White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$24,171.80

Service Code	MSDRG 735
Min. Negotiated Rate	$11,131.75
Max. Negotiated Rate	$24,171.80
Rate for Payer: BCBS of TX Blue Advantage	$11,739.00
Rate for Payer: BCBS of TX Blue Essentials	$14,085.43
Rate for Payer: BCBS of TX PPO	$15,651.09

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES

Facility

$4,605.10

Service Code	APR-DRG 5101
Min. Negotiated Rate	$4,341.85
Max. Negotiated Rate	$4,605.10
Rate for Payer: Amerigroup CHIP/Medicaid	$4,341.85
Rate for Payer: Cigna Medicaid	$4,341.85
Rate for Payer: Molina CHIP/Medicaid	$4,341.85
Rate for Payer: Parkland Medicaid	$4,341.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,605.10

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES

Facility

$14,072.17

Service Code	APR-DRG 5103
Min. Negotiated Rate	$13,267.73
Max. Negotiated Rate	$14,072.17
Rate for Payer: Amerigroup CHIP/Medicaid	$13,267.73
Rate for Payer: Cigna Medicaid	$13,267.73
Rate for Payer: Molina CHIP/Medicaid	$13,267.73
Rate for Payer: Parkland Medicaid	$13,267.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,072.17

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES

Facility

$5,779.29

Service Code	APR-DRG 5102
Min. Negotiated Rate	$5,448.92
Max. Negotiated Rate	$5,779.29
Rate for Payer: Amerigroup CHIP/Medicaid	$5,448.92
Rate for Payer: Cigna Medicaid	$5,448.92
Rate for Payer: Molina CHIP/Medicaid	$5,448.92
Rate for Payer: Parkland Medicaid	$5,448.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,779.29

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES

Facility

$26,292.34

Service Code	APR-DRG 5104
Min. Negotiated Rate	$24,789.34
Max. Negotiated Rate	$26,292.34
Rate for Payer: Amerigroup CHIP/Medicaid	$24,789.34
Rate for Payer: Cigna Medicaid	$24,789.34
Rate for Payer: Molina CHIP/Medicaid	$24,789.34
Rate for Payer: Parkland Medicaid	$24,789.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26,292.34

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH 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: Amerigroup Dual Medicare/Medicaid	$20,370.90
Rate for Payer: Amerigroup Medicare	$20,370.90
Rate for Payer: BCBS of TX Medicare	$20,370.90
Rate for Payer: Cigna Commercial	$27,434.40
Rate for Payer: Cigna Medicare	$20,370.90
Rate for Payer: Employer Direct Commercial	$20,370.90
Rate for Payer: Humana Medicare/TRICARE	$20,370.90
Rate for Payer: Molina Dual Medicare/Medicaid	$20,370.90
Rate for Payer: Molina Medicare	$20,370.90
Rate for Payer: Multiplan Auto	$41,518.80
Rate for Payer: Multiplan Commercial	$41,518.80
Rate for Payer: Multiplan Workers Comp	$41,518.80
Rate for Payer: Scott and White EPO/PPO	$19,120.50
Rate for Payer: Scott and White Medicare	$20,370.90
Rate for Payer: Superior Health Plan EPO	$20,370.90
Rate for Payer: Superior Health Plan Medicare	$20,370.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,370.90
Rate for Payer: Universal American Medicare	$20,370.90
Rate for Payer: Wellcare Medicare	$20,370.90
Rate for Payer: Wellmed Medicare	$20,370.90

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC

Facility

$24,171.80

Service Code	MSDRG 735
Min. Negotiated Rate	$11,131.75
Max. Negotiated Rate	$24,171.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,621.28
Rate for Payer: Amerigroup Medicare	$14,621.28
Rate for Payer: BCBS of TX Medicare	$14,621.28
Rate for Payer: Cigna Commercial	$17,330.04
Rate for Payer: Cigna Medicare	$14,621.28
Rate for Payer: Employer Direct Commercial	$14,621.28
Rate for Payer: Humana Medicare/TRICARE	$14,621.28
Rate for Payer: Molina Dual Medicare/Medicaid	$14,621.28
Rate for Payer: Molina Medicare	$14,621.28
Rate for Payer: Multiplan Auto	$24,171.80
Rate for Payer: Multiplan Commercial	$24,171.80
Rate for Payer: Multiplan Workers Comp	$24,171.80
Rate for Payer: Scott and White EPO/PPO	$11,131.75
Rate for Payer: Scott and White Medicare	$14,621.28
Rate for Payer: Superior Health Plan EPO	$14,621.28
Rate for Payer: Superior Health Plan Medicare	$14,621.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,621.28
Rate for Payer: Universal American Medicare	$14,621.28
Rate for Payer: Wellcare Medicare	$14,621.28
Rate for Payer: Wellmed Medicare	$14,621.28

PENCIL BOVIE STRYKER SMOKE EVAC NEPTUNE

Facility

$132.97

Hospital Charge Code	8708544
Hospital Revenue Code	272
Rate for Payer: Cash Price	$90.42

PENCIL BOVIE STRYKER SMOKE EVAC NEPTUNE

Facility

$132.97

Hospital Charge Code	8708544
Hospital Revenue Code	272
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$95.74
Rate for Payer: Amerigroup CHIP/Medicaid	$11.97
Rate for Payer: BCBS of TX Blue Advantage	$39.89
Rate for Payer: BCBS of TX Blue Essentials	$47.87
Rate for Payer: BCBS of TX PPO	$53.19
Rate for Payer: Cash Price	$90.42
Rate for Payer: Cigna Medicaid	$95.74
Rate for Payer: Molina CHIP/Medicaid	$95.74
Rate for Payer: Multiplan Auto	$86.43
Rate for Payer: Multiplan Commercial	$86.43
Rate for Payer: Multiplan Workers Comp	$86.43
Rate for Payer: Parkland Medicaid	$95.74
Rate for Payer: Scott and White EPO/PPO	$66.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$95.74
Rate for Payer: Superior Health Plan EPO	$18.08

PENCIL ROCKER SWITCH W/DSP BLADE

Facility

$28.78

Hospital Charge Code	993740
Hospital Revenue Code	272
Rate for Payer: Cash Price	$19.57

PENCIL ROCKER SWITCH W/DSP BLADE

Facility

$28.78

Hospital Charge Code	993740
Hospital Revenue Code	272
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$20.72
Rate for Payer: Amerigroup CHIP/Medicaid	$2.59
Rate for Payer: BCBS of TX Blue Advantage	$8.63
Rate for Payer: BCBS of TX Blue Essentials	$10.36
Rate for Payer: BCBS of TX PPO	$11.51
Rate for Payer: Cash Price	$19.57
Rate for Payer: Cigna Medicaid	$20.72
Rate for Payer: Molina CHIP/Medicaid	$20.72
Rate for Payer: Multiplan Auto	$18.71
Rate for Payer: Multiplan Commercial	$18.71
Rate for Payer: Multiplan Workers Comp	$18.71
Rate for Payer: Parkland Medicaid	$20.72
Rate for Payer: Scott and White EPO/PPO	$14.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.72
Rate for Payer: Superior Health Plan EPO	$3.91

penicillin V potassium 250 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77751361
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

penicillin V potassium 250 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77751361
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

PENIS PROCEDURES W CC/MCC

Facility

$45,828.00

Service Code	MSDRG 709
Min. Negotiated Rate	$17,473.48
Max. Negotiated Rate	$45,828.00
Rate for Payer: BCBS of TX Blue Advantage	$17,473.48
Rate for Payer: BCBS of TX Blue Essentials	$20,966.14
Rate for Payer: BCBS of TX PPO	$23,296.62

PENIS PROCEDURES WITH CC/MCC

Facility

$45,828.00

Service Code	MSDRG 709
Min. Negotiated Rate	$17,473.48
Max. Negotiated Rate	$45,828.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,815.46
Rate for Payer: Amerigroup Medicare	$21,815.46
Rate for Payer: BCBS of TX Medicare	$21,815.46
Rate for Payer: Cigna Commercial	$29,973.05
Rate for Payer: Cigna Medicare	$21,815.46
Rate for Payer: Employer Direct Commercial	$21,815.46
Rate for Payer: Humana Medicare/TRICARE	$21,815.46
Rate for Payer: Molina Dual Medicare/Medicaid	$21,815.46
Rate for Payer: Molina Medicare	$21,815.46
Rate for Payer: Multiplan Auto	$45,828.00
Rate for Payer: Multiplan Commercial	$45,828.00
Rate for Payer: Multiplan Workers Comp	$45,828.00
Rate for Payer: Scott and White EPO/PPO	$21,105.00
Rate for Payer: Scott and White Medicare	$21,815.46
Rate for Payer: Superior Health Plan EPO	$21,815.46
Rate for Payer: Superior Health Plan Medicare	$21,815.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,815.46
Rate for Payer: Universal American Medicare	$21,815.46
Rate for Payer: Wellcare Medicare	$21,815.46
Rate for Payer: Wellmed Medicare	$21,815.46

PENIS PROCEDURES WITHOUT CC/MCC

Facility

$27,386.60

Service Code	MSDRG 710
Min. Negotiated Rate	$12,612.25
Max. Negotiated Rate	$27,386.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,029.52
Rate for Payer: Amerigroup Medicare	$15,029.52
Rate for Payer: BCBS of TX Medicare	$15,029.52
Rate for Payer: Cigna Commercial	$18,047.46
Rate for Payer: Cigna Medicare	$15,029.52
Rate for Payer: Employer Direct Commercial	$15,029.52
Rate for Payer: Humana Medicare/TRICARE	$15,029.52
Rate for Payer: Molina Dual Medicare/Medicaid	$15,029.52
Rate for Payer: Molina Medicare	$15,029.52
Rate for Payer: Multiplan Auto	$27,386.60
Rate for Payer: Multiplan Commercial	$27,386.60
Rate for Payer: Multiplan Workers Comp	$27,386.60
Rate for Payer: Scott and White EPO/PPO	$12,612.25
Rate for Payer: Scott and White Medicare	$15,029.52
Rate for Payer: Superior Health Plan EPO	$15,029.52
Rate for Payer: Superior Health Plan Medicare	$15,029.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,029.52
Rate for Payer: Universal American Medicare	$15,029.52
Rate for Payer: Wellcare Medicare	$15,029.52
Rate for Payer: Wellmed Medicare	$15,029.52

PENIS PROCEDURES W/O CC/MCC

Facility

$27,386.60

Service Code	MSDRG 710
Min. Negotiated Rate	$12,612.25
Max. Negotiated Rate	$27,386.60
Rate for Payer: BCBS of TX Blue Advantage	$14,357.70
Rate for Payer: BCBS of TX Blue Essentials	$17,227.57
Rate for Payer: BCBS of TX PPO	$19,142.49

PENIS, TESTES AND SCROTAL PROCEDURES

Facility

$37,771.33

Service Code	APR-DRG 4834
Min. Negotiated Rate	$35,612.13
Max. Negotiated Rate	$37,771.33
Rate for Payer: Amerigroup CHIP/Medicaid	$35,612.13
Rate for Payer: Cigna Medicaid	$35,612.13
Rate for Payer: Molina CHIP/Medicaid	$35,612.13
Rate for Payer: Parkland Medicaid	$35,612.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37,771.33

PENIS, TESTES AND SCROTAL PROCEDURES

Facility

$4,295.43

Service Code	APR-DRG 4831
Min. Negotiated Rate	$4,049.88
Max. Negotiated Rate	$4,295.43
Rate for Payer: Amerigroup CHIP/Medicaid	$4,049.88
Rate for Payer: Cigna Medicaid	$4,049.88
Rate for Payer: Molina CHIP/Medicaid	$4,049.88
Rate for Payer: Parkland Medicaid	$4,049.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,295.43

PENIS, TESTES AND SCROTAL PROCEDURES

Facility

$6,116.12

Service Code	APR-DRG 4832
Min. Negotiated Rate	$5,766.49
Max. Negotiated Rate	$6,116.12
Rate for Payer: Amerigroup CHIP/Medicaid	$5,766.49
Rate for Payer: Cigna Medicaid	$5,766.49
Rate for Payer: Molina CHIP/Medicaid	$5,766.49
Rate for Payer: Parkland Medicaid	$5,766.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,116.12

PENIS, TESTES AND SCROTAL PROCEDURES

Facility

$7,084.36

Service Code	APR-DRG 4833
Min. Negotiated Rate	$6,679.39
Max. Negotiated Rate	$7,084.36
Rate for Payer: Amerigroup CHIP/Medicaid	$6,679.39
Rate for Payer: Cigna Medicaid	$6,679.39
Rate for Payer: Molina CHIP/Medicaid	$6,679.39
Rate for Payer: Parkland Medicaid	$6,679.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,084.36

PEPTIC ULCER AND GASTRITIS

Facility

$3,742.09

Service Code	APR-DRG 2412
Min. Negotiated Rate	$3,528.18
Max. Negotiated Rate	$3,742.09
Rate for Payer: Amerigroup CHIP/Medicaid	$3,528.18
Rate for Payer: Cigna Medicaid	$3,528.18
Rate for Payer: Molina CHIP/Medicaid	$3,528.18
Rate for Payer: Parkland Medicaid	$3,528.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,742.09

PEPTIC ULCER AND GASTRITIS

Facility

$14,878.97

Service Code	APR-DRG 2414
Min. Negotiated Rate	$14,028.42
Max. Negotiated Rate	$14,878.97
Rate for Payer: Amerigroup CHIP/Medicaid	$14,028.42
Rate for Payer: Cigna Medicaid	$14,028.42
Rate for Payer: Molina CHIP/Medicaid	$14,028.42
Rate for Payer: Parkland Medicaid	$14,028.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,878.97

PEPTIC ULCER AND GASTRITIS

Facility

$6,123.66

Service Code	APR-DRG 2413
Min. Negotiated Rate	$5,773.60
Max. Negotiated Rate	$6,123.66
Rate for Payer: Amerigroup CHIP/Medicaid	$5,773.60
Rate for Payer: Cigna Medicaid	$5,773.60
Rate for Payer: Molina CHIP/Medicaid	$5,773.60
Rate for Payer: Parkland Medicaid	$5,773.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,123.66

PEPTIC ULCER AND GASTRITIS

Facility

$3,197.05

Service Code	APR-DRG 2411
Min. Negotiated Rate	$3,014.29
Max. Negotiated Rate	$3,197.05
Rate for Payer: Amerigroup CHIP/Medicaid	$3,014.29
Rate for Payer: Cigna Medicaid	$3,014.29
Rate for Payer: Molina CHIP/Medicaid	$3,014.29
Rate for Payer: Parkland Medicaid	$3,014.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,197.05

Know your out-of-pocket cost for care.

All Charges