White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$87.16

Digoxin Level

Facility

$389.00

Service Code	HCPCS 80162
Hospital Charge Code	1602812
Hospital Revenue Code	300
Rate for Payer: Cash Price	$264.52

Digoxin Level

Facility

$389.00

Service Code	HCPCS 80162
Hospital Charge Code	1602812
Hospital Revenue Code	300
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$280.08
Rate for Payer: Amerigroup CHIP/Medicaid	$5.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.28
Rate for Payer: Amerigroup Medicare	$13.28
Rate for Payer: BCBS of TX Blue Advantage	$116.70
Rate for Payer: BCBS of TX Blue Essentials	$140.04
Rate for Payer: BCBS of TX Medicare	$13.28
Rate for Payer: BCBS of TX PPO	$155.60
Rate for Payer: Cash Price	$264.52
Rate for Payer: Cash Price	$264.52
Rate for Payer: Cigna Medicaid	$280.08
Rate for Payer: Cigna Medicare	$13.28
Rate for Payer: Employer Direct Commercial	$13.28
Rate for Payer: Humana Medicare/TRICARE	$13.28
Rate for Payer: Molina CHIP/Medicaid	$280.08
Rate for Payer: Molina Dual Medicare/Medicaid	$13.28
Rate for Payer: Molina Medicare	$13.28
Rate for Payer: Multiplan Auto	$252.85
Rate for Payer: Multiplan Commercial	$252.85
Rate for Payer: Multiplan Workers Comp	$252.85
Rate for Payer: Parkland Medicaid	$280.08
Rate for Payer: Scott and White EPO/PPO	$16.60
Rate for Payer: Scott and White Medicare	$13.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$280.08
Rate for Payer: Superior Health Plan EPO	$13.28
Rate for Payer: Superior Health Plan Medicare	$13.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.28
Rate for Payer: Universal American Medicare	$13.28
Rate for Payer: Wellcare Medicare	$13.28
Rate for Payer: Wellmed Medicare	$13.28

Digoxin, Serum SO

Facility

$104.00

Service Code	HCPCS 80162
Hospital Charge Code	9130978
Hospital Revenue Code	301
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$74.88
Rate for Payer: Amerigroup CHIP/Medicaid	$5.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.28
Rate for Payer: Amerigroup Medicare	$13.28
Rate for Payer: BCBS of TX Blue Advantage	$31.20
Rate for Payer: BCBS of TX Blue Essentials	$37.44
Rate for Payer: BCBS of TX Medicare	$13.28
Rate for Payer: BCBS of TX PPO	$41.60
Rate for Payer: Cash Price	$70.72
Rate for Payer: Cash Price	$70.72
Rate for Payer: Cigna Medicaid	$74.88
Rate for Payer: Cigna Medicare	$13.28
Rate for Payer: Employer Direct Commercial	$13.28
Rate for Payer: Humana Medicare/TRICARE	$13.28
Rate for Payer: Molina CHIP/Medicaid	$74.88
Rate for Payer: Molina Dual Medicare/Medicaid	$13.28
Rate for Payer: Molina Medicare	$13.28
Rate for Payer: Multiplan Auto	$67.60
Rate for Payer: Multiplan Commercial	$67.60
Rate for Payer: Multiplan Workers Comp	$67.60
Rate for Payer: Parkland Medicaid	$74.88
Rate for Payer: Scott and White EPO/PPO	$16.60
Rate for Payer: Scott and White Medicare	$13.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.88
Rate for Payer: Superior Health Plan EPO	$13.28
Rate for Payer: Superior Health Plan Medicare	$13.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.28
Rate for Payer: Universal American Medicare	$13.28
Rate for Payer: Wellcare Medicare	$13.28
Rate for Payer: Wellmed Medicare	$13.28

Digoxin, Serum SO

Facility

$104.00

Service Code	HCPCS 80162
Hospital Charge Code	9130978
Hospital Revenue Code	301
Rate for Payer: Cash Price	$70.72

DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$19,161.96

Service Code	APR-DRG 5174
Min. Negotiated Rate	$18,066.56
Max. Negotiated Rate	$19,161.96
Rate for Payer: Amerigroup CHIP/Medicaid	$18,066.56
Rate for Payer: Cigna Medicaid	$18,066.56
Rate for Payer: Molina CHIP/Medicaid	$18,066.56
Rate for Payer: Parkland Medicaid	$18,066.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,161.96

DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$4,554.93

Service Code	APR-DRG 5172
Min. Negotiated Rate	$4,294.55
Max. Negotiated Rate	$4,554.93
Rate for Payer: Amerigroup CHIP/Medicaid	$4,294.55
Rate for Payer: Cigna Medicaid	$4,294.55
Rate for Payer: Molina CHIP/Medicaid	$4,294.55
Rate for Payer: Parkland Medicaid	$4,294.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,554.93

DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$3,041.27

Service Code	APR-DRG 5171
Min. Negotiated Rate	$2,867.42
Max. Negotiated Rate	$3,041.27
Rate for Payer: Amerigroup CHIP/Medicaid	$2,867.42
Rate for Payer: Cigna Medicaid	$2,867.42
Rate for Payer: Molina CHIP/Medicaid	$2,867.42
Rate for Payer: Parkland Medicaid	$2,867.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,041.27

DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$7,002.51

Service Code	APR-DRG 5173
Min. Negotiated Rate	$6,602.22
Max. Negotiated Rate	$7,002.51
Rate for Payer: Amerigroup CHIP/Medicaid	$6,602.22
Rate for Payer: Cigna Medicaid	$6,602.22
Rate for Payer: Molina CHIP/Medicaid	$6,602.22
Rate for Payer: Parkland Medicaid	$6,602.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,002.51

Dilation of esophagus, over guide wire

Facility

$4,617.17

Service Code	HCPCS 43453
Hospital Charge Code	9900683
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,139.68

Dilation of esophagus, over guide wire

Facility

$4,617.17

Service Code	HCPCS 43453
Hospital Charge Code	9900683
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: Cash Price	$3,139.68
Rate for Payer: Cash Price	$3,139.68
Rate for Payer: Cash Price	$3,139.68
Rate for Payer: Cigna Commercial	$4,074.70
Rate for Payer: Cigna Medicaid	$3,324.36
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 CHIP/Medicaid	$3,324.36
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: Parkland Medicaid	$3,324.36
Rate for Payer: Scott and White EPO/PPO	$3,219.41
Rate for Payer: Scott and White Medicare	$1,927.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,324.36
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

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	$3,219.41
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	$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

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

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
Rate for Payer: Cash Price	$5.44

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 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

Know your out-of-pocket cost for care.

All Charges