White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

AVN, ONQ TBLOC ULTRA NBPT

Facility

$21.69

Hospital Charge Code	992618
Hospital Revenue Code	272
Rate for Payer: Cash Price	$14.75

AVN, ONQ TBLOC ULTRA NBPT

Facility

$21.69

Hospital Charge Code	992618
Hospital Revenue Code	272
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$15.62
Rate for Payer: Amerigroup CHIP/Medicaid	$1.95
Rate for Payer: BCBS of TX Blue Advantage	$6.51
Rate for Payer: BCBS of TX Blue Essentials	$7.81
Rate for Payer: BCBS of TX PPO	$8.68
Rate for Payer: Cash Price	$14.75
Rate for Payer: Cigna Medicaid	$15.62
Rate for Payer: Molina CHIP/Medicaid	$15.62
Rate for Payer: Multiplan Auto	$14.10
Rate for Payer: Multiplan Commercial	$14.10
Rate for Payer: Multiplan Workers Comp	$14.10
Rate for Payer: Parkland Medicaid	$15.62
Rate for Payer: Scott and White EPO/PPO	$10.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.62
Rate for Payer: Superior Health Plan EPO	$2.95

Avulsion of nail plate, partial or complete, simple; each addtl. nail plate

Facility

$993.50

Service Code	HCPCS 11732
Hospital Charge Code	994052
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

Avulsion of nail plate, partial or complete, simple; each addtl. nail plate

Facility

$993.50

Service Code	HCPCS 11732
Hospital Charge Code	994052
Hospital Revenue Code	361
Min. Negotiated Rate	$89.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$89.42
Rate for Payer: BCBS of TX Blue Advantage	$298.05
Rate for Payer: BCBS of TX Blue Essentials	$357.66
Rate for Payer: BCBS of TX PPO	$397.40
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Molina CHIP/Medicaid	$715.32
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	$715.32
Rate for Payer: Scott and White EPO/PPO	$496.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$135.12

Avulsion of nail plate, partial or complete, simple; single

Facility

$993.50

Service Code	HCPCS 11730
Hospital Charge Code	9900099
Hospital Revenue Code	360
Min. Negotiated Rate	$89.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$89.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
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	$715.32
Rate for Payer: Scott and White EPO/PPO	$338.72
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

Avulsion of nail plate, partial or complete, simple; single

Facility

$10,000.00

Service Code	CPT 11730
Hospital Charge Code	36011730
Hospital Revenue Code	360
Min. Negotiated Rate	$201.55
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
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: Scott and White EPO/PPO	$338.72
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

Avulsion of nail plate, partial or complete, simple; single

Facility

$993.50

Service Code	HCPCS 11730
Hospital Charge Code	9900099
Hospital Revenue Code	360
Rate for Payer: Cash Price	$675.58

AW LARYNGEAL MSK 2 -- DHF

Facility

$70.84

Hospital Charge Code	82011099
Hospital Revenue Code	272
Min. Negotiated Rate	$6.38
Max. Negotiated Rate	$51.00
Rate for Payer: Amerigroup CHIP/Medicaid	$6.38
Rate for Payer: BCBS of TX Blue Advantage	$21.25
Rate for Payer: BCBS of TX Blue Essentials	$25.50
Rate for Payer: BCBS of TX PPO	$28.34
Rate for Payer: Cash Price	$48.17
Rate for Payer: Cigna Medicaid	$51.00
Rate for Payer: Molina CHIP/Medicaid	$51.00
Rate for Payer: Multiplan Auto	$46.05
Rate for Payer: Multiplan Commercial	$46.05
Rate for Payer: Multiplan Workers Comp	$46.05
Rate for Payer: Parkland Medicaid	$51.00
Rate for Payer: Scott and White EPO/PPO	$35.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.00
Rate for Payer: Superior Health Plan EPO	$9.63

AW LARYNGEAL MSK 2 -- DHF

Facility

$70.84

Hospital Charge Code	82011099
Hospital Revenue Code	272
Rate for Payer: Cash Price	$48.17

AW NASO-PHARYNGL -- DHF

Facility

$66.15

Hospital Charge Code	82011156
Hospital Revenue Code	270
Rate for Payer: Cash Price	$44.98

AW NASO-PHARYNGL -- DHF

Facility

$66.15

Hospital Charge Code	82011156
Hospital Revenue Code	270
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$47.63
Rate for Payer: Amerigroup CHIP/Medicaid	$5.95
Rate for Payer: BCBS of TX Blue Advantage	$19.84
Rate for Payer: BCBS of TX Blue Essentials	$23.81
Rate for Payer: BCBS of TX PPO	$26.46
Rate for Payer: Cash Price	$44.98
Rate for Payer: Cigna Medicaid	$47.63
Rate for Payer: Molina CHIP/Medicaid	$47.63
Rate for Payer: Multiplan Auto	$43.00
Rate for Payer: Multiplan Commercial	$43.00
Rate for Payer: Multiplan Workers Comp	$43.00
Rate for Payer: Parkland Medicaid	$47.63
Rate for Payer: Scott and White EPO/PPO	$33.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47.63
Rate for Payer: Superior Health Plan EPO	$9.00

Axiom Procedure Kit

Facility

$6,054.22

Hospital Charge Code	993124
Hospital Revenue Code	270
Min. Negotiated Rate	$544.88
Max. Negotiated Rate	$4,359.04
Rate for Payer: Amerigroup CHIP/Medicaid	$544.88
Rate for Payer: BCBS of TX Blue Advantage	$1,816.27
Rate for Payer: BCBS of TX Blue Essentials	$2,179.52
Rate for Payer: BCBS of TX PPO	$2,421.69
Rate for Payer: Cash Price	$4,116.87
Rate for Payer: Cigna Medicaid	$4,359.04
Rate for Payer: Molina CHIP/Medicaid	$4,359.04
Rate for Payer: Multiplan Auto	$3,935.24
Rate for Payer: Multiplan Commercial	$3,935.24
Rate for Payer: Multiplan Workers Comp	$3,935.24
Rate for Payer: Parkland Medicaid	$4,359.04
Rate for Payer: Scott and White EPO/PPO	$3,027.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,359.04
Rate for Payer: Superior Health Plan EPO	$823.37

Axiom Procedure Kit

Facility

$6,054.22

Hospital Charge Code	993124
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4,116.87

Axiom PSR Tibial Cut Guide, Left

Facility

$7,228.92

Hospital Charge Code	993126
Hospital Revenue Code	270
Min. Negotiated Rate	$650.60
Max. Negotiated Rate	$5,204.82
Rate for Payer: Amerigroup CHIP/Medicaid	$650.60
Rate for Payer: BCBS of TX Blue Advantage	$2,168.68
Rate for Payer: BCBS of TX Blue Essentials	$2,602.41
Rate for Payer: BCBS of TX PPO	$2,891.57
Rate for Payer: Cash Price	$4,915.67
Rate for Payer: Cigna Medicaid	$5,204.82
Rate for Payer: Molina CHIP/Medicaid	$5,204.82
Rate for Payer: Multiplan Auto	$4,698.80
Rate for Payer: Multiplan Commercial	$4,698.80
Rate for Payer: Multiplan Workers Comp	$4,698.80
Rate for Payer: Parkland Medicaid	$5,204.82
Rate for Payer: Scott and White EPO/PPO	$3,614.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,204.82
Rate for Payer: Superior Health Plan EPO	$983.13

Axiom PSR Tibial Cut Guide, Left

Facility

$7,228.92

Hospital Charge Code	993126
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4,915.67

azithromycin 100 mg/5 mL Oral Liquid 15 mL

Facility

$59.64

Service Code	HCPCS Q0144
Hospital Charge Code	77390281
Hospital Revenue Code	636
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$29.82
Rate for Payer: Cash Price	$40.56
Rate for Payer: Cigna Commercial	$14.91
Rate for Payer: Scott and White EPO/PPO	$29.82

azithromycin 100 mg/5 mL Oral Liquid 15 mL

Facility

$59.64

Service Code	HCPCS Q0144
Hospital Charge Code	77390281
Hospital Revenue Code	636
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$42.94
Rate for Payer: Amerigroup CHIP/Medicaid	$5.37
Rate for Payer: BCBS of TX Blue Advantage	$24.27
Rate for Payer: BCBS of TX Blue Essentials	$29.13
Rate for Payer: BCBS of TX PPO	$32.31
Rate for Payer: Cash Price	$40.56
Rate for Payer: Cash Price	$40.56
Rate for Payer: Cigna Medicaid	$42.94
Rate for Payer: Molina CHIP/Medicaid	$42.94
Rate for Payer: Multiplan Auto	$38.77
Rate for Payer: Multiplan Commercial	$38.77
Rate for Payer: Multiplan Workers Comp	$38.77
Rate for Payer: Parkland Medicaid	$42.94
Rate for Payer: Scott and White EPO/PPO	$29.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.94
Rate for Payer: Superior Health Plan EPO	$8.11

azithromycin 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77390617
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

azithromycin 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77390617
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

azithromycin 500 mg in NS; 250 mL connect

Facility

$128.17

Service Code	HCPCS J0456
Hospital Charge Code	79477098
Hospital Revenue Code	636
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$6.02
Rate for Payer: BCBS of TX Blue Essentials	$7.22
Rate for Payer: BCBS of TX PPO	$8.01
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

azithromycin 500 mg in NS; 250 mL connect

Facility

$128.17

Service Code	HCPCS J0456
Hospital Charge Code	79477098
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

azithromycin 500 mg IV Inj

Facility

$128.17

Service Code	HCPCS J0456
Hospital Charge Code	77390668
Hospital Revenue Code	636
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$6.02
Rate for Payer: BCBS of TX Blue Essentials	$7.22
Rate for Payer: BCBS of TX PPO	$8.01
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

azithromycin 500 mg IV Inj

Facility

$128.17

Service Code	HCPCS J0456
Hospital Charge Code	77390668
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

azithromycin 500 mg Tab

Facility

$36.52

Service Code	HCPCS J3490
Hospital Charge Code	77390723
Hospital Revenue Code	250
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$26.29
Rate for Payer: Amerigroup CHIP/Medicaid	$3.29
Rate for Payer: BCBS of TX Blue Advantage	$10.96
Rate for Payer: BCBS of TX Blue Essentials	$13.15
Rate for Payer: BCBS of TX PPO	$14.61
Rate for Payer: Cash Price	$24.83
Rate for Payer: Cigna Medicaid	$26.29
Rate for Payer: Molina CHIP/Medicaid	$26.29
Rate for Payer: Multiplan Auto	$23.74
Rate for Payer: Multiplan Commercial	$23.74
Rate for Payer: Multiplan Workers Comp	$23.74
Rate for Payer: Parkland Medicaid	$26.29
Rate for Payer: Scott and White EPO/PPO	$18.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.29
Rate for Payer: Superior Health Plan EPO	$4.97

Know your out-of-pocket cost for care.

All Charges