White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Jam Shidi Needle/Bone Marrow Aspitation

Facility

$454.00

Service Code	HCPCS C1830
Hospital Charge Code	993664
Hospital Revenue Code	272
Min. Negotiated Rate	$40.86
Max. Negotiated Rate	$326.88
Rate for Payer: Amerigroup CHIP/Medicaid	$40.86
Rate for Payer: BCBS of TX Blue Advantage	$136.20
Rate for Payer: BCBS of TX Blue Essentials	$163.44
Rate for Payer: BCBS of TX PPO	$181.60
Rate for Payer: Cash Price	$308.72
Rate for Payer: Cigna Medicaid	$326.88
Rate for Payer: Molina CHIP/Medicaid	$326.88
Rate for Payer: Multiplan Auto	$295.10
Rate for Payer: Multiplan Commercial	$295.10
Rate for Payer: Multiplan Workers Comp	$295.10
Rate for Payer: Parkland Medicaid	$326.88
Rate for Payer: Scott and White EPO/PPO	$227.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$326.88
Rate for Payer: Superior Health Plan EPO	$61.74

JELLY, LUBE, STERILE, FIOL PACK, 2.7G

Facility

$0.31

Hospital Charge Code	993235
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.21

JELLY, LUBE, STERILE, FIOL PACK, 2.7G

Facility

$0.31

Hospital Charge Code	993235
Hospital Revenue Code	270
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.22
Rate for Payer: Amerigroup CHIP/Medicaid	$0.03
Rate for Payer: BCBS of TX Blue Advantage	$0.09
Rate for Payer: BCBS of TX Blue Essentials	$0.11
Rate for Payer: BCBS of TX PPO	$0.12
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna Medicaid	$0.22
Rate for Payer: Molina CHIP/Medicaid	$0.22
Rate for Payer: Multiplan Auto	$0.20
Rate for Payer: Multiplan Commercial	$0.20
Rate for Payer: Multiplan Workers Comp	$0.20
Rate for Payer: Parkland Medicaid	$0.22
Rate for Payer: Scott and White EPO/PPO	$0.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.22
Rate for Payer: Superior Health Plan EPO	$0.04

JET1 Accessary kit

Facility

$2,560.25

Hospital Charge Code	13558164
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,740.97

JET1 Accessary kit

Facility

$2,560.25

Hospital Charge Code	13558164
Hospital Revenue Code	270
Min. Negotiated Rate	$230.42
Max. Negotiated Rate	$1,843.38
Rate for Payer: Amerigroup CHIP/Medicaid	$230.42
Rate for Payer: BCBS of TX Blue Advantage	$768.08
Rate for Payer: BCBS of TX Blue Essentials	$921.69
Rate for Payer: BCBS of TX PPO	$1,024.10
Rate for Payer: Cash Price	$1,740.97
Rate for Payer: Cigna Medicaid	$1,843.38
Rate for Payer: Molina CHIP/Medicaid	$1,843.38
Rate for Payer: Multiplan Auto	$1,664.16
Rate for Payer: Multiplan Commercial	$1,664.16
Rate for Payer: Multiplan Workers Comp	$1,664.16
Rate for Payer: Parkland Medicaid	$1,843.38
Rate for Payer: Scott and White EPO/PPO	$1,280.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,843.38
Rate for Payer: Superior Health Plan EPO	$348.19

JETi 6 fr sterile kit throbectomy

Facility

$23,494.00

Hospital Charge Code	13557910
Hospital Revenue Code	270
Rate for Payer: Cash Price	$15,975.92

JETi 6 fr sterile kit throbectomy

Facility

$23,494.00

Hospital Charge Code	13557910
Hospital Revenue Code	270
Min. Negotiated Rate	$2,114.46
Max. Negotiated Rate	$16,915.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2,114.46
Rate for Payer: BCBS of TX Blue Advantage	$7,048.20
Rate for Payer: BCBS of TX Blue Essentials	$8,457.84
Rate for Payer: BCBS of TX PPO	$9,397.60
Rate for Payer: Cash Price	$15,975.92
Rate for Payer: Cigna Medicaid	$16,915.68
Rate for Payer: Molina CHIP/Medicaid	$16,915.68
Rate for Payer: Multiplan Auto	$15,271.10
Rate for Payer: Multiplan Commercial	$15,271.10
Rate for Payer: Multiplan Workers Comp	$15,271.10
Rate for Payer: Parkland Medicaid	$16,915.68
Rate for Payer: Scott and White EPO/PPO	$11,747.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,915.68
Rate for Payer: Superior Health Plan EPO	$3,195.18

JL 3.5 Diagnostic Catheter

Facility

$154.36

Service Code	HCPCS C1887
Hospital Charge Code	992460
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

JL 3.5 Diagnostic Catheter

Facility

$154.36

Service Code	HCPCS C1887
Hospital Charge Code	992460
Hospital Revenue Code	272
Rate for Payer: Cash Price	$104.96

Joint device (implantable)

Facility

$1,404.00

Service Code	HCPCS C1776
Hospital Charge Code	990927
Hospital Revenue Code	278
Min. Negotiated Rate	$351.00
Max. Negotiated Rate	$702.00
Rate for Payer: Cash Price	$954.72
Rate for Payer: Cigna Commercial	$351.00
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: Scott and White EPO/PPO	$702.00

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
Rate for Payer: Cash Price	$787.24

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 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

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

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 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 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	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	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	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	992461
Hospital Revenue Code	272
Rate for Payer: Cash Price	$104.96

Know your out-of-pocket cost for care.

All Charges