White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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

etomidate 2 mg/mL IV Sol 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	81405158
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

etomidate 2 mg/mL IV Sol 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	81405158
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
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

etomidate 2 mg/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78470396
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

etomidate 2 mg/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78470396
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
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

ETS Linear Culter, Articulating, Flex, 45 mm

Facility

$882.53

Hospital Charge Code	992860
Hospital Revenue Code	272
Rate for Payer: Cash Price	$600.12

ETS Linear Culter, Articulating, Flex, 45 mm

Facility

$882.53

Hospital Charge Code	992860
Hospital Revenue Code	272
Min. Negotiated Rate	$79.43
Max. Negotiated Rate	$635.42
Rate for Payer: Amerigroup CHIP/Medicaid	$79.43
Rate for Payer: BCBS of TX Blue Advantage	$264.76
Rate for Payer: BCBS of TX Blue Essentials	$317.71
Rate for Payer: BCBS of TX PPO	$353.01
Rate for Payer: Cash Price	$600.12
Rate for Payer: Cigna Medicaid	$635.42
Rate for Payer: Molina CHIP/Medicaid	$635.42
Rate for Payer: Multiplan Auto	$573.64
Rate for Payer: Multiplan Commercial	$573.64
Rate for Payer: Multiplan Workers Comp	$573.64
Rate for Payer: Parkland Medicaid	$635.42
Rate for Payer: Scott and White EPO/PPO	$441.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$635.42
Rate for Payer: Superior Health Plan EPO	$120.02

Eudermic MP Power-Free 12' High-Risk Exam Gloves, Size L

Facility

$0.91

Hospital Charge Code	992983
Hospital Revenue Code	272
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.66
Rate for Payer: Amerigroup CHIP/Medicaid	$0.08
Rate for Payer: BCBS of TX Blue Advantage	$0.27
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.36
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna Medicaid	$0.66
Rate for Payer: Molina CHIP/Medicaid	$0.66
Rate for Payer: Multiplan Auto	$0.59
Rate for Payer: Multiplan Commercial	$0.59
Rate for Payer: Multiplan Workers Comp	$0.59
Rate for Payer: Parkland Medicaid	$0.66
Rate for Payer: Scott and White EPO/PPO	$0.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.66
Rate for Payer: Superior Health Plan EPO	$0.12

Eudermic MP Power-Free 12' High-Risk Exam Gloves, Size L

Facility

$0.91

Hospital Charge Code	992983
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.62

Eudermic MP Power-Free 12' High-Risk Exam Gloves, Size M

Facility

$0.91

Hospital Charge Code	992984
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.62

Eudermic MP Power-Free 12' High-Risk Exam Gloves, Size M

Facility

$0.91

Hospital Charge Code	992984
Hospital Revenue Code	272
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.66
Rate for Payer: Amerigroup CHIP/Medicaid	$0.08
Rate for Payer: BCBS of TX Blue Advantage	$0.27
Rate for Payer: BCBS of TX Blue Essentials	$0.33
Rate for Payer: BCBS of TX PPO	$0.36
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna Medicaid	$0.66
Rate for Payer: Molina CHIP/Medicaid	$0.66
Rate for Payer: Multiplan Auto	$0.59
Rate for Payer: Multiplan Commercial	$0.59
Rate for Payer: Multiplan Workers Comp	$0.59
Rate for Payer: Parkland Medicaid	$0.66
Rate for Payer: Scott and White EPO/PPO	$0.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.66
Rate for Payer: Superior Health Plan EPO	$0.12

euphora balloon

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992568
Hospital Revenue Code	272
Min. Negotiated Rate	$69.46
Max. Negotiated Rate	$555.70
Rate for Payer: Amerigroup CHIP/Medicaid	$69.46
Rate for Payer: BCBS of TX Blue Advantage	$231.54
Rate for Payer: BCBS of TX Blue Essentials	$277.85
Rate for Payer: BCBS of TX PPO	$308.72
Rate for Payer: Cash Price	$524.82
Rate for Payer: Cigna Medicaid	$555.70
Rate for Payer: Molina CHIP/Medicaid	$555.70
Rate for Payer: Multiplan Auto	$501.67
Rate for Payer: Multiplan Commercial	$501.67
Rate for Payer: Multiplan Workers Comp	$501.67
Rate for Payer: Parkland Medicaid	$555.70
Rate for Payer: Scott and White EPO/PPO	$385.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$555.70
Rate for Payer: Superior Health Plan EPO	$104.96

euphora balloon

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992568
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

EVACUATOR, SILICONE, 100CC, STERILE

Facility

$22.48

Hospital Charge Code	992849
Hospital Revenue Code	272
Rate for Payer: Cash Price	$15.29

EVACUATOR, SILICONE, 100CC, STERILE

Facility

$22.48

Hospital Charge Code	992849
Hospital Revenue Code	272
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$16.19
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: BCBS of TX Blue Advantage	$6.74
Rate for Payer: BCBS of TX Blue Essentials	$8.09
Rate for Payer: BCBS of TX PPO	$8.99
Rate for Payer: Cash Price	$15.29
Rate for Payer: Cigna Medicaid	$16.19
Rate for Payer: Molina CHIP/Medicaid	$16.19
Rate for Payer: Multiplan Auto	$14.61
Rate for Payer: Multiplan Commercial	$14.61
Rate for Payer: Multiplan Workers Comp	$14.61
Rate for Payer: Parkland Medicaid	$16.19
Rate for Payer: Scott and White EPO/PPO	$11.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.19
Rate for Payer: Superior Health Plan EPO	$3.06

Evoked Potential Charges -> Auditory (AEP)

Facility

$1,769.00

Service Code	HCPCS 92652
Hospital Charge Code	4802587
Hospital Revenue Code	471
Min. Negotiated Rate	$138.31
Max. Negotiated Rate	$1,273.68
Rate for Payer: Amerigroup CHIP/Medicaid	$159.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$530.70
Rate for Payer: BCBS of TX Blue Essentials	$636.84
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$707.60
Rate for Payer: Cash Price	$1,202.92
Rate for Payer: Cash Price	$1,202.92
Rate for Payer: Cash Price	$1,202.92
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$1,273.68
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$1,273.68
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$1,149.85
Rate for Payer: Multiplan Commercial	$1,149.85
Rate for Payer: Multiplan Workers Comp	$1,149.85
Rate for Payer: Parkland Medicaid	$1,273.68
Rate for Payer: Scott and White EPO/PPO	$138.31
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,273.68
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

Evoked Potential Charges -> Auditory (AEP)

Facility

$1,769.00

Service Code	HCPCS 92652
Hospital Charge Code	4802587
Hospital Revenue Code	471
Rate for Payer: Cash Price	$1,202.92

Know your out-of-pocket cost for care.

All Charges