White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CEMT BN ANTIFUL STRY CAP -- DHF

Facility

$1,491.02

Service Code	HCPCS C1713
Hospital Charge Code	40118655
Hospital Revenue Code	278
Min. Negotiated Rate	$134.19
Max. Negotiated Rate	$745.51
Rate for Payer: Aetna Commercial	$447.31
Rate for Payer: Amerigroup CHIP/Medicaid	$134.19
Rate for Payer: BCBS of TX Blue Advantage	$447.31
Rate for Payer: BCBS of TX Blue Essentials	$536.77
Rate for Payer: BCBS of TX PPO	$596.41
Rate for Payer: Cash Price	$1,312.10
Rate for Payer: Multiplan Auto	$745.51
Rate for Payer: Multiplan Commercial	$745.51
Rate for Payer: Multiplan Workers Comp	$745.51
Rate for Payer: Scott and White EPO/PPO	$745.51
Rate for Payer: Superior Health Plan EPO	$202.78

CEMT BN ANTIFUL STRY CAP -- DHF

Facility

$1,491.02

Service Code	HCPCS C1713
Hospital Charge Code	40118655
Hospital Revenue Code	278
Min. Negotiated Rate	$372.75
Max. Negotiated Rate	$745.51
Rate for Payer: Aetna Commercial	$447.31
Rate for Payer: Cash Price	$1,312.10
Rate for Payer: Cigna Commercial	$372.75
Rate for Payer: Multiplan Auto	$745.51
Rate for Payer: Multiplan Commercial	$745.51
Rate for Payer: Multiplan Workers Comp	$745.51
Rate for Payer: Scott and White EPO/PPO	$745.51

CEMT BN INJECT -- DHF

Facility

$3,557.89

Service Code	HCPCS C1713
Hospital Charge Code	81735086
Hospital Revenue Code	278
Min. Negotiated Rate	$889.47
Max. Negotiated Rate	$1,778.94
Rate for Payer: Aetna Commercial	$1,067.37
Rate for Payer: Cash Price	$3,130.94
Rate for Payer: Cigna Commercial	$889.47
Rate for Payer: Multiplan Auto	$1,778.94
Rate for Payer: Multiplan Commercial	$1,778.94
Rate for Payer: Multiplan Workers Comp	$1,778.94
Rate for Payer: Scott and White EPO/PPO	$1,778.94

CEMT BN INJECT -- DHF

Facility

$3,557.89

Service Code	HCPCS C1713
Hospital Charge Code	81735086
Hospital Revenue Code	278
Min. Negotiated Rate	$320.21
Max. Negotiated Rate	$1,778.94
Rate for Payer: Aetna Commercial	$1,067.37
Rate for Payer: Amerigroup CHIP/Medicaid	$320.21
Rate for Payer: BCBS of TX Blue Advantage	$1,067.37
Rate for Payer: BCBS of TX Blue Essentials	$1,280.84
Rate for Payer: BCBS of TX PPO	$1,423.16
Rate for Payer: Cash Price	$3,130.94
Rate for Payer: Multiplan Auto	$1,778.94
Rate for Payer: Multiplan Commercial	$1,778.94
Rate for Payer: Multiplan Workers Comp	$1,778.94
Rate for Payer: Scott and White EPO/PPO	$1,778.94
Rate for Payer: Superior Health Plan EPO	$483.87

CEMT BN W/ANTIBIOTIC -- DHF

Facility

$1,491.02

Service Code	HCPCS C1713
Hospital Charge Code	81315228
Hospital Revenue Code	278
Min. Negotiated Rate	$372.75
Max. Negotiated Rate	$745.51
Rate for Payer: Aetna Commercial	$447.31
Rate for Payer: Cash Price	$1,312.10
Rate for Payer: Cigna Commercial	$372.75
Rate for Payer: Multiplan Auto	$745.51
Rate for Payer: Multiplan Commercial	$745.51
Rate for Payer: Multiplan Workers Comp	$745.51
Rate for Payer: Scott and White EPO/PPO	$745.51

CEMT BN W/ANTIBIOTIC -- DHF

Facility

$1,491.02

Service Code	HCPCS C1713
Hospital Charge Code	81315228
Hospital Revenue Code	278
Min. Negotiated Rate	$134.19
Max. Negotiated Rate	$745.51
Rate for Payer: Aetna Commercial	$447.31
Rate for Payer: Amerigroup CHIP/Medicaid	$134.19
Rate for Payer: BCBS of TX Blue Advantage	$447.31
Rate for Payer: BCBS of TX Blue Essentials	$536.77
Rate for Payer: BCBS of TX PPO	$596.41
Rate for Payer: Cash Price	$1,312.10
Rate for Payer: Multiplan Auto	$745.51
Rate for Payer: Multiplan Commercial	$745.51
Rate for Payer: Multiplan Workers Comp	$745.51
Rate for Payer: Scott and White EPO/PPO	$745.51
Rate for Payer: Superior Health Plan EPO	$202.78

CEMT CARTRIDGE -- DHF

Facility

$2,207.79

Hospital Charge Code	81735151
Hospital Revenue Code	272
Min. Negotiated Rate	$198.70
Max. Negotiated Rate	$1,435.06
Rate for Payer: Aetna Commercial	$1,214.28
Rate for Payer: Amerigroup CHIP/Medicaid	$198.70
Rate for Payer: BCBS of TX Blue Advantage	$662.34
Rate for Payer: BCBS of TX Blue Essentials	$794.80
Rate for Payer: BCBS of TX PPO	$883.12
Rate for Payer: Cash Price	$1,942.86
Rate for Payer: Multiplan Auto	$1,435.06
Rate for Payer: Multiplan Commercial	$1,435.06
Rate for Payer: Multiplan Workers Comp	$1,435.06
Rate for Payer: Scott and White EPO/PPO	$1,103.89
Rate for Payer: Superior Health Plan EPO	$300.26

CEMT CARTRIDGE -- DHF

Facility

$2,207.79

Hospital Charge Code	81735151
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,942.86

CEMT MIX-E-VAL -- DHF

Facility

$469.81

Hospital Charge Code	81735409
Hospital Revenue Code	272
Min. Negotiated Rate	$42.28
Max. Negotiated Rate	$305.38
Rate for Payer: Aetna Commercial	$258.40
Rate for Payer: Amerigroup CHIP/Medicaid	$42.28
Rate for Payer: BCBS of TX Blue Advantage	$140.94
Rate for Payer: BCBS of TX Blue Essentials	$169.13
Rate for Payer: BCBS of TX PPO	$187.92
Rate for Payer: Cash Price	$413.43
Rate for Payer: Multiplan Auto	$305.38
Rate for Payer: Multiplan Commercial	$305.38
Rate for Payer: Multiplan Workers Comp	$305.38
Rate for Payer: Scott and White EPO/PPO	$234.91
Rate for Payer: Superior Health Plan EPO	$63.89

CEMT MIX-E-VAL -- DHF

Facility

$469.81

Hospital Charge Code	81735409
Hospital Revenue Code	272
Rate for Payer: Cash Price	$413.43

CEMT RESTRC RG -- DHF

Facility

$279.14

Hospital Charge Code	81735607
Hospital Revenue Code	272
Rate for Payer: Cash Price	$245.64

CEMT RESTRC RG -- DHF

Facility

$279.14

Hospital Charge Code	81735607
Hospital Revenue Code	272
Min. Negotiated Rate	$25.12
Max. Negotiated Rate	$181.44
Rate for Payer: Aetna Commercial	$153.53
Rate for Payer: Amerigroup CHIP/Medicaid	$25.12
Rate for Payer: BCBS of TX Blue Advantage	$83.74
Rate for Payer: BCBS of TX Blue Essentials	$100.49
Rate for Payer: BCBS of TX PPO	$111.66
Rate for Payer: Cash Price	$245.64
Rate for Payer: Multiplan Auto	$181.44
Rate for Payer: Multiplan Commercial	$181.44
Rate for Payer: Multiplan Workers Comp	$181.44
Rate for Payer: Scott and White EPO/PPO	$139.57
Rate for Payer: Superior Health Plan EPO	$37.96

cephalexin 125 mg/5 mL Oral Liquid 100 mL

Facility

$40.00

Service Code	HCPCS J3490
Hospital Charge Code	77451451
Hospital Revenue Code	250
Rate for Payer: Cash Price	$27.20

cephalexin 125 mg/5 mL Oral Liquid 100 mL

Facility

$40.00

Service Code	HCPCS J3490
Hospital Charge Code	77451451
Hospital Revenue Code	250
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$26.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$27.20
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan EPO	$5.44

cephalexin 250 mg capsule

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77451557
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

cephalexin 250 mg capsule

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77451557
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	$2.29
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: 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	$3.83
Rate for Payer: Superior Health Plan EPO	$1.04

cephalexin 500 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77451769
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	$2.29
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: 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	$3.83
Rate for Payer: Superior Health Plan EPO	$1.04

cephalexin 500 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77451769
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Cerebral Death Eval Only 95824

Facility

$1,212.00

Service Code	CPT 95824
Hospital Charge Code	3000189
Hospital Revenue Code	740
Min. Negotiated Rate	$70.85
Max. Negotiated Rate	$1,110.40
Rate for Payer: Aetna Commercial	$666.60
Rate for Payer: Aetna Medicare	$735.27
Rate for Payer: Amerigroup CHIP/Medicaid	$109.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$490.18
Rate for Payer: Amerigroup Medicare	$490.18
Rate for Payer: BCBS of TX Blue Advantage	$70.85
Rate for Payer: BCBS of TX Blue Essentials	$84.70
Rate for Payer: BCBS of TX Medicare	$490.18
Rate for Payer: BCBS of TX PPO	$94.47
Rate for Payer: Cash Price	$1,066.56
Rate for Payer: Cash Price	$1,066.56
Rate for Payer: Cash Price	$1,066.56
Rate for Payer: Cigna Commercial	$1,110.40
Rate for Payer: Cigna Medicare	$490.18
Rate for Payer: Employer Direct Commercial	$490.18
Rate for Payer: Humana Medicare/TRICARE	$490.18
Rate for Payer: Molina Dual Medicare/Medicaid	$490.18
Rate for Payer: Molina Medicare	$490.18
Rate for Payer: Multiplan Auto	$787.80
Rate for Payer: Multiplan Commercial	$787.80
Rate for Payer: Multiplan Workers Comp	$787.80
Rate for Payer: Scott and White EPO/PPO	$606.00
Rate for Payer: Scott and White Medicare	$490.18
Rate for Payer: Superior Health Plan EPO	$490.18
Rate for Payer: Superior Health Plan Medicare	$490.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$490.18
Rate for Payer: Universal American Medicare	$490.18
Rate for Payer: Wellcare Medicare	$490.18
Rate for Payer: Wellmed Medicare	$490.18

Cerebral Death Eval Only 95824

Facility

$1,212.00

Service Code	CPT 95824
Hospital Charge Code	3000189
Hospital Revenue Code	740
Rate for Payer: Cash Price	$1,066.56

Cerebral Death Eval Only 95824 BCE

Facility

$1,212.00

Service Code	CPT 95824
Hospital Charge Code	3000189
Hospital Revenue Code	740
Min. Negotiated Rate	$70.85
Max. Negotiated Rate	$1,110.40
Rate for Payer: Aetna Commercial	$666.60
Rate for Payer: Aetna Medicare	$735.27
Rate for Payer: Amerigroup CHIP/Medicaid	$109.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$490.18
Rate for Payer: Amerigroup Medicare	$490.18
Rate for Payer: BCBS of TX Blue Advantage	$70.85
Rate for Payer: BCBS of TX Blue Essentials	$84.70
Rate for Payer: BCBS of TX Medicare	$490.18
Rate for Payer: BCBS of TX PPO	$94.47
Rate for Payer: Cash Price	$1,066.56
Rate for Payer: Cash Price	$1,066.56
Rate for Payer: Cash Price	$1,066.56
Rate for Payer: Cigna Commercial	$1,110.40
Rate for Payer: Cigna Medicare	$490.18
Rate for Payer: Employer Direct Commercial	$490.18
Rate for Payer: Humana Medicare/TRICARE	$490.18
Rate for Payer: Molina Dual Medicare/Medicaid	$490.18
Rate for Payer: Molina Medicare	$490.18
Rate for Payer: Multiplan Auto	$787.80
Rate for Payer: Multiplan Commercial	$787.80
Rate for Payer: Multiplan Workers Comp	$787.80
Rate for Payer: Scott and White EPO/PPO	$606.00
Rate for Payer: Scott and White Medicare	$490.18
Rate for Payer: Superior Health Plan EPO	$490.18
Rate for Payer: Superior Health Plan Medicare	$490.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$490.18
Rate for Payer: Universal American Medicare	$490.18
Rate for Payer: Wellcare Medicare	$490.18
Rate for Payer: Wellmed Medicare	$490.18

Cerebrospinal Fluid Culture

Facility

$309.00

Service Code	CPT 87070
Hospital Charge Code	4107078
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$200.85
Rate for Payer: Aetna Commercial	$9.05
Rate for Payer: Aetna Medicare	$12.93
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$14.22
Rate for Payer: BCBS of TX Blue Essentials	$17.07
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$19.05
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cigna Medicaid	$8.62
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$8.62
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$8.62
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.62
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

Cerebrospinal Fluid Culture

Facility

$309.00

Service Code	CPT 87070
Hospital Charge Code	4107078
Hospital Revenue Code	306
Rate for Payer: Cash Price	$271.92

Ceruloplasmin SO

Facility

$155.00

Service Code	CPT 82390
Hospital Charge Code	1701325
Hospital Revenue Code	301
Min. Negotiated Rate	$4.19
Max. Negotiated Rate	$100.75
Rate for Payer: Aetna Commercial	$11.27
Rate for Payer: Aetna Medicare	$16.11
Rate for Payer: Amerigroup CHIP/Medicaid	$4.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.74
Rate for Payer: Amerigroup Medicare	$10.74
Rate for Payer: BCBS of TX Blue Advantage	$17.72
Rate for Payer: BCBS of TX Blue Essentials	$21.27
Rate for Payer: BCBS of TX Medicare	$10.74
Rate for Payer: BCBS of TX PPO	$23.74
Rate for Payer: Cash Price	$136.40
Rate for Payer: Cash Price	$136.40
Rate for Payer: Cigna Medicaid	$10.74
Rate for Payer: Cigna Medicare	$10.74
Rate for Payer: Employer Direct Commercial	$10.74
Rate for Payer: Humana Medicare/TRICARE	$10.74
Rate for Payer: Molina CHIP/Medicaid	$10.74
Rate for Payer: Molina Dual Medicare/Medicaid	$10.74
Rate for Payer: Molina Medicare	$10.74
Rate for Payer: Multiplan Auto	$100.75
Rate for Payer: Multiplan Commercial	$100.75
Rate for Payer: Multiplan Workers Comp	$100.75
Rate for Payer: Parkland Medicaid	$10.74
Rate for Payer: Scott and White EPO/PPO	$13.43
Rate for Payer: Scott and White Medicare	$10.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.74
Rate for Payer: Superior Health Plan EPO	$10.74
Rate for Payer: Superior Health Plan Medicare	$10.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.74
Rate for Payer: Universal American Medicare	$10.74
Rate for Payer: Wellcare Medicare	$10.74
Rate for Payer: Wellmed Medicare	$10.74

Ceruloplasmin SO

Facility

$155.00

Service Code	CPT 82390
Hospital Charge Code	1701325
Hospital Revenue Code	301
Rate for Payer: Cash Price	$136.40

Know your out-of-pocket cost for care.

All Charges