White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Joint device (implantable)

Facility

$1,404.00

Service Code	HCPCS C1776
Hospital Charge Code	990927
Hospital Revenue Code	278
Min. Negotiated Rate	$126.36
Max. Negotiated Rate	$1,010.88
Rate for Payer: Amerigroup CHIP/Medicaid	$126.36
Rate for Payer: BCBS of TX Blue Advantage	$421.20
Rate for Payer: BCBS of TX Blue Essentials	$505.44
Rate for Payer: BCBS of TX PPO	$561.60
Rate for Payer: Cash Price	$954.72
Rate for Payer: Cigna Medicaid	$1,010.88
Rate for Payer: Molina CHIP/Medicaid	$1,010.88
Rate for Payer: Multiplan Auto	$702.00
Rate for Payer: Multiplan Commercial	$702.00
Rate for Payer: Multiplan Workers Comp	$702.00
Rate for Payer: Parkland Medicaid	$1,010.88
Rate for Payer: Scott and White EPO/PPO	$702.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,010.88
Rate for Payer: Superior Health Plan EPO	$190.94

Jones cannulated tap 5.5mm charlotte f&a system

Facility

$1,391.57

Service Code	HCPCS C1713
Hospital Charge Code	992210
Hospital Revenue Code	278
Min. Negotiated Rate	$347.89
Max. Negotiated Rate	$695.78
Rate for Payer: Cash Price	$946.27
Rate for Payer: Cigna Commercial	$347.89
Rate for Payer: Multiplan Auto	$695.78
Rate for Payer: Multiplan Commercial	$695.78
Rate for Payer: Multiplan Workers Comp	$695.78
Rate for Payer: Scott and White EPO/PPO	$695.78

Jones cannulated tap 5.5mm charlotte f&a system

Facility

$1,391.57

Service Code	HCPCS C1713
Hospital Charge Code	992210
Hospital Revenue Code	278
Min. Negotiated Rate	$125.24
Max. Negotiated Rate	$1,001.93
Rate for Payer: Amerigroup CHIP/Medicaid	$125.24
Rate for Payer: BCBS of TX Blue Advantage	$417.47
Rate for Payer: BCBS of TX Blue Essentials	$500.97
Rate for Payer: BCBS of TX PPO	$556.63
Rate for Payer: Cash Price	$946.27
Rate for Payer: Cigna Medicaid	$1,001.93
Rate for Payer: Molina CHIP/Medicaid	$1,001.93
Rate for Payer: Multiplan Auto	$695.78
Rate for Payer: Multiplan Commercial	$695.78
Rate for Payer: Multiplan Workers Comp	$695.78
Rate for Payer: Parkland Medicaid	$1,001.93
Rate for Payer: Scott and White EPO/PPO	$695.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,001.93
Rate for Payer: Superior Health Plan EPO	$189.25

Jones drill 3.2mm cannulated charlotte f&a system

Facility

$1,157.70

Hospital Charge Code	993412
Hospital Revenue Code	272
Min. Negotiated Rate	$104.19
Max. Negotiated Rate	$833.54
Rate for Payer: Amerigroup CHIP/Medicaid	$104.19
Rate for Payer: BCBS of TX Blue Advantage	$347.31
Rate for Payer: BCBS of TX Blue Essentials	$416.77
Rate for Payer: BCBS of TX PPO	$463.08
Rate for Payer: Cash Price	$787.24
Rate for Payer: Cigna Medicaid	$833.54
Rate for Payer: Molina CHIP/Medicaid	$833.54
Rate for Payer: Multiplan Auto	$752.50
Rate for Payer: Multiplan Commercial	$752.50
Rate for Payer: Multiplan Workers Comp	$752.50
Rate for Payer: Parkland Medicaid	$833.54
Rate for Payer: Scott and White EPO/PPO	$578.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$833.54
Rate for Payer: Superior Health Plan EPO	$157.45

Jones drill 3.2mm cannulated charlotte f&a system

Facility

$1,157.70

Hospital Charge Code	993412
Hospital Revenue Code	272
Rate for Payer: Cash Price	$787.24

Jones K- wire 228mm charlotte f&a system

Facility

$167.98

Hospital Charge Code	993411
Hospital Revenue Code	272
Rate for Payer: Cash Price	$114.23

Jones K- wire 228mm charlotte f&a system

Facility

$167.98

Hospital Charge Code	993411
Hospital Revenue Code	272
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$120.95
Rate for Payer: Amerigroup CHIP/Medicaid	$15.12
Rate for Payer: BCBS of TX Blue Advantage	$50.39
Rate for Payer: BCBS of TX Blue Essentials	$60.47
Rate for Payer: BCBS of TX PPO	$67.19
Rate for Payer: Cash Price	$114.23
Rate for Payer: Cigna Medicaid	$120.95
Rate for Payer: Molina CHIP/Medicaid	$120.95
Rate for Payer: Multiplan Auto	$109.19
Rate for Payer: Multiplan Commercial	$109.19
Rate for Payer: Multiplan Workers Comp	$109.19
Rate for Payer: Parkland Medicaid	$120.95
Rate for Payer: Scott and White EPO/PPO	$83.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.95
Rate for Payer: Superior Health Plan EPO	$22.85

JR 3.5 diagnostic catheter

Facility

$154.36

Service Code	HCPCS C1887
Hospital Charge Code	992459
Hospital Revenue Code	272
Min. Negotiated Rate	$13.89
Max. Negotiated Rate	$111.14
Rate for Payer: Amerigroup CHIP/Medicaid	$13.89
Rate for Payer: BCBS of TX Blue Advantage	$46.31
Rate for Payer: BCBS of TX Blue Essentials	$55.57
Rate for Payer: BCBS of TX PPO	$61.74
Rate for Payer: Cash Price	$104.96
Rate for Payer: Cigna Medicaid	$111.14
Rate for Payer: Molina CHIP/Medicaid	$111.14
Rate for Payer: Multiplan Auto	$100.33
Rate for Payer: Multiplan Commercial	$100.33
Rate for Payer: Multiplan Workers Comp	$100.33
Rate for Payer: Parkland Medicaid	$111.14
Rate for Payer: Scott and White EPO/PPO	$77.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111.14
Rate for Payer: Superior Health Plan EPO	$20.99

JR 3.5 diagnostic catheter

Facility

$154.36

Service Code	HCPCS C1887
Hospital Charge Code	992459
Hospital Revenue Code	272
Rate for Payer: Cash Price	$104.96

JR 3.5 Guide Cathater

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992446
Hospital Revenue Code	272
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$140.56
Rate for Payer: Amerigroup CHIP/Medicaid	$17.57
Rate for Payer: BCBS of TX Blue Advantage	$58.57
Rate for Payer: BCBS of TX Blue Essentials	$70.28
Rate for Payer: BCBS of TX PPO	$78.09
Rate for Payer: Cash Price	$132.75
Rate for Payer: Cigna Medicaid	$140.56
Rate for Payer: Molina CHIP/Medicaid	$140.56
Rate for Payer: Multiplan Auto	$126.89
Rate for Payer: Multiplan Commercial	$126.89
Rate for Payer: Multiplan Workers Comp	$126.89
Rate for Payer: Parkland Medicaid	$140.56
Rate for Payer: Scott and White EPO/PPO	$97.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.56
Rate for Payer: Superior Health Plan EPO	$26.55

JR 3.5 Guide Cathater

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992446
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

JR 4.0 Diagnostic Catheter

Facility

$154.36

Service Code	HCPCS C1887
Hospital Charge Code	992462
Hospital Revenue Code	272
Min. Negotiated Rate	$13.89
Max. Negotiated Rate	$111.14
Rate for Payer: Amerigroup CHIP/Medicaid	$13.89
Rate for Payer: BCBS of TX Blue Advantage	$46.31
Rate for Payer: BCBS of TX Blue Essentials	$55.57
Rate for Payer: BCBS of TX PPO	$61.74
Rate for Payer: Cash Price	$104.96
Rate for Payer: Cigna Medicaid	$111.14
Rate for Payer: Molina CHIP/Medicaid	$111.14
Rate for Payer: Multiplan Auto	$100.33
Rate for Payer: Multiplan Commercial	$100.33
Rate for Payer: Multiplan Workers Comp	$100.33
Rate for Payer: Parkland Medicaid	$111.14
Rate for Payer: Scott and White EPO/PPO	$77.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111.14
Rate for Payer: Superior Health Plan EPO	$20.99

JR 4.0 Diagnostic Catheter

Facility

$154.36

Service Code	HCPCS C1887
Hospital Charge Code	992462
Hospital Revenue Code	272
Rate for Payer: Cash Price	$104.96

JR 4.0 Diagnostic Catheter

Facility

$154.36

Service Code	HCPCS C1887
Hospital Charge Code	992461
Hospital Revenue Code	272
Min. Negotiated Rate	$13.89
Max. Negotiated Rate	$111.14
Rate for Payer: Amerigroup CHIP/Medicaid	$13.89
Rate for Payer: BCBS of TX Blue Advantage	$46.31
Rate for Payer: BCBS of TX Blue Essentials	$55.57
Rate for Payer: BCBS of TX PPO	$61.74
Rate for Payer: Cash Price	$104.96
Rate for Payer: Cigna Medicaid	$111.14
Rate for Payer: Molina CHIP/Medicaid	$111.14
Rate for Payer: Multiplan Auto	$100.33
Rate for Payer: Multiplan Commercial	$100.33
Rate for Payer: Multiplan Workers Comp	$100.33
Rate for Payer: Parkland Medicaid	$111.14
Rate for Payer: Scott and White EPO/PPO	$77.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111.14
Rate for Payer: Superior Health Plan EPO	$20.99

JR 4.0 Diagnostic Catheter

Facility

$154.36

Service Code	HCPCS C1887
Hospital Charge Code	992461
Hospital Revenue Code	272
Rate for Payer: Cash Price	$104.96

JR 4.0 Guide Catheter

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992450
Hospital Revenue Code	272
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$140.56
Rate for Payer: Amerigroup CHIP/Medicaid	$17.57
Rate for Payer: BCBS of TX Blue Advantage	$58.57
Rate for Payer: BCBS of TX Blue Essentials	$70.28
Rate for Payer: BCBS of TX PPO	$78.09
Rate for Payer: Cash Price	$132.75
Rate for Payer: Cigna Medicaid	$140.56
Rate for Payer: Molina CHIP/Medicaid	$140.56
Rate for Payer: Multiplan Auto	$126.89
Rate for Payer: Multiplan Commercial	$126.89
Rate for Payer: Multiplan Workers Comp	$126.89
Rate for Payer: Parkland Medicaid	$140.56
Rate for Payer: Scott and White EPO/PPO	$97.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.56
Rate for Payer: Superior Health Plan EPO	$26.55

JR 4.0 Guide Catheter

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992450
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

Juggerknot 2.9 Drill Bit Short

Facility

$728.91

Hospital Charge Code	145816
Hospital Revenue Code	272
Rate for Payer: Cash Price	$495.66

Juggerknot 2.9 Drill Bit Short

Facility

$728.91

Hospital Charge Code	145816
Hospital Revenue Code	272
Min. Negotiated Rate	$65.60
Max. Negotiated Rate	$524.82
Rate for Payer: Amerigroup CHIP/Medicaid	$65.60
Rate for Payer: BCBS of TX Blue Advantage	$218.67
Rate for Payer: BCBS of TX Blue Essentials	$262.41
Rate for Payer: BCBS of TX PPO	$291.56
Rate for Payer: Cash Price	$495.66
Rate for Payer: Cigna Medicaid	$524.82
Rate for Payer: Molina CHIP/Medicaid	$524.82
Rate for Payer: Multiplan Auto	$473.79
Rate for Payer: Multiplan Commercial	$473.79
Rate for Payer: Multiplan Workers Comp	$473.79
Rate for Payer: Parkland Medicaid	$524.82
Rate for Payer: Scott and White EPO/PPO	$364.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$524.82
Rate for Payer: Superior Health Plan EPO	$99.13

Juggerknot 2.9 W/Tapered NDLS

Facility

$2,771.08

Hospital Charge Code	145815
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,884.33

Juggerknot 2.9 W/Tapered NDLS

Facility

$2,771.08

Hospital Charge Code	145815
Hospital Revenue Code	272
Min. Negotiated Rate	$249.40
Max. Negotiated Rate	$1,995.18
Rate for Payer: Amerigroup CHIP/Medicaid	$249.40
Rate for Payer: BCBS of TX Blue Advantage	$831.32
Rate for Payer: BCBS of TX Blue Essentials	$997.59
Rate for Payer: BCBS of TX PPO	$1,108.43
Rate for Payer: Cash Price	$1,884.33
Rate for Payer: Cigna Medicaid	$1,995.18
Rate for Payer: Molina CHIP/Medicaid	$1,995.18
Rate for Payer: Multiplan Auto	$1,801.20
Rate for Payer: Multiplan Commercial	$1,801.20
Rate for Payer: Multiplan Workers Comp	$1,801.20
Rate for Payer: Parkland Medicaid	$1,995.18
Rate for Payer: Scott and White EPO/PPO	$1,385.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,995.18
Rate for Payer: Superior Health Plan EPO	$376.87

juggerloc bone to bone

Facility

$4,301.00

Service Code	HCPCS C1734
Hospital Charge Code	8660509
Hospital Revenue Code	278
Min. Negotiated Rate	$1,075.25
Max. Negotiated Rate	$2,150.50
Rate for Payer: Cash Price	$2,924.68
Rate for Payer: Cigna Commercial	$1,075.25
Rate for Payer: Multiplan Auto	$2,150.50
Rate for Payer: Multiplan Commercial	$2,150.50
Rate for Payer: Multiplan Workers Comp	$2,150.50
Rate for Payer: Scott and White EPO/PPO	$2,150.50

juggerloc bone to bone

Facility

$4,301.00

Service Code	HCPCS C1734
Hospital Charge Code	8660509
Hospital Revenue Code	278
Min. Negotiated Rate	$387.09
Max. Negotiated Rate	$3,096.72
Rate for Payer: Amerigroup CHIP/Medicaid	$387.09
Rate for Payer: BCBS of TX Blue Advantage	$1,290.30
Rate for Payer: BCBS of TX Blue Essentials	$1,548.36
Rate for Payer: BCBS of TX PPO	$1,720.40
Rate for Payer: Cash Price	$2,924.68
Rate for Payer: Cigna Medicaid	$3,096.72
Rate for Payer: Molina CHIP/Medicaid	$3,096.72
Rate for Payer: Multiplan Auto	$2,150.50
Rate for Payer: Multiplan Commercial	$2,150.50
Rate for Payer: Multiplan Workers Comp	$2,150.50
Rate for Payer: Parkland Medicaid	$3,096.72
Rate for Payer: Scott and White EPO/PPO	$2,150.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,096.72
Rate for Payer: Superior Health Plan EPO	$584.94

juggerloc kit

Facility

$723.22

Hospital Charge Code	8720589
Hospital Revenue Code	272
Rate for Payer: Cash Price	$491.79

juggerloc kit

Facility

$723.22

Hospital Charge Code	8720589
Hospital Revenue Code	272
Min. Negotiated Rate	$65.09
Max. Negotiated Rate	$520.72
Rate for Payer: Amerigroup CHIP/Medicaid	$65.09
Rate for Payer: BCBS of TX Blue Advantage	$216.97
Rate for Payer: BCBS of TX Blue Essentials	$260.36
Rate for Payer: BCBS of TX PPO	$289.29
Rate for Payer: Cash Price	$491.79
Rate for Payer: Cigna Medicaid	$520.72
Rate for Payer: Molina CHIP/Medicaid	$520.72
Rate for Payer: Multiplan Auto	$470.09
Rate for Payer: Multiplan Commercial	$470.09
Rate for Payer: Multiplan Workers Comp	$470.09
Rate for Payer: Parkland Medicaid	$520.72
Rate for Payer: Scott and White EPO/PPO	$361.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$520.72
Rate for Payer: Superior Health Plan EPO	$98.36

Know your out-of-pocket cost for care.

All Charges