White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIT CENT VEN CATH 3 LMN 7F 16CM EXP INTERSAFETY

Facility

$267.24

Service Code	HCPCS C1725
Hospital Charge Code	993590
Hospital Revenue Code	270
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$192.41
Rate for Payer: Amerigroup CHIP/Medicaid	$24.05
Rate for Payer: BCBS of TX Blue Advantage	$80.17
Rate for Payer: BCBS of TX Blue Essentials	$96.21
Rate for Payer: BCBS of TX PPO	$106.90
Rate for Payer: Cash Price	$181.72
Rate for Payer: Cigna Medicaid	$192.41
Rate for Payer: Molina CHIP/Medicaid	$192.41
Rate for Payer: Multiplan Auto	$173.71
Rate for Payer: Multiplan Commercial	$173.71
Rate for Payer: Multiplan Workers Comp	$173.71
Rate for Payer: Parkland Medicaid	$192.41
Rate for Payer: Scott and White EPO/PPO	$133.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.41
Rate for Payer: Superior Health Plan EPO	$36.34

KIT, CIRCUIT, BIPAP, EX PORT

Facility

$136.45

Hospital Charge Code	993828
Hospital Revenue Code	270
Min. Negotiated Rate	$12.28
Max. Negotiated Rate	$98.24
Rate for Payer: Amerigroup CHIP/Medicaid	$12.28
Rate for Payer: BCBS of TX Blue Advantage	$40.94
Rate for Payer: BCBS of TX Blue Essentials	$49.12
Rate for Payer: BCBS of TX PPO	$54.58
Rate for Payer: Cash Price	$92.79
Rate for Payer: Cigna Medicaid	$98.24
Rate for Payer: Molina CHIP/Medicaid	$98.24
Rate for Payer: Multiplan Auto	$88.69
Rate for Payer: Multiplan Commercial	$88.69
Rate for Payer: Multiplan Workers Comp	$88.69
Rate for Payer: Parkland Medicaid	$98.24
Rate for Payer: Scott and White EPO/PPO	$68.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.24
Rate for Payer: Superior Health Plan EPO	$18.56

KIT, CIRCUIT, BIPAP, EX PORT

Facility

$136.45

Hospital Charge Code	993828
Hospital Revenue Code	270
Rate for Payer: Cash Price	$92.79

KIT CIRCUIT PATIENT WITH CHAMBER FLOW GENERATOR

Facility

$272.89

Hospital Charge Code	992744
Hospital Revenue Code	270
Min. Negotiated Rate	$24.56
Max. Negotiated Rate	$196.48
Rate for Payer: Amerigroup CHIP/Medicaid	$24.56
Rate for Payer: BCBS of TX Blue Advantage	$81.87
Rate for Payer: BCBS of TX Blue Essentials	$98.24
Rate for Payer: BCBS of TX PPO	$109.16
Rate for Payer: Cash Price	$185.57
Rate for Payer: Cigna Medicaid	$196.48
Rate for Payer: Molina CHIP/Medicaid	$196.48
Rate for Payer: Multiplan Auto	$177.38
Rate for Payer: Multiplan Commercial	$177.38
Rate for Payer: Multiplan Workers Comp	$177.38
Rate for Payer: Parkland Medicaid	$196.48
Rate for Payer: Scott and White EPO/PPO	$136.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$196.48
Rate for Payer: Superior Health Plan EPO	$37.11

KIT CIRCUIT PATIENT WITH CHAMBER FLOW GENERATOR

Facility

$272.89

Hospital Charge Code	992744
Hospital Revenue Code	270
Rate for Payer: Cash Price	$185.57

KIT, CLOSURE PROCEDURE 5MM & 10-12MM TROCAR DISP

Facility

$180.91

Hospital Charge Code	130957
Hospital Revenue Code	272
Min. Negotiated Rate	$16.28
Max. Negotiated Rate	$130.26
Rate for Payer: Amerigroup CHIP/Medicaid	$16.28
Rate for Payer: BCBS of TX Blue Advantage	$54.27
Rate for Payer: BCBS of TX Blue Essentials	$65.13
Rate for Payer: BCBS of TX PPO	$72.36
Rate for Payer: Cash Price	$123.02
Rate for Payer: Cigna Medicaid	$130.26
Rate for Payer: Molina CHIP/Medicaid	$130.26
Rate for Payer: Multiplan Auto	$117.59
Rate for Payer: Multiplan Commercial	$117.59
Rate for Payer: Multiplan Workers Comp	$117.59
Rate for Payer: Parkland Medicaid	$130.26
Rate for Payer: Scott and White EPO/PPO	$90.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$130.26
Rate for Payer: Superior Health Plan EPO	$24.60

KIT, CLOSURE PROCEDURE 5MM & 10-12MM TROCAR DISP

Facility

$180.91

Hospital Charge Code	130957
Hospital Revenue Code	272
Rate for Payer: Cash Price	$123.02

KIT CLOSURE SUTURE PASSER W/ 10/12MM & 15MM GUIDE

Facility

$363.31

Hospital Charge Code	992659
Hospital Revenue Code	270
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$261.58
Rate for Payer: Amerigroup CHIP/Medicaid	$32.70
Rate for Payer: BCBS of TX Blue Advantage	$108.99
Rate for Payer: BCBS of TX Blue Essentials	$130.79
Rate for Payer: BCBS of TX PPO	$145.32
Rate for Payer: Cash Price	$247.05
Rate for Payer: Cigna Medicaid	$261.58
Rate for Payer: Molina CHIP/Medicaid	$261.58
Rate for Payer: Multiplan Auto	$236.15
Rate for Payer: Multiplan Commercial	$236.15
Rate for Payer: Multiplan Workers Comp	$236.15
Rate for Payer: Parkland Medicaid	$261.58
Rate for Payer: Scott and White EPO/PPO	$181.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$261.58
Rate for Payer: Superior Health Plan EPO	$49.41

KIT CLOSURE SUTURE PASSER W/ 10/12MM & 15MM GUIDE

Facility

$363.31

Hospital Charge Code	992659
Hospital Revenue Code	270
Rate for Payer: Cash Price	$247.05

KIT, COLLECTION CLR NON-CONDUCT PLSTC 3/8' 6' DISP -- DHF

Facility

$261.97

Hospital Charge Code	80343007
Hospital Revenue Code	270
Rate for Payer: Cash Price	$178.14

KIT, COLLECTION CLR NON-CONDUCT PLSTC 3/8' 6' DISP -- DHF

Facility

$261.97

Hospital Charge Code	80343007
Hospital Revenue Code	270
Min. Negotiated Rate	$23.58
Max. Negotiated Rate	$188.62
Rate for Payer: Amerigroup CHIP/Medicaid	$23.58
Rate for Payer: BCBS of TX Blue Advantage	$78.59
Rate for Payer: BCBS of TX Blue Essentials	$94.31
Rate for Payer: BCBS of TX PPO	$104.79
Rate for Payer: Cash Price	$178.14
Rate for Payer: Cigna Medicaid	$188.62
Rate for Payer: Molina CHIP/Medicaid	$188.62
Rate for Payer: Multiplan Auto	$170.28
Rate for Payer: Multiplan Commercial	$170.28
Rate for Payer: Multiplan Workers Comp	$170.28
Rate for Payer: Parkland Medicaid	$188.62
Rate for Payer: Scott and White EPO/PPO	$130.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$188.62
Rate for Payer: Superior Health Plan EPO	$35.63

KIT COOLIEF

Facility

$5,675.00

Hospital Charge Code	146476
Hospital Revenue Code	272
Min. Negotiated Rate	$510.75
Max. Negotiated Rate	$4,086.00
Rate for Payer: Amerigroup CHIP/Medicaid	$510.75
Rate for Payer: BCBS of TX Blue Advantage	$1,702.50
Rate for Payer: BCBS of TX Blue Essentials	$2,043.00
Rate for Payer: BCBS of TX PPO	$2,270.00
Rate for Payer: Cash Price	$3,859.00
Rate for Payer: Cigna Medicaid	$4,086.00
Rate for Payer: Molina CHIP/Medicaid	$4,086.00
Rate for Payer: Multiplan Auto	$3,688.75
Rate for Payer: Multiplan Commercial	$3,688.75
Rate for Payer: Multiplan Workers Comp	$3,688.75
Rate for Payer: Parkland Medicaid	$4,086.00
Rate for Payer: Scott and White EPO/PPO	$2,837.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,086.00
Rate for Payer: Superior Health Plan EPO	$771.80

KIT COOLIEF

Facility

$5,675.00

Hospital Charge Code	146476
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,859.00

KIT, CRANIAL ACCESS W/O D

Facility

$1,622.28

Hospital Charge Code	992724
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,103.15

KIT, CRANIAL ACCESS W/O D

Facility

$1,622.28

Hospital Charge Code	992724
Hospital Revenue Code	272
Min. Negotiated Rate	$146.01
Max. Negotiated Rate	$1,168.04
Rate for Payer: Amerigroup CHIP/Medicaid	$146.01
Rate for Payer: BCBS of TX Blue Advantage	$486.68
Rate for Payer: BCBS of TX Blue Essentials	$584.02
Rate for Payer: BCBS of TX PPO	$648.91
Rate for Payer: Cash Price	$1,103.15
Rate for Payer: Cigna Medicaid	$1,168.04
Rate for Payer: Molina CHIP/Medicaid	$1,168.04
Rate for Payer: Multiplan Auto	$1,054.48
Rate for Payer: Multiplan Commercial	$1,054.48
Rate for Payer: Multiplan Workers Comp	$1,054.48
Rate for Payer: Parkland Medicaid	$1,168.04
Rate for Payer: Scott and White EPO/PPO	$811.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,168.04
Rate for Payer: Superior Health Plan EPO	$220.63

KIT CROSSFIX DISPOSABLE PROCEDURE

Facility

$1,316.60

Hospital Charge Code	145086
Hospital Revenue Code	272
Rate for Payer: Cash Price	$895.29

KIT CROSSFIX DISPOSABLE PROCEDURE

Facility

$1,316.60

Hospital Charge Code	145086
Hospital Revenue Code	272
Min. Negotiated Rate	$118.49
Max. Negotiated Rate	$947.95
Rate for Payer: Amerigroup CHIP/Medicaid	$118.49
Rate for Payer: BCBS of TX Blue Advantage	$394.98
Rate for Payer: BCBS of TX Blue Essentials	$473.98
Rate for Payer: BCBS of TX PPO	$526.64
Rate for Payer: Cash Price	$895.29
Rate for Payer: Cigna Medicaid	$947.95
Rate for Payer: Molina CHIP/Medicaid	$947.95
Rate for Payer: Multiplan Auto	$855.79
Rate for Payer: Multiplan Commercial	$855.79
Rate for Payer: Multiplan Workers Comp	$855.79
Rate for Payer: Parkland Medicaid	$947.95
Rate for Payer: Scott and White EPO/PPO	$658.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$947.95
Rate for Payer: Superior Health Plan EPO	$179.06

KIT CUSTOM EPIDURAL

Facility

$150.68

Hospital Charge Code	131551
Hospital Revenue Code	272
Rate for Payer: Cash Price	$102.46

KIT CUSTOM EPIDURAL

Facility

$150.68

Hospital Charge Code	131551
Hospital Revenue Code	272
Min. Negotiated Rate	$13.56
Max. Negotiated Rate	$108.49
Rate for Payer: Amerigroup CHIP/Medicaid	$13.56
Rate for Payer: BCBS of TX Blue Advantage	$45.20
Rate for Payer: BCBS of TX Blue Essentials	$54.24
Rate for Payer: BCBS of TX PPO	$60.27
Rate for Payer: Cash Price	$102.46
Rate for Payer: Cigna Medicaid	$108.49
Rate for Payer: Molina CHIP/Medicaid	$108.49
Rate for Payer: Multiplan Auto	$97.94
Rate for Payer: Multiplan Commercial	$97.94
Rate for Payer: Multiplan Workers Comp	$97.94
Rate for Payer: Parkland Medicaid	$108.49
Rate for Payer: Scott and White EPO/PPO	$75.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.49
Rate for Payer: Superior Health Plan EPO	$20.49

KIT CUSTOM EPIDURAL CATH 19G FOR PLACENTIA LINDA

Facility

$171.29

Hospital Charge Code	80828700
Hospital Revenue Code	272
Min. Negotiated Rate	$15.42
Max. Negotiated Rate	$123.33
Rate for Payer: Amerigroup CHIP/Medicaid	$15.42
Rate for Payer: BCBS of TX Blue Advantage	$51.39
Rate for Payer: BCBS of TX Blue Essentials	$61.66
Rate for Payer: BCBS of TX PPO	$68.52
Rate for Payer: Cash Price	$116.48
Rate for Payer: Cigna Medicaid	$123.33
Rate for Payer: Molina CHIP/Medicaid	$123.33
Rate for Payer: Multiplan Auto	$111.34
Rate for Payer: Multiplan Commercial	$111.34
Rate for Payer: Multiplan Workers Comp	$111.34
Rate for Payer: Parkland Medicaid	$123.33
Rate for Payer: Scott and White EPO/PPO	$85.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$123.33
Rate for Payer: Superior Health Plan EPO	$23.30

KIT CUSTOM EPIDURAL CATH 19G FOR PLACENTIA LINDA

Facility

$171.29

Hospital Charge Code	80828700
Hospital Revenue Code	272
Rate for Payer: Cash Price	$116.48

KIT, CUSTOM INFECTIOUS CONTROL DOCTORS HOSPITAL WR -- DHF

Facility

$55.45

Hospital Charge Code	80821358
Hospital Revenue Code	271
Min. Negotiated Rate	$4.99
Max. Negotiated Rate	$39.92
Rate for Payer: Amerigroup CHIP/Medicaid	$4.99
Rate for Payer: BCBS of TX Blue Advantage	$16.64
Rate for Payer: BCBS of TX Blue Essentials	$19.96
Rate for Payer: BCBS of TX PPO	$22.18
Rate for Payer: Cash Price	$37.71
Rate for Payer: Cigna Medicaid	$39.92
Rate for Payer: Molina CHIP/Medicaid	$39.92
Rate for Payer: Multiplan Auto	$36.04
Rate for Payer: Multiplan Commercial	$36.04
Rate for Payer: Multiplan Workers Comp	$36.04
Rate for Payer: Parkland Medicaid	$39.92
Rate for Payer: Scott and White EPO/PPO	$27.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.92
Rate for Payer: Superior Health Plan EPO	$7.54

KIT, CUSTOM INFECTIOUS CONTROL DOCTORS HOSPITAL WR -- DHF

Facility

$55.45

Hospital Charge Code	80821358
Hospital Revenue Code	271
Rate for Payer: Cash Price	$37.71

KIT CUSTOM MANIFOLD

Facility

$23.13

Hospital Charge Code	993049
Hospital Revenue Code	270
Rate for Payer: Cash Price	$15.73

KIT CUSTOM MANIFOLD

Facility

$23.13

Hospital Charge Code	993049
Hospital Revenue Code	270
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$16.65
Rate for Payer: Amerigroup CHIP/Medicaid	$2.08
Rate for Payer: BCBS of TX Blue Advantage	$6.94
Rate for Payer: BCBS of TX Blue Essentials	$8.33
Rate for Payer: BCBS of TX PPO	$9.25
Rate for Payer: Cash Price	$15.73
Rate for Payer: Cigna Medicaid	$16.65
Rate for Payer: Molina CHIP/Medicaid	$16.65
Rate for Payer: Multiplan Auto	$15.03
Rate for Payer: Multiplan Commercial	$15.03
Rate for Payer: Multiplan Workers Comp	$15.03
Rate for Payer: Parkland Medicaid	$16.65
Rate for Payer: Scott and White EPO/PPO	$11.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.65
Rate for Payer: Superior Health Plan EPO	$3.15

Know your out-of-pocket cost for care.

All Charges