White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 4 mg/mL IV Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2272
Hospital Charge Code	77714056
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 4 mg/mL IV Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2272
Hospital Charge Code	77714056
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

.Morphology

Facility

$73.00

Service Code	HCPCS 85008
Hospital Charge Code	1600428
Hospital Revenue Code	305
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$52.56
Rate for Payer: Amerigroup CHIP/Medicaid	$1.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.43
Rate for Payer: Amerigroup Medicare	$3.43
Rate for Payer: BCBS of TX Blue Advantage	$21.90
Rate for Payer: BCBS of TX Blue Essentials	$26.28
Rate for Payer: BCBS of TX Medicare	$3.43
Rate for Payer: BCBS of TX PPO	$29.20
Rate for Payer: Cash Price	$49.64
Rate for Payer: Cash Price	$49.64
Rate for Payer: Cigna Medicaid	$52.56
Rate for Payer: Cigna Medicare	$3.43
Rate for Payer: Employer Direct Commercial	$3.43
Rate for Payer: Humana Medicare/TRICARE	$3.43
Rate for Payer: Molina CHIP/Medicaid	$52.56
Rate for Payer: Molina Dual Medicare/Medicaid	$3.43
Rate for Payer: Molina Medicare	$3.43
Rate for Payer: Multiplan Auto	$47.45
Rate for Payer: Multiplan Commercial	$47.45
Rate for Payer: Multiplan Workers Comp	$47.45
Rate for Payer: Parkland Medicaid	$52.56
Rate for Payer: Scott and White EPO/PPO	$4.29
Rate for Payer: Scott and White Medicare	$3.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.56
Rate for Payer: Superior Health Plan EPO	$3.43
Rate for Payer: Superior Health Plan Medicare	$3.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.43
Rate for Payer: Universal American Medicare	$3.43
Rate for Payer: Wellcare Medicare	$3.43
Rate for Payer: Wellmed Medicare	$3.43

.Morphology

Facility

$73.00

Service Code	HCPCS 85008
Hospital Charge Code	1600428
Hospital Revenue Code	305
Rate for Payer: Cash Price	$49.64

MOUTH PROCEDURES W CC/MCC

Facility

$28,492.40

Service Code	MSDRG 137
Min. Negotiated Rate	$11,843.06
Max. Negotiated Rate	$28,492.40
Rate for Payer: BCBS of TX Blue Advantage	$11,843.06
Rate for Payer: BCBS of TX Blue Essentials	$14,210.29
Rate for Payer: BCBS of TX PPO	$15,789.83

MOUTH PROCEDURES WITH CC/MCC

Facility

$28,492.40

Service Code	MSDRG 137
Min. Negotiated Rate	$11,843.06
Max. Negotiated Rate	$28,492.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,703.78
Rate for Payer: Amerigroup Medicare	$15,703.78
Rate for Payer: BCBS of TX Medicare	$15,703.78
Rate for Payer: Cigna Commercial	$19,232.42
Rate for Payer: Cigna Medicare	$15,703.78
Rate for Payer: Employer Direct Commercial	$15,703.78
Rate for Payer: Humana Medicare/TRICARE	$15,703.78
Rate for Payer: Molina Dual Medicare/Medicaid	$15,703.78
Rate for Payer: Molina Medicare	$15,703.78
Rate for Payer: Multiplan Auto	$28,492.40
Rate for Payer: Multiplan Commercial	$28,492.40
Rate for Payer: Multiplan Workers Comp	$28,492.40
Rate for Payer: Scott and White EPO/PPO	$13,121.50
Rate for Payer: Scott and White Medicare	$15,703.78
Rate for Payer: Superior Health Plan EPO	$15,703.78
Rate for Payer: Superior Health Plan Medicare	$15,703.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,703.78
Rate for Payer: Universal American Medicare	$15,703.78
Rate for Payer: Wellcare Medicare	$15,703.78
Rate for Payer: Wellmed Medicare	$15,703.78

MOUTH PROCEDURES WITHOUT CC/MCC

Facility

$16,801.70

Service Code	MSDRG 138
Min. Negotiated Rate	$7,268.72
Max. Negotiated Rate	$16,801.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,255.06
Rate for Payer: Amerigroup Medicare	$11,255.06
Rate for Payer: BCBS of TX Medicare	$11,255.06
Rate for Payer: Cigna Commercial	$11,414.26
Rate for Payer: Cigna Medicare	$11,255.06
Rate for Payer: Employer Direct Commercial	$11,255.06
Rate for Payer: Humana Medicare/TRICARE	$11,255.06
Rate for Payer: Molina Dual Medicare/Medicaid	$11,255.06
Rate for Payer: Molina Medicare	$11,255.06
Rate for Payer: Multiplan Auto	$16,801.70
Rate for Payer: Multiplan Commercial	$16,801.70
Rate for Payer: Multiplan Workers Comp	$16,801.70
Rate for Payer: Scott and White EPO/PPO	$7,737.62
Rate for Payer: Scott and White Medicare	$11,255.06
Rate for Payer: Superior Health Plan EPO	$11,255.06
Rate for Payer: Superior Health Plan Medicare	$11,255.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,255.06
Rate for Payer: Universal American Medicare	$11,255.06
Rate for Payer: Wellcare Medicare	$11,255.06
Rate for Payer: Wellmed Medicare	$11,255.06

MOUTH PROCEDURES W/O CC/MCC

Facility

$16,801.70

Service Code	MSDRG 138
Min. Negotiated Rate	$7,268.72
Max. Negotiated Rate	$16,801.70
Rate for Payer: BCBS of TX Blue Advantage	$7,268.72
Rate for Payer: BCBS of TX Blue Essentials	$8,721.62
Rate for Payer: BCBS of TX PPO	$9,691.06

MPLANT, SCREW LAG TITANIUM 10.5MM X 75MM L

Facility

$5,048.19

Service Code	HCPCS C1713
Hospital Charge Code	992157
Hospital Revenue Code	278
Min. Negotiated Rate	$454.34
Max. Negotiated Rate	$3,634.70
Rate for Payer: Amerigroup CHIP/Medicaid	$454.34
Rate for Payer: BCBS of TX Blue Advantage	$1,514.46
Rate for Payer: BCBS of TX Blue Essentials	$1,817.35
Rate for Payer: BCBS of TX PPO	$2,019.28
Rate for Payer: Cash Price	$3,432.77
Rate for Payer: Cigna Medicaid	$3,634.70
Rate for Payer: Molina CHIP/Medicaid	$3,634.70
Rate for Payer: Multiplan Auto	$2,524.09
Rate for Payer: Multiplan Commercial	$2,524.09
Rate for Payer: Multiplan Workers Comp	$2,524.09
Rate for Payer: Parkland Medicaid	$3,634.70
Rate for Payer: Scott and White EPO/PPO	$2,524.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,634.70
Rate for Payer: Superior Health Plan EPO	$686.55

MPLANT, SCREW LAG TITANIUM 10.5MM X 75MM L

Facility

$5,048.19

Service Code	HCPCS C1713
Hospital Charge Code	992157
Hospital Revenue Code	278
Min. Negotiated Rate	$1,262.05
Max. Negotiated Rate	$2,524.09
Rate for Payer: Cash Price	$3,432.77
Rate for Payer: Cigna Commercial	$1,262.05
Rate for Payer: Multiplan Auto	$2,524.09
Rate for Payer: Multiplan Commercial	$2,524.09
Rate for Payer: Multiplan Workers Comp	$2,524.09
Rate for Payer: Scott and White EPO/PPO	$2,524.09

MPLANT, STAPLE FOOT/HAND FUSE FORCE 12MMX12MMX2MM

Facility

$7,096.39

Service Code	HCPCS C1734
Hospital Charge Code	992130
Hospital Revenue Code	278
Min. Negotiated Rate	$638.68
Max. Negotiated Rate	$5,109.40
Rate for Payer: Amerigroup CHIP/Medicaid	$638.68
Rate for Payer: BCBS of TX Blue Advantage	$2,128.92
Rate for Payer: BCBS of TX Blue Essentials	$2,554.70
Rate for Payer: BCBS of TX PPO	$2,838.56
Rate for Payer: Cash Price	$4,825.55
Rate for Payer: Cigna Medicaid	$5,109.40
Rate for Payer: Molina CHIP/Medicaid	$5,109.40
Rate for Payer: Multiplan Auto	$3,548.20
Rate for Payer: Multiplan Commercial	$3,548.20
Rate for Payer: Multiplan Workers Comp	$3,548.20
Rate for Payer: Parkland Medicaid	$5,109.40
Rate for Payer: Scott and White EPO/PPO	$3,548.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,109.40
Rate for Payer: Superior Health Plan EPO	$965.11

MPLANT, STAPLE FOOT/HAND FUSE FORCE 12MMX12MMX2MM

Facility

$7,096.39

Service Code	HCPCS C1734
Hospital Charge Code	992130
Hospital Revenue Code	278
Min. Negotiated Rate	$1,774.10
Max. Negotiated Rate	$3,548.20
Rate for Payer: Cash Price	$4,825.55
Rate for Payer: Cigna Commercial	$1,774.10
Rate for Payer: Multiplan Auto	$3,548.20
Rate for Payer: Multiplan Commercial	$3,548.20
Rate for Payer: Multiplan Workers Comp	$3,548.20
Rate for Payer: Scott and White EPO/PPO	$3,548.20

MRA Abdomen w/ Contrast

Facility

$8,435.00

Service Code	HCPCS 74185
Hospital Charge Code	3710092
Hospital Revenue Code	610
Min. Negotiated Rate	$427.85
Max. Negotiated Rate	$6,073.20
Rate for Payer: Amerigroup CHIP/Medicaid	$759.15
Rate for Payer: BCBS of TX Blue Advantage	$510.81
Rate for Payer: BCBS of TX Blue Essentials	$612.97
Rate for Payer: BCBS of TX PPO	$684.17
Rate for Payer: Cash Price	$5,735.80
Rate for Payer: Cash Price	$5,735.80
Rate for Payer: Cigna Medicaid	$6,073.20
Rate for Payer: Molina CHIP/Medicaid	$6,073.20
Rate for Payer: Multiplan Auto	$5,482.75
Rate for Payer: Multiplan Commercial	$5,482.75
Rate for Payer: Multiplan Workers Comp	$5,482.75
Rate for Payer: Parkland Medicaid	$6,073.20
Rate for Payer: Scott and White EPO/PPO	$427.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,073.20
Rate for Payer: Superior Health Plan EPO	$1,147.16

MRA Abdomen w/ Contrast

Facility

$8,435.00

Service Code	HCPCS 74185
Hospital Charge Code	3710092
Hospital Revenue Code	610
Rate for Payer: Cash Price	$5,735.80

MRA Abdomen w/o Contrast

Facility

$8,435.00

Service Code	HCPCS 74185
Hospital Charge Code	3700853
Hospital Revenue Code	610
Min. Negotiated Rate	$427.85
Max. Negotiated Rate	$6,073.20
Rate for Payer: Amerigroup CHIP/Medicaid	$759.15
Rate for Payer: BCBS of TX Blue Advantage	$510.81
Rate for Payer: BCBS of TX Blue Essentials	$612.97
Rate for Payer: BCBS of TX PPO	$684.17
Rate for Payer: Cash Price	$5,735.80
Rate for Payer: Cash Price	$5,735.80
Rate for Payer: Cigna Medicaid	$6,073.20
Rate for Payer: Molina CHIP/Medicaid	$6,073.20
Rate for Payer: Multiplan Auto	$5,482.75
Rate for Payer: Multiplan Commercial	$5,482.75
Rate for Payer: Multiplan Workers Comp	$5,482.75
Rate for Payer: Parkland Medicaid	$6,073.20
Rate for Payer: Scott and White EPO/PPO	$427.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,073.20
Rate for Payer: Superior Health Plan EPO	$1,147.16

MRA Abdomen w/o Contrast

Facility

$8,435.00

Service Code	HCPCS 74185
Hospital Charge Code	3700853
Hospital Revenue Code	610
Rate for Payer: Cash Price	$5,735.80

MRA Abdomen w/ + w/o Contrast

Facility

$8,435.00

Service Code	HCPCS 74185
Hospital Charge Code	5258899
Hospital Revenue Code	610
Min. Negotiated Rate	$427.85
Max. Negotiated Rate	$6,073.20
Rate for Payer: Amerigroup CHIP/Medicaid	$759.15
Rate for Payer: BCBS of TX Blue Advantage	$510.81
Rate for Payer: BCBS of TX Blue Essentials	$612.97
Rate for Payer: BCBS of TX PPO	$684.17
Rate for Payer: Cash Price	$5,735.80
Rate for Payer: Cash Price	$5,735.80
Rate for Payer: Cigna Medicaid	$6,073.20
Rate for Payer: Molina CHIP/Medicaid	$6,073.20
Rate for Payer: Multiplan Auto	$5,482.75
Rate for Payer: Multiplan Commercial	$5,482.75
Rate for Payer: Multiplan Workers Comp	$5,482.75
Rate for Payer: Parkland Medicaid	$6,073.20
Rate for Payer: Scott and White EPO/PPO	$427.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,073.20
Rate for Payer: Superior Health Plan EPO	$1,147.16

MRA Abdomen w/ + w/o Contrast

Facility

$8,435.00

Service Code	HCPCS 74185
Hospital Charge Code	5258899
Hospital Revenue Code	610
Rate for Payer: Cash Price	$5,735.80

MRA Brain/Head w/ Contrast

Facility

$6,311.00

Service Code	HCPCS 70545
Hospital Charge Code	3750049
Hospital Revenue Code	610
Rate for Payer: Cash Price	$4,291.48

MRA Brain/Head w/ Contrast

Facility

$6,311.00

Service Code	HCPCS 70545
Hospital Charge Code	3750049
Hospital Revenue Code	610
Min. Negotiated Rate	$234.23
Max. Negotiated Rate	$4,543.92
Rate for Payer: Amerigroup CHIP/Medicaid	$234.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX Medicare	$350.46
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$4,291.48
Rate for Payer: Cash Price	$4,291.48
Rate for Payer: Cash Price	$4,291.48
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$4,543.92
Rate for Payer: Cigna Medicare	$350.46
Rate for Payer: Employer Direct Commercial	$350.46
Rate for Payer: Humana Medicare/TRICARE	$350.46
Rate for Payer: Molina CHIP/Medicaid	$4,543.92
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$4,102.15
Rate for Payer: Multiplan Commercial	$4,102.15
Rate for Payer: Multiplan Workers Comp	$4,102.15
Rate for Payer: Parkland Medicaid	$4,543.92
Rate for Payer: Scott and White EPO/PPO	$288.65
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,543.92
Rate for Payer: Superior Health Plan EPO	$350.46
Rate for Payer: Superior Health Plan Medicare	$350.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$350.46
Rate for Payer: Universal American Medicare	$350.46
Rate for Payer: Wellcare Medicare	$350.46
Rate for Payer: Wellmed Medicare	$350.46

MRA Brain/Head w/o Contrast

Facility

$5,737.00

Service Code	HCPCS 70544
Hospital Charge Code	3750478
Hospital Revenue Code	615
Rate for Payer: Cash Price	$3,901.16

MRA Brain/Head w/o Contrast

Facility

$5,737.00

Service Code	HCPCS 70544
Hospital Charge Code	3750478
Hospital Revenue Code	615
Min. Negotiated Rate	$222.20
Max. Negotiated Rate	$4,130.64
Rate for Payer: Amerigroup CHIP/Medicaid	$222.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$384.52
Rate for Payer: BCBS of TX Blue Essentials	$461.42
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$515.02
Rate for Payer: Cash Price	$3,901.16
Rate for Payer: Cash Price	$3,901.16
Rate for Payer: Cash Price	$3,901.16
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$4,130.64
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$4,130.64
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$3,729.05
Rate for Payer: Multiplan Commercial	$3,729.05
Rate for Payer: Multiplan Workers Comp	$3,729.05
Rate for Payer: Parkland Medicaid	$4,130.64
Rate for Payer: Scott and White EPO/PPO	$273.81
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,130.64
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

MRA Chest w/ + w/o Contrast

Facility

$7,091.00

Service Code	HCPCS 71555
Hospital Charge Code	3740090
Hospital Revenue Code	610
Rate for Payer: Cash Price	$4,821.88

MRA Chest w/ + w/o Contrast

Facility

$7,091.00

Service Code	HCPCS 71555
Hospital Charge Code	3740090
Hospital Revenue Code	610
Min. Negotiated Rate	$424.14
Max. Negotiated Rate	$5,105.52
Rate for Payer: Amerigroup CHIP/Medicaid	$638.19
Rate for Payer: BCBS of TX Blue Advantage	$504.85
Rate for Payer: BCBS of TX Blue Essentials	$605.82
Rate for Payer: BCBS of TX PPO	$676.19
Rate for Payer: Cash Price	$4,821.88
Rate for Payer: Cash Price	$4,821.88
Rate for Payer: Cigna Medicaid	$5,105.52
Rate for Payer: Molina CHIP/Medicaid	$5,105.52
Rate for Payer: Multiplan Auto	$4,609.15
Rate for Payer: Multiplan Commercial	$4,609.15
Rate for Payer: Multiplan Workers Comp	$4,609.15
Rate for Payer: Parkland Medicaid	$5,105.52
Rate for Payer: Scott and White EPO/PPO	$424.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,105.52
Rate for Payer: Superior Health Plan EPO	$964.38

Know your out-of-pocket cost for care.

All Charges