White Rock Medical Center

All Charges

Charge

Type

Setting

Price

HYDROmorphone 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1171
Hospital Charge Code	77620956
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

HYDROmorphone 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1171
Hospital Charge Code	77620956
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

HYDROmorphone 1 mg/mL-NaCl 0.9% 30 mL

Facility

$128.17

Service Code	HCPCS J1171
Hospital Charge Code	77621066
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

HYDROmorphone 1 mg/mL-NaCl 0.9% 30 mL

Facility

$128.17

Service Code	HCPCS J1171
Hospital Charge Code	77621066
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

HYDROmorphone 2 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1171
Hospital Charge Code	78407954
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

HYDROmorphone 2 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1171
Hospital Charge Code	78407954
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

HYDROmorphone 2mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	1.24478E+11
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

HYDROmorphone 2mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	1.24478E+11
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

HYDROmorphone 2mg Tab

Facility

$7.65

Service Code	HCPCS J1171
Hospital Charge Code	77622103
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

HYDROmorphone 2mg Tab

Facility

$7.65

Service Code	HCPCS J1171
Hospital Charge Code	77622103
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

HYDROSET XT 15CC

Facility

$38,998.92

Service Code	HCPCS C1734
Hospital Charge Code	992238
Hospital Revenue Code	278
Min. Negotiated Rate	$9,749.73
Max. Negotiated Rate	$19,499.46
Rate for Payer: Cash Price	$26,519.27
Rate for Payer: Cigna Commercial	$9,749.73
Rate for Payer: Multiplan Auto	$19,499.46
Rate for Payer: Multiplan Commercial	$19,499.46
Rate for Payer: Multiplan Workers Comp	$19,499.46
Rate for Payer: Scott and White EPO/PPO	$19,499.46

HYDROSET XT 15CC

Facility

$38,998.92

Service Code	HCPCS C1734
Hospital Charge Code	992238
Hospital Revenue Code	278
Min. Negotiated Rate	$3,509.90
Max. Negotiated Rate	$28,079.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,509.90
Rate for Payer: BCBS of TX Blue Advantage	$11,699.68
Rate for Payer: BCBS of TX Blue Essentials	$14,039.61
Rate for Payer: BCBS of TX PPO	$15,599.57
Rate for Payer: Cash Price	$26,519.27
Rate for Payer: Cigna Medicaid	$28,079.22
Rate for Payer: Molina CHIP/Medicaid	$28,079.22
Rate for Payer: Multiplan Auto	$19,499.46
Rate for Payer: Multiplan Commercial	$19,499.46
Rate for Payer: Multiplan Workers Comp	$19,499.46
Rate for Payer: Parkland Medicaid	$28,079.22
Rate for Payer: Scott and White EPO/PPO	$19,499.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28,079.22
Rate for Payer: Superior Health Plan EPO	$5,303.85

HYDROSET XT 5CC

Facility

$14,278.07

Service Code	HCPCS C1734
Hospital Charge Code	992237
Hospital Revenue Code	278
Min. Negotiated Rate	$1,285.03
Max. Negotiated Rate	$10,280.21
Rate for Payer: Amerigroup CHIP/Medicaid	$1,285.03
Rate for Payer: BCBS of TX Blue Advantage	$4,283.42
Rate for Payer: BCBS of TX Blue Essentials	$5,140.11
Rate for Payer: BCBS of TX PPO	$5,711.23
Rate for Payer: Cash Price	$9,709.09
Rate for Payer: Cigna Medicaid	$10,280.21
Rate for Payer: Molina CHIP/Medicaid	$10,280.21
Rate for Payer: Multiplan Auto	$7,139.03
Rate for Payer: Multiplan Commercial	$7,139.03
Rate for Payer: Multiplan Workers Comp	$7,139.03
Rate for Payer: Parkland Medicaid	$10,280.21
Rate for Payer: Scott and White EPO/PPO	$7,139.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,280.21
Rate for Payer: Superior Health Plan EPO	$1,941.82

HYDROSET XT 5CC

Facility

$14,278.07

Service Code	HCPCS C1734
Hospital Charge Code	992237
Hospital Revenue Code	278
Min. Negotiated Rate	$3,569.52
Max. Negotiated Rate	$7,139.03
Rate for Payer: Cash Price	$9,709.09
Rate for Payer: Cigna Commercial	$3,569.52
Rate for Payer: Multiplan Auto	$7,139.03
Rate for Payer: Multiplan Commercial	$7,139.03
Rate for Payer: Multiplan Workers Comp	$7,139.03
Rate for Payer: Scott and White EPO/PPO	$7,139.03

HYDROSURG LAP IRR W/TIP

Facility

$335.17

Hospital Charge Code	992773
Hospital Revenue Code	272
Min. Negotiated Rate	$30.17
Max. Negotiated Rate	$241.32
Rate for Payer: Amerigroup CHIP/Medicaid	$30.17
Rate for Payer: BCBS of TX Blue Advantage	$100.55
Rate for Payer: BCBS of TX Blue Essentials	$120.66
Rate for Payer: BCBS of TX PPO	$134.07
Rate for Payer: Cash Price	$227.92
Rate for Payer: Cigna Medicaid	$241.32
Rate for Payer: Molina CHIP/Medicaid	$241.32
Rate for Payer: Multiplan Auto	$217.86
Rate for Payer: Multiplan Commercial	$217.86
Rate for Payer: Multiplan Workers Comp	$217.86
Rate for Payer: Parkland Medicaid	$241.32
Rate for Payer: Scott and White EPO/PPO	$167.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$241.32
Rate for Payer: Superior Health Plan EPO	$45.58

HYDROSURG LAP IRR W/TIP

Facility

$335.17

Hospital Charge Code	992773
Hospital Revenue Code	272
Rate for Payer: Cash Price	$227.92

HYDROXYUREA 500 MG CAP

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77624134
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

HYDROXYUREA 500 MG CAP

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77624134
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

hydrOXYzine hydrochloride 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77624617
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

hydrOXYzine hydrochloride 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77624617
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

hyoscyamine 0.125 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77625326
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

hyoscyamine 0.125 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77625326
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

HYPERBARIC O2 FULL BODY CHMBR/30MIN

Facility

$582.00

Hospital Charge Code	7150920
Hospital Revenue Code	413
Rate for Payer: Cash Price	$395.76

HYPERBARIC O2 FULL BODY CHMBR/30MIN

Facility

$582.00

Hospital Charge Code	7150920
Hospital Revenue Code	413
Min. Negotiated Rate	$52.38
Max. Negotiated Rate	$419.04
Rate for Payer: Amerigroup CHIP/Medicaid	$52.38
Rate for Payer: BCBS of TX Blue Advantage	$174.60
Rate for Payer: BCBS of TX Blue Essentials	$209.52
Rate for Payer: BCBS of TX PPO	$232.80
Rate for Payer: Cash Price	$395.76
Rate for Payer: Cash Price	$395.76
Rate for Payer: Cigna Medicaid	$419.04
Rate for Payer: Molina CHIP/Medicaid	$419.04
Rate for Payer: Multiplan Auto	$378.30
Rate for Payer: Multiplan Commercial	$378.30
Rate for Payer: Multiplan Workers Comp	$378.30
Rate for Payer: Parkland Medicaid	$419.04
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$419.04
Rate for Payer: Superior Health Plan EPO	$79.15

HYPERTENSION

Facility

$4,397.65

Service Code	APR-DRG 1993
Min. Negotiated Rate	$4,146.26
Max. Negotiated Rate	$4,397.65
Rate for Payer: Amerigroup CHIP/Medicaid	$4,146.26
Rate for Payer: Cigna Medicaid	$4,146.26
Rate for Payer: Molina CHIP/Medicaid	$4,146.26
Rate for Payer: Parkland Medicaid	$4,146.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,397.65

Know your out-of-pocket cost for care.

All Charges