White Rock Medical Center

All Charges

Charge

Type

Setting

Price

POLISH, WOOD-STAINLESS STEEL, 32OZ

Facility

$47.88

Hospital Charge Code	993369
Hospital Revenue Code	270
Min. Negotiated Rate	$4.31
Max. Negotiated Rate	$34.47
Rate for Payer: Amerigroup CHIP/Medicaid	$4.31
Rate for Payer: BCBS of TX Blue Advantage	$14.36
Rate for Payer: BCBS of TX Blue Essentials	$17.24
Rate for Payer: BCBS of TX PPO	$19.15
Rate for Payer: Cash Price	$32.56
Rate for Payer: Cigna Medicaid	$34.47
Rate for Payer: Molina CHIP/Medicaid	$34.47
Rate for Payer: Multiplan Auto	$31.12
Rate for Payer: Multiplan Commercial	$31.12
Rate for Payer: Multiplan Workers Comp	$31.12
Rate for Payer: Parkland Medicaid	$34.47
Rate for Payer: Scott and White EPO/PPO	$23.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.47
Rate for Payer: Superior Health Plan EPO	$6.51

POLISH, WOOD-STAINLESS STEEL, 32OZ

Facility

$47.88

Hospital Charge Code	993369
Hospital Revenue Code	270
Rate for Payer: Cash Price	$32.56

polyethylene glycol 3350 Oral Powder-Recon 17 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77765270
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

polyethylene glycol 3350 Oral Powder-Recon 17 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77765270
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

polyethylene glycol 3350 Oral Powder-Recon 238 g

Facility

$51.11

Service Code	HCPCS J3490
Hospital Charge Code	77765378
Hospital Revenue Code	250
Rate for Payer: Cash Price	$34.75

polyethylene glycol 3350 Oral Powder-Recon 238 g

Facility

$51.11

Service Code	HCPCS J3490
Hospital Charge Code	77765378
Hospital Revenue Code	250
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$36.80
Rate for Payer: Amerigroup CHIP/Medicaid	$4.60
Rate for Payer: BCBS of TX Blue Advantage	$15.33
Rate for Payer: BCBS of TX Blue Essentials	$18.40
Rate for Payer: BCBS of TX PPO	$20.44
Rate for Payer: Cash Price	$34.75
Rate for Payer: Cigna Medicaid	$36.80
Rate for Payer: Molina CHIP/Medicaid	$36.80
Rate for Payer: Multiplan Auto	$33.22
Rate for Payer: Multiplan Commercial	$33.22
Rate for Payer: Multiplan Workers Comp	$33.22
Rate for Payer: Parkland Medicaid	$36.80
Rate for Payer: Scott and White EPO/PPO	$25.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.80
Rate for Payer: Superior Health Plan EPO	$6.95

polyethylene glycol 400 Eye lubricant eye drop

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	78364592
Hospital Revenue Code	250
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$18.72
Rate for Payer: Amerigroup CHIP/Medicaid	$2.34
Rate for Payer: BCBS of TX Blue Advantage	$7.80
Rate for Payer: BCBS of TX Blue Essentials	$9.36
Rate for Payer: BCBS of TX PPO	$10.40
Rate for Payer: Cash Price	$17.68
Rate for Payer: Cigna Medicaid	$18.72
Rate for Payer: Molina CHIP/Medicaid	$18.72
Rate for Payer: Multiplan Auto	$16.90
Rate for Payer: Multiplan Commercial	$16.90
Rate for Payer: Multiplan Workers Comp	$16.90
Rate for Payer: Parkland Medicaid	$18.72
Rate for Payer: Scott and White EPO/PPO	$13.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.72
Rate for Payer: Superior Health Plan EPO	$3.54

polyethylene glycol 400 Eye lubricant eye drop

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	78364592
Hospital Revenue Code	250
Rate for Payer: Cash Price	$17.68

Porphobilinogen, Qn, Random Ur SO

Facility

$112.00

Service Code	HCPCS 84110
Hospital Charge Code	1704873
Hospital Revenue Code	301
Rate for Payer: Cash Price	$76.16

Porphobilinogen, Qn, Random Ur SO

Facility

$112.00

Service Code	HCPCS 84110
Hospital Charge Code	1704873
Hospital Revenue Code	301
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$80.64
Rate for Payer: Amerigroup CHIP/Medicaid	$3.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.44
Rate for Payer: Amerigroup Medicare	$8.44
Rate for Payer: BCBS of TX Blue Advantage	$33.60
Rate for Payer: BCBS of TX Blue Essentials	$40.32
Rate for Payer: BCBS of TX Medicare	$8.44
Rate for Payer: BCBS of TX PPO	$44.80
Rate for Payer: Cash Price	$76.16
Rate for Payer: Cash Price	$76.16
Rate for Payer: Cigna Medicaid	$80.64
Rate for Payer: Cigna Medicare	$8.44
Rate for Payer: Employer Direct Commercial	$8.44
Rate for Payer: Humana Medicare/TRICARE	$8.44
Rate for Payer: Molina CHIP/Medicaid	$80.64
Rate for Payer: Molina Dual Medicare/Medicaid	$8.44
Rate for Payer: Molina Medicare	$8.44
Rate for Payer: Multiplan Auto	$72.80
Rate for Payer: Multiplan Commercial	$72.80
Rate for Payer: Multiplan Workers Comp	$72.80
Rate for Payer: Parkland Medicaid	$80.64
Rate for Payer: Scott and White EPO/PPO	$10.55
Rate for Payer: Scott and White Medicare	$8.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$80.64
Rate for Payer: Superior Health Plan EPO	$8.44
Rate for Payer: Superior Health Plan Medicare	$8.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.44
Rate for Payer: Universal American Medicare	$8.44
Rate for Payer: Wellcare Medicare	$8.44
Rate for Payer: Wellmed Medicare	$8.44

Porphyrins, Qn, Random U SO

Facility

$168.00

Service Code	HCPCS 84120
Hospital Charge Code	1740109
Hospital Revenue Code	301
Rate for Payer: Cash Price	$114.24

Porphyrins, Qn, Random U SO

Facility

$168.00

Service Code	HCPCS 84120
Hospital Charge Code	1740109
Hospital Revenue Code	301
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$120.96
Rate for Payer: Amerigroup CHIP/Medicaid	$5.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.71
Rate for Payer: Amerigroup Medicare	$14.71
Rate for Payer: BCBS of TX Blue Advantage	$50.40
Rate for Payer: BCBS of TX Blue Essentials	$60.48
Rate for Payer: BCBS of TX Medicare	$14.71
Rate for Payer: BCBS of TX PPO	$67.20
Rate for Payer: Cash Price	$114.24
Rate for Payer: Cash Price	$114.24
Rate for Payer: Cigna Medicaid	$120.96
Rate for Payer: Cigna Medicare	$14.71
Rate for Payer: Employer Direct Commercial	$14.71
Rate for Payer: Humana Medicare/TRICARE	$14.71
Rate for Payer: Molina CHIP/Medicaid	$120.96
Rate for Payer: Molina Dual Medicare/Medicaid	$14.71
Rate for Payer: Molina Medicare	$14.71
Rate for Payer: Multiplan Auto	$109.20
Rate for Payer: Multiplan Commercial	$109.20
Rate for Payer: Multiplan Workers Comp	$109.20
Rate for Payer: Parkland Medicaid	$120.96
Rate for Payer: Scott and White EPO/PPO	$18.39
Rate for Payer: Scott and White Medicare	$14.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.96
Rate for Payer: Superior Health Plan EPO	$14.71
Rate for Payer: Superior Health Plan Medicare	$14.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.71
Rate for Payer: Universal American Medicare	$14.71
Rate for Payer: Wellcare Medicare	$14.71
Rate for Payer: Wellmed Medicare	$14.71

PORT, IMPLANTABLE, MRI, POWERPORT

Facility

$8,998.87

Service Code	HCPCS C1788
Hospital Charge Code	992878
Hospital Revenue Code	278
Min. Negotiated Rate	$2,249.72
Max. Negotiated Rate	$4,499.44
Rate for Payer: Cash Price	$6,119.23
Rate for Payer: Cigna Commercial	$2,249.72
Rate for Payer: Multiplan Auto	$4,499.44
Rate for Payer: Multiplan Commercial	$4,499.44
Rate for Payer: Multiplan Workers Comp	$4,499.44
Rate for Payer: Scott and White EPO/PPO	$4,499.44

PORT, IMPLANTABLE, MRI, POWERPORT

Facility

$8,998.87

Service Code	HCPCS C1788
Hospital Charge Code	992878
Hospital Revenue Code	278
Min. Negotiated Rate	$809.90
Max. Negotiated Rate	$6,479.19
Rate for Payer: Amerigroup CHIP/Medicaid	$809.90
Rate for Payer: BCBS of TX Blue Advantage	$2,699.66
Rate for Payer: BCBS of TX Blue Essentials	$3,239.59
Rate for Payer: BCBS of TX PPO	$3,599.55
Rate for Payer: Cash Price	$6,119.23
Rate for Payer: Cigna Medicaid	$6,479.19
Rate for Payer: Molina CHIP/Medicaid	$6,479.19
Rate for Payer: Multiplan Auto	$4,499.44
Rate for Payer: Multiplan Commercial	$4,499.44
Rate for Payer: Multiplan Workers Comp	$4,499.44
Rate for Payer: Parkland Medicaid	$6,479.19
Rate for Payer: Scott and White EPO/PPO	$4,499.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,479.19
Rate for Payer: Superior Health Plan EPO	$1,223.85

POST, EXTERNAL FIXATION 1 HOLE

Facility

$668.06

Hospital Charge Code	138308
Hospital Revenue Code	272
Min. Negotiated Rate	$60.13
Max. Negotiated Rate	$481.00
Rate for Payer: Amerigroup CHIP/Medicaid	$60.13
Rate for Payer: BCBS of TX Blue Advantage	$200.42
Rate for Payer: BCBS of TX Blue Essentials	$240.50
Rate for Payer: BCBS of TX PPO	$267.22
Rate for Payer: Cash Price	$454.28
Rate for Payer: Cigna Medicaid	$481.00
Rate for Payer: Molina CHIP/Medicaid	$481.00
Rate for Payer: Multiplan Auto	$434.24
Rate for Payer: Multiplan Commercial	$434.24
Rate for Payer: Multiplan Workers Comp	$434.24
Rate for Payer: Parkland Medicaid	$481.00
Rate for Payer: Scott and White EPO/PPO	$334.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$481.00
Rate for Payer: Superior Health Plan EPO	$90.86

POST, EXTERNAL FIXATION 1 HOLE

Facility

$668.06

Hospital Charge Code	138308
Hospital Revenue Code	272
Rate for Payer: Cash Price	$454.28

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC

Facility

$34,752.90

Service Code	MSDRG 862
Min. Negotiated Rate	$15,718.22
Max. Negotiated Rate	$34,752.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,126.02
Rate for Payer: Amerigroup Medicare	$18,126.02
Rate for Payer: BCBS of TX Medicare	$18,126.02
Rate for Payer: Cigna Commercial	$23,489.26
Rate for Payer: Cigna Medicare	$18,126.02
Rate for Payer: Employer Direct Commercial	$18,126.02
Rate for Payer: Humana Medicare/TRICARE	$18,126.02
Rate for Payer: Molina Dual Medicare/Medicaid	$18,126.02
Rate for Payer: Molina Medicare	$18,126.02
Rate for Payer: Multiplan Auto	$34,752.90
Rate for Payer: Multiplan Commercial	$34,752.90
Rate for Payer: Multiplan Workers Comp	$34,752.90
Rate for Payer: Scott and White EPO/PPO	$16,004.62
Rate for Payer: Scott and White Medicare	$18,126.02
Rate for Payer: Superior Health Plan EPO	$18,126.02
Rate for Payer: Superior Health Plan Medicare	$18,126.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,126.02
Rate for Payer: Universal American Medicare	$18,126.02
Rate for Payer: Wellcare Medicare	$18,126.02
Rate for Payer: Wellmed Medicare	$18,126.02

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC

Facility

$19,112.10

Service Code	MSDRG 863
Min. Negotiated Rate	$8,469.28
Max. Negotiated Rate	$19,112.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,073.70
Rate for Payer: Amerigroup Medicare	$12,073.70
Rate for Payer: BCBS of TX Medicare	$12,073.70
Rate for Payer: Cigna Commercial	$12,852.95
Rate for Payer: Cigna Medicare	$12,073.70
Rate for Payer: Employer Direct Commercial	$12,073.70
Rate for Payer: Humana Medicare/TRICARE	$12,073.70
Rate for Payer: Molina Dual Medicare/Medicaid	$12,073.70
Rate for Payer: Molina Medicare	$12,073.70
Rate for Payer: Multiplan Auto	$19,112.10
Rate for Payer: Multiplan Commercial	$19,112.10
Rate for Payer: Multiplan Workers Comp	$19,112.10
Rate for Payer: Scott and White EPO/PPO	$8,801.62
Rate for Payer: Scott and White Medicare	$12,073.70
Rate for Payer: Superior Health Plan EPO	$12,073.70
Rate for Payer: Superior Health Plan Medicare	$12,073.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,073.70
Rate for Payer: Universal American Medicare	$12,073.70
Rate for Payer: Wellcare Medicare	$12,073.70
Rate for Payer: Wellmed Medicare	$12,073.70

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC

Facility

$40,071.00

Service Code	MSDRG 857
Min. Negotiated Rate	$17,687.62
Max. Negotiated Rate	$40,071.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,455.19
Rate for Payer: Amerigroup Medicare	$20,455.19
Rate for Payer: BCBS of TX Medicare	$20,455.19
Rate for Payer: Cigna Commercial	$27,582.52
Rate for Payer: Cigna Medicare	$20,455.19
Rate for Payer: Employer Direct Commercial	$20,455.19
Rate for Payer: Humana Medicare/TRICARE	$20,455.19
Rate for Payer: Molina Dual Medicare/Medicaid	$20,455.19
Rate for Payer: Molina Medicare	$20,455.19
Rate for Payer: Multiplan Auto	$40,071.00
Rate for Payer: Multiplan Commercial	$40,071.00
Rate for Payer: Multiplan Workers Comp	$40,071.00
Rate for Payer: Scott and White EPO/PPO	$18,453.75
Rate for Payer: Scott and White Medicare	$20,455.19
Rate for Payer: Superior Health Plan EPO	$20,455.19
Rate for Payer: Superior Health Plan Medicare	$20,455.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,455.19
Rate for Payer: Universal American Medicare	$20,455.19
Rate for Payer: Wellcare Medicare	$20,455.19
Rate for Payer: Wellmed Medicare	$20,455.19

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC

Facility

$83,841.30

Service Code	MSDRG 856
Min. Negotiated Rate	$38,097.62
Max. Negotiated Rate	$83,841.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$38,097.62
Rate for Payer: Amerigroup Medicare	$38,097.62
Rate for Payer: BCBS of TX Medicare	$38,097.62
Rate for Payer: Cigna Commercial	$58,587.26
Rate for Payer: Cigna Medicare	$38,097.62
Rate for Payer: Employer Direct Commercial	$38,097.62
Rate for Payer: Humana Medicare/TRICARE	$38,097.62
Rate for Payer: Molina Dual Medicare/Medicaid	$38,097.62
Rate for Payer: Molina Medicare	$38,097.62
Rate for Payer: Multiplan Auto	$83,841.30
Rate for Payer: Multiplan Commercial	$83,841.30
Rate for Payer: Multiplan Workers Comp	$83,841.30
Rate for Payer: Scott and White EPO/PPO	$38,611.12
Rate for Payer: Scott and White Medicare	$38,097.62
Rate for Payer: Superior Health Plan EPO	$38,097.62
Rate for Payer: Superior Health Plan Medicare	$38,097.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$38,097.62
Rate for Payer: Universal American Medicare	$38,097.62
Rate for Payer: Wellcare Medicare	$38,097.62
Rate for Payer: Wellmed Medicare	$38,097.62

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$26,877.40

Service Code	MSDRG 858
Min. Negotiated Rate	$11,868.86
Max. Negotiated Rate	$26,877.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,968.69
Rate for Payer: Amerigroup Medicare	$14,968.69
Rate for Payer: BCBS of TX Medicare	$14,968.69
Rate for Payer: Cigna Commercial	$17,940.55
Rate for Payer: Cigna Medicare	$14,968.69
Rate for Payer: Employer Direct Commercial	$14,968.69
Rate for Payer: Humana Medicare/TRICARE	$14,968.69
Rate for Payer: Molina Dual Medicare/Medicaid	$14,968.69
Rate for Payer: Molina Medicare	$14,968.69
Rate for Payer: Multiplan Auto	$26,877.40
Rate for Payer: Multiplan Commercial	$26,877.40
Rate for Payer: Multiplan Workers Comp	$26,877.40
Rate for Payer: Scott and White EPO/PPO	$12,377.75
Rate for Payer: Scott and White Medicare	$14,968.69
Rate for Payer: Superior Health Plan EPO	$14,968.69
Rate for Payer: Superior Health Plan Medicare	$14,968.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,968.69
Rate for Payer: Universal American Medicare	$14,968.69
Rate for Payer: Wellcare Medicare	$14,968.69
Rate for Payer: Wellmed Medicare	$14,968.69

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC

Facility

$40,071.00

Service Code	MSDRG 857
Min. Negotiated Rate	$17,687.62
Max. Negotiated Rate	$40,071.00
Rate for Payer: BCBS of TX Blue Advantage	$17,687.62
Rate for Payer: BCBS of TX Blue Essentials	$21,223.09
Rate for Payer: BCBS of TX PPO	$23,582.12

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC

Facility

$83,841.30

Service Code	MSDRG 856
Min. Negotiated Rate	$38,097.62
Max. Negotiated Rate	$83,841.30
Rate for Payer: BCBS of TX Blue Advantage	$38,599.38
Rate for Payer: BCBS of TX Blue Essentials	$46,314.77
Rate for Payer: BCBS of TX PPO	$51,462.85

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC

Facility

$26,877.40

Service Code	MSDRG 858
Min. Negotiated Rate	$11,868.86
Max. Negotiated Rate	$26,877.40
Rate for Payer: BCBS of TX Blue Advantage	$11,868.86
Rate for Payer: BCBS of TX Blue Essentials	$14,241.25
Rate for Payer: BCBS of TX PPO	$15,824.23

POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE

Facility

$14,131.76

Service Code	APR-DRG 7113
Min. Negotiated Rate	$13,323.92
Max. Negotiated Rate	$14,131.76
Rate for Payer: Amerigroup CHIP/Medicaid	$13,323.92
Rate for Payer: Cigna Medicaid	$13,323.92
Rate for Payer: Molina CHIP/Medicaid	$13,323.92
Rate for Payer: Parkland Medicaid	$13,323.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,131.76

Know your out-of-pocket cost for care.

All Charges