White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ENDOSTITCH SUTURE DEVICE

Facility

$1,955.55

Hospital Charge Code	8538527
Hospital Revenue Code	272
Min. Negotiated Rate	$176.00
Max. Negotiated Rate	$1,408.00
Rate for Payer: Amerigroup CHIP/Medicaid	$176.00
Rate for Payer: BCBS of TX Blue Advantage	$586.66
Rate for Payer: BCBS of TX Blue Essentials	$704.00
Rate for Payer: BCBS of TX PPO	$782.22
Rate for Payer: Cash Price	$1,329.77
Rate for Payer: Cigna Medicaid	$1,408.00
Rate for Payer: Molina CHIP/Medicaid	$1,408.00
Rate for Payer: Multiplan Auto	$1,271.11
Rate for Payer: Multiplan Commercial	$1,271.11
Rate for Payer: Multiplan Workers Comp	$1,271.11
Rate for Payer: Parkland Medicaid	$1,408.00
Rate for Payer: Scott and White EPO/PPO	$977.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,408.00
Rate for Payer: Superior Health Plan EPO	$265.95

ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES

Facility

$108,431.10

Service Code	MSDRG 213
Min. Negotiated Rate	$46,586.10
Max. Negotiated Rate	$108,431.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$46,586.10
Rate for Payer: Amerigroup Medicare	$46,586.10
Rate for Payer: BCBS of TX Medicare	$46,586.10
Rate for Payer: Cigna Commercial	$73,504.87
Rate for Payer: Cigna Medicare	$46,586.10
Rate for Payer: Employer Direct Commercial	$46,586.10
Rate for Payer: Humana Medicare/TRICARE	$46,586.10
Rate for Payer: Molina Dual Medicare/Medicaid	$46,586.10
Rate for Payer: Molina Medicare	$46,586.10
Rate for Payer: Multiplan Auto	$108,431.10
Rate for Payer: Multiplan Commercial	$108,431.10
Rate for Payer: Multiplan Workers Comp	$108,431.10
Rate for Payer: Scott and White EPO/PPO	$49,935.38
Rate for Payer: Scott and White Medicare	$46,586.10
Rate for Payer: Superior Health Plan EPO	$46,586.10
Rate for Payer: Superior Health Plan Medicare	$46,586.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$46,586.10
Rate for Payer: Universal American Medicare	$46,586.10
Rate for Payer: Wellcare Medicare	$46,586.10
Rate for Payer: Wellmed Medicare	$46,586.10

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC

Facility

$116,439.60

Service Code	MSDRG 266
Min. Negotiated Rate	$49,675.27
Max. Negotiated Rate	$116,439.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$49,675.27
Rate for Payer: Amerigroup Medicare	$49,675.27
Rate for Payer: BCBS of TX Medicare	$49,675.27
Rate for Payer: Cigna Commercial	$78,933.79
Rate for Payer: Cigna Medicare	$49,675.27
Rate for Payer: Employer Direct Commercial	$49,675.27
Rate for Payer: Humana Medicare/TRICARE	$49,675.27
Rate for Payer: Molina Dual Medicare/Medicaid	$49,675.27
Rate for Payer: Molina Medicare	$49,675.27
Rate for Payer: Multiplan Auto	$116,439.60
Rate for Payer: Multiplan Commercial	$116,439.60
Rate for Payer: Multiplan Workers Comp	$116,439.60
Rate for Payer: Scott and White EPO/PPO	$53,623.50
Rate for Payer: Scott and White Medicare	$49,675.27
Rate for Payer: Superior Health Plan EPO	$49,675.27
Rate for Payer: Superior Health Plan Medicare	$49,675.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$49,675.27
Rate for Payer: Universal American Medicare	$49,675.27
Rate for Payer: Wellcare Medicare	$49,675.27
Rate for Payer: Wellmed Medicare	$49,675.27

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC

Facility

$90,455.20

Service Code	MSDRG 267
Min. Negotiated Rate	$39,652.11
Max. Negotiated Rate	$90,455.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$39,652.11
Rate for Payer: Amerigroup Medicare	$39,652.11
Rate for Payer: BCBS of TX Medicare	$39,652.11
Rate for Payer: Cigna Commercial	$61,319.10
Rate for Payer: Cigna Medicare	$39,652.11
Rate for Payer: Employer Direct Commercial	$39,652.11
Rate for Payer: Humana Medicare/TRICARE	$39,652.11
Rate for Payer: Molina Dual Medicare/Medicaid	$39,652.11
Rate for Payer: Molina Medicare	$39,652.11
Rate for Payer: Multiplan Auto	$90,455.20
Rate for Payer: Multiplan Commercial	$90,455.20
Rate for Payer: Multiplan Workers Comp	$90,455.20
Rate for Payer: Scott and White EPO/PPO	$41,657.00
Rate for Payer: Scott and White Medicare	$39,652.11
Rate for Payer: Superior Health Plan EPO	$39,652.11
Rate for Payer: Superior Health Plan Medicare	$39,652.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$39,652.11
Rate for Payer: Universal American Medicare	$39,652.11
Rate for Payer: Wellcare Medicare	$39,652.11
Rate for Payer: Wellmed Medicare	$39,652.11

ENDOVASCULAR CARDIAC VALVE REPLACEMENT W MCC

Facility

$116,439.60

Service Code	MSDRG 266
Min. Negotiated Rate	$49,675.27
Max. Negotiated Rate	$116,439.60
Rate for Payer: BCBS of TX Blue Advantage	$61,846.90
Rate for Payer: BCBS of TX Blue Essentials	$74,209.09
Rate for Payer: BCBS of TX PPO	$82,457.74

ENDOVASCULAR CARDIAC VALVE REPLACEMENT W/O MCC

Facility

$90,455.20

Service Code	MSDRG 267
Min. Negotiated Rate	$39,652.11
Max. Negotiated Rate	$90,455.20
Rate for Payer: BCBS of TX Blue Advantage	$50,293.66
Rate for Payer: BCBS of TX Blue Essentials	$60,346.54
Rate for Payer: BCBS of TX PPO	$67,054.31

Endovascular repair of thoracic aorta, inc pre-px sizing; device selection, nonselective catheterization

Facility

$12,400.00

Service Code	HCPCS 33881
Hospital Charge Code	994187
Hospital Revenue Code	480
Min. Negotiated Rate	$1,116.00
Max. Negotiated Rate	$8,928.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,116.00
Rate for Payer: BCBS of TX Blue Advantage	$2,686.68
Rate for Payer: BCBS of TX Blue Essentials	$3,217.58
Rate for Payer: BCBS of TX PPO	$4,054.15
Rate for Payer: Cash Price	$8,432.00
Rate for Payer: Cash Price	$8,432.00
Rate for Payer: Cigna Medicaid	$8,928.00
Rate for Payer: Molina CHIP/Medicaid	$8,928.00
Rate for Payer: Multiplan Auto	$8,060.00
Rate for Payer: Multiplan Commercial	$8,060.00
Rate for Payer: Multiplan Workers Comp	$8,060.00
Rate for Payer: Parkland Medicaid	$8,928.00
Rate for Payer: Scott and White EPO/PPO	$6,200.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,928.00
Rate for Payer: Superior Health Plan EPO	$1,686.40

Endovascular repair of thoracic aorta, inc pre-px sizing; device selection, nonselective catheterization

Facility

$12,400.00

Service Code	HCPCS 33881
Hospital Charge Code	994187
Hospital Revenue Code	480
Rate for Payer: Cash Price	$8,432.00

EndoWrist Bipolar Forceps

Facility

$13,166.00

Hospital Charge Code	993686
Hospital Revenue Code	270
Min. Negotiated Rate	$1,184.94
Max. Negotiated Rate	$9,479.52
Rate for Payer: Amerigroup CHIP/Medicaid	$1,184.94
Rate for Payer: BCBS of TX Blue Advantage	$3,949.80
Rate for Payer: BCBS of TX Blue Essentials	$4,739.76
Rate for Payer: BCBS of TX PPO	$5,266.40
Rate for Payer: Cash Price	$8,952.88
Rate for Payer: Cigna Medicaid	$9,479.52
Rate for Payer: Molina CHIP/Medicaid	$9,479.52
Rate for Payer: Multiplan Auto	$8,557.90
Rate for Payer: Multiplan Commercial	$8,557.90
Rate for Payer: Multiplan Workers Comp	$8,557.90
Rate for Payer: Parkland Medicaid	$9,479.52
Rate for Payer: Scott and White EPO/PPO	$6,583.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,479.52
Rate for Payer: Superior Health Plan EPO	$1,790.58

EndoWrist Bipolar Forceps

Facility

$13,166.00

Hospital Charge Code	993686
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8,952.88

ENEMA ADMIN ST -- DHF

Facility

$87.80

Hospital Charge Code	80321508
Hospital Revenue Code	270
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$63.22
Rate for Payer: Amerigroup CHIP/Medicaid	$7.90
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.61
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$59.70
Rate for Payer: Cigna Medicaid	$63.22
Rate for Payer: Molina CHIP/Medicaid	$63.22
Rate for Payer: Multiplan Auto	$57.07
Rate for Payer: Multiplan Commercial	$57.07
Rate for Payer: Multiplan Workers Comp	$57.07
Rate for Payer: Parkland Medicaid	$63.22
Rate for Payer: Scott and White EPO/PPO	$43.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.22
Rate for Payer: Superior Health Plan EPO	$11.94

ENEMA ADMIN ST -- DHF

Facility

$87.80

Hospital Charge Code	80321508
Hospital Revenue Code	270
Rate for Payer: Cash Price	$59.70

enoxaparin 100 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77545925
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

enoxaparin 100 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77545925
Hospital Revenue Code	636
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.77
Rate for Payer: BCBS of TX Blue Essentials	$2.12
Rate for Payer: BCBS of TX PPO	$2.35
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

enoxaparin 120 mg/0.8 mL Inj Soln 0.8 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77545982
Hospital Revenue Code	636
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.77
Rate for Payer: BCBS of TX Blue Essentials	$2.12
Rate for Payer: BCBS of TX PPO	$2.35
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

enoxaparin 120 mg/0.8 mL Inj Soln 0.8 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77545982
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

enoxaparin 30 mg/0.3 mL Inj Soln 0.3 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77546094
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

enoxaparin 30 mg/0.3 mL Inj Soln 0.3 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77546094
Hospital Revenue Code	636
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.77
Rate for Payer: BCBS of TX Blue Essentials	$2.12
Rate for Payer: BCBS of TX PPO	$2.35
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

enoxaparin 40 mg/0.4 mL Inj Soln 0.4 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77546202
Hospital Revenue Code	636
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.77
Rate for Payer: BCBS of TX Blue Essentials	$2.12
Rate for Payer: BCBS of TX PPO	$2.35
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

enoxaparin 40 mg/0.4 mL Inj Soln 0.4 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77546202
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

enoxaparin 60 mg/0.6 mL Inj Soln 0.6 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77546257
Hospital Revenue Code	636
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.77
Rate for Payer: BCBS of TX Blue Essentials	$2.12
Rate for Payer: BCBS of TX PPO	$2.35
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

enoxaparin 60 mg/0.6 mL Inj Soln 0.6 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77546257
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

enoxaparin 80 mg/0.8 mL Inj Soln 0.8 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77546312
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

enoxaparin 80 mg/0.8 mL Inj Soln 0.8 mL

Facility

$128.17

Service Code	HCPCS J1650
Hospital Charge Code	77546312
Hospital Revenue Code	636
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.77
Rate for Payer: BCBS of TX Blue Essentials	$2.12
Rate for Payer: BCBS of TX PPO	$2.35
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

ENSEAL, CURVED JAW, 45CM

Facility

$2,249.10

Hospital Charge Code	992754
Hospital Revenue Code	272
Min. Negotiated Rate	$202.42
Max. Negotiated Rate	$1,619.35
Rate for Payer: Amerigroup CHIP/Medicaid	$202.42
Rate for Payer: BCBS of TX Blue Advantage	$674.73
Rate for Payer: BCBS of TX Blue Essentials	$809.68
Rate for Payer: BCBS of TX PPO	$899.64
Rate for Payer: Cash Price	$1,529.39
Rate for Payer: Cigna Medicaid	$1,619.35
Rate for Payer: Molina CHIP/Medicaid	$1,619.35
Rate for Payer: Multiplan Auto	$1,461.91
Rate for Payer: Multiplan Commercial	$1,461.91
Rate for Payer: Multiplan Workers Comp	$1,461.91
Rate for Payer: Parkland Medicaid	$1,619.35
Rate for Payer: Scott and White EPO/PPO	$1,124.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,619.35
Rate for Payer: Superior Health Plan EPO	$305.88

Know your out-of-pocket cost for care.

All Charges