White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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 DISPOSABLE

Facility

$637.69

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

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 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
Rate for Payer: Cash Price	$86.63

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, 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, 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 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

kit avaflex balloon 11g

Facility

$11,361.35

Hospital Charge Code	8634512
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7,725.72

kit avaflex balloon 11g

Facility

$11,361.35

Hospital Charge Code	8634512
Hospital Revenue Code	272
Min. Negotiated Rate	$1,022.52
Max. Negotiated Rate	$8,180.17
Rate for Payer: Amerigroup CHIP/Medicaid	$1,022.52
Rate for Payer: BCBS of TX Blue Advantage	$3,408.41
Rate for Payer: BCBS of TX Blue Essentials	$4,090.09
Rate for Payer: BCBS of TX PPO	$4,544.54
Rate for Payer: Cash Price	$7,725.72
Rate for Payer: Cigna Medicaid	$8,180.17
Rate for Payer: Molina CHIP/Medicaid	$8,180.17
Rate for Payer: Multiplan Auto	$7,384.88
Rate for Payer: Multiplan Commercial	$7,384.88
Rate for Payer: Multiplan Workers Comp	$7,384.88
Rate for Payer: Parkland Medicaid	$8,180.17
Rate for Payer: Scott and White EPO/PPO	$5,680.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,180.17
Rate for Payer: Superior Health Plan EPO	$1,545.14

KIT BIOPSY BASIC W/O NEEDLESAFETY

Facility

$174.93

Hospital Charge Code	993749
Hospital Revenue Code	272
Rate for Payer: Cash Price	$118.95

KIT BIOPSY BASIC W/O NEEDLESAFETY

Facility

$174.93

Hospital Charge Code	993749
Hospital Revenue Code	272
Min. Negotiated Rate	$15.74
Max. Negotiated Rate	$125.95
Rate for Payer: Amerigroup CHIP/Medicaid	$15.74
Rate for Payer: BCBS of TX Blue Advantage	$52.48
Rate for Payer: BCBS of TX Blue Essentials	$62.97
Rate for Payer: BCBS of TX PPO	$69.97
Rate for Payer: Cash Price	$118.95
Rate for Payer: Cigna Medicaid	$125.95
Rate for Payer: Molina CHIP/Medicaid	$125.95
Rate for Payer: Multiplan Auto	$113.70
Rate for Payer: Multiplan Commercial	$113.70
Rate for Payer: Multiplan Workers Comp	$113.70
Rate for Payer: Parkland Medicaid	$125.95
Rate for Payer: Scott and White EPO/PPO	$87.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.95
Rate for Payer: Superior Health Plan EPO	$23.79

KIT, BLOOD SAMPLING, PRO-VENT PLUS

Facility

$9.88

Hospital Charge Code	993080
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.72

KIT, BLOOD SAMPLING, PRO-VENT PLUS

Facility

$9.88

Hospital Charge Code	993080
Hospital Revenue Code	270
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$7.11
Rate for Payer: Amerigroup CHIP/Medicaid	$0.89
Rate for Payer: BCBS of TX Blue Advantage	$2.96
Rate for Payer: BCBS of TX Blue Essentials	$3.56
Rate for Payer: BCBS of TX PPO	$3.95
Rate for Payer: Cash Price	$6.72
Rate for Payer: Cigna Medicaid	$7.11
Rate for Payer: Molina CHIP/Medicaid	$7.11
Rate for Payer: Multiplan Auto	$6.42
Rate for Payer: Multiplan Commercial	$6.42
Rate for Payer: Multiplan Workers Comp	$6.42
Rate for Payer: Parkland Medicaid	$7.11
Rate for Payer: Scott and White EPO/PPO	$4.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.11
Rate for Payer: Superior Health Plan EPO	$1.34

KIT BONE MARROW ASPIRATION

Facility

$9,080.00

Hospital Charge Code	8394474
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6,174.40

KIT BONE MARROW ASPIRATION

Facility

$9,080.00

Hospital Charge Code	8394474
Hospital Revenue Code	272
Min. Negotiated Rate	$817.20
Max. Negotiated Rate	$6,537.60
Rate for Payer: Amerigroup CHIP/Medicaid	$817.20
Rate for Payer: BCBS of TX Blue Advantage	$2,724.00
Rate for Payer: BCBS of TX Blue Essentials	$3,268.80
Rate for Payer: BCBS of TX PPO	$3,632.00
Rate for Payer: Cash Price	$6,174.40
Rate for Payer: Cigna Medicaid	$6,537.60
Rate for Payer: Molina CHIP/Medicaid	$6,537.60
Rate for Payer: Multiplan Auto	$5,902.00
Rate for Payer: Multiplan Commercial	$5,902.00
Rate for Payer: Multiplan Workers Comp	$5,902.00
Rate for Payer: Parkland Medicaid	$6,537.60
Rate for Payer: Scott and White EPO/PPO	$4,540.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,537.60
Rate for Payer: Superior Health Plan EPO	$1,234.88

KIT CALIBRATOR S-CAL 1 X 3.3ML

Facility

$326.88

Hospital Charge Code	993801
Hospital Revenue Code	270
Min. Negotiated Rate	$29.42
Max. Negotiated Rate	$235.35
Rate for Payer: Amerigroup CHIP/Medicaid	$29.42
Rate for Payer: BCBS of TX Blue Advantage	$98.06
Rate for Payer: BCBS of TX Blue Essentials	$117.68
Rate for Payer: BCBS of TX PPO	$130.75
Rate for Payer: Cash Price	$222.28
Rate for Payer: Cigna Medicaid	$235.35
Rate for Payer: Molina CHIP/Medicaid	$235.35
Rate for Payer: Multiplan Auto	$212.47
Rate for Payer: Multiplan Commercial	$212.47
Rate for Payer: Multiplan Workers Comp	$212.47
Rate for Payer: Parkland Medicaid	$235.35
Rate for Payer: Scott and White EPO/PPO	$163.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$235.35
Rate for Payer: Superior Health Plan EPO	$44.46

KIT CALIBRATOR S-CAL 1 X 3.3ML

Facility

$326.88

Hospital Charge Code	993801
Hospital Revenue Code	270
Rate for Payer: Cash Price	$222.28

Know your out-of-pocket cost for care.

All Charges