White Rock Medical Center

All Charges

Charge

Type

Setting

Price

patiromer 8.4 g Pow

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78872129
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

PCH T NSP 13/4 -- DHF

Facility

$55.15

Hospital Charge Code	80333008
Hospital Revenue Code	270
Rate for Payer: Cash Price	$48.53

PCH T NSP 13/4 -- DHF

Facility

$55.15

Hospital Charge Code	80333008
Hospital Revenue Code	270
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$35.85
Rate for Payer: Aetna Commercial	$30.33
Rate for Payer: Amerigroup CHIP/Medicaid	$4.96
Rate for Payer: BCBS of TX Blue Advantage	$16.54
Rate for Payer: BCBS of TX Blue Essentials	$19.85
Rate for Payer: BCBS of TX PPO	$22.06
Rate for Payer: Cash Price	$48.53
Rate for Payer: Multiplan Auto	$35.85
Rate for Payer: Multiplan Commercial	$35.85
Rate for Payer: Multiplan Workers Comp	$35.85
Rate for Payer: Scott and White EPO/PPO	$27.58
Rate for Payer: Superior Health Plan EPO	$7.50

PCP Screen Urine

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640103
Hospital Revenue Code	300
Rate for Payer: Cash Price	$278.96

PCP Screen Urine

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640103
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$206.05
Rate for Payer: Aetna Commercial	$65.24
Rate for Payer: Aetna Medicare	$93.21
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$102.53
Rate for Payer: BCBS of TX Blue Essentials	$123.04
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$137.33
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cigna Medicaid	$62.14
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$62.14
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$62.14
Rate for Payer: Scott and White EPO/PPO	$77.68
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.14
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

PD CAUTERY GRO -- DHF

Facility

$312.71

Hospital Charge Code	81845505
Hospital Revenue Code	270
Rate for Payer: Cash Price	$275.18

PD CAUTERY GRO -- DHF

Facility

$312.71

Hospital Charge Code	81845505
Hospital Revenue Code	270
Min. Negotiated Rate	$28.14
Max. Negotiated Rate	$203.26
Rate for Payer: Aetna Commercial	$171.99
Rate for Payer: Amerigroup CHIP/Medicaid	$28.14
Rate for Payer: BCBS of TX Blue Advantage	$93.81
Rate for Payer: BCBS of TX Blue Essentials	$112.58
Rate for Payer: BCBS of TX PPO	$125.08
Rate for Payer: Cash Price	$275.18
Rate for Payer: Multiplan Auto	$203.26
Rate for Payer: Multiplan Commercial	$203.26
Rate for Payer: Multiplan Workers Comp	$203.26
Rate for Payer: Scott and White EPO/PPO	$156.36
Rate for Payer: Superior Health Plan EPO	$42.53

PD COLD THERAPY -- DHF

Facility

$638.69

Hospital Charge Code	80333636
Hospital Revenue Code	272
Rate for Payer: Cash Price	$562.05

PD COLD THERAPY -- DHF

Facility

$638.69

Hospital Charge Code	80333636
Hospital Revenue Code	272
Min. Negotiated Rate	$57.48
Max. Negotiated Rate	$415.15
Rate for Payer: Aetna Commercial	$351.28
Rate for Payer: Amerigroup CHIP/Medicaid	$57.48
Rate for Payer: BCBS of TX Blue Advantage	$191.61
Rate for Payer: BCBS of TX Blue Essentials	$229.93
Rate for Payer: BCBS of TX PPO	$255.48
Rate for Payer: Cash Price	$562.05
Rate for Payer: Multiplan Auto	$415.15
Rate for Payer: Multiplan Commercial	$415.15
Rate for Payer: Multiplan Workers Comp	$415.15
Rate for Payer: Scott and White EPO/PPO	$319.34
Rate for Payer: Superior Health Plan EPO	$86.86

PD ELCTRD RESUSITATION -- DHF

Facility

$385.90

Hospital Charge Code	80333792
Hospital Revenue Code	272
Min. Negotiated Rate	$34.73
Max. Negotiated Rate	$250.84
Rate for Payer: Aetna Commercial	$212.24
Rate for Payer: Amerigroup CHIP/Medicaid	$34.73
Rate for Payer: BCBS of TX Blue Advantage	$115.77
Rate for Payer: BCBS of TX Blue Essentials	$138.92
Rate for Payer: BCBS of TX PPO	$154.36
Rate for Payer: Cash Price	$339.59
Rate for Payer: Multiplan Auto	$250.84
Rate for Payer: Multiplan Commercial	$250.84
Rate for Payer: Multiplan Workers Comp	$250.84
Rate for Payer: Scott and White EPO/PPO	$192.95
Rate for Payer: Superior Health Plan EPO	$52.48

PD ELCTRD RESUSITATION -- DHF

Facility

$385.90

Hospital Charge Code	80333792
Hospital Revenue Code	272
Rate for Payer: Cash Price	$339.59

Pediatric Echo Complete 93303

Facility

$2,448.00

Service Code	CPT 93303
Hospital Charge Code	2810001
Hospital Revenue Code	480
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$1,591.20
Rate for Payer: Aetna Commercial	$280.52
Rate for Payer: Aetna Medicare	$756.80
Rate for Payer: Amerigroup CHIP/Medicaid	$220.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$504.53
Rate for Payer: Amerigroup Medicare	$504.53
Rate for Payer: BCBS of TX Blue Advantage	$303.51
Rate for Payer: BCBS of TX Blue Essentials	$362.81
Rate for Payer: BCBS of TX Medicare	$504.53
Rate for Payer: BCBS of TX PPO	$404.68
Rate for Payer: Cash Price	$2,154.24
Rate for Payer: Cash Price	$2,154.24
Rate for Payer: Cash Price	$2,154.24
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicaid	$220.19
Rate for Payer: Cigna Medicare	$504.53
Rate for Payer: Employer Direct Commercial	$504.53
Rate for Payer: Humana Medicare/TRICARE	$504.53
Rate for Payer: Molina CHIP/Medicaid	$220.19
Rate for Payer: Molina Dual Medicare/Medicaid	$504.53
Rate for Payer: Molina Medicare	$504.53
Rate for Payer: Multiplan Auto	$1,591.20
Rate for Payer: Multiplan Commercial	$1,591.20
Rate for Payer: Multiplan Workers Comp	$1,591.20
Rate for Payer: Parkland Medicaid	$220.19
Rate for Payer: Scott and White EPO/PPO	$9.02
Rate for Payer: Scott and White Medicare	$504.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$220.19
Rate for Payer: Superior Health Plan EPO	$504.53
Rate for Payer: Superior Health Plan Medicare	$504.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$504.53
Rate for Payer: Universal American Medicare	$504.53
Rate for Payer: Wellcare Medicare	$504.53
Rate for Payer: Wellmed Medicare	$504.53

Pediatric Echo Complete 93303 BCE

Facility

$2,448.00

Service Code	CPT 93303
Hospital Charge Code	2810001
Hospital Revenue Code	480
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$1,591.20
Rate for Payer: Aetna Commercial	$280.52
Rate for Payer: Aetna Medicare	$756.80
Rate for Payer: Amerigroup CHIP/Medicaid	$220.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$504.53
Rate for Payer: Amerigroup Medicare	$504.53
Rate for Payer: BCBS of TX Blue Advantage	$303.51
Rate for Payer: BCBS of TX Blue Essentials	$362.81
Rate for Payer: BCBS of TX Medicare	$504.53
Rate for Payer: BCBS of TX PPO	$404.68
Rate for Payer: Cash Price	$2,154.24
Rate for Payer: Cash Price	$2,154.24
Rate for Payer: Cash Price	$2,154.24
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicaid	$220.19
Rate for Payer: Cigna Medicare	$504.53
Rate for Payer: Employer Direct Commercial	$504.53
Rate for Payer: Humana Medicare/TRICARE	$504.53
Rate for Payer: Molina CHIP/Medicaid	$220.19
Rate for Payer: Molina Dual Medicare/Medicaid	$504.53
Rate for Payer: Molina Medicare	$504.53
Rate for Payer: Multiplan Auto	$1,591.20
Rate for Payer: Multiplan Commercial	$1,591.20
Rate for Payer: Multiplan Workers Comp	$1,591.20
Rate for Payer: Parkland Medicaid	$220.19
Rate for Payer: Scott and White EPO/PPO	$9.02
Rate for Payer: Scott and White Medicare	$504.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$220.19
Rate for Payer: Superior Health Plan EPO	$504.53
Rate for Payer: Superior Health Plan Medicare	$504.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$504.53
Rate for Payer: Universal American Medicare	$504.53
Rate for Payer: Wellcare Medicare	$504.53
Rate for Payer: Wellmed Medicare	$504.53

Pediatric Echo Complete 93303 BCE

Facility

$2,448.00

Service Code	CPT 93303
Hospital Charge Code	2810001
Hospital Revenue Code	480
Rate for Payer: Cash Price	$2,154.24

PE+Interp(Rfx IFE),24-Hr U SO

Facility

$160.00

Service Code	CPT 84156
Hospital Charge Code	8604526
Hospital Revenue Code	301
Rate for Payer: Cash Price	$140.80

PE+Interp(Rfx IFE),24-Hr U SO

Facility

$160.00

Service Code	CPT 84156
Hospital Charge Code	8604526
Hospital Revenue Code	301
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$104.00
Rate for Payer: Aetna Commercial	$3.85
Rate for Payer: Aetna Medicare	$5.50
Rate for Payer: Amerigroup CHIP/Medicaid	$1.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.67
Rate for Payer: Amerigroup Medicare	$3.67
Rate for Payer: BCBS of TX Blue Advantage	$6.06
Rate for Payer: BCBS of TX Blue Essentials	$7.27
Rate for Payer: BCBS of TX Medicare	$3.67
Rate for Payer: BCBS of TX PPO	$8.11
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cigna Medicaid	$3.67
Rate for Payer: Cigna Medicare	$3.67
Rate for Payer: Employer Direct Commercial	$3.67
Rate for Payer: Humana Medicare/TRICARE	$3.67
Rate for Payer: Molina CHIP/Medicaid	$3.67
Rate for Payer: Molina Dual Medicare/Medicaid	$3.67
Rate for Payer: Molina Medicare	$3.67
Rate for Payer: Multiplan Auto	$104.00
Rate for Payer: Multiplan Commercial	$104.00
Rate for Payer: Multiplan Workers Comp	$104.00
Rate for Payer: Parkland Medicaid	$3.67
Rate for Payer: Scott and White EPO/PPO	$4.59
Rate for Payer: Scott and White Medicare	$3.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.67
Rate for Payer: Superior Health Plan EPO	$3.67
Rate for Payer: Superior Health Plan Medicare	$3.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.67
Rate for Payer: Universal American Medicare	$3.67
Rate for Payer: Wellcare Medicare	$3.67
Rate for Payer: Wellmed Medicare	$3.67

PE+Interp(Rfx IFE),S SO

Facility

$441.00

Service Code	CPT 84165
Hospital Charge Code	8604527
Hospital Revenue Code	301
Min. Negotiated Rate	$4.19
Max. Negotiated Rate	$286.65
Rate for Payer: Aetna Commercial	$11.27
Rate for Payer: Aetna Medicare	$16.11
Rate for Payer: Amerigroup CHIP/Medicaid	$4.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.74
Rate for Payer: Amerigroup Medicare	$10.74
Rate for Payer: BCBS of TX Blue Advantage	$17.72
Rate for Payer: BCBS of TX Blue Essentials	$21.27
Rate for Payer: BCBS of TX Medicare	$10.74
Rate for Payer: BCBS of TX PPO	$23.74
Rate for Payer: Cash Price	$388.08
Rate for Payer: Cash Price	$388.08
Rate for Payer: Cigna Medicaid	$10.74
Rate for Payer: Cigna Medicare	$10.74
Rate for Payer: Employer Direct Commercial	$10.74
Rate for Payer: Humana Medicare/TRICARE	$10.74
Rate for Payer: Molina CHIP/Medicaid	$10.74
Rate for Payer: Molina Dual Medicare/Medicaid	$10.74
Rate for Payer: Molina Medicare	$10.74
Rate for Payer: Multiplan Auto	$286.65
Rate for Payer: Multiplan Commercial	$286.65
Rate for Payer: Multiplan Workers Comp	$286.65
Rate for Payer: Parkland Medicaid	$10.74
Rate for Payer: Scott and White EPO/PPO	$13.42
Rate for Payer: Scott and White Medicare	$10.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.74
Rate for Payer: Superior Health Plan EPO	$10.74
Rate for Payer: Superior Health Plan Medicare	$10.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.74
Rate for Payer: Universal American Medicare	$10.74
Rate for Payer: Wellcare Medicare	$10.74
Rate for Payer: Wellmed Medicare	$10.74

PE+Interp(Rfx IFE),S SO

Facility

$441.00

Service Code	CPT 84165
Hospital Charge Code	8604527
Hospital Revenue Code	301
Rate for Payer: Cash Price	$388.08

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC

Facility

$41,298.40

Service Code	MSDRG 734
Min. Negotiated Rate	$18,365.72
Max. Negotiated Rate	$41,298.40
Rate for Payer: Aetna Commercial	$24,453.00
Rate for Payer: Aetna Medicare	$27,548.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,365.72
Rate for Payer: Amerigroup Medicare	$18,365.72
Rate for Payer: BCBS of TX Blue Advantage	$23,385.12
Rate for Payer: BCBS of TX Blue Essentials	$23,794.58
Rate for Payer: BCBS of TX Medicare	$18,365.72
Rate for Payer: BCBS of TX PPO	$26,439.45
Rate for Payer: Cigna Commercial	$27,995.97
Rate for Payer: Cigna Medicare	$18,365.72
Rate for Payer: Employer Direct Commercial	$18,365.72
Rate for Payer: Humana Medicare/TRICARE	$18,365.72
Rate for Payer: Molina Dual Medicare/Medicaid	$18,365.72
Rate for Payer: Molina Medicare	$18,365.72
Rate for Payer: Multiplan Auto	$41,298.40
Rate for Payer: Multiplan Commercial	$41,298.40
Rate for Payer: Multiplan Workers Comp	$41,298.40
Rate for Payer: Scott and White EPO/PPO	$19,019.00
Rate for Payer: Scott and White Medicare	$18,365.72
Rate for Payer: Superior Health Plan EPO	$18,365.72
Rate for Payer: Superior Health Plan Medicare	$18,365.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,365.72
Rate for Payer: Universal American Medicare	$18,365.72
Rate for Payer: Wellcare Medicare	$18,365.72
Rate for Payer: Wellmed Medicare	$18,365.72

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC

Facility

$23,943.80

Service Code	MSDRG 735
Min. Negotiated Rate	$10,688.08
Max. Negotiated Rate	$23,943.80
Rate for Payer: Aetna Commercial	$14,177.25
Rate for Payer: Aetna Medicare	$17,771.49
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,847.66
Rate for Payer: Amerigroup Medicare	$11,847.66
Rate for Payer: BCBS of TX Blue Advantage	$10,688.08
Rate for Payer: BCBS of TX Blue Essentials	$14,085.44
Rate for Payer: BCBS of TX Medicare	$11,847.66
Rate for Payer: BCBS of TX PPO	$15,651.09
Rate for Payer: Cigna Commercial	$16,231.38
Rate for Payer: Cigna Medicare	$11,847.66
Rate for Payer: Employer Direct Commercial	$11,847.66
Rate for Payer: Humana Medicare/TRICARE	$11,847.66
Rate for Payer: Molina Dual Medicare/Medicaid	$11,847.66
Rate for Payer: Molina Medicare	$11,847.66
Rate for Payer: Multiplan Auto	$23,943.80
Rate for Payer: Multiplan Commercial	$23,943.80
Rate for Payer: Multiplan Workers Comp	$23,943.80
Rate for Payer: Scott and White EPO/PPO	$11,026.75
Rate for Payer: Scott and White Medicare	$11,847.66
Rate for Payer: Superior Health Plan EPO	$11,847.66
Rate for Payer: Superior Health Plan Medicare	$11,847.66
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,847.66
Rate for Payer: Universal American Medicare	$11,847.66
Rate for Payer: Wellcare Medicare	$11,847.66
Rate for Payer: Wellmed Medicare	$11,847.66

PENCIL BOVIE STRYKER SMOKE EVAC NEPTUNE

Facility

$132.97

Hospital Charge Code	8708544
Hospital Revenue Code	272
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$86.43
Rate for Payer: Aetna Commercial	$73.13
Rate for Payer: Amerigroup CHIP/Medicaid	$11.97
Rate for Payer: BCBS of TX Blue Advantage	$39.89
Rate for Payer: BCBS of TX Blue Essentials	$47.87
Rate for Payer: BCBS of TX PPO	$53.19
Rate for Payer: Cash Price	$117.01
Rate for Payer: Multiplan Auto	$86.43
Rate for Payer: Multiplan Commercial	$86.43
Rate for Payer: Multiplan Workers Comp	$86.43
Rate for Payer: Scott and White EPO/PPO	$66.48
Rate for Payer: Superior Health Plan EPO	$18.08

PENCIL BOVIE STRYKER SMOKE EVAC NEPTUNE

Facility

$132.97

Hospital Charge Code	8708544
Hospital Revenue Code	272
Rate for Payer: Cash Price	$117.01

penicillin V potassium 250 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77751361
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

penicillin V potassium 250 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77751361
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

PENIS PROCEDURES WITH CC/MCC

Facility

$40,280.00

Service Code	MSDRG 709
Min. Negotiated Rate	$18,345.75
Max. Negotiated Rate	$40,280.00
Rate for Payer: Aetna Commercial	$23,850.00
Rate for Payer: Aetna Medicare	$27,518.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,345.75
Rate for Payer: Amerigroup Medicare	$18,345.75
Rate for Payer: BCBS of TX Blue Advantage	$18,703.28
Rate for Payer: BCBS of TX Blue Essentials	$20,966.14
Rate for Payer: BCBS of TX Medicare	$18,345.75
Rate for Payer: BCBS of TX PPO	$23,296.62
Rate for Payer: Cigna Commercial	$27,305.60
Rate for Payer: Cigna Medicare	$18,345.75
Rate for Payer: Employer Direct Commercial	$18,345.75
Rate for Payer: Humana Medicare/TRICARE	$18,345.75
Rate for Payer: Molina Dual Medicare/Medicaid	$18,345.75
Rate for Payer: Molina Medicare	$18,345.75
Rate for Payer: Multiplan Auto	$40,280.00
Rate for Payer: Multiplan Commercial	$40,280.00
Rate for Payer: Multiplan Workers Comp	$40,280.00
Rate for Payer: Scott and White EPO/PPO	$18,550.00
Rate for Payer: Scott and White Medicare	$18,345.75
Rate for Payer: Superior Health Plan EPO	$18,345.75
Rate for Payer: Superior Health Plan Medicare	$18,345.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,345.75
Rate for Payer: Universal American Medicare	$18,345.75
Rate for Payer: Wellcare Medicare	$18,345.75
Rate for Payer: Wellmed Medicare	$18,345.75

Know your out-of-pocket cost for care.

All Charges