White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIT CATHETER ARTERIAL PE

Facility

$88.80

Hospital Charge Code	135266
Hospital Revenue Code	272
Rate for Payer: Cash Price	$78.14

KIT CATHETER ARTERIAL PE

Facility

$88.80

Hospital Charge Code	135266
Hospital Revenue Code	272
Min. Negotiated Rate	$7.99
Max. Negotiated Rate	$57.72
Rate for Payer: Aetna Commercial	$48.84
Rate for Payer: Amerigroup CHIP/Medicaid	$7.99
Rate for Payer: BCBS of TX Blue Advantage	$26.64
Rate for Payer: BCBS of TX Blue Essentials	$31.97
Rate for Payer: BCBS of TX PPO	$35.52
Rate for Payer: Cash Price	$78.14
Rate for Payer: Multiplan Auto	$57.72
Rate for Payer: Multiplan Commercial	$57.72
Rate for Payer: Multiplan Workers Comp	$57.72
Rate for Payer: Scott and White EPO/PPO	$44.40
Rate for Payer: Superior Health Plan EPO	$12.08

kit cath venous vantex cvc

Facility

$866.51

Service Code	HCPCS C1894
Hospital Charge Code	8666509
Hospital Revenue Code	278
Min. Negotiated Rate	$216.63
Max. Negotiated Rate	$433.26
Rate for Payer: Aetna Commercial	$259.95
Rate for Payer: Cash Price	$762.53
Rate for Payer: Cigna Commercial	$216.63
Rate for Payer: Multiplan Auto	$433.26
Rate for Payer: Multiplan Commercial	$433.26
Rate for Payer: Multiplan Workers Comp	$433.26
Rate for Payer: Scott and White EPO/PPO	$433.26

kit cath venous vantex cvc

Facility

$866.51

Service Code	HCPCS C1894
Hospital Charge Code	8666509
Hospital Revenue Code	278
Min. Negotiated Rate	$77.99
Max. Negotiated Rate	$433.26
Rate for Payer: Aetna Commercial	$259.95
Rate for Payer: Amerigroup CHIP/Medicaid	$77.99
Rate for Payer: BCBS of TX Blue Advantage	$259.95
Rate for Payer: BCBS of TX Blue Essentials	$311.94
Rate for Payer: BCBS of TX PPO	$346.60
Rate for Payer: Cash Price	$762.53
Rate for Payer: Multiplan Auto	$433.26
Rate for Payer: Multiplan Commercial	$433.26
Rate for Payer: Multiplan Workers Comp	$433.26
Rate for Payer: Scott and White EPO/PPO	$433.26
Rate for Payer: Superior Health Plan EPO	$117.85

KIT, COLLECTION CLR NON-CONDUCT PLSTC 3/8'''' 6' DISP -- DHF

Facility

$261.97

Hospital Charge Code	80343007
Hospital Revenue Code	270
Rate for Payer: Cash Price	$230.53

KIT, COLLECTION CLR NON-CONDUCT PLSTC 3/8'''' 6' DISP -- DHF

Facility

$261.97

Hospital Charge Code	80343007
Hospital Revenue Code	270
Min. Negotiated Rate	$23.58
Max. Negotiated Rate	$170.28
Rate for Payer: Aetna Commercial	$144.08
Rate for Payer: Amerigroup CHIP/Medicaid	$23.58
Rate for Payer: BCBS of TX Blue Advantage	$78.59
Rate for Payer: BCBS of TX Blue Essentials	$94.31
Rate for Payer: BCBS of TX PPO	$104.79
Rate for Payer: Cash Price	$230.53
Rate for Payer: Multiplan Auto	$170.28
Rate for Payer: Multiplan Commercial	$170.28
Rate for Payer: Multiplan Workers Comp	$170.28
Rate for Payer: Scott and White EPO/PPO	$130.98
Rate for Payer: Superior Health Plan EPO	$35.63

KIT CROSSFIX DISPOSABLE

Facility

$1,316.60

Hospital Charge Code	145086
Hospital Revenue Code	272
Min. Negotiated Rate	$118.49
Max. Negotiated Rate	$855.79
Rate for Payer: Aetna Commercial	$724.13
Rate for Payer: Amerigroup CHIP/Medicaid	$118.49
Rate for Payer: BCBS of TX Blue Advantage	$394.98
Rate for Payer: BCBS of TX Blue Essentials	$473.98
Rate for Payer: BCBS of TX PPO	$526.64
Rate for Payer: Cash Price	$1,158.61
Rate for Payer: Multiplan Auto	$855.79
Rate for Payer: Multiplan Commercial	$855.79
Rate for Payer: Multiplan Workers Comp	$855.79
Rate for Payer: Scott and White EPO/PPO	$658.30
Rate for Payer: Superior Health Plan EPO	$179.06

KIT CROSSFIX DISPOSABLE

Facility

$1,316.60

Hospital Charge Code	145086
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,158.61

KIT, CUSTOM INFECTIOUS CONTROL DOCTORS HOSPITAL WR -- DHF

Facility

$55.45

Hospital Charge Code	80821358
Hospital Revenue Code	271
Min. Negotiated Rate	$4.99
Max. Negotiated Rate	$36.04
Rate for Payer: Aetna Commercial	$30.50
Rate for Payer: Amerigroup CHIP/Medicaid	$4.99
Rate for Payer: BCBS of TX Blue Advantage	$16.64
Rate for Payer: BCBS of TX Blue Essentials	$19.96
Rate for Payer: BCBS of TX PPO	$22.18
Rate for Payer: Cash Price	$48.80
Rate for Payer: Multiplan Auto	$36.04
Rate for Payer: Multiplan Commercial	$36.04
Rate for Payer: Multiplan Workers Comp	$36.04
Rate for Payer: Scott and White EPO/PPO	$27.72
Rate for Payer: Superior Health Plan EPO	$7.54

KIT, DEVICE NOVASURE ENDOMETRIAL ABLATION -- DHF

Facility

$4,677.01

Hospital Charge Code	81750697
Hospital Revenue Code	272
Min. Negotiated Rate	$420.93
Max. Negotiated Rate	$3,040.06
Rate for Payer: Aetna Commercial	$2,572.36
Rate for Payer: Amerigroup CHIP/Medicaid	$420.93
Rate for Payer: BCBS of TX Blue Advantage	$1,403.10
Rate for Payer: BCBS of TX Blue Essentials	$1,683.72
Rate for Payer: BCBS of TX PPO	$1,870.80
Rate for Payer: Cash Price	$4,115.77
Rate for Payer: Multiplan Auto	$3,040.06
Rate for Payer: Multiplan Commercial	$3,040.06
Rate for Payer: Multiplan Workers Comp	$3,040.06
Rate for Payer: Scott and White EPO/PPO	$2,338.50
Rate for Payer: Superior Health Plan EPO	$636.07

KIT, DEVICE NOVASURE ENDOMETRIAL ABLATION -- DHF

Facility

$4,677.01

Hospital Charge Code	81750697
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,115.77

kit dilator disposable

Facility

$22,223.30

Hospital Charge Code	8672531
Hospital Revenue Code	272
Min. Negotiated Rate	$2,000.10
Max. Negotiated Rate	$14,445.14
Rate for Payer: Aetna Commercial	$12,222.82
Rate for Payer: Amerigroup CHIP/Medicaid	$2,000.10
Rate for Payer: BCBS of TX Blue Advantage	$6,666.99
Rate for Payer: BCBS of TX Blue Essentials	$8,000.39
Rate for Payer: BCBS of TX PPO	$8,889.32
Rate for Payer: Cash Price	$19,556.50
Rate for Payer: Multiplan Auto	$14,445.14
Rate for Payer: Multiplan Commercial	$14,445.14
Rate for Payer: Multiplan Workers Comp	$14,445.14
Rate for Payer: Scott and White EPO/PPO	$11,111.65
Rate for Payer: Superior Health Plan EPO	$3,022.37

kit dilator disposable

Facility

$22,223.30

Hospital Charge Code	8672531
Hospital Revenue Code	272
Rate for Payer: Cash Price	$19,556.50

kit emr oblique or straight

Facility

$806.39

Hospital Charge Code	144834
Hospital Revenue Code	272
Min. Negotiated Rate	$72.58
Max. Negotiated Rate	$524.15
Rate for Payer: Aetna Commercial	$443.51
Rate for Payer: Amerigroup CHIP/Medicaid	$72.58
Rate for Payer: BCBS of TX Blue Advantage	$241.92
Rate for Payer: BCBS of TX Blue Essentials	$290.30
Rate for Payer: BCBS of TX PPO	$322.56
Rate for Payer: Cash Price	$709.62
Rate for Payer: Multiplan Auto	$524.15
Rate for Payer: Multiplan Commercial	$524.15
Rate for Payer: Multiplan Workers Comp	$524.15
Rate for Payer: Scott and White EPO/PPO	$403.20
Rate for Payer: Superior Health Plan EPO	$109.67

kit emr oblique or straight

Facility

$806.39

Hospital Charge Code	144834
Hospital Revenue Code	272
Rate for Payer: Cash Price	$709.62

kit endo compliance

Facility

$80.09

Hospital Charge Code	80820400
Hospital Revenue Code	272
Min. Negotiated Rate	$7.21
Max. Negotiated Rate	$52.06
Rate for Payer: Aetna Commercial	$44.05
Rate for Payer: Amerigroup CHIP/Medicaid	$7.21
Rate for Payer: BCBS of TX Blue Advantage	$24.03
Rate for Payer: BCBS of TX Blue Essentials	$28.83
Rate for Payer: BCBS of TX PPO	$32.04
Rate for Payer: Cash Price	$70.48
Rate for Payer: Multiplan Auto	$52.06
Rate for Payer: Multiplan Commercial	$52.06
Rate for Payer: Multiplan Workers Comp	$52.06
Rate for Payer: Scott and White EPO/PPO	$40.04
Rate for Payer: Superior Health Plan EPO	$10.89

kit endo compliance

Facility

$80.09

Hospital Charge Code	80820400
Hospital Revenue Code	272
Rate for Payer: Cash Price	$70.48

KIT, EXPANSION ON-Q W/2.5'''' ANTIMICROB SOAKER CATH -- DHF

Facility

$298.12

Hospital Charge Code	80325574
Hospital Revenue Code	272
Rate for Payer: Cash Price	$262.35

KIT, EXPANSION ON-Q W/2.5'''' ANTIMICROB SOAKER CATH -- DHF

Facility

$298.12

Hospital Charge Code	80325574
Hospital Revenue Code	272
Min. Negotiated Rate	$26.83
Max. Negotiated Rate	$193.78
Rate for Payer: Aetna Commercial	$163.97
Rate for Payer: Amerigroup CHIP/Medicaid	$26.83
Rate for Payer: BCBS of TX Blue Advantage	$89.44
Rate for Payer: BCBS of TX Blue Essentials	$107.32
Rate for Payer: BCBS of TX PPO	$119.25
Rate for Payer: Cash Price	$262.35
Rate for Payer: Multiplan Auto	$193.78
Rate for Payer: Multiplan Commercial	$193.78
Rate for Payer: Multiplan Workers Comp	$193.78
Rate for Payer: Scott and White EPO/PPO	$149.06
Rate for Payer: Superior Health Plan EPO	$40.54

KIT, FIBRIN SEALANT SURGICAL 5.0ML -- DHF

Facility

$2,678.73

Hospital Charge Code	80325970
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,357.28

KIT, FIBRIN SEALANT SURGICAL 5.0ML -- DHF

Facility

$2,678.73

Hospital Charge Code	80325970
Hospital Revenue Code	272
Min. Negotiated Rate	$241.09
Max. Negotiated Rate	$1,741.17
Rate for Payer: Aetna Commercial	$1,473.30
Rate for Payer: Amerigroup CHIP/Medicaid	$241.09
Rate for Payer: BCBS of TX Blue Advantage	$803.62
Rate for Payer: BCBS of TX Blue Essentials	$964.34
Rate for Payer: BCBS of TX PPO	$1,071.49
Rate for Payer: Cash Price	$2,357.28
Rate for Payer: Multiplan Auto	$1,741.17
Rate for Payer: Multiplan Commercial	$1,741.17
Rate for Payer: Multiplan Workers Comp	$1,741.17
Rate for Payer: Scott and White EPO/PPO	$1,339.36
Rate for Payer: Superior Health Plan EPO	$364.31

KIT HIP W/32" REACHER,SHOEHORN,SOCKAID

Facility

$73.55

Hospital Charge Code	133980
Hospital Revenue Code	272
Min. Negotiated Rate	$6.62
Max. Negotiated Rate	$47.81
Rate for Payer: Aetna Commercial	$40.45
Rate for Payer: Amerigroup CHIP/Medicaid	$6.62
Rate for Payer: BCBS of TX Blue Advantage	$22.06
Rate for Payer: BCBS of TX Blue Essentials	$26.48
Rate for Payer: BCBS of TX PPO	$29.42
Rate for Payer: Cash Price	$64.72
Rate for Payer: Multiplan Auto	$47.81
Rate for Payer: Multiplan Commercial	$47.81
Rate for Payer: Multiplan Workers Comp	$47.81
Rate for Payer: Scott and White EPO/PPO	$36.78
Rate for Payer: Superior Health Plan EPO	$10.00

KIT HIP W/32" REACHER,SHOEHORN,SOCKAID

Facility

$73.55

Hospital Charge Code	133980
Hospital Revenue Code	272
Rate for Payer: Cash Price	$64.72

KIT IB PLUS BC/CC FT & JUMPSTART

Facility

$12,867.47

Service Code	HCPCS C1713
Hospital Charge Code	145405
Hospital Revenue Code	278
Min. Negotiated Rate	$3,216.87
Max. Negotiated Rate	$6,433.74
Rate for Payer: Aetna Commercial	$3,860.24
Rate for Payer: Cash Price	$11,323.37
Rate for Payer: Cigna Commercial	$3,216.87
Rate for Payer: Multiplan Auto	$6,433.74
Rate for Payer: Multiplan Commercial	$6,433.74
Rate for Payer: Multiplan Workers Comp	$6,433.74
Rate for Payer: Scott and White EPO/PPO	$6,433.74

KIT IB PLUS BC/CC FT & JUMPSTART

Facility

$12,867.47

Service Code	HCPCS C1713
Hospital Charge Code	145405
Hospital Revenue Code	278
Min. Negotiated Rate	$1,158.07
Max. Negotiated Rate	$6,433.74
Rate for Payer: Aetna Commercial	$3,860.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,158.07
Rate for Payer: BCBS of TX Blue Advantage	$3,860.24
Rate for Payer: BCBS of TX Blue Essentials	$4,632.29
Rate for Payer: BCBS of TX PPO	$5,146.99
Rate for Payer: Cash Price	$11,323.37
Rate for Payer: Multiplan Auto	$6,433.74
Rate for Payer: Multiplan Commercial	$6,433.74
Rate for Payer: Multiplan Workers Comp	$6,433.74
Rate for Payer: Scott and White EPO/PPO	$6,433.74
Rate for Payer: Superior Health Plan EPO	$1,749.98

Know your out-of-pocket cost for care.

All Charges