White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$40,487.10

Service Code	MSDRG 243
Min. Negotiated Rate	$18,645.38
Max. Negotiated Rate	$40,487.10
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	$40,487.10
Rate for Payer: Multiplan Commercial	$40,487.10
Rate for Payer: Multiplan Workers Comp	$40,487.10
Rate for Payer: Scott and White EPO/PPO	$18,645.38
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

PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC

Facility

$60,663.20

Service Code	MSDRG 242
Min. Negotiated Rate	$27,937.00
Max. Negotiated Rate	$60,663.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,160.20
Rate for Payer: Amerigroup Medicare	$28,160.20
Rate for Payer: BCBS of TX Medicare	$28,160.20
Rate for Payer: Cigna Commercial	$41,123.26
Rate for Payer: Cigna Medicare	$28,160.20
Rate for Payer: Employer Direct Commercial	$28,160.20
Rate for Payer: Humana Medicare/TRICARE	$28,160.20
Rate for Payer: Molina Dual Medicare/Medicaid	$28,160.20
Rate for Payer: Molina Medicare	$28,160.20
Rate for Payer: Multiplan Auto	$60,663.20
Rate for Payer: Multiplan Commercial	$60,663.20
Rate for Payer: Multiplan Workers Comp	$60,663.20
Rate for Payer: Scott and White EPO/PPO	$27,937.00
Rate for Payer: Scott and White Medicare	$28,160.20
Rate for Payer: Superior Health Plan EPO	$28,160.20
Rate for Payer: Superior Health Plan Medicare	$28,160.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,160.20
Rate for Payer: Universal American Medicare	$28,160.20
Rate for Payer: Wellcare Medicare	$28,160.20
Rate for Payer: Wellmed Medicare	$28,160.20

PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK

Facility

$6,438.62

Service Code	APR-DRG 1711
Min. Negotiated Rate	$6,070.55
Max. Negotiated Rate	$6,438.62
Rate for Payer: Amerigroup CHIP/Medicaid	$6,070.55
Rate for Payer: Cigna Medicaid	$6,070.55
Rate for Payer: Molina CHIP/Medicaid	$6,070.55
Rate for Payer: Parkland Medicaid	$6,070.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,438.62

PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK

Facility

$26,872.45

Service Code	APR-DRG 1714
Min. Negotiated Rate	$25,336.29
Max. Negotiated Rate	$26,872.45
Rate for Payer: Amerigroup CHIP/Medicaid	$25,336.29
Rate for Payer: Cigna Medicaid	$25,336.29
Rate for Payer: Molina CHIP/Medicaid	$25,336.29
Rate for Payer: Parkland Medicaid	$25,336.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26,872.45

PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK

Facility

$11,158.38

Service Code	APR-DRG 1713
Min. Negotiated Rate	$10,520.51
Max. Negotiated Rate	$11,158.38
Rate for Payer: Amerigroup CHIP/Medicaid	$10,520.51
Rate for Payer: Cigna Medicaid	$10,520.51
Rate for Payer: Molina CHIP/Medicaid	$10,520.51
Rate for Payer: Parkland Medicaid	$10,520.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,158.38

PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK

Facility

$7,798.38

Service Code	APR-DRG 1712
Min. Negotiated Rate	$7,352.59
Max. Negotiated Rate	$7,798.38
Rate for Payer: Amerigroup CHIP/Medicaid	$7,352.59
Rate for Payer: Cigna Medicaid	$7,352.59
Rate for Payer: Molina CHIP/Medicaid	$7,352.59
Rate for Payer: Parkland Medicaid	$7,352.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,798.38

PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC

Facility

$34,342.50

Service Code	MSDRG 244
Min. Negotiated Rate	$15,815.62
Max. Negotiated Rate	$34,342.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,007.30
Rate for Payer: Amerigroup Medicare	$18,007.30
Rate for Payer: BCBS of TX Medicare	$18,007.30
Rate for Payer: Cigna Commercial	$23,280.60
Rate for Payer: Cigna Medicare	$18,007.30
Rate for Payer: Employer Direct Commercial	$18,007.30
Rate for Payer: Humana Medicare/TRICARE	$18,007.30
Rate for Payer: Molina Dual Medicare/Medicaid	$18,007.30
Rate for Payer: Molina Medicare	$18,007.30
Rate for Payer: Multiplan Auto	$34,342.50
Rate for Payer: Multiplan Commercial	$34,342.50
Rate for Payer: Multiplan Workers Comp	$34,342.50
Rate for Payer: Scott and White EPO/PPO	$15,815.62
Rate for Payer: Scott and White Medicare	$18,007.30
Rate for Payer: Superior Health Plan EPO	$18,007.30
Rate for Payer: Superior Health Plan Medicare	$18,007.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,007.30
Rate for Payer: Universal American Medicare	$18,007.30
Rate for Payer: Wellcare Medicare	$18,007.30
Rate for Payer: Wellmed Medicare	$18,007.30

PERMANENT CARDIAC PACEMAKER IMPLANT W MCC

Facility

$60,663.20

Service Code	MSDRG 242
Min. Negotiated Rate	$27,937.00
Max. Negotiated Rate	$60,663.20
Rate for Payer: BCBS of TX Blue Advantage	$32,137.34
Rate for Payer: BCBS of TX Blue Essentials	$38,561.07
Rate for Payer: BCBS of TX PPO	$42,847.30

PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC

Facility

$34,342.50

Service Code	MSDRG 244
Min. Negotiated Rate	$15,815.62
Max. Negotiated Rate	$34,342.50
Rate for Payer: BCBS of TX Blue Advantage	$18,152.88
Rate for Payer: BCBS of TX Blue Essentials	$21,781.35
Rate for Payer: BCBS of TX PPO	$24,202.43

permethrin 5% Cream 60 g

Facility

$201.78

Service Code	HCPCS J3490
Hospital Charge Code	77753486
Hospital Revenue Code	250
Rate for Payer: Cash Price	$137.21

permethrin 5% Cream 60 g

Facility

$201.78

Service Code	HCPCS J3490
Hospital Charge Code	77753486
Hospital Revenue Code	250
Min. Negotiated Rate	$18.16
Max. Negotiated Rate	$145.28
Rate for Payer: Amerigroup CHIP/Medicaid	$18.16
Rate for Payer: BCBS of TX Blue Advantage	$60.53
Rate for Payer: BCBS of TX Blue Essentials	$72.64
Rate for Payer: BCBS of TX PPO	$80.71
Rate for Payer: Cash Price	$137.21
Rate for Payer: Cigna Medicaid	$145.28
Rate for Payer: Molina CHIP/Medicaid	$145.28
Rate for Payer: Multiplan Auto	$131.16
Rate for Payer: Multiplan Commercial	$131.16
Rate for Payer: Multiplan Workers Comp	$131.16
Rate for Payer: Parkland Medicaid	$145.28
Rate for Payer: Scott and White EPO/PPO	$100.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.28
Rate for Payer: Superior Health Plan EPO	$27.44

PERQ DIA-CIRC THRO+PLST+IMG S&I

Facility

$17,889.00

Service Code	HCPCS 36905
Hospital Charge Code	2351104
Hospital Revenue Code	360
Rate for Payer: Cash Price	$12,164.52

PERQ DIA-CIRC THRO+PLST+IMG S&I

Facility

$17,889.00

Service Code	HCPCS 36905
Hospital Charge Code	2351104
Hospital Revenue Code	360
Min. Negotiated Rate	$4,535.02
Max. Negotiated Rate	$24,969.37
Rate for Payer: Amerigroup CHIP/Medicaid	$4,535.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Amerigroup Medicare	$11,596.79
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$11,596.79
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$12,164.52
Rate for Payer: Cash Price	$12,164.52
Rate for Payer: Cash Price	$12,164.52
Rate for Payer: Cigna Commercial	$24,513.51
Rate for Payer: Cigna Medicaid	$12,880.08
Rate for Payer: Cigna Medicare	$11,596.79
Rate for Payer: Employer Direct Commercial	$11,596.79
Rate for Payer: Humana Medicare/TRICARE	$11,596.79
Rate for Payer: Molina CHIP/Medicaid	$12,880.08
Rate for Payer: Molina Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Molina Medicare	$11,596.79
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	$12,880.08
Rate for Payer: Scott and White EPO/PPO	$21,454.06
Rate for Payer: Scott and White Medicare	$11,596.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,880.08
Rate for Payer: Superior Health Plan EPO	$11,596.79
Rate for Payer: Superior Health Plan Medicare	$11,596.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Universal American Medicare	$11,596.79
Rate for Payer: Wellcare Medicare	$11,596.79
Rate for Payer: Wellmed Medicare	$11,596.79

PERQ DIA-CIR THRO+IMG+S&I

Facility

$8,559.00

Service Code	HCPCS 36904
Hospital Charge Code	2351103
Hospital Revenue Code	360
Min. Negotiated Rate	$2,362.78
Max. Negotiated Rate	$12,483.85
Rate for Payer: Amerigroup CHIP/Medicaid	$2,362.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Amerigroup Medicare	$5,717.50
Rate for Payer: BCBS of TX Blue Advantage	$8,273.03
Rate for Payer: BCBS of TX Blue Essentials	$9,907.82
Rate for Payer: BCBS of TX Medicare	$5,717.50
Rate for Payer: BCBS of TX PPO	$12,483.85
Rate for Payer: Cash Price	$5,820.12
Rate for Payer: Cash Price	$5,820.12
Rate for Payer: Cash Price	$5,820.12
Rate for Payer: Cigna Commercial	$12,085.75
Rate for Payer: Cigna Medicaid	$6,162.48
Rate for Payer: Cigna Medicare	$5,717.50
Rate for Payer: Employer Direct Commercial	$5,717.50
Rate for Payer: Humana Medicare/TRICARE	$5,717.50
Rate for Payer: Molina CHIP/Medicaid	$6,162.48
Rate for Payer: Molina Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Molina Medicare	$5,717.50
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	$6,162.48
Rate for Payer: Scott and White EPO/PPO	$10,577.38
Rate for Payer: Scott and White Medicare	$5,717.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,162.48
Rate for Payer: Superior Health Plan EPO	$5,717.50
Rate for Payer: Superior Health Plan Medicare	$5,717.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Universal American Medicare	$5,717.50
Rate for Payer: Wellcare Medicare	$5,717.50
Rate for Payer: Wellmed Medicare	$5,717.50

PERQ DIA-CIR THRO+IMG+S&I

Facility

$8,559.00

Service Code	HCPCS 36904
Hospital Charge Code	2351103
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,820.12

PERQ DIA+CIR THRO+STN+IMG+S&I

Facility

$40,051.00

Service Code	HCPCS 36906
Hospital Charge Code	2351105
Hospital Revenue Code	360
Min. Negotiated Rate	$8,719.70
Max. Negotiated Rate	$40,168.72
Rate for Payer: Amerigroup CHIP/Medicaid	$8,719.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,415.17
Rate for Payer: Amerigroup Medicare	$18,415.17
Rate for Payer: BCBS of TX Blue Advantage	$26,619.75
Rate for Payer: BCBS of TX Blue Essentials	$31,879.94
Rate for Payer: BCBS of TX Medicare	$18,415.17
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cash Price	$27,234.68
Rate for Payer: Cash Price	$27,234.68
Rate for Payer: Cash Price	$27,234.68
Rate for Payer: Cigna Commercial	$38,926.35
Rate for Payer: Cigna Medicaid	$28,836.72
Rate for Payer: Cigna Medicare	$18,415.17
Rate for Payer: Employer Direct Commercial	$18,415.17
Rate for Payer: Humana Medicare/TRICARE	$18,415.17
Rate for Payer: Molina CHIP/Medicaid	$28,836.72
Rate for Payer: Molina Dual Medicare/Medicaid	$18,415.17
Rate for Payer: Molina Medicare	$18,415.17
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	$28,836.72
Rate for Payer: Scott and White EPO/PPO	$34,068.06
Rate for Payer: Scott and White Medicare	$18,415.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28,836.72
Rate for Payer: Superior Health Plan EPO	$18,415.17
Rate for Payer: Superior Health Plan Medicare	$18,415.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,415.17
Rate for Payer: Universal American Medicare	$18,415.17
Rate for Payer: Wellcare Medicare	$18,415.17
Rate for Payer: Wellmed Medicare	$18,415.17

PERQ DIA+CIR THRO+STN+IMG+S&I

Facility

$40,051.00

Service Code	HCPCS 36906
Hospital Charge Code	2351105
Hospital Revenue Code	360
Rate for Payer: Cash Price	$27,234.68

PFT Indirect Cal Study 94690 BCE

Facility

$546.00

Service Code	HCPCS 94690
Hospital Charge Code	4010013
Hospital Revenue Code	460
Rate for Payer: Cash Price	$371.28

PFT Indirect Cal Study 94690 BCE

Facility

$546.00

Service Code	HCPCS 94690
Hospital Charge Code	4010013
Hospital Revenue Code	460
Min. Negotiated Rate	$49.14
Max. Negotiated Rate	$393.12
Rate for Payer: Amerigroup CHIP/Medicaid	$49.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$163.80
Rate for Payer: BCBS of TX Blue Essentials	$196.56
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$218.40
Rate for Payer: Cash Price	$371.28
Rate for Payer: Cash Price	$371.28
Rate for Payer: Cash Price	$371.28
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$393.12
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$393.12
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
Rate for Payer: Multiplan Auto	$354.90
Rate for Payer: Multiplan Commercial	$354.90
Rate for Payer: Multiplan Workers Comp	$354.90
Rate for Payer: Parkland Medicaid	$393.12
Rate for Payer: Scott and White EPO/PPO	$273.00
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$393.12
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

Phasix Mesh 8x10

Facility

$49,096.00

Service Code	HCPCS C1781
Hospital Charge Code	119005
Hospital Revenue Code	272
Rate for Payer: Cash Price	$33,385.28

Phasix Mesh 8x10

Facility

$49,096.00

Service Code	HCPCS C1781
Hospital Charge Code	119005
Hospital Revenue Code	272
Min. Negotiated Rate	$4,418.64
Max. Negotiated Rate	$35,349.12
Rate for Payer: Amerigroup CHIP/Medicaid	$4,418.64
Rate for Payer: BCBS of TX Blue Advantage	$14,728.80
Rate for Payer: BCBS of TX Blue Essentials	$17,674.56
Rate for Payer: BCBS of TX PPO	$19,638.40
Rate for Payer: Cash Price	$33,385.28
Rate for Payer: Cigna Medicaid	$35,349.12
Rate for Payer: Molina CHIP/Medicaid	$35,349.12
Rate for Payer: Multiplan Auto	$31,912.40
Rate for Payer: Multiplan Commercial	$31,912.40
Rate for Payer: Multiplan Workers Comp	$31,912.40
Rate for Payer: Parkland Medicaid	$35,349.12
Rate for Payer: Scott and White EPO/PPO	$24,548.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35,349.12
Rate for Payer: Superior Health Plan EPO	$6,677.06

pH, Body Fluid SO

Facility

$85.00

Service Code	HCPCS 83986 QW
Hospital Charge Code	1605179
Hospital Revenue Code	301
Rate for Payer: Cash Price	$57.80

pH, Body Fluid SO

Facility

$85.00

Service Code	HCPCS 83986 QW
Hospital Charge Code	1605179
Hospital Revenue Code	301
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$61.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.58
Rate for Payer: Amerigroup Medicare	$3.58
Rate for Payer: BCBS of TX Blue Advantage	$25.50
Rate for Payer: BCBS of TX Blue Essentials	$30.60
Rate for Payer: BCBS of TX Medicare	$3.58
Rate for Payer: BCBS of TX PPO	$34.00
Rate for Payer: Cash Price	$57.80
Rate for Payer: Cash Price	$57.80
Rate for Payer: Cigna Medicaid	$61.20
Rate for Payer: Cigna Medicare	$3.58
Rate for Payer: Employer Direct Commercial	$3.58
Rate for Payer: Humana Medicare/TRICARE	$3.58
Rate for Payer: Molina CHIP/Medicaid	$61.20
Rate for Payer: Molina Dual Medicare/Medicaid	$3.58
Rate for Payer: Molina Medicare	$3.58
Rate for Payer: Multiplan Auto	$55.25
Rate for Payer: Multiplan Commercial	$55.25
Rate for Payer: Multiplan Workers Comp	$55.25
Rate for Payer: Parkland Medicaid	$61.20
Rate for Payer: Scott and White EPO/PPO	$4.47
Rate for Payer: Scott and White Medicare	$3.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$61.20
Rate for Payer: Superior Health Plan EPO	$3.58
Rate for Payer: Superior Health Plan Medicare	$3.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.58
Rate for Payer: Universal American Medicare	$3.58
Rate for Payer: Wellcare Medicare	$3.58
Rate for Payer: Wellmed Medicare	$3.58

phenAZOpyridine 100 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78404780
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Know your out-of-pocket cost for care.

All Charges