White Rock Medical Center

All Charges

Charge

Type

Setting

Price

diazepam 2 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77510651
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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: 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

diazepam 2 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77510651
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

diazepam 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77510806
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

diazepam 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77510806
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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: 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

diclofenac 1% Topical Gel 100 g

Facility

$89.98

Service Code	HCPCS J3490
Hospital Charge Code	77511495
Hospital Revenue Code	250
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$64.79
Rate for Payer: Amerigroup CHIP/Medicaid	$8.10
Rate for Payer: BCBS of TX Blue Advantage	$26.99
Rate for Payer: BCBS of TX Blue Essentials	$32.39
Rate for Payer: BCBS of TX PPO	$35.99
Rate for Payer: Cash Price	$61.19
Rate for Payer: Cigna Medicaid	$64.79
Rate for Payer: Molina CHIP/Medicaid	$64.79
Rate for Payer: Multiplan Auto	$58.49
Rate for Payer: Multiplan Commercial	$58.49
Rate for Payer: Multiplan Workers Comp	$58.49
Rate for Payer: Parkland Medicaid	$64.79
Rate for Payer: Scott and White EPO/PPO	$44.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$64.79
Rate for Payer: Superior Health Plan EPO	$12.24

diclofenac 1% Topical Gel 100 g

Facility

$89.98

Service Code	HCPCS J3490
Hospital Charge Code	77511495
Hospital Revenue Code	250
Rate for Payer: Cash Price	$61.19

dicyclomine 10 mg Cap

Facility

$7.65

Service Code	HCPCS J0500
Hospital Charge Code	77512411
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

dicyclomine 10 mg Cap

Facility

$7.65

Service Code	HCPCS J0500
Hospital Charge Code	77512411
Hospital Revenue Code	636
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$54.19
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$40.72
Rate for Payer: BCBS of TX Blue Essentials	$48.86
Rate for Payer: BCBS of TX PPO	$54.19
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

dicyclomine HCl ORAL TABLET 20 MG

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77512412
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

dicyclomine HCl ORAL TABLET 20 MG

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77512412
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

DIGESTIVE MALIGNANCY

Facility

$3,946.53

Service Code	APR-DRG 2401
Min. Negotiated Rate	$3,720.93
Max. Negotiated Rate	$3,946.53
Rate for Payer: Amerigroup CHIP/Medicaid	$3,720.93
Rate for Payer: Cigna Medicaid	$3,720.93
Rate for Payer: Molina CHIP/Medicaid	$3,720.93
Rate for Payer: Parkland Medicaid	$3,720.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,946.53

DIGESTIVE MALIGNANCY

Facility

$10,672.19

Service Code	APR-DRG 2404
Min. Negotiated Rate	$10,062.11
Max. Negotiated Rate	$10,672.19
Rate for Payer: Amerigroup CHIP/Medicaid	$10,062.11
Rate for Payer: Cigna Medicaid	$10,062.11
Rate for Payer: Molina CHIP/Medicaid	$10,062.11
Rate for Payer: Parkland Medicaid	$10,062.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,672.19

DIGESTIVE MALIGNANCY

Facility

$6,343.19

Service Code	APR-DRG 2403
Min. Negotiated Rate	$5,980.58
Max. Negotiated Rate	$6,343.19
Rate for Payer: Amerigroup CHIP/Medicaid	$5,980.58
Rate for Payer: Cigna Medicaid	$5,980.58
Rate for Payer: Molina CHIP/Medicaid	$5,980.58
Rate for Payer: Parkland Medicaid	$5,980.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,343.19

DIGESTIVE MALIGNANCY

Facility

$4,521.36

Service Code	APR-DRG 2402
Min. Negotiated Rate	$4,262.90
Max. Negotiated Rate	$4,521.36
Rate for Payer: Amerigroup CHIP/Medicaid	$4,262.90
Rate for Payer: Cigna Medicaid	$4,262.90
Rate for Payer: Molina CHIP/Medicaid	$4,262.90
Rate for Payer: Parkland Medicaid	$4,262.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,521.36

DIGESTIVE MALIGNANCY W CC

Facility

$22,887.40

Service Code	MSDRG 375
Min. Negotiated Rate	$10,377.62
Max. Negotiated Rate	$22,887.40
Rate for Payer: BCBS of TX Blue Advantage	$10,377.62
Rate for Payer: BCBS of TX Blue Essentials	$12,451.94
Rate for Payer: BCBS of TX PPO	$13,836.02

DIGESTIVE MALIGNANCY WITH CC

Facility

$22,887.40

Service Code	MSDRG 375
Min. Negotiated Rate	$10,377.62
Max. Negotiated Rate	$22,887.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,625.27
Rate for Payer: Amerigroup Medicare	$13,625.27
Rate for Payer: BCBS of TX Medicare	$13,625.27
Rate for Payer: Cigna Commercial	$15,579.65
Rate for Payer: Cigna Medicare	$13,625.27
Rate for Payer: Employer Direct Commercial	$13,625.27
Rate for Payer: Humana Medicare/TRICARE	$13,625.27
Rate for Payer: Molina Dual Medicare/Medicaid	$13,625.27
Rate for Payer: Molina Medicare	$13,625.27
Rate for Payer: Multiplan Auto	$22,887.40
Rate for Payer: Multiplan Commercial	$22,887.40
Rate for Payer: Multiplan Workers Comp	$22,887.40
Rate for Payer: Scott and White EPO/PPO	$10,540.25
Rate for Payer: Scott and White Medicare	$13,625.27
Rate for Payer: Superior Health Plan EPO	$13,625.27
Rate for Payer: Superior Health Plan Medicare	$13,625.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,625.27
Rate for Payer: Universal American Medicare	$13,625.27
Rate for Payer: Wellcare Medicare	$13,625.27
Rate for Payer: Wellmed Medicare	$13,625.27

DIGESTIVE MALIGNANCY WITH MCC

Facility

$37,872.70

Service Code	MSDRG 374
Min. Negotiated Rate	$17,441.38
Max. Negotiated Rate	$37,872.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,434.66
Rate for Payer: Amerigroup Medicare	$20,434.66
Rate for Payer: BCBS of TX Medicare	$20,434.66
Rate for Payer: Cigna Commercial	$27,546.46
Rate for Payer: Cigna Medicare	$20,434.66
Rate for Payer: Employer Direct Commercial	$20,434.66
Rate for Payer: Humana Medicare/TRICARE	$20,434.66
Rate for Payer: Molina Dual Medicare/Medicaid	$20,434.66
Rate for Payer: Molina Medicare	$20,434.66
Rate for Payer: Multiplan Auto	$37,872.70
Rate for Payer: Multiplan Commercial	$37,872.70
Rate for Payer: Multiplan Workers Comp	$37,872.70
Rate for Payer: Scott and White EPO/PPO	$17,441.38
Rate for Payer: Scott and White Medicare	$20,434.66
Rate for Payer: Superior Health Plan EPO	$20,434.66
Rate for Payer: Superior Health Plan Medicare	$20,434.66
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,434.66
Rate for Payer: Universal American Medicare	$20,434.66
Rate for Payer: Wellcare Medicare	$20,434.66
Rate for Payer: Wellmed Medicare	$20,434.66

DIGESTIVE MALIGNANCY WITHOUT CC/MCC

Facility

$16,678.20

Service Code	MSDRG 376
Min. Negotiated Rate	$7,680.75
Max. Negotiated Rate	$16,678.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,534.30
Rate for Payer: Amerigroup Medicare	$11,534.30
Rate for Payer: BCBS of TX Medicare	$11,534.30
Rate for Payer: Cigna Commercial	$11,904.98
Rate for Payer: Cigna Medicare	$11,534.30
Rate for Payer: Employer Direct Commercial	$11,534.30
Rate for Payer: Humana Medicare/TRICARE	$11,534.30
Rate for Payer: Molina Dual Medicare/Medicaid	$11,534.30
Rate for Payer: Molina Medicare	$11,534.30
Rate for Payer: Multiplan Auto	$16,678.20
Rate for Payer: Multiplan Commercial	$16,678.20
Rate for Payer: Multiplan Workers Comp	$16,678.20
Rate for Payer: Scott and White EPO/PPO	$7,680.75
Rate for Payer: Scott and White Medicare	$11,534.30
Rate for Payer: Superior Health Plan EPO	$11,534.30
Rate for Payer: Superior Health Plan Medicare	$11,534.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,534.30
Rate for Payer: Universal American Medicare	$11,534.30
Rate for Payer: Wellcare Medicare	$11,534.30
Rate for Payer: Wellmed Medicare	$11,534.30

DIGESTIVE MALIGNANCY W MCC

Facility

$37,872.70

Service Code	MSDRG 374
Min. Negotiated Rate	$17,441.38
Max. Negotiated Rate	$37,872.70
Rate for Payer: BCBS of TX Blue Advantage	$17,759.00
Rate for Payer: BCBS of TX Blue Essentials	$21,308.74
Rate for Payer: BCBS of TX PPO	$23,677.29

DIGESTIVE MALIGNANCY W/O CC/MCC

Facility

$16,678.20

Service Code	MSDRG 376
Min. Negotiated Rate	$7,680.75
Max. Negotiated Rate	$16,678.20
Rate for Payer: BCBS of TX Blue Advantage	$7,875.02
Rate for Payer: BCBS of TX Blue Essentials	$9,449.11
Rate for Payer: BCBS of TX PPO	$10,499.42

digoxin 125 mcg (0.125 mg) Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77513612
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

digoxin 125 mcg (0.125 mg) Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77513612
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

digoxin 250 mcg (0.25 mg) Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77513714
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

digoxin 250 mcg (0.25 mg) Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77513714
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

digoxin 250 mcg/mL (0.25 mg/mL) Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77513767
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

Know your out-of-pocket cost for care.

All Charges