White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHWR DILATOR ANY SIZE

Facility

$77.63

Hospital Charge Code	8174035
Hospital Revenue Code	272
Rate for Payer: Cash Price	$52.79

CHWR DOBHOFF TUBE FEEDING TUBE

Facility

$64.05

Service Code	HCPCS B4148
Hospital Charge Code	8034690
Hospital Revenue Code	270
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$46.12
Rate for Payer: Amerigroup CHIP/Medicaid	$5.76
Rate for Payer: BCBS of TX Blue Advantage	$13.24
Rate for Payer: BCBS of TX Blue Essentials	$15.89
Rate for Payer: BCBS of TX PPO	$17.62
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cigna Medicaid	$46.12
Rate for Payer: Molina CHIP/Medicaid	$46.12
Rate for Payer: Multiplan Auto	$41.63
Rate for Payer: Multiplan Commercial	$41.63
Rate for Payer: Multiplan Workers Comp	$41.63
Rate for Payer: Parkland Medicaid	$46.12
Rate for Payer: Scott and White EPO/PPO	$32.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.12
Rate for Payer: Superior Health Plan EPO	$8.71

CHWR DOBHOFF TUBE FEEDING TUBE

Facility

$64.05

Service Code	HCPCS B4148
Hospital Charge Code	8034690
Hospital Revenue Code	270
Rate for Payer: Cash Price	$43.55

CHWR DRAIN BAG

Facility

$90.80

Hospital Charge Code	8041055
Hospital Revenue Code	272
Min. Negotiated Rate	$8.17
Max. Negotiated Rate	$65.38
Rate for Payer: Amerigroup CHIP/Medicaid	$8.17
Rate for Payer: BCBS of TX Blue Advantage	$27.24
Rate for Payer: BCBS of TX Blue Essentials	$32.69
Rate for Payer: BCBS of TX PPO	$36.32
Rate for Payer: Cash Price	$61.74
Rate for Payer: Cigna Medicaid	$65.38
Rate for Payer: Molina CHIP/Medicaid	$65.38
Rate for Payer: Multiplan Auto	$59.02
Rate for Payer: Multiplan Commercial	$59.02
Rate for Payer: Multiplan Workers Comp	$59.02
Rate for Payer: Parkland Medicaid	$65.38
Rate for Payer: Scott and White EPO/PPO	$45.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.38
Rate for Payer: Superior Health Plan EPO	$12.35

CHWR DRAIN BAG

Facility

$90.80

Hospital Charge Code	8041055
Hospital Revenue Code	272
Rate for Payer: Cash Price	$61.74

CHWR DRESSING 3X4 STERILE

Facility

$9.12

Hospital Charge Code	8024927
Hospital Revenue Code	270
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$6.57
Rate for Payer: Amerigroup CHIP/Medicaid	$0.82
Rate for Payer: BCBS of TX Blue Advantage	$2.74
Rate for Payer: BCBS of TX Blue Essentials	$3.28
Rate for Payer: BCBS of TX PPO	$3.65
Rate for Payer: Cash Price	$6.20
Rate for Payer: Cigna Medicaid	$6.57
Rate for Payer: Molina CHIP/Medicaid	$6.57
Rate for Payer: Multiplan Auto	$5.93
Rate for Payer: Multiplan Commercial	$5.93
Rate for Payer: Multiplan Workers Comp	$5.93
Rate for Payer: Parkland Medicaid	$6.57
Rate for Payer: Scott and White EPO/PPO	$4.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.57
Rate for Payer: Superior Health Plan EPO	$1.24

CHWR DRESSING 3X4 STERILE

Facility

$9.12

Hospital Charge Code	8024927
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.20

CHWR ECG MRI QUADTRODE PAD

Facility

$68.92

Hospital Charge Code	8203025
Hospital Revenue Code	270
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$49.62
Rate for Payer: Amerigroup CHIP/Medicaid	$6.20
Rate for Payer: BCBS of TX Blue Advantage	$20.68
Rate for Payer: BCBS of TX Blue Essentials	$24.81
Rate for Payer: BCBS of TX PPO	$27.57
Rate for Payer: Cash Price	$46.87
Rate for Payer: Cigna Medicaid	$49.62
Rate for Payer: Molina CHIP/Medicaid	$49.62
Rate for Payer: Multiplan Auto	$44.80
Rate for Payer: Multiplan Commercial	$44.80
Rate for Payer: Multiplan Workers Comp	$44.80
Rate for Payer: Parkland Medicaid	$49.62
Rate for Payer: Scott and White EPO/PPO	$34.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.62
Rate for Payer: Superior Health Plan EPO	$9.37

CHWR ECG MRI QUADTRODE PAD

Facility

$68.92

Hospital Charge Code	8203025
Hospital Revenue Code	270
Rate for Payer: Cash Price	$46.87

CHWR FEEDING TUBE

Facility

$134.88

Service Code	HCPCS B4148
Hospital Charge Code	8034688
Hospital Revenue Code	272
Min. Negotiated Rate	$12.14
Max. Negotiated Rate	$97.11
Rate for Payer: Amerigroup CHIP/Medicaid	$12.14
Rate for Payer: BCBS of TX Blue Advantage	$13.24
Rate for Payer: BCBS of TX Blue Essentials	$15.89
Rate for Payer: BCBS of TX PPO	$17.62
Rate for Payer: Cash Price	$91.72
Rate for Payer: Cash Price	$91.72
Rate for Payer: Cigna Medicaid	$97.11
Rate for Payer: Molina CHIP/Medicaid	$97.11
Rate for Payer: Multiplan Auto	$87.67
Rate for Payer: Multiplan Commercial	$87.67
Rate for Payer: Multiplan Workers Comp	$87.67
Rate for Payer: Parkland Medicaid	$97.11
Rate for Payer: Scott and White EPO/PPO	$67.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.11
Rate for Payer: Superior Health Plan EPO	$18.34

CHWR FEEDING TUBE

Facility

$134.88

Service Code	HCPCS B4148
Hospital Charge Code	8034688
Hospital Revenue Code	272
Rate for Payer: Cash Price	$91.72

CHWR FILTER BIOPSY BREAST TISSUE

Facility

$18.44

Hospital Charge Code	8174682
Hospital Revenue Code	272
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$13.28
Rate for Payer: Amerigroup CHIP/Medicaid	$1.66
Rate for Payer: BCBS of TX Blue Advantage	$5.53
Rate for Payer: BCBS of TX Blue Essentials	$6.64
Rate for Payer: BCBS of TX PPO	$7.38
Rate for Payer: Cash Price	$12.54
Rate for Payer: Cigna Medicaid	$13.28
Rate for Payer: Molina CHIP/Medicaid	$13.28
Rate for Payer: Multiplan Auto	$11.99
Rate for Payer: Multiplan Commercial	$11.99
Rate for Payer: Multiplan Workers Comp	$11.99
Rate for Payer: Parkland Medicaid	$13.28
Rate for Payer: Scott and White EPO/PPO	$9.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.28
Rate for Payer: Superior Health Plan EPO	$2.51

CHWR FILTER BIOPSY BREAST TISSUE

Facility

$18.44

Hospital Charge Code	8174682
Hospital Revenue Code	272
Rate for Payer: Cash Price	$12.54

CHWR FNA BX W/US GDN EA ADDL

Facility

$1,037.00

Service Code	HCPCS 10006
Hospital Charge Code	8734522
Hospital Revenue Code	361
Min. Negotiated Rate	$93.33
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$93.33
Rate for Payer: BCBS of TX Blue Advantage	$311.10
Rate for Payer: BCBS of TX Blue Essentials	$373.32
Rate for Payer: BCBS of TX PPO	$414.80
Rate for Payer: Cash Price	$705.16
Rate for Payer: Cash Price	$705.16
Rate for Payer: Cigna Medicaid	$746.64
Rate for Payer: Molina CHIP/Medicaid	$746.64
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$746.64
Rate for Payer: Scott and White EPO/PPO	$518.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$746.64
Rate for Payer: Superior Health Plan EPO	$141.03

CHWR FNA BX W/US GDN EA ADDL

Facility

$1,037.00

Service Code	HCPCS 10006
Hospital Charge Code	8734522
Hospital Revenue Code	361
Rate for Payer: Cash Price	$705.16

CHWR FOLEY CATHETER ANY SIZE

Facility

$88.06

Hospital Charge Code	8041150
Hospital Revenue Code	272
Min. Negotiated Rate	$7.93
Max. Negotiated Rate	$63.40
Rate for Payer: Amerigroup CHIP/Medicaid	$7.93
Rate for Payer: BCBS of TX Blue Advantage	$26.42
Rate for Payer: BCBS of TX Blue Essentials	$31.70
Rate for Payer: BCBS of TX PPO	$35.22
Rate for Payer: Cash Price	$59.88
Rate for Payer: Cigna Medicaid	$63.40
Rate for Payer: Molina CHIP/Medicaid	$63.40
Rate for Payer: Multiplan Auto	$57.24
Rate for Payer: Multiplan Commercial	$57.24
Rate for Payer: Multiplan Workers Comp	$57.24
Rate for Payer: Parkland Medicaid	$63.40
Rate for Payer: Scott and White EPO/PPO	$44.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.40
Rate for Payer: Superior Health Plan EPO	$11.98

CHWR FOLEY CATHETER ANY SIZE

Facility

$88.06

Hospital Charge Code	8041150
Hospital Revenue Code	272
Rate for Payer: Cash Price	$59.88

CHWR HYSTERSALPINGOGRAM TRAY

Facility

$254.05

Hospital Charge Code	8083175
Hospital Revenue Code	272
Min. Negotiated Rate	$22.86
Max. Negotiated Rate	$182.92
Rate for Payer: Amerigroup CHIP/Medicaid	$22.86
Rate for Payer: BCBS of TX Blue Advantage	$76.22
Rate for Payer: BCBS of TX Blue Essentials	$91.46
Rate for Payer: BCBS of TX PPO	$101.62
Rate for Payer: Cash Price	$172.75
Rate for Payer: Cigna Medicaid	$182.92
Rate for Payer: Molina CHIP/Medicaid	$182.92
Rate for Payer: Multiplan Auto	$165.13
Rate for Payer: Multiplan Commercial	$165.13
Rate for Payer: Multiplan Workers Comp	$165.13
Rate for Payer: Parkland Medicaid	$182.92
Rate for Payer: Scott and White EPO/PPO	$127.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$182.92
Rate for Payer: Superior Health Plan EPO	$34.55

CHWR HYSTERSALPINGOGRAM TRAY

Facility

$254.05

Hospital Charge Code	8083175
Hospital Revenue Code	272
Rate for Payer: Cash Price	$172.75

CHWR INJECTOR SYRINGE MEDRAD

Facility

$47.03

Hospital Charge Code	8034546
Hospital Revenue Code	272
Rate for Payer: Cash Price	$31.98

CHWR INJECTOR SYRINGE MEDRAD

Facility

$47.03

Hospital Charge Code	8034546
Hospital Revenue Code	272
Min. Negotiated Rate	$4.23
Max. Negotiated Rate	$33.86
Rate for Payer: Amerigroup CHIP/Medicaid	$4.23
Rate for Payer: BCBS of TX Blue Advantage	$14.11
Rate for Payer: BCBS of TX Blue Essentials	$16.93
Rate for Payer: BCBS of TX PPO	$18.81
Rate for Payer: Cash Price	$31.98
Rate for Payer: Cigna Medicaid	$33.86
Rate for Payer: Molina CHIP/Medicaid	$33.86
Rate for Payer: Multiplan Auto	$30.57
Rate for Payer: Multiplan Commercial	$30.57
Rate for Payer: Multiplan Workers Comp	$30.57
Rate for Payer: Parkland Medicaid	$33.86
Rate for Payer: Scott and White EPO/PPO	$23.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.86
Rate for Payer: Superior Health Plan EPO	$6.40

CHWR IV START KIT

Facility

$110.27

Hospital Charge Code	5420101
Hospital Revenue Code	270
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$79.39
Rate for Payer: Amerigroup CHIP/Medicaid	$9.92
Rate for Payer: BCBS of TX Blue Advantage	$33.08
Rate for Payer: BCBS of TX Blue Essentials	$39.70
Rate for Payer: BCBS of TX PPO	$44.11
Rate for Payer: Cash Price	$74.98
Rate for Payer: Cigna Medicaid	$79.39
Rate for Payer: Molina CHIP/Medicaid	$79.39
Rate for Payer: Multiplan Auto	$71.68
Rate for Payer: Multiplan Commercial	$71.68
Rate for Payer: Multiplan Workers Comp	$71.68
Rate for Payer: Parkland Medicaid	$79.39
Rate for Payer: Scott and White EPO/PPO	$55.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.39
Rate for Payer: Superior Health Plan EPO	$15.00

CHWR IV START KIT

Facility

$110.27

Hospital Charge Code	5420101
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.98

CHWR JAMSHIDI NEEDLE - ALL

Facility

$138.28

Hospital Charge Code	8032740
Hospital Revenue Code	272
Min. Negotiated Rate	$12.45
Max. Negotiated Rate	$99.56
Rate for Payer: Amerigroup CHIP/Medicaid	$12.45
Rate for Payer: BCBS of TX Blue Advantage	$41.48
Rate for Payer: BCBS of TX Blue Essentials	$49.78
Rate for Payer: BCBS of TX PPO	$55.31
Rate for Payer: Cash Price	$94.03
Rate for Payer: Cigna Medicaid	$99.56
Rate for Payer: Molina CHIP/Medicaid	$99.56
Rate for Payer: Multiplan Auto	$89.88
Rate for Payer: Multiplan Commercial	$89.88
Rate for Payer: Multiplan Workers Comp	$89.88
Rate for Payer: Parkland Medicaid	$99.56
Rate for Payer: Scott and White EPO/PPO	$69.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$99.56
Rate for Payer: Superior Health Plan EPO	$18.81

CHWR JAMSHIDI NEEDLE - ALL

Facility

$138.28

Hospital Charge Code	8032740
Hospital Revenue Code	272
Rate for Payer: Cash Price	$94.03

Know your out-of-pocket cost for care.

All Charges