White Rock Medical Center

All Charges

Charge

Type

Setting

Price

metoclopramide 10 mg Tab

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	77698186
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

metoclopramide 10 mg Tab

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	77698186
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

metoclopramide 5 mg/mL Sol

Facility

$128.00

Service Code	HCPCS J2765
Hospital Charge Code	78398727
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

metoclopramide 5 mg/mL Sol

Facility

$128.00

Service Code	HCPCS J2765
Hospital Charge Code	78398727
Hospital Revenue Code	636
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$2.20
Rate for Payer: BCBS of TX Blue Essentials	$2.64
Rate for Payer: BCBS of TX PPO	$2.93
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

metoprolol 1 mg/mL Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78425888
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

metoprolol 1 mg/mL Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78425888
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

metoprolol 25mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78437123
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

metoprolol 25mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78437123
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

metoprolol succinate 100 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77698999
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

metoprolol succinate 100 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77698999
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

metoprolol succinate 25 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78870184
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

metoprolol succinate 25 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78870184
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

metoprolol succinate 50 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77699160
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

metoprolol succinate 50 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77699160
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

metroNIDAZOLE 500 mg/100 mL IV Soln 100 mL

Facility

$128.00

Service Code	HCPCS J1836
Hospital Charge Code	7448162
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

metroNIDAZOLE 500 mg/100 mL IV Soln 100 mL

Facility

$128.00

Service Code	HCPCS J1836
Hospital Charge Code	7448162
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$83.20
Rate for Payer: Aetna Medicare	$0.04
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$0.02
Rate for Payer: Amerigroup Medicare	$0.02
Rate for Payer: BCBS of TX Blue Advantage	$0.03
Rate for Payer: BCBS of TX Blue Essentials	$0.03
Rate for Payer: BCBS of TX Medicare	$0.02
Rate for Payer: BCBS of TX PPO	$0.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicare	$0.02
Rate for Payer: Employer Direct Commercial	$0.02
Rate for Payer: Humana Medicare/TRICARE	$0.02
Rate for Payer: Molina Dual Medicare/Medicaid	$0.02
Rate for Payer: Molina Medicare	$0.02
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	$0.02
Rate for Payer: Superior Health Plan EPO	$0.02
Rate for Payer: Superior Health Plan Medicare	$0.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$0.02
Rate for Payer: Universal American Medicare	$0.02
Rate for Payer: Wellcare Medicare	$0.02
Rate for Payer: Wellmed Medicare	$0.02

metroNIDAZOLE 500 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78402560
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

metroNIDAZOLE 500 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78402560
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

MG Breast Biopsy w/ Stereo Guide Left

Facility

$5,741.00

Service Code	CPT 19081 LT
Hospital Charge Code	3620223
Hospital Revenue Code	361
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,482.74
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$5,052.08
Rate for Payer: Cash Price	$5,052.08
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$128.57
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$128.57
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
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	$128.57
Rate for Payer: Scott and White EPO/PPO	$32.70
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$486.45
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

MG Breast Biopsy w/ Stereo Guide Left BCE

Facility

$5,741.00

Service Code	CPT 19081 LT
Hospital Charge Code	3620223
Hospital Revenue Code	361
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,482.74
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$5,052.08
Rate for Payer: Cash Price	$5,052.08
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$128.57
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$128.57
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
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	$128.57
Rate for Payer: Scott and White EPO/PPO	$32.70
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$486.45
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

MG Breast Biopsy w/ Stereo Guide Left BCE

Facility

$5,741.00

Service Code	CPT 19081 LT
Hospital Charge Code	3620223
Hospital Revenue Code	361
Rate for Payer: Cash Price	$5,052.08

MG Breast Biopsy w/ Stereo Guide Right

Facility

$5,741.00

Service Code	CPT 19081 RT
Hospital Charge Code	3620221
Hospital Revenue Code	361
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,482.74
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$5,052.08
Rate for Payer: Cash Price	$5,052.08
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$128.57
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$128.57
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
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	$128.57
Rate for Payer: Scott and White EPO/PPO	$32.70
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$486.45
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

MG Breast Biopsy w/ Stereo Guide Right BCE

Facility

$5,741.00

Service Code	CPT 19081 RT
Hospital Charge Code	3620221
Hospital Revenue Code	361
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,482.74
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$5,052.08
Rate for Payer: Cash Price	$5,052.08
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$128.57
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$128.57
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
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	$128.57
Rate for Payer: Scott and White EPO/PPO	$32.70
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$486.45
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

MG Breast Biopsy w/ Stereo Guide Right BCE

Facility

$5,741.00

Service Code	CPT 19081 RT
Hospital Charge Code	3620221
Hospital Revenue Code	361
Rate for Payer: Cash Price	$5,052.08

MG Breast Tissue Specimen Surgical Left

Facility

$333.00

Service Code	CPT 76098 LT
Hospital Charge Code	3600111
Hospital Revenue Code	320
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$1,142.91
Rate for Payer: Aetna Commercial	$29.10
Rate for Payer: Aetna Medicare	$756.80
Rate for Payer: Amerigroup CHIP/Medicaid	$42.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$504.53
Rate for Payer: Amerigroup Medicare	$504.53
Rate for Payer: BCBS of TX Blue Advantage	$794.61
Rate for Payer: BCBS of TX Blue Essentials	$953.53
Rate for Payer: BCBS of TX Medicare	$504.53
Rate for Payer: BCBS of TX PPO	$1,064.29
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cash Price	$293.04
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicaid	$12.03
Rate for Payer: Cigna Medicare	$504.53
Rate for Payer: Employer Direct Commercial	$504.53
Rate for Payer: Humana Medicare/TRICARE	$504.53
Rate for Payer: Molina CHIP/Medicaid	$12.03
Rate for Payer: Molina Dual Medicare/Medicaid	$504.53
Rate for Payer: Molina Medicare	$504.53
Rate for Payer: Multiplan Auto	$216.45
Rate for Payer: Multiplan Commercial	$216.45
Rate for Payer: Multiplan Workers Comp	$216.45
Rate for Payer: Parkland Medicaid	$12.03
Rate for Payer: Scott and White EPO/PPO	$9.02
Rate for Payer: Scott and White Medicare	$504.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.03
Rate for Payer: Superior Health Plan EPO	$504.53
Rate for Payer: Superior Health Plan Medicare	$504.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$504.53
Rate for Payer: Universal American Medicare	$504.53
Rate for Payer: Wellcare Medicare	$504.53
Rate for Payer: Wellmed Medicare	$504.53

Know your out-of-pocket cost for care.

All Charges