White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MG Mammo Digital Diagnostic Left BCE

Facility

$483.00

Service Code	CPT 77065 LT
Hospital Charge Code	3641096
Hospital Revenue Code	401
Min. Negotiated Rate	$30.47
Max. Negotiated Rate	$313.95
Rate for Payer: Aetna Commercial	$100.75
Rate for Payer: Amerigroup CHIP/Medicaid	$43.47
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$425.04
Rate for Payer: Cash Price	$425.04
Rate for Payer: Cigna Medicaid	$30.47
Rate for Payer: Molina CHIP/Medicaid	$30.47
Rate for Payer: Multiplan Auto	$313.95
Rate for Payer: Multiplan Commercial	$313.95
Rate for Payer: Multiplan Workers Comp	$313.95
Rate for Payer: Parkland Medicaid	$30.47
Rate for Payer: Scott and White EPO/PPO	$241.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.47
Rate for Payer: Superior Health Plan EPO	$65.69

MG Mammo Digital Diagnostic Right

Facility

$483.00

Service Code	CPT 77065 RT
Hospital Charge Code	3641096
Hospital Revenue Code	401
Min. Negotiated Rate	$30.47
Max. Negotiated Rate	$313.95
Rate for Payer: Aetna Commercial	$100.75
Rate for Payer: Amerigroup CHIP/Medicaid	$43.47
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$425.04
Rate for Payer: Cash Price	$425.04
Rate for Payer: Cigna Medicaid	$30.47
Rate for Payer: Molina CHIP/Medicaid	$30.47
Rate for Payer: Multiplan Auto	$313.95
Rate for Payer: Multiplan Commercial	$313.95
Rate for Payer: Multiplan Workers Comp	$313.95
Rate for Payer: Parkland Medicaid	$30.47
Rate for Payer: Scott and White EPO/PPO	$241.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.47
Rate for Payer: Superior Health Plan EPO	$65.69

MG Mammo Digital Diagnostic Right BCE

Facility

$483.00

Service Code	CPT 77065 RT
Hospital Charge Code	3641096
Hospital Revenue Code	401
Rate for Payer: Cash Price	$425.04

MG Mammo Digital Diagnostic Right BCE

Facility

$483.00

Service Code	CPT 77065 RT
Hospital Charge Code	3641096
Hospital Revenue Code	401
Min. Negotiated Rate	$30.47
Max. Negotiated Rate	$313.95
Rate for Payer: Aetna Commercial	$100.75
Rate for Payer: Amerigroup CHIP/Medicaid	$43.47
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$425.04
Rate for Payer: Cash Price	$425.04
Rate for Payer: Cigna Medicaid	$30.47
Rate for Payer: Molina CHIP/Medicaid	$30.47
Rate for Payer: Multiplan Auto	$313.95
Rate for Payer: Multiplan Commercial	$313.95
Rate for Payer: Multiplan Workers Comp	$313.95
Rate for Payer: Parkland Medicaid	$30.47
Rate for Payer: Scott and White EPO/PPO	$241.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.47
Rate for Payer: Superior Health Plan EPO	$65.69

MG Mammo Digital Screening

Facility

$512.00

Service Code	CPT 77067
Hospital Charge Code	3620241
Hospital Revenue Code	403
Min. Negotiated Rate	$46.08
Max. Negotiated Rate	$332.80
Rate for Payer: Aetna Commercial	$106.14
Rate for Payer: Amerigroup CHIP/Medicaid	$46.08
Rate for Payer: BCBS of TX Blue Advantage	$164.13
Rate for Payer: BCBS of TX Blue Essentials	$196.95
Rate for Payer: BCBS of TX PPO	$219.83
Rate for Payer: Cash Price	$450.56
Rate for Payer: Cash Price	$450.56
Rate for Payer: Multiplan Auto	$332.80
Rate for Payer: Multiplan Commercial	$332.80
Rate for Payer: Multiplan Workers Comp	$332.80
Rate for Payer: Scott and White EPO/PPO	$256.00
Rate for Payer: Superior Health Plan EPO	$69.63

MG Mammo Digital Screening BCE

Facility

$512.00

Service Code	CPT 77067
Hospital Charge Code	3620241
Hospital Revenue Code	403
Min. Negotiated Rate	$46.08
Max. Negotiated Rate	$332.80
Rate for Payer: Aetna Commercial	$106.14
Rate for Payer: Amerigroup CHIP/Medicaid	$46.08
Rate for Payer: BCBS of TX Blue Advantage	$164.13
Rate for Payer: BCBS of TX Blue Essentials	$196.95
Rate for Payer: BCBS of TX PPO	$219.83
Rate for Payer: Cash Price	$450.56
Rate for Payer: Cash Price	$450.56
Rate for Payer: Multiplan Auto	$332.80
Rate for Payer: Multiplan Commercial	$332.80
Rate for Payer: Multiplan Workers Comp	$332.80
Rate for Payer: Scott and White EPO/PPO	$256.00
Rate for Payer: Superior Health Plan EPO	$69.63

MG Mammo Digital Screening BCE

Facility

$512.00

Service Code	CPT 77067
Hospital Charge Code	3620241
Hospital Revenue Code	403
Rate for Payer: Cash Price	$450.56

MG Mammo Digital Screening Bilateral

Facility

$512.00

Service Code	CPT 77067
Hospital Charge Code	3620241
Hospital Revenue Code	403
Min. Negotiated Rate	$46.08
Max. Negotiated Rate	$332.80
Rate for Payer: Aetna Commercial	$106.14
Rate for Payer: Amerigroup CHIP/Medicaid	$46.08
Rate for Payer: BCBS of TX Blue Advantage	$164.13
Rate for Payer: BCBS of TX Blue Essentials	$196.95
Rate for Payer: BCBS of TX PPO	$219.83
Rate for Payer: Cash Price	$450.56
Rate for Payer: Cash Price	$450.56
Rate for Payer: Multiplan Auto	$332.80
Rate for Payer: Multiplan Commercial	$332.80
Rate for Payer: Multiplan Workers Comp	$332.80
Rate for Payer: Scott and White EPO/PPO	$256.00
Rate for Payer: Superior Health Plan EPO	$69.63

MG Mammo Digital Screening Bilateral BCE

Facility

$512.00

Service Code	CPT 77067
Hospital Charge Code	3620241
Hospital Revenue Code	403
Min. Negotiated Rate	$46.08
Max. Negotiated Rate	$332.80
Rate for Payer: Aetna Commercial	$106.14
Rate for Payer: Amerigroup CHIP/Medicaid	$46.08
Rate for Payer: BCBS of TX Blue Advantage	$164.13
Rate for Payer: BCBS of TX Blue Essentials	$196.95
Rate for Payer: BCBS of TX PPO	$219.83
Rate for Payer: Cash Price	$450.56
Rate for Payer: Cash Price	$450.56
Rate for Payer: Multiplan Auto	$332.80
Rate for Payer: Multiplan Commercial	$332.80
Rate for Payer: Multiplan Workers Comp	$332.80
Rate for Payer: Scott and White EPO/PPO	$256.00
Rate for Payer: Superior Health Plan EPO	$69.63

micafungin 100 mg IV Inj

Facility

$616.00

Service Code	HCPCS J2248
Hospital Charge Code	77700522
Hospital Revenue Code	636
Min. Negotiated Rate	$154.00
Max. Negotiated Rate	$308.00
Rate for Payer: Cash Price	$418.88
Rate for Payer: Cigna Commercial	$154.00
Rate for Payer: Scott and White EPO/PPO	$308.00

micafungin 100 mg IV Inj

Facility

$616.00

Service Code	HCPCS J2248
Hospital Charge Code	77700522
Hospital Revenue Code	636
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$400.40
Rate for Payer: Amerigroup CHIP/Medicaid	$55.44
Rate for Payer: BCBS of TX Blue Advantage	$2.71
Rate for Payer: BCBS of TX Blue Essentials	$3.25
Rate for Payer: BCBS of TX PPO	$3.61
Rate for Payer: Cash Price	$418.88
Rate for Payer: Cash Price	$418.88
Rate for Payer: Multiplan Auto	$400.40
Rate for Payer: Multiplan Commercial	$400.40
Rate for Payer: Multiplan Workers Comp	$400.40
Rate for Payer: Scott and White EPO/PPO	$308.00
Rate for Payer: Superior Health Plan EPO	$83.78

midazolam 1 mg/mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS J2250
Hospital Charge Code	77703797
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

midazolam 1 mg/mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS J2250
Hospital Charge Code	77703797
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.12
Rate for Payer: BCBS of TX Blue Essentials	$0.14
Rate for Payer: BCBS of TX PPO	$0.15
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

midazolam 1 mg/mL Inj Soln 5 mL

Facility

$128.00

Service Code	HCPCS J2250
Hospital Charge Code	77703856
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.12
Rate for Payer: BCBS of TX Blue Essentials	$0.14
Rate for Payer: BCBS of TX PPO	$0.15
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

midazolam 1 mg/mL Inj Soln 5 mL

Facility

$128.00

Service Code	HCPCS J2250
Hospital Charge Code	77703856
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

midazolam 1 mg/mL PF Inj Soln 5 mL

Facility

$128.00

Service Code	HCPCS J2250
Hospital Charge Code	77704029
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

midazolam 1 mg/mL PF Inj Soln 5 mL

Facility

$128.00

Service Code	HCPCS J2250
Hospital Charge Code	77704029
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.12
Rate for Payer: BCBS of TX Blue Essentials	$0.14
Rate for Payer: BCBS of TX PPO	$0.15
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

midazolam 5 mg/mL Inj Soln 10 mL

Facility

$128.19

Service Code	HCPCS J2250
Hospital Charge Code	77704922
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$83.32
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.12
Rate for Payer: BCBS of TX Blue Essentials	$0.14
Rate for Payer: BCBS of TX PPO	$0.15
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cash Price	$87.17
Rate for Payer: Multiplan Auto	$83.32
Rate for Payer: Multiplan Commercial	$83.32
Rate for Payer: Multiplan Workers Comp	$83.32
Rate for Payer: Scott and White EPO/PPO	$64.10
Rate for Payer: Superior Health Plan EPO	$17.43

midazolam 5 mg/mL Inj Soln 10 mL

Facility

$128.19

Service Code	HCPCS J2250
Hospital Charge Code	77704922
Hospital Revenue Code	636
Min. Negotiated Rate	$32.05
Max. Negotiated Rate	$64.10
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cigna Commercial	$32.05
Rate for Payer: Scott and White EPO/PPO	$64.10

midazolam PF 2 mg 2 ml injection

Facility

$128.19

Service Code	HCPCS J2250
Hospital Charge Code	78404062
Hospital Revenue Code	636
Min. Negotiated Rate	$32.05
Max. Negotiated Rate	$64.10
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cigna Commercial	$32.05
Rate for Payer: Scott and White EPO/PPO	$64.10

midazolam PF 2 mg 2 ml injection

Facility

$128.19

Service Code	HCPCS J2250
Hospital Charge Code	78404062
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$83.32
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.12
Rate for Payer: BCBS of TX Blue Essentials	$0.14
Rate for Payer: BCBS of TX PPO	$0.15
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cash Price	$87.17
Rate for Payer: Multiplan Auto	$83.32
Rate for Payer: Multiplan Commercial	$83.32
Rate for Payer: Multiplan Workers Comp	$83.32
Rate for Payer: Scott and White EPO/PPO	$64.10
Rate for Payer: Superior Health Plan EPO	$17.43

midodrine 10 mg Tab

Facility

$37.00

Service Code	HCPCS J3490
Hospital Charge Code	77705270
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.16

midodrine 10 mg Tab

Facility

$37.00

Service Code	HCPCS J3490
Hospital Charge Code	77705270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$24.05
Rate for Payer: Amerigroup CHIP/Medicaid	$3.33
Rate for Payer: BCBS of TX Blue Advantage	$11.10
Rate for Payer: BCBS of TX Blue Essentials	$13.32
Rate for Payer: BCBS of TX PPO	$14.80
Rate for Payer: Cash Price	$25.16
Rate for Payer: Multiplan Auto	$24.05
Rate for Payer: Multiplan Commercial	$24.05
Rate for Payer: Multiplan Workers Comp	$24.05
Rate for Payer: Scott and White EPO/PPO	$18.50
Rate for Payer: Superior Health Plan EPO	$5.03

midodrine 5 mg Tab

Facility

$18.00

Service Code	HCPCS J3490
Hospital Charge Code	77705378
Hospital Revenue Code	250
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$11.70
Rate for Payer: Amerigroup CHIP/Medicaid	$1.62
Rate for Payer: BCBS of TX Blue Advantage	$5.40
Rate for Payer: BCBS of TX Blue Essentials	$6.48
Rate for Payer: BCBS of TX PPO	$7.20
Rate for Payer: Cash Price	$12.24
Rate for Payer: Multiplan Auto	$11.70
Rate for Payer: Multiplan Commercial	$11.70
Rate for Payer: Multiplan Workers Comp	$11.70
Rate for Payer: Scott and White EPO/PPO	$9.00
Rate for Payer: Superior Health Plan EPO	$2.45

midodrine 5 mg Tab

Facility

$18.00

Service Code	HCPCS J3490
Hospital Charge Code	77705378
Hospital Revenue Code	250
Rate for Payer: Cash Price	$12.24

Know your out-of-pocket cost for care.

All Charges