White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

CLIP, LIGATING TITANIUM MEDIUM 6/CR -- DHF

Facility

$51.50

Hospital Charge Code	81941155
Hospital Revenue Code	272
Rate for Payer: Cash Price	$35.02

CLIP, LIGATING TITANIUM MEDIUM 6/CR -- DHF

Facility

$51.50

Hospital Charge Code	81941155
Hospital Revenue Code	272
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$37.08
Rate for Payer: Amerigroup CHIP/Medicaid	$4.63
Rate for Payer: BCBS of TX Blue Advantage	$15.45
Rate for Payer: BCBS of TX Blue Essentials	$18.54
Rate for Payer: BCBS of TX PPO	$20.60
Rate for Payer: Cash Price	$35.02
Rate for Payer: Cigna Medicaid	$37.08
Rate for Payer: Molina CHIP/Medicaid	$37.08
Rate for Payer: Multiplan Auto	$33.48
Rate for Payer: Multiplan Commercial	$33.48
Rate for Payer: Multiplan Workers Comp	$33.48
Rate for Payer: Parkland Medicaid	$37.08
Rate for Payer: Scott and White EPO/PPO	$25.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.08
Rate for Payer: Superior Health Plan EPO	$7.00

CLIP, NOSE PLASTIC DISPOSABLE

Facility

$12.09

Hospital Charge Code	993662
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.22

CLIP, NOSE PLASTIC DISPOSABLE

Facility

$12.09

Hospital Charge Code	993662
Hospital Revenue Code	270
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$8.70
Rate for Payer: Amerigroup CHIP/Medicaid	$1.09
Rate for Payer: BCBS of TX Blue Advantage	$3.63
Rate for Payer: BCBS of TX Blue Essentials	$4.35
Rate for Payer: BCBS of TX PPO	$4.84
Rate for Payer: Cash Price	$8.22
Rate for Payer: Cigna Medicaid	$8.70
Rate for Payer: Molina CHIP/Medicaid	$8.70
Rate for Payer: Multiplan Auto	$7.86
Rate for Payer: Multiplan Commercial	$7.86
Rate for Payer: Multiplan Workers Comp	$7.86
Rate for Payer: Parkland Medicaid	$8.70
Rate for Payer: Scott and White EPO/PPO	$6.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.70
Rate for Payer: Superior Health Plan EPO	$1.64

CLIPPER, SURGICAL, PIVOTING HEAD

Facility

$233.63

Hospital Charge Code	992848
Hospital Revenue Code	272
Min. Negotiated Rate	$21.03
Max. Negotiated Rate	$168.21
Rate for Payer: Amerigroup CHIP/Medicaid	$21.03
Rate for Payer: BCBS of TX Blue Advantage	$70.09
Rate for Payer: BCBS of TX Blue Essentials	$84.11
Rate for Payer: BCBS of TX PPO	$93.45
Rate for Payer: Cash Price	$158.87
Rate for Payer: Cigna Medicaid	$168.21
Rate for Payer: Molina CHIP/Medicaid	$168.21
Rate for Payer: Multiplan Auto	$151.86
Rate for Payer: Multiplan Commercial	$151.86
Rate for Payer: Multiplan Workers Comp	$151.86
Rate for Payer: Parkland Medicaid	$168.21
Rate for Payer: Scott and White EPO/PPO	$116.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$168.21
Rate for Payer: Superior Health Plan EPO	$31.77

CLIPPER, SURGICAL, PIVOTING HEAD

Facility

$233.63

Hospital Charge Code	992848
Hospital Revenue Code	272
Rate for Payer: Cash Price	$158.87

CLIP RESOLUTION 360 ULTRA

Facility

$1,317.42

Hospital Charge Code	144856
Hospital Revenue Code	272
Min. Negotiated Rate	$118.57
Max. Negotiated Rate	$948.54
Rate for Payer: Amerigroup CHIP/Medicaid	$118.57
Rate for Payer: BCBS of TX Blue Advantage	$395.23
Rate for Payer: BCBS of TX Blue Essentials	$474.27
Rate for Payer: BCBS of TX PPO	$526.97
Rate for Payer: Cash Price	$895.85
Rate for Payer: Cigna Medicaid	$948.54
Rate for Payer: Molina CHIP/Medicaid	$948.54
Rate for Payer: Multiplan Auto	$856.32
Rate for Payer: Multiplan Commercial	$856.32
Rate for Payer: Multiplan Workers Comp	$856.32
Rate for Payer: Parkland Medicaid	$948.54
Rate for Payer: Scott and White EPO/PPO	$658.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$948.54
Rate for Payer: Superior Health Plan EPO	$179.17

CLIP RESOLUTION 360 ULTRA

Facility

$1,317.42

Hospital Charge Code	144856
Hospital Revenue Code	272
Rate for Payer: Cash Price	$895.85

CLIP, SUTURE ABSORABLE 2-0 3-0 4-0 COATED VICRYL -- DHF

Facility

$561.83

Hospital Charge Code	81926214
Hospital Revenue Code	272
Rate for Payer: Cash Price	$382.04

CLIP, SUTURE ABSORABLE 2-0 3-0 4-0 COATED VICRYL -- DHF

Facility

$561.83

Hospital Charge Code	81926214
Hospital Revenue Code	272
Min. Negotiated Rate	$50.56
Max. Negotiated Rate	$404.52
Rate for Payer: Amerigroup CHIP/Medicaid	$50.56
Rate for Payer: BCBS of TX Blue Advantage	$168.55
Rate for Payer: BCBS of TX Blue Essentials	$202.26
Rate for Payer: BCBS of TX PPO	$224.73
Rate for Payer: Cash Price	$382.04
Rate for Payer: Cigna Medicaid	$404.52
Rate for Payer: Molina CHIP/Medicaid	$404.52
Rate for Payer: Multiplan Auto	$365.19
Rate for Payer: Multiplan Commercial	$365.19
Rate for Payer: Multiplan Workers Comp	$365.19
Rate for Payer: Parkland Medicaid	$404.52
Rate for Payer: Scott and White EPO/PPO	$280.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$404.52
Rate for Payer: Superior Health Plan EPO	$76.41

CLIP, SUTURE, ENDO, ABS,2-0/3-0/4-0, VICRYL

Facility

$261.81

Hospital Charge Code	992820
Hospital Revenue Code	272
Rate for Payer: Cash Price	$178.03

CLIP, SUTURE, ENDO, ABS,2-0/3-0/4-0, VICRYL

Facility

$261.81

Hospital Charge Code	992820
Hospital Revenue Code	272
Min. Negotiated Rate	$23.56
Max. Negotiated Rate	$188.50
Rate for Payer: Amerigroup CHIP/Medicaid	$23.56
Rate for Payer: BCBS of TX Blue Advantage	$78.54
Rate for Payer: BCBS of TX Blue Essentials	$94.25
Rate for Payer: BCBS of TX PPO	$104.72
Rate for Payer: Cash Price	$178.03
Rate for Payer: Cigna Medicaid	$188.50
Rate for Payer: Molina CHIP/Medicaid	$188.50
Rate for Payer: Multiplan Auto	$170.18
Rate for Payer: Multiplan Commercial	$170.18
Rate for Payer: Multiplan Workers Comp	$170.18
Rate for Payer: Parkland Medicaid	$188.50
Rate for Payer: Scott and White EPO/PPO	$130.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$188.50
Rate for Payer: Superior Health Plan EPO	$35.61

CLMP CORD UMBIL -- DHF

Facility

$74.24

Hospital Charge Code	80810559
Hospital Revenue Code	272
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$53.45
Rate for Payer: Amerigroup CHIP/Medicaid	$6.68
Rate for Payer: BCBS of TX Blue Advantage	$22.27
Rate for Payer: BCBS of TX Blue Essentials	$26.73
Rate for Payer: BCBS of TX PPO	$29.70
Rate for Payer: Cash Price	$50.48
Rate for Payer: Cigna Medicaid	$53.45
Rate for Payer: Molina CHIP/Medicaid	$53.45
Rate for Payer: Multiplan Auto	$48.26
Rate for Payer: Multiplan Commercial	$48.26
Rate for Payer: Multiplan Workers Comp	$48.26
Rate for Payer: Parkland Medicaid	$53.45
Rate for Payer: Scott and White EPO/PPO	$37.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53.45
Rate for Payer: Superior Health Plan EPO	$10.10

CLMP CORD UMBIL -- DHF

Facility

$74.24

Hospital Charge Code	80810559
Hospital Revenue Code	272
Rate for Payer: Cash Price	$50.48

CLNR ACID PERACETIC 4SETS/CA

Facility

$1,066.90

Hospital Charge Code	993932
Hospital Revenue Code	272
Rate for Payer: Cash Price	$725.49

CLNR ACID PERACETIC 4SETS/CA

Facility

$1,066.90

Hospital Charge Code	993932
Hospital Revenue Code	272
Min. Negotiated Rate	$96.02
Max. Negotiated Rate	$768.17
Rate for Payer: Amerigroup CHIP/Medicaid	$96.02
Rate for Payer: BCBS of TX Blue Advantage	$320.07
Rate for Payer: BCBS of TX Blue Essentials	$384.08
Rate for Payer: BCBS of TX PPO	$426.76
Rate for Payer: Cash Price	$725.49
Rate for Payer: Cigna Medicaid	$768.17
Rate for Payer: Molina CHIP/Medicaid	$768.17
Rate for Payer: Multiplan Auto	$693.49
Rate for Payer: Multiplan Commercial	$693.49
Rate for Payer: Multiplan Workers Comp	$693.49
Rate for Payer: Parkland Medicaid	$768.17
Rate for Payer: Scott and White EPO/PPO	$533.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$768.17
Rate for Payer: Superior Health Plan EPO	$145.10

CLN WND -- DHF

Facility

$35.55

Hospital Charge Code	80317209
Hospital Revenue Code	270
Rate for Payer: Cash Price	$24.17

CLN WND -- DHF

Facility

$35.55

Hospital Charge Code	80317209
Hospital Revenue Code	270
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$25.60
Rate for Payer: Amerigroup CHIP/Medicaid	$3.20
Rate for Payer: BCBS of TX Blue Advantage	$10.66
Rate for Payer: BCBS of TX Blue Essentials	$12.80
Rate for Payer: BCBS of TX PPO	$14.22
Rate for Payer: Cash Price	$24.17
Rate for Payer: Cigna Medicaid	$25.60
Rate for Payer: Molina CHIP/Medicaid	$25.60
Rate for Payer: Multiplan Auto	$23.11
Rate for Payer: Multiplan Commercial	$23.11
Rate for Payer: Multiplan Workers Comp	$23.11
Rate for Payer: Parkland Medicaid	$25.60
Rate for Payer: Scott and White EPO/PPO	$17.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25.60
Rate for Payer: Superior Health Plan EPO	$4.83

clonazePAM 0.5 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77475449
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

clonazePAM 0.5 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77475449
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

cloNIDine 0.1 mg/24 hr TD Film, ER

Facility

$56.00

Service Code	HCPCS J3490
Hospital Charge Code	77475822
Hospital Revenue Code	250
Rate for Payer: Cash Price	$38.08

cloNIDine 0.1 mg/24 hr TD Film, ER

Facility

$56.00

Service Code	HCPCS J3490
Hospital Charge Code	77475822
Hospital Revenue Code	250
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$40.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5.04
Rate for Payer: BCBS of TX Blue Advantage	$16.80
Rate for Payer: BCBS of TX Blue Essentials	$20.16
Rate for Payer: BCBS of TX PPO	$22.40
Rate for Payer: Cash Price	$38.08
Rate for Payer: Cigna Medicaid	$40.32
Rate for Payer: Molina CHIP/Medicaid	$40.32
Rate for Payer: Multiplan Auto	$36.40
Rate for Payer: Multiplan Commercial	$36.40
Rate for Payer: Multiplan Workers Comp	$36.40
Rate for Payer: Parkland Medicaid	$40.32
Rate for Payer: Scott and White EPO/PPO	$28.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.32
Rate for Payer: Superior Health Plan EPO	$7.62

cloNIDine 0.1 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77475718
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

cloNIDine 0.1 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77475718
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Know your out-of-pocket cost for care.

All Charges