
Rate for Payer: Superior Health Plan EPO	$196.66

rod 5.5 x 80mm

Facility

$1,446.00

Service Code	HCPCS C1776
Hospital Charge Code	8708545
Hospital Revenue Code	278
Min. Negotiated Rate	$361.50
Max. Negotiated Rate	$723.00
Rate for Payer: Cash Price	$983.28
Rate for Payer: Cigna Commercial	$361.50
Rate for Payer: Multiplan Auto	$723.00
Rate for Payer: Multiplan Commercial	$723.00
Rate for Payer: Multiplan Workers Comp	$723.00
Rate for Payer: Scott and White EPO/PPO	$723.00

ROD CARBON HOFFMAN 11 X400

Facility

$2,460.00

Service Code	HCPCS C1776
Hospital Charge Code	141018
Hospital Revenue Code	278
Min. Negotiated Rate	$615.00
Max. Negotiated Rate	$1,230.00
Rate for Payer: Cash Price	$1,672.80
Rate for Payer: Cigna Commercial	$615.00
Rate for Payer: Multiplan Auto	$1,230.00
Rate for Payer: Multiplan Commercial	$1,230.00
Rate for Payer: Multiplan Workers Comp	$1,230.00
Rate for Payer: Scott and White EPO/PPO	$1,230.00

ROD CARBON HOFFMAN 11 X400

Facility

$2,460.00

Service Code	HCPCS C1776
Hospital Charge Code	141018
Hospital Revenue Code	278
Min. Negotiated Rate	$221.40
Max. Negotiated Rate	$1,771.20
Rate for Payer: Amerigroup CHIP/Medicaid	$221.40
Rate for Payer: BCBS of TX Blue Advantage	$738.00
Rate for Payer: BCBS of TX Blue Essentials	$885.60
Rate for Payer: BCBS of TX PPO	$984.00
Rate for Payer: Cash Price	$1,672.80
Rate for Payer: Cigna Medicaid	$1,771.20
Rate for Payer: Molina CHIP/Medicaid	$1,771.20
Rate for Payer: Multiplan Auto	$1,230.00
Rate for Payer: Multiplan Commercial	$1,230.00
Rate for Payer: Multiplan Workers Comp	$1,230.00
Rate for Payer: Parkland Medicaid	$1,771.20
Rate for Payer: Scott and White EPO/PPO	$1,230.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,771.20
Rate for Payer: Superior Health Plan EPO	$334.56

ROD CONNECTING CARBON 11X350MM HOFFMAN 3

Facility

$2,146.00

Service Code	HCPCS C1776
Hospital Charge Code	132368
Hospital Revenue Code	278
Min. Negotiated Rate	$536.50
Max. Negotiated Rate	$1,073.00
Rate for Payer: Cash Price	$1,459.28
Rate for Payer: Cigna Commercial	$536.50
Rate for Payer: Multiplan Auto	$1,073.00
Rate for Payer: Multiplan Commercial	$1,073.00
Rate for Payer: Multiplan Workers Comp	$1,073.00
Rate for Payer: Scott and White EPO/PPO	$1,073.00

ROD CONNECTING CARBON 11X350MM HOFFMAN 3

Facility

$2,146.00

Service Code	HCPCS C1776
Hospital Charge Code	132368
Hospital Revenue Code	278
Min. Negotiated Rate	$193.14
Max. Negotiated Rate	$1,545.12
Rate for Payer: Amerigroup CHIP/Medicaid	$193.14
Rate for Payer: BCBS of TX Blue Advantage	$643.80
Rate for Payer: BCBS of TX Blue Essentials	$772.56
Rate for Payer: BCBS of TX PPO	$858.40
Rate for Payer: Cash Price	$1,459.28
Rate for Payer: Cigna Medicaid	$1,545.12
Rate for Payer: Molina CHIP/Medicaid	$1,545.12
Rate for Payer: Multiplan Auto	$1,073.00
Rate for Payer: Multiplan Commercial	$1,073.00
Rate for Payer: Multiplan Workers Comp	$1,073.00
Rate for Payer: Parkland Medicaid	$1,545.12
Rate for Payer: Scott and White EPO/PPO	$1,073.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,545.12
Rate for Payer: Superior Health Plan EPO	$291.86

ROD FIXED

Facility

$1,386.00

Service Code	HCPCS C1776
Hospital Charge Code	8504490
Hospital Revenue Code	278
Min. Negotiated Rate	$124.74
Max. Negotiated Rate	$997.92
Rate for Payer: Amerigroup CHIP/Medicaid	$124.74
Rate for Payer: BCBS of TX Blue Advantage	$415.80
Rate for Payer: BCBS of TX Blue Essentials	$498.96
Rate for Payer: BCBS of TX PPO	$554.40
Rate for Payer: Cash Price	$942.48
Rate for Payer: Cigna Medicaid	$997.92
Rate for Payer: Molina CHIP/Medicaid	$997.92
Rate for Payer: Multiplan Auto	$693.00
Rate for Payer: Multiplan Commercial	$693.00
Rate for Payer: Multiplan Workers Comp	$693.00
Rate for Payer: Parkland Medicaid	$997.92
Rate for Payer: Scott and White EPO/PPO	$693.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$997.92
Rate for Payer: Superior Health Plan EPO	$188.50

ROD FIXED

Facility

$1,386.00

Service Code	HCPCS C1776
Hospital Charge Code	8504490
Hospital Revenue Code	278
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$693.00
Rate for Payer: Cash Price	$942.48
Rate for Payer: Cigna Commercial	$346.50
Rate for Payer: Multiplan Auto	$693.00
Rate for Payer: Multiplan Commercial	$693.00
Rate for Payer: Multiplan Workers Comp	$693.00
Rate for Payer: Scott and White EPO/PPO	$693.00

ROD LUMBAR 65MM

Facility

$1,506.00

Service Code	HCPCS C1776
Hospital Charge Code	145315
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.00
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Scott and White EPO/PPO	$753.00

ROD LUMBAR 65MM

Facility

$1,506.00

Service Code	HCPCS C1776
Hospital Charge Code	145315
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$1,084.32
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.80
Rate for Payer: BCBS of TX Blue Essentials	$542.16
Rate for Payer: BCBS of TX PPO	$602.40
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Medicaid	$1,084.32
Rate for Payer: Molina CHIP/Medicaid	$1,084.32
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Parkland Medicaid	$1,084.32
Rate for Payer: Scott and White EPO/PPO	$753.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,084.32
Rate for Payer: Superior Health Plan EPO	$204.82

ROD LUMBAR 70MM

Facility

$1,506.00

Service Code	HCPCS C1776
Hospital Charge Code	145368
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.00
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Scott and White EPO/PPO	$753.00

ROD LUMBAR 70MM

Facility

$1,506.00

Service Code	HCPCS C1776
Hospital Charge Code	145368
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$1,084.32
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.80
Rate for Payer: BCBS of TX Blue Essentials	$542.16
Rate for Payer: BCBS of TX PPO	$602.40
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Medicaid	$1,084.32
Rate for Payer: Molina CHIP/Medicaid	$1,084.32
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Parkland Medicaid	$1,084.32
Rate for Payer: Scott and White EPO/PPO	$753.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,084.32
Rate for Payer: Superior Health Plan EPO	$204.82

ROD RM 2.5X950MM BALL TIP STRL

Facility

$1,466.42

Hospital Charge Code	117557
Hospital Revenue Code	272
Min. Negotiated Rate	$131.98
Max. Negotiated Rate	$1,055.82
Rate for Payer: Amerigroup CHIP/Medicaid	$131.98
Rate for Payer: BCBS of TX Blue Advantage	$439.93
Rate for Payer: BCBS of TX Blue Essentials	$527.91
Rate for Payer: BCBS of TX PPO	$586.57
Rate for Payer: Cash Price	$997.17
Rate for Payer: Cigna Medicaid	$1,055.82
Rate for Payer: Molina CHIP/Medicaid	$1,055.82
Rate for Payer: Multiplan Auto	$953.17
Rate for Payer: Multiplan Commercial	$953.17
Rate for Payer: Multiplan Workers Comp	$953.17
Rate for Payer: Parkland Medicaid	$1,055.82
Rate for Payer: Scott and White EPO/PPO	$733.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,055.82
Rate for Payer: Superior Health Plan EPO	$199.43

Know your out-of-pocket cost for care.

All Charges