White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CA 19-9 SO

Facility

$300.00

Service Code	HCPCS 86301
Hospital Charge Code	1706258
Hospital Revenue Code	302
Rate for Payer: Cash Price	$204.00

CABLE 301-CD

Facility

$202.71

Hospital Charge Code	145067
Hospital Revenue Code	272
Rate for Payer: Cash Price	$137.84

CABLE 301-CD

Facility

$202.71

Hospital Charge Code	145067
Hospital Revenue Code	272
Min. Negotiated Rate	$18.24
Max. Negotiated Rate	$145.95
Rate for Payer: Amerigroup CHIP/Medicaid	$18.24
Rate for Payer: BCBS of TX Blue Advantage	$60.81
Rate for Payer: BCBS of TX Blue Essentials	$72.98
Rate for Payer: BCBS of TX PPO	$81.08
Rate for Payer: Cash Price	$137.84
Rate for Payer: Cigna Medicaid	$145.95
Rate for Payer: Molina CHIP/Medicaid	$145.95
Rate for Payer: Multiplan Auto	$131.76
Rate for Payer: Multiplan Commercial	$131.76
Rate for Payer: Multiplan Workers Comp	$131.76
Rate for Payer: Parkland Medicaid	$145.95
Rate for Payer: Scott and White EPO/PPO	$101.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.95
Rate for Payer: Superior Health Plan EPO	$27.57

CABLE 5833SL SURGICAL DISP SM CLIP 12FT

Facility

$238.35

Hospital Charge Code	993853
Hospital Revenue Code	272
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$171.61
Rate for Payer: Amerigroup CHIP/Medicaid	$21.45
Rate for Payer: BCBS of TX Blue Advantage	$71.50
Rate for Payer: BCBS of TX Blue Essentials	$85.81
Rate for Payer: BCBS of TX PPO	$95.34
Rate for Payer: Cash Price	$162.08
Rate for Payer: Cigna Medicaid	$171.61
Rate for Payer: Molina CHIP/Medicaid	$171.61
Rate for Payer: Multiplan Auto	$154.93
Rate for Payer: Multiplan Commercial	$154.93
Rate for Payer: Multiplan Workers Comp	$154.93
Rate for Payer: Parkland Medicaid	$171.61
Rate for Payer: Scott and White EPO/PPO	$119.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$171.61
Rate for Payer: Superior Health Plan EPO	$32.42

CABLE 5833SL SURGICAL DISP SM CLIP 12FT

Facility

$238.35

Hospital Charge Code	993853
Hospital Revenue Code	272
Rate for Payer: Cash Price	$162.08

CABLE, CONNECTING, 400 SERIES, C400MP-M C02

Facility

$121.08

Hospital Charge Code	992887
Hospital Revenue Code	272
Rate for Payer: Cash Price	$82.33

CABLE, CONNECTING, 400 SERIES, C400MP-M C02

Facility

$121.08

Hospital Charge Code	992887
Hospital Revenue Code	272
Min. Negotiated Rate	$10.90
Max. Negotiated Rate	$87.18
Rate for Payer: Amerigroup CHIP/Medicaid	$10.90
Rate for Payer: BCBS of TX Blue Advantage	$36.32
Rate for Payer: BCBS of TX Blue Essentials	$43.59
Rate for Payer: BCBS of TX PPO	$48.43
Rate for Payer: Cash Price	$82.33
Rate for Payer: Cigna Medicaid	$87.18
Rate for Payer: Molina CHIP/Medicaid	$87.18
Rate for Payer: Multiplan Auto	$78.70
Rate for Payer: Multiplan Commercial	$78.70
Rate for Payer: Multiplan Workers Comp	$78.70
Rate for Payer: Parkland Medicaid	$87.18
Rate for Payer: Scott and White EPO/PPO	$60.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$87.18
Rate for Payer: Superior Health Plan EPO	$16.47

Cable CPM ECG Patient Harness, US

Facility

$2,265.46

Hospital Charge Code	993838
Hospital Revenue Code	279
Min. Negotiated Rate	$203.89
Max. Negotiated Rate	$1,631.13
Rate for Payer: Amerigroup CHIP/Medicaid	$203.89
Rate for Payer: BCBS of TX Blue Advantage	$679.64
Rate for Payer: BCBS of TX Blue Essentials	$815.57
Rate for Payer: BCBS of TX PPO	$906.18
Rate for Payer: Cash Price	$1,540.51
Rate for Payer: Cigna Medicaid	$1,631.13
Rate for Payer: Molina CHIP/Medicaid	$1,631.13
Rate for Payer: Multiplan Auto	$1,472.55
Rate for Payer: Multiplan Commercial	$1,472.55
Rate for Payer: Multiplan Workers Comp	$1,472.55
Rate for Payer: Parkland Medicaid	$1,631.13
Rate for Payer: Scott and White EPO/PPO	$1,132.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,631.13
Rate for Payer: Superior Health Plan EPO	$308.10

Cable CPM ECG Patient Harness, US

Facility

$2,265.46

Hospital Charge Code	993838
Hospital Revenue Code	279
Rate for Payer: Cash Price	$1,540.51

CABLE PACING

Facility

$136.20

Hospital Charge Code	8414452
Hospital Revenue Code	272
Rate for Payer: Cash Price	$92.62

CABLE PACING

Facility

$136.20

Hospital Charge Code	8414452
Hospital Revenue Code	272
Min. Negotiated Rate	$12.26
Max. Negotiated Rate	$98.06
Rate for Payer: Amerigroup CHIP/Medicaid	$12.26
Rate for Payer: BCBS of TX Blue Advantage	$40.86
Rate for Payer: BCBS of TX Blue Essentials	$49.03
Rate for Payer: BCBS of TX PPO	$54.48
Rate for Payer: Cash Price	$92.62
Rate for Payer: Cigna Medicaid	$98.06
Rate for Payer: Molina CHIP/Medicaid	$98.06
Rate for Payer: Multiplan Auto	$88.53
Rate for Payer: Multiplan Commercial	$88.53
Rate for Payer: Multiplan Workers Comp	$88.53
Rate for Payer: Parkland Medicaid	$98.06
Rate for Payer: Scott and White EPO/PPO	$68.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.06
Rate for Payer: Superior Health Plan EPO	$18.52

CABLE PACING 4051I

Facility

$127.71

Hospital Charge Code	8478522
Hospital Revenue Code	272
Min. Negotiated Rate	$11.49
Max. Negotiated Rate	$91.95
Rate for Payer: Amerigroup CHIP/Medicaid	$11.49
Rate for Payer: BCBS of TX Blue Advantage	$38.31
Rate for Payer: BCBS of TX Blue Essentials	$45.98
Rate for Payer: BCBS of TX PPO	$51.08
Rate for Payer: Cash Price	$86.84
Rate for Payer: Cigna Medicaid	$91.95
Rate for Payer: Molina CHIP/Medicaid	$91.95
Rate for Payer: Multiplan Auto	$83.01
Rate for Payer: Multiplan Commercial	$83.01
Rate for Payer: Multiplan Workers Comp	$83.01
Rate for Payer: Parkland Medicaid	$91.95
Rate for Payer: Scott and White EPO/PPO	$63.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.95
Rate for Payer: Superior Health Plan EPO	$17.37

CABLE PACING 4051I

Facility

$127.71

Hospital Charge Code	8478522
Hospital Revenue Code	272
Rate for Payer: Cash Price	$86.84

CABLE PCNG 12FT SFTY ALGTR CLIP TEMP

Facility

$272.40

Hospital Charge Code	110177
Hospital Revenue Code	272
Min. Negotiated Rate	$24.52
Max. Negotiated Rate	$196.13
Rate for Payer: Amerigroup CHIP/Medicaid	$24.52
Rate for Payer: BCBS of TX Blue Advantage	$81.72
Rate for Payer: BCBS of TX Blue Essentials	$98.06
Rate for Payer: BCBS of TX PPO	$108.96
Rate for Payer: Cash Price	$185.23
Rate for Payer: Cigna Medicaid	$196.13
Rate for Payer: Molina CHIP/Medicaid	$196.13
Rate for Payer: Multiplan Auto	$177.06
Rate for Payer: Multiplan Commercial	$177.06
Rate for Payer: Multiplan Workers Comp	$177.06
Rate for Payer: Parkland Medicaid	$196.13
Rate for Payer: Scott and White EPO/PPO	$136.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$196.13
Rate for Payer: Superior Health Plan EPO	$37.05

CABLE PCNG 12FT SFTY ALGTR CLIP TEMP

Facility

$272.40

Hospital Charge Code	110177
Hospital Revenue Code	272
Rate for Payer: Cash Price	$185.23

CABLE THRESHOLD PM SJ4 -- DHF

Facility

$136.20

Hospital Charge Code	40082505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$92.62

CABLE THRESHOLD PM SJ4 -- DHF

Facility

$136.20

Hospital Charge Code	40082505
Hospital Revenue Code	272
Min. Negotiated Rate	$12.26
Max. Negotiated Rate	$98.06
Rate for Payer: Amerigroup CHIP/Medicaid	$12.26
Rate for Payer: BCBS of TX Blue Advantage	$40.86
Rate for Payer: BCBS of TX Blue Essentials	$49.03
Rate for Payer: BCBS of TX PPO	$54.48
Rate for Payer: Cash Price	$92.62
Rate for Payer: Cigna Medicaid	$98.06
Rate for Payer: Molina CHIP/Medicaid	$98.06
Rate for Payer: Multiplan Auto	$88.53
Rate for Payer: Multiplan Commercial	$88.53
Rate for Payer: Multiplan Workers Comp	$88.53
Rate for Payer: Parkland Medicaid	$98.06
Rate for Payer: Scott and White EPO/PPO	$68.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.06
Rate for Payer: Superior Health Plan EPO	$18.52

CAGE ACIF

Facility

$10,241.00

Service Code	HCPCS C1831
Hospital Charge Code	8420465
Hospital Revenue Code	278
Min. Negotiated Rate	$2,560.25
Max. Negotiated Rate	$5,120.50
Rate for Payer: Cash Price	$6,963.88
Rate for Payer: Cigna Commercial	$2,560.25
Rate for Payer: Multiplan Auto	$5,120.50
Rate for Payer: Multiplan Commercial	$5,120.50
Rate for Payer: Multiplan Workers Comp	$5,120.50
Rate for Payer: Scott and White EPO/PPO	$5,120.50

CAGE ACIF

Facility

$10,241.00

Service Code	HCPCS C1831
Hospital Charge Code	8420465
Hospital Revenue Code	278
Min. Negotiated Rate	$921.69
Max. Negotiated Rate	$7,373.52
Rate for Payer: Amerigroup CHIP/Medicaid	$921.69
Rate for Payer: Cash Price	$6,963.88
Rate for Payer: Cigna Medicaid	$7,373.52
Rate for Payer: Molina CHIP/Medicaid	$7,373.52
Rate for Payer: Multiplan Auto	$5,120.50
Rate for Payer: Multiplan Commercial	$5,120.50
Rate for Payer: Multiplan Workers Comp	$5,120.50
Rate for Payer: Parkland Medicaid	$7,373.52
Rate for Payer: Scott and White EPO/PPO	$5,120.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,373.52
Rate for Payer: Superior Health Plan EPO	$1,392.78

cage interbody acif

Facility

$7,831.00

Service Code	HCPCS C1831
Hospital Charge Code	8672536
Hospital Revenue Code	278
Min. Negotiated Rate	$704.79
Max. Negotiated Rate	$5,638.32
Rate for Payer: Amerigroup CHIP/Medicaid	$704.79
Rate for Payer: Cash Price	$5,325.08
Rate for Payer: Cigna Medicaid	$5,638.32
Rate for Payer: Molina CHIP/Medicaid	$5,638.32
Rate for Payer: Multiplan Auto	$3,915.50
Rate for Payer: Multiplan Commercial	$3,915.50
Rate for Payer: Multiplan Workers Comp	$3,915.50
Rate for Payer: Parkland Medicaid	$5,638.32
Rate for Payer: Scott and White EPO/PPO	$3,915.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,638.32
Rate for Payer: Superior Health Plan EPO	$1,065.02

cage interbody acif

Facility

$7,831.00

Service Code	HCPCS C1831
Hospital Charge Code	8672536
Hospital Revenue Code	278
Min. Negotiated Rate	$1,957.75
Max. Negotiated Rate	$3,915.50
Rate for Payer: Cash Price	$5,325.08
Rate for Payer: Cigna Commercial	$1,957.75
Rate for Payer: Multiplan Auto	$3,915.50
Rate for Payer: Multiplan Commercial	$3,915.50
Rate for Payer: Multiplan Workers Comp	$3,915.50
Rate for Payer: Scott and White EPO/PPO	$3,915.50

CAGE PEEK VAULT 32MMX8X15MM

Facility

$36,145.00

Service Code	HCPCS C1831
Hospital Charge Code	8394470
Hospital Revenue Code	278
Min. Negotiated Rate	$3,253.05
Max. Negotiated Rate	$26,024.40
Rate for Payer: Amerigroup CHIP/Medicaid	$3,253.05
Rate for Payer: Cash Price	$24,578.60
Rate for Payer: Cigna Medicaid	$26,024.40
Rate for Payer: Molina CHIP/Medicaid	$26,024.40
Rate for Payer: Multiplan Auto	$18,072.50
Rate for Payer: Multiplan Commercial	$18,072.50
Rate for Payer: Multiplan Workers Comp	$18,072.50
Rate for Payer: Parkland Medicaid	$26,024.40
Rate for Payer: Scott and White EPO/PPO	$18,072.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26,024.40
Rate for Payer: Superior Health Plan EPO	$4,915.72

CAGE PEEK VAULT 32MMX8X15MM

Facility

$36,145.00

Service Code	HCPCS C1831
Hospital Charge Code	8394470
Hospital Revenue Code	278
Min. Negotiated Rate	$9,036.25
Max. Negotiated Rate	$18,072.50
Rate for Payer: Cash Price	$24,578.60
Rate for Payer: Cigna Commercial	$9,036.25
Rate for Payer: Multiplan Auto	$18,072.50
Rate for Payer: Multiplan Commercial	$18,072.50
Rate for Payer: Multiplan Workers Comp	$18,072.50
Rate for Payer: Scott and White EPO/PPO	$18,072.50

cage vault peek 32mmx15x15mm

Facility

$36,145.00

Service Code	HCPCS C1831
Hospital Charge Code	8394463
Hospital Revenue Code	278
Min. Negotiated Rate	$9,036.25
Max. Negotiated Rate	$18,072.50
Rate for Payer: Cash Price	$24,578.60
Rate for Payer: Cigna Commercial	$9,036.25
Rate for Payer: Multiplan Auto	$18,072.50
Rate for Payer: Multiplan Commercial	$18,072.50
Rate for Payer: Multiplan Workers Comp	$18,072.50
Rate for Payer: Scott and White EPO/PPO	$18,072.50

cage vault peek 32mmx15x15mm

Facility

$36,145.00

Service Code	HCPCS C1831
Hospital Charge Code	8394463
Hospital Revenue Code	278
Min. Negotiated Rate	$3,253.05
Max. Negotiated Rate	$26,024.40
Rate for Payer: Amerigroup CHIP/Medicaid	$3,253.05
Rate for Payer: Cash Price	$24,578.60
Rate for Payer: Cigna Medicaid	$26,024.40
Rate for Payer: Molina CHIP/Medicaid	$26,024.40
Rate for Payer: Multiplan Auto	$18,072.50
Rate for Payer: Multiplan Commercial	$18,072.50
Rate for Payer: Multiplan Workers Comp	$18,072.50
Rate for Payer: Parkland Medicaid	$26,024.40
Rate for Payer: Scott and White EPO/PPO	$18,072.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26,024.40
Rate for Payer: Superior Health Plan EPO	$4,915.72

Know your out-of-pocket cost for care.

All Charges