White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DUST SHEET, 5X6, 500 SHEETS/CS

Facility

$0.76

Hospital Charge Code	993967
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.52

DUST SHEET, 5X6, 500 SHEETS/CS

Facility

$0.76

Hospital Charge Code	993967
Hospital Revenue Code	270
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.55
Rate for Payer: Amerigroup CHIP/Medicaid	$0.07
Rate for Payer: BCBS of TX Blue Advantage	$0.23
Rate for Payer: BCBS of TX Blue Essentials	$0.27
Rate for Payer: BCBS of TX PPO	$0.30
Rate for Payer: Cash Price	$0.52
Rate for Payer: Cigna Medicaid	$0.55
Rate for Payer: Molina CHIP/Medicaid	$0.55
Rate for Payer: Multiplan Auto	$0.49
Rate for Payer: Multiplan Commercial	$0.49
Rate for Payer: Multiplan Workers Comp	$0.49
Rate for Payer: Parkland Medicaid	$0.55
Rate for Payer: Scott and White EPO/PPO	$0.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.55
Rate for Payer: Superior Health Plan EPO	$0.10

DVCE ASPIRATING -- DHF

Facility

$216.11

Hospital Charge Code	80321151
Hospital Revenue Code	270
Rate for Payer: Cash Price	$146.95

DVCE ASPIRATING -- DHF

Facility

$216.11

Hospital Charge Code	80321151
Hospital Revenue Code	270
Min. Negotiated Rate	$19.45
Max. Negotiated Rate	$155.60
Rate for Payer: Amerigroup CHIP/Medicaid	$19.45
Rate for Payer: BCBS of TX Blue Advantage	$64.83
Rate for Payer: BCBS of TX Blue Essentials	$77.80
Rate for Payer: BCBS of TX PPO	$86.44
Rate for Payer: Cash Price	$146.95
Rate for Payer: Cigna Medicaid	$155.60
Rate for Payer: Molina CHIP/Medicaid	$155.60
Rate for Payer: Multiplan Auto	$140.47
Rate for Payer: Multiplan Commercial	$140.47
Rate for Payer: Multiplan Workers Comp	$140.47
Rate for Payer: Parkland Medicaid	$155.60
Rate for Payer: Scott and White EPO/PPO	$108.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$155.60
Rate for Payer: Superior Health Plan EPO	$29.39

DVCE CIRC AS -- DHF

Facility

$110.27

Hospital Charge Code	81741001
Hospital Revenue Code	270
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$79.39
Rate for Payer: Amerigroup CHIP/Medicaid	$9.92
Rate for Payer: BCBS of TX Blue Advantage	$33.08
Rate for Payer: BCBS of TX Blue Essentials	$39.70
Rate for Payer: BCBS of TX PPO	$44.11
Rate for Payer: Cash Price	$74.98
Rate for Payer: Cigna Medicaid	$79.39
Rate for Payer: Molina CHIP/Medicaid	$79.39
Rate for Payer: Multiplan Auto	$71.68
Rate for Payer: Multiplan Commercial	$71.68
Rate for Payer: Multiplan Workers Comp	$71.68
Rate for Payer: Parkland Medicaid	$79.39
Rate for Payer: Scott and White EPO/PPO	$55.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.39
Rate for Payer: Superior Health Plan EPO	$15.00

DVCE CIRC AS -- DHF

Facility

$110.27

Hospital Charge Code	81741001
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.98

DVC EMBLZTN MICROSPHERE -- DHF

Facility

$794.05

Hospital Charge Code	80321268
Hospital Revenue Code	272
Rate for Payer: Cash Price	$539.95

DVC EMBLZTN MICROSPHERE -- DHF

Facility

$794.05

Hospital Charge Code	80321268
Hospital Revenue Code	272
Min. Negotiated Rate	$71.46
Max. Negotiated Rate	$571.72
Rate for Payer: Amerigroup CHIP/Medicaid	$71.46
Rate for Payer: BCBS of TX Blue Advantage	$238.22
Rate for Payer: BCBS of TX Blue Essentials	$285.86
Rate for Payer: BCBS of TX PPO	$317.62
Rate for Payer: Cash Price	$539.95
Rate for Payer: Cigna Medicaid	$571.72
Rate for Payer: Molina CHIP/Medicaid	$571.72
Rate for Payer: Multiplan Auto	$516.13
Rate for Payer: Multiplan Commercial	$516.13
Rate for Payer: Multiplan Workers Comp	$516.13
Rate for Payer: Parkland Medicaid	$571.72
Rate for Payer: Scott and White EPO/PPO	$397.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$571.72
Rate for Payer: Superior Health Plan EPO	$107.99

DVCE SIZING -- DHF

Facility

$285.37

Hospital Charge Code	80811086
Hospital Revenue Code	270
Min. Negotiated Rate	$25.68
Max. Negotiated Rate	$205.47
Rate for Payer: Amerigroup CHIP/Medicaid	$25.68
Rate for Payer: BCBS of TX Blue Advantage	$85.61
Rate for Payer: BCBS of TX Blue Essentials	$102.73
Rate for Payer: BCBS of TX PPO	$114.15
Rate for Payer: Cash Price	$194.05
Rate for Payer: Cigna Medicaid	$205.47
Rate for Payer: Molina CHIP/Medicaid	$205.47
Rate for Payer: Multiplan Auto	$185.49
Rate for Payer: Multiplan Commercial	$185.49
Rate for Payer: Multiplan Workers Comp	$185.49
Rate for Payer: Parkland Medicaid	$205.47
Rate for Payer: Scott and White EPO/PPO	$142.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$205.47
Rate for Payer: Superior Health Plan EPO	$38.81

DVCE SIZING -- DHF

Facility

$285.37

Hospital Charge Code	80811086
Hospital Revenue Code	270
Rate for Payer: Cash Price	$194.05

DVCE TORQUE -- DHF

Facility

$71.50

Hospital Charge Code	80811102
Hospital Revenue Code	272
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$51.48
Rate for Payer: Amerigroup CHIP/Medicaid	$6.43
Rate for Payer: BCBS of TX Blue Advantage	$21.45
Rate for Payer: BCBS of TX Blue Essentials	$25.74
Rate for Payer: BCBS of TX PPO	$28.60
Rate for Payer: Cash Price	$48.62
Rate for Payer: Cigna Medicaid	$51.48
Rate for Payer: Molina CHIP/Medicaid	$51.48
Rate for Payer: Multiplan Auto	$46.48
Rate for Payer: Multiplan Commercial	$46.48
Rate for Payer: Multiplan Workers Comp	$46.48
Rate for Payer: Parkland Medicaid	$51.48
Rate for Payer: Scott and White EPO/PPO	$35.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.48
Rate for Payer: Superior Health Plan EPO	$9.72

DVCE TORQUE -- DHF

Facility

$71.50

Hospital Charge Code	80811102
Hospital Revenue Code	272
Rate for Payer: Cash Price	$48.62

DVC INFLAT SINUS BLLN -- DHF

Facility

$338.45

Hospital Charge Code	81741118
Hospital Revenue Code	272
Min. Negotiated Rate	$30.46
Max. Negotiated Rate	$243.68
Rate for Payer: Amerigroup CHIP/Medicaid	$30.46
Rate for Payer: BCBS of TX Blue Advantage	$101.53
Rate for Payer: BCBS of TX Blue Essentials	$121.84
Rate for Payer: BCBS of TX PPO	$135.38
Rate for Payer: Cash Price	$230.15
Rate for Payer: Cigna Medicaid	$243.68
Rate for Payer: Molina CHIP/Medicaid	$243.68
Rate for Payer: Multiplan Auto	$219.99
Rate for Payer: Multiplan Commercial	$219.99
Rate for Payer: Multiplan Workers Comp	$219.99
Rate for Payer: Parkland Medicaid	$243.68
Rate for Payer: Scott and White EPO/PPO	$169.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$243.68
Rate for Payer: Superior Health Plan EPO	$46.03

DVC INFLAT SINUS BLLN -- DHF

Facility

$338.45

Hospital Charge Code	81741118
Hospital Revenue Code	272
Rate for Payer: Cash Price	$230.15

DVC MONITR INTRAABD PRES -- DHF

Facility

$360.68

Hospital Charge Code	80412885
Hospital Revenue Code	272
Rate for Payer: Cash Price	$245.26

DVC MONITR INTRAABD PRES -- DHF

Facility

$360.68

Hospital Charge Code	80412885
Hospital Revenue Code	272
Min. Negotiated Rate	$32.46
Max. Negotiated Rate	$259.69
Rate for Payer: Amerigroup CHIP/Medicaid	$32.46
Rate for Payer: BCBS of TX Blue Advantage	$108.20
Rate for Payer: BCBS of TX Blue Essentials	$129.84
Rate for Payer: BCBS of TX PPO	$144.27
Rate for Payer: Cash Price	$245.26
Rate for Payer: Cigna Medicaid	$259.69
Rate for Payer: Molina CHIP/Medicaid	$259.69
Rate for Payer: Multiplan Auto	$234.44
Rate for Payer: Multiplan Commercial	$234.44
Rate for Payer: Multiplan Workers Comp	$234.44
Rate for Payer: Parkland Medicaid	$259.69
Rate for Payer: Scott and White EPO/PPO	$180.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$259.69
Rate for Payer: Superior Health Plan EPO	$49.05

DVC STONE ANTIRETROPULSN -- DHF

Facility

$2,427.66

Hospital Charge Code	80412869
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,650.81

DVC STONE ANTIRETROPULSN -- DHF

Facility

$2,427.66

Hospital Charge Code	80412869
Hospital Revenue Code	272
Min. Negotiated Rate	$218.49
Max. Negotiated Rate	$1,747.92
Rate for Payer: Amerigroup CHIP/Medicaid	$218.49
Rate for Payer: BCBS of TX Blue Advantage	$728.30
Rate for Payer: BCBS of TX Blue Essentials	$873.96
Rate for Payer: BCBS of TX PPO	$971.06
Rate for Payer: Cash Price	$1,650.81
Rate for Payer: Cigna Medicaid	$1,747.92
Rate for Payer: Molina CHIP/Medicaid	$1,747.92
Rate for Payer: Multiplan Auto	$1,577.98
Rate for Payer: Multiplan Commercial	$1,577.98
Rate for Payer: Multiplan Workers Comp	$1,577.98
Rate for Payer: Parkland Medicaid	$1,747.92
Rate for Payer: Scott and White EPO/PPO	$1,213.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,747.92
Rate for Payer: Superior Health Plan EPO	$330.16

DVD-R Discs, 4.7GB, 16X, Spindle, Silver

Facility

$1.59

Hospital Charge Code	993324
Hospital Revenue Code	270
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$1.14
Rate for Payer: Amerigroup CHIP/Medicaid	$0.14
Rate for Payer: BCBS of TX Blue Advantage	$0.48
Rate for Payer: BCBS of TX Blue Essentials	$0.57
Rate for Payer: BCBS of TX PPO	$0.64
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna Medicaid	$1.14
Rate for Payer: Molina CHIP/Medicaid	$1.14
Rate for Payer: Multiplan Auto	$1.03
Rate for Payer: Multiplan Commercial	$1.03
Rate for Payer: Multiplan Workers Comp	$1.03
Rate for Payer: Parkland Medicaid	$1.14
Rate for Payer: Scott and White EPO/PPO	$0.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.14
Rate for Payer: Superior Health Plan EPO	$0.22

DVD-R Discs, 4.7GB, 16X, Spindle, Silver

Facility

$1.59

Hospital Charge Code	993324
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.08

DVR LOCK NARROW L

Facility

$4,261.70

Hospital Charge Code	993175
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2,897.96

DVR LOCK NARROW L

Facility

$4,261.70

Hospital Charge Code	993175
Hospital Revenue Code	270
Min. Negotiated Rate	$383.55
Max. Negotiated Rate	$3,068.42
Rate for Payer: Amerigroup CHIP/Medicaid	$383.55
Rate for Payer: BCBS of TX Blue Advantage	$1,278.51
Rate for Payer: BCBS of TX Blue Essentials	$1,534.21
Rate for Payer: BCBS of TX PPO	$1,704.68
Rate for Payer: Cash Price	$2,897.96
Rate for Payer: Cigna Medicaid	$3,068.42
Rate for Payer: Molina CHIP/Medicaid	$3,068.42
Rate for Payer: Multiplan Auto	$2,770.11
Rate for Payer: Multiplan Commercial	$2,770.11
Rate for Payer: Multiplan Workers Comp	$2,770.11
Rate for Payer: Parkland Medicaid	$3,068.42
Rate for Payer: Scott and White EPO/PPO	$2,130.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,068.42
Rate for Payer: Superior Health Plan EPO	$579.59

DWD017MWJ126MWJ004DWJ505DWJ021DWF601ADWF356CDWJ22DWJ18DWJ130

Facility

$21,672.70

Service Code	HCPCS C1734
Hospital Charge Code	991242
Hospital Revenue Code	278
Min. Negotiated Rate	$5,418.18
Max. Negotiated Rate	$10,836.35
Rate for Payer: Cash Price	$14,737.44
Rate for Payer: Cigna Commercial	$5,418.18
Rate for Payer: Multiplan Auto	$10,836.35
Rate for Payer: Multiplan Commercial	$10,836.35
Rate for Payer: Multiplan Workers Comp	$10,836.35
Rate for Payer: Scott and White EPO/PPO	$10,836.35

DWD017MWJ126MWJ004DWJ505DWJ021DWF601ADWF356CDWJ22DWJ18DWJ130

Facility

$21,672.70

Service Code	HCPCS C1734
Hospital Charge Code	991242
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.54
Max. Negotiated Rate	$15,604.34
Rate for Payer: Amerigroup CHIP/Medicaid	$1,950.54
Rate for Payer: BCBS of TX Blue Advantage	$6,501.81
Rate for Payer: BCBS of TX Blue Essentials	$7,802.17
Rate for Payer: BCBS of TX PPO	$8,669.08
Rate for Payer: Cash Price	$14,737.44
Rate for Payer: Cigna Medicaid	$15,604.34
Rate for Payer: Molina CHIP/Medicaid	$15,604.34
Rate for Payer: Multiplan Auto	$10,836.35
Rate for Payer: Multiplan Commercial	$10,836.35
Rate for Payer: Multiplan Workers Comp	$10,836.35
Rate for Payer: Parkland Medicaid	$15,604.34
Rate for Payer: Scott and White EPO/PPO	$10,836.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,604.34
Rate for Payer: Superior Health Plan EPO	$2,947.49

DWF510

Facility

$34,469.88

Service Code	HCPCS C1776
Hospital Charge Code	991241
Hospital Revenue Code	278
Min. Negotiated Rate	$8,617.47
Max. Negotiated Rate	$17,234.94
Rate for Payer: Cash Price	$23,439.52
Rate for Payer: Cigna Commercial	$8,617.47
Rate for Payer: Multiplan Auto	$17,234.94
Rate for Payer: Multiplan Commercial	$17,234.94
Rate for Payer: Multiplan Workers Comp	$17,234.94
Rate for Payer: Scott and White EPO/PPO	$17,234.94

Know your out-of-pocket cost for care.

All Charges