White Rock Medical Center

All Charges

Charge

Type

Setting

Price

docusate sodium 100 mg Cap

Facility

$7.65

Service Code	HCPCS j3490
Hospital Charge Code	77522438
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

docusate sodium 100 mg Cap

Facility

$7.65

Service Code	HCPCS j3490
Hospital Charge Code	77522438
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

donepezil 5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77523612
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

donepezil 5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77523612
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

Donut Positioner McKesson 9 Inch Diameter Foam Freestanding

Facility

$38.20

Hospital Charge Code	993038
Hospital Revenue Code	270
Rate for Payer: Cash Price	$25.98

Donut Positioner McKesson 9 Inch Diameter Foam Freestanding

Facility

$38.20

Hospital Charge Code	993038
Hospital Revenue Code	270
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$27.50
Rate for Payer: Amerigroup CHIP/Medicaid	$3.44
Rate for Payer: BCBS of TX Blue Advantage	$11.46
Rate for Payer: BCBS of TX Blue Essentials	$13.75
Rate for Payer: BCBS of TX PPO	$15.28
Rate for Payer: Cash Price	$25.98
Rate for Payer: Cigna Medicaid	$27.50
Rate for Payer: Molina CHIP/Medicaid	$27.50
Rate for Payer: Multiplan Auto	$24.83
Rate for Payer: Multiplan Commercial	$24.83
Rate for Payer: Multiplan Workers Comp	$24.83
Rate for Payer: Parkland Medicaid	$27.50
Rate for Payer: Scott and White EPO/PPO	$19.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.50
Rate for Payer: Superior Health Plan EPO	$5.20

DOPamine 40 mg/mL IV Soln 10 mL

Facility

$128.00

Service Code	HCPCS J1265
Hospital Charge Code	77523883
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

DOPamine 40 mg/mL IV Soln 10 mL

Facility

$128.00

Service Code	HCPCS J1265
Hospital Charge Code	77523883
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.36
Rate for Payer: BCBS of TX Blue Essentials	$0.44
Rate for Payer: BCBS of TX PPO	$0.48
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

DOPamine 40 mg/mL IV Soln 10 mL

Facility

$128.00

Service Code	HCPCS J1265
Hospital Charge Code	77523828
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.36
Rate for Payer: BCBS of TX Blue Essentials	$0.44
Rate for Payer: BCBS of TX PPO	$0.48
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

DOPamine 40 mg/mL IV Soln 10 mL

Facility

$128.00

Service Code	HCPCS J1265
Hospital Charge Code	77523828
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

DOPP FLW/PR MSMNT ADDL

Facility

$1,626.00

Service Code	HCPCS 93572
Hospital Charge Code	2320515
Hospital Revenue Code	481
Min. Negotiated Rate	$146.34
Max. Negotiated Rate	$1,170.72
Rate for Payer: Amerigroup CHIP/Medicaid	$146.34
Rate for Payer: BCBS of TX Blue Advantage	$487.80
Rate for Payer: BCBS of TX Blue Essentials	$585.36
Rate for Payer: BCBS of TX PPO	$650.40
Rate for Payer: Cash Price	$1,105.68
Rate for Payer: Cigna Medicaid	$1,170.72
Rate for Payer: Molina CHIP/Medicaid	$1,170.72
Rate for Payer: Multiplan Auto	$1,056.90
Rate for Payer: Multiplan Commercial	$1,056.90
Rate for Payer: Multiplan Workers Comp	$1,056.90
Rate for Payer: Parkland Medicaid	$1,170.72
Rate for Payer: Scott and White EPO/PPO	$813.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,170.72
Rate for Payer: Superior Health Plan EPO	$221.14

DOPP FLW/PR MSMNT ADDL

Facility

$1,626.00

Service Code	HCPCS 93572
Hospital Charge Code	2320515
Hospital Revenue Code	481
Rate for Payer: Cash Price	$1,105.68

DOPP FLW/PR MSMNT INIT

Facility

$2,213.00

Service Code	HCPCS 93571
Hospital Charge Code	2320514
Hospital Revenue Code	481
Rate for Payer: Cash Price	$1,504.84

DOPP FLW/PR MSMNT INIT

Facility

$2,213.00

Service Code	HCPCS 93571
Hospital Charge Code	2320514
Hospital Revenue Code	481
Min. Negotiated Rate	$199.17
Max. Negotiated Rate	$1,593.36
Rate for Payer: Amerigroup CHIP/Medicaid	$199.17
Rate for Payer: BCBS of TX Blue Advantage	$663.90
Rate for Payer: BCBS of TX Blue Essentials	$796.68
Rate for Payer: BCBS of TX PPO	$885.20
Rate for Payer: Cash Price	$1,504.84
Rate for Payer: Cigna Medicaid	$1,593.36
Rate for Payer: Molina CHIP/Medicaid	$1,593.36
Rate for Payer: Multiplan Auto	$1,438.45
Rate for Payer: Multiplan Commercial	$1,438.45
Rate for Payer: Multiplan Workers Comp	$1,438.45
Rate for Payer: Parkland Medicaid	$1,593.36
Rate for Payer: Scott and White EPO/PPO	$1,106.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,593.36
Rate for Payer: Superior Health Plan EPO	$300.97

DOPPLER, AUDIO MINI W/VASCULAR PROBE 8MHZ

Facility

$1,955.74

Hospital Charge Code	992595
Hospital Revenue Code	270
Min. Negotiated Rate	$176.02
Max. Negotiated Rate	$1,408.13
Rate for Payer: Amerigroup CHIP/Medicaid	$176.02
Rate for Payer: BCBS of TX Blue Advantage	$586.72
Rate for Payer: BCBS of TX Blue Essentials	$704.07
Rate for Payer: BCBS of TX PPO	$782.30
Rate for Payer: Cash Price	$1,329.90
Rate for Payer: Cigna Medicaid	$1,408.13
Rate for Payer: Molina CHIP/Medicaid	$1,408.13
Rate for Payer: Multiplan Auto	$1,271.23
Rate for Payer: Multiplan Commercial	$1,271.23
Rate for Payer: Multiplan Workers Comp	$1,271.23
Rate for Payer: Parkland Medicaid	$1,408.13
Rate for Payer: Scott and White EPO/PPO	$977.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,408.13
Rate for Payer: Superior Health Plan EPO	$265.98

DOPPLER, AUDIO MINI W/VASCULAR PROBE 8MHZ

Facility

$1,955.74

Hospital Charge Code	992595
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,329.90

DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK

Facility

$41,786.88

Service Code	APR-DRG 3044
Min. Negotiated Rate	$39,398.14
Max. Negotiated Rate	$41,786.88
Rate for Payer: Amerigroup CHIP/Medicaid	$39,398.14
Rate for Payer: Cigna Medicaid	$39,398.14
Rate for Payer: Molina CHIP/Medicaid	$39,398.14
Rate for Payer: Parkland Medicaid	$39,398.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41,786.88

DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK

Facility

$16,077.68

Service Code	APR-DRG 3042
Min. Negotiated Rate	$15,158.60
Max. Negotiated Rate	$16,077.68
Rate for Payer: Amerigroup CHIP/Medicaid	$15,158.60
Rate for Payer: Cigna Medicaid	$15,158.60
Rate for Payer: Molina CHIP/Medicaid	$15,158.60
Rate for Payer: Parkland Medicaid	$15,158.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,077.68

DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK

Facility

$13,325.33

Service Code	APR-DRG 3041
Min. Negotiated Rate	$12,563.59
Max. Negotiated Rate	$13,325.33
Rate for Payer: Amerigroup CHIP/Medicaid	$12,563.59
Rate for Payer: Cigna Medicaid	$12,563.59
Rate for Payer: Molina CHIP/Medicaid	$12,563.59
Rate for Payer: Parkland Medicaid	$12,563.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,325.33

DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK

Facility

$26,165.22

Service Code	APR-DRG 3043
Min. Negotiated Rate	$24,669.49
Max. Negotiated Rate	$26,165.22
Rate for Payer: Amerigroup CHIP/Medicaid	$24,669.49
Rate for Payer: Cigna Medicaid	$24,669.49
Rate for Payer: Molina CHIP/Medicaid	$24,669.49
Rate for Payer: Parkland Medicaid	$24,669.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26,165.22

DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK

Facility

$22,743.74

Service Code	APR-DRG 3031
Min. Negotiated Rate	$21,443.60
Max. Negotiated Rate	$22,743.74
Rate for Payer: Amerigroup CHIP/Medicaid	$21,443.60
Rate for Payer: Cigna Medicaid	$21,443.60
Rate for Payer: Molina CHIP/Medicaid	$21,443.60
Rate for Payer: Parkland Medicaid	$21,443.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,743.74

DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK

Facility

$50,300.42

Service Code	APR-DRG 3034
Min. Negotiated Rate	$47,424.99
Max. Negotiated Rate	$50,300.42
Rate for Payer: Amerigroup CHIP/Medicaid	$47,424.99
Rate for Payer: Cigna Medicaid	$47,424.99
Rate for Payer: Molina CHIP/Medicaid	$47,424.99
Rate for Payer: Parkland Medicaid	$47,424.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50,300.42

DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK

Facility

$42,552.20

Service Code	APR-DRG 3033
Min. Negotiated Rate	$40,119.70
Max. Negotiated Rate	$42,552.20
Rate for Payer: Amerigroup CHIP/Medicaid	$40,119.70
Rate for Payer: Cigna Medicaid	$40,119.70
Rate for Payer: Molina CHIP/Medicaid	$40,119.70
Rate for Payer: Parkland Medicaid	$40,119.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42,552.20

DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK

Facility

$30,873.67

Service Code	APR-DRG 3032
Min. Negotiated Rate	$29,108.78
Max. Negotiated Rate	$30,873.67
Rate for Payer: Amerigroup CHIP/Medicaid	$29,108.78
Rate for Payer: Cigna Medicaid	$29,108.78
Rate for Payer: Molina CHIP/Medicaid	$29,108.78
Rate for Payer: Parkland Medicaid	$29,108.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30,873.67

dorzolamide 2% Ophth Soln 10 mL

Facility

$124.40

Service Code	HCPCS J3490
Hospital Charge Code	77524384
Hospital Revenue Code	250
Rate for Payer: Cash Price	$84.59

Know your out-of-pocket cost for care.

All Charges