White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Phenobarbital Level

Facility

$490.00

Service Code	CPT 80184
Hospital Charge Code	1602945
Hospital Revenue Code	300
Rate for Payer: Cash Price	$431.20

phenol 1.4% Topical Spray 180 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77756142
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

phenol 1.4% Topical Spray 180 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77756142
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
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: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

phenylephrine 10 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J2370
Hospital Charge Code	77758767
Hospital Revenue Code	636
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

phenylephrine 10 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J2370
Hospital Charge Code	77758767
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

phenytoin 100 mg ER Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77760348
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

phenytoin 100 mg ER Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77760348
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

phenytoin 50 mg/mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS J1165
Hospital Charge Code	77760778
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

phenytoin 50 mg/mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS J1165
Hospital Charge Code	77760778
Hospital Revenue Code	636
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.48
Rate for Payer: BCBS of TX Blue Essentials	$0.57
Rate for Payer: BCBS of TX PPO	$0.64
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
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: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

phenytoin 50 mg/mL Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J1165
Hospital Charge Code	77760837
Hospital Revenue Code	636
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.48
Rate for Payer: BCBS of TX Blue Essentials	$0.57
Rate for Payer: BCBS of TX PPO	$0.64
Rate for Payer: Cash Price	$87.16
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

phenytoin 50 mg/mL Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J1165
Hospital Charge Code	77760837
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

Phenytoin, Free, Serum SO

Facility

$166.00

Service Code	CPT 80186
Hospital Charge Code	1700871
Hospital Revenue Code	300
Rate for Payer: Cash Price	$146.08

Phenytoin, Free, Serum SO

Facility

$166.00

Service Code	CPT 80186
Hospital Charge Code	1700871
Hospital Revenue Code	300
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$107.90
Rate for Payer: Aetna Commercial	$14.46
Rate for Payer: Aetna Medicare	$20.64
Rate for Payer: Amerigroup CHIP/Medicaid	$5.37
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.76
Rate for Payer: Amerigroup Medicare	$13.76
Rate for Payer: BCBS of TX Blue Advantage	$22.70
Rate for Payer: BCBS of TX Blue Essentials	$27.24
Rate for Payer: BCBS of TX Medicare	$13.76
Rate for Payer: BCBS of TX PPO	$30.41
Rate for Payer: Cash Price	$146.08
Rate for Payer: Cash Price	$146.08
Rate for Payer: Cigna Medicaid	$13.76
Rate for Payer: Cigna Medicare	$13.76
Rate for Payer: Employer Direct Commercial	$13.76
Rate for Payer: Humana Medicare/TRICARE	$13.76
Rate for Payer: Molina CHIP/Medicaid	$13.76
Rate for Payer: Molina Dual Medicare/Medicaid	$13.76
Rate for Payer: Molina Medicare	$13.76
Rate for Payer: Multiplan Auto	$107.90
Rate for Payer: Multiplan Commercial	$107.90
Rate for Payer: Multiplan Workers Comp	$107.90
Rate for Payer: Parkland Medicaid	$13.76
Rate for Payer: Scott and White EPO/PPO	$17.20
Rate for Payer: Scott and White Medicare	$13.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.76
Rate for Payer: Superior Health Plan EPO	$13.76
Rate for Payer: Superior Health Plan Medicare	$13.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.76
Rate for Payer: Universal American Medicare	$13.76
Rate for Payer: Wellcare Medicare	$13.76
Rate for Payer: Wellmed Medicare	$13.76

Phenytoin Level Total

Facility

$487.00

Service Code	CPT 80185
Hospital Charge Code	1602994
Hospital Revenue Code	300
Rate for Payer: Cash Price	$428.56

Phenytoin Level Total

Facility

$487.00

Service Code	CPT 80185
Hospital Charge Code	1602994
Hospital Revenue Code	300
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$316.55
Rate for Payer: Aetna Commercial	$13.91
Rate for Payer: Aetna Medicare	$19.88
Rate for Payer: Amerigroup CHIP/Medicaid	$5.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.25
Rate for Payer: Amerigroup Medicare	$13.25
Rate for Payer: BCBS of TX Blue Advantage	$21.86
Rate for Payer: BCBS of TX Blue Essentials	$26.24
Rate for Payer: BCBS of TX Medicare	$13.25
Rate for Payer: BCBS of TX PPO	$29.28
Rate for Payer: Cash Price	$428.56
Rate for Payer: Cash Price	$428.56
Rate for Payer: Cigna Medicaid	$13.25
Rate for Payer: Cigna Medicare	$13.25
Rate for Payer: Employer Direct Commercial	$13.25
Rate for Payer: Humana Medicare/TRICARE	$13.25
Rate for Payer: Molina CHIP/Medicaid	$13.25
Rate for Payer: Molina Dual Medicare/Medicaid	$13.25
Rate for Payer: Molina Medicare	$13.25
Rate for Payer: Multiplan Auto	$316.55
Rate for Payer: Multiplan Commercial	$316.55
Rate for Payer: Multiplan Workers Comp	$316.55
Rate for Payer: Parkland Medicaid	$13.25
Rate for Payer: Scott and White EPO/PPO	$16.56
Rate for Payer: Scott and White Medicare	$13.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.25
Rate for Payer: Superior Health Plan EPO	$13.25
Rate for Payer: Superior Health Plan Medicare	$13.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.25
Rate for Payer: Universal American Medicare	$13.25
Rate for Payer: Wellcare Medicare	$13.25
Rate for Payer: Wellmed Medicare	$13.25

pH Gastric

Facility

$85.00

Service Code	CPT 83986
Hospital Charge Code	8452499
Hospital Revenue Code	301
Rate for Payer: Cash Price	$74.80

pH Gastric

Facility

$85.00

Service Code	CPT 83986
Hospital Charge Code	8452499
Hospital Revenue Code	301
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$55.25
Rate for Payer: Aetna Commercial	$3.76
Rate for Payer: Aetna Medicare	$5.37
Rate for Payer: Amerigroup CHIP/Medicaid	$1.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.58
Rate for Payer: Amerigroup Medicare	$3.58
Rate for Payer: BCBS of TX Blue Advantage	$5.91
Rate for Payer: BCBS of TX Blue Essentials	$7.09
Rate for Payer: BCBS of TX Medicare	$3.58
Rate for Payer: BCBS of TX PPO	$7.91
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cigna Medicaid	$3.58
Rate for Payer: Cigna Medicare	$3.58
Rate for Payer: Employer Direct Commercial	$3.58
Rate for Payer: Humana Medicare/TRICARE	$3.58
Rate for Payer: Molina CHIP/Medicaid	$3.58
Rate for Payer: Molina Dual Medicare/Medicaid	$3.58
Rate for Payer: Molina Medicare	$3.58
Rate for Payer: Multiplan Auto	$55.25
Rate for Payer: Multiplan Commercial	$55.25
Rate for Payer: Multiplan Workers Comp	$55.25
Rate for Payer: Parkland Medicaid	$3.58
Rate for Payer: Scott and White EPO/PPO	$4.48
Rate for Payer: Scott and White Medicare	$3.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.58
Rate for Payer: Superior Health Plan EPO	$3.58
Rate for Payer: Superior Health Plan Medicare	$3.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.58
Rate for Payer: Universal American Medicare	$3.58
Rate for Payer: Wellcare Medicare	$3.58
Rate for Payer: Wellmed Medicare	$3.58

PHOSPHATASE ISOENZYMES

Facility

$72.00

Service Code	CPT 84080
Hospital Charge Code	1701549
Hospital Revenue Code	301
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna Commercial	$15.52
Rate for Payer: Aetna Medicare	$22.17
Rate for Payer: Amerigroup CHIP/Medicaid	$5.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.78
Rate for Payer: Amerigroup Medicare	$14.78
Rate for Payer: BCBS of TX Blue Advantage	$24.39
Rate for Payer: BCBS of TX Blue Essentials	$29.26
Rate for Payer: BCBS of TX Medicare	$14.78
Rate for Payer: BCBS of TX PPO	$32.66
Rate for Payer: Cash Price	$63.36
Rate for Payer: Cash Price	$63.36
Rate for Payer: Cigna Medicaid	$14.78
Rate for Payer: Cigna Medicare	$14.78
Rate for Payer: Employer Direct Commercial	$14.78
Rate for Payer: Humana Medicare/TRICARE	$14.78
Rate for Payer: Molina CHIP/Medicaid	$14.78
Rate for Payer: Molina Dual Medicare/Medicaid	$14.78
Rate for Payer: Molina Medicare	$14.78
Rate for Payer: Multiplan Auto	$46.80
Rate for Payer: Multiplan Commercial	$46.80
Rate for Payer: Multiplan Workers Comp	$46.80
Rate for Payer: Parkland Medicaid	$14.78
Rate for Payer: Scott and White EPO/PPO	$18.48
Rate for Payer: Scott and White Medicare	$14.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.78
Rate for Payer: Superior Health Plan EPO	$14.78
Rate for Payer: Superior Health Plan Medicare	$14.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.78
Rate for Payer: Universal American Medicare	$14.78
Rate for Payer: Wellcare Medicare	$14.78
Rate for Payer: Wellmed Medicare	$14.78

Phospholipids SO

Facility

$334.00

Service Code	CPT 84311
Hospital Charge Code	1708650
Hospital Revenue Code	301
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$217.10
Rate for Payer: Aetna Commercial	$8.50
Rate for Payer: Aetna Medicare	$12.15
Rate for Payer: Amerigroup CHIP/Medicaid	$3.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.10
Rate for Payer: Amerigroup Medicare	$8.10
Rate for Payer: BCBS of TX Blue Advantage	$13.36
Rate for Payer: BCBS of TX Blue Essentials	$16.04
Rate for Payer: BCBS of TX Medicare	$8.10
Rate for Payer: BCBS of TX PPO	$17.90
Rate for Payer: Cash Price	$293.92
Rate for Payer: Cash Price	$293.92
Rate for Payer: Cigna Medicaid	$8.10
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Employer Direct Commercial	$8.10
Rate for Payer: Humana Medicare/TRICARE	$8.10
Rate for Payer: Molina CHIP/Medicaid	$8.10
Rate for Payer: Molina Dual Medicare/Medicaid	$8.10
Rate for Payer: Molina Medicare	$8.10
Rate for Payer: Multiplan Auto	$217.10
Rate for Payer: Multiplan Commercial	$217.10
Rate for Payer: Multiplan Workers Comp	$217.10
Rate for Payer: Parkland Medicaid	$8.10
Rate for Payer: Scott and White EPO/PPO	$10.12
Rate for Payer: Scott and White Medicare	$8.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.10
Rate for Payer: Superior Health Plan EPO	$8.10
Rate for Payer: Superior Health Plan Medicare	$8.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.10
Rate for Payer: Universal American Medicare	$8.10
Rate for Payer: Wellcare Medicare	$8.10
Rate for Payer: Wellmed Medicare	$8.10

Phosphorus Level

Facility

$221.00

Service Code	CPT 84100
Hospital Charge Code	1602184
Hospital Revenue Code	301
Rate for Payer: Cash Price	$194.48

Phosphorus Level

Facility

$221.00

Service Code	CPT 84100
Hospital Charge Code	1602184
Hospital Revenue Code	301
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$143.65
Rate for Payer: Aetna Commercial	$4.97
Rate for Payer: Aetna Medicare	$7.11
Rate for Payer: Amerigroup CHIP/Medicaid	$1.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.74
Rate for Payer: Amerigroup Medicare	$4.74
Rate for Payer: BCBS of TX Blue Advantage	$7.82
Rate for Payer: BCBS of TX Blue Essentials	$9.39
Rate for Payer: BCBS of TX Medicare	$4.74
Rate for Payer: BCBS of TX PPO	$10.48
Rate for Payer: Cash Price	$194.48
Rate for Payer: Cash Price	$194.48
Rate for Payer: Cigna Medicaid	$4.74
Rate for Payer: Cigna Medicare	$4.74
Rate for Payer: Employer Direct Commercial	$4.74
Rate for Payer: Humana Medicare/TRICARE	$4.74
Rate for Payer: Molina CHIP/Medicaid	$4.74
Rate for Payer: Molina Dual Medicare/Medicaid	$4.74
Rate for Payer: Molina Medicare	$4.74
Rate for Payer: Multiplan Auto	$143.65
Rate for Payer: Multiplan Commercial	$143.65
Rate for Payer: Multiplan Workers Comp	$143.65
Rate for Payer: Parkland Medicaid	$4.74
Rate for Payer: Scott and White EPO/PPO	$5.92
Rate for Payer: Scott and White Medicare	$4.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.74
Rate for Payer: Superior Health Plan EPO	$4.74
Rate for Payer: Superior Health Plan Medicare	$4.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.74
Rate for Payer: Universal American Medicare	$4.74
Rate for Payer: Wellcare Medicare	$4.74
Rate for Payer: Wellmed Medicare	$4.74

Phototherapy Activity BCE

Facility

$143.00

Service Code	CPT 96900
Hospital Charge Code	300574
Hospital Revenue Code	940
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$92.95
Rate for Payer: Aetna Commercial	$78.65
Rate for Payer: Aetna Medicare	$55.02
Rate for Payer: Amerigroup CHIP/Medicaid	$12.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$36.68
Rate for Payer: Amerigroup Medicare	$36.68
Rate for Payer: BCBS of TX Blue Advantage	$58.17
Rate for Payer: BCBS of TX Blue Essentials	$69.53
Rate for Payer: BCBS of TX Medicare	$36.68
Rate for Payer: BCBS of TX PPO	$77.56
Rate for Payer: Cash Price	$125.84
Rate for Payer: Cash Price	$125.84
Rate for Payer: Cash Price	$125.84
Rate for Payer: Cigna Commercial	$83.09
Rate for Payer: Cigna Medicare	$36.68
Rate for Payer: Employer Direct Commercial	$36.68
Rate for Payer: Humana Medicare/TRICARE	$36.68
Rate for Payer: Molina Dual Medicare/Medicaid	$36.68
Rate for Payer: Molina Medicare	$36.68
Rate for Payer: Multiplan Auto	$92.95
Rate for Payer: Multiplan Commercial	$92.95
Rate for Payer: Multiplan Workers Comp	$92.95
Rate for Payer: Scott and White EPO/PPO	$0.66
Rate for Payer: Scott and White Medicare	$36.68
Rate for Payer: Superior Health Plan EPO	$36.68
Rate for Payer: Superior Health Plan Medicare	$36.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$36.68
Rate for Payer: Universal American Medicare	$36.68
Rate for Payer: Wellcare Medicare	$36.68
Rate for Payer: Wellmed Medicare	$36.68

Phototherapy Activity BCE

Facility

$143.00

Service Code	CPT 96900
Hospital Charge Code	300574
Hospital Revenue Code	940
Rate for Payer: Cash Price	$125.84

Phototherapy Activity:Initiated

Facility

$143.00

Service Code	CPT 96900
Hospital Charge Code	300574
Hospital Revenue Code	940
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$92.95
Rate for Payer: Aetna Commercial	$78.65
Rate for Payer: Aetna Medicare	$55.02
Rate for Payer: Amerigroup CHIP/Medicaid	$12.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$36.68
Rate for Payer: Amerigroup Medicare	$36.68
Rate for Payer: BCBS of TX Blue Advantage	$58.17
Rate for Payer: BCBS of TX Blue Essentials	$69.53
Rate for Payer: BCBS of TX Medicare	$36.68
Rate for Payer: BCBS of TX PPO	$77.56
Rate for Payer: Cash Price	$125.84
Rate for Payer: Cash Price	$125.84
Rate for Payer: Cash Price	$125.84
Rate for Payer: Cigna Commercial	$83.09
Rate for Payer: Cigna Medicare	$36.68
Rate for Payer: Employer Direct Commercial	$36.68
Rate for Payer: Humana Medicare/TRICARE	$36.68
Rate for Payer: Molina Dual Medicare/Medicaid	$36.68
Rate for Payer: Molina Medicare	$36.68
Rate for Payer: Multiplan Auto	$92.95
Rate for Payer: Multiplan Commercial	$92.95
Rate for Payer: Multiplan Workers Comp	$92.95
Rate for Payer: Scott and White EPO/PPO	$0.66
Rate for Payer: Scott and White Medicare	$36.68
Rate for Payer: Superior Health Plan EPO	$36.68
Rate for Payer: Superior Health Plan Medicare	$36.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$36.68
Rate for Payer: Universal American Medicare	$36.68
Rate for Payer: Wellcare Medicare	$36.68
Rate for Payer: Wellmed Medicare	$36.68

PILLOW, ABDUCTION FOAM LARGE 6'''' X 18'''' X 25'''' -- DHF

Facility

$977.36

Hospital Charge Code	80335250
Hospital Revenue Code	270
Min. Negotiated Rate	$87.96
Max. Negotiated Rate	$635.28
Rate for Payer: Aetna Commercial	$537.55
Rate for Payer: Amerigroup CHIP/Medicaid	$87.96
Rate for Payer: BCBS of TX Blue Advantage	$293.21
Rate for Payer: BCBS of TX Blue Essentials	$351.85
Rate for Payer: BCBS of TX PPO	$390.94
Rate for Payer: Cash Price	$860.08
Rate for Payer: Multiplan Auto	$635.28
Rate for Payer: Multiplan Commercial	$635.28
Rate for Payer: Multiplan Workers Comp	$635.28
Rate for Payer: Scott and White EPO/PPO	$488.68
Rate for Payer: Superior Health Plan EPO	$132.92

Know your out-of-pocket cost for care.

All Charges