White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Immunoglobulins A/E/G/M, Serum SO

Facility

$246.00

Service Code	HCPCS 82785
Hospital Charge Code	1701408
Hospital Revenue Code	301
Rate for Payer: Cash Price	$167.28

Immunoglobulins A/E/G/M, Serum SO

Facility

$246.00

Service Code	HCPCS 82785
Hospital Charge Code	1701408
Hospital Revenue Code	301
Min. Negotiated Rate	$6.42
Max. Negotiated Rate	$177.12
Rate for Payer: Amerigroup CHIP/Medicaid	$6.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.46
Rate for Payer: Amerigroup Medicare	$16.46
Rate for Payer: BCBS of TX Blue Advantage	$73.80
Rate for Payer: BCBS of TX Blue Essentials	$88.56
Rate for Payer: BCBS of TX Medicare	$16.46
Rate for Payer: BCBS of TX PPO	$98.40
Rate for Payer: Cash Price	$167.28
Rate for Payer: Cash Price	$167.28
Rate for Payer: Cigna Medicaid	$177.12
Rate for Payer: Cigna Medicare	$16.46
Rate for Payer: Employer Direct Commercial	$16.46
Rate for Payer: Humana Medicare/TRICARE	$16.46
Rate for Payer: Molina CHIP/Medicaid	$177.12
Rate for Payer: Molina Dual Medicare/Medicaid	$16.46
Rate for Payer: Molina Medicare	$16.46
Rate for Payer: Multiplan Auto	$159.90
Rate for Payer: Multiplan Commercial	$159.90
Rate for Payer: Multiplan Workers Comp	$159.90
Rate for Payer: Parkland Medicaid	$177.12
Rate for Payer: Scott and White EPO/PPO	$20.57
Rate for Payer: Scott and White Medicare	$16.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$177.12
Rate for Payer: Superior Health Plan EPO	$16.46
Rate for Payer: Superior Health Plan Medicare	$16.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.46
Rate for Payer: Universal American Medicare	$16.46
Rate for Payer: Wellcare Medicare	$16.46
Rate for Payer: Wellmed Medicare	$16.46

IMOBL SHLDR -- DHF

Facility

$130.67

Hospital Charge Code	81143505
Hospital Revenue Code	270
Min. Negotiated Rate	$11.76
Max. Negotiated Rate	$94.08
Rate for Payer: Amerigroup CHIP/Medicaid	$11.76
Rate for Payer: BCBS of TX Blue Advantage	$39.20
Rate for Payer: BCBS of TX Blue Essentials	$47.04
Rate for Payer: BCBS of TX PPO	$52.27
Rate for Payer: Cash Price	$88.86
Rate for Payer: Cigna Medicaid	$94.08
Rate for Payer: Molina CHIP/Medicaid	$94.08
Rate for Payer: Multiplan Auto	$84.94
Rate for Payer: Multiplan Commercial	$84.94
Rate for Payer: Multiplan Workers Comp	$84.94
Rate for Payer: Parkland Medicaid	$94.08
Rate for Payer: Scott and White EPO/PPO	$65.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$94.08
Rate for Payer: Superior Health Plan EPO	$17.77

IMOBL SHLDR -- DHF

Facility

$130.67

Hospital Charge Code	81143505
Hospital Revenue Code	270
Rate for Payer: Cash Price	$88.86

IMP BN SUBST FOAM 5CC -- DHF

Facility

$10,538.00

Service Code	HCPCS C1734
Hospital Charge Code	40112013
Hospital Revenue Code	278
Min. Negotiated Rate	$948.42
Max. Negotiated Rate	$7,587.36
Rate for Payer: Amerigroup CHIP/Medicaid	$948.42
Rate for Payer: BCBS of TX Blue Advantage	$3,161.40
Rate for Payer: BCBS of TX Blue Essentials	$3,793.68
Rate for Payer: BCBS of TX PPO	$4,215.20
Rate for Payer: Cash Price	$7,165.84
Rate for Payer: Cigna Medicaid	$7,587.36
Rate for Payer: Molina CHIP/Medicaid	$7,587.36
Rate for Payer: Multiplan Auto	$5,269.00
Rate for Payer: Multiplan Commercial	$5,269.00
Rate for Payer: Multiplan Workers Comp	$5,269.00
Rate for Payer: Parkland Medicaid	$7,587.36
Rate for Payer: Scott and White EPO/PPO	$5,269.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,587.36
Rate for Payer: Superior Health Plan EPO	$1,433.17

IMP BN SUBST FOAM 5CC -- DHF

Facility

$10,538.00

Service Code	HCPCS C1734
Hospital Charge Code	40112013
Hospital Revenue Code	278
Min. Negotiated Rate	$2,634.50
Max. Negotiated Rate	$5,269.00
Rate for Payer: Cash Price	$7,165.84
Rate for Payer: Cigna Commercial	$2,634.50
Rate for Payer: Multiplan Auto	$5,269.00
Rate for Payer: Multiplan Commercial	$5,269.00
Rate for Payer: Multiplan Workers Comp	$5,269.00
Rate for Payer: Scott and White EPO/PPO	$5,269.00

imp bone vitoss 5ml

Facility

$13,044.00

Service Code	HCPCS C1734
Hospital Charge Code	8666519
Hospital Revenue Code	278
Min. Negotiated Rate	$1,173.96
Max. Negotiated Rate	$9,391.68
Rate for Payer: Amerigroup CHIP/Medicaid	$1,173.96
Rate for Payer: BCBS of TX Blue Advantage	$3,913.20
Rate for Payer: BCBS of TX Blue Essentials	$4,695.84
Rate for Payer: BCBS of TX PPO	$5,217.60
Rate for Payer: Cash Price	$8,869.92
Rate for Payer: Cigna Medicaid	$9,391.68
Rate for Payer: Molina CHIP/Medicaid	$9,391.68
Rate for Payer: Multiplan Auto	$6,522.00
Rate for Payer: Multiplan Commercial	$6,522.00
Rate for Payer: Multiplan Workers Comp	$6,522.00
Rate for Payer: Parkland Medicaid	$9,391.68
Rate for Payer: Scott and White EPO/PPO	$6,522.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,391.68
Rate for Payer: Superior Health Plan EPO	$1,773.98

imp bone vitoss 5ml

Facility

$13,044.00

Service Code	HCPCS C1734
Hospital Charge Code	8666519
Hospital Revenue Code	278
Min. Negotiated Rate	$3,261.00
Max. Negotiated Rate	$6,522.00
Rate for Payer: Cash Price	$8,869.92
Rate for Payer: Cigna Commercial	$3,261.00
Rate for Payer: Multiplan Auto	$6,522.00
Rate for Payer: Multiplan Commercial	$6,522.00
Rate for Payer: Multiplan Workers Comp	$6,522.00
Rate for Payer: Scott and White EPO/PPO	$6,522.00

IMPL ANCHOR SUTURE WITH ORTHOCORD

Facility

$5,215.00

Service Code	HCPCS C1713
Hospital Charge Code	8446469
Hospital Revenue Code	278
Min. Negotiated Rate	$469.35
Max. Negotiated Rate	$3,754.80
Rate for Payer: Amerigroup CHIP/Medicaid	$469.35
Rate for Payer: BCBS of TX Blue Advantage	$1,564.50
Rate for Payer: BCBS of TX Blue Essentials	$1,877.40
Rate for Payer: BCBS of TX PPO	$2,086.00
Rate for Payer: Cash Price	$3,546.20
Rate for Payer: Cigna Medicaid	$3,754.80
Rate for Payer: Molina CHIP/Medicaid	$3,754.80
Rate for Payer: Multiplan Auto	$2,607.50
Rate for Payer: Multiplan Commercial	$2,607.50
Rate for Payer: Multiplan Workers Comp	$2,607.50
Rate for Payer: Parkland Medicaid	$3,754.80
Rate for Payer: Scott and White EPO/PPO	$2,607.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,754.80
Rate for Payer: Superior Health Plan EPO	$709.24

IMPL ANCHOR SUTURE WITH ORTHOCORD

Facility

$5,215.00

Service Code	HCPCS C1713
Hospital Charge Code	8446469
Hospital Revenue Code	278
Min. Negotiated Rate	$1,303.75
Max. Negotiated Rate	$2,607.50
Rate for Payer: Cash Price	$3,546.20
Rate for Payer: Cigna Commercial	$1,303.75
Rate for Payer: Multiplan Auto	$2,607.50
Rate for Payer: Multiplan Commercial	$2,607.50
Rate for Payer: Multiplan Workers Comp	$2,607.50
Rate for Payer: Scott and White EPO/PPO	$2,607.50

Implantable access catheter (e.g., venous, arterial, epidural subarachnoid, or peritoneal

Facility

$220.00

Service Code	HCPCS A4300
Hospital Charge Code	991112
Hospital Revenue Code	272
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$158.40
Rate for Payer: Amerigroup CHIP/Medicaid	$19.80
Rate for Payer: BCBS of TX Blue Advantage	$66.00
Rate for Payer: BCBS of TX Blue Essentials	$79.20
Rate for Payer: BCBS of TX PPO	$88.00
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cigna Medicaid	$158.40
Rate for Payer: Molina CHIP/Medicaid	$158.40
Rate for Payer: Multiplan Auto	$143.00
Rate for Payer: Multiplan Commercial	$143.00
Rate for Payer: Multiplan Workers Comp	$143.00
Rate for Payer: Parkland Medicaid	$158.40
Rate for Payer: Scott and White EPO/PPO	$110.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$158.40
Rate for Payer: Superior Health Plan EPO	$29.92

Implantable access catheter (e.g., venous, arterial, epidural subarachnoid, or peritoneal

Facility

$220.00

Service Code	HCPCS A4300
Hospital Charge Code	991112
Hospital Revenue Code	272
Rate for Payer: Cash Price	$149.60

Implantable D142 Inogen El ICD DF4 - DRExtended Longevity Implantable Cardioverter Defibrillator

Facility

$83,759.03

Service Code	HCPCS 33241
Hospital Charge Code	991148
Hospital Revenue Code	481
Rate for Payer: Cash Price	$56,956.14

Implantable D142 Inogen El ICD DF4 - DRExtended Longevity Implantable Cardioverter Defibrillator

Facility

$83,759.03

Service Code	HCPCS 33241
Hospital Charge Code	991148
Hospital Revenue Code	481
Min. Negotiated Rate	$259.32
Max. Negotiated Rate	$60,306.50
Rate for Payer: Amerigroup CHIP/Medicaid	$7,538.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,753.99
Rate for Payer: Amerigroup Medicare	$3,753.99
Rate for Payer: BCBS of TX Blue Advantage	$4,983.30
Rate for Payer: BCBS of TX Blue Essentials	$5,968.02
Rate for Payer: BCBS of TX Medicare	$3,753.99
Rate for Payer: BCBS of TX PPO	$7,519.71
Rate for Payer: Cash Price	$56,956.14
Rate for Payer: Cash Price	$56,956.14
Rate for Payer: Cash Price	$56,956.14
Rate for Payer: Cigna Commercial	$7,935.26
Rate for Payer: Cigna Medicaid	$60,306.50
Rate for Payer: Cigna Medicare	$3,753.99
Rate for Payer: Employer Direct Commercial	$3,753.99
Rate for Payer: Humana Medicare/TRICARE	$3,753.99
Rate for Payer: Molina CHIP/Medicaid	$60,306.50
Rate for Payer: Molina Dual Medicare/Medicaid	$3,753.99
Rate for Payer: Molina Medicare	$3,753.99
Rate for Payer: Multiplan Auto	$54,443.37
Rate for Payer: Multiplan Commercial	$54,443.37
Rate for Payer: Multiplan Workers Comp	$54,443.37
Rate for Payer: Parkland Medicaid	$60,306.50
Rate for Payer: Scott and White EPO/PPO	$259.32
Rate for Payer: Scott and White Medicare	$3,753.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60,306.50
Rate for Payer: Superior Health Plan EPO	$3,753.99
Rate for Payer: Superior Health Plan Medicare	$3,753.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,753.99
Rate for Payer: Universal American Medicare	$3,753.99
Rate for Payer: Wellcare Medicare	$3,753.99
Rate for Payer: Wellmed Medicare	$3,753.99

Implantable D142 Inogen El ICD DF4 - DRExtended Longevity Implantable Cardioverter Defibrillator

Facility

$5,613.00

Service Code	HCPCS 33241
Hospital Charge Code	2302313
Hospital Revenue Code	275
Min. Negotiated Rate	$505.17
Max. Negotiated Rate	$7,935.26
Rate for Payer: Amerigroup CHIP/Medicaid	$505.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,753.99
Rate for Payer: Amerigroup Medicare	$3,753.99
Rate for Payer: BCBS of TX Blue Advantage	$4,983.30
Rate for Payer: BCBS of TX Blue Essentials	$5,968.02
Rate for Payer: BCBS of TX Medicare	$3,753.99
Rate for Payer: BCBS of TX PPO	$7,519.71
Rate for Payer: Cash Price	$3,816.84
Rate for Payer: Cash Price	$3,816.84
Rate for Payer: Cash Price	$3,816.84
Rate for Payer: Cigna Commercial	$7,935.26
Rate for Payer: Cigna Medicaid	$4,041.36
Rate for Payer: Cigna Medicare	$3,753.99
Rate for Payer: Employer Direct Commercial	$3,753.99
Rate for Payer: Humana Medicare/TRICARE	$3,753.99
Rate for Payer: Molina CHIP/Medicaid	$4,041.36
Rate for Payer: Molina Dual Medicare/Medicaid	$3,753.99
Rate for Payer: Molina Medicare	$3,753.99
Rate for Payer: Multiplan Auto	$2,806.50
Rate for Payer: Multiplan Commercial	$2,806.50
Rate for Payer: Multiplan Workers Comp	$2,806.50
Rate for Payer: Parkland Medicaid	$4,041.36
Rate for Payer: Scott and White EPO/PPO	$2,806.50
Rate for Payer: Scott and White Medicare	$3,753.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,041.36
Rate for Payer: Superior Health Plan EPO	$3,753.99
Rate for Payer: Superior Health Plan Medicare	$3,753.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,753.99
Rate for Payer: Universal American Medicare	$3,753.99
Rate for Payer: Wellcare Medicare	$3,753.99
Rate for Payer: Wellmed Medicare	$3,753.99

Implantable D142 Inogen El ICD DF4 - DRExtended Longevity Implantable Cardioverter Defibrillator

Facility

$5,613.00

Service Code	HCPCS 33241
Hospital Charge Code	2302313
Hospital Revenue Code	275
Min. Negotiated Rate	$1,403.25
Max. Negotiated Rate	$2,806.50
Rate for Payer: Cash Price	$3,816.84
Rate for Payer: Cigna Commercial	$1,403.25
Rate for Payer: Multiplan Auto	$2,806.50
Rate for Payer: Multiplan Commercial	$2,806.50
Rate for Payer: Multiplan Workers Comp	$2,806.50
Rate for Payer: Scott and White EPO/PPO	$2,806.50

IMPLANTABLE HEART ASSIST SYSTEMS

Facility

$62,572.26

Service Code	APR-DRG 1611
Min. Negotiated Rate	$58,995.32
Max. Negotiated Rate	$62,572.26
Rate for Payer: Amerigroup CHIP/Medicaid	$58,995.32
Rate for Payer: Cigna Medicaid	$58,995.32
Rate for Payer: Molina CHIP/Medicaid	$58,995.32
Rate for Payer: Parkland Medicaid	$58,995.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62,572.26

IMPLANTABLE HEART ASSIST SYSTEMS

Facility

$65,976.01

Service Code	APR-DRG 1612
Min. Negotiated Rate	$62,204.50
Max. Negotiated Rate	$65,976.01
Rate for Payer: Amerigroup CHIP/Medicaid	$62,204.50
Rate for Payer: Cigna Medicaid	$62,204.50
Rate for Payer: Molina CHIP/Medicaid	$62,204.50
Rate for Payer: Parkland Medicaid	$62,204.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65,976.01

IMPLANTABLE HEART ASSIST SYSTEMS

Facility

$176,090.31

Service Code	APR-DRG 1614
Min. Negotiated Rate	$166,024.11
Max. Negotiated Rate	$176,090.31
Rate for Payer: Amerigroup CHIP/Medicaid	$166,024.11
Rate for Payer: Cigna Medicaid	$166,024.11
Rate for Payer: Molina CHIP/Medicaid	$166,024.11
Rate for Payer: Parkland Medicaid	$166,024.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$176,090.31

IMPLANTABLE HEART ASSIST SYSTEMS

Facility

$91,780.64

Service Code	APR-DRG 1613
Min. Negotiated Rate	$86,534.01
Max. Negotiated Rate	$91,780.64
Rate for Payer: Amerigroup CHIP/Medicaid	$86,534.01
Rate for Payer: Cigna Medicaid	$86,534.01
Rate for Payer: Molina CHIP/Medicaid	$86,534.01
Rate for Payer: Parkland Medicaid	$86,534.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91,780.64

IMPLANT, ANCHOR SUTURE W/PROKNOT PEEK GRYPHON

Facility

$3,651.00

Service Code	HCPCS C1713
Hospital Charge Code	139089
Hospital Revenue Code	278
Min. Negotiated Rate	$328.59
Max. Negotiated Rate	$2,628.72
Rate for Payer: Amerigroup CHIP/Medicaid	$328.59
Rate for Payer: BCBS of TX Blue Advantage	$1,095.30
Rate for Payer: BCBS of TX Blue Essentials	$1,314.36
Rate for Payer: BCBS of TX PPO	$1,460.40
Rate for Payer: Cash Price	$2,482.68
Rate for Payer: Cigna Medicaid	$2,628.72
Rate for Payer: Molina CHIP/Medicaid	$2,628.72
Rate for Payer: Multiplan Auto	$1,825.50
Rate for Payer: Multiplan Commercial	$1,825.50
Rate for Payer: Multiplan Workers Comp	$1,825.50
Rate for Payer: Parkland Medicaid	$2,628.72
Rate for Payer: Scott and White EPO/PPO	$1,825.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,628.72
Rate for Payer: Superior Health Plan EPO	$496.54

IMPLANT, ANCHOR SUTURE W/PROKNOT PEEK GRYPHON

Facility

$3,651.00

Service Code	HCPCS C1713
Hospital Charge Code	139089
Hospital Revenue Code	278
Min. Negotiated Rate	$912.75
Max. Negotiated Rate	$1,825.50
Rate for Payer: Cash Price	$2,482.68
Rate for Payer: Cigna Commercial	$912.75
Rate for Payer: Multiplan Auto	$1,825.50
Rate for Payer: Multiplan Commercial	$1,825.50
Rate for Payer: Multiplan Workers Comp	$1,825.50
Rate for Payer: Scott and White EPO/PPO	$1,825.50

Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, br

Facility

$878.48

Service Code	HCPCS 15777
Hospital Charge Code	9900138
Hospital Revenue Code	360
Rate for Payer: Cash Price	$597.37

Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, br

Facility

$878.48

Service Code	HCPCS 15777
Hospital Charge Code	9900138
Hospital Revenue Code	360
Min. Negotiated Rate	$79.06
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$79.06
Rate for Payer: BCBS of TX Blue Advantage	$263.54
Rate for Payer: BCBS of TX Blue Essentials	$316.25
Rate for Payer: BCBS of TX PPO	$351.39
Rate for Payer: Cash Price	$597.37
Rate for Payer: Cash Price	$597.37
Rate for Payer: Cigna Medicaid	$632.51
Rate for Payer: Molina CHIP/Medicaid	$632.51
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	$632.51
Rate for Payer: Scott and White EPO/PPO	$439.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$632.51
Rate for Payer: Superior Health Plan EPO	$119.47

Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, br

Facility

$10,000.00

Service Code	CPT 15777
Hospital Charge Code	36015777
Hospital Revenue Code	360
Min. Negotiated Rate	$259.38
Max. Negotiated Rate	$10,000.00
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	$259.38

Know your out-of-pocket cost for care.

All Charges