White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Bone Removal Screw

Facility

$3,012.05

Service Code	HCPCS C1713
Hospital Charge Code	993125
Hospital Revenue Code	278
Min. Negotiated Rate	$753.01
Max. Negotiated Rate	$1,506.03
Rate for Payer: Cash Price	$2,048.19
Rate for Payer: Cigna Commercial	$753.01
Rate for Payer: Multiplan Auto	$1,506.03
Rate for Payer: Multiplan Commercial	$1,506.03
Rate for Payer: Multiplan Workers Comp	$1,506.03
Rate for Payer: Scott and White EPO/PPO	$1,506.03

Bone Removal Screw

Facility

$3,012.05

Service Code	HCPCS C1713
Hospital Charge Code	993125
Hospital Revenue Code	278
Min. Negotiated Rate	$271.08
Max. Negotiated Rate	$2,168.68
Rate for Payer: Amerigroup CHIP/Medicaid	$271.08
Rate for Payer: BCBS of TX Blue Advantage	$903.62
Rate for Payer: BCBS of TX Blue Essentials	$1,084.34
Rate for Payer: BCBS of TX PPO	$1,204.82
Rate for Payer: Cash Price	$2,048.19
Rate for Payer: Cigna Medicaid	$2,168.68
Rate for Payer: Molina CHIP/Medicaid	$2,168.68
Rate for Payer: Multiplan Auto	$1,506.03
Rate for Payer: Multiplan Commercial	$1,506.03
Rate for Payer: Multiplan Workers Comp	$1,506.03
Rate for Payer: Parkland Medicaid	$2,168.68
Rate for Payer: Scott and White EPO/PPO	$1,506.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,168.68
Rate for Payer: Superior Health Plan EPO	$409.64

Bone Screw T10 FULL THREAD 3.5mm X L18mm

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992197
Hospital Revenue Code	278
Min. Negotiated Rate	$159.64
Max. Negotiated Rate	$319.27
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Commercial	$159.64
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Scott and White EPO/PPO	$319.27

Bone Screw T10 FULL THREAD 3.5mm X L18mm

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992197
Hospital Revenue Code	278
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$459.76
Rate for Payer: Amerigroup CHIP/Medicaid	$57.47
Rate for Payer: BCBS of TX Blue Advantage	$191.56
Rate for Payer: BCBS of TX Blue Essentials	$229.88
Rate for Payer: BCBS of TX PPO	$255.42
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Medicaid	$459.76
Rate for Payer: Molina CHIP/Medicaid	$459.76
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Parkland Medicaid	$459.76
Rate for Payer: Scott and White EPO/PPO	$319.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$459.76
Rate for Payer: Superior Health Plan EPO	$86.84

Bone Screw T10 FULL THREAD 3.5mm X L28mm

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992198
Hospital Revenue Code	278
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$459.76
Rate for Payer: Amerigroup CHIP/Medicaid	$57.47
Rate for Payer: BCBS of TX Blue Advantage	$191.56
Rate for Payer: BCBS of TX Blue Essentials	$229.88
Rate for Payer: BCBS of TX PPO	$255.42
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Medicaid	$459.76
Rate for Payer: Molina CHIP/Medicaid	$459.76
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Parkland Medicaid	$459.76
Rate for Payer: Scott and White EPO/PPO	$319.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$459.76
Rate for Payer: Superior Health Plan EPO	$86.84

Bone Screw T10 FULL THREAD 3.5mm X L28mm

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992198
Hospital Revenue Code	278
Min. Negotiated Rate	$159.64
Max. Negotiated Rate	$319.27
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Commercial	$159.64
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Scott and White EPO/PPO	$319.27

BONE VITOSS 10ML

Facility

$19,989.00

Service Code	HCPCS C1734
Hospital Charge Code	138881
Hospital Revenue Code	278
Min. Negotiated Rate	$4,997.25
Max. Negotiated Rate	$9,994.50
Rate for Payer: Cash Price	$13,592.52
Rate for Payer: Cigna Commercial	$4,997.25
Rate for Payer: Multiplan Auto	$9,994.50
Rate for Payer: Multiplan Commercial	$9,994.50
Rate for Payer: Multiplan Workers Comp	$9,994.50
Rate for Payer: Scott and White EPO/PPO	$9,994.50

BONE VITOSS 10ML

Facility

$19,989.00

Service Code	HCPCS C1734
Hospital Charge Code	138881
Hospital Revenue Code	278
Min. Negotiated Rate	$1,799.01
Max. Negotiated Rate	$14,392.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1,799.01
Rate for Payer: BCBS of TX Blue Advantage	$5,996.70
Rate for Payer: BCBS of TX Blue Essentials	$7,196.04
Rate for Payer: BCBS of TX PPO	$7,995.60
Rate for Payer: Cash Price	$13,592.52
Rate for Payer: Cigna Medicaid	$14,392.08
Rate for Payer: Molina CHIP/Medicaid	$14,392.08
Rate for Payer: Multiplan Auto	$9,994.50
Rate for Payer: Multiplan Commercial	$9,994.50
Rate for Payer: Multiplan Workers Comp	$9,994.50
Rate for Payer: Parkland Medicaid	$14,392.08
Rate for Payer: Scott and White EPO/PPO	$9,994.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,392.08
Rate for Payer: Superior Health Plan EPO	$2,718.50

BOOT BUNNY -- DHF

Facility

$915.61

Hospital Charge Code	80313851
Hospital Revenue Code	270
Rate for Payer: Cash Price	$622.61

BOOT BUNNY -- DHF

Facility

$915.61

Hospital Charge Code	80313851
Hospital Revenue Code	270
Min. Negotiated Rate	$82.40
Max. Negotiated Rate	$659.24
Rate for Payer: Amerigroup CHIP/Medicaid	$82.40
Rate for Payer: BCBS of TX Blue Advantage	$274.68
Rate for Payer: BCBS of TX Blue Essentials	$329.62
Rate for Payer: BCBS of TX PPO	$366.24
Rate for Payer: Cash Price	$622.61
Rate for Payer: Cigna Medicaid	$659.24
Rate for Payer: Molina CHIP/Medicaid	$659.24
Rate for Payer: Multiplan Auto	$595.15
Rate for Payer: Multiplan Commercial	$595.15
Rate for Payer: Multiplan Workers Comp	$595.15
Rate for Payer: Parkland Medicaid	$659.24
Rate for Payer: Scott and White EPO/PPO	$457.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$659.24
Rate for Payer: Superior Health Plan EPO	$124.52

BOOT EQUALIZER -- DHF

Facility

$928.84

Hospital Charge Code	80313968
Hospital Revenue Code	270
Min. Negotiated Rate	$83.60
Max. Negotiated Rate	$668.76
Rate for Payer: Amerigroup CHIP/Medicaid	$83.60
Rate for Payer: BCBS of TX Blue Advantage	$278.65
Rate for Payer: BCBS of TX Blue Essentials	$334.38
Rate for Payer: BCBS of TX PPO	$371.54
Rate for Payer: Cash Price	$631.61
Rate for Payer: Cigna Medicaid	$668.76
Rate for Payer: Molina CHIP/Medicaid	$668.76
Rate for Payer: Multiplan Auto	$603.75
Rate for Payer: Multiplan Commercial	$603.75
Rate for Payer: Multiplan Workers Comp	$603.75
Rate for Payer: Parkland Medicaid	$668.76
Rate for Payer: Scott and White EPO/PPO	$464.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$668.76
Rate for Payer: Superior Health Plan EPO	$126.32

BOOT EQUALIZER -- DHF

Facility

$928.84

Hospital Charge Code	80313968
Hospital Revenue Code	270
Rate for Payer: Cash Price	$631.61

BOOT HI GRD REG FULL -- DHF

Facility

$300.35

Hospital Charge Code	80313984
Hospital Revenue Code	270
Min. Negotiated Rate	$27.03
Max. Negotiated Rate	$216.25
Rate for Payer: Amerigroup CHIP/Medicaid	$27.03
Rate for Payer: BCBS of TX Blue Advantage	$90.11
Rate for Payer: BCBS of TX Blue Essentials	$108.13
Rate for Payer: BCBS of TX PPO	$120.14
Rate for Payer: Cash Price	$204.24
Rate for Payer: Cigna Medicaid	$216.25
Rate for Payer: Molina CHIP/Medicaid	$216.25
Rate for Payer: Multiplan Auto	$195.23
Rate for Payer: Multiplan Commercial	$195.23
Rate for Payer: Multiplan Workers Comp	$195.23
Rate for Payer: Parkland Medicaid	$216.25
Rate for Payer: Scott and White EPO/PPO	$150.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.25
Rate for Payer: Superior Health Plan EPO	$40.85

BOOT HI GRD REG FULL -- DHF

Facility

$300.35

Hospital Charge Code	80313984
Hospital Revenue Code	270
Rate for Payer: Cash Price	$204.24

BOSTON SCIENTIFIC RADIAL JAW 4 BIOPSY FORCEPS LARGE CAPACITY WITH NEEDLE, 2.8MM X 240CM X 2.4MM

Facility

$26.56

Hospital Charge Code	993638
Hospital Revenue Code	272
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$19.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2.39
Rate for Payer: BCBS of TX Blue Advantage	$7.97
Rate for Payer: BCBS of TX Blue Essentials	$9.56
Rate for Payer: BCBS of TX PPO	$10.62
Rate for Payer: Cash Price	$18.06
Rate for Payer: Cigna Medicaid	$19.12
Rate for Payer: Molina CHIP/Medicaid	$19.12
Rate for Payer: Multiplan Auto	$17.26
Rate for Payer: Multiplan Commercial	$17.26
Rate for Payer: Multiplan Workers Comp	$17.26
Rate for Payer: Parkland Medicaid	$19.12
Rate for Payer: Scott and White EPO/PPO	$13.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.12
Rate for Payer: Superior Health Plan EPO	$3.61

BOSTON SCIENTIFIC RADIAL JAW 4 BIOPSY FORCEPS LARGE CAPACITY WITH NEEDLE, 2.8MM X 240CM X 2.4MM

Facility

$26.56

Hospital Charge Code	993638
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18.06

BOTTLE, ENDOSCOPIC WATER W/CO2 LENS CLEANING -- DHF

Facility

$46.80

Hospital Charge Code	81777054
Hospital Revenue Code	270
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$33.70
Rate for Payer: Amerigroup CHIP/Medicaid	$4.21
Rate for Payer: BCBS of TX Blue Advantage	$14.04
Rate for Payer: BCBS of TX Blue Essentials	$16.85
Rate for Payer: BCBS of TX PPO	$18.72
Rate for Payer: Cash Price	$31.82
Rate for Payer: Cigna Medicaid	$33.70
Rate for Payer: Molina CHIP/Medicaid	$33.70
Rate for Payer: Multiplan Auto	$30.42
Rate for Payer: Multiplan Commercial	$30.42
Rate for Payer: Multiplan Workers Comp	$30.42
Rate for Payer: Parkland Medicaid	$33.70
Rate for Payer: Scott and White EPO/PPO	$23.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.70
Rate for Payer: Superior Health Plan EPO	$6.36

BOTTLE, ENDOSCOPIC WATER W/CO2 LENS CLEANING -- DHF

Facility

$46.80

Hospital Charge Code	81777054
Hospital Revenue Code	270
Rate for Payer: Cash Price	$31.82

BOTTLE VASHE WOUND IRRIGATION 34OZ

Facility

$267.13

Hospital Charge Code	80314057
Hospital Revenue Code	270
Rate for Payer: Cash Price	$181.65

BOTTLE VASHE WOUND IRRIGATION 34OZ

Facility

$267.13

Hospital Charge Code	80314057
Hospital Revenue Code	270
Min. Negotiated Rate	$24.04
Max. Negotiated Rate	$192.33
Rate for Payer: Amerigroup CHIP/Medicaid	$24.04
Rate for Payer: BCBS of TX Blue Advantage	$80.14
Rate for Payer: BCBS of TX Blue Essentials	$96.17
Rate for Payer: BCBS of TX PPO	$106.85
Rate for Payer: Cash Price	$181.65
Rate for Payer: Cigna Medicaid	$192.33
Rate for Payer: Molina CHIP/Medicaid	$192.33
Rate for Payer: Multiplan Auto	$173.63
Rate for Payer: Multiplan Commercial	$173.63
Rate for Payer: Multiplan Workers Comp	$173.63
Rate for Payer: Parkland Medicaid	$192.33
Rate for Payer: Scott and White EPO/PPO	$133.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.33
Rate for Payer: Superior Health Plan EPO	$36.33

BOUGIE, ESOPHAGEAL

Facility

$1,879.56

Hospital Charge Code	993658
Hospital Revenue Code	272
Min. Negotiated Rate	$169.16
Max. Negotiated Rate	$1,353.28
Rate for Payer: Amerigroup CHIP/Medicaid	$169.16
Rate for Payer: BCBS of TX Blue Advantage	$563.87
Rate for Payer: BCBS of TX Blue Essentials	$676.64
Rate for Payer: BCBS of TX PPO	$751.82
Rate for Payer: Cash Price	$1,278.10
Rate for Payer: Cigna Medicaid	$1,353.28
Rate for Payer: Molina CHIP/Medicaid	$1,353.28
Rate for Payer: Multiplan Auto	$1,221.71
Rate for Payer: Multiplan Commercial	$1,221.71
Rate for Payer: Multiplan Workers Comp	$1,221.71
Rate for Payer: Parkland Medicaid	$1,353.28
Rate for Payer: Scott and White EPO/PPO	$939.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,353.28
Rate for Payer: Superior Health Plan EPO	$255.62

BOUGIE, ESOPHAGEAL

Facility

$1,879.56

Hospital Charge Code	993658
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,278.10

BOUGIE ESOPHAGEAL ROUND TIP TUNGSTEN FILL 34FR

Facility

$1,879.56

Hospital Charge Code	993656
Hospital Revenue Code	270
Min. Negotiated Rate	$169.16
Max. Negotiated Rate	$1,353.28
Rate for Payer: Amerigroup CHIP/Medicaid	$169.16
Rate for Payer: BCBS of TX Blue Advantage	$563.87
Rate for Payer: BCBS of TX Blue Essentials	$676.64
Rate for Payer: BCBS of TX PPO	$751.82
Rate for Payer: Cash Price	$1,278.10
Rate for Payer: Cigna Medicaid	$1,353.28
Rate for Payer: Molina CHIP/Medicaid	$1,353.28
Rate for Payer: Multiplan Auto	$1,221.71
Rate for Payer: Multiplan Commercial	$1,221.71
Rate for Payer: Multiplan Workers Comp	$1,221.71
Rate for Payer: Parkland Medicaid	$1,353.28
Rate for Payer: Scott and White EPO/PPO	$939.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,353.28
Rate for Payer: Superior Health Plan EPO	$255.62

BOUGIE ESOPHAGEAL ROUND TIP TUNGSTEN FILL 34FR

Facility

$1,879.56

Hospital Charge Code	993656
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,278.10

BOWL MX PLC BNCMNT KIT

Facility

$843.37

Service Code	HCPCS C1734
Hospital Charge Code	992138
Hospital Revenue Code	278
Min. Negotiated Rate	$75.90
Max. Negotiated Rate	$607.23
Rate for Payer: Amerigroup CHIP/Medicaid	$75.90
Rate for Payer: BCBS of TX Blue Advantage	$253.01
Rate for Payer: BCBS of TX Blue Essentials	$303.61
Rate for Payer: BCBS of TX PPO	$337.35
Rate for Payer: Cash Price	$573.49
Rate for Payer: Cigna Medicaid	$607.23
Rate for Payer: Molina CHIP/Medicaid	$607.23
Rate for Payer: Multiplan Auto	$421.69
Rate for Payer: Multiplan Commercial	$421.69
Rate for Payer: Multiplan Workers Comp	$421.69
Rate for Payer: Parkland Medicaid	$607.23
Rate for Payer: Scott and White EPO/PPO	$421.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$607.23
Rate for Payer: Superior Health Plan EPO	$114.70

Know your out-of-pocket cost for care.

All Charges