White Rock Medical Center

All Charges

Charge

Type

Setting

Price

acetaminophen 80 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77344385
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

acetaminophen 80 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77344385
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

acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liquid 5 mL

Facility

$27.23

Service Code	HCPCS J3490
Hospital Charge Code	77351712
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.52

acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liquid 5 mL

Facility

$27.23

Service Code	HCPCS J3490
Hospital Charge Code	77351712
Hospital Revenue Code	250
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$17.70
Rate for Payer: Amerigroup CHIP/Medicaid	$2.45
Rate for Payer: BCBS of TX Blue Advantage	$8.17
Rate for Payer: BCBS of TX Blue Essentials	$9.80
Rate for Payer: BCBS of TX PPO	$10.89
Rate for Payer: Cash Price	$18.52
Rate for Payer: Multiplan Auto	$17.70
Rate for Payer: Multiplan Commercial	$17.70
Rate for Payer: Multiplan Workers Comp	$17.70
Rate for Payer: Scott and White EPO/PPO	$13.62
Rate for Payer: Superior Health Plan EPO	$3.70

acetaminophen-codeine 300 mg-30 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77351926
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen-codeine 300 mg-30 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77351926
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	$2.30
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	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

acetaminophen-HYDROcodone 325 mg-10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78405241
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen-HYDROcodone 325 mg-10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78405241
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	$2.30
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	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

acetaminophen-HYDROcodone 325 mg-5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78412260
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen-HYDROcodone 325 mg-5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78412260
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	$2.30
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	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

acetaminophen-HYDROcodone 325 mg-7.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78868024
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	$2.30
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	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

acetaminophen-HYDROcodone 325 mg-7.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78868024
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Acetaminophen Level

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640122
Hospital Revenue Code	300
Rate for Payer: Cash Price	$278.96

Acetaminophen Level

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640122
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$206.05
Rate for Payer: Aetna Commercial	$65.24
Rate for Payer: Aetna Medicare	$93.21
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$102.53
Rate for Payer: BCBS of TX Blue Essentials	$123.04
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$137.33
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cigna Medicaid	$62.14
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$62.14
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$62.14
Rate for Payer: Scott and White EPO/PPO	$77.68
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.14
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

acetaminophen-oxyCODONE 325 mg-5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77353929
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen-oxyCODONE 325 mg-5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77353929
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	$2.30
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	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

acetylcysteine 10% Inh Soln 4 mL

Facility

$8.00

Service Code	HCPCS J7608
Hospital Charge Code	77355711
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

acetylcysteine 10% Inh Soln 4 mL

Facility

$8.00

Service Code	HCPCS J7608
Hospital Charge Code	77355711
Hospital Revenue Code	636
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	$2.22
Rate for Payer: BCBS of TX Blue Essentials	$2.66
Rate for Payer: BCBS of TX PPO	$2.95
Rate for Payer: Cash Price	$5.44
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

AChR Binding Abs, Serum SO

Facility

$309.00

Service Code	CPT 83519
Hospital Charge Code	1703461
Hospital Revenue Code	301
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$200.85
Rate for Payer: Aetna Commercial	$19.32
Rate for Payer: Aetna Medicare	$27.60
Rate for Payer: Amerigroup CHIP/Medicaid	$7.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.40
Rate for Payer: Amerigroup Medicare	$18.40
Rate for Payer: BCBS of TX Blue Advantage	$30.36
Rate for Payer: BCBS of TX Blue Essentials	$36.43
Rate for Payer: BCBS of TX Medicare	$18.40
Rate for Payer: BCBS of TX PPO	$40.66
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cigna Medicaid	$18.40
Rate for Payer: Cigna Medicare	$18.40
Rate for Payer: Employer Direct Commercial	$18.40
Rate for Payer: Humana Medicare/TRICARE	$18.40
Rate for Payer: Molina CHIP/Medicaid	$18.40
Rate for Payer: Molina Dual Medicare/Medicaid	$18.40
Rate for Payer: Molina Medicare	$18.40
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	$18.40
Rate for Payer: Scott and White EPO/PPO	$23.00
Rate for Payer: Scott and White Medicare	$18.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.40
Rate for Payer: Superior Health Plan EPO	$18.40
Rate for Payer: Superior Health Plan Medicare	$18.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.40
Rate for Payer: Universal American Medicare	$18.40
Rate for Payer: Wellcare Medicare	$18.40
Rate for Payer: Wellmed Medicare	$18.40

AChR Blocking Abs, Serum SO

Facility

$309.00

Service Code	CPT 83519
Hospital Charge Code	1703461
Hospital Revenue Code	301
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$200.85
Rate for Payer: Aetna Commercial	$19.32
Rate for Payer: Aetna Medicare	$27.60
Rate for Payer: Amerigroup CHIP/Medicaid	$7.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.40
Rate for Payer: Amerigroup Medicare	$18.40
Rate for Payer: BCBS of TX Blue Advantage	$30.36
Rate for Payer: BCBS of TX Blue Essentials	$36.43
Rate for Payer: BCBS of TX Medicare	$18.40
Rate for Payer: BCBS of TX PPO	$40.66
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cigna Medicaid	$18.40
Rate for Payer: Cigna Medicare	$18.40
Rate for Payer: Employer Direct Commercial	$18.40
Rate for Payer: Humana Medicare/TRICARE	$18.40
Rate for Payer: Molina CHIP/Medicaid	$18.40
Rate for Payer: Molina Dual Medicare/Medicaid	$18.40
Rate for Payer: Molina Medicare	$18.40
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	$18.40
Rate for Payer: Scott and White EPO/PPO	$23.00
Rate for Payer: Scott and White Medicare	$18.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.40
Rate for Payer: Superior Health Plan EPO	$18.40
Rate for Payer: Superior Health Plan Medicare	$18.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.40
Rate for Payer: Universal American Medicare	$18.40
Rate for Payer: Wellcare Medicare	$18.40
Rate for Payer: Wellmed Medicare	$18.40

Acid Fast Smear+Culture SO

Facility

$24.00

Service Code	CPT 87116
Hospital Charge Code	1604248
Hospital Revenue Code	306
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$23.87
Rate for Payer: Aetna Commercial	$11.34
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.80
Rate for Payer: Amerigroup Medicare	$10.80
Rate for Payer: BCBS of TX Blue Advantage	$17.82
Rate for Payer: BCBS of TX Blue Essentials	$21.38
Rate for Payer: BCBS of TX Medicare	$10.80
Rate for Payer: BCBS of TX PPO	$23.87
Rate for Payer: Cash Price	$21.12
Rate for Payer: Cash Price	$21.12
Rate for Payer: Cigna Medicaid	$10.80
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Employer Direct Commercial	$10.80
Rate for Payer: Humana Medicare/TRICARE	$10.80
Rate for Payer: Molina CHIP/Medicaid	$10.80
Rate for Payer: Molina Dual Medicare/Medicaid	$10.80
Rate for Payer: Molina Medicare	$10.80
Rate for Payer: Multiplan Auto	$15.60
Rate for Payer: Multiplan Commercial	$15.60
Rate for Payer: Multiplan Workers Comp	$15.60
Rate for Payer: Parkland Medicaid	$10.80
Rate for Payer: Scott and White EPO/PPO	$13.50
Rate for Payer: Scott and White Medicare	$10.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.80
Rate for Payer: Superior Health Plan EPO	$10.80
Rate for Payer: Superior Health Plan Medicare	$10.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.80
Rate for Payer: Universal American Medicare	$10.80
Rate for Payer: Wellcare Medicare	$10.80
Rate for Payer: Wellmed Medicare	$10.80

Acid Fast Smear+Culture SO

Facility

$24.00

Service Code	CPT 87116
Hospital Charge Code	1604248
Hospital Revenue Code	306
Rate for Payer: Cash Price	$21.12

Acid Fast Smear+Culture W/Rflx SO

Facility

$24.00

Service Code	CPT 87116
Hospital Charge Code	1604248
Hospital Revenue Code	306
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$23.87
Rate for Payer: Aetna Commercial	$11.34
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.80
Rate for Payer: Amerigroup Medicare	$10.80
Rate for Payer: BCBS of TX Blue Advantage	$17.82
Rate for Payer: BCBS of TX Blue Essentials	$21.38
Rate for Payer: BCBS of TX Medicare	$10.80
Rate for Payer: BCBS of TX PPO	$23.87
Rate for Payer: Cash Price	$21.12
Rate for Payer: Cash Price	$21.12
Rate for Payer: Cigna Medicaid	$10.80
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Employer Direct Commercial	$10.80
Rate for Payer: Humana Medicare/TRICARE	$10.80
Rate for Payer: Molina CHIP/Medicaid	$10.80
Rate for Payer: Molina Dual Medicare/Medicaid	$10.80
Rate for Payer: Molina Medicare	$10.80
Rate for Payer: Multiplan Auto	$15.60
Rate for Payer: Multiplan Commercial	$15.60
Rate for Payer: Multiplan Workers Comp	$15.60
Rate for Payer: Parkland Medicaid	$10.80
Rate for Payer: Scott and White EPO/PPO	$13.50
Rate for Payer: Scott and White Medicare	$10.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.80
Rate for Payer: Superior Health Plan EPO	$10.80
Rate for Payer: Superior Health Plan Medicare	$10.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.80
Rate for Payer: Universal American Medicare	$10.80
Rate for Payer: Wellcare Medicare	$10.80
Rate for Payer: Wellmed Medicare	$10.80

ACL DISPOSABLE KIT

Facility

$1,203.10

Hospital Charge Code	8420459
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,058.73

ACL DISPOSABLE KIT

Facility

$1,203.10

Hospital Charge Code	8420459
Hospital Revenue Code	272
Min. Negotiated Rate	$108.28
Max. Negotiated Rate	$782.02
Rate for Payer: Aetna Commercial	$661.70
Rate for Payer: Amerigroup CHIP/Medicaid	$108.28
Rate for Payer: BCBS of TX Blue Advantage	$360.93
Rate for Payer: BCBS of TX Blue Essentials	$433.12
Rate for Payer: BCBS of TX PPO	$481.24
Rate for Payer: Cash Price	$1,058.73
Rate for Payer: Multiplan Auto	$782.02
Rate for Payer: Multiplan Commercial	$782.02
Rate for Payer: Multiplan Workers Comp	$782.02
Rate for Payer: Scott and White EPO/PPO	$601.55
Rate for Payer: Superior Health Plan EPO	$163.62

Know your out-of-pocket cost for care.

All Charges