White Rock Medical Center

All Charges

Charge

Type

Setting

Price

APPLIER, CLIP ENDO MULTIPLE TITANIUM 9 3/8" 20 SML

Facility

$376.32

Hospital Charge Code	81941056
Hospital Revenue Code	272
Min. Negotiated Rate	$33.87
Max. Negotiated Rate	$244.61
Rate for Payer: Aetna Commercial	$206.98
Rate for Payer: Amerigroup CHIP/Medicaid	$33.87
Rate for Payer: BCBS of TX Blue Advantage	$112.90
Rate for Payer: BCBS of TX Blue Essentials	$135.48
Rate for Payer: BCBS of TX PPO	$150.53
Rate for Payer: Cash Price	$331.16
Rate for Payer: Multiplan Auto	$244.61
Rate for Payer: Multiplan Commercial	$244.61
Rate for Payer: Multiplan Workers Comp	$244.61
Rate for Payer: Scott and White EPO/PPO	$188.16
Rate for Payer: Superior Health Plan EPO	$51.18

APPLIER, CLIP ENDO MULTIPLE TITANIUM 9 3/8" 20 SML

Facility

$376.32

Hospital Charge Code	81941056
Hospital Revenue Code	272
Rate for Payer: Cash Price	$331.16

APPLIER, ENDO MULTI CLIP MED/LG 5MM SHFT STRL DISP -- DHF

Facility

$1,735.94

Hospital Charge Code	81941056
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,527.63

APPLIER, ENDO MULTI CLIP MED/LG 5MM SHFT STRL DISP -- DHF

Facility

$1,735.94

Hospital Charge Code	81941056
Hospital Revenue Code	272
Min. Negotiated Rate	$156.23
Max. Negotiated Rate	$1,128.36
Rate for Payer: Aetna Commercial	$954.77
Rate for Payer: Amerigroup CHIP/Medicaid	$156.23
Rate for Payer: BCBS of TX Blue Advantage	$520.78
Rate for Payer: BCBS of TX Blue Essentials	$624.94
Rate for Payer: BCBS of TX PPO	$694.38
Rate for Payer: Cash Price	$1,527.63
Rate for Payer: Multiplan Auto	$1,128.36
Rate for Payer: Multiplan Commercial	$1,128.36
Rate for Payer: Multiplan Workers Comp	$1,128.36
Rate for Payer: Scott and White EPO/PPO	$867.97
Rate for Payer: Superior Health Plan EPO	$236.09

APPLIER, ENDOSCOPIC M-CLIP W/ROTATE SHAFT 20/LARGE -- DHF

Facility

$624.70

Hospital Charge Code	81910358
Hospital Revenue Code	272
Min. Negotiated Rate	$56.22
Max. Negotiated Rate	$406.06
Rate for Payer: Aetna Commercial	$343.58
Rate for Payer: Amerigroup CHIP/Medicaid	$56.22
Rate for Payer: BCBS of TX Blue Advantage	$187.41
Rate for Payer: BCBS of TX Blue Essentials	$224.89
Rate for Payer: BCBS of TX PPO	$249.88
Rate for Payer: Cash Price	$549.74
Rate for Payer: Multiplan Auto	$406.06
Rate for Payer: Multiplan Commercial	$406.06
Rate for Payer: Multiplan Workers Comp	$406.06
Rate for Payer: Scott and White EPO/PPO	$312.35
Rate for Payer: Superior Health Plan EPO	$84.96

APPLIER, ENDOSCOPIC M-CLIP W/ROTATE SHAFT 20/LARGE -- DHF

Facility

$624.70

Hospital Charge Code	81910358
Hospital Revenue Code	272
Rate for Payer: Cash Price	$549.74

APPLY RIGID LEG CAST LT

Facility

$874.00

Service Code	CPT 29445 LT
Hospital Charge Code	7150828
Hospital Revenue Code	761
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$568.10
Rate for Payer: Aetna Commercial	$480.70
Rate for Payer: Aetna Medicare	$368.42
Rate for Payer: Amerigroup CHIP/Medicaid	$78.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$245.61
Rate for Payer: Amerigroup Medicare	$245.61
Rate for Payer: BCBS of TX Blue Advantage	$103.66
Rate for Payer: BCBS of TX Blue Essentials	$124.14
Rate for Payer: BCBS of TX Medicare	$245.61
Rate for Payer: BCBS of TX PPO	$156.42
Rate for Payer: Cash Price	$769.12
Rate for Payer: Cash Price	$769.12
Rate for Payer: Cash Price	$769.12
Rate for Payer: Cigna Commercial	$556.38
Rate for Payer: Cigna Medicaid	$49.56
Rate for Payer: Cigna Medicare	$245.61
Rate for Payer: Employer Direct Commercial	$245.61
Rate for Payer: Humana Medicare/TRICARE	$245.61
Rate for Payer: Molina CHIP/Medicaid	$49.56
Rate for Payer: Molina Dual Medicare/Medicaid	$245.61
Rate for Payer: Molina Medicare	$245.61
Rate for Payer: Multiplan Auto	$568.10
Rate for Payer: Multiplan Commercial	$568.10
Rate for Payer: Multiplan Workers Comp	$568.10
Rate for Payer: Parkland Medicaid	$49.56
Rate for Payer: Scott and White EPO/PPO	$4.39
Rate for Payer: Scott and White Medicare	$245.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.56
Rate for Payer: Superior Health Plan EPO	$245.61
Rate for Payer: Superior Health Plan Medicare	$245.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$245.61
Rate for Payer: Universal American Medicare	$245.61
Rate for Payer: Wellcare Medicare	$245.61
Rate for Payer: Wellmed Medicare	$245.61

APPLY RIGID LEG CAST RT

Facility

$874.00

Service Code	CPT 29445 RT
Hospital Charge Code	7150827
Hospital Revenue Code	761
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$568.10
Rate for Payer: Aetna Commercial	$480.70
Rate for Payer: Aetna Medicare	$368.42
Rate for Payer: Amerigroup CHIP/Medicaid	$78.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$245.61
Rate for Payer: Amerigroup Medicare	$245.61
Rate for Payer: BCBS of TX Blue Advantage	$103.66
Rate for Payer: BCBS of TX Blue Essentials	$124.14
Rate for Payer: BCBS of TX Medicare	$245.61
Rate for Payer: BCBS of TX PPO	$156.42
Rate for Payer: Cash Price	$769.12
Rate for Payer: Cash Price	$769.12
Rate for Payer: Cash Price	$769.12
Rate for Payer: Cigna Commercial	$556.38
Rate for Payer: Cigna Medicaid	$49.56
Rate for Payer: Cigna Medicare	$245.61
Rate for Payer: Employer Direct Commercial	$245.61
Rate for Payer: Humana Medicare/TRICARE	$245.61
Rate for Payer: Molina CHIP/Medicaid	$49.56
Rate for Payer: Molina Dual Medicare/Medicaid	$245.61
Rate for Payer: Molina Medicare	$245.61
Rate for Payer: Multiplan Auto	$568.10
Rate for Payer: Multiplan Commercial	$568.10
Rate for Payer: Multiplan Workers Comp	$568.10
Rate for Payer: Parkland Medicaid	$49.56
Rate for Payer: Scott and White EPO/PPO	$4.39
Rate for Payer: Scott and White Medicare	$245.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.56
Rate for Payer: Superior Health Plan EPO	$245.61
Rate for Payer: Superior Health Plan Medicare	$245.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$245.61
Rate for Payer: Universal American Medicare	$245.61
Rate for Payer: Wellcare Medicare	$245.61
Rate for Payer: Wellmed Medicare	$245.61

AQUACEL AG 3.5 14

Facility

$157.72

Hospital Charge Code	120680
Hospital Revenue Code	272
Min. Negotiated Rate	$14.19
Max. Negotiated Rate	$102.52
Rate for Payer: Aetna Commercial	$86.75
Rate for Payer: Amerigroup CHIP/Medicaid	$14.19
Rate for Payer: BCBS of TX Blue Advantage	$47.32
Rate for Payer: BCBS of TX Blue Essentials	$56.78
Rate for Payer: BCBS of TX PPO	$63.09
Rate for Payer: Cash Price	$138.79
Rate for Payer: Multiplan Auto	$102.52
Rate for Payer: Multiplan Commercial	$102.52
Rate for Payer: Multiplan Workers Comp	$102.52
Rate for Payer: Scott and White EPO/PPO	$78.86
Rate for Payer: Superior Health Plan EPO	$21.45

AQUACEL AG 3.5 14

Facility

$157.72

Hospital Charge Code	120680
Hospital Revenue Code	272
Rate for Payer: Cash Price	$138.79

AQUACEL AG 3.5 X 4

Facility

$106.69

Hospital Charge Code	138274
Hospital Revenue Code	272
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$69.35
Rate for Payer: Aetna Commercial	$58.68
Rate for Payer: Amerigroup CHIP/Medicaid	$9.60
Rate for Payer: BCBS of TX Blue Advantage	$32.01
Rate for Payer: BCBS of TX Blue Essentials	$38.41
Rate for Payer: BCBS of TX PPO	$42.68
Rate for Payer: Cash Price	$93.89
Rate for Payer: Multiplan Auto	$69.35
Rate for Payer: Multiplan Commercial	$69.35
Rate for Payer: Multiplan Workers Comp	$69.35
Rate for Payer: Scott and White EPO/PPO	$53.34
Rate for Payer: Superior Health Plan EPO	$14.51

AQUACEL AG 3.5 X 4

Facility

$106.69

Hospital Charge Code	138274
Hospital Revenue Code	272
Rate for Payer: Cash Price	$93.89

Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft

Facility

$10,000.00

Service Code	CPT 66180
Hospital Charge Code	36066180
Hospital Revenue Code	360
Min. Negotiated Rate	$82.02
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$5,577.60
Rate for Payer: Amerigroup CHIP/Medicaid	$2,064.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,718.40
Rate for Payer: Amerigroup Medicare	$3,718.40
Rate for Payer: BCBS of TX Blue Advantage	$6,376.61
Rate for Payer: BCBS of TX Blue Essentials	$7,636.66
Rate for Payer: BCBS of TX Medicare	$3,718.40
Rate for Payer: BCBS of TX PPO	$9,622.19
Rate for Payer: Cigna Commercial	$8,423.25
Rate for Payer: Cigna Medicaid	$2,064.63
Rate for Payer: Cigna Medicare	$3,718.40
Rate for Payer: Employer Direct Commercial	$3,718.40
Rate for Payer: Humana Medicare/TRICARE	$3,718.40
Rate for Payer: Molina CHIP/Medicaid	$2,064.63
Rate for Payer: Molina Dual Medicare/Medicaid	$3,718.40
Rate for Payer: Molina Medicare	$3,718.40
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	$2,064.63
Rate for Payer: Scott and White EPO/PPO	$82.02
Rate for Payer: Scott and White Medicare	$3,718.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,064.63
Rate for Payer: Superior Health Plan EPO	$3,718.40
Rate for Payer: Superior Health Plan Medicare	$3,718.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,718.40
Rate for Payer: Universal American Medicare	$3,718.40
Rate for Payer: Wellcare Medicare	$3,718.40
Rate for Payer: Wellmed Medicare	$3,718.40

arformoterol 15 mcg/2 mL Inh Soln 2 mL

Facility

$65.05

Service Code	HCPCS J7605
Hospital Charge Code	7442059
Hospital Revenue Code	636
Min. Negotiated Rate	$16.26
Max. Negotiated Rate	$32.52
Rate for Payer: Cash Price	$44.23
Rate for Payer: Cigna Commercial	$16.26
Rate for Payer: Scott and White EPO/PPO	$32.52

arformoterol 15 mcg/2 mL Inh Soln 2 mL

Facility

$65.05

Service Code	HCPCS J7605
Hospital Charge Code	7442059
Hospital Revenue Code	636
Min. Negotiated Rate	$5.85
Max. Negotiated Rate	$42.28
Rate for Payer: Amerigroup CHIP/Medicaid	$5.85
Rate for Payer: BCBS of TX Blue Advantage	$24.88
Rate for Payer: BCBS of TX Blue Essentials	$29.86
Rate for Payer: BCBS of TX PPO	$33.12
Rate for Payer: Cash Price	$44.23
Rate for Payer: Cash Price	$44.23
Rate for Payer: Multiplan Auto	$42.28
Rate for Payer: Multiplan Commercial	$42.28
Rate for Payer: Multiplan Workers Comp	$42.28
Rate for Payer: Scott and White EPO/PPO	$32.52
Rate for Payer: Superior Health Plan EPO	$8.85

ARIPiprazole 10 mg Tab

Facility

$54.83

Service Code	HCPCS J3490
Hospital Charge Code	77381627
Hospital Revenue Code	250
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$35.64
Rate for Payer: Amerigroup CHIP/Medicaid	$4.93
Rate for Payer: BCBS of TX Blue Advantage	$16.45
Rate for Payer: BCBS of TX Blue Essentials	$19.74
Rate for Payer: BCBS of TX PPO	$21.93
Rate for Payer: Cash Price	$37.28
Rate for Payer: Multiplan Auto	$35.64
Rate for Payer: Multiplan Commercial	$35.64
Rate for Payer: Multiplan Workers Comp	$35.64
Rate for Payer: Scott and White EPO/PPO	$27.42
Rate for Payer: Superior Health Plan EPO	$7.46

ARIPiprazole 10 mg Tab

Facility

$54.83

Service Code	HCPCS J3490
Hospital Charge Code	77381627
Hospital Revenue Code	250
Rate for Payer: Cash Price	$37.28

ARIPiprazole 5 mg Tab

Facility

$55.00

Service Code	HCPCS J3490
Hospital Charge Code	77382039
Hospital Revenue Code	250
Rate for Payer: Cash Price	$37.40

ARIPiprazole 5 mg Tab

Facility

$55.00

Service Code	HCPCS J3490
Hospital Charge Code	77382039
Hospital Revenue Code	250
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$35.75
Rate for Payer: Amerigroup CHIP/Medicaid	$4.95
Rate for Payer: BCBS of TX Blue Advantage	$16.50
Rate for Payer: BCBS of TX Blue Essentials	$19.80
Rate for Payer: BCBS of TX PPO	$22.00
Rate for Payer: Cash Price	$37.40
Rate for Payer: Multiplan Auto	$35.75
Rate for Payer: Multiplan Commercial	$35.75
Rate for Payer: Multiplan Workers Comp	$35.75
Rate for Payer: Scott and White EPO/PPO	$27.50
Rate for Payer: Superior Health Plan EPO	$7.48

ARTEGRAFT - AG715

Facility

$7,825.30

Service Code	HCPCS C1768
Hospital Charge Code	131728
Hospital Revenue Code	278
Min. Negotiated Rate	$1,956.32
Max. Negotiated Rate	$3,912.65
Rate for Payer: Aetna Commercial	$2,347.59
Rate for Payer: Cash Price	$6,886.26
Rate for Payer: Cigna Commercial	$1,956.32
Rate for Payer: Multiplan Auto	$3,912.65
Rate for Payer: Multiplan Commercial	$3,912.65
Rate for Payer: Multiplan Workers Comp	$3,912.65
Rate for Payer: Scott and White EPO/PPO	$3,912.65

ARTEGRAFT - AG715

Facility

$7,825.30

Service Code	HCPCS C1768
Hospital Charge Code	131728
Hospital Revenue Code	278
Min. Negotiated Rate	$704.28
Max. Negotiated Rate	$3,912.65
Rate for Payer: Aetna Commercial	$2,347.59
Rate for Payer: Amerigroup CHIP/Medicaid	$704.28
Rate for Payer: BCBS of TX Blue Advantage	$2,347.59
Rate for Payer: BCBS of TX Blue Essentials	$2,817.11
Rate for Payer: BCBS of TX PPO	$3,130.12
Rate for Payer: Cash Price	$6,886.26
Rate for Payer: Multiplan Auto	$3,912.65
Rate for Payer: Multiplan Commercial	$3,912.65
Rate for Payer: Multiplan Workers Comp	$3,912.65
Rate for Payer: Scott and White EPO/PPO	$3,912.65
Rate for Payer: Superior Health Plan EPO	$1,064.24

ARTEGRAFT -- DHF

Facility

$10,234.94

Service Code	HCPCS C1768
Hospital Charge Code	81410151
Hospital Revenue Code	278
Min. Negotiated Rate	$921.14
Max. Negotiated Rate	$5,117.47
Rate for Payer: Aetna Commercial	$3,070.48
Rate for Payer: Amerigroup CHIP/Medicaid	$921.14
Rate for Payer: BCBS of TX Blue Advantage	$3,070.48
Rate for Payer: BCBS of TX Blue Essentials	$3,684.58
Rate for Payer: BCBS of TX PPO	$4,093.98
Rate for Payer: Cash Price	$9,006.75
Rate for Payer: Multiplan Auto	$5,117.47
Rate for Payer: Multiplan Commercial	$5,117.47
Rate for Payer: Multiplan Workers Comp	$5,117.47
Rate for Payer: Scott and White EPO/PPO	$5,117.47
Rate for Payer: Superior Health Plan EPO	$1,391.95

ARTEGRAFT -- DHF

Facility

$10,234.94

Service Code	HCPCS C1768
Hospital Charge Code	81410151
Hospital Revenue Code	278
Min. Negotiated Rate	$2,558.74
Max. Negotiated Rate	$5,117.47
Rate for Payer: Aetna Commercial	$3,070.48
Rate for Payer: Cash Price	$9,006.75
Rate for Payer: Cigna Commercial	$2,558.74
Rate for Payer: Multiplan Auto	$5,117.47
Rate for Payer: Multiplan Commercial	$5,117.47
Rate for Payer: Multiplan Workers Comp	$5,117.47
Rate for Payer: Scott and White EPO/PPO	$5,117.47

ARTELON FLEXBAND PLUS 0.7X8CM 41055

Facility

$15,060.24

Service Code	HCPCS C1713
Hospital Charge Code	145246
Hospital Revenue Code	278
Min. Negotiated Rate	$3,765.06
Max. Negotiated Rate	$7,530.12
Rate for Payer: Aetna Commercial	$4,518.07
Rate for Payer: Cash Price	$13,253.01
Rate for Payer: Cigna Commercial	$3,765.06
Rate for Payer: Multiplan Auto	$7,530.12
Rate for Payer: Multiplan Commercial	$7,530.12
Rate for Payer: Multiplan Workers Comp	$7,530.12
Rate for Payer: Scott and White EPO/PPO	$7,530.12

ARTELON FLEXBAND PLUS 0.7X8CM 41055

Facility

$15,060.24

Service Code	HCPCS C1713
Hospital Charge Code	145246
Hospital Revenue Code	278
Min. Negotiated Rate	$1,355.42
Max. Negotiated Rate	$7,530.12
Rate for Payer: Aetna Commercial	$4,518.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1,355.42
Rate for Payer: BCBS of TX Blue Advantage	$4,518.07
Rate for Payer: BCBS of TX Blue Essentials	$5,421.69
Rate for Payer: BCBS of TX PPO	$6,024.10
Rate for Payer: Cash Price	$13,253.01
Rate for Payer: Multiplan Auto	$7,530.12
Rate for Payer: Multiplan Commercial	$7,530.12
Rate for Payer: Multiplan Workers Comp	$7,530.12
Rate for Payer: Scott and White EPO/PPO	$7,530.12
Rate for Payer: Superior Health Plan EPO	$2,048.19

Know your out-of-pocket cost for care.

All Charges