White Rock Medical Center

All Charges

Charge

Type

Setting

Price

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

$7,317.09

Service Code	APR-DRG 5142
Min. Negotiated Rate	$6,898.81
Max. Negotiated Rate	$7,317.09
Rate for Payer: Amerigroup CHIP/Medicaid	$6,898.81
Rate for Payer: Cigna Medicaid	$6,898.81
Rate for Payer: Molina CHIP/Medicaid	$6,898.81
Rate for Payer: Parkland Medicaid	$6,898.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,317.09

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

$12,513.25

Service Code	APR-DRG 5143
Min. Negotiated Rate	$11,797.93
Max. Negotiated Rate	$12,513.25
Rate for Payer: Amerigroup CHIP/Medicaid	$11,797.93
Rate for Payer: Cigna Medicaid	$11,797.93
Rate for Payer: Molina CHIP/Medicaid	$11,797.93
Rate for Payer: Parkland Medicaid	$11,797.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,513.25

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

$5,384.75

Service Code	APR-DRG 5141
Min. Negotiated Rate	$5,076.93
Max. Negotiated Rate	$5,384.75
Rate for Payer: Amerigroup CHIP/Medicaid	$5,076.93
Rate for Payer: Cigna Medicaid	$5,076.93
Rate for Payer: Molina CHIP/Medicaid	$5,076.93
Rate for Payer: Parkland Medicaid	$5,076.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,384.75

FEM COMP ARCH -- DHF

Facility

$530.57

Hospital Charge Code	80846017
Hospital Revenue Code	272
Min. Negotiated Rate	$47.75
Max. Negotiated Rate	$382.01
Rate for Payer: Amerigroup CHIP/Medicaid	$47.75
Rate for Payer: BCBS of TX Blue Advantage	$159.17
Rate for Payer: BCBS of TX Blue Essentials	$191.01
Rate for Payer: BCBS of TX PPO	$212.23
Rate for Payer: Cash Price	$360.79
Rate for Payer: Cigna Medicaid	$382.01
Rate for Payer: Molina CHIP/Medicaid	$382.01
Rate for Payer: Multiplan Auto	$344.87
Rate for Payer: Multiplan Commercial	$344.87
Rate for Payer: Multiplan Workers Comp	$344.87
Rate for Payer: Parkland Medicaid	$382.01
Rate for Payer: Scott and White EPO/PPO	$265.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$382.01
Rate for Payer: Superior Health Plan EPO	$72.16

FEM COMP ARCH -- DHF

Facility

$530.57

Hospital Charge Code	80846017
Hospital Revenue Code	272
Rate for Payer: Cash Price	$360.79

Fem Hd FZ/I D<=4.7cm

Facility

$8,834.82

Service Code	HCPCS C1734
Hospital Charge Code	992267
Hospital Revenue Code	278
Min. Negotiated Rate	$2,208.70
Max. Negotiated Rate	$4,417.41
Rate for Payer: Cash Price	$6,007.68
Rate for Payer: Cigna Commercial	$2,208.70
Rate for Payer: Multiplan Auto	$4,417.41
Rate for Payer: Multiplan Commercial	$4,417.41
Rate for Payer: Multiplan Workers Comp	$4,417.41
Rate for Payer: Scott and White EPO/PPO	$4,417.41

Fem Hd FZ/I D<=4.7cm

Facility

$8,834.82

Service Code	HCPCS C1734
Hospital Charge Code	992267
Hospital Revenue Code	278
Min. Negotiated Rate	$795.13
Max. Negotiated Rate	$6,361.07
Rate for Payer: Amerigroup CHIP/Medicaid	$795.13
Rate for Payer: BCBS of TX Blue Advantage	$2,650.45
Rate for Payer: BCBS of TX Blue Essentials	$3,180.54
Rate for Payer: BCBS of TX PPO	$3,533.93
Rate for Payer: Cash Price	$6,007.68
Rate for Payer: Cigna Medicaid	$6,361.07
Rate for Payer: Molina CHIP/Medicaid	$6,361.07
Rate for Payer: Multiplan Auto	$4,417.41
Rate for Payer: Multiplan Commercial	$4,417.41
Rate for Payer: Multiplan Workers Comp	$4,417.41
Rate for Payer: Parkland Medicaid	$6,361.07
Rate for Payer: Scott and White EPO/PPO	$4,417.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,361.07
Rate for Payer: Superior Health Plan EPO	$1,201.54

fenofibrate 48 mg Tab

Facility

$21.80

Service Code	HCPCS J3490
Hospital Charge Code	77563789
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.82

fenofibrate 48 mg Tab

Facility

$21.80

Service Code	HCPCS J3490
Hospital Charge Code	77563789
Hospital Revenue Code	250
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$15.70
Rate for Payer: Amerigroup CHIP/Medicaid	$1.96
Rate for Payer: BCBS of TX Blue Advantage	$6.54
Rate for Payer: BCBS of TX Blue Essentials	$7.85
Rate for Payer: BCBS of TX PPO	$8.72
Rate for Payer: Cash Price	$14.82
Rate for Payer: Cigna Medicaid	$15.70
Rate for Payer: Molina CHIP/Medicaid	$15.70
Rate for Payer: Multiplan Auto	$14.17
Rate for Payer: Multiplan Commercial	$14.17
Rate for Payer: Multiplan Workers Comp	$14.17
Rate for Payer: Parkland Medicaid	$15.70
Rate for Payer: Scott and White EPO/PPO	$10.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.70
Rate for Payer: Superior Health Plan EPO	$2.96

fentaNYL 10 mcg/mL-NS PCA; 100 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	8348677
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

fentaNYL 10 mcg/mL-NS PCA; 100 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	8348677
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

fentaNYL 10 mcg/mL-NS PCA; 100 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	77567607
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

fentaNYL 10 mcg/mL-NS PCA; 100 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	77567607
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

fentaNYL 25 mcg/hr TD Film, ER

Facility

$55.35

Service Code	HCPCS J3490
Hospital Charge Code	77566382
Hospital Revenue Code	250
Min. Negotiated Rate	$4.98
Max. Negotiated Rate	$39.85
Rate for Payer: Amerigroup CHIP/Medicaid	$4.98
Rate for Payer: BCBS of TX Blue Advantage	$16.61
Rate for Payer: BCBS of TX Blue Essentials	$19.93
Rate for Payer: BCBS of TX PPO	$22.14
Rate for Payer: Cash Price	$37.64
Rate for Payer: Cigna Medicaid	$39.85
Rate for Payer: Molina CHIP/Medicaid	$39.85
Rate for Payer: Multiplan Auto	$35.98
Rate for Payer: Multiplan Commercial	$35.98
Rate for Payer: Multiplan Workers Comp	$35.98
Rate for Payer: Parkland Medicaid	$39.85
Rate for Payer: Scott and White EPO/PPO	$27.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.85
Rate for Payer: Superior Health Plan EPO	$7.53

fentaNYL 25 mcg/hr TD Film, ER

Facility

$55.35

Service Code	HCPCS J3490
Hospital Charge Code	77566382
Hospital Revenue Code	250
Rate for Payer: Cash Price	$37.64

fentaNYL 50 mcg/hr TD Film, ER

Facility

$66.48

Service Code	HCPCS J3490
Hospital Charge Code	77567326
Hospital Revenue Code	250
Rate for Payer: Cash Price	$45.21

fentaNYL 50 mcg/hr TD Film, ER

Facility

$66.48

Service Code	HCPCS J3490
Hospital Charge Code	77567326
Hospital Revenue Code	250
Min. Negotiated Rate	$5.98
Max. Negotiated Rate	$47.87
Rate for Payer: Amerigroup CHIP/Medicaid	$5.98
Rate for Payer: BCBS of TX Blue Advantage	$19.94
Rate for Payer: BCBS of TX Blue Essentials	$23.93
Rate for Payer: BCBS of TX PPO	$26.59
Rate for Payer: Cash Price	$45.21
Rate for Payer: Cigna Medicaid	$47.87
Rate for Payer: Molina CHIP/Medicaid	$47.87
Rate for Payer: Multiplan Auto	$43.21
Rate for Payer: Multiplan Commercial	$43.21
Rate for Payer: Multiplan Workers Comp	$43.21
Rate for Payer: Parkland Medicaid	$47.87
Rate for Payer: Scott and White EPO/PPO	$33.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47.87
Rate for Payer: Superior Health Plan EPO	$9.04

fentaNYL 50 mcg/mL Inj Soln 10 mL

Facility

$128.00

Service Code	HCPCS J3010
Hospital Charge Code	77567432
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

fentaNYL 50 mcg/mL Inj Soln 10 mL

Facility

$128.00

Service Code	HCPCS J3010
Hospital Charge Code	77567432
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
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

fentaNYL 50 mcg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	77567548
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

fentaNYL 50 mcg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	77567548
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

fentaNYL 50 mcg/mL Inj Soln 50 mL

Facility

$128.19

Service Code	HCPCS J3010
Hospital Charge Code	77567841
Hospital Revenue Code	636
Min. Negotiated Rate	$32.05
Max. Negotiated Rate	$64.09
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cigna Commercial	$32.05
Rate for Payer: Scott and White EPO/PPO	$64.09

fentaNYL 50 mcg/mL Inj Soln 50 mL

Facility

$128.19

Service Code	HCPCS J3010
Hospital Charge Code	77567841
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$92.30
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cigna Medicaid	$92.30
Rate for Payer: Molina CHIP/Medicaid	$92.30
Rate for Payer: Multiplan Auto	$83.32
Rate for Payer: Multiplan Commercial	$83.32
Rate for Payer: Multiplan Workers Comp	$83.32
Rate for Payer: Parkland Medicaid	$92.30
Rate for Payer: Scott and White EPO/PPO	$64.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.30
Rate for Payer: Superior Health Plan EPO	$17.43

fentaNYL 50 mcg/mL Inj Soln 5 mL

Facility

$128.00

Service Code	HCPCS J3010
Hospital Charge Code	77567782
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

fentaNYL 50 mcg/mL Inj Soln 5 mL

Facility

$128.00

Service Code	HCPCS J3010
Hospital Charge Code	77567782
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
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	$1.21
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