White Rock Medical Center

All Charges

Charge

Type

Setting

Price

emerel plus mutisurface cream cleanser

Facility

$15.00

Hospital Charge Code	993299
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10.20

EMERGENCY BIRTH

Facility

$160.97

Hospital Charge Code	993308
Hospital Revenue Code	270
Rate for Payer: Cash Price	$109.46

EMERGENCY BIRTH

Facility

$160.97

Hospital Charge Code	993308
Hospital Revenue Code	270
Min. Negotiated Rate	$14.49
Max. Negotiated Rate	$115.90
Rate for Payer: Amerigroup CHIP/Medicaid	$14.49
Rate for Payer: BCBS of TX Blue Advantage	$48.29
Rate for Payer: BCBS of TX Blue Essentials	$57.95
Rate for Payer: BCBS of TX PPO	$64.39
Rate for Payer: Cash Price	$109.46
Rate for Payer: Cigna Medicaid	$115.90
Rate for Payer: Molina CHIP/Medicaid	$115.90
Rate for Payer: Multiplan Auto	$104.63
Rate for Payer: Multiplan Commercial	$104.63
Rate for Payer: Multiplan Workers Comp	$104.63
Rate for Payer: Parkland Medicaid	$115.90
Rate for Payer: Scott and White EPO/PPO	$80.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.90
Rate for Payer: Superior Health Plan EPO	$21.89

Emesis Bag 5.5x7.5' Blue Top Ring Plastic 24 / Pk, 6 PK / CA

Facility

$60.29

Hospital Charge Code	993835
Hospital Revenue Code	271
Rate for Payer: Cash Price	$41.00

Emesis Bag 5.5x7.5' Blue Top Ring Plastic 24 / Pk, 6 PK / CA

Facility

$60.29

Hospital Charge Code	993835
Hospital Revenue Code	271
Min. Negotiated Rate	$5.43
Max. Negotiated Rate	$43.41
Rate for Payer: Amerigroup CHIP/Medicaid	$5.43
Rate for Payer: BCBS of TX Blue Advantage	$18.09
Rate for Payer: BCBS of TX Blue Essentials	$21.70
Rate for Payer: BCBS of TX PPO	$24.12
Rate for Payer: Cash Price	$41.00
Rate for Payer: Cigna Medicaid	$43.41
Rate for Payer: Molina CHIP/Medicaid	$43.41
Rate for Payer: Multiplan Auto	$39.19
Rate for Payer: Multiplan Commercial	$39.19
Rate for Payer: Multiplan Workers Comp	$39.19
Rate for Payer: Parkland Medicaid	$43.41
Rate for Payer: Scott and White EPO/PPO	$30.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.41
Rate for Payer: Superior Health Plan EPO	$8.20

empagliflozin 10mg tab

Facility

$71.82

Service Code	HCPCS J3490
Hospital Charge Code	78364595
Hospital Revenue Code	999
Rate for Payer: Cash Price	$48.84

empagliflozin 10mg tab

Facility

$71.82

Service Code	HCPCS J3490
Hospital Charge Code	78364595
Hospital Revenue Code	999
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$51.71
Rate for Payer: Amerigroup CHIP/Medicaid	$6.46
Rate for Payer: BCBS of TX Blue Advantage	$21.55
Rate for Payer: BCBS of TX Blue Essentials	$25.86
Rate for Payer: BCBS of TX PPO	$28.73
Rate for Payer: Cash Price	$48.84
Rate for Payer: Cigna Medicaid	$51.71
Rate for Payer: Molina CHIP/Medicaid	$51.71
Rate for Payer: Multiplan Auto	$46.68
Rate for Payer: Multiplan Commercial	$46.68
Rate for Payer: Multiplan Workers Comp	$46.68
Rate for Payer: Parkland Medicaid	$51.71
Rate for Payer: Scott and White EPO/PPO	$35.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.71
Rate for Payer: Superior Health Plan EPO	$9.77

empagliflozin 25mg

Facility

$41.78

Service Code	HCPCS j3490
Hospital Charge Code	78364591
Hospital Revenue Code	250
Rate for Payer: Cash Price	$28.41

empagliflozin 25mg

Facility

$41.78

Service Code	HCPCS j3490
Hospital Charge Code	78364591
Hospital Revenue Code	250
Min. Negotiated Rate	$3.76
Max. Negotiated Rate	$30.08
Rate for Payer: Amerigroup CHIP/Medicaid	$3.76
Rate for Payer: BCBS of TX Blue Advantage	$12.53
Rate for Payer: BCBS of TX Blue Essentials	$15.04
Rate for Payer: BCBS of TX PPO	$16.71
Rate for Payer: Cash Price	$28.41
Rate for Payer: Cigna Medicaid	$30.08
Rate for Payer: Molina CHIP/Medicaid	$30.08
Rate for Payer: Multiplan Auto	$27.16
Rate for Payer: Multiplan Commercial	$27.16
Rate for Payer: Multiplan Workers Comp	$27.16
Rate for Payer: Parkland Medicaid	$30.08
Rate for Payer: Scott and White EPO/PPO	$20.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.08
Rate for Payer: Superior Health Plan EPO	$5.68

empagliflozin ORAL TABLET 10 MG

Facility

$71.82

Service Code	HCPCS J3490
Hospital Charge Code	78364594
Hospital Revenue Code	250
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$51.71
Rate for Payer: Amerigroup CHIP/Medicaid	$6.46
Rate for Payer: BCBS of TX Blue Advantage	$21.55
Rate for Payer: BCBS of TX Blue Essentials	$25.86
Rate for Payer: BCBS of TX PPO	$28.73
Rate for Payer: Cash Price	$48.84
Rate for Payer: Cigna Medicaid	$51.71
Rate for Payer: Molina CHIP/Medicaid	$51.71
Rate for Payer: Multiplan Auto	$46.68
Rate for Payer: Multiplan Commercial	$46.68
Rate for Payer: Multiplan Workers Comp	$46.68
Rate for Payer: Parkland Medicaid	$51.71
Rate for Payer: Scott and White EPO/PPO	$35.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.71
Rate for Payer: Superior Health Plan EPO	$9.77

empagliflozin ORAL TABLET 10 MG

Facility

$71.82

Service Code	HCPCS J3490
Hospital Charge Code	78364594
Hospital Revenue Code	250
Rate for Payer: Cash Price	$48.84

.ENA+DNA/DS+Sjogren's 016123 SO

Facility

$426.00

Service Code	HCPCS 86225
Hospital Charge Code	1605344
Hospital Revenue Code	302
Rate for Payer: Cash Price	$289.68

.ENA+DNA/DS+Sjogren's 016123 SO

Facility

$426.00

Service Code	HCPCS 86225
Hospital Charge Code	1605344
Hospital Revenue Code	302
Min. Negotiated Rate	$5.36
Max. Negotiated Rate	$306.72
Rate for Payer: Amerigroup CHIP/Medicaid	$5.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.74
Rate for Payer: Amerigroup Medicare	$13.74
Rate for Payer: BCBS of TX Blue Advantage	$127.80
Rate for Payer: BCBS of TX Blue Essentials	$153.36
Rate for Payer: BCBS of TX Medicare	$13.74
Rate for Payer: BCBS of TX PPO	$170.40
Rate for Payer: Cash Price	$289.68
Rate for Payer: Cash Price	$289.68
Rate for Payer: Cigna Medicaid	$306.72
Rate for Payer: Cigna Medicare	$13.74
Rate for Payer: Employer Direct Commercial	$13.74
Rate for Payer: Humana Medicare/TRICARE	$13.74
Rate for Payer: Molina CHIP/Medicaid	$306.72
Rate for Payer: Molina Dual Medicare/Medicaid	$13.74
Rate for Payer: Molina Medicare	$13.74
Rate for Payer: Multiplan Auto	$276.90
Rate for Payer: Multiplan Commercial	$276.90
Rate for Payer: Multiplan Workers Comp	$276.90
Rate for Payer: Parkland Medicaid	$306.72
Rate for Payer: Scott and White EPO/PPO	$17.18
Rate for Payer: Scott and White Medicare	$13.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$306.72
Rate for Payer: Superior Health Plan EPO	$13.74
Rate for Payer: Superior Health Plan Medicare	$13.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.74
Rate for Payer: Universal American Medicare	$13.74
Rate for Payer: Wellcare Medicare	$13.74
Rate for Payer: Wellmed Medicare	$13.74

enalapril 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77545401
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

enalapril 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77545401
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

enalaprilat 1.25 mg/mL IV Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77545617
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

enalaprilat 1.25 mg/mL IV Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77545617
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

END CAP T2 SUPER CONDYLAR NAIL

Facility

$1,205.00

Service Code	HCPCS C1776
Hospital Charge Code	140511
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

END CAP T2 SUPER CONDYLAR NAIL

Facility

$1,205.00

Service Code	HCPCS C1776
Hospital Charge Code	140511
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

ENDO CATCH/SAC -- DHF

Facility

$1,541.75

Hospital Charge Code	80811110
Hospital Revenue Code	272
Min. Negotiated Rate	$138.76
Max. Negotiated Rate	$1,110.06
Rate for Payer: Amerigroup CHIP/Medicaid	$138.76
Rate for Payer: BCBS of TX Blue Advantage	$462.52
Rate for Payer: BCBS of TX Blue Essentials	$555.03
Rate for Payer: BCBS of TX PPO	$616.70
Rate for Payer: Cash Price	$1,048.39
Rate for Payer: Cigna Medicaid	$1,110.06
Rate for Payer: Molina CHIP/Medicaid	$1,110.06
Rate for Payer: Multiplan Auto	$1,002.14
Rate for Payer: Multiplan Commercial	$1,002.14
Rate for Payer: Multiplan Workers Comp	$1,002.14
Rate for Payer: Parkland Medicaid	$1,110.06
Rate for Payer: Scott and White EPO/PPO	$770.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,110.06
Rate for Payer: Superior Health Plan EPO	$209.68

ENDO CATCH/SAC -- DHF

Facility

$1,541.75

Hospital Charge Code	80811110
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,048.39

ENDOCLOSE

Facility

$220.64

Hospital Charge Code	992695
Hospital Revenue Code	272
Min. Negotiated Rate	$19.86
Max. Negotiated Rate	$158.86
Rate for Payer: Amerigroup CHIP/Medicaid	$19.86
Rate for Payer: BCBS of TX Blue Advantage	$66.19
Rate for Payer: BCBS of TX Blue Essentials	$79.43
Rate for Payer: BCBS of TX PPO	$88.26
Rate for Payer: Cash Price	$150.04
Rate for Payer: Cigna Medicaid	$158.86
Rate for Payer: Molina CHIP/Medicaid	$158.86
Rate for Payer: Multiplan Auto	$143.42
Rate for Payer: Multiplan Commercial	$143.42
Rate for Payer: Multiplan Workers Comp	$143.42
Rate for Payer: Parkland Medicaid	$158.86
Rate for Payer: Scott and White EPO/PPO	$110.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$158.86
Rate for Payer: Superior Health Plan EPO	$30.01

ENDOCLOSE

Facility

$220.64

Hospital Charge Code	992695
Hospital Revenue Code	272
Rate for Payer: Cash Price	$150.04

ENDOCLOSE -- DHF

Facility

$356.09

Hospital Charge Code	80811177
Hospital Revenue Code	272
Min. Negotiated Rate	$32.05
Max. Negotiated Rate	$256.38
Rate for Payer: Amerigroup CHIP/Medicaid	$32.05
Rate for Payer: BCBS of TX Blue Advantage	$106.83
Rate for Payer: BCBS of TX Blue Essentials	$128.19
Rate for Payer: BCBS of TX PPO	$142.44
Rate for Payer: Cash Price	$242.14
Rate for Payer: Cigna Medicaid	$256.38
Rate for Payer: Molina CHIP/Medicaid	$256.38
Rate for Payer: Multiplan Auto	$231.46
Rate for Payer: Multiplan Commercial	$231.46
Rate for Payer: Multiplan Workers Comp	$231.46
Rate for Payer: Parkland Medicaid	$256.38
Rate for Payer: Scott and White EPO/PPO	$178.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$256.38
Rate for Payer: Superior Health Plan EPO	$48.43

ENDOCLOSE -- DHF

Facility

$356.09

Hospital Charge Code	80811177
Hospital Revenue Code	272
Rate for Payer: Cash Price	$242.14

Know your out-of-pocket cost for care.

All Charges