White Rock Medical Center

All Charges

Charge

Type

Setting

Price

INTRODUCER SHTH 6FR 45CM XCUT PN DSTN

Facility

$70.14

Service Code	HCPCS C1766
Hospital Charge Code	992499
Hospital Revenue Code	272
Min. Negotiated Rate	$6.31
Max. Negotiated Rate	$50.50
Rate for Payer: Amerigroup CHIP/Medicaid	$6.31
Rate for Payer: BCBS of TX Blue Advantage	$21.04
Rate for Payer: BCBS of TX Blue Essentials	$25.25
Rate for Payer: BCBS of TX PPO	$28.06
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Medicaid	$50.50
Rate for Payer: Molina CHIP/Medicaid	$50.50
Rate for Payer: Multiplan Auto	$45.59
Rate for Payer: Multiplan Commercial	$45.59
Rate for Payer: Multiplan Workers Comp	$45.59
Rate for Payer: Parkland Medicaid	$50.50
Rate for Payer: Scott and White EPO/PPO	$35.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50.50
Rate for Payer: Superior Health Plan EPO	$9.54

INTRODUCER, TRCH, BOUGIE, CODE, 15FR 70CM

Facility

$33.85

Hospital Charge Code	992943
Hospital Revenue Code	270
Rate for Payer: Cash Price	$23.02

INTRODUCER, TRCH, BOUGIE, CODE, 15FR 70CM

Facility

$33.85

Hospital Charge Code	992943
Hospital Revenue Code	270
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$24.37
Rate for Payer: Amerigroup CHIP/Medicaid	$3.05
Rate for Payer: BCBS of TX Blue Advantage	$10.15
Rate for Payer: BCBS of TX Blue Essentials	$12.19
Rate for Payer: BCBS of TX PPO	$13.54
Rate for Payer: Cash Price	$23.02
Rate for Payer: Cigna Medicaid	$24.37
Rate for Payer: Molina CHIP/Medicaid	$24.37
Rate for Payer: Multiplan Auto	$22.00
Rate for Payer: Multiplan Commercial	$22.00
Rate for Payer: Multiplan Workers Comp	$22.00
Rate for Payer: Parkland Medicaid	$24.37
Rate for Payer: Scott and White EPO/PPO	$16.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.37
Rate for Payer: Superior Health Plan EPO	$4.60

Introduction, Revision, Removal; Removal of peritoneal foreign body from peritoneal cavity

Facility

$14,116.24

Service Code	HCPCS 49402
Hospital Charge Code	994059
Hospital Revenue Code	361
Rate for Payer: Cash Price	$9,599.04

Introduction, Revision, Removal; Removal of peritoneal foreign body from peritoneal cavity

Facility

$14,116.24

Service Code	HCPCS 49402
Hospital Charge Code	994059
Hospital Revenue Code	361
Min. Negotiated Rate	$1,151.54
Max. Negotiated Rate	$10,163.69
Rate for Payer: Amerigroup CHIP/Medicaid	$1,151.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Amerigroup Medicare	$3,596.72
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX Medicare	$3,596.72
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cash Price	$9,599.04
Rate for Payer: Cash Price	$9,599.04
Rate for Payer: Cash Price	$9,599.04
Rate for Payer: Cigna Commercial	$7,602.81
Rate for Payer: Cigna Medicaid	$10,163.69
Rate for Payer: Cigna Medicare	$3,596.72
Rate for Payer: Employer Direct Commercial	$3,596.72
Rate for Payer: Humana Medicare/TRICARE	$3,596.72
Rate for Payer: Molina CHIP/Medicaid	$10,163.69
Rate for Payer: Molina Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Molina Medicare	$3,596.72
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	$10,163.69
Rate for Payer: Scott and White EPO/PPO	$6,653.93
Rate for Payer: Scott and White Medicare	$3,596.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,163.69
Rate for Payer: Superior Health Plan EPO	$3,596.72
Rate for Payer: Superior Health Plan Medicare	$3,596.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Universal American Medicare	$3,596.72
Rate for Payer: Wellcare Medicare	$3,596.72
Rate for Payer: Wellmed Medicare	$3,596.72

INTRO EP IC N-LSR N-GD 2 -- DHF

Facility

$367.22

Hospital Charge Code	82402298
Hospital Revenue Code	272
Min. Negotiated Rate	$33.05
Max. Negotiated Rate	$264.40
Rate for Payer: Amerigroup CHIP/Medicaid	$33.05
Rate for Payer: BCBS of TX Blue Advantage	$110.17
Rate for Payer: BCBS of TX Blue Essentials	$132.20
Rate for Payer: BCBS of TX PPO	$146.89
Rate for Payer: Cash Price	$249.71
Rate for Payer: Cigna Medicaid	$264.40
Rate for Payer: Molina CHIP/Medicaid	$264.40
Rate for Payer: Multiplan Auto	$238.69
Rate for Payer: Multiplan Commercial	$238.69
Rate for Payer: Multiplan Workers Comp	$238.69
Rate for Payer: Parkland Medicaid	$264.40
Rate for Payer: Scott and White EPO/PPO	$183.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$264.40
Rate for Payer: Superior Health Plan EPO	$49.94

INTRO EP IC N-LSR N-GD 2 -- DHF

Facility

$367.22

Hospital Charge Code	82402298
Hospital Revenue Code	272
Rate for Payer: Cash Price	$249.71

INTRO G 7F RDC I 55CM .035'

Facility

$386.13

Service Code	HCPCS C1766
Hospital Charge Code	992489
Hospital Revenue Code	272
Min. Negotiated Rate	$34.75
Max. Negotiated Rate	$278.01
Rate for Payer: Amerigroup CHIP/Medicaid	$34.75
Rate for Payer: BCBS of TX Blue Advantage	$115.84
Rate for Payer: BCBS of TX Blue Essentials	$139.01
Rate for Payer: BCBS of TX PPO	$154.45
Rate for Payer: Cash Price	$262.57
Rate for Payer: Cigna Medicaid	$278.01
Rate for Payer: Molina CHIP/Medicaid	$278.01
Rate for Payer: Multiplan Auto	$250.98
Rate for Payer: Multiplan Commercial	$250.98
Rate for Payer: Multiplan Workers Comp	$250.98
Rate for Payer: Parkland Medicaid	$278.01
Rate for Payer: Scott and White EPO/PPO	$193.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$278.01
Rate for Payer: Superior Health Plan EPO	$52.51

INTRO G 7F RDC I 55CM .035'

Facility

$386.13

Service Code	HCPCS C1766
Hospital Charge Code	992489
Hospital Revenue Code	272
Rate for Payer: Cash Price	$262.57

INTRO NDL DIAL-CIRC BAL-PLASTY+S&I

Facility

$11,501.00

Service Code	HCPCS 36902
Hospital Charge Code	2351101
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,820.68

INTRO NDL DIAL-CIRC BAL-PLASTY+S&I

Facility

$11,501.00

Service Code	HCPCS 36902
Hospital Charge Code	2351101
Hospital Revenue Code	360
Min. Negotiated Rate	$1,764.89
Max. Negotiated Rate	$12,483.85
Rate for Payer: Amerigroup CHIP/Medicaid	$1,764.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Amerigroup Medicare	$5,717.50
Rate for Payer: BCBS of TX Blue Advantage	$8,273.03
Rate for Payer: BCBS of TX Blue Essentials	$9,907.82
Rate for Payer: BCBS of TX Medicare	$5,717.50
Rate for Payer: BCBS of TX PPO	$12,483.85
Rate for Payer: Cash Price	$7,820.68
Rate for Payer: Cash Price	$7,820.68
Rate for Payer: Cash Price	$7,820.68
Rate for Payer: Cigna Commercial	$12,085.75
Rate for Payer: Cigna Medicaid	$8,280.72
Rate for Payer: Cigna Medicare	$5,717.50
Rate for Payer: Employer Direct Commercial	$5,717.50
Rate for Payer: Humana Medicare/TRICARE	$5,717.50
Rate for Payer: Molina CHIP/Medicaid	$8,280.72
Rate for Payer: Molina Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Molina Medicare	$5,717.50
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	$8,280.72
Rate for Payer: Scott and White EPO/PPO	$10,577.38
Rate for Payer: Scott and White Medicare	$5,717.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,280.72
Rate for Payer: Superior Health Plan EPO	$5,717.50
Rate for Payer: Superior Health Plan Medicare	$5,717.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Universal American Medicare	$5,717.50
Rate for Payer: Wellcare Medicare	$5,717.50
Rate for Payer: Wellmed Medicare	$5,717.50

INTRO NDL DIAL-CIRC STNT+PLSTY+S&I

Facility

$15,356.00

Service Code	HCPCS 36903
Hospital Charge Code	2351102
Hospital Revenue Code	360
Min. Negotiated Rate	$5,270.09
Max. Negotiated Rate	$24,969.37
Rate for Payer: Amerigroup CHIP/Medicaid	$5,270.09
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Amerigroup Medicare	$11,596.79
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$11,596.79
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$10,442.08
Rate for Payer: Cash Price	$10,442.08
Rate for Payer: Cash Price	$10,442.08
Rate for Payer: Cigna Commercial	$24,513.51
Rate for Payer: Cigna Medicaid	$11,056.32
Rate for Payer: Cigna Medicare	$11,596.79
Rate for Payer: Employer Direct Commercial	$11,596.79
Rate for Payer: Humana Medicare/TRICARE	$11,596.79
Rate for Payer: Molina CHIP/Medicaid	$11,056.32
Rate for Payer: Molina Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Molina Medicare	$11,596.79
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	$11,056.32
Rate for Payer: Scott and White EPO/PPO	$21,454.06
Rate for Payer: Scott and White Medicare	$11,596.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,056.32
Rate for Payer: Superior Health Plan EPO	$11,596.79
Rate for Payer: Superior Health Plan Medicare	$11,596.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Universal American Medicare	$11,596.79
Rate for Payer: Wellcare Medicare	$11,596.79
Rate for Payer: Wellmed Medicare	$11,596.79

INTRO NDL DIAL-CIRC STNT+PLSTY+S&I

Facility

$15,356.00

Service Code	HCPCS 36903
Hospital Charge Code	2351102
Hospital Revenue Code	360
Rate for Payer: Cash Price	$10,442.08

INTRO SHEATH GD LONG

Facility

$350.71

Hospital Charge Code	8470490
Hospital Revenue Code	272
Rate for Payer: Cash Price	$238.48

INTRO SHEATH GD LONG

Facility

$350.71

Hospital Charge Code	8470490
Hospital Revenue Code	272
Min. Negotiated Rate	$31.56
Max. Negotiated Rate	$252.51
Rate for Payer: Amerigroup CHIP/Medicaid	$31.56
Rate for Payer: BCBS of TX Blue Advantage	$105.21
Rate for Payer: BCBS of TX Blue Essentials	$126.26
Rate for Payer: BCBS of TX PPO	$140.28
Rate for Payer: Cash Price	$238.48
Rate for Payer: Cigna Medicaid	$252.51
Rate for Payer: Molina CHIP/Medicaid	$252.51
Rate for Payer: Multiplan Auto	$227.96
Rate for Payer: Multiplan Commercial	$227.96
Rate for Payer: Multiplan Workers Comp	$227.96
Rate for Payer: Parkland Medicaid	$252.51
Rate for Payer: Scott and White EPO/PPO	$175.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$252.51
Rate for Payer: Superior Health Plan EPO	$47.70

INTR SHTH PERIPH PINNACL -- DHF

Facility

$49.00

Hospital Charge Code	82415068
Hospital Revenue Code	272
Min. Negotiated Rate	$4.41
Max. Negotiated Rate	$35.28
Rate for Payer: Amerigroup CHIP/Medicaid	$4.41
Rate for Payer: BCBS of TX Blue Advantage	$14.70
Rate for Payer: BCBS of TX Blue Essentials	$17.64
Rate for Payer: BCBS of TX PPO	$19.60
Rate for Payer: Cash Price	$33.32
Rate for Payer: Cigna Medicaid	$35.28
Rate for Payer: Molina CHIP/Medicaid	$35.28
Rate for Payer: Multiplan Auto	$31.85
Rate for Payer: Multiplan Commercial	$31.85
Rate for Payer: Multiplan Workers Comp	$31.85
Rate for Payer: Parkland Medicaid	$35.28
Rate for Payer: Scott and White EPO/PPO	$24.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.28
Rate for Payer: Superior Health Plan EPO	$6.66

INTR SHTH PERIPH PINNACL -- DHF

Facility

$49.00

Hospital Charge Code	82415068
Hospital Revenue Code	272
Rate for Payer: Cash Price	$33.32

IOBP KNEE CLOSED TIP PROCEDURE KIT

Facility

$4,353.86

Hospital Charge Code	146694
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,960.62

IOBP KNEE CLOSED TIP PROCEDURE KIT

Facility

$4,353.86

Hospital Charge Code	146694
Hospital Revenue Code	272
Min. Negotiated Rate	$391.85
Max. Negotiated Rate	$3,134.78
Rate for Payer: Amerigroup CHIP/Medicaid	$391.85
Rate for Payer: BCBS of TX Blue Advantage	$1,306.16
Rate for Payer: BCBS of TX Blue Essentials	$1,567.39
Rate for Payer: BCBS of TX PPO	$1,741.54
Rate for Payer: Cash Price	$2,960.62
Rate for Payer: Cigna Medicaid	$3,134.78
Rate for Payer: Molina CHIP/Medicaid	$3,134.78
Rate for Payer: Multiplan Auto	$2,830.01
Rate for Payer: Multiplan Commercial	$2,830.01
Rate for Payer: Multiplan Workers Comp	$2,830.01
Rate for Payer: Parkland Medicaid	$3,134.78
Rate for Payer: Scott and White EPO/PPO	$2,176.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,134.78
Rate for Payer: Superior Health Plan EPO	$592.12

IODINE-B

Facility

$179.69

Hospital Charge Code	992630
Hospital Revenue Code	270
Min. Negotiated Rate	$16.17
Max. Negotiated Rate	$129.38
Rate for Payer: Amerigroup CHIP/Medicaid	$16.17
Rate for Payer: BCBS of TX Blue Advantage	$53.91
Rate for Payer: BCBS of TX Blue Essentials	$64.69
Rate for Payer: BCBS of TX PPO	$71.88
Rate for Payer: Cash Price	$122.19
Rate for Payer: Cigna Medicaid	$129.38
Rate for Payer: Molina CHIP/Medicaid	$129.38
Rate for Payer: Multiplan Auto	$116.80
Rate for Payer: Multiplan Commercial	$116.80
Rate for Payer: Multiplan Workers Comp	$116.80
Rate for Payer: Parkland Medicaid	$129.38
Rate for Payer: Scott and White EPO/PPO	$89.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$129.38
Rate for Payer: Superior Health Plan EPO	$24.44

IODINE-B

Facility

$179.69

Hospital Charge Code	992630
Hospital Revenue Code	270
Rate for Payer: Cash Price	$122.19

iodixanol 320 mg 50 ml bottle

Facility

$128.00

Service Code	HCPCS Q9966
Hospital Charge Code	00407-2222-16
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.04

iodixanol 320 mg 50 ml bottle

Facility

$128.00

Service Code	HCPCS Q9966
Hospital Charge Code	00407-2222-16
Hospital Revenue Code	258
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.41
Rate for Payer: BCBS of TX Blue Essentials	$0.49
Rate for Payer: BCBS of TX PPO	$0.54
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

iodixanol 320 mg/mL Inj Soln 100 mL

Facility

$217.00

Service Code	HCPCS Q9967
Hospital Charge Code	77636834
Hospital Revenue Code	258
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$156.24
Rate for Payer: Amerigroup CHIP/Medicaid	$19.53
Rate for Payer: BCBS of TX Blue Advantage	$0.46
Rate for Payer: BCBS of TX Blue Essentials	$0.56
Rate for Payer: BCBS of TX PPO	$0.62
Rate for Payer: Cash Price	$147.56
Rate for Payer: Cash Price	$147.56
Rate for Payer: Cigna Medicaid	$156.24
Rate for Payer: Molina CHIP/Medicaid	$156.24
Rate for Payer: Multiplan Auto	$141.05
Rate for Payer: Multiplan Commercial	$141.05
Rate for Payer: Multiplan Workers Comp	$141.05
Rate for Payer: Parkland Medicaid	$156.24
Rate for Payer: Scott and White EPO/PPO	$108.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$156.24
Rate for Payer: Superior Health Plan EPO	$29.51

iodixanol 320 mg/mL Inj Soln 100 mL

Facility

$217.00

Service Code	HCPCS Q9967
Hospital Charge Code	77636834
Hospital Revenue Code	258
Rate for Payer: Cash Price	$147.56

Know your out-of-pocket cost for care.

All Charges