White Rock Medical Center

All Charges

Charge

Type

Setting

Price

amiodarone 50 mg/mL IV Soln 3 mL

Facility

$128.17

Service Code	HCPCS J0282
Hospital Charge Code	77370199
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.29
Rate for Payer: BCBS of TX Blue Essentials	$0.35
Rate for Payer: BCBS of TX PPO	$0.39
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

amiodarone 50 mg/mL IV Soln 3 mL

Facility

$128.17

Service Code	HCPCS J0282
Hospital Charge Code	77370199
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

amiodarone 50 mg/mL IV Soln 9 mL

Facility

$128.17

Service Code	HCPCS J0282
Hospital Charge Code	77370258
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.29
Rate for Payer: BCBS of TX Blue Essentials	$0.35
Rate for Payer: BCBS of TX PPO	$0.39
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

amiodarone 50 mg/mL IV Soln 9 mL

Facility

$128.17

Service Code	HCPCS J0282
Hospital Charge Code	77370258
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

Amiodarone (Cordarone), S/P SO

Facility

$195.73

Service Code	HCPCS 80151
Hospital Charge Code	8572492
Hospital Revenue Code	301
Min. Negotiated Rate	$7.27
Max. Negotiated Rate	$140.93
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	$58.72
Rate for Payer: BCBS of TX Blue Essentials	$70.46
Rate for Payer: BCBS of TX Medicare	$18.64
Rate for Payer: BCBS of TX PPO	$78.29
Rate for Payer: Cash Price	$133.10
Rate for Payer: Cash Price	$133.10
Rate for Payer: Cigna Medicaid	$140.93
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	$140.93
Rate for Payer: Molina Dual Medicare/Medicaid	$18.64
Rate for Payer: Molina Medicare	$18.64
Rate for Payer: Multiplan Auto	$127.22
Rate for Payer: Multiplan Commercial	$127.22
Rate for Payer: Multiplan Workers Comp	$127.22
Rate for Payer: Parkland Medicaid	$140.93
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	$140.93
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

Amiodarone (Cordarone), S/P SO

Facility

$195.73

Service Code	HCPCS 80151
Hospital Charge Code	8572492
Hospital Revenue Code	301
Rate for Payer: Cash Price	$133.10

amitriptyline 25 mg tablet

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	77370529
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.80

amitriptyline 25 mg tablet

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	77370529
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$7.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.90
Rate for Payer: BCBS of TX Blue Advantage	$3.00
Rate for Payer: BCBS of TX Blue Essentials	$3.60
Rate for Payer: BCBS of TX PPO	$4.00
Rate for Payer: Cash Price	$6.80
Rate for Payer: Cigna Medicaid	$7.20
Rate for Payer: Molina CHIP/Medicaid	$7.20
Rate for Payer: Multiplan Auto	$6.50
Rate for Payer: Multiplan Commercial	$6.50
Rate for Payer: Multiplan Workers Comp	$6.50
Rate for Payer: Parkland Medicaid	$7.20
Rate for Payer: Scott and White EPO/PPO	$5.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.20
Rate for Payer: Superior Health Plan EPO	$1.36

amLODIPine 10 mg Tab

Facility

$10.35

Service Code	HCPCS J0282
Hospital Charge Code	77371035
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$7.45
Rate for Payer: Amerigroup CHIP/Medicaid	$0.93
Rate for Payer: BCBS of TX Blue Advantage	$0.29
Rate for Payer: BCBS of TX Blue Essentials	$0.35
Rate for Payer: BCBS of TX PPO	$0.39
Rate for Payer: Cash Price	$7.04
Rate for Payer: Cash Price	$7.04
Rate for Payer: Cigna Medicaid	$7.45
Rate for Payer: Molina CHIP/Medicaid	$7.45
Rate for Payer: Multiplan Auto	$6.73
Rate for Payer: Multiplan Commercial	$6.73
Rate for Payer: Multiplan Workers Comp	$6.73
Rate for Payer: Parkland Medicaid	$7.45
Rate for Payer: Scott and White EPO/PPO	$5.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.45
Rate for Payer: Superior Health Plan EPO	$1.41

amLODIPine 10 mg Tab

Facility

$10.35

Service Code	HCPCS J0282
Hospital Charge Code	77371035
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.04

amLODIPine 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77371143
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

amLODIPine 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77371143
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Amnioinfusion

Facility

$1,024.00

Service Code	HCPCS 59070
Hospital Charge Code	315093
Hospital Revenue Code	361
Min. Negotiated Rate	$92.16
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$92.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$306.12
Rate for Payer: Amerigroup Medicare	$306.12
Rate for Payer: BCBS of TX Blue Advantage	$452.10
Rate for Payer: BCBS of TX Blue Essentials	$541.44
Rate for Payer: BCBS of TX Medicare	$306.12
Rate for Payer: BCBS of TX PPO	$682.21
Rate for Payer: Cash Price	$696.32
Rate for Payer: Cash Price	$696.32
Rate for Payer: Cash Price	$696.32
Rate for Payer: Cigna Commercial	$647.08
Rate for Payer: Cigna Medicaid	$737.28
Rate for Payer: Cigna Medicare	$306.12
Rate for Payer: Employer Direct Commercial	$306.12
Rate for Payer: Humana Medicare/TRICARE	$306.12
Rate for Payer: Molina CHIP/Medicaid	$737.28
Rate for Payer: Molina Dual Medicare/Medicaid	$306.12
Rate for Payer: Molina Medicare	$306.12
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$737.28
Rate for Payer: Scott and White EPO/PPO	$542.77
Rate for Payer: Scott and White Medicare	$306.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$737.28
Rate for Payer: Superior Health Plan EPO	$306.12
Rate for Payer: Superior Health Plan Medicare	$306.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$306.12
Rate for Payer: Universal American Medicare	$306.12
Rate for Payer: Wellcare Medicare	$306.12
Rate for Payer: Wellmed Medicare	$306.12

Amnioinfusion

Facility

$1,024.00

Service Code	HCPCS 59070
Hospital Charge Code	315093
Hospital Revenue Code	361
Rate for Payer: Cash Price	$696.32

amoxicillin 125 mg/5 mL Oral Liquid 125 mL

Facility

$10.75

Service Code	HCPCS J3490
Hospital Charge Code	77374607
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.31

amoxicillin 125 mg/5 mL Oral Liquid 125 mL

Facility

$10.75

Service Code	HCPCS J3490
Hospital Charge Code	77374607
Hospital Revenue Code	250
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$7.74
Rate for Payer: Amerigroup CHIP/Medicaid	$0.97
Rate for Payer: BCBS of TX Blue Advantage	$3.23
Rate for Payer: BCBS of TX Blue Essentials	$3.87
Rate for Payer: BCBS of TX PPO	$4.30
Rate for Payer: Cash Price	$7.31
Rate for Payer: Cigna Medicaid	$7.74
Rate for Payer: Molina CHIP/Medicaid	$7.74
Rate for Payer: Multiplan Auto	$6.99
Rate for Payer: Multiplan Commercial	$6.99
Rate for Payer: Multiplan Workers Comp	$6.99
Rate for Payer: Parkland Medicaid	$7.74
Rate for Payer: Scott and White EPO/PPO	$5.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.74
Rate for Payer: Superior Health Plan EPO	$1.46

amoxicillin 200 mg/5 mL Oral

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	7441947
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

amoxicillin 200 mg/5 mL Oral

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	7441947
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

amoxicillin 200 mg/5 mL Oral Liquid

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	7441946
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

amoxicillin 200 mg/5 mL Oral Liquid

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	7441946
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

amoxicillin 250 mg/5 mL Pow

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	79159141
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.83

amoxicillin 250 mg/5 mL Pow

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	79159141
Hospital Revenue Code	636
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

amoxicillin 250 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77374925
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

amoxicillin 250 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77374925
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

amoxicillin 250 mg Cap

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77374925
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Know your out-of-pocket cost for care.

All Charges