White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Gore Propaten Thin Wall Removable Ringed Vascular Graft, 6 m

Facility

$5,876.12

Service Code	HCPCS C1760
Hospital Charge Code	82401332
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,995.76

GOWN, SIRUS, FABRNF, XL, 20/CS

Facility

$9.81

Hospital Charge Code	992772
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6.67

GOWN, SIRUS, FABRNF, XL, 20/CS

Facility

$9.81

Hospital Charge Code	992772
Hospital Revenue Code	272
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$7.06
Rate for Payer: Amerigroup CHIP/Medicaid	$0.88
Rate for Payer: BCBS of TX Blue Advantage	$2.94
Rate for Payer: BCBS of TX Blue Essentials	$3.53
Rate for Payer: BCBS of TX PPO	$3.92
Rate for Payer: Cash Price	$6.67
Rate for Payer: Cigna Medicaid	$7.06
Rate for Payer: Molina CHIP/Medicaid	$7.06
Rate for Payer: Multiplan Auto	$6.38
Rate for Payer: Multiplan Commercial	$6.38
Rate for Payer: Multiplan Workers Comp	$6.38
Rate for Payer: Parkland Medicaid	$7.06
Rate for Payer: Scott and White EPO/PPO	$4.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.06
Rate for Payer: Superior Health Plan EPO	$1.33

GOWN, SIRUS, NONRNF, RAGLAN, XL, ST, 30/CS

Facility

$22.76

Hospital Charge Code	993065
Hospital Revenue Code	270
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$16.39
Rate for Payer: Amerigroup CHIP/Medicaid	$2.05
Rate for Payer: BCBS of TX Blue Advantage	$6.83
Rate for Payer: BCBS of TX Blue Essentials	$8.19
Rate for Payer: BCBS of TX PPO	$9.10
Rate for Payer: Cash Price	$15.48
Rate for Payer: Cigna Medicaid	$16.39
Rate for Payer: Molina CHIP/Medicaid	$16.39
Rate for Payer: Multiplan Auto	$14.79
Rate for Payer: Multiplan Commercial	$14.79
Rate for Payer: Multiplan Workers Comp	$14.79
Rate for Payer: Parkland Medicaid	$16.39
Rate for Payer: Scott and White EPO/PPO	$11.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.39
Rate for Payer: Superior Health Plan EPO	$3.10

GOWN, SIRUS, NONRNF, RAGLAN, XL, ST, 30/CS

Facility

$22.76

Hospital Charge Code	993065
Hospital Revenue Code	270
Rate for Payer: Cash Price	$15.48

GOWN, SIRUS, NONRNF, XLN/2XL, 18/C

Facility

$15.73

Hospital Charge Code	992801
Hospital Revenue Code	272
Rate for Payer: Cash Price	$10.70

GOWN, SIRUS, NONRNF, XLN/2XL, 18/C

Facility

$15.73

Hospital Charge Code	992801
Hospital Revenue Code	272
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$11.33
Rate for Payer: Amerigroup CHIP/Medicaid	$1.42
Rate for Payer: BCBS of TX Blue Advantage	$4.72
Rate for Payer: BCBS of TX Blue Essentials	$5.66
Rate for Payer: BCBS of TX PPO	$6.29
Rate for Payer: Cash Price	$10.70
Rate for Payer: Cigna Medicaid	$11.33
Rate for Payer: Molina CHIP/Medicaid	$11.33
Rate for Payer: Multiplan Auto	$10.22
Rate for Payer: Multiplan Commercial	$10.22
Rate for Payer: Multiplan Workers Comp	$10.22
Rate for Payer: Parkland Medicaid	$11.33
Rate for Payer: Scott and White EPO/PPO	$7.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.33
Rate for Payer: Superior Health Plan EPO	$2.14

GOWN, SIRUS, NONRNF, XLN/XL, 20/CS

Facility

$12.26

Hospital Charge Code	992802
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8.34

GOWN, SIRUS, NONRNF, XLN/XL, 20/CS

Facility

$12.26

Hospital Charge Code	992802
Hospital Revenue Code	272
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$8.83
Rate for Payer: Amerigroup CHIP/Medicaid	$1.10
Rate for Payer: BCBS of TX Blue Advantage	$3.68
Rate for Payer: BCBS of TX Blue Essentials	$4.41
Rate for Payer: BCBS of TX PPO	$4.90
Rate for Payer: Cash Price	$8.34
Rate for Payer: Cigna Medicaid	$8.83
Rate for Payer: Molina CHIP/Medicaid	$8.83
Rate for Payer: Multiplan Auto	$7.97
Rate for Payer: Multiplan Commercial	$7.97
Rate for Payer: Multiplan Workers Comp	$7.97
Rate for Payer: Parkland Medicaid	$8.83
Rate for Payer: Scott and White EPO/PPO	$6.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.83
Rate for Payer: Superior Health Plan EPO	$1.67

GOWN, SIRUS, POLYRNF, XLN/XL, 20/CS

Facility

$12.84

Hospital Charge Code	992909
Hospital Revenue Code	270
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$9.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1.16
Rate for Payer: BCBS of TX Blue Advantage	$3.85
Rate for Payer: BCBS of TX Blue Essentials	$4.62
Rate for Payer: BCBS of TX PPO	$5.14
Rate for Payer: Cash Price	$8.73
Rate for Payer: Cigna Medicaid	$9.24
Rate for Payer: Molina CHIP/Medicaid	$9.24
Rate for Payer: Multiplan Auto	$8.35
Rate for Payer: Multiplan Commercial	$8.35
Rate for Payer: Multiplan Workers Comp	$8.35
Rate for Payer: Parkland Medicaid	$9.24
Rate for Payer: Scott and White EPO/PPO	$6.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.24
Rate for Payer: Superior Health Plan EPO	$1.75

GOWN, SIRUS, POLYRNF, XLN/XL, 20/CS

Facility

$12.84

Hospital Charge Code	992909
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.73

Grafix CORE / Stravix PRIME - per unit/ sq. cm

Facility

$903.62

Service Code	HCPCS Q4133
Hospital Charge Code	994158
Hospital Revenue Code	278
Min. Negotiated Rate	$81.33
Max. Negotiated Rate	$650.61
Rate for Payer: Amerigroup CHIP/Medicaid	$81.33
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$271.09
Rate for Payer: BCBS of TX Blue Essentials	$325.30
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$361.45
Rate for Payer: Cash Price	$614.46
Rate for Payer: Cash Price	$614.46
Rate for Payer: Cash Price	$614.46
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$650.61
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$650.61
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$451.81
Rate for Payer: Multiplan Commercial	$451.81
Rate for Payer: Multiplan Workers Comp	$451.81
Rate for Payer: Parkland Medicaid	$650.61
Rate for Payer: Scott and White EPO/PPO	$451.81
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$650.61
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

Grafix CORE / Stravix PRIME - per unit/ sq. cm

Facility

$903.62

Service Code	HCPCS Q4133
Hospital Charge Code	994158
Hospital Revenue Code	278
Min. Negotiated Rate	$225.91
Max. Negotiated Rate	$451.81
Rate for Payer: Cash Price	$614.46
Rate for Payer: Cigna Commercial	$225.91
Rate for Payer: Multiplan Auto	$451.81
Rate for Payer: Multiplan Commercial	$451.81
Rate for Payer: Multiplan Workers Comp	$451.81
Rate for Payer: Scott and White EPO/PPO	$451.81

Graft 15cmx20cm

Facility

$57,108.00

Service Code	HCPCS Q4205
Hospital Charge Code	118999
Hospital Revenue Code	278
Min. Negotiated Rate	$14,277.00
Max. Negotiated Rate	$28,554.00
Rate for Payer: Cash Price	$38,833.44
Rate for Payer: Cigna Commercial	$14,277.00
Rate for Payer: Multiplan Auto	$28,554.00
Rate for Payer: Multiplan Commercial	$28,554.00
Rate for Payer: Multiplan Workers Comp	$28,554.00
Rate for Payer: Scott and White EPO/PPO	$28,554.00

Graft 15cmx20cm

Facility

$57,108.00

Service Code	HCPCS Q4205
Hospital Charge Code	118999
Hospital Revenue Code	278
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$41,117.76
Rate for Payer: Amerigroup CHIP/Medicaid	$5,139.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$14.83
Rate for Payer: BCBS of TX Blue Essentials	$17.80
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$19.74
Rate for Payer: Cash Price	$38,833.44
Rate for Payer: Cash Price	$38,833.44
Rate for Payer: Cash Price	$38,833.44
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$41,117.76
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$41,117.76
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$28,554.00
Rate for Payer: Multiplan Commercial	$28,554.00
Rate for Payer: Multiplan Workers Comp	$28,554.00
Rate for Payer: Parkland Medicaid	$41,117.76
Rate for Payer: Scott and White EPO/PPO	$28,554.00
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41,117.76
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

GRAFT ART 50CM HMDIAL TI

Facility

$4,994.00

Hospital Charge Code	993864
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3,395.92

GRAFT ART 50CM HMDIAL TI

Facility

$4,994.00

Hospital Charge Code	993864
Hospital Revenue Code	270
Min. Negotiated Rate	$449.46
Max. Negotiated Rate	$3,595.68
Rate for Payer: Amerigroup CHIP/Medicaid	$449.46
Rate for Payer: BCBS of TX Blue Advantage	$1,498.20
Rate for Payer: BCBS of TX Blue Essentials	$1,797.84
Rate for Payer: BCBS of TX PPO	$1,997.60
Rate for Payer: Cash Price	$3,395.92
Rate for Payer: Cigna Medicaid	$3,595.68
Rate for Payer: Molina CHIP/Medicaid	$3,595.68
Rate for Payer: Multiplan Auto	$3,246.10
Rate for Payer: Multiplan Commercial	$3,246.10
Rate for Payer: Multiplan Workers Comp	$3,246.10
Rate for Payer: Parkland Medicaid	$3,595.68
Rate for Payer: Scott and White EPO/PPO	$2,497.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,595.68
Rate for Payer: Superior Health Plan EPO	$679.18

GRAFT CV 40CMX6MM BVN CLGN

Facility

$9,665.66

Service Code	HCPCS C1768
Hospital Charge Code	992739
Hospital Revenue Code	278
Min. Negotiated Rate	$2,416.41
Max. Negotiated Rate	$4,832.83
Rate for Payer: Cash Price	$6,572.65
Rate for Payer: Cigna Commercial	$2,416.41
Rate for Payer: Multiplan Auto	$4,832.83
Rate for Payer: Multiplan Commercial	$4,832.83
Rate for Payer: Multiplan Workers Comp	$4,832.83
Rate for Payer: Scott and White EPO/PPO	$4,832.83

GRAFT CV 40CMX6MM BVN CLGN

Facility

$9,665.66

Service Code	HCPCS C1768
Hospital Charge Code	992739
Hospital Revenue Code	278
Min. Negotiated Rate	$869.91
Max. Negotiated Rate	$6,959.28
Rate for Payer: Amerigroup CHIP/Medicaid	$869.91
Rate for Payer: BCBS of TX Blue Advantage	$2,899.70
Rate for Payer: BCBS of TX Blue Essentials	$3,479.64
Rate for Payer: BCBS of TX PPO	$3,866.26
Rate for Payer: Cash Price	$6,572.65
Rate for Payer: Cigna Medicaid	$6,959.28
Rate for Payer: Molina CHIP/Medicaid	$6,959.28
Rate for Payer: Multiplan Auto	$4,832.83
Rate for Payer: Multiplan Commercial	$4,832.83
Rate for Payer: Multiplan Workers Comp	$4,832.83
Rate for Payer: Parkland Medicaid	$6,959.28
Rate for Payer: Scott and White EPO/PPO	$4,832.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,959.28
Rate for Payer: Superior Health Plan EPO	$1,314.53

GRAFT CV 80CMX6MM 60CM REM RNG PRPTN

Facility

$17,108.43

Service Code	HCPCS C1768
Hospital Charge Code	992349
Hospital Revenue Code	278
Min. Negotiated Rate	$4,277.11
Max. Negotiated Rate	$8,554.22
Rate for Payer: Cash Price	$11,633.73
Rate for Payer: Cigna Commercial	$4,277.11
Rate for Payer: Multiplan Auto	$8,554.22
Rate for Payer: Multiplan Commercial	$8,554.22
Rate for Payer: Multiplan Workers Comp	$8,554.22
Rate for Payer: Scott and White EPO/PPO	$8,554.22

GRAFT CV 80CMX6MM 60CM REM RNG PRPTN

Facility

$17,108.43

Service Code	HCPCS C1768
Hospital Charge Code	992349
Hospital Revenue Code	278
Min. Negotiated Rate	$1,539.76
Max. Negotiated Rate	$12,318.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1,539.76
Rate for Payer: BCBS of TX Blue Advantage	$5,132.53
Rate for Payer: BCBS of TX Blue Essentials	$6,159.03
Rate for Payer: BCBS of TX PPO	$6,843.37
Rate for Payer: Cash Price	$11,633.73
Rate for Payer: Cigna Medicaid	$12,318.07
Rate for Payer: Molina CHIP/Medicaid	$12,318.07
Rate for Payer: Multiplan Auto	$8,554.22
Rate for Payer: Multiplan Commercial	$8,554.22
Rate for Payer: Multiplan Workers Comp	$8,554.22
Rate for Payer: Parkland Medicaid	$12,318.07
Rate for Payer: Scott and White EPO/PPO	$8,554.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,318.07
Rate for Payer: Superior Health Plan EPO	$2,326.75

Graft derma-fat-fascia

Facility

$10,992.01

Service Code	HCPCS 15770
Hospital Charge Code	9900136
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,474.57

Graft derma-fat-fascia

Facility

$10,000.00

Service Code	CPT 15770
Hospital Charge Code	36015770
Hospital Revenue Code	360
Min. Negotiated Rate	$1,457.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,457.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,559.87
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
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	$6,585.76
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

Graft derma-fat-fascia

Facility

$10,992.01

Service Code	HCPCS 15770
Hospital Charge Code	9900136
Hospital Revenue Code	360
Min. Negotiated Rate	$1,457.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,457.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,559.87
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cash Price	$7,474.57
Rate for Payer: Cash Price	$7,474.57
Rate for Payer: Cash Price	$7,474.57
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicaid	$7,914.25
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina CHIP/Medicaid	$7,914.25
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
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	$7,914.25
Rate for Payer: Scott and White EPO/PPO	$6,585.76
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,914.25
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

GRAFT DURAL DURAGEN 2IN X 2IN REGENERATION SUTURABLE ABSORBA

Facility

$2,934.88

Service Code	HCPCS C1768
Hospital Charge Code	992338
Hospital Revenue Code	278
Min. Negotiated Rate	$733.72
Max. Negotiated Rate	$1,467.44
Rate for Payer: Cash Price	$1,995.72
Rate for Payer: Cigna Commercial	$733.72
Rate for Payer: Multiplan Auto	$1,467.44
Rate for Payer: Multiplan Commercial	$1,467.44
Rate for Payer: Multiplan Workers Comp	$1,467.44
Rate for Payer: Scott and White EPO/PPO	$1,467.44

Know your out-of-pocket cost for care.

All Charges