White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ACECIDE-C PERACETIC ACID 6 SETS/CASE

Facility

$4,668.12

Hospital Charge Code	993938
Hospital Revenue Code	271
Rate for Payer: Cash Price	$3,174.32

ACECIDE-C TEST TEST STRIPS 100

Facility

$437.38

Hospital Charge Code	993939
Hospital Revenue Code	271
Min. Negotiated Rate	$39.36
Max. Negotiated Rate	$314.91
Rate for Payer: Amerigroup CHIP/Medicaid	$39.36
Rate for Payer: BCBS of TX Blue Advantage	$131.21
Rate for Payer: BCBS of TX Blue Essentials	$157.46
Rate for Payer: BCBS of TX PPO	$174.95
Rate for Payer: Cash Price	$297.42
Rate for Payer: Cigna Medicaid	$314.91
Rate for Payer: Molina CHIP/Medicaid	$314.91
Rate for Payer: Multiplan Auto	$284.30
Rate for Payer: Multiplan Commercial	$284.30
Rate for Payer: Multiplan Workers Comp	$284.30
Rate for Payer: Parkland Medicaid	$314.91
Rate for Payer: Scott and White EPO/PPO	$218.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$314.91
Rate for Payer: Superior Health Plan EPO	$59.48

ACECIDE-C TEST TEST STRIPS 100

Facility

$437.38

Hospital Charge Code	993939
Hospital Revenue Code	271
Rate for Payer: Cash Price	$297.42

Acetabular Components

Facility

$5,421.69

Service Code	HCPCS C1734
Hospital Charge Code	992148
Hospital Revenue Code	278
Min. Negotiated Rate	$1,355.42
Max. Negotiated Rate	$2,710.84
Rate for Payer: Cash Price	$3,686.75
Rate for Payer: Cigna Commercial	$1,355.42
Rate for Payer: Multiplan Auto	$2,710.84
Rate for Payer: Multiplan Commercial	$2,710.84
Rate for Payer: Multiplan Workers Comp	$2,710.84
Rate for Payer: Scott and White EPO/PPO	$2,710.84

Acetabular Components

Facility

$5,421.69

Service Code	HCPCS C1734
Hospital Charge Code	992148
Hospital Revenue Code	278
Min. Negotiated Rate	$487.95
Max. Negotiated Rate	$3,903.62
Rate for Payer: Amerigroup CHIP/Medicaid	$487.95
Rate for Payer: BCBS of TX Blue Advantage	$1,626.51
Rate for Payer: BCBS of TX Blue Essentials	$1,951.81
Rate for Payer: BCBS of TX PPO	$2,168.68
Rate for Payer: Cash Price	$3,686.75
Rate for Payer: Cigna Medicaid	$3,903.62
Rate for Payer: Molina CHIP/Medicaid	$3,903.62
Rate for Payer: Multiplan Auto	$2,710.84
Rate for Payer: Multiplan Commercial	$2,710.84
Rate for Payer: Multiplan Workers Comp	$2,710.84
Rate for Payer: Parkland Medicaid	$3,903.62
Rate for Payer: Scott and White EPO/PPO	$2,710.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,903.62
Rate for Payer: Superior Health Plan EPO	$737.35

acetaminophen 10 mg/mL IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J0131
Hospital Charge Code	77343156
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.44
Rate for Payer: BCBS of TX Blue Essentials	$0.52
Rate for Payer: BCBS of TX PPO	$0.58
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

acetaminophen 10 mg/mL IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J0131
Hospital Charge Code	77343156
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

acetaminophen 160 mg/5 mL Oral Liquid 20.3 mL

Facility

$21.20

Service Code	HCPCS J3490
Hospital Charge Code	77343423
Hospital Revenue Code	250
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$15.26
Rate for Payer: Amerigroup CHIP/Medicaid	$1.91
Rate for Payer: BCBS of TX Blue Advantage	$6.36
Rate for Payer: BCBS of TX Blue Essentials	$7.63
Rate for Payer: BCBS of TX PPO	$8.48
Rate for Payer: Cash Price	$14.42
Rate for Payer: Cigna Medicaid	$15.26
Rate for Payer: Molina CHIP/Medicaid	$15.26
Rate for Payer: Multiplan Auto	$13.78
Rate for Payer: Multiplan Commercial	$13.78
Rate for Payer: Multiplan Workers Comp	$13.78
Rate for Payer: Parkland Medicaid	$15.26
Rate for Payer: Scott and White EPO/PPO	$10.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.26
Rate for Payer: Superior Health Plan EPO	$2.88

acetaminophen 160 mg/5 mL Oral Liquid 20.3 mL

Facility

$21.20

Service Code	HCPCS J3490
Hospital Charge Code	77343423
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.42

acetaminophen 160 mg/5 mL Oral Liquid 5 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77343584
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

acetaminophen 160 mg/5 mL Oral Liquid 5 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77343584
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

acetaminophen 325 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77343853
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

acetaminophen 325 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77343853
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

acetaminophen 325 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78405332
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

acetaminophen 325 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78405332
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen 500 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77343959
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

acetaminophen 500 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77343959
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen 650 mg Rectal Supp

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	79977309
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

acetaminophen 650 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	acetaminophen 650 mg Re
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

acetaminophen 650 mg Rectal Supp

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	79977309
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

acetaminophen 650 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77344228
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

acetaminophen 650 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77344228
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

acetaminophen 650 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	acetaminophen 650 mg Re
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

acetaminophen 80 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77344385
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

acetaminophen 80 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77344385
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Know your out-of-pocket cost for care.

All Charges