White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Procedure Cath Pack

Facility

$230.13

Hospital Charge Code	993889
Hospital Revenue Code	272
Rate for Payer: Cash Price	$156.49

PROCEDURES FOR OBESITY

Facility

$12,498.16

Service Code	APR-DRG 4034
Min. Negotiated Rate	$11,783.70
Max. Negotiated Rate	$12,498.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11,783.70
Rate for Payer: Cigna Medicaid	$11,783.70
Rate for Payer: Molina CHIP/Medicaid	$11,783.70
Rate for Payer: Parkland Medicaid	$11,783.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,498.16

PROCEDURES FOR OBESITY

Facility

$5,923.00

Service Code	APR-DRG 4032
Min. Negotiated Rate	$5,584.41
Max. Negotiated Rate	$5,923.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,584.41
Rate for Payer: Cigna Medicaid	$5,584.41
Rate for Payer: Molina CHIP/Medicaid	$5,584.41
Rate for Payer: Parkland Medicaid	$5,584.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,923.00

PROCEDURES FOR OBESITY

Facility

$5,250.47

Service Code	APR-DRG 4031
Min. Negotiated Rate	$4,950.33
Max. Negotiated Rate	$5,250.47
Rate for Payer: Amerigroup CHIP/Medicaid	$4,950.33
Rate for Payer: Cigna Medicaid	$4,950.33
Rate for Payer: Molina CHIP/Medicaid	$4,950.33
Rate for Payer: Parkland Medicaid	$4,950.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,250.47

PROCEDURES FOR OBESITY

Facility

$10,075.85

Service Code	APR-DRG 4033
Min. Negotiated Rate	$9,499.86
Max. Negotiated Rate	$10,075.85
Rate for Payer: Amerigroup CHIP/Medicaid	$9,499.86
Rate for Payer: Cigna Medicaid	$9,499.86
Rate for Payer: Molina CHIP/Medicaid	$9,499.86
Rate for Payer: Parkland Medicaid	$9,499.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,075.85

PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES

Facility

$12,811.60

Service Code	APR-DRG 8502
Min. Negotiated Rate	$12,079.23
Max. Negotiated Rate	$12,811.60
Rate for Payer: Amerigroup CHIP/Medicaid	$12,079.23
Rate for Payer: Cigna Medicaid	$12,079.23
Rate for Payer: Molina CHIP/Medicaid	$12,079.23
Rate for Payer: Parkland Medicaid	$12,079.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,811.60

PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES

Facility

$19,549.71

Service Code	APR-DRG 8503
Min. Negotiated Rate	$18,432.15
Max. Negotiated Rate	$19,549.71
Rate for Payer: Amerigroup CHIP/Medicaid	$18,432.15
Rate for Payer: Cigna Medicaid	$18,432.15
Rate for Payer: Molina CHIP/Medicaid	$18,432.15
Rate for Payer: Parkland Medicaid	$18,432.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,549.71

PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES

Facility

$92,719.47

Service Code	APR-DRG 8504
Min. Negotiated Rate	$87,419.16
Max. Negotiated Rate	$92,719.47
Rate for Payer: Amerigroup CHIP/Medicaid	$87,419.16
Rate for Payer: Cigna Medicaid	$87,419.16
Rate for Payer: Molina CHIP/Medicaid	$87,419.16
Rate for Payer: Parkland Medicaid	$87,419.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92,719.47

PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES

Facility

$7,185.83

Service Code	APR-DRG 8501
Min. Negotiated Rate	$6,775.05
Max. Negotiated Rate	$7,185.83
Rate for Payer: Amerigroup CHIP/Medicaid	$6,775.05
Rate for Payer: Cigna Medicaid	$6,775.05
Rate for Payer: Molina CHIP/Medicaid	$6,775.05
Rate for Payer: Parkland Medicaid	$6,775.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,185.83

prochlorperazine 5 mg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J0780
Hospital Charge Code	77779958
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$18.04
Rate for Payer: BCBS of TX Blue Essentials	$21.65
Rate for Payer: BCBS of TX PPO	$24.01
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

prochlorperazine 5 mg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J0780
Hospital Charge Code	77779958
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

Progesterone SO

Facility

$133.00

Service Code	HCPCS 84144
Hospital Charge Code	1704006
Hospital Revenue Code	301
Min. Negotiated Rate	$8.14
Max. Negotiated Rate	$95.76
Rate for Payer: Amerigroup CHIP/Medicaid	$8.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.86
Rate for Payer: Amerigroup Medicare	$20.86
Rate for Payer: BCBS of TX Blue Advantage	$39.90
Rate for Payer: BCBS of TX Blue Essentials	$47.88
Rate for Payer: BCBS of TX Medicare	$20.86
Rate for Payer: BCBS of TX PPO	$53.20
Rate for Payer: Cash Price	$90.44
Rate for Payer: Cash Price	$90.44
Rate for Payer: Cigna Medicaid	$95.76
Rate for Payer: Cigna Medicare	$20.86
Rate for Payer: Employer Direct Commercial	$20.86
Rate for Payer: Humana Medicare/TRICARE	$20.86
Rate for Payer: Molina CHIP/Medicaid	$95.76
Rate for Payer: Molina Dual Medicare/Medicaid	$20.86
Rate for Payer: Molina Medicare	$20.86
Rate for Payer: Multiplan Auto	$86.45
Rate for Payer: Multiplan Commercial	$86.45
Rate for Payer: Multiplan Workers Comp	$86.45
Rate for Payer: Parkland Medicaid	$95.76
Rate for Payer: Scott and White EPO/PPO	$26.07
Rate for Payer: Scott and White Medicare	$20.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$95.76
Rate for Payer: Superior Health Plan EPO	$20.86
Rate for Payer: Superior Health Plan Medicare	$20.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.86
Rate for Payer: Universal American Medicare	$20.86
Rate for Payer: Wellcare Medicare	$20.86
Rate for Payer: Wellmed Medicare	$20.86

Progesterone SO

Facility

$133.00

Service Code	HCPCS 84144
Hospital Charge Code	1704006
Hospital Revenue Code	301
Rate for Payer: Cash Price	$90.44

Proinsulin SO

Facility

$260.97

Service Code	HCPCS 84206
Hospital Charge Code	1705896
Hospital Revenue Code	301
Min. Negotiated Rate	$10.41
Max. Negotiated Rate	$187.90
Rate for Payer: Amerigroup CHIP/Medicaid	$10.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.69
Rate for Payer: Amerigroup Medicare	$26.69
Rate for Payer: BCBS of TX Blue Advantage	$78.29
Rate for Payer: BCBS of TX Blue Essentials	$93.95
Rate for Payer: BCBS of TX Medicare	$26.69
Rate for Payer: BCBS of TX PPO	$104.39
Rate for Payer: Cash Price	$177.46
Rate for Payer: Cash Price	$177.46
Rate for Payer: Cigna Medicaid	$187.90
Rate for Payer: Cigna Medicare	$26.69
Rate for Payer: Employer Direct Commercial	$26.69
Rate for Payer: Humana Medicare/TRICARE	$26.69
Rate for Payer: Molina CHIP/Medicaid	$187.90
Rate for Payer: Molina Dual Medicare/Medicaid	$26.69
Rate for Payer: Molina Medicare	$26.69
Rate for Payer: Multiplan Auto	$169.63
Rate for Payer: Multiplan Commercial	$169.63
Rate for Payer: Multiplan Workers Comp	$169.63
Rate for Payer: Parkland Medicaid	$187.90
Rate for Payer: Scott and White EPO/PPO	$33.36
Rate for Payer: Scott and White Medicare	$26.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$187.90
Rate for Payer: Superior Health Plan EPO	$26.69
Rate for Payer: Superior Health Plan Medicare	$26.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.69
Rate for Payer: Universal American Medicare	$26.69
Rate for Payer: Wellcare Medicare	$26.69
Rate for Payer: Wellmed Medicare	$26.69

Proinsulin SO

Facility

$260.97

Service Code	HCPCS 84206
Hospital Charge Code	1705896
Hospital Revenue Code	301
Rate for Payer: Cash Price	$177.46

Prolactin SO

Facility

$376.00

Service Code	HCPCS 84146
Hospital Charge Code	1602218
Hospital Revenue Code	301
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$270.72
Rate for Payer: Amerigroup CHIP/Medicaid	$7.56
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19.38
Rate for Payer: Amerigroup Medicare	$19.38
Rate for Payer: BCBS of TX Blue Advantage	$112.80
Rate for Payer: BCBS of TX Blue Essentials	$135.36
Rate for Payer: BCBS of TX Medicare	$19.38
Rate for Payer: BCBS of TX PPO	$150.40
Rate for Payer: Cash Price	$255.68
Rate for Payer: Cash Price	$255.68
Rate for Payer: Cigna Medicaid	$270.72
Rate for Payer: Cigna Medicare	$19.38
Rate for Payer: Employer Direct Commercial	$19.38
Rate for Payer: Humana Medicare/TRICARE	$19.38
Rate for Payer: Molina CHIP/Medicaid	$270.72
Rate for Payer: Molina Dual Medicare/Medicaid	$19.38
Rate for Payer: Molina Medicare	$19.38
Rate for Payer: Multiplan Auto	$244.40
Rate for Payer: Multiplan Commercial	$244.40
Rate for Payer: Multiplan Workers Comp	$244.40
Rate for Payer: Parkland Medicaid	$270.72
Rate for Payer: Scott and White EPO/PPO	$24.23
Rate for Payer: Scott and White Medicare	$19.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$270.72
Rate for Payer: Superior Health Plan EPO	$19.38
Rate for Payer: Superior Health Plan Medicare	$19.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$19.38
Rate for Payer: Universal American Medicare	$19.38
Rate for Payer: Wellcare Medicare	$19.38
Rate for Payer: Wellmed Medicare	$19.38

Prolactin SO

Facility

$376.00

Service Code	HCPCS 84146
Hospital Charge Code	1602218
Hospital Revenue Code	301
Rate for Payer: Cash Price	$255.68

prolene non-absorbable monofilament polypropylene suture

Facility

$62.93

Hospital Charge Code	993692
Hospital Revenue Code	270
Rate for Payer: Cash Price	$42.79

prolene non-absorbable monofilament polypropylene suture

Facility

$62.93

Hospital Charge Code	993692
Hospital Revenue Code	270
Min. Negotiated Rate	$5.66
Max. Negotiated Rate	$45.31
Rate for Payer: Amerigroup CHIP/Medicaid	$5.66
Rate for Payer: BCBS of TX Blue Advantage	$18.88
Rate for Payer: BCBS of TX Blue Essentials	$22.65
Rate for Payer: BCBS of TX PPO	$25.17
Rate for Payer: Cash Price	$42.79
Rate for Payer: Cigna Medicaid	$45.31
Rate for Payer: Molina CHIP/Medicaid	$45.31
Rate for Payer: Multiplan Auto	$40.90
Rate for Payer: Multiplan Commercial	$40.90
Rate for Payer: Multiplan Workers Comp	$40.90
Rate for Payer: Parkland Medicaid	$45.31
Rate for Payer: Scott and White EPO/PPO	$31.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$45.31
Rate for Payer: Superior Health Plan EPO	$8.56

prolene non-absorbable monofilament suture

Facility

$68.44

Hospital Charge Code	993693
Hospital Revenue Code	270
Rate for Payer: Cash Price	$46.54

prolene non-absorbable monofilament suture

Facility

$68.44

Hospital Charge Code	993693
Hospital Revenue Code	270
Min. Negotiated Rate	$6.16
Max. Negotiated Rate	$49.28
Rate for Payer: Amerigroup CHIP/Medicaid	$6.16
Rate for Payer: BCBS of TX Blue Advantage	$20.53
Rate for Payer: BCBS of TX Blue Essentials	$24.64
Rate for Payer: BCBS of TX PPO	$27.38
Rate for Payer: Cash Price	$46.54
Rate for Payer: Cigna Medicaid	$49.28
Rate for Payer: Molina CHIP/Medicaid	$49.28
Rate for Payer: Multiplan Auto	$44.49
Rate for Payer: Multiplan Commercial	$44.49
Rate for Payer: Multiplan Workers Comp	$44.49
Rate for Payer: Parkland Medicaid	$49.28
Rate for Payer: Scott and White EPO/PPO	$34.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.28
Rate for Payer: Superior Health Plan EPO	$9.31

Prolystica Enzymatic Ultra Presoak and Cleaner, 1 gal.

Facility

$155.63

Hospital Charge Code	992985
Hospital Revenue Code	272
Min. Negotiated Rate	$14.01
Max. Negotiated Rate	$112.05
Rate for Payer: Amerigroup CHIP/Medicaid	$14.01
Rate for Payer: BCBS of TX Blue Advantage	$46.69
Rate for Payer: BCBS of TX Blue Essentials	$56.03
Rate for Payer: BCBS of TX PPO	$62.25
Rate for Payer: Cash Price	$105.83
Rate for Payer: Cigna Medicaid	$112.05
Rate for Payer: Molina CHIP/Medicaid	$112.05
Rate for Payer: Multiplan Auto	$101.16
Rate for Payer: Multiplan Commercial	$101.16
Rate for Payer: Multiplan Workers Comp	$101.16
Rate for Payer: Parkland Medicaid	$112.05
Rate for Payer: Scott and White EPO/PPO	$77.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$112.05
Rate for Payer: Superior Health Plan EPO	$21.17

Prolystica Enzymatic Ultra Presoak and Cleaner, 1 gal.

Facility

$155.63

Hospital Charge Code	992985
Hospital Revenue Code	272
Rate for Payer: Cash Price	$105.83

promethazine 25 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J2550
Hospital Charge Code	77780906
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

promethazine 25 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J2550
Hospital Charge Code	77780906
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.44
Rate for Payer: BCBS of TX Blue Essentials	$0.52
Rate for Payer: BCBS of TX PPO	$0.58
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Know your out-of-pocket cost for care.

All Charges