White Rock Medical Center

All Charges

Charge

Type

Setting

Price

mineral oil Oral Liquid 30 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77706917
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

mineral oil Oral Liquid 30 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77706917
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Minimum Inhibitory Concentration

Facility

$251.00

Service Code	HCPCS 87186
Hospital Charge Code	4157186
Hospital Revenue Code	306
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$180.72
Rate for Payer: Amerigroup CHIP/Medicaid	$3.37
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.65
Rate for Payer: Amerigroup Medicare	$8.65
Rate for Payer: BCBS of TX Blue Advantage	$75.30
Rate for Payer: BCBS of TX Blue Essentials	$90.36
Rate for Payer: BCBS of TX Medicare	$8.65
Rate for Payer: BCBS of TX PPO	$100.40
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cigna Medicaid	$180.72
Rate for Payer: Cigna Medicare	$8.65
Rate for Payer: Employer Direct Commercial	$8.65
Rate for Payer: Humana Medicare/TRICARE	$8.65
Rate for Payer: Molina CHIP/Medicaid	$180.72
Rate for Payer: Molina Dual Medicare/Medicaid	$8.65
Rate for Payer: Molina Medicare	$8.65
Rate for Payer: Multiplan Auto	$163.15
Rate for Payer: Multiplan Commercial	$163.15
Rate for Payer: Multiplan Workers Comp	$163.15
Rate for Payer: Parkland Medicaid	$180.72
Rate for Payer: Scott and White EPO/PPO	$10.81
Rate for Payer: Scott and White Medicare	$8.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.72
Rate for Payer: Superior Health Plan EPO	$8.65
Rate for Payer: Superior Health Plan Medicare	$8.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.65
Rate for Payer: Universal American Medicare	$8.65
Rate for Payer: Wellcare Medicare	$8.65
Rate for Payer: Wellmed Medicare	$8.65

Minimum Inhibitory Concentration

Facility

$251.00

Service Code	HCPCS 87186
Hospital Charge Code	4157186
Hospital Revenue Code	306
Rate for Payer: Cash Price	$170.68

MINOR BLADDER PROCEDURES W CC

Facility

$28,883.80

Service Code	MSDRG 663
Min. Negotiated Rate	$13,301.75
Max. Negotiated Rate	$28,883.80
Rate for Payer: BCBS of TX Blue Advantage	$14,106.58
Rate for Payer: BCBS of TX Blue Essentials	$16,926.26
Rate for Payer: BCBS of TX PPO	$18,807.68

MINOR BLADDER PROCEDURES WITH CC

Facility

$28,883.80

Service Code	MSDRG 663
Min. Negotiated Rate	$13,301.75
Max. Negotiated Rate	$28,883.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,901.67
Rate for Payer: Amerigroup Medicare	$15,901.67
Rate for Payer: BCBS of TX Medicare	$15,901.67
Rate for Payer: Cigna Commercial	$19,580.18
Rate for Payer: Cigna Medicare	$15,901.67
Rate for Payer: Employer Direct Commercial	$15,901.67
Rate for Payer: Humana Medicare/TRICARE	$15,901.67
Rate for Payer: Molina Dual Medicare/Medicaid	$15,901.67
Rate for Payer: Molina Medicare	$15,901.67
Rate for Payer: Multiplan Auto	$28,883.80
Rate for Payer: Multiplan Commercial	$28,883.80
Rate for Payer: Multiplan Workers Comp	$28,883.80
Rate for Payer: Scott and White EPO/PPO	$13,301.75
Rate for Payer: Scott and White Medicare	$15,901.67
Rate for Payer: Superior Health Plan EPO	$15,901.67
Rate for Payer: Superior Health Plan Medicare	$15,901.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,901.67
Rate for Payer: Universal American Medicare	$15,901.67
Rate for Payer: Wellcare Medicare	$15,901.67
Rate for Payer: Wellmed Medicare	$15,901.67

MINOR BLADDER PROCEDURES WITH MCC

Facility

$58,168.50

Service Code	MSDRG 662
Min. Negotiated Rate	$26,788.12
Max. Negotiated Rate	$58,168.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27,197.90
Rate for Payer: Amerigroup Medicare	$27,197.90
Rate for Payer: BCBS of TX Medicare	$27,197.90
Rate for Payer: Cigna Commercial	$39,432.12
Rate for Payer: Cigna Medicare	$27,197.90
Rate for Payer: Employer Direct Commercial	$27,197.90
Rate for Payer: Humana Medicare/TRICARE	$27,197.90
Rate for Payer: Molina Dual Medicare/Medicaid	$27,197.90
Rate for Payer: Molina Medicare	$27,197.90
Rate for Payer: Multiplan Auto	$58,168.50
Rate for Payer: Multiplan Commercial	$58,168.50
Rate for Payer: Multiplan Workers Comp	$58,168.50
Rate for Payer: Scott and White EPO/PPO	$26,788.12
Rate for Payer: Scott and White Medicare	$27,197.90
Rate for Payer: Superior Health Plan EPO	$27,197.90
Rate for Payer: Superior Health Plan Medicare	$27,197.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$27,197.90
Rate for Payer: Universal American Medicare	$27,197.90
Rate for Payer: Wellcare Medicare	$27,197.90
Rate for Payer: Wellmed Medicare	$27,197.90

MINOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$19,891.10

Service Code	MSDRG 664
Min. Negotiated Rate	$9,160.38
Max. Negotiated Rate	$19,891.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,432.83
Rate for Payer: Amerigroup Medicare	$12,432.83
Rate for Payer: BCBS of TX Medicare	$12,432.83
Rate for Payer: Cigna Commercial	$13,484.07
Rate for Payer: Cigna Medicare	$12,432.83
Rate for Payer: Employer Direct Commercial	$12,432.83
Rate for Payer: Humana Medicare/TRICARE	$12,432.83
Rate for Payer: Molina Dual Medicare/Medicaid	$12,432.83
Rate for Payer: Molina Medicare	$12,432.83
Rate for Payer: Multiplan Auto	$19,891.10
Rate for Payer: Multiplan Commercial	$19,891.10
Rate for Payer: Multiplan Workers Comp	$19,891.10
Rate for Payer: Scott and White EPO/PPO	$9,160.38
Rate for Payer: Scott and White Medicare	$12,432.83
Rate for Payer: Superior Health Plan EPO	$12,432.83
Rate for Payer: Superior Health Plan Medicare	$12,432.83
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,432.83
Rate for Payer: Universal American Medicare	$12,432.83
Rate for Payer: Wellcare Medicare	$12,432.83
Rate for Payer: Wellmed Medicare	$12,432.83

MINOR BLADDER PROCEDURES W MCC

Facility

$58,168.50

Service Code	MSDRG 662
Min. Negotiated Rate	$26,788.12
Max. Negotiated Rate	$58,168.50
Rate for Payer: BCBS of TX Blue Advantage	$27,336.82
Rate for Payer: BCBS of TX Blue Essentials	$32,801.01
Rate for Payer: BCBS of TX PPO	$36,446.97

MINOR BLADDER PROCEDURES W/O CC/MCC

Facility

$19,891.10

Service Code	MSDRG 664
Min. Negotiated Rate	$9,160.38
Max. Negotiated Rate	$19,891.10
Rate for Payer: BCBS of TX Blue Advantage	$10,197.02
Rate for Payer: BCBS of TX Blue Essentials	$12,235.24
Rate for Payer: BCBS of TX PPO	$13,595.24

MINOR SKIN DISORDERS WITH MCC

Facility

$28,750.80

Service Code	MSDRG 606
Min. Negotiated Rate	$11,874.88
Max. Negotiated Rate	$28,750.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,850.37
Rate for Payer: Amerigroup Medicare	$15,850.37
Rate for Payer: BCBS of TX Medicare	$15,850.37
Rate for Payer: Cigna Commercial	$19,490.02
Rate for Payer: Cigna Medicare	$15,850.37
Rate for Payer: Employer Direct Commercial	$15,850.37
Rate for Payer: Humana Medicare/TRICARE	$15,850.37
Rate for Payer: Molina Dual Medicare/Medicaid	$15,850.37
Rate for Payer: Molina Medicare	$15,850.37
Rate for Payer: Multiplan Auto	$28,750.80
Rate for Payer: Multiplan Commercial	$28,750.80
Rate for Payer: Multiplan Workers Comp	$28,750.80
Rate for Payer: Scott and White EPO/PPO	$13,240.50
Rate for Payer: Scott and White Medicare	$15,850.37
Rate for Payer: Superior Health Plan EPO	$15,850.37
Rate for Payer: Superior Health Plan Medicare	$15,850.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,850.37
Rate for Payer: Universal American Medicare	$15,850.37
Rate for Payer: Wellcare Medicare	$15,850.37
Rate for Payer: Wellmed Medicare	$15,850.37

MINOR SKIN DISORDERS WITHOUT MCC

Facility

$17,221.60

Service Code	MSDRG 607
Min. Negotiated Rate	$6,888.60
Max. Negotiated Rate	$17,221.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,403.11
Rate for Payer: Amerigroup Medicare	$11,403.11
Rate for Payer: BCBS of TX Medicare	$11,403.11
Rate for Payer: Cigna Commercial	$11,674.43
Rate for Payer: Cigna Medicare	$11,403.11
Rate for Payer: Employer Direct Commercial	$11,403.11
Rate for Payer: Humana Medicare/TRICARE	$11,403.11
Rate for Payer: Molina Dual Medicare/Medicaid	$11,403.11
Rate for Payer: Molina Medicare	$11,403.11
Rate for Payer: Multiplan Auto	$17,221.60
Rate for Payer: Multiplan Commercial	$17,221.60
Rate for Payer: Multiplan Workers Comp	$17,221.60
Rate for Payer: Scott and White EPO/PPO	$7,931.00
Rate for Payer: Scott and White Medicare	$11,403.11
Rate for Payer: Superior Health Plan EPO	$11,403.11
Rate for Payer: Superior Health Plan Medicare	$11,403.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,403.11
Rate for Payer: Universal American Medicare	$11,403.11
Rate for Payer: Wellcare Medicare	$11,403.11
Rate for Payer: Wellmed Medicare	$11,403.11

MINOR SKIN DISORDERS W MCC

Facility

$28,750.80

Service Code	MSDRG 606
Min. Negotiated Rate	$11,874.88
Max. Negotiated Rate	$28,750.80
Rate for Payer: BCBS of TX Blue Advantage	$11,874.88
Rate for Payer: BCBS of TX Blue Essentials	$14,248.48
Rate for Payer: BCBS of TX PPO	$15,832.25

MINOR SKIN DISORDERS W/O MCC

Facility

$17,221.60

Service Code	MSDRG 607
Min. Negotiated Rate	$6,888.60
Max. Negotiated Rate	$17,221.60
Rate for Payer: BCBS of TX Blue Advantage	$6,888.60
Rate for Payer: BCBS of TX Blue Essentials	$8,265.52
Rate for Payer: BCBS of TX PPO	$9,184.27

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC

Facility

$28,589.30

Service Code	MSDRG 345
Min. Negotiated Rate	$13,166.12
Max. Negotiated Rate	$28,589.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,788.07
Rate for Payer: Amerigroup Medicare	$15,788.07
Rate for Payer: BCBS of TX Medicare	$15,788.07
Rate for Payer: Cigna Commercial	$19,380.54
Rate for Payer: Cigna Medicare	$15,788.07
Rate for Payer: Employer Direct Commercial	$15,788.07
Rate for Payer: Humana Medicare/TRICARE	$15,788.07
Rate for Payer: Molina Dual Medicare/Medicaid	$15,788.07
Rate for Payer: Molina Medicare	$15,788.07
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	$15,788.07
Rate for Payer: Superior Health Plan EPO	$15,788.07
Rate for Payer: Superior Health Plan Medicare	$15,788.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,788.07
Rate for Payer: Universal American Medicare	$15,788.07
Rate for Payer: Wellcare Medicare	$15,788.07
Rate for Payer: Wellmed Medicare	$15,788.07

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC

Facility

$49,073.20

Service Code	MSDRG 344
Min. Negotiated Rate	$22,599.50
Max. Negotiated Rate	$49,073.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,689.49
Rate for Payer: Amerigroup Medicare	$23,689.49
Rate for Payer: BCBS of TX Medicare	$23,689.49
Rate for Payer: Cigna Commercial	$33,266.46
Rate for Payer: Cigna Medicare	$23,689.49
Rate for Payer: Employer Direct Commercial	$23,689.49
Rate for Payer: Humana Medicare/TRICARE	$23,689.49
Rate for Payer: Molina Dual Medicare/Medicaid	$23,689.49
Rate for Payer: Molina Medicare	$23,689.49
Rate for Payer: Multiplan Auto	$49,073.20
Rate for Payer: Multiplan Commercial	$49,073.20
Rate for Payer: Multiplan Workers Comp	$49,073.20
Rate for Payer: Scott and White EPO/PPO	$22,599.50
Rate for Payer: Scott and White Medicare	$23,689.49
Rate for Payer: Superior Health Plan EPO	$23,689.49
Rate for Payer: Superior Health Plan Medicare	$23,689.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,689.49
Rate for Payer: Universal American Medicare	$23,689.49
Rate for Payer: Wellcare Medicare	$23,689.49
Rate for Payer: Wellmed Medicare	$23,689.49

MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC

Facility

$22,537.80

Service Code	MSDRG 346
Min. Negotiated Rate	$10,379.25
Max. Negotiated Rate	$22,537.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,453.78
Rate for Payer: Amerigroup Medicare	$13,453.78
Rate for Payer: BCBS of TX Medicare	$13,453.78
Rate for Payer: Cigna Commercial	$15,278.26
Rate for Payer: Cigna Medicare	$13,453.78
Rate for Payer: Employer Direct Commercial	$13,453.78
Rate for Payer: Humana Medicare/TRICARE	$13,453.78
Rate for Payer: Molina Dual Medicare/Medicaid	$13,453.78
Rate for Payer: Molina Medicare	$13,453.78
Rate for Payer: Multiplan Auto	$22,537.80
Rate for Payer: Multiplan Commercial	$22,537.80
Rate for Payer: Multiplan Workers Comp	$22,537.80
Rate for Payer: Scott and White EPO/PPO	$10,379.25
Rate for Payer: Scott and White Medicare	$13,453.78
Rate for Payer: Superior Health Plan EPO	$13,453.78
Rate for Payer: Superior Health Plan Medicare	$13,453.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,453.78
Rate for Payer: Universal American Medicare	$13,453.78
Rate for Payer: Wellcare Medicare	$13,453.78
Rate for Payer: Wellmed Medicare	$13,453.78

MINOR SMALL & LARGE BOWEL PROCEDURES W CC

Facility

$28,589.30

Service Code	MSDRG 345
Min. Negotiated Rate	$13,166.12
Max. Negotiated Rate	$28,589.30
Rate for Payer: BCBS of TX Blue Advantage	$14,083.36
Rate for Payer: BCBS of TX Blue Essentials	$16,898.39
Rate for Payer: BCBS of TX PPO	$18,776.72

MINOR SMALL & LARGE BOWEL PROCEDURES W MCC

Facility

$49,073.20

Service Code	MSDRG 344
Min. Negotiated Rate	$22,599.50
Max. Negotiated Rate	$49,073.20
Rate for Payer: BCBS of TX Blue Advantage	$25,689.92
Rate for Payer: BCBS of TX Blue Essentials	$30,824.92
Rate for Payer: BCBS of TX PPO	$34,251.24

MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC

Facility

$22,537.80

Service Code	MSDRG 346
Min. Negotiated Rate	$10,379.25
Max. Negotiated Rate	$22,537.80
Rate for Payer: BCBS of TX Blue Advantage	$10,634.76
Rate for Payer: BCBS of TX Blue Essentials	$12,760.48
Rate for Payer: BCBS of TX PPO	$14,178.86

minoxidil 2.5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77708261
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

minoxidil 2.5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77708261
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

mirtazapine 15 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77708620
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

mirtazapine 15 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77708620
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

MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC

Facility

$25,376.40

Service Code	MSDRG 640
Min. Negotiated Rate	$10,235.72
Max. Negotiated Rate	$25,376.40
Rate for Payer: BCBS of TX Blue Advantage	$10,235.72
Rate for Payer: BCBS of TX Blue Essentials	$12,281.67
Rate for Payer: BCBS of TX PPO	$13,646.83

Know your out-of-pocket cost for care.

All Charges