White Rock Medical Center

All Charges

Charge

Type

Setting

Price

atorvastatin 40 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77386846
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
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: 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

atorvastatin 40 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77386846
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

atropine 1 mg 10 ml syringe

Facility

$128.17

Service Code	HCPCS J0461
Hospital Charge Code	77387594
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.07
Rate for Payer: BCBS of TX Blue Essentials	$0.09
Rate for Payer: BCBS of TX PPO	$0.10
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

atropine 1 mg 10 ml syringe

Facility

$128.17

Service Code	HCPCS J0461
Hospital Charge Code	77387594
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

atropine 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J0461
Hospital Charge Code	77388095
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

atropine 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J0461
Hospital Charge Code	77388095
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.07
Rate for Payer: BCBS of TX Blue Essentials	$0.09
Rate for Payer: BCBS of TX PPO	$0.10
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

atropine-diphenoxylate 0.025 mg-2.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77388841
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

atropine-diphenoxylate 0.025 mg-2.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77388841
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

atropine-diphenoxylate 0.025 mg-2.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77388741
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

atropine-diphenoxylate 0.025 mg-2.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77388741
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

Audiogram

Facility

$515.60

Service Code	HCPCS 92552
Hospital Charge Code	994064
Hospital Revenue Code	470
Rate for Payer: Cash Price	$350.61

Audiogram

Facility

$515.60

Service Code	HCPCS 92552
Hospital Charge Code	994064
Hospital Revenue Code	470
Min. Negotiated Rate	$46.40
Max. Negotiated Rate	$371.23
Rate for Payer: Amerigroup CHIP/Medicaid	$46.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$154.68
Rate for Payer: BCBS of TX Blue Essentials	$185.62
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$206.24
Rate for Payer: Cash Price	$350.61
Rate for Payer: Cash Price	$350.61
Rate for Payer: Cash Price	$350.61
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$371.23
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$371.23
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$335.14
Rate for Payer: Multiplan Commercial	$335.14
Rate for Payer: Multiplan Workers Comp	$335.14
Rate for Payer: Parkland Medicaid	$371.23
Rate for Payer: Scott and White EPO/PPO	$46.94
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$371.23
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

Augment injectable kit 3.0occinhectable usa

Facility

$21,632.53

Service Code	HCPCS C1734
Hospital Charge Code	992199
Hospital Revenue Code	278
Min. Negotiated Rate	$1,946.93
Max. Negotiated Rate	$15,575.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1,946.93
Rate for Payer: BCBS of TX Blue Advantage	$6,489.76
Rate for Payer: BCBS of TX Blue Essentials	$7,787.71
Rate for Payer: BCBS of TX PPO	$8,653.01
Rate for Payer: Cash Price	$14,710.12
Rate for Payer: Cigna Medicaid	$15,575.42
Rate for Payer: Molina CHIP/Medicaid	$15,575.42
Rate for Payer: Multiplan Auto	$10,816.26
Rate for Payer: Multiplan Commercial	$10,816.26
Rate for Payer: Multiplan Workers Comp	$10,816.26
Rate for Payer: Parkland Medicaid	$15,575.42
Rate for Payer: Scott and White EPO/PPO	$10,816.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,575.42
Rate for Payer: Superior Health Plan EPO	$2,942.02

Augment injectable kit 3.0occinhectable usa

Facility

$21,632.53

Service Code	HCPCS C1734
Hospital Charge Code	992199
Hospital Revenue Code	278
Min. Negotiated Rate	$5,408.13
Max. Negotiated Rate	$10,816.26
Rate for Payer: Cash Price	$14,710.12
Rate for Payer: Cigna Commercial	$5,408.13
Rate for Payer: Multiplan Auto	$10,816.26
Rate for Payer: Multiplan Commercial	$10,816.26
Rate for Payer: Multiplan Workers Comp	$10,816.26
Rate for Payer: Scott and White EPO/PPO	$10,816.26

AUTOLOGOUS BONE MARROW TRANSPLANT

Facility

$29,294.38

Service Code	APR-DRG 0082
Min. Negotiated Rate	$27,619.77
Max. Negotiated Rate	$29,294.38
Rate for Payer: Amerigroup CHIP/Medicaid	$27,619.77
Rate for Payer: Cigna Medicaid	$27,619.77
Rate for Payer: Molina CHIP/Medicaid	$27,619.77
Rate for Payer: Parkland Medicaid	$27,619.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,294.38

AUTOLOGOUS BONE MARROW TRANSPLANT

Facility

$56,275.47

Service Code	APR-DRG 0083
Min. Negotiated Rate	$53,058.48
Max. Negotiated Rate	$56,275.47
Rate for Payer: Amerigroup CHIP/Medicaid	$53,058.48
Rate for Payer: Cigna Medicaid	$53,058.48
Rate for Payer: Molina CHIP/Medicaid	$53,058.48
Rate for Payer: Parkland Medicaid	$53,058.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56,275.47

AUTOLOGOUS BONE MARROW TRANSPLANT

Facility

$24,535.77

Service Code	APR-DRG 0081
Min. Negotiated Rate	$23,133.18
Max. Negotiated Rate	$24,535.77
Rate for Payer: Amerigroup CHIP/Medicaid	$23,133.18
Rate for Payer: Cigna Medicaid	$23,133.18
Rate for Payer: Molina CHIP/Medicaid	$23,133.18
Rate for Payer: Parkland Medicaid	$23,133.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,535.77

AUTOLOGOUS BONE MARROW TRANSPLANT

Facility

$83,256.93

Service Code	APR-DRG 0084
Min. Negotiated Rate	$78,497.55
Max. Negotiated Rate	$83,256.93
Rate for Payer: Amerigroup CHIP/Medicaid	$78,497.55
Rate for Payer: Cigna Medicaid	$78,497.55
Rate for Payer: Molina CHIP/Medicaid	$78,497.55
Rate for Payer: Parkland Medicaid	$78,497.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83,256.93

AUTOLOGOUS BONE MARROW TRANSPLANT W CC/MCC OR T-CELL IMMUNOTHERAPY

Facility

$115,603.60

Service Code	MSDRG 016
Min. Negotiated Rate	$48,219.01
Max. Negotiated Rate	$115,603.60
Rate for Payer: BCBS of TX Blue Advantage	$56,238.84
Rate for Payer: BCBS of TX Blue Essentials	$67,480.07
Rate for Payer: BCBS of TX PPO	$74,980.76

AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC

Facility

$115,603.60

Service Code	MSDRG 016
Min. Negotiated Rate	$48,219.01
Max. Negotiated Rate	$115,603.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$48,219.01
Rate for Payer: Amerigroup Medicare	$48,219.01
Rate for Payer: BCBS of TX Medicare	$48,219.01
Rate for Payer: Cigna Commercial	$76,374.54
Rate for Payer: Cigna Medicare	$48,219.01
Rate for Payer: Employer Direct Commercial	$48,219.01
Rate for Payer: Humana Medicare/TRICARE	$48,219.01
Rate for Payer: Molina Dual Medicare/Medicaid	$48,219.01
Rate for Payer: Molina Medicare	$48,219.01
Rate for Payer: Multiplan Auto	$115,603.60
Rate for Payer: Multiplan Commercial	$115,603.60
Rate for Payer: Multiplan Workers Comp	$115,603.60
Rate for Payer: Scott and White EPO/PPO	$53,238.50
Rate for Payer: Scott and White Medicare	$48,219.01
Rate for Payer: Superior Health Plan EPO	$48,219.01
Rate for Payer: Superior Health Plan Medicare	$48,219.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$48,219.01
Rate for Payer: Universal American Medicare	$48,219.01
Rate for Payer: Wellcare Medicare	$48,219.01
Rate for Payer: Wellmed Medicare	$48,219.01

AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC

Facility

$83,031.90

Service Code	MSDRG 017
Min. Negotiated Rate	$37,677.46
Max. Negotiated Rate	$83,031.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$44,573.55
Rate for Payer: Amerigroup Medicare	$44,573.55
Rate for Payer: BCBS of TX Medicare	$44,573.55
Rate for Payer: Cigna Commercial	$62,317.30
Rate for Payer: Cigna Medicare	$44,573.55
Rate for Payer: Employer Direct Commercial	$44,573.55
Rate for Payer: Humana Medicare/TRICARE	$44,573.55
Rate for Payer: Molina Dual Medicare/Medicaid	$44,573.55
Rate for Payer: Molina Medicare	$44,573.55
Rate for Payer: Multiplan Auto	$83,031.90
Rate for Payer: Multiplan Commercial	$83,031.90
Rate for Payer: Multiplan Workers Comp	$83,031.90
Rate for Payer: Scott and White EPO/PPO	$38,238.38
Rate for Payer: Scott and White Medicare	$44,573.55
Rate for Payer: Superior Health Plan EPO	$44,573.55
Rate for Payer: Superior Health Plan Medicare	$44,573.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$44,573.55
Rate for Payer: Universal American Medicare	$44,573.55
Rate for Payer: Wellcare Medicare	$44,573.55
Rate for Payer: Wellmed Medicare	$44,573.55

AUTOLOGOUS BONE MARROW TRANSPLANT W/O CC/MCC

Facility

$83,031.90

Service Code	MSDRG 017
Min. Negotiated Rate	$37,677.46
Max. Negotiated Rate	$83,031.90
Rate for Payer: BCBS of TX Blue Advantage	$37,677.46
Rate for Payer: BCBS of TX Blue Essentials	$45,208.57
Rate for Payer: BCBS of TX PPO	$50,233.69

AVANTI + 5f STD W/GW

Facility

$28.38

Service Code	HCPCS C1766
Hospital Charge Code	992498
Hospital Revenue Code	272
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$20.43
Rate for Payer: Amerigroup CHIP/Medicaid	$2.55
Rate for Payer: BCBS of TX Blue Advantage	$8.51
Rate for Payer: BCBS of TX Blue Essentials	$10.22
Rate for Payer: BCBS of TX PPO	$11.35
Rate for Payer: Cash Price	$19.30
Rate for Payer: Cigna Medicaid	$20.43
Rate for Payer: Molina CHIP/Medicaid	$20.43
Rate for Payer: Multiplan Auto	$18.45
Rate for Payer: Multiplan Commercial	$18.45
Rate for Payer: Multiplan Workers Comp	$18.45
Rate for Payer: Parkland Medicaid	$20.43
Rate for Payer: Scott and White EPO/PPO	$14.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.43
Rate for Payer: Superior Health Plan EPO	$3.86

AVANTI + 5f STD W/GW

Facility

$28.38

Service Code	HCPCS C1766
Hospital Charge Code	992498
Hospital Revenue Code	272
Rate for Payer: Cash Price	$19.30

AVN, ONQ QBLOC OTN CTH STM, 20G, 100MM

Facility

$13.68

Hospital Charge Code	992617
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.30

Know your out-of-pocket cost for care.

All Charges