White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DETERGENT CA II SIEMENS 45ML

Facility

$267.86

Hospital Charge Code	993825
Hospital Revenue Code	270
Rate for Payer: Cash Price	$182.14

DETERGENT CA II SIEMENS 45ML

Facility

$267.86

Hospital Charge Code	993825
Hospital Revenue Code	270
Min. Negotiated Rate	$24.11
Max. Negotiated Rate	$192.86
Rate for Payer: Amerigroup CHIP/Medicaid	$24.11
Rate for Payer: BCBS of TX Blue Advantage	$80.36
Rate for Payer: BCBS of TX Blue Essentials	$96.43
Rate for Payer: BCBS of TX PPO	$107.14
Rate for Payer: Cash Price	$182.14
Rate for Payer: Cigna Medicaid	$192.86
Rate for Payer: Molina CHIP/Medicaid	$192.86
Rate for Payer: Multiplan Auto	$174.11
Rate for Payer: Multiplan Commercial	$174.11
Rate for Payer: Multiplan Workers Comp	$174.11
Rate for Payer: Parkland Medicaid	$192.86
Rate for Payer: Scott and White EPO/PPO	$133.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.86
Rate for Payer: Superior Health Plan EPO	$36.43

DETERGENT ENDOQUICK-ELITE 3BTLS/CA

Facility

$260.29

Hospital Charge Code	993933
Hospital Revenue Code	270
Min. Negotiated Rate	$23.43
Max. Negotiated Rate	$187.41
Rate for Payer: Amerigroup CHIP/Medicaid	$23.43
Rate for Payer: BCBS of TX Blue Advantage	$78.09
Rate for Payer: BCBS of TX Blue Essentials	$93.70
Rate for Payer: BCBS of TX PPO	$104.12
Rate for Payer: Cash Price	$177.00
Rate for Payer: Cigna Medicaid	$187.41
Rate for Payer: Molina CHIP/Medicaid	$187.41
Rate for Payer: Multiplan Auto	$169.19
Rate for Payer: Multiplan Commercial	$169.19
Rate for Payer: Multiplan Workers Comp	$169.19
Rate for Payer: Parkland Medicaid	$187.41
Rate for Payer: Scott and White EPO/PPO	$130.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$187.41
Rate for Payer: Superior Health Plan EPO	$35.40

DETERGENT ENDOQUICK-ELITE 3BTLS/CA

Facility

$260.29

Hospital Charge Code	993933
Hospital Revenue Code	270
Rate for Payer: Cash Price	$177.00

DETERGENT PROLYSTICA 2X CONCENTRATE NEUTRAL 1 GAL

Facility

$106.91

Hospital Charge Code	993194
Hospital Revenue Code	270
Rate for Payer: Cash Price	$72.70

DETERGENT PROLYSTICA 2X CONCENTRATE NEUTRAL 1 GAL

Facility

$106.91

Hospital Charge Code	993194
Hospital Revenue Code	270
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$76.98
Rate for Payer: Amerigroup CHIP/Medicaid	$9.62
Rate for Payer: BCBS of TX Blue Advantage	$32.07
Rate for Payer: BCBS of TX Blue Essentials	$38.49
Rate for Payer: BCBS of TX PPO	$42.76
Rate for Payer: Cash Price	$72.70
Rate for Payer: Cigna Medicaid	$76.98
Rate for Payer: Molina CHIP/Medicaid	$76.98
Rate for Payer: Multiplan Auto	$69.49
Rate for Payer: Multiplan Commercial	$69.49
Rate for Payer: Multiplan Workers Comp	$69.49
Rate for Payer: Parkland Medicaid	$76.98
Rate for Payer: Scott and White EPO/PPO	$53.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.98
Rate for Payer: Superior Health Plan EPO	$14.54

DETERGENT, PROLYSTICA 2X CONC NEUTRAL GAL

Facility

$109.85

Hospital Charge Code	993019
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.70

DETERGENT, PROLYSTICA 2X CONC NEUTRAL GAL

Facility

$109.85

Hospital Charge Code	993019
Hospital Revenue Code	270
Min. Negotiated Rate	$9.89
Max. Negotiated Rate	$79.09
Rate for Payer: Amerigroup CHIP/Medicaid	$9.89
Rate for Payer: BCBS of TX Blue Advantage	$32.95
Rate for Payer: BCBS of TX Blue Essentials	$39.55
Rate for Payer: BCBS of TX PPO	$43.94
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cigna Medicaid	$79.09
Rate for Payer: Molina CHIP/Medicaid	$79.09
Rate for Payer: Multiplan Auto	$71.40
Rate for Payer: Multiplan Commercial	$71.40
Rate for Payer: Multiplan Workers Comp	$71.40
Rate for Payer: Parkland Medicaid	$79.09
Rate for Payer: Scott and White EPO/PPO	$54.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.09
Rate for Payer: Superior Health Plan EPO	$14.94

DETERGENT, PROLYSTICA, ULTRA, NEUTRAL, 2 X 5L

Facility

$600.71

Hospital Charge Code	993815
Hospital Revenue Code	270
Min. Negotiated Rate	$54.06
Max. Negotiated Rate	$432.51
Rate for Payer: Amerigroup CHIP/Medicaid	$54.06
Rate for Payer: BCBS of TX Blue Advantage	$180.21
Rate for Payer: BCBS of TX Blue Essentials	$216.26
Rate for Payer: BCBS of TX PPO	$240.28
Rate for Payer: Cash Price	$408.48
Rate for Payer: Cigna Medicaid	$432.51
Rate for Payer: Molina CHIP/Medicaid	$432.51
Rate for Payer: Multiplan Auto	$390.46
Rate for Payer: Multiplan Commercial	$390.46
Rate for Payer: Multiplan Workers Comp	$390.46
Rate for Payer: Parkland Medicaid	$432.51
Rate for Payer: Scott and White EPO/PPO	$300.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$432.51
Rate for Payer: Superior Health Plan EPO	$81.70

DETERGENT, PROLYSTICA, ULTRA, NEUTRAL, 2 X 5L

Facility

$600.71

Hospital Charge Code	993815
Hospital Revenue Code	270
Rate for Payer: Cash Price	$408.48

DETERGENT, PROLYSTICA, ULTRA, NTRL, 10LTR

Facility

$1,201.42

Hospital Charge Code	993020
Hospital Revenue Code	272
Min. Negotiated Rate	$108.13
Max. Negotiated Rate	$865.02
Rate for Payer: Amerigroup CHIP/Medicaid	$108.13
Rate for Payer: BCBS of TX Blue Advantage	$360.43
Rate for Payer: BCBS of TX Blue Essentials	$432.51
Rate for Payer: BCBS of TX PPO	$480.57
Rate for Payer: Cash Price	$816.97
Rate for Payer: Cigna Medicaid	$865.02
Rate for Payer: Molina CHIP/Medicaid	$865.02
Rate for Payer: Multiplan Auto	$780.92
Rate for Payer: Multiplan Commercial	$780.92
Rate for Payer: Multiplan Workers Comp	$780.92
Rate for Payer: Parkland Medicaid	$865.02
Rate for Payer: Scott and White EPO/PPO	$600.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$865.02
Rate for Payer: Superior Health Plan EPO	$163.39

DETERGENT, PROLYSTICA, ULTRA, NTRL, 10LTR

Facility

$1,201.42

Hospital Charge Code	993020
Hospital Revenue Code	272
Rate for Payer: Cash Price	$816.97

DETR CP CO2 -- DHF

Facility

$46.99

Hospital Charge Code	82022005
Hospital Revenue Code	271
Min. Negotiated Rate	$4.23
Max. Negotiated Rate	$33.83
Rate for Payer: Amerigroup CHIP/Medicaid	$4.23
Rate for Payer: BCBS of TX Blue Advantage	$14.10
Rate for Payer: BCBS of TX Blue Essentials	$16.92
Rate for Payer: BCBS of TX PPO	$18.80
Rate for Payer: Cash Price	$31.95
Rate for Payer: Cigna Medicaid	$33.83
Rate for Payer: Molina CHIP/Medicaid	$33.83
Rate for Payer: Multiplan Auto	$30.54
Rate for Payer: Multiplan Commercial	$30.54
Rate for Payer: Multiplan Workers Comp	$30.54
Rate for Payer: Parkland Medicaid	$33.83
Rate for Payer: Scott and White EPO/PPO	$23.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.83
Rate for Payer: Superior Health Plan EPO	$6.39

DETR CP CO2 -- DHF

Facility

$46.99

Hospital Charge Code	82022005
Hospital Revenue Code	271
Rate for Payer: Cash Price	$31.95

DEV CLS VASCULAR MVP VASCADE

Facility

$5,876.12

Service Code	HCPCS C1760
Hospital Charge Code	993689
Hospital Revenue Code	278
Min. Negotiated Rate	$528.85
Max. Negotiated Rate	$4,230.81
Rate for Payer: Amerigroup CHIP/Medicaid	$528.85
Rate for Payer: BCBS of TX Blue Advantage	$1,762.84
Rate for Payer: BCBS of TX Blue Essentials	$2,115.40
Rate for Payer: BCBS of TX PPO	$2,350.45
Rate for Payer: Cash Price	$3,995.76
Rate for Payer: Cigna Medicaid	$4,230.81
Rate for Payer: Molina CHIP/Medicaid	$4,230.81
Rate for Payer: Multiplan Auto	$2,938.06
Rate for Payer: Multiplan Commercial	$2,938.06
Rate for Payer: Multiplan Workers Comp	$2,938.06
Rate for Payer: Parkland Medicaid	$4,230.81
Rate for Payer: Scott and White EPO/PPO	$2,938.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,230.81
Rate for Payer: Superior Health Plan EPO	$799.15

DEV CLS VASCULAR MVP VASCADE

Facility

$5,876.12

Service Code	HCPCS C1760
Hospital Charge Code	993689
Hospital Revenue Code	278
Min. Negotiated Rate	$1,469.03
Max. Negotiated Rate	$2,938.06
Rate for Payer: Cash Price	$3,995.76
Rate for Payer: Cigna Commercial	$1,469.03
Rate for Payer: Multiplan Auto	$2,938.06
Rate for Payer: Multiplan Commercial	$2,938.06
Rate for Payer: Multiplan Workers Comp	$2,938.06
Rate for Payer: Scott and White EPO/PPO	$2,938.06

DEVICE ABBOTT PERCLOSE PROGLIDE

Facility

$1,355.00

Service Code	HCPCS C1760
Hospital Charge Code	8692542
Hospital Revenue Code	278
Min. Negotiated Rate	$121.95
Max. Negotiated Rate	$975.60
Rate for Payer: Amerigroup CHIP/Medicaid	$121.95
Rate for Payer: BCBS of TX Blue Advantage	$406.50
Rate for Payer: BCBS of TX Blue Essentials	$487.80
Rate for Payer: BCBS of TX PPO	$542.00
Rate for Payer: Cash Price	$921.40
Rate for Payer: Cigna Medicaid	$975.60
Rate for Payer: Molina CHIP/Medicaid	$975.60
Rate for Payer: Multiplan Auto	$677.50
Rate for Payer: Multiplan Commercial	$677.50
Rate for Payer: Multiplan Workers Comp	$677.50
Rate for Payer: Parkland Medicaid	$975.60
Rate for Payer: Scott and White EPO/PPO	$677.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$975.60
Rate for Payer: Superior Health Plan EPO	$184.28

DEVICE ABBOTT PERCLOSE PROGLIDE

Facility

$1,355.00

Service Code	HCPCS C1760
Hospital Charge Code	8692542
Hospital Revenue Code	278
Min. Negotiated Rate	$338.75
Max. Negotiated Rate	$677.50
Rate for Payer: Cash Price	$921.40
Rate for Payer: Cigna Commercial	$338.75
Rate for Payer: Multiplan Auto	$677.50
Rate for Payer: Multiplan Commercial	$677.50
Rate for Payer: Multiplan Workers Comp	$677.50
Rate for Payer: Scott and White EPO/PPO	$677.50

DEVICE, ASEPTIC DECANTING BAG STERILE -- DHF

Facility

$101.36

Hospital Charge Code	80312259
Hospital Revenue Code	270
Rate for Payer: Cash Price	$68.92

DEVICE, ASEPTIC DECANTING BAG STERILE -- DHF

Facility

$101.36

Hospital Charge Code	80312259
Hospital Revenue Code	270
Min. Negotiated Rate	$9.12
Max. Negotiated Rate	$72.98
Rate for Payer: Amerigroup CHIP/Medicaid	$9.12
Rate for Payer: BCBS of TX Blue Advantage	$30.41
Rate for Payer: BCBS of TX Blue Essentials	$36.49
Rate for Payer: BCBS of TX PPO	$40.54
Rate for Payer: Cash Price	$68.92
Rate for Payer: Cigna Medicaid	$72.98
Rate for Payer: Molina CHIP/Medicaid	$72.98
Rate for Payer: Multiplan Auto	$65.88
Rate for Payer: Multiplan Commercial	$65.88
Rate for Payer: Multiplan Workers Comp	$65.88
Rate for Payer: Parkland Medicaid	$72.98
Rate for Payer: Scott and White EPO/PPO	$50.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$72.98
Rate for Payer: Superior Health Plan EPO	$13.78

DEVICE, CLOSURE SKIN LARG

Facility

$435.25

Hospital Charge Code	993599
Hospital Revenue Code	272
Rate for Payer: Cash Price	$295.97

DEVICE, CLOSURE SKIN LARG

Facility

$435.25

Hospital Charge Code	993599
Hospital Revenue Code	272
Min. Negotiated Rate	$39.17
Max. Negotiated Rate	$313.38
Rate for Payer: Amerigroup CHIP/Medicaid	$39.17
Rate for Payer: BCBS of TX Blue Advantage	$130.57
Rate for Payer: BCBS of TX Blue Essentials	$156.69
Rate for Payer: BCBS of TX PPO	$174.10
Rate for Payer: Cash Price	$295.97
Rate for Payer: Cigna Medicaid	$313.38
Rate for Payer: Molina CHIP/Medicaid	$313.38
Rate for Payer: Multiplan Auto	$282.91
Rate for Payer: Multiplan Commercial	$282.91
Rate for Payer: Multiplan Workers Comp	$282.91
Rate for Payer: Parkland Medicaid	$313.38
Rate for Payer: Scott and White EPO/PPO	$217.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$313.38
Rate for Payer: Superior Health Plan EPO	$59.19

DEVICE, CLOSURE SKIN UP T

Facility

$319.34

Hospital Charge Code	993600
Hospital Revenue Code	272
Rate for Payer: Cash Price	$217.15

DEVICE, CLOSURE SKIN UP T

Facility

$319.34

Hospital Charge Code	993600
Hospital Revenue Code	272
Min. Negotiated Rate	$28.74
Max. Negotiated Rate	$229.92
Rate for Payer: Amerigroup CHIP/Medicaid	$28.74
Rate for Payer: BCBS of TX Blue Advantage	$95.80
Rate for Payer: BCBS of TX Blue Essentials	$114.96
Rate for Payer: BCBS of TX PPO	$127.74
Rate for Payer: Cash Price	$217.15
Rate for Payer: Cigna Medicaid	$229.92
Rate for Payer: Molina CHIP/Medicaid	$229.92
Rate for Payer: Multiplan Auto	$207.57
Rate for Payer: Multiplan Commercial	$207.57
Rate for Payer: Multiplan Workers Comp	$207.57
Rate for Payer: Parkland Medicaid	$229.92
Rate for Payer: Scott and White EPO/PPO	$159.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$229.92
Rate for Payer: Superior Health Plan EPO	$43.43

DEVICE, CLOSURE SKIN UP TO 24CM LENGTH ZIPLINE -- DHF

Facility

$617.08

Hospital Charge Code	81920258
Hospital Revenue Code	272
Rate for Payer: Cash Price	$419.61

Know your out-of-pocket cost for care.

All Charges