White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 MONITR INTRAABD PRES -- DHF

Facility

$360.68

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

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
Rate for Payer: Cash Price	$1.08

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

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

DVR LOCK NARROW L

Facility

$4,261.70

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

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	$3,102.29
Max. Negotiated Rate	$24,818.31
Rate for Payer: Amerigroup CHIP/Medicaid	$3,102.29
Rate for Payer: BCBS of TX Blue Advantage	$10,340.96
Rate for Payer: BCBS of TX Blue Essentials	$12,409.16
Rate for Payer: BCBS of TX PPO	$13,787.95
Rate for Payer: Cash Price	$23,439.52
Rate for Payer: Cigna Medicaid	$24,818.31
Rate for Payer: Molina CHIP/Medicaid	$24,818.31
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: Parkland Medicaid	$24,818.31
Rate for Payer: Scott and White EPO/PPO	$17,234.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,818.31
Rate for Payer: Superior Health Plan EPO	$4,687.90

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

DX BONE MARROW ASP/BX MULTI

Facility

$4,639.00

Service Code	HCPCS 38222
Hospital Charge Code	4613822
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,154.52

DX BONE MARROW ASP/BX MULTI

Facility

$4,639.00

Service Code	HCPCS 38222
Hospital Charge Code	4613822
Hospital Revenue Code	360
Min. Negotiated Rate	$815.20
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$815.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Amerigroup Medicare	$2,917.95
Rate for Payer: BCBS of TX Blue Advantage	$3,872.55
Rate for Payer: BCBS of TX Blue Essentials	$4,637.78
Rate for Payer: BCBS of TX Medicare	$2,917.95
Rate for Payer: BCBS of TX PPO	$5,843.60
Rate for Payer: Cash Price	$3,154.52
Rate for Payer: Cash Price	$3,154.52
Rate for Payer: Cash Price	$3,154.52
Rate for Payer: Cigna Commercial	$6,168.03
Rate for Payer: Cigna Medicaid	$3,340.08
Rate for Payer: Cigna Medicare	$2,917.95
Rate for Payer: Employer Direct Commercial	$2,917.95
Rate for Payer: Humana Medicare/TRICARE	$2,917.95
Rate for Payer: Molina CHIP/Medicaid	$3,340.08
Rate for Payer: Molina Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Molina Medicare	$2,917.95
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$3,340.08
Rate for Payer: Scott and White EPO/PPO	$4,807.56
Rate for Payer: Scott and White Medicare	$2,917.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,340.08
Rate for Payer: Superior Health Plan EPO	$2,917.95
Rate for Payer: Superior Health Plan Medicare	$2,917.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Universal American Medicare	$2,917.95
Rate for Payer: Wellcare Medicare	$2,917.95
Rate for Payer: Wellmed Medicare	$2,917.95

DX FIBERTAX SUTURE ANCHOR, #2 MTS W/ NDL

Facility

$5,975.90

Service Code	HCPCS C1713
Hospital Charge Code	992311
Hospital Revenue Code	278
Min. Negotiated Rate	$537.83
Max. Negotiated Rate	$4,302.65
Rate for Payer: Amerigroup CHIP/Medicaid	$537.83
Rate for Payer: BCBS of TX Blue Advantage	$1,792.77
Rate for Payer: BCBS of TX Blue Essentials	$2,151.32
Rate for Payer: BCBS of TX PPO	$2,390.36
Rate for Payer: Cash Price	$4,063.61
Rate for Payer: Cigna Medicaid	$4,302.65
Rate for Payer: Molina CHIP/Medicaid	$4,302.65
Rate for Payer: Multiplan Auto	$2,987.95
Rate for Payer: Multiplan Commercial	$2,987.95
Rate for Payer: Multiplan Workers Comp	$2,987.95
Rate for Payer: Parkland Medicaid	$4,302.65
Rate for Payer: Scott and White EPO/PPO	$2,987.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,302.65
Rate for Payer: Superior Health Plan EPO	$812.72

DX FIBERTAX SUTURE ANCHOR, #2 MTS W/ NDL

Facility

$5,975.90

Service Code	HCPCS C1713
Hospital Charge Code	992311
Hospital Revenue Code	278
Min. Negotiated Rate	$1,493.97
Max. Negotiated Rate	$2,987.95
Rate for Payer: Cash Price	$4,063.61
Rate for Payer: Cigna Commercial	$1,493.97
Rate for Payer: Multiplan Auto	$2,987.95
Rate for Payer: Multiplan Commercial	$2,987.95
Rate for Payer: Multiplan Workers Comp	$2,987.95
Rate for Payer: Scott and White EPO/PPO	$2,987.95

DxH 800 Sample Diluent

Facility

$4,520.48

Hospital Charge Code	992713
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3,073.93

DxH 800 Sample Diluent

Facility

$4,520.48

Hospital Charge Code	992713
Hospital Revenue Code	270
Min. Negotiated Rate	$406.84
Max. Negotiated Rate	$3,254.75
Rate for Payer: Amerigroup CHIP/Medicaid	$406.84
Rate for Payer: BCBS of TX Blue Advantage	$1,356.14
Rate for Payer: BCBS of TX Blue Essentials	$1,627.37
Rate for Payer: BCBS of TX PPO	$1,808.19
Rate for Payer: Cash Price	$3,073.93
Rate for Payer: Cigna Medicaid	$3,254.75
Rate for Payer: Molina CHIP/Medicaid	$3,254.75
Rate for Payer: Multiplan Auto	$2,938.31
Rate for Payer: Multiplan Commercial	$2,938.31
Rate for Payer: Multiplan Workers Comp	$2,938.31
Rate for Payer: Parkland Medicaid	$3,254.75
Rate for Payer: Scott and White EPO/PPO	$2,260.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,254.75
Rate for Payer: Superior Health Plan EPO	$614.79

DYNACLIP FIXATION SYSTEM

Facility

$5,970.10

Hospital Charge Code	145502
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,059.67

DYNACLIP FIXATION SYSTEM

Facility

$5,970.10

Hospital Charge Code	145502
Hospital Revenue Code	272
Min. Negotiated Rate	$537.31
Max. Negotiated Rate	$4,298.47
Rate for Payer: Amerigroup CHIP/Medicaid	$537.31
Rate for Payer: BCBS of TX Blue Advantage	$1,791.03
Rate for Payer: BCBS of TX Blue Essentials	$2,149.24
Rate for Payer: BCBS of TX PPO	$2,388.04
Rate for Payer: Cash Price	$4,059.67
Rate for Payer: Cigna Medicaid	$4,298.47
Rate for Payer: Molina CHIP/Medicaid	$4,298.47
Rate for Payer: Multiplan Auto	$3,880.57
Rate for Payer: Multiplan Commercial	$3,880.57
Rate for Payer: Multiplan Workers Comp	$3,880.57
Rate for Payer: Parkland Medicaid	$4,298.47
Rate for Payer: Scott and White EPO/PPO	$2,985.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,298.47
Rate for Payer: Superior Health Plan EPO	$811.93

DYNACORD

Facility

$754.78

Service Code	HCPCS C1713
Hospital Charge Code	992669
Hospital Revenue Code	278
Min. Negotiated Rate	$67.93
Max. Negotiated Rate	$543.44
Rate for Payer: Amerigroup CHIP/Medicaid	$67.93
Rate for Payer: BCBS of TX Blue Advantage	$226.43
Rate for Payer: BCBS of TX Blue Essentials	$271.72
Rate for Payer: BCBS of TX PPO	$301.91
Rate for Payer: Cash Price	$513.25
Rate for Payer: Cigna Medicaid	$543.44
Rate for Payer: Molina CHIP/Medicaid	$543.44
Rate for Payer: Multiplan Auto	$377.39
Rate for Payer: Multiplan Commercial	$377.39
Rate for Payer: Multiplan Workers Comp	$377.39
Rate for Payer: Parkland Medicaid	$543.44
Rate for Payer: Scott and White EPO/PPO	$377.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$543.44
Rate for Payer: Superior Health Plan EPO	$102.65

DYNACORD

Facility

$754.78

Service Code	HCPCS C1713
Hospital Charge Code	992669
Hospital Revenue Code	278
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$377.39
Rate for Payer: Cash Price	$513.25
Rate for Payer: Cigna Commercial	$188.69
Rate for Payer: Multiplan Auto	$377.39
Rate for Payer: Multiplan Commercial	$377.39
Rate for Payer: Multiplan Workers Comp	$377.39
Rate for Payer: Scott and White EPO/PPO	$377.39

DYSEQUILIBRIUM

Facility

$14,345.00

Service Code	MSDRG 149
Min. Negotiated Rate	$6,115.46
Max. Negotiated Rate	$14,345.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,268.57
Rate for Payer: Amerigroup Medicare	$10,268.57
Rate for Payer: BCBS of TX Blue Advantage	$6,115.46
Rate for Payer: BCBS of TX Blue Essentials	$7,337.84
Rate for Payer: BCBS of TX Medicare	$10,268.57
Rate for Payer: BCBS of TX PPO	$8,153.47
Rate for Payer: Cigna Commercial	$9,680.61
Rate for Payer: Cigna Medicare	$10,268.57
Rate for Payer: Employer Direct Commercial	$10,268.57
Rate for Payer: Humana Medicare/TRICARE	$10,268.57
Rate for Payer: Molina Dual Medicare/Medicaid	$10,268.57
Rate for Payer: Molina Medicare	$10,268.57
Rate for Payer: Multiplan Auto	$14,345.00
Rate for Payer: Multiplan Commercial	$14,345.00
Rate for Payer: Multiplan Workers Comp	$14,345.00
Rate for Payer: Scott and White EPO/PPO	$6,606.25
Rate for Payer: Scott and White Medicare	$10,268.57
Rate for Payer: Superior Health Plan EPO	$10,268.57
Rate for Payer: Superior Health Plan Medicare	$10,268.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,268.57
Rate for Payer: Universal American Medicare	$10,268.57
Rate for Payer: Wellcare Medicare	$10,268.57
Rate for Payer: Wellmed Medicare	$10,268.57

E0033 Whole Blood CPD 500 LR

Facility

$818.00

Hospital Charge Code	2404036
Hospital Revenue Code	390
Rate for Payer: Cash Price	$556.24

E0033 Whole Blood CPD 500 LR

Facility

$818.00

Hospital Charge Code	2404036
Hospital Revenue Code	390
Min. Negotiated Rate	$73.62
Max. Negotiated Rate	$588.96
Rate for Payer: Amerigroup CHIP/Medicaid	$73.62
Rate for Payer: BCBS of TX Blue Advantage	$245.40
Rate for Payer: BCBS of TX Blue Essentials	$294.48
Rate for Payer: BCBS of TX PPO	$327.20
Rate for Payer: Cash Price	$556.24
Rate for Payer: Cigna Medicaid	$588.96
Rate for Payer: Molina CHIP/Medicaid	$588.96
Rate for Payer: Multiplan Auto	$531.70
Rate for Payer: Multiplan Commercial	$531.70
Rate for Payer: Multiplan Workers Comp	$531.70
Rate for Payer: Parkland Medicaid	$588.96
Rate for Payer: Scott and White EPO/PPO	$409.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$588.96
Rate for Payer: Superior Health Plan EPO	$111.25

Know your out-of-pocket cost for care.

All Charges