White Rock Medical Center

All Charges

Charge

Type

Setting

Price

metFORMIN 500 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77687513
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
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: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

metFORMIN 500 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77687513
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Methadone Screen Urine

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640112
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$206.05
Rate for Payer: Aetna Commercial	$65.24
Rate for Payer: Aetna Medicare	$93.21
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$102.53
Rate for Payer: BCBS of TX Blue Essentials	$123.04
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$137.33
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cigna Medicaid	$62.14
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$62.14
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$62.14
Rate for Payer: Scott and White EPO/PPO	$77.68
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.14
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

Methadone Screen Urine

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640112
Hospital Revenue Code	300
Rate for Payer: Cash Price	$278.96

Methanol SO

Facility

$184.00

Service Code	CPT 80320
Hospital Charge Code	8486566
Hospital Revenue Code	301
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$119.60
Rate for Payer: Aetna Commercial	$0.02
Rate for Payer: Amerigroup CHIP/Medicaid	$4.37
Rate for Payer: Cash Price	$161.92
Rate for Payer: Cash Price	$161.92
Rate for Payer: Cigna Medicaid	$11.21
Rate for Payer: Molina CHIP/Medicaid	$11.21
Rate for Payer: Multiplan Auto	$119.60
Rate for Payer: Multiplan Commercial	$119.60
Rate for Payer: Multiplan Workers Comp	$119.60
Rate for Payer: Parkland Medicaid	$11.21
Rate for Payer: Scott and White EPO/PPO	$92.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.21
Rate for Payer: Superior Health Plan EPO	$25.02

Methanol SO

Facility

$184.00

Service Code	CPT 80320
Hospital Charge Code	8486566
Hospital Revenue Code	301
Rate for Payer: Cash Price	$161.92

Methemoglobin

Facility

$131.00

Service Code	CPT 83050
Hospital Charge Code	4049193
Hospital Revenue Code	301
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$85.15
Rate for Payer: Aetna Commercial	$8.61
Rate for Payer: Aetna Medicare	$12.30
Rate for Payer: Amerigroup CHIP/Medicaid	$3.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.20
Rate for Payer: Amerigroup Medicare	$8.20
Rate for Payer: BCBS of TX Blue Advantage	$13.53
Rate for Payer: BCBS of TX Blue Essentials	$16.24
Rate for Payer: BCBS of TX Medicare	$8.20
Rate for Payer: BCBS of TX PPO	$18.12
Rate for Payer: Cash Price	$115.28
Rate for Payer: Cash Price	$115.28
Rate for Payer: Cigna Medicaid	$8.20
Rate for Payer: Cigna Medicare	$8.20
Rate for Payer: Employer Direct Commercial	$8.20
Rate for Payer: Humana Medicare/TRICARE	$8.20
Rate for Payer: Molina CHIP/Medicaid	$8.20
Rate for Payer: Molina Dual Medicare/Medicaid	$8.20
Rate for Payer: Molina Medicare	$8.20
Rate for Payer: Multiplan Auto	$85.15
Rate for Payer: Multiplan Commercial	$85.15
Rate for Payer: Multiplan Workers Comp	$85.15
Rate for Payer: Parkland Medicaid	$8.20
Rate for Payer: Scott and White EPO/PPO	$10.25
Rate for Payer: Scott and White Medicare	$8.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.20
Rate for Payer: Superior Health Plan EPO	$8.20
Rate for Payer: Superior Health Plan Medicare	$8.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.20
Rate for Payer: Universal American Medicare	$8.20
Rate for Payer: Wellcare Medicare	$8.20
Rate for Payer: Wellmed Medicare	$8.20

Methicillin Resistant Staph Screen

Facility

$229.00

Service Code	CPT 87081
Hospital Charge Code	4108781
Hospital Revenue Code	306
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$148.85
Rate for Payer: Aetna Commercial	$6.96
Rate for Payer: Aetna Medicare	$9.94
Rate for Payer: Amerigroup CHIP/Medicaid	$2.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.63
Rate for Payer: Amerigroup Medicare	$6.63
Rate for Payer: BCBS of TX Blue Advantage	$10.94
Rate for Payer: BCBS of TX Blue Essentials	$13.13
Rate for Payer: BCBS of TX Medicare	$6.63
Rate for Payer: BCBS of TX PPO	$14.65
Rate for Payer: Cash Price	$201.52
Rate for Payer: Cash Price	$201.52
Rate for Payer: Cigna Medicaid	$6.63
Rate for Payer: Cigna Medicare	$6.63
Rate for Payer: Employer Direct Commercial	$6.63
Rate for Payer: Humana Medicare/TRICARE	$6.63
Rate for Payer: Molina CHIP/Medicaid	$6.63
Rate for Payer: Molina Dual Medicare/Medicaid	$6.63
Rate for Payer: Molina Medicare	$6.63
Rate for Payer: Multiplan Auto	$148.85
Rate for Payer: Multiplan Commercial	$148.85
Rate for Payer: Multiplan Workers Comp	$148.85
Rate for Payer: Parkland Medicaid	$6.63
Rate for Payer: Scott and White EPO/PPO	$8.29
Rate for Payer: Scott and White Medicare	$6.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.63
Rate for Payer: Superior Health Plan EPO	$6.63
Rate for Payer: Superior Health Plan Medicare	$6.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.63
Rate for Payer: Universal American Medicare	$6.63
Rate for Payer: Wellcare Medicare	$6.63
Rate for Payer: Wellmed Medicare	$6.63

Methicillin Resistant Staph Screen

Facility

$229.00

Service Code	CPT 87081
Hospital Charge Code	4108781
Hospital Revenue Code	306
Rate for Payer: Cash Price	$201.52

methocarbamol 100 mg/mL Inj Soln 10 mL

Facility

$128.00

Service Code	HCPCS J2800
Hospital Charge Code	77689748
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

methocarbamol 100 mg/mL Inj Soln 10 mL

Facility

$128.00

Service Code	HCPCS J2800
Hospital Charge Code	77689748
Hospital Revenue Code	636
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$18.26
Rate for Payer: BCBS of TX Blue Essentials	$21.91
Rate for Payer: BCBS of TX PPO	$24.30
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
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: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

methocarbamol 500 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77689807
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

methocarbamol 500 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77689807
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
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: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

methocarbamol 750 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77689860
Hospital Revenue Code	636
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
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: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

methocarbamol 750 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77689860
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

methylene blue 10 mg/mL Sol

Facility

$128.00

Service Code	HCPCS Q9968
Hospital Charge Code	78870046
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

methylene blue 10 mg/mL Sol

Facility

$128.00

Service Code	HCPCS Q9968
Hospital Charge Code	78870046
Hospital Revenue Code	636
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$83.20
Rate for Payer: Aetna Commercial	$70.40
Rate for Payer: Aetna Medicare	$11.92
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.95
Rate for Payer: Amerigroup Medicare	$7.95
Rate for Payer: BCBS of TX Blue Advantage	$1.68
Rate for Payer: BCBS of TX Blue Essentials	$2.02
Rate for Payer: BCBS of TX Medicare	$7.95
Rate for Payer: BCBS of TX PPO	$2.24
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicare	$7.95
Rate for Payer: Employer Direct Commercial	$7.95
Rate for Payer: Humana Medicare/TRICARE	$7.95
Rate for Payer: Molina Dual Medicare/Medicaid	$7.95
Rate for Payer: Molina Medicare	$7.95
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: Scott and White EPO/PPO	$64.00
Rate for Payer: Scott and White Medicare	$7.95
Rate for Payer: Superior Health Plan EPO	$7.95
Rate for Payer: Superior Health Plan Medicare	$7.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.95
Rate for Payer: Universal American Medicare	$7.95
Rate for Payer: Wellcare Medicare	$7.95
Rate for Payer: Wellmed Medicare	$7.95

Methylmalonic Acid, Serum SO

Facility

$349.00

Service Code	CPT 83921
Hospital Charge Code	1709112
Hospital Revenue Code	301
Rate for Payer: Cash Price	$307.12

Methylmalonic Acid, Serum SO

Facility

$349.00

Service Code	CPT 83921
Hospital Charge Code	1709112
Hospital Revenue Code	301
Min. Negotiated Rate	$8.27
Max. Negotiated Rate	$226.85
Rate for Payer: Aetna Commercial	$22.28
Rate for Payer: Aetna Medicare	$31.82
Rate for Payer: Amerigroup CHIP/Medicaid	$8.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.21
Rate for Payer: Amerigroup Medicare	$21.21
Rate for Payer: BCBS of TX Blue Advantage	$35.00
Rate for Payer: BCBS of TX Blue Essentials	$42.00
Rate for Payer: BCBS of TX Medicare	$21.21
Rate for Payer: BCBS of TX PPO	$46.87
Rate for Payer: Cash Price	$307.12
Rate for Payer: Cash Price	$307.12
Rate for Payer: Cigna Medicaid	$21.21
Rate for Payer: Cigna Medicare	$21.21
Rate for Payer: Employer Direct Commercial	$21.21
Rate for Payer: Humana Medicare/TRICARE	$21.21
Rate for Payer: Molina CHIP/Medicaid	$21.21
Rate for Payer: Molina Dual Medicare/Medicaid	$21.21
Rate for Payer: Molina Medicare	$21.21
Rate for Payer: Multiplan Auto	$226.85
Rate for Payer: Multiplan Commercial	$226.85
Rate for Payer: Multiplan Workers Comp	$226.85
Rate for Payer: Parkland Medicaid	$21.21
Rate for Payer: Scott and White EPO/PPO	$26.51
Rate for Payer: Scott and White Medicare	$21.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.21
Rate for Payer: Superior Health Plan EPO	$21.21
Rate for Payer: Superior Health Plan Medicare	$21.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.21
Rate for Payer: Universal American Medicare	$21.21
Rate for Payer: Wellcare Medicare	$21.21
Rate for Payer: Wellmed Medicare	$21.21

methylPREDNISolone 125. mg Powder-Inj

Facility

$128.00

Service Code	HCPCS J2919
Hospital Charge Code	78418466
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.45
Rate for Payer: BCBS of TX Blue Essentials	$0.54
Rate for Payer: BCBS of TX PPO	$0.60
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
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: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

methylPREDNISolone 125. mg Powder-Inj

Facility

$128.00

Service Code	HCPCS J2919
Hospital Charge Code	78418466
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

methylPREDNISolone sodium succ 40 mg Inj

Facility

$128.00

Service Code	HCPCS J2919
Hospital Charge Code	78411206
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

methylPREDNISolone sodium succ 40 mg Inj

Facility

$128.00

Service Code	HCPCS J2919
Hospital Charge Code	78411206
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.45
Rate for Payer: BCBS of TX Blue Essentials	$0.54
Rate for Payer: BCBS of TX PPO	$0.60
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
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: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

methylPREDNISolone sodium succ 40 mg PF Inj

Facility

$128.00

Service Code	HCPCS J2919
Hospital Charge Code	77697369
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

methylPREDNISolone sodium succ 40 mg PF Inj

Facility

$128.00

Service Code	HCPCS J2919
Hospital Charge Code	77697369
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.45
Rate for Payer: BCBS of TX Blue Essentials	$0.54
Rate for Payer: BCBS of TX PPO	$0.60
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
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: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

Know your out-of-pocket cost for care.

All Charges