White Rock Medical Center

All Charges

Charge

Type

Setting

Price

oxybutynin 5 mg/24 hours ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	7740342
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

oxybutynin 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77740289
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

oxybutynin 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77740289
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

oxyCODONE 10 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77740613
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	$2.40
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

oxyCODONE 10 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77740613
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

oxyCODONE 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77740666
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

oxyCODONE 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77740666
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

oxyCODONE 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77741233
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

oxyCODONE 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77741233
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

OXYGEN PER HOUR Units

Facility

$29.68

Hospital Charge Code	6034600
Hospital Revenue Code	270
Rate for Payer: Cash Price	$20.18

OXYGEN PER HOUR Units

Facility

$29.68

Hospital Charge Code	6034600
Hospital Revenue Code	270
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$21.37
Rate for Payer: Amerigroup CHIP/Medicaid	$2.67
Rate for Payer: BCBS of TX Blue Advantage	$8.90
Rate for Payer: BCBS of TX Blue Essentials	$10.68
Rate for Payer: BCBS of TX PPO	$11.87
Rate for Payer: Cash Price	$20.18
Rate for Payer: Cigna Medicaid	$21.37
Rate for Payer: Molina CHIP/Medicaid	$21.37
Rate for Payer: Multiplan Auto	$19.29
Rate for Payer: Multiplan Commercial	$19.29
Rate for Payer: Multiplan Workers Comp	$19.29
Rate for Payer: Parkland Medicaid	$21.37
Rate for Payer: Scott and White EPO/PPO	$14.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.37
Rate for Payer: Superior Health Plan EPO	$4.04

oxymetazoline 0.05% Nasal Spray 15 mL

Facility

$8.90

Service Code	HCPCS J3490
Hospital Charge Code	77741759
Hospital Revenue Code	250
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$6.41
Rate for Payer: Amerigroup CHIP/Medicaid	$0.80
Rate for Payer: BCBS of TX Blue Advantage	$2.67
Rate for Payer: BCBS of TX Blue Essentials	$3.20
Rate for Payer: BCBS of TX PPO	$3.56
Rate for Payer: Cash Price	$6.05
Rate for Payer: Cigna Medicaid	$6.41
Rate for Payer: Molina CHIP/Medicaid	$6.41
Rate for Payer: Multiplan Auto	$5.79
Rate for Payer: Multiplan Commercial	$5.79
Rate for Payer: Multiplan Workers Comp	$5.79
Rate for Payer: Parkland Medicaid	$6.41
Rate for Payer: Scott and White EPO/PPO	$4.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.41
Rate for Payer: Superior Health Plan EPO	$1.21

oxymetazoline 0.05% Nasal Spray 15 mL

Facility

$8.90

Service Code	HCPCS J3490
Hospital Charge Code	77741759
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.05

oxytocin 10 units/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	77742832
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

oxytocin 10 units/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	77742832
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

Oxytocin Challenge Test

Facility

$878.00

Service Code	HCPCS 59020
Hospital Charge Code	10140
Hospital Revenue Code	361
Rate for Payer: Cash Price	$597.04

Oxytocin Challenge Test

Facility

$878.00

Service Code	HCPCS 59020
Hospital Charge Code	10140
Hospital Revenue Code	361
Min. Negotiated Rate	$27.13
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$27.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$203.09
Rate for Payer: Amerigroup Medicare	$203.09
Rate for Payer: BCBS of TX Blue Advantage	$263.40
Rate for Payer: BCBS of TX Blue Essentials	$316.08
Rate for Payer: BCBS of TX Medicare	$203.09
Rate for Payer: BCBS of TX PPO	$351.20
Rate for Payer: Cash Price	$597.04
Rate for Payer: Cash Price	$597.04
Rate for Payer: Cash Price	$597.04
Rate for Payer: Cigna Commercial	$429.31
Rate for Payer: Cigna Medicaid	$632.16
Rate for Payer: Cigna Medicare	$203.09
Rate for Payer: Employer Direct Commercial	$203.09
Rate for Payer: Humana Medicare/TRICARE	$203.09
Rate for Payer: Molina CHIP/Medicaid	$632.16
Rate for Payer: Molina Dual Medicare/Medicaid	$203.09
Rate for Payer: Molina Medicare	$203.09
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	$632.16
Rate for Payer: Scott and White EPO/PPO	$375.72
Rate for Payer: Scott and White Medicare	$203.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$632.16
Rate for Payer: Superior Health Plan EPO	$203.09
Rate for Payer: Superior Health Plan Medicare	$203.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$203.09
Rate for Payer: Universal American Medicare	$203.09
Rate for Payer: Wellcare Medicare	$203.09
Rate for Payer: Wellmed Medicare	$203.09

P06N0332P06N0341

Facility

$295.18

Service Code	HCPCS C1769
Hospital Charge Code	991208
Hospital Revenue Code	272
Rate for Payer: Cash Price	$200.72

P06N0332P06N0341

Facility

$295.18

Service Code	HCPCS C1769
Hospital Charge Code	991208
Hospital Revenue Code	272
Min. Negotiated Rate	$26.57
Max. Negotiated Rate	$212.53
Rate for Payer: Amerigroup CHIP/Medicaid	$26.57
Rate for Payer: BCBS of TX Blue Advantage	$88.55
Rate for Payer: BCBS of TX Blue Essentials	$106.26
Rate for Payer: BCBS of TX PPO	$118.07
Rate for Payer: Cash Price	$200.72
Rate for Payer: Cigna Medicaid	$212.53
Rate for Payer: Molina CHIP/Medicaid	$212.53
Rate for Payer: Multiplan Auto	$191.87
Rate for Payer: Multiplan Commercial	$191.87
Rate for Payer: Multiplan Workers Comp	$191.87
Rate for Payer: Parkland Medicaid	$212.53
Rate for Payer: Scott and White EPO/PPO	$147.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$212.53
Rate for Payer: Superior Health Plan EPO	$40.14

P06N0461P06N0562

Facility

$1,343.37

Service Code	HCPCS C1713
Hospital Charge Code	991209
Hospital Revenue Code	278
Min. Negotiated Rate	$335.84
Max. Negotiated Rate	$671.68
Rate for Payer: Cash Price	$913.49
Rate for Payer: Cigna Commercial	$335.84
Rate for Payer: Multiplan Auto	$671.68
Rate for Payer: Multiplan Commercial	$671.68
Rate for Payer: Multiplan Workers Comp	$671.68
Rate for Payer: Scott and White EPO/PPO	$671.68

P06N0461P06N0562

Facility

$1,343.37

Service Code	HCPCS C1713
Hospital Charge Code	991209
Hospital Revenue Code	278
Min. Negotiated Rate	$120.90
Max. Negotiated Rate	$967.23
Rate for Payer: Amerigroup CHIP/Medicaid	$120.90
Rate for Payer: BCBS of TX Blue Advantage	$403.01
Rate for Payer: BCBS of TX Blue Essentials	$483.61
Rate for Payer: BCBS of TX PPO	$537.35
Rate for Payer: Cash Price	$913.49
Rate for Payer: Cigna Medicaid	$967.23
Rate for Payer: Molina CHIP/Medicaid	$967.23
Rate for Payer: Multiplan Auto	$671.68
Rate for Payer: Multiplan Commercial	$671.68
Rate for Payer: Multiplan Workers Comp	$671.68
Rate for Payer: Parkland Medicaid	$967.23
Rate for Payer: Scott and White EPO/PPO	$671.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$967.23
Rate for Payer: Superior Health Plan EPO	$182.70

P65 ST567

Facility

$4,308.64

Service Code	HCPCS C1713
Hospital Charge Code	991218
Hospital Revenue Code	278
Min. Negotiated Rate	$1,077.16
Max. Negotiated Rate	$2,154.32
Rate for Payer: Cash Price	$2,929.88
Rate for Payer: Cigna Commercial	$1,077.16
Rate for Payer: Multiplan Auto	$2,154.32
Rate for Payer: Multiplan Commercial	$2,154.32
Rate for Payer: Multiplan Workers Comp	$2,154.32
Rate for Payer: Scott and White EPO/PPO	$2,154.32

P65 ST567

Facility

$4,308.64

Service Code	HCPCS C1713
Hospital Charge Code	991218
Hospital Revenue Code	278
Min. Negotiated Rate	$387.78
Max. Negotiated Rate	$3,102.22
Rate for Payer: Amerigroup CHIP/Medicaid	$387.78
Rate for Payer: BCBS of TX Blue Advantage	$1,292.59
Rate for Payer: BCBS of TX Blue Essentials	$1,551.11
Rate for Payer: BCBS of TX PPO	$1,723.46
Rate for Payer: Cash Price	$2,929.88
Rate for Payer: Cigna Medicaid	$3,102.22
Rate for Payer: Molina CHIP/Medicaid	$3,102.22
Rate for Payer: Multiplan Auto	$2,154.32
Rate for Payer: Multiplan Commercial	$2,154.32
Rate for Payer: Multiplan Workers Comp	$2,154.32
Rate for Payer: Parkland Medicaid	$3,102.22
Rate for Payer: Scott and White EPO/PPO	$2,154.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,102.22
Rate for Payer: Superior Health Plan EPO	$585.98

P65 ST650

Facility

$5,543.00

Service Code	HCPCS C1713
Hospital Charge Code	991217
Hospital Revenue Code	278
Min. Negotiated Rate	$1,385.75
Max. Negotiated Rate	$2,771.50
Rate for Payer: Cash Price	$3,769.24
Rate for Payer: Cigna Commercial	$1,385.75
Rate for Payer: Multiplan Auto	$2,771.50
Rate for Payer: Multiplan Commercial	$2,771.50
Rate for Payer: Multiplan Workers Comp	$2,771.50
Rate for Payer: Scott and White EPO/PPO	$2,771.50

P65 ST650

Facility

$5,543.00

Service Code	HCPCS C1713
Hospital Charge Code	991217
Hospital Revenue Code	278
Min. Negotiated Rate	$498.87
Max. Negotiated Rate	$3,990.96
Rate for Payer: Amerigroup CHIP/Medicaid	$498.87
Rate for Payer: BCBS of TX Blue Advantage	$1,662.90
Rate for Payer: BCBS of TX Blue Essentials	$1,995.48
Rate for Payer: BCBS of TX PPO	$2,217.20
Rate for Payer: Cash Price	$3,769.24
Rate for Payer: Cigna Medicaid	$3,990.96
Rate for Payer: Molina CHIP/Medicaid	$3,990.96
Rate for Payer: Multiplan Auto	$2,771.50
Rate for Payer: Multiplan Commercial	$2,771.50
Rate for Payer: Multiplan Workers Comp	$2,771.50
Rate for Payer: Parkland Medicaid	$3,990.96
Rate for Payer: Scott and White EPO/PPO	$2,771.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,990.96
Rate for Payer: Superior Health Plan EPO	$753.85

Know your out-of-pocket cost for care.

All Charges