White Rock Medical Center

All Charges

Charge

Type

Setting

Price

predniSONE 20 mg Tab

Facility

$7.65

Service Code	HCPCS J7512
Hospital Charge Code	77776950
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

pregabalin 25 mg capsule

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77777700
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

pregabalin 25 mg capsule

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77777700
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

pregabalin 50 mg Cap

Facility

$34.20

Service Code	HCPCS J3490
Hospital Charge Code	77777798
Hospital Revenue Code	250
Rate for Payer: Cash Price	$23.26

pregabalin 50 mg Cap

Facility

$34.20

Service Code	HCPCS J3490
Hospital Charge Code	77777798
Hospital Revenue Code	250
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$24.62
Rate for Payer: Amerigroup CHIP/Medicaid	$3.08
Rate for Payer: BCBS of TX Blue Advantage	$10.26
Rate for Payer: BCBS of TX Blue Essentials	$12.31
Rate for Payer: BCBS of TX PPO	$13.68
Rate for Payer: Cash Price	$23.26
Rate for Payer: Cigna Medicaid	$24.62
Rate for Payer: Molina CHIP/Medicaid	$24.62
Rate for Payer: Multiplan Auto	$22.23
Rate for Payer: Multiplan Commercial	$22.23
Rate for Payer: Multiplan Workers Comp	$22.23
Rate for Payer: Parkland Medicaid	$24.62
Rate for Payer: Scott and White EPO/PPO	$17.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.62
Rate for Payer: Superior Health Plan EPO	$4.65

PREM-25+W35 -- DHF

Facility

$404.00

Hospital Charge Code	81910903
Hospital Revenue Code	272
Rate for Payer: Cash Price	$274.72

PREM-25+W35 -- DHF

Facility

$404.00

Hospital Charge Code	81910903
Hospital Revenue Code	272
Min. Negotiated Rate	$36.36
Max. Negotiated Rate	$290.88
Rate for Payer: Amerigroup CHIP/Medicaid	$36.36
Rate for Payer: BCBS of TX Blue Advantage	$121.20
Rate for Payer: BCBS of TX Blue Essentials	$145.44
Rate for Payer: BCBS of TX PPO	$161.60
Rate for Payer: Cash Price	$274.72
Rate for Payer: Cigna Medicaid	$290.88
Rate for Payer: Molina CHIP/Medicaid	$290.88
Rate for Payer: Multiplan Auto	$262.60
Rate for Payer: Multiplan Commercial	$262.60
Rate for Payer: Multiplan Workers Comp	$262.60
Rate for Payer: Parkland Medicaid	$290.88
Rate for Payer: Scott and White EPO/PPO	$202.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$290.88
Rate for Payer: Superior Health Plan EPO	$54.94

PREMATURITY WITH MAJOR PROBLEMS

Facility

$78,129.90

Service Code	MSDRG 791
Min. Negotiated Rate	$32,224.20
Max. Negotiated Rate	$78,129.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$34,508.60
Rate for Payer: Amerigroup Medicare	$34,508.60
Rate for Payer: BCBS of TX Medicare	$34,508.60
Rate for Payer: Cigna Commercial	$52,279.92
Rate for Payer: Cigna Medicare	$34,508.60
Rate for Payer: Employer Direct Commercial	$34,508.60
Rate for Payer: Humana Medicare/TRICARE	$34,508.60
Rate for Payer: Molina Dual Medicare/Medicaid	$34,508.60
Rate for Payer: Molina Medicare	$34,508.60
Rate for Payer: Multiplan Auto	$78,129.90
Rate for Payer: Multiplan Commercial	$78,129.90
Rate for Payer: Multiplan Workers Comp	$78,129.90
Rate for Payer: Scott and White EPO/PPO	$35,980.88
Rate for Payer: Scott and White Medicare	$34,508.60
Rate for Payer: Superior Health Plan EPO	$34,508.60
Rate for Payer: Superior Health Plan Medicare	$34,508.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$34,508.60
Rate for Payer: Universal American Medicare	$34,508.60
Rate for Payer: Wellcare Medicare	$34,508.60
Rate for Payer: Wellmed Medicare	$34,508.60

PREMATURITY WITHOUT MAJOR PROBLEMS

Facility

$47,142.80

Service Code	MSDRG 792
Min. Negotiated Rate	$19,442.88
Max. Negotiated Rate	$47,142.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,710.33
Rate for Payer: Amerigroup Medicare	$22,710.33
Rate for Payer: BCBS of TX Medicare	$22,710.33
Rate for Payer: Cigna Commercial	$31,545.70
Rate for Payer: Cigna Medicare	$22,710.33
Rate for Payer: Employer Direct Commercial	$22,710.33
Rate for Payer: Humana Medicare/TRICARE	$22,710.33
Rate for Payer: Molina Dual Medicare/Medicaid	$22,710.33
Rate for Payer: Molina Medicare	$22,710.33
Rate for Payer: Multiplan Auto	$47,142.80
Rate for Payer: Multiplan Commercial	$47,142.80
Rate for Payer: Multiplan Workers Comp	$47,142.80
Rate for Payer: Scott and White EPO/PPO	$21,710.50
Rate for Payer: Scott and White Medicare	$22,710.33
Rate for Payer: Superior Health Plan EPO	$22,710.33
Rate for Payer: Superior Health Plan Medicare	$22,710.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,710.33
Rate for Payer: Universal American Medicare	$22,710.33
Rate for Payer: Wellcare Medicare	$22,710.33
Rate for Payer: Wellmed Medicare	$22,710.33

PREMATURITY W MAJOR PROBLEMS

Facility

$78,129.90

Service Code	MSDRG 791
Min. Negotiated Rate	$32,224.20
Max. Negotiated Rate	$78,129.90
Rate for Payer: BCBS of TX Blue Advantage	$32,224.20
Rate for Payer: BCBS of TX Blue Essentials	$38,665.29
Rate for Payer: BCBS of TX PPO	$42,963.10

PREMATURITY W/O MAJOR PROBLEMS

Facility

$47,142.80

Service Code	MSDRG 792
Min. Negotiated Rate	$19,442.88
Max. Negotiated Rate	$47,142.80
Rate for Payer: BCBS of TX Blue Advantage	$19,442.88
Rate for Payer: BCBS of TX Blue Essentials	$23,329.20
Rate for Payer: BCBS of TX PPO	$25,922.33

PREMIX midazolam 50 mg in 0.9% NaCl; 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8348674
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

PREMIX midazolam 50 mg in 0.9% NaCl; 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8348674
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

PREMIX niCARdipine 25 mg in D5W; 250 mL

Facility

$128.00

Service Code	HCPCS J2404
Hospital Charge Code	77724665
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

PREMIX niCARdipine 25 mg in D5W; 250 mL

Facility

$128.00

Service Code	HCPCS J2404
Hospital Charge Code	8348673
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.15
Rate for Payer: BCBS of TX Blue Essentials	$0.17
Rate for Payer: BCBS of TX PPO	$0.19
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

PREMIX niCARdipine 25 mg in D5W; 250 mL

Facility

$128.00

Service Code	HCPCS J2404
Hospital Charge Code	8348673
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

PREMIX niCARdipine 25 mg in D5W; 250 mL

Facility

$128.00

Service Code	HCPCS J2404
Hospital Charge Code	77724665
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.15
Rate for Payer: BCBS of TX Blue Essentials	$0.17
Rate for Payer: BCBS of TX PPO	$0.19
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

PREMIX nitroglycerin 50 mg/D5W 250 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78352160
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

PREMIX nitroglycerin 50 mg/D5W 250 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78352160
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

Prenatal Multivitamins with Folic Acid 0.8 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77778214
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

Prenatal Multivitamins with Folic Acid 0.8 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77778214
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

PRESS TB -- DHF

Facility

$147.62

Hospital Charge Code	80337355
Hospital Revenue Code	270
Min. Negotiated Rate	$13.29
Max. Negotiated Rate	$106.29
Rate for Payer: Amerigroup CHIP/Medicaid	$13.29
Rate for Payer: BCBS of TX Blue Advantage	$44.29
Rate for Payer: BCBS of TX Blue Essentials	$53.14
Rate for Payer: BCBS of TX PPO	$59.05
Rate for Payer: Cash Price	$100.38
Rate for Payer: Cigna Medicaid	$106.29
Rate for Payer: Molina CHIP/Medicaid	$106.29
Rate for Payer: Multiplan Auto	$95.95
Rate for Payer: Multiplan Commercial	$95.95
Rate for Payer: Multiplan Workers Comp	$95.95
Rate for Payer: Parkland Medicaid	$106.29
Rate for Payer: Scott and White EPO/PPO	$73.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$106.29
Rate for Payer: Superior Health Plan EPO	$20.08

PRESS TB -- DHF

Facility

$147.62

Hospital Charge Code	80337355
Hospital Revenue Code	270
Rate for Payer: Cash Price	$100.38

PRESS TRNSDU -- DHF

Facility

$689.34

Hospital Charge Code	80337405
Hospital Revenue Code	270
Min. Negotiated Rate	$62.04
Max. Negotiated Rate	$496.32
Rate for Payer: Amerigroup CHIP/Medicaid	$62.04
Rate for Payer: BCBS of TX Blue Advantage	$206.80
Rate for Payer: BCBS of TX Blue Essentials	$248.16
Rate for Payer: BCBS of TX PPO	$275.74
Rate for Payer: Cash Price	$468.75
Rate for Payer: Cigna Medicaid	$496.32
Rate for Payer: Molina CHIP/Medicaid	$496.32
Rate for Payer: Multiplan Auto	$448.07
Rate for Payer: Multiplan Commercial	$448.07
Rate for Payer: Multiplan Workers Comp	$448.07
Rate for Payer: Parkland Medicaid	$496.32
Rate for Payer: Scott and White EPO/PPO	$344.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$496.32
Rate for Payer: Superior Health Plan EPO	$93.75

PRESS TRNSDU -- DHF

Facility

$689.34

Hospital Charge Code	80337405
Hospital Revenue Code	270
Rate for Payer: Cash Price	$468.75

Know your out-of-pocket cost for care.

All Charges