White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PLATE VOLAR 10 HOLE SHORT

Facility

$7,180.00

Service Code	HCPCS C1776
Hospital Charge Code	141238
Hospital Revenue Code	278
Min. Negotiated Rate	$1,795.00
Max. Negotiated Rate	$3,590.00
Rate for Payer: Cash Price	$4,882.40
Rate for Payer: Cigna Commercial	$1,795.00
Rate for Payer: Multiplan Auto	$3,590.00
Rate for Payer: Multiplan Commercial	$3,590.00
Rate for Payer: Multiplan Workers Comp	$3,590.00
Rate for Payer: Scott and White EPO/PPO	$3,590.00

PLATE VOLAR 10 HOLE SHORT

Facility

$7,180.00

Service Code	HCPCS C1776
Hospital Charge Code	141238
Hospital Revenue Code	278
Min. Negotiated Rate	$646.20
Max. Negotiated Rate	$5,169.60
Rate for Payer: Amerigroup CHIP/Medicaid	$646.20
Rate for Payer: BCBS of TX Blue Advantage	$2,154.00
Rate for Payer: BCBS of TX Blue Essentials	$2,584.80
Rate for Payer: BCBS of TX PPO	$2,872.00
Rate for Payer: Cash Price	$4,882.40
Rate for Payer: Cigna Medicaid	$5,169.60
Rate for Payer: Molina CHIP/Medicaid	$5,169.60
Rate for Payer: Multiplan Auto	$3,590.00
Rate for Payer: Multiplan Commercial	$3,590.00
Rate for Payer: Multiplan Workers Comp	$3,590.00
Rate for Payer: Parkland Medicaid	$5,169.60
Rate for Payer: Scott and White EPO/PPO	$3,590.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,169.60
Rate for Payer: Superior Health Plan EPO	$976.48

PLC CATH ART 1ST ORDR

Facility

$2,418.00

Service Code	HCPCS 36215
Hospital Charge Code	4617835
Hospital Revenue Code	361
Min. Negotiated Rate	$217.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$217.62
Rate for Payer: BCBS of TX Blue Advantage	$725.40
Rate for Payer: BCBS of TX Blue Essentials	$870.48
Rate for Payer: BCBS of TX PPO	$967.20
Rate for Payer: Cash Price	$1,644.24
Rate for Payer: Cash Price	$1,644.24
Rate for Payer: Cigna Medicaid	$1,740.96
Rate for Payer: Molina CHIP/Medicaid	$1,740.96
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	$1,740.96
Rate for Payer: Scott and White EPO/PPO	$1,209.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,740.96
Rate for Payer: Superior Health Plan EPO	$328.85

PLC CATH ART 1ST ORDR

Facility

$2,418.00

Service Code	HCPCS 36215
Hospital Charge Code	4617835
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,644.24

PLC CATH EXTRM ARTERY

Facility

$1,270.00

Service Code	HCPCS 36140
Hospital Charge Code	4617860
Hospital Revenue Code	361
Min. Negotiated Rate	$114.30
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$114.30
Rate for Payer: BCBS of TX Blue Advantage	$381.00
Rate for Payer: BCBS of TX Blue Essentials	$457.20
Rate for Payer: BCBS of TX PPO	$508.00
Rate for Payer: Cash Price	$863.60
Rate for Payer: Cash Price	$863.60
Rate for Payer: Cigna Medicaid	$914.40
Rate for Payer: Molina CHIP/Medicaid	$914.40
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	$914.40
Rate for Payer: Scott and White EPO/PPO	$635.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$914.40
Rate for Payer: Superior Health Plan EPO	$172.72

PLC CATH EXTRM ARTERY

Facility

$1,270.00

Service Code	HCPCS 36140
Hospital Charge Code	4617860
Hospital Revenue Code	361
Rate for Payer: Cash Price	$863.60

PLC CATH VEIN 1ST ORDR

Facility

$1,905.00

Service Code	HCPCS 36011
Hospital Charge Code	4616011
Hospital Revenue Code	361
Min. Negotiated Rate	$171.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$171.45
Rate for Payer: BCBS of TX Blue Advantage	$571.50
Rate for Payer: BCBS of TX Blue Essentials	$685.80
Rate for Payer: BCBS of TX PPO	$762.00
Rate for Payer: Cash Price	$1,295.40
Rate for Payer: Cash Price	$1,295.40
Rate for Payer: Cigna Medicaid	$1,371.60
Rate for Payer: Molina CHIP/Medicaid	$1,371.60
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	$1,371.60
Rate for Payer: Scott and White EPO/PPO	$952.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,371.60
Rate for Payer: Superior Health Plan EPO	$259.08

PLC CATH VEIN 1ST ORDR

Facility

$1,905.00

Service Code	HCPCS 36011
Hospital Charge Code	4616011
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,295.40

PLC CATH VEIN 2ND ORDR

Facility

$2,105.00

Service Code	HCPCS 36012
Hospital Charge Code	4616012
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,431.40

PLC CATH VEIN 2ND ORDR

Facility

$2,105.00

Service Code	HCPCS 36012
Hospital Charge Code	4616012
Hospital Revenue Code	361
Min. Negotiated Rate	$189.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$189.45
Rate for Payer: BCBS of TX Blue Advantage	$631.50
Rate for Payer: BCBS of TX Blue Essentials	$757.80
Rate for Payer: BCBS of TX PPO	$842.00
Rate for Payer: Cash Price	$1,431.40
Rate for Payer: Cash Price	$1,431.40
Rate for Payer: Cigna Medicaid	$1,515.60
Rate for Payer: Molina CHIP/Medicaid	$1,515.60
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	$1,515.60
Rate for Payer: Scott and White EPO/PPO	$1,052.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,515.60
Rate for Payer: Superior Health Plan EPO	$286.28

PLC NEPHROSTOMY CATH

Facility

$3,335.00

Service Code	HCPCS 50432
Hospital Charge Code	4610392
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,267.80

PLC NEPHROSTOMY CATH

Facility

$3,335.00

Service Code	HCPCS 50432
Hospital Charge Code	4610392
Hospital Revenue Code	361
Min. Negotiated Rate	$652.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$652.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Amerigroup Medicare	$2,099.91
Rate for Payer: BCBS of TX Blue Advantage	$2,958.49
Rate for Payer: BCBS of TX Blue Essentials	$3,543.10
Rate for Payer: BCBS of TX Medicare	$2,099.91
Rate for Payer: BCBS of TX PPO	$4,464.31
Rate for Payer: Cash Price	$2,267.80
Rate for Payer: Cash Price	$2,267.80
Rate for Payer: Cash Price	$2,267.80
Rate for Payer: Cigna Commercial	$4,438.84
Rate for Payer: Cigna Medicaid	$2,401.20
Rate for Payer: Cigna Medicare	$2,099.91
Rate for Payer: Employer Direct Commercial	$2,099.91
Rate for Payer: Humana Medicare/TRICARE	$2,099.91
Rate for Payer: Molina CHIP/Medicaid	$2,401.20
Rate for Payer: Molina Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Molina Medicare	$2,099.91
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	$2,401.20
Rate for Payer: Scott and White EPO/PPO	$3,446.11
Rate for Payer: Scott and White Medicare	$2,099.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,401.20
Rate for Payer: Superior Health Plan EPO	$2,099.91
Rate for Payer: Superior Health Plan Medicare	$2,099.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,099.91
Rate for Payer: Universal American Medicare	$2,099.91
Rate for Payer: Wellcare Medicare	$2,099.91
Rate for Payer: Wellmed Medicare	$2,099.91

PLEURAL EFFUSION W CC

Facility

$19,872.10

Service Code	MSDRG 187
Min. Negotiated Rate	$9,064.40
Max. Negotiated Rate	$19,872.10
Rate for Payer: BCBS of TX Blue Advantage	$9,064.40
Rate for Payer: BCBS of TX Blue Essentials	$10,876.23
Rate for Payer: BCBS of TX PPO	$12,085.16

PLEURAL EFFUSION WITH CC

Facility

$19,872.10

Service Code	MSDRG 187
Min. Negotiated Rate	$9,064.40
Max. Negotiated Rate	$19,872.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,009.23
Rate for Payer: Amerigroup Medicare	$12,009.23
Rate for Payer: BCBS of TX Medicare	$12,009.23
Rate for Payer: Cigna Commercial	$12,739.61
Rate for Payer: Cigna Medicare	$12,009.23
Rate for Payer: Employer Direct Commercial	$12,009.23
Rate for Payer: Humana Medicare/TRICARE	$12,009.23
Rate for Payer: Molina Dual Medicare/Medicaid	$12,009.23
Rate for Payer: Molina Medicare	$12,009.23
Rate for Payer: Multiplan Auto	$19,872.10
Rate for Payer: Multiplan Commercial	$19,872.10
Rate for Payer: Multiplan Workers Comp	$19,872.10
Rate for Payer: Scott and White EPO/PPO	$9,151.62
Rate for Payer: Scott and White Medicare	$12,009.23
Rate for Payer: Superior Health Plan EPO	$12,009.23
Rate for Payer: Superior Health Plan Medicare	$12,009.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,009.23
Rate for Payer: Universal American Medicare	$12,009.23
Rate for Payer: Wellcare Medicare	$12,009.23
Rate for Payer: Wellmed Medicare	$12,009.23

PLEURAL EFFUSION WITH MCC

Facility

$29,009.20

Service Code	MSDRG 186
Min. Negotiated Rate	$13,359.50
Max. Negotiated Rate	$29,009.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,182.37
Rate for Payer: Amerigroup Medicare	$16,182.37
Rate for Payer: BCBS of TX Medicare	$16,182.37
Rate for Payer: Cigna Commercial	$20,073.48
Rate for Payer: Cigna Medicare	$16,182.37
Rate for Payer: Employer Direct Commercial	$16,182.37
Rate for Payer: Humana Medicare/TRICARE	$16,182.37
Rate for Payer: Molina Dual Medicare/Medicaid	$16,182.37
Rate for Payer: Molina Medicare	$16,182.37
Rate for Payer: Multiplan Auto	$29,009.20
Rate for Payer: Multiplan Commercial	$29,009.20
Rate for Payer: Multiplan Workers Comp	$29,009.20
Rate for Payer: Scott and White EPO/PPO	$13,359.50
Rate for Payer: Scott and White Medicare	$16,182.37
Rate for Payer: Superior Health Plan EPO	$16,182.37
Rate for Payer: Superior Health Plan Medicare	$16,182.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,182.37
Rate for Payer: Universal American Medicare	$16,182.37
Rate for Payer: Wellcare Medicare	$16,182.37
Rate for Payer: Wellmed Medicare	$16,182.37

PLEURAL EFFUSION WITHOUT CC/MCC

Facility

$13,756.00

Service Code	MSDRG 188
Min. Negotiated Rate	$6,335.00
Max. Negotiated Rate	$13,756.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,016.46
Rate for Payer: Amerigroup Medicare	$10,016.46
Rate for Payer: BCBS of TX Medicare	$10,016.46
Rate for Payer: Cigna Commercial	$9,237.54
Rate for Payer: Cigna Medicare	$10,016.46
Rate for Payer: Employer Direct Commercial	$10,016.46
Rate for Payer: Humana Medicare/TRICARE	$10,016.46
Rate for Payer: Molina Dual Medicare/Medicaid	$10,016.46
Rate for Payer: Molina Medicare	$10,016.46
Rate for Payer: Multiplan Auto	$13,756.00
Rate for Payer: Multiplan Commercial	$13,756.00
Rate for Payer: Multiplan Workers Comp	$13,756.00
Rate for Payer: Scott and White EPO/PPO	$6,335.00
Rate for Payer: Scott and White Medicare	$10,016.46
Rate for Payer: Superior Health Plan EPO	$10,016.46
Rate for Payer: Superior Health Plan Medicare	$10,016.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,016.46
Rate for Payer: Universal American Medicare	$10,016.46
Rate for Payer: Wellcare Medicare	$10,016.46
Rate for Payer: Wellmed Medicare	$10,016.46

PLEURAL EFFUSION W MCC

Facility

$29,009.20

Service Code	MSDRG 186
Min. Negotiated Rate	$13,359.50
Max. Negotiated Rate	$29,009.20
Rate for Payer: BCBS of TX Blue Advantage	$13,411.70
Rate for Payer: BCBS of TX Blue Essentials	$16,092.48
Rate for Payer: BCBS of TX PPO	$17,881.23

PLEURAL EFFUSION W/O CC/MCC

Facility

$13,756.00

Service Code	MSDRG 188
Min. Negotiated Rate	$6,335.00
Max. Negotiated Rate	$13,756.00
Rate for Payer: BCBS of TX Blue Advantage	$6,597.92
Rate for Payer: BCBS of TX Blue Essentials	$7,916.74
Rate for Payer: BCBS of TX PPO	$8,796.72

PLS-1007 Merit Prelude7F 13cm

Facility

$227.00

Hospital Charge Code	993904
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$163.44
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$154.36
Rate for Payer: Cigna Medicaid	$163.44
Rate for Payer: Molina CHIP/Medicaid	$163.44
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Parkland Medicaid	$163.44
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.44
Rate for Payer: Superior Health Plan EPO	$30.87

PLS-1007 Merit Prelude7F 13cm

Facility

$227.00

Hospital Charge Code	993904
Hospital Revenue Code	272
Rate for Payer: Cash Price	$154.36

PM ASSURITY MRI PM2272

Facility

$41,414.16

Service Code	HCPCS C1785
Hospital Charge Code	3.1324E+11
Hospital Revenue Code	275
Min. Negotiated Rate	$10,353.54
Max. Negotiated Rate	$20,707.08
Rate for Payer: Cash Price	$28,161.63
Rate for Payer: Cigna Commercial	$10,353.54
Rate for Payer: Multiplan Auto	$20,707.08
Rate for Payer: Multiplan Commercial	$20,707.08
Rate for Payer: Multiplan Workers Comp	$20,707.08
Rate for Payer: Scott and White EPO/PPO	$20,707.08

PM ASSURITY MRI PM2272

Facility

$41,414.16

Service Code	HCPCS C1785
Hospital Charge Code	3.1324E+11
Hospital Revenue Code	275
Min. Negotiated Rate	$3,727.27
Max. Negotiated Rate	$29,818.20
Rate for Payer: Amerigroup CHIP/Medicaid	$3,727.27
Rate for Payer: BCBS of TX Blue Advantage	$12,424.25
Rate for Payer: BCBS of TX Blue Essentials	$14,909.10
Rate for Payer: BCBS of TX PPO	$16,565.66
Rate for Payer: Cash Price	$28,161.63
Rate for Payer: Cigna Medicaid	$29,818.20
Rate for Payer: Molina CHIP/Medicaid	$29,818.20
Rate for Payer: Multiplan Auto	$20,707.08
Rate for Payer: Multiplan Commercial	$20,707.08
Rate for Payer: Multiplan Workers Comp	$20,707.08
Rate for Payer: Parkland Medicaid	$29,818.20
Rate for Payer: Scott and White EPO/PPO	$20,707.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,818.20
Rate for Payer: Superior Health Plan EPO	$5,632.33

PM ASSURITY MRI PM2272

Facility

$41,414.16

Service Code	HCPCS C1785
Hospital Charge Code	40004335
Hospital Revenue Code	275
Min. Negotiated Rate	$10,353.54
Max. Negotiated Rate	$20,707.08
Rate for Payer: Cash Price	$28,161.63
Rate for Payer: Cigna Commercial	$10,353.54
Rate for Payer: Multiplan Auto	$20,707.08
Rate for Payer: Multiplan Commercial	$20,707.08
Rate for Payer: Multiplan Workers Comp	$20,707.08
Rate for Payer: Scott and White EPO/PPO	$20,707.08

PM ASSURITY MRI PM2272

Facility

$41,414.16

Service Code	HCPCS C1785
Hospital Charge Code	40004335
Hospital Revenue Code	275
Min. Negotiated Rate	$3,727.27
Max. Negotiated Rate	$29,818.20
Rate for Payer: Amerigroup CHIP/Medicaid	$3,727.27
Rate for Payer: BCBS of TX Blue Advantage	$12,424.25
Rate for Payer: BCBS of TX Blue Essentials	$14,909.10
Rate for Payer: BCBS of TX PPO	$16,565.66
Rate for Payer: Cash Price	$28,161.63
Rate for Payer: Cigna Medicaid	$29,818.20
Rate for Payer: Molina CHIP/Medicaid	$29,818.20
Rate for Payer: Multiplan Auto	$20,707.08
Rate for Payer: Multiplan Commercial	$20,707.08
Rate for Payer: Multiplan Workers Comp	$20,707.08
Rate for Payer: Parkland Medicaid	$29,818.20
Rate for Payer: Scott and White EPO/PPO	$20,707.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,818.20
Rate for Payer: Superior Health Plan EPO	$5,632.33

PM AZURE XT SR MRI W1SR01 -- DHF

Facility

$27,314.04

Service Code	HCPCS C1785
Hospital Charge Code	40004350
Hospital Revenue Code	275
Min. Negotiated Rate	$2,458.26
Max. Negotiated Rate	$19,666.11
Rate for Payer: Amerigroup CHIP/Medicaid	$2,458.26
Rate for Payer: BCBS of TX Blue Advantage	$8,194.21
Rate for Payer: BCBS of TX Blue Essentials	$9,833.05
Rate for Payer: BCBS of TX PPO	$10,925.62
Rate for Payer: Cash Price	$18,573.55
Rate for Payer: Cigna Medicaid	$19,666.11
Rate for Payer: Molina CHIP/Medicaid	$19,666.11
Rate for Payer: Multiplan Auto	$13,657.02
Rate for Payer: Multiplan Commercial	$13,657.02
Rate for Payer: Multiplan Workers Comp	$13,657.02
Rate for Payer: Parkland Medicaid	$19,666.11
Rate for Payer: Scott and White EPO/PPO	$13,657.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,666.11
Rate for Payer: Superior Health Plan EPO	$3,714.71

Know your out-of-pocket cost for care.

All Charges