White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIDNEY & URETER PROCEDURES FOR NEOPLASM W MCC

Facility

$60,492.20

Service Code	MSDRG 656
Min. Negotiated Rate	$27,858.25
Max. Negotiated Rate	$60,492.20
Rate for Payer: BCBS of TX Blue Advantage	$28,617.36
Rate for Payer: BCBS of TX Blue Essentials	$34,337.50
Rate for Payer: BCBS of TX PPO	$38,154.26

KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC

Facility

$29,484.20

Service Code	MSDRG 658
Min. Negotiated Rate	$13,471.04
Max. Negotiated Rate	$29,484.20
Rate for Payer: BCBS of TX Blue Advantage	$13,471.04
Rate for Payer: BCBS of TX Blue Essentials	$16,163.68
Rate for Payer: BCBS of TX PPO	$17,960.34

KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC

Facility

$25,112.30

Service Code	MSDRG 660
Min. Negotiated Rate	$11,564.88
Max. Negotiated Rate	$25,112.30
Rate for Payer: BCBS of TX Blue Advantage	$12,449.36
Rate for Payer: BCBS of TX Blue Essentials	$14,937.78
Rate for Payer: BCBS of TX PPO	$16,598.18

KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC

Facility

$48,277.10

Service Code	MSDRG 659
Min. Negotiated Rate	$22,232.88
Max. Negotiated Rate	$48,277.10
Rate for Payer: BCBS of TX Blue Advantage	$23,453.06
Rate for Payer: BCBS of TX Blue Essentials	$28,140.94
Rate for Payer: BCBS of TX PPO	$31,268.93

KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC

Facility

$19,672.60

Service Code	MSDRG 661
Min. Negotiated Rate	$9,059.75
Max. Negotiated Rate	$19,672.60
Rate for Payer: BCBS of TX Blue Advantage	$9,226.08
Rate for Payer: BCBS of TX Blue Essentials	$11,070.22
Rate for Payer: BCBS of TX PPO	$12,300.72

KIDNEY & URINARY TRACT INFECTIONS W MCC

Facility

$22,045.70

Service Code	MSDRG 689
Min. Negotiated Rate	$9,559.76
Max. Negotiated Rate	$22,045.70
Rate for Payer: BCBS of TX Blue Advantage	$9,559.76
Rate for Payer: BCBS of TX Blue Essentials	$11,470.60
Rate for Payer: BCBS of TX PPO	$12,745.61

KIDNEY & URINARY TRACT INFECTIONS W/O MCC

Facility

$15,380.50

Service Code	MSDRG 690
Min. Negotiated Rate	$6,829.26
Max. Negotiated Rate	$15,380.50
Rate for Payer: BCBS of TX Blue Advantage	$6,829.26
Rate for Payer: BCBS of TX Blue Essentials	$8,194.32
Rate for Payer: BCBS of TX PPO	$9,105.15

KIDNEY & URINARY TRACT NEOPLASMS W CC

Facility

$19,908.20

Service Code	MSDRG 687
Min. Negotiated Rate	$9,061.82
Max. Negotiated Rate	$19,908.20
Rate for Payer: BCBS of TX Blue Advantage	$9,061.82
Rate for Payer: BCBS of TX Blue Essentials	$10,873.13
Rate for Payer: BCBS of TX PPO	$12,081.72

KIDNEY & URINARY TRACT NEOPLASMS W MCC

Facility

$34,270.30

Service Code	MSDRG 686
Min. Negotiated Rate	$14,771.36
Max. Negotiated Rate	$34,270.30
Rate for Payer: BCBS of TX Blue Advantage	$14,771.36
Rate for Payer: BCBS of TX Blue Essentials	$17,723.91
Rate for Payer: BCBS of TX PPO	$19,694.00

KIDNEY & URINARY TRACT NEOPLASMS W/O CC/MCC

Facility

$15,015.70

Service Code	MSDRG 688
Min. Negotiated Rate	$6,801.74
Max. Negotiated Rate	$15,015.70
Rate for Payer: BCBS of TX Blue Advantage	$6,801.74
Rate for Payer: BCBS of TX Blue Essentials	$8,161.30
Rate for Payer: BCBS of TX PPO	$9,068.46

KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W MCC

Facility

$21,732.20

Service Code	MSDRG 695
Min. Negotiated Rate	$9,878.82
Max. Negotiated Rate	$21,732.20
Rate for Payer: BCBS of TX Blue Advantage	$9,878.82
Rate for Payer: BCBS of TX Blue Essentials	$11,853.44
Rate for Payer: BCBS of TX PPO	$13,170.99

KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC

Facility

$13,091.00

Service Code	MSDRG 696
Min. Negotiated Rate	$5,921.96
Max. Negotiated Rate	$13,091.00
Rate for Payer: BCBS of TX Blue Advantage	$5,921.96
Rate for Payer: BCBS of TX Blue Essentials	$7,105.66
Rate for Payer: BCBS of TX PPO	$7,895.49

kit 15mm elite fracture inflation

Facility

$9,783.70

Hospital Charge Code	8634509
Hospital Revenue Code	272
Min. Negotiated Rate	$880.53
Max. Negotiated Rate	$7,044.26
Rate for Payer: Amerigroup CHIP/Medicaid	$880.53
Rate for Payer: BCBS of TX Blue Advantage	$2,935.11
Rate for Payer: BCBS of TX Blue Essentials	$3,522.13
Rate for Payer: BCBS of TX PPO	$3,913.48
Rate for Payer: Cash Price	$6,652.92
Rate for Payer: Cigna Medicaid	$7,044.26
Rate for Payer: Molina CHIP/Medicaid	$7,044.26
Rate for Payer: Multiplan Auto	$6,359.40
Rate for Payer: Multiplan Commercial	$6,359.40
Rate for Payer: Multiplan Workers Comp	$6,359.40
Rate for Payer: Parkland Medicaid	$7,044.26
Rate for Payer: Scott and White EPO/PPO	$4,891.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,044.26
Rate for Payer: Superior Health Plan EPO	$1,330.58

kit 15mm elite fracture inflation

Facility

$9,783.70

Hospital Charge Code	8634509
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6,652.92

KIT 6FT 3/8IN VAC CRTG HNDL SLP RNG TBG

Facility

$166.57

Hospital Charge Code	993937
Hospital Revenue Code	272
Min. Negotiated Rate	$14.99
Max. Negotiated Rate	$119.93
Rate for Payer: Amerigroup CHIP/Medicaid	$14.99
Rate for Payer: BCBS of TX Blue Advantage	$49.97
Rate for Payer: BCBS of TX Blue Essentials	$59.97
Rate for Payer: BCBS of TX PPO	$66.63
Rate for Payer: Cash Price	$113.27
Rate for Payer: Cigna Medicaid	$119.93
Rate for Payer: Molina CHIP/Medicaid	$119.93
Rate for Payer: Multiplan Auto	$108.27
Rate for Payer: Multiplan Commercial	$108.27
Rate for Payer: Multiplan Workers Comp	$108.27
Rate for Payer: Parkland Medicaid	$119.93
Rate for Payer: Scott and White EPO/PPO	$83.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$119.93
Rate for Payer: Superior Health Plan EPO	$22.65

KIT 6FT 3/8IN VAC CRTG HNDL SLP RNG TBG

Facility

$166.57

Hospital Charge Code	993937
Hospital Revenue Code	272
Rate for Payer: Cash Price	$113.27

KIT ABG 1ML 25GX5/8IN 25IU DRY LIHEP STRL

Facility

$2.99

Hospital Charge Code	993617
Hospital Revenue Code	270
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$2.15
Rate for Payer: Amerigroup CHIP/Medicaid	$0.27
Rate for Payer: BCBS of TX Blue Advantage	$0.90
Rate for Payer: BCBS of TX Blue Essentials	$1.08
Rate for Payer: BCBS of TX PPO	$1.20
Rate for Payer: Cash Price	$2.03
Rate for Payer: Cigna Medicaid	$2.15
Rate for Payer: Molina CHIP/Medicaid	$2.15
Rate for Payer: Multiplan Auto	$1.94
Rate for Payer: Multiplan Commercial	$1.94
Rate for Payer: Multiplan Workers Comp	$1.94
Rate for Payer: Parkland Medicaid	$2.15
Rate for Payer: Scott and White EPO/PPO	$1.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.15
Rate for Payer: Superior Health Plan EPO	$0.41

KIT ABG 1ML 25GX5/8IN 25IU DRY LIHEP STRL

Facility

$2.99

Hospital Charge Code	993617
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.03

KIT ABG PRO VENT 3CC SYR 22GX1 W/PT LOCK

Facility

$2.82

Hospital Charge Code	993616
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.92

KIT ABG PRO VENT 3CC SYR 22GX1 W/PT LOCK

Facility

$2.82

Hospital Charge Code	993616
Hospital Revenue Code	270
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$2.03
Rate for Payer: Amerigroup CHIP/Medicaid	$0.25
Rate for Payer: BCBS of TX Blue Advantage	$0.85
Rate for Payer: BCBS of TX Blue Essentials	$1.02
Rate for Payer: BCBS of TX PPO	$1.13
Rate for Payer: Cash Price	$1.92
Rate for Payer: Cigna Medicaid	$2.03
Rate for Payer: Molina CHIP/Medicaid	$2.03
Rate for Payer: Multiplan Auto	$1.83
Rate for Payer: Multiplan Commercial	$1.83
Rate for Payer: Multiplan Workers Comp	$1.83
Rate for Payer: Parkland Medicaid	$2.03
Rate for Payer: Scott and White EPO/PPO	$1.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.03
Rate for Payer: Superior Health Plan EPO	$0.38

KIT, ACCESSORY 3 ARM CANN SEAL W/CAM&INST DRP 8MM -- DHF

Facility

$14,348.05

Hospital Charge Code	81763161
Hospital Revenue Code	272
Min. Negotiated Rate	$1,291.32
Max. Negotiated Rate	$10,330.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1,291.32
Rate for Payer: BCBS of TX Blue Advantage	$4,304.41
Rate for Payer: BCBS of TX Blue Essentials	$5,165.30
Rate for Payer: BCBS of TX PPO	$5,739.22
Rate for Payer: Cash Price	$9,756.67
Rate for Payer: Cigna Medicaid	$10,330.60
Rate for Payer: Molina CHIP/Medicaid	$10,330.60
Rate for Payer: Multiplan Auto	$9,326.23
Rate for Payer: Multiplan Commercial	$9,326.23
Rate for Payer: Multiplan Workers Comp	$9,326.23
Rate for Payer: Parkland Medicaid	$10,330.60
Rate for Payer: Scott and White EPO/PPO	$7,174.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,330.60
Rate for Payer: Superior Health Plan EPO	$1,951.33

KIT, ACCESSORY 3 ARM CANN SEAL W/CAM&INST DRP 8MM -- DHF

Facility

$14,348.05

Hospital Charge Code	81763161
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9,756.67

KIT ACCESSORY INSTAFIX -- DHF

Facility

$2,111.10

Hospital Charge Code	80899057
Hospital Revenue Code	272
Min. Negotiated Rate	$190.00
Max. Negotiated Rate	$1,519.99
Rate for Payer: Amerigroup CHIP/Medicaid	$190.00
Rate for Payer: BCBS of TX Blue Advantage	$633.33
Rate for Payer: BCBS of TX Blue Essentials	$760.00
Rate for Payer: BCBS of TX PPO	$844.44
Rate for Payer: Cash Price	$1,435.55
Rate for Payer: Cigna Medicaid	$1,519.99
Rate for Payer: Molina CHIP/Medicaid	$1,519.99
Rate for Payer: Multiplan Auto	$1,372.21
Rate for Payer: Multiplan Commercial	$1,372.21
Rate for Payer: Multiplan Workers Comp	$1,372.21
Rate for Payer: Parkland Medicaid	$1,519.99
Rate for Payer: Scott and White EPO/PPO	$1,055.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,519.99
Rate for Payer: Superior Health Plan EPO	$287.11

KIT ACCESSORY INSTAFIX -- DHF

Facility

$2,111.10

Hospital Charge Code	80899057
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,435.55

KIT ACESSORY DSO6003

Facility

$317.80

Hospital Charge Code	145163
Hospital Revenue Code	272
Rate for Payer: Cash Price	$216.10

Know your out-of-pocket cost for care.

All Charges