White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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	$5.76
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

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 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	$5.76
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

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
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

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 tartrate 50 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77699376
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

metoprolol tartrate 50 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77699376
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

metroNIDAZOLE 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77700039
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

metroNIDAZOLE 250 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77700039
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

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	$0.03
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
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 PPO	$0.04
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

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 Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78402560
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
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

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

MG Breast Biopsy w/ Stereo Guide Left

Facility

$5,741.00

Service Code	HCPCS 19081
Hospital Charge Code	3620223
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
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	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$3,903.88
Rate for Payer: Cash Price	$3,903.88
Rate for Payer: Cash Price	$3,903.88
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,133.52
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$4,133.52
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$4,133.52
Rate for Payer: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,133.52
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

MG Breast Biopsy w/ Stereo Guide Left

Facility

$5,741.00

Service Code	HCPCS 19081
Hospital Charge Code	3620223
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,903.88

MG Breast Biopsy w/ Stereo Guide Right

Facility

$5,741.00

Service Code	HCPCS 19081
Hospital Charge Code	3620221
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,903.88

MG Breast Biopsy w/ Stereo Guide Right

Facility

$5,741.00

Service Code	HCPCS 19081
Hospital Charge Code	3620221
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
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	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$3,903.88
Rate for Payer: Cash Price	$3,903.88
Rate for Payer: Cash Price	$3,903.88
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,133.52
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$4,133.52
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$4,133.52
Rate for Payer: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,133.52
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

MG Breast Tissue Specimen Surgical Right

Facility

$333.00

Service Code	HCPCS 76098
Hospital Charge Code	3600111
Hospital Revenue Code	320
Min. Negotiated Rate	$42.78
Max. Negotiated Rate	$1,160.29
Rate for Payer: Amerigroup CHIP/Medicaid	$42.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$548.90
Rate for Payer: Amerigroup Medicare	$548.90
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	$548.90
Rate for Payer: BCBS of TX PPO	$1,064.29
Rate for Payer: Cash Price	$226.44
Rate for Payer: Cash Price	$226.44
Rate for Payer: Cash Price	$226.44
Rate for Payer: Cigna Commercial	$1,160.29
Rate for Payer: Cigna Medicaid	$239.76
Rate for Payer: Cigna Medicare	$548.90
Rate for Payer: Employer Direct Commercial	$548.90
Rate for Payer: Humana Medicare/TRICARE	$548.90
Rate for Payer: Molina CHIP/Medicaid	$239.76
Rate for Payer: Molina Dual Medicare/Medicaid	$548.90
Rate for Payer: Molina Medicare	$548.90
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	$239.76
Rate for Payer: Scott and White EPO/PPO	$52.65
Rate for Payer: Scott and White Medicare	$548.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$239.76
Rate for Payer: Superior Health Plan EPO	$548.90
Rate for Payer: Superior Health Plan Medicare	$548.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$548.90
Rate for Payer: Universal American Medicare	$548.90
Rate for Payer: Wellcare Medicare	$548.90
Rate for Payer: Wellmed Medicare	$548.90

MG Breast Tissue Specimen Surgical Right

Facility

$333.00

Service Code	HCPCS 76098
Hospital Charge Code	3600111
Hospital Revenue Code	320
Rate for Payer: Cash Price	$226.44

MG Breast Tomo 3D Digital Diag Bilateral

Facility

$218.00

Service Code	HCPCS 77062
Hospital Charge Code	5017062
Hospital Revenue Code	401
Min. Negotiated Rate	$19.62
Max. Negotiated Rate	$207.87
Rate for Payer: Amerigroup CHIP/Medicaid	$19.62
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	$148.24
Rate for Payer: Cash Price	$148.24
Rate for Payer: Cigna Medicaid	$156.96
Rate for Payer: Molina CHIP/Medicaid	$156.96
Rate for Payer: Multiplan Auto	$141.70
Rate for Payer: Multiplan Commercial	$141.70
Rate for Payer: Multiplan Workers Comp	$141.70
Rate for Payer: Parkland Medicaid	$156.96
Rate for Payer: Scott and White EPO/PPO	$109.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$156.96
Rate for Payer: Superior Health Plan EPO	$29.65

MG Breast Tomo 3D Digital Diag Bilateral

Facility

$218.00

Service Code	HCPCS 77062
Hospital Charge Code	5017062
Hospital Revenue Code	401
Rate for Payer: Cash Price	$148.24

MG Breast Tomo 3D Digital Diag Right

Facility

$183.00

Service Code	HCPCS 77061 RT
Hospital Charge Code	5017061
Hospital Revenue Code	401
Rate for Payer: Cash Price	$124.44

MG Breast Tomo 3D Digital Diag Right

Facility

$183.00

Service Code	HCPCS 77061 RT
Hospital Charge Code	5017061
Hospital Revenue Code	401
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$207.87
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
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	$124.44
Rate for Payer: Cash Price	$124.44
Rate for Payer: Cigna Medicaid	$131.76
Rate for Payer: Molina CHIP/Medicaid	$131.76
Rate for Payer: Multiplan Auto	$118.95
Rate for Payer: Multiplan Commercial	$118.95
Rate for Payer: Multiplan Workers Comp	$118.95
Rate for Payer: Parkland Medicaid	$131.76
Rate for Payer: Scott and White EPO/PPO	$91.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.76
Rate for Payer: Superior Health Plan EPO	$24.89

Know your out-of-pocket cost for care.

All Charges