White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIT TACTILE ACCESS PARADIGM

Facility

$3,291.50

Hospital Charge Code	8428500
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,896.52

KIT TACTILE ACCESS PARADIGM

Facility

$3,291.50

Hospital Charge Code	8428500
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

KITTNER, ENDOSCOPIC SINGLE TIP -- DHF

Facility

$100.00

Hospital Charge Code	81750002
Hospital Revenue Code	272
Rate for Payer: Cash Price	$88.00

KITTNER, ENDOSCOPIC SINGLE TIP -- DHF

Facility

$100.00

Hospital Charge Code	81750002
Hospital Revenue Code	272
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$55.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.00
Rate for Payer: BCBS of TX Blue Advantage	$30.00
Rate for Payer: BCBS of TX Blue Essentials	$36.00
Rate for Payer: BCBS of TX PPO	$40.00
Rate for Payer: Cash Price	$88.00
Rate for Payer: Multiplan Auto	$65.00
Rate for Payer: Multiplan Commercial	$65.00
Rate for Payer: Multiplan Workers Comp	$65.00
Rate for Payer: Scott and White EPO/PPO	$50.00
Rate for Payer: Superior Health Plan EPO	$13.60

KIT TOGGLELOC W/ZIPLOOP 13MM

Facility

$10,409.64

Hospital Charge Code	145478
Hospital Revenue Code	278
Min. Negotiated Rate	$936.87
Max. Negotiated Rate	$5,204.82
Rate for Payer: Aetna Commercial	$3,122.89
Rate for Payer: Amerigroup CHIP/Medicaid	$936.87
Rate for Payer: BCBS of TX Blue Advantage	$3,122.89
Rate for Payer: BCBS of TX Blue Essentials	$3,747.47
Rate for Payer: BCBS of TX PPO	$4,163.86
Rate for Payer: Cash Price	$9,160.48
Rate for Payer: Multiplan Auto	$5,204.82
Rate for Payer: Multiplan Commercial	$5,204.82
Rate for Payer: Multiplan Workers Comp	$5,204.82
Rate for Payer: Scott and White EPO/PPO	$5,204.82
Rate for Payer: Superior Health Plan EPO	$1,415.71

KIT TOGGLELOC W/ZIPLOOP 13MM

Facility

$10,409.64

Hospital Charge Code	145478
Hospital Revenue Code	278
Min. Negotiated Rate	$2,602.41
Max. Negotiated Rate	$5,204.82
Rate for Payer: Aetna Commercial	$3,122.89
Rate for Payer: Cash Price	$9,160.48
Rate for Payer: Cigna Commercial	$2,602.41
Rate for Payer: Multiplan Auto	$5,204.82
Rate for Payer: Multiplan Commercial	$5,204.82
Rate for Payer: Multiplan Workers Comp	$5,204.82
Rate for Payer: Scott and White EPO/PPO	$5,204.82

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Facility

$11,204.82

Service Code	HCPCS C1713
Hospital Charge Code	144815
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.20
Max. Negotiated Rate	$5,602.41
Rate for Payer: Aetna Commercial	$3,361.45
Rate for Payer: Cash Price	$9,860.24
Rate for Payer: Cigna Commercial	$2,801.20
Rate for Payer: Multiplan Auto	$5,602.41
Rate for Payer: Multiplan Commercial	$5,602.41
Rate for Payer: Multiplan Workers Comp	$5,602.41
Rate for Payer: Scott and White EPO/PPO	$5,602.41

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Facility

$11,204.82

Service Code	HCPCS C1713
Hospital Charge Code	144815
Hospital Revenue Code	278
Min. Negotiated Rate	$1,008.43
Max. Negotiated Rate	$5,602.41
Rate for Payer: Aetna Commercial	$3,361.45
Rate for Payer: Amerigroup CHIP/Medicaid	$1,008.43
Rate for Payer: BCBS of TX Blue Advantage	$3,361.45
Rate for Payer: BCBS of TX Blue Essentials	$4,033.74
Rate for Payer: BCBS of TX PPO	$4,481.93
Rate for Payer: Cash Price	$9,860.24
Rate for Payer: Multiplan Auto	$5,602.41
Rate for Payer: Multiplan Commercial	$5,602.41
Rate for Payer: Multiplan Workers Comp	$5,602.41
Rate for Payer: Scott and White EPO/PPO	$5,602.41
Rate for Payer: Superior Health Plan EPO	$1,523.86

KIT UNIVERSAL ARTERIAL

Facility

$299.14

Hospital Charge Code	145162
Hospital Revenue Code	272
Min. Negotiated Rate	$26.92
Max. Negotiated Rate	$194.44
Rate for Payer: Aetna Commercial	$164.53
Rate for Payer: Amerigroup CHIP/Medicaid	$26.92
Rate for Payer: BCBS of TX Blue Advantage	$89.74
Rate for Payer: BCBS of TX Blue Essentials	$107.69
Rate for Payer: BCBS of TX PPO	$119.66
Rate for Payer: Cash Price	$263.24
Rate for Payer: Multiplan Auto	$194.44
Rate for Payer: Multiplan Commercial	$194.44
Rate for Payer: Multiplan Workers Comp	$194.44
Rate for Payer: Scott and White EPO/PPO	$149.57
Rate for Payer: Superior Health Plan EPO	$40.68

KIT UNIVERSAL ARTERIAL

Facility

$299.14

Hospital Charge Code	145162
Hospital Revenue Code	272
Rate for Payer: Cash Price	$263.24

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Facility

$1,663.27

Hospital Charge Code	8634508
Hospital Revenue Code	272
Min. Negotiated Rate	$149.69
Max. Negotiated Rate	$1,081.13
Rate for Payer: Aetna Commercial	$914.80
Rate for Payer: Amerigroup CHIP/Medicaid	$149.69
Rate for Payer: BCBS of TX Blue Advantage	$498.98
Rate for Payer: BCBS of TX Blue Essentials	$598.78
Rate for Payer: BCBS of TX PPO	$665.31
Rate for Payer: Cash Price	$1,463.68
Rate for Payer: Multiplan Auto	$1,081.13
Rate for Payer: Multiplan Commercial	$1,081.13
Rate for Payer: Multiplan Workers Comp	$1,081.13
Rate for Payer: Scott and White EPO/PPO	$831.64
Rate for Payer: Superior Health Plan EPO	$226.20

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Facility

$1,663.27

Hospital Charge Code	8634508
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,463.68

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC

Facility

$40,025.40

Service Code	MSDRG 488
Min. Negotiated Rate	$15,052.58
Max. Negotiated Rate	$40,025.40
Rate for Payer: Aetna Commercial	$23,699.25
Rate for Payer: Aetna Medicare	$26,831.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,887.61
Rate for Payer: Amerigroup Medicare	$17,887.61
Rate for Payer: BCBS of TX Blue Advantage	$15,052.58
Rate for Payer: BCBS of TX Blue Essentials	$21,798.89
Rate for Payer: BCBS of TX Medicare	$17,887.61
Rate for Payer: BCBS of TX PPO	$24,221.92
Rate for Payer: Cigna Commercial	$27,133.01
Rate for Payer: Cigna Medicare	$17,887.61
Rate for Payer: Employer Direct Commercial	$17,887.61
Rate for Payer: Humana Medicare/TRICARE	$17,887.61
Rate for Payer: Molina Dual Medicare/Medicaid	$17,887.61
Rate for Payer: Molina Medicare	$17,887.61
Rate for Payer: Multiplan Auto	$40,025.40
Rate for Payer: Multiplan Commercial	$40,025.40
Rate for Payer: Multiplan Workers Comp	$40,025.40
Rate for Payer: Scott and White EPO/PPO	$18,432.75
Rate for Payer: Scott and White Medicare	$17,887.61
Rate for Payer: Superior Health Plan EPO	$17,887.61
Rate for Payer: Superior Health Plan Medicare	$17,887.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,887.61
Rate for Payer: Universal American Medicare	$17,887.61
Rate for Payer: Wellcare Medicare	$17,887.61
Rate for Payer: Wellmed Medicare	$17,887.61

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$23,516.30

Service Code	MSDRG 489
Min. Negotiated Rate	$10,829.88
Max. Negotiated Rate	$23,516.30
Rate for Payer: Aetna Commercial	$13,924.12
Rate for Payer: Aetna Medicare	$17,530.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,687.07
Rate for Payer: Amerigroup Medicare	$11,687.07
Rate for Payer: BCBS of TX Blue Advantage	$11,062.18
Rate for Payer: BCBS of TX Blue Essentials	$13,387.87
Rate for Payer: BCBS of TX Medicare	$11,687.07
Rate for Payer: BCBS of TX PPO	$14,875.99
Rate for Payer: Cigna Commercial	$15,941.58
Rate for Payer: Cigna Medicare	$11,687.07
Rate for Payer: Employer Direct Commercial	$11,687.07
Rate for Payer: Humana Medicare/TRICARE	$11,687.07
Rate for Payer: Molina Dual Medicare/Medicaid	$11,687.07
Rate for Payer: Molina Medicare	$11,687.07
Rate for Payer: Multiplan Auto	$23,516.30
Rate for Payer: Multiplan Commercial	$23,516.30
Rate for Payer: Multiplan Workers Comp	$23,516.30
Rate for Payer: Scott and White EPO/PPO	$10,829.88
Rate for Payer: Scott and White Medicare	$11,687.07
Rate for Payer: Superior Health Plan EPO	$11,687.07
Rate for Payer: Superior Health Plan Medicare	$11,687.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,687.07
Rate for Payer: Universal American Medicare	$11,687.07
Rate for Payer: Wellcare Medicare	$11,687.07
Rate for Payer: Wellmed Medicare	$11,687.07

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC

Facility

$38,157.70

Service Code	MSDRG 486
Min. Negotiated Rate	$17,186.13
Max. Negotiated Rate	$38,157.70
Rate for Payer: Aetna Commercial	$22,593.38
Rate for Payer: Aetna Medicare	$25,779.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,186.13
Rate for Payer: Amerigroup Medicare	$17,186.13
Rate for Payer: BCBS of TX Blue Advantage	$17,761.58
Rate for Payer: BCBS of TX Blue Essentials	$22,891.67
Rate for Payer: BCBS of TX Medicare	$17,186.13
Rate for Payer: BCBS of TX PPO	$25,436.17
Rate for Payer: Cigna Commercial	$25,866.90
Rate for Payer: Cigna Medicare	$17,186.13
Rate for Payer: Employer Direct Commercial	$17,186.13
Rate for Payer: Humana Medicare/TRICARE	$17,186.13
Rate for Payer: Molina Dual Medicare/Medicaid	$17,186.13
Rate for Payer: Molina Medicare	$17,186.13
Rate for Payer: Multiplan Auto	$38,157.70
Rate for Payer: Multiplan Commercial	$38,157.70
Rate for Payer: Multiplan Workers Comp	$38,157.70
Rate for Payer: Scott and White EPO/PPO	$17,572.62
Rate for Payer: Scott and White Medicare	$17,186.13
Rate for Payer: Superior Health Plan EPO	$17,186.13
Rate for Payer: Superior Health Plan Medicare	$17,186.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,186.13
Rate for Payer: Universal American Medicare	$17,186.13
Rate for Payer: Wellcare Medicare	$17,186.13
Rate for Payer: Wellmed Medicare	$17,186.13

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC

Facility

$62,586.00

Service Code	MSDRG 485
Min. Negotiated Rate	$26,260.96
Max. Negotiated Rate	$62,586.00
Rate for Payer: Aetna Commercial	$37,057.50
Rate for Payer: Aetna Medicare	$39,541.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,360.96
Rate for Payer: Amerigroup Medicare	$26,360.96
Rate for Payer: BCBS of TX Blue Advantage	$26,260.96
Rate for Payer: BCBS of TX Blue Essentials	$34,095.01
Rate for Payer: BCBS of TX Medicare	$26,360.96
Rate for Payer: BCBS of TX PPO	$37,884.81
Rate for Payer: Cigna Commercial	$42,426.72
Rate for Payer: Cigna Medicare	$26,360.96
Rate for Payer: Employer Direct Commercial	$26,360.96
Rate for Payer: Humana Medicare/TRICARE	$26,360.96
Rate for Payer: Molina Dual Medicare/Medicaid	$26,360.96
Rate for Payer: Molina Medicare	$26,360.96
Rate for Payer: Multiplan Auto	$62,586.00
Rate for Payer: Multiplan Commercial	$62,586.00
Rate for Payer: Multiplan Workers Comp	$62,586.00
Rate for Payer: Scott and White EPO/PPO	$28,822.50
Rate for Payer: Scott and White Medicare	$26,360.96
Rate for Payer: Superior Health Plan EPO	$26,360.96
Rate for Payer: Superior Health Plan Medicare	$26,360.96
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,360.96
Rate for Payer: Universal American Medicare	$26,360.96
Rate for Payer: Wellcare Medicare	$26,360.96
Rate for Payer: Wellmed Medicare	$26,360.96

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$29,353.10

Service Code	MSDRG 487
Min. Negotiated Rate	$13,256.90
Max. Negotiated Rate	$29,353.10
Rate for Payer: Aetna Commercial	$17,380.12
Rate for Payer: Aetna Medicare	$20,818.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,879.27
Rate for Payer: Amerigroup Medicare	$13,879.27
Rate for Payer: BCBS of TX Blue Advantage	$13,256.90
Rate for Payer: BCBS of TX Blue Essentials	$17,028.41
Rate for Payer: BCBS of TX Medicare	$13,879.27
Rate for Payer: BCBS of TX PPO	$18,921.19
Rate for Payer: Cigna Commercial	$19,898.31
Rate for Payer: Cigna Medicare	$13,879.27
Rate for Payer: Employer Direct Commercial	$13,879.27
Rate for Payer: Humana Medicare/TRICARE	$13,879.27
Rate for Payer: Molina Dual Medicare/Medicaid	$13,879.27
Rate for Payer: Molina Medicare	$13,879.27
Rate for Payer: Multiplan Auto	$29,353.10
Rate for Payer: Multiplan Commercial	$29,353.10
Rate for Payer: Multiplan Workers Comp	$29,353.10
Rate for Payer: Scott and White EPO/PPO	$13,517.88
Rate for Payer: Scott and White Medicare	$13,879.27
Rate for Payer: Superior Health Plan EPO	$13,879.27
Rate for Payer: Superior Health Plan Medicare	$13,879.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,879.27
Rate for Payer: Universal American Medicare	$13,879.27
Rate for Payer: Wellcare Medicare	$13,879.27
Rate for Payer: Wellmed Medicare	$13,879.27

KNIFE, RETROGRADE LIGAMENT DISPOSABLE STERILE -- DHF

Facility

$1,362.00

Hospital Charge Code	81828014
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,198.56

KNIFE, RETROGRADE LIGAMENT DISPOSABLE STERILE -- DHF

Facility

$1,362.00

Hospital Charge Code	81828014
Hospital Revenue Code	272
Min. Negotiated Rate	$122.58
Max. Negotiated Rate	$885.30
Rate for Payer: Aetna Commercial	$749.10
Rate for Payer: Amerigroup CHIP/Medicaid	$122.58
Rate for Payer: BCBS of TX Blue Advantage	$408.60
Rate for Payer: BCBS of TX Blue Essentials	$490.32
Rate for Payer: BCBS of TX PPO	$544.80
Rate for Payer: Cash Price	$1,198.56
Rate for Payer: Multiplan Auto	$885.30
Rate for Payer: Multiplan Commercial	$885.30
Rate for Payer: Multiplan Workers Comp	$885.30
Rate for Payer: Scott and White EPO/PPO	$681.00
Rate for Payer: Superior Health Plan EPO	$185.23

KORE FIBER 5CC

Facility

$6,283.13

Service Code	HCPCS C1713
Hospital Charge Code	145101
Hospital Revenue Code	278
Min. Negotiated Rate	$1,570.78
Max. Negotiated Rate	$3,141.56
Rate for Payer: Aetna Commercial	$1,884.94
Rate for Payer: Cash Price	$5,529.15
Rate for Payer: Cigna Commercial	$1,570.78
Rate for Payer: Multiplan Auto	$3,141.56
Rate for Payer: Multiplan Commercial	$3,141.56
Rate for Payer: Multiplan Workers Comp	$3,141.56
Rate for Payer: Scott and White EPO/PPO	$3,141.56

KORE FIBER 5CC

Facility

$6,283.13

Service Code	HCPCS C1713
Hospital Charge Code	145101
Hospital Revenue Code	278
Min. Negotiated Rate	$565.48
Max. Negotiated Rate	$3,141.56
Rate for Payer: Aetna Commercial	$1,884.94
Rate for Payer: Amerigroup CHIP/Medicaid	$565.48
Rate for Payer: BCBS of TX Blue Advantage	$1,884.94
Rate for Payer: BCBS of TX Blue Essentials	$2,261.93
Rate for Payer: BCBS of TX PPO	$2,513.25
Rate for Payer: Cash Price	$5,529.15
Rate for Payer: Multiplan Auto	$3,141.56
Rate for Payer: Multiplan Commercial	$3,141.56
Rate for Payer: Multiplan Workers Comp	$3,141.56
Rate for Payer: Scott and White EPO/PPO	$3,141.56
Rate for Payer: Superior Health Plan EPO	$854.51

KT ACCESS COMP HERO -- DHF

Facility

$2,447.84

Hospital Charge Code	81741233
Hospital Revenue Code	272
Min. Negotiated Rate	$220.31
Max. Negotiated Rate	$1,591.10
Rate for Payer: Aetna Commercial	$1,346.31
Rate for Payer: Amerigroup CHIP/Medicaid	$220.31
Rate for Payer: BCBS of TX Blue Advantage	$734.35
Rate for Payer: BCBS of TX Blue Essentials	$881.22
Rate for Payer: BCBS of TX PPO	$979.14
Rate for Payer: Cash Price	$2,154.10
Rate for Payer: Multiplan Auto	$1,591.10
Rate for Payer: Multiplan Commercial	$1,591.10
Rate for Payer: Multiplan Workers Comp	$1,591.10
Rate for Payer: Scott and White EPO/PPO	$1,223.92
Rate for Payer: Superior Health Plan EPO	$332.91

KT ACCESS COMP HERO -- DHF

Facility

$2,447.84

Hospital Charge Code	81741233
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,154.10

KT ANGIO LEFT HEART

Facility

$136.20

Hospital Charge Code	80325772
Hospital Revenue Code	270
Min. Negotiated Rate	$12.26
Max. Negotiated Rate	$88.53
Rate for Payer: Aetna Commercial	$74.91
Rate for Payer: Amerigroup CHIP/Medicaid	$12.26
Rate for Payer: BCBS of TX Blue Advantage	$40.86
Rate for Payer: BCBS of TX Blue Essentials	$49.03
Rate for Payer: BCBS of TX PPO	$54.48
Rate for Payer: Cash Price	$119.86
Rate for Payer: Multiplan Auto	$88.53
Rate for Payer: Multiplan Commercial	$88.53
Rate for Payer: Multiplan Workers Comp	$88.53
Rate for Payer: Scott and White EPO/PPO	$68.10
Rate for Payer: Superior Health Plan EPO	$18.52

KT ANGIO LEFT HEART

Facility

$136.20

Hospital Charge Code	80325772
Hospital Revenue Code	270
Rate for Payer: Cash Price	$119.86

Know your out-of-pocket cost for care.

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