White Rock Medical Center

All Charges

Charge

Type

Setting

Price

coated vicryl absorbable braided polyglactin 910 suture

Facility

$11.98

Hospital Charge Code	993698
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.15

coated vicryl absorbable braided polyglactin 910 suture

Facility

$11.98

Hospital Charge Code	993698
Hospital Revenue Code	270
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$8.63
Rate for Payer: Amerigroup CHIP/Medicaid	$1.08
Rate for Payer: BCBS of TX Blue Advantage	$3.59
Rate for Payer: BCBS of TX Blue Essentials	$4.31
Rate for Payer: BCBS of TX PPO	$4.79
Rate for Payer: Cash Price	$8.15
Rate for Payer: Cigna Medicaid	$8.63
Rate for Payer: Molina CHIP/Medicaid	$8.63
Rate for Payer: Multiplan Auto	$7.79
Rate for Payer: Multiplan Commercial	$7.79
Rate for Payer: Multiplan Workers Comp	$7.79
Rate for Payer: Parkland Medicaid	$8.63
Rate for Payer: Scott and White EPO/PPO	$5.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.63
Rate for Payer: Superior Health Plan EPO	$1.63

Coban Wrap Bandage Elastic 2'x5yd Tan Sterile 36 / Ca

Facility

$6.01

Hospital Charge Code	993834
Hospital Revenue Code	272
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$4.33
Rate for Payer: Amerigroup CHIP/Medicaid	$0.54
Rate for Payer: BCBS of TX Blue Advantage	$1.80
Rate for Payer: BCBS of TX Blue Essentials	$2.16
Rate for Payer: BCBS of TX PPO	$2.40
Rate for Payer: Cash Price	$4.09
Rate for Payer: Cigna Medicaid	$4.33
Rate for Payer: Molina CHIP/Medicaid	$4.33
Rate for Payer: Multiplan Auto	$3.91
Rate for Payer: Multiplan Commercial	$3.91
Rate for Payer: Multiplan Workers Comp	$3.91
Rate for Payer: Parkland Medicaid	$4.33
Rate for Payer: Scott and White EPO/PPO	$3.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.33
Rate for Payer: Superior Health Plan EPO	$0.82

Coban Wrap Bandage Elastic 2'x5yd Tan Sterile 36 / Ca

Facility

$6.01

Hospital Charge Code	993834
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.09

COCAINE ABUSE AND DEPENDENCE

Facility

$3,097.10

Service Code	APR-DRG 7743
Min. Negotiated Rate	$2,920.05
Max. Negotiated Rate	$3,097.10
Rate for Payer: Amerigroup CHIP/Medicaid	$2,920.05
Rate for Payer: Cigna Medicaid	$2,920.05
Rate for Payer: Molina CHIP/Medicaid	$2,920.05
Rate for Payer: Parkland Medicaid	$2,920.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,097.10

COCAINE ABUSE AND DEPENDENCE

Facility

$1,265.85

Service Code	APR-DRG 7741
Min. Negotiated Rate	$1,193.48
Max. Negotiated Rate	$1,265.85
Rate for Payer: Amerigroup CHIP/Medicaid	$1,193.48
Rate for Payer: Cigna Medicaid	$1,193.48
Rate for Payer: Molina CHIP/Medicaid	$1,193.48
Rate for Payer: Parkland Medicaid	$1,193.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,265.85

COCAINE ABUSE AND DEPENDENCE

Facility

$2,110.00

Service Code	APR-DRG 7742
Min. Negotiated Rate	$1,989.38
Max. Negotiated Rate	$2,110.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,989.38
Rate for Payer: Cigna Medicaid	$1,989.38
Rate for Payer: Molina CHIP/Medicaid	$1,989.38
Rate for Payer: Parkland Medicaid	$1,989.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,110.00

COCAINE ABUSE AND DEPENDENCE

Facility

$8,089.20

Service Code	APR-DRG 7744
Min. Negotiated Rate	$7,626.78
Max. Negotiated Rate	$8,089.20
Rate for Payer: Amerigroup CHIP/Medicaid	$7,626.78
Rate for Payer: Cigna Medicaid	$7,626.78
Rate for Payer: Molina CHIP/Medicaid	$7,626.78
Rate for Payer: Parkland Medicaid	$7,626.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,089.20

Coccidioides CF Antibody SO

Facility

$93.36

Service Code	HCPCS 86635
Hospital Charge Code	1704022
Hospital Revenue Code	302
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$67.22
Rate for Payer: Amerigroup CHIP/Medicaid	$4.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.47
Rate for Payer: Amerigroup Medicare	$11.47
Rate for Payer: BCBS of TX Blue Advantage	$28.01
Rate for Payer: BCBS of TX Blue Essentials	$33.61
Rate for Payer: BCBS of TX Medicare	$11.47
Rate for Payer: BCBS of TX PPO	$37.34
Rate for Payer: Cash Price	$63.48
Rate for Payer: Cash Price	$63.48
Rate for Payer: Cigna Medicaid	$67.22
Rate for Payer: Cigna Medicare	$11.47
Rate for Payer: Employer Direct Commercial	$11.47
Rate for Payer: Humana Medicare/TRICARE	$11.47
Rate for Payer: Molina CHIP/Medicaid	$67.22
Rate for Payer: Molina Dual Medicare/Medicaid	$11.47
Rate for Payer: Molina Medicare	$11.47
Rate for Payer: Multiplan Auto	$60.68
Rate for Payer: Multiplan Commercial	$60.68
Rate for Payer: Multiplan Workers Comp	$60.68
Rate for Payer: Parkland Medicaid	$67.22
Rate for Payer: Scott and White EPO/PPO	$14.34
Rate for Payer: Scott and White Medicare	$11.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$67.22
Rate for Payer: Superior Health Plan EPO	$11.47
Rate for Payer: Superior Health Plan Medicare	$11.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.47
Rate for Payer: Universal American Medicare	$11.47
Rate for Payer: Wellcare Medicare	$11.47
Rate for Payer: Wellmed Medicare	$11.47

Coccidioides CF Antibody SO

Facility

$93.36

Service Code	HCPCS 86635
Hospital Charge Code	1704022
Hospital Revenue Code	302
Rate for Payer: Cash Price	$63.48

codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 5 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77482140
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

codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 5 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77482140
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

COLAG CANNULATED LAG SCREW REAMER, 3.3MM - 5.0 SCREWS

Facility

$1,343.37

Service Code	HCPCS C1713
Hospital Charge Code	992655
Hospital Revenue Code	278
Min. Negotiated Rate	$120.90
Max. Negotiated Rate	$967.23
Rate for Payer: Amerigroup CHIP/Medicaid	$120.90
Rate for Payer: BCBS of TX Blue Advantage	$403.01
Rate for Payer: BCBS of TX Blue Essentials	$483.61
Rate for Payer: BCBS of TX PPO	$537.35
Rate for Payer: Cash Price	$913.49
Rate for Payer: Cigna Medicaid	$967.23
Rate for Payer: Molina CHIP/Medicaid	$967.23
Rate for Payer: Multiplan Auto	$671.68
Rate for Payer: Multiplan Commercial	$671.68
Rate for Payer: Multiplan Workers Comp	$671.68
Rate for Payer: Parkland Medicaid	$967.23
Rate for Payer: Scott and White EPO/PPO	$671.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$967.23
Rate for Payer: Superior Health Plan EPO	$182.70

COLAG CANNULATED LAG SCREW REAMER, 3.3MM - 5.0 SCREWS

Facility

$1,343.37

Service Code	HCPCS C1713
Hospital Charge Code	992655
Hospital Revenue Code	278
Min. Negotiated Rate	$335.84
Max. Negotiated Rate	$671.68
Rate for Payer: Cash Price	$913.49
Rate for Payer: Cigna Commercial	$335.84
Rate for Payer: Multiplan Auto	$671.68
Rate for Payer: Multiplan Commercial	$671.68
Rate for Payer: Multiplan Workers Comp	$671.68
Rate for Payer: Scott and White EPO/PPO	$671.68

COLAG CANNULATED LAG SCREW REAMER, 4.8MM - HUDSON - 6.7 SCREWS

Facility

$1,343.37

Service Code	HCPCS C1713
Hospital Charge Code	992656
Hospital Revenue Code	278
Min. Negotiated Rate	$120.90
Max. Negotiated Rate	$967.23
Rate for Payer: Amerigroup CHIP/Medicaid	$120.90
Rate for Payer: BCBS of TX Blue Advantage	$403.01
Rate for Payer: BCBS of TX Blue Essentials	$483.61
Rate for Payer: BCBS of TX PPO	$537.35
Rate for Payer: Cash Price	$913.49
Rate for Payer: Cigna Medicaid	$967.23
Rate for Payer: Molina CHIP/Medicaid	$967.23
Rate for Payer: Multiplan Auto	$671.68
Rate for Payer: Multiplan Commercial	$671.68
Rate for Payer: Multiplan Workers Comp	$671.68
Rate for Payer: Parkland Medicaid	$967.23
Rate for Payer: Scott and White EPO/PPO	$671.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$967.23
Rate for Payer: Superior Health Plan EPO	$182.70

COLAG CANNULATED LAG SCREW REAMER, 4.8MM - HUDSON - 6.7 SCREWS

Facility

$1,343.37

Service Code	HCPCS C1713
Hospital Charge Code	992656
Hospital Revenue Code	278
Min. Negotiated Rate	$335.84
Max. Negotiated Rate	$671.68
Rate for Payer: Cash Price	$913.49
Rate for Payer: Cigna Commercial	$335.84
Rate for Payer: Multiplan Auto	$671.68
Rate for Payer: Multiplan Commercial	$671.68
Rate for Payer: Multiplan Workers Comp	$671.68
Rate for Payer: Scott and White EPO/PPO	$671.68

COLAG GUIDE-WIRE, SINGLE TROCAR, .062 X 7' - 4.0/5.0 SCREWS

Facility

$295.18

Service Code	HCPCS C1713
Hospital Charge Code	992653
Hospital Revenue Code	278
Min. Negotiated Rate	$73.80
Max. Negotiated Rate	$147.59
Rate for Payer: Cash Price	$200.72
Rate for Payer: Cigna Commercial	$73.80
Rate for Payer: Multiplan Auto	$147.59
Rate for Payer: Multiplan Commercial	$147.59
Rate for Payer: Multiplan Workers Comp	$147.59
Rate for Payer: Scott and White EPO/PPO	$147.59

COLAG GUIDE-WIRE, SINGLE TROCAR, .062 X 7' - 4.0/5.0 SCREWS

Facility

$295.18

Service Code	HCPCS C1713
Hospital Charge Code	992653
Hospital Revenue Code	278
Min. Negotiated Rate	$26.57
Max. Negotiated Rate	$212.53
Rate for Payer: Amerigroup CHIP/Medicaid	$26.57
Rate for Payer: BCBS of TX Blue Advantage	$88.55
Rate for Payer: BCBS of TX Blue Essentials	$106.26
Rate for Payer: BCBS of TX PPO	$118.07
Rate for Payer: Cash Price	$200.72
Rate for Payer: Cigna Medicaid	$212.53
Rate for Payer: Molina CHIP/Medicaid	$212.53
Rate for Payer: Multiplan Auto	$147.59
Rate for Payer: Multiplan Commercial	$147.59
Rate for Payer: Multiplan Workers Comp	$147.59
Rate for Payer: Parkland Medicaid	$212.53
Rate for Payer: Scott and White EPO/PPO	$147.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$212.53
Rate for Payer: Superior Health Plan EPO	$40.14

COLAG GUIDE-WIRE, SINGLE TROCAR, .087 X 7' - 6.7 SCREWS

Facility

$295.18

Service Code	HCPCS C1713
Hospital Charge Code	992654
Hospital Revenue Code	278
Min. Negotiated Rate	$26.57
Max. Negotiated Rate	$212.53
Rate for Payer: Amerigroup CHIP/Medicaid	$26.57
Rate for Payer: BCBS of TX Blue Advantage	$88.55
Rate for Payer: BCBS of TX Blue Essentials	$106.26
Rate for Payer: BCBS of TX PPO	$118.07
Rate for Payer: Cash Price	$200.72
Rate for Payer: Cigna Medicaid	$212.53
Rate for Payer: Molina CHIP/Medicaid	$212.53
Rate for Payer: Multiplan Auto	$147.59
Rate for Payer: Multiplan Commercial	$147.59
Rate for Payer: Multiplan Workers Comp	$147.59
Rate for Payer: Parkland Medicaid	$212.53
Rate for Payer: Scott and White EPO/PPO	$147.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$212.53
Rate for Payer: Superior Health Plan EPO	$40.14

COLAG GUIDE-WIRE, SINGLE TROCAR, .087 X 7' - 6.7 SCREWS

Facility

$295.18

Service Code	HCPCS C1713
Hospital Charge Code	992654
Hospital Revenue Code	278
Min. Negotiated Rate	$73.80
Max. Negotiated Rate	$147.59
Rate for Payer: Cash Price	$200.72
Rate for Payer: Cigna Commercial	$73.80
Rate for Payer: Multiplan Auto	$147.59
Rate for Payer: Multiplan Commercial	$147.59
Rate for Payer: Multiplan Workers Comp	$147.59
Rate for Payer: Scott and White EPO/PPO	$147.59

COLAG SCREW, 5.0 X 67.5MM - STERILE

Facility

$4,204.82

Service Code	HCPCS C1713
Hospital Charge Code	992658
Hospital Revenue Code	278
Min. Negotiated Rate	$1,051.20
Max. Negotiated Rate	$2,102.41
Rate for Payer: Cash Price	$2,859.28
Rate for Payer: Cigna Commercial	$1,051.20
Rate for Payer: Multiplan Auto	$2,102.41
Rate for Payer: Multiplan Commercial	$2,102.41
Rate for Payer: Multiplan Workers Comp	$2,102.41
Rate for Payer: Scott and White EPO/PPO	$2,102.41

COLAG SCREW, 5.0 X 67.5MM - STERILE

Facility

$4,204.82

Service Code	HCPCS C1713
Hospital Charge Code	992658
Hospital Revenue Code	278
Min. Negotiated Rate	$378.43
Max. Negotiated Rate	$3,027.47
Rate for Payer: Amerigroup CHIP/Medicaid	$378.43
Rate for Payer: BCBS of TX Blue Advantage	$1,261.45
Rate for Payer: BCBS of TX Blue Essentials	$1,513.74
Rate for Payer: BCBS of TX PPO	$1,681.93
Rate for Payer: Cash Price	$2,859.28
Rate for Payer: Cigna Medicaid	$3,027.47
Rate for Payer: Molina CHIP/Medicaid	$3,027.47
Rate for Payer: Multiplan Auto	$2,102.41
Rate for Payer: Multiplan Commercial	$2,102.41
Rate for Payer: Multiplan Workers Comp	$2,102.41
Rate for Payer: Parkland Medicaid	$3,027.47
Rate for Payer: Scott and White EPO/PPO	$2,102.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,027.47
Rate for Payer: Superior Health Plan EPO	$571.86

COLAG SCREW, 6.7 X 50.0MM - STERILE

Facility

$5,409.64

Service Code	HCPCS C1713
Hospital Charge Code	992657
Hospital Revenue Code	278
Min. Negotiated Rate	$486.87
Max. Negotiated Rate	$3,894.94
Rate for Payer: Amerigroup CHIP/Medicaid	$486.87
Rate for Payer: BCBS of TX Blue Advantage	$1,622.89
Rate for Payer: BCBS of TX Blue Essentials	$1,947.47
Rate for Payer: BCBS of TX PPO	$2,163.86
Rate for Payer: Cash Price	$3,678.56
Rate for Payer: Cigna Medicaid	$3,894.94
Rate for Payer: Molina CHIP/Medicaid	$3,894.94
Rate for Payer: Multiplan Auto	$2,704.82
Rate for Payer: Multiplan Commercial	$2,704.82
Rate for Payer: Multiplan Workers Comp	$2,704.82
Rate for Payer: Parkland Medicaid	$3,894.94
Rate for Payer: Scott and White EPO/PPO	$2,704.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,894.94
Rate for Payer: Superior Health Plan EPO	$735.71

COLAG SCREW, 6.7 X 50.0MM - STERILE

Facility

$5,409.64

Service Code	HCPCS C1713
Hospital Charge Code	992657
Hospital Revenue Code	278
Min. Negotiated Rate	$1,352.41
Max. Negotiated Rate	$2,704.82
Rate for Payer: Cash Price	$3,678.56
Rate for Payer: Cigna Commercial	$1,352.41
Rate for Payer: Multiplan Auto	$2,704.82
Rate for Payer: Multiplan Commercial	$2,704.82
Rate for Payer: Multiplan Workers Comp	$2,704.82
Rate for Payer: Scott and White EPO/PPO	$2,704.82

colchicine 0.6 mg Tab

Facility

$22.95

Service Code	HCPCS J3490
Hospital Charge Code	77483415
Hospital Revenue Code	250
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$16.52
Rate for Payer: Amerigroup CHIP/Medicaid	$2.07
Rate for Payer: BCBS of TX Blue Advantage	$6.88
Rate for Payer: BCBS of TX Blue Essentials	$8.26
Rate for Payer: BCBS of TX PPO	$9.18
Rate for Payer: Cash Price	$15.61
Rate for Payer: Cigna Medicaid	$16.52
Rate for Payer: Molina CHIP/Medicaid	$16.52
Rate for Payer: Multiplan Auto	$14.92
Rate for Payer: Multiplan Commercial	$14.92
Rate for Payer: Multiplan Workers Comp	$14.92
Rate for Payer: Parkland Medicaid	$16.52
Rate for Payer: Scott and White EPO/PPO	$11.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.52
Rate for Payer: Superior Health Plan EPO	$3.12

Know your out-of-pocket cost for care.

All Charges