White Rock Medical Center

All Charges

Charge

Type

Setting

Price

INSRT/REPLC PERM PACER,ATRIAL LEAD

Facility

$19,520.00

Service Code	HCPCS 33206
Hospital Charge Code	2302404
Hospital Revenue Code	481
Min. Negotiated Rate	$545.33
Max. Negotiated Rate	$25,834.89
Rate for Payer: Amerigroup CHIP/Medicaid	$1,756.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Amerigroup Medicare	$10,499.62
Rate for Payer: BCBS of TX Blue Advantage	$17,120.74
Rate for Payer: BCBS of TX Blue Essentials	$20,503.88
Rate for Payer: BCBS of TX Medicare	$10,499.62
Rate for Payer: BCBS of TX PPO	$25,834.89
Rate for Payer: Cash Price	$13,273.60
Rate for Payer: Cash Price	$13,273.60
Rate for Payer: Cash Price	$13,273.60
Rate for Payer: Cigna Commercial	$22,194.30
Rate for Payer: Cigna Medicaid	$14,054.40
Rate for Payer: Cigna Medicare	$10,499.62
Rate for Payer: Employer Direct Commercial	$10,499.62
Rate for Payer: Humana Medicare/TRICARE	$10,499.62
Rate for Payer: Molina CHIP/Medicaid	$14,054.40
Rate for Payer: Molina Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Molina Medicare	$10,499.62
Rate for Payer: Multiplan Auto	$12,688.00
Rate for Payer: Multiplan Commercial	$12,688.00
Rate for Payer: Multiplan Workers Comp	$12,688.00
Rate for Payer: Parkland Medicaid	$14,054.40
Rate for Payer: Scott and White EPO/PPO	$545.33
Rate for Payer: Scott and White Medicare	$10,499.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,054.40
Rate for Payer: Superior Health Plan EPO	$10,499.62
Rate for Payer: Superior Health Plan Medicare	$10,499.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Universal American Medicare	$10,499.62
Rate for Payer: Wellcare Medicare	$10,499.62
Rate for Payer: Wellmed Medicare	$10,499.62

INSRT/REPLC PERM PACER,ATRIAL LEAD

Facility

$19,520.00

Service Code	HCPCS 33206
Hospital Charge Code	2302404
Hospital Revenue Code	481
Rate for Payer: Cash Price	$13,273.60

INSRT/REPLC PERM PACER, A&V LEAD

Facility

$22,224.00

Service Code	HCPCS 33208
Hospital Charge Code	2302420
Hospital Revenue Code	481
Min. Negotiated Rate	$619.67
Max. Negotiated Rate	$25,834.89
Rate for Payer: Amerigroup CHIP/Medicaid	$2,000.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Amerigroup Medicare	$10,499.62
Rate for Payer: BCBS of TX Blue Advantage	$17,120.74
Rate for Payer: BCBS of TX Blue Essentials	$20,503.88
Rate for Payer: BCBS of TX Medicare	$10,499.62
Rate for Payer: BCBS of TX PPO	$25,834.89
Rate for Payer: Cash Price	$15,112.32
Rate for Payer: Cash Price	$15,112.32
Rate for Payer: Cash Price	$15,112.32
Rate for Payer: Cigna Commercial	$22,194.30
Rate for Payer: Cigna Medicaid	$16,001.28
Rate for Payer: Cigna Medicare	$10,499.62
Rate for Payer: Employer Direct Commercial	$10,499.62
Rate for Payer: Humana Medicare/TRICARE	$10,499.62
Rate for Payer: Molina CHIP/Medicaid	$16,001.28
Rate for Payer: Molina Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Molina Medicare	$10,499.62
Rate for Payer: Multiplan Auto	$14,445.60
Rate for Payer: Multiplan Commercial	$14,445.60
Rate for Payer: Multiplan Workers Comp	$14,445.60
Rate for Payer: Parkland Medicaid	$16,001.28
Rate for Payer: Scott and White EPO/PPO	$619.67
Rate for Payer: Scott and White Medicare	$10,499.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,001.28
Rate for Payer: Superior Health Plan EPO	$10,499.62
Rate for Payer: Superior Health Plan Medicare	$10,499.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Universal American Medicare	$10,499.62
Rate for Payer: Wellcare Medicare	$10,499.62
Rate for Payer: Wellmed Medicare	$10,499.62

INSRT/REPLC PERM PACER, A&V LEAD

Facility

$22,224.00

Service Code	HCPCS 33208
Hospital Charge Code	2302420
Hospital Revenue Code	481
Rate for Payer: Cash Price	$15,112.32

INSRT/REPLC PERM PACER, VENT LEAD

Facility

$20,365.00

Service Code	HCPCS 33207
Hospital Charge Code	2302412
Hospital Revenue Code	481
Rate for Payer: Cash Price	$13,848.20

INSRT/REPLC PERM PACER, VENT LEAD

Facility

$20,365.00

Service Code	HCPCS 33207
Hospital Charge Code	2302412
Hospital Revenue Code	481
Min. Negotiated Rate	$572.60
Max. Negotiated Rate	$25,834.89
Rate for Payer: Amerigroup CHIP/Medicaid	$1,832.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Amerigroup Medicare	$10,499.62
Rate for Payer: BCBS of TX Blue Advantage	$17,120.74
Rate for Payer: BCBS of TX Blue Essentials	$20,503.88
Rate for Payer: BCBS of TX Medicare	$10,499.62
Rate for Payer: BCBS of TX PPO	$25,834.89
Rate for Payer: Cash Price	$13,848.20
Rate for Payer: Cash Price	$13,848.20
Rate for Payer: Cash Price	$13,848.20
Rate for Payer: Cigna Commercial	$22,194.30
Rate for Payer: Cigna Medicaid	$14,662.80
Rate for Payer: Cigna Medicare	$10,499.62
Rate for Payer: Employer Direct Commercial	$10,499.62
Rate for Payer: Humana Medicare/TRICARE	$10,499.62
Rate for Payer: Molina CHIP/Medicaid	$14,662.80
Rate for Payer: Molina Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Molina Medicare	$10,499.62
Rate for Payer: Multiplan Auto	$13,237.25
Rate for Payer: Multiplan Commercial	$13,237.25
Rate for Payer: Multiplan Workers Comp	$13,237.25
Rate for Payer: Parkland Medicaid	$14,662.80
Rate for Payer: Scott and White EPO/PPO	$572.60
Rate for Payer: Scott and White Medicare	$10,499.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,662.80
Rate for Payer: Superior Health Plan EPO	$10,499.62
Rate for Payer: Superior Health Plan Medicare	$10,499.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,499.62
Rate for Payer: Universal American Medicare	$10,499.62
Rate for Payer: Wellcare Medicare	$10,499.62
Rate for Payer: Wellmed Medicare	$10,499.62

INSRT/REPOSIT SINGL CHAMBER LEAD

Facility

$13,918.00

Service Code	HCPCS 33216
Hospital Charge Code	2302255
Hospital Revenue Code	481
Min. Negotiated Rate	$446.73
Max. Negotiated Rate	$19,257.46
Rate for Payer: Amerigroup CHIP/Medicaid	$1,252.62
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	$9,464.24
Rate for Payer: Cash Price	$9,464.24
Rate for Payer: Cash Price	$9,464.24
Rate for Payer: Cigna Commercial	$17,572.38
Rate for Payer: Cigna Medicaid	$10,020.96
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	$10,020.96
Rate for Payer: Molina Dual Medicare/Medicaid	$8,313.10
Rate for Payer: Molina Medicare	$8,313.10
Rate for Payer: Multiplan Auto	$9,046.70
Rate for Payer: Multiplan Commercial	$9,046.70
Rate for Payer: Multiplan Workers Comp	$9,046.70
Rate for Payer: Parkland Medicaid	$10,020.96
Rate for Payer: Scott and White EPO/PPO	$446.73
Rate for Payer: Scott and White Medicare	$8,313.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,020.96
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

INSRT/REPOSIT SINGL CHAMBER LEAD

Facility

$13,918.00

Service Code	HCPCS 33216
Hospital Charge Code	2302255
Hospital Revenue Code	481
Rate for Payer: Cash Price	$9,464.24

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: 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 EPO/PPO	$55,662.34
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
Min. Negotiated Rate	$104.31
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	$104.31
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

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

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
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	$264.29
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

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

INST ENDO KITTNER DISP -- DHF

Facility

$45.58

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

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

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	$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, 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, POOLE STERILE -- DHF

Facility

$152.04

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

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 Sharpening

Facility

$6,693.96

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

Know your out-of-pocket cost for care.

All Charges