White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$9,756.67

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 INSTAFIX -- DHF

Facility

$2,111.10

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

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 ACESSORY DSO6003

Facility

$317.80

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

KIT ACESSORY DSO6003

Facility

$317.80

Hospital Charge Code	145163
Hospital Revenue Code	272
Min. Negotiated Rate	$28.60
Max. Negotiated Rate	$228.82
Rate for Payer: Amerigroup CHIP/Medicaid	$28.60
Rate for Payer: BCBS of TX Blue Advantage	$95.34
Rate for Payer: BCBS of TX Blue Essentials	$114.41
Rate for Payer: BCBS of TX PPO	$127.12
Rate for Payer: Cash Price	$216.10
Rate for Payer: Cigna Medicaid	$228.82
Rate for Payer: Molina CHIP/Medicaid	$228.82
Rate for Payer: Multiplan Auto	$206.57
Rate for Payer: Multiplan Commercial	$206.57
Rate for Payer: Multiplan Workers Comp	$206.57
Rate for Payer: Parkland Medicaid	$228.82
Rate for Payer: Scott and White EPO/PPO	$158.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$228.82
Rate for Payer: Superior Health Plan EPO	$43.22

KIT, ACL ANATOMIC DISPOSABLE W/XACTPIN GRAF PIN

Facility

$1,375.78

Service Code	HCPCS C1776
Hospital Charge Code	992123
Hospital Revenue Code	278
Min. Negotiated Rate	$123.82
Max. Negotiated Rate	$990.56
Rate for Payer: Amerigroup CHIP/Medicaid	$123.82
Rate for Payer: BCBS of TX Blue Advantage	$412.73
Rate for Payer: BCBS of TX Blue Essentials	$495.28
Rate for Payer: BCBS of TX PPO	$550.31
Rate for Payer: Cash Price	$935.53
Rate for Payer: Cigna Medicaid	$990.56
Rate for Payer: Molina CHIP/Medicaid	$990.56
Rate for Payer: Multiplan Auto	$687.89
Rate for Payer: Multiplan Commercial	$687.89
Rate for Payer: Multiplan Workers Comp	$687.89
Rate for Payer: Parkland Medicaid	$990.56
Rate for Payer: Scott and White EPO/PPO	$687.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$990.56
Rate for Payer: Superior Health Plan EPO	$187.11

KIT, ACL ANATOMIC DISPOSABLE W/XACTPIN GRAF PIN

Facility

$1,375.78

Service Code	HCPCS C1776
Hospital Charge Code	992123
Hospital Revenue Code	278
Min. Negotiated Rate	$343.94
Max. Negotiated Rate	$687.89
Rate for Payer: Cash Price	$935.53
Rate for Payer: Cigna Commercial	$343.94
Rate for Payer: Multiplan Auto	$687.89
Rate for Payer: Multiplan Commercial	$687.89
Rate for Payer: Multiplan Workers Comp	$687.89
Rate for Payer: Scott and White EPO/PPO	$687.89

KIT ACL DISPOSABLE

Facility

$637.69

Hospital Charge Code	145131
Hospital Revenue Code	272
Min. Negotiated Rate	$57.39
Max. Negotiated Rate	$459.14
Rate for Payer: Amerigroup CHIP/Medicaid	$57.39
Rate for Payer: BCBS of TX Blue Advantage	$191.31
Rate for Payer: BCBS of TX Blue Essentials	$229.57
Rate for Payer: BCBS of TX PPO	$255.08
Rate for Payer: Cash Price	$433.63
Rate for Payer: Cigna Medicaid	$459.14
Rate for Payer: Molina CHIP/Medicaid	$459.14
Rate for Payer: Multiplan Auto	$414.50
Rate for Payer: Multiplan Commercial	$414.50
Rate for Payer: Multiplan Workers Comp	$414.50
Rate for Payer: Parkland Medicaid	$459.14
Rate for Payer: Scott and White EPO/PPO	$318.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$459.14
Rate for Payer: Superior Health Plan EPO	$86.73

KIT ACL DISPOSABLE

Facility

$637.69

Hospital Charge Code	145131
Hospital Revenue Code	272
Rate for Payer: Cash Price	$433.63

KIT ACL UNIVERSAL DISPOSIBLE

Facility

$582.26

Hospital Charge Code	144129
Hospital Revenue Code	272
Rate for Payer: Cash Price	$395.94

KIT ACL UNIVERSAL DISPOSIBLE

Facility

$582.26

Hospital Charge Code	144129
Hospital Revenue Code	272
Min. Negotiated Rate	$52.40
Max. Negotiated Rate	$419.23
Rate for Payer: Amerigroup CHIP/Medicaid	$52.40
Rate for Payer: BCBS of TX Blue Advantage	$174.68
Rate for Payer: BCBS of TX Blue Essentials	$209.61
Rate for Payer: BCBS of TX PPO	$232.90
Rate for Payer: Cash Price	$395.94
Rate for Payer: Cigna Medicaid	$419.23
Rate for Payer: Molina CHIP/Medicaid	$419.23
Rate for Payer: Multiplan Auto	$378.47
Rate for Payer: Multiplan Commercial	$378.47
Rate for Payer: Multiplan Workers Comp	$378.47
Rate for Payer: Parkland Medicaid	$419.23
Rate for Payer: Scott and White EPO/PPO	$291.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$419.23
Rate for Payer: Superior Health Plan EPO	$79.19

KIT ANESTHESIA SAMPLING COMB W/1 PRES TRANS 68

Facility

$127.39

Hospital Charge Code	132498
Hospital Revenue Code	272
Min. Negotiated Rate	$11.47
Max. Negotiated Rate	$91.72
Rate for Payer: Amerigroup CHIP/Medicaid	$11.47
Rate for Payer: BCBS of TX Blue Advantage	$38.22
Rate for Payer: BCBS of TX Blue Essentials	$45.86
Rate for Payer: BCBS of TX PPO	$50.96
Rate for Payer: Cash Price	$86.63
Rate for Payer: Cigna Medicaid	$91.72
Rate for Payer: Molina CHIP/Medicaid	$91.72
Rate for Payer: Multiplan Auto	$82.80
Rate for Payer: Multiplan Commercial	$82.80
Rate for Payer: Multiplan Workers Comp	$82.80
Rate for Payer: Parkland Medicaid	$91.72
Rate for Payer: Scott and White EPO/PPO	$63.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.72
Rate for Payer: Superior Health Plan EPO	$17.33

KIT ANESTHESIA SAMPLING COMB W/1 PRES TRANS 68

Facility

$127.39

Hospital Charge Code	132498
Hospital Revenue Code	272
Rate for Payer: Cash Price	$86.63

KIT, ANTI FOG, W/SPONGE & FLUID, SOFT PACK

Facility

$7.11

Hospital Charge Code	992777
Hospital Revenue Code	272
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$5.12
Rate for Payer: Amerigroup CHIP/Medicaid	$0.64
Rate for Payer: BCBS of TX Blue Advantage	$2.13
Rate for Payer: BCBS of TX Blue Essentials	$2.56
Rate for Payer: BCBS of TX PPO	$2.84
Rate for Payer: Cash Price	$4.83
Rate for Payer: Cigna Medicaid	$5.12
Rate for Payer: Molina CHIP/Medicaid	$5.12
Rate for Payer: Multiplan Auto	$4.62
Rate for Payer: Multiplan Commercial	$4.62
Rate for Payer: Multiplan Workers Comp	$4.62
Rate for Payer: Parkland Medicaid	$5.12
Rate for Payer: Scott and White EPO/PPO	$3.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.12
Rate for Payer: Superior Health Plan EPO	$0.97

KIT, ANTI FOG, W/SPONGE & FLUID, SOFT PACK

Facility

$7.11

Hospital Charge Code	992777
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.83

KIT ARTHROSCOPY DISP

Facility

$1,490.53

Hospital Charge Code	146668
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,013.56

KIT ARTHROSCOPY DISP

Facility

$1,490.53

Hospital Charge Code	146668
Hospital Revenue Code	272
Min. Negotiated Rate	$134.15
Max. Negotiated Rate	$1,073.18
Rate for Payer: Amerigroup CHIP/Medicaid	$134.15
Rate for Payer: BCBS of TX Blue Advantage	$447.16
Rate for Payer: BCBS of TX Blue Essentials	$536.59
Rate for Payer: BCBS of TX PPO	$596.21
Rate for Payer: Cash Price	$1,013.56
Rate for Payer: Cigna Medicaid	$1,073.18
Rate for Payer: Molina CHIP/Medicaid	$1,073.18
Rate for Payer: Multiplan Auto	$968.84
Rate for Payer: Multiplan Commercial	$968.84
Rate for Payer: Multiplan Workers Comp	$968.84
Rate for Payer: Parkland Medicaid	$1,073.18
Rate for Payer: Scott and White EPO/PPO	$745.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,073.18
Rate for Payer: Superior Health Plan EPO	$202.71

KIT ATRIAL UNIVERSAL

Facility

$295.10

Hospital Charge Code	8568964
Hospital Revenue Code	272
Min. Negotiated Rate	$26.56
Max. Negotiated Rate	$212.47
Rate for Payer: Amerigroup CHIP/Medicaid	$26.56
Rate for Payer: BCBS of TX Blue Advantage	$88.53
Rate for Payer: BCBS of TX Blue Essentials	$106.24
Rate for Payer: BCBS of TX PPO	$118.04
Rate for Payer: Cash Price	$200.67
Rate for Payer: Cigna Medicaid	$212.47
Rate for Payer: Molina CHIP/Medicaid	$212.47
Rate for Payer: Multiplan Auto	$191.81
Rate for Payer: Multiplan Commercial	$191.81
Rate for Payer: Multiplan Workers Comp	$191.81
Rate for Payer: Parkland Medicaid	$212.47
Rate for Payer: Scott and White EPO/PPO	$147.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$212.47
Rate for Payer: Superior Health Plan EPO	$40.13

KIT ATRIAL UNIVERSAL

Facility

$295.10

Hospital Charge Code	8568964
Hospital Revenue Code	272
Rate for Payer: Cash Price	$200.67

Know your out-of-pocket cost for care.

All Charges