White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 SECURE STRAP 25

Facility

$2,331.01

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

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
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, TISSUE REMOVAL TR

Facility

$1,058.53

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

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 tk t-knot 5mm

Facility

$903.46

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

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

DEV INFLATION -- DHF

Facility

$312.81

Hospital Charge Code	80320070
Hospital Revenue Code	272
Rate for Payer: Cash Price	$212.71

DEV RETRIEVAL INSERTABLE -- DHF

Facility

$1,694.96

Hospital Charge Code	82401399
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,152.57

DEV RETRIEVAL INSERTABLE -- DHF

Facility

$1,694.96

Hospital Charge Code	82401399
Hospital Revenue Code	272
Min. Negotiated Rate	$152.55
Max. Negotiated Rate	$1,220.37
Rate for Payer: Amerigroup CHIP/Medicaid	$152.55
Rate for Payer: BCBS of TX Blue Advantage	$508.49
Rate for Payer: BCBS of TX Blue Essentials	$610.19
Rate for Payer: BCBS of TX PPO	$677.98
Rate for Payer: Cash Price	$1,152.57
Rate for Payer: Cigna Medicaid	$1,220.37
Rate for Payer: Molina CHIP/Medicaid	$1,220.37
Rate for Payer: Multiplan Auto	$1,101.72
Rate for Payer: Multiplan Commercial	$1,101.72
Rate for Payer: Multiplan Workers Comp	$1,101.72
Rate for Payer: Parkland Medicaid	$1,220.37
Rate for Payer: Scott and White EPO/PPO	$847.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,220.37
Rate for Payer: Superior Health Plan EPO	$230.51

dexamethasone 0.5 mg/5 mL Oral Liquid 500 mL

Facility

$7.65

Service Code	HCPCS J8540
Hospital Charge Code	77498028
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.01
Rate for Payer: BCBS of TX Blue Essentials	$0.02
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

dexamethasone 0.5 mg/5 mL Oral Liquid 500 mL

Facility

$7.65

Service Code	HCPCS J8540
Hospital Charge Code	77498028
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.83

dexamethasone 10 mg/mL PF Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1100
Hospital Charge Code	77498478
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.03
Rate for Payer: BCBS of TX Blue Essentials	$0.03
Rate for Payer: BCBS of TX PPO	$0.04
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

dexamethasone 10 mg/mL PF Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1100
Hospital Charge Code	77498478
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

dexamethasone 4 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1100
Hospital Charge Code	77498645
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.03
Rate for Payer: BCBS of TX Blue Essentials	$0.03
Rate for Payer: BCBS of TX PPO	$0.04
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

dexamethasone 4 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1100
Hospital Charge Code	77498645
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

dexamethasone 4 mg Tab

Facility

$15.50

Service Code	HCPCS J8540
Hospital Charge Code	77498588
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$11.16
Rate for Payer: Amerigroup CHIP/Medicaid	$1.40
Rate for Payer: BCBS of TX Blue Advantage	$0.01
Rate for Payer: BCBS of TX Blue Essentials	$0.02
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$10.54
Rate for Payer: Cash Price	$10.54
Rate for Payer: Cigna Medicaid	$11.16
Rate for Payer: Molina CHIP/Medicaid	$11.16
Rate for Payer: Multiplan Auto	$10.07
Rate for Payer: Multiplan Commercial	$10.07
Rate for Payer: Multiplan Workers Comp	$10.07
Rate for Payer: Parkland Medicaid	$11.16
Rate for Payer: Scott and White EPO/PPO	$7.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.16
Rate for Payer: Superior Health Plan EPO	$2.11

dexamethasone 4 mg Tab

Facility

$15.50

Service Code	HCPCS J8540
Hospital Charge Code	77498588
Hospital Revenue Code	636
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$7.75
Rate for Payer: Cash Price	$10.54
Rate for Payer: Cigna Commercial	$3.88
Rate for Payer: Scott and White EPO/PPO	$7.75

dexmedetomidine 100 mcg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77500496
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

Know your out-of-pocket cost for care.

All Charges