White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Esophagoscopy, rigid, transoral diagnostic, including collection of specimen(s) by brushing or wash

Facility

$7,857.10

Service Code	HCPCS 43191
Hospital Charge Code	9900667
Hospital Revenue Code	360
Min. Negotiated Rate	$564.97
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Amerigroup Medicare	$1,927.65
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX Medicare	$1,927.65
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cash Price	$5,342.83
Rate for Payer: Cash Price	$5,342.83
Rate for Payer: Cash Price	$5,342.83
Rate for Payer: Cigna Commercial	$4,074.70
Rate for Payer: Cigna Medicaid	$5,657.11
Rate for Payer: Cigna Medicare	$1,927.65
Rate for Payer: Employer Direct Commercial	$1,927.65
Rate for Payer: Humana Medicare/TRICARE	$1,927.65
Rate for Payer: Molina CHIP/Medicaid	$5,657.11
Rate for Payer: Molina Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Molina Medicare	$1,927.65
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	$5,657.11
Rate for Payer: Scott and White EPO/PPO	$3,566.15
Rate for Payer: Scott and White Medicare	$1,927.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,657.11
Rate for Payer: Superior Health Plan EPO	$1,927.65
Rate for Payer: Superior Health Plan Medicare	$1,927.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Universal American Medicare	$1,927.65
Rate for Payer: Wellcare Medicare	$1,927.65
Rate for Payer: Wellmed Medicare	$1,927.65

Estradiol, Sensitive SO

Facility

$194.00

Service Code	HCPCS 82670
Hospital Charge Code	1603364
Hospital Revenue Code	301
Rate for Payer: Cash Price	$131.92

Estradiol, Sensitive SO

Facility

$194.00

Service Code	HCPCS 82670
Hospital Charge Code	1603364
Hospital Revenue Code	301
Min. Negotiated Rate	$10.90
Max. Negotiated Rate	$139.68
Rate for Payer: Amerigroup CHIP/Medicaid	$10.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.94
Rate for Payer: Amerigroup Medicare	$27.94
Rate for Payer: BCBS of TX Blue Advantage	$58.20
Rate for Payer: BCBS of TX Blue Essentials	$69.84
Rate for Payer: BCBS of TX Medicare	$27.94
Rate for Payer: BCBS of TX PPO	$77.60
Rate for Payer: Cash Price	$131.92
Rate for Payer: Cash Price	$131.92
Rate for Payer: Cigna Medicaid	$139.68
Rate for Payer: Cigna Medicare	$27.94
Rate for Payer: Employer Direct Commercial	$27.94
Rate for Payer: Humana Medicare/TRICARE	$27.94
Rate for Payer: Molina CHIP/Medicaid	$139.68
Rate for Payer: Molina Dual Medicare/Medicaid	$27.94
Rate for Payer: Molina Medicare	$27.94
Rate for Payer: Multiplan Auto	$126.10
Rate for Payer: Multiplan Commercial	$126.10
Rate for Payer: Multiplan Workers Comp	$126.10
Rate for Payer: Parkland Medicaid	$139.68
Rate for Payer: Scott and White EPO/PPO	$34.92
Rate for Payer: Scott and White Medicare	$27.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$139.68
Rate for Payer: Superior Health Plan EPO	$27.94
Rate for Payer: Superior Health Plan Medicare	$27.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.94
Rate for Payer: Universal American Medicare	$27.94
Rate for Payer: Wellcare Medicare	$27.94
Rate for Payer: Wellmed Medicare	$27.94

Estrogens, Total SO

Facility

$246.00

Service Code	HCPCS 82672
Hospital Charge Code	1702000
Hospital Revenue Code	301
Min. Negotiated Rate	$8.46
Max. Negotiated Rate	$177.12
Rate for Payer: Amerigroup CHIP/Medicaid	$8.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.70
Rate for Payer: Amerigroup Medicare	$21.70
Rate for Payer: BCBS of TX Blue Advantage	$73.80
Rate for Payer: BCBS of TX Blue Essentials	$88.56
Rate for Payer: BCBS of TX Medicare	$21.70
Rate for Payer: BCBS of TX PPO	$98.40
Rate for Payer: Cash Price	$167.28
Rate for Payer: Cash Price	$167.28
Rate for Payer: Cigna Medicaid	$177.12
Rate for Payer: Cigna Medicare	$21.70
Rate for Payer: Employer Direct Commercial	$21.70
Rate for Payer: Humana Medicare/TRICARE	$21.70
Rate for Payer: Molina CHIP/Medicaid	$177.12
Rate for Payer: Molina Dual Medicare/Medicaid	$21.70
Rate for Payer: Molina Medicare	$21.70
Rate for Payer: Multiplan Auto	$159.90
Rate for Payer: Multiplan Commercial	$159.90
Rate for Payer: Multiplan Workers Comp	$159.90
Rate for Payer: Parkland Medicaid	$177.12
Rate for Payer: Scott and White EPO/PPO	$27.12
Rate for Payer: Scott and White Medicare	$21.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$177.12
Rate for Payer: Superior Health Plan EPO	$21.70
Rate for Payer: Superior Health Plan Medicare	$21.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.70
Rate for Payer: Universal American Medicare	$21.70
Rate for Payer: Wellcare Medicare	$21.70
Rate for Payer: Wellmed Medicare	$21.70

Estrogens, Total SO

Facility

$246.00

Service Code	HCPCS 82672
Hospital Charge Code	1702000
Hospital Revenue Code	301
Rate for Payer: Cash Price	$167.28

ETERNA IMPLANT PULSE GENERATOR

Facility

$117,469.88

Service Code	HCPCS C1820
Hospital Charge Code	991300
Hospital Revenue Code	278
Min. Negotiated Rate	$10,572.29
Max. Negotiated Rate	$84,578.31
Rate for Payer: Amerigroup CHIP/Medicaid	$10,572.29
Rate for Payer: BCBS of TX Blue Advantage	$35,240.96
Rate for Payer: BCBS of TX Blue Essentials	$42,289.16
Rate for Payer: BCBS of TX PPO	$46,987.95
Rate for Payer: Cash Price	$79,879.52
Rate for Payer: Cigna Medicaid	$84,578.31
Rate for Payer: Molina CHIP/Medicaid	$84,578.31
Rate for Payer: Multiplan Auto	$58,734.94
Rate for Payer: Multiplan Commercial	$58,734.94
Rate for Payer: Multiplan Workers Comp	$58,734.94
Rate for Payer: Parkland Medicaid	$84,578.31
Rate for Payer: Scott and White EPO/PPO	$58,734.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84,578.31
Rate for Payer: Superior Health Plan EPO	$15,975.90

ETERNA IMPLANT PULSE GENERATOR

Facility

$117,469.88

Service Code	HCPCS C1820
Hospital Charge Code	991300
Hospital Revenue Code	278
Min. Negotiated Rate	$29,367.47
Max. Negotiated Rate	$58,734.94
Rate for Payer: Cash Price	$79,879.52
Rate for Payer: Cigna Commercial	$29,367.47
Rate for Payer: Multiplan Auto	$58,734.94
Rate for Payer: Multiplan Commercial	$58,734.94
Rate for Payer: Multiplan Workers Comp	$58,734.94
Rate for Payer: Scott and White EPO/PPO	$58,734.94

ETHIBOND EXCEL SUTURE O 30' POLYESTER BRAID SH GREEN

Facility

$6.38

Hospital Charge Code	992708
Hospital Revenue Code	272
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$4.59
Rate for Payer: Amerigroup CHIP/Medicaid	$0.57
Rate for Payer: BCBS of TX Blue Advantage	$1.91
Rate for Payer: BCBS of TX Blue Essentials	$2.30
Rate for Payer: BCBS of TX PPO	$2.55
Rate for Payer: Cash Price	$4.34
Rate for Payer: Cigna Medicaid	$4.59
Rate for Payer: Molina CHIP/Medicaid	$4.59
Rate for Payer: Multiplan Auto	$4.15
Rate for Payer: Multiplan Commercial	$4.15
Rate for Payer: Multiplan Workers Comp	$4.15
Rate for Payer: Parkland Medicaid	$4.59
Rate for Payer: Scott and White EPO/PPO	$3.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.59
Rate for Payer: Superior Health Plan EPO	$0.87

ETHIBOND EXCEL SUTURE O 30' POLYESTER BRAID SH GREEN

Facility

$6.38

Hospital Charge Code	992708
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.34

ETHICON 3-0 18 PROLENE (POLYPROPYLENE) BLUE MONOFILAMENT NON- ABSORBABLE SUTURE PS-2 19MM 3/8C REVERSE CUTTING (BOX OF 36) (BLUE)

Facility

$1,562.35

Hospital Charge Code	993160
Hospital Revenue Code	270
Min. Negotiated Rate	$140.61
Max. Negotiated Rate	$1,124.89
Rate for Payer: Amerigroup CHIP/Medicaid	$140.61
Rate for Payer: BCBS of TX Blue Advantage	$468.70
Rate for Payer: BCBS of TX Blue Essentials	$562.45
Rate for Payer: BCBS of TX PPO	$624.94
Rate for Payer: Cash Price	$1,062.40
Rate for Payer: Cigna Medicaid	$1,124.89
Rate for Payer: Molina CHIP/Medicaid	$1,124.89
Rate for Payer: Multiplan Auto	$1,015.53
Rate for Payer: Multiplan Commercial	$1,015.53
Rate for Payer: Multiplan Workers Comp	$1,015.53
Rate for Payer: Parkland Medicaid	$1,124.89
Rate for Payer: Scott and White EPO/PPO	$781.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,124.89
Rate for Payer: Superior Health Plan EPO	$212.48

ETHICON 3-0 18 PROLENE (POLYPROPYLENE) BLUE MONOFILAMENT NON- ABSORBABLE SUTURE PS-2 19MM 3/8C REVERSE CUTTING (BOX OF 36) (BLUE)

Facility

$1,562.35

Hospital Charge Code	993160
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,062.40

ETHICON CIRCULAR STAPLER 21MM

Facility

$2,025.00

Hospital Charge Code	992344
Hospital Revenue Code	272
Min. Negotiated Rate	$182.25
Max. Negotiated Rate	$1,458.00
Rate for Payer: Amerigroup CHIP/Medicaid	$182.25
Rate for Payer: BCBS of TX Blue Advantage	$607.50
Rate for Payer: BCBS of TX Blue Essentials	$729.00
Rate for Payer: BCBS of TX PPO	$810.00
Rate for Payer: Cash Price	$1,377.00
Rate for Payer: Cigna Medicaid	$1,458.00
Rate for Payer: Molina CHIP/Medicaid	$1,458.00
Rate for Payer: Multiplan Auto	$1,316.25
Rate for Payer: Multiplan Commercial	$1,316.25
Rate for Payer: Multiplan Workers Comp	$1,316.25
Rate for Payer: Parkland Medicaid	$1,458.00
Rate for Payer: Scott and White EPO/PPO	$1,012.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,458.00
Rate for Payer: Superior Health Plan EPO	$275.40

ETHICON CIRCULAR STAPLER 21MM

Facility

$2,025.00

Hospital Charge Code	992344
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,377.00

ETHICON ENDOSURGERY ECHELON CIRCULAR POWERED STAPLER

Facility

$1,305.84

Hospital Charge Code	993640
Hospital Revenue Code	272
Min. Negotiated Rate	$117.53
Max. Negotiated Rate	$940.20
Rate for Payer: Amerigroup CHIP/Medicaid	$117.53
Rate for Payer: BCBS of TX Blue Advantage	$391.75
Rate for Payer: BCBS of TX Blue Essentials	$470.10
Rate for Payer: BCBS of TX PPO	$522.34
Rate for Payer: Cash Price	$887.97
Rate for Payer: Cigna Medicaid	$940.20
Rate for Payer: Molina CHIP/Medicaid	$940.20
Rate for Payer: Multiplan Auto	$848.80
Rate for Payer: Multiplan Commercial	$848.80
Rate for Payer: Multiplan Workers Comp	$848.80
Rate for Payer: Parkland Medicaid	$940.20
Rate for Payer: Scott and White EPO/PPO	$652.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$940.20
Rate for Payer: Superior Health Plan EPO	$177.59

ETHICON ENDOSURGERY ECHELON CIRCULAR POWERED STAPLER

Facility

$1,305.84

Hospital Charge Code	993640
Hospital Revenue Code	272
Rate for Payer: Cash Price	$887.97

ETHICON ENDO-SURGERY ENDOPATH XCEL 12MM BLADELESS TROCAR WITH STABILITY SLEEVE, 100MM

Facility

$199.22

Hospital Charge Code	993637
Hospital Revenue Code	272
Min. Negotiated Rate	$17.93
Max. Negotiated Rate	$143.44
Rate for Payer: Amerigroup CHIP/Medicaid	$17.93
Rate for Payer: BCBS of TX Blue Advantage	$59.77
Rate for Payer: BCBS of TX Blue Essentials	$71.72
Rate for Payer: BCBS of TX PPO	$79.69
Rate for Payer: Cash Price	$135.47
Rate for Payer: Cigna Medicaid	$143.44
Rate for Payer: Molina CHIP/Medicaid	$143.44
Rate for Payer: Multiplan Auto	$129.49
Rate for Payer: Multiplan Commercial	$129.49
Rate for Payer: Multiplan Workers Comp	$129.49
Rate for Payer: Parkland Medicaid	$143.44
Rate for Payer: Scott and White EPO/PPO	$99.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$143.44
Rate for Payer: Superior Health Plan EPO	$27.09

ETHICON ENDO-SURGERY ENDOPATH XCEL 12MM BLADELESS TROCAR WITH STABILITY SLEEVE, 100MM

Facility

$199.22

Hospital Charge Code	993637
Hospital Revenue Code	272
Rate for Payer: Cash Price	$135.47

ETHICON ENDO-SURGERY HARMONIC ACE +7 SHEARS WITH ADVANCED HEMOSTASIS FOR USE WITH GENERATOR G11, 5MM X 23CM

Facility

$7,518.07

Hospital Charge Code	993159
Hospital Revenue Code	270
Min. Negotiated Rate	$676.63
Max. Negotiated Rate	$5,413.01
Rate for Payer: Amerigroup CHIP/Medicaid	$676.63
Rate for Payer: BCBS of TX Blue Advantage	$2,255.42
Rate for Payer: BCBS of TX Blue Essentials	$2,706.51
Rate for Payer: BCBS of TX PPO	$3,007.23
Rate for Payer: Cash Price	$5,112.29
Rate for Payer: Cigna Medicaid	$5,413.01
Rate for Payer: Molina CHIP/Medicaid	$5,413.01
Rate for Payer: Multiplan Auto	$4,886.75
Rate for Payer: Multiplan Commercial	$4,886.75
Rate for Payer: Multiplan Workers Comp	$4,886.75
Rate for Payer: Parkland Medicaid	$5,413.01
Rate for Payer: Scott and White EPO/PPO	$3,759.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,413.01
Rate for Payer: Superior Health Plan EPO	$1,022.46

ETHICON ENDO-SURGERY HARMONIC ACE +7 SHEARS WITH ADVANCED HEMOSTASIS FOR USE WITH GENERATOR G11, 5MM X 23CM

Facility

$7,518.07

Hospital Charge Code	993159
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5,112.29

ETHICON LARGE CLIP APPLIER

Facility

$1,180.40

Hospital Charge Code	992686
Hospital Revenue Code	272
Rate for Payer: Cash Price	$802.67

ETHICON LARGE CLIP APPLIER

Facility

$1,180.40

Hospital Charge Code	992686
Hospital Revenue Code	272
Min. Negotiated Rate	$106.24
Max. Negotiated Rate	$849.89
Rate for Payer: Amerigroup CHIP/Medicaid	$106.24
Rate for Payer: BCBS of TX Blue Advantage	$354.12
Rate for Payer: BCBS of TX Blue Essentials	$424.94
Rate for Payer: BCBS of TX PPO	$472.16
Rate for Payer: Cash Price	$802.67
Rate for Payer: Cigna Medicaid	$849.89
Rate for Payer: Molina CHIP/Medicaid	$849.89
Rate for Payer: Multiplan Auto	$767.26
Rate for Payer: Multiplan Commercial	$767.26
Rate for Payer: Multiplan Workers Comp	$767.26
Rate for Payer: Parkland Medicaid	$849.89
Rate for Payer: Scott and White EPO/PPO	$590.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$849.89
Rate for Payer: Superior Health Plan EPO	$160.53

ETHILON SUTURE 2-0 18'

Facility

$14.35

Hospital Charge Code	992704
Hospital Revenue Code	272
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$10.33
Rate for Payer: Amerigroup CHIP/Medicaid	$1.29
Rate for Payer: BCBS of TX Blue Advantage	$4.30
Rate for Payer: BCBS of TX Blue Essentials	$5.17
Rate for Payer: BCBS of TX PPO	$5.74
Rate for Payer: Cash Price	$9.76
Rate for Payer: Cigna Medicaid	$10.33
Rate for Payer: Molina CHIP/Medicaid	$10.33
Rate for Payer: Multiplan Auto	$9.33
Rate for Payer: Multiplan Commercial	$9.33
Rate for Payer: Multiplan Workers Comp	$9.33
Rate for Payer: Parkland Medicaid	$10.33
Rate for Payer: Scott and White EPO/PPO	$7.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.33
Rate for Payer: Superior Health Plan EPO	$1.95

ETHILON SUTURE 2-0 18'

Facility

$14.35

Hospital Charge Code	992704
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.76

Ethylene Glycol, Serum SO

Facility

$112.00

Service Code	HCPCS 82693
Hospital Charge Code	1707207
Hospital Revenue Code	301
Min. Negotiated Rate	$5.81
Max. Negotiated Rate	$80.64
Rate for Payer: Amerigroup CHIP/Medicaid	$5.81
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.90
Rate for Payer: Amerigroup Medicare	$14.90
Rate for Payer: BCBS of TX Blue Advantage	$33.60
Rate for Payer: BCBS of TX Blue Essentials	$40.32
Rate for Payer: BCBS of TX Medicare	$14.90
Rate for Payer: BCBS of TX PPO	$44.80
Rate for Payer: Cash Price	$76.16
Rate for Payer: Cash Price	$76.16
Rate for Payer: Cigna Medicaid	$80.64
Rate for Payer: Cigna Medicare	$14.90
Rate for Payer: Employer Direct Commercial	$14.90
Rate for Payer: Humana Medicare/TRICARE	$14.90
Rate for Payer: Molina CHIP/Medicaid	$80.64
Rate for Payer: Molina Dual Medicare/Medicaid	$14.90
Rate for Payer: Molina Medicare	$14.90
Rate for Payer: Multiplan Auto	$72.80
Rate for Payer: Multiplan Commercial	$72.80
Rate for Payer: Multiplan Workers Comp	$72.80
Rate for Payer: Parkland Medicaid	$80.64
Rate for Payer: Scott and White EPO/PPO	$18.62
Rate for Payer: Scott and White Medicare	$14.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$80.64
Rate for Payer: Superior Health Plan EPO	$14.90
Rate for Payer: Superior Health Plan Medicare	$14.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.90
Rate for Payer: Universal American Medicare	$14.90
Rate for Payer: Wellcare Medicare	$14.90
Rate for Payer: Wellmed Medicare	$14.90

Ethylene Glycol, Serum SO

Facility

$112.00

Service Code	HCPCS 82693
Hospital Charge Code	1707207
Hospital Revenue Code	301
Rate for Payer: Cash Price	$76.16

Know your out-of-pocket cost for care.

All Charges