White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MODULE O2DEL YLW

Facility

$72.64

Hospital Charge Code	993496
Hospital Revenue Code	270
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$52.30
Rate for Payer: Amerigroup CHIP/Medicaid	$6.54
Rate for Payer: BCBS of TX Blue Advantage	$21.79
Rate for Payer: BCBS of TX Blue Essentials	$26.15
Rate for Payer: BCBS of TX PPO	$29.06
Rate for Payer: Cash Price	$49.40
Rate for Payer: Cigna Medicaid	$52.30
Rate for Payer: Molina CHIP/Medicaid	$52.30
Rate for Payer: Multiplan Auto	$47.22
Rate for Payer: Multiplan Commercial	$47.22
Rate for Payer: Multiplan Workers Comp	$47.22
Rate for Payer: Parkland Medicaid	$52.30
Rate for Payer: Scott and White EPO/PPO	$36.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.30
Rate for Payer: Superior Health Plan EPO	$9.88

MODULE O2DEL YLW

Facility

$72.64

Hospital Charge Code	993496
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.40

MOIST DRML -- DHF

Facility

$53.71

Hospital Charge Code	80327059
Hospital Revenue Code	270
Min. Negotiated Rate	$4.83
Max. Negotiated Rate	$38.67
Rate for Payer: Amerigroup CHIP/Medicaid	$4.83
Rate for Payer: BCBS of TX Blue Advantage	$16.11
Rate for Payer: BCBS of TX Blue Essentials	$19.34
Rate for Payer: BCBS of TX PPO	$21.48
Rate for Payer: Cash Price	$36.52
Rate for Payer: Cigna Medicaid	$38.67
Rate for Payer: Molina CHIP/Medicaid	$38.67
Rate for Payer: Multiplan Auto	$34.91
Rate for Payer: Multiplan Commercial	$34.91
Rate for Payer: Multiplan Workers Comp	$34.91
Rate for Payer: Parkland Medicaid	$38.67
Rate for Payer: Scott and White EPO/PPO	$26.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.67
Rate for Payer: Superior Health Plan EPO	$7.30

MOIST DRML -- DHF

Facility

$53.71

Hospital Charge Code	80327059
Hospital Revenue Code	270
Rate for Payer: Cash Price	$36.52

Monitored Anesthesia Care, per interval cumulative, 15 Minutes

Facility

$2,105.00

Hospital Charge Code	9900038
Hospital Revenue Code	370
Min. Negotiated Rate	$189.45
Max. Negotiated Rate	$1,515.60
Rate for Payer: Amerigroup CHIP/Medicaid	$189.45
Rate for Payer: BCBS of TX Blue Advantage	$631.50
Rate for Payer: BCBS of TX Blue Essentials	$757.80
Rate for Payer: BCBS of TX PPO	$842.00
Rate for Payer: Cash Price	$1,431.40
Rate for Payer: Cigna Medicaid	$1,515.60
Rate for Payer: Molina CHIP/Medicaid	$1,515.60
Rate for Payer: Multiplan Auto	$1,368.25
Rate for Payer: Multiplan Commercial	$1,368.25
Rate for Payer: Multiplan Workers Comp	$1,368.25
Rate for Payer: Parkland Medicaid	$1,515.60
Rate for Payer: Scott and White EPO/PPO	$1,052.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,515.60
Rate for Payer: Superior Health Plan EPO	$286.28

Monitored Anesthesia Care, per interval cumulative, 15 Minutes

Facility

$2,105.00

Hospital Charge Code	9900038
Hospital Revenue Code	370
Rate for Payer: Cash Price	$1,431.40

Monitored Anesthesia Care, per unit cumulative, 15 Minutes

Facility

$625.00

Hospital Charge Code	9900039
Hospital Revenue Code	370
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$450.00
Rate for Payer: Amerigroup CHIP/Medicaid	$56.25
Rate for Payer: BCBS of TX Blue Advantage	$187.50
Rate for Payer: BCBS of TX Blue Essentials	$225.00
Rate for Payer: BCBS of TX PPO	$250.00
Rate for Payer: Cash Price	$425.00
Rate for Payer: Cigna Medicaid	$450.00
Rate for Payer: Molina CHIP/Medicaid	$450.00
Rate for Payer: Multiplan Auto	$406.25
Rate for Payer: Multiplan Commercial	$406.25
Rate for Payer: Multiplan Workers Comp	$406.25
Rate for Payer: Parkland Medicaid	$450.00
Rate for Payer: Scott and White EPO/PPO	$312.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$450.00
Rate for Payer: Superior Health Plan EPO	$85.00

Monitored Anesthesia Care, per unit cumulative, 15 Minutes

Facility

$625.00

Hospital Charge Code	9900039
Hospital Revenue Code	370
Rate for Payer: Cash Price	$425.00

MONITOR INSRT CARDIAC ASSERT IQ EL+ ICM UMRI

Facility

$35,099.00

Service Code	HCPCS C1833
Hospital Charge Code	146574
Hospital Revenue Code	278
Min. Negotiated Rate	$8,774.75
Max. Negotiated Rate	$17,549.50
Rate for Payer: Cash Price	$23,867.32
Rate for Payer: Cigna Commercial	$8,774.75
Rate for Payer: Multiplan Auto	$17,549.50
Rate for Payer: Multiplan Commercial	$17,549.50
Rate for Payer: Multiplan Workers Comp	$17,549.50
Rate for Payer: Scott and White EPO/PPO	$17,549.50

MONITOR INSRT CARDIAC ASSERT IQ EL+ ICM UMRI

Facility

$35,099.00

Service Code	HCPCS C1833
Hospital Charge Code	146574
Hospital Revenue Code	278
Min. Negotiated Rate	$761.25
Max. Negotiated Rate	$25,271.28
Rate for Payer: Amerigroup CHIP/Medicaid	$3,158.91
Rate for Payer: BCBS of TX Blue Advantage	$761.25
Rate for Payer: BCBS of TX Blue Essentials	$913.50
Rate for Payer: BCBS of TX PPO	$1,013.25
Rate for Payer: Cash Price	$23,867.32
Rate for Payer: Cash Price	$23,867.32
Rate for Payer: Cigna Medicaid	$25,271.28
Rate for Payer: Molina CHIP/Medicaid	$25,271.28
Rate for Payer: Multiplan Auto	$17,549.50
Rate for Payer: Multiplan Commercial	$17,549.50
Rate for Payer: Multiplan Workers Comp	$17,549.50
Rate for Payer: Parkland Medicaid	$25,271.28
Rate for Payer: Scott and White EPO/PPO	$17,549.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,271.28
Rate for Payer: Superior Health Plan EPO	$4,773.46

Monkeypox (Orthopoxvirus), PCR SO

Facility

$353.53

Service Code	HCPCS 87798
Hospital Charge Code	8918553
Hospital Revenue Code	306
Rate for Payer: Cash Price	$240.40

Monkeypox (Orthopoxvirus), PCR SO

Facility

$353.53

Service Code	HCPCS 87798
Hospital Charge Code	8918553
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$254.54
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$106.06
Rate for Payer: BCBS of TX Blue Essentials	$127.27
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$141.41
Rate for Payer: Cash Price	$240.40
Rate for Payer: Cash Price	$240.40
Rate for Payer: Cigna Medicaid	$254.54
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$254.54
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$229.79
Rate for Payer: Multiplan Commercial	$229.79
Rate for Payer: Multiplan Workers Comp	$229.79
Rate for Payer: Parkland Medicaid	$254.54
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$254.54
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

Mononucleosis Screen

Facility

$156.00

Service Code	HCPCS 86308
Hospital Charge Code	1605435
Hospital Revenue Code	302
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$112.32
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$46.80
Rate for Payer: BCBS of TX Blue Essentials	$56.16
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$62.40
Rate for Payer: Cash Price	$106.08
Rate for Payer: Cash Price	$106.08
Rate for Payer: Cigna Medicaid	$112.32
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$112.32
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$101.40
Rate for Payer: Multiplan Commercial	$101.40
Rate for Payer: Multiplan Workers Comp	$101.40
Rate for Payer: Parkland Medicaid	$112.32
Rate for Payer: Scott and White EPO/PPO	$6.47
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$112.32
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

Mononucleosis Screen

Facility

$156.00

Service Code	HCPCS 86308
Hospital Charge Code	1605435
Hospital Revenue Code	302
Rate for Payer: Cash Price	$106.08

Monopolar scissor XI

Facility

$15,254.40

Hospital Charge Code	992731
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10,372.99

Monopolar scissor XI

Facility

$15,254.40

Hospital Charge Code	992731
Hospital Revenue Code	270
Min. Negotiated Rate	$1,372.90
Max. Negotiated Rate	$10,983.17
Rate for Payer: Amerigroup CHIP/Medicaid	$1,372.90
Rate for Payer: BCBS of TX Blue Advantage	$4,576.32
Rate for Payer: BCBS of TX Blue Essentials	$5,491.58
Rate for Payer: BCBS of TX PPO	$6,101.76
Rate for Payer: Cash Price	$10,372.99
Rate for Payer: Cigna Medicaid	$10,983.17
Rate for Payer: Molina CHIP/Medicaid	$10,983.17
Rate for Payer: Multiplan Auto	$9,915.36
Rate for Payer: Multiplan Commercial	$9,915.36
Rate for Payer: Multiplan Workers Comp	$9,915.36
Rate for Payer: Parkland Medicaid	$10,983.17
Rate for Payer: Scott and White EPO/PPO	$7,627.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,983.17
Rate for Payer: Superior Health Plan EPO	$2,074.60

montelukast 10 mg Tab

Facility

$22.00

Service Code	HCPCS J3490
Hospital Charge Code	77710171
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$15.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1.98
Rate for Payer: BCBS of TX Blue Advantage	$6.60
Rate for Payer: BCBS of TX Blue Essentials	$7.92
Rate for Payer: BCBS of TX PPO	$8.80
Rate for Payer: Cash Price	$14.96
Rate for Payer: Cigna Medicaid	$15.84
Rate for Payer: Molina CHIP/Medicaid	$15.84
Rate for Payer: Multiplan Auto	$14.30
Rate for Payer: Multiplan Commercial	$14.30
Rate for Payer: Multiplan Workers Comp	$14.30
Rate for Payer: Parkland Medicaid	$15.84
Rate for Payer: Scott and White EPO/PPO	$11.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.84
Rate for Payer: Superior Health Plan EPO	$2.99

montelukast 10 mg Tab

Facility

$22.00

Service Code	HCPCS J3490
Hospital Charge Code	77710171
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.96

morphine 15 mg/12 hr ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78352865
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

morphine 15 mg/12 hr ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78352865
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

morphine 1 mg/mL Inj Soln 30 mL

Facility

$128.00

Service Code	HCPCS J2270
Hospital Charge Code	77710558
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

morphine 1 mg/mL Inj Soln 30 mL

Facility

$128.00

Service Code	HCPCS J2270
Hospital Charge Code	77710558
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.10
Rate for Payer: BCBS of TX Blue Essentials	$0.12
Rate for Payer: BCBS of TX PPO	$0.14
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

morphine 2 mg/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2272
Hospital Charge Code	78350877
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	$12.04
Rate for Payer: BCBS of TX Blue Essentials	$14.44
Rate for Payer: BCBS of TX PPO	$16.02
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

morphine 2 mg/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2272
Hospital Charge Code	77712550
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

morphine 2 mg/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2272
Hospital Charge Code	77712550
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	$12.04
Rate for Payer: BCBS of TX Blue Essentials	$14.44
Rate for Payer: BCBS of TX PPO	$16.02
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