White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ALTERATION IN CONSCIOUSNESS

Facility

$3,646.29

Service Code	APR-DRG 0522
Min. Negotiated Rate	$3,437.85
Max. Negotiated Rate	$3,646.29
Rate for Payer: Amerigroup CHIP/Medicaid	$3,437.85
Rate for Payer: Cigna Medicaid	$3,437.85
Rate for Payer: Molina CHIP/Medicaid	$3,437.85
Rate for Payer: Parkland Medicaid	$3,437.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,646.29

ALTERATION IN CONSCIOUSNESS

Facility

$12,553.23

Service Code	APR-DRG 0524
Min. Negotiated Rate	$11,835.62
Max. Negotiated Rate	$12,553.23
Rate for Payer: Amerigroup CHIP/Medicaid	$11,835.62
Rate for Payer: Cigna Medicaid	$11,835.62
Rate for Payer: Molina CHIP/Medicaid	$11,835.62
Rate for Payer: Parkland Medicaid	$11,835.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,553.23

ALTERATION IN CONSCIOUSNESS

Facility

$4,638.29

Service Code	APR-DRG 0523
Min. Negotiated Rate	$4,373.15
Max. Negotiated Rate	$4,638.29
Rate for Payer: Amerigroup CHIP/Medicaid	$4,373.15
Rate for Payer: Cigna Medicaid	$4,373.15
Rate for Payer: Molina CHIP/Medicaid	$4,373.15
Rate for Payer: Parkland Medicaid	$4,373.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,638.29

aluminum hydroxide/magnesium hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL Oral Susp 30 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77367101
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

aluminum hydroxide/magnesium hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL Oral Susp 30 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77367101
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

aluminum hydroxide/magnesium hydroxide/simethicone 400 mg-400 mg-40 mg/5 mL Oral Susp 30 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77367474
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

aluminum hydroxide/magnesium hydroxide/simethicone 400 mg-400 mg-40 mg/5 mL Oral Susp 30 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77367474
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

amantadine 50 mg/5 mL Oral Syrup 10 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77368481
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

amantadine 50 mg/5 mL Oral Syrup 10 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77368481
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

AMBU SPURII INFANT RESUSCITATOR

Facility

$30.01

Hospital Charge Code	993631
Hospital Revenue Code	270
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$21.61
Rate for Payer: Amerigroup CHIP/Medicaid	$2.70
Rate for Payer: BCBS of TX Blue Advantage	$9.00
Rate for Payer: BCBS of TX Blue Essentials	$10.80
Rate for Payer: BCBS of TX PPO	$12.00
Rate for Payer: Cash Price	$20.41
Rate for Payer: Cigna Medicaid	$21.61
Rate for Payer: Molina CHIP/Medicaid	$21.61
Rate for Payer: Multiplan Auto	$19.51
Rate for Payer: Multiplan Commercial	$19.51
Rate for Payer: Multiplan Workers Comp	$19.51
Rate for Payer: Parkland Medicaid	$21.61
Rate for Payer: Scott and White EPO/PPO	$15.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.61
Rate for Payer: Superior Health Plan EPO	$4.08

AMBU SPURII INFANT RESUSCITATOR

Facility

$30.01

Hospital Charge Code	993631
Hospital Revenue Code	270
Rate for Payer: Cash Price	$20.41

Amebiasis Antibodies SO

Facility

$142.00

Service Code	HCPCS 86753
Hospital Charge Code	1702935
Hospital Revenue Code	302
Min. Negotiated Rate	$4.83
Max. Negotiated Rate	$102.24
Rate for Payer: Amerigroup CHIP/Medicaid	$4.83
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.39
Rate for Payer: Amerigroup Medicare	$12.39
Rate for Payer: BCBS of TX Blue Advantage	$42.60
Rate for Payer: BCBS of TX Blue Essentials	$51.12
Rate for Payer: BCBS of TX Medicare	$12.39
Rate for Payer: BCBS of TX PPO	$56.80
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cigna Medicaid	$102.24
Rate for Payer: Cigna Medicare	$12.39
Rate for Payer: Employer Direct Commercial	$12.39
Rate for Payer: Humana Medicare/TRICARE	$12.39
Rate for Payer: Molina CHIP/Medicaid	$102.24
Rate for Payer: Molina Dual Medicare/Medicaid	$12.39
Rate for Payer: Molina Medicare	$12.39
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Parkland Medicaid	$102.24
Rate for Payer: Scott and White EPO/PPO	$15.49
Rate for Payer: Scott and White Medicare	$12.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.24
Rate for Payer: Superior Health Plan EPO	$12.39
Rate for Payer: Superior Health Plan Medicare	$12.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.39
Rate for Payer: Universal American Medicare	$12.39
Rate for Payer: Wellcare Medicare	$12.39
Rate for Payer: Wellmed Medicare	$12.39

Amebiasis Antibodies SO

Facility

$142.00

Service Code	HCPCS 86753
Hospital Charge Code	1702935
Hospital Revenue Code	302
Rate for Payer: Cash Price	$96.56

Amikacin Random, Serum SO

Facility

$198.00

Service Code	HCPCS 80150
Hospital Charge Code	1601442
Hospital Revenue Code	300
Rate for Payer: Cash Price	$134.64

Amikacin Random, Serum SO

Facility

$198.00

Service Code	HCPCS 80150
Hospital Charge Code	1601442
Hospital Revenue Code	300
Min. Negotiated Rate	$5.88
Max. Negotiated Rate	$142.56
Rate for Payer: Amerigroup CHIP/Medicaid	$5.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.08
Rate for Payer: Amerigroup Medicare	$15.08
Rate for Payer: BCBS of TX Blue Advantage	$59.40
Rate for Payer: BCBS of TX Blue Essentials	$71.28
Rate for Payer: BCBS of TX Medicare	$15.08
Rate for Payer: BCBS of TX PPO	$79.20
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cigna Medicaid	$142.56
Rate for Payer: Cigna Medicare	$15.08
Rate for Payer: Employer Direct Commercial	$15.08
Rate for Payer: Humana Medicare/TRICARE	$15.08
Rate for Payer: Molina CHIP/Medicaid	$142.56
Rate for Payer: Molina Dual Medicare/Medicaid	$15.08
Rate for Payer: Molina Medicare	$15.08
Rate for Payer: Multiplan Auto	$128.70
Rate for Payer: Multiplan Commercial	$128.70
Rate for Payer: Multiplan Workers Comp	$128.70
Rate for Payer: Parkland Medicaid	$142.56
Rate for Payer: Scott and White EPO/PPO	$18.85
Rate for Payer: Scott and White Medicare	$15.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$142.56
Rate for Payer: Superior Health Plan EPO	$15.08
Rate for Payer: Superior Health Plan Medicare	$15.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.08
Rate for Payer: Universal American Medicare	$15.08
Rate for Payer: Wellcare Medicare	$15.08
Rate for Payer: Wellmed Medicare	$15.08

Amino Acids 2.36%, 6.8% Dextrose, 3.5% Lipids, and Electrolytes (Perikabiven) IV Emulsion 1440 mL

Facility

$128.00

Service Code	HCPCS j3490
Hospital Charge Code	78869541
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

Amino Acids 2.36%, 6.8% Dextrose, 3.5% Lipids, and Electrolytes (Perikabiven) IV Emulsion 1440 mL

Facility

$128.00

Service Code	HCPCS j3490
Hospital Charge Code	78869541
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

Amino Acids 3.31% with 9.8% Dextrose, 3.9% Lipids, and Electrolytes (Kabiven) intravenous emulsion Amino Acids 3.31% with 9.8% Dextrose, 3.9% Lipids (Kabiven) EMU

Facility

$128.00

Service Code	HCPCS j3490
Hospital Charge Code	6332371210
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

Amino Acids 3.31% with 9.8% Dextrose, 3.9% Lipids, and Electrolytes (Kabiven) intravenous emulsion Amino Acids 3.31% with 9.8% Dextrose, 3.9% Lipids (Kabiven) EMU

Facility

$128.00

Service Code	HCPCS j3490
Hospital Charge Code	6332371210
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

Amino Acids 3.31% with 9.8% Dextrose, 3.9% Lipids, and Electrolytes (Kabiven) intravenous emulsion Amino Acids 3.31% with 9.8% Dextrose, 3.9% Lipids (Kabiven) EMU

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	79645442
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

Amino Acids 3.31% with 9.8% Dextrose, 3.9% Lipids, and Electrolytes (Kabiven) intravenous emulsion Amino Acids 3.31% with 9.8% Dextrose, 3.9% Lipids (Kabiven) EMU

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	79645442
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

Amino Acids 4.25% with 5% Dextrose (Clinimix Sulfite-Free) intravenous solution Amino Acids 4.25% wi

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	8694541
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

Amino Acids 4.25% with 5% Dextrose (Clinimix Sulfite-Free) intravenous solution Amino Acids 4.25% wi

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	8694541
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

amiodarone 200 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77369932
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

amiodarone 200 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77369932
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Know your out-of-pocket cost for care.

All Charges