White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$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

$12,715.13

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	$11,001.60
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 42145
Hospital Charge Code	9900650
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,646.29

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	$11,001.60
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

$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

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

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

PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC

Facility

$55,103.80

Service Code	MSDRG 406
Min. Negotiated Rate	$24,360.36
Max. Negotiated Rate	$55,103.80
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	$55,103.80
Rate for Payer: Multiplan Commercial	$55,103.80
Rate for Payer: Multiplan Workers Comp	$55,103.80
Rate for Payer: Scott and White EPO/PPO	$25,376.75
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

$103,939.50

Service Code	MSDRG 405
Min. Negotiated Rate	$44,853.52
Max. Negotiated Rate	$103,939.50
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	$103,939.50
Rate for Payer: Multiplan Commercial	$103,939.50
Rate for Payer: Multiplan Workers Comp	$103,939.50
Rate for Payer: Scott and White EPO/PPO	$47,866.88
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

$42,172.40

Service Code	MSDRG 407
Min. Negotiated Rate	$17,258.48
Max. Negotiated Rate	$42,172.40
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	$42,172.40
Rate for Payer: Multiplan Commercial	$42,172.40
Rate for Payer: Multiplan Workers Comp	$42,172.40
Rate for Payer: Scott and White EPO/PPO	$19,421.50
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

$55,103.80

Service Code	MSDRG 406
Min. Negotiated Rate	$24,360.36
Max. Negotiated Rate	$55,103.80
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

PANCREAS, LIVER & SHUNT PROCEDURES W MCC

Facility

$103,939.50

Service Code	MSDRG 405
Min. Negotiated Rate	$44,853.52
Max. Negotiated Rate	$103,939.50
Rate for Payer: BCBS of TX Blue Advantage	$46,260.26
Rate for Payer: BCBS of TX Blue Essentials	$55,506.93
Rate for Payer: BCBS of TX PPO	$61,676.76

PANCREAS, LIVER & SHUNT PROCEDURES W/O CC/MCC

Facility

$42,172.40

Service Code	MSDRG 407
Min. Negotiated Rate	$17,258.48
Max. Negotiated Rate	$42,172.40
Rate for Payer: BCBS of TX Blue Advantage	$17,258.48
Rate for Payer: BCBS of TX Blue Essentials	$20,708.17
Rate for Payer: BCBS of TX PPO	$23,009.97

PANCREAS TRANSPLANT

Facility

$49,450.23

Service Code	APR-DRG 0063
Min. Negotiated Rate	$46,623.41
Max. Negotiated Rate	$49,450.23
Rate for Payer: Amerigroup CHIP/Medicaid	$46,623.41
Rate for Payer: Cigna Medicaid	$46,623.41
Rate for Payer: Molina CHIP/Medicaid	$46,623.41
Rate for Payer: Parkland Medicaid	$46,623.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49,450.23

PANCREAS TRANSPLANT

Facility

$76,519.96

Service Code	APR-DRG 0064
Min. Negotiated Rate	$72,145.69
Max. Negotiated Rate	$76,519.96
Rate for Payer: Amerigroup CHIP/Medicaid	$72,145.69
Rate for Payer: Cigna Medicaid	$72,145.69
Rate for Payer: Molina CHIP/Medicaid	$72,145.69
Rate for Payer: Parkland Medicaid	$72,145.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76,519.96

PANCREAS TRANSPLANT

Facility

$44,149.60

Service Code	APR-DRG 0061
Min. Negotiated Rate	$41,625.78
Max. Negotiated Rate	$44,149.60
Rate for Payer: Amerigroup CHIP/Medicaid	$41,625.78
Rate for Payer: Cigna Medicaid	$41,625.78
Rate for Payer: Molina CHIP/Medicaid	$41,625.78
Rate for Payer: Parkland Medicaid	$41,625.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44,149.60

PANCREAS TRANSPLANT

Facility

$58,328.10

Service Code	MSDRG 010
Min. Negotiated Rate	$26,861.62
Max. Negotiated Rate	$58,328.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$57,350.97
Rate for Payer: Amerigroup Medicare	$57,350.97
Rate for Payer: BCBS of TX Blue Advantage	$38,819.54
Rate for Payer: BCBS of TX Blue Essentials	$46,578.93
Rate for Payer: BCBS of TX Medicare	$57,350.97
Rate for Payer: BCBS of TX PPO	$51,756.38
Rate for Payer: Cigna Commercial	$39,540.31
Rate for Payer: Cigna Medicare	$57,350.97
Rate for Payer: Employer Direct Commercial	$57,350.97
Rate for Payer: Molina Dual Medicare/Medicaid	$57,350.97
Rate for Payer: Molina Medicare	$57,350.97
Rate for Payer: Multiplan Auto	$58,328.10
Rate for Payer: Multiplan Commercial	$58,328.10
Rate for Payer: Multiplan Workers Comp	$58,328.10
Rate for Payer: Scott and White EPO/PPO	$26,861.62
Rate for Payer: Scott and White Medicare	$57,350.97
Rate for Payer: Superior Health Plan EPO	$57,350.97
Rate for Payer: Superior Health Plan Medicare	$57,350.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$57,350.97
Rate for Payer: Universal American Medicare	$57,350.97
Rate for Payer: Wellcare Medicare	$57,350.97
Rate for Payer: Wellmed Medicare	$57,350.97

PANCREAS TRANSPLANT

Facility

$44,727.07

Service Code	APR-DRG 0062
Min. Negotiated Rate	$42,170.25
Max. Negotiated Rate	$44,727.07
Rate for Payer: Amerigroup CHIP/Medicaid	$42,170.25
Rate for Payer: Cigna Medicaid	$42,170.25
Rate for Payer: Molina CHIP/Medicaid	$42,170.25
Rate for Payer: Parkland Medicaid	$42,170.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44,727.07

Pancreatic Elastase, Fecal SO

Facility

$415.00

Service Code	HCPCS 82656
Hospital Charge Code	1720077
Hospital Revenue Code	301
Rate for Payer: Cash Price	$282.20

Pancreatic Elastase, Fecal SO

Facility

$415.00

Service Code	HCPCS 82656
Hospital Charge Code	1720077
Hospital Revenue Code	301
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$298.80
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.53
Rate for Payer: Amerigroup Medicare	$11.53
Rate for Payer: BCBS of TX Blue Advantage	$124.50
Rate for Payer: BCBS of TX Blue Essentials	$149.40
Rate for Payer: BCBS of TX Medicare	$11.53
Rate for Payer: BCBS of TX PPO	$166.00
Rate for Payer: Cash Price	$282.20
Rate for Payer: Cash Price	$282.20
Rate for Payer: Cigna Medicaid	$298.80
Rate for Payer: Cigna Medicare	$11.53
Rate for Payer: Employer Direct Commercial	$11.53
Rate for Payer: Humana Medicare/TRICARE	$11.53
Rate for Payer: Molina CHIP/Medicaid	$298.80
Rate for Payer: Molina Dual Medicare/Medicaid	$11.53
Rate for Payer: Molina Medicare	$11.53
Rate for Payer: Multiplan Auto	$269.75
Rate for Payer: Multiplan Commercial	$269.75
Rate for Payer: Multiplan Workers Comp	$269.75
Rate for Payer: Parkland Medicaid	$298.80
Rate for Payer: Scott and White EPO/PPO	$14.41
Rate for Payer: Scott and White Medicare	$11.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$298.80
Rate for Payer: Superior Health Plan EPO	$11.53
Rate for Payer: Superior Health Plan Medicare	$11.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.53
Rate for Payer: Universal American Medicare	$11.53
Rate for Payer: Wellcare Medicare	$11.53
Rate for Payer: Wellmed Medicare	$11.53

PAN, SPECIMEN, URINE/STOOL, GRAD, 900ML

Facility

$1.95

Hospital Charge Code	993221
Hospital Revenue Code	270
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$1.40
Rate for Payer: Amerigroup CHIP/Medicaid	$0.18
Rate for Payer: BCBS of TX Blue Advantage	$0.59
Rate for Payer: BCBS of TX Blue Essentials	$0.70
Rate for Payer: BCBS of TX PPO	$0.78
Rate for Payer: Cash Price	$1.33
Rate for Payer: Cigna Medicaid	$1.40
Rate for Payer: Molina CHIP/Medicaid	$1.40
Rate for Payer: Multiplan Auto	$1.27
Rate for Payer: Multiplan Commercial	$1.27
Rate for Payer: Multiplan Workers Comp	$1.27
Rate for Payer: Parkland Medicaid	$1.40
Rate for Payer: Scott and White EPO/PPO	$0.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.40
Rate for Payer: Superior Health Plan EPO	$0.27

PAN, SPECIMEN, URINE/STOOL, GRAD, 900ML

Facility

$1.95

Hospital Charge Code	993221
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.33

pantoprazole 40 mg DR Tab

Facility

$20.05

Service Code	HCPCS J3490
Hospital Charge Code	77747563
Hospital Revenue Code	250
Rate for Payer: Cash Price	$13.63

pantoprazole 40 mg DR Tab

Facility

$20.05

Service Code	HCPCS J3490
Hospital Charge Code	77747563
Hospital Revenue Code	250
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$14.44
Rate for Payer: Amerigroup CHIP/Medicaid	$1.80
Rate for Payer: BCBS of TX Blue Advantage	$6.01
Rate for Payer: BCBS of TX Blue Essentials	$7.22
Rate for Payer: BCBS of TX PPO	$8.02
Rate for Payer: Cash Price	$13.63
Rate for Payer: Cigna Medicaid	$14.44
Rate for Payer: Molina CHIP/Medicaid	$14.44
Rate for Payer: Multiplan Auto	$13.03
Rate for Payer: Multiplan Commercial	$13.03
Rate for Payer: Multiplan Workers Comp	$13.03
Rate for Payer: Parkland Medicaid	$14.44
Rate for Payer: Scott and White EPO/PPO	$10.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.44
Rate for Payer: Superior Health Plan EPO	$2.73

Know your out-of-pocket cost for care.

All Charges