White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MOIST DRML -- DHF

Facility

$53.71

Hospital Charge Code	80327059
Hospital Revenue Code	270
Min. Negotiated Rate	$4.83
Max. Negotiated Rate	$34.91
Rate for Payer: Aetna Commercial	$29.54
Rate for Payer: Amerigroup CHIP/Medicaid	$4.83
Rate for Payer: BCBS of TX Blue Advantage	$16.11
Rate for Payer: BCBS of TX Blue Essentials	$19.34
Rate for Payer: BCBS of TX PPO	$21.48
Rate for Payer: Cash Price	$47.26
Rate for Payer: Multiplan Auto	$34.91
Rate for Payer: Multiplan Commercial	$34.91
Rate for Payer: Multiplan Workers Comp	$34.91
Rate for Payer: Scott and White EPO/PPO	$26.86
Rate for Payer: Superior Health Plan EPO	$7.30

MOIST DRML -- DHF

Facility

$53.71

Hospital Charge Code	80327059
Hospital Revenue Code	270
Rate for Payer: Cash Price	$47.26

Monkeypox (Orthopoxvirus), PCR SO

Facility

$353.53

Service Code	CPT 87798
Hospital Charge Code	8918553
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$229.79
Rate for Payer: Aetna Commercial	$36.84
Rate for Payer: Aetna Medicare	$52.64
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$57.90
Rate for Payer: BCBS of TX Blue Essentials	$69.48
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$77.55
Rate for Payer: Cash Price	$311.11
Rate for Payer: Cash Price	$311.11
Rate for Payer: Cigna Medicaid	$35.09
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$35.09
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$229.79
Rate for Payer: Multiplan Commercial	$229.79
Rate for Payer: Multiplan Workers Comp	$229.79
Rate for Payer: Parkland Medicaid	$35.09
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.09
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

Monkeypox (Orthopoxvirus), PCR SO

Facility

$353.53

Service Code	CPT 87798
Hospital Charge Code	8918553
Hospital Revenue Code	306
Rate for Payer: Cash Price	$311.11

Mononucleosis Screen

Facility

$156.00

Service Code	CPT 86308
Hospital Charge Code	1605435
Hospital Revenue Code	302
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$101.40
Rate for Payer: Aetna Commercial	$5.44
Rate for Payer: Aetna Medicare	$7.77
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$8.55
Rate for Payer: BCBS of TX Blue Essentials	$10.26
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$11.45
Rate for Payer: Cash Price	$137.28
Rate for Payer: Cash Price	$137.28
Rate for Payer: Cigna Medicaid	$5.18
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$5.18
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$101.40
Rate for Payer: Multiplan Commercial	$101.40
Rate for Payer: Multiplan Workers Comp	$101.40
Rate for Payer: Parkland Medicaid	$5.18
Rate for Payer: Scott and White EPO/PPO	$6.48
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.18
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

Mononucleosis Screen

Facility

$156.00

Service Code	CPT 86308
Hospital Charge Code	1605435
Hospital Revenue Code	302
Rate for Payer: Cash Price	$137.28

montelukast 10 mg Tab

Facility

$22.00

Service Code	HCPCS J3490
Hospital Charge Code	77710171
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.96

montelukast 10 mg Tab

Facility

$22.00

Service Code	HCPCS J3490
Hospital Charge Code	77710171
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$14.30
Rate for Payer: Amerigroup CHIP/Medicaid	$1.98
Rate for Payer: BCBS of TX Blue Advantage	$6.60
Rate for Payer: BCBS of TX Blue Essentials	$7.92
Rate for Payer: BCBS of TX PPO	$8.80
Rate for Payer: Cash Price	$14.96
Rate for Payer: Multiplan Auto	$14.30
Rate for Payer: Multiplan Commercial	$14.30
Rate for Payer: Multiplan Workers Comp	$14.30
Rate for Payer: Scott and White EPO/PPO	$11.00
Rate for Payer: Superior Health Plan EPO	$2.99

morphine 1 mg/mL Inj Soln 30 mL

Facility

$128.00

Service Code	HCPCS J2274
Hospital Charge Code	77710558
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

morphine 1 mg/mL Inj Soln 30 mL

Facility

$128.00

Service Code	HCPCS J2274
Hospital Charge Code	77710558
Hospital Revenue Code	636
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$6.76
Rate for Payer: BCBS of TX Blue Essentials	$8.11
Rate for Payer: BCBS of TX PPO	$8.99
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

morphine 2 mg/mL PF Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2274
Hospital Charge Code	78350877
Hospital Revenue Code	636
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$6.76
Rate for Payer: BCBS of TX Blue Essentials	$8.11
Rate for Payer: BCBS of TX PPO	$8.99
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

morphine 2 mg/mL PF Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2274
Hospital Charge Code	78350877
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

morphine 2 mg/mL preservative-free IV Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2274
Hospital Charge Code	77712550
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

morphine 2 mg/mL preservative-free IV Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2274
Hospital Charge Code	77712550
Hospital Revenue Code	636
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$6.76
Rate for Payer: BCBS of TX Blue Essentials	$8.11
Rate for Payer: BCBS of TX PPO	$8.99
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

morphine 4 mg/mL PF IV Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2274
Hospital Charge Code	77714056
Hospital Revenue Code	636
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$6.76
Rate for Payer: BCBS of TX Blue Essentials	$8.11
Rate for Payer: BCBS of TX PPO	$8.99
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

morphine 4 mg/mL PF IV Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2274
Hospital Charge Code	77714056
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

.Morphology

Facility

$73.00

Service Code	CPT 85008
Hospital Charge Code	1600428
Hospital Revenue Code	305
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$47.45
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: Aetna Medicare	$5.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.43
Rate for Payer: Amerigroup Medicare	$3.43
Rate for Payer: BCBS of TX Blue Advantage	$5.66
Rate for Payer: BCBS of TX Blue Essentials	$6.79
Rate for Payer: BCBS of TX Medicare	$3.43
Rate for Payer: BCBS of TX PPO	$7.58
Rate for Payer: Cash Price	$64.24
Rate for Payer: Cash Price	$64.24
Rate for Payer: Cigna Medicaid	$3.43
Rate for Payer: Cigna Medicare	$3.43
Rate for Payer: Employer Direct Commercial	$3.43
Rate for Payer: Humana Medicare/TRICARE	$3.43
Rate for Payer: Molina CHIP/Medicaid	$3.43
Rate for Payer: Molina Dual Medicare/Medicaid	$3.43
Rate for Payer: Molina Medicare	$3.43
Rate for Payer: Multiplan Auto	$47.45
Rate for Payer: Multiplan Commercial	$47.45
Rate for Payer: Multiplan Workers Comp	$47.45
Rate for Payer: Parkland Medicaid	$3.43
Rate for Payer: Scott and White EPO/PPO	$4.29
Rate for Payer: Scott and White Medicare	$3.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.43
Rate for Payer: Superior Health Plan EPO	$3.43
Rate for Payer: Superior Health Plan Medicare	$3.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.43
Rate for Payer: Universal American Medicare	$3.43
Rate for Payer: Wellcare Medicare	$3.43
Rate for Payer: Wellmed Medicare	$3.43

.Morphology

Facility

$73.00

Service Code	CPT 85008
Hospital Charge Code	1600428
Hospital Revenue Code	305
Rate for Payer: Cash Price	$64.24

MOUTH PROCEDURES WITH CC/MCC

Facility

$28,589.30

Service Code	MSDRG 137
Min. Negotiated Rate	$12,195.66
Max. Negotiated Rate	$28,589.30
Rate for Payer: Aetna Commercial	$16,927.88
Rate for Payer: Aetna Medicare	$20,388.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,592.42
Rate for Payer: Amerigroup Medicare	$13,592.42
Rate for Payer: BCBS of TX Blue Advantage	$12,195.66
Rate for Payer: BCBS of TX Blue Essentials	$14,210.29
Rate for Payer: BCBS of TX Medicare	$13,592.42
Rate for Payer: BCBS of TX PPO	$15,789.83
Rate for Payer: Cigna Commercial	$19,380.54
Rate for Payer: Cigna Medicare	$13,592.42
Rate for Payer: Employer Direct Commercial	$13,592.42
Rate for Payer: Humana Medicare/TRICARE	$13,592.42
Rate for Payer: Molina Dual Medicare/Medicaid	$13,592.42
Rate for Payer: Molina Medicare	$13,592.42
Rate for Payer: Multiplan Auto	$28,589.30
Rate for Payer: Multiplan Commercial	$28,589.30
Rate for Payer: Multiplan Workers Comp	$28,589.30
Rate for Payer: Scott and White EPO/PPO	$13,166.12
Rate for Payer: Scott and White Medicare	$13,592.42
Rate for Payer: Superior Health Plan EPO	$13,592.42
Rate for Payer: Superior Health Plan Medicare	$13,592.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,592.42
Rate for Payer: Universal American Medicare	$13,592.42
Rate for Payer: Wellcare Medicare	$13,592.42
Rate for Payer: Wellmed Medicare	$13,592.42

MOUTH PROCEDURES WITHOUT CC/MCC

Facility

$16,448.30

Service Code	MSDRG 138
Min. Negotiated Rate	$7,273.02
Max. Negotiated Rate	$16,448.30
Rate for Payer: Aetna Commercial	$9,739.12
Rate for Payer: Aetna Medicare	$13,548.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,032.47
Rate for Payer: Amerigroup Medicare	$9,032.47
Rate for Payer: BCBS of TX Blue Advantage	$7,273.02
Rate for Payer: BCBS of TX Blue Essentials	$8,721.62
Rate for Payer: BCBS of TX Medicare	$9,032.47
Rate for Payer: BCBS of TX PPO	$9,691.06
Rate for Payer: Cigna Commercial	$11,150.22
Rate for Payer: Cigna Medicare	$9,032.47
Rate for Payer: Employer Direct Commercial	$9,032.47
Rate for Payer: Humana Medicare/TRICARE	$9,032.47
Rate for Payer: Molina Dual Medicare/Medicaid	$9,032.47
Rate for Payer: Molina Medicare	$9,032.47
Rate for Payer: Multiplan Auto	$16,448.30
Rate for Payer: Multiplan Commercial	$16,448.30
Rate for Payer: Multiplan Workers Comp	$16,448.30
Rate for Payer: Scott and White EPO/PPO	$7,574.88
Rate for Payer: Scott and White Medicare	$9,032.47
Rate for Payer: Superior Health Plan EPO	$9,032.47
Rate for Payer: Superior Health Plan Medicare	$9,032.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,032.47
Rate for Payer: Universal American Medicare	$9,032.47
Rate for Payer: Wellcare Medicare	$9,032.47
Rate for Payer: Wellmed Medicare	$9,032.47

MRA Abdomen w/ Contrast

Facility

$8,435.00

Service Code	CPT 74185
Hospital Charge Code	5258899
Hospital Revenue Code	610
Min. Negotiated Rate	$396.69
Max. Negotiated Rate	$5,482.75
Rate for Payer: Aetna Commercial	$396.69
Rate for Payer: Amerigroup CHIP/Medicaid	$759.15
Rate for Payer: BCBS of TX Blue Advantage	$510.81
Rate for Payer: BCBS of TX Blue Essentials	$612.97
Rate for Payer: BCBS of TX PPO	$684.17
Rate for Payer: Cash Price	$7,422.80
Rate for Payer: Cash Price	$7,422.80
Rate for Payer: Multiplan Auto	$5,482.75
Rate for Payer: Multiplan Commercial	$5,482.75
Rate for Payer: Multiplan Workers Comp	$5,482.75
Rate for Payer: Scott and White EPO/PPO	$4,217.50
Rate for Payer: Superior Health Plan EPO	$1,147.16

MRA Abdomen w/ Contrast BCE

Facility

$8,435.00

Service Code	CPT 74185
Hospital Charge Code	5258899
Hospital Revenue Code	610
Rate for Payer: Cash Price	$7,422.80

MRA Abdomen w/ Contrast BCE

Facility

$8,435.00

Service Code	CPT 74185
Hospital Charge Code	5258899
Hospital Revenue Code	610
Min. Negotiated Rate	$396.69
Max. Negotiated Rate	$5,482.75
Rate for Payer: Aetna Commercial	$396.69
Rate for Payer: Amerigroup CHIP/Medicaid	$759.15
Rate for Payer: BCBS of TX Blue Advantage	$510.81
Rate for Payer: BCBS of TX Blue Essentials	$612.97
Rate for Payer: BCBS of TX PPO	$684.17
Rate for Payer: Cash Price	$7,422.80
Rate for Payer: Cash Price	$7,422.80
Rate for Payer: Multiplan Auto	$5,482.75
Rate for Payer: Multiplan Commercial	$5,482.75
Rate for Payer: Multiplan Workers Comp	$5,482.75
Rate for Payer: Scott and White EPO/PPO	$4,217.50
Rate for Payer: Superior Health Plan EPO	$1,147.16

MRA Abdomen w/o Contrast

Facility

$8,435.00

Service Code	CPT 74185
Hospital Charge Code	3700853
Hospital Revenue Code	610
Min. Negotiated Rate	$396.69
Max. Negotiated Rate	$5,482.75
Rate for Payer: Aetna Commercial	$396.69
Rate for Payer: Amerigroup CHIP/Medicaid	$759.15
Rate for Payer: BCBS of TX Blue Advantage	$510.81
Rate for Payer: BCBS of TX Blue Essentials	$612.97
Rate for Payer: BCBS of TX PPO	$684.17
Rate for Payer: Cash Price	$7,422.80
Rate for Payer: Cash Price	$7,422.80
Rate for Payer: Multiplan Auto	$5,482.75
Rate for Payer: Multiplan Commercial	$5,482.75
Rate for Payer: Multiplan Workers Comp	$5,482.75
Rate for Payer: Scott and White EPO/PPO	$4,217.50
Rate for Payer: Superior Health Plan EPO	$1,147.16

MRA Abdomen w/o Contrast BCE

Facility

$8,435.00

Service Code	CPT 74185
Hospital Charge Code	3700853
Hospital Revenue Code	610
Min. Negotiated Rate	$396.69
Max. Negotiated Rate	$5,482.75
Rate for Payer: Aetna Commercial	$396.69
Rate for Payer: Amerigroup CHIP/Medicaid	$759.15
Rate for Payer: BCBS of TX Blue Advantage	$510.81
Rate for Payer: BCBS of TX Blue Essentials	$612.97
Rate for Payer: BCBS of TX PPO	$684.17
Rate for Payer: Cash Price	$7,422.80
Rate for Payer: Cash Price	$7,422.80
Rate for Payer: Multiplan Auto	$5,482.75
Rate for Payer: Multiplan Commercial	$5,482.75
Rate for Payer: Multiplan Workers Comp	$5,482.75
Rate for Payer: Scott and White EPO/PPO	$4,217.50
Rate for Payer: Superior Health Plan EPO	$1,147.16

Know your out-of-pocket cost for care.

All Charges