White Rock Medical Center

All Charges

Charge

Type

Setting

Price

FIBERTAPE CERCLAGE 2MM W/ TIGERLINK SHUTTLE SUTURE

Facility

$4,889.00

Service Code	HCPCS C1776
Hospital Charge Code	146431
Hospital Revenue Code	278
Min. Negotiated Rate	$440.01
Max. Negotiated Rate	$3,520.08
Rate for Payer: Amerigroup CHIP/Medicaid	$440.01
Rate for Payer: BCBS of TX Blue Advantage	$1,466.70
Rate for Payer: BCBS of TX Blue Essentials	$1,760.04
Rate for Payer: BCBS of TX PPO	$1,955.60
Rate for Payer: Cash Price	$3,324.52
Rate for Payer: Cigna Medicaid	$3,520.08
Rate for Payer: Molina CHIP/Medicaid	$3,520.08
Rate for Payer: Multiplan Auto	$2,444.50
Rate for Payer: Multiplan Commercial	$2,444.50
Rate for Payer: Multiplan Workers Comp	$2,444.50
Rate for Payer: Parkland Medicaid	$3,520.08
Rate for Payer: Scott and White EPO/PPO	$2,444.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,520.08
Rate for Payer: Superior Health Plan EPO	$664.90

Fibrinogen Activity SO

Facility

$240.00

Service Code	HCPCS 85384
Hospital Charge Code	1600311
Hospital Revenue Code	305
Rate for Payer: Cash Price	$163.20

Fibrinogen Activity SO

Facility

$240.00

Service Code	HCPCS 85384
Hospital Charge Code	1600311
Hospital Revenue Code	305
Min. Negotiated Rate	$3.79
Max. Negotiated Rate	$172.80
Rate for Payer: Amerigroup CHIP/Medicaid	$3.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.72
Rate for Payer: Amerigroup Medicare	$9.72
Rate for Payer: BCBS of TX Blue Advantage	$72.00
Rate for Payer: BCBS of TX Blue Essentials	$86.40
Rate for Payer: BCBS of TX Medicare	$9.72
Rate for Payer: BCBS of TX PPO	$96.00
Rate for Payer: Cash Price	$163.20
Rate for Payer: Cash Price	$163.20
Rate for Payer: Cigna Medicaid	$172.80
Rate for Payer: Cigna Medicare	$9.72
Rate for Payer: Employer Direct Commercial	$9.72
Rate for Payer: Humana Medicare/TRICARE	$9.72
Rate for Payer: Molina CHIP/Medicaid	$172.80
Rate for Payer: Molina Dual Medicare/Medicaid	$9.72
Rate for Payer: Molina Medicare	$9.72
Rate for Payer: Multiplan Auto	$156.00
Rate for Payer: Multiplan Commercial	$156.00
Rate for Payer: Multiplan Workers Comp	$156.00
Rate for Payer: Parkland Medicaid	$172.80
Rate for Payer: Scott and White EPO/PPO	$12.15
Rate for Payer: Scott and White Medicare	$9.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$172.80
Rate for Payer: Superior Health Plan EPO	$9.72
Rate for Payer: Superior Health Plan Medicare	$9.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.72
Rate for Payer: Universal American Medicare	$9.72
Rate for Payer: Wellcare Medicare	$9.72
Rate for Payer: Wellmed Medicare	$9.72

Fibrinogen antigen

Facility

$57.84

Service Code	HCPCS 85385
Hospital Charge Code	994035
Hospital Revenue Code	305
Min. Negotiated Rate	$5.64
Max. Negotiated Rate	$41.64
Rate for Payer: Amerigroup CHIP/Medicaid	$5.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.46
Rate for Payer: Amerigroup Medicare	$14.46
Rate for Payer: BCBS of TX Blue Advantage	$17.35
Rate for Payer: BCBS of TX Blue Essentials	$20.82
Rate for Payer: BCBS of TX Medicare	$14.46
Rate for Payer: BCBS of TX PPO	$23.14
Rate for Payer: Cash Price	$39.33
Rate for Payer: Cash Price	$39.33
Rate for Payer: Cigna Medicaid	$41.64
Rate for Payer: Cigna Medicare	$14.46
Rate for Payer: Employer Direct Commercial	$14.46
Rate for Payer: Humana Medicare/TRICARE	$14.46
Rate for Payer: Molina CHIP/Medicaid	$41.64
Rate for Payer: Molina Dual Medicare/Medicaid	$14.46
Rate for Payer: Molina Medicare	$14.46
Rate for Payer: Multiplan Auto	$37.60
Rate for Payer: Multiplan Commercial	$37.60
Rate for Payer: Multiplan Workers Comp	$37.60
Rate for Payer: Parkland Medicaid	$41.64
Rate for Payer: Scott and White EPO/PPO	$18.07
Rate for Payer: Scott and White Medicare	$14.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41.64
Rate for Payer: Superior Health Plan EPO	$14.46
Rate for Payer: Superior Health Plan Medicare	$14.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.46
Rate for Payer: Universal American Medicare	$14.46
Rate for Payer: Wellcare Medicare	$14.46
Rate for Payer: Wellmed Medicare	$14.46

Fibrinogen antigen

Facility

$57.84

Service Code	HCPCS 85385
Hospital Charge Code	994035
Hospital Revenue Code	305
Rate for Payer: Cash Price	$39.33

Filleted finger or toe flap, including preparation of recipient site

Facility

$6,003.76

Service Code	HCPCS 14350
Hospital Charge Code	9900122
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,082.56

Filleted finger or toe flap, including preparation of recipient site

Facility

$6,003.76

Service Code	HCPCS 14350
Hospital Charge Code	9900122
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$4,082.56
Rate for Payer: Cash Price	$4,082.56
Rate for Payer: Cash Price	$4,082.56
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$4,322.71
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$4,322.71
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$4,322.71
Rate for Payer: Scott and White EPO/PPO	$3,834.46
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,322.71
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Filleted finger or toe flap, including preparation of recipient site

Facility

$10,000.00

Service Code	CPT 14350
Hospital Charge Code	36014350
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$3,834.46
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

FILTER, AIRVO DISINFECTION

Facility

$12.76

Hospital Charge Code	993548
Hospital Revenue Code	270
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$9.19
Rate for Payer: Amerigroup CHIP/Medicaid	$1.15
Rate for Payer: BCBS of TX Blue Advantage	$3.83
Rate for Payer: BCBS of TX Blue Essentials	$4.59
Rate for Payer: BCBS of TX PPO	$5.10
Rate for Payer: Cash Price	$8.68
Rate for Payer: Cigna Medicaid	$9.19
Rate for Payer: Molina CHIP/Medicaid	$9.19
Rate for Payer: Multiplan Auto	$8.29
Rate for Payer: Multiplan Commercial	$8.29
Rate for Payer: Multiplan Workers Comp	$8.29
Rate for Payer: Parkland Medicaid	$9.19
Rate for Payer: Scott and White EPO/PPO	$6.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.19
Rate for Payer: Superior Health Plan EPO	$1.74

FILTER, AIRVO DISINFECTION

Facility

$12.76

Hospital Charge Code	993548
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.68

FILTER AIRVO O2 2/PK

Facility

$12.30

Hospital Charge Code	993519
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.36

FILTER AIRVO O2 2/PK

Facility

$12.30

Hospital Charge Code	993519
Hospital Revenue Code	270
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$8.86
Rate for Payer: Amerigroup CHIP/Medicaid	$1.11
Rate for Payer: BCBS of TX Blue Advantage	$3.69
Rate for Payer: BCBS of TX Blue Essentials	$4.43
Rate for Payer: BCBS of TX PPO	$4.92
Rate for Payer: Cash Price	$8.36
Rate for Payer: Cigna Medicaid	$8.86
Rate for Payer: Molina CHIP/Medicaid	$8.86
Rate for Payer: Multiplan Auto	$8.00
Rate for Payer: Multiplan Commercial	$8.00
Rate for Payer: Multiplan Workers Comp	$8.00
Rate for Payer: Parkland Medicaid	$8.86
Rate for Payer: Scott and White EPO/PPO	$6.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.86
Rate for Payer: Superior Health Plan EPO	$1.67

FILTER BACTERIA HEPA GAS 5MPL

Facility

$40.52

Hospital Charge Code	993527
Hospital Revenue Code	270
Rate for Payer: Cash Price	$27.55

FILTER BACTERIA HEPA GAS 5MPL

Facility

$40.52

Hospital Charge Code	993527
Hospital Revenue Code	270
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$29.17
Rate for Payer: Amerigroup CHIP/Medicaid	$3.65
Rate for Payer: BCBS of TX Blue Advantage	$12.16
Rate for Payer: BCBS of TX Blue Essentials	$14.59
Rate for Payer: BCBS of TX PPO	$16.21
Rate for Payer: Cash Price	$27.55
Rate for Payer: Cigna Medicaid	$29.17
Rate for Payer: Molina CHIP/Medicaid	$29.17
Rate for Payer: Multiplan Auto	$26.34
Rate for Payer: Multiplan Commercial	$26.34
Rate for Payer: Multiplan Workers Comp	$26.34
Rate for Payer: Parkland Medicaid	$29.17
Rate for Payer: Scott and White EPO/PPO	$20.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.17
Rate for Payer: Superior Health Plan EPO	$5.51

FILTER BCTR/VIR 1.5CM 60 LPM ANES CRCT

Facility

$10.91

Hospital Charge Code	993475
Hospital Revenue Code	270
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$7.86
Rate for Payer: Amerigroup CHIP/Medicaid	$0.98
Rate for Payer: BCBS of TX Blue Advantage	$3.27
Rate for Payer: BCBS of TX Blue Essentials	$3.93
Rate for Payer: BCBS of TX PPO	$4.36
Rate for Payer: Cash Price	$7.42
Rate for Payer: Cigna Medicaid	$7.86
Rate for Payer: Molina CHIP/Medicaid	$7.86
Rate for Payer: Multiplan Auto	$7.09
Rate for Payer: Multiplan Commercial	$7.09
Rate for Payer: Multiplan Workers Comp	$7.09
Rate for Payer: Parkland Medicaid	$7.86
Rate for Payer: Scott and White EPO/PPO	$5.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.86
Rate for Payer: Superior Health Plan EPO	$1.48

FILTER BCTR/VIR 1.5CM 60 LPM ANES CRCT

Facility

$10.91

Hospital Charge Code	993475
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.42

FILTER BCTR/VIR 22MM 1.5MM D/X800

Facility

$18.74

Hospital Charge Code	993294
Hospital Revenue Code	270
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$13.49
Rate for Payer: Amerigroup CHIP/Medicaid	$1.69
Rate for Payer: BCBS of TX Blue Advantage	$5.62
Rate for Payer: BCBS of TX Blue Essentials	$6.75
Rate for Payer: BCBS of TX PPO	$7.50
Rate for Payer: Cash Price	$12.74
Rate for Payer: Cigna Medicaid	$13.49
Rate for Payer: Molina CHIP/Medicaid	$13.49
Rate for Payer: Multiplan Auto	$12.18
Rate for Payer: Multiplan Commercial	$12.18
Rate for Payer: Multiplan Workers Comp	$12.18
Rate for Payer: Parkland Medicaid	$13.49
Rate for Payer: Scott and White EPO/PPO	$9.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.49
Rate for Payer: Superior Health Plan EPO	$2.55

FILTER BCTR/VIR 22MM 1.5MM D/X800

Facility

$18.74

Hospital Charge Code	993294
Hospital Revenue Code	270
Rate for Payer: Cash Price	$12.74

filter capnoline

Facility

$118.40

Hospital Charge Code	132277
Hospital Revenue Code	270
Rate for Payer: Cash Price	$80.51

filter capnoline

Facility

$118.40

Hospital Charge Code	132277
Hospital Revenue Code	270
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$85.25
Rate for Payer: Amerigroup CHIP/Medicaid	$10.66
Rate for Payer: BCBS of TX Blue Advantage	$35.52
Rate for Payer: BCBS of TX Blue Essentials	$42.62
Rate for Payer: BCBS of TX PPO	$47.36
Rate for Payer: Cash Price	$80.51
Rate for Payer: Cigna Medicaid	$85.25
Rate for Payer: Molina CHIP/Medicaid	$85.25
Rate for Payer: Multiplan Auto	$76.96
Rate for Payer: Multiplan Commercial	$76.96
Rate for Payer: Multiplan Workers Comp	$76.96
Rate for Payer: Parkland Medicaid	$85.25
Rate for Payer: Scott and White EPO/PPO	$59.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$85.25
Rate for Payer: Superior Health Plan EPO	$16.10

FILTER CHARCOAL GAS VAPOR OER-PRO

Facility

$194.77

Hospital Charge Code	993927
Hospital Revenue Code	272
Min. Negotiated Rate	$17.53
Max. Negotiated Rate	$140.23
Rate for Payer: Amerigroup CHIP/Medicaid	$17.53
Rate for Payer: BCBS of TX Blue Advantage	$58.43
Rate for Payer: BCBS of TX Blue Essentials	$70.12
Rate for Payer: BCBS of TX PPO	$77.91
Rate for Payer: Cash Price	$132.44
Rate for Payer: Cigna Medicaid	$140.23
Rate for Payer: Molina CHIP/Medicaid	$140.23
Rate for Payer: Multiplan Auto	$126.60
Rate for Payer: Multiplan Commercial	$126.60
Rate for Payer: Multiplan Workers Comp	$126.60
Rate for Payer: Parkland Medicaid	$140.23
Rate for Payer: Scott and White EPO/PPO	$97.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.23
Rate for Payer: Superior Health Plan EPO	$26.49

FILTER CHARCOAL GAS VAPOR OER-PRO

Facility

$194.77

Hospital Charge Code	993927
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.44

FILTER EXPIRATORY DISPOSABLE ADULT

Facility

$71.43

Hospital Charge Code	993091
Hospital Revenue Code	270
Rate for Payer: Cash Price	$48.57

FILTER EXPIRATORY DISPOSABLE ADULT

Facility

$71.43

Hospital Charge Code	993091
Hospital Revenue Code	270
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$51.43
Rate for Payer: Amerigroup CHIP/Medicaid	$6.43
Rate for Payer: BCBS of TX Blue Advantage	$21.43
Rate for Payer: BCBS of TX Blue Essentials	$25.71
Rate for Payer: BCBS of TX PPO	$28.57
Rate for Payer: Cash Price	$48.57
Rate for Payer: Cigna Medicaid	$51.43
Rate for Payer: Molina CHIP/Medicaid	$51.43
Rate for Payer: Multiplan Auto	$46.43
Rate for Payer: Multiplan Commercial	$46.43
Rate for Payer: Multiplan Workers Comp	$46.43
Rate for Payer: Parkland Medicaid	$51.43
Rate for Payer: Scott and White EPO/PPO	$35.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.43
Rate for Payer: Superior Health Plan EPO	$9.71

FILTER EXTERNAL WATER

Facility

$106.69

Hospital Charge Code	993929
Hospital Revenue Code	272
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$76.82
Rate for Payer: Amerigroup CHIP/Medicaid	$9.60
Rate for Payer: BCBS of TX Blue Advantage	$32.01
Rate for Payer: BCBS of TX Blue Essentials	$38.41
Rate for Payer: BCBS of TX PPO	$42.68
Rate for Payer: Cash Price	$72.55
Rate for Payer: Cigna Medicaid	$76.82
Rate for Payer: Molina CHIP/Medicaid	$76.82
Rate for Payer: Multiplan Auto	$69.35
Rate for Payer: Multiplan Commercial	$69.35
Rate for Payer: Multiplan Workers Comp	$69.35
Rate for Payer: Parkland Medicaid	$76.82
Rate for Payer: Scott and White EPO/PPO	$53.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.82
Rate for Payer: Superior Health Plan EPO	$14.51

Know your out-of-pocket cost for care.

All Charges