White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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
Rate for Payer: Cash Price	$92.65

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 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, 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 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

DEVICE CLSR ENDO 173022

Facility

$109.02

Service Code	HCPCS C9901
Hospital Charge Code	992813
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.13

DEVICE CLSR MYNX GRIP 6FR/7FR VASC BLN CATH

Facility

$3,399.85

Service Code	HCPCS C1760
Hospital Charge Code	991306
Hospital Revenue Code	278
Min. Negotiated Rate	$849.96
Max. Negotiated Rate	$1,699.92
Rate for Payer: Cash Price	$2,311.90
Rate for Payer: Cigna Commercial	$849.96
Rate for Payer: Multiplan Auto	$1,699.92
Rate for Payer: Multiplan Commercial	$1,699.92
Rate for Payer: Multiplan Workers Comp	$1,699.92
Rate for Payer: Scott and White EPO/PPO	$1,699.92

DEVICE CLSR MYNX GRIP 6FR/7FR VASC BLN CATH

Facility

$3,399.85

Service Code	HCPCS C1760
Hospital Charge Code	991306
Hospital Revenue Code	278
Min. Negotiated Rate	$305.99
Max. Negotiated Rate	$2,447.89
Rate for Payer: Amerigroup CHIP/Medicaid	$305.99
Rate for Payer: BCBS of TX Blue Advantage	$1,019.96
Rate for Payer: BCBS of TX Blue Essentials	$1,223.95
Rate for Payer: BCBS of TX PPO	$1,359.94
Rate for Payer: Cash Price	$2,311.90
Rate for Payer: Cigna Medicaid	$2,447.89
Rate for Payer: Molina CHIP/Medicaid	$2,447.89
Rate for Payer: Multiplan Auto	$1,699.92
Rate for Payer: Multiplan Commercial	$1,699.92
Rate for Payer: Multiplan Workers Comp	$1,699.92
Rate for Payer: Parkland Medicaid	$2,447.89
Rate for Payer: Scott and White EPO/PPO	$1,699.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,447.89
Rate for Payer: Superior Health Plan EPO	$462.38

DEVICE CMPR FMSTP SYS

Facility

$940.93

Hospital Charge Code	993595
Hospital Revenue Code	270
Min. Negotiated Rate	$84.68
Max. Negotiated Rate	$677.47
Rate for Payer: Amerigroup CHIP/Medicaid	$84.68
Rate for Payer: BCBS of TX Blue Advantage	$282.28
Rate for Payer: BCBS of TX Blue Essentials	$338.73
Rate for Payer: BCBS of TX PPO	$376.37
Rate for Payer: Cash Price	$639.83
Rate for Payer: Cigna Medicaid	$677.47
Rate for Payer: Molina CHIP/Medicaid	$677.47
Rate for Payer: Multiplan Auto	$611.60
Rate for Payer: Multiplan Commercial	$611.60
Rate for Payer: Multiplan Workers Comp	$611.60
Rate for Payer: Parkland Medicaid	$677.47
Rate for Payer: Scott and White EPO/PPO	$470.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$677.47
Rate for Payer: Superior Health Plan EPO	$127.97

DEVICE CMPR FMSTP SYS

Facility

$940.93

Hospital Charge Code	993595
Hospital Revenue Code	270
Rate for Payer: Cash Price	$639.83

DEVICE ENDO CLOSE TROCAR SITE CLOSURE 173022

Facility

$348.04

Hospital Charge Code	80819188
Hospital Revenue Code	272
Rate for Payer: Cash Price	$236.67

DEVICE ENDO CLOSE TROCAR SITE CLOSURE 173022

Facility

$348.04

Hospital Charge Code	80819188
Hospital Revenue Code	272
Min. Negotiated Rate	$31.32
Max. Negotiated Rate	$250.59
Rate for Payer: Amerigroup CHIP/Medicaid	$31.32
Rate for Payer: BCBS of TX Blue Advantage	$104.41
Rate for Payer: BCBS of TX Blue Essentials	$125.29
Rate for Payer: BCBS of TX PPO	$139.22
Rate for Payer: Cash Price	$236.67
Rate for Payer: Cigna Medicaid	$250.59
Rate for Payer: Molina CHIP/Medicaid	$250.59
Rate for Payer: Multiplan Auto	$226.23
Rate for Payer: Multiplan Commercial	$226.23
Rate for Payer: Multiplan Workers Comp	$226.23
Rate for Payer: Parkland Medicaid	$250.59
Rate for Payer: Scott and White EPO/PPO	$174.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$250.59
Rate for Payer: Superior Health Plan EPO	$47.33

DEVICE, ENSEAL CURVED JAW 45CM

Facility

$836.12

Hospital Charge Code	992684
Hospital Revenue Code	272
Min. Negotiated Rate	$75.25
Max. Negotiated Rate	$602.01
Rate for Payer: Amerigroup CHIP/Medicaid	$75.25
Rate for Payer: BCBS of TX Blue Advantage	$250.84
Rate for Payer: BCBS of TX Blue Essentials	$301.00
Rate for Payer: BCBS of TX PPO	$334.45
Rate for Payer: Cash Price	$568.56
Rate for Payer: Cigna Medicaid	$602.01
Rate for Payer: Molina CHIP/Medicaid	$602.01
Rate for Payer: Multiplan Auto	$543.48
Rate for Payer: Multiplan Commercial	$543.48
Rate for Payer: Multiplan Workers Comp	$543.48
Rate for Payer: Parkland Medicaid	$602.01
Rate for Payer: Scott and White EPO/PPO	$418.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$602.01
Rate for Payer: Superior Health Plan EPO	$113.71

DEVICE, ENSEAL CURVED JAW 45CM

Facility

$836.12

Hospital Charge Code	992684
Hospital Revenue Code	272
Rate for Payer: Cash Price	$568.56

DEVICE, LAPAROSCOPIC SEALER/DIVIDER MARYLAND 44CM -- DHF

Facility

$3,109.81

Hospital Charge Code	81740052
Hospital Revenue Code	272
Min. Negotiated Rate	$279.88
Max. Negotiated Rate	$2,239.06
Rate for Payer: Amerigroup CHIP/Medicaid	$279.88
Rate for Payer: BCBS of TX Blue Advantage	$932.94
Rate for Payer: BCBS of TX Blue Essentials	$1,119.53
Rate for Payer: BCBS of TX PPO	$1,243.92
Rate for Payer: Cash Price	$2,114.67
Rate for Payer: Cigna Medicaid	$2,239.06
Rate for Payer: Molina CHIP/Medicaid	$2,239.06
Rate for Payer: Multiplan Auto	$2,021.38
Rate for Payer: Multiplan Commercial	$2,021.38
Rate for Payer: Multiplan Workers Comp	$2,021.38
Rate for Payer: Parkland Medicaid	$2,239.06
Rate for Payer: Scott and White EPO/PPO	$1,554.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,239.06
Rate for Payer: Superior Health Plan EPO	$422.93

DEVICE, LAPAROSCOPIC SEALER/DIVIDER MARYLAND 44CM -- DHF

Facility

$3,109.81

Hospital Charge Code	81740052
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,114.67

DEVICE LAPROSHARK FASCIAL PORT CLOSURE

Facility

$276.94

Hospital Charge Code	8550486
Hospital Revenue Code	272
Rate for Payer: Cash Price	$188.32

DEVICE LAPROSHARK FASCIAL PORT CLOSURE

Facility

$276.94

Hospital Charge Code	8550486
Hospital Revenue Code	272
Min. Negotiated Rate	$24.92
Max. Negotiated Rate	$199.40
Rate for Payer: Amerigroup CHIP/Medicaid	$24.92
Rate for Payer: BCBS of TX Blue Advantage	$83.08
Rate for Payer: BCBS of TX Blue Essentials	$99.70
Rate for Payer: BCBS of TX PPO	$110.78
Rate for Payer: Cash Price	$188.32
Rate for Payer: Cigna Medicaid	$199.40
Rate for Payer: Molina CHIP/Medicaid	$199.40
Rate for Payer: Multiplan Auto	$180.01
Rate for Payer: Multiplan Commercial	$180.01
Rate for Payer: Multiplan Workers Comp	$180.01
Rate for Payer: Parkland Medicaid	$199.40
Rate for Payer: Scott and White EPO/PPO	$138.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$199.40
Rate for Payer: Superior Health Plan EPO	$37.66

Know your out-of-pocket cost for care.

All Charges