White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PINNACLE STD IK 6FR 10CM .035 MINI GW 1BX=10EA

Facility

$153.91

Service Code	HCPCS C1893
Hospital Charge Code	993710
Hospital Revenue Code	272
Min. Negotiated Rate	$13.85
Max. Negotiated Rate	$110.82
Rate for Payer: Amerigroup CHIP/Medicaid	$13.85
Rate for Payer: BCBS of TX Blue Advantage	$46.17
Rate for Payer: BCBS of TX Blue Essentials	$55.41
Rate for Payer: BCBS of TX PPO	$61.56
Rate for Payer: Cash Price	$104.66
Rate for Payer: Cigna Medicaid	$110.82
Rate for Payer: Molina CHIP/Medicaid	$110.82
Rate for Payer: Multiplan Auto	$100.04
Rate for Payer: Multiplan Commercial	$100.04
Rate for Payer: Multiplan Workers Comp	$100.04
Rate for Payer: Parkland Medicaid	$110.82
Rate for Payer: Scott and White EPO/PPO	$76.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.82
Rate for Payer: Superior Health Plan EPO	$20.93

PINNACLE STD IK 6FR 10CM .035 MINI GW 1BX=10EA

Facility

$153.91

Service Code	HCPCS C1893
Hospital Charge Code	993711
Hospital Revenue Code	272
Min. Negotiated Rate	$13.85
Max. Negotiated Rate	$110.82
Rate for Payer: Amerigroup CHIP/Medicaid	$13.85
Rate for Payer: BCBS of TX Blue Advantage	$46.17
Rate for Payer: BCBS of TX Blue Essentials	$55.41
Rate for Payer: BCBS of TX PPO	$61.56
Rate for Payer: Cash Price	$104.66
Rate for Payer: Cigna Medicaid	$110.82
Rate for Payer: Molina CHIP/Medicaid	$110.82
Rate for Payer: Multiplan Auto	$100.04
Rate for Payer: Multiplan Commercial	$100.04
Rate for Payer: Multiplan Workers Comp	$100.04
Rate for Payer: Parkland Medicaid	$110.82
Rate for Payer: Scott and White EPO/PPO	$76.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.82
Rate for Payer: Superior Health Plan EPO	$20.93

PINNACLE STD IK 6FR 25CM NO WIRE

Facility

$103.15

Service Code	HCPCS C1887
Hospital Charge Code	992456
Hospital Revenue Code	272
Min. Negotiated Rate	$9.28
Max. Negotiated Rate	$74.27
Rate for Payer: Amerigroup CHIP/Medicaid	$9.28
Rate for Payer: BCBS of TX Blue Advantage	$30.95
Rate for Payer: BCBS of TX Blue Essentials	$37.13
Rate for Payer: BCBS of TX PPO	$41.26
Rate for Payer: Cash Price	$70.14
Rate for Payer: Cigna Medicaid	$74.27
Rate for Payer: Molina CHIP/Medicaid	$74.27
Rate for Payer: Multiplan Auto	$67.05
Rate for Payer: Multiplan Commercial	$67.05
Rate for Payer: Multiplan Workers Comp	$67.05
Rate for Payer: Parkland Medicaid	$74.27
Rate for Payer: Scott and White EPO/PPO	$51.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.27
Rate for Payer: Superior Health Plan EPO	$14.03

PINNACLE STD IK 6FR 25CM NO WIRE

Facility

$103.15

Service Code	HCPCS C1887
Hospital Charge Code	992456
Hospital Revenue Code	272
Rate for Payer: Cash Price	$70.14

PIN, RIGIDFIX CROSS FEMORAL KIT FOR FIXATION

Facility

$3,759.00

Service Code	HCPCS C1713
Hospital Charge Code	132899
Hospital Revenue Code	278
Min. Negotiated Rate	$939.75
Max. Negotiated Rate	$1,879.50
Rate for Payer: Cash Price	$2,556.12
Rate for Payer: Cigna Commercial	$939.75
Rate for Payer: Multiplan Auto	$1,879.50
Rate for Payer: Multiplan Commercial	$1,879.50
Rate for Payer: Multiplan Workers Comp	$1,879.50
Rate for Payer: Scott and White EPO/PPO	$1,879.50

PIN, RIGIDFIX CROSS FEMORAL KIT FOR FIXATION

Facility

$3,759.00

Service Code	HCPCS C1713
Hospital Charge Code	132899
Hospital Revenue Code	278
Min. Negotiated Rate	$338.31
Max. Negotiated Rate	$2,706.48
Rate for Payer: Amerigroup CHIP/Medicaid	$338.31
Rate for Payer: BCBS of TX Blue Advantage	$1,127.70
Rate for Payer: BCBS of TX Blue Essentials	$1,353.24
Rate for Payer: BCBS of TX PPO	$1,503.60
Rate for Payer: Cash Price	$2,556.12
Rate for Payer: Cigna Medicaid	$2,706.48
Rate for Payer: Molina CHIP/Medicaid	$2,706.48
Rate for Payer: Multiplan Auto	$1,879.50
Rate for Payer: Multiplan Commercial	$1,879.50
Rate for Payer: Multiplan Workers Comp	$1,879.50
Rate for Payer: Parkland Medicaid	$2,706.48
Rate for Payer: Scott and White EPO/PPO	$1,879.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,706.48
Rate for Payer: Superior Health Plan EPO	$511.22

PIN TEMP FIX ACF 300-1005

Facility

$602.00

Service Code	HCPCS C1713
Hospital Charge Code	8556473
Hospital Revenue Code	278
Min. Negotiated Rate	$54.18
Max. Negotiated Rate	$433.44
Rate for Payer: Amerigroup CHIP/Medicaid	$54.18
Rate for Payer: BCBS of TX Blue Advantage	$180.60
Rate for Payer: BCBS of TX Blue Essentials	$216.72
Rate for Payer: BCBS of TX PPO	$240.80
Rate for Payer: Cash Price	$409.36
Rate for Payer: Cigna Medicaid	$433.44
Rate for Payer: Molina CHIP/Medicaid	$433.44
Rate for Payer: Multiplan Auto	$301.00
Rate for Payer: Multiplan Commercial	$301.00
Rate for Payer: Multiplan Workers Comp	$301.00
Rate for Payer: Parkland Medicaid	$433.44
Rate for Payer: Scott and White EPO/PPO	$301.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$433.44
Rate for Payer: Superior Health Plan EPO	$81.87

PIN TEMP FIX ACF 300-1005

Facility

$602.00

Service Code	HCPCS C1713
Hospital Charge Code	8556473
Hospital Revenue Code	278
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$301.00
Rate for Payer: Cash Price	$409.36
Rate for Payer: Cigna Commercial	$150.50
Rate for Payer: Multiplan Auto	$301.00
Rate for Payer: Multiplan Commercial	$301.00
Rate for Payer: Multiplan Workers Comp	$301.00
Rate for Payer: Scott and White EPO/PPO	$301.00

PIN THRD TIP STNM COMP SHOULDER

Facility

$1,157.00

Service Code	HCPCS C1713
Hospital Charge Code	144858
Hospital Revenue Code	278
Min. Negotiated Rate	$104.13
Max. Negotiated Rate	$833.04
Rate for Payer: Amerigroup CHIP/Medicaid	$104.13
Rate for Payer: BCBS of TX Blue Advantage	$347.10
Rate for Payer: BCBS of TX Blue Essentials	$416.52
Rate for Payer: BCBS of TX PPO	$462.80
Rate for Payer: Cash Price	$786.76
Rate for Payer: Cigna Medicaid	$833.04
Rate for Payer: Molina CHIP/Medicaid	$833.04
Rate for Payer: Multiplan Auto	$578.50
Rate for Payer: Multiplan Commercial	$578.50
Rate for Payer: Multiplan Workers Comp	$578.50
Rate for Payer: Parkland Medicaid	$833.04
Rate for Payer: Scott and White EPO/PPO	$578.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$833.04
Rate for Payer: Superior Health Plan EPO	$157.35

PIN THRD TIP STNM COMP SHOULDER

Facility

$1,157.00

Service Code	HCPCS C1713
Hospital Charge Code	144858
Hospital Revenue Code	278
Min. Negotiated Rate	$289.25
Max. Negotiated Rate	$578.50
Rate for Payer: Cash Price	$786.76
Rate for Payer: Cigna Commercial	$289.25
Rate for Payer: Multiplan Auto	$578.50
Rate for Payer: Multiplan Commercial	$578.50
Rate for Payer: Multiplan Workers Comp	$578.50
Rate for Payer: Scott and White EPO/PPO	$578.50

PIN TYPE II -- DHF

Facility

$4,574.00

Service Code	HCPCS C1713
Hospital Charge Code	81336364
Hospital Revenue Code	278
Min. Negotiated Rate	$1,143.50
Max. Negotiated Rate	$2,287.00
Rate for Payer: Cash Price	$3,110.32
Rate for Payer: Cigna Commercial	$1,143.50
Rate for Payer: Multiplan Auto	$2,287.00
Rate for Payer: Multiplan Commercial	$2,287.00
Rate for Payer: Multiplan Workers Comp	$2,287.00
Rate for Payer: Scott and White EPO/PPO	$2,287.00

PIN TYPE II -- DHF

Facility

$4,574.00

Service Code	HCPCS C1713
Hospital Charge Code	81336364
Hospital Revenue Code	278
Min. Negotiated Rate	$411.66
Max. Negotiated Rate	$3,293.28
Rate for Payer: Amerigroup CHIP/Medicaid	$411.66
Rate for Payer: BCBS of TX Blue Advantage	$1,372.20
Rate for Payer: BCBS of TX Blue Essentials	$1,646.64
Rate for Payer: BCBS of TX PPO	$1,829.60
Rate for Payer: Cash Price	$3,110.32
Rate for Payer: Cigna Medicaid	$3,293.28
Rate for Payer: Molina CHIP/Medicaid	$3,293.28
Rate for Payer: Multiplan Auto	$2,287.00
Rate for Payer: Multiplan Commercial	$2,287.00
Rate for Payer: Multiplan Workers Comp	$2,287.00
Rate for Payer: Parkland Medicaid	$3,293.28
Rate for Payer: Scott and White EPO/PPO	$2,287.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,293.28
Rate for Payer: Superior Health Plan EPO	$622.06

pioglitazone 15 mg Tab

Facility

$8.00

Service Code	NDC 33342005407
Hospital Charge Code	777629110
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

pioglitazone 15 mg Tab

Facility

$8.00

Service Code	NDC 33342005407
Hospital Charge Code	777629110
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

piperacillin-tazobactam 3.375g

Facility

$128.00

Service Code	HCPCS J2543
Hospital Charge Code	78398905
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

piperacillin-tazobactam 3.375g

Facility

$128.00

Service Code	HCPCS J2543
Hospital Charge Code	78398905
Hospital Revenue Code	636
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$3.35
Rate for Payer: BCBS of TX Blue Essentials	$4.02
Rate for Payer: BCBS of TX PPO	$4.46
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

Piperacillin-tazobactam 3.375gm

Facility

$128.17

Service Code	HCPCS J2543
Hospital Charge Code	79488971
Hospital Revenue Code	636
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.35
Rate for Payer: BCBS of TX Blue Essentials	$4.02
Rate for Payer: BCBS of TX PPO	$4.46
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

Piperacillin-tazobactam 3.375gm

Facility

$128.17

Service Code	HCPCS J2543
Hospital Charge Code	79488971
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

piperacillin-tazobactam 4 g-0.5 g Pow

Facility

$128.17

Service Code	HCPCS J2543
Hospital Charge Code	78398949
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

piperacillin-tazobactam 4 g-0.5 g Pow

Facility

$128.17

Service Code	HCPCS J2543
Hospital Charge Code	78398949
Hospital Revenue Code	636
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.35
Rate for Payer: BCBS of TX Blue Essentials	$4.02
Rate for Payer: BCBS of TX PPO	$4.46
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

pipetts

Facility

$0.30

Hospital Charge Code	993281
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.20

pipetts

Facility

$0.30

Hospital Charge Code	993281
Hospital Revenue Code	270
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.22
Rate for Payer: Amerigroup CHIP/Medicaid	$0.03
Rate for Payer: BCBS of TX Blue Advantage	$0.09
Rate for Payer: BCBS of TX Blue Essentials	$0.11
Rate for Payer: BCBS of TX PPO	$0.12
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna Medicaid	$0.22
Rate for Payer: Molina CHIP/Medicaid	$0.22
Rate for Payer: Multiplan Auto	$0.20
Rate for Payer: Multiplan Commercial	$0.20
Rate for Payer: Multiplan Workers Comp	$0.20
Rate for Payer: Parkland Medicaid	$0.22
Rate for Payer: Scott and White EPO/PPO	$0.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.22
Rate for Payer: Superior Health Plan EPO	$0.04

PKG.AGG. PLUS SHAVER BLADE SMALL JOINT

Facility

$239.49

Hospital Charge Code	993154
Hospital Revenue Code	270
Rate for Payer: Cash Price	$162.85

PKG.AGG. PLUS SHAVER BLADE SMALL JOINT

Facility

$239.49

Hospital Charge Code	993154
Hospital Revenue Code	270
Min. Negotiated Rate	$21.55
Max. Negotiated Rate	$172.43
Rate for Payer: Amerigroup CHIP/Medicaid	$21.55
Rate for Payer: BCBS of TX Blue Advantage	$71.85
Rate for Payer: BCBS of TX Blue Essentials	$86.22
Rate for Payer: BCBS of TX PPO	$95.80
Rate for Payer: Cash Price	$162.85
Rate for Payer: Cigna Medicaid	$172.43
Rate for Payer: Molina CHIP/Medicaid	$172.43
Rate for Payer: Multiplan Auto	$155.67
Rate for Payer: Multiplan Commercial	$155.67
Rate for Payer: Multiplan Workers Comp	$155.67
Rate for Payer: Parkland Medicaid	$172.43
Rate for Payer: Scott and White EPO/PPO	$119.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$172.43
Rate for Payer: Superior Health Plan EPO	$32.57

PKG. HOODED ABRASION BUR SMALL JOINT F

Facility

$2,316.27

Hospital Charge Code	993157
Hospital Revenue Code	270
Min. Negotiated Rate	$208.46
Max. Negotiated Rate	$1,667.71
Rate for Payer: Amerigroup CHIP/Medicaid	$208.46
Rate for Payer: BCBS of TX Blue Advantage	$694.88
Rate for Payer: BCBS of TX Blue Essentials	$833.86
Rate for Payer: BCBS of TX PPO	$926.51
Rate for Payer: Cash Price	$1,575.06
Rate for Payer: Cigna Medicaid	$1,667.71
Rate for Payer: Molina CHIP/Medicaid	$1,667.71
Rate for Payer: Multiplan Auto	$1,505.58
Rate for Payer: Multiplan Commercial	$1,505.58
Rate for Payer: Multiplan Workers Comp	$1,505.58
Rate for Payer: Parkland Medicaid	$1,667.71
Rate for Payer: Scott and White EPO/PPO	$1,158.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,667.71
Rate for Payer: Superior Health Plan EPO	$315.01

Know your out-of-pocket cost for care.

All Charges