White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 ELCTRD RESUSITATION -- DHF

Facility

$385.90

Hospital Charge Code	80333792
Hospital Revenue Code	272
Rate for Payer: Cash Price	$262.41

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-IN-DPD-IT

Facility

$584.34

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

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

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

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

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

$40,470.00

Service Code	MSDRG 734
Min. Negotiated Rate	$18,637.50
Max. Negotiated Rate	$40,470.00
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

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

Facility

$25,564.50

Service Code	MSDRG 735
Min. Negotiated Rate	$11,739.00
Max. Negotiated Rate	$25,564.50
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

$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

$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

$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

$40,470.00

Service Code	MSDRG 734
Min. Negotiated Rate	$18,637.50
Max. Negotiated Rate	$40,470.00
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	$40,470.00
Rate for Payer: Multiplan Commercial	$40,470.00
Rate for Payer: Multiplan Workers Comp	$40,470.00
Rate for Payer: Scott and White EPO/PPO	$18,637.50
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

$25,564.50

Service Code	MSDRG 735
Min. Negotiated Rate	$11,739.00
Max. Negotiated Rate	$25,564.50
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	$25,564.50
Rate for Payer: Multiplan Commercial	$25,564.50
Rate for Payer: Multiplan Workers Comp	$25,564.50
Rate for Payer: Scott and White EPO/PPO	$11,773.12
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
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 BOVIE STRYKER SMOKE EVAC NEPTUNE

Facility

$132.97

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

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

PENCIL ROCKER SWITCH W/DSP BLADE

Facility

$28.78

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

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

$44,214.90

Service Code	MSDRG 709
Min. Negotiated Rate	$17,473.48
Max. Negotiated Rate	$44,214.90
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

$44,214.90

Service Code	MSDRG 709
Min. Negotiated Rate	$17,473.48
Max. Negotiated Rate	$44,214.90
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	$44,214.90
Rate for Payer: Multiplan Commercial	$44,214.90
Rate for Payer: Multiplan Workers Comp	$44,214.90
Rate for Payer: Scott and White EPO/PPO	$20,362.12
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

Know your out-of-pocket cost for care.

All Charges