White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CLEFT LIP AND PALATE REPAIR

Facility

$4,369.36

Service Code	APR-DRG 0951
Min. Negotiated Rate	$4,119.58
Max. Negotiated Rate	$4,369.36
Rate for Payer: Amerigroup CHIP/Medicaid	$4,119.58
Rate for Payer: Cigna Medicaid	$4,119.58
Rate for Payer: Molina CHIP/Medicaid	$4,119.58
Rate for Payer: Parkland Medicaid	$4,119.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,369.36

CLEFT LIP AND PALATE REPAIR

Facility

$17,832.74

Service Code	APR-DRG 0954
Min. Negotiated Rate	$16,813.33
Max. Negotiated Rate	$17,832.74
Rate for Payer: Amerigroup CHIP/Medicaid	$16,813.33
Rate for Payer: Cigna Medicaid	$16,813.33
Rate for Payer: Molina CHIP/Medicaid	$16,813.33
Rate for Payer: Parkland Medicaid	$16,813.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,832.74

CLIK X ANCHOR STERILE KIT

Facility

$1,204.82

Service Code	HCPCS C1713
Hospital Charge Code	992355
Hospital Revenue Code	278
Min. Negotiated Rate	$301.20
Max. Negotiated Rate	$602.41
Rate for Payer: Cash Price	$819.28
Rate for Payer: Cigna Commercial	$301.20
Rate for Payer: Multiplan Auto	$602.41
Rate for Payer: Multiplan Commercial	$602.41
Rate for Payer: Multiplan Workers Comp	$602.41
Rate for Payer: Scott and White EPO/PPO	$602.41

CLIK X ANCHOR STERILE KIT

Facility

$1,204.82

Service Code	HCPCS C1713
Hospital Charge Code	992355
Hospital Revenue Code	278
Min. Negotiated Rate	$108.43
Max. Negotiated Rate	$867.47
Rate for Payer: Amerigroup CHIP/Medicaid	$108.43
Rate for Payer: BCBS of TX Blue Advantage	$361.45
Rate for Payer: BCBS of TX Blue Essentials	$433.74
Rate for Payer: BCBS of TX PPO	$481.93
Rate for Payer: Cash Price	$819.28
Rate for Payer: Cigna Medicaid	$867.47
Rate for Payer: Molina CHIP/Medicaid	$867.47
Rate for Payer: Multiplan Auto	$602.41
Rate for Payer: Multiplan Commercial	$602.41
Rate for Payer: Multiplan Workers Comp	$602.41
Rate for Payer: Parkland Medicaid	$867.47
Rate for Payer: Scott and White EPO/PPO	$602.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$867.47
Rate for Payer: Superior Health Plan EPO	$163.86

clindamycin 150 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77472566
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

clindamycin 150 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77472566
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

clindamycin 150 mg/mL Inj Soln 4 mL

Facility

$128.17

Service Code	HCPCS J0736
Hospital Charge Code	7443828
Hospital Revenue Code	636
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.60
Rate for Payer: BCBS of TX Blue Essentials	$3.11
Rate for Payer: BCBS of TX PPO	$3.45
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

clindamycin 150 mg/mL Inj Soln 4 mL

Facility

$128.17

Service Code	HCPCS J0736
Hospital Charge Code	7443828
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

clindamycin 300 mg Cap

Facility

$16.15

Service Code	HCPCS J3490
Hospital Charge Code	77472892
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.98

clindamycin 300 mg Cap

Facility

$16.15

Service Code	HCPCS J3490
Hospital Charge Code	77472892
Hospital Revenue Code	250
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$11.63
Rate for Payer: Amerigroup CHIP/Medicaid	$1.45
Rate for Payer: BCBS of TX Blue Advantage	$4.84
Rate for Payer: BCBS of TX Blue Essentials	$5.81
Rate for Payer: BCBS of TX PPO	$6.46
Rate for Payer: Cash Price	$10.98
Rate for Payer: Cigna Medicaid	$11.63
Rate for Payer: Molina CHIP/Medicaid	$11.63
Rate for Payer: Multiplan Auto	$10.50
Rate for Payer: Multiplan Commercial	$10.50
Rate for Payer: Multiplan Workers Comp	$10.50
Rate for Payer: Parkland Medicaid	$11.63
Rate for Payer: Scott and White EPO/PPO	$8.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.63
Rate for Payer: Superior Health Plan EPO	$2.20

clindamycin 600 mg/50 mL-NaCl 0.9% Sol

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8134766
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

clindamycin 600 mg/50 mL-NaCl 0.9% Sol

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8134766
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

clindamycin 600 mg/NS 50 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	78872572
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

clindamycin 600 mg/NS 50 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	78872572
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

clindamycin 900 mg/50 mL-NaCl 0.9% Sol

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8134767
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

clindamycin 900 mg/50 mL-NaCl 0.9% Sol

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	8134767
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

CLIP, ANASTAMOTIC S105 UCLIP REG FLEX REG NDLE 2PK -- DHF

Facility

$899.29

Hospital Charge Code	82020777
Hospital Revenue Code	272
Rate for Payer: Cash Price	$611.52

CLIP, ANASTAMOTIC S105 UCLIP REG FLEX REG NDLE 2PK -- DHF

Facility

$899.29

Hospital Charge Code	82020777
Hospital Revenue Code	272
Min. Negotiated Rate	$80.94
Max. Negotiated Rate	$647.49
Rate for Payer: Amerigroup CHIP/Medicaid	$80.94
Rate for Payer: BCBS of TX Blue Advantage	$269.79
Rate for Payer: BCBS of TX Blue Essentials	$323.74
Rate for Payer: BCBS of TX PPO	$359.72
Rate for Payer: Cash Price	$611.52
Rate for Payer: Cigna Medicaid	$647.49
Rate for Payer: Molina CHIP/Medicaid	$647.49
Rate for Payer: Multiplan Auto	$584.54
Rate for Payer: Multiplan Commercial	$584.54
Rate for Payer: Multiplan Workers Comp	$584.54
Rate for Payer: Parkland Medicaid	$647.49
Rate for Payer: Scott and White EPO/PPO	$449.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$647.49
Rate for Payer: Superior Health Plan EPO	$122.30

CLIP EAR MP SEMSPR FOR USE W/W

Facility

$620.53

Hospital Charge Code	992965
Hospital Revenue Code	270
Min. Negotiated Rate	$55.85
Max. Negotiated Rate	$446.78
Rate for Payer: Amerigroup CHIP/Medicaid	$55.85
Rate for Payer: BCBS of TX Blue Advantage	$186.16
Rate for Payer: BCBS of TX Blue Essentials	$223.39
Rate for Payer: BCBS of TX PPO	$248.21
Rate for Payer: Cash Price	$421.96
Rate for Payer: Cigna Medicaid	$446.78
Rate for Payer: Molina CHIP/Medicaid	$446.78
Rate for Payer: Multiplan Auto	$403.34
Rate for Payer: Multiplan Commercial	$403.34
Rate for Payer: Multiplan Workers Comp	$403.34
Rate for Payer: Parkland Medicaid	$446.78
Rate for Payer: Scott and White EPO/PPO	$310.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$446.78
Rate for Payer: Superior Health Plan EPO	$84.39

CLIP EAR MP SEMSPR FOR USE W/W

Facility

$620.53

Hospital Charge Code	992965
Hospital Revenue Code	270
Rate for Payer: Cash Price	$421.96

clip hemolok large 6 purple

Facility

$137.77

Hospital Charge Code	81560302
Hospital Revenue Code	270
Rate for Payer: Cash Price	$93.68

clip hemolok large 6 purple

Facility

$137.77

Hospital Charge Code	81560302
Hospital Revenue Code	270
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$99.19
Rate for Payer: Amerigroup CHIP/Medicaid	$12.40
Rate for Payer: BCBS of TX Blue Advantage	$41.33
Rate for Payer: BCBS of TX Blue Essentials	$49.60
Rate for Payer: BCBS of TX PPO	$55.11
Rate for Payer: Cash Price	$93.68
Rate for Payer: Cigna Medicaid	$99.19
Rate for Payer: Molina CHIP/Medicaid	$99.19
Rate for Payer: Multiplan Auto	$89.55
Rate for Payer: Multiplan Commercial	$89.55
Rate for Payer: Multiplan Workers Comp	$89.55
Rate for Payer: Parkland Medicaid	$99.19
Rate for Payer: Scott and White EPO/PPO	$68.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$99.19
Rate for Payer: Superior Health Plan EPO	$18.74

clip hemolok med/large green

Facility

$143.96

Hospital Charge Code	8692546
Hospital Revenue Code	270
Min. Negotiated Rate	$12.96
Max. Negotiated Rate	$103.65
Rate for Payer: Amerigroup CHIP/Medicaid	$12.96
Rate for Payer: BCBS of TX Blue Advantage	$43.19
Rate for Payer: BCBS of TX Blue Essentials	$51.83
Rate for Payer: BCBS of TX PPO	$57.58
Rate for Payer: Cash Price	$97.89
Rate for Payer: Cigna Medicaid	$103.65
Rate for Payer: Molina CHIP/Medicaid	$103.65
Rate for Payer: Multiplan Auto	$93.57
Rate for Payer: Multiplan Commercial	$93.57
Rate for Payer: Multiplan Workers Comp	$93.57
Rate for Payer: Parkland Medicaid	$103.65
Rate for Payer: Scott and White EPO/PPO	$71.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$103.65
Rate for Payer: Superior Health Plan EPO	$19.58

clip hemolok med/large green

Facility

$143.96

Hospital Charge Code	8692546
Hospital Revenue Code	270
Rate for Payer: Cash Price	$97.89

CLIP, HEM-O-LOK, MED/LG, 14 CART/BX, PACK

Facility

$53.94

Hospital Charge Code	992295
Hospital Revenue Code	272
Rate for Payer: Cash Price	$36.68

Know your out-of-pocket cost for care.

All Charges