White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$6,828.51
Max. Negotiated Rate	$13,657.02
Rate for Payer: Cash Price	$18,573.55
Rate for Payer: Cigna Commercial	$6,828.51
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: Scott and White EPO/PPO	$13,657.02

PML,24,ADULT,FLL-MLL,PG

Facility

$40.24

Hospital Charge Code	993114
Hospital Revenue Code	270
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$28.97
Rate for Payer: Amerigroup CHIP/Medicaid	$3.62
Rate for Payer: BCBS of TX Blue Advantage	$12.07
Rate for Payer: BCBS of TX Blue Essentials	$14.49
Rate for Payer: BCBS of TX PPO	$16.10
Rate for Payer: Cash Price	$27.36
Rate for Payer: Cigna Medicaid	$28.97
Rate for Payer: Molina CHIP/Medicaid	$28.97
Rate for Payer: Multiplan Auto	$26.16
Rate for Payer: Multiplan Commercial	$26.16
Rate for Payer: Multiplan Workers Comp	$26.16
Rate for Payer: Parkland Medicaid	$28.97
Rate for Payer: Scott and White EPO/PPO	$20.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.97
Rate for Payer: Superior Health Plan EPO	$5.47

PML,24,ADULT,FLL-MLL,PG

Facility

$40.24

Hospital Charge Code	993114
Hospital Revenue Code	270
Rate for Payer: Cash Price	$27.36

PM MRI ASSURITY 1272

Facility

$35,685.24

Service Code	HCPCS C1785
Hospital Charge Code	31298450466
Hospital Revenue Code	275
Min. Negotiated Rate	$8,921.31
Max. Negotiated Rate	$17,842.62
Rate for Payer: Cash Price	$24,265.96
Rate for Payer: Cigna Commercial	$8,921.31
Rate for Payer: Multiplan Auto	$17,842.62
Rate for Payer: Multiplan Commercial	$17,842.62
Rate for Payer: Multiplan Workers Comp	$17,842.62
Rate for Payer: Scott and White EPO/PPO	$17,842.62

PM MRI ASSURITY 1272

Facility

$35,685.24

Service Code	HCPCS C1785
Hospital Charge Code	31298450466
Hospital Revenue Code	275
Min. Negotiated Rate	$3,211.67
Max. Negotiated Rate	$25,693.37
Rate for Payer: Amerigroup CHIP/Medicaid	$3,211.67
Rate for Payer: BCBS of TX Blue Advantage	$10,705.57
Rate for Payer: BCBS of TX Blue Essentials	$12,846.69
Rate for Payer: BCBS of TX PPO	$14,274.10
Rate for Payer: Cash Price	$24,265.96
Rate for Payer: Cigna Medicaid	$25,693.37
Rate for Payer: Molina CHIP/Medicaid	$25,693.37
Rate for Payer: Multiplan Auto	$17,842.62
Rate for Payer: Multiplan Commercial	$17,842.62
Rate for Payer: Multiplan Workers Comp	$17,842.62
Rate for Payer: Parkland Medicaid	$25,693.37
Rate for Payer: Scott and White EPO/PPO	$17,842.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,693.37
Rate for Payer: Superior Health Plan EPO	$4,853.19

PM MRI ASSURITY 1272

Facility

$35,685.24

Service Code	HCPCS C1785
Hospital Charge Code	8450466
Hospital Revenue Code	275
Min. Negotiated Rate	$8,921.31
Max. Negotiated Rate	$17,842.62
Rate for Payer: Cash Price	$24,265.96
Rate for Payer: Cigna Commercial	$8,921.31
Rate for Payer: Multiplan Auto	$17,842.62
Rate for Payer: Multiplan Commercial	$17,842.62
Rate for Payer: Multiplan Workers Comp	$17,842.62
Rate for Payer: Scott and White EPO/PPO	$17,842.62

PM MRI ASSURITY 1272

Facility

$35,685.24

Service Code	HCPCS C1785
Hospital Charge Code	8450466
Hospital Revenue Code	275
Min. Negotiated Rate	$3,211.67
Max. Negotiated Rate	$25,693.37
Rate for Payer: Amerigroup CHIP/Medicaid	$3,211.67
Rate for Payer: BCBS of TX Blue Advantage	$10,705.57
Rate for Payer: BCBS of TX Blue Essentials	$12,846.69
Rate for Payer: BCBS of TX PPO	$14,274.10
Rate for Payer: Cash Price	$24,265.96
Rate for Payer: Cigna Medicaid	$25,693.37
Rate for Payer: Molina CHIP/Medicaid	$25,693.37
Rate for Payer: Multiplan Auto	$17,842.62
Rate for Payer: Multiplan Commercial	$17,842.62
Rate for Payer: Multiplan Workers Comp	$17,842.62
Rate for Payer: Parkland Medicaid	$25,693.37
Rate for Payer: Scott and White EPO/PPO	$17,842.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,693.37
Rate for Payer: Superior Health Plan EPO	$4,853.19

PNEUMOCLEAR TUBING

Facility

$85.81

Hospital Charge Code	992691
Hospital Revenue Code	272
Min. Negotiated Rate	$7.72
Max. Negotiated Rate	$61.78
Rate for Payer: Amerigroup CHIP/Medicaid	$7.72
Rate for Payer: BCBS of TX Blue Advantage	$25.74
Rate for Payer: BCBS of TX Blue Essentials	$30.89
Rate for Payer: BCBS of TX PPO	$34.32
Rate for Payer: Cash Price	$58.35
Rate for Payer: Cigna Medicaid	$61.78
Rate for Payer: Molina CHIP/Medicaid	$61.78
Rate for Payer: Multiplan Auto	$55.78
Rate for Payer: Multiplan Commercial	$55.78
Rate for Payer: Multiplan Workers Comp	$55.78
Rate for Payer: Parkland Medicaid	$61.78
Rate for Payer: Scott and White EPO/PPO	$42.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$61.78
Rate for Payer: Superior Health Plan EPO	$11.67

PNEUMOCLEAR TUBING

Facility

$85.81

Hospital Charge Code	992691
Hospital Revenue Code	272
Rate for Payer: Cash Price	$58.35

pneumococcal 23-polyvalent vaccine Inj Soln 0.5 mL

Facility

$307.40

Service Code	HCPCS 90732
Hospital Charge Code	77764479
Hospital Revenue Code	636
Min. Negotiated Rate	$27.67
Max. Negotiated Rate	$226.23
Rate for Payer: Amerigroup CHIP/Medicaid	$27.67
Rate for Payer: BCBS of TX Blue Advantage	$169.97
Rate for Payer: BCBS of TX Blue Essentials	$203.96
Rate for Payer: BCBS of TX PPO	$226.23
Rate for Payer: Cash Price	$209.03
Rate for Payer: Cash Price	$209.03
Rate for Payer: Cigna Medicaid	$221.33
Rate for Payer: Molina CHIP/Medicaid	$221.33
Rate for Payer: Multiplan Auto	$199.81
Rate for Payer: Multiplan Commercial	$199.81
Rate for Payer: Multiplan Workers Comp	$199.81
Rate for Payer: Parkland Medicaid	$221.33
Rate for Payer: Scott and White EPO/PPO	$153.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$221.33
Rate for Payer: Superior Health Plan EPO	$41.81

pneumococcal 23-polyvalent vaccine Inj Soln 0.5 mL

Facility

$307.40

Service Code	HCPCS 90732
Hospital Charge Code	77764479
Hospital Revenue Code	636
Min. Negotiated Rate	$76.85
Max. Negotiated Rate	$153.70
Rate for Payer: Cash Price	$209.03
Rate for Payer: Cigna Commercial	$76.85
Rate for Payer: Scott and White EPO/PPO	$153.70

PNEUMOTHORAX W CC

Facility

$20,368.00

Service Code	MSDRG 200
Min. Negotiated Rate	$9,243.28
Max. Negotiated Rate	$20,368.00
Rate for Payer: BCBS of TX Blue Advantage	$9,243.28
Rate for Payer: BCBS of TX Blue Essentials	$11,090.86
Rate for Payer: BCBS of TX PPO	$12,323.66

PNEUMOTHORAX WITH CC

Facility

$20,368.00

Service Code	MSDRG 200
Min. Negotiated Rate	$9,243.28
Max. Negotiated Rate	$20,368.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,816.88
Rate for Payer: Amerigroup Medicare	$12,816.88
Rate for Payer: BCBS of TX Medicare	$12,816.88
Rate for Payer: Cigna Commercial	$14,158.98
Rate for Payer: Cigna Medicare	$12,816.88
Rate for Payer: Employer Direct Commercial	$12,816.88
Rate for Payer: Humana Medicare/TRICARE	$12,816.88
Rate for Payer: Molina Dual Medicare/Medicaid	$12,816.88
Rate for Payer: Molina Medicare	$12,816.88
Rate for Payer: Multiplan Auto	$20,368.00
Rate for Payer: Multiplan Commercial	$20,368.00
Rate for Payer: Multiplan Workers Comp	$20,368.00
Rate for Payer: Scott and White EPO/PPO	$9,380.00
Rate for Payer: Scott and White Medicare	$12,816.88
Rate for Payer: Superior Health Plan EPO	$12,816.88
Rate for Payer: Superior Health Plan Medicare	$12,816.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,816.88
Rate for Payer: Universal American Medicare	$12,816.88
Rate for Payer: Wellcare Medicare	$12,816.88
Rate for Payer: Wellmed Medicare	$12,816.88

PNEUMOTHORAX WITH MCC

Facility

$33,413.40

Service Code	MSDRG 199
Min. Negotiated Rate	$15,332.08
Max. Negotiated Rate	$33,413.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,689.23
Rate for Payer: Amerigroup Medicare	$17,689.23
Rate for Payer: BCBS of TX Medicare	$17,689.23
Rate for Payer: Cigna Commercial	$22,721.61
Rate for Payer: Cigna Medicare	$17,689.23
Rate for Payer: Employer Direct Commercial	$17,689.23
Rate for Payer: Humana Medicare/TRICARE	$17,689.23
Rate for Payer: Molina Dual Medicare/Medicaid	$17,689.23
Rate for Payer: Molina Medicare	$17,689.23
Rate for Payer: Multiplan Auto	$33,413.40
Rate for Payer: Multiplan Commercial	$33,413.40
Rate for Payer: Multiplan Workers Comp	$33,413.40
Rate for Payer: Scott and White EPO/PPO	$15,387.75
Rate for Payer: Scott and White Medicare	$17,689.23
Rate for Payer: Superior Health Plan EPO	$17,689.23
Rate for Payer: Superior Health Plan Medicare	$17,689.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,689.23
Rate for Payer: Universal American Medicare	$17,689.23
Rate for Payer: Wellcare Medicare	$17,689.23
Rate for Payer: Wellmed Medicare	$17,689.23

PNEUMOTHORAX WITHOUT CC/MCC

Facility

$13,830.10

Service Code	MSDRG 201
Min. Negotiated Rate	$6,010.54
Max. Negotiated Rate	$13,830.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,001.07
Rate for Payer: Amerigroup Medicare	$10,001.07
Rate for Payer: BCBS of TX Medicare	$10,001.07
Rate for Payer: Cigna Commercial	$9,210.49
Rate for Payer: Cigna Medicare	$10,001.07
Rate for Payer: Employer Direct Commercial	$10,001.07
Rate for Payer: Humana Medicare/TRICARE	$10,001.07
Rate for Payer: Molina Dual Medicare/Medicaid	$10,001.07
Rate for Payer: Molina Medicare	$10,001.07
Rate for Payer: Multiplan Auto	$13,830.10
Rate for Payer: Multiplan Commercial	$13,830.10
Rate for Payer: Multiplan Workers Comp	$13,830.10
Rate for Payer: Scott and White EPO/PPO	$6,369.12
Rate for Payer: Scott and White Medicare	$10,001.07
Rate for Payer: Superior Health Plan EPO	$10,001.07
Rate for Payer: Superior Health Plan Medicare	$10,001.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,001.07
Rate for Payer: Universal American Medicare	$10,001.07
Rate for Payer: Wellcare Medicare	$10,001.07
Rate for Payer: Wellmed Medicare	$10,001.07

PNEUMOTHORAX W MCC

Facility

$33,413.40

Service Code	MSDRG 199
Min. Negotiated Rate	$15,332.08
Max. Negotiated Rate	$33,413.40
Rate for Payer: BCBS of TX Blue Advantage	$15,332.08
Rate for Payer: BCBS of TX Blue Essentials	$18,396.71
Rate for Payer: BCBS of TX PPO	$20,441.58

PNEUMOTHORAX W/O CC/MCC

Facility

$13,830.10

Service Code	MSDRG 201
Min. Negotiated Rate	$6,010.54
Max. Negotiated Rate	$13,830.10
Rate for Payer: BCBS of TX Blue Advantage	$6,010.54
Rate for Payer: BCBS of TX Blue Essentials	$7,211.95
Rate for Payer: BCBS of TX PPO	$8,013.59

POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC

Facility

$28,927.50

Service Code	MSDRG 917
Min. Negotiated Rate	$12,673.82
Max. Negotiated Rate	$28,927.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,254.92
Rate for Payer: Amerigroup Medicare	$16,254.92
Rate for Payer: BCBS of TX Medicare	$16,254.92
Rate for Payer: Cigna Commercial	$20,200.99
Rate for Payer: Cigna Medicare	$16,254.92
Rate for Payer: Employer Direct Commercial	$16,254.92
Rate for Payer: Humana Medicare/TRICARE	$16,254.92
Rate for Payer: Molina Dual Medicare/Medicaid	$16,254.92
Rate for Payer: Molina Medicare	$16,254.92
Rate for Payer: Multiplan Auto	$28,927.50
Rate for Payer: Multiplan Commercial	$28,927.50
Rate for Payer: Multiplan Workers Comp	$28,927.50
Rate for Payer: Scott and White EPO/PPO	$13,321.88
Rate for Payer: Scott and White Medicare	$16,254.92
Rate for Payer: Superior Health Plan EPO	$16,254.92
Rate for Payer: Superior Health Plan Medicare	$16,254.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,254.92
Rate for Payer: Universal American Medicare	$16,254.92
Rate for Payer: Wellcare Medicare	$16,254.92
Rate for Payer: Wellmed Medicare	$16,254.92

POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC

Facility

$15,536.30

Service Code	MSDRG 918
Min. Negotiated Rate	$6,696.82
Max. Negotiated Rate	$15,536.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,041.79
Rate for Payer: Amerigroup Medicare	$11,041.79
Rate for Payer: BCBS of TX Medicare	$11,041.79
Rate for Payer: Cigna Commercial	$11,039.45
Rate for Payer: Cigna Medicare	$11,041.79
Rate for Payer: Employer Direct Commercial	$11,041.79
Rate for Payer: Humana Medicare/TRICARE	$11,041.79
Rate for Payer: Molina Dual Medicare/Medicaid	$11,041.79
Rate for Payer: Molina Medicare	$11,041.79
Rate for Payer: Multiplan Auto	$15,536.30
Rate for Payer: Multiplan Commercial	$15,536.30
Rate for Payer: Multiplan Workers Comp	$15,536.30
Rate for Payer: Scott and White EPO/PPO	$7,154.88
Rate for Payer: Scott and White Medicare	$11,041.79
Rate for Payer: Superior Health Plan EPO	$11,041.79
Rate for Payer: Superior Health Plan Medicare	$11,041.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,041.79
Rate for Payer: Universal American Medicare	$11,041.79
Rate for Payer: Wellcare Medicare	$11,041.79
Rate for Payer: Wellmed Medicare	$11,041.79

POISONING OF MEDICINAL AGENTS

Facility

$1,603.05

Service Code	APR-DRG 8121
Min. Negotiated Rate	$1,511.41
Max. Negotiated Rate	$1,603.05
Rate for Payer: Amerigroup CHIP/Medicaid	$1,511.41
Rate for Payer: Cigna Medicaid	$1,511.41
Rate for Payer: Molina CHIP/Medicaid	$1,511.41
Rate for Payer: Parkland Medicaid	$1,511.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,603.05

POISONING OF MEDICINAL AGENTS

Facility

$3,598.01

Service Code	APR-DRG 8123
Min. Negotiated Rate	$3,392.33
Max. Negotiated Rate	$3,598.01
Rate for Payer: Amerigroup CHIP/Medicaid	$3,392.33
Rate for Payer: Cigna Medicaid	$3,392.33
Rate for Payer: Molina CHIP/Medicaid	$3,392.33
Rate for Payer: Parkland Medicaid	$3,392.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,598.01

POISONING OF MEDICINAL AGENTS

Facility

$7,429.49

Service Code	APR-DRG 8124
Min. Negotiated Rate	$7,004.79
Max. Negotiated Rate	$7,429.49
Rate for Payer: Amerigroup CHIP/Medicaid	$7,004.79
Rate for Payer: Cigna Medicaid	$7,004.79
Rate for Payer: Molina CHIP/Medicaid	$7,004.79
Rate for Payer: Parkland Medicaid	$7,004.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,429.49

POISONING OF MEDICINAL AGENTS

Facility

$2,389.49

Service Code	APR-DRG 8122
Min. Negotiated Rate	$2,252.90
Max. Negotiated Rate	$2,389.49
Rate for Payer: Amerigroup CHIP/Medicaid	$2,252.90
Rate for Payer: Cigna Medicaid	$2,252.90
Rate for Payer: Molina CHIP/Medicaid	$2,252.90
Rate for Payer: Parkland Medicaid	$2,252.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,389.49

POISONING & TOXIC EFFECTS OF DRUGS W MCC

Facility

$28,927.50

Service Code	MSDRG 917
Min. Negotiated Rate	$12,673.82
Max. Negotiated Rate	$28,927.50
Rate for Payer: BCBS of TX Blue Advantage	$12,673.82
Rate for Payer: BCBS of TX Blue Essentials	$15,207.11
Rate for Payer: BCBS of TX PPO	$16,897.44

POISONING & TOXIC EFFECTS OF DRUGS W/O MCC

Facility

$15,536.30

Service Code	MSDRG 918
Min. Negotiated Rate	$6,696.82
Max. Negotiated Rate	$15,536.30
Rate for Payer: BCBS of TX Blue Advantage	$6,696.82
Rate for Payer: BCBS of TX Blue Essentials	$8,035.41
Rate for Payer: BCBS of TX PPO	$8,928.57

Know your out-of-pocket cost for care.

All Charges