White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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

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

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

Facility

$24,040.70

Service Code	MSDRG 640
Min. Negotiated Rate	$10,235.72
Max. Negotiated Rate	$24,040.70
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

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

Facility

$14,633.80

Service Code	MSDRG 641
Min. Negotiated Rate	$6,466.34
Max. Negotiated Rate	$14,633.80
Rate for Payer: BCBS of TX Blue Advantage	$6,466.34
Rate for Payer: BCBS of TX Blue Essentials	$7,758.86
Rate for Payer: BCBS of TX PPO	$8,621.29

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC

Facility

$24,040.70

Service Code	MSDRG 640
Min. Negotiated Rate	$10,235.72
Max. Negotiated Rate	$24,040.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,548.73
Rate for Payer: Amerigroup Medicare	$14,548.73
Rate for Payer: BCBS of TX Medicare	$14,548.73
Rate for Payer: Cigna Commercial	$17,202.53
Rate for Payer: Cigna Medicare	$14,548.73
Rate for Payer: Employer Direct Commercial	$14,548.73
Rate for Payer: Humana Medicare/TRICARE	$14,548.73
Rate for Payer: Molina Dual Medicare/Medicaid	$14,548.73
Rate for Payer: Molina Medicare	$14,548.73
Rate for Payer: Multiplan Auto	$24,040.70
Rate for Payer: Multiplan Commercial	$24,040.70
Rate for Payer: Multiplan Workers Comp	$24,040.70
Rate for Payer: Scott and White EPO/PPO	$11,071.38
Rate for Payer: Scott and White Medicare	$14,548.73
Rate for Payer: Superior Health Plan EPO	$14,548.73
Rate for Payer: Superior Health Plan Medicare	$14,548.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,548.73
Rate for Payer: Universal American Medicare	$14,548.73
Rate for Payer: Wellcare Medicare	$14,548.73
Rate for Payer: Wellmed Medicare	$14,548.73

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC

Facility

$14,633.80

Service Code	MSDRG 641
Min. Negotiated Rate	$6,466.34
Max. Negotiated Rate	$14,633.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,463.53
Rate for Payer: Amerigroup Medicare	$10,463.53
Rate for Payer: BCBS of TX Medicare	$10,463.53
Rate for Payer: Cigna Commercial	$10,023.22
Rate for Payer: Cigna Medicare	$10,463.53
Rate for Payer: Employer Direct Commercial	$10,463.53
Rate for Payer: Humana Medicare/TRICARE	$10,463.53
Rate for Payer: Molina Dual Medicare/Medicaid	$10,463.53
Rate for Payer: Molina Medicare	$10,463.53
Rate for Payer: Multiplan Auto	$14,633.80
Rate for Payer: Multiplan Commercial	$14,633.80
Rate for Payer: Multiplan Workers Comp	$14,633.80
Rate for Payer: Scott and White EPO/PPO	$6,739.25
Rate for Payer: Scott and White Medicare	$10,463.53
Rate for Payer: Superior Health Plan EPO	$10,463.53
Rate for Payer: Superior Health Plan Medicare	$10,463.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,463.53
Rate for Payer: Universal American Medicare	$10,463.53
Rate for Payer: Wellcare Medicare	$10,463.53
Rate for Payer: Wellmed Medicare	$10,463.53

MITSUBISHI HD PRINTER PAPER, 110MM X 21M

Facility

$182.51

Hospital Charge Code	993821
Hospital Revenue Code	270
Rate for Payer: Cash Price	$124.11

MITSUBISHI HD PRINTER PAPER, 110MM X 21M

Facility

$182.51

Hospital Charge Code	993821
Hospital Revenue Code	270
Min. Negotiated Rate	$16.43
Max. Negotiated Rate	$131.41
Rate for Payer: Amerigroup CHIP/Medicaid	$16.43
Rate for Payer: BCBS of TX Blue Advantage	$54.75
Rate for Payer: BCBS of TX Blue Essentials	$65.70
Rate for Payer: BCBS of TX PPO	$73.00
Rate for Payer: Cash Price	$124.11
Rate for Payer: Cigna Medicaid	$131.41
Rate for Payer: Molina CHIP/Medicaid	$131.41
Rate for Payer: Multiplan Auto	$118.63
Rate for Payer: Multiplan Commercial	$118.63
Rate for Payer: Multiplan Workers Comp	$118.63
Rate for Payer: Parkland Medicaid	$131.41
Rate for Payer: Scott and White EPO/PPO	$91.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.41
Rate for Payer: Superior Health Plan EPO	$24.82

modafinil 100 mg Tab

Facility

$38.00

Service Code	HCPCS J3490
Hospital Charge Code	77709492
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.84

modafinil 100 mg Tab

Facility

$38.00

Service Code	HCPCS J3490
Hospital Charge Code	77709492
Hospital Revenue Code	250
Min. Negotiated Rate	$3.42
Max. Negotiated Rate	$27.36
Rate for Payer: Amerigroup CHIP/Medicaid	$3.42
Rate for Payer: BCBS of TX Blue Advantage	$11.40
Rate for Payer: BCBS of TX Blue Essentials	$13.68
Rate for Payer: BCBS of TX PPO	$15.20
Rate for Payer: Cash Price	$25.84
Rate for Payer: Cigna Medicaid	$27.36
Rate for Payer: Molina CHIP/Medicaid	$27.36
Rate for Payer: Multiplan Auto	$24.70
Rate for Payer: Multiplan Commercial	$24.70
Rate for Payer: Multiplan Workers Comp	$24.70
Rate for Payer: Parkland Medicaid	$27.36
Rate for Payer: Scott and White EPO/PPO	$19.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.36
Rate for Payer: Superior Health Plan EPO	$5.17

MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$22,758.83

Service Code	APR-DRG 7934
Min. Negotiated Rate	$21,457.82
Max. Negotiated Rate	$22,758.83
Rate for Payer: Amerigroup CHIP/Medicaid	$21,457.82
Rate for Payer: Cigna Medicaid	$21,457.82
Rate for Payer: Molina CHIP/Medicaid	$21,457.82
Rate for Payer: Parkland Medicaid	$21,457.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,758.83

MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$3,725.87

Service Code	APR-DRG 7931
Min. Negotiated Rate	$3,512.88
Max. Negotiated Rate	$3,725.87
Rate for Payer: Amerigroup CHIP/Medicaid	$3,512.88
Rate for Payer: Cigna Medicaid	$3,512.88
Rate for Payer: Molina CHIP/Medicaid	$3,512.88
Rate for Payer: Parkland Medicaid	$3,512.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,725.87

MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$17,402.37

Service Code	APR-DRG 7933
Min. Negotiated Rate	$16,407.56
Max. Negotiated Rate	$17,402.37
Rate for Payer: Amerigroup CHIP/Medicaid	$16,407.56
Rate for Payer: Cigna Medicaid	$16,407.56
Rate for Payer: Molina CHIP/Medicaid	$16,407.56
Rate for Payer: Parkland Medicaid	$16,407.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,402.37

MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$6,939.15

Service Code	APR-DRG 7932
Min. Negotiated Rate	$6,542.47
Max. Negotiated Rate	$6,939.15
Rate for Payer: Amerigroup CHIP/Medicaid	$6,542.47
Rate for Payer: Cigna Medicaid	$6,542.47
Rate for Payer: Molina CHIP/Medicaid	$6,542.47
Rate for Payer: Parkland Medicaid	$6,542.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,939.15

MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$31,069.81

Service Code	APR-DRG 9514
Min. Negotiated Rate	$29,293.71
Max. Negotiated Rate	$31,069.81
Rate for Payer: Amerigroup CHIP/Medicaid	$29,293.71
Rate for Payer: Cigna Medicaid	$29,293.71
Rate for Payer: Molina CHIP/Medicaid	$29,293.71
Rate for Payer: Parkland Medicaid	$29,293.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31,069.81

MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$6,513.68

Service Code	APR-DRG 9512
Min. Negotiated Rate	$6,141.32
Max. Negotiated Rate	$6,513.68
Rate for Payer: Amerigroup CHIP/Medicaid	$6,141.32
Rate for Payer: Cigna Medicaid	$6,141.32
Rate for Payer: Molina CHIP/Medicaid	$6,141.32
Rate for Payer: Parkland Medicaid	$6,141.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,513.68

MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$12,983.60

Service Code	APR-DRG 9513
Min. Negotiated Rate	$12,241.39
Max. Negotiated Rate	$12,983.60
Rate for Payer: Amerigroup CHIP/Medicaid	$12,241.39
Rate for Payer: Cigna Medicaid	$12,241.39
Rate for Payer: Molina CHIP/Medicaid	$12,241.39
Rate for Payer: Parkland Medicaid	$12,241.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,983.60

MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$4,344.46

Service Code	APR-DRG 9511
Min. Negotiated Rate	$4,096.11
Max. Negotiated Rate	$4,344.46
Rate for Payer: Amerigroup CHIP/Medicaid	$4,096.11
Rate for Payer: Cigna Medicaid	$4,096.11
Rate for Payer: Molina CHIP/Medicaid	$4,096.11
Rate for Payer: Parkland Medicaid	$4,096.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,344.46

Moderate Sedation, per interval cumulative, 15 Minutes

Facility

$494.50

Hospital Charge Code	9900036
Hospital Revenue Code	370
Min. Negotiated Rate	$44.51
Max. Negotiated Rate	$356.04
Rate for Payer: Amerigroup CHIP/Medicaid	$44.51
Rate for Payer: BCBS of TX Blue Advantage	$148.35
Rate for Payer: BCBS of TX Blue Essentials	$178.02
Rate for Payer: BCBS of TX PPO	$197.80
Rate for Payer: Cash Price	$336.26
Rate for Payer: Cigna Medicaid	$356.04
Rate for Payer: Molina CHIP/Medicaid	$356.04
Rate for Payer: Multiplan Auto	$321.43
Rate for Payer: Multiplan Commercial	$321.43
Rate for Payer: Multiplan Workers Comp	$321.43
Rate for Payer: Parkland Medicaid	$356.04
Rate for Payer: Scott and White EPO/PPO	$247.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$356.04
Rate for Payer: Superior Health Plan EPO	$67.25

Moderate Sedation, per interval cumulative, 15 Minutes

Facility

$494.50

Hospital Charge Code	9900036
Hospital Revenue Code	370
Rate for Payer: Cash Price	$336.26

Moderate Sedation, per unit cumulative, 15 Minutes

Facility

$206.95

Hospital Charge Code	9900037
Hospital Revenue Code	370
Rate for Payer: Cash Price	$140.73

Moderate Sedation, per unit cumulative, 15 Minutes

Facility

$206.95

Hospital Charge Code	9900037
Hospital Revenue Code	370
Min. Negotiated Rate	$18.63
Max. Negotiated Rate	$149.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.63
Rate for Payer: BCBS of TX Blue Advantage	$62.09
Rate for Payer: BCBS of TX Blue Essentials	$74.50
Rate for Payer: BCBS of TX PPO	$82.78
Rate for Payer: Cash Price	$140.73
Rate for Payer: Cigna Medicaid	$149.00
Rate for Payer: Molina CHIP/Medicaid	$149.00
Rate for Payer: Multiplan Auto	$134.52
Rate for Payer: Multiplan Commercial	$134.52
Rate for Payer: Multiplan Workers Comp	$134.52
Rate for Payer: Parkland Medicaid	$149.00
Rate for Payer: Scott and White EPO/PPO	$103.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$149.00
Rate for Payer: Superior Health Plan EPO	$28.15

MODIFIED MOD SHAFT

Facility

$2,759.04

Service Code	HCPCS C1776
Hospital Charge Code	992137
Hospital Revenue Code	278
Min. Negotiated Rate	$689.76
Max. Negotiated Rate	$1,379.52
Rate for Payer: Cash Price	$1,876.15
Rate for Payer: Cigna Commercial	$689.76
Rate for Payer: Multiplan Auto	$1,379.52
Rate for Payer: Multiplan Commercial	$1,379.52
Rate for Payer: Multiplan Workers Comp	$1,379.52
Rate for Payer: Scott and White EPO/PPO	$1,379.52

MODIFIED MOD SHAFT

Facility

$2,759.04

Service Code	HCPCS C1776
Hospital Charge Code	992137
Hospital Revenue Code	278
Min. Negotiated Rate	$248.31
Max. Negotiated Rate	$1,986.51
Rate for Payer: Amerigroup CHIP/Medicaid	$248.31
Rate for Payer: BCBS of TX Blue Advantage	$827.71
Rate for Payer: BCBS of TX Blue Essentials	$993.25
Rate for Payer: BCBS of TX PPO	$1,103.62
Rate for Payer: Cash Price	$1,876.15
Rate for Payer: Cigna Medicaid	$1,986.51
Rate for Payer: Molina CHIP/Medicaid	$1,986.51
Rate for Payer: Multiplan Auto	$1,379.52
Rate for Payer: Multiplan Commercial	$1,379.52
Rate for Payer: Multiplan Workers Comp	$1,379.52
Rate for Payer: Parkland Medicaid	$1,986.51
Rate for Payer: Scott and White EPO/PPO	$1,379.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,986.51
Rate for Payer: Superior Health Plan EPO	$375.23

Know your out-of-pocket cost for care.

All Charges