White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PRIM ART MECH THROMBECTOMY

Facility

$12,192.00

Service Code	HCPCS 37184
Hospital Charge Code	2320208
Hospital Revenue Code	481
Rate for Payer: Cash Price	$8,290.56

PRIM ART MECH THROMBECTOMY

Facility

$12,192.00

Service Code	HCPCS 37184
Hospital Charge Code	2320208
Hospital Revenue Code	481
Min. Negotiated Rate	$510.29
Max. Negotiated Rate	$38,926.35
Rate for Payer: Amerigroup CHIP/Medicaid	$1,097.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,415.17
Rate for Payer: Amerigroup Medicare	$18,415.17
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$18,415.17
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$8,290.56
Rate for Payer: Cash Price	$8,290.56
Rate for Payer: Cash Price	$8,290.56
Rate for Payer: Cigna Commercial	$38,926.35
Rate for Payer: Cigna Medicaid	$8,778.24
Rate for Payer: Cigna Medicare	$18,415.17
Rate for Payer: Employer Direct Commercial	$18,415.17
Rate for Payer: Humana Medicare/TRICARE	$18,415.17
Rate for Payer: Molina CHIP/Medicaid	$8,778.24
Rate for Payer: Molina Dual Medicare/Medicaid	$18,415.17
Rate for Payer: Molina Medicare	$18,415.17
Rate for Payer: Multiplan Auto	$7,924.80
Rate for Payer: Multiplan Commercial	$7,924.80
Rate for Payer: Multiplan Workers Comp	$7,924.80
Rate for Payer: Parkland Medicaid	$8,778.24
Rate for Payer: Scott and White EPO/PPO	$510.29
Rate for Payer: Scott and White Medicare	$18,415.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,778.24
Rate for Payer: Superior Health Plan EPO	$18,415.17
Rate for Payer: Superior Health Plan Medicare	$18,415.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,415.17
Rate for Payer: Universal American Medicare	$18,415.17
Rate for Payer: Wellcare Medicare	$18,415.17
Rate for Payer: Wellmed Medicare	$18,415.17

Primidone

Facility

$112.89

Service Code	HCPCS 80188
Hospital Charge Code	4202135
Hospital Revenue Code	301
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$81.28
Rate for Payer: Amerigroup CHIP/Medicaid	$6.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.59
Rate for Payer: Amerigroup Medicare	$16.59
Rate for Payer: BCBS of TX Blue Advantage	$33.87
Rate for Payer: BCBS of TX Blue Essentials	$40.64
Rate for Payer: BCBS of TX Medicare	$16.59
Rate for Payer: BCBS of TX PPO	$45.16
Rate for Payer: Cash Price	$76.77
Rate for Payer: Cash Price	$76.77
Rate for Payer: Cigna Medicaid	$81.28
Rate for Payer: Cigna Medicare	$16.59
Rate for Payer: Employer Direct Commercial	$16.59
Rate for Payer: Humana Medicare/TRICARE	$16.59
Rate for Payer: Molina CHIP/Medicaid	$81.28
Rate for Payer: Molina Dual Medicare/Medicaid	$16.59
Rate for Payer: Molina Medicare	$16.59
Rate for Payer: Multiplan Auto	$73.38
Rate for Payer: Multiplan Commercial	$73.38
Rate for Payer: Multiplan Workers Comp	$73.38
Rate for Payer: Parkland Medicaid	$81.28
Rate for Payer: Scott and White EPO/PPO	$20.74
Rate for Payer: Scott and White Medicare	$16.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.28
Rate for Payer: Superior Health Plan EPO	$16.59
Rate for Payer: Superior Health Plan Medicare	$16.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.59
Rate for Payer: Universal American Medicare	$16.59
Rate for Payer: Wellcare Medicare	$16.59
Rate for Payer: Wellmed Medicare	$16.59

Primidone

Facility

$112.89

Service Code	HCPCS 80188
Hospital Charge Code	4202135
Hospital Revenue Code	301
Rate for Payer: Cash Price	$76.77

Primidone (Mysoline(R)), Serum SO

Facility

$112.89

Service Code	HCPCS 80188
Hospital Charge Code	9030973
Hospital Revenue Code	301
Rate for Payer: Cash Price	$76.77

Primidone (Mysoline(R)), Serum SO

Facility

$112.89

Service Code	HCPCS 80188
Hospital Charge Code	9030973
Hospital Revenue Code	301
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$81.28
Rate for Payer: Amerigroup CHIP/Medicaid	$6.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.59
Rate for Payer: Amerigroup Medicare	$16.59
Rate for Payer: BCBS of TX Blue Advantage	$33.87
Rate for Payer: BCBS of TX Blue Essentials	$40.64
Rate for Payer: BCBS of TX Medicare	$16.59
Rate for Payer: BCBS of TX PPO	$45.16
Rate for Payer: Cash Price	$76.77
Rate for Payer: Cash Price	$76.77
Rate for Payer: Cigna Medicaid	$81.28
Rate for Payer: Cigna Medicare	$16.59
Rate for Payer: Employer Direct Commercial	$16.59
Rate for Payer: Humana Medicare/TRICARE	$16.59
Rate for Payer: Molina CHIP/Medicaid	$81.28
Rate for Payer: Molina Dual Medicare/Medicaid	$16.59
Rate for Payer: Molina Medicare	$16.59
Rate for Payer: Multiplan Auto	$73.38
Rate for Payer: Multiplan Commercial	$73.38
Rate for Payer: Multiplan Workers Comp	$73.38
Rate for Payer: Parkland Medicaid	$81.28
Rate for Payer: Scott and White EPO/PPO	$20.74
Rate for Payer: Scott and White Medicare	$16.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.28
Rate for Payer: Superior Health Plan EPO	$16.59
Rate for Payer: Superior Health Plan Medicare	$16.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.59
Rate for Payer: Universal American Medicare	$16.59
Rate for Payer: Wellcare Medicare	$16.59
Rate for Payer: Wellmed Medicare	$16.59

PROBE ARTHROSCOPIC 180MM RAD FRQ 50 DEGREE

Facility

$1,248.50

Hospital Charge Code	8394466
Hospital Revenue Code	272
Rate for Payer: Cash Price	$848.98

PROBE ARTHROSCOPIC 180MM RAD FRQ 50 DEGREE

Facility

$1,248.50

Hospital Charge Code	8394466
Hospital Revenue Code	272
Min. Negotiated Rate	$112.36
Max. Negotiated Rate	$898.92
Rate for Payer: Amerigroup CHIP/Medicaid	$112.36
Rate for Payer: BCBS of TX Blue Advantage	$374.55
Rate for Payer: BCBS of TX Blue Essentials	$449.46
Rate for Payer: BCBS of TX PPO	$499.40
Rate for Payer: Cash Price	$848.98
Rate for Payer: Cigna Medicaid	$898.92
Rate for Payer: Molina CHIP/Medicaid	$898.92
Rate for Payer: Multiplan Auto	$811.52
Rate for Payer: Multiplan Commercial	$811.52
Rate for Payer: Multiplan Workers Comp	$811.52
Rate for Payer: Parkland Medicaid	$898.92
Rate for Payer: Scott and White EPO/PPO	$624.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$898.92
Rate for Payer: Superior Health Plan EPO	$169.80

PROBE, ARTHROSCOPIC CRUISE 90 DEGREE 3.5MM 90-S -- DHF

Facility

$816.48

Hospital Charge Code	81754616
Hospital Revenue Code	272
Min. Negotiated Rate	$73.48
Max. Negotiated Rate	$587.87
Rate for Payer: Amerigroup CHIP/Medicaid	$73.48
Rate for Payer: BCBS of TX Blue Advantage	$244.94
Rate for Payer: BCBS of TX Blue Essentials	$293.93
Rate for Payer: BCBS of TX PPO	$326.59
Rate for Payer: Cash Price	$555.21
Rate for Payer: Cigna Medicaid	$587.87
Rate for Payer: Molina CHIP/Medicaid	$587.87
Rate for Payer: Multiplan Auto	$530.71
Rate for Payer: Multiplan Commercial	$530.71
Rate for Payer: Multiplan Workers Comp	$530.71
Rate for Payer: Parkland Medicaid	$587.87
Rate for Payer: Scott and White EPO/PPO	$408.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$587.87
Rate for Payer: Superior Health Plan EPO	$111.04

PROBE, ARTHROSCOPIC CRUISE 90 DEGREE 3.5MM 90-S -- DHF

Facility

$816.48

Hospital Charge Code	81754616
Hospital Revenue Code	272
Rate for Payer: Cash Price	$555.21

PROBE ARTHROSCOPIC ENERGY 30 DEGREE

Facility

$740.02

Hospital Charge Code	146206
Hospital Revenue Code	272
Rate for Payer: Cash Price	$503.21

PROBE ARTHROSCOPIC ENERGY 30 DEGREE

Facility

$740.02

Hospital Charge Code	146206
Hospital Revenue Code	272
Min. Negotiated Rate	$66.60
Max. Negotiated Rate	$532.81
Rate for Payer: Amerigroup CHIP/Medicaid	$66.60
Rate for Payer: BCBS of TX Blue Advantage	$222.01
Rate for Payer: BCBS of TX Blue Essentials	$266.41
Rate for Payer: BCBS of TX PPO	$296.01
Rate for Payer: Cash Price	$503.21
Rate for Payer: Cigna Medicaid	$532.81
Rate for Payer: Molina CHIP/Medicaid	$532.81
Rate for Payer: Multiplan Auto	$481.01
Rate for Payer: Multiplan Commercial	$481.01
Rate for Payer: Multiplan Workers Comp	$481.01
Rate for Payer: Parkland Medicaid	$532.81
Rate for Payer: Scott and White EPO/PPO	$370.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$532.81
Rate for Payer: Superior Health Plan EPO	$100.64

PROBE COVER CRM 6X96

Facility

$202.71

Hospital Charge Code	145068
Hospital Revenue Code	272
Min. Negotiated Rate	$18.24
Max. Negotiated Rate	$145.95
Rate for Payer: Amerigroup CHIP/Medicaid	$18.24
Rate for Payer: BCBS of TX Blue Advantage	$60.81
Rate for Payer: BCBS of TX Blue Essentials	$72.98
Rate for Payer: BCBS of TX PPO	$81.08
Rate for Payer: Cash Price	$137.84
Rate for Payer: Cigna Medicaid	$145.95
Rate for Payer: Molina CHIP/Medicaid	$145.95
Rate for Payer: Multiplan Auto	$131.76
Rate for Payer: Multiplan Commercial	$131.76
Rate for Payer: Multiplan Workers Comp	$131.76
Rate for Payer: Parkland Medicaid	$145.95
Rate for Payer: Scott and White EPO/PPO	$101.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.95
Rate for Payer: Superior Health Plan EPO	$27.57

PROBE COVER CRM 6X96

Facility

$202.71

Hospital Charge Code	145068
Hospital Revenue Code	272
Rate for Payer: Cash Price	$137.84

probe disposable

Facility

$158.90

Hospital Charge Code	8672530
Hospital Revenue Code	272
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$114.41
Rate for Payer: Amerigroup CHIP/Medicaid	$14.30
Rate for Payer: BCBS of TX Blue Advantage	$47.67
Rate for Payer: BCBS of TX Blue Essentials	$57.20
Rate for Payer: BCBS of TX PPO	$63.56
Rate for Payer: Cash Price	$108.05
Rate for Payer: Cigna Medicaid	$114.41
Rate for Payer: Molina CHIP/Medicaid	$114.41
Rate for Payer: Multiplan Auto	$103.28
Rate for Payer: Multiplan Commercial	$103.28
Rate for Payer: Multiplan Workers Comp	$103.28
Rate for Payer: Parkland Medicaid	$114.41
Rate for Payer: Scott and White EPO/PPO	$79.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$114.41
Rate for Payer: Superior Health Plan EPO	$21.61

probe disposable

Facility

$158.90

Hospital Charge Code	8672530
Hospital Revenue Code	272
Rate for Payer: Cash Price	$108.05

PROBE RADIOFREQUENCY COOLIEF COOLED

Facility

$1,865.94

Hospital Charge Code	8568959
Hospital Revenue Code	272
Min. Negotiated Rate	$167.93
Max. Negotiated Rate	$1,343.48
Rate for Payer: Amerigroup CHIP/Medicaid	$167.93
Rate for Payer: BCBS of TX Blue Advantage	$559.78
Rate for Payer: BCBS of TX Blue Essentials	$671.74
Rate for Payer: BCBS of TX PPO	$746.38
Rate for Payer: Cash Price	$1,268.84
Rate for Payer: Cigna Medicaid	$1,343.48
Rate for Payer: Molina CHIP/Medicaid	$1,343.48
Rate for Payer: Multiplan Auto	$1,212.86
Rate for Payer: Multiplan Commercial	$1,212.86
Rate for Payer: Multiplan Workers Comp	$1,212.86
Rate for Payer: Parkland Medicaid	$1,343.48
Rate for Payer: Scott and White EPO/PPO	$932.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,343.48
Rate for Payer: Superior Health Plan EPO	$253.77

PROBE RADIOFREQUENCY COOLIEF COOLED

Facility

$1,865.94

Hospital Charge Code	8568959
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,268.84

PROBE, SENSOR, ADULT, DIGI,DURASENSOR

Facility

$635.01

Hospital Charge Code	993310
Hospital Revenue Code	270
Min. Negotiated Rate	$57.15
Max. Negotiated Rate	$457.21
Rate for Payer: Amerigroup CHIP/Medicaid	$57.15
Rate for Payer: BCBS of TX Blue Advantage	$190.50
Rate for Payer: BCBS of TX Blue Essentials	$228.60
Rate for Payer: BCBS of TX PPO	$254.00
Rate for Payer: Cash Price	$431.81
Rate for Payer: Cigna Medicaid	$457.21
Rate for Payer: Molina CHIP/Medicaid	$457.21
Rate for Payer: Multiplan Auto	$412.76
Rate for Payer: Multiplan Commercial	$412.76
Rate for Payer: Multiplan Workers Comp	$412.76
Rate for Payer: Parkland Medicaid	$457.21
Rate for Payer: Scott and White EPO/PPO	$317.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$457.21
Rate for Payer: Superior Health Plan EPO	$86.36

PROBE, SENSOR, ADULT, DIGI,DURASENSOR

Facility

$635.01

Hospital Charge Code	993310
Hospital Revenue Code	270
Rate for Payer: Cash Price	$431.81

Procalcitonin SO

Facility

$341.00

Service Code	HCPCS 84145
Hospital Charge Code	1740965
Hospital Revenue Code	301
Min. Negotiated Rate	$10.62
Max. Negotiated Rate	$245.52
Rate for Payer: Amerigroup CHIP/Medicaid	$10.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.22
Rate for Payer: Amerigroup Medicare	$27.22
Rate for Payer: BCBS of TX Blue Advantage	$102.30
Rate for Payer: BCBS of TX Blue Essentials	$122.76
Rate for Payer: BCBS of TX Medicare	$27.22
Rate for Payer: BCBS of TX PPO	$136.40
Rate for Payer: Cash Price	$231.88
Rate for Payer: Cash Price	$231.88
Rate for Payer: Cigna Medicaid	$245.52
Rate for Payer: Cigna Medicare	$27.22
Rate for Payer: Employer Direct Commercial	$27.22
Rate for Payer: Humana Medicare/TRICARE	$27.22
Rate for Payer: Molina CHIP/Medicaid	$245.52
Rate for Payer: Molina Dual Medicare/Medicaid	$27.22
Rate for Payer: Molina Medicare	$27.22
Rate for Payer: Multiplan Auto	$221.65
Rate for Payer: Multiplan Commercial	$221.65
Rate for Payer: Multiplan Workers Comp	$221.65
Rate for Payer: Parkland Medicaid	$245.52
Rate for Payer: Scott and White EPO/PPO	$34.02
Rate for Payer: Scott and White Medicare	$27.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$245.52
Rate for Payer: Superior Health Plan EPO	$27.22
Rate for Payer: Superior Health Plan Medicare	$27.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.22
Rate for Payer: Universal American Medicare	$27.22
Rate for Payer: Wellcare Medicare	$27.22
Rate for Payer: Wellmed Medicare	$27.22

Procalcitonin SO

Facility

$341.00

Service Code	HCPCS 84145
Hospital Charge Code	7258374
Hospital Revenue Code	301
Min. Negotiated Rate	$10.62
Max. Negotiated Rate	$245.52
Rate for Payer: Amerigroup CHIP/Medicaid	$10.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.22
Rate for Payer: Amerigroup Medicare	$27.22
Rate for Payer: BCBS of TX Blue Advantage	$102.30
Rate for Payer: BCBS of TX Blue Essentials	$122.76
Rate for Payer: BCBS of TX Medicare	$27.22
Rate for Payer: BCBS of TX PPO	$136.40
Rate for Payer: Cash Price	$231.88
Rate for Payer: Cash Price	$231.88
Rate for Payer: Cigna Medicaid	$245.52
Rate for Payer: Cigna Medicare	$27.22
Rate for Payer: Employer Direct Commercial	$27.22
Rate for Payer: Humana Medicare/TRICARE	$27.22
Rate for Payer: Molina CHIP/Medicaid	$245.52
Rate for Payer: Molina Dual Medicare/Medicaid	$27.22
Rate for Payer: Molina Medicare	$27.22
Rate for Payer: Multiplan Auto	$221.65
Rate for Payer: Multiplan Commercial	$221.65
Rate for Payer: Multiplan Workers Comp	$221.65
Rate for Payer: Parkland Medicaid	$245.52
Rate for Payer: Scott and White EPO/PPO	$34.02
Rate for Payer: Scott and White Medicare	$27.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$245.52
Rate for Payer: Superior Health Plan EPO	$27.22
Rate for Payer: Superior Health Plan Medicare	$27.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.22
Rate for Payer: Universal American Medicare	$27.22
Rate for Payer: Wellcare Medicare	$27.22
Rate for Payer: Wellmed Medicare	$27.22

Procalcitonin SO

Facility

$341.00

Service Code	HCPCS 84145
Hospital Charge Code	1740965
Hospital Revenue Code	301
Rate for Payer: Cash Price	$231.88

Procalcitonin SO

Facility

$341.00

Service Code	HCPCS 84145
Hospital Charge Code	7258374
Hospital Revenue Code	301
Rate for Payer: Cash Price	$231.88

Procedure Cath Pack

Facility

$230.13

Hospital Charge Code	993889
Hospital Revenue Code	272
Min. Negotiated Rate	$20.71
Max. Negotiated Rate	$165.69
Rate for Payer: Amerigroup CHIP/Medicaid	$20.71
Rate for Payer: BCBS of TX Blue Advantage	$69.04
Rate for Payer: BCBS of TX Blue Essentials	$82.85
Rate for Payer: BCBS of TX PPO	$92.05
Rate for Payer: Cash Price	$156.49
Rate for Payer: Cigna Medicaid	$165.69
Rate for Payer: Molina CHIP/Medicaid	$165.69
Rate for Payer: Multiplan Auto	$149.58
Rate for Payer: Multiplan Commercial	$149.58
Rate for Payer: Multiplan Workers Comp	$149.58
Rate for Payer: Parkland Medicaid	$165.69
Rate for Payer: Scott and White EPO/PPO	$115.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$165.69
Rate for Payer: Superior Health Plan EPO	$31.30

Know your out-of-pocket cost for care.

All Charges