White Rock Medical Center

All Charges

Charge

Type

Setting

Price

0.025cm J-Wire

Facility

$221.32

Service Code	HCPCS C1769
Hospital Charge Code	992476
Hospital Revenue Code	272
Min. Negotiated Rate	$19.92
Max. Negotiated Rate	$159.35
Rate for Payer: Amerigroup CHIP/Medicaid	$19.92
Rate for Payer: BCBS of TX Blue Advantage	$66.40
Rate for Payer: BCBS of TX Blue Essentials	$79.68
Rate for Payer: BCBS of TX PPO	$88.53
Rate for Payer: Cash Price	$150.50
Rate for Payer: Cigna Medicaid	$159.35
Rate for Payer: Molina CHIP/Medicaid	$159.35
Rate for Payer: Multiplan Auto	$143.86
Rate for Payer: Multiplan Commercial	$143.86
Rate for Payer: Multiplan Workers Comp	$143.86
Rate for Payer: Parkland Medicaid	$159.35
Rate for Payer: Scott and White EPO/PPO	$110.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$159.35
Rate for Payer: Superior Health Plan EPO	$30.10

0.025cm J-Wire

Facility

$221.32

Service Code	HCPCS C1769
Hospital Charge Code	992476
Hospital Revenue Code	272
Rate for Payer: Cash Price	$150.50

0.035 150cm J Wire

Facility

$221.32

Service Code	HCPCS C1769
Hospital Charge Code	992475
Hospital Revenue Code	272
Min. Negotiated Rate	$19.92
Max. Negotiated Rate	$159.35
Rate for Payer: Amerigroup CHIP/Medicaid	$19.92
Rate for Payer: BCBS of TX Blue Advantage	$66.40
Rate for Payer: BCBS of TX Blue Essentials	$79.68
Rate for Payer: BCBS of TX PPO	$88.53
Rate for Payer: Cash Price	$150.50
Rate for Payer: Cigna Medicaid	$159.35
Rate for Payer: Molina CHIP/Medicaid	$159.35
Rate for Payer: Multiplan Auto	$143.86
Rate for Payer: Multiplan Commercial	$143.86
Rate for Payer: Multiplan Workers Comp	$143.86
Rate for Payer: Parkland Medicaid	$159.35
Rate for Payer: Scott and White EPO/PPO	$110.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$159.35
Rate for Payer: Superior Health Plan EPO	$30.10

0.035 150cm J Wire

Facility

$221.32

Service Code	HCPCS C1769
Hospital Charge Code	992475
Hospital Revenue Code	272
Rate for Payer: Cash Price	$150.50

0.035 260cm J-Wire

Facility

$221.32

Service Code	HCPCS C1769
Hospital Charge Code	992474
Hospital Revenue Code	272
Rate for Payer: Cash Price	$150.50

0.035 260cm J-Wire

Facility

$221.32

Service Code	HCPCS C1769
Hospital Charge Code	992474
Hospital Revenue Code	272
Min. Negotiated Rate	$19.92
Max. Negotiated Rate	$159.35
Rate for Payer: Amerigroup CHIP/Medicaid	$19.92
Rate for Payer: BCBS of TX Blue Advantage	$66.40
Rate for Payer: BCBS of TX Blue Essentials	$79.68
Rate for Payer: BCBS of TX PPO	$88.53
Rate for Payer: Cash Price	$150.50
Rate for Payer: Cigna Medicaid	$159.35
Rate for Payer: Molina CHIP/Medicaid	$159.35
Rate for Payer: Multiplan Auto	$143.86
Rate for Payer: Multiplan Commercial	$143.86
Rate for Payer: Multiplan Workers Comp	$143.86
Rate for Payer: Parkland Medicaid	$159.35
Rate for Payer: Scott and White EPO/PPO	$110.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$159.35
Rate for Payer: Superior Health Plan EPO	$30.10

0227-8510S

Facility

$4,246.99

Service Code	HCPCS C1713
Hospital Charge Code	991181
Hospital Revenue Code	278
Min. Negotiated Rate	$1,061.75
Max. Negotiated Rate	$2,123.49
Rate for Payer: Cash Price	$2,887.95
Rate for Payer: Cigna Commercial	$1,061.75
Rate for Payer: Multiplan Auto	$2,123.49
Rate for Payer: Multiplan Commercial	$2,123.49
Rate for Payer: Multiplan Workers Comp	$2,123.49
Rate for Payer: Scott and White EPO/PPO	$2,123.49

0227-8510S

Facility

$4,246.99

Service Code	HCPCS C1713
Hospital Charge Code	991181
Hospital Revenue Code	278
Min. Negotiated Rate	$382.23
Max. Negotiated Rate	$3,057.83
Rate for Payer: Amerigroup CHIP/Medicaid	$382.23
Rate for Payer: BCBS of TX Blue Advantage	$1,274.10
Rate for Payer: BCBS of TX Blue Essentials	$1,528.92
Rate for Payer: BCBS of TX PPO	$1,698.80
Rate for Payer: Cash Price	$2,887.95
Rate for Payer: Cigna Medicaid	$3,057.83
Rate for Payer: Molina CHIP/Medicaid	$3,057.83
Rate for Payer: Multiplan Auto	$2,123.49
Rate for Payer: Multiplan Commercial	$2,123.49
Rate for Payer: Multiplan Workers Comp	$2,123.49
Rate for Payer: Parkland Medicaid	$3,057.83
Rate for Payer: Scott and White EPO/PPO	$2,123.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,057.83
Rate for Payer: Superior Health Plan EPO	$577.59

082724.23A

Facility

$96,386.00

Service Code	HCPCS C1776
Hospital Charge Code	991042
Hospital Revenue Code	278
Min. Negotiated Rate	$8,674.74
Max. Negotiated Rate	$69,397.92
Rate for Payer: Amerigroup CHIP/Medicaid	$8,674.74
Rate for Payer: BCBS of TX Blue Advantage	$28,915.80
Rate for Payer: BCBS of TX Blue Essentials	$34,698.96
Rate for Payer: BCBS of TX PPO	$38,554.40
Rate for Payer: Cash Price	$65,542.48
Rate for Payer: Cigna Medicaid	$69,397.92
Rate for Payer: Molina CHIP/Medicaid	$69,397.92
Rate for Payer: Multiplan Auto	$48,193.00
Rate for Payer: Multiplan Commercial	$48,193.00
Rate for Payer: Multiplan Workers Comp	$48,193.00
Rate for Payer: Parkland Medicaid	$69,397.92
Rate for Payer: Scott and White EPO/PPO	$48,193.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69,397.92
Rate for Payer: Superior Health Plan EPO	$13,108.50

082724.23A

Facility

$96,386.00

Service Code	HCPCS C1776
Hospital Charge Code	991042
Hospital Revenue Code	278
Min. Negotiated Rate	$24,096.50
Max. Negotiated Rate	$48,193.00
Rate for Payer: Cash Price	$65,542.48
Rate for Payer: Cigna Commercial	$24,096.50
Rate for Payer: Multiplan Auto	$48,193.00
Rate for Payer: Multiplan Commercial	$48,193.00
Rate for Payer: Multiplan Workers Comp	$48,193.00
Rate for Payer: Scott and White EPO/PPO	$48,193.00

%09 V-LOC NON ABSORB 0 SUTURE 9' GS-22

Facility

$147.10

Hospital Charge Code	992689
Hospital Revenue Code	272
Rate for Payer: Cash Price	$100.03

%09 V-LOC NON ABSORB 0 SUTURE 9' GS-22

Facility

$147.10

Hospital Charge Code	992689
Hospital Revenue Code	272
Min. Negotiated Rate	$13.24
Max. Negotiated Rate	$105.91
Rate for Payer: Amerigroup CHIP/Medicaid	$13.24
Rate for Payer: BCBS of TX Blue Advantage	$44.13
Rate for Payer: BCBS of TX Blue Essentials	$52.96
Rate for Payer: BCBS of TX PPO	$58.84
Rate for Payer: Cash Price	$100.03
Rate for Payer: Cigna Medicaid	$105.91
Rate for Payer: Molina CHIP/Medicaid	$105.91
Rate for Payer: Multiplan Auto	$95.61
Rate for Payer: Multiplan Commercial	$95.61
Rate for Payer: Multiplan Workers Comp	$95.61
Rate for Payer: Parkland Medicaid	$105.91
Rate for Payer: Scott and White EPO/PPO	$73.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$105.91
Rate for Payer: Superior Health Plan EPO	$20.01

#0 fiberwire

Facility

$1,724.10

Hospital Charge Code	992165
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,172.39

#0 fiberwire

Facility

$1,724.10

Hospital Charge Code	992165
Hospital Revenue Code	272
Min. Negotiated Rate	$155.17
Max. Negotiated Rate	$1,241.35
Rate for Payer: Amerigroup CHIP/Medicaid	$155.17
Rate for Payer: BCBS of TX Blue Advantage	$517.23
Rate for Payer: BCBS of TX Blue Essentials	$620.68
Rate for Payer: BCBS of TX PPO	$689.64
Rate for Payer: Cash Price	$1,172.39
Rate for Payer: Cigna Medicaid	$1,241.35
Rate for Payer: Molina CHIP/Medicaid	$1,241.35
Rate for Payer: Multiplan Auto	$1,120.66
Rate for Payer: Multiplan Commercial	$1,120.66
Rate for Payer: Multiplan Workers Comp	$1,120.66
Rate for Payer: Parkland Medicaid	$1,241.35
Rate for Payer: Scott and White EPO/PPO	$862.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,241.35
Rate for Payer: Superior Health Plan EPO	$234.48

100824.06B

Facility

$96,385.54

Service Code	HCPCS C1734
Hospital Charge Code	992002
Hospital Revenue Code	278
Min. Negotiated Rate	$8,674.70
Max. Negotiated Rate	$69,397.59
Rate for Payer: Amerigroup CHIP/Medicaid	$8,674.70
Rate for Payer: BCBS of TX Blue Advantage	$28,915.66
Rate for Payer: BCBS of TX Blue Essentials	$34,698.79
Rate for Payer: BCBS of TX PPO	$38,554.22
Rate for Payer: Cash Price	$65,542.17
Rate for Payer: Cigna Medicaid	$69,397.59
Rate for Payer: Molina CHIP/Medicaid	$69,397.59
Rate for Payer: Multiplan Auto	$48,192.77
Rate for Payer: Multiplan Commercial	$48,192.77
Rate for Payer: Multiplan Workers Comp	$48,192.77
Rate for Payer: Parkland Medicaid	$69,397.59
Rate for Payer: Scott and White EPO/PPO	$48,192.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69,397.59
Rate for Payer: Superior Health Plan EPO	$13,108.43

100824.06B

Facility

$96,385.54

Service Code	HCPCS C1734
Hospital Charge Code	992002
Hospital Revenue Code	278
Min. Negotiated Rate	$24,096.38
Max. Negotiated Rate	$48,192.77
Rate for Payer: Cash Price	$65,542.17
Rate for Payer: Cigna Commercial	$24,096.38
Rate for Payer: Multiplan Auto	$48,192.77
Rate for Payer: Multiplan Commercial	$48,192.77
Rate for Payer: Multiplan Workers Comp	$48,192.77
Rate for Payer: Scott and White EPO/PPO	$48,192.77

100MM, RED, GUEDEL, AIRWAY

Facility

$1.46

Hospital Charge Code	993727
Hospital Revenue Code	272
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$1.05
Rate for Payer: Amerigroup CHIP/Medicaid	$0.13
Rate for Payer: BCBS of TX Blue Advantage	$0.44
Rate for Payer: BCBS of TX Blue Essentials	$0.53
Rate for Payer: BCBS of TX PPO	$0.58
Rate for Payer: Cash Price	$0.99
Rate for Payer: Cigna Medicaid	$1.05
Rate for Payer: Molina CHIP/Medicaid	$1.05
Rate for Payer: Multiplan Auto	$0.95
Rate for Payer: Multiplan Commercial	$0.95
Rate for Payer: Multiplan Workers Comp	$0.95
Rate for Payer: Parkland Medicaid	$1.05
Rate for Payer: Scott and White EPO/PPO	$0.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.05
Rate for Payer: Superior Health Plan EPO	$0.20

100MM, RED, GUEDEL, AIRWAY

Facility

$1.46

Hospital Charge Code	993727
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.99

100NX PM1 KIT

Facility

$2,252.43

Hospital Charge Code	992743
Hospital Revenue Code	270
Min. Negotiated Rate	$202.72
Max. Negotiated Rate	$1,621.75
Rate for Payer: Amerigroup CHIP/Medicaid	$202.72
Rate for Payer: BCBS of TX Blue Advantage	$675.73
Rate for Payer: BCBS of TX Blue Essentials	$810.87
Rate for Payer: BCBS of TX PPO	$900.97
Rate for Payer: Cash Price	$1,531.65
Rate for Payer: Cigna Medicaid	$1,621.75
Rate for Payer: Molina CHIP/Medicaid	$1,621.75
Rate for Payer: Multiplan Auto	$1,464.08
Rate for Payer: Multiplan Commercial	$1,464.08
Rate for Payer: Multiplan Workers Comp	$1,464.08
Rate for Payer: Parkland Medicaid	$1,621.75
Rate for Payer: Scott and White EPO/PPO	$1,126.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,621.75
Rate for Payer: Superior Health Plan EPO	$306.33

100NX PM1 KIT

Facility

$2,252.43

Hospital Charge Code	992743
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,531.65

10mm Acorn Reamer

Facility

$2,142.88

Hospital Charge Code	992672
Hospital Revenue Code	272
Min. Negotiated Rate	$192.86
Max. Negotiated Rate	$1,542.87
Rate for Payer: Amerigroup CHIP/Medicaid	$192.86
Rate for Payer: BCBS of TX Blue Advantage	$642.86
Rate for Payer: BCBS of TX Blue Essentials	$771.44
Rate for Payer: BCBS of TX PPO	$857.15
Rate for Payer: Cash Price	$1,457.16
Rate for Payer: Cigna Medicaid	$1,542.87
Rate for Payer: Molina CHIP/Medicaid	$1,542.87
Rate for Payer: Multiplan Auto	$1,392.87
Rate for Payer: Multiplan Commercial	$1,392.87
Rate for Payer: Multiplan Workers Comp	$1,392.87
Rate for Payer: Parkland Medicaid	$1,542.87
Rate for Payer: Scott and White EPO/PPO	$1,071.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,542.87
Rate for Payer: Superior Health Plan EPO	$291.43

10mm Acorn Reamer

Facility

$2,142.88

Hospital Charge Code	992672
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,457.16

10mm Flutled Reamer

Facility

$2,142.88

Hospital Charge Code	992673
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,457.16

10mm Flutled Reamer

Facility

$2,142.88

Hospital Charge Code	992673
Hospital Revenue Code	272
Min. Negotiated Rate	$192.86
Max. Negotiated Rate	$1,542.87
Rate for Payer: Amerigroup CHIP/Medicaid	$192.86
Rate for Payer: BCBS of TX Blue Advantage	$642.86
Rate for Payer: BCBS of TX Blue Essentials	$771.44
Rate for Payer: BCBS of TX PPO	$857.15
Rate for Payer: Cash Price	$1,457.16
Rate for Payer: Cigna Medicaid	$1,542.87
Rate for Payer: Molina CHIP/Medicaid	$1,542.87
Rate for Payer: Multiplan Auto	$1,392.87
Rate for Payer: Multiplan Commercial	$1,392.87
Rate for Payer: Multiplan Workers Comp	$1,392.87
Rate for Payer: Parkland Medicaid	$1,542.87
Rate for Payer: Scott and White EPO/PPO	$1,071.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,542.87
Rate for Payer: Superior Health Plan EPO	$291.43

10 x 30mm Intrafix Adv

Facility

$5,439.76

Service Code	HCPCS C1713
Hospital Charge Code	992194
Hospital Revenue Code	278
Min. Negotiated Rate	$489.58
Max. Negotiated Rate	$3,916.63
Rate for Payer: Amerigroup CHIP/Medicaid	$489.58
Rate for Payer: BCBS of TX Blue Advantage	$1,631.93
Rate for Payer: BCBS of TX Blue Essentials	$1,958.31
Rate for Payer: BCBS of TX PPO	$2,175.90
Rate for Payer: Cash Price	$3,699.04
Rate for Payer: Cigna Medicaid	$3,916.63
Rate for Payer: Molina CHIP/Medicaid	$3,916.63
Rate for Payer: Multiplan Auto	$2,719.88
Rate for Payer: Multiplan Commercial	$2,719.88
Rate for Payer: Multiplan Workers Comp	$2,719.88
Rate for Payer: Parkland Medicaid	$3,916.63
Rate for Payer: Scott and White EPO/PPO	$2,719.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,916.63
Rate for Payer: Superior Health Plan EPO	$739.81

Know your out-of-pocket cost for care.

All Charges