White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DEV INFLATION -- DHF

Facility

$312.81

Hospital Charge Code	80320070
Hospital Revenue Code	272
Rate for Payer: Cash Price	$212.71

DEV RETRIEVAL INSERTABLE -- DHF

Facility

$1,694.96

Hospital Charge Code	82401399
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,152.57

DEV RETRIEVAL INSERTABLE -- DHF

Facility

$1,694.96

Hospital Charge Code	82401399
Hospital Revenue Code	272
Min. Negotiated Rate	$152.55
Max. Negotiated Rate	$1,220.37
Rate for Payer: Amerigroup CHIP/Medicaid	$152.55
Rate for Payer: BCBS of TX Blue Advantage	$508.49
Rate for Payer: BCBS of TX Blue Essentials	$610.19
Rate for Payer: BCBS of TX PPO	$677.98
Rate for Payer: Cash Price	$1,152.57
Rate for Payer: Cigna Medicaid	$1,220.37
Rate for Payer: Molina CHIP/Medicaid	$1,220.37
Rate for Payer: Multiplan Auto	$1,101.72
Rate for Payer: Multiplan Commercial	$1,101.72
Rate for Payer: Multiplan Workers Comp	$1,101.72
Rate for Payer: Parkland Medicaid	$1,220.37
Rate for Payer: Scott and White EPO/PPO	$847.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,220.37
Rate for Payer: Superior Health Plan EPO	$230.51

dexamethasone 0.5 mg/5 mL Oral Liquid 500 mL

Facility

$7.65

Service Code	HCPCS J8540
Hospital Charge Code	77498028
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.83

dexamethasone 0.5 mg/5 mL Oral Liquid 500 mL

Facility

$7.65

Service Code	HCPCS J8540
Hospital Charge Code	77498028
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.01
Rate for Payer: BCBS of TX Blue Essentials	$0.02
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$5.20
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

dexamethasone 10 mg/mL PF Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1100
Hospital Charge Code	77498478
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.03
Rate for Payer: BCBS of TX Blue Essentials	$0.03
Rate for Payer: BCBS of TX PPO	$0.04
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

dexamethasone 10 mg/mL PF Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1100
Hospital Charge Code	77498478
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

dexamethasone 4 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1100
Hospital Charge Code	77498645
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.03
Rate for Payer: BCBS of TX Blue Essentials	$0.03
Rate for Payer: BCBS of TX PPO	$0.04
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

dexamethasone 4 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1100
Hospital Charge Code	77498645
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

dexamethasone 4 mg Tab

Facility

$15.50

Service Code	HCPCS J8540
Hospital Charge Code	77498588
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$11.16
Rate for Payer: Amerigroup CHIP/Medicaid	$1.40
Rate for Payer: BCBS of TX Blue Advantage	$0.01
Rate for Payer: BCBS of TX Blue Essentials	$0.02
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$10.54
Rate for Payer: Cash Price	$10.54
Rate for Payer: Cigna Medicaid	$11.16
Rate for Payer: Molina CHIP/Medicaid	$11.16
Rate for Payer: Multiplan Auto	$10.07
Rate for Payer: Multiplan Commercial	$10.07
Rate for Payer: Multiplan Workers Comp	$10.07
Rate for Payer: Parkland Medicaid	$11.16
Rate for Payer: Scott and White EPO/PPO	$7.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.16
Rate for Payer: Superior Health Plan EPO	$2.11

dexamethasone 4 mg Tab

Facility

$15.50

Service Code	HCPCS J8540
Hospital Charge Code	77498588
Hospital Revenue Code	636
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$7.75
Rate for Payer: Cash Price	$10.54
Rate for Payer: Cigna Commercial	$3.88
Rate for Payer: Scott and White EPO/PPO	$7.75

dexmedetomidine 100 mcg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77500496
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

dexmedetomidine 100 mcg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77500496
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

dexmedetomidine 100 mcg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	0496
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

dexmedetomidine 100 mcg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	0496
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

dexmedetomidine 200 mcg/NaCl 0.9% 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77500602
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

dexmedetomidine 200 mcg/NaCl 0.9% 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77500602
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

dextrometh-guaiFEN 20-200mg 10 ml liquid

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77507820
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

dextrometh-guaiFEN 20-200mg 10 ml liquid

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77507820
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Dextrose 10% in Water IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77339245
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 10% in Water IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77339245
Hospital Revenue Code	258
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Dextrose 50% in Water IV Soln 500 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77338837
Hospital Revenue Code	258
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Dextrose 50% in Water IV Soln 500 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77338837
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 50% IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78432418
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Dextrose 50% IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78432418
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

Know your out-of-pocket cost for care.

All Charges