White Rock Medical Center

All Charges

Charge

Type

Setting

Price

6720-0330

Facility

$5,077.16

Service Code	HCPCS C1734
Hospital Charge Code	994003
Hospital Revenue Code	278
Min. Negotiated Rate	$456.94
Max. Negotiated Rate	$3,655.56
Rate for Payer: Amerigroup CHIP/Medicaid	$456.94
Rate for Payer: BCBS of TX Blue Advantage	$1,523.15
Rate for Payer: BCBS of TX Blue Essentials	$1,827.78
Rate for Payer: BCBS of TX PPO	$2,030.86
Rate for Payer: Cash Price	$3,452.47
Rate for Payer: Cigna Medicaid	$3,655.56
Rate for Payer: Molina CHIP/Medicaid	$3,655.56
Rate for Payer: Multiplan Auto	$2,538.58
Rate for Payer: Multiplan Commercial	$2,538.58
Rate for Payer: Multiplan Workers Comp	$2,538.58
Rate for Payer: Parkland Medicaid	$3,655.56
Rate for Payer: Scott and White EPO/PPO	$2,538.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,655.56
Rate for Payer: Superior Health Plan EPO	$690.49

6720-0330

Facility

$5,077.16

Service Code	HCPCS C1734
Hospital Charge Code	994003
Hospital Revenue Code	278
Min. Negotiated Rate	$1,269.29
Max. Negotiated Rate	$2,538.58
Rate for Payer: Cash Price	$3,452.47
Rate for Payer: Cigna Commercial	$1,269.29
Rate for Payer: Multiplan Auto	$2,538.58
Rate for Payer: Multiplan Commercial	$2,538.58
Rate for Payer: Multiplan Workers Comp	$2,538.58
Rate for Payer: Scott and White EPO/PPO	$2,538.58

6C PLUS CELL CONTROL

Facility

$1,539.06

Hospital Charge Code	993857
Hospital Revenue Code	279
Min. Negotiated Rate	$138.52
Max. Negotiated Rate	$1,108.12
Rate for Payer: Amerigroup CHIP/Medicaid	$138.52
Rate for Payer: BCBS of TX Blue Advantage	$461.72
Rate for Payer: BCBS of TX Blue Essentials	$554.06
Rate for Payer: BCBS of TX PPO	$615.62
Rate for Payer: Cash Price	$1,046.56
Rate for Payer: Cigna Medicaid	$1,108.12
Rate for Payer: Molina CHIP/Medicaid	$1,108.12
Rate for Payer: Multiplan Auto	$1,000.39
Rate for Payer: Multiplan Commercial	$1,000.39
Rate for Payer: Multiplan Workers Comp	$1,000.39
Rate for Payer: Parkland Medicaid	$1,108.12
Rate for Payer: Scott and White EPO/PPO	$769.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,108.12
Rate for Payer: Superior Health Plan EPO	$209.31

6C PLUS CELL CONTROL

Facility

$1,539.06

Hospital Charge Code	993857
Hospital Revenue Code	279
Rate for Payer: Cash Price	$1,046.56

6F CELT Arterial Closure Device Individual Units

Facility

$1,135.00

Hospital Charge Code	993891
Hospital Revenue Code	279
Min. Negotiated Rate	$102.15
Max. Negotiated Rate	$817.20
Rate for Payer: Amerigroup CHIP/Medicaid	$102.15
Rate for Payer: BCBS of TX Blue Advantage	$340.50
Rate for Payer: BCBS of TX Blue Essentials	$408.60
Rate for Payer: BCBS of TX PPO	$454.00
Rate for Payer: Cash Price	$771.80
Rate for Payer: Cigna Medicaid	$817.20
Rate for Payer: Molina CHIP/Medicaid	$817.20
Rate for Payer: Multiplan Auto	$737.75
Rate for Payer: Multiplan Commercial	$737.75
Rate for Payer: Multiplan Workers Comp	$737.75
Rate for Payer: Parkland Medicaid	$817.20
Rate for Payer: Scott and White EPO/PPO	$567.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$817.20
Rate for Payer: Superior Health Plan EPO	$154.36

6F CELT Arterial Closure Device Individual Units

Facility

$1,135.00

Hospital Charge Code	993891
Hospital Revenue Code	279
Rate for Payer: Cash Price	$771.80

6mm x 100mm .035 Saber PTA balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992559
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

6mm x 100mm .035 Saber PTA balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992559
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

6mm x 10xm x 135cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992556
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

6mm x 10xm x 135cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992556
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

6mm x 20cm x 135cm Saber Balloon

Facility

$612.90

Service Code	HCPCS C1726
Hospital Charge Code	992558
Hospital Revenue Code	272
Rate for Payer: Cash Price	$416.77

6mm x 20cm x 135cm Saber Balloon

Facility

$612.90

Service Code	HCPCS C1726
Hospital Charge Code	992558
Hospital Revenue Code	272
Min. Negotiated Rate	$55.16
Max. Negotiated Rate	$441.29
Rate for Payer: Amerigroup CHIP/Medicaid	$55.16
Rate for Payer: BCBS of TX Blue Advantage	$183.87
Rate for Payer: BCBS of TX Blue Essentials	$220.64
Rate for Payer: BCBS of TX PPO	$245.16
Rate for Payer: Cash Price	$416.77
Rate for Payer: Cigna Medicaid	$441.29
Rate for Payer: Molina CHIP/Medicaid	$441.29
Rate for Payer: Multiplan Auto	$398.38
Rate for Payer: Multiplan Commercial	$398.38
Rate for Payer: Multiplan Workers Comp	$398.38
Rate for Payer: Parkland Medicaid	$441.29
Rate for Payer: Scott and White EPO/PPO	$306.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$441.29
Rate for Payer: Superior Health Plan EPO	$83.35

6mm x4cm x 80cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992553
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

6mm x4cm x 80cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992553
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

6mm x 6cm x 135cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992554
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

6mm x 6cm x 135cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992554
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

6mm x 8cm x 135cm

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992555
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

6mm x 8cm x 135cm

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992555
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

70-0303

Facility

$15,763.88

Service Code	HCPCS C1713
Hospital Charge Code	994026
Hospital Revenue Code	278
Min. Negotiated Rate	$1,418.75
Max. Negotiated Rate	$11,349.99
Rate for Payer: Amerigroup CHIP/Medicaid	$1,418.75
Rate for Payer: BCBS of TX Blue Advantage	$4,729.16
Rate for Payer: BCBS of TX Blue Essentials	$5,675.00
Rate for Payer: BCBS of TX PPO	$6,305.55
Rate for Payer: Cash Price	$10,719.44
Rate for Payer: Cigna Medicaid	$11,349.99
Rate for Payer: Molina CHIP/Medicaid	$11,349.99
Rate for Payer: Multiplan Auto	$7,881.94
Rate for Payer: Multiplan Commercial	$7,881.94
Rate for Payer: Multiplan Workers Comp	$7,881.94
Rate for Payer: Parkland Medicaid	$11,349.99
Rate for Payer: Scott and White EPO/PPO	$7,881.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,349.99
Rate for Payer: Superior Health Plan EPO	$2,143.89

70-0303

Facility

$15,763.88

Service Code	HCPCS C1713
Hospital Charge Code	994026
Hospital Revenue Code	278
Min. Negotiated Rate	$3,940.97
Max. Negotiated Rate	$7,881.94
Rate for Payer: Cash Price	$10,719.44
Rate for Payer: Cigna Commercial	$3,940.97
Rate for Payer: Multiplan Auto	$7,881.94
Rate for Payer: Multiplan Commercial	$7,881.94
Rate for Payer: Multiplan Workers Comp	$7,881.94
Rate for Payer: Scott and White EPO/PPO	$7,881.94

702-04-48D

Facility

$4,909.21

Service Code	HCPCS C1776
Hospital Charge Code	994002
Hospital Revenue Code	278
Min. Negotiated Rate	$1,227.30
Max. Negotiated Rate	$2,454.61
Rate for Payer: Cash Price	$3,338.26
Rate for Payer: Cigna Commercial	$1,227.30
Rate for Payer: Multiplan Auto	$2,454.61
Rate for Payer: Multiplan Commercial	$2,454.61
Rate for Payer: Multiplan Workers Comp	$2,454.61
Rate for Payer: Scott and White EPO/PPO	$2,454.61

702-04-48D

Facility

$4,909.21

Service Code	HCPCS C1776
Hospital Charge Code	994002
Hospital Revenue Code	278
Min. Negotiated Rate	$441.83
Max. Negotiated Rate	$3,534.63
Rate for Payer: Amerigroup CHIP/Medicaid	$441.83
Rate for Payer: BCBS of TX Blue Advantage	$1,472.76
Rate for Payer: BCBS of TX Blue Essentials	$1,767.32
Rate for Payer: BCBS of TX PPO	$1,963.68
Rate for Payer: Cash Price	$3,338.26
Rate for Payer: Cigna Medicaid	$3,534.63
Rate for Payer: Molina CHIP/Medicaid	$3,534.63
Rate for Payer: Multiplan Auto	$2,454.61
Rate for Payer: Multiplan Commercial	$2,454.61
Rate for Payer: Multiplan Workers Comp	$2,454.61
Rate for Payer: Parkland Medicaid	$3,534.63
Rate for Payer: Scott and White EPO/PPO	$2,454.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,534.63
Rate for Payer: Superior Health Plan EPO	$667.65

702449

Facility

$2,867.47

Hospital Charge Code	994041
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,949.88

702449

Facility

$2,867.47

Hospital Charge Code	994041
Hospital Revenue Code	272
Min. Negotiated Rate	$258.07
Max. Negotiated Rate	$2,064.58
Rate for Payer: Amerigroup CHIP/Medicaid	$258.07
Rate for Payer: BCBS of TX Blue Advantage	$860.24
Rate for Payer: BCBS of TX Blue Essentials	$1,032.29
Rate for Payer: BCBS of TX PPO	$1,146.99
Rate for Payer: Cash Price	$1,949.88
Rate for Payer: Cigna Medicaid	$2,064.58
Rate for Payer: Molina CHIP/Medicaid	$2,064.58
Rate for Payer: Multiplan Auto	$1,863.86
Rate for Payer: Multiplan Commercial	$1,863.86
Rate for Payer: Multiplan Workers Comp	$1,863.86
Rate for Payer: Parkland Medicaid	$2,064.58
Rate for Payer: Scott and White EPO/PPO	$1,433.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,064.58
Rate for Payer: Superior Health Plan EPO	$389.98

702459

Facility

$728.92

Service Code	HCPCS C1769
Hospital Charge Code	994040
Hospital Revenue Code	272
Rate for Payer: Cash Price	$495.67

Know your out-of-pocket cost for care.

All Charges