White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DETR CP CO2 -- DHF

Facility

$46.99

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

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

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
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 LARG

Facility

$435.25

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

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
Min. Negotiated Rate	$55.54
Max. Negotiated Rate	$444.30
Rate for Payer: Amerigroup CHIP/Medicaid	$55.54
Rate for Payer: BCBS of TX Blue Advantage	$185.12
Rate for Payer: BCBS of TX Blue Essentials	$222.15
Rate for Payer: BCBS of TX PPO	$246.83
Rate for Payer: Cash Price	$419.61
Rate for Payer: Cigna Medicaid	$444.30
Rate for Payer: Molina CHIP/Medicaid	$444.30
Rate for Payer: Multiplan Auto	$401.10
Rate for Payer: Multiplan Commercial	$401.10
Rate for Payer: Multiplan Workers Comp	$401.10
Rate for Payer: Parkland Medicaid	$444.30
Rate for Payer: Scott and White EPO/PPO	$308.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$444.30
Rate for Payer: Superior Health Plan EPO	$83.92

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

DEVICE, CLOSURE WOUND ABSRB GS-22 NDL 2-0 12' TPR -- DHF

Facility

$108.79

Hospital Charge Code	136729
Hospital Revenue Code	272
Rate for Payer: Cash Price	$73.98

DEVICE, CLOSURE WOUND ABSRB GS-22 NDL 2-0 12' TPR -- DHF

Facility

$108.79

Hospital Charge Code	136729
Hospital Revenue Code	272
Min. Negotiated Rate	$9.79
Max. Negotiated Rate	$78.33
Rate for Payer: Amerigroup CHIP/Medicaid	$9.79
Rate for Payer: BCBS of TX Blue Advantage	$32.64
Rate for Payer: BCBS of TX Blue Essentials	$39.16
Rate for Payer: BCBS of TX PPO	$43.52
Rate for Payer: Cash Price	$73.98
Rate for Payer: Cigna Medicaid	$78.33
Rate for Payer: Molina CHIP/Medicaid	$78.33
Rate for Payer: Multiplan Auto	$70.71
Rate for Payer: Multiplan Commercial	$70.71
Rate for Payer: Multiplan Workers Comp	$70.71
Rate for Payer: Parkland Medicaid	$78.33
Rate for Payer: Scott and White EPO/PPO	$54.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$78.33
Rate for Payer: Superior Health Plan EPO	$14.80

DEVICE, CLOSURE WOUND NON

Facility

$136.25

Hospital Charge Code	136341
Hospital Revenue Code	272
Min. Negotiated Rate	$12.26
Max. Negotiated Rate	$98.10
Rate for Payer: Amerigroup CHIP/Medicaid	$12.26
Rate for Payer: BCBS of TX Blue Advantage	$40.88
Rate for Payer: BCBS of TX Blue Essentials	$49.05
Rate for Payer: BCBS of TX PPO	$54.50
Rate for Payer: Cash Price	$92.65
Rate for Payer: Cigna Medicaid	$98.10
Rate for Payer: Molina CHIP/Medicaid	$98.10
Rate for Payer: Multiplan Auto	$88.56
Rate for Payer: Multiplan Commercial	$88.56
Rate for Payer: Multiplan Workers Comp	$88.56
Rate for Payer: Parkland Medicaid	$98.10
Rate for Payer: Scott and White EPO/PPO	$68.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.10
Rate for Payer: Superior Health Plan EPO	$18.53

DEVICE, CLOSURE WOUND NON

Facility

$136.25

Hospital Charge Code	136341
Hospital Revenue Code	272
Rate for Payer: Cash Price	$92.65

DEVICE, CLOSURE WOUND NONABSORB V-20 NDL 3-0 9' -- DHF

Facility

$250.52

Hospital Charge Code	81943458
Hospital Revenue Code	272
Rate for Payer: Cash Price	$170.35

DEVICE, CLOSURE WOUND NONABSORB V-20 NDL 3-0 9' -- DHF

Facility

$250.52

Hospital Charge Code	81943458
Hospital Revenue Code	272
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$180.37
Rate for Payer: Amerigroup CHIP/Medicaid	$22.55
Rate for Payer: BCBS of TX Blue Advantage	$75.16
Rate for Payer: BCBS of TX Blue Essentials	$90.19
Rate for Payer: BCBS of TX PPO	$100.21
Rate for Payer: Cash Price	$170.35
Rate for Payer: Cigna Medicaid	$180.37
Rate for Payer: Molina CHIP/Medicaid	$180.37
Rate for Payer: Multiplan Auto	$162.84
Rate for Payer: Multiplan Commercial	$162.84
Rate for Payer: Multiplan Workers Comp	$162.84
Rate for Payer: Parkland Medicaid	$180.37
Rate for Payer: Scott and White EPO/PPO	$125.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.37
Rate for Payer: Superior Health Plan EPO	$34.07

DEVICE CLSR 6FR VASC SUT MDT SNR

Facility

$2,710.84

Service Code	HCPCS C1760
Hospital Charge Code	991205
Hospital Revenue Code	278
Min. Negotiated Rate	$677.71
Max. Negotiated Rate	$1,355.42
Rate for Payer: Cash Price	$1,843.37
Rate for Payer: Cigna Commercial	$677.71
Rate for Payer: Multiplan Auto	$1,355.42
Rate for Payer: Multiplan Commercial	$1,355.42
Rate for Payer: Multiplan Workers Comp	$1,355.42
Rate for Payer: Scott and White EPO/PPO	$1,355.42

DEVICE CLSR 6FR VASC SUT MDT SNR

Facility

$2,710.84

Service Code	HCPCS C1760
Hospital Charge Code	991205
Hospital Revenue Code	278
Min. Negotiated Rate	$243.98
Max. Negotiated Rate	$1,951.80
Rate for Payer: Amerigroup CHIP/Medicaid	$243.98
Rate for Payer: BCBS of TX Blue Advantage	$813.25
Rate for Payer: BCBS of TX Blue Essentials	$975.90
Rate for Payer: BCBS of TX PPO	$1,084.34
Rate for Payer: Cash Price	$1,843.37
Rate for Payer: Cigna Medicaid	$1,951.80
Rate for Payer: Molina CHIP/Medicaid	$1,951.80
Rate for Payer: Multiplan Auto	$1,355.42
Rate for Payer: Multiplan Commercial	$1,355.42
Rate for Payer: Multiplan Workers Comp	$1,355.42
Rate for Payer: Parkland Medicaid	$1,951.80
Rate for Payer: Scott and White EPO/PPO	$1,355.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,951.80
Rate for Payer: Superior Health Plan EPO	$368.67

DEVICE CLSR ANGIOSEAL 6FR

Facility

$567.50

Service Code	HCPCS C1760
Hospital Charge Code	993671
Hospital Revenue Code	278
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$283.75
Rate for Payer: Multiplan Commercial	$283.75
Rate for Payer: Multiplan Workers Comp	$283.75
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

DEVICE CLSR ANGIOSEAL 6FR

Facility

$567.50

Service Code	HCPCS C1760
Hospital Charge Code	993671
Hospital Revenue Code	278
Min. Negotiated Rate	$141.88
Max. Negotiated Rate	$283.75
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Commercial	$141.88
Rate for Payer: Multiplan Auto	$283.75
Rate for Payer: Multiplan Commercial	$283.75
Rate for Payer: Multiplan Workers Comp	$283.75
Rate for Payer: Scott and White EPO/PPO	$283.75

DEVICE CLSR ENDO 173022

Facility

$109.02

Service Code	HCPCS C9901
Hospital Charge Code	992813
Hospital Revenue Code	270
Min. Negotiated Rate	$9.81
Max. Negotiated Rate	$22,571.94
Rate for Payer: Amerigroup CHIP/Medicaid	$9.81
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Amerigroup Medicare	$10,678.27
Rate for Payer: BCBS of TX Blue Advantage	$32.71
Rate for Payer: BCBS of TX Blue Essentials	$39.25
Rate for Payer: BCBS of TX Medicare	$10,678.27
Rate for Payer: BCBS of TX PPO	$43.61
Rate for Payer: Cash Price	$74.13
Rate for Payer: Cash Price	$74.13
Rate for Payer: Cash Price	$74.13
Rate for Payer: Cigna Commercial	$22,571.94
Rate for Payer: Cigna Medicaid	$78.49
Rate for Payer: Cigna Medicare	$10,678.27
Rate for Payer: Employer Direct Commercial	$10,678.27
Rate for Payer: Humana Medicare/TRICARE	$10,678.27
Rate for Payer: Molina CHIP/Medicaid	$78.49
Rate for Payer: Molina Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Molina Medicare	$10,678.27
Rate for Payer: Multiplan Auto	$70.86
Rate for Payer: Multiplan Commercial	$70.86
Rate for Payer: Multiplan Workers Comp	$70.86
Rate for Payer: Parkland Medicaid	$78.49
Rate for Payer: Scott and White EPO/PPO	$54.51
Rate for Payer: Scott and White Medicare	$10,678.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$78.49
Rate for Payer: Superior Health Plan EPO	$10,678.27
Rate for Payer: Superior Health Plan Medicare	$10,678.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Universal American Medicare	$10,678.27
Rate for Payer: Wellcare Medicare	$10,678.27
Rate for Payer: Wellmed Medicare	$10,678.27

Know your out-of-pocket cost for care.

All Charges