White Rock Medical Center

All Charges

Charge

Type

Setting

Price

INSRT/REPOSTN ELECT SNGL/DUAL AICD

Facility

$41,346.00

Service Code	HCPCS 33249
Hospital Charge Code	2300127
Hospital Revenue Code	360
Rate for Payer: Cash Price	$28,115.28

INSRT/REPOSTN ELECT SNGL/DUAL AICD

Facility

$41,346.00

Service Code	HCPCS 33249
Hospital Charge Code	2300127
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$81,352.25
Rate for Payer: Scott and White EPO/PPO	$58,334.01
Rate for Payer: Amerigroup CHIP/Medicaid	$21,852.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$31,531.90
Rate for Payer: Amerigroup Medicare	$31,531.90
Rate for Payer: BCBS of TX Blue Advantage	$53,912.01
Rate for Payer: BCBS of TX Blue Essentials	$64,565.28
Rate for Payer: BCBS of TX Medicare	$31,531.90
Rate for Payer: BCBS of TX PPO	$81,352.25
Rate for Payer: Cash Price	$28,115.28
Rate for Payer: Cash Price	$28,115.28
Rate for Payer: Cash Price	$28,115.28
Rate for Payer: Cigna Commercial	$66,652.72
Rate for Payer: Cigna Medicaid	$29,769.12
Rate for Payer: Cigna Medicare	$31,531.90
Rate for Payer: Employer Direct Commercial	$31,531.90
Rate for Payer: Humana Medicare/TRICARE	$31,531.90
Rate for Payer: Molina CHIP/Medicaid	$29,769.12
Rate for Payer: Molina Dual Medicare/Medicaid	$31,531.90
Rate for Payer: Molina Medicare	$31,531.90
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	$29,769.12
Rate for Payer: Scott and White Medicare	$31,531.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,769.12
Rate for Payer: Superior Health Plan EPO	$31,531.90
Rate for Payer: Superior Health Plan Medicare	$31,531.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$31,531.90
Rate for Payer: Universal American Medicare	$31,531.90
Rate for Payer: Wellcare Medicare	$31,531.90
Rate for Payer: Wellmed Medicare	$31,531.90

INSRT SUBQ CAR RHYTHM MNTR

Facility

$18,217.00

Service Code	HCPCS 33285
Hospital Charge Code	2300090
Hospital Revenue Code	481
Rate for Payer: Cash Price	$12,387.56

INSRT SUBQ CAR RHYTHM MNTR

Facility

$18,217.00

Service Code	HCPCS 33285
Hospital Charge Code	2300090
Hospital Revenue Code	481
Min. Negotiated Rate	$1,639.53
Max. Negotiated Rate	$19,257.46
Rate for Payer: Amerigroup CHIP/Medicaid	$1,639.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,313.10
Rate for Payer: Amerigroup Medicare	$8,313.10
Rate for Payer: BCBS of TX Blue Advantage	$12,761.89
Rate for Payer: BCBS of TX Blue Essentials	$15,283.70
Rate for Payer: BCBS of TX Medicare	$8,313.10
Rate for Payer: BCBS of TX PPO	$19,257.46
Rate for Payer: Cash Price	$12,387.56
Rate for Payer: Cash Price	$12,387.56
Rate for Payer: Cash Price	$12,387.56
Rate for Payer: Cigna Commercial	$17,572.38
Rate for Payer: Cigna Medicaid	$13,116.24
Rate for Payer: Cigna Medicare	$8,313.10
Rate for Payer: Employer Direct Commercial	$8,313.10
Rate for Payer: Humana Medicare/TRICARE	$8,313.10
Rate for Payer: Molina CHIP/Medicaid	$13,116.24
Rate for Payer: Molina Dual Medicare/Medicaid	$8,313.10
Rate for Payer: Molina Medicare	$8,313.10
Rate for Payer: Multiplan Auto	$11,841.05
Rate for Payer: Multiplan Commercial	$11,841.05
Rate for Payer: Multiplan Workers Comp	$11,841.05
Rate for Payer: Parkland Medicaid	$13,116.24
Rate for Payer: Scott and White EPO/PPO	$9,108.50
Rate for Payer: Scott and White Medicare	$8,313.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,116.24
Rate for Payer: Superior Health Plan EPO	$8,313.10
Rate for Payer: Superior Health Plan Medicare	$8,313.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,313.10
Rate for Payer: Universal American Medicare	$8,313.10
Rate for Payer: Wellcare Medicare	$8,313.10
Rate for Payer: Wellmed Medicare	$8,313.10

INST BIOPSY DISP -- DHF

Facility

$249.70

Hospital Charge Code	80812290
Hospital Revenue Code	272
Rate for Payer: Cash Price	$169.80

INST BIOPSY DISP -- DHF

Facility

$249.70

Hospital Charge Code	80812290
Hospital Revenue Code	272
Min. Negotiated Rate	$22.47
Max. Negotiated Rate	$179.78
Rate for Payer: Amerigroup CHIP/Medicaid	$22.47
Rate for Payer: BCBS of TX Blue Advantage	$74.91
Rate for Payer: BCBS of TX Blue Essentials	$89.89
Rate for Payer: BCBS of TX PPO	$99.88
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cigna Medicaid	$179.78
Rate for Payer: Molina CHIP/Medicaid	$179.78
Rate for Payer: Multiplan Auto	$162.31
Rate for Payer: Multiplan Commercial	$162.31
Rate for Payer: Multiplan Workers Comp	$162.31
Rate for Payer: Parkland Medicaid	$179.78
Rate for Payer: Scott and White EPO/PPO	$124.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$179.78
Rate for Payer: Superior Health Plan EPO	$33.96

INS TEMP BLAD CTH COMPLX

Facility

$919.00

Service Code	HCPCS 51703
Hospital Charge Code	4619901
Hospital Revenue Code	360
Rate for Payer: Cash Price	$624.92

INS TEMP BLAD CTH COMPLX

Facility

$919.00

Service Code	HCPCS 51703
Hospital Charge Code	4619901
Hospital Revenue Code	360
Min. Negotiated Rate	$57.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$57.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$129.26
Rate for Payer: Amerigroup Medicare	$129.26
Rate for Payer: BCBS of TX Blue Advantage	$116.75
Rate for Payer: BCBS of TX Blue Essentials	$139.82
Rate for Payer: BCBS of TX Medicare	$129.26
Rate for Payer: BCBS of TX PPO	$176.17
Rate for Payer: Cash Price	$624.92
Rate for Payer: Cash Price	$624.92
Rate for Payer: Cash Price	$624.92
Rate for Payer: Cigna Commercial	$273.24
Rate for Payer: Cigna Medicaid	$661.68
Rate for Payer: Cigna Medicare	$129.26
Rate for Payer: Employer Direct Commercial	$129.26
Rate for Payer: Humana Medicare/TRICARE	$129.26
Rate for Payer: Molina CHIP/Medicaid	$661.68
Rate for Payer: Molina Dual Medicare/Medicaid	$129.26
Rate for Payer: Molina Medicare	$129.26
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	$661.68
Rate for Payer: Scott and White EPO/PPO	$239.13
Rate for Payer: Scott and White Medicare	$129.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$661.68
Rate for Payer: Superior Health Plan EPO	$129.26
Rate for Payer: Superior Health Plan Medicare	$129.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$129.26
Rate for Payer: Universal American Medicare	$129.26
Rate for Payer: Wellcare Medicare	$129.26
Rate for Payer: Wellmed Medicare	$129.26

INST ENDO KITTNER DISP -- DHF

Facility

$45.58

Hospital Charge Code	80814155
Hospital Revenue Code	270
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$32.82
Rate for Payer: Amerigroup CHIP/Medicaid	$4.10
Rate for Payer: BCBS of TX Blue Advantage	$13.67
Rate for Payer: BCBS of TX Blue Essentials	$16.41
Rate for Payer: BCBS of TX PPO	$18.23
Rate for Payer: Cash Price	$30.99
Rate for Payer: Cigna Medicaid	$32.82
Rate for Payer: Molina CHIP/Medicaid	$32.82
Rate for Payer: Multiplan Auto	$29.63
Rate for Payer: Multiplan Commercial	$29.63
Rate for Payer: Multiplan Workers Comp	$29.63
Rate for Payer: Parkland Medicaid	$32.82
Rate for Payer: Scott and White EPO/PPO	$22.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.82
Rate for Payer: Superior Health Plan EPO	$6.20

INST ENDO KITTNER DISP -- DHF

Facility

$45.58

Hospital Charge Code	80814155
Hospital Revenue Code	270
Rate for Payer: Cash Price	$30.99

INSTR STAPLER SUREFORM 60

Facility

$2,406.20

Hospital Charge Code	8690510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,636.22

INSTR STAPLER SUREFORM 60

Facility

$2,406.20

Hospital Charge Code	8690510
Hospital Revenue Code	272
Min. Negotiated Rate	$216.56
Max. Negotiated Rate	$1,732.46
Rate for Payer: Amerigroup CHIP/Medicaid	$216.56
Rate for Payer: BCBS of TX Blue Advantage	$721.86
Rate for Payer: BCBS of TX Blue Essentials	$866.23
Rate for Payer: BCBS of TX PPO	$962.48
Rate for Payer: Cash Price	$1,636.22
Rate for Payer: Cigna Medicaid	$1,732.46
Rate for Payer: Molina CHIP/Medicaid	$1,732.46
Rate for Payer: Multiplan Auto	$1,564.03
Rate for Payer: Multiplan Commercial	$1,564.03
Rate for Payer: Multiplan Workers Comp	$1,564.03
Rate for Payer: Parkland Medicaid	$1,732.46
Rate for Payer: Scott and White EPO/PPO	$1,203.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,732.46
Rate for Payer: Superior Health Plan EPO	$327.24

INSTRUMENT, GUIDE SPEED 2.6MM FOR 3.5MM T10 30MM

Facility

$2,592.34

Hospital Charge Code	141426
Hospital Revenue Code	274
Min. Negotiated Rate	$648.09
Max. Negotiated Rate	$1,296.17
Rate for Payer: Cash Price	$1,762.79
Rate for Payer: Cigna Commercial	$648.09
Rate for Payer: Multiplan Auto	$1,296.17
Rate for Payer: Multiplan Commercial	$1,296.17
Rate for Payer: Multiplan Workers Comp	$1,296.17
Rate for Payer: Scott and White EPO/PPO	$1,296.17

INSTRUMENT, GUIDE SPEED 2.6MM FOR 3.5MM T10 30MM

Facility

$2,592.34

Hospital Charge Code	141426
Hospital Revenue Code	274
Min. Negotiated Rate	$233.31
Max. Negotiated Rate	$1,866.48
Rate for Payer: Amerigroup CHIP/Medicaid	$233.31
Rate for Payer: BCBS of TX Blue Advantage	$777.70
Rate for Payer: BCBS of TX Blue Essentials	$933.24
Rate for Payer: BCBS of TX PPO	$1,036.94
Rate for Payer: Cash Price	$1,762.79
Rate for Payer: Cigna Medicaid	$1,866.48
Rate for Payer: Molina CHIP/Medicaid	$1,866.48
Rate for Payer: Multiplan Auto	$1,296.17
Rate for Payer: Multiplan Commercial	$1,296.17
Rate for Payer: Multiplan Workers Comp	$1,296.17
Rate for Payer: Parkland Medicaid	$1,866.48
Rate for Payer: Scott and White EPO/PPO	$1,296.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,866.48
Rate for Payer: Superior Health Plan EPO	$352.56

INSTRUMENT, POOLE STERILE -- DHF

Facility

$152.04

Hospital Charge Code	81855504
Hospital Revenue Code	270
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$109.47
Rate for Payer: Amerigroup CHIP/Medicaid	$13.68
Rate for Payer: BCBS of TX Blue Advantage	$45.61
Rate for Payer: BCBS of TX Blue Essentials	$54.73
Rate for Payer: BCBS of TX PPO	$60.82
Rate for Payer: Cash Price	$103.39
Rate for Payer: Cigna Medicaid	$109.47
Rate for Payer: Molina CHIP/Medicaid	$109.47
Rate for Payer: Multiplan Auto	$98.83
Rate for Payer: Multiplan Commercial	$98.83
Rate for Payer: Multiplan Workers Comp	$98.83
Rate for Payer: Parkland Medicaid	$109.47
Rate for Payer: Scott and White EPO/PPO	$76.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.47
Rate for Payer: Superior Health Plan EPO	$20.68

INSTRUMENT, POOLE STERILE -- DHF

Facility

$152.04

Hospital Charge Code	81855504
Hospital Revenue Code	270
Rate for Payer: Cash Price	$103.39

Instrument Sharpening

Facility

$6,693.96

Hospital Charge Code	992590
Hospital Revenue Code	270
Min. Negotiated Rate	$602.46
Max. Negotiated Rate	$4,819.65
Rate for Payer: Amerigroup CHIP/Medicaid	$602.46
Rate for Payer: BCBS of TX Blue Advantage	$2,008.19
Rate for Payer: BCBS of TX Blue Essentials	$2,409.83
Rate for Payer: BCBS of TX PPO	$2,677.58
Rate for Payer: Cash Price	$4,551.89
Rate for Payer: Cigna Medicaid	$4,819.65
Rate for Payer: Molina CHIP/Medicaid	$4,819.65
Rate for Payer: Multiplan Auto	$4,351.07
Rate for Payer: Multiplan Commercial	$4,351.07
Rate for Payer: Multiplan Workers Comp	$4,351.07
Rate for Payer: Parkland Medicaid	$4,819.65
Rate for Payer: Scott and White EPO/PPO	$3,346.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,819.65
Rate for Payer: Superior Health Plan EPO	$910.38

Instrument Sharpening

Facility

$6,693.96

Hospital Charge Code	992590
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4,551.89

Insulin Antibodies SO

Facility

$120.00

Service Code	HCPCS 86337
Hospital Charge Code	1701424
Hospital Revenue Code	302
Rate for Payer: Cash Price	$81.60

Insulin Antibodies SO

Facility

$120.00

Service Code	HCPCS 86337
Hospital Charge Code	1701424
Hospital Revenue Code	302
Min. Negotiated Rate	$8.35
Max. Negotiated Rate	$86.40
Rate for Payer: Amerigroup CHIP/Medicaid	$8.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.41
Rate for Payer: Amerigroup Medicare	$21.41
Rate for Payer: BCBS of TX Blue Advantage	$36.00
Rate for Payer: BCBS of TX Blue Essentials	$43.20
Rate for Payer: BCBS of TX Medicare	$21.41
Rate for Payer: BCBS of TX PPO	$48.00
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna Medicaid	$86.40
Rate for Payer: Cigna Medicare	$21.41
Rate for Payer: Employer Direct Commercial	$21.41
Rate for Payer: Humana Medicare/TRICARE	$21.41
Rate for Payer: Molina CHIP/Medicaid	$86.40
Rate for Payer: Molina Dual Medicare/Medicaid	$21.41
Rate for Payer: Molina Medicare	$21.41
Rate for Payer: Multiplan Auto	$78.00
Rate for Payer: Multiplan Commercial	$78.00
Rate for Payer: Multiplan Workers Comp	$78.00
Rate for Payer: Parkland Medicaid	$86.40
Rate for Payer: Scott and White EPO/PPO	$26.76
Rate for Payer: Scott and White Medicare	$21.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.40
Rate for Payer: Superior Health Plan EPO	$21.41
Rate for Payer: Superior Health Plan Medicare	$21.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.41
Rate for Payer: Universal American Medicare	$21.41
Rate for Payer: Wellcare Medicare	$21.41
Rate for Payer: Wellmed Medicare	$21.41

insulin glargine 100 units/mL Subcut Soln 10 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	77634802
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

insulin glargine 100 units/mL Subcut Soln 10 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	79510212
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

insulin glargine 100 units/mL Subcut Soln 10 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	77634802
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

insulin glargine 100 units/mL Subcut Soln 10 mL

Facility

$128.17

Service Code	HCPCS J1815
Hospital Charge Code	79510212
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

insulin isophane 100 units/mL human recombinant Subcut Susp 10 mL

Facility

$128.00

Service Code	HCPCS J1815
Hospital Charge Code	77634055
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

Know your out-of-pocket cost for care.

All Charges