White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

aztreonam 1 g Inj

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	77390829
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

aztreonam 1 g Inj

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	77390829
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

B11LT ENDPH XCEL BLADELESS TRACAR, W/ST

Facility

$132.57

Hospital Charge Code	992774
Hospital Revenue Code	272
Rate for Payer: Cash Price	$90.15

B11LT ENDPH XCEL BLADELESS TRACAR, W/ST

Facility

$132.57

Hospital Charge Code	992774
Hospital Revenue Code	272
Min. Negotiated Rate	$11.93
Max. Negotiated Rate	$95.45
Rate for Payer: Amerigroup CHIP/Medicaid	$11.93
Rate for Payer: BCBS of TX Blue Advantage	$39.77
Rate for Payer: BCBS of TX Blue Essentials	$47.73
Rate for Payer: BCBS of TX PPO	$53.03
Rate for Payer: Cash Price	$90.15
Rate for Payer: Cigna Medicaid	$95.45
Rate for Payer: Molina CHIP/Medicaid	$95.45
Rate for Payer: Multiplan Auto	$86.17
Rate for Payer: Multiplan Commercial	$86.17
Rate for Payer: Multiplan Workers Comp	$86.17
Rate for Payer: Parkland Medicaid	$95.45
Rate for Payer: Scott and White EPO/PPO	$66.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$95.45
Rate for Payer: Superior Health Plan EPO	$18.03

B12LTR ENDPH XCEL BLADELESS TROCAR, W/ST

Facility

$137.92

Hospital Charge Code	992866
Hospital Revenue Code	272
Min. Negotiated Rate	$12.41
Max. Negotiated Rate	$99.30
Rate for Payer: Amerigroup CHIP/Medicaid	$12.41
Rate for Payer: BCBS of TX Blue Advantage	$41.38
Rate for Payer: BCBS of TX Blue Essentials	$49.65
Rate for Payer: BCBS of TX PPO	$55.17
Rate for Payer: Cash Price	$93.79
Rate for Payer: Cigna Medicaid	$99.30
Rate for Payer: Molina CHIP/Medicaid	$99.30
Rate for Payer: Multiplan Auto	$89.65
Rate for Payer: Multiplan Commercial	$89.65
Rate for Payer: Multiplan Workers Comp	$89.65
Rate for Payer: Parkland Medicaid	$99.30
Rate for Payer: Scott and White EPO/PPO	$68.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$99.30
Rate for Payer: Superior Health Plan EPO	$18.76

B12LTR ENDPH XCEL BLADELESS TROCAR, W/ST

Facility

$137.92

Hospital Charge Code	992866
Hospital Revenue Code	272
Rate for Payer: Cash Price	$93.79

B15LTR @ENDPH XCEL BLADELESS TROCAR, W/ST

Facility

$265.70

Hospital Charge Code	992847
Hospital Revenue Code	272
Min. Negotiated Rate	$23.91
Max. Negotiated Rate	$191.30
Rate for Payer: Amerigroup CHIP/Medicaid	$23.91
Rate for Payer: BCBS of TX Blue Advantage	$79.71
Rate for Payer: BCBS of TX Blue Essentials	$95.65
Rate for Payer: BCBS of TX PPO	$106.28
Rate for Payer: Cash Price	$180.68
Rate for Payer: Cigna Medicaid	$191.30
Rate for Payer: Molina CHIP/Medicaid	$191.30
Rate for Payer: Multiplan Auto	$172.71
Rate for Payer: Multiplan Commercial	$172.71
Rate for Payer: Multiplan Workers Comp	$172.71
Rate for Payer: Parkland Medicaid	$191.30
Rate for Payer: Scott and White EPO/PPO	$132.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$191.30
Rate for Payer: Superior Health Plan EPO	$36.14

B15LTR @ENDPH XCEL BLADELESS TROCAR, W/ST

Facility

$265.70

Hospital Charge Code	992847
Hospital Revenue Code	272
Rate for Payer: Cash Price	$180.68

bacitracin 500 units/g Topical Oint

Facility

$56.00

Service Code	HCPCS J3490
Hospital Charge Code	77391251
Hospital Revenue Code	250
Rate for Payer: Cash Price	$38.08

bacitracin 500 units/g Topical Oint

Facility

$56.00

Service Code	HCPCS J3490
Hospital Charge Code	77391251
Hospital Revenue Code	250
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$40.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5.04
Rate for Payer: BCBS of TX Blue Advantage	$16.80
Rate for Payer: BCBS of TX Blue Essentials	$20.16
Rate for Payer: BCBS of TX PPO	$22.40
Rate for Payer: Cash Price	$38.08
Rate for Payer: Cigna Medicaid	$40.32
Rate for Payer: Molina CHIP/Medicaid	$40.32
Rate for Payer: Multiplan Auto	$36.40
Rate for Payer: Multiplan Commercial	$36.40
Rate for Payer: Multiplan Workers Comp	$36.40
Rate for Payer: Parkland Medicaid	$40.32
Rate for Payer: Scott and White EPO/PPO	$28.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.32
Rate for Payer: Superior Health Plan EPO	$7.62

bacitracin 500 units/g Topical Oint 30 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77391514
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

bacitracin 500 units/g Topical Oint 30 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77391514
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

bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin UD

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78747386
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin UD

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78747386
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

bacitracin zinc 500 units/g Topical Oint

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77391673
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

bacitracin zinc 500 units/g Topical Oint

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77391673
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC

Facility

$37,986.70

Service Code	MSDRG 519
Min. Negotiated Rate	$16,013.20
Max. Negotiated Rate	$37,986.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,419.59
Rate for Payer: Amerigroup Medicare	$19,419.59
Rate for Payer: BCBS of TX Medicare	$19,419.59
Rate for Payer: Cigna Commercial	$25,762.58
Rate for Payer: Cigna Medicare	$19,419.59
Rate for Payer: Employer Direct Commercial	$19,419.59
Rate for Payer: Humana Medicare/TRICARE	$19,419.59
Rate for Payer: Molina Dual Medicare/Medicaid	$19,419.59
Rate for Payer: Molina Medicare	$19,419.59
Rate for Payer: Multiplan Auto	$37,986.70
Rate for Payer: Multiplan Commercial	$37,986.70
Rate for Payer: Multiplan Workers Comp	$37,986.70
Rate for Payer: Scott and White EPO/PPO	$17,493.88
Rate for Payer: Scott and White Medicare	$19,419.59
Rate for Payer: Superior Health Plan EPO	$19,419.59
Rate for Payer: Superior Health Plan Medicare	$19,419.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,419.59
Rate for Payer: Universal American Medicare	$19,419.59
Rate for Payer: Wellcare Medicare	$19,419.59
Rate for Payer: Wellmed Medicare	$19,419.59

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR

Facility

$70,826.30

Service Code	MSDRG 518
Min. Negotiated Rate	$26,661.72
Max. Negotiated Rate	$70,826.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$32,150.85
Rate for Payer: Amerigroup Medicare	$32,150.85
Rate for Payer: BCBS of TX Medicare	$32,150.85
Rate for Payer: Cigna Commercial	$48,136.42
Rate for Payer: Cigna Medicare	$32,150.85
Rate for Payer: Employer Direct Commercial	$32,150.85
Rate for Payer: Humana Medicare/TRICARE	$32,150.85
Rate for Payer: Molina Dual Medicare/Medicaid	$32,150.85
Rate for Payer: Molina Medicare	$32,150.85
Rate for Payer: Multiplan Auto	$70,826.30
Rate for Payer: Multiplan Commercial	$70,826.30
Rate for Payer: Multiplan Workers Comp	$70,826.30
Rate for Payer: Scott and White EPO/PPO	$32,617.38
Rate for Payer: Scott and White Medicare	$32,150.85
Rate for Payer: Superior Health Plan EPO	$32,150.85
Rate for Payer: Superior Health Plan Medicare	$32,150.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$32,150.85
Rate for Payer: Universal American Medicare	$32,150.85
Rate for Payer: Wellcare Medicare	$32,150.85
Rate for Payer: Wellmed Medicare	$32,150.85

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC

Facility

$28,116.20

Service Code	MSDRG 520
Min. Negotiated Rate	$11,301.26
Max. Negotiated Rate	$28,116.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,708.90
Rate for Payer: Amerigroup Medicare	$15,708.90
Rate for Payer: BCBS of TX Medicare	$15,708.90
Rate for Payer: Cigna Commercial	$19,241.43
Rate for Payer: Cigna Medicare	$15,708.90
Rate for Payer: Employer Direct Commercial	$15,708.90
Rate for Payer: Humana Medicare/TRICARE	$15,708.90
Rate for Payer: Molina Dual Medicare/Medicaid	$15,708.90
Rate for Payer: Molina Medicare	$15,708.90
Rate for Payer: Multiplan Auto	$28,116.20
Rate for Payer: Multiplan Commercial	$28,116.20
Rate for Payer: Multiplan Workers Comp	$28,116.20
Rate for Payer: Scott and White EPO/PPO	$12,948.25
Rate for Payer: Scott and White Medicare	$15,708.90
Rate for Payer: Superior Health Plan EPO	$15,708.90
Rate for Payer: Superior Health Plan Medicare	$15,708.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,708.90
Rate for Payer: Universal American Medicare	$15,708.90
Rate for Payer: Wellcare Medicare	$15,708.90
Rate for Payer: Wellmed Medicare	$15,708.90

BACK & NECK PROC EXC SPINAL FUSION W CC

Facility

$37,986.70

Service Code	MSDRG 519
Min. Negotiated Rate	$16,013.20
Max. Negotiated Rate	$37,986.70
Rate for Payer: BCBS of TX Blue Advantage	$16,013.20
Rate for Payer: BCBS of TX Blue Essentials	$19,213.98
Rate for Payer: BCBS of TX PPO	$21,349.69

BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM

Facility

$70,826.30

Service Code	MSDRG 518
Min. Negotiated Rate	$26,661.72
Max. Negotiated Rate	$70,826.30
Rate for Payer: BCBS of TX Blue Advantage	$26,661.72
Rate for Payer: BCBS of TX Blue Essentials	$31,990.96
Rate for Payer: BCBS of TX PPO	$35,546.89

BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC

Facility

$28,116.20

Service Code	MSDRG 520
Min. Negotiated Rate	$11,301.26
Max. Negotiated Rate	$28,116.20
Rate for Payer: BCBS of TX Blue Advantage	$11,301.26
Rate for Payer: BCBS of TX Blue Essentials	$13,560.20
Rate for Payer: BCBS of TX PPO	$15,067.47

baclofen 10 mg Tab

Facility

$10.75

Service Code	HCPCS J3490
Hospital Charge Code	77393400
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.31

baclofen 10 mg Tab

Facility

$10.75

Service Code	HCPCS J3490
Hospital Charge Code	77393400
Hospital Revenue Code	250
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$7.74
Rate for Payer: Amerigroup CHIP/Medicaid	$0.97
Rate for Payer: BCBS of TX Blue Advantage	$3.23
Rate for Payer: BCBS of TX Blue Essentials	$3.87
Rate for Payer: BCBS of TX PPO	$4.30
Rate for Payer: Cash Price	$7.31
Rate for Payer: Cigna Medicaid	$7.74
Rate for Payer: Molina CHIP/Medicaid	$7.74
Rate for Payer: Multiplan Auto	$6.99
Rate for Payer: Multiplan Commercial	$6.99
Rate for Payer: Multiplan Workers Comp	$6.99
Rate for Payer: Parkland Medicaid	$7.74
Rate for Payer: Scott and White EPO/PPO	$5.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.74
Rate for Payer: Superior Health Plan EPO	$1.46

Know your out-of-pocket cost for care.

All Charges