White Rock Medical Center

All Charges

Charge

Type

Setting

Price

pH Gastric

Facility

$85.00

Service Code	HCPCS 83986
Hospital Charge Code	4186161
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
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

Phosphorus Level

Facility

$221.00

Service Code	HCPCS 84100
Hospital Charge Code	1602184
Hospital Revenue Code	301
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$159.12
Rate for Payer: Amerigroup CHIP/Medicaid	$1.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.74
Rate for Payer: Amerigroup Medicare	$4.74
Rate for Payer: BCBS of TX Blue Advantage	$66.30
Rate for Payer: BCBS of TX Blue Essentials	$79.56
Rate for Payer: BCBS of TX Medicare	$4.74
Rate for Payer: BCBS of TX PPO	$88.40
Rate for Payer: Cash Price	$150.28
Rate for Payer: Cash Price	$150.28
Rate for Payer: Cigna Medicaid	$159.12
Rate for Payer: Cigna Medicare	$4.74
Rate for Payer: Employer Direct Commercial	$4.74
Rate for Payer: Humana Medicare/TRICARE	$4.74
Rate for Payer: Molina CHIP/Medicaid	$159.12
Rate for Payer: Molina Dual Medicare/Medicaid	$4.74
Rate for Payer: Molina Medicare	$4.74
Rate for Payer: Multiplan Auto	$143.65
Rate for Payer: Multiplan Commercial	$143.65
Rate for Payer: Multiplan Workers Comp	$143.65
Rate for Payer: Parkland Medicaid	$159.12
Rate for Payer: Scott and White EPO/PPO	$5.92
Rate for Payer: Scott and White Medicare	$4.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$159.12
Rate for Payer: Superior Health Plan EPO	$4.74
Rate for Payer: Superior Health Plan Medicare	$4.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.74
Rate for Payer: Universal American Medicare	$4.74
Rate for Payer: Wellcare Medicare	$4.74
Rate for Payer: Wellmed Medicare	$4.74

Phosphorus Level

Facility

$221.00

Service Code	HCPCS 84100
Hospital Charge Code	1602184
Hospital Revenue Code	301
Rate for Payer: Cash Price	$150.28

Phototherapy Activity -> Initiated

Facility

$143.00

Service Code	HCPCS 96900
Hospital Charge Code	300574
Hospital Revenue Code	940
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$102.96
Rate for Payer: Amerigroup CHIP/Medicaid	$12.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37.52
Rate for Payer: Amerigroup Medicare	$37.52
Rate for Payer: BCBS of TX Blue Advantage	$42.90
Rate for Payer: BCBS of TX Blue Essentials	$51.48
Rate for Payer: BCBS of TX Medicare	$37.52
Rate for Payer: BCBS of TX PPO	$57.20
Rate for Payer: Cash Price	$97.24
Rate for Payer: Cash Price	$97.24
Rate for Payer: Cash Price	$97.24
Rate for Payer: Cigna Commercial	$79.31
Rate for Payer: Cigna Medicaid	$102.96
Rate for Payer: Cigna Medicare	$37.52
Rate for Payer: Employer Direct Commercial	$37.52
Rate for Payer: Humana Medicare/TRICARE	$37.52
Rate for Payer: Molina CHIP/Medicaid	$102.96
Rate for Payer: Molina Dual Medicare/Medicaid	$37.52
Rate for Payer: Molina Medicare	$37.52
Rate for Payer: Multiplan Auto	$92.95
Rate for Payer: Multiplan Commercial	$92.95
Rate for Payer: Multiplan Workers Comp	$92.95
Rate for Payer: Parkland Medicaid	$102.96
Rate for Payer: Scott and White EPO/PPO	$30.86
Rate for Payer: Scott and White Medicare	$37.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.96
Rate for Payer: Superior Health Plan EPO	$37.52
Rate for Payer: Superior Health Plan Medicare	$37.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$37.52
Rate for Payer: Universal American Medicare	$37.52
Rate for Payer: Wellcare Medicare	$37.52
Rate for Payer: Wellmed Medicare	$37.52

Phototherapy Activity -> Initiated

Facility

$143.00

Service Code	HCPCS 96900
Hospital Charge Code	300574
Hospital Revenue Code	940
Rate for Payer: Cash Price	$97.24

phytonadione 1 mg/0.5 mL Inj Soln 0.5 mL

Facility

$128.00

Service Code	HCPCS J3430
Hospital Charge Code	77761775
Hospital Revenue Code	636
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$4.57
Rate for Payer: BCBS of TX Blue Essentials	$5.48
Rate for Payer: BCBS of TX PPO	$6.08
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

phytonadione 1 mg/0.5 mL Inj Soln 0.5 mL

Facility

$128.00

Service Code	HCPCS J3430
Hospital Charge Code	77761775
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

Phytonadione 2.5mg/2.5ml Oral Soln

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	79872627
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
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

Phytonadione 2.5mg/2.5ml Oral Soln

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	79872627
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

PICC LINE DRSG CHANGE TRAY W/BIOPATCH

Facility

$128.54

Hospital Charge Code	993097
Hospital Revenue Code	270
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$92.55
Rate for Payer: Amerigroup CHIP/Medicaid	$11.57
Rate for Payer: BCBS of TX Blue Advantage	$38.56
Rate for Payer: BCBS of TX Blue Essentials	$46.27
Rate for Payer: BCBS of TX PPO	$51.42
Rate for Payer: Cash Price	$87.41
Rate for Payer: Cigna Medicaid	$92.55
Rate for Payer: Molina CHIP/Medicaid	$92.55
Rate for Payer: Multiplan Auto	$83.55
Rate for Payer: Multiplan Commercial	$83.55
Rate for Payer: Multiplan Workers Comp	$83.55
Rate for Payer: Parkland Medicaid	$92.55
Rate for Payer: Scott and White EPO/PPO	$64.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.55
Rate for Payer: Superior Health Plan EPO	$17.48

PICC LINE DRSG CHANGE TRAY W/BIOPATCH

Facility

$128.54

Hospital Charge Code	993097
Hospital Revenue Code	270
Rate for Payer: Cash Price	$87.41

Pigtail Diagnostic Catheter

Facility

$154.36

Service Code	HCPCS C1887
Hospital Charge Code	992463
Hospital Revenue Code	272
Min. Negotiated Rate	$13.89
Max. Negotiated Rate	$111.14
Rate for Payer: Amerigroup CHIP/Medicaid	$13.89
Rate for Payer: BCBS of TX Blue Advantage	$46.31
Rate for Payer: BCBS of TX Blue Essentials	$55.57
Rate for Payer: BCBS of TX PPO	$61.74
Rate for Payer: Cash Price	$104.96
Rate for Payer: Cigna Medicaid	$111.14
Rate for Payer: Molina CHIP/Medicaid	$111.14
Rate for Payer: Multiplan Auto	$100.33
Rate for Payer: Multiplan Commercial	$100.33
Rate for Payer: Multiplan Workers Comp	$100.33
Rate for Payer: Parkland Medicaid	$111.14
Rate for Payer: Scott and White EPO/PPO	$77.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111.14
Rate for Payer: Superior Health Plan EPO	$20.99

Pigtail Diagnostic Catheter

Facility

$154.36

Service Code	HCPCS C1887
Hospital Charge Code	992463
Hospital Revenue Code	272
Rate for Payer: Cash Price	$104.96

Pigtail Diagnostic Catheter

Facility

$154.36

Service Code	HCPCS C1887
Hospital Charge Code	992454
Hospital Revenue Code	272
Min. Negotiated Rate	$13.89
Max. Negotiated Rate	$111.14
Rate for Payer: Amerigroup CHIP/Medicaid	$13.89
Rate for Payer: BCBS of TX Blue Advantage	$46.31
Rate for Payer: BCBS of TX Blue Essentials	$55.57
Rate for Payer: BCBS of TX PPO	$61.74
Rate for Payer: Cash Price	$104.96
Rate for Payer: Cigna Medicaid	$111.14
Rate for Payer: Molina CHIP/Medicaid	$111.14
Rate for Payer: Multiplan Auto	$100.33
Rate for Payer: Multiplan Commercial	$100.33
Rate for Payer: Multiplan Workers Comp	$100.33
Rate for Payer: Parkland Medicaid	$111.14
Rate for Payer: Scott and White EPO/PPO	$77.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111.14
Rate for Payer: Superior Health Plan EPO	$20.99

Pigtail Diagnostic Catheter

Facility

$154.36

Service Code	HCPCS C1887
Hospital Charge Code	992454
Hospital Revenue Code	272
Rate for Payer: Cash Price	$104.96

PILLOW, ABDCT FOAM SMALL

Facility

$120.61

Hospital Charge Code	993757
Hospital Revenue Code	279
Rate for Payer: Cash Price	$82.01

PILLOW, ABDCT FOAM SMALL

Facility

$120.61

Hospital Charge Code	993757
Hospital Revenue Code	279
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$86.84
Rate for Payer: Amerigroup CHIP/Medicaid	$10.85
Rate for Payer: BCBS of TX Blue Advantage	$36.18
Rate for Payer: BCBS of TX Blue Essentials	$43.42
Rate for Payer: BCBS of TX PPO	$48.24
Rate for Payer: Cash Price	$82.01
Rate for Payer: Cigna Medicaid	$86.84
Rate for Payer: Molina CHIP/Medicaid	$86.84
Rate for Payer: Multiplan Auto	$78.40
Rate for Payer: Multiplan Commercial	$78.40
Rate for Payer: Multiplan Workers Comp	$78.40
Rate for Payer: Parkland Medicaid	$86.84
Rate for Payer: Scott and White EPO/PPO	$60.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.84
Rate for Payer: Superior Health Plan EPO	$16.40

PILLOW, ABDUCTION FOAM LARGE 6' X 18 X 25' -- DHF

Facility

$977.36

Hospital Charge Code	80335250
Hospital Revenue Code	270
Min. Negotiated Rate	$87.96
Max. Negotiated Rate	$703.70
Rate for Payer: Amerigroup CHIP/Medicaid	$87.96
Rate for Payer: BCBS of TX Blue Advantage	$293.21
Rate for Payer: BCBS of TX Blue Essentials	$351.85
Rate for Payer: BCBS of TX PPO	$390.94
Rate for Payer: Cash Price	$664.60
Rate for Payer: Cigna Medicaid	$703.70
Rate for Payer: Molina CHIP/Medicaid	$703.70
Rate for Payer: Multiplan Auto	$635.28
Rate for Payer: Multiplan Commercial	$635.28
Rate for Payer: Multiplan Workers Comp	$635.28
Rate for Payer: Parkland Medicaid	$703.70
Rate for Payer: Scott and White EPO/PPO	$488.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$703.70
Rate for Payer: Superior Health Plan EPO	$132.92

PILLOW, ABDUCTION FOAM LARGE 6' X 18 X 25' -- DHF

Facility

$977.36

Hospital Charge Code	80335250
Hospital Revenue Code	270
Rate for Payer: Cash Price	$664.60

pillows

Facility

$20.80

Hospital Charge Code	993030
Hospital Revenue Code	270
Rate for Payer: Cash Price	$14.14

pillows

Facility

$20.80

Hospital Charge Code	993030
Hospital Revenue Code	270
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$14.98
Rate for Payer: Amerigroup CHIP/Medicaid	$1.87
Rate for Payer: BCBS of TX Blue Advantage	$6.24
Rate for Payer: BCBS of TX Blue Essentials	$7.49
Rate for Payer: BCBS of TX PPO	$8.32
Rate for Payer: Cash Price	$14.14
Rate for Payer: Cigna Medicaid	$14.98
Rate for Payer: Molina CHIP/Medicaid	$14.98
Rate for Payer: Multiplan Auto	$13.52
Rate for Payer: Multiplan Commercial	$13.52
Rate for Payer: Multiplan Workers Comp	$13.52
Rate for Payer: Parkland Medicaid	$14.98
Rate for Payer: Scott and White EPO/PPO	$10.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.98
Rate for Payer: Superior Health Plan EPO	$2.83

PIN CAP A/S -- DHF

Facility

$59.39

Hospital Charge Code	81033466
Hospital Revenue Code	272
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$42.76
Rate for Payer: Amerigroup CHIP/Medicaid	$5.35
Rate for Payer: BCBS of TX Blue Advantage	$17.82
Rate for Payer: BCBS of TX Blue Essentials	$21.38
Rate for Payer: BCBS of TX PPO	$23.76
Rate for Payer: Cash Price	$40.39
Rate for Payer: Cigna Medicaid	$42.76
Rate for Payer: Molina CHIP/Medicaid	$42.76
Rate for Payer: Multiplan Auto	$38.60
Rate for Payer: Multiplan Commercial	$38.60
Rate for Payer: Multiplan Workers Comp	$38.60
Rate for Payer: Parkland Medicaid	$42.76
Rate for Payer: Scott and White EPO/PPO	$29.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.76
Rate for Payer: Superior Health Plan EPO	$8.08

PIN CAP A/S -- DHF

Facility

$59.39

Hospital Charge Code	81033466
Hospital Revenue Code	272
Rate for Payer: Cash Price	$40.39

PIN CERVICAL DISTRACTION 12MM

Facility

$126.00

Service Code	HCPCS C1713
Hospital Charge Code	8504482
Hospital Revenue Code	278
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$63.00
Rate for Payer: Cash Price	$85.68
Rate for Payer: Cigna Commercial	$31.50
Rate for Payer: Multiplan Auto	$63.00
Rate for Payer: Multiplan Commercial	$63.00
Rate for Payer: Multiplan Workers Comp	$63.00
Rate for Payer: Scott and White EPO/PPO	$63.00

Know your out-of-pocket cost for care.

All Charges