White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PAD POLISH SUPER WHITE 24'

Facility

$14.86

Hospital Charge Code	993275
Hospital Revenue Code	270
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$10.70
Rate for Payer: Amerigroup CHIP/Medicaid	$1.34
Rate for Payer: BCBS of TX Blue Advantage	$4.46
Rate for Payer: BCBS of TX Blue Essentials	$5.35
Rate for Payer: BCBS of TX PPO	$5.94
Rate for Payer: Cash Price	$10.10
Rate for Payer: Cigna Medicaid	$10.70
Rate for Payer: Molina CHIP/Medicaid	$10.70
Rate for Payer: Multiplan Auto	$9.66
Rate for Payer: Multiplan Commercial	$9.66
Rate for Payer: Multiplan Workers Comp	$9.66
Rate for Payer: Parkland Medicaid	$10.70
Rate for Payer: Scott and White EPO/PPO	$7.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.70
Rate for Payer: Superior Health Plan EPO	$2.02

PAD, PREP, ALCOHOL, MEDIUM, STRL, BULK

Facility

$0.06

Hospital Charge Code	992990
Hospital Revenue Code	270
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Amerigroup CHIP/Medicaid	$0.01
Rate for Payer: BCBS of TX Blue Advantage	$0.02
Rate for Payer: BCBS of TX Blue Essentials	$0.02
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna Medicaid	$0.04
Rate for Payer: Molina CHIP/Medicaid	$0.04
Rate for Payer: Multiplan Auto	$0.04
Rate for Payer: Multiplan Commercial	$0.04
Rate for Payer: Multiplan Workers Comp	$0.04
Rate for Payer: Parkland Medicaid	$0.04
Rate for Payer: Scott and White EPO/PPO	$0.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.04
Rate for Payer: Superior Health Plan EPO	$0.01

PAD, PREP, ALCOHOL, MEDIUM, STRL, BULK

Facility

$0.06

Hospital Charge Code	992990
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.04

PAD, PREP, ALCOHOL, STRL, MEDIUM, 2-PLY

Facility

$0.14

Hospital Charge Code	993084
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.10

PAD, PREP, ALCOHOL, STRL, MEDIUM, 2-PLY

Facility

$0.14

Hospital Charge Code	993084
Hospital Revenue Code	270
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.10
Rate for Payer: Amerigroup CHIP/Medicaid	$0.01
Rate for Payer: BCBS of TX Blue Advantage	$0.04
Rate for Payer: BCBS of TX Blue Essentials	$0.05
Rate for Payer: BCBS of TX PPO	$0.06
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna Medicaid	$0.10
Rate for Payer: Molina CHIP/Medicaid	$0.10
Rate for Payer: Multiplan Auto	$0.09
Rate for Payer: Multiplan Commercial	$0.09
Rate for Payer: Multiplan Workers Comp	$0.09
Rate for Payer: Parkland Medicaid	$0.10
Rate for Payer: Scott and White EPO/PPO	$0.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.10
Rate for Payer: Superior Health Plan EPO	$0.02

PAD, SANITARY, 11 IN, MAXI, N-STRL, IND WRAP

Facility

$0.51

Hospital Charge Code	993969
Hospital Revenue Code	271
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.37
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.15
Rate for Payer: BCBS of TX Blue Essentials	$0.18
Rate for Payer: BCBS of TX PPO	$0.20
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna Medicaid	$0.37
Rate for Payer: Molina CHIP/Medicaid	$0.37
Rate for Payer: Multiplan Auto	$0.33
Rate for Payer: Multiplan Commercial	$0.33
Rate for Payer: Multiplan Workers Comp	$0.33
Rate for Payer: Parkland Medicaid	$0.37
Rate for Payer: Scott and White EPO/PPO	$0.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.37
Rate for Payer: Superior Health Plan EPO	$0.07

PAD, SANITARY, 11 IN, MAXI, N-STRL, IND WRAP

Facility

$0.51

Hospital Charge Code	993969
Hospital Revenue Code	271
Rate for Payer: Cash Price	$0.35

PAD, SANITARY, 9 IN, MAXI, ADH, STRL, IND BOX

Facility

$1.59

Hospital Charge Code	993214
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.08

PAD, SANITARY, 9 IN, MAXI, ADH, STRL, IND BOX

Facility

$1.59

Hospital Charge Code	993214
Hospital Revenue Code	270
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$1.14
Rate for Payer: Amerigroup CHIP/Medicaid	$0.14
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	$1.08
Rate for Payer: Cigna Medicaid	$1.14
Rate for Payer: Molina CHIP/Medicaid	$1.14
Rate for Payer: Multiplan Auto	$1.03
Rate for Payer: Multiplan Commercial	$1.03
Rate for Payer: Multiplan Workers Comp	$1.03
Rate for Payer: Parkland Medicaid	$1.14
Rate for Payer: Scott and White EPO/PPO	$0.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.14
Rate for Payer: Superior Health Plan EPO	$0.22

PAD, TIP CLEANER ELECTRO SURGICAL LARGE STERILE -- DHF

Facility

$183.92

Hospital Charge Code	80322159
Hospital Revenue Code	270
Rate for Payer: Cash Price	$125.07

PAD, TIP CLEANER ELECTRO SURGICAL LARGE STERILE -- DHF

Facility

$183.92

Hospital Charge Code	80322159
Hospital Revenue Code	270
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$132.42
Rate for Payer: Amerigroup CHIP/Medicaid	$16.55
Rate for Payer: BCBS of TX Blue Advantage	$55.18
Rate for Payer: BCBS of TX Blue Essentials	$66.21
Rate for Payer: BCBS of TX PPO	$73.57
Rate for Payer: Cash Price	$125.07
Rate for Payer: Cigna Medicaid	$132.42
Rate for Payer: Molina CHIP/Medicaid	$132.42
Rate for Payer: Multiplan Auto	$119.55
Rate for Payer: Multiplan Commercial	$119.55
Rate for Payer: Multiplan Workers Comp	$119.55
Rate for Payer: Parkland Medicaid	$132.42
Rate for Payer: Scott and White EPO/PPO	$91.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.42
Rate for Payer: Superior Health Plan EPO	$25.01

PAIN DSTRJ NULYT AGT GNCLR NRV BCE

Facility

$6,240.55

Service Code	HCPCS 64624
Hospital Charge Code	6100006
Hospital Revenue Code	761
Min. Negotiated Rate	$178.89
Max. Negotiated Rate	$4,493.20
Rate for Payer: Amerigroup CHIP/Medicaid	$561.65
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$532.18
Rate for Payer: BCBS of TX Blue Essentials	$637.34
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$803.05
Rate for Payer: Cash Price	$4,243.57
Rate for Payer: Cash Price	$4,243.57
Rate for Payer: Cash Price	$4,243.57
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$4,493.20
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$4,493.20
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
Rate for Payer: Multiplan Auto	$4,056.36
Rate for Payer: Multiplan Commercial	$4,056.36
Rate for Payer: Multiplan Workers Comp	$4,056.36
Rate for Payer: Parkland Medicaid	$4,493.20
Rate for Payer: Scott and White EPO/PPO	$178.89
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,493.20
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

PAIN DSTRJ NULYT AGT GNCLR NRV BCE

Facility

$6,240.55

Service Code	HCPCS 64624
Hospital Charge Code	6100006
Hospital Revenue Code	761
Rate for Payer: Cash Price	$4,243.57

Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Facility

$12,715.13

Service Code	HCPCS 42156
Hospital Charge Code	9900651
Hospital Revenue Code	360
Min. Negotiated Rate	$1,144.36
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,144.36
Rate for Payer: BCBS of TX Blue Advantage	$3,814.54
Rate for Payer: BCBS of TX Blue Essentials	$4,577.45
Rate for Payer: BCBS of TX PPO	$5,086.05
Rate for Payer: Cash Price	$8,646.29
Rate for Payer: Cash Price	$8,646.29
Rate for Payer: Cigna Medicaid	$9,154.89
Rate for Payer: Molina CHIP/Medicaid	$9,154.89
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$9,154.89
Rate for Payer: Scott and White EPO/PPO	$6,357.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,154.89
Rate for Payer: Superior Health Plan EPO	$1,729.26

Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Facility

$12,570.48

Service Code	CPT 42145
Hospital Charge Code	36042145
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Facility

$12,715.13

Service Code	HCPCS 42145
Hospital Charge Code	9900650
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cash Price	$8,646.29
Rate for Payer: Cash Price	$8,646.29
Rate for Payer: Cash Price	$8,646.29
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicaid	$9,154.89
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina CHIP/Medicaid	$9,154.89
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$9,154.89
Rate for Payer: Scott and White EPO/PPO	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,154.89
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Facility

$12,715.13

Service Code	HCPCS 42156
Hospital Charge Code	9900651
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,646.29

Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Facility

$10,000.00

Service Code	CPT 42156
Hospital Charge Code	36042156
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$10,000.00
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00

Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Facility

$12,715.13

Service Code	HCPCS 42145
Hospital Charge Code	9900650
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,646.29

Palmaz Blue

Facility

$4,585.84

Service Code	HCPCS C1876
Hospital Charge Code	991296
Hospital Revenue Code	278
Min. Negotiated Rate	$1,146.46
Max. Negotiated Rate	$2,292.92
Rate for Payer: Cash Price	$3,118.37
Rate for Payer: Cigna Commercial	$1,146.46
Rate for Payer: Multiplan Auto	$2,292.92
Rate for Payer: Multiplan Commercial	$2,292.92
Rate for Payer: Multiplan Workers Comp	$2,292.92
Rate for Payer: Scott and White EPO/PPO	$2,292.92

Palmaz Blue

Facility

$4,585.84

Service Code	HCPCS C1876
Hospital Charge Code	991296
Hospital Revenue Code	278
Min. Negotiated Rate	$412.73
Max. Negotiated Rate	$3,301.80
Rate for Payer: Amerigroup CHIP/Medicaid	$412.73
Rate for Payer: BCBS of TX Blue Advantage	$1,375.75
Rate for Payer: BCBS of TX Blue Essentials	$1,650.90
Rate for Payer: BCBS of TX PPO	$1,834.34
Rate for Payer: Cash Price	$3,118.37
Rate for Payer: Cigna Medicaid	$3,301.80
Rate for Payer: Molina CHIP/Medicaid	$3,301.80
Rate for Payer: Multiplan Auto	$2,292.92
Rate for Payer: Multiplan Commercial	$2,292.92
Rate for Payer: Multiplan Workers Comp	$2,292.92
Rate for Payer: Parkland Medicaid	$3,301.80
Rate for Payer: Scott and White EPO/PPO	$2,292.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,301.80
Rate for Payer: Superior Health Plan EPO	$623.67

PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC

Facility

$55,664.30

Service Code	MSDRG 406
Min. Negotiated Rate	$24,360.36
Max. Negotiated Rate	$55,664.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,015.72
Rate for Payer: Amerigroup Medicare	$26,015.72
Rate for Payer: BCBS of TX Medicare	$26,015.72
Rate for Payer: Cigna Commercial	$37,354.58
Rate for Payer: Cigna Medicare	$26,015.72
Rate for Payer: Employer Direct Commercial	$26,015.72
Rate for Payer: Humana Medicare/TRICARE	$26,015.72
Rate for Payer: Molina Dual Medicare/Medicaid	$26,015.72
Rate for Payer: Molina Medicare	$26,015.72
Rate for Payer: Multiplan Auto	$55,664.30
Rate for Payer: Multiplan Commercial	$55,664.30
Rate for Payer: Multiplan Workers Comp	$55,664.30
Rate for Payer: Scott and White EPO/PPO	$25,634.88
Rate for Payer: Scott and White Medicare	$26,015.72
Rate for Payer: Superior Health Plan EPO	$26,015.72
Rate for Payer: Superior Health Plan Medicare	$26,015.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,015.72
Rate for Payer: Universal American Medicare	$26,015.72
Rate for Payer: Wellcare Medicare	$26,015.72
Rate for Payer: Wellmed Medicare	$26,015.72

PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC

Facility

$105,296.10

Service Code	MSDRG 405
Min. Negotiated Rate	$44,853.52
Max. Negotiated Rate	$105,296.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$44,853.52
Rate for Payer: Amerigroup Medicare	$44,853.52
Rate for Payer: BCBS of TX Medicare	$44,853.52
Rate for Payer: Cigna Commercial	$70,460.04
Rate for Payer: Cigna Medicare	$44,853.52
Rate for Payer: Employer Direct Commercial	$44,853.52
Rate for Payer: Humana Medicare/TRICARE	$44,853.52
Rate for Payer: Molina Dual Medicare/Medicaid	$44,853.52
Rate for Payer: Molina Medicare	$44,853.52
Rate for Payer: Multiplan Auto	$105,296.10
Rate for Payer: Multiplan Commercial	$105,296.10
Rate for Payer: Multiplan Workers Comp	$105,296.10
Rate for Payer: Scott and White EPO/PPO	$48,491.62
Rate for Payer: Scott and White Medicare	$44,853.52
Rate for Payer: Superior Health Plan EPO	$44,853.52
Rate for Payer: Superior Health Plan Medicare	$44,853.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$44,853.52
Rate for Payer: Universal American Medicare	$44,853.52
Rate for Payer: Wellcare Medicare	$44,853.52
Rate for Payer: Wellmed Medicare	$44,853.52

PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC

Facility

$42,288.30

Service Code	MSDRG 407
Min. Negotiated Rate	$17,258.48
Max. Negotiated Rate	$42,288.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,027.58
Rate for Payer: Amerigroup Medicare	$21,027.58
Rate for Payer: BCBS of TX Medicare	$21,027.58
Rate for Payer: Cigna Commercial	$28,588.45
Rate for Payer: Cigna Medicare	$21,027.58
Rate for Payer: Employer Direct Commercial	$21,027.58
Rate for Payer: Humana Medicare/TRICARE	$21,027.58
Rate for Payer: Molina Dual Medicare/Medicaid	$21,027.58
Rate for Payer: Molina Medicare	$21,027.58
Rate for Payer: Multiplan Auto	$42,288.30
Rate for Payer: Multiplan Commercial	$42,288.30
Rate for Payer: Multiplan Workers Comp	$42,288.30
Rate for Payer: Scott and White EPO/PPO	$19,474.88
Rate for Payer: Scott and White Medicare	$21,027.58
Rate for Payer: Superior Health Plan EPO	$21,027.58
Rate for Payer: Superior Health Plan Medicare	$21,027.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,027.58
Rate for Payer: Universal American Medicare	$21,027.58
Rate for Payer: Wellcare Medicare	$21,027.58
Rate for Payer: Wellmed Medicare	$21,027.58

PANCREAS, LIVER & SHUNT PROCEDURES W CC

Facility

$55,664.30

Service Code	MSDRG 406
Min. Negotiated Rate	$24,360.36
Max. Negotiated Rate	$55,664.30
Rate for Payer: BCBS of TX Blue Advantage	$24,360.36
Rate for Payer: BCBS of TX Blue Essentials	$29,229.60
Rate for Payer: BCBS of TX PPO	$32,478.59

Know your out-of-pocket cost for care.

All Charges