White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CT Tibia Fibula w/ Contrast Right

Facility

$3,797.00

Service Code	HCPCS 73701 RT
Hospital Charge Code	3801875
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,581.96

CT Tibia Fibula w/o Contrast Left

Facility

$3,266.00

Service Code	HCPCS 73700 LT
Hospital Charge Code	3800141
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$2,351.52
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$2,351.52
Rate for Payer: Molina CHIP/Medicaid	$2,351.52
Rate for Payer: Multiplan Auto	$2,122.90
Rate for Payer: Multiplan Commercial	$2,122.90
Rate for Payer: Multiplan Workers Comp	$2,122.90
Rate for Payer: Parkland Medicaid	$2,351.52
Rate for Payer: Scott and White EPO/PPO	$1,633.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,351.52
Rate for Payer: Superior Health Plan EPO	$444.18

CT Tibia Fibula w/o Contrast Left

Facility

$3,266.00

Service Code	HCPCS 73700 LT
Hospital Charge Code	3800141
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,220.88

CT Tibia Fibula w/o Contrast Right

Facility

$3,266.00

Service Code	HCPCS 73700 RT
Hospital Charge Code	3801867
Hospital Revenue Code	352
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$2,351.52
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$2,351.52
Rate for Payer: Molina CHIP/Medicaid	$2,351.52
Rate for Payer: Multiplan Auto	$2,122.90
Rate for Payer: Multiplan Commercial	$2,122.90
Rate for Payer: Multiplan Workers Comp	$2,122.90
Rate for Payer: Parkland Medicaid	$2,351.52
Rate for Payer: Scott and White EPO/PPO	$1,633.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,351.52
Rate for Payer: Superior Health Plan EPO	$444.18

CT Tibia Fibula w/o Contrast Right

Facility

$3,266.00

Service Code	HCPCS 73700 RT
Hospital Charge Code	3801867
Hospital Revenue Code	352
Rate for Payer: Cash Price	$2,220.88

CUFF, BLD PRES.REG ADULT

Facility

$6.28

Hospital Charge Code	993041
Hospital Revenue Code	270
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$4.52
Rate for Payer: Amerigroup CHIP/Medicaid	$0.57
Rate for Payer: BCBS of TX Blue Advantage	$1.88
Rate for Payer: BCBS of TX Blue Essentials	$2.26
Rate for Payer: BCBS of TX PPO	$2.51
Rate for Payer: Cash Price	$4.27
Rate for Payer: Cigna Medicaid	$4.52
Rate for Payer: Molina CHIP/Medicaid	$4.52
Rate for Payer: Multiplan Auto	$4.08
Rate for Payer: Multiplan Commercial	$4.08
Rate for Payer: Multiplan Workers Comp	$4.08
Rate for Payer: Parkland Medicaid	$4.52
Rate for Payer: Scott and White EPO/PPO	$3.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.52
Rate for Payer: Superior Health Plan EPO	$0.85

CUFF, BLD PRES.REG ADULT

Facility

$6.28

Hospital Charge Code	993041
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.27

CUFF, BP, ADULT, 1 TB, HP, CS

Facility

$37.68

Hospital Charge Code	993085
Hospital Revenue Code	270
Min. Negotiated Rate	$3.39
Max. Negotiated Rate	$27.13
Rate for Payer: Amerigroup CHIP/Medicaid	$3.39
Rate for Payer: BCBS of TX Blue Advantage	$11.30
Rate for Payer: BCBS of TX Blue Essentials	$13.56
Rate for Payer: BCBS of TX PPO	$15.07
Rate for Payer: Cash Price	$25.62
Rate for Payer: Cigna Medicaid	$27.13
Rate for Payer: Molina CHIP/Medicaid	$27.13
Rate for Payer: Multiplan Auto	$24.49
Rate for Payer: Multiplan Commercial	$24.49
Rate for Payer: Multiplan Workers Comp	$24.49
Rate for Payer: Parkland Medicaid	$27.13
Rate for Payer: Scott and White EPO/PPO	$18.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.13
Rate for Payer: Superior Health Plan EPO	$5.12

CUFF, BP, ADULT, 1 TB, HP, CS

Facility

$37.68

Hospital Charge Code	993085
Hospital Revenue Code	270
Rate for Payer: Cash Price	$25.62

CUFF BP CLASSIC-CUF ADLT 23-33CM 1 TUBE

Facility

$13.67

Hospital Charge Code	993602
Hospital Revenue Code	270
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$9.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1.23
Rate for Payer: BCBS of TX Blue Advantage	$4.10
Rate for Payer: BCBS of TX Blue Essentials	$4.92
Rate for Payer: BCBS of TX PPO	$5.47
Rate for Payer: Cash Price	$9.30
Rate for Payer: Cigna Medicaid	$9.84
Rate for Payer: Molina CHIP/Medicaid	$9.84
Rate for Payer: Multiplan Auto	$8.89
Rate for Payer: Multiplan Commercial	$8.89
Rate for Payer: Multiplan Workers Comp	$8.89
Rate for Payer: Parkland Medicaid	$9.84
Rate for Payer: Scott and White EPO/PPO	$6.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.84
Rate for Payer: Superior Health Plan EPO	$1.86

CUFF BP CLASSIC-CUF ADLT 23-33CM 1 TUBE

Facility

$13.67

Hospital Charge Code	993602
Hospital Revenue Code	270
Rate for Payer: Cash Price	$9.30

CUFF, BP, LRG ADULT, 1 TB, HP, CS

Facility

$7.30

Hospital Charge Code	993265
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.96

CUFF, BP, LRG ADULT, 1 TB, HP, CS

Facility

$7.30

Hospital Charge Code	993265
Hospital Revenue Code	270
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$5.26
Rate for Payer: Amerigroup CHIP/Medicaid	$0.66
Rate for Payer: BCBS of TX Blue Advantage	$2.19
Rate for Payer: BCBS of TX Blue Essentials	$2.63
Rate for Payer: BCBS of TX PPO	$2.92
Rate for Payer: Cash Price	$4.96
Rate for Payer: Cigna Medicaid	$5.26
Rate for Payer: Molina CHIP/Medicaid	$5.26
Rate for Payer: Multiplan Auto	$4.75
Rate for Payer: Multiplan Commercial	$4.75
Rate for Payer: Multiplan Workers Comp	$4.75
Rate for Payer: Parkland Medicaid	$5.26
Rate for Payer: Scott and White EPO/PPO	$3.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.26
Rate for Payer: Superior Health Plan EPO	$0.99

CUFF, BP, SM ADULT, 1 TB, HP, CS

Facility

$6.23

Hospital Charge Code	993186
Hospital Revenue Code	270
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$4.49
Rate for Payer: Amerigroup CHIP/Medicaid	$0.56
Rate for Payer: BCBS of TX Blue Advantage	$1.87
Rate for Payer: BCBS of TX Blue Essentials	$2.24
Rate for Payer: BCBS of TX PPO	$2.49
Rate for Payer: Cash Price	$4.24
Rate for Payer: Cigna Medicaid	$4.49
Rate for Payer: Molina CHIP/Medicaid	$4.49
Rate for Payer: Multiplan Auto	$4.05
Rate for Payer: Multiplan Commercial	$4.05
Rate for Payer: Multiplan Workers Comp	$4.05
Rate for Payer: Parkland Medicaid	$4.49
Rate for Payer: Scott and White EPO/PPO	$3.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.49
Rate for Payer: Superior Health Plan EPO	$0.85

CUFF, BP, SM ADULT, 1 TB, HP, CS

Facility

$6.23

Hospital Charge Code	993186
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.24

CUFF CONNECTOR 22MM ID/OD

Facility

$2.89

Hospital Charge Code	993627
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.97

CUFF CONNECTOR 22MM ID/OD

Facility

$2.89

Hospital Charge Code	993627
Hospital Revenue Code	270
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$2.08
Rate for Payer: Amerigroup CHIP/Medicaid	$0.26
Rate for Payer: BCBS of TX Blue Advantage	$0.87
Rate for Payer: BCBS of TX Blue Essentials	$1.04
Rate for Payer: BCBS of TX PPO	$1.16
Rate for Payer: Cash Price	$1.97
Rate for Payer: Cigna Medicaid	$2.08
Rate for Payer: Molina CHIP/Medicaid	$2.08
Rate for Payer: Multiplan Auto	$1.88
Rate for Payer: Multiplan Commercial	$1.88
Rate for Payer: Multiplan Workers Comp	$1.88
Rate for Payer: Parkland Medicaid	$2.08
Rate for Payer: Scott and White EPO/PPO	$1.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.08
Rate for Payer: Superior Health Plan EPO	$0.39

CUFF, DPSB, 34 X 4.125 DISPOSABLE, STRL

Facility

$266.97

Hospital Charge Code	993770
Hospital Revenue Code	272
Min. Negotiated Rate	$24.03
Max. Negotiated Rate	$192.22
Rate for Payer: Amerigroup CHIP/Medicaid	$24.03
Rate for Payer: BCBS of TX Blue Advantage	$80.09
Rate for Payer: BCBS of TX Blue Essentials	$96.11
Rate for Payer: BCBS of TX PPO	$106.79
Rate for Payer: Cash Price	$181.54
Rate for Payer: Cigna Medicaid	$192.22
Rate for Payer: Molina CHIP/Medicaid	$192.22
Rate for Payer: Multiplan Auto	$173.53
Rate for Payer: Multiplan Commercial	$173.53
Rate for Payer: Multiplan Workers Comp	$173.53
Rate for Payer: Parkland Medicaid	$192.22
Rate for Payer: Scott and White EPO/PPO	$133.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.22
Rate for Payer: Superior Health Plan EPO	$36.31

CUFF, DPSB, 34 X 4.125 DISPOSABLE, STRL

Facility

$266.97

Hospital Charge Code	993770
Hospital Revenue Code	272
Rate for Payer: Cash Price	$181.54

CUFF TOURNIQUET DPSB

Facility

$133.48

Hospital Charge Code	8490526
Hospital Revenue Code	270
Min. Negotiated Rate	$12.01
Max. Negotiated Rate	$96.11
Rate for Payer: Amerigroup CHIP/Medicaid	$12.01
Rate for Payer: BCBS of TX Blue Advantage	$40.04
Rate for Payer: BCBS of TX Blue Essentials	$48.05
Rate for Payer: BCBS of TX PPO	$53.39
Rate for Payer: Cash Price	$90.77
Rate for Payer: Cigna Medicaid	$96.11
Rate for Payer: Molina CHIP/Medicaid	$96.11
Rate for Payer: Multiplan Auto	$86.76
Rate for Payer: Multiplan Commercial	$86.76
Rate for Payer: Multiplan Workers Comp	$86.76
Rate for Payer: Parkland Medicaid	$96.11
Rate for Payer: Scott and White EPO/PPO	$66.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96.11
Rate for Payer: Superior Health Plan EPO	$18.15

CUFF TOURNIQUET DPSB

Facility

$133.48

Hospital Charge Code	8490526
Hospital Revenue Code	270
Rate for Payer: Cash Price	$90.77

CUFF, TRIMLINE, SOFT, IT, SM, ADULT, HP

Facility

$6.79

Hospital Charge Code	992959
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.62

CUFF, TRIMLINE, SOFT, IT, SM, ADULT, HP

Facility

$6.79

Hospital Charge Code	992959
Hospital Revenue Code	270
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$4.89
Rate for Payer: Amerigroup CHIP/Medicaid	$0.61
Rate for Payer: BCBS of TX Blue Advantage	$2.04
Rate for Payer: BCBS of TX Blue Essentials	$2.44
Rate for Payer: BCBS of TX PPO	$2.72
Rate for Payer: Cash Price	$4.62
Rate for Payer: Cigna Medicaid	$4.89
Rate for Payer: Molina CHIP/Medicaid	$4.89
Rate for Payer: Multiplan Auto	$4.41
Rate for Payer: Multiplan Commercial	$4.41
Rate for Payer: Multiplan Workers Comp	$4.41
Rate for Payer: Parkland Medicaid	$4.89
Rate for Payer: Scott and White EPO/PPO	$3.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.89
Rate for Payer: Superior Health Plan EPO	$0.92

CUFF TRNQT 18IN 2 PORT 1 BLDR ATS

Facility

$49.80

Hospital Charge Code	993045
Hospital Revenue Code	270
Rate for Payer: Cash Price	$33.86

CUFF TRNQT 18IN 2 PORT 1 BLDR ATS

Facility

$49.80

Hospital Charge Code	993045
Hospital Revenue Code	270
Min. Negotiated Rate	$4.48
Max. Negotiated Rate	$35.86
Rate for Payer: Amerigroup CHIP/Medicaid	$4.48
Rate for Payer: BCBS of TX Blue Advantage	$14.94
Rate for Payer: BCBS of TX Blue Essentials	$17.93
Rate for Payer: BCBS of TX PPO	$19.92
Rate for Payer: Cash Price	$33.86
Rate for Payer: Cigna Medicaid	$35.86
Rate for Payer: Molina CHIP/Medicaid	$35.86
Rate for Payer: Multiplan Auto	$32.37
Rate for Payer: Multiplan Commercial	$32.37
Rate for Payer: Multiplan Workers Comp	$32.37
Rate for Payer: Parkland Medicaid	$35.86
Rate for Payer: Scott and White EPO/PPO	$24.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.86
Rate for Payer: Superior Health Plan EPO	$6.77

Know your out-of-pocket cost for care.

All Charges