White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Phenobarbital, Serum

Facility

$187.00

Service Code	HCPCS 80184
Hospital Charge Code	1602945
Hospital Revenue Code	301
Min. Negotiated Rate	$5.97
Max. Negotiated Rate	$134.64
Rate for Payer: Amerigroup CHIP/Medicaid	$5.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.30
Rate for Payer: Amerigroup Medicare	$15.30
Rate for Payer: BCBS of TX Blue Advantage	$56.10
Rate for Payer: BCBS of TX Blue Essentials	$67.32
Rate for Payer: BCBS of TX Medicare	$15.30
Rate for Payer: BCBS of TX PPO	$74.80
Rate for Payer: Cash Price	$127.16
Rate for Payer: Cash Price	$127.16
Rate for Payer: Cigna Medicaid	$134.64
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Employer Direct Commercial	$15.30
Rate for Payer: Humana Medicare/TRICARE	$15.30
Rate for Payer: Molina CHIP/Medicaid	$134.64
Rate for Payer: Molina Dual Medicare/Medicaid	$15.30
Rate for Payer: Molina Medicare	$15.30
Rate for Payer: Multiplan Auto	$121.55
Rate for Payer: Multiplan Commercial	$121.55
Rate for Payer: Multiplan Workers Comp	$121.55
Rate for Payer: Parkland Medicaid	$134.64
Rate for Payer: Scott and White EPO/PPO	$19.12
Rate for Payer: Scott and White Medicare	$15.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.64
Rate for Payer: Superior Health Plan EPO	$15.30
Rate for Payer: Superior Health Plan Medicare	$15.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.30
Rate for Payer: Universal American Medicare	$15.30
Rate for Payer: Wellcare Medicare	$15.30
Rate for Payer: Wellmed Medicare	$15.30

Phenobarbital, Serum SO

Facility

$107.00

Service Code	HCPCS 80184
Hospital Charge Code	9311001
Hospital Revenue Code	301
Min. Negotiated Rate	$5.97
Max. Negotiated Rate	$77.04
Rate for Payer: Amerigroup CHIP/Medicaid	$5.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.30
Rate for Payer: Amerigroup Medicare	$15.30
Rate for Payer: BCBS of TX Blue Advantage	$32.10
Rate for Payer: BCBS of TX Blue Essentials	$38.52
Rate for Payer: BCBS of TX Medicare	$15.30
Rate for Payer: BCBS of TX PPO	$42.80
Rate for Payer: Cash Price	$72.76
Rate for Payer: Cash Price	$72.76
Rate for Payer: Cigna Medicaid	$77.04
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Employer Direct Commercial	$15.30
Rate for Payer: Humana Medicare/TRICARE	$15.30
Rate for Payer: Molina CHIP/Medicaid	$77.04
Rate for Payer: Molina Dual Medicare/Medicaid	$15.30
Rate for Payer: Molina Medicare	$15.30
Rate for Payer: Multiplan Auto	$69.55
Rate for Payer: Multiplan Commercial	$69.55
Rate for Payer: Multiplan Workers Comp	$69.55
Rate for Payer: Parkland Medicaid	$77.04
Rate for Payer: Scott and White EPO/PPO	$19.12
Rate for Payer: Scott and White Medicare	$15.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$77.04
Rate for Payer: Superior Health Plan EPO	$15.30
Rate for Payer: Superior Health Plan Medicare	$15.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.30
Rate for Payer: Universal American Medicare	$15.30
Rate for Payer: Wellcare Medicare	$15.30
Rate for Payer: Wellmed Medicare	$15.30

Phenobarbital, Serum SO

Facility

$107.00

Service Code	HCPCS 80184
Hospital Charge Code	9311001
Hospital Revenue Code	301
Rate for Payer: Cash Price	$72.76

phenol 1.4% Topical Spray 180 mL

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77756142
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

phenol 1.4% Topical Spray 180 mL

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77756142
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

phenylephrine 10 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J2371
Hospital Charge Code	77758767
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.01
Rate for Payer: BCBS of TX Blue Essentials	$0.02
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$87.16
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

phenylephrine 10 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J2371
Hospital Charge Code	77758767
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

phenytoin 100 mg ER Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77760348
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

phenytoin 100 mg ER Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77760348
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

phenytoin 50 mg/mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS J1165
Hospital Charge Code	77760837
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

phenytoin 50 mg/mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS J1165
Hospital Charge Code	77760837
Hospital Revenue Code	636
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.48
Rate for Payer: BCBS of TX Blue Essentials	$0.57
Rate for Payer: BCBS of TX PPO	$0.64
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

phenytoin 50 mg/mL Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J1165
Hospital Charge Code	77760778
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

phenytoin 50 mg/mL Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J1165
Hospital Charge Code	77760778
Hospital Revenue Code	636
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.48
Rate for Payer: BCBS of TX Blue Essentials	$0.57
Rate for Payer: BCBS of TX PPO	$0.64
Rate for Payer: Cash Price	$87.16
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

Phenytoin, Free, Serum SO

Facility

$166.00

Service Code	HCPCS 80186
Hospital Charge Code	1700871
Hospital Revenue Code	300
Rate for Payer: Cash Price	$112.88

Phenytoin, Free, Serum SO

Facility

$166.00

Service Code	HCPCS 80186
Hospital Charge Code	1700871
Hospital Revenue Code	300
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$119.52
Rate for Payer: Amerigroup CHIP/Medicaid	$5.37
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.76
Rate for Payer: Amerigroup Medicare	$13.76
Rate for Payer: BCBS of TX Blue Advantage	$49.80
Rate for Payer: BCBS of TX Blue Essentials	$59.76
Rate for Payer: BCBS of TX Medicare	$13.76
Rate for Payer: BCBS of TX PPO	$66.40
Rate for Payer: Cash Price	$112.88
Rate for Payer: Cash Price	$112.88
Rate for Payer: Cigna Medicaid	$119.52
Rate for Payer: Cigna Medicare	$13.76
Rate for Payer: Employer Direct Commercial	$13.76
Rate for Payer: Humana Medicare/TRICARE	$13.76
Rate for Payer: Molina CHIP/Medicaid	$119.52
Rate for Payer: Molina Dual Medicare/Medicaid	$13.76
Rate for Payer: Molina Medicare	$13.76
Rate for Payer: Multiplan Auto	$107.90
Rate for Payer: Multiplan Commercial	$107.90
Rate for Payer: Multiplan Workers Comp	$107.90
Rate for Payer: Parkland Medicaid	$119.52
Rate for Payer: Scott and White EPO/PPO	$17.20
Rate for Payer: Scott and White Medicare	$13.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$119.52
Rate for Payer: Superior Health Plan EPO	$13.76
Rate for Payer: Superior Health Plan Medicare	$13.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.76
Rate for Payer: Universal American Medicare	$13.76
Rate for Payer: Wellcare Medicare	$13.76
Rate for Payer: Wellmed Medicare	$13.76

Phenytoin Level Total

Facility

$487.00

Service Code	HCPCS 80185
Hospital Charge Code	1602994
Hospital Revenue Code	300
Rate for Payer: Cash Price	$331.16

Phenytoin Level Total

Facility

$487.00

Service Code	HCPCS 80185
Hospital Charge Code	1602994
Hospital Revenue Code	300
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$350.64
Rate for Payer: Amerigroup CHIP/Medicaid	$5.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.25
Rate for Payer: Amerigroup Medicare	$13.25
Rate for Payer: BCBS of TX Blue Advantage	$146.10
Rate for Payer: BCBS of TX Blue Essentials	$175.32
Rate for Payer: BCBS of TX Medicare	$13.25
Rate for Payer: BCBS of TX PPO	$194.80
Rate for Payer: Cash Price	$331.16
Rate for Payer: Cash Price	$331.16
Rate for Payer: Cigna Medicaid	$350.64
Rate for Payer: Cigna Medicare	$13.25
Rate for Payer: Employer Direct Commercial	$13.25
Rate for Payer: Humana Medicare/TRICARE	$13.25
Rate for Payer: Molina CHIP/Medicaid	$350.64
Rate for Payer: Molina Dual Medicare/Medicaid	$13.25
Rate for Payer: Molina Medicare	$13.25
Rate for Payer: Multiplan Auto	$316.55
Rate for Payer: Multiplan Commercial	$316.55
Rate for Payer: Multiplan Workers Comp	$316.55
Rate for Payer: Parkland Medicaid	$350.64
Rate for Payer: Scott and White EPO/PPO	$16.56
Rate for Payer: Scott and White Medicare	$13.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$350.64
Rate for Payer: Superior Health Plan EPO	$13.25
Rate for Payer: Superior Health Plan Medicare	$13.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.25
Rate for Payer: Universal American Medicare	$13.25
Rate for Payer: Wellcare Medicare	$13.25
Rate for Payer: Wellmed Medicare	$13.25

PHG-02C

Facility

$8,929.88

Service Code	HCPCS C1734
Hospital Charge Code	991235
Hospital Revenue Code	278
Min. Negotiated Rate	$803.69
Max. Negotiated Rate	$6,429.51
Rate for Payer: Amerigroup CHIP/Medicaid	$803.69
Rate for Payer: BCBS of TX Blue Advantage	$2,678.96
Rate for Payer: BCBS of TX Blue Essentials	$3,214.76
Rate for Payer: BCBS of TX PPO	$3,571.95
Rate for Payer: Cash Price	$6,072.32
Rate for Payer: Cigna Medicaid	$6,429.51
Rate for Payer: Molina CHIP/Medicaid	$6,429.51
Rate for Payer: Multiplan Auto	$4,464.94
Rate for Payer: Multiplan Commercial	$4,464.94
Rate for Payer: Multiplan Workers Comp	$4,464.94
Rate for Payer: Parkland Medicaid	$6,429.51
Rate for Payer: Scott and White EPO/PPO	$4,464.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,429.51
Rate for Payer: Superior Health Plan EPO	$1,214.46

PHG-02C

Facility

$8,929.88

Service Code	HCPCS C1734
Hospital Charge Code	991235
Hospital Revenue Code	278
Min. Negotiated Rate	$2,232.47
Max. Negotiated Rate	$4,464.94
Rate for Payer: Cash Price	$6,072.32
Rate for Payer: Cigna Commercial	$2,232.47
Rate for Payer: Multiplan Auto	$4,464.94
Rate for Payer: Multiplan Commercial	$4,464.94
Rate for Payer: Multiplan Workers Comp	$4,464.94
Rate for Payer: Scott and White EPO/PPO	$4,464.94

PHG-05C

Facility

$12,754.00

Service Code	HCPCS C1734
Hospital Charge Code	991236
Hospital Revenue Code	278
Min. Negotiated Rate	$3,188.50
Max. Negotiated Rate	$6,377.00
Rate for Payer: Cash Price	$8,672.72
Rate for Payer: Cigna Commercial	$3,188.50
Rate for Payer: Multiplan Auto	$6,377.00
Rate for Payer: Multiplan Commercial	$6,377.00
Rate for Payer: Multiplan Workers Comp	$6,377.00
Rate for Payer: Scott and White EPO/PPO	$6,377.00

PHG-05C

Facility

$12,754.00

Service Code	HCPCS C1734
Hospital Charge Code	991236
Hospital Revenue Code	278
Min. Negotiated Rate	$1,147.86
Max. Negotiated Rate	$9,182.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1,147.86
Rate for Payer: BCBS of TX Blue Advantage	$3,826.20
Rate for Payer: BCBS of TX Blue Essentials	$4,591.44
Rate for Payer: BCBS of TX PPO	$5,101.60
Rate for Payer: Cash Price	$8,672.72
Rate for Payer: Cigna Medicaid	$9,182.88
Rate for Payer: Molina CHIP/Medicaid	$9,182.88
Rate for Payer: Multiplan Auto	$6,377.00
Rate for Payer: Multiplan Commercial	$6,377.00
Rate for Payer: Multiplan Workers Comp	$6,377.00
Rate for Payer: Parkland Medicaid	$9,182.88
Rate for Payer: Scott and White EPO/PPO	$6,377.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,182.88
Rate for Payer: Superior Health Plan EPO	$1,734.54

PHG-10CPHG-05C

Facility

$18,047.00

Service Code	HCPCS C1734
Hospital Charge Code	991036
Hospital Revenue Code	278
Min. Negotiated Rate	$1,624.23
Max. Negotiated Rate	$12,993.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1,624.23
Rate for Payer: BCBS of TX Blue Advantage	$5,414.10
Rate for Payer: BCBS of TX Blue Essentials	$6,496.92
Rate for Payer: BCBS of TX PPO	$7,218.80
Rate for Payer: Cash Price	$12,271.96
Rate for Payer: Cigna Medicaid	$12,993.84
Rate for Payer: Molina CHIP/Medicaid	$12,993.84
Rate for Payer: Multiplan Auto	$9,023.50
Rate for Payer: Multiplan Commercial	$9,023.50
Rate for Payer: Multiplan Workers Comp	$9,023.50
Rate for Payer: Parkland Medicaid	$12,993.84
Rate for Payer: Scott and White EPO/PPO	$9,023.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,993.84
Rate for Payer: Superior Health Plan EPO	$2,454.39

PHG-10CPHG-05C

Facility

$18,047.00

Service Code	HCPCS C1734
Hospital Charge Code	991036
Hospital Revenue Code	278
Min. Negotiated Rate	$4,511.75
Max. Negotiated Rate	$9,023.50
Rate for Payer: Cash Price	$12,271.96
Rate for Payer: Cigna Commercial	$4,511.75
Rate for Payer: Multiplan Auto	$9,023.50
Rate for Payer: Multiplan Commercial	$9,023.50
Rate for Payer: Multiplan Workers Comp	$9,023.50
Rate for Payer: Scott and White EPO/PPO	$9,023.50

pH Gastric

Facility

$85.00

Service Code	HCPCS 83986
Hospital Charge Code	8452499
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

pH Gastric

Facility

$85.00

Service Code	HCPCS 83986
Hospital Charge Code	8452499
Hospital Revenue Code	301
Rate for Payer: Cash Price	$57.80

Know your out-of-pocket cost for care.

All Charges