White Rock Medical Center

All Charges

Charge

Type

Setting

Price

POUCH, STERILIZATION, SELF-SEAL, 7.5 X 13

Facility

$0.75

Hospital Charge Code	993025
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.51

POUCH, STERILIZATION, SELF-SEAL, 7.5 X 13

Facility

$0.75

Hospital Charge Code	993025
Hospital Revenue Code	270
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.54
Rate for Payer: Amerigroup CHIP/Medicaid	$0.07
Rate for Payer: BCBS of TX Blue Advantage	$0.23
Rate for Payer: BCBS of TX Blue Essentials	$0.27
Rate for Payer: BCBS of TX PPO	$0.30
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cigna Medicaid	$0.54
Rate for Payer: Molina CHIP/Medicaid	$0.54
Rate for Payer: Multiplan Auto	$0.49
Rate for Payer: Multiplan Commercial	$0.49
Rate for Payer: Multiplan Workers Comp	$0.49
Rate for Payer: Parkland Medicaid	$0.54
Rate for Payer: Scott and White EPO/PPO	$0.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.54
Rate for Payer: Superior Health Plan EPO	$0.10

POUCH TELEMETRY POLYESTER W/STRAP

Facility

$3.80

Hospital Charge Code	993271
Hospital Revenue Code	270
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$2.74
Rate for Payer: Amerigroup CHIP/Medicaid	$0.34
Rate for Payer: BCBS of TX Blue Advantage	$1.14
Rate for Payer: BCBS of TX Blue Essentials	$1.37
Rate for Payer: BCBS of TX PPO	$1.52
Rate for Payer: Cash Price	$2.58
Rate for Payer: Cigna Medicaid	$2.74
Rate for Payer: Molina CHIP/Medicaid	$2.74
Rate for Payer: Multiplan Auto	$2.47
Rate for Payer: Multiplan Commercial	$2.47
Rate for Payer: Multiplan Workers Comp	$2.47
Rate for Payer: Parkland Medicaid	$2.74
Rate for Payer: Scott and White EPO/PPO	$1.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.74
Rate for Payer: Superior Health Plan EPO	$0.52

POUCH TELEMETRY POLYESTER W/STRAP

Facility

$3.80

Hospital Charge Code	993271
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.58

POWERPORT 8FR

Facility

$2,431.63

Service Code	HCPCS C1788
Hospital Charge Code	992341
Hospital Revenue Code	278
Min. Negotiated Rate	$218.85
Max. Negotiated Rate	$1,750.77
Rate for Payer: Amerigroup CHIP/Medicaid	$218.85
Rate for Payer: BCBS of TX Blue Advantage	$729.49
Rate for Payer: BCBS of TX Blue Essentials	$875.39
Rate for Payer: BCBS of TX PPO	$972.65
Rate for Payer: Cash Price	$1,653.51
Rate for Payer: Cigna Medicaid	$1,750.77
Rate for Payer: Molina CHIP/Medicaid	$1,750.77
Rate for Payer: Multiplan Auto	$1,215.82
Rate for Payer: Multiplan Commercial	$1,215.82
Rate for Payer: Multiplan Workers Comp	$1,215.82
Rate for Payer: Parkland Medicaid	$1,750.77
Rate for Payer: Scott and White EPO/PPO	$1,215.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,750.77
Rate for Payer: Superior Health Plan EPO	$330.70

POWERPORT 8FR

Facility

$2,431.63

Service Code	HCPCS C1788
Hospital Charge Code	992341
Hospital Revenue Code	278
Min. Negotiated Rate	$607.91
Max. Negotiated Rate	$1,215.82
Rate for Payer: Cash Price	$1,653.51
Rate for Payer: Cigna Commercial	$607.91
Rate for Payer: Multiplan Auto	$1,215.82
Rate for Payer: Multiplan Commercial	$1,215.82
Rate for Payer: Multiplan Workers Comp	$1,215.82
Rate for Payer: Scott and White EPO/PPO	$1,215.82

POWERSEAL 5MM, 44CM, CURVED JAW SEALER

Facility

$3,132.53

Service Code	HCPCS C1889
Hospital Charge Code	994089
Hospital Revenue Code	278
Min. Negotiated Rate	$281.93
Max. Negotiated Rate	$2,255.42
Rate for Payer: Amerigroup CHIP/Medicaid	$281.93
Rate for Payer: BCBS of TX Blue Advantage	$939.76
Rate for Payer: BCBS of TX Blue Essentials	$1,127.71
Rate for Payer: BCBS of TX PPO	$1,253.01
Rate for Payer: Cash Price	$2,130.12
Rate for Payer: Cigna Medicaid	$2,255.42
Rate for Payer: Molina CHIP/Medicaid	$2,255.42
Rate for Payer: Multiplan Auto	$1,566.27
Rate for Payer: Multiplan Commercial	$1,566.27
Rate for Payer: Multiplan Workers Comp	$1,566.27
Rate for Payer: Parkland Medicaid	$2,255.42
Rate for Payer: Scott and White EPO/PPO	$1,566.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,255.42
Rate for Payer: Superior Health Plan EPO	$426.02

POWERSEAL 5MM, 44CM, CURVED JAW SEALER

Facility

$3,132.53

Service Code	HCPCS C1889
Hospital Charge Code	994089
Hospital Revenue Code	278
Min. Negotiated Rate	$783.13
Max. Negotiated Rate	$1,566.27
Rate for Payer: Cash Price	$2,130.12
Rate for Payer: Cigna Commercial	$783.13
Rate for Payer: Multiplan Auto	$1,566.27
Rate for Payer: Multiplan Commercial	$1,566.27
Rate for Payer: Multiplan Workers Comp	$1,566.27
Rate for Payer: Scott and White EPO/PPO	$1,566.27

prazosin 1 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77774065
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

prazosin 1 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77774065
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

PRC ABLTN EXT INIT VN LS

Facility

$11,222.00

Service Code	HCPCS 36478
Hospital Charge Code	4616478
Hospital Revenue Code	361
Min. Negotiated Rate	$1,118.22
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$7,630.96
Rate for Payer: Cash Price	$7,630.96
Rate for Payer: Cash Price	$7,630.96
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$8,079.84
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$8,079.84
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$8,079.84
Rate for Payer: Scott and White EPO/PPO	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,079.84
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

PRC ABLTN EXT INIT VN LS

Facility

$11,222.00

Service Code	HCPCS 36478
Hospital Charge Code	4616478
Hospital Revenue Code	361
Rate for Payer: Cash Price	$7,630.96

Prealbumin SO

Facility

$110.00

Service Code	HCPCS 84134
Hospital Charge Code	1703750
Hospital Revenue Code	301
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$79.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.59
Rate for Payer: Amerigroup Medicare	$14.59
Rate for Payer: BCBS of TX Blue Advantage	$33.00
Rate for Payer: BCBS of TX Blue Essentials	$39.60
Rate for Payer: BCBS of TX Medicare	$14.59
Rate for Payer: BCBS of TX PPO	$44.00
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cigna Medicaid	$79.20
Rate for Payer: Cigna Medicare	$14.59
Rate for Payer: Employer Direct Commercial	$14.59
Rate for Payer: Humana Medicare/TRICARE	$14.59
Rate for Payer: Molina CHIP/Medicaid	$79.20
Rate for Payer: Molina Dual Medicare/Medicaid	$14.59
Rate for Payer: Molina Medicare	$14.59
Rate for Payer: Multiplan Auto	$71.50
Rate for Payer: Multiplan Commercial	$71.50
Rate for Payer: Multiplan Workers Comp	$71.50
Rate for Payer: Parkland Medicaid	$79.20
Rate for Payer: Scott and White EPO/PPO	$18.24
Rate for Payer: Scott and White Medicare	$14.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$14.59
Rate for Payer: Superior Health Plan Medicare	$14.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.59
Rate for Payer: Universal American Medicare	$14.59
Rate for Payer: Wellcare Medicare	$14.59
Rate for Payer: Wellmed Medicare	$14.59

Prealbumin SO

Facility

$110.00

Service Code	HCPCS 84134
Hospital Charge Code	1703750
Hospital Revenue Code	301
Rate for Payer: Cash Price	$74.80

PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC

Facility

$26,867.90

Service Code	MSDRG 067
Min. Negotiated Rate	$12,373.38
Max. Negotiated Rate	$26,867.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,524.22
Rate for Payer: Amerigroup Medicare	$15,524.22
Rate for Payer: BCBS of TX Medicare	$15,524.22
Rate for Payer: Cigna Commercial	$18,916.86
Rate for Payer: Cigna Medicare	$15,524.22
Rate for Payer: Employer Direct Commercial	$15,524.22
Rate for Payer: Humana Medicare/TRICARE	$15,524.22
Rate for Payer: Molina Dual Medicare/Medicaid	$15,524.22
Rate for Payer: Molina Medicare	$15,524.22
Rate for Payer: Scott and White Medicare	$15,524.22
Rate for Payer: Superior Health Plan EPO	$15,524.22
Rate for Payer: Superior Health Plan Medicare	$15,524.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,524.22
Rate for Payer: Universal American Medicare	$15,524.22
Rate for Payer: Wellcare Medicare	$15,524.22
Rate for Payer: Wellmed Medicare	$15,524.22

PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC

Facility

$17,170.30

Service Code	MSDRG 068
Min. Negotiated Rate	$7,728.82
Max. Negotiated Rate	$17,170.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,095.29
Rate for Payer: Amerigroup Medicare	$11,095.29
Rate for Payer: BCBS of TX Medicare	$11,095.29
Rate for Payer: Cigna Commercial	$11,133.47
Rate for Payer: Cigna Medicare	$11,095.29
Rate for Payer: Employer Direct Commercial	$11,095.29
Rate for Payer: Humana Medicare/TRICARE	$11,095.29
Rate for Payer: Molina Dual Medicare/Medicaid	$11,095.29
Rate for Payer: Molina Medicare	$11,095.29
Rate for Payer: Scott and White Medicare	$11,095.29
Rate for Payer: Superior Health Plan EPO	$11,095.29
Rate for Payer: Superior Health Plan Medicare	$11,095.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,095.29
Rate for Payer: Universal American Medicare	$11,095.29
Rate for Payer: Wellcare Medicare	$11,095.29
Rate for Payer: Wellmed Medicare	$11,095.29

prednisoLONE 15 mg/5 mL Oral Syrup 5 mL

Facility

$7.65

Service Code	HCPCS J7510
Hospital Charge Code	77775511
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.28
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.37
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$0.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

prednisoLONE 15 mg/5 mL Oral Syrup 5 mL

Facility

$7.65

Service Code	HCPCS J7510
Hospital Charge Code	77775511
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

prednisoLONE (as sodium phosphate) 5 mg/5 mL Oral Liquid 120 mL

Facility

$18.00

Service Code	HCPCS J7510
Hospital Charge Code	77774664
Hospital Revenue Code	636
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$12.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1.62
Rate for Payer: BCBS of TX Blue Advantage	$0.28
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.37
Rate for Payer: Cash Price	$12.24
Rate for Payer: Cash Price	$12.24
Rate for Payer: Cigna Medicaid	$12.96
Rate for Payer: Molina CHIP/Medicaid	$12.96
Rate for Payer: Multiplan Auto	$11.70
Rate for Payer: Multiplan Commercial	$11.70
Rate for Payer: Multiplan Workers Comp	$11.70
Rate for Payer: Parkland Medicaid	$12.96
Rate for Payer: Scott and White EPO/PPO	$9.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.96
Rate for Payer: Superior Health Plan EPO	$2.45

prednisoLONE (as sodium phosphate) 5 mg/5 mL Oral Liquid 120 mL

Facility

$18.00

Service Code	HCPCS J7510
Hospital Charge Code	77774664
Hospital Revenue Code	636
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$9.00
Rate for Payer: Cash Price	$12.24
Rate for Payer: Cigna Commercial	$4.50
Rate for Payer: Scott and White EPO/PPO	$9.00

prednisoLONE sodium phosphate 15 mg/5 mL Oral Liquid 5 mL REPACK

Facility

$7.65

Service Code	HCPCS J7510
Hospital Charge Code	79171020
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.83

prednisoLONE sodium phosphate 15 mg/5 mL Oral Liquid 5 mL REPACK

Facility

$7.65

Service Code	HCPCS J7510
Hospital Charge Code	79171020
Hospital Revenue Code	636
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.28
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.37
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

predniSONE 10 mg Tab

Facility

$8.00

Service Code	HCPCS J7512
Hospital Charge Code	77776787
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$0.01
Rate for Payer: BCBS of TX Blue Essentials	$0.02
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$5.44
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

predniSONE 10 mg Tab

Facility

$8.00

Service Code	HCPCS J7512
Hospital Charge Code	77776787
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

predniSONE 20 mg Tab

Facility

$7.65

Service Code	HCPCS J7512
Hospital Charge Code	77776950
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.01
Rate for Payer: BCBS of TX Blue Essentials	$0.02
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

Know your out-of-pocket cost for care.

All Charges