White Rock Medical Center

All Charges

Charge

Type

Setting

Price

cefuroxime 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77450660
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

celecoxib 100 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77451090
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

celecoxib 100 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77451090
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

Celiac Disease Ab Screen w/Rfx SO

Facility

$199.00

Service Code	CPT 82784
Hospital Charge Code	1602069
Hospital Revenue Code	301
Min. Negotiated Rate	$3.63
Max. Negotiated Rate	$129.35
Rate for Payer: Aetna Commercial	$9.77
Rate for Payer: Aetna Medicare	$13.95
Rate for Payer: Amerigroup CHIP/Medicaid	$3.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.30
Rate for Payer: Amerigroup Medicare	$9.30
Rate for Payer: BCBS of TX Blue Advantage	$15.35
Rate for Payer: BCBS of TX Blue Essentials	$18.41
Rate for Payer: BCBS of TX Medicare	$9.30
Rate for Payer: BCBS of TX PPO	$20.55
Rate for Payer: Cash Price	$175.12
Rate for Payer: Cash Price	$175.12
Rate for Payer: Cigna Medicaid	$9.30
Rate for Payer: Cigna Medicare	$9.30
Rate for Payer: Employer Direct Commercial	$9.30
Rate for Payer: Humana Medicare/TRICARE	$9.30
Rate for Payer: Molina CHIP/Medicaid	$9.30
Rate for Payer: Molina Dual Medicare/Medicaid	$9.30
Rate for Payer: Molina Medicare	$9.30
Rate for Payer: Multiplan Auto	$129.35
Rate for Payer: Multiplan Commercial	$129.35
Rate for Payer: Multiplan Workers Comp	$129.35
Rate for Payer: Parkland Medicaid	$9.30
Rate for Payer: Scott and White EPO/PPO	$11.62
Rate for Payer: Scott and White Medicare	$9.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.30
Rate for Payer: Superior Health Plan EPO	$9.30
Rate for Payer: Superior Health Plan Medicare	$9.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.30
Rate for Payer: Universal American Medicare	$9.30
Rate for Payer: Wellcare Medicare	$9.30
Rate for Payer: Wellmed Medicare	$9.30

Celiac Disease Comprehensive SO

Facility

$372.00

Service Code	CPT 86364
Hospital Charge Code	1707074
Hospital Revenue Code	302
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$241.80
Rate for Payer: Aetna Commercial	$12.11
Rate for Payer: Aetna Medicare	$17.30
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.53
Rate for Payer: Amerigroup Medicare	$11.53
Rate for Payer: BCBS of TX Blue Advantage	$19.02
Rate for Payer: BCBS of TX Blue Essentials	$22.83
Rate for Payer: BCBS of TX Medicare	$11.53
Rate for Payer: BCBS of TX PPO	$25.48
Rate for Payer: Cash Price	$327.36
Rate for Payer: Cash Price	$327.36
Rate for Payer: Cigna Medicaid	$11.53
Rate for Payer: Cigna Medicare	$11.53
Rate for Payer: Employer Direct Commercial	$11.53
Rate for Payer: Humana Medicare/TRICARE	$11.53
Rate for Payer: Molina CHIP/Medicaid	$11.53
Rate for Payer: Molina Dual Medicare/Medicaid	$11.53
Rate for Payer: Molina Medicare	$11.53
Rate for Payer: Multiplan Auto	$241.80
Rate for Payer: Multiplan Commercial	$241.80
Rate for Payer: Multiplan Workers Comp	$241.80
Rate for Payer: Parkland Medicaid	$11.53
Rate for Payer: Scott and White EPO/PPO	$14.41
Rate for Payer: Scott and White Medicare	$11.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.53
Rate for Payer: Superior Health Plan EPO	$11.53
Rate for Payer: Superior Health Plan Medicare	$11.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.53
Rate for Payer: Universal American Medicare	$11.53
Rate for Payer: Wellcare Medicare	$11.53
Rate for Payer: Wellmed Medicare	$11.53

Celiac Disease Panel SO

Facility

$372.00

Service Code	CPT 86364
Hospital Charge Code	1707074
Hospital Revenue Code	302
Rate for Payer: Cash Price	$327.36

Celiac Disease Panel SO

Facility

$372.00

Service Code	CPT 86364
Hospital Charge Code	1707074
Hospital Revenue Code	302
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$241.80
Rate for Payer: Aetna Commercial	$12.11
Rate for Payer: Aetna Medicare	$17.30
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.53
Rate for Payer: Amerigroup Medicare	$11.53
Rate for Payer: BCBS of TX Blue Advantage	$19.02
Rate for Payer: BCBS of TX Blue Essentials	$22.83
Rate for Payer: BCBS of TX Medicare	$11.53
Rate for Payer: BCBS of TX PPO	$25.48
Rate for Payer: Cash Price	$327.36
Rate for Payer: Cash Price	$327.36
Rate for Payer: Cigna Medicaid	$11.53
Rate for Payer: Cigna Medicare	$11.53
Rate for Payer: Employer Direct Commercial	$11.53
Rate for Payer: Humana Medicare/TRICARE	$11.53
Rate for Payer: Molina CHIP/Medicaid	$11.53
Rate for Payer: Molina Dual Medicare/Medicaid	$11.53
Rate for Payer: Molina Medicare	$11.53
Rate for Payer: Multiplan Auto	$241.80
Rate for Payer: Multiplan Commercial	$241.80
Rate for Payer: Multiplan Workers Comp	$241.80
Rate for Payer: Parkland Medicaid	$11.53
Rate for Payer: Scott and White EPO/PPO	$14.41
Rate for Payer: Scott and White Medicare	$11.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.53
Rate for Payer: Superior Health Plan EPO	$11.53
Rate for Payer: Superior Health Plan Medicare	$11.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.53
Rate for Payer: Universal American Medicare	$11.53
Rate for Payer: Wellcare Medicare	$11.53
Rate for Payer: Wellmed Medicare	$11.53

CELLULITIS WITH MCC

Facility

$20,204.51

Service Code	MSDRG 602
Min. Negotiated Rate	$12,519.88
Max. Negotiated Rate	$20,204.51
Rate for Payer: Aetna Commercial	$16,734.38
Rate for Payer: Aetna Medicare	$20,204.51
Rate for Payer: BCBS of TX Blue Advantage	$12,519.88
Rate for Payer: BCBS of TX Blue Essentials	$14,900.64
Rate for Payer: BCBS of TX PPO	$16,556.90
Rate for Payer: Cigna Commercial	$19,159.00

CELLULITIS WITHOUT MCC

Facility

$13,752.08

Service Code	MSDRG 603
Min. Negotiated Rate	$7,262.70
Max. Negotiated Rate	$13,752.08
Rate for Payer: Aetna Commercial	$9,952.88
Rate for Payer: Aetna Medicare	$13,752.08
Rate for Payer: BCBS of TX Blue Advantage	$7,262.70
Rate for Payer: BCBS of TX Blue Essentials	$8,747.42
Rate for Payer: BCBS of TX PPO	$9,719.73
Rate for Payer: Cigna Commercial	$11,394.94

Cement bn refobacin

Facility

$1,716.86

Service Code	HCPCS C1713
Hospital Charge Code	8602524
Hospital Revenue Code	278
Min. Negotiated Rate	$154.52
Max. Negotiated Rate	$858.43
Rate for Payer: Aetna Commercial	$515.06
Rate for Payer: Amerigroup CHIP/Medicaid	$154.52
Rate for Payer: BCBS of TX Blue Advantage	$515.06
Rate for Payer: BCBS of TX Blue Essentials	$618.07
Rate for Payer: BCBS of TX PPO	$686.74
Rate for Payer: Cash Price	$1,510.84
Rate for Payer: Multiplan Auto	$858.43
Rate for Payer: Multiplan Commercial	$858.43
Rate for Payer: Multiplan Workers Comp	$858.43
Rate for Payer: Scott and White EPO/PPO	$858.43
Rate for Payer: Superior Health Plan EPO	$233.49

Cement bn refobacin

Facility

$1,716.86

Service Code	HCPCS C1713
Hospital Charge Code	8602524
Hospital Revenue Code	278
Min. Negotiated Rate	$429.21
Max. Negotiated Rate	$858.43
Rate for Payer: Aetna Commercial	$515.06
Rate for Payer: Cash Price	$1,510.84
Rate for Payer: Cigna Commercial	$429.21
Rate for Payer: Multiplan Auto	$858.43
Rate for Payer: Multiplan Commercial	$858.43
Rate for Payer: Multiplan Workers Comp	$858.43
Rate for Payer: Scott and White EPO/PPO	$858.43

CEMENT BONE BIOMET

Facility

$722.89

Service Code	HCPCS C1713
Hospital Charge Code	8692539
Hospital Revenue Code	278
Min. Negotiated Rate	$180.72
Max. Negotiated Rate	$361.44
Rate for Payer: Aetna Commercial	$216.87
Rate for Payer: Cash Price	$636.14
Rate for Payer: Cigna Commercial	$180.72
Rate for Payer: Multiplan Auto	$361.44
Rate for Payer: Multiplan Commercial	$361.44
Rate for Payer: Multiplan Workers Comp	$361.44
Rate for Payer: Scott and White EPO/PPO	$361.44

CEMENT BONE BIOMET

Facility

$722.89

Service Code	HCPCS C1713
Hospital Charge Code	8692539
Hospital Revenue Code	278
Min. Negotiated Rate	$65.06
Max. Negotiated Rate	$361.44
Rate for Payer: Aetna Commercial	$216.87
Rate for Payer: Amerigroup CHIP/Medicaid	$65.06
Rate for Payer: BCBS of TX Blue Advantage	$216.87
Rate for Payer: BCBS of TX Blue Essentials	$260.24
Rate for Payer: BCBS of TX PPO	$289.16
Rate for Payer: Cash Price	$636.14
Rate for Payer: Multiplan Auto	$361.44
Rate for Payer: Multiplan Commercial	$361.44
Rate for Payer: Multiplan Workers Comp	$361.44
Rate for Payer: Scott and White EPO/PPO	$361.44
Rate for Payer: Superior Health Plan EPO	$98.31

CEMENT BONE RADIPAQUE VCF-1009

Facility

$2,590.36

Service Code	HCPCS C1713
Hospital Charge Code	144865
Hospital Revenue Code	278
Min. Negotiated Rate	$233.13
Max. Negotiated Rate	$1,295.18
Rate for Payer: Aetna Commercial	$777.11
Rate for Payer: Amerigroup CHIP/Medicaid	$233.13
Rate for Payer: BCBS of TX Blue Advantage	$777.11
Rate for Payer: BCBS of TX Blue Essentials	$932.53
Rate for Payer: BCBS of TX PPO	$1,036.14
Rate for Payer: Cash Price	$2,279.52
Rate for Payer: Multiplan Auto	$1,295.18
Rate for Payer: Multiplan Commercial	$1,295.18
Rate for Payer: Multiplan Workers Comp	$1,295.18
Rate for Payer: Scott and White EPO/PPO	$1,295.18
Rate for Payer: Superior Health Plan EPO	$352.29

CEMENT BONE RADIPAQUE VCF-1009

Facility

$2,590.36

Service Code	HCPCS C1713
Hospital Charge Code	144865
Hospital Revenue Code	278
Min. Negotiated Rate	$647.59
Max. Negotiated Rate	$1,295.18
Rate for Payer: Aetna Commercial	$777.11
Rate for Payer: Cash Price	$2,279.52
Rate for Payer: Cigna Commercial	$647.59
Rate for Payer: Multiplan Auto	$1,295.18
Rate for Payer: Multiplan Commercial	$1,295.18
Rate for Payer: Multiplan Workers Comp	$1,295.18
Rate for Payer: Scott and White EPO/PPO	$1,295.18

CEMENT BONE SPEEDSET

Facility

$656.02

Service Code	HCPCS C1713
Hospital Charge Code	134363
Hospital Revenue Code	278
Min. Negotiated Rate	$59.04
Max. Negotiated Rate	$328.01
Rate for Payer: Aetna Commercial	$196.81
Rate for Payer: Amerigroup CHIP/Medicaid	$59.04
Rate for Payer: BCBS of TX Blue Advantage	$196.81
Rate for Payer: BCBS of TX Blue Essentials	$236.17
Rate for Payer: BCBS of TX PPO	$262.41
Rate for Payer: Cash Price	$577.30
Rate for Payer: Multiplan Auto	$328.01
Rate for Payer: Multiplan Commercial	$328.01
Rate for Payer: Multiplan Workers Comp	$328.01
Rate for Payer: Scott and White EPO/PPO	$328.01
Rate for Payer: Superior Health Plan EPO	$89.22

CEMENT BONE SPEEDSET

Facility

$656.02

Service Code	HCPCS C1713
Hospital Charge Code	134363
Hospital Revenue Code	278
Min. Negotiated Rate	$164.00
Max. Negotiated Rate	$328.01
Rate for Payer: Aetna Commercial	$196.81
Rate for Payer: Cash Price	$577.30
Rate for Payer: Cigna Commercial	$164.00
Rate for Payer: Multiplan Auto	$328.01
Rate for Payer: Multiplan Commercial	$328.01
Rate for Payer: Multiplan Workers Comp	$328.01
Rate for Payer: Scott and White EPO/PPO	$328.01

CEMENT CARTRIDGE KYPHON CC02A

Facility

$499.40

Hospital Charge Code	8574473
Hospital Revenue Code	272
Min. Negotiated Rate	$44.95
Max. Negotiated Rate	$324.61
Rate for Payer: Aetna Commercial	$274.67
Rate for Payer: Amerigroup CHIP/Medicaid	$44.95
Rate for Payer: BCBS of TX Blue Advantage	$149.82
Rate for Payer: BCBS of TX Blue Essentials	$179.78
Rate for Payer: BCBS of TX PPO	$199.76
Rate for Payer: Cash Price	$439.47
Rate for Payer: Multiplan Auto	$324.61
Rate for Payer: Multiplan Commercial	$324.61
Rate for Payer: Multiplan Workers Comp	$324.61
Rate for Payer: Scott and White EPO/PPO	$249.70
Rate for Payer: Superior Health Plan EPO	$67.92

CEMENT CARTRIDGE KYPHON CC02A

Facility

$499.40

Hospital Charge Code	8574473
Hospital Revenue Code	272
Rate for Payer: Cash Price	$439.47

CEMENT KYPHON CX01A

Facility

$1,283.49

Service Code	HCPCS C1713
Hospital Charge Code	8478523
Hospital Revenue Code	278
Min. Negotiated Rate	$320.87
Max. Negotiated Rate	$641.75
Rate for Payer: Aetna Commercial	$385.05
Rate for Payer: Cash Price	$1,129.47
Rate for Payer: Cigna Commercial	$320.87
Rate for Payer: Multiplan Auto	$641.75
Rate for Payer: Multiplan Commercial	$641.75
Rate for Payer: Multiplan Workers Comp	$641.75
Rate for Payer: Scott and White EPO/PPO	$641.75

CEMENT KYPHON CX01A

Facility

$1,283.49

Service Code	HCPCS C1713
Hospital Charge Code	8478523
Hospital Revenue Code	278
Min. Negotiated Rate	$115.51
Max. Negotiated Rate	$641.75
Rate for Payer: Aetna Commercial	$385.05
Rate for Payer: Amerigroup CHIP/Medicaid	$115.51
Rate for Payer: BCBS of TX Blue Advantage	$385.05
Rate for Payer: BCBS of TX Blue Essentials	$462.06
Rate for Payer: BCBS of TX PPO	$513.40
Rate for Payer: Cash Price	$1,129.47
Rate for Payer: Multiplan Auto	$641.75
Rate for Payer: Multiplan Commercial	$641.75
Rate for Payer: Multiplan Workers Comp	$641.75
Rate for Payer: Scott and White EPO/PPO	$641.75
Rate for Payer: Superior Health Plan EPO	$174.55

CEMENT KYPHON DELIVERY SYSTEM CDS2A

Facility

$2,474.30

Hospital Charge Code	8478526
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,177.38

CEMENT KYPHON DELIVERY SYSTEM CDS2A

Facility

$2,474.30

Hospital Charge Code	8478526
Hospital Revenue Code	272
Min. Negotiated Rate	$222.69
Max. Negotiated Rate	$1,608.30
Rate for Payer: Aetna Commercial	$1,360.87
Rate for Payer: Amerigroup CHIP/Medicaid	$222.69
Rate for Payer: BCBS of TX Blue Advantage	$742.29
Rate for Payer: BCBS of TX Blue Essentials	$890.75
Rate for Payer: BCBS of TX PPO	$989.72
Rate for Payer: Cash Price	$2,177.38
Rate for Payer: Multiplan Auto	$1,608.30
Rate for Payer: Multiplan Commercial	$1,608.30
Rate for Payer: Multiplan Workers Comp	$1,608.30
Rate for Payer: Scott and White EPO/PPO	$1,237.15
Rate for Payer: Superior Health Plan EPO	$336.50

cement mixing compact vac-zimmer

Facility

$635.60

Hospital Charge Code	8614537
Hospital Revenue Code	272
Min. Negotiated Rate	$57.20
Max. Negotiated Rate	$413.14
Rate for Payer: Aetna Commercial	$349.58
Rate for Payer: Amerigroup CHIP/Medicaid	$57.20
Rate for Payer: BCBS of TX Blue Advantage	$190.68
Rate for Payer: BCBS of TX Blue Essentials	$228.82
Rate for Payer: BCBS of TX PPO	$254.24
Rate for Payer: Cash Price	$559.33
Rate for Payer: Multiplan Auto	$413.14
Rate for Payer: Multiplan Commercial	$413.14
Rate for Payer: Multiplan Workers Comp	$413.14
Rate for Payer: Scott and White EPO/PPO	$317.80
Rate for Payer: Superior Health Plan EPO	$86.44

cement mixing compact vac-zimmer

Facility

$635.60

Hospital Charge Code	8614537
Hospital Revenue Code	272
Rate for Payer: Cash Price	$559.33

Know your out-of-pocket cost for care.

All Charges