White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIT PARADIGMACCESS EZ SWITCH

Facility

$8,172.00

Hospital Charge Code	144851
Hospital Revenue Code	272
Min. Negotiated Rate	$735.48
Max. Negotiated Rate	$5,311.80
Rate for Payer: Aetna Commercial	$4,494.60
Rate for Payer: Amerigroup CHIP/Medicaid	$735.48
Rate for Payer: BCBS of TX Blue Advantage	$2,451.60
Rate for Payer: BCBS of TX Blue Essentials	$2,941.92
Rate for Payer: BCBS of TX PPO	$3,268.80
Rate for Payer: Cash Price	$7,191.36
Rate for Payer: Multiplan Auto	$5,311.80
Rate for Payer: Multiplan Commercial	$5,311.80
Rate for Payer: Multiplan Workers Comp	$5,311.80
Rate for Payer: Scott and White EPO/PPO	$4,086.00
Rate for Payer: Superior Health Plan EPO	$1,111.39

KIT PEG FLOW 20 PUSH

Facility

$431.30

Hospital Charge Code	8568963
Hospital Revenue Code	272
Rate for Payer: Cash Price	$379.54

KIT PEG FLOW 20 PUSH

Facility

$431.30

Hospital Charge Code	8568963
Hospital Revenue Code	272
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$280.34
Rate for Payer: Aetna Commercial	$237.22
Rate for Payer: Amerigroup CHIP/Medicaid	$38.82
Rate for Payer: BCBS of TX Blue Advantage	$129.39
Rate for Payer: BCBS of TX Blue Essentials	$155.27
Rate for Payer: BCBS of TX PPO	$172.52
Rate for Payer: Cash Price	$379.54
Rate for Payer: Multiplan Auto	$280.34
Rate for Payer: Multiplan Commercial	$280.34
Rate for Payer: Multiplan Workers Comp	$280.34
Rate for Payer: Scott and White EPO/PPO	$215.65
Rate for Payer: Superior Health Plan EPO	$58.66

KIT PEG TUBE FEED 20FR

Facility

$370.42

Hospital Charge Code	8504484
Hospital Revenue Code	278
Min. Negotiated Rate	$92.60
Max. Negotiated Rate	$185.21
Rate for Payer: Aetna Commercial	$111.13
Rate for Payer: Cash Price	$325.97
Rate for Payer: Cigna Commercial	$92.60
Rate for Payer: Multiplan Auto	$185.21
Rate for Payer: Multiplan Commercial	$185.21
Rate for Payer: Multiplan Workers Comp	$185.21
Rate for Payer: Scott and White EPO/PPO	$185.21

KIT PEG TUBE FEED 20FR

Facility

$370.42

Hospital Charge Code	8504484
Hospital Revenue Code	278
Min. Negotiated Rate	$33.34
Max. Negotiated Rate	$185.21
Rate for Payer: Aetna Commercial	$111.13
Rate for Payer: Amerigroup CHIP/Medicaid	$33.34
Rate for Payer: BCBS of TX Blue Advantage	$111.13
Rate for Payer: BCBS of TX Blue Essentials	$133.35
Rate for Payer: BCBS of TX PPO	$148.17
Rate for Payer: Cash Price	$325.97
Rate for Payer: Multiplan Auto	$185.21
Rate for Payer: Multiplan Commercial	$185.21
Rate for Payer: Multiplan Workers Comp	$185.21
Rate for Payer: Scott and White EPO/PPO	$185.21
Rate for Payer: Superior Health Plan EPO	$50.38

KIT PERICARDIOCENTESIS PC101

Facility

$452.87

Hospital Charge Code	133128
Hospital Revenue Code	272
Rate for Payer: Cash Price	$398.53

KIT PERICARDIOCENTESIS PC101

Facility

$452.87

Hospital Charge Code	133128
Hospital Revenue Code	272
Min. Negotiated Rate	$40.76
Max. Negotiated Rate	$294.37
Rate for Payer: Aetna Commercial	$249.08
Rate for Payer: Amerigroup CHIP/Medicaid	$40.76
Rate for Payer: BCBS of TX Blue Advantage	$135.86
Rate for Payer: BCBS of TX Blue Essentials	$163.03
Rate for Payer: BCBS of TX PPO	$181.15
Rate for Payer: Cash Price	$398.53
Rate for Payer: Multiplan Auto	$294.37
Rate for Payer: Multiplan Commercial	$294.37
Rate for Payer: Multiplan Workers Comp	$294.37
Rate for Payer: Scott and White EPO/PPO	$226.44
Rate for Payer: Superior Health Plan EPO	$61.59

KIT PLEURX CATHETER

Facility

$2,682.27

Hospital Charge Code	8422509
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,360.40

KIT PLEURX CATHETER

Facility

$2,682.27

Hospital Charge Code	8422509
Hospital Revenue Code	272
Min. Negotiated Rate	$241.40
Max. Negotiated Rate	$1,743.48
Rate for Payer: Aetna Commercial	$1,475.25
Rate for Payer: Amerigroup CHIP/Medicaid	$241.40
Rate for Payer: BCBS of TX Blue Advantage	$804.68
Rate for Payer: BCBS of TX Blue Essentials	$965.62
Rate for Payer: BCBS of TX PPO	$1,072.91
Rate for Payer: Cash Price	$2,360.40
Rate for Payer: Multiplan Auto	$1,743.48
Rate for Payer: Multiplan Commercial	$1,743.48
Rate for Payer: Multiplan Workers Comp	$1,743.48
Rate for Payer: Scott and White EPO/PPO	$1,341.14
Rate for Payer: Superior Health Plan EPO	$364.79

KIT RADIOFREQUENCY COOLIEF COOLED

Facility

$3,291.50

Hospital Charge Code	8568957
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,896.52

KIT RADIOFREQUENCY COOLIEF COOLED

Facility

$3,291.50

Hospital Charge Code	8568957
Hospital Revenue Code	272
Min. Negotiated Rate	$296.24
Max. Negotiated Rate	$2,139.48
Rate for Payer: Aetna Commercial	$1,810.32
Rate for Payer: Amerigroup CHIP/Medicaid	$296.24
Rate for Payer: BCBS of TX Blue Advantage	$987.45
Rate for Payer: BCBS of TX Blue Essentials	$1,184.94
Rate for Payer: BCBS of TX PPO	$1,316.60
Rate for Payer: Cash Price	$2,896.52
Rate for Payer: Multiplan Auto	$2,139.48
Rate for Payer: Multiplan Commercial	$2,139.48
Rate for Payer: Multiplan Workers Comp	$2,139.48
Rate for Payer: Scott and White EPO/PPO	$1,645.75
Rate for Payer: Superior Health Plan EPO	$447.64

KIT, RETRACTOR W/SCREW & 13G ASPIRATION NEEDLE SET -- DHF

Facility

$1,398.11

Hospital Charge Code	80811250
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,230.34

KIT, RETRACTOR W/SCREW & 13G ASPIRATION NEEDLE SET -- DHF

Facility

$1,398.11

Hospital Charge Code	80811250
Hospital Revenue Code	272
Min. Negotiated Rate	$125.83
Max. Negotiated Rate	$908.77
Rate for Payer: Aetna Commercial	$768.96
Rate for Payer: Amerigroup CHIP/Medicaid	$125.83
Rate for Payer: BCBS of TX Blue Advantage	$419.43
Rate for Payer: BCBS of TX Blue Essentials	$503.32
Rate for Payer: BCBS of TX PPO	$559.24
Rate for Payer: Cash Price	$1,230.34
Rate for Payer: Multiplan Auto	$908.77
Rate for Payer: Multiplan Commercial	$908.77
Rate for Payer: Multiplan Workers Comp	$908.77
Rate for Payer: Scott and White EPO/PPO	$699.06
Rate for Payer: Superior Health Plan EPO	$190.14

kit rigidloop

Facility

$3,777.28

Hospital Charge Code	8612545
Hospital Revenue Code	272
Min. Negotiated Rate	$339.96
Max. Negotiated Rate	$2,455.23
Rate for Payer: Aetna Commercial	$2,077.50
Rate for Payer: Amerigroup CHIP/Medicaid	$339.96
Rate for Payer: BCBS of TX Blue Advantage	$1,133.18
Rate for Payer: BCBS of TX Blue Essentials	$1,359.82
Rate for Payer: BCBS of TX PPO	$1,510.91
Rate for Payer: Cash Price	$3,324.01
Rate for Payer: Multiplan Auto	$2,455.23
Rate for Payer: Multiplan Commercial	$2,455.23
Rate for Payer: Multiplan Workers Comp	$2,455.23
Rate for Payer: Scott and White EPO/PPO	$1,888.64
Rate for Payer: Superior Health Plan EPO	$513.71

kit rigidloop

Facility

$3,777.28

Hospital Charge Code	8612545
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,324.01

kit scp knee

Facility

$27,650.60

Service Code	HCPCS C1889
Hospital Charge Code	8720610
Hospital Revenue Code	278
Min. Negotiated Rate	$2,488.55
Max. Negotiated Rate	$13,825.30
Rate for Payer: Aetna Commercial	$8,295.18
Rate for Payer: Amerigroup CHIP/Medicaid	$2,488.55
Rate for Payer: BCBS of TX Blue Advantage	$8,295.18
Rate for Payer: BCBS of TX Blue Essentials	$9,954.22
Rate for Payer: BCBS of TX PPO	$11,060.24
Rate for Payer: Cash Price	$24,332.53
Rate for Payer: Multiplan Auto	$13,825.30
Rate for Payer: Multiplan Commercial	$13,825.30
Rate for Payer: Multiplan Workers Comp	$13,825.30
Rate for Payer: Scott and White EPO/PPO	$13,825.30
Rate for Payer: Superior Health Plan EPO	$3,760.48

kit scp knee

Facility

$27,650.60

Service Code	HCPCS C1889
Hospital Charge Code	8720610
Hospital Revenue Code	278
Min. Negotiated Rate	$6,912.65
Max. Negotiated Rate	$13,825.30
Rate for Payer: Aetna Commercial	$8,295.18
Rate for Payer: Cash Price	$24,332.53
Rate for Payer: Cigna Commercial	$6,912.65
Rate for Payer: Multiplan Auto	$13,825.30
Rate for Payer: Multiplan Commercial	$13,825.30
Rate for Payer: Multiplan Workers Comp	$13,825.30
Rate for Payer: Scott and White EPO/PPO	$13,825.30

KIT SIZERS INSTAFIX -- DHF

Facility

$794.50

Hospital Charge Code	80899065
Hospital Revenue Code	272
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$516.42
Rate for Payer: Aetna Commercial	$436.98
Rate for Payer: Amerigroup CHIP/Medicaid	$71.50
Rate for Payer: BCBS of TX Blue Advantage	$238.35
Rate for Payer: BCBS of TX Blue Essentials	$286.02
Rate for Payer: BCBS of TX PPO	$317.80
Rate for Payer: Cash Price	$699.16
Rate for Payer: Multiplan Auto	$516.42
Rate for Payer: Multiplan Commercial	$516.42
Rate for Payer: Multiplan Workers Comp	$516.42
Rate for Payer: Scott and White EPO/PPO	$397.25
Rate for Payer: Superior Health Plan EPO	$108.05

KIT SIZERS INSTAFIX -- DHF

Facility

$794.50

Hospital Charge Code	80899065
Hospital Revenue Code	272
Rate for Payer: Cash Price	$699.16

KIT SONIC ANCHOR

Facility

$2,971.02

Service Code	HCPCS C1713
Hospital Charge Code	139445
Hospital Revenue Code	278
Min. Negotiated Rate	$742.76
Max. Negotiated Rate	$1,485.51
Rate for Payer: Aetna Commercial	$891.31
Rate for Payer: Cash Price	$2,614.50
Rate for Payer: Cigna Commercial	$742.76
Rate for Payer: Multiplan Auto	$1,485.51
Rate for Payer: Multiplan Commercial	$1,485.51
Rate for Payer: Multiplan Workers Comp	$1,485.51
Rate for Payer: Scott and White EPO/PPO	$1,485.51

KIT SONIC ANCHOR

Facility

$2,971.02

Service Code	HCPCS C1713
Hospital Charge Code	139445
Hospital Revenue Code	278
Min. Negotiated Rate	$267.39
Max. Negotiated Rate	$1,485.51
Rate for Payer: Aetna Commercial	$891.31
Rate for Payer: Amerigroup CHIP/Medicaid	$267.39
Rate for Payer: BCBS of TX Blue Advantage	$891.31
Rate for Payer: BCBS of TX Blue Essentials	$1,069.57
Rate for Payer: BCBS of TX PPO	$1,188.41
Rate for Payer: Cash Price	$2,614.50
Rate for Payer: Multiplan Auto	$1,485.51
Rate for Payer: Multiplan Commercial	$1,485.51
Rate for Payer: Multiplan Workers Comp	$1,485.51
Rate for Payer: Scott and White EPO/PPO	$1,485.51
Rate for Payer: Superior Health Plan EPO	$404.06

KIT, SUCT WOUND CLSED 3-SPRING 400ML MD W/NDL 1/8'''' -- DHF

Facility

$41.57

Hospital Charge Code	81821159
Hospital Revenue Code	272
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$27.02
Rate for Payer: Aetna Commercial	$22.86
Rate for Payer: Amerigroup CHIP/Medicaid	$3.74
Rate for Payer: BCBS of TX Blue Advantage	$12.47
Rate for Payer: BCBS of TX Blue Essentials	$14.97
Rate for Payer: BCBS of TX PPO	$16.63
Rate for Payer: Cash Price	$36.58
Rate for Payer: Multiplan Auto	$27.02
Rate for Payer: Multiplan Commercial	$27.02
Rate for Payer: Multiplan Workers Comp	$27.02
Rate for Payer: Scott and White EPO/PPO	$20.78
Rate for Payer: Superior Health Plan EPO	$5.65

KIT, SUCT WOUND CLSED 3-SPRING 400ML MD W/NDL 1/8'''' -- DHF

Facility

$41.57

Hospital Charge Code	81821159
Hospital Revenue Code	272
Rate for Payer: Cash Price	$36.58

KIT SUTURE IMPLANT W/SUTURE TAPE

Facility

$12,867.47

Service Code	HCPCS C1713
Hospital Charge Code	130280
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 SUTURE IMPLANT W/SUTURE TAPE

Facility

$12,867.47

Service Code	HCPCS C1713
Hospital Charge Code	130280
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