White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Pulmonary Rehab w/o Cont Oximetry Monitoring BCE

Facility

$56.25

Service Code	HCPCS 94625
Hospital Charge Code	8846559
Hospital Revenue Code	948
Rate for Payer: Cash Price	$38.25

punch poplok 4.5

Facility

$1,385.56

Hospital Charge Code	8646516
Hospital Revenue Code	272
Min. Negotiated Rate	$124.70
Max. Negotiated Rate	$997.60
Rate for Payer: Amerigroup CHIP/Medicaid	$124.70
Rate for Payer: BCBS of TX Blue Advantage	$415.67
Rate for Payer: BCBS of TX Blue Essentials	$498.80
Rate for Payer: BCBS of TX PPO	$554.22
Rate for Payer: Cash Price	$942.18
Rate for Payer: Cigna Medicaid	$997.60
Rate for Payer: Molina CHIP/Medicaid	$997.60
Rate for Payer: Multiplan Auto	$900.61
Rate for Payer: Multiplan Commercial	$900.61
Rate for Payer: Multiplan Workers Comp	$900.61
Rate for Payer: Parkland Medicaid	$997.60
Rate for Payer: Scott and White EPO/PPO	$692.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$997.60
Rate for Payer: Superior Health Plan EPO	$188.44

punch poplok 4.5

Facility

$1,385.56

Hospital Charge Code	8646516
Hospital Revenue Code	272
Rate for Payer: Cash Price	$942.18

PUNCTURE DRAINAGE OF LESION

Facility

$895.00

Service Code	HCPCS 10160
Hospital Charge Code	7150113
Hospital Revenue Code	761
Min. Negotiated Rate	$80.55
Max. Negotiated Rate	$863.21
Rate for Payer: Amerigroup CHIP/Medicaid	$80.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$139.23
Rate for Payer: BCBS of TX Blue Essentials	$166.74
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$210.09
Rate for Payer: Cash Price	$608.60
Rate for Payer: Cash Price	$608.60
Rate for Payer: Cash Price	$608.60
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$644.40
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$644.40
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$581.75
Rate for Payer: Multiplan Commercial	$581.75
Rate for Payer: Multiplan Workers Comp	$581.75
Rate for Payer: Parkland Medicaid	$644.40
Rate for Payer: Scott and White EPO/PPO	$119.30
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$644.40
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

PUNCTURE DRAINAGE OF LESION

Facility

$895.00

Service Code	HCPCS 10160
Hospital Charge Code	7150113
Hospital Revenue Code	761
Rate for Payer: Cash Price	$608.60

Puncture of shunt tubing or reservoir for aspiration or injection procedure

Facility

$2,855.66

Service Code	HCPCS 61070
Hospital Charge Code	9900737
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,941.85

Puncture of shunt tubing or reservoir for aspiration or injection procedure

Facility

$2,855.66

Service Code	HCPCS 61070
Hospital Charge Code	9900737
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$1,941.85
Rate for Payer: Cash Price	$1,941.85
Rate for Payer: Cash Price	$1,941.85
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$2,056.08
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$2,056.08
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$2,056.08
Rate for Payer: Scott and White EPO/PPO	$1,170.03
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,056.08
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

Puncture of shunt tubing or reservoir for aspiration or injection procedure

Facility

$10,000.00

Service Code	CPT 61070
Hospital Charge Code	36061070
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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: Scott and White EPO/PPO	$1,170.03
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

PUTTY DBM 5CC

Facility

$3,519.00

Service Code	HCPCS C9359
Hospital Charge Code	146444
Hospital Revenue Code	278
Min. Negotiated Rate	$316.71
Max. Negotiated Rate	$2,533.68
Rate for Payer: Amerigroup CHIP/Medicaid	$316.71
Rate for Payer: BCBS of TX Blue Advantage	$1,055.70
Rate for Payer: BCBS of TX Blue Essentials	$1,266.84
Rate for Payer: BCBS of TX PPO	$1,407.60
Rate for Payer: Cash Price	$2,392.92
Rate for Payer: Cigna Medicaid	$2,533.68
Rate for Payer: Molina CHIP/Medicaid	$2,533.68
Rate for Payer: Multiplan Auto	$1,759.50
Rate for Payer: Multiplan Commercial	$1,759.50
Rate for Payer: Multiplan Workers Comp	$1,759.50
Rate for Payer: Parkland Medicaid	$2,533.68
Rate for Payer: Scott and White EPO/PPO	$1,759.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,533.68
Rate for Payer: Superior Health Plan EPO	$478.58

PUTTY DBM 5CC

Facility

$18,046.87

Service Code	HCPCS C9359
Hospital Charge Code	992200
Hospital Revenue Code	278
Min. Negotiated Rate	$1,624.22
Max. Negotiated Rate	$12,993.75
Rate for Payer: Amerigroup CHIP/Medicaid	$1,624.22
Rate for Payer: BCBS of TX Blue Advantage	$5,414.06
Rate for Payer: BCBS of TX Blue Essentials	$6,496.87
Rate for Payer: BCBS of TX PPO	$7,218.75
Rate for Payer: Cash Price	$12,271.87
Rate for Payer: Cigna Medicaid	$12,993.75
Rate for Payer: Molina CHIP/Medicaid	$12,993.75
Rate for Payer: Multiplan Auto	$9,023.43
Rate for Payer: Multiplan Commercial	$9,023.43
Rate for Payer: Multiplan Workers Comp	$9,023.43
Rate for Payer: Parkland Medicaid	$12,993.75
Rate for Payer: Scott and White EPO/PPO	$9,023.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,993.75
Rate for Payer: Superior Health Plan EPO	$2,454.37

PUTTY DBM 5CC

Facility

$3,519.00

Service Code	HCPCS C9359
Hospital Charge Code	146444
Hospital Revenue Code	278
Min. Negotiated Rate	$879.75
Max. Negotiated Rate	$1,759.50
Rate for Payer: Cash Price	$2,392.92
Rate for Payer: Cigna Commercial	$879.75
Rate for Payer: Multiplan Auto	$1,759.50
Rate for Payer: Multiplan Commercial	$1,759.50
Rate for Payer: Multiplan Workers Comp	$1,759.50
Rate for Payer: Scott and White EPO/PPO	$1,759.50

PUTTY DBM 5CC

Facility

$18,046.87

Service Code	HCPCS C9359
Hospital Charge Code	992200
Hospital Revenue Code	278
Min. Negotiated Rate	$4,511.72
Max. Negotiated Rate	$9,023.43
Rate for Payer: Cash Price	$12,271.87
Rate for Payer: Cigna Commercial	$4,511.72
Rate for Payer: Multiplan Auto	$9,023.43
Rate for Payer: Multiplan Commercial	$9,023.43
Rate for Payer: Multiplan Workers Comp	$9,023.43
Rate for Payer: Scott and White EPO/PPO	$9,023.43

PVY0901X

Facility

$1,618.92

Service Code	HCPCS C1781
Hospital Charge Code	991200
Hospital Revenue Code	272
Min. Negotiated Rate	$145.70
Max. Negotiated Rate	$1,165.62
Rate for Payer: Amerigroup CHIP/Medicaid	$145.70
Rate for Payer: BCBS of TX Blue Advantage	$485.68
Rate for Payer: BCBS of TX Blue Essentials	$582.81
Rate for Payer: BCBS of TX PPO	$647.57
Rate for Payer: Cash Price	$1,100.87
Rate for Payer: Cigna Medicaid	$1,165.62
Rate for Payer: Molina CHIP/Medicaid	$1,165.62
Rate for Payer: Multiplan Auto	$1,052.30
Rate for Payer: Multiplan Commercial	$1,052.30
Rate for Payer: Multiplan Workers Comp	$1,052.30
Rate for Payer: Parkland Medicaid	$1,165.62
Rate for Payer: Scott and White EPO/PPO	$809.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,165.62
Rate for Payer: Superior Health Plan EPO	$220.17

PVY0901X

Facility

$1,618.92

Service Code	HCPCS C1781
Hospital Charge Code	991200
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,100.87

pyridostigmine 60 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77788218
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

pyridostigmine 60 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77788218
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Quadricepsplasty (eg, Bennett or Thompson type)

Facility

$38,382.30

Service Code	HCPCS 27430
Hospital Charge Code	9900407
Hospital Revenue Code	360
Rate for Payer: Cash Price	$26,099.96

Quadricepsplasty (eg, Bennett or Thompson type)

Facility

$38,382.30

Service Code	HCPCS 27430
Hospital Charge Code	9900407
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$27,635.26
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$26,099.96
Rate for Payer: Cash Price	$26,099.96
Rate for Payer: Cash Price	$26,099.96
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$27,635.26
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$27,635.26
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$27,635.26
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,635.26
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Quadricepsplasty (eg, Bennett or Thompson type)

Facility

$15,408.22

Service Code	CPT 27430
Hospital Charge Code	36027430
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

QuantiFERON-TB Gold Plus SO

Facility

$234.00

Service Code	HCPCS 86480
Hospital Charge Code	1620046
Hospital Revenue Code	302
Rate for Payer: Cash Price	$159.12

QuantiFERON-TB Gold Plus SO

Facility

$234.00

Service Code	HCPCS 86480
Hospital Charge Code	1620046
Hospital Revenue Code	302
Min. Negotiated Rate	$24.17
Max. Negotiated Rate	$168.48
Rate for Payer: Amerigroup CHIP/Medicaid	$24.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$61.98
Rate for Payer: Amerigroup Medicare	$61.98
Rate for Payer: BCBS of TX Blue Advantage	$70.20
Rate for Payer: BCBS of TX Blue Essentials	$84.24
Rate for Payer: BCBS of TX Medicare	$61.98
Rate for Payer: BCBS of TX PPO	$93.60
Rate for Payer: Cash Price	$159.12
Rate for Payer: Cash Price	$159.12
Rate for Payer: Cigna Medicaid	$168.48
Rate for Payer: Cigna Medicare	$61.98
Rate for Payer: Employer Direct Commercial	$61.98
Rate for Payer: Humana Medicare/TRICARE	$61.98
Rate for Payer: Molina CHIP/Medicaid	$168.48
Rate for Payer: Molina Dual Medicare/Medicaid	$61.98
Rate for Payer: Molina Medicare	$61.98
Rate for Payer: Multiplan Auto	$152.10
Rate for Payer: Multiplan Commercial	$152.10
Rate for Payer: Multiplan Workers Comp	$152.10
Rate for Payer: Parkland Medicaid	$168.48
Rate for Payer: Scott and White EPO/PPO	$77.47
Rate for Payer: Scott and White Medicare	$61.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$168.48
Rate for Payer: Superior Health Plan EPO	$61.98
Rate for Payer: Superior Health Plan Medicare	$61.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$61.98
Rate for Payer: Universal American Medicare	$61.98
Rate for Payer: Wellcare Medicare	$61.98
Rate for Payer: Wellmed Medicare	$61.98

QUEtiapine 100 mg Tab

Facility

$49.90

Service Code	HCPCS J3490
Hospital Charge Code	77789050
Hospital Revenue Code	250
Rate for Payer: Cash Price	$33.93

QUEtiapine 100 mg Tab

Facility

$49.90

Service Code	HCPCS J3490
Hospital Charge Code	77789050
Hospital Revenue Code	250
Min. Negotiated Rate	$4.49
Max. Negotiated Rate	$35.93
Rate for Payer: Amerigroup CHIP/Medicaid	$4.49
Rate for Payer: BCBS of TX Blue Advantage	$14.97
Rate for Payer: BCBS of TX Blue Essentials	$17.96
Rate for Payer: BCBS of TX PPO	$19.96
Rate for Payer: Cash Price	$33.93
Rate for Payer: Cigna Medicaid	$35.93
Rate for Payer: Molina CHIP/Medicaid	$35.93
Rate for Payer: Multiplan Auto	$32.44
Rate for Payer: Multiplan Commercial	$32.44
Rate for Payer: Multiplan Workers Comp	$32.44
Rate for Payer: Parkland Medicaid	$35.93
Rate for Payer: Scott and White EPO/PPO	$24.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.93
Rate for Payer: Superior Health Plan EPO	$6.79

QUEtiapine 25 mg Tab

Facility

$17.35

Service Code	HCPCS J3490
Hospital Charge Code	77789254
Hospital Revenue Code	250
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$12.49
Rate for Payer: Amerigroup CHIP/Medicaid	$1.56
Rate for Payer: BCBS of TX Blue Advantage	$5.21
Rate for Payer: BCBS of TX Blue Essentials	$6.25
Rate for Payer: BCBS of TX PPO	$6.94
Rate for Payer: Cash Price	$11.80
Rate for Payer: Cigna Medicaid	$12.49
Rate for Payer: Molina CHIP/Medicaid	$12.49
Rate for Payer: Multiplan Auto	$11.28
Rate for Payer: Multiplan Commercial	$11.28
Rate for Payer: Multiplan Workers Comp	$11.28
Rate for Payer: Parkland Medicaid	$12.49
Rate for Payer: Scott and White EPO/PPO	$8.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.49
Rate for Payer: Superior Health Plan EPO	$2.36

QUEtiapine 25 mg Tab

Facility

$17.35

Service Code	HCPCS J3490
Hospital Charge Code	77789254
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.80

Know your out-of-pocket cost for care.

All Charges