White Rock Medical Center

All Charges

Charge

Type

Setting

Price

hydrALAZINE 10 mg Tab

Facility

$9.30

Service Code	HCPCS J3490
Hospital Charge Code	77607802
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.32

hydrALAZINE 20 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J0360
Hospital Charge Code	77607908
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

hydrALAZINE 20 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J0360
Hospital Charge Code	77607908
Hospital Revenue Code	636
Min. Negotiated Rate	$9.40
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$9.40
Rate for Payer: BCBS of TX Blue Essentials	$11.28
Rate for Payer: BCBS of TX PPO	$12.51
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

hydrALAZINE 25 mg Tab

Facility

$8.85

Service Code	HCPCS J3490
Hospital Charge Code	77607965
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.02

hydrALAZINE 25 mg Tab

Facility

$8.85

Service Code	HCPCS J3490
Hospital Charge Code	77607965
Hospital Revenue Code	250
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$6.37
Rate for Payer: Amerigroup CHIP/Medicaid	$0.80
Rate for Payer: BCBS of TX Blue Advantage	$2.65
Rate for Payer: BCBS of TX Blue Essentials	$3.19
Rate for Payer: BCBS of TX PPO	$3.54
Rate for Payer: Cash Price	$6.02
Rate for Payer: Cigna Medicaid	$6.37
Rate for Payer: Molina CHIP/Medicaid	$6.37
Rate for Payer: Multiplan Auto	$5.75
Rate for Payer: Multiplan Commercial	$5.75
Rate for Payer: Multiplan Workers Comp	$5.75
Rate for Payer: Parkland Medicaid	$6.37
Rate for Payer: Scott and White EPO/PPO	$4.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.37
Rate for Payer: Superior Health Plan EPO	$1.20

HYDRATOME RX 44 SPHINCTEROTOME

Facility

$177.06

Hospital Charge Code	144810
Hospital Revenue Code	272
Rate for Payer: Cash Price	$120.40

HYDRATOME RX 44 SPHINCTEROTOME

Facility

$177.06

Hospital Charge Code	144810
Hospital Revenue Code	272
Min. Negotiated Rate	$15.94
Max. Negotiated Rate	$127.48
Rate for Payer: Amerigroup CHIP/Medicaid	$15.94
Rate for Payer: BCBS of TX Blue Advantage	$53.12
Rate for Payer: BCBS of TX Blue Essentials	$63.74
Rate for Payer: BCBS of TX PPO	$70.82
Rate for Payer: Cash Price	$120.40
Rate for Payer: Cigna Medicaid	$127.48
Rate for Payer: Molina CHIP/Medicaid	$127.48
Rate for Payer: Multiplan Auto	$115.09
Rate for Payer: Multiplan Commercial	$115.09
Rate for Payer: Multiplan Workers Comp	$115.09
Rate for Payer: Parkland Medicaid	$127.48
Rate for Payer: Scott and White EPO/PPO	$88.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$127.48
Rate for Payer: Superior Health Plan EPO	$24.08

hydroCHLOROthiazide 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77608222
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

hydroCHLOROthiazide 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77608222
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

HYDROcodone-acetaminophen 7.5 mg 15 ml solution

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78432557
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

HYDROcodone-acetaminophen 7.5 mg 15 ml solution

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78432557
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

hydrocortisone 100 mg preservative-free Inj

Facility

$128.17

Service Code	HCPCS J1720
Hospital Charge Code	77614034
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

hydrocortisone 100 mg preservative-free Inj

Facility

$128.17

Service Code	HCPCS J1720
Hospital Charge Code	77614034
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	$14.41
Rate for Payer: BCBS of TX Blue Essentials	$17.30
Rate for Payer: BCBS of TX PPO	$19.18
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	$22.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

hydrocortisone 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77613820
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

hydrocortisone 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77613820
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

hydrocortisone 1% Cream 30 g

Facility

$12.85

Service Code	HCPCS J3490
Hospital Charge Code	77612091
Hospital Revenue Code	250
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$9.25
Rate for Payer: Amerigroup CHIP/Medicaid	$1.16
Rate for Payer: BCBS of TX Blue Advantage	$3.85
Rate for Payer: BCBS of TX Blue Essentials	$4.63
Rate for Payer: BCBS of TX PPO	$5.14
Rate for Payer: Cash Price	$8.74
Rate for Payer: Cigna Medicaid	$9.25
Rate for Payer: Molina CHIP/Medicaid	$9.25
Rate for Payer: Multiplan Auto	$8.35
Rate for Payer: Multiplan Commercial	$8.35
Rate for Payer: Multiplan Workers Comp	$8.35
Rate for Payer: Parkland Medicaid	$9.25
Rate for Payer: Scott and White EPO/PPO	$6.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.25
Rate for Payer: Superior Health Plan EPO	$1.75

hydrocortisone 1% Cream 30 g

Facility

$12.85

Service Code	HCPCS J3490
Hospital Charge Code	77612091
Hospital Revenue Code	250
Rate for Payer: Cash Price	$8.74

hydrocortisone 25 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77615269
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

hydrocortisone 25 mg Rectal Supp

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77615269
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

hydrocortisone 2.5% Topical Oint 28.35 g

Facility

$31.35

Service Code	HCPCS j3490
Hospital Charge Code	77615020
Hospital Revenue Code	250
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$22.57
Rate for Payer: Amerigroup CHIP/Medicaid	$2.82
Rate for Payer: BCBS of TX Blue Advantage	$9.40
Rate for Payer: BCBS of TX Blue Essentials	$11.29
Rate for Payer: BCBS of TX PPO	$12.54
Rate for Payer: Cash Price	$21.32
Rate for Payer: Cigna Medicaid	$22.57
Rate for Payer: Molina CHIP/Medicaid	$22.57
Rate for Payer: Multiplan Auto	$20.38
Rate for Payer: Multiplan Commercial	$20.38
Rate for Payer: Multiplan Workers Comp	$20.38
Rate for Payer: Parkland Medicaid	$22.57
Rate for Payer: Scott and White EPO/PPO	$15.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.57
Rate for Payer: Superior Health Plan EPO	$4.26

hydrocortisone 2.5% Topical Oint 28.35 g

Facility

$31.35

Service Code	HCPCS j3490
Hospital Charge Code	77615020
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.32

HYDROGEN PEROXIDE, BOTTLE, 16-OZ

Facility

$4.45

Hospital Charge Code	993311
Hospital Revenue Code	270
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$3.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.40
Rate for Payer: BCBS of TX Blue Advantage	$1.33
Rate for Payer: BCBS of TX Blue Essentials	$1.60
Rate for Payer: BCBS of TX PPO	$1.78
Rate for Payer: Cash Price	$3.03
Rate for Payer: Cigna Medicaid	$3.20
Rate for Payer: Molina CHIP/Medicaid	$3.20
Rate for Payer: Multiplan Auto	$2.89
Rate for Payer: Multiplan Commercial	$2.89
Rate for Payer: Multiplan Workers Comp	$2.89
Rate for Payer: Parkland Medicaid	$3.20
Rate for Payer: Scott and White EPO/PPO	$2.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.20
Rate for Payer: Superior Health Plan EPO	$0.61

HYDROGEN PEROXIDE, BOTTLE, 16-OZ

Facility

$4.45

Hospital Charge Code	993311
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.03

HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

Facility

$128.00

Service Code	HCPCS J1100
Hospital Charge Code	77620897
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

HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

Facility

$128.00

Service Code	HCPCS J1100
Hospital Charge Code	77620897
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.03
Rate for Payer: BCBS of TX Blue Essentials	$0.03
Rate for Payer: BCBS of TX PPO	$0.04
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

Know your out-of-pocket cost for care.

All Charges