White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Patient belongings bag with drawstring, white, 18' x 20'

Facility

$0.87

Hospital Charge Code	993934
Hospital Revenue Code	271
Rate for Payer: Cash Price	$0.59

Patient belongings bag with drawstring, white, 18' x 20'

Facility

$0.87

Hospital Charge Code	993934
Hospital Revenue Code	271
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.63
Rate for Payer: Amerigroup CHIP/Medicaid	$0.08
Rate for Payer: BCBS of TX Blue Advantage	$0.26
Rate for Payer: BCBS of TX Blue Essentials	$0.31
Rate for Payer: BCBS of TX PPO	$0.35
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna Medicaid	$0.63
Rate for Payer: Molina CHIP/Medicaid	$0.63
Rate for Payer: Multiplan Auto	$0.57
Rate for Payer: Multiplan Commercial	$0.57
Rate for Payer: Multiplan Workers Comp	$0.57
Rate for Payer: Parkland Medicaid	$0.63
Rate for Payer: Scott and White EPO/PPO	$0.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.63
Rate for Payer: Superior Health Plan EPO	$0.12

Patient Urinal Reusable translucent 32oz

Facility

$11.80

Hospital Charge Code	992709
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.02

Patient Urinal Reusable translucent 32oz

Facility

$11.80

Hospital Charge Code	992709
Hospital Revenue Code	270
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$8.50
Rate for Payer: Amerigroup CHIP/Medicaid	$1.06
Rate for Payer: BCBS of TX Blue Advantage	$3.54
Rate for Payer: BCBS of TX Blue Essentials	$4.25
Rate for Payer: BCBS of TX PPO	$4.72
Rate for Payer: Cash Price	$8.02
Rate for Payer: Cigna Medicaid	$8.50
Rate for Payer: Molina CHIP/Medicaid	$8.50
Rate for Payer: Multiplan Auto	$7.67
Rate for Payer: Multiplan Commercial	$7.67
Rate for Payer: Multiplan Workers Comp	$7.67
Rate for Payer: Parkland Medicaid	$8.50
Rate for Payer: Scott and White EPO/PPO	$5.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.50
Rate for Payer: Superior Health Plan EPO	$1.60

patiromer 8.4 g Pow

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78872129
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

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	$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

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	$39.71
Rate for Payer: Amerigroup CHIP/Medicaid	$4.96
Rate for Payer: BCBS of TX Blue Advantage	$16.55
Rate for Payer: BCBS of TX Blue Essentials	$19.85
Rate for Payer: BCBS of TX PPO	$22.06
Rate for Payer: Cash Price	$37.50
Rate for Payer: Cigna Medicaid	$39.71
Rate for Payer: Molina CHIP/Medicaid	$39.71
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: Parkland Medicaid	$39.71
Rate for Payer: Scott and White EPO/PPO	$27.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.71
Rate for Payer: Superior Health Plan EPO	$7.50

PCH T NSP 13/4 -- DHF

Facility

$55.15

Hospital Charge Code	80333008
Hospital Revenue Code	270
Rate for Payer: Cash Price	$37.50

PCK, ATTEST SUPR RAPD 5 STEAM-PLS CHL

Facility

$31.95

Hospital Charge Code	992972
Hospital Revenue Code	270
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$23.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2.88
Rate for Payer: BCBS of TX Blue Advantage	$9.59
Rate for Payer: BCBS of TX Blue Essentials	$11.50
Rate for Payer: BCBS of TX PPO	$12.78
Rate for Payer: Cash Price	$21.73
Rate for Payer: Cigna Medicaid	$23.00
Rate for Payer: Molina CHIP/Medicaid	$23.00
Rate for Payer: Multiplan Auto	$20.77
Rate for Payer: Multiplan Commercial	$20.77
Rate for Payer: Multiplan Workers Comp	$20.77
Rate for Payer: Parkland Medicaid	$23.00
Rate for Payer: Scott and White EPO/PPO	$15.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.00
Rate for Payer: Superior Health Plan EPO	$4.35

PCK, ATTEST SUPR RAPD 5 STEAM-PLS CHL

Facility

$31.95

Hospital Charge Code	992972
Hospital Revenue Code	270
Rate for Payer: Cash Price	$21.73

PD CAUTERY GRO -- DHF

Facility

$312.71

Hospital Charge Code	81845505
Hospital Revenue Code	270
Min. Negotiated Rate	$28.14
Max. Negotiated Rate	$225.15
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	$212.64
Rate for Payer: Cigna Medicaid	$225.15
Rate for Payer: Molina CHIP/Medicaid	$225.15
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: Parkland Medicaid	$225.15
Rate for Payer: Scott and White EPO/PPO	$156.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$225.15
Rate for Payer: Superior Health Plan EPO	$42.53

PD CAUTERY GRO -- DHF

Facility

$312.71

Hospital Charge Code	81845505
Hospital Revenue Code	270
Rate for Payer: Cash Price	$212.64

PD COLD THERAPY -- DHF

Facility

$638.69

Hospital Charge Code	80333636
Hospital Revenue Code	272
Min. Negotiated Rate	$57.48
Max. Negotiated Rate	$459.86
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	$434.31
Rate for Payer: Cigna Medicaid	$459.86
Rate for Payer: Molina CHIP/Medicaid	$459.86
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: Parkland Medicaid	$459.86
Rate for Payer: Scott and White EPO/PPO	$319.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$459.86
Rate for Payer: Superior Health Plan EPO	$86.86

PD COLD THERAPY -- DHF

Facility

$638.69

Hospital Charge Code	80333636
Hospital Revenue Code	272
Rate for Payer: Cash Price	$434.31

PD ELCTRD RESUSITATION -- DHF

Facility

$385.90

Hospital Charge Code	80333792
Hospital Revenue Code	272
Min. Negotiated Rate	$34.73
Max. Negotiated Rate	$277.85
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	$262.41
Rate for Payer: Cigna Medicaid	$277.85
Rate for Payer: Molina CHIP/Medicaid	$277.85
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: Parkland Medicaid	$277.85
Rate for Payer: Scott and White EPO/PPO	$192.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$277.85
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	$262.41

PD-IN-DPD-IT

Facility

$584.34

Hospital Charge Code	991162
Hospital Revenue Code	272
Min. Negotiated Rate	$52.59
Max. Negotiated Rate	$420.72
Rate for Payer: Amerigroup CHIP/Medicaid	$52.59
Rate for Payer: BCBS of TX Blue Advantage	$175.30
Rate for Payer: BCBS of TX Blue Essentials	$210.36
Rate for Payer: BCBS of TX PPO	$233.74
Rate for Payer: Cash Price	$397.35
Rate for Payer: Cigna Medicaid	$420.72
Rate for Payer: Molina CHIP/Medicaid	$420.72
Rate for Payer: Multiplan Auto	$379.82
Rate for Payer: Multiplan Commercial	$379.82
Rate for Payer: Multiplan Workers Comp	$379.82
Rate for Payer: Parkland Medicaid	$420.72
Rate for Payer: Scott and White EPO/PPO	$292.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$420.72
Rate for Payer: Superior Health Plan EPO	$79.47

PD-IN-DPD-IT

Facility

$584.34

Hospital Charge Code	991162
Hospital Revenue Code	272
Rate for Payer: Cash Price	$397.35

Pedicle MIS Pre-Bent Rod, 5.5mm x 40mm

Facility

$1,506.02

Service Code	HCPCS C1734
Hospital Charge Code	992228
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.01
Rate for Payer: Cash Price	$1,024.09
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.01
Rate for Payer: Multiplan Commercial	$753.01
Rate for Payer: Multiplan Workers Comp	$753.01
Rate for Payer: Scott and White EPO/PPO	$753.01

Pedicle MIS Pre-Bent Rod, 5.5mm x 40mm

Facility

$1,506.02

Service Code	HCPCS C1734
Hospital Charge Code	992228
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$1,084.33
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.81
Rate for Payer: BCBS of TX Blue Essentials	$542.17
Rate for Payer: BCBS of TX PPO	$602.41
Rate for Payer: Cash Price	$1,024.09
Rate for Payer: Cigna Medicaid	$1,084.33
Rate for Payer: Molina CHIP/Medicaid	$1,084.33
Rate for Payer: Multiplan Auto	$753.01
Rate for Payer: Multiplan Commercial	$753.01
Rate for Payer: Multiplan Workers Comp	$753.01
Rate for Payer: Parkland Medicaid	$1,084.33
Rate for Payer: Scott and White EPO/PPO	$753.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,084.33
Rate for Payer: Superior Health Plan EPO	$204.82

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

Facility

$160.00

Service Code	HCPCS 84156
Hospital Charge Code	8604526
Hospital Revenue Code	301
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$115.20
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	$48.00
Rate for Payer: BCBS of TX Blue Essentials	$57.60
Rate for Payer: BCBS of TX Medicare	$3.67
Rate for Payer: BCBS of TX PPO	$64.00
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cigna Medicaid	$115.20
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	$115.20
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	$115.20
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	$115.20
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),24-Hr U SO

Facility

$160.00

Service Code	HCPCS 84156
Hospital Charge Code	8604526
Hospital Revenue Code	301
Rate for Payer: Cash Price	$108.80

PE+Interp(Rfx IFE),S SO

Facility

$441.00

Service Code	HCPCS 84165
Hospital Charge Code	8604527
Hospital Revenue Code	301
Rate for Payer: Cash Price	$299.88

PE+Interp(Rfx IFE),S SO

Facility

$441.00

Service Code	HCPCS 84165
Hospital Charge Code	8604527
Hospital Revenue Code	301
Min. Negotiated Rate	$4.19
Max. Negotiated Rate	$317.52
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	$132.30
Rate for Payer: BCBS of TX Blue Essentials	$158.76
Rate for Payer: BCBS of TX Medicare	$10.74
Rate for Payer: BCBS of TX PPO	$176.40
Rate for Payer: Cash Price	$299.88
Rate for Payer: Cash Price	$299.88
Rate for Payer: Cigna Medicaid	$317.52
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	$317.52
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	$317.52
Rate for Payer: Scott and White EPO/PPO	$13.43
Rate for Payer: Scott and White Medicare	$10.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$317.52
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

PELVIC EVISCERATION, RAD HYSTERECTOMY & RAD VULVECTOMY W CC/MCC

Facility

$41,518.80

Service Code	MSDRG 734
Min. Negotiated Rate	$19,120.50
Max. Negotiated Rate	$41,518.80
Rate for Payer: BCBS of TX Blue Advantage	$19,830.74
Rate for Payer: BCBS of TX Blue Essentials	$23,794.58
Rate for Payer: BCBS of TX PPO	$26,439.45

Know your out-of-pocket cost for care.

All Charges