White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DOBUTamine 250 mg/250 mL-D5W

Facility

$128.17

Service Code	HCPCS J1250
Hospital Charge Code	77521130
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

docusate 100 mg capsule

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77526832
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

docusate 100 mg capsule

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77526832
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

docusate sodium 100 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77522438
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

docusate sodium 100 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77522438
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

DOPP FLW/PR MSMNT ADDL

Facility

$1,626.00

Service Code	CPT 93572
Hospital Charge Code	2320515
Hospital Revenue Code	481
Rate for Payer: Cash Price	$1,430.88

DOPP FLW/PR MSMNT ADDL

Facility

$1,626.00

Service Code	CPT 93572
Hospital Charge Code	2320515
Hospital Revenue Code	481
Min. Negotiated Rate	$146.34
Max. Negotiated Rate	$1,056.90
Rate for Payer: Aetna Commercial	$894.30
Rate for Payer: Amerigroup CHIP/Medicaid	$146.34
Rate for Payer: Cash Price	$1,430.88
Rate for Payer: Multiplan Auto	$1,056.90
Rate for Payer: Multiplan Commercial	$1,056.90
Rate for Payer: Multiplan Workers Comp	$1,056.90
Rate for Payer: Scott and White EPO/PPO	$813.00
Rate for Payer: Superior Health Plan EPO	$221.14

DOPP FLW/PR MSMNT INIT

Facility

$2,213.00

Service Code	CPT 93571
Hospital Charge Code	2320514
Hospital Revenue Code	481
Min. Negotiated Rate	$199.17
Max. Negotiated Rate	$1,438.45
Rate for Payer: Aetna Commercial	$1,217.15
Rate for Payer: Amerigroup CHIP/Medicaid	$199.17
Rate for Payer: Cash Price	$1,947.44
Rate for Payer: Multiplan Auto	$1,438.45
Rate for Payer: Multiplan Commercial	$1,438.45
Rate for Payer: Multiplan Workers Comp	$1,438.45
Rate for Payer: Scott and White EPO/PPO	$1,106.50
Rate for Payer: Superior Health Plan EPO	$300.97

DOPP FLW/PR MSMNT INIT

Facility

$2,213.00

Service Code	CPT 93571
Hospital Charge Code	2320514
Hospital Revenue Code	481
Rate for Payer: Cash Price	$1,947.44

dorzolamide 2% Ophth Soln 10 mL

Facility

$124.40

Service Code	HCPCS J3490
Hospital Charge Code	77524384
Hospital Revenue Code	250
Rate for Payer: Cash Price	$84.59

dorzolamide 2% Ophth Soln 10 mL

Facility

$124.40

Service Code	HCPCS J3490
Hospital Charge Code	77524384
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$80.86
Rate for Payer: Amerigroup CHIP/Medicaid	$11.20
Rate for Payer: BCBS of TX Blue Advantage	$37.32
Rate for Payer: BCBS of TX Blue Essentials	$44.78
Rate for Payer: BCBS of TX PPO	$49.76
Rate for Payer: Cash Price	$84.59
Rate for Payer: Multiplan Auto	$80.86
Rate for Payer: Multiplan Commercial	$80.86
Rate for Payer: Multiplan Workers Comp	$80.86
Rate for Payer: Scott and White EPO/PPO	$62.20
Rate for Payer: Superior Health Plan EPO	$16.92

doxepin 25 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77525226
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

doxepin 25 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77525226
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

doxycycline 100 mg Inj

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77526422
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

doxycycline 100 mg Inj

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77526422
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

doxycycline hyclate 50 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77527136
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

doxycycline hyclate 50 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77527136
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

doxycycline monohydrate 100 mg Cap

Facility

$10.30

Service Code	HCPCS J3490
Hospital Charge Code	77527289
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.00

doxycycline monohydrate 100 mg Cap

Facility

$10.30

Service Code	HCPCS J3490
Hospital Charge Code	77527289
Hospital Revenue Code	250
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$6.70
Rate for Payer: Amerigroup CHIP/Medicaid	$0.93
Rate for Payer: BCBS of TX Blue Advantage	$3.09
Rate for Payer: BCBS of TX Blue Essentials	$3.71
Rate for Payer: BCBS of TX PPO	$4.12
Rate for Payer: Cash Price	$7.00
Rate for Payer: Multiplan Auto	$6.70
Rate for Payer: Multiplan Commercial	$6.70
Rate for Payer: Multiplan Workers Comp	$6.70
Rate for Payer: Scott and White EPO/PPO	$5.15
Rate for Payer: Superior Health Plan EPO	$1.40

DRAIN 10 FR SILICONE 70310

Facility

$31.55

Hospital Charge Code	8570492
Hospital Revenue Code	272
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$20.51
Rate for Payer: Aetna Commercial	$17.35
Rate for Payer: Amerigroup CHIP/Medicaid	$2.84
Rate for Payer: BCBS of TX Blue Advantage	$9.46
Rate for Payer: BCBS of TX Blue Essentials	$11.36
Rate for Payer: BCBS of TX PPO	$12.62
Rate for Payer: Cash Price	$27.76
Rate for Payer: Multiplan Auto	$20.51
Rate for Payer: Multiplan Commercial	$20.51
Rate for Payer: Multiplan Workers Comp	$20.51
Rate for Payer: Scott and White EPO/PPO	$15.78
Rate for Payer: Superior Health Plan EPO	$4.29

DRAIN 10 FR SILICONE 70310

Facility

$31.55

Hospital Charge Code	8570492
Hospital Revenue Code	272
Rate for Payer: Cash Price	$27.76

DRAIN, 7MM FLAT 0070430

Facility

$20.97

Hospital Charge Code	8612530
Hospital Revenue Code	272
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$13.63
Rate for Payer: Aetna Commercial	$11.53
Rate for Payer: Amerigroup CHIP/Medicaid	$1.89
Rate for Payer: BCBS of TX Blue Advantage	$6.29
Rate for Payer: BCBS of TX Blue Essentials	$7.55
Rate for Payer: BCBS of TX PPO	$8.39
Rate for Payer: Cash Price	$18.45
Rate for Payer: Multiplan Auto	$13.63
Rate for Payer: Multiplan Commercial	$13.63
Rate for Payer: Multiplan Workers Comp	$13.63
Rate for Payer: Scott and White EPO/PPO	$10.48
Rate for Payer: Superior Health Plan EPO	$2.85

DRAIN, 7MM FLAT 0070430

Facility

$20.97

Hospital Charge Code	8612530
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18.45

Drainage abscess or hematoma, nasal septum

Facility

$10,000.00

Service Code	CPT 30020
Hospital Charge Code	36030020
Hospital Revenue Code	360
Min. Negotiated Rate	$11.10
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$754.78
Rate for Payer: Amerigroup CHIP/Medicaid	$180.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$503.19
Rate for Payer: Amerigroup Medicare	$503.19
Rate for Payer: BCBS of TX Blue Advantage	$334.50
Rate for Payer: BCBS of TX Blue Essentials	$400.60
Rate for Payer: BCBS of TX Medicare	$503.19
Rate for Payer: BCBS of TX PPO	$504.76
Rate for Payer: Cigna Commercial	$1,139.87
Rate for Payer: Cigna Medicaid	$180.23
Rate for Payer: Cigna Medicare	$503.19
Rate for Payer: Employer Direct Commercial	$503.19
Rate for Payer: Humana Medicare/TRICARE	$503.19
Rate for Payer: Molina CHIP/Medicaid	$180.23
Rate for Payer: Molina Dual Medicare/Medicaid	$503.19
Rate for Payer: Molina Medicare	$503.19
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	$180.23
Rate for Payer: Scott and White EPO/PPO	$11.10
Rate for Payer: Scott and White Medicare	$503.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.23
Rate for Payer: Superior Health Plan EPO	$503.19
Rate for Payer: Superior Health Plan Medicare	$503.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$503.19
Rate for Payer: Universal American Medicare	$503.19
Rate for Payer: Wellcare Medicare	$503.19
Rate for Payer: Wellmed Medicare	$503.19

Drainage of finger abscess complicated (eg, felon)

Facility

$10,000.00

Service Code	CPT 26011
Hospital Charge Code	36026011
Hospital Revenue Code	360
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,482.74
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$486.45
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$486.45
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
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	$486.45
Rate for Payer: Scott and White EPO/PPO	$32.70
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$486.45
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

Know your out-of-pocket cost for care.

All Charges