White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DARCO HEADED SCR 3.5X42 FULL

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992327
Hospital Revenue Code	278
Min. Negotiated Rate	$326.81
Max. Negotiated Rate	$653.62
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Commercial	$326.81
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Scott and White EPO/PPO	$653.62

DARCO HEADED SCR 3.5X42 FULL

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992327
Hospital Revenue Code	278
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$941.21
Rate for Payer: Amerigroup CHIP/Medicaid	$117.65
Rate for Payer: BCBS of TX Blue Advantage	$392.17
Rate for Payer: BCBS of TX Blue Essentials	$470.60
Rate for Payer: BCBS of TX PPO	$522.89
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Medicaid	$941.21
Rate for Payer: Molina CHIP/Medicaid	$941.21
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Parkland Medicaid	$941.21
Rate for Payer: Scott and White EPO/PPO	$653.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.21
Rate for Payer: Superior Health Plan EPO	$177.78

DARCO HEADED SCR 3.5X48 LONG

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992280
Hospital Revenue Code	278
Min. Negotiated Rate	$326.81
Max. Negotiated Rate	$653.62
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Commercial	$326.81
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Scott and White EPO/PPO	$653.62

DARCO HEADED SCR 3.5X48 LONG

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992280
Hospital Revenue Code	278
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$941.21
Rate for Payer: Amerigroup CHIP/Medicaid	$117.65
Rate for Payer: BCBS of TX Blue Advantage	$392.17
Rate for Payer: BCBS of TX Blue Essentials	$470.60
Rate for Payer: BCBS of TX PPO	$522.89
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Medicaid	$941.21
Rate for Payer: Molina CHIP/Medicaid	$941.21
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Parkland Medicaid	$941.21
Rate for Payer: Scott and White EPO/PPO	$653.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.21
Rate for Payer: Superior Health Plan EPO	$177.78

DARCO HEADED SCR 3.5X50 LONG

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992273
Hospital Revenue Code	278
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$941.21
Rate for Payer: Amerigroup CHIP/Medicaid	$117.65
Rate for Payer: BCBS of TX Blue Advantage	$392.17
Rate for Payer: BCBS of TX Blue Essentials	$470.60
Rate for Payer: BCBS of TX PPO	$522.89
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Medicaid	$941.21
Rate for Payer: Molina CHIP/Medicaid	$941.21
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Parkland Medicaid	$941.21
Rate for Payer: Scott and White EPO/PPO	$653.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.21
Rate for Payer: Superior Health Plan EPO	$177.78

DARCO HEADED SCR 3.5X50 LONG

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992273
Hospital Revenue Code	278
Min. Negotiated Rate	$326.81
Max. Negotiated Rate	$653.62
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Commercial	$326.81
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Scott and White EPO/PPO	$653.62

DARCO HEADED SCR 4.5X55 LONG

Facility

$1,560.24

Service Code	HCPCS C1713
Hospital Charge Code	992301
Hospital Revenue Code	278
Min. Negotiated Rate	$140.42
Max. Negotiated Rate	$1,123.37
Rate for Payer: Amerigroup CHIP/Medicaid	$140.42
Rate for Payer: BCBS of TX Blue Advantage	$468.07
Rate for Payer: BCBS of TX Blue Essentials	$561.69
Rate for Payer: BCBS of TX PPO	$624.10
Rate for Payer: Cash Price	$1,060.96
Rate for Payer: Cigna Medicaid	$1,123.37
Rate for Payer: Molina CHIP/Medicaid	$1,123.37
Rate for Payer: Multiplan Auto	$780.12
Rate for Payer: Multiplan Commercial	$780.12
Rate for Payer: Multiplan Workers Comp	$780.12
Rate for Payer: Parkland Medicaid	$1,123.37
Rate for Payer: Scott and White EPO/PPO	$780.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,123.37
Rate for Payer: Superior Health Plan EPO	$212.19

DARCO HEADED SCR 4.5X55 LONG

Facility

$1,560.24

Service Code	HCPCS C1713
Hospital Charge Code	992301
Hospital Revenue Code	278
Min. Negotiated Rate	$390.06
Max. Negotiated Rate	$780.12
Rate for Payer: Cash Price	$1,060.96
Rate for Payer: Cigna Commercial	$390.06
Rate for Payer: Multiplan Auto	$780.12
Rate for Payer: Multiplan Commercial	$780.12
Rate for Payer: Multiplan Workers Comp	$780.12
Rate for Payer: Scott and White EPO/PPO	$780.12

DARCO HEADED SCR 6.5X55 16MM

Facility

$2,584.34

Service Code	HCPCS C1713
Hospital Charge Code	992375
Hospital Revenue Code	278
Min. Negotiated Rate	$646.09
Max. Negotiated Rate	$1,292.17
Rate for Payer: Cash Price	$1,757.35
Rate for Payer: Cigna Commercial	$646.09
Rate for Payer: Multiplan Auto	$1,292.17
Rate for Payer: Multiplan Commercial	$1,292.17
Rate for Payer: Multiplan Workers Comp	$1,292.17
Rate for Payer: Scott and White EPO/PPO	$1,292.17

DARCO HEADED SCR 6.5X55 16MM

Facility

$2,584.34

Service Code	HCPCS C1713
Hospital Charge Code	992375
Hospital Revenue Code	278
Min. Negotiated Rate	$232.59
Max. Negotiated Rate	$1,860.72
Rate for Payer: Amerigroup CHIP/Medicaid	$232.59
Rate for Payer: BCBS of TX Blue Advantage	$775.30
Rate for Payer: BCBS of TX Blue Essentials	$930.36
Rate for Payer: BCBS of TX PPO	$1,033.74
Rate for Payer: Cash Price	$1,757.35
Rate for Payer: Cigna Medicaid	$1,860.72
Rate for Payer: Molina CHIP/Medicaid	$1,860.72
Rate for Payer: Multiplan Auto	$1,292.17
Rate for Payer: Multiplan Commercial	$1,292.17
Rate for Payer: Multiplan Workers Comp	$1,292.17
Rate for Payer: Parkland Medicaid	$1,860.72
Rate for Payer: Scott and White EPO/PPO	$1,292.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,860.72
Rate for Payer: Superior Health Plan EPO	$351.47

DARCO HEADED SCR 6.5 X 65 16 MM

Facility

$2,584.34

Service Code	HCPCS C1713
Hospital Charge Code	993139
Hospital Revenue Code	278
Min. Negotiated Rate	$232.59
Max. Negotiated Rate	$1,860.72
Rate for Payer: Amerigroup CHIP/Medicaid	$232.59
Rate for Payer: BCBS of TX Blue Advantage	$775.30
Rate for Payer: BCBS of TX Blue Essentials	$930.36
Rate for Payer: BCBS of TX PPO	$1,033.74
Rate for Payer: Cash Price	$1,757.35
Rate for Payer: Cigna Medicaid	$1,860.72
Rate for Payer: Molina CHIP/Medicaid	$1,860.72
Rate for Payer: Multiplan Auto	$1,292.17
Rate for Payer: Multiplan Commercial	$1,292.17
Rate for Payer: Multiplan Workers Comp	$1,292.17
Rate for Payer: Parkland Medicaid	$1,860.72
Rate for Payer: Scott and White EPO/PPO	$1,292.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,860.72
Rate for Payer: Superior Health Plan EPO	$351.47

DARCO HEADED SCR 6.5 X 65 16 MM

Facility

$2,584.34

Service Code	HCPCS C1713
Hospital Charge Code	993139
Hospital Revenue Code	278
Min. Negotiated Rate	$646.09
Max. Negotiated Rate	$1,292.17
Rate for Payer: Cash Price	$1,757.35
Rate for Payer: Cigna Commercial	$646.09
Rate for Payer: Multiplan Auto	$1,292.17
Rate for Payer: Multiplan Commercial	$1,292.17
Rate for Payer: Multiplan Workers Comp	$1,292.17
Rate for Payer: Scott and White EPO/PPO	$1,292.17

Datascope 3 Lead Set

Facility

$308.72

Hospital Charge Code	993892
Hospital Revenue Code	270
Min. Negotiated Rate	$27.78
Max. Negotiated Rate	$222.28
Rate for Payer: Amerigroup CHIP/Medicaid	$27.78
Rate for Payer: BCBS of TX Blue Advantage	$92.62
Rate for Payer: BCBS of TX Blue Essentials	$111.14
Rate for Payer: BCBS of TX PPO	$123.49
Rate for Payer: Cash Price	$209.93
Rate for Payer: Cigna Medicaid	$222.28
Rate for Payer: Molina CHIP/Medicaid	$222.28
Rate for Payer: Multiplan Auto	$200.67
Rate for Payer: Multiplan Commercial	$200.67
Rate for Payer: Multiplan Workers Comp	$200.67
Rate for Payer: Parkland Medicaid	$222.28
Rate for Payer: Scott and White EPO/PPO	$154.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.28
Rate for Payer: Superior Health Plan EPO	$41.99

Datascope 3 Lead Set

Facility

$308.72

Hospital Charge Code	993892
Hospital Revenue Code	270
Rate for Payer: Cash Price	$209.93

Datascope 5 Lead Set

Facility

$340.50

Hospital Charge Code	993893
Hospital Revenue Code	270
Rate for Payer: Cash Price	$231.54

Datascope 5 Lead Set

Facility

$340.50

Hospital Charge Code	993893
Hospital Revenue Code	270
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$245.16
Rate for Payer: Amerigroup CHIP/Medicaid	$30.64
Rate for Payer: BCBS of TX Blue Advantage	$102.15
Rate for Payer: BCBS of TX Blue Essentials	$122.58
Rate for Payer: BCBS of TX PPO	$136.20
Rate for Payer: Cash Price	$231.54
Rate for Payer: Cigna Medicaid	$245.16
Rate for Payer: Molina CHIP/Medicaid	$245.16
Rate for Payer: Multiplan Auto	$221.32
Rate for Payer: Multiplan Commercial	$221.32
Rate for Payer: Multiplan Workers Comp	$221.32
Rate for Payer: Parkland Medicaid	$245.16
Rate for Payer: Scott and White EPO/PPO	$170.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$245.16
Rate for Payer: Superior Health Plan EPO	$46.31

Davol 5106115 Probe, 5mm x 46cm

Facility

$68.05

Hospital Charge Code	992674
Hospital Revenue Code	272
Rate for Payer: Cash Price	$46.27

Davol 5106115 Probe, 5mm x 46cm

Facility

$68.05

Hospital Charge Code	992674
Hospital Revenue Code	272
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$49.00
Rate for Payer: Amerigroup CHIP/Medicaid	$6.12
Rate for Payer: BCBS of TX Blue Advantage	$20.41
Rate for Payer: BCBS of TX Blue Essentials	$24.50
Rate for Payer: BCBS of TX PPO	$27.22
Rate for Payer: Cash Price	$46.27
Rate for Payer: Cigna Medicaid	$49.00
Rate for Payer: Molina CHIP/Medicaid	$49.00
Rate for Payer: Multiplan Auto	$44.23
Rate for Payer: Multiplan Commercial	$44.23
Rate for Payer: Multiplan Workers Comp	$44.23
Rate for Payer: Parkland Medicaid	$49.00
Rate for Payer: Scott and White EPO/PPO	$34.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.00
Rate for Payer: Superior Health Plan EPO	$9.25

DBACK PERIPH 1.50mm CL 145CM OAD US

Facility

$15,413.30

Hospital Charge Code	993878
Hospital Revenue Code	279
Rate for Payer: Cash Price	$10,481.04

DBACK PERIPH 1.50mm CL 145CM OAD US

Facility

$15,413.30

Hospital Charge Code	993878
Hospital Revenue Code	279
Min. Negotiated Rate	$1,387.20
Max. Negotiated Rate	$11,097.58
Rate for Payer: Amerigroup CHIP/Medicaid	$1,387.20
Rate for Payer: BCBS of TX Blue Advantage	$4,623.99
Rate for Payer: BCBS of TX Blue Essentials	$5,548.79
Rate for Payer: BCBS of TX PPO	$6,165.32
Rate for Payer: Cash Price	$10,481.04
Rate for Payer: Cigna Medicaid	$11,097.58
Rate for Payer: Molina CHIP/Medicaid	$11,097.58
Rate for Payer: Multiplan Auto	$10,018.65
Rate for Payer: Multiplan Commercial	$10,018.65
Rate for Payer: Multiplan Workers Comp	$10,018.65
Rate for Payer: Parkland Medicaid	$11,097.58
Rate for Payer: Scott and White EPO/PPO	$7,706.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,097.58
Rate for Payer: Superior Health Plan EPO	$2,096.21

DBACK PERIPH 1.50mm SL 145cm OAD US

Facility

$15,413.30

Hospital Charge Code	993877
Hospital Revenue Code	279
Min. Negotiated Rate	$1,387.20
Max. Negotiated Rate	$11,097.58
Rate for Payer: Amerigroup CHIP/Medicaid	$1,387.20
Rate for Payer: BCBS of TX Blue Advantage	$4,623.99
Rate for Payer: BCBS of TX Blue Essentials	$5,548.79
Rate for Payer: BCBS of TX PPO	$6,165.32
Rate for Payer: Cash Price	$10,481.04
Rate for Payer: Cigna Medicaid	$11,097.58
Rate for Payer: Molina CHIP/Medicaid	$11,097.58
Rate for Payer: Multiplan Auto	$10,018.65
Rate for Payer: Multiplan Commercial	$10,018.65
Rate for Payer: Multiplan Workers Comp	$10,018.65
Rate for Payer: Parkland Medicaid	$11,097.58
Rate for Payer: Scott and White EPO/PPO	$7,706.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,097.58
Rate for Payer: Superior Health Plan EPO	$2,096.21

DBACK PERIPH 1.50mm SL 145cm OAD US

Facility

$15,413.30

Hospital Charge Code	993877
Hospital Revenue Code	279
Rate for Payer: Cash Price	$10,481.04

DBM-CATHETER, EXTERNAL, FEMALE, PUREWICK

Facility

$30.32

Service Code	HCPCS C1758
Hospital Charge Code	992507
Hospital Revenue Code	270
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$21.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2.73
Rate for Payer: BCBS of TX Blue Advantage	$9.10
Rate for Payer: BCBS of TX Blue Essentials	$10.92
Rate for Payer: BCBS of TX PPO	$12.13
Rate for Payer: Cash Price	$20.62
Rate for Payer: Cigna Medicaid	$21.83
Rate for Payer: Molina CHIP/Medicaid	$21.83
Rate for Payer: Multiplan Auto	$19.71
Rate for Payer: Multiplan Commercial	$19.71
Rate for Payer: Multiplan Workers Comp	$19.71
Rate for Payer: Parkland Medicaid	$21.83
Rate for Payer: Scott and White EPO/PPO	$15.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.83
Rate for Payer: Superior Health Plan EPO	$4.12

DBM-CATHETER, EXTERNAL, FEMALE, PUREWICK

Facility

$30.32

Service Code	HCPCS C1758
Hospital Charge Code	992507
Hospital Revenue Code	270
Rate for Payer: Cash Price	$20.62

DBM Cortical Fiber, 10cc

Facility

$9,006.02

Service Code	HCPCS C9359
Hospital Charge Code	992117
Hospital Revenue Code	278
Min. Negotiated Rate	$810.54
Max. Negotiated Rate	$6,484.33
Rate for Payer: Amerigroup CHIP/Medicaid	$810.54
Rate for Payer: BCBS of TX Blue Advantage	$2,701.81
Rate for Payer: BCBS of TX Blue Essentials	$3,242.17
Rate for Payer: BCBS of TX PPO	$3,602.41
Rate for Payer: Cash Price	$6,124.09
Rate for Payer: Cigna Medicaid	$6,484.33
Rate for Payer: Molina CHIP/Medicaid	$6,484.33
Rate for Payer: Multiplan Auto	$4,503.01
Rate for Payer: Multiplan Commercial	$4,503.01
Rate for Payer: Multiplan Workers Comp	$4,503.01
Rate for Payer: Parkland Medicaid	$6,484.33
Rate for Payer: Scott and White EPO/PPO	$4,503.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,484.33
Rate for Payer: Superior Health Plan EPO	$1,224.82

Know your out-of-pocket cost for care.

All Charges