White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$385.90

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 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
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

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	$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

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

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

702449

Facility

$2,867.47

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

702459

Facility

$1,405.58

Service Code	HCPCS C1769
Hospital Charge Code	991172
Hospital Revenue Code	272
Min. Negotiated Rate	$126.50
Max. Negotiated Rate	$1,012.02
Rate for Payer: Amerigroup CHIP/Medicaid	$126.50
Rate for Payer: BCBS of TX Blue Advantage	$421.67
Rate for Payer: BCBS of TX Blue Essentials	$506.01
Rate for Payer: BCBS of TX PPO	$562.23
Rate for Payer: Cash Price	$955.79
Rate for Payer: Cigna Medicaid	$1,012.02
Rate for Payer: Molina CHIP/Medicaid	$1,012.02
Rate for Payer: Multiplan Auto	$913.63
Rate for Payer: Multiplan Commercial	$913.63
Rate for Payer: Multiplan Workers Comp	$913.63
Rate for Payer: Parkland Medicaid	$1,012.02
Rate for Payer: Scott and White EPO/PPO	$702.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,012.02
Rate for Payer: Superior Health Plan EPO	$191.16

702459

Facility

$728.92

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

702459

Facility

$728.92

Service Code	HCPCS C1769
Hospital Charge Code	994040
Hospital Revenue Code	272
Min. Negotiated Rate	$65.60
Max. Negotiated Rate	$524.82
Rate for Payer: Amerigroup CHIP/Medicaid	$65.60
Rate for Payer: BCBS of TX Blue Advantage	$218.68
Rate for Payer: BCBS of TX Blue Essentials	$262.41
Rate for Payer: BCBS of TX PPO	$291.57
Rate for Payer: Cash Price	$495.67
Rate for Payer: Cigna Medicaid	$524.82
Rate for Payer: Molina CHIP/Medicaid	$524.82
Rate for Payer: Multiplan Auto	$473.80
Rate for Payer: Multiplan Commercial	$473.80
Rate for Payer: Multiplan Workers Comp	$473.80
Rate for Payer: Parkland Medicaid	$524.82
Rate for Payer: Scott and White EPO/PPO	$364.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$524.82
Rate for Payer: Superior Health Plan EPO	$99.13

702459

Facility

$1,405.58

Service Code	HCPCS C1769
Hospital Charge Code	991172
Hospital Revenue Code	272
Rate for Payer: Cash Price	$955.79

7030-6525

Facility

$284.35

Service Code	HCPCS C1713
Hospital Charge Code	993999
Hospital Revenue Code	278
Min. Negotiated Rate	$71.09
Max. Negotiated Rate	$142.18
Rate for Payer: Cash Price	$193.36
Rate for Payer: Cigna Commercial	$71.09
Rate for Payer: Multiplan Auto	$142.18
Rate for Payer: Multiplan Commercial	$142.18
Rate for Payer: Multiplan Workers Comp	$142.18
Rate for Payer: Scott and White EPO/PPO	$142.18

7030-6525

Facility

$284.35

Service Code	HCPCS C1713
Hospital Charge Code	993999
Hospital Revenue Code	278
Min. Negotiated Rate	$25.59
Max. Negotiated Rate	$204.73
Rate for Payer: Amerigroup CHIP/Medicaid	$25.59
Rate for Payer: BCBS of TX Blue Advantage	$85.31
Rate for Payer: BCBS of TX Blue Essentials	$102.37
Rate for Payer: BCBS of TX PPO	$113.74
Rate for Payer: Cash Price	$193.36
Rate for Payer: Cigna Medicaid	$204.73
Rate for Payer: Molina CHIP/Medicaid	$204.73
Rate for Payer: Multiplan Auto	$142.18
Rate for Payer: Multiplan Commercial	$142.18
Rate for Payer: Multiplan Workers Comp	$142.18
Rate for Payer: Parkland Medicaid	$204.73
Rate for Payer: Scott and White EPO/PPO	$142.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$204.73
Rate for Payer: Superior Health Plan EPO	$38.67

7.03962E+17

Facility

$1,373.49

Service Code	HCPCS A4649
Hospital Charge Code	994143
Hospital Revenue Code	272
Rate for Payer: Cash Price	$933.97

7.03962E+17

Facility

$1,373.49

Service Code	HCPCS A4649
Hospital Charge Code	994143
Hospital Revenue Code	272
Min. Negotiated Rate	$123.61
Max. Negotiated Rate	$988.91
Rate for Payer: Amerigroup CHIP/Medicaid	$123.61
Rate for Payer: BCBS of TX Blue Advantage	$412.05
Rate for Payer: BCBS of TX Blue Essentials	$494.46
Rate for Payer: BCBS of TX PPO	$549.40
Rate for Payer: Cash Price	$933.97
Rate for Payer: Cigna Medicaid	$988.91
Rate for Payer: Molina CHIP/Medicaid	$988.91
Rate for Payer: Multiplan Auto	$892.77
Rate for Payer: Multiplan Commercial	$892.77
Rate for Payer: Multiplan Workers Comp	$892.77
Rate for Payer: Parkland Medicaid	$988.91
Rate for Payer: Scott and White EPO/PPO	$686.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$988.91
Rate for Payer: Superior Health Plan EPO	$186.79

7.03962E+17

Facility

$14.46

Service Code	HCPCS A4649
Hospital Charge Code	994095
Hospital Revenue Code	272
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$10.41
Rate for Payer: Amerigroup CHIP/Medicaid	$1.30
Rate for Payer: BCBS of TX Blue Advantage	$4.34
Rate for Payer: BCBS of TX Blue Essentials	$5.21
Rate for Payer: BCBS of TX PPO	$5.78
Rate for Payer: Cash Price	$9.83
Rate for Payer: Cigna Medicaid	$10.41
Rate for Payer: Molina CHIP/Medicaid	$10.41
Rate for Payer: Multiplan Auto	$9.40
Rate for Payer: Multiplan Commercial	$9.40
Rate for Payer: Multiplan Workers Comp	$9.40
Rate for Payer: Parkland Medicaid	$10.41
Rate for Payer: Scott and White EPO/PPO	$7.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.41
Rate for Payer: Superior Health Plan EPO	$1.97

7.03962E+17

Facility

$14.46

Service Code	HCPCS A4649
Hospital Charge Code	994095
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.83

705235

Facility

$801.20

Service Code	HCPCS C1769
Hospital Charge Code	992005
Hospital Revenue Code	278
Min. Negotiated Rate	$72.11
Max. Negotiated Rate	$576.86
Rate for Payer: Amerigroup CHIP/Medicaid	$72.11
Rate for Payer: BCBS of TX Blue Advantage	$240.36
Rate for Payer: BCBS of TX Blue Essentials	$288.43
Rate for Payer: BCBS of TX PPO	$320.48
Rate for Payer: Cash Price	$544.82
Rate for Payer: Cigna Medicaid	$576.86
Rate for Payer: Molina CHIP/Medicaid	$576.86
Rate for Payer: Multiplan Auto	$400.60
Rate for Payer: Multiplan Commercial	$400.60
Rate for Payer: Multiplan Workers Comp	$400.60
Rate for Payer: Parkland Medicaid	$576.86
Rate for Payer: Scott and White EPO/PPO	$400.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$576.86
Rate for Payer: Superior Health Plan EPO	$108.96

705235

Facility

$801.20

Service Code	HCPCS C1769
Hospital Charge Code	992005
Hospital Revenue Code	278
Min. Negotiated Rate	$200.30
Max. Negotiated Rate	$400.60
Rate for Payer: Cash Price	$544.82
Rate for Payer: Cigna Commercial	$200.30
Rate for Payer: Multiplan Auto	$400.60
Rate for Payer: Multiplan Commercial	$400.60
Rate for Payer: Multiplan Workers Comp	$400.60
Rate for Payer: Scott and White EPO/PPO	$400.60

Know your out-of-pocket cost for care.

All Charges