White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Protein Body Fluid

Facility

$193.00

Service Code	HCPCS 84157
Hospital Charge Code	4104196
Hospital Revenue Code	301
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$138.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1.56
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.00
Rate for Payer: Amerigroup Medicare	$4.00
Rate for Payer: BCBS of TX Blue Advantage	$57.90
Rate for Payer: BCBS of TX Blue Essentials	$69.48
Rate for Payer: BCBS of TX Medicare	$4.00
Rate for Payer: BCBS of TX PPO	$77.20
Rate for Payer: Cash Price	$131.24
Rate for Payer: Cash Price	$131.24
Rate for Payer: Cigna Medicaid	$138.96
Rate for Payer: Cigna Medicare	$4.00
Rate for Payer: Employer Direct Commercial	$4.00
Rate for Payer: Humana Medicare/TRICARE	$4.00
Rate for Payer: Molina CHIP/Medicaid	$138.96
Rate for Payer: Molina Dual Medicare/Medicaid	$4.00
Rate for Payer: Molina Medicare	$4.00
Rate for Payer: Multiplan Auto	$125.45
Rate for Payer: Multiplan Commercial	$125.45
Rate for Payer: Multiplan Workers Comp	$125.45
Rate for Payer: Parkland Medicaid	$138.96
Rate for Payer: Scott and White EPO/PPO	$5.00
Rate for Payer: Scott and White Medicare	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$138.96
Rate for Payer: Superior Health Plan EPO	$4.00
Rate for Payer: Superior Health Plan Medicare	$4.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.00
Rate for Payer: Universal American Medicare	$4.00
Rate for Payer: Wellcare Medicare	$4.00
Rate for Payer: Wellmed Medicare	$4.00

Protein Body Fluid

Facility

$193.00

Service Code	HCPCS 84157
Hospital Charge Code	4104196
Hospital Revenue Code	301
Rate for Payer: Cash Price	$131.24

Protein C Antigen SO

Facility

$255.34

Service Code	HCPCS 85302
Hospital Charge Code	1708312
Hospital Revenue Code	305
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$183.84
Rate for Payer: Amerigroup CHIP/Medicaid	$4.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.01
Rate for Payer: Amerigroup Medicare	$12.01
Rate for Payer: BCBS of TX Blue Advantage	$76.60
Rate for Payer: BCBS of TX Blue Essentials	$91.92
Rate for Payer: BCBS of TX Medicare	$12.01
Rate for Payer: BCBS of TX PPO	$102.14
Rate for Payer: Cash Price	$173.63
Rate for Payer: Cash Price	$173.63
Rate for Payer: Cigna Medicaid	$183.84
Rate for Payer: Cigna Medicare	$12.01
Rate for Payer: Employer Direct Commercial	$12.01
Rate for Payer: Humana Medicare/TRICARE	$12.01
Rate for Payer: Molina CHIP/Medicaid	$183.84
Rate for Payer: Molina Dual Medicare/Medicaid	$12.01
Rate for Payer: Molina Medicare	$12.01
Rate for Payer: Multiplan Auto	$165.97
Rate for Payer: Multiplan Commercial	$165.97
Rate for Payer: Multiplan Workers Comp	$165.97
Rate for Payer: Parkland Medicaid	$183.84
Rate for Payer: Scott and White EPO/PPO	$15.01
Rate for Payer: Scott and White Medicare	$12.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$183.84
Rate for Payer: Superior Health Plan EPO	$12.01
Rate for Payer: Superior Health Plan Medicare	$12.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.01
Rate for Payer: Universal American Medicare	$12.01
Rate for Payer: Wellcare Medicare	$12.01
Rate for Payer: Wellmed Medicare	$12.01

Protein C Antigen SO

Facility

$255.34

Service Code	HCPCS 85302
Hospital Charge Code	1708312
Hospital Revenue Code	305
Rate for Payer: Cash Price	$173.63

Protein C-Functional SO

Facility

$288.00

Service Code	HCPCS 85303
Hospital Charge Code	1704915
Hospital Revenue Code	305
Rate for Payer: Cash Price	$195.84

Protein C-Functional SO

Facility

$288.00

Service Code	HCPCS 85303
Hospital Charge Code	1704915
Hospital Revenue Code	305
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$207.36
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.84
Rate for Payer: Amerigroup Medicare	$13.84
Rate for Payer: BCBS of TX Blue Advantage	$86.40
Rate for Payer: BCBS of TX Blue Essentials	$103.68
Rate for Payer: BCBS of TX Medicare	$13.84
Rate for Payer: BCBS of TX PPO	$115.20
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cigna Medicaid	$207.36
Rate for Payer: Cigna Medicare	$13.84
Rate for Payer: Employer Direct Commercial	$13.84
Rate for Payer: Humana Medicare/TRICARE	$13.84
Rate for Payer: Molina CHIP/Medicaid	$207.36
Rate for Payer: Molina Dual Medicare/Medicaid	$13.84
Rate for Payer: Molina Medicare	$13.84
Rate for Payer: Multiplan Auto	$187.20
Rate for Payer: Multiplan Commercial	$187.20
Rate for Payer: Multiplan Workers Comp	$187.20
Rate for Payer: Parkland Medicaid	$207.36
Rate for Payer: Scott and White EPO/PPO	$17.30
Rate for Payer: Scott and White Medicare	$13.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$207.36
Rate for Payer: Superior Health Plan EPO	$13.84
Rate for Payer: Superior Health Plan Medicare	$13.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.84
Rate for Payer: Universal American Medicare	$13.84
Rate for Payer: Wellcare Medicare	$13.84
Rate for Payer: Wellmed Medicare	$13.84

Protein CSF

Facility

$193.00

Service Code	HCPCS 84157
Hospital Charge Code	1605831
Hospital Revenue Code	301
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$138.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1.56
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.00
Rate for Payer: Amerigroup Medicare	$4.00
Rate for Payer: BCBS of TX Blue Advantage	$57.90
Rate for Payer: BCBS of TX Blue Essentials	$69.48
Rate for Payer: BCBS of TX Medicare	$4.00
Rate for Payer: BCBS of TX PPO	$77.20
Rate for Payer: Cash Price	$131.24
Rate for Payer: Cash Price	$131.24
Rate for Payer: Cigna Medicaid	$138.96
Rate for Payer: Cigna Medicare	$4.00
Rate for Payer: Employer Direct Commercial	$4.00
Rate for Payer: Humana Medicare/TRICARE	$4.00
Rate for Payer: Molina CHIP/Medicaid	$138.96
Rate for Payer: Molina Dual Medicare/Medicaid	$4.00
Rate for Payer: Molina Medicare	$4.00
Rate for Payer: Multiplan Auto	$125.45
Rate for Payer: Multiplan Commercial	$125.45
Rate for Payer: Multiplan Workers Comp	$125.45
Rate for Payer: Parkland Medicaid	$138.96
Rate for Payer: Scott and White EPO/PPO	$5.00
Rate for Payer: Scott and White Medicare	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$138.96
Rate for Payer: Superior Health Plan EPO	$4.00
Rate for Payer: Superior Health Plan Medicare	$4.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.00
Rate for Payer: Universal American Medicare	$4.00
Rate for Payer: Wellcare Medicare	$4.00
Rate for Payer: Wellmed Medicare	$4.00

Protein CSF

Facility

$193.00

Service Code	HCPCS 84157
Hospital Charge Code	1605831
Hospital Revenue Code	301
Rate for Payer: Cash Price	$131.24

Protein S-Functional SO

Facility

$299.00

Service Code	HCPCS 85306
Hospital Charge Code	1708437
Hospital Revenue Code	305
Min. Negotiated Rate	$5.97
Max. Negotiated Rate	$215.28
Rate for Payer: Amerigroup CHIP/Medicaid	$5.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.32
Rate for Payer: Amerigroup Medicare	$15.32
Rate for Payer: BCBS of TX Blue Advantage	$89.70
Rate for Payer: BCBS of TX Blue Essentials	$107.64
Rate for Payer: BCBS of TX Medicare	$15.32
Rate for Payer: BCBS of TX PPO	$119.60
Rate for Payer: Cash Price	$203.32
Rate for Payer: Cash Price	$203.32
Rate for Payer: Cigna Medicaid	$215.28
Rate for Payer: Cigna Medicare	$15.32
Rate for Payer: Employer Direct Commercial	$15.32
Rate for Payer: Humana Medicare/TRICARE	$15.32
Rate for Payer: Molina CHIP/Medicaid	$215.28
Rate for Payer: Molina Dual Medicare/Medicaid	$15.32
Rate for Payer: Molina Medicare	$15.32
Rate for Payer: Multiplan Auto	$194.35
Rate for Payer: Multiplan Commercial	$194.35
Rate for Payer: Multiplan Workers Comp	$194.35
Rate for Payer: Parkland Medicaid	$215.28
Rate for Payer: Scott and White EPO/PPO	$19.15
Rate for Payer: Scott and White Medicare	$15.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$215.28
Rate for Payer: Superior Health Plan EPO	$15.32
Rate for Payer: Superior Health Plan Medicare	$15.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.32
Rate for Payer: Universal American Medicare	$15.32
Rate for Payer: Wellcare Medicare	$15.32
Rate for Payer: Wellmed Medicare	$15.32

Protein S-Functional SO

Facility

$299.00

Service Code	HCPCS 85306
Hospital Charge Code	1708437
Hospital Revenue Code	305
Rate for Payer: Cash Price	$203.32

Prothrombin complex concentrate (human), kcentra, per i.u. of factor ix activity

Facility

$3,244.55

Service Code	HCPCS J7168
Hospital Charge Code	77783483
Hospital Revenue Code	636
Min. Negotiated Rate	$811.14
Max. Negotiated Rate	$1,622.28
Rate for Payer: Cash Price	$2,206.29
Rate for Payer: Cigna Commercial	$811.14
Rate for Payer: Scott and White EPO/PPO	$1,622.28

Prothrombin complex concentrate (human), kcentra, per i.u. of factor ix activity

Facility

$3,244.55

Service Code	HCPCS J7168
Hospital Charge Code	77783483
Hospital Revenue Code	636
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$2,336.08
Rate for Payer: Amerigroup CHIP/Medicaid	$292.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.09
Rate for Payer: Amerigroup Medicare	$2.09
Rate for Payer: BCBS of TX Blue Advantage	$3.78
Rate for Payer: BCBS of TX Blue Essentials	$4.54
Rate for Payer: BCBS of TX Medicare	$2.09
Rate for Payer: BCBS of TX PPO	$5.04
Rate for Payer: Cash Price	$2,206.29
Rate for Payer: Cash Price	$2,206.29
Rate for Payer: Cigna Medicaid	$2,336.08
Rate for Payer: Cigna Medicare	$2.09
Rate for Payer: Employer Direct Commercial	$2.09
Rate for Payer: Humana Medicare/TRICARE	$2.09
Rate for Payer: Molina CHIP/Medicaid	$2,336.08
Rate for Payer: Molina Dual Medicare/Medicaid	$2.09
Rate for Payer: Molina Medicare	$2.09
Rate for Payer: Multiplan Auto	$2,108.96
Rate for Payer: Multiplan Commercial	$2,108.96
Rate for Payer: Multiplan Workers Comp	$2,108.96
Rate for Payer: Parkland Medicaid	$2,336.08
Rate for Payer: Scott and White EPO/PPO	$1,622.28
Rate for Payer: Scott and White Medicare	$2.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,336.08
Rate for Payer: Superior Health Plan EPO	$2.09
Rate for Payer: Superior Health Plan Medicare	$2.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.09
Rate for Payer: Universal American Medicare	$2.09
Rate for Payer: Wellcare Medicare	$2.09
Rate for Payer: Wellmed Medicare	$2.09

Prothrombin Time (PT)

Facility

$184.00

Service Code	HCPCS 85610
Hospital Charge Code	1600550
Hospital Revenue Code	305
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$132.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.29
Rate for Payer: Amerigroup Medicare	$4.29
Rate for Payer: BCBS of TX Blue Advantage	$55.20
Rate for Payer: BCBS of TX Blue Essentials	$66.24
Rate for Payer: BCBS of TX Medicare	$4.29
Rate for Payer: BCBS of TX PPO	$73.60
Rate for Payer: Cash Price	$125.12
Rate for Payer: Cash Price	$125.12
Rate for Payer: Cigna Medicaid	$132.48
Rate for Payer: Cigna Medicare	$4.29
Rate for Payer: Employer Direct Commercial	$4.29
Rate for Payer: Humana Medicare/TRICARE	$4.29
Rate for Payer: Molina CHIP/Medicaid	$132.48
Rate for Payer: Molina Dual Medicare/Medicaid	$4.29
Rate for Payer: Molina Medicare	$4.29
Rate for Payer: Multiplan Auto	$119.60
Rate for Payer: Multiplan Commercial	$119.60
Rate for Payer: Multiplan Workers Comp	$119.60
Rate for Payer: Parkland Medicaid	$132.48
Rate for Payer: Scott and White EPO/PPO	$5.36
Rate for Payer: Scott and White Medicare	$4.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.48
Rate for Payer: Superior Health Plan EPO	$4.29
Rate for Payer: Superior Health Plan Medicare	$4.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.29
Rate for Payer: Universal American Medicare	$4.29
Rate for Payer: Wellcare Medicare	$4.29
Rate for Payer: Wellmed Medicare	$4.29

Prothrombin Time (PT)

Facility

$184.00

Service Code	HCPCS 85610
Hospital Charge Code	1600550
Hospital Revenue Code	305
Rate for Payer: Cash Price	$125.12

PROVENT 3ML BLOOD GAS SAMPLING

Facility

$2.30

Hospital Charge Code	993629
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.56

PROVENT 3ML BLOOD GAS SAMPLING

Facility

$2.30

Hospital Charge Code	993629
Hospital Revenue Code	270
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$1.66
Rate for Payer: Amerigroup CHIP/Medicaid	$0.21
Rate for Payer: BCBS of TX Blue Advantage	$0.69
Rate for Payer: BCBS of TX Blue Essentials	$0.83
Rate for Payer: BCBS of TX PPO	$0.92
Rate for Payer: Cash Price	$1.56
Rate for Payer: Cigna Medicaid	$1.66
Rate for Payer: Molina CHIP/Medicaid	$1.66
Rate for Payer: Multiplan Auto	$1.50
Rate for Payer: Multiplan Commercial	$1.50
Rate for Payer: Multiplan Workers Comp	$1.50
Rate for Payer: Parkland Medicaid	$1.66
Rate for Payer: Scott and White EPO/PPO	$1.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.66
Rate for Payer: Superior Health Plan EPO	$0.31

Pro-Vent Plus 1 mL Dry Lithium Heparin

Facility

$53.54

Hospital Charge Code	993538
Hospital Revenue Code	270
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$38.55
Rate for Payer: Amerigroup CHIP/Medicaid	$4.82
Rate for Payer: BCBS of TX Blue Advantage	$16.06
Rate for Payer: BCBS of TX Blue Essentials	$19.27
Rate for Payer: BCBS of TX PPO	$21.42
Rate for Payer: Cash Price	$36.41
Rate for Payer: Cigna Medicaid	$38.55
Rate for Payer: Molina CHIP/Medicaid	$38.55
Rate for Payer: Multiplan Auto	$34.80
Rate for Payer: Multiplan Commercial	$34.80
Rate for Payer: Multiplan Workers Comp	$34.80
Rate for Payer: Parkland Medicaid	$38.55
Rate for Payer: Scott and White EPO/PPO	$26.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.55
Rate for Payer: Superior Health Plan EPO	$7.28

Pro-Vent Plus 1 mL Dry Lithium Heparin

Facility

$53.54

Hospital Charge Code	993538
Hospital Revenue Code	270
Rate for Payer: Cash Price	$36.41

Pro-Vent Plus Blood Sampling Kit with Luer Slip Syringe, 1 mL, 25G x 5/8', 23G x 1'

Facility

$7.74

Hospital Charge Code	993768
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.26

Pro-Vent Plus Blood Sampling Kit with Luer Slip Syringe, 1 mL, 25G x 5/8', 23G x 1'

Facility

$7.74

Hospital Charge Code	993768
Hospital Revenue Code	272
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$5.57
Rate for Payer: Amerigroup CHIP/Medicaid	$0.70
Rate for Payer: BCBS of TX Blue Advantage	$2.32
Rate for Payer: BCBS of TX Blue Essentials	$2.79
Rate for Payer: BCBS of TX PPO	$3.10
Rate for Payer: Cash Price	$5.26
Rate for Payer: Cigna Medicaid	$5.57
Rate for Payer: Molina CHIP/Medicaid	$5.57
Rate for Payer: Multiplan Auto	$5.03
Rate for Payer: Multiplan Commercial	$5.03
Rate for Payer: Multiplan Workers Comp	$5.03
Rate for Payer: Parkland Medicaid	$5.57
Rate for Payer: Scott and White EPO/PPO	$3.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.57
Rate for Payer: Superior Health Plan EPO	$1.05

Proximal Medial Tibia Plate for Left Tibia 4 Hole/L71MM

Facility

$10,485.00

Service Code	HCPCS C1776
Hospital Charge Code	145795
Hospital Revenue Code	278
Min. Negotiated Rate	$943.65
Max. Negotiated Rate	$7,549.20
Rate for Payer: Amerigroup CHIP/Medicaid	$943.65
Rate for Payer: BCBS of TX Blue Advantage	$3,145.50
Rate for Payer: BCBS of TX Blue Essentials	$3,774.60
Rate for Payer: BCBS of TX PPO	$4,194.00
Rate for Payer: Cash Price	$7,129.80
Rate for Payer: Cigna Medicaid	$7,549.20
Rate for Payer: Molina CHIP/Medicaid	$7,549.20
Rate for Payer: Multiplan Auto	$5,242.50
Rate for Payer: Multiplan Commercial	$5,242.50
Rate for Payer: Multiplan Workers Comp	$5,242.50
Rate for Payer: Parkland Medicaid	$7,549.20
Rate for Payer: Scott and White EPO/PPO	$5,242.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,549.20
Rate for Payer: Superior Health Plan EPO	$1,425.96

Proximal Medial Tibia Plate for Left Tibia 4 Hole/L71MM

Facility

$10,485.00

Service Code	HCPCS C1776
Hospital Charge Code	145795
Hospital Revenue Code	278
Min. Negotiated Rate	$2,621.25
Max. Negotiated Rate	$5,242.50
Rate for Payer: Cash Price	$7,129.80
Rate for Payer: Cigna Commercial	$2,621.25
Rate for Payer: Multiplan Auto	$5,242.50
Rate for Payer: Multiplan Commercial	$5,242.50
Rate for Payer: Multiplan Workers Comp	$5,242.50
Rate for Payer: Scott and White EPO/PPO	$5,242.50

Proximate Linear Culter, Safety Lockout

Facility

$714.38

Hospital Charge Code	992986
Hospital Revenue Code	270
Min. Negotiated Rate	$64.29
Max. Negotiated Rate	$514.35
Rate for Payer: Amerigroup CHIP/Medicaid	$64.29
Rate for Payer: BCBS of TX Blue Advantage	$214.31
Rate for Payer: BCBS of TX Blue Essentials	$257.18
Rate for Payer: BCBS of TX PPO	$285.75
Rate for Payer: Cash Price	$485.78
Rate for Payer: Cigna Medicaid	$514.35
Rate for Payer: Molina CHIP/Medicaid	$514.35
Rate for Payer: Multiplan Auto	$464.35
Rate for Payer: Multiplan Commercial	$464.35
Rate for Payer: Multiplan Workers Comp	$464.35
Rate for Payer: Parkland Medicaid	$514.35
Rate for Payer: Scott and White EPO/PPO	$357.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$514.35
Rate for Payer: Superior Health Plan EPO	$97.16

Proximate Linear Culter, Safety Lockout

Facility

$714.38

Hospital Charge Code	992986
Hospital Revenue Code	270
Rate for Payer: Cash Price	$485.78

PR PRM ST/G7 CP/VE LN/CER

Facility

$27,710.84

Service Code	HCPCS C1734
Hospital Charge Code	992139
Hospital Revenue Code	278
Min. Negotiated Rate	$2,493.98
Max. Negotiated Rate	$19,951.80
Rate for Payer: Amerigroup CHIP/Medicaid	$2,493.98
Rate for Payer: BCBS of TX Blue Advantage	$8,313.25
Rate for Payer: BCBS of TX Blue Essentials	$9,975.90
Rate for Payer: BCBS of TX PPO	$11,084.34
Rate for Payer: Cash Price	$18,843.37
Rate for Payer: Cigna Medicaid	$19,951.80
Rate for Payer: Molina CHIP/Medicaid	$19,951.80
Rate for Payer: Multiplan Auto	$13,855.42
Rate for Payer: Multiplan Commercial	$13,855.42
Rate for Payer: Multiplan Workers Comp	$13,855.42
Rate for Payer: Parkland Medicaid	$19,951.80
Rate for Payer: Scott and White EPO/PPO	$13,855.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,951.80
Rate for Payer: Superior Health Plan EPO	$3,768.67

Know your out-of-pocket cost for care.

All Charges