White Rock Medical Center

All Charges

Charge

Type

Setting

Price

magnesium oxide 400 mg (241.3 mg elemental magnesium) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77676264
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

magnesium sulfate 1 gram/D5W 100 mL (PMX)

Facility

$128.17

Service Code	HCPCS J3475
Hospital Charge Code	77676782
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.10
Rate for Payer: BCBS of TX Blue Essentials	$0.12
Rate for Payer: BCBS of TX PPO	$0.14
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

magnesium sulfate 1 gram/D5W 100 mL (PMX)

Facility

$128.17

Service Code	HCPCS J3475
Hospital Charge Code	77676782
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

Magnesium sulfate 2 grams IV Soln 50 mL (PMX)

Facility

$128.17

Service Code	HCPCS J3475
Hospital Charge Code	77677593
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.10
Rate for Payer: BCBS of TX Blue Essentials	$0.12
Rate for Payer: BCBS of TX PPO	$0.14
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

Magnesium sulfate 2 grams IV Soln 50 mL (PMX)

Facility

$128.17

Service Code	HCPCS J3475
Hospital Charge Code	77677593
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

magnesium sulfate 50% Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3475
Hospital Charge Code	78740463
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.10
Rate for Payer: BCBS of TX Blue Essentials	$0.12
Rate for Payer: BCBS of TX PPO	$0.14
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

magnesium sulfate 50% Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3475
Hospital Charge Code	78740463
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

MAJOR BLADDER PROCEDURES WITH CC

Facility

$35,259.00

Service Code	MSDRG 654
Min. Negotiated Rate	$26,476.82
Max. Negotiated Rate	$35,259.00
Rate for Payer: Aetna Commercial	$30,796.88
Rate for Payer: Aetna Medicare	$33,584.61
Rate for Payer: BCBS of TX Blue Advantage	$26,476.82
Rate for Payer: BCBS of TX Blue Essentials	$29,649.58
Rate for Payer: BCBS of TX PPO	$32,945.26
Rate for Payer: Cigna Commercial	$35,259.00

MAJOR BLADDER PROCEDURES WITH MCC

Facility

$69,727.17

Service Code	MSDRG 653
Min. Negotiated Rate	$49,450.86
Max. Negotiated Rate	$69,727.17
Rate for Payer: Aetna Commercial	$60,903.00
Rate for Payer: Aetna Medicare	$62,229.81
Rate for Payer: BCBS of TX Blue Advantage	$49,450.86
Rate for Payer: BCBS of TX Blue Essentials	$56,640.99
Rate for Payer: BCBS of TX PPO	$62,936.87
Rate for Payer: Cigna Commercial	$69,727.17

MAJOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$27,148.46

Service Code	MSDRG 655
Min. Negotiated Rate	$18,606.10
Max. Negotiated Rate	$27,148.46
Rate for Payer: Aetna Commercial	$23,712.75
Rate for Payer: Aetna Medicare	$26,844.26
Rate for Payer: BCBS of TX Blue Advantage	$18,606.10
Rate for Payer: BCBS of TX Blue Essentials	$21,434.63
Rate for Payer: BCBS of TX PPO	$23,817.18
Rate for Payer: Cigna Commercial	$27,148.46

MAJOR CHEST PROCEDURES WITH CC

Facility

$32,849.15

Service Code	MSDRG 164
Min. Negotiated Rate	$22,202.62
Max. Negotiated Rate	$32,849.15
Rate for Payer: Aetna Commercial	$28,692.00
Rate for Payer: Aetna Medicare	$31,581.88
Rate for Payer: BCBS of TX Blue Advantage	$22,202.62
Rate for Payer: BCBS of TX Blue Essentials	$26,508.48
Rate for Payer: BCBS of TX PPO	$29,455.01
Rate for Payer: Cigna Commercial	$32,849.15

MAJOR CHEST PROCEDURES WITH MCC

Facility

$60,711.17

Service Code	MSDRG 163
Min. Negotiated Rate	$43,166.84
Max. Negotiated Rate	$60,711.17
Rate for Payer: Aetna Commercial	$53,028.00
Rate for Payer: Aetna Medicare	$54,736.95
Rate for Payer: BCBS of TX Blue Advantage	$43,166.84
Rate for Payer: BCBS of TX Blue Essentials	$50,762.26
Rate for Payer: BCBS of TX PPO	$56,404.69
Rate for Payer: Cigna Commercial	$60,711.17

MAJOR CHEST PROCEDURES WITHOUT CC/MCC

Facility

$24,367.32

Service Code	MSDRG 165
Min. Negotiated Rate	$15,392.28
Max. Negotiated Rate	$24,367.32
Rate for Payer: Aetna Commercial	$21,109.50
Rate for Payer: Aetna Medicare	$24,367.32
Rate for Payer: BCBS of TX Blue Advantage	$15,392.28
Rate for Payer: BCBS of TX Blue Essentials	$19,114.92
Rate for Payer: BCBS of TX PPO	$21,239.62
Rate for Payer: Cigna Commercial	$24,168.03

MAJOR CHEST TRAUMA WITH CC

Facility

$15,541.82

Service Code	MSDRG 184
Min. Negotiated Rate	$8,480.46
Max. Negotiated Rate	$15,541.82
Rate for Payer: Aetna Commercial	$11,833.88
Rate for Payer: Aetna Medicare	$15,541.82
Rate for Payer: BCBS of TX Blue Advantage	$8,480.46
Rate for Payer: BCBS of TX Blue Essentials	$10,364.40
Rate for Payer: BCBS of TX PPO	$11,516.45
Rate for Payer: Cigna Commercial	$13,548.47

MAJOR CHEST TRAUMA WITH MCC

Facility

$21,135.75

Service Code	MSDRG 183
Min. Negotiated Rate	$12,825.18
Max. Negotiated Rate	$21,135.75
Rate for Payer: Aetna Commercial	$17,713.12
Rate for Payer: Aetna Medicare	$21,135.75
Rate for Payer: BCBS of TX Blue Advantage	$12,825.18
Rate for Payer: BCBS of TX Blue Essentials	$15,384.60
Rate for Payer: BCBS of TX PPO	$17,094.66
Rate for Payer: Cigna Commercial	$20,279.56

MAJOR CHEST TRAUMA WITHOUT CC/MCC

Facility

$12,371.22

Service Code	MSDRG 185
Min. Negotiated Rate	$6,241.02
Max. Negotiated Rate	$12,371.22
Rate for Payer: Aetna Commercial	$8,501.62
Rate for Payer: Aetna Medicare	$12,371.22
Rate for Payer: BCBS of TX Blue Advantage	$6,241.02
Rate for Payer: BCBS of TX Blue Essentials	$7,556.60
Rate for Payer: BCBS of TX PPO	$8,396.55
Rate for Payer: Cigna Commercial	$9,733.42

MAJOR ESOPHAGEAL DISORDERS WITH CC

Facility

$14,861.02

Service Code	MSDRG 369
Min. Negotiated Rate	$9,091.92
Max. Negotiated Rate	$14,861.02
Rate for Payer: Aetna Commercial	$11,118.38
Rate for Payer: Aetna Medicare	$14,861.02
Rate for Payer: BCBS of TX Blue Advantage	$9,091.92
Rate for Payer: BCBS of TX Blue Essentials	$11,441.71
Rate for Payer: BCBS of TX PPO	$12,713.50
Rate for Payer: Cigna Commercial	$12,729.30

MAJOR ESOPHAGEAL DISORDERS WITH MCC

Facility

$22,289.90

Service Code	MSDRG 368
Min. Negotiated Rate	$16,128.44
Max. Negotiated Rate	$22,289.90
Rate for Payer: Aetna Commercial	$18,585.00
Rate for Payer: Aetna Medicare	$21,965.33
Rate for Payer: BCBS of TX Blue Advantage	$16,128.44
Rate for Payer: BCBS of TX Blue Essentials	$20,060.14
Rate for Payer: BCBS of TX PPO	$22,289.90
Rate for Payer: Cigna Commercial	$21,277.76

MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC

Facility

$12,242.77

Service Code	MSDRG 370
Min. Negotiated Rate	$6,450.00
Max. Negotiated Rate	$12,242.77
Rate for Payer: Aetna Commercial	$8,366.62
Rate for Payer: Aetna Medicare	$12,242.77
Rate for Payer: BCBS of TX Blue Advantage	$6,450.00
Rate for Payer: BCBS of TX Blue Essentials	$7,670.11
Rate for Payer: BCBS of TX PPO	$8,522.68
Rate for Payer: Cigna Commercial	$9,578.86

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC

Facility

$15,439.07

Service Code	MSDRG 372
Min. Negotiated Rate	$9,337.88
Max. Negotiated Rate	$15,439.07
Rate for Payer: Aetna Commercial	$11,725.88
Rate for Payer: Aetna Medicare	$15,439.07
Rate for Payer: BCBS of TX Blue Advantage	$9,337.88
Rate for Payer: BCBS of TX Blue Essentials	$10,715.25
Rate for Payer: BCBS of TX PPO	$11,906.29
Rate for Payer: Cigna Commercial	$13,424.82

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC

Facility

$22,989.71

Service Code	MSDRG 371
Min. Negotiated Rate	$15,041.40
Max. Negotiated Rate	$22,989.71
Rate for Payer: Aetna Commercial	$19,661.62
Rate for Payer: Aetna Medicare	$22,989.71
Rate for Payer: BCBS of TX Blue Advantage	$15,041.40
Rate for Payer: BCBS of TX Blue Essentials	$17,942.68
Rate for Payer: BCBS of TX PPO	$19,937.08
Rate for Payer: Cigna Commercial	$22,510.38

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC

Facility

$11,951.66

Service Code	MSDRG 373
Min. Negotiated Rate	$6,615.98
Max. Negotiated Rate	$11,951.66
Rate for Payer: Aetna Commercial	$8,060.62
Rate for Payer: Aetna Medicare	$11,951.66
Rate for Payer: BCBS of TX Blue Advantage	$6,615.98
Rate for Payer: BCBS of TX Blue Essentials	$7,817.67
Rate for Payer: BCBS of TX PPO	$8,686.64
Rate for Payer: Cigna Commercial	$9,228.52

MAJOR HEAD AND NECK PROCEDURES WITH CC

Facility

$26,683.50

Service Code	MSDRG 141
Min. Negotiated Rate	$23,306.62
Max. Negotiated Rate	$26,683.50
Rate for Payer: Aetna Commercial	$23,306.62
Rate for Payer: Aetna Medicare	$26,457.83
Rate for Payer: Cigna Commercial	$26,683.50

MAJOR HEAD AND NECK PROCEDURES WITH MCC

Facility

$48,661.93

Service Code	MSDRG 140
Min. Negotiated Rate	$42,503.62
Max. Negotiated Rate	$48,661.93
Rate for Payer: Aetna Commercial	$42,503.62
Rate for Payer: Aetna Medicare	$44,723.29
Rate for Payer: Cigna Commercial	$48,661.93

MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC

Facility

$20,819.99

Service Code	MSDRG 142
Min. Negotiated Rate	$17,381.25
Max. Negotiated Rate	$20,819.99
Rate for Payer: Aetna Commercial	$17,381.25
Rate for Payer: Aetna Medicare	$20,819.99
Rate for Payer: Cigna Commercial	$19,899.60

Know your out-of-pocket cost for care.

All Charges