White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PATCH VENTRAL PARIETEX COMPOSITE 6.6 CM

Facility

$3,277.00

Service Code	HCPCS C1781
Hospital Charge Code	146127
Hospital Revenue Code	272
Min. Negotiated Rate	$294.93
Max. Negotiated Rate	$2,359.44
Rate for Payer: Amerigroup CHIP/Medicaid	$294.93
Rate for Payer: BCBS of TX Blue Advantage	$983.10
Rate for Payer: BCBS of TX Blue Essentials	$1,179.72
Rate for Payer: BCBS of TX PPO	$1,310.80
Rate for Payer: Cash Price	$2,228.36
Rate for Payer: Cigna Medicaid	$2,359.44
Rate for Payer: Molina CHIP/Medicaid	$2,359.44
Rate for Payer: Multiplan Auto	$2,130.05
Rate for Payer: Multiplan Commercial	$2,130.05
Rate for Payer: Multiplan Workers Comp	$2,130.05
Rate for Payer: Parkland Medicaid	$2,359.44
Rate for Payer: Scott and White EPO/PPO	$1,638.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,359.44
Rate for Payer: Superior Health Plan EPO	$445.67

PATCH VENTRAL PARIETEX COMPOSITE 6.6 CM

Facility

$3,277.00

Service Code	HCPCS C1781
Hospital Charge Code	146127
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,228.36

PATCH VENTRAL PARIETEX COMPOSITE 8.6 CM

Facility

$4,108.00

Service Code	HCPCS C1781
Hospital Charge Code	146128
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,793.44

PATCH VENTRAL PARIETEX COMPOSITE 8.6 CM

Facility

$4,108.00

Service Code	HCPCS C1781
Hospital Charge Code	146128
Hospital Revenue Code	272
Min. Negotiated Rate	$369.72
Max. Negotiated Rate	$2,957.76
Rate for Payer: Amerigroup CHIP/Medicaid	$369.72
Rate for Payer: BCBS of TX Blue Advantage	$1,232.40
Rate for Payer: BCBS of TX Blue Essentials	$1,478.88
Rate for Payer: BCBS of TX PPO	$1,643.20
Rate for Payer: Cash Price	$2,793.44
Rate for Payer: Cigna Medicaid	$2,957.76
Rate for Payer: Molina CHIP/Medicaid	$2,957.76
Rate for Payer: Multiplan Auto	$2,670.20
Rate for Payer: Multiplan Commercial	$2,670.20
Rate for Payer: Multiplan Workers Comp	$2,670.20
Rate for Payer: Parkland Medicaid	$2,957.76
Rate for Payer: Scott and White EPO/PPO	$2,054.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,957.76
Rate for Payer: Superior Health Plan EPO	$558.69

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC

Facility

$19,532.00

Service Code	MSDRG 543
Min. Negotiated Rate	$8,995.00
Max. Negotiated Rate	$19,532.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,294.32
Rate for Payer: Amerigroup Medicare	$12,294.32
Rate for Payer: BCBS of TX Medicare	$12,294.32
Rate for Payer: Cigna Commercial	$13,240.64
Rate for Payer: Cigna Medicare	$12,294.32
Rate for Payer: Employer Direct Commercial	$12,294.32
Rate for Payer: Humana Medicare/TRICARE	$12,294.32
Rate for Payer: Molina Dual Medicare/Medicaid	$12,294.32
Rate for Payer: Molina Medicare	$12,294.32
Rate for Payer: Multiplan Auto	$19,532.00
Rate for Payer: Multiplan Commercial	$19,532.00
Rate for Payer: Multiplan Workers Comp	$19,532.00
Rate for Payer: Scott and White EPO/PPO	$8,995.00
Rate for Payer: Scott and White Medicare	$12,294.32
Rate for Payer: Superior Health Plan EPO	$12,294.32
Rate for Payer: Superior Health Plan Medicare	$12,294.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,294.32
Rate for Payer: Universal American Medicare	$12,294.32
Rate for Payer: Wellcare Medicare	$12,294.32
Rate for Payer: Wellmed Medicare	$12,294.32

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC

Facility

$33,563.50

Service Code	MSDRG 542
Min. Negotiated Rate	$15,456.88
Max. Negotiated Rate	$33,563.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,706.80
Rate for Payer: Amerigroup Medicare	$17,706.80
Rate for Payer: BCBS of TX Medicare	$17,706.80
Rate for Payer: Cigna Commercial	$22,752.52
Rate for Payer: Cigna Medicare	$17,706.80
Rate for Payer: Employer Direct Commercial	$17,706.80
Rate for Payer: Humana Medicare/TRICARE	$17,706.80
Rate for Payer: Molina Dual Medicare/Medicaid	$17,706.80
Rate for Payer: Molina Medicare	$17,706.80
Rate for Payer: Multiplan Auto	$33,563.50
Rate for Payer: Multiplan Commercial	$33,563.50
Rate for Payer: Multiplan Workers Comp	$33,563.50
Rate for Payer: Scott and White EPO/PPO	$15,456.88
Rate for Payer: Scott and White Medicare	$17,706.80
Rate for Payer: Superior Health Plan EPO	$17,706.80
Rate for Payer: Superior Health Plan Medicare	$17,706.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,706.80
Rate for Payer: Universal American Medicare	$17,706.80
Rate for Payer: Wellcare Medicare	$17,706.80
Rate for Payer: Wellmed Medicare	$17,706.80

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC

Facility

$14,337.40

Service Code	MSDRG 544
Min. Negotiated Rate	$6,602.75
Max. Negotiated Rate	$14,337.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,290.56
Rate for Payer: Amerigroup Medicare	$10,290.56
Rate for Payer: BCBS of TX Medicare	$10,290.56
Rate for Payer: Cigna Commercial	$9,719.25
Rate for Payer: Cigna Medicare	$10,290.56
Rate for Payer: Employer Direct Commercial	$10,290.56
Rate for Payer: Humana Medicare/TRICARE	$10,290.56
Rate for Payer: Molina Dual Medicare/Medicaid	$10,290.56
Rate for Payer: Molina Medicare	$10,290.56
Rate for Payer: Multiplan Auto	$14,337.40
Rate for Payer: Multiplan Commercial	$14,337.40
Rate for Payer: Multiplan Workers Comp	$14,337.40
Rate for Payer: Scott and White EPO/PPO	$6,602.75
Rate for Payer: Scott and White Medicare	$10,290.56
Rate for Payer: Superior Health Plan EPO	$10,290.56
Rate for Payer: Superior Health Plan Medicare	$10,290.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,290.56
Rate for Payer: Universal American Medicare	$10,290.56
Rate for Payer: Wellcare Medicare	$10,290.56
Rate for Payer: Wellmed Medicare	$10,290.56

PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC

Facility

$19,532.00

Service Code	MSDRG 543
Min. Negotiated Rate	$8,995.00
Max. Negotiated Rate	$19,532.00
Rate for Payer: BCBS of TX Blue Advantage	$9,223.50
Rate for Payer: BCBS of TX Blue Essentials	$11,067.13
Rate for Payer: BCBS of TX PPO	$12,297.28

PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W MCC

Facility

$33,563.50

Service Code	MSDRG 542
Min. Negotiated Rate	$15,456.88
Max. Negotiated Rate	$33,563.50
Rate for Payer: BCBS of TX Blue Advantage	$15,697.58
Rate for Payer: BCBS of TX Blue Essentials	$18,835.27
Rate for Payer: BCBS of TX PPO	$20,928.89

PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W/O CC/MCC

Facility

$14,337.40

Service Code	MSDRG 544
Min. Negotiated Rate	$6,602.75
Max. Negotiated Rate	$14,337.40
Rate for Payer: BCBS of TX Blue Advantage	$6,866.24
Rate for Payer: BCBS of TX Blue Essentials	$8,238.69
Rate for Payer: BCBS of TX PPO	$9,154.45

Patient Antigen Type Bill Quantity -> 3

Facility

$124.00

Service Code	HCPCS 86905
Hospital Charge Code	2402949
Hospital Revenue Code	300
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$761.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1.49
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.83
Rate for Payer: Amerigroup Medicare	$3.83
Rate for Payer: BCBS of TX Blue Advantage	$37.20
Rate for Payer: BCBS of TX Blue Essentials	$44.64
Rate for Payer: BCBS of TX Medicare	$3.83
Rate for Payer: BCBS of TX PPO	$49.60
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cigna Commercial	$761.14
Rate for Payer: Cigna Medicaid	$89.28
Rate for Payer: Cigna Medicare	$3.83
Rate for Payer: Employer Direct Commercial	$3.83
Rate for Payer: Humana Medicare/TRICARE	$3.83
Rate for Payer: Molina CHIP/Medicaid	$89.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3.83
Rate for Payer: Molina Medicare	$3.83
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Parkland Medicaid	$89.28
Rate for Payer: Scott and White EPO/PPO	$4.79
Rate for Payer: Scott and White Medicare	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.28
Rate for Payer: Superior Health Plan EPO	$3.83
Rate for Payer: Superior Health Plan Medicare	$3.83
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.83
Rate for Payer: Universal American Medicare	$3.83
Rate for Payer: Wellcare Medicare	$3.83
Rate for Payer: Wellmed Medicare	$3.83

Patient Antigen Type Bill Quantity -> 3

Facility

$124.00

Service Code	HCPCS 86905
Hospital Charge Code	2402949
Hospital Revenue Code	300
Rate for Payer: Cash Price	$84.32

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
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

Patient Urinal Reusable translucent 32oz

Facility

$11.80

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

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

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

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
Rate for Payer: Cash Price	$434.31

Know your out-of-pocket cost for care.

All Charges