White Rock Medical Center

All Charges

Charge

Type

Setting

Price

amiodarone 50 mg/mL IV Soln 3 mL

Facility

$128.17

Service Code	HCPCS J0282
Hospital Charge Code	77370199
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.29
Rate for Payer: BCBS of TX Blue Essentials	$0.35
Rate for Payer: BCBS of TX PPO	$0.39
Rate for Payer: Cash Price	$87.16
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

amiodarone 50 mg/mL IV Soln 9 mL

Facility

$128.17

Service Code	HCPCS J0282
Hospital Charge Code	77370258
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

amiodarone 50 mg/mL IV Soln 9 mL

Facility

$128.17

Service Code	HCPCS J0282
Hospital Charge Code	77370258
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.29
Rate for Payer: BCBS of TX Blue Essentials	$0.35
Rate for Payer: BCBS of TX PPO	$0.39
Rate for Payer: Cash Price	$87.16
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

Amiodarone (Cordarone(R)), S SO

Facility

$245.00

Service Code	CPT 80299
Hospital Charge Code	1707082
Hospital Revenue Code	300
Rate for Payer: Cash Price	$215.60

Amiodarone (Cordarone(R)), S SO

Facility

$245.00

Service Code	CPT 80299
Hospital Charge Code	1707082
Hospital Revenue Code	300
Min. Negotiated Rate	$7.27
Max. Negotiated Rate	$159.25
Rate for Payer: Aetna Commercial	$19.56
Rate for Payer: Aetna Medicare	$27.96
Rate for Payer: Amerigroup CHIP/Medicaid	$7.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.64
Rate for Payer: Amerigroup Medicare	$18.64
Rate for Payer: BCBS of TX Blue Advantage	$30.76
Rate for Payer: BCBS of TX Blue Essentials	$36.91
Rate for Payer: BCBS of TX Medicare	$18.64
Rate for Payer: BCBS of TX PPO	$41.19
Rate for Payer: Cash Price	$215.60
Rate for Payer: Cash Price	$215.60
Rate for Payer: Cigna Medicaid	$18.64
Rate for Payer: Cigna Medicare	$18.64
Rate for Payer: Employer Direct Commercial	$18.64
Rate for Payer: Humana Medicare/TRICARE	$18.64
Rate for Payer: Molina CHIP/Medicaid	$18.64
Rate for Payer: Molina Dual Medicare/Medicaid	$18.64
Rate for Payer: Molina Medicare	$18.64
Rate for Payer: Multiplan Auto	$159.25
Rate for Payer: Multiplan Commercial	$159.25
Rate for Payer: Multiplan Workers Comp	$159.25
Rate for Payer: Parkland Medicaid	$18.64
Rate for Payer: Scott and White EPO/PPO	$23.30
Rate for Payer: Scott and White Medicare	$18.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.64
Rate for Payer: Superior Health Plan EPO	$18.64
Rate for Payer: Superior Health Plan Medicare	$18.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.64
Rate for Payer: Universal American Medicare	$18.64
Rate for Payer: Wellcare Medicare	$18.64
Rate for Payer: Wellmed Medicare	$18.64

Amiodarone (Cordarone), S/P SO

Facility

$93.00

Service Code	CPT 80151
Hospital Charge Code	8572492
Hospital Revenue Code	301
Rate for Payer: Cash Price	$81.84

Amiodarone (Cordarone), S/P SO

Facility

$93.00

Service Code	CPT 80151
Hospital Charge Code	8572492
Hospital Revenue Code	301
Min. Negotiated Rate	$7.27
Max. Negotiated Rate	$60.45
Rate for Payer: Aetna Commercial	$19.56
Rate for Payer: Aetna Medicare	$27.96
Rate for Payer: Amerigroup CHIP/Medicaid	$7.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.64
Rate for Payer: Amerigroup Medicare	$18.64
Rate for Payer: BCBS of TX Blue Advantage	$30.76
Rate for Payer: BCBS of TX Blue Essentials	$36.91
Rate for Payer: BCBS of TX Medicare	$18.64
Rate for Payer: BCBS of TX PPO	$41.19
Rate for Payer: Cash Price	$81.84
Rate for Payer: Cash Price	$81.84
Rate for Payer: Cigna Medicaid	$18.64
Rate for Payer: Cigna Medicare	$18.64
Rate for Payer: Employer Direct Commercial	$18.64
Rate for Payer: Humana Medicare/TRICARE	$18.64
Rate for Payer: Molina CHIP/Medicaid	$18.64
Rate for Payer: Molina Dual Medicare/Medicaid	$18.64
Rate for Payer: Molina Medicare	$18.64
Rate for Payer: Multiplan Auto	$60.45
Rate for Payer: Multiplan Commercial	$60.45
Rate for Payer: Multiplan Workers Comp	$60.45
Rate for Payer: Parkland Medicaid	$18.64
Rate for Payer: Scott and White EPO/PPO	$23.30
Rate for Payer: Scott and White Medicare	$18.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.64
Rate for Payer: Superior Health Plan EPO	$18.64
Rate for Payer: Superior Health Plan Medicare	$18.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.64
Rate for Payer: Universal American Medicare	$18.64
Rate for Payer: Wellcare Medicare	$18.64
Rate for Payer: Wellmed Medicare	$18.64

amitriptyline 25 mg tablet

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	77370529
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.80

amitriptyline 25 mg tablet

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	77370529
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$6.50
Rate for Payer: Amerigroup CHIP/Medicaid	$0.90
Rate for Payer: BCBS of TX Blue Advantage	$3.00
Rate for Payer: BCBS of TX Blue Essentials	$3.60
Rate for Payer: BCBS of TX PPO	$4.00
Rate for Payer: Cash Price	$6.80
Rate for Payer: Multiplan Auto	$6.50
Rate for Payer: Multiplan Commercial	$6.50
Rate for Payer: Multiplan Workers Comp	$6.50
Rate for Payer: Scott and White EPO/PPO	$5.00
Rate for Payer: Superior Health Plan EPO	$1.36

amLODIPine 10 mg Tab

Facility

$10.35

Service Code	HCPCS J0282
Hospital Charge Code	77371035
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.04

amLODIPine 10 mg Tab

Facility

$10.35

Service Code	HCPCS J0282
Hospital Charge Code	77371035
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$6.73
Rate for Payer: Amerigroup CHIP/Medicaid	$0.93
Rate for Payer: BCBS of TX Blue Advantage	$0.29
Rate for Payer: BCBS of TX Blue Essentials	$0.35
Rate for Payer: BCBS of TX PPO	$0.39
Rate for Payer: Cash Price	$7.04
Rate for Payer: Cash Price	$7.04
Rate for Payer: Multiplan Auto	$6.73
Rate for Payer: Multiplan Commercial	$6.73
Rate for Payer: Multiplan Workers Comp	$6.73
Rate for Payer: Scott and White EPO/PPO	$5.18
Rate for Payer: Superior Health Plan EPO	$1.41

amLODIPine 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77371143
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

amLODIPine 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77371143
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Ammonia Level

Facility

$316.00

Service Code	CPT 82140
Hospital Charge Code	1601616
Hospital Revenue Code	301
Rate for Payer: Cash Price	$278.08

Ammonia Level

Facility

$316.00

Service Code	CPT 82140
Hospital Charge Code	1601616
Hospital Revenue Code	301
Min. Negotiated Rate	$5.68
Max. Negotiated Rate	$205.40
Rate for Payer: Aetna Commercial	$15.30
Rate for Payer: Aetna Medicare	$21.86
Rate for Payer: Amerigroup CHIP/Medicaid	$5.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.57
Rate for Payer: Amerigroup Medicare	$14.57
Rate for Payer: BCBS of TX Blue Advantage	$24.04
Rate for Payer: BCBS of TX Blue Essentials	$28.85
Rate for Payer: BCBS of TX Medicare	$14.57
Rate for Payer: BCBS of TX PPO	$32.20
Rate for Payer: Cash Price	$278.08
Rate for Payer: Cash Price	$278.08
Rate for Payer: Cigna Medicaid	$14.57
Rate for Payer: Cigna Medicare	$14.57
Rate for Payer: Employer Direct Commercial	$14.57
Rate for Payer: Humana Medicare/TRICARE	$14.57
Rate for Payer: Molina CHIP/Medicaid	$14.57
Rate for Payer: Molina Dual Medicare/Medicaid	$14.57
Rate for Payer: Molina Medicare	$14.57
Rate for Payer: Multiplan Auto	$205.40
Rate for Payer: Multiplan Commercial	$205.40
Rate for Payer: Multiplan Workers Comp	$205.40
Rate for Payer: Parkland Medicaid	$14.57
Rate for Payer: Scott and White EPO/PPO	$18.21
Rate for Payer: Scott and White Medicare	$14.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.57
Rate for Payer: Superior Health Plan EPO	$14.57
Rate for Payer: Superior Health Plan Medicare	$14.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.57
Rate for Payer: Universal American Medicare	$14.57
Rate for Payer: Wellcare Medicare	$14.57
Rate for Payer: Wellmed Medicare	$14.57

Amnioinfusion

Facility

$1,024.00

Service Code	CPT 59070
Hospital Charge Code	315093
Hospital Revenue Code	361
Rate for Payer: Cash Price	$901.12

Amnioinfusion

Facility

$1,024.00

Service Code	CPT 59070
Hospital Charge Code	315093
Hospital Revenue Code	361
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$563.20
Rate for Payer: Aetna Medicare	$440.08
Rate for Payer: Amerigroup CHIP/Medicaid	$92.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$293.39
Rate for Payer: Amerigroup Medicare	$293.39
Rate for Payer: BCBS of TX Blue Advantage	$452.10
Rate for Payer: BCBS of TX Blue Essentials	$541.44
Rate for Payer: BCBS of TX Medicare	$293.39
Rate for Payer: BCBS of TX PPO	$682.21
Rate for Payer: Cash Price	$901.12
Rate for Payer: Cash Price	$901.12
Rate for Payer: Cash Price	$901.12
Rate for Payer: Cigna Commercial	$664.62
Rate for Payer: Cigna Medicare	$293.39
Rate for Payer: Employer Direct Commercial	$293.39
Rate for Payer: Humana Medicare/TRICARE	$293.39
Rate for Payer: Molina Dual Medicare/Medicaid	$293.39
Rate for Payer: Molina Medicare	$293.39
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	$6.47
Rate for Payer: Scott and White Medicare	$293.39
Rate for Payer: Superior Health Plan EPO	$293.39
Rate for Payer: Superior Health Plan Medicare	$293.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$293.39
Rate for Payer: Universal American Medicare	$293.39
Rate for Payer: Wellcare Medicare	$293.39
Rate for Payer: Wellmed Medicare	$293.39

amoxicillin 125 mg/5 mL Oral Liquid 125 mL

Facility

$10.75

Service Code	HCPCS J3490
Hospital Charge Code	77374607
Hospital Revenue Code	250
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$6.99
Rate for Payer: Amerigroup CHIP/Medicaid	$0.97
Rate for Payer: BCBS of TX Blue Advantage	$3.22
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: Multiplan Auto	$6.99
Rate for Payer: Multiplan Commercial	$6.99
Rate for Payer: Multiplan Workers Comp	$6.99
Rate for Payer: Scott and White EPO/PPO	$5.38
Rate for Payer: Superior Health Plan EPO	$1.46

amoxicillin 125 mg/5 mL Oral Liquid 125 mL

Facility

$10.75

Service Code	HCPCS J3490
Hospital Charge Code	77374607
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.31

amoxicillin 250 mg/5 mL Pow

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	79159141
Hospital Revenue Code	636
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

amoxicillin 250 mg/5 mL Pow

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	79159141
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.82
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.82

amoxicillin 250 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77374925
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

amoxicillin 250 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77374925
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

amoxicillin-clavulanate 125 mg-31.25 mg/5 mL Oral Liquid 5 mL REPACK

Facility

$9.80

Service Code	HCPCS J3490
Hospital Charge Code	79159331
Hospital Revenue Code	250
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$6.37
Rate for Payer: Amerigroup CHIP/Medicaid	$0.88
Rate for Payer: BCBS of TX Blue Advantage	$2.94
Rate for Payer: BCBS of TX Blue Essentials	$3.53
Rate for Payer: BCBS of TX PPO	$3.92
Rate for Payer: Cash Price	$6.66
Rate for Payer: Multiplan Auto	$6.37
Rate for Payer: Multiplan Commercial	$6.37
Rate for Payer: Multiplan Workers Comp	$6.37
Rate for Payer: Scott and White EPO/PPO	$4.90
Rate for Payer: Superior Health Plan EPO	$1.33

amoxicillin-clavulanate 125 mg-31.25 mg/5 mL Oral Liquid 5 mL REPACK

Facility

$9.80

Service Code	HCPCS J3490
Hospital Charge Code	79159331
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.66

Know your out-of-pocket cost for care.

All Charges