White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ceFAZolin 1 g and D5W; 50 mL connect

Facility

$128.17

Service Code	HCPCS J0690
Hospital Charge Code	79498093
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

ceFAZolin 1 g and D5W; 50 mL connect

Facility

$128.17

Service Code	HCPCS J0690
Hospital Charge Code	79498093
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.55
Rate for Payer: BCBS of TX Blue Essentials	$0.66
Rate for Payer: BCBS of TX PPO	$0.73
Rate for Payer: Cash Price	$87.16
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

ceFAZolin 1 g Inj

Facility

$128.17

Service Code	HCPCS J0690
Hospital Charge Code	77446122
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.55
Rate for Payer: BCBS of TX Blue Essentials	$0.66
Rate for Payer: BCBS of TX PPO	$0.73
Rate for Payer: Cash Price	$87.16
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

ceFAZolin 1 g Inj

Facility

$128.17

Service Code	HCPCS J0690
Hospital Charge Code	77446122
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

ceFAZolin 1 g Pow

Facility

$128.17

Service Code	HCPCS J0690
Hospital Charge Code	78872080
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.55
Rate for Payer: BCBS of TX Blue Essentials	$0.66
Rate for Payer: BCBS of TX PPO	$0.73
Rate for Payer: Cash Price	$87.16
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

ceFAZolin 1 g Pow

Facility

$128.17

Service Code	HCPCS J0690
Hospital Charge Code	78872080
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

cefepime 1 g/50 mL Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77446933
Hospital Revenue Code	636
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.49
Rate for Payer: BCBS of TX Blue Essentials	$2.99
Rate for Payer: BCBS of TX PPO	$3.32
Rate for Payer: Cash Price	$87.16
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

cefepime 1 g/50 mL Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77446933
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

cefepime 2 g/50 mL Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77447098
Hospital Revenue Code	636
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.49
Rate for Payer: BCBS of TX Blue Essentials	$2.99
Rate for Payer: BCBS of TX PPO	$3.32
Rate for Payer: Cash Price	$87.16
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

cefepime 2 g/50 mL Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77447098
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

cefepime 2 g Inj

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77446988
Hospital Revenue Code	636
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.49
Rate for Payer: BCBS of TX Blue Essentials	$2.99
Rate for Payer: BCBS of TX PPO	$3.32
Rate for Payer: Cash Price	$87.16
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

cefepime 2 g Inj

Facility

$128.17

Service Code	HCPCS J0692
Hospital Charge Code	77446988
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

cefOXitin 2 g Inj

Facility

$128.17

Service Code	HCPCS J0694
Hospital Charge Code	77448372
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

cefOXitin 2 g Inj

Facility

$128.17

Service Code	HCPCS J0694
Hospital Charge Code	77448372
Hospital Revenue Code	636
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$6.39
Rate for Payer: BCBS of TX Blue Essentials	$7.67
Rate for Payer: BCBS of TX PPO	$8.51
Rate for Payer: Cash Price	$87.16
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

cefTRIAXone 1 g and NS; 50 mL connect

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	79364329
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

cefTRIAXone 1 g and NS; 50 mL connect

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	79364329
Hospital Revenue Code	636
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.67
Rate for Payer: BCBS of TX Blue Essentials	$4.40
Rate for Payer: BCBS of TX PPO	$4.88
Rate for Payer: Cash Price	$87.16
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

cefTRIAXone 1 g Inj

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	78398414
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

cefTRIAXone 1 g Inj

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	78398414
Hospital Revenue Code	636
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.67
Rate for Payer: BCBS of TX Blue Essentials	$4.40
Rate for Payer: BCBS of TX PPO	$4.88
Rate for Payer: Cash Price	$87.16
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

cefTRIAXone 250 mg Inj

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	77450277
Hospital Revenue Code	636
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.67
Rate for Payer: BCBS of TX Blue Essentials	$4.40
Rate for Payer: BCBS of TX PPO	$4.88
Rate for Payer: Cash Price	$87.16
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

cefTRIAXone 250 mg Inj

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	77450277
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

cefTRIAXone 2 g and NS; 50 mL connect

Facility

$128.17

Service Code	HCPCS J7999
Hospital Charge Code	79364444
Hospital Revenue Code	636
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

cefTRIAXone 2 g and NS; 50 mL connect

Facility

$128.17

Service Code	HCPCS J7999
Hospital Charge Code	79364444
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

cefTRIAXone 2 g Inj

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	77450163
Hospital Revenue Code	636
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.67
Rate for Payer: BCBS of TX Blue Essentials	$4.40
Rate for Payer: BCBS of TX PPO	$4.88
Rate for Payer: Cash Price	$87.16
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

cefTRIAXone 2 g Inj

Facility

$128.17

Service Code	HCPCS J0696
Hospital Charge Code	77450163
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

cefuroxime 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77450660
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

Know your out-of-pocket cost for care.

All Charges