White Rock Medical Center

All Charges

Charge

Type

Setting

Price

FORCEP, TISSUE ADSON S/S 1X2 TEETH TP 4 3/4' REUSE

Facility

$42.54

Hospital Charge Code	992726
Hospital Revenue Code	272
Rate for Payer: Cash Price	$28.93

FORCEP, TISSUE ADSON S/S 1X2 TEETH TP 4 3/4' REUSE

Facility

$42.54

Hospital Charge Code	992726
Hospital Revenue Code	272
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$30.63
Rate for Payer: Amerigroup CHIP/Medicaid	$3.83
Rate for Payer: BCBS of TX Blue Advantage	$12.76
Rate for Payer: BCBS of TX Blue Essentials	$15.31
Rate for Payer: BCBS of TX PPO	$17.02
Rate for Payer: Cash Price	$28.93
Rate for Payer: Cigna Medicaid	$30.63
Rate for Payer: Molina CHIP/Medicaid	$30.63
Rate for Payer: Multiplan Auto	$27.65
Rate for Payer: Multiplan Commercial	$27.65
Rate for Payer: Multiplan Workers Comp	$27.65
Rate for Payer: Parkland Medicaid	$30.63
Rate for Payer: Scott and White EPO/PPO	$21.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.63
Rate for Payer: Superior Health Plan EPO	$5.79

FORCEP, TISSUE ADSON STD PATTERN 2X3 BRN TEETH 5'

Facility

$84.17

Hospital Charge Code	992720
Hospital Revenue Code	272
Rate for Payer: Cash Price	$57.24

FORCEP, TISSUE ADSON STD PATTERN 2X3 BRN TEETH 5'

Facility

$84.17

Hospital Charge Code	992720
Hospital Revenue Code	272
Min. Negotiated Rate	$7.58
Max. Negotiated Rate	$60.60
Rate for Payer: Amerigroup CHIP/Medicaid	$7.58
Rate for Payer: BCBS of TX Blue Advantage	$25.25
Rate for Payer: BCBS of TX Blue Essentials	$30.30
Rate for Payer: BCBS of TX PPO	$33.67
Rate for Payer: Cash Price	$57.24
Rate for Payer: Cigna Medicaid	$60.60
Rate for Payer: Molina CHIP/Medicaid	$60.60
Rate for Payer: Multiplan Auto	$54.71
Rate for Payer: Multiplan Commercial	$54.71
Rate for Payer: Multiplan Workers Comp	$54.71
Rate for Payer: Parkland Medicaid	$60.60
Rate for Payer: Scott and White EPO/PPO	$42.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60.60
Rate for Payer: Superior Health Plan EPO	$11.45

FORCEP, VANGUARD CRILE CURVED 5 1/2'

Facility

$36.14

Hospital Charge Code	992722
Hospital Revenue Code	272
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$26.02
Rate for Payer: Amerigroup CHIP/Medicaid	$3.25
Rate for Payer: BCBS of TX Blue Advantage	$10.84
Rate for Payer: BCBS of TX Blue Essentials	$13.01
Rate for Payer: BCBS of TX PPO	$14.46
Rate for Payer: Cash Price	$24.58
Rate for Payer: Cigna Medicaid	$26.02
Rate for Payer: Molina CHIP/Medicaid	$26.02
Rate for Payer: Multiplan Auto	$23.49
Rate for Payer: Multiplan Commercial	$23.49
Rate for Payer: Multiplan Workers Comp	$23.49
Rate for Payer: Parkland Medicaid	$26.02
Rate for Payer: Scott and White EPO/PPO	$18.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.02
Rate for Payer: Superior Health Plan EPO	$4.92

FORCEP, VANGUARD CRILE CURVED 5 1/2'

Facility

$36.14

Hospital Charge Code	992722
Hospital Revenue Code	272
Rate for Payer: Cash Price	$24.58

Formula Fluted Standard Barrel Burr, 4 mm Diameter

Facility

$141.65

Hospital Charge Code	993688
Hospital Revenue Code	270
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$101.99
Rate for Payer: Amerigroup CHIP/Medicaid	$12.75
Rate for Payer: BCBS of TX Blue Advantage	$42.49
Rate for Payer: BCBS of TX Blue Essentials	$50.99
Rate for Payer: BCBS of TX PPO	$56.66
Rate for Payer: Cash Price	$96.32
Rate for Payer: Cigna Medicaid	$101.99
Rate for Payer: Molina CHIP/Medicaid	$101.99
Rate for Payer: Multiplan Auto	$92.07
Rate for Payer: Multiplan Commercial	$92.07
Rate for Payer: Multiplan Workers Comp	$92.07
Rate for Payer: Parkland Medicaid	$101.99
Rate for Payer: Scott and White EPO/PPO	$70.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$101.99
Rate for Payer: Superior Health Plan EPO	$19.26

Formula Fluted Standard Barrel Burr, 4 mm Diameter

Facility

$141.65

Hospital Charge Code	993688
Hospital Revenue Code	270
Rate for Payer: Cash Price	$96.32

Formula Shaver Handpiece Single Procedure

Facility

$3,012.05

Hospital Charge Code	993153
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2,048.19

Formula Shaver Handpiece Single Procedure

Facility

$3,012.05

Hospital Charge Code	993153
Hospital Revenue Code	270
Min. Negotiated Rate	$271.08
Max. Negotiated Rate	$2,168.68
Rate for Payer: Amerigroup CHIP/Medicaid	$271.08
Rate for Payer: BCBS of TX Blue Advantage	$903.62
Rate for Payer: BCBS of TX Blue Essentials	$1,084.34
Rate for Payer: BCBS of TX PPO	$1,204.82
Rate for Payer: Cash Price	$2,048.19
Rate for Payer: Cigna Medicaid	$2,168.68
Rate for Payer: Molina CHIP/Medicaid	$2,168.68
Rate for Payer: Multiplan Auto	$1,957.83
Rate for Payer: Multiplan Commercial	$1,957.83
Rate for Payer: Multiplan Workers Comp	$1,957.83
Rate for Payer: Parkland Medicaid	$2,168.68
Rate for Payer: Scott and White EPO/PPO	$1,506.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,168.68
Rate for Payer: Superior Health Plan EPO	$409.64

fosphenytoin 100 mg (as PE)/2 mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS Q2009
Hospital Charge Code	77584859
Hospital Revenue Code	636
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1.34
Rate for Payer: Amerigroup Medicare	$1.34
Rate for Payer: BCBS of TX Blue Advantage	$4.76
Rate for Payer: BCBS of TX Blue Essentials	$5.71
Rate for Payer: BCBS of TX Medicare	$1.34
Rate for Payer: BCBS of TX PPO	$6.33
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Cigna Medicare	$1.34
Rate for Payer: Employer Direct Commercial	$1.34
Rate for Payer: Humana Medicare/TRICARE	$1.34
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Molina Dual Medicare/Medicaid	$1.34
Rate for Payer: Molina Medicare	$1.34
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: Scott and White Medicare	$1.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$1.34
Rate for Payer: Superior Health Plan Medicare	$1.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$1.34
Rate for Payer: Universal American Medicare	$1.34
Rate for Payer: Wellcare Medicare	$1.34
Rate for Payer: Wellmed Medicare	$1.34

fosphenytoin 100 mg (as PE)/2 mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS Q2009
Hospital Charge Code	77584859
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

FRACTURE OF FEMUR

Facility

$11,329.25

Service Code	APR-DRG 3404
Min. Negotiated Rate	$10,681.61
Max. Negotiated Rate	$11,329.25
Rate for Payer: Amerigroup CHIP/Medicaid	$10,681.61
Rate for Payer: Cigna Medicaid	$10,681.61
Rate for Payer: Molina CHIP/Medicaid	$10,681.61
Rate for Payer: Parkland Medicaid	$10,681.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,329.25

FRACTURE OF FEMUR

Facility

$3,067.30

Service Code	APR-DRG 3402
Min. Negotiated Rate	$2,891.96
Max. Negotiated Rate	$3,067.30
Rate for Payer: Amerigroup CHIP/Medicaid	$2,891.96
Rate for Payer: Cigna Medicaid	$2,891.96
Rate for Payer: Molina CHIP/Medicaid	$2,891.96
Rate for Payer: Parkland Medicaid	$2,891.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,067.30

FRACTURE OF FEMUR

Facility

$5,125.62

Service Code	APR-DRG 3403
Min. Negotiated Rate	$4,832.62
Max. Negotiated Rate	$5,125.62
Rate for Payer: Amerigroup CHIP/Medicaid	$4,832.62
Rate for Payer: Cigna Medicaid	$4,832.62
Rate for Payer: Molina CHIP/Medicaid	$4,832.62
Rate for Payer: Parkland Medicaid	$4,832.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,125.62

FRACTURE OF FEMUR

Facility

$1,899.15

Service Code	APR-DRG 3401
Min. Negotiated Rate	$1,790.58
Max. Negotiated Rate	$1,899.15
Rate for Payer: Amerigroup CHIP/Medicaid	$1,790.58
Rate for Payer: Cigna Medicaid	$1,790.58
Rate for Payer: Molina CHIP/Medicaid	$1,790.58
Rate for Payer: Parkland Medicaid	$1,790.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,899.15

FRACTURE OF PELVIS OR DISLOCATION OF HIP

Facility

$3,967.27

Service Code	APR-DRG 3412
Min. Negotiated Rate	$3,740.48
Max. Negotiated Rate	$3,967.27
Rate for Payer: Amerigroup CHIP/Medicaid	$3,740.48
Rate for Payer: Cigna Medicaid	$3,740.48
Rate for Payer: Molina CHIP/Medicaid	$3,740.48
Rate for Payer: Parkland Medicaid	$3,740.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,967.27

FRACTURE OF PELVIS OR DISLOCATION OF HIP

Facility

$9,520.25

Service Code	APR-DRG 3414
Min. Negotiated Rate	$8,976.03
Max. Negotiated Rate	$9,520.25
Rate for Payer: Amerigroup CHIP/Medicaid	$8,976.03
Rate for Payer: Cigna Medicaid	$8,976.03
Rate for Payer: Molina CHIP/Medicaid	$8,976.03
Rate for Payer: Parkland Medicaid	$8,976.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,520.25

FRACTURE OF PELVIS OR DISLOCATION OF HIP

Facility

$4,705.43

Service Code	APR-DRG 3413
Min. Negotiated Rate	$4,436.45
Max. Negotiated Rate	$4,705.43
Rate for Payer: Amerigroup CHIP/Medicaid	$4,436.45
Rate for Payer: Cigna Medicaid	$4,436.45
Rate for Payer: Molina CHIP/Medicaid	$4,436.45
Rate for Payer: Parkland Medicaid	$4,436.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,705.43

FRACTURE OF PELVIS OR DISLOCATION OF HIP

Facility

$2,566.77

Service Code	APR-DRG 3411
Min. Negotiated Rate	$2,420.04
Max. Negotiated Rate	$2,566.77
Rate for Payer: Amerigroup CHIP/Medicaid	$2,420.04
Rate for Payer: Cigna Medicaid	$2,420.04
Rate for Payer: Molina CHIP/Medicaid	$2,420.04
Rate for Payer: Parkland Medicaid	$2,420.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,566.77

FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK

Facility

$6,046.34

Service Code	APR-DRG 3423
Min. Negotiated Rate	$5,700.70
Max. Negotiated Rate	$6,046.34
Rate for Payer: Amerigroup CHIP/Medicaid	$5,700.70
Rate for Payer: Cigna Medicaid	$5,700.70
Rate for Payer: Molina CHIP/Medicaid	$5,700.70
Rate for Payer: Parkland Medicaid	$5,700.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,046.34

FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK

Facility

$2,733.49

Service Code	APR-DRG 3421
Min. Negotiated Rate	$2,577.23
Max. Negotiated Rate	$2,733.49
Rate for Payer: Amerigroup CHIP/Medicaid	$2,577.23
Rate for Payer: Cigna Medicaid	$2,577.23
Rate for Payer: Molina CHIP/Medicaid	$2,577.23
Rate for Payer: Parkland Medicaid	$2,577.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,733.49

FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK

Facility

$3,000.92

Service Code	APR-DRG 3422
Min. Negotiated Rate	$2,829.37
Max. Negotiated Rate	$3,000.92
Rate for Payer: Amerigroup CHIP/Medicaid	$2,829.37
Rate for Payer: Cigna Medicaid	$2,829.37
Rate for Payer: Molina CHIP/Medicaid	$2,829.37
Rate for Payer: Parkland Medicaid	$2,829.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,000.92

FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK

Facility

$8,257.80

Service Code	APR-DRG 3424
Min. Negotiated Rate	$7,785.74
Max. Negotiated Rate	$8,257.80
Rate for Payer: Amerigroup CHIP/Medicaid	$7,785.74
Rate for Payer: Cigna Medicaid	$7,785.74
Rate for Payer: Molina CHIP/Medicaid	$7,785.74
Rate for Payer: Parkland Medicaid	$7,785.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,257.80

FRACTURES OF FEMUR WITH MCC

Facility

$27,099.70

Service Code	MSDRG 533
Min. Negotiated Rate	$12,480.12
Max. Negotiated Rate	$27,099.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,249.80
Rate for Payer: Amerigroup Medicare	$16,249.80
Rate for Payer: BCBS of TX Medicare	$16,249.80
Rate for Payer: Cigna Commercial	$20,191.98
Rate for Payer: Cigna Medicare	$16,249.80
Rate for Payer: Employer Direct Commercial	$16,249.80
Rate for Payer: Humana Medicare/TRICARE	$16,249.80
Rate for Payer: Molina Dual Medicare/Medicaid	$16,249.80
Rate for Payer: Molina Medicare	$16,249.80
Rate for Payer: Multiplan Auto	$27,099.70
Rate for Payer: Multiplan Commercial	$27,099.70
Rate for Payer: Multiplan Workers Comp	$27,099.70
Rate for Payer: Scott and White EPO/PPO	$12,480.12
Rate for Payer: Scott and White Medicare	$16,249.80
Rate for Payer: Superior Health Plan EPO	$16,249.80
Rate for Payer: Superior Health Plan Medicare	$16,249.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,249.80
Rate for Payer: Universal American Medicare	$16,249.80
Rate for Payer: Wellcare Medicare	$16,249.80
Rate for Payer: Wellmed Medicare	$16,249.80

Know your out-of-pocket cost for care.

All Charges