White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Dilation of esophagus, over guide wire

Facility

$10,000.00

Service Code	CPT 43453
Hospital Charge Code	36043453
Hospital Revenue Code	360
Min. Negotiated Rate	$564.97
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Amerigroup Medicare	$1,927.65
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX Medicare	$1,927.65
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cigna Commercial	$4,074.70
Rate for Payer: Cigna Medicare	$1,927.65
Rate for Payer: Employer Direct Commercial	$1,927.65
Rate for Payer: Humana Medicare/TRICARE	$1,927.65
Rate for Payer: Molina Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Molina Medicare	$1,927.65
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	$3,566.15
Rate for Payer: Scott and White Medicare	$1,927.65
Rate for Payer: Superior Health Plan EPO	$1,927.65
Rate for Payer: Superior Health Plan Medicare	$1,927.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Universal American Medicare	$1,927.65
Rate for Payer: Wellcare Medicare	$1,927.65
Rate for Payer: Wellmed Medicare	$1,927.65

DIL BLN ESOPH/PYLORIC -- DHF

Facility

$1,205.00

Service Code	HCPCS C1726
Hospital Charge Code	82461807
Hospital Revenue Code	278
Min. Negotiated Rate	$108.45
Max. Negotiated Rate	$867.60
Rate for Payer: Amerigroup CHIP/Medicaid	$108.45
Rate for Payer: BCBS of TX Blue Advantage	$361.50
Rate for Payer: BCBS of TX Blue Essentials	$433.80
Rate for Payer: BCBS of TX PPO	$482.00
Rate for Payer: Cash Price	$819.40
Rate for Payer: Cigna Medicaid	$867.60
Rate for Payer: Molina CHIP/Medicaid	$867.60
Rate for Payer: Multiplan Auto	$602.50
Rate for Payer: Multiplan Commercial	$602.50
Rate for Payer: Multiplan Workers Comp	$602.50
Rate for Payer: Parkland Medicaid	$867.60
Rate for Payer: Scott and White EPO/PPO	$602.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$867.60
Rate for Payer: Superior Health Plan EPO	$163.88

DIL BLN ESOPH/PYLORIC -- DHF

Facility

$1,205.00

Service Code	HCPCS C1726
Hospital Charge Code	82461807
Hospital Revenue Code	278
Min. Negotiated Rate	$301.25
Max. Negotiated Rate	$602.50
Rate for Payer: Cash Price	$819.40
Rate for Payer: Cigna Commercial	$301.25
Rate for Payer: Multiplan Auto	$602.50
Rate for Payer: Multiplan Commercial	$602.50
Rate for Payer: Multiplan Workers Comp	$602.50
Rate for Payer: Scott and White EPO/PPO	$602.50

diltiazem 100 mg IV Inj

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	77514419
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

diltiazem 100 mg IV Inj

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	77514419
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

DiltiAZem 120mg/24 Hour ER Cap

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	78422099
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

DiltiAZem 120mg/24 Hour ER Cap

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	78422099
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

diltiazem 180 mg/24 hours ER Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77514835
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

diltiazem 180 mg/24 hours ER Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77514835
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

dilTIAZem 30 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77515096
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

dilTIAZem 30 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77515096
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

dilTIAZem 5 mg/mL IV Soln 5 mL

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	77515579
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

dilTIAZem 5 mg/mL IV Soln 5 mL

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	77515579
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

diltiazem 60 mg Tab

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	77515634
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

diltiazem 60 mg Tab

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	77515634
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

DILTIAZEM HCL 125 MG SDV 25 ML

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	78420216
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
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

DILTIAZEM HCL 125 MG SDV 25 ML

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	78420216
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

Diluent f/DXH 10L

Facility

$160.53

Hospital Charge Code	993846
Hospital Revenue Code	270
Rate for Payer: Cash Price	$109.16

Diluent f/DXH 10L

Facility

$160.53

Hospital Charge Code	993846
Hospital Revenue Code	270
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$115.58
Rate for Payer: Amerigroup CHIP/Medicaid	$14.45
Rate for Payer: BCBS of TX Blue Advantage	$48.16
Rate for Payer: BCBS of TX Blue Essentials	$57.79
Rate for Payer: BCBS of TX PPO	$64.21
Rate for Payer: Cash Price	$109.16
Rate for Payer: Cigna Medicaid	$115.58
Rate for Payer: Molina CHIP/Medicaid	$115.58
Rate for Payer: Multiplan Auto	$104.34
Rate for Payer: Multiplan Commercial	$104.34
Rate for Payer: Multiplan Workers Comp	$104.34
Rate for Payer: Parkland Medicaid	$115.58
Rate for Payer: Scott and White EPO/PPO	$80.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.58
Rate for Payer: Superior Health Plan EPO	$21.83

DIL VESSEL -- DHF

Facility

$77.63

Hospital Charge Code	81740359
Hospital Revenue Code	272
Rate for Payer: Cash Price	$52.79

DIL VESSEL -- DHF

Facility

$77.63

Hospital Charge Code	81740359
Hospital Revenue Code	272
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$55.89
Rate for Payer: Amerigroup CHIP/Medicaid	$6.99
Rate for Payer: BCBS of TX Blue Advantage	$23.29
Rate for Payer: BCBS of TX Blue Essentials	$27.95
Rate for Payer: BCBS of TX PPO	$31.05
Rate for Payer: Cash Price	$52.79
Rate for Payer: Cigna Medicaid	$55.89
Rate for Payer: Molina CHIP/Medicaid	$55.89
Rate for Payer: Multiplan Auto	$50.46
Rate for Payer: Multiplan Commercial	$50.46
Rate for Payer: Multiplan Workers Comp	$50.46
Rate for Payer: Parkland Medicaid	$55.89
Rate for Payer: Scott and White EPO/PPO	$38.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$55.89
Rate for Payer: Superior Health Plan EPO	$10.56

diphenhydrAMINE 12.5 mg/5 mL Oral Liquid 5 mL

Facility

$19.80

Service Code	HCPCS A9150
Hospital Charge Code	77517580
Hospital Revenue Code	636
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$9.90
Rate for Payer: Cash Price	$13.46
Rate for Payer: Cigna Commercial	$4.95
Rate for Payer: Scott and White EPO/PPO	$9.90

diphenhydrAMINE 12.5 mg/5 mL Oral Liquid 5 mL

Facility

$19.80

Service Code	HCPCS A9150
Hospital Charge Code	77517580
Hospital Revenue Code	636
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$14.26
Rate for Payer: Amerigroup CHIP/Medicaid	$1.78
Rate for Payer: BCBS of TX Blue Advantage	$5.94
Rate for Payer: BCBS of TX Blue Essentials	$7.13
Rate for Payer: BCBS of TX PPO	$7.92
Rate for Payer: Cash Price	$13.46
Rate for Payer: Cigna Medicaid	$14.26
Rate for Payer: Molina CHIP/Medicaid	$14.26
Rate for Payer: Multiplan Auto	$12.87
Rate for Payer: Multiplan Commercial	$12.87
Rate for Payer: Multiplan Workers Comp	$12.87
Rate for Payer: Parkland Medicaid	$14.26
Rate for Payer: Scott and White EPO/PPO	$9.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.26
Rate for Payer: Superior Health Plan EPO	$2.69

diphenhydrAMINE 25 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77518039
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

diphenhydrAMINE 25 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77518039
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

Know your out-of-pocket cost for care.

All Charges