White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	496
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	496
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

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
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 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 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

Dextrose 5% in Lactated Ringers IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J7121
Hospital Charge Code	77337318
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% in Lactated Ringers IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J7121
Hospital Charge Code	77337318
Hospital Revenue Code	258
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$7.18
Rate for Payer: BCBS of TX Blue Essentials	$8.61
Rate for Payer: BCBS of TX PPO	$9.55
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

Dextrose 5% in Water IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337479
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% in Water IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337479
Hospital Revenue Code	258
Min. Negotiated Rate	$2.41
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.99
Rate for Payer: BCBS of TX Blue Essentials	$13.19
Rate for Payer: BCBS of TX PPO	$14.63
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	$2.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Dextrose 5% in Water IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337699
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% in Water IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337699
Hospital Revenue Code	258
Min. Negotiated Rate	$2.41
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.99
Rate for Payer: BCBS of TX Blue Essentials	$13.19
Rate for Payer: BCBS of TX PPO	$14.63
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	$2.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Dextrose 5% in Water IV Soln 250 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337589
Hospital Revenue Code	258
Min. Negotiated Rate	$2.41
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.99
Rate for Payer: BCBS of TX Blue Essentials	$13.19
Rate for Payer: BCBS of TX PPO	$14.63
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	$2.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Dextrose 5% in Water IV Soln 250 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337589
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% in Water IV Soln 500 mL

Facility

$128.00

Service Code	HCPCS J7060
Hospital Charge Code	77337534
Hospital Revenue Code	636
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$10.99
Rate for Payer: BCBS of TX Blue Essentials	$13.19
Rate for Payer: BCBS of TX PPO	$14.63
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

Dextrose 5% in Water IV Soln 500 mL

Facility

$128.00

Service Code	HCPCS J7060
Hospital Charge Code	77337534
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

Dextrose 5% in Water IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337754
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% in Water IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337754
Hospital Revenue Code	258
Min. Negotiated Rate	$2.41
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.99
Rate for Payer: BCBS of TX Blue Essentials	$13.19
Rate for Payer: BCBS of TX PPO	$14.63
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	$2.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Know your out-of-pocket cost for care.

All Charges