White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DEVICE, LAPAROSCOPIC VESSEL FUSION 5MM X 45CM DISP -- DHF

Facility

$4,309.06

Hospital Charge Code	80811300
Hospital Revenue Code	272
Min. Negotiated Rate	$387.82
Max. Negotiated Rate	$2,800.89
Rate for Payer: Aetna Commercial	$2,369.98
Rate for Payer: Amerigroup CHIP/Medicaid	$387.82
Rate for Payer: BCBS of TX Blue Advantage	$1,292.72
Rate for Payer: BCBS of TX Blue Essentials	$1,551.26
Rate for Payer: BCBS of TX PPO	$1,723.62
Rate for Payer: Cash Price	$3,791.97
Rate for Payer: Multiplan Auto	$2,800.89
Rate for Payer: Multiplan Commercial	$2,800.89
Rate for Payer: Multiplan Workers Comp	$2,800.89
Rate for Payer: Scott and White EPO/PPO	$2,154.53
Rate for Payer: Superior Health Plan EPO	$586.03

DEVICE, LAPAROSCOPIC VESSEL FUSION 5MM X 45CM DISP -- DHF

Facility

$4,309.06

Hospital Charge Code	80811300
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,791.97

DEVICE LAPROSHARK FASCIAL PORT CLOSURE

Facility

$276.94

Hospital Charge Code	8550486
Hospital Revenue Code	272
Rate for Payer: Cash Price	$243.71

DEVICE LAPROSHARK FASCIAL PORT CLOSURE

Facility

$276.94

Hospital Charge Code	8550486
Hospital Revenue Code	272
Min. Negotiated Rate	$24.92
Max. Negotiated Rate	$180.01
Rate for Payer: Aetna Commercial	$152.32
Rate for Payer: Amerigroup CHIP/Medicaid	$24.92
Rate for Payer: BCBS of TX Blue Advantage	$83.08
Rate for Payer: BCBS of TX Blue Essentials	$99.70
Rate for Payer: BCBS of TX PPO	$110.78
Rate for Payer: Cash Price	$243.71
Rate for Payer: Multiplan Auto	$180.01
Rate for Payer: Multiplan Commercial	$180.01
Rate for Payer: Multiplan Workers Comp	$180.01
Rate for Payer: Scott and White EPO/PPO	$138.47
Rate for Payer: Superior Health Plan EPO	$37.66

device ligasure blunt 5x44 lf1844

Facility

$2,195.00

Hospital Charge Code	8666516
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,931.60

device ligasure blunt 5x44 lf1844

Facility

$2,195.00

Hospital Charge Code	8666516
Hospital Revenue Code	272
Min. Negotiated Rate	$197.55
Max. Negotiated Rate	$1,426.75
Rate for Payer: Aetna Commercial	$1,207.25
Rate for Payer: Amerigroup CHIP/Medicaid	$197.55
Rate for Payer: BCBS of TX Blue Advantage	$658.50
Rate for Payer: BCBS of TX Blue Essentials	$790.20
Rate for Payer: BCBS of TX PPO	$878.00
Rate for Payer: Cash Price	$1,931.60
Rate for Payer: Multiplan Auto	$1,426.75
Rate for Payer: Multiplan Commercial	$1,426.75
Rate for Payer: Multiplan Workers Comp	$1,426.75
Rate for Payer: Scott and White EPO/PPO	$1,097.50
Rate for Payer: Superior Health Plan EPO	$298.52

DEVICE LIGASURE IMPACT LF4418

Facility

$2,822.92

Hospital Charge Code	8524478
Hospital Revenue Code	272
Min. Negotiated Rate	$254.06
Max. Negotiated Rate	$1,834.90
Rate for Payer: Aetna Commercial	$1,552.61
Rate for Payer: Amerigroup CHIP/Medicaid	$254.06
Rate for Payer: BCBS of TX Blue Advantage	$846.88
Rate for Payer: BCBS of TX Blue Essentials	$1,016.25
Rate for Payer: BCBS of TX PPO	$1,129.17
Rate for Payer: Cash Price	$2,484.17
Rate for Payer: Multiplan Auto	$1,834.90
Rate for Payer: Multiplan Commercial	$1,834.90
Rate for Payer: Multiplan Workers Comp	$1,834.90
Rate for Payer: Scott and White EPO/PPO	$1,411.46
Rate for Payer: Superior Health Plan EPO	$383.92

DEVICE LIGASURE IMPACT LF4418

Facility

$2,822.92

Hospital Charge Code	8524478
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,484.17

DEVICE MENISCL REPAIR AIR

Facility

$2,771.08

Service Code	HCPCS C1713
Hospital Charge Code	40111122
Hospital Revenue Code	278
Min. Negotiated Rate	$249.40
Max. Negotiated Rate	$1,385.54
Rate for Payer: Aetna Commercial	$831.32
Rate for Payer: Amerigroup CHIP/Medicaid	$249.40
Rate for Payer: BCBS of TX Blue Advantage	$831.32
Rate for Payer: BCBS of TX Blue Essentials	$997.59
Rate for Payer: BCBS of TX PPO	$1,108.43
Rate for Payer: Cash Price	$2,438.55
Rate for Payer: Multiplan Auto	$1,385.54
Rate for Payer: Multiplan Commercial	$1,385.54
Rate for Payer: Multiplan Workers Comp	$1,385.54
Rate for Payer: Scott and White EPO/PPO	$1,385.54
Rate for Payer: Superior Health Plan EPO	$376.87

DEVICE MENISCL REPAIR AIR

Facility

$2,771.08

Service Code	HCPCS C1713
Hospital Charge Code	40111122
Hospital Revenue Code	278
Min. Negotiated Rate	$692.77
Max. Negotiated Rate	$1,385.54
Rate for Payer: Aetna Commercial	$831.32
Rate for Payer: Cash Price	$2,438.55
Rate for Payer: Cigna Commercial	$692.77
Rate for Payer: Multiplan Auto	$1,385.54
Rate for Payer: Multiplan Commercial	$1,385.54
Rate for Payer: Multiplan Workers Comp	$1,385.54
Rate for Payer: Scott and White EPO/PPO	$1,385.54

DEVICE MENISC REPAIR TRUESPAN

Facility

$3,152.77

Service Code	HCPCS C1713
Hospital Charge Code	8538529
Hospital Revenue Code	278
Min. Negotiated Rate	$788.19
Max. Negotiated Rate	$1,576.38
Rate for Payer: Aetna Commercial	$945.83
Rate for Payer: Cash Price	$2,774.44
Rate for Payer: Cigna Commercial	$788.19
Rate for Payer: Multiplan Auto	$1,576.38
Rate for Payer: Multiplan Commercial	$1,576.38
Rate for Payer: Multiplan Workers Comp	$1,576.38
Rate for Payer: Scott and White EPO/PPO	$1,576.38

DEVICE MENISC REPAIR TRUESPAN

Facility

$3,152.77

Service Code	HCPCS C1713
Hospital Charge Code	8538529
Hospital Revenue Code	278
Min. Negotiated Rate	$283.75
Max. Negotiated Rate	$1,576.38
Rate for Payer: Aetna Commercial	$945.83
Rate for Payer: Amerigroup CHIP/Medicaid	$283.75
Rate for Payer: BCBS of TX Blue Advantage	$945.83
Rate for Payer: BCBS of TX Blue Essentials	$1,135.00
Rate for Payer: BCBS of TX PPO	$1,261.11
Rate for Payer: Cash Price	$2,774.44
Rate for Payer: Multiplan Auto	$1,576.38
Rate for Payer: Multiplan Commercial	$1,576.38
Rate for Payer: Multiplan Workers Comp	$1,576.38
Rate for Payer: Scott and White EPO/PPO	$1,576.38
Rate for Payer: Superior Health Plan EPO	$428.78

DEVICE SECURE STRAP 25

Facility

$2,331.01

Hospital Charge Code	8554476
Hospital Revenue Code	272
Min. Negotiated Rate	$209.79
Max. Negotiated Rate	$1,515.16
Rate for Payer: Aetna Commercial	$1,282.06
Rate for Payer: Amerigroup CHIP/Medicaid	$209.79
Rate for Payer: BCBS of TX Blue Advantage	$699.30
Rate for Payer: BCBS of TX Blue Essentials	$839.16
Rate for Payer: BCBS of TX PPO	$932.40
Rate for Payer: Cash Price	$2,051.29
Rate for Payer: Multiplan Auto	$1,515.16
Rate for Payer: Multiplan Commercial	$1,515.16
Rate for Payer: Multiplan Workers Comp	$1,515.16
Rate for Payer: Scott and White EPO/PPO	$1,165.50
Rate for Payer: Superior Health Plan EPO	$317.02

DEVICE SECURE STRAP 25

Facility

$2,331.01

Hospital Charge Code	8554476
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,051.29

DEVICE, SMOKE ELIMINATOR BUTTON STER DISPOSABLE -- DHF

Facility

$93.77

Hospital Charge Code	81746679
Hospital Revenue Code	270
Min. Negotiated Rate	$8.44
Max. Negotiated Rate	$60.95
Rate for Payer: Aetna Commercial	$51.57
Rate for Payer: Amerigroup CHIP/Medicaid	$8.44
Rate for Payer: BCBS of TX Blue Advantage	$28.13
Rate for Payer: BCBS of TX Blue Essentials	$33.76
Rate for Payer: BCBS of TX PPO	$37.51
Rate for Payer: Cash Price	$82.52
Rate for Payer: Multiplan Auto	$60.95
Rate for Payer: Multiplan Commercial	$60.95
Rate for Payer: Multiplan Workers Comp	$60.95
Rate for Payer: Scott and White EPO/PPO	$46.88
Rate for Payer: Superior Health Plan EPO	$12.75

DEVICE, TISSUE SEALER SUPER JAW 22CM -- DHF

Facility

$2,457.37

Hospital Charge Code	80811300
Hospital Revenue Code	272
Min. Negotiated Rate	$221.16
Max. Negotiated Rate	$1,597.29
Rate for Payer: Aetna Commercial	$1,351.55
Rate for Payer: Amerigroup CHIP/Medicaid	$221.16
Rate for Payer: BCBS of TX Blue Advantage	$737.21
Rate for Payer: BCBS of TX Blue Essentials	$884.65
Rate for Payer: BCBS of TX PPO	$982.95
Rate for Payer: Cash Price	$2,162.49
Rate for Payer: Multiplan Auto	$1,597.29
Rate for Payer: Multiplan Commercial	$1,597.29
Rate for Payer: Multiplan Workers Comp	$1,597.29
Rate for Payer: Scott and White EPO/PPO	$1,228.68
Rate for Payer: Superior Health Plan EPO	$334.20

DEV INFLATION -- DHF

Facility

$312.81

Hospital Charge Code	80320070
Hospital Revenue Code	272
Min. Negotiated Rate	$28.15
Max. Negotiated Rate	$203.33
Rate for Payer: Aetna Commercial	$172.05
Rate for Payer: Amerigroup CHIP/Medicaid	$28.15
Rate for Payer: BCBS of TX Blue Advantage	$93.84
Rate for Payer: BCBS of TX Blue Essentials	$112.61
Rate for Payer: BCBS of TX PPO	$125.12
Rate for Payer: Cash Price	$275.27
Rate for Payer: Multiplan Auto	$203.33
Rate for Payer: Multiplan Commercial	$203.33
Rate for Payer: Multiplan Workers Comp	$203.33
Rate for Payer: Scott and White EPO/PPO	$156.40
Rate for Payer: Superior Health Plan EPO	$42.54

DEV INFLATION -- DHF

Facility

$312.81

Hospital Charge Code	80320070
Hospital Revenue Code	272
Rate for Payer: Cash Price	$275.27

DEV RETRIEVAL INSERTABLE -- DHF

Facility

$1,694.96

Service Code	HCPCS C1773
Hospital Charge Code	82401399
Hospital Revenue Code	272
Min. Negotiated Rate	$152.55
Max. Negotiated Rate	$1,101.72
Rate for Payer: Aetna Commercial	$932.23
Rate for Payer: Amerigroup CHIP/Medicaid	$152.55
Rate for Payer: BCBS of TX Blue Advantage	$508.49
Rate for Payer: BCBS of TX Blue Essentials	$610.19
Rate for Payer: BCBS of TX PPO	$677.98
Rate for Payer: Cash Price	$1,491.56
Rate for Payer: Multiplan Auto	$1,101.72
Rate for Payer: Multiplan Commercial	$1,101.72
Rate for Payer: Multiplan Workers Comp	$1,101.72
Rate for Payer: Scott and White EPO/PPO	$847.48
Rate for Payer: Superior Health Plan EPO	$230.51

DEV RETRIEVAL INSERTABLE -- DHF

Facility

$1,694.96

Service Code	HCPCS C1773
Hospital Charge Code	82401399
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,491.56

dexamethasone 0.5 mg/5 mL Oral Liquid 500 mL

Facility

$7.65

Service Code	HCPCS J8540
Hospital Charge Code	77498028
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.01
Rate for Payer: BCBS of TX Blue Essentials	$0.02
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

dexamethasone 0.5 mg/5 mL Oral Liquid 500 mL

Facility

$7.65

Service Code	HCPCS J8540
Hospital Charge Code	77498028
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.82
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.82

dexamethasone 10 mg/mL PF Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1100
Hospital Charge Code	77498478
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.03
Rate for Payer: BCBS of TX Blue Essentials	$0.03
Rate for Payer: BCBS of TX PPO	$0.04
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

dexamethasone 10 mg/mL PF Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1100
Hospital Charge Code	77498478
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

dexamethasone 4 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1100
Hospital Charge Code	77498645
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.03
Rate for Payer: BCBS of TX Blue Essentials	$0.03
Rate for Payer: BCBS of TX PPO	$0.04
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

Know your out-of-pocket cost for care.

All Charges