White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$1,900.97

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, 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
Rate for Payer: Cash Price	$57.56

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 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

DEVICE SECURE STRAP 25

Facility

$2,331.01

Hospital Charge Code	8554476
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,585.09

DEVICE SECURE STRAP 25

Facility

$2,331.01

Hospital Charge Code	8554476
Hospital Revenue Code	272
Min. Negotiated Rate	$209.79
Max. Negotiated Rate	$1,678.33
Rate for Payer: Amerigroup CHIP/Medicaid	$209.79
Rate for Payer: BCBS of TX Blue Advantage	$699.30
Rate for Payer: BCBS of TX Blue Essentials	$839.16
Rate for Payer: BCBS of TX PPO	$932.40
Rate for Payer: Cash Price	$1,585.09
Rate for Payer: Cigna Medicaid	$1,678.33
Rate for Payer: Molina CHIP/Medicaid	$1,678.33
Rate for Payer: Multiplan Auto	$1,515.16
Rate for Payer: Multiplan Commercial	$1,515.16
Rate for Payer: Multiplan Workers Comp	$1,515.16
Rate for Payer: Parkland Medicaid	$1,678.33
Rate for Payer: Scott and White EPO/PPO	$1,165.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,678.33
Rate for Payer: Superior Health Plan EPO	$317.02

DEVICE, SMOKE ELIMINATOR BUTTON STER DISPOSABLE -- DHF

Facility

$93.77

Hospital Charge Code	81746679
Hospital Revenue Code	270
Min. Negotiated Rate	$8.44
Max. Negotiated Rate	$67.51
Rate for Payer: Amerigroup CHIP/Medicaid	$8.44
Rate for Payer: BCBS of TX Blue Advantage	$28.13
Rate for Payer: BCBS of TX Blue Essentials	$33.76
Rate for Payer: BCBS of TX PPO	$37.51
Rate for Payer: Cash Price	$63.76
Rate for Payer: Cigna Medicaid	$67.51
Rate for Payer: Molina CHIP/Medicaid	$67.51
Rate for Payer: Multiplan Auto	$60.95
Rate for Payer: Multiplan Commercial	$60.95
Rate for Payer: Multiplan Workers Comp	$60.95
Rate for Payer: Parkland Medicaid	$67.51
Rate for Payer: Scott and White EPO/PPO	$46.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$67.51
Rate for Payer: Superior Health Plan EPO	$12.75

DEVICE, SMOKE ELIMINATOR BUTTON STER DISPOSABLE -- DHF

Facility

$93.77

Hospital Charge Code	81746679
Hospital Revenue Code	270
Rate for Payer: Cash Price	$63.76

DEVICE, TISSUE REMOVAL TR

Facility

$1,058.53

Hospital Charge Code	136710
Hospital Revenue Code	272
Rate for Payer: Cash Price	$719.80

DEVICE, TISSUE REMOVAL TR

Facility

$1,058.53

Hospital Charge Code	136710
Hospital Revenue Code	272
Min. Negotiated Rate	$95.27
Max. Negotiated Rate	$762.14
Rate for Payer: Amerigroup CHIP/Medicaid	$95.27
Rate for Payer: BCBS of TX Blue Advantage	$317.56
Rate for Payer: BCBS of TX Blue Essentials	$381.07
Rate for Payer: BCBS of TX PPO	$423.41
Rate for Payer: Cash Price	$719.80
Rate for Payer: Cigna Medicaid	$762.14
Rate for Payer: Molina CHIP/Medicaid	$762.14
Rate for Payer: Multiplan Auto	$688.04
Rate for Payer: Multiplan Commercial	$688.04
Rate for Payer: Multiplan Workers Comp	$688.04
Rate for Payer: Parkland Medicaid	$762.14
Rate for Payer: Scott and White EPO/PPO	$529.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$762.14
Rate for Payer: Superior Health Plan EPO	$143.96

device tk t-knot 5mm

Facility

$903.46

Hospital Charge Code	8452482
Hospital Revenue Code	272
Rate for Payer: Cash Price	$614.35

device tk t-knot 5mm

Facility

$903.46

Hospital Charge Code	8452482
Hospital Revenue Code	272
Min. Negotiated Rate	$81.31
Max. Negotiated Rate	$650.49
Rate for Payer: Amerigroup CHIP/Medicaid	$81.31
Rate for Payer: BCBS of TX Blue Advantage	$271.04
Rate for Payer: BCBS of TX Blue Essentials	$325.25
Rate for Payer: BCBS of TX PPO	$361.38
Rate for Payer: Cash Price	$614.35
Rate for Payer: Cigna Medicaid	$650.49
Rate for Payer: Molina CHIP/Medicaid	$650.49
Rate for Payer: Multiplan Auto	$587.25
Rate for Payer: Multiplan Commercial	$587.25
Rate for Payer: Multiplan Workers Comp	$587.25
Rate for Payer: Parkland Medicaid	$650.49
Rate for Payer: Scott and White EPO/PPO	$451.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$650.49
Rate for Payer: Superior Health Plan EPO	$122.87

DEVICE, ZIP, 16, SURGICAL, SKIN, CLOSURE

Facility

$514.92

Hospital Charge Code	993750
Hospital Revenue Code	272
Rate for Payer: Cash Price	$350.15

DEVICE, ZIP, 16, SURGICAL, SKIN, CLOSURE

Facility

$514.92

Hospital Charge Code	993750
Hospital Revenue Code	272
Min. Negotiated Rate	$46.34
Max. Negotiated Rate	$370.74
Rate for Payer: Amerigroup CHIP/Medicaid	$46.34
Rate for Payer: BCBS of TX Blue Advantage	$154.48
Rate for Payer: BCBS of TX Blue Essentials	$185.37
Rate for Payer: BCBS of TX PPO	$205.97
Rate for Payer: Cash Price	$350.15
Rate for Payer: Cigna Medicaid	$370.74
Rate for Payer: Molina CHIP/Medicaid	$370.74
Rate for Payer: Multiplan Auto	$334.70
Rate for Payer: Multiplan Commercial	$334.70
Rate for Payer: Multiplan Workers Comp	$334.70
Rate for Payer: Parkland Medicaid	$370.74
Rate for Payer: Scott and White EPO/PPO	$257.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$370.74
Rate for Payer: Superior Health Plan EPO	$70.03

DEVICE, ZIP, 24, SURGICAL, SKIN, CLOSURE

Facility

$755.58

Hospital Charge Code	993751
Hospital Revenue Code	272
Min. Negotiated Rate	$68.00
Max. Negotiated Rate	$544.02
Rate for Payer: Amerigroup CHIP/Medicaid	$68.00
Rate for Payer: BCBS of TX Blue Advantage	$226.67
Rate for Payer: BCBS of TX Blue Essentials	$272.01
Rate for Payer: BCBS of TX PPO	$302.23
Rate for Payer: Cash Price	$513.79
Rate for Payer: Cigna Medicaid	$544.02
Rate for Payer: Molina CHIP/Medicaid	$544.02
Rate for Payer: Multiplan Auto	$491.13
Rate for Payer: Multiplan Commercial	$491.13
Rate for Payer: Multiplan Workers Comp	$491.13
Rate for Payer: Parkland Medicaid	$544.02
Rate for Payer: Scott and White EPO/PPO	$377.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$544.02
Rate for Payer: Superior Health Plan EPO	$102.76

DEVICE, ZIP, 24, SURGICAL, SKIN, CLOSURE

Facility

$755.58

Hospital Charge Code	993751
Hospital Revenue Code	272
Rate for Payer: Cash Price	$513.79

DEV INFLATION -- DHF

Facility

$312.81

Hospital Charge Code	80320070
Hospital Revenue Code	272
Min. Negotiated Rate	$28.15
Max. Negotiated Rate	$225.22
Rate for Payer: Amerigroup CHIP/Medicaid	$28.15
Rate for Payer: BCBS of TX Blue Advantage	$93.84
Rate for Payer: BCBS of TX Blue Essentials	$112.61
Rate for Payer: BCBS of TX PPO	$125.12
Rate for Payer: Cash Price	$212.71
Rate for Payer: Cigna Medicaid	$225.22
Rate for Payer: Molina CHIP/Medicaid	$225.22
Rate for Payer: Multiplan Auto	$203.33
Rate for Payer: Multiplan Commercial	$203.33
Rate for Payer: Multiplan Workers Comp	$203.33
Rate for Payer: Parkland Medicaid	$225.22
Rate for Payer: Scott and White EPO/PPO	$156.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$225.22
Rate for Payer: Superior Health Plan EPO	$42.54

Know your out-of-pocket cost for care.

All Charges