White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$87.04

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

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 C9399
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 C9399
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
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

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 50 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1200
Hospital Charge Code	77518369
Hospital Revenue Code	636
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.00
Rate for Payer: BCBS of TX Blue Essentials	$1.20
Rate for Payer: BCBS of TX PPO	$1.33
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

diphenhydrAMINE 50 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1200
Hospital Charge Code	77518369
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

Direct Admit to Hospital Obs Care G0379 BCE

Facility

$796.02

Service Code	HCPCS G0379
Hospital Charge Code	100017
Hospital Revenue Code	762
Rate for Payer: Cash Price	$541.29

Direct Admit to Hospital Obs Care G0379 BCE

Facility

$796.02

Service Code	HCPCS G0379
Hospital Charge Code	100017
Hospital Revenue Code	762
Min. Negotiated Rate	$398.01
Max. Negotiated Rate	$3,660.00
Rate for Payer: Amerigroup CHIP/Medicaid	$400.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$598.24
Rate for Payer: Amerigroup Medicare	$598.24
Rate for Payer: BCBS of TX Blue Advantage	$2,745.00
Rate for Payer: BCBS of TX Blue Essentials	$3,294.00
Rate for Payer: BCBS of TX Medicare	$598.24
Rate for Payer: BCBS of TX PPO	$3,660.00
Rate for Payer: Cash Price	$541.29
Rate for Payer: Cash Price	$541.29
Rate for Payer: Cash Price	$541.29
Rate for Payer: Cigna Commercial	$1,264.58
Rate for Payer: Cigna Medicaid	$573.13
Rate for Payer: Cigna Medicare	$598.24
Rate for Payer: Employer Direct Commercial	$598.24
Rate for Payer: Humana Medicare/TRICARE	$598.24
Rate for Payer: Molina CHIP/Medicaid	$573.13
Rate for Payer: Molina Dual Medicare/Medicaid	$598.24
Rate for Payer: Molina Medicare	$598.24
Rate for Payer: Multiplan Auto	$517.41
Rate for Payer: Multiplan Commercial	$517.41
Rate for Payer: Multiplan Workers Comp	$517.41
Rate for Payer: Parkland Medicaid	$573.13
Rate for Payer: Scott and White EPO/PPO	$398.01
Rate for Payer: Scott and White Medicare	$598.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$573.13
Rate for Payer: Superior Health Plan EPO	$598.24
Rate for Payer: Superior Health Plan Medicare	$598.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$598.24
Rate for Payer: Universal American Medicare	$598.24
Rate for Payer: Wellcare Medicare	$598.24
Rate for Payer: Wellmed Medicare	$598.24

Discography, lumbar, radiological supervision and interpretation

Facility

$8,966.55

Service Code	HCPCS 72295
Hospital Charge Code	9900899
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,097.25

Discography, lumbar, radiological supervision and interpretation

Facility

$8,966.55

Service Code	HCPCS 72295
Hospital Charge Code	9900899
Hospital Revenue Code	360
Min. Negotiated Rate	$137.54
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$806.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,836.93
Rate for Payer: BCBS of TX Blue Essentials	$3,404.31
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$3,799.76
Rate for Payer: Cash Price	$6,097.25
Rate for Payer: Cash Price	$6,097.25
Rate for Payer: Cash Price	$6,097.25
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$6,455.92
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$6,455.92
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$6,455.92
Rate for Payer: Scott and White EPO/PPO	$137.54
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,455.92
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Discography, lumbar, radiological supervision and interpretation

Facility

$10,000.00

Service Code	CPT 72295
Hospital Charge Code	36072295
Hospital Revenue Code	360
Min. Negotiated Rate	$137.54
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,836.93
Rate for Payer: BCBS of TX Blue Essentials	$3,404.31
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$3,799.76
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$137.54
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

DISINFECTION SYS SONEX-HL TROPHON, 80ML

Facility

$10.03

Hospital Charge Code	993601
Hospital Revenue Code	270
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$7.22
Rate for Payer: Amerigroup CHIP/Medicaid	$0.90
Rate for Payer: BCBS of TX Blue Advantage	$3.01
Rate for Payer: BCBS of TX Blue Essentials	$3.61
Rate for Payer: BCBS of TX PPO	$4.01
Rate for Payer: Cash Price	$6.82
Rate for Payer: Cigna Medicaid	$7.22
Rate for Payer: Molina CHIP/Medicaid	$7.22
Rate for Payer: Multiplan Auto	$6.52
Rate for Payer: Multiplan Commercial	$6.52
Rate for Payer: Multiplan Workers Comp	$6.52
Rate for Payer: Parkland Medicaid	$7.22
Rate for Payer: Scott and White EPO/PPO	$5.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.22
Rate for Payer: Superior Health Plan EPO	$1.36

DISINFECTION SYS SONEX-HL TROPHON, 80ML

Facility

$10.03

Hospital Charge Code	993601
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.82

DISORDERS OF GALLBLADDER AND BILIARY TRACT

Facility

$4,249.41

Service Code	APR-DRG 2842
Min. Negotiated Rate	$4,006.49
Max. Negotiated Rate	$4,249.41
Rate for Payer: Amerigroup CHIP/Medicaid	$4,006.49
Rate for Payer: Cigna Medicaid	$4,006.49
Rate for Payer: Molina CHIP/Medicaid	$4,006.49
Rate for Payer: Parkland Medicaid	$4,006.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,249.41

DISORDERS OF GALLBLADDER AND BILIARY TRACT

Facility

$6,373.36

Service Code	APR-DRG 2843
Min. Negotiated Rate	$6,009.03
Max. Negotiated Rate	$6,373.36
Rate for Payer: Amerigroup CHIP/Medicaid	$6,009.03
Rate for Payer: Cigna Medicaid	$6,009.03
Rate for Payer: Molina CHIP/Medicaid	$6,009.03
Rate for Payer: Parkland Medicaid	$6,009.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,373.36

DISORDERS OF GALLBLADDER AND BILIARY TRACT

Facility

$3,200.07

Service Code	APR-DRG 2841
Min. Negotiated Rate	$3,017.14
Max. Negotiated Rate	$3,200.07
Rate for Payer: Amerigroup CHIP/Medicaid	$3,017.14
Rate for Payer: Cigna Medicaid	$3,017.14
Rate for Payer: Molina CHIP/Medicaid	$3,017.14
Rate for Payer: Parkland Medicaid	$3,017.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,200.07

DISORDERS OF GALLBLADDER AND BILIARY TRACT

Facility

$11,993.10

Service Code	APR-DRG 2844
Min. Negotiated Rate	$11,307.52
Max. Negotiated Rate	$11,993.10
Rate for Payer: Amerigroup CHIP/Medicaid	$11,307.52
Rate for Payer: Cigna Medicaid	$11,307.52
Rate for Payer: Molina CHIP/Medicaid	$11,307.52
Rate for Payer: Parkland Medicaid	$11,307.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,993.10

DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC

Facility

$17,974.00

Service Code	MSDRG 442
Min. Negotiated Rate	$8,074.54
Max. Negotiated Rate	$17,974.00
Rate for Payer: BCBS of TX Blue Advantage	$8,074.54
Rate for Payer: BCBS of TX Blue Essentials	$9,688.51
Rate for Payer: BCBS of TX PPO	$10,765.43

Know your out-of-pocket cost for care.

All Charges