White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Microfilter CO2 Sampling & O2 Cannula

Facility

$10.52

Hospital Charge Code	993269
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.15

Micropuncture

Facility

$2,753.06

Hospital Charge Code	993752
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,872.08

Micropuncture

Facility

$2,753.06

Hospital Charge Code	993752
Hospital Revenue Code	272
Min. Negotiated Rate	$247.78
Max. Negotiated Rate	$1,982.20
Rate for Payer: Amerigroup CHIP/Medicaid	$247.78
Rate for Payer: BCBS of TX Blue Advantage	$825.92
Rate for Payer: BCBS of TX Blue Essentials	$991.10
Rate for Payer: BCBS of TX PPO	$1,101.22
Rate for Payer: Cash Price	$1,872.08
Rate for Payer: Cigna Medicaid	$1,982.20
Rate for Payer: Molina CHIP/Medicaid	$1,982.20
Rate for Payer: Multiplan Auto	$1,789.49
Rate for Payer: Multiplan Commercial	$1,789.49
Rate for Payer: Multiplan Workers Comp	$1,789.49
Rate for Payer: Parkland Medicaid	$1,982.20
Rate for Payer: Scott and White EPO/PPO	$1,376.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,982.20
Rate for Payer: Superior Health Plan EPO	$374.42

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	$92.16
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: 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

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 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	$92.16
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: 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

midazolam 1 mg/mL PF Inj Soln 5 mL

Facility

$128.00

Service Code	HCPCS J2250
Hospital Charge Code	78404062
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$92.16
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: 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

midazolam 1 mg/mL PF Inj Soln 5 mL

Facility

$128.00

Service Code	HCPCS J2250
Hospital Charge Code	78404062
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 5 mg/mL Inj Soln 10 mL

Facility

$128.00

Service Code	HCPCS J2250
Hospital Charge Code	77704922
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 5 mg/mL Inj Soln 10 mL

Facility

$128.00

Service Code	HCPCS J2250
Hospital Charge Code	77704922
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$92.16
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: 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

midazolam PF 2 mg 2 ml injection

Facility

$128.00

Service Code	HCPCS J2250
Hospital Charge Code	77704029
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$92.16
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: 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

midazolam PF 2 mg 2 ml injection

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

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	$26.64
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: Cigna Medicaid	$26.64
Rate for Payer: Molina CHIP/Medicaid	$26.64
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: Parkland Medicaid	$26.64
Rate for Payer: Scott and White EPO/PPO	$18.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.64
Rate for Payer: Superior Health Plan EPO	$5.03

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 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	$12.96
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: Cigna Medicaid	$12.96
Rate for Payer: Molina CHIP/Medicaid	$12.96
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: Parkland Medicaid	$12.96
Rate for Payer: Scott and White EPO/PPO	$9.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.96
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

MI Fusion, Sacroiliac Joint

Facility

$95,208.78

Service Code	HCPCS 27279
Hospital Charge Code	9900386
Hospital Revenue Code	360
Rate for Payer: Cash Price	$64,741.97

MI Fusion, Sacroiliac Joint

Facility

$40,184.12

Service Code	CPT 27279
Hospital Charge Code	36027279
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$40,184.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,613.72
Rate for Payer: Amerigroup Medicare	$17,613.72
Rate for Payer: BCBS of TX Blue Advantage	$26,629.95
Rate for Payer: BCBS of TX Blue Essentials	$31,892.16
Rate for Payer: BCBS of TX Medicare	$17,613.72
Rate for Payer: BCBS of TX PPO	$40,184.12
Rate for Payer: Cigna Commercial	$37,232.21
Rate for Payer: Cigna Medicare	$17,613.72
Rate for Payer: Employer Direct Commercial	$17,613.72
Rate for Payer: Humana Medicare/TRICARE	$17,613.72
Rate for Payer: Molina Dual Medicare/Medicaid	$17,613.72
Rate for Payer: Molina Medicare	$17,613.72
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: Scott and White EPO/PPO	$31,530.55
Rate for Payer: Scott and White Medicare	$17,613.72
Rate for Payer: Superior Health Plan EPO	$17,613.72
Rate for Payer: Superior Health Plan Medicare	$17,613.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,613.72
Rate for Payer: Universal American Medicare	$17,613.72
Rate for Payer: Wellcare Medicare	$17,613.72
Rate for Payer: Wellmed Medicare	$17,613.72

MI Fusion, Sacroiliac Joint

Facility

$95,208.78

Service Code	HCPCS 27279
Hospital Charge Code	9900386
Hospital Revenue Code	360
Min. Negotiated Rate	$8,568.79
Max. Negotiated Rate	$68,550.32
Rate for Payer: Amerigroup CHIP/Medicaid	$8,568.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,613.72
Rate for Payer: Amerigroup Medicare	$17,613.72
Rate for Payer: BCBS of TX Blue Advantage	$26,629.95
Rate for Payer: BCBS of TX Blue Essentials	$31,892.16
Rate for Payer: BCBS of TX Medicare	$17,613.72
Rate for Payer: BCBS of TX PPO	$40,184.12
Rate for Payer: Cash Price	$64,741.97
Rate for Payer: Cash Price	$64,741.97
Rate for Payer: Cash Price	$64,741.97
Rate for Payer: Cigna Commercial	$37,232.21
Rate for Payer: Cigna Medicaid	$68,550.32
Rate for Payer: Cigna Medicare	$17,613.72
Rate for Payer: Employer Direct Commercial	$17,613.72
Rate for Payer: Humana Medicare/TRICARE	$17,613.72
Rate for Payer: Molina CHIP/Medicaid	$68,550.32
Rate for Payer: Molina Dual Medicare/Medicaid	$17,613.72
Rate for Payer: Molina Medicare	$17,613.72
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	$68,550.32
Rate for Payer: Scott and White EPO/PPO	$31,530.55
Rate for Payer: Scott and White Medicare	$17,613.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$68,550.32
Rate for Payer: Superior Health Plan EPO	$17,613.72
Rate for Payer: Superior Health Plan Medicare	$17,613.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,613.72
Rate for Payer: Universal American Medicare	$17,613.72
Rate for Payer: Wellcare Medicare	$17,613.72
Rate for Payer: Wellmed Medicare	$17,613.72

MIGRAINE AND OTHER HEADACHES

Facility

$9,599.08

Service Code	APR-DRG 0544
Min. Negotiated Rate	$9,050.35
Max. Negotiated Rate	$9,599.08
Rate for Payer: Amerigroup CHIP/Medicaid	$9,050.35
Rate for Payer: Cigna Medicaid	$9,050.35
Rate for Payer: Molina CHIP/Medicaid	$9,050.35
Rate for Payer: Parkland Medicaid	$9,050.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,599.08

MIGRAINE AND OTHER HEADACHES

Facility

$4,293.54

Service Code	APR-DRG 0543
Min. Negotiated Rate	$4,048.10
Max. Negotiated Rate	$4,293.54
Rate for Payer: Amerigroup CHIP/Medicaid	$4,048.10
Rate for Payer: Cigna Medicaid	$4,048.10
Rate for Payer: Molina CHIP/Medicaid	$4,048.10
Rate for Payer: Parkland Medicaid	$4,048.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,293.54

MIGRAINE AND OTHER HEADACHES

Facility

$2,698.79

Service Code	APR-DRG 0541
Min. Negotiated Rate	$2,544.51
Max. Negotiated Rate	$2,698.79
Rate for Payer: Amerigroup CHIP/Medicaid	$2,544.51
Rate for Payer: Cigna Medicaid	$2,544.51
Rate for Payer: Molina CHIP/Medicaid	$2,544.51
Rate for Payer: Parkland Medicaid	$2,544.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,698.79

MIGRAINE AND OTHER HEADACHES

Facility

$3,370.94

Service Code	APR-DRG 0542
Min. Negotiated Rate	$3,178.24
Max. Negotiated Rate	$3,370.94
Rate for Payer: Amerigroup CHIP/Medicaid	$3,178.24
Rate for Payer: Cigna Medicaid	$3,178.24
Rate for Payer: Molina CHIP/Medicaid	$3,178.24
Rate for Payer: Parkland Medicaid	$3,178.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,370.94

mild bowl cleaner

Facility

$11.17

Hospital Charge Code	993364
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.60

Know your out-of-pocket cost for care.

All Charges