White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PROS SIZER BRST IMP 2 -- DHF

Facility

$1,061.13

Hospital Charge Code	81541872
Hospital Revenue Code	272
Rate for Payer: Cash Price	$721.57

PROSTATECTOMY W CC

Facility

$32,716.10

Service Code	MSDRG 666
Min. Negotiated Rate	$15,066.62
Max. Negotiated Rate	$32,716.10
Rate for Payer: BCBS of TX Blue Advantage	$15,300.26
Rate for Payer: BCBS of TX Blue Essentials	$18,358.53
Rate for Payer: BCBS of TX PPO	$20,399.16

PROSTATECTOMY WITH CC

Facility

$32,716.10

Service Code	MSDRG 666
Min. Negotiated Rate	$15,066.62
Max. Negotiated Rate	$32,716.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,580.76
Rate for Payer: Amerigroup Medicare	$17,580.76
Rate for Payer: BCBS of TX Medicare	$17,580.76
Rate for Payer: Cigna Commercial	$22,530.98
Rate for Payer: Cigna Medicare	$17,580.76
Rate for Payer: Employer Direct Commercial	$17,580.76
Rate for Payer: Humana Medicare/TRICARE	$17,580.76
Rate for Payer: Molina Dual Medicare/Medicaid	$17,580.76
Rate for Payer: Molina Medicare	$17,580.76
Rate for Payer: Multiplan Auto	$32,716.10
Rate for Payer: Multiplan Commercial	$32,716.10
Rate for Payer: Multiplan Workers Comp	$32,716.10
Rate for Payer: Scott and White EPO/PPO	$15,066.62
Rate for Payer: Scott and White Medicare	$17,580.76
Rate for Payer: Superior Health Plan EPO	$17,580.76
Rate for Payer: Superior Health Plan Medicare	$17,580.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,580.76
Rate for Payer: Universal American Medicare	$17,580.76
Rate for Payer: Wellcare Medicare	$17,580.76
Rate for Payer: Wellmed Medicare	$17,580.76

PROSTATECTOMY WITH MCC

Facility

$58,145.70

Service Code	MSDRG 665
Min. Negotiated Rate	$26,777.62
Max. Negotiated Rate	$58,145.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27,635.44
Rate for Payer: Amerigroup Medicare	$27,635.44
Rate for Payer: BCBS of TX Medicare	$27,635.44
Rate for Payer: Cigna Commercial	$40,201.06
Rate for Payer: Cigna Medicare	$27,635.44
Rate for Payer: Employer Direct Commercial	$27,635.44
Rate for Payer: Humana Medicare/TRICARE	$27,635.44
Rate for Payer: Molina Dual Medicare/Medicaid	$27,635.44
Rate for Payer: Molina Medicare	$27,635.44
Rate for Payer: Multiplan Auto	$58,145.70
Rate for Payer: Multiplan Commercial	$58,145.70
Rate for Payer: Multiplan Workers Comp	$58,145.70
Rate for Payer: Scott and White EPO/PPO	$26,777.62
Rate for Payer: Scott and White Medicare	$27,635.44
Rate for Payer: Superior Health Plan EPO	$27,635.44
Rate for Payer: Superior Health Plan Medicare	$27,635.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$27,635.44
Rate for Payer: Universal American Medicare	$27,635.44
Rate for Payer: Wellcare Medicare	$27,635.44
Rate for Payer: Wellmed Medicare	$27,635.44

PROSTATECTOMY WITHOUT CC/MCC

Facility

$18,694.10

Service Code	MSDRG 667
Min. Negotiated Rate	$8,609.12
Max. Negotiated Rate	$18,694.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,867.45
Rate for Payer: Amerigroup Medicare	$12,867.45
Rate for Payer: BCBS of TX Medicare	$12,867.45
Rate for Payer: Cigna Commercial	$14,247.86
Rate for Payer: Cigna Medicare	$12,867.45
Rate for Payer: Employer Direct Commercial	$12,867.45
Rate for Payer: Humana Medicare/TRICARE	$12,867.45
Rate for Payer: Molina Dual Medicare/Medicaid	$12,867.45
Rate for Payer: Molina Medicare	$12,867.45
Rate for Payer: Multiplan Auto	$18,694.10
Rate for Payer: Multiplan Commercial	$18,694.10
Rate for Payer: Multiplan Workers Comp	$18,694.10
Rate for Payer: Scott and White EPO/PPO	$8,609.12
Rate for Payer: Scott and White Medicare	$12,867.45
Rate for Payer: Superior Health Plan EPO	$12,867.45
Rate for Payer: Superior Health Plan Medicare	$12,867.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,867.45
Rate for Payer: Universal American Medicare	$12,867.45
Rate for Payer: Wellcare Medicare	$12,867.45
Rate for Payer: Wellmed Medicare	$12,867.45

PROSTATECTOMY W MCC

Facility

$58,145.70

Service Code	MSDRG 665
Min. Negotiated Rate	$26,777.62
Max. Negotiated Rate	$58,145.70
Rate for Payer: BCBS of TX Blue Advantage	$27,337.68
Rate for Payer: BCBS of TX Blue Essentials	$32,802.04
Rate for Payer: BCBS of TX PPO	$36,448.12

PROSTATECTOMY W/O CC/MCC

Facility

$18,694.10

Service Code	MSDRG 667
Min. Negotiated Rate	$8,609.12
Max. Negotiated Rate	$18,694.10
Rate for Payer: BCBS of TX Blue Advantage	$9,291.44
Rate for Payer: BCBS of TX Blue Essentials	$11,148.65
Rate for Payer: BCBS of TX PPO	$12,387.87

Prostate-Specific Ag, Serum SO

Facility

$227.00

Service Code	HCPCS 84153
Hospital Charge Code	1601376
Hospital Revenue Code	301
Min. Negotiated Rate	$7.17
Max. Negotiated Rate	$163.44
Rate for Payer: Amerigroup CHIP/Medicaid	$7.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.39
Rate for Payer: Amerigroup Medicare	$18.39
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX Medicare	$18.39
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$154.36
Rate for Payer: Cash Price	$154.36
Rate for Payer: Cigna Medicaid	$163.44
Rate for Payer: Cigna Medicare	$18.39
Rate for Payer: Employer Direct Commercial	$18.39
Rate for Payer: Humana Medicare/TRICARE	$18.39
Rate for Payer: Molina CHIP/Medicaid	$163.44
Rate for Payer: Molina Dual Medicare/Medicaid	$18.39
Rate for Payer: Molina Medicare	$18.39
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Parkland Medicaid	$163.44
Rate for Payer: Scott and White EPO/PPO	$22.99
Rate for Payer: Scott and White Medicare	$18.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.44
Rate for Payer: Superior Health Plan EPO	$18.39
Rate for Payer: Superior Health Plan Medicare	$18.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.39
Rate for Payer: Universal American Medicare	$18.39
Rate for Payer: Wellcare Medicare	$18.39
Rate for Payer: Wellmed Medicare	$18.39

Prostate-Specific Ag, Serum SO

Facility

$227.00

Service Code	HCPCS 84153
Hospital Charge Code	1601376
Hospital Revenue Code	301
Rate for Payer: Cash Price	$154.36

PROSTEP MICA SCREW 4.0 X 50MM STERILE

Facility

$5,254.82

Service Code	HCPCS C1713
Hospital Charge Code	992395
Hospital Revenue Code	278
Min. Negotiated Rate	$1,313.70
Max. Negotiated Rate	$2,627.41
Rate for Payer: Cash Price	$3,573.28
Rate for Payer: Cigna Commercial	$1,313.70
Rate for Payer: Multiplan Auto	$2,627.41
Rate for Payer: Multiplan Commercial	$2,627.41
Rate for Payer: Multiplan Workers Comp	$2,627.41
Rate for Payer: Scott and White EPO/PPO	$2,627.41

PROSTEP MICA SCREW 4.0 X 50MM STERILE

Facility

$5,254.82

Service Code	HCPCS C1713
Hospital Charge Code	992395
Hospital Revenue Code	278
Min. Negotiated Rate	$472.93
Max. Negotiated Rate	$3,783.47
Rate for Payer: Amerigroup CHIP/Medicaid	$472.93
Rate for Payer: BCBS of TX Blue Advantage	$1,576.45
Rate for Payer: BCBS of TX Blue Essentials	$1,891.74
Rate for Payer: BCBS of TX PPO	$2,101.93
Rate for Payer: Cash Price	$3,573.28
Rate for Payer: Cigna Medicaid	$3,783.47
Rate for Payer: Molina CHIP/Medicaid	$3,783.47
Rate for Payer: Multiplan Auto	$2,627.41
Rate for Payer: Multiplan Commercial	$2,627.41
Rate for Payer: Multiplan Workers Comp	$2,627.41
Rate for Payer: Parkland Medicaid	$3,783.47
Rate for Payer: Scott and White EPO/PPO	$2,627.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,783.47
Rate for Payer: Superior Health Plan EPO	$714.66

Prostep mica screw 4.0 X 54mm sterile

Facility

$4,777.11

Service Code	HCPCS C1713
Hospital Charge Code	992202
Hospital Revenue Code	278
Min. Negotiated Rate	$429.94
Max. Negotiated Rate	$3,439.52
Rate for Payer: Amerigroup CHIP/Medicaid	$429.94
Rate for Payer: BCBS of TX Blue Advantage	$1,433.13
Rate for Payer: BCBS of TX Blue Essentials	$1,719.76
Rate for Payer: BCBS of TX PPO	$1,910.84
Rate for Payer: Cash Price	$3,248.43
Rate for Payer: Cigna Medicaid	$3,439.52
Rate for Payer: Molina CHIP/Medicaid	$3,439.52
Rate for Payer: Multiplan Auto	$2,388.55
Rate for Payer: Multiplan Commercial	$2,388.55
Rate for Payer: Multiplan Workers Comp	$2,388.55
Rate for Payer: Parkland Medicaid	$3,439.52
Rate for Payer: Scott and White EPO/PPO	$2,388.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,439.52
Rate for Payer: Superior Health Plan EPO	$649.69

Prostep mica screw 4.0 X 54mm sterile

Facility

$4,777.11

Service Code	HCPCS C1713
Hospital Charge Code	992202
Hospital Revenue Code	278
Min. Negotiated Rate	$1,194.28
Max. Negotiated Rate	$2,388.55
Rate for Payer: Cash Price	$3,248.43
Rate for Payer: Cigna Commercial	$1,194.28
Rate for Payer: Multiplan Auto	$2,388.55
Rate for Payer: Multiplan Commercial	$2,388.55
Rate for Payer: Multiplan Workers Comp	$2,388.55
Rate for Payer: Scott and White EPO/PPO	$2,388.55

protamine 10 mg/mL Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J2720
Hospital Charge Code	77783316
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

protamine 10 mg/mL Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J2720
Hospital Charge Code	77783373
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

protamine 10 mg/mL Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J2720
Hospital Charge Code	77783373
Hospital Revenue Code	636
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.74
Rate for Payer: BCBS of TX Blue Essentials	$2.09
Rate for Payer: BCBS of TX PPO	$2.32
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

protamine 10 mg/mL Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J2720
Hospital Charge Code	77783316
Hospital Revenue Code	636
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.74
Rate for Payer: BCBS of TX Blue Essentials	$2.09
Rate for Payer: BCBS of TX PPO	$2.32
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

PROTECTOR, EYE, OPTI-GRAD, STERILE

Facility

$26.09

Hospital Charge Code	992910
Hospital Revenue Code	272
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$18.78
Rate for Payer: Amerigroup CHIP/Medicaid	$2.35
Rate for Payer: BCBS of TX Blue Advantage	$7.83
Rate for Payer: BCBS of TX Blue Essentials	$9.39
Rate for Payer: BCBS of TX PPO	$10.44
Rate for Payer: Cash Price	$17.74
Rate for Payer: Cigna Medicaid	$18.78
Rate for Payer: Molina CHIP/Medicaid	$18.78
Rate for Payer: Multiplan Auto	$16.96
Rate for Payer: Multiplan Commercial	$16.96
Rate for Payer: Multiplan Workers Comp	$16.96
Rate for Payer: Parkland Medicaid	$18.78
Rate for Payer: Scott and White EPO/PPO	$13.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.78
Rate for Payer: Superior Health Plan EPO	$3.55

PROTECTOR, EYE, OPTI-GRAD, STERILE

Facility

$26.09

Hospital Charge Code	992910
Hospital Revenue Code	272
Rate for Payer: Cash Price	$17.74

PROTECTOR, INSTRUMENT, STEAM/EO, 3.5'X65/8'

Facility

$0.76

Hospital Charge Code	993027
Hospital Revenue Code	270
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.55
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	$0.52
Rate for Payer: Cigna Medicaid	$0.55
Rate for Payer: Molina CHIP/Medicaid	$0.55
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	$0.55
Rate for Payer: Scott and White EPO/PPO	$0.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.55
Rate for Payer: Superior Health Plan EPO	$0.10

PROTECTOR, INSTRUMENT, STEAM/EO, 3.5'X65/8'

Facility

$0.76

Hospital Charge Code	993027
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.52

PROTECTOR, INSTRUMENT, STEAM/EO, 5.5'X9.5'

Facility

$1.03

Hospital Charge Code	993028
Hospital Revenue Code	270
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.74
Rate for Payer: Amerigroup CHIP/Medicaid	$0.09
Rate for Payer: BCBS of TX Blue Advantage	$0.31
Rate for Payer: BCBS of TX Blue Essentials	$0.37
Rate for Payer: BCBS of TX PPO	$0.41
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cigna Medicaid	$0.74
Rate for Payer: Molina CHIP/Medicaid	$0.74
Rate for Payer: Multiplan Auto	$0.67
Rate for Payer: Multiplan Commercial	$0.67
Rate for Payer: Multiplan Workers Comp	$0.67
Rate for Payer: Parkland Medicaid	$0.74
Rate for Payer: Scott and White EPO/PPO	$0.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.74
Rate for Payer: Superior Health Plan EPO	$0.14

PROTECTOR, INSTRUMENT, STEAM/EO, 5.5'X9.5'

Facility

$1.03

Hospital Charge Code	993028
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.70

PROTECTOR, NERVE, SURG, POSITIONER

Facility

$13.46

Hospital Charge Code	992926
Hospital Revenue Code	270
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$9.69
Rate for Payer: Amerigroup CHIP/Medicaid	$1.21
Rate for Payer: BCBS of TX Blue Advantage	$4.04
Rate for Payer: BCBS of TX Blue Essentials	$4.85
Rate for Payer: BCBS of TX PPO	$5.38
Rate for Payer: Cash Price	$9.15
Rate for Payer: Cigna Medicaid	$9.69
Rate for Payer: Molina CHIP/Medicaid	$9.69
Rate for Payer: Multiplan Auto	$8.75
Rate for Payer: Multiplan Commercial	$8.75
Rate for Payer: Multiplan Workers Comp	$8.75
Rate for Payer: Parkland Medicaid	$9.69
Rate for Payer: Scott and White EPO/PPO	$6.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.69
Rate for Payer: Superior Health Plan EPO	$1.83

PROTECTOR, NERVE, SURG, POSITIONER

Facility

$13.46

Hospital Charge Code	992926
Hospital Revenue Code	270
Rate for Payer: Cash Price	$9.15

Know your out-of-pocket cost for care.

All Charges