White Rock Medical Center

All Charges

Charge

Type

Setting

Price

fenofibrate 48 mg Tab

Facility

$21.80

Service Code	HCPCS J3490
Hospital Charge Code	77563789
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.82

fenofibrate 48 mg Tab

Facility

$21.80

Service Code	HCPCS J3490
Hospital Charge Code	77563789
Hospital Revenue Code	250
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$15.70
Rate for Payer: Amerigroup CHIP/Medicaid	$1.96
Rate for Payer: BCBS of TX Blue Advantage	$6.54
Rate for Payer: BCBS of TX Blue Essentials	$7.85
Rate for Payer: BCBS of TX PPO	$8.72
Rate for Payer: Cash Price	$14.82
Rate for Payer: Cigna Medicaid	$15.70
Rate for Payer: Molina CHIP/Medicaid	$15.70
Rate for Payer: Multiplan Auto	$14.17
Rate for Payer: Multiplan Commercial	$14.17
Rate for Payer: Multiplan Workers Comp	$14.17
Rate for Payer: Parkland Medicaid	$15.70
Rate for Payer: Scott and White EPO/PPO	$10.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.70
Rate for Payer: Superior Health Plan EPO	$2.96

fentaNYL 10 mcg/mL-NS PCA; 100 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	77567607
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

fentaNYL 10 mcg/mL-NS PCA; 100 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	77567607
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
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

fentaNYL 10 mcg/mL-NS PCA; 100 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	8348677
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

fentaNYL 10 mcg/mL-NS PCA; 100 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	8348677
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
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

fentaNYL 25 mcg/hr TD Film, ER

Facility

$55.35

Service Code	HCPCS J3490
Hospital Charge Code	77566382
Hospital Revenue Code	250
Rate for Payer: Cash Price	$37.64

fentaNYL 25 mcg/hr TD Film, ER

Facility

$55.35

Service Code	HCPCS J3490
Hospital Charge Code	77566382
Hospital Revenue Code	250
Min. Negotiated Rate	$4.98
Max. Negotiated Rate	$39.85
Rate for Payer: Amerigroup CHIP/Medicaid	$4.98
Rate for Payer: BCBS of TX Blue Advantage	$16.61
Rate for Payer: BCBS of TX Blue Essentials	$19.93
Rate for Payer: BCBS of TX PPO	$22.14
Rate for Payer: Cash Price	$37.64
Rate for Payer: Cigna Medicaid	$39.85
Rate for Payer: Molina CHIP/Medicaid	$39.85
Rate for Payer: Multiplan Auto	$35.98
Rate for Payer: Multiplan Commercial	$35.98
Rate for Payer: Multiplan Workers Comp	$35.98
Rate for Payer: Parkland Medicaid	$39.85
Rate for Payer: Scott and White EPO/PPO	$27.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.85
Rate for Payer: Superior Health Plan EPO	$7.53

fentaNYL 50 mcg/hr TD Film, ER

Facility

$66.48

Service Code	HCPCS J3490
Hospital Charge Code	77567326
Hospital Revenue Code	250
Min. Negotiated Rate	$5.98
Max. Negotiated Rate	$47.87
Rate for Payer: Amerigroup CHIP/Medicaid	$5.98
Rate for Payer: BCBS of TX Blue Advantage	$19.94
Rate for Payer: BCBS of TX Blue Essentials	$23.93
Rate for Payer: BCBS of TX PPO	$26.59
Rate for Payer: Cash Price	$45.21
Rate for Payer: Cigna Medicaid	$47.87
Rate for Payer: Molina CHIP/Medicaid	$47.87
Rate for Payer: Multiplan Auto	$43.21
Rate for Payer: Multiplan Commercial	$43.21
Rate for Payer: Multiplan Workers Comp	$43.21
Rate for Payer: Parkland Medicaid	$47.87
Rate for Payer: Scott and White EPO/PPO	$33.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47.87
Rate for Payer: Superior Health Plan EPO	$9.04

fentaNYL 50 mcg/hr TD Film, ER

Facility

$66.48

Service Code	HCPCS J3490
Hospital Charge Code	77567326
Hospital Revenue Code	250
Rate for Payer: Cash Price	$45.21

fentaNYL 50 mcg/mL Inj Soln 10 mL

Facility

$128.00

Service Code	HCPCS J3010
Hospital Charge Code	77567432
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

fentaNYL 50 mcg/mL Inj Soln 10 mL

Facility

$128.00

Service Code	HCPCS J3010
Hospital Charge Code	77567432
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
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

fentaNYL 50 mcg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	77567548
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

fentaNYL 50 mcg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	77567548
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
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

fentaNYL 50 mcg/mL Inj Soln 50 mL

Facility

$128.19

Service Code	HCPCS J3010
Hospital Charge Code	77567841
Hospital Revenue Code	636
Min. Negotiated Rate	$32.05
Max. Negotiated Rate	$64.09
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cigna Commercial	$32.05
Rate for Payer: Scott and White EPO/PPO	$64.09

fentaNYL 50 mcg/mL Inj Soln 50 mL

Facility

$128.19

Service Code	HCPCS J3010
Hospital Charge Code	77567841
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$92.30
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cigna Medicaid	$92.30
Rate for Payer: Molina CHIP/Medicaid	$92.30
Rate for Payer: Multiplan Auto	$83.32
Rate for Payer: Multiplan Commercial	$83.32
Rate for Payer: Multiplan Workers Comp	$83.32
Rate for Payer: Parkland Medicaid	$92.30
Rate for Payer: Scott and White EPO/PPO	$64.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.30
Rate for Payer: Superior Health Plan EPO	$17.43

fentaNYL 50 mcg/mL Inj Soln 5 mL

Facility

$128.00

Service Code	HCPCS J3010
Hospital Charge Code	77567782
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
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

fentaNYL 50 mcg/mL Inj Soln 5 mL

Facility

$128.00

Service Code	HCPCS J3010
Hospital Charge Code	77567782
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

Ferritin

Facility

$271.00

Service Code	HCPCS 82728
Hospital Charge Code	1602028
Hospital Revenue Code	301
Rate for Payer: Cash Price	$184.28

Ferritin

Facility

$271.00

Service Code	HCPCS 82728
Hospital Charge Code	1602028
Hospital Revenue Code	301
Min. Negotiated Rate	$5.32
Max. Negotiated Rate	$195.12
Rate for Payer: Amerigroup CHIP/Medicaid	$5.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.63
Rate for Payer: Amerigroup Medicare	$13.63
Rate for Payer: BCBS of TX Blue Advantage	$81.30
Rate for Payer: BCBS of TX Blue Essentials	$97.56
Rate for Payer: BCBS of TX Medicare	$13.63
Rate for Payer: BCBS of TX PPO	$108.40
Rate for Payer: Cash Price	$184.28
Rate for Payer: Cash Price	$184.28
Rate for Payer: Cigna Medicaid	$195.12
Rate for Payer: Cigna Medicare	$13.63
Rate for Payer: Employer Direct Commercial	$13.63
Rate for Payer: Humana Medicare/TRICARE	$13.63
Rate for Payer: Molina CHIP/Medicaid	$195.12
Rate for Payer: Molina Dual Medicare/Medicaid	$13.63
Rate for Payer: Molina Medicare	$13.63
Rate for Payer: Multiplan Auto	$176.15
Rate for Payer: Multiplan Commercial	$176.15
Rate for Payer: Multiplan Workers Comp	$176.15
Rate for Payer: Parkland Medicaid	$195.12
Rate for Payer: Scott and White EPO/PPO	$17.04
Rate for Payer: Scott and White Medicare	$13.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.12
Rate for Payer: Superior Health Plan EPO	$13.63
Rate for Payer: Superior Health Plan Medicare	$13.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.63
Rate for Payer: Universal American Medicare	$13.63
Rate for Payer: Wellcare Medicare	$13.63
Rate for Payer: Wellmed Medicare	$13.63

ferrous gluconate 324 mg (38 mg elemental iron) Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77569993
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

ferrous gluconate 324 mg (38 mg elemental iron) Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77569993
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

ferrous sulfate 325 mg (65 mg elemental iron) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77570678
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

ferrous sulfate 325 mg (65 mg elemental iron) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77570678
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

ferrous sulfate (as elemental iron) 15 mg/mL Oral Liquid 5 mL

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	79165028
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.80

Know your out-of-pocket cost for care.

All Charges