White Rock Medical Center

All Charges

Charge

Type

Setting

Price

acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77344801
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77344801
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-codeine 120 mg-12 mg/5 mL Oral Liquid 5 mL

Facility

$27.23

Service Code	HCPCS J3490
Hospital Charge Code	77351712
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.52

acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liquid 5 mL

Facility

$27.23

Service Code	HCPCS J3490
Hospital Charge Code	77351712
Hospital Revenue Code	250
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$19.61
Rate for Payer: Amerigroup CHIP/Medicaid	$2.45
Rate for Payer: BCBS of TX Blue Advantage	$8.17
Rate for Payer: BCBS of TX Blue Essentials	$9.80
Rate for Payer: BCBS of TX PPO	$10.89
Rate for Payer: Cash Price	$18.52
Rate for Payer: Cigna Medicaid	$19.61
Rate for Payer: Molina CHIP/Medicaid	$19.61
Rate for Payer: Multiplan Auto	$17.70
Rate for Payer: Multiplan Commercial	$17.70
Rate for Payer: Multiplan Workers Comp	$17.70
Rate for Payer: Parkland Medicaid	$19.61
Rate for Payer: Scott and White EPO/PPO	$13.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.61
Rate for Payer: Superior Health Plan EPO	$3.70

acetaminophen-codeine 300 mg-30 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77351926
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen-codeine 300 mg-30 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77351926
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-HYDROcodone 325 mg-10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78405241
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-HYDROcodone 325 mg-10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78405241
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen-HYDROcodone 325 mg-5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78412260
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-HYDROcodone 325 mg-5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78412260
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen-HYDROcodone 325 mg-7.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78868024
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen-HYDROcodone 325 mg-7.5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78868024
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 Level

Facility

$164.76

Service Code	HCPCS 80143
Hospital Charge Code	993991
Hospital Revenue Code	300
Rate for Payer: Cash Price	$112.04

Acetaminophen Level

Facility

$164.76

Service Code	HCPCS 80143
Hospital Charge Code	993991
Hospital Revenue Code	300
Min. Negotiated Rate	$7.27
Max. Negotiated Rate	$118.63
Rate for Payer: Amerigroup CHIP/Medicaid	$7.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.64
Rate for Payer: Amerigroup Medicare	$18.64
Rate for Payer: BCBS of TX Blue Advantage	$49.43
Rate for Payer: BCBS of TX Blue Essentials	$59.31
Rate for Payer: BCBS of TX Medicare	$18.64
Rate for Payer: BCBS of TX PPO	$65.90
Rate for Payer: Cash Price	$112.04
Rate for Payer: Cash Price	$112.04
Rate for Payer: Cigna Medicaid	$118.63
Rate for Payer: Cigna Medicare	$18.64
Rate for Payer: Employer Direct Commercial	$18.64
Rate for Payer: Humana Medicare/TRICARE	$18.64
Rate for Payer: Molina CHIP/Medicaid	$118.63
Rate for Payer: Molina Dual Medicare/Medicaid	$18.64
Rate for Payer: Molina Medicare	$18.64
Rate for Payer: Multiplan Auto	$107.09
Rate for Payer: Multiplan Commercial	$107.09
Rate for Payer: Multiplan Workers Comp	$107.09
Rate for Payer: Parkland Medicaid	$118.63
Rate for Payer: Scott and White EPO/PPO	$23.30
Rate for Payer: Scott and White Medicare	$18.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.63
Rate for Payer: Superior Health Plan EPO	$18.64
Rate for Payer: Superior Health Plan Medicare	$18.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.64
Rate for Payer: Universal American Medicare	$18.64
Rate for Payer: Wellcare Medicare	$18.64
Rate for Payer: Wellmed Medicare	$18.64

acetaminophen-oxyCODONE 325 mg-5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77353929
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

acetaminophen-oxyCODONE 325 mg-5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77353929
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

acetaZOLAMIDE 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77354851
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

acetaZOLAMIDE 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77354851
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

acetaZOLAMIDE 500 mg IV Inj

Facility

$128.00

Service Code	HCPCS J1120
Hospital Charge Code	77354955
Hospital Revenue Code	636
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	$36.50
Rate for Payer: BCBS of TX Blue Essentials	$43.80
Rate for Payer: BCBS of TX PPO	$48.58
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

acetaZOLAMIDE 500 mg IV Inj

Facility

$128.00

Service Code	HCPCS J1120
Hospital Charge Code	77354955
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

ACETONE SAFRANIN-A

Facility

$318.34

Hospital Charge Code	992629
Hospital Revenue Code	270
Min. Negotiated Rate	$28.65
Max. Negotiated Rate	$229.20
Rate for Payer: Amerigroup CHIP/Medicaid	$28.65
Rate for Payer: BCBS of TX Blue Advantage	$95.50
Rate for Payer: BCBS of TX Blue Essentials	$114.60
Rate for Payer: BCBS of TX PPO	$127.34
Rate for Payer: Cash Price	$216.47
Rate for Payer: Cigna Medicaid	$229.20
Rate for Payer: Molina CHIP/Medicaid	$229.20
Rate for Payer: Multiplan Auto	$206.92
Rate for Payer: Multiplan Commercial	$206.92
Rate for Payer: Multiplan Workers Comp	$206.92
Rate for Payer: Parkland Medicaid	$229.20
Rate for Payer: Scott and White EPO/PPO	$159.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$229.20
Rate for Payer: Superior Health Plan EPO	$43.29

ACETONE SAFRANIN-A

Facility

$318.34

Hospital Charge Code	992629
Hospital Revenue Code	270
Rate for Payer: Cash Price	$216.47

acetylcysteine 20% Inh Soln 4 mL

Facility

$49.79

Service Code	HCPCS J7608
Hospital Charge Code	77355711
Hospital Revenue Code	636
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$35.85
Rate for Payer: Amerigroup CHIP/Medicaid	$4.48
Rate for Payer: BCBS of TX Blue Advantage	$2.22
Rate for Payer: BCBS of TX Blue Essentials	$2.66
Rate for Payer: BCBS of TX PPO	$2.95
Rate for Payer: Cash Price	$33.86
Rate for Payer: Cash Price	$33.86
Rate for Payer: Cigna Medicaid	$35.85
Rate for Payer: Molina CHIP/Medicaid	$35.85
Rate for Payer: Multiplan Auto	$32.36
Rate for Payer: Multiplan Commercial	$32.36
Rate for Payer: Multiplan Workers Comp	$32.36
Rate for Payer: Parkland Medicaid	$35.85
Rate for Payer: Scott and White EPO/PPO	$24.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.85
Rate for Payer: Superior Health Plan EPO	$6.77

acetylcysteine 20% Inh Soln 4 mL

Facility

$8.00

Service Code	HCPCS J7608
Hospital Charge Code	77355888
Hospital Revenue Code	636
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	$2.22
Rate for Payer: BCBS of TX Blue Essentials	$2.66
Rate for Payer: BCBS of TX PPO	$2.95
Rate for Payer: Cash Price	$5.44
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

acetylcysteine 20% Inh Soln 4 mL

Facility

$8.00

Service Code	HCPCS J7608
Hospital Charge Code	77355888
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

Know your out-of-pocket cost for care.

All Charges