White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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 CMPR FMSTP SYS

Facility

$940.93

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

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 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
Rate for Payer: Cash Price	$568.56

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, 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, 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 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

device ligasure blunt 5x44 lf1844

Facility

$2,195.00

Hospital Charge Code	8666516
Hospital Revenue Code	272
Min. Negotiated Rate	$197.55
Max. Negotiated Rate	$1,580.40
Rate for Payer: Amerigroup CHIP/Medicaid	$197.55
Rate for Payer: BCBS of TX Blue Advantage	$658.50
Rate for Payer: BCBS of TX Blue Essentials	$790.20
Rate for Payer: BCBS of TX PPO	$878.00
Rate for Payer: Cash Price	$1,492.60
Rate for Payer: Cigna Medicaid	$1,580.40
Rate for Payer: Molina CHIP/Medicaid	$1,580.40
Rate for Payer: Multiplan Auto	$1,426.75
Rate for Payer: Multiplan Commercial	$1,426.75
Rate for Payer: Multiplan Workers Comp	$1,426.75
Rate for Payer: Parkland Medicaid	$1,580.40
Rate for Payer: Scott and White EPO/PPO	$1,097.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,580.40
Rate for Payer: Superior Health Plan EPO	$298.52

device ligasure blunt 5x44 lf1844

Facility

$2,195.00

Hospital Charge Code	8666516
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,492.60

DEVICE LIGASURE IMPACT LF4418

Facility

$2,822.92

Hospital Charge Code	8524478
Hospital Revenue Code	272
Min. Negotiated Rate	$254.06
Max. Negotiated Rate	$2,032.50
Rate for Payer: Amerigroup CHIP/Medicaid	$254.06
Rate for Payer: BCBS of TX Blue Advantage	$846.88
Rate for Payer: BCBS of TX Blue Essentials	$1,016.25
Rate for Payer: BCBS of TX PPO	$1,129.17
Rate for Payer: Cash Price	$1,919.59
Rate for Payer: Cigna Medicaid	$2,032.50
Rate for Payer: Molina CHIP/Medicaid	$2,032.50
Rate for Payer: Multiplan Auto	$1,834.90
Rate for Payer: Multiplan Commercial	$1,834.90
Rate for Payer: Multiplan Workers Comp	$1,834.90
Rate for Payer: Parkland Medicaid	$2,032.50
Rate for Payer: Scott and White EPO/PPO	$1,411.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,032.50
Rate for Payer: Superior Health Plan EPO	$383.92

DEVICE LIGASURE IMPACT LF4418

Facility

$2,822.92

Hospital Charge Code	8524478
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,919.59

DEVICE, LIGASURE, MARYLAND, JAW

Facility

$2,795.55

Hospital Charge Code	993762
Hospital Revenue Code	272
Min. Negotiated Rate	$251.60
Max. Negotiated Rate	$2,012.80
Rate for Payer: Amerigroup CHIP/Medicaid	$251.60
Rate for Payer: BCBS of TX Blue Advantage	$838.66
Rate for Payer: BCBS of TX Blue Essentials	$1,006.40
Rate for Payer: BCBS of TX PPO	$1,118.22
Rate for Payer: Cash Price	$1,900.97
Rate for Payer: Cigna Medicaid	$2,012.80
Rate for Payer: Molina CHIP/Medicaid	$2,012.80
Rate for Payer: Multiplan Auto	$1,817.11
Rate for Payer: Multiplan Commercial	$1,817.11
Rate for Payer: Multiplan Workers Comp	$1,817.11
Rate for Payer: Parkland Medicaid	$2,012.80
Rate for Payer: Scott and White EPO/PPO	$1,397.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,012.80
Rate for Payer: Superior Health Plan EPO	$380.19

DEVICE, LIGASURE, MARYLAND, JAW

Facility

$2,795.55

Hospital Charge Code	993762
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,900.97

DEVICE, MARYLAND JAW, LAPAROSCOPIC

Facility

$2,989.28

Hospital Charge Code	992809
Hospital Revenue Code	272
Min. Negotiated Rate	$269.04
Max. Negotiated Rate	$2,152.28
Rate for Payer: Amerigroup CHIP/Medicaid	$269.04
Rate for Payer: BCBS of TX Blue Advantage	$896.78
Rate for Payer: BCBS of TX Blue Essentials	$1,076.14
Rate for Payer: BCBS of TX PPO	$1,195.71
Rate for Payer: Cash Price	$2,032.71
Rate for Payer: Cigna Medicaid	$2,152.28
Rate for Payer: Molina CHIP/Medicaid	$2,152.28
Rate for Payer: Multiplan Auto	$1,943.03
Rate for Payer: Multiplan Commercial	$1,943.03
Rate for Payer: Multiplan Workers Comp	$1,943.03
Rate for Payer: Parkland Medicaid	$2,152.28
Rate for Payer: Scott and White EPO/PPO	$1,494.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,152.28
Rate for Payer: Superior Health Plan EPO	$406.54

DEVICE, MARYLAND JAW, LAPAROSCOPIC

Facility

$2,989.28

Hospital Charge Code	992809
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,032.71

DEVICE PAP EZPAP 22MM NS LF

Facility

$84.64

Hospital Charge Code	993613
Hospital Revenue Code	270
Min. Negotiated Rate	$7.62
Max. Negotiated Rate	$60.94
Rate for Payer: Amerigroup CHIP/Medicaid	$7.62
Rate for Payer: BCBS of TX Blue Advantage	$25.39
Rate for Payer: BCBS of TX Blue Essentials	$30.47
Rate for Payer: BCBS of TX PPO	$33.86
Rate for Payer: Cash Price	$57.56
Rate for Payer: Cigna Medicaid	$60.94
Rate for Payer: Molina CHIP/Medicaid	$60.94
Rate for Payer: Multiplan Auto	$55.02
Rate for Payer: Multiplan Commercial	$55.02
Rate for Payer: Multiplan Workers Comp	$55.02
Rate for Payer: Parkland Medicaid	$60.94
Rate for Payer: Scott and White EPO/PPO	$42.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60.94
Rate for Payer: Superior Health Plan EPO	$11.51

DEVICE PAP EZPAP 22MM NS LF

Facility

$84.64

Hospital Charge Code	993613
Hospital Revenue Code	270
Rate for Payer: Cash Price	$57.56

DEVICE RF 3.5MM HK

Facility

$686.18

Hospital Charge Code	993199
Hospital Revenue Code	272
Min. Negotiated Rate	$61.76
Max. Negotiated Rate	$494.05
Rate for Payer: Amerigroup CHIP/Medicaid	$61.76
Rate for Payer: BCBS of TX Blue Advantage	$205.85
Rate for Payer: BCBS of TX Blue Essentials	$247.02
Rate for Payer: BCBS of TX PPO	$274.47
Rate for Payer: Cash Price	$466.60
Rate for Payer: Cigna Medicaid	$494.05
Rate for Payer: Molina CHIP/Medicaid	$494.05
Rate for Payer: Multiplan Auto	$446.02
Rate for Payer: Multiplan Commercial	$446.02
Rate for Payer: Multiplan Workers Comp	$446.02
Rate for Payer: Parkland Medicaid	$494.05
Rate for Payer: Scott and White EPO/PPO	$343.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$494.05
Rate for Payer: Superior Health Plan EPO	$93.32

DEVICE RF 3.5MM HK

Facility

$686.18

Hospital Charge Code	993199
Hospital Revenue Code	272
Rate for Payer: Cash Price	$466.60

Know your out-of-pocket cost for care.

All Charges