White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MESH SYMBOTEX COMPOSITE 9 CM

Facility

$1,804.92

Service Code	HCPCS C1781
Hospital Charge Code	81420804
Hospital Revenue Code	272
Min. Negotiated Rate	$162.44
Max. Negotiated Rate	$1,299.54
Rate for Payer: Amerigroup CHIP/Medicaid	$162.44
Rate for Payer: BCBS of TX Blue Advantage	$541.48
Rate for Payer: BCBS of TX Blue Essentials	$649.77
Rate for Payer: BCBS of TX PPO	$721.97
Rate for Payer: Cash Price	$1,227.35
Rate for Payer: Cigna Medicaid	$1,299.54
Rate for Payer: Molina CHIP/Medicaid	$1,299.54
Rate for Payer: Multiplan Auto	$1,173.20
Rate for Payer: Multiplan Commercial	$1,173.20
Rate for Payer: Multiplan Workers Comp	$1,173.20
Rate for Payer: Parkland Medicaid	$1,299.54
Rate for Payer: Scott and White EPO/PPO	$902.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,299.54
Rate for Payer: Superior Health Plan EPO	$245.47

MESH VENTRALEX ST MED CIRCLE

Facility

$4,858.00

Service Code	HCPCS C1781
Hospital Charge Code	8538530
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,303.44

MESH VENTRALEX ST MED CIRCLE

Facility

$4,858.00

Service Code	HCPCS C1781
Hospital Charge Code	8538530
Hospital Revenue Code	272
Min. Negotiated Rate	$437.22
Max. Negotiated Rate	$3,497.76
Rate for Payer: Amerigroup CHIP/Medicaid	$437.22
Rate for Payer: BCBS of TX Blue Advantage	$1,457.40
Rate for Payer: BCBS of TX Blue Essentials	$1,748.88
Rate for Payer: BCBS of TX PPO	$1,943.20
Rate for Payer: Cash Price	$3,303.44
Rate for Payer: Cigna Medicaid	$3,497.76
Rate for Payer: Molina CHIP/Medicaid	$3,497.76
Rate for Payer: Multiplan Auto	$3,157.70
Rate for Payer: Multiplan Commercial	$3,157.70
Rate for Payer: Multiplan Workers Comp	$3,157.70
Rate for Payer: Parkland Medicaid	$3,497.76
Rate for Payer: Scott and White EPO/PPO	$2,429.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,497.76
Rate for Payer: Superior Health Plan EPO	$660.69

Metanephrines, Frac., Pl. Free SO

Facility

$285.00

Service Code	HCPCS 83835
Hospital Charge Code	1702117
Hospital Revenue Code	301
Rate for Payer: Cash Price	$193.80

Metanephrines, Frac., Pl. Free SO

Facility

$285.00

Service Code	HCPCS 83835
Hospital Charge Code	1702117
Hospital Revenue Code	301
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$205.20
Rate for Payer: Amerigroup CHIP/Medicaid	$6.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.94
Rate for Payer: Amerigroup Medicare	$16.94
Rate for Payer: BCBS of TX Blue Advantage	$85.50
Rate for Payer: BCBS of TX Blue Essentials	$102.60
Rate for Payer: BCBS of TX Medicare	$16.94
Rate for Payer: BCBS of TX PPO	$114.00
Rate for Payer: Cash Price	$193.80
Rate for Payer: Cash Price	$193.80
Rate for Payer: Cigna Medicaid	$205.20
Rate for Payer: Cigna Medicare	$16.94
Rate for Payer: Employer Direct Commercial	$16.94
Rate for Payer: Humana Medicare/TRICARE	$16.94
Rate for Payer: Molina CHIP/Medicaid	$205.20
Rate for Payer: Molina Dual Medicare/Medicaid	$16.94
Rate for Payer: Molina Medicare	$16.94
Rate for Payer: Multiplan Auto	$185.25
Rate for Payer: Multiplan Commercial	$185.25
Rate for Payer: Multiplan Workers Comp	$185.25
Rate for Payer: Parkland Medicaid	$205.20
Rate for Payer: Scott and White EPO/PPO	$21.18
Rate for Payer: Scott and White Medicare	$16.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$205.20
Rate for Payer: Superior Health Plan EPO	$16.94
Rate for Payer: Superior Health Plan Medicare	$16.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.94
Rate for Payer: Universal American Medicare	$16.94
Rate for Payer: Wellcare Medicare	$16.94
Rate for Payer: Wellmed Medicare	$16.94

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	$5.76
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: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
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 5 mg Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77689155
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
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: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

methadone 5 mg Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77689155
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Methemoglobin

Facility

$131.00

Service Code	HCPCS 83050
Hospital Charge Code	4049193
Hospital Revenue Code	301
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$94.32
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	$39.30
Rate for Payer: BCBS of TX Blue Essentials	$47.16
Rate for Payer: BCBS of TX Medicare	$8.20
Rate for Payer: BCBS of TX PPO	$52.40
Rate for Payer: Cash Price	$89.08
Rate for Payer: Cash Price	$89.08
Rate for Payer: Cigna Medicaid	$94.32
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	$94.32
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	$94.32
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	$94.32
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

Methemoglobin

Facility

$131.00

Service Code	HCPCS 83050
Hospital Charge Code	4049193
Hospital Revenue Code	301
Rate for Payer: Cash Price	$89.08

Methicillin Resistant Staph Screen

Facility

$229.00

Service Code	HCPCS 87081
Hospital Charge Code	4107053
Hospital Revenue Code	306
Rate for Payer: Cash Price	$155.72

Methicillin Resistant Staph Screen

Facility

$229.00

Service Code	HCPCS 87081
Hospital Charge Code	4108781
Hospital Revenue Code	306
Rate for Payer: Cash Price	$155.72

Methicillin Resistant Staph Screen

Facility

$229.00

Service Code	HCPCS 87081
Hospital Charge Code	4107053
Hospital Revenue Code	306
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$164.88
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	$68.70
Rate for Payer: BCBS of TX Blue Essentials	$82.44
Rate for Payer: BCBS of TX Medicare	$6.63
Rate for Payer: BCBS of TX PPO	$91.60
Rate for Payer: Cash Price	$155.72
Rate for Payer: Cash Price	$155.72
Rate for Payer: Cigna Medicaid	$164.88
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	$164.88
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	$164.88
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	$164.88
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	HCPCS 87081
Hospital Charge Code	4108781
Hospital Revenue Code	306
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$164.88
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	$68.70
Rate for Payer: BCBS of TX Blue Essentials	$82.44
Rate for Payer: BCBS of TX Medicare	$6.63
Rate for Payer: BCBS of TX PPO	$91.60
Rate for Payer: Cash Price	$155.72
Rate for Payer: Cash Price	$155.72
Rate for Payer: Cigna Medicaid	$164.88
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	$164.88
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	$164.88
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	$164.88
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

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	$92.16
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: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
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: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

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 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	$5.76
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: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
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	$5.76
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: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
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	$1.68
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.81
Rate for Payer: Amerigroup Medicare	$9.81
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	$9.81
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 Medicaid	$92.16
Rate for Payer: Cigna Medicare	$9.81
Rate for Payer: Employer Direct Commercial	$9.81
Rate for Payer: Humana Medicare/TRICARE	$9.81
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Molina Dual Medicare/Medicaid	$9.81
Rate for Payer: Molina Medicare	$9.81
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: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Scott and White Medicare	$9.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$9.81
Rate for Payer: Superior Health Plan Medicare	$9.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.81
Rate for Payer: Universal American Medicare	$9.81
Rate for Payer: Wellcare Medicare	$9.81
Rate for Payer: Wellmed Medicare	$9.81

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

METHYLERGONOVINE MAL 0.2MG

Facility

$128.00

Service Code	HCPCS J2210
Hospital Charge Code	77695092
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

METHYLERGONOVINE MAL 0.2MG

Facility

$128.00

Service Code	HCPCS J2210
Hospital Charge Code	77695092
Hospital Revenue Code	636
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$19.81
Rate for Payer: BCBS of TX Blue Essentials	$23.77
Rate for Payer: BCBS of TX PPO	$26.36
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
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: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

Know your out-of-pocket cost for care.

All Charges