White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Periprosthetic capsulectomy, breast

Facility

$9,473.22

Service Code	HCPCS 19371
Hospital Charge Code	9900164
Hospital Revenue Code	360
Min. Negotiated Rate	$963.66
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$963.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Amerigroup Medicare	$3,933.28
Rate for Payer: BCBS of TX Blue Advantage	$5,059.35
Rate for Payer: BCBS of TX Blue Essentials	$6,059.10
Rate for Payer: BCBS of TX Medicare	$3,933.28
Rate for Payer: BCBS of TX PPO	$7,634.47
Rate for Payer: Cash Price	$6,441.79
Rate for Payer: Cash Price	$6,441.79
Rate for Payer: Cash Price	$6,441.79
Rate for Payer: Cigna Commercial	$8,314.23
Rate for Payer: Cigna Medicaid	$6,820.72
Rate for Payer: Cigna Medicare	$3,933.28
Rate for Payer: Employer Direct Commercial	$3,933.28
Rate for Payer: Humana Medicare/TRICARE	$3,933.28
Rate for Payer: Molina CHIP/Medicaid	$6,820.72
Rate for Payer: Molina Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Molina Medicare	$3,933.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$6,820.72
Rate for Payer: Scott and White EPO/PPO	$6,449.12
Rate for Payer: Scott and White Medicare	$3,933.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,820.72
Rate for Payer: Superior Health Plan EPO	$3,933.28
Rate for Payer: Superior Health Plan Medicare	$3,933.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Universal American Medicare	$3,933.28
Rate for Payer: Wellcare Medicare	$3,933.28
Rate for Payer: Wellmed Medicare	$3,933.28

Periprosthetic capsulectomy, breast

Facility

$9,473.22

Service Code	HCPCS 19371
Hospital Charge Code	9900164
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,441.79

Periprosthetic capsulectomy, breast

Facility

$10,000.00

Service Code	CPT 19371
Hospital Charge Code	36019371
Hospital Revenue Code	360
Min. Negotiated Rate	$963.66
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$963.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Amerigroup Medicare	$3,933.28
Rate for Payer: BCBS of TX Blue Advantage	$5,059.35
Rate for Payer: BCBS of TX Blue Essentials	$6,059.10
Rate for Payer: BCBS of TX Medicare	$3,933.28
Rate for Payer: BCBS of TX PPO	$7,634.47
Rate for Payer: Cigna Commercial	$8,314.23
Rate for Payer: Cigna Medicare	$3,933.28
Rate for Payer: Employer Direct Commercial	$3,933.28
Rate for Payer: Humana Medicare/TRICARE	$3,933.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Molina Medicare	$3,933.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$6,449.12
Rate for Payer: Scott and White Medicare	$3,933.28
Rate for Payer: Superior Health Plan EPO	$3,933.28
Rate for Payer: Superior Health Plan Medicare	$3,933.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Universal American Medicare	$3,933.28
Rate for Payer: Wellcare Medicare	$3,933.28
Rate for Payer: Wellmed Medicare	$3,933.28

PERITONEAL ADHESIOLYSIS

Facility

$12,563.79

Service Code	APR-DRG 2243
Min. Negotiated Rate	$11,845.58
Max. Negotiated Rate	$12,563.79
Rate for Payer: Amerigroup CHIP/Medicaid	$11,845.58
Rate for Payer: Cigna Medicaid	$11,845.58
Rate for Payer: Molina CHIP/Medicaid	$11,845.58
Rate for Payer: Parkland Medicaid	$11,845.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,563.79

PERITONEAL ADHESIOLYSIS

Facility

$34,484.13

Service Code	APR-DRG 2244
Min. Negotiated Rate	$32,512.84
Max. Negotiated Rate	$34,484.13
Rate for Payer: Amerigroup CHIP/Medicaid	$32,512.84
Rate for Payer: Cigna Medicaid	$32,512.84
Rate for Payer: Molina CHIP/Medicaid	$32,512.84
Rate for Payer: Parkland Medicaid	$32,512.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34,484.13

PERITONEAL ADHESIOLYSIS

Facility

$8,258.93

Service Code	APR-DRG 2242
Min. Negotiated Rate	$7,786.81
Max. Negotiated Rate	$8,258.93
Rate for Payer: Amerigroup CHIP/Medicaid	$7,786.81
Rate for Payer: Cigna Medicaid	$7,786.81
Rate for Payer: Molina CHIP/Medicaid	$7,786.81
Rate for Payer: Parkland Medicaid	$7,786.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,258.93

PERITONEAL ADHESIOLYSIS

Facility

$5,670.66

Service Code	APR-DRG 2241
Min. Negotiated Rate	$5,346.50
Max. Negotiated Rate	$5,670.66
Rate for Payer: Amerigroup CHIP/Medicaid	$5,346.50
Rate for Payer: Cigna Medicaid	$5,346.50
Rate for Payer: Molina CHIP/Medicaid	$5,346.50
Rate for Payer: Parkland Medicaid	$5,346.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,670.66

PERITONEAL ADHESIOLYSIS W CC

Facility

$40,413.00

Service Code	MSDRG 336
Min. Negotiated Rate	$18,611.25
Max. Negotiated Rate	$40,413.00
Rate for Payer: BCBS of TX Blue Advantage	$19,764.52
Rate for Payer: BCBS of TX Blue Essentials	$23,715.13
Rate for Payer: BCBS of TX PPO	$26,351.16

PERITONEAL ADHESIOLYSIS WITH CC

Facility

$40,413.00

Service Code	MSDRG 336
Min. Negotiated Rate	$18,611.25
Max. Negotiated Rate	$40,413.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,214.79
Rate for Payer: Amerigroup Medicare	$20,214.79
Rate for Payer: BCBS of TX Medicare	$20,214.79
Rate for Payer: Cigna Commercial	$27,160.06
Rate for Payer: Cigna Medicare	$20,214.79
Rate for Payer: Employer Direct Commercial	$20,214.79
Rate for Payer: Humana Medicare/TRICARE	$20,214.79
Rate for Payer: Molina Dual Medicare/Medicaid	$20,214.79
Rate for Payer: Molina Medicare	$20,214.79
Rate for Payer: Multiplan Auto	$40,413.00
Rate for Payer: Multiplan Commercial	$40,413.00
Rate for Payer: Multiplan Workers Comp	$40,413.00
Rate for Payer: Scott and White EPO/PPO	$18,611.25
Rate for Payer: Scott and White Medicare	$20,214.79
Rate for Payer: Superior Health Plan EPO	$20,214.79
Rate for Payer: Superior Health Plan Medicare	$20,214.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,214.79
Rate for Payer: Universal American Medicare	$20,214.79
Rate for Payer: Wellcare Medicare	$20,214.79
Rate for Payer: Wellmed Medicare	$20,214.79

PERITONEAL ADHESIOLYSIS WITH MCC

Facility

$69,992.20

Service Code	MSDRG 335
Min. Negotiated Rate	$30,931.29
Max. Negotiated Rate	$69,992.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,931.29
Rate for Payer: Amerigroup Medicare	$30,931.29
Rate for Payer: BCBS of TX Medicare	$30,931.29
Rate for Payer: Cigna Commercial	$45,993.19
Rate for Payer: Cigna Medicare	$30,931.29
Rate for Payer: Employer Direct Commercial	$30,931.29
Rate for Payer: Humana Medicare/TRICARE	$30,931.29
Rate for Payer: Molina Dual Medicare/Medicaid	$30,931.29
Rate for Payer: Molina Medicare	$30,931.29
Rate for Payer: Multiplan Auto	$69,992.20
Rate for Payer: Multiplan Commercial	$69,992.20
Rate for Payer: Multiplan Workers Comp	$69,992.20
Rate for Payer: Scott and White EPO/PPO	$32,233.25
Rate for Payer: Scott and White Medicare	$30,931.29
Rate for Payer: Superior Health Plan EPO	$30,931.29
Rate for Payer: Superior Health Plan Medicare	$30,931.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,931.29
Rate for Payer: Universal American Medicare	$30,931.29
Rate for Payer: Wellcare Medicare	$30,931.29
Rate for Payer: Wellmed Medicare	$30,931.29

PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC

Facility

$29,934.50

Service Code	MSDRG 337
Min. Negotiated Rate	$13,785.62
Max. Negotiated Rate	$29,934.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,010.14
Rate for Payer: Amerigroup Medicare	$16,010.14
Rate for Payer: BCBS of TX Medicare	$16,010.14
Rate for Payer: Cigna Commercial	$19,770.80
Rate for Payer: Cigna Medicare	$16,010.14
Rate for Payer: Employer Direct Commercial	$16,010.14
Rate for Payer: Humana Medicare/TRICARE	$16,010.14
Rate for Payer: Molina Dual Medicare/Medicaid	$16,010.14
Rate for Payer: Molina Medicare	$16,010.14
Rate for Payer: Multiplan Auto	$29,934.50
Rate for Payer: Multiplan Commercial	$29,934.50
Rate for Payer: Multiplan Workers Comp	$29,934.50
Rate for Payer: Scott and White EPO/PPO	$13,785.62
Rate for Payer: Scott and White Medicare	$16,010.14
Rate for Payer: Superior Health Plan EPO	$16,010.14
Rate for Payer: Superior Health Plan Medicare	$16,010.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,010.14
Rate for Payer: Universal American Medicare	$16,010.14
Rate for Payer: Wellcare Medicare	$16,010.14
Rate for Payer: Wellmed Medicare	$16,010.14

PERITONEAL ADHESIOLYSIS W MCC

Facility

$69,992.20

Service Code	MSDRG 335
Min. Negotiated Rate	$30,931.29
Max. Negotiated Rate	$69,992.20
Rate for Payer: BCBS of TX Blue Advantage	$34,933.20
Rate for Payer: BCBS of TX Blue Essentials	$41,915.78
Rate for Payer: BCBS of TX PPO	$46,574.89

PERITONEAL ADHESIOLYSIS W/O CC/MCC

Facility

$29,934.50

Service Code	MSDRG 337
Min. Negotiated Rate	$13,785.62
Max. Negotiated Rate	$29,934.50
Rate for Payer: BCBS of TX Blue Advantage	$13,788.38
Rate for Payer: BCBS of TX Blue Essentials	$16,544.45
Rate for Payer: BCBS of TX PPO	$18,383.44

Peritoneal Cath

Facility

$516.87

Service Code	HCPCS A4301
Hospital Charge Code	991239
Hospital Revenue Code	278
Min. Negotiated Rate	$46.52
Max. Negotiated Rate	$372.15
Rate for Payer: Amerigroup CHIP/Medicaid	$46.52
Rate for Payer: BCBS of TX Blue Advantage	$155.06
Rate for Payer: BCBS of TX Blue Essentials	$186.07
Rate for Payer: BCBS of TX PPO	$206.75
Rate for Payer: Cash Price	$351.47
Rate for Payer: Cigna Medicaid	$372.15
Rate for Payer: Molina CHIP/Medicaid	$372.15
Rate for Payer: Multiplan Auto	$258.44
Rate for Payer: Multiplan Commercial	$258.44
Rate for Payer: Multiplan Workers Comp	$258.44
Rate for Payer: Parkland Medicaid	$372.15
Rate for Payer: Scott and White EPO/PPO	$258.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$372.15
Rate for Payer: Superior Health Plan EPO	$70.29

Peritoneal Cath

Facility

$516.87

Service Code	HCPCS A4301
Hospital Charge Code	991239
Hospital Revenue Code	278
Min. Negotiated Rate	$129.22
Max. Negotiated Rate	$258.44
Rate for Payer: Cash Price	$351.47
Rate for Payer: Cigna Commercial	$129.22
Rate for Payer: Multiplan Auto	$258.44
Rate for Payer: Multiplan Commercial	$258.44
Rate for Payer: Multiplan Workers Comp	$258.44
Rate for Payer: Scott and White EPO/PPO	$258.44

perma-hand non absorbable braided silk suture

Facility

$7.09

Hospital Charge Code	993697
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.82

perma-hand non absorbable braided silk suture

Facility

$7.09

Hospital Charge Code	993697
Hospital Revenue Code	270
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$5.10
Rate for Payer: Amerigroup CHIP/Medicaid	$0.64
Rate for Payer: BCBS of TX Blue Advantage	$2.13
Rate for Payer: BCBS of TX Blue Essentials	$2.55
Rate for Payer: BCBS of TX PPO	$2.84
Rate for Payer: Cash Price	$4.82
Rate for Payer: Cigna Medicaid	$5.10
Rate for Payer: Molina CHIP/Medicaid	$5.10
Rate for Payer: Multiplan Auto	$4.61
Rate for Payer: Multiplan Commercial	$4.61
Rate for Payer: Multiplan Workers Comp	$4.61
Rate for Payer: Parkland Medicaid	$5.10
Rate for Payer: Scott and White EPO/PPO	$3.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.10
Rate for Payer: Superior Health Plan EPO	$0.96

perma-hand non absorbable raided silk suture

Facility

$11.93

Hospital Charge Code	993695
Hospital Revenue Code	270
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$8.59
Rate for Payer: Amerigroup CHIP/Medicaid	$1.07
Rate for Payer: BCBS of TX Blue Advantage	$3.58
Rate for Payer: BCBS of TX Blue Essentials	$4.29
Rate for Payer: BCBS of TX PPO	$4.77
Rate for Payer: Cash Price	$8.11
Rate for Payer: Cigna Medicaid	$8.59
Rate for Payer: Molina CHIP/Medicaid	$8.59
Rate for Payer: Multiplan Auto	$7.75
Rate for Payer: Multiplan Commercial	$7.75
Rate for Payer: Multiplan Workers Comp	$7.75
Rate for Payer: Parkland Medicaid	$8.59
Rate for Payer: Scott and White EPO/PPO	$5.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.59
Rate for Payer: Superior Health Plan EPO	$1.62

perma-hand non absorbable raided silk suture

Facility

$11.93

Hospital Charge Code	993695
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.11

PERMANENT CARDIAC PACEMAKER IMPLANT W CC

Facility

$44,536.00

Service Code	MSDRG 243
Min. Negotiated Rate	$20,377.50
Max. Negotiated Rate	$44,536.00
Rate for Payer: BCBS of TX Blue Advantage	$21,966.98
Rate for Payer: BCBS of TX Blue Essentials	$26,357.82
Rate for Payer: BCBS of TX PPO	$29,287.60

PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK

Facility

$10,983.37

Service Code	APR-DRG 1701
Min. Negotiated Rate	$10,355.50
Max. Negotiated Rate	$10,983.37
Rate for Payer: Amerigroup CHIP/Medicaid	$10,355.50
Rate for Payer: Cigna Medicaid	$10,355.50
Rate for Payer: Molina CHIP/Medicaid	$10,355.50
Rate for Payer: Parkland Medicaid	$10,355.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,983.37

PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK

Facility

$15,440.99

Service Code	APR-DRG 1703
Min. Negotiated Rate	$14,558.30
Max. Negotiated Rate	$15,440.99
Rate for Payer: Amerigroup CHIP/Medicaid	$14,558.30
Rate for Payer: Cigna Medicaid	$14,558.30
Rate for Payer: Molina CHIP/Medicaid	$14,558.30
Rate for Payer: Parkland Medicaid	$14,558.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,440.99

PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK

Facility

$23,725.94

Service Code	APR-DRG 1704
Min. Negotiated Rate	$22,369.65
Max. Negotiated Rate	$23,725.94
Rate for Payer: Amerigroup CHIP/Medicaid	$22,369.65
Rate for Payer: Cigna Medicaid	$22,369.65
Rate for Payer: Molina CHIP/Medicaid	$22,369.65
Rate for Payer: Parkland Medicaid	$22,369.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,725.94

PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK

Facility

$12,599.24

Service Code	APR-DRG 1702
Min. Negotiated Rate	$11,879.01
Max. Negotiated Rate	$12,599.24
Rate for Payer: Amerigroup CHIP/Medicaid	$11,879.01
Rate for Payer: Cigna Medicaid	$11,879.01
Rate for Payer: Molina CHIP/Medicaid	$11,879.01
Rate for Payer: Parkland Medicaid	$11,879.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,599.24

PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC

Facility

$44,536.00

Service Code	MSDRG 243
Min. Negotiated Rate	$20,377.50
Max. Negotiated Rate	$44,536.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,377.50
Rate for Payer: Amerigroup Medicare	$20,377.50
Rate for Payer: BCBS of TX Medicare	$20,377.50
Rate for Payer: Cigna Commercial	$27,445.99
Rate for Payer: Cigna Medicare	$20,377.50
Rate for Payer: Employer Direct Commercial	$20,377.50
Rate for Payer: Humana Medicare/TRICARE	$20,377.50
Rate for Payer: Molina Dual Medicare/Medicaid	$20,377.50
Rate for Payer: Molina Medicare	$20,377.50
Rate for Payer: Multiplan Auto	$44,536.00
Rate for Payer: Multiplan Commercial	$44,536.00
Rate for Payer: Multiplan Workers Comp	$44,536.00
Rate for Payer: Scott and White EPO/PPO	$20,510.00
Rate for Payer: Scott and White Medicare	$20,377.50
Rate for Payer: Superior Health Plan EPO	$20,377.50
Rate for Payer: Superior Health Plan Medicare	$20,377.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,377.50
Rate for Payer: Universal American Medicare	$20,377.50
Rate for Payer: Wellcare Medicare	$20,377.50
Rate for Payer: Wellmed Medicare	$20,377.50

Know your out-of-pocket cost for care.

All Charges