White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIT IMPLANT INSTAFIX -- DHF

Facility

$14,462.80

Service Code	HCPCS C1713
Hospital Charge Code	40199036
Hospital Revenue Code	278
Min. Negotiated Rate	$3,615.70
Max. Negotiated Rate	$7,231.40
Rate for Payer: Aetna Commercial	$4,338.84
Rate for Payer: Cash Price	$12,727.26
Rate for Payer: Cigna Commercial	$3,615.70
Rate for Payer: Multiplan Auto	$7,231.40
Rate for Payer: Multiplan Commercial	$7,231.40
Rate for Payer: Multiplan Workers Comp	$7,231.40
Rate for Payer: Scott and White EPO/PPO	$7,231.40

KIT IMPLANT INSTAFIX -- DHF

Facility

$14,462.80

Service Code	HCPCS C1713
Hospital Charge Code	40199036
Hospital Revenue Code	278
Min. Negotiated Rate	$1,301.65
Max. Negotiated Rate	$7,231.40
Rate for Payer: Aetna Commercial	$4,338.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1,301.65
Rate for Payer: BCBS of TX Blue Advantage	$4,338.84
Rate for Payer: BCBS of TX Blue Essentials	$5,206.61
Rate for Payer: BCBS of TX PPO	$5,785.12
Rate for Payer: Cash Price	$12,727.26
Rate for Payer: Multiplan Auto	$7,231.40
Rate for Payer: Multiplan Commercial	$7,231.40
Rate for Payer: Multiplan Workers Comp	$7,231.40
Rate for Payer: Scott and White EPO/PPO	$7,231.40
Rate for Payer: Superior Health Plan EPO	$1,966.94

KIT, INFECTIOUS CONTROL TURNOVER CITY HOSPITAL WR -- DHF

Facility

$55.45

Hospital Charge Code	80821358
Hospital Revenue Code	271
Rate for Payer: Cash Price	$48.80

KIT, INFECTIOUS CONTROL TURNOVER CITY 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

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Facility

$97.39

Hospital Charge Code	8660704
Hospital Revenue Code	272
Min. Negotiated Rate	$8.77
Max. Negotiated Rate	$63.30
Rate for Payer: Aetna Commercial	$53.56
Rate for Payer: Amerigroup CHIP/Medicaid	$8.77
Rate for Payer: BCBS of TX Blue Advantage	$29.22
Rate for Payer: BCBS of TX Blue Essentials	$35.06
Rate for Payer: BCBS of TX PPO	$38.96
Rate for Payer: Cash Price	$85.70
Rate for Payer: Multiplan Auto	$63.30
Rate for Payer: Multiplan Commercial	$63.30
Rate for Payer: Multiplan Workers Comp	$63.30
Rate for Payer: Scott and White EPO/PPO	$48.70
Rate for Payer: Superior Health Plan EPO	$13.25

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Facility

$97.39

Hospital Charge Code	8660704
Hospital Revenue Code	272
Rate for Payer: Cash Price	$85.70

KIT, INTRODUCER 16FR PTFE .038'''' 50CM L DBL FLX TIP -- DHF

Facility

$598.48

Hospital Charge Code	80620404
Hospital Revenue Code	272
Min. Negotiated Rate	$53.86
Max. Negotiated Rate	$389.01
Rate for Payer: Aetna Commercial	$329.16
Rate for Payer: Amerigroup CHIP/Medicaid	$53.86
Rate for Payer: BCBS of TX Blue Advantage	$179.54
Rate for Payer: BCBS of TX Blue Essentials	$215.45
Rate for Payer: BCBS of TX PPO	$239.39
Rate for Payer: Cash Price	$526.66
Rate for Payer: Multiplan Auto	$389.01
Rate for Payer: Multiplan Commercial	$389.01
Rate for Payer: Multiplan Workers Comp	$389.01
Rate for Payer: Scott and White EPO/PPO	$299.24
Rate for Payer: Superior Health Plan EPO	$81.39

KIT, INTRODUCER 16FR PTFE .038'''' 50CM L DBL FLX TIP -- DHF

Facility

$598.48

Hospital Charge Code	80620404
Hospital Revenue Code	272
Rate for Payer: Cash Price	$526.66

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Facility

$82.90

Hospital Charge Code	144755
Hospital Revenue Code	270
Rate for Payer: Cash Price	$72.95

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Facility

$82.90

Hospital Charge Code	144755
Hospital Revenue Code	270
Min. Negotiated Rate	$7.46
Max. Negotiated Rate	$53.88
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Amerigroup CHIP/Medicaid	$7.46
Rate for Payer: BCBS of TX Blue Advantage	$24.87
Rate for Payer: BCBS of TX Blue Essentials	$29.84
Rate for Payer: BCBS of TX PPO	$33.16
Rate for Payer: Cash Price	$72.95
Rate for Payer: Multiplan Auto	$53.88
Rate for Payer: Multiplan Commercial	$53.88
Rate for Payer: Multiplan Workers Comp	$53.88
Rate for Payer: Scott and White EPO/PPO	$41.45
Rate for Payer: Superior Health Plan EPO	$11.27

KIT KYPHOPAK EXPRESS FIRST FIX KEX152EB-A

Facility

$21,565.00

Hospital Charge Code	145217
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18,977.20

KIT KYPHOPAK EXPRESS FIRST FIX KEX152EB-A

Facility

$21,565.00

Hospital Charge Code	145217
Hospital Revenue Code	272
Min. Negotiated Rate	$1,940.85
Max. Negotiated Rate	$14,017.25
Rate for Payer: Aetna Commercial	$11,860.75
Rate for Payer: Amerigroup CHIP/Medicaid	$1,940.85
Rate for Payer: BCBS of TX Blue Advantage	$6,469.50
Rate for Payer: BCBS of TX Blue Essentials	$7,763.40
Rate for Payer: BCBS of TX PPO	$8,626.00
Rate for Payer: Cash Price	$18,977.20
Rate for Payer: Multiplan Auto	$14,017.25
Rate for Payer: Multiplan Commercial	$14,017.25
Rate for Payer: Multiplan Workers Comp	$14,017.25
Rate for Payer: Scott and White EPO/PPO	$10,782.50
Rate for Payer: Superior Health Plan EPO	$2,932.84

KIT, LAVAGE FEM IRRIGATION & OPN SUCT SEPARABL TIP -- DHF

Facility

$431.79

Hospital Charge Code	81775751
Hospital Revenue Code	270
Min. Negotiated Rate	$38.86
Max. Negotiated Rate	$280.66
Rate for Payer: Aetna Commercial	$237.48
Rate for Payer: Amerigroup CHIP/Medicaid	$38.86
Rate for Payer: BCBS of TX Blue Advantage	$129.54
Rate for Payer: BCBS of TX Blue Essentials	$155.44
Rate for Payer: BCBS of TX PPO	$172.72
Rate for Payer: Cash Price	$379.98
Rate for Payer: Multiplan Auto	$280.66
Rate for Payer: Multiplan Commercial	$280.66
Rate for Payer: Multiplan Workers Comp	$280.66
Rate for Payer: Scott and White EPO/PPO	$215.90
Rate for Payer: Superior Health Plan EPO	$58.72

KIT, LAVAGE FEM IRRIGATION & OPN SUCT SEPARABL TIP -- DHF

Facility

$431.79

Hospital Charge Code	81775751
Hospital Revenue Code	270
Rate for Payer: Cash Price	$379.98

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Facility

$1,452.80

Hospital Charge Code	8702506
Hospital Revenue Code	272
Min. Negotiated Rate	$130.75
Max. Negotiated Rate	$944.32
Rate for Payer: Aetna Commercial	$799.04
Rate for Payer: Amerigroup CHIP/Medicaid	$130.75
Rate for Payer: BCBS of TX Blue Advantage	$435.84
Rate for Payer: BCBS of TX Blue Essentials	$523.01
Rate for Payer: BCBS of TX PPO	$581.12
Rate for Payer: Cash Price	$1,278.46
Rate for Payer: Multiplan Auto	$944.32
Rate for Payer: Multiplan Commercial	$944.32
Rate for Payer: Multiplan Workers Comp	$944.32
Rate for Payer: Scott and White EPO/PPO	$726.40
Rate for Payer: Superior Health Plan EPO	$197.58

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Facility

$1,452.80

Hospital Charge Code	8702506
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,278.46

KIT ORAL CARE #6912

Facility

$167.03

Hospital Charge Code	145421
Hospital Revenue Code	272
Min. Negotiated Rate	$15.03
Max. Negotiated Rate	$108.57
Rate for Payer: Aetna Commercial	$91.87
Rate for Payer: Amerigroup CHIP/Medicaid	$15.03
Rate for Payer: BCBS of TX Blue Advantage	$50.11
Rate for Payer: BCBS of TX Blue Essentials	$60.13
Rate for Payer: BCBS of TX PPO	$66.81
Rate for Payer: Cash Price	$146.99
Rate for Payer: Multiplan Auto	$108.57
Rate for Payer: Multiplan Commercial	$108.57
Rate for Payer: Multiplan Workers Comp	$108.57
Rate for Payer: Scott and White EPO/PPO	$83.52
Rate for Payer: Superior Health Plan EPO	$22.72

KIT ORAL CARE #6912

Facility

$167.03

Hospital Charge Code	145421
Hospital Revenue Code	272
Rate for Payer: Cash Price	$146.99

KIT ORTHOLOCK 2 JOINT PREP

Facility

$2,120.18

Hospital Charge Code	145483
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,865.76

KIT ORTHOLOCK 2 JOINT PREP

Facility

$2,120.18

Hospital Charge Code	145483
Hospital Revenue Code	272
Min. Negotiated Rate	$190.82
Max. Negotiated Rate	$1,378.12
Rate for Payer: Aetna Commercial	$1,166.10
Rate for Payer: Amerigroup CHIP/Medicaid	$190.82
Rate for Payer: BCBS of TX Blue Advantage	$636.05
Rate for Payer: BCBS of TX Blue Essentials	$763.26
Rate for Payer: BCBS of TX PPO	$848.07
Rate for Payer: Cash Price	$1,865.76
Rate for Payer: Multiplan Auto	$1,378.12
Rate for Payer: Multiplan Commercial	$1,378.12
Rate for Payer: Multiplan Workers Comp	$1,378.12
Rate for Payer: Scott and White EPO/PPO	$1,060.09
Rate for Payer: Superior Health Plan EPO	$288.34

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Facility

$7,572.29

Service Code	HCPCS C1713
Hospital Charge Code	8628562
Hospital Revenue Code	278
Min. Negotiated Rate	$681.51
Max. Negotiated Rate	$3,786.14
Rate for Payer: Aetna Commercial	$2,271.69
Rate for Payer: Amerigroup CHIP/Medicaid	$681.51
Rate for Payer: BCBS of TX Blue Advantage	$2,271.69
Rate for Payer: BCBS of TX Blue Essentials	$2,726.02
Rate for Payer: BCBS of TX PPO	$3,028.92
Rate for Payer: Cash Price	$6,663.62
Rate for Payer: Multiplan Auto	$3,786.14
Rate for Payer: Multiplan Commercial	$3,786.14
Rate for Payer: Multiplan Workers Comp	$3,786.14
Rate for Payer: Scott and White EPO/PPO	$3,786.14
Rate for Payer: Superior Health Plan EPO	$1,029.83

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Facility

$7,572.29

Service Code	HCPCS C1713
Hospital Charge Code	8628562
Hospital Revenue Code	278
Min. Negotiated Rate	$1,893.07
Max. Negotiated Rate	$3,786.14
Rate for Payer: Aetna Commercial	$2,271.69
Rate for Payer: Cash Price	$6,663.62
Rate for Payer: Cigna Commercial	$1,893.07
Rate for Payer: Multiplan Auto	$3,786.14
Rate for Payer: Multiplan Commercial	$3,786.14
Rate for Payer: Multiplan Workers Comp	$3,786.14
Rate for Payer: Scott and White EPO/PPO	$3,786.14

KIT OSTEOSET RESORBABLE BEAD 5CC

Facility

$4,505.24

Hospital Charge Code	133606
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,964.61

KIT OSTEOSET RESORBABLE BEAD 5CC

Facility

$4,505.24

Hospital Charge Code	133606
Hospital Revenue Code	272
Min. Negotiated Rate	$405.47
Max. Negotiated Rate	$2,928.41
Rate for Payer: Aetna Commercial	$2,477.88
Rate for Payer: Amerigroup CHIP/Medicaid	$405.47
Rate for Payer: BCBS of TX Blue Advantage	$1,351.57
Rate for Payer: BCBS of TX Blue Essentials	$1,621.89
Rate for Payer: BCBS of TX PPO	$1,802.10
Rate for Payer: Cash Price	$3,964.61
Rate for Payer: Multiplan Auto	$2,928.41
Rate for Payer: Multiplan Commercial	$2,928.41
Rate for Payer: Multiplan Workers Comp	$2,928.41
Rate for Payer: Scott and White EPO/PPO	$2,252.62
Rate for Payer: Superior Health Plan EPO	$612.71

KIT PARADIGMACCESS EZ SWITCH

Facility

$8,172.00

Hospital Charge Code	144851
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7,191.36

Know your out-of-pocket cost for care.

All Charges