White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PANCREAS, LIVER & SHUNT PROCEDURES W MCC

Facility

$105,296.10

Service Code	MSDRG 405
Min. Negotiated Rate	$44,853.52
Max. Negotiated Rate	$105,296.10
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

$42,288.30

Service Code	MSDRG 407
Min. Negotiated Rate	$17,258.48
Max. Negotiated Rate	$42,288.30
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

$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

$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

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

$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

$78,789.20

Service Code	MSDRG 010
Min. Negotiated Rate	$36,284.50
Max. Negotiated Rate	$78,789.20
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	$78,789.20
Rate for Payer: Multiplan Commercial	$78,789.20
Rate for Payer: Multiplan Workers Comp	$78,789.20
Rate for Payer: Scott and White EPO/PPO	$36,284.50
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

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

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

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
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

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 iv

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78414989
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

pantoprazole 40 mg iv

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78414989
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

pantoprazole 40 mg IV Inj

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8037080
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

pantoprazole 40 mg IV Inj

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8037080
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

PAPER AND INK CRTDG SEPC 110

Facility

$1,471.91

Hospital Charge Code	993201
Hospital Revenue Code	270
Min. Negotiated Rate	$132.47
Max. Negotiated Rate	$1,059.78
Rate for Payer: Amerigroup CHIP/Medicaid	$132.47
Rate for Payer: BCBS of TX Blue Advantage	$441.57
Rate for Payer: BCBS of TX Blue Essentials	$529.89
Rate for Payer: BCBS of TX PPO	$588.76
Rate for Payer: Cash Price	$1,000.90
Rate for Payer: Cigna Medicaid	$1,059.78
Rate for Payer: Molina CHIP/Medicaid	$1,059.78
Rate for Payer: Multiplan Auto	$956.74
Rate for Payer: Multiplan Commercial	$956.74
Rate for Payer: Multiplan Workers Comp	$956.74
Rate for Payer: Parkland Medicaid	$1,059.78
Rate for Payer: Scott and White EPO/PPO	$735.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,059.78
Rate for Payer: Superior Health Plan EPO	$200.18

PAPER AND INK CRTDG SEPC 110

Facility

$1,471.91

Hospital Charge Code	993201
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,000.90

PAPER, AUTOCLAVE

Facility

$318.98

Hospital Charge Code	992944
Hospital Revenue Code	270
Rate for Payer: Cash Price	$216.91

PAPER, AUTOCLAVE

Facility

$318.98

Hospital Charge Code	992944
Hospital Revenue Code	270
Min. Negotiated Rate	$28.71
Max. Negotiated Rate	$229.67
Rate for Payer: Amerigroup CHIP/Medicaid	$28.71
Rate for Payer: BCBS of TX Blue Advantage	$95.69
Rate for Payer: BCBS of TX Blue Essentials	$114.83
Rate for Payer: BCBS of TX PPO	$127.59
Rate for Payer: Cash Price	$216.91
Rate for Payer: Cigna Medicaid	$229.67
Rate for Payer: Molina CHIP/Medicaid	$229.67
Rate for Payer: Multiplan Auto	$207.34
Rate for Payer: Multiplan Commercial	$207.34
Rate for Payer: Multiplan Workers Comp	$207.34
Rate for Payer: Parkland Medicaid	$229.67
Rate for Payer: Scott and White EPO/PPO	$159.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$229.67
Rate for Payer: Superior Health Plan EPO	$43.38

Paper CD / DVD Sleeves, White

Facility

$1.10

Hospital Charge Code	993323
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.75

Paper CD / DVD Sleeves, White

Facility

$1.10

Hospital Charge Code	993323
Hospital Revenue Code	270
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.79
Rate for Payer: Amerigroup CHIP/Medicaid	$0.10
Rate for Payer: BCBS of TX Blue Advantage	$0.33
Rate for Payer: BCBS of TX Blue Essentials	$0.40
Rate for Payer: BCBS of TX PPO	$0.44
Rate for Payer: Cash Price	$0.75
Rate for Payer: Cigna Medicaid	$0.79
Rate for Payer: Molina CHIP/Medicaid	$0.79
Rate for Payer: Multiplan Auto	$0.72
Rate for Payer: Multiplan Commercial	$0.72
Rate for Payer: Multiplan Workers Comp	$0.72
Rate for Payer: Parkland Medicaid	$0.79
Rate for Payer: Scott and White EPO/PPO	$0.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.79
Rate for Payer: Superior Health Plan EPO	$0.15

PAPER CHART RCRD ECG Z FOLD 8.5X11 ELI-250/350

Facility

$99.48

Hospital Charge Code	993535
Hospital Revenue Code	270
Rate for Payer: Cash Price	$67.65

PAPER CHART RCRD ECG Z FOLD 8.5X11 ELI-250/350

Facility

$99.48

Hospital Charge Code	993535
Hospital Revenue Code	270
Min. Negotiated Rate	$8.95
Max. Negotiated Rate	$71.63
Rate for Payer: Amerigroup CHIP/Medicaid	$8.95
Rate for Payer: BCBS of TX Blue Advantage	$29.84
Rate for Payer: BCBS of TX Blue Essentials	$35.81
Rate for Payer: BCBS of TX PPO	$39.79
Rate for Payer: Cash Price	$67.65
Rate for Payer: Cigna Medicaid	$71.63
Rate for Payer: Molina CHIP/Medicaid	$71.63
Rate for Payer: Multiplan Auto	$64.66
Rate for Payer: Multiplan Commercial	$64.66
Rate for Payer: Multiplan Workers Comp	$64.66
Rate for Payer: Parkland Medicaid	$71.63
Rate for Payer: Scott and White EPO/PPO	$49.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$71.63
Rate for Payer: Superior Health Plan EPO	$13.53

Know your out-of-pocket cost for care.

All Charges