White Rock Medical Center

All Charges

Charge

Type

Setting

Price

hydrocortisone 100 mg preservative-free Inj

Facility

$128.17

Service Code	HCPCS J1720
Hospital Charge Code	77614034
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	$14.41
Rate for Payer: BCBS of TX Blue Essentials	$17.30
Rate for Payer: BCBS of TX PPO	$19.18
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

hydrocortisone 100 mg preservative-free Inj

Facility

$128.17

Service Code	HCPCS J1720
Hospital Charge Code	77614034
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

hydrocortisone 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77613820
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

hydrocortisone 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77613820
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

hydrocortisone 1% Cream 30 g

Facility

$12.85

Service Code	HCPCS J3490
Hospital Charge Code	77612091
Hospital Revenue Code	250
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$8.35
Rate for Payer: Amerigroup CHIP/Medicaid	$1.16
Rate for Payer: BCBS of TX Blue Advantage	$3.86
Rate for Payer: BCBS of TX Blue Essentials	$4.63
Rate for Payer: BCBS of TX PPO	$5.14
Rate for Payer: Cash Price	$8.74
Rate for Payer: Multiplan Auto	$8.35
Rate for Payer: Multiplan Commercial	$8.35
Rate for Payer: Multiplan Workers Comp	$8.35
Rate for Payer: Scott and White EPO/PPO	$6.42
Rate for Payer: Superior Health Plan EPO	$1.75

hydrocortisone 1% Cream 30 g

Facility

$12.85

Service Code	HCPCS J3490
Hospital Charge Code	77612091
Hospital Revenue Code	250
Rate for Payer: Cash Price	$8.74

HYDROmorphone 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77620956
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

HYDROmorphone 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77620956
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

HYDROmorphone 1 mg/mL-NaCl 0.9% 30 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77621066
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

HYDROmorphone 1 mg/mL-NaCl 0.9% 30 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77621066
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

HYDROmorphone 2 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77622103
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

HYDROmorphone 2 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77622103
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

HYDROmorphone 2mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78407954
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

HYDROmorphone 2mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78407954
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

hydrOXYzine hydrochloride 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77624617
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

hydrOXYzine hydrochloride 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77624617
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

HYPERBARIC O2 FULL BODY CHMBR/30MIN

Facility

$582.00

Service Code	HCPCS G0277
Hospital Charge Code	7150920
Hospital Revenue Code	413
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$378.30
Rate for Payer: Aetna Commercial	$320.10
Rate for Payer: Aetna Medicare	$190.35
Rate for Payer: Amerigroup CHIP/Medicaid	$52.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$126.90
Rate for Payer: Amerigroup Medicare	$126.90
Rate for Payer: BCBS of TX Blue Advantage	$200.20
Rate for Payer: BCBS of TX Blue Essentials	$239.32
Rate for Payer: BCBS of TX Medicare	$126.90
Rate for Payer: BCBS of TX PPO	$266.94
Rate for Payer: Cash Price	$512.16
Rate for Payer: Cash Price	$512.16
Rate for Payer: Cash Price	$512.16
Rate for Payer: Cigna Commercial	$287.47
Rate for Payer: Cigna Medicare	$126.90
Rate for Payer: Employer Direct Commercial	$126.90
Rate for Payer: Humana Medicare/TRICARE	$126.90
Rate for Payer: Molina Dual Medicare/Medicaid	$126.90
Rate for Payer: Molina Medicare	$126.90
Rate for Payer: Multiplan Auto	$378.30
Rate for Payer: Multiplan Commercial	$378.30
Rate for Payer: Multiplan Workers Comp	$378.30
Rate for Payer: Scott and White EPO/PPO	$2.27
Rate for Payer: Scott and White Medicare	$126.90
Rate for Payer: Superior Health Plan EPO	$126.90
Rate for Payer: Superior Health Plan Medicare	$126.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$126.90
Rate for Payer: Universal American Medicare	$126.90
Rate for Payer: Wellcare Medicare	$126.90
Rate for Payer: Wellmed Medicare	$126.90

HYPERTENSION WITH MCC

Facility

$21,831.00

Service Code	MSDRG 304
Min. Negotiated Rate	$8,710.08
Max. Negotiated Rate	$21,831.00
Rate for Payer: Aetna Commercial	$12,926.25
Rate for Payer: Aetna Medicare	$16,581.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,054.11
Rate for Payer: Amerigroup Medicare	$11,054.11
Rate for Payer: BCBS of TX Blue Advantage	$8,710.08
Rate for Payer: BCBS of TX Blue Essentials	$11,155.87
Rate for Payer: BCBS of TX Medicare	$11,054.11
Rate for Payer: BCBS of TX PPO	$12,395.89
Rate for Payer: Cigna Commercial	$14,799.12
Rate for Payer: Cigna Medicare	$11,054.11
Rate for Payer: Employer Direct Commercial	$11,054.11
Rate for Payer: Humana Medicare/TRICARE	$11,054.11
Rate for Payer: Molina Dual Medicare/Medicaid	$11,054.11
Rate for Payer: Molina Medicare	$11,054.11
Rate for Payer: Multiplan Auto	$21,831.00
Rate for Payer: Multiplan Commercial	$21,831.00
Rate for Payer: Multiplan Workers Comp	$21,831.00
Rate for Payer: Scott and White EPO/PPO	$10,053.75
Rate for Payer: Scott and White Medicare	$11,054.11
Rate for Payer: Superior Health Plan EPO	$11,054.11
Rate for Payer: Superior Health Plan Medicare	$11,054.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,054.11
Rate for Payer: Universal American Medicare	$11,054.11
Rate for Payer: Wellcare Medicare	$11,054.11
Rate for Payer: Wellmed Medicare	$11,054.11

HYPERTENSION WITHOUT MCC

Facility

$14,316.50

Service Code	MSDRG 305
Min. Negotiated Rate	$5,805.00
Max. Negotiated Rate	$14,316.50
Rate for Payer: Aetna Commercial	$8,476.88
Rate for Payer: Aetna Medicare	$12,347.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,231.80
Rate for Payer: Amerigroup Medicare	$8,231.80
Rate for Payer: BCBS of TX Blue Advantage	$5,805.00
Rate for Payer: BCBS of TX Blue Essentials	$7,428.65
Rate for Payer: BCBS of TX Medicare	$8,231.80
Rate for Payer: BCBS of TX PPO	$8,254.37
Rate for Payer: Cigna Commercial	$9,705.08
Rate for Payer: Cigna Medicare	$8,231.80
Rate for Payer: Employer Direct Commercial	$8,231.80
Rate for Payer: Humana Medicare/TRICARE	$8,231.80
Rate for Payer: Molina Dual Medicare/Medicaid	$8,231.80
Rate for Payer: Molina Medicare	$8,231.80
Rate for Payer: Multiplan Auto	$14,316.50
Rate for Payer: Multiplan Commercial	$14,316.50
Rate for Payer: Multiplan Workers Comp	$14,316.50
Rate for Payer: Scott and White EPO/PPO	$6,593.12
Rate for Payer: Scott and White Medicare	$8,231.80
Rate for Payer: Superior Health Plan EPO	$8,231.80
Rate for Payer: Superior Health Plan Medicare	$8,231.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,231.80
Rate for Payer: Universal American Medicare	$8,231.80
Rate for Payer: Wellcare Medicare	$8,231.80
Rate for Payer: Wellmed Medicare	$8,231.80

HYPERTENSIVE ENCEPHALOPATHY WITH CC

Facility

$19,321.10

Service Code	MSDRG 078
Min. Negotiated Rate	$8,145.06
Max. Negotiated Rate	$19,321.10
Rate for Payer: Aetna Commercial	$11,440.12
Rate for Payer: Aetna Medicare	$15,167.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,111.44
Rate for Payer: Amerigroup Medicare	$10,111.44
Rate for Payer: BCBS of TX Blue Advantage	$8,145.06
Rate for Payer: BCBS of TX Blue Essentials	$10,010.46
Rate for Payer: BCBS of TX Medicare	$10,111.44
Rate for Payer: BCBS of TX PPO	$11,123.17
Rate for Payer: Cigna Commercial	$13,097.67
Rate for Payer: Cigna Medicare	$10,111.44
Rate for Payer: Employer Direct Commercial	$10,111.44
Rate for Payer: Humana Medicare/TRICARE	$10,111.44
Rate for Payer: Molina Dual Medicare/Medicaid	$10,111.44
Rate for Payer: Molina Medicare	$10,111.44
Rate for Payer: Multiplan Auto	$19,321.10
Rate for Payer: Multiplan Commercial	$19,321.10
Rate for Payer: Multiplan Workers Comp	$19,321.10
Rate for Payer: Scott and White EPO/PPO	$8,897.88
Rate for Payer: Scott and White Medicare	$10,111.44
Rate for Payer: Superior Health Plan EPO	$10,111.44
Rate for Payer: Superior Health Plan Medicare	$10,111.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,111.44
Rate for Payer: Universal American Medicare	$10,111.44
Rate for Payer: Wellcare Medicare	$10,111.44
Rate for Payer: Wellmed Medicare	$10,111.44

HYPERTENSIVE ENCEPHALOPATHY WITH MCC

Facility

$28,707.10

Service Code	MSDRG 077
Min. Negotiated Rate	$13,220.38
Max. Negotiated Rate	$28,707.10
Rate for Payer: Aetna Commercial	$16,997.62
Rate for Payer: Aetna Medicare	$20,454.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,636.65
Rate for Payer: Amerigroup Medicare	$13,636.65
Rate for Payer: BCBS of TX Blue Advantage	$13,551.02
Rate for Payer: BCBS of TX Blue Essentials	$16,015.09
Rate for Payer: BCBS of TX Medicare	$13,636.65
Rate for Payer: BCBS of TX PPO	$17,795.23
Rate for Payer: Cigna Commercial	$19,460.39
Rate for Payer: Cigna Medicare	$13,636.65
Rate for Payer: Employer Direct Commercial	$13,636.65
Rate for Payer: Humana Medicare/TRICARE	$13,636.65
Rate for Payer: Molina Dual Medicare/Medicaid	$13,636.65
Rate for Payer: Molina Medicare	$13,636.65
Rate for Payer: Multiplan Auto	$28,707.10
Rate for Payer: Multiplan Commercial	$28,707.10
Rate for Payer: Multiplan Workers Comp	$28,707.10
Rate for Payer: Scott and White EPO/PPO	$13,220.38
Rate for Payer: Scott and White Medicare	$13,636.65
Rate for Payer: Superior Health Plan EPO	$13,636.65
Rate for Payer: Superior Health Plan Medicare	$13,636.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,636.65
Rate for Payer: Universal American Medicare	$13,636.65
Rate for Payer: Wellcare Medicare	$13,636.65
Rate for Payer: Wellmed Medicare	$13,636.65

HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC

Facility

$14,075.20

Service Code	MSDRG 079
Min. Negotiated Rate	$6,032.04
Max. Negotiated Rate	$14,075.20
Rate for Payer: Aetna Commercial	$8,334.00
Rate for Payer: Aetna Medicare	$12,211.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,141.16
Rate for Payer: Amerigroup Medicare	$8,141.16
Rate for Payer: BCBS of TX Blue Advantage	$6,032.04
Rate for Payer: BCBS of TX Blue Essentials	$7,703.13
Rate for Payer: BCBS of TX Medicare	$8,141.16
Rate for Payer: BCBS of TX PPO	$8,559.37
Rate for Payer: Cigna Commercial	$9,541.50
Rate for Payer: Cigna Medicare	$8,141.16
Rate for Payer: Employer Direct Commercial	$8,141.16
Rate for Payer: Humana Medicare/TRICARE	$8,141.16
Rate for Payer: Molina Dual Medicare/Medicaid	$8,141.16
Rate for Payer: Molina Medicare	$8,141.16
Rate for Payer: Multiplan Auto	$14,075.20
Rate for Payer: Multiplan Commercial	$14,075.20
Rate for Payer: Multiplan Workers Comp	$14,075.20
Rate for Payer: Scott and White EPO/PPO	$6,482.00
Rate for Payer: Scott and White Medicare	$8,141.16
Rate for Payer: Superior Health Plan EPO	$8,141.16
Rate for Payer: Superior Health Plan Medicare	$8,141.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,141.16
Rate for Payer: Universal American Medicare	$8,141.16
Rate for Payer: Wellcare Medicare	$8,141.16
Rate for Payer: Wellmed Medicare	$8,141.16

IABP INSERTION PERCUTANEOUS

Facility

$7,398.00

Service Code	CPT 33967
Hospital Charge Code	2302784
Hospital Revenue Code	481
Min. Negotiated Rate	$455.01
Max. Negotiated Rate	$13,390.00
Rate for Payer: Aetna Commercial	$13,390.00
Rate for Payer: Amerigroup CHIP/Medicaid	$665.82
Rate for Payer: BCBS of TX Blue Advantage	$455.01
Rate for Payer: BCBS of TX Blue Essentials	$544.92
Rate for Payer: BCBS of TX PPO	$686.60
Rate for Payer: Cash Price	$6,510.24
Rate for Payer: Cash Price	$6,510.24
Rate for Payer: Cash Price	$6,510.24
Rate for Payer: Multiplan Auto	$4,808.70
Rate for Payer: Multiplan Commercial	$4,808.70
Rate for Payer: Multiplan Workers Comp	$4,808.70
Rate for Payer: Scott and White EPO/PPO	$3,699.00
Rate for Payer: Superior Health Plan EPO	$1,006.13

IABP INSERTION PERCUTANEOUS

Facility

$7,398.00

Service Code	CPT 33967
Hospital Charge Code	2302784
Hospital Revenue Code	481
Rate for Payer: Cash Price	$6,510.24

ibuprofen 100 mg/5 mL Oral Susp 480 mL

Facility

$81.95

Service Code	HCPCS J3490
Hospital Charge Code	77627059
Hospital Revenue Code	250
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$53.27
Rate for Payer: Amerigroup CHIP/Medicaid	$7.38
Rate for Payer: BCBS of TX Blue Advantage	$24.58
Rate for Payer: BCBS of TX Blue Essentials	$29.50
Rate for Payer: BCBS of TX PPO	$32.78
Rate for Payer: Cash Price	$55.73
Rate for Payer: Multiplan Auto	$53.27
Rate for Payer: Multiplan Commercial	$53.27
Rate for Payer: Multiplan Workers Comp	$53.27
Rate for Payer: Scott and White EPO/PPO	$40.98
Rate for Payer: Superior Health Plan EPO	$11.15

Know your out-of-pocket cost for care.

All Charges