White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIT CUSTOM PICC DRESSING W/4 ID BIOPATCH ADULT

Facility

$21.01

Hospital Charge Code	993048
Hospital Revenue Code	270
Rate for Payer: Cash Price	$14.29

KIT CUSTOM PICC DRESSING W/4 ID BIOPATCH ADULT

Facility

$21.01

Hospital Charge Code	993048
Hospital Revenue Code	270
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$15.13
Rate for Payer: Amerigroup CHIP/Medicaid	$1.89
Rate for Payer: BCBS of TX Blue Advantage	$6.30
Rate for Payer: BCBS of TX Blue Essentials	$7.56
Rate for Payer: BCBS of TX PPO	$8.40
Rate for Payer: Cash Price	$14.29
Rate for Payer: Cigna Medicaid	$15.13
Rate for Payer: Molina CHIP/Medicaid	$15.13
Rate for Payer: Multiplan Auto	$13.66
Rate for Payer: Multiplan Commercial	$13.66
Rate for Payer: Multiplan Workers Comp	$13.66
Rate for Payer: Parkland Medicaid	$15.13
Rate for Payer: Scott and White EPO/PPO	$10.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.13
Rate for Payer: Superior Health Plan EPO	$2.86

KIT DENSICEK PLUS STANDARDS

Facility

$1,012.06

Hospital Charge Code	992624
Hospital Revenue Code	270
Min. Negotiated Rate	$91.09
Max. Negotiated Rate	$728.68
Rate for Payer: Amerigroup CHIP/Medicaid	$91.09
Rate for Payer: BCBS of TX Blue Advantage	$303.62
Rate for Payer: BCBS of TX Blue Essentials	$364.34
Rate for Payer: BCBS of TX PPO	$404.82
Rate for Payer: Cash Price	$688.20
Rate for Payer: Cigna Medicaid	$728.68
Rate for Payer: Molina CHIP/Medicaid	$728.68
Rate for Payer: Multiplan Auto	$657.84
Rate for Payer: Multiplan Commercial	$657.84
Rate for Payer: Multiplan Workers Comp	$657.84
Rate for Payer: Parkland Medicaid	$728.68
Rate for Payer: Scott and White EPO/PPO	$506.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$728.68
Rate for Payer: Superior Health Plan EPO	$137.64

KIT DENSICEK PLUS STANDARDS

Facility

$1,012.06

Hospital Charge Code	992624
Hospital Revenue Code	270
Rate for Payer: Cash Price	$688.20

KIT, DEVICE NOVASURE ENDOMETRIAL ABLATION -- DHF

Facility

$4,677.01

Hospital Charge Code	81750697
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,180.37

KIT, DEVICE NOVASURE ENDOMETRIAL ABLATION -- DHF

Facility

$4,677.01

Hospital Charge Code	81750697
Hospital Revenue Code	272
Min. Negotiated Rate	$420.93
Max. Negotiated Rate	$3,367.45
Rate for Payer: Amerigroup CHIP/Medicaid	$420.93
Rate for Payer: BCBS of TX Blue Advantage	$1,403.10
Rate for Payer: BCBS of TX Blue Essentials	$1,683.72
Rate for Payer: BCBS of TX PPO	$1,870.80
Rate for Payer: Cash Price	$3,180.37
Rate for Payer: Cigna Medicaid	$3,367.45
Rate for Payer: Molina CHIP/Medicaid	$3,367.45
Rate for Payer: Multiplan Auto	$3,040.06
Rate for Payer: Multiplan Commercial	$3,040.06
Rate for Payer: Multiplan Workers Comp	$3,040.06
Rate for Payer: Parkland Medicaid	$3,367.45
Rate for Payer: Scott and White EPO/PPO	$2,338.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,367.45
Rate for Payer: Superior Health Plan EPO	$636.07

kit dilator disposable

Facility

$22,223.30

Hospital Charge Code	8672531
Hospital Revenue Code	272
Rate for Payer: Cash Price	$15,111.84

kit dilator disposable

Facility

$22,223.30

Hospital Charge Code	8672531
Hospital Revenue Code	272
Min. Negotiated Rate	$2,000.10
Max. Negotiated Rate	$16,000.78
Rate for Payer: Amerigroup CHIP/Medicaid	$2,000.10
Rate for Payer: BCBS of TX Blue Advantage	$6,666.99
Rate for Payer: BCBS of TX Blue Essentials	$8,000.39
Rate for Payer: BCBS of TX PPO	$8,889.32
Rate for Payer: Cash Price	$15,111.84
Rate for Payer: Cigna Medicaid	$16,000.78
Rate for Payer: Molina CHIP/Medicaid	$16,000.78
Rate for Payer: Multiplan Auto	$14,445.15
Rate for Payer: Multiplan Commercial	$14,445.15
Rate for Payer: Multiplan Workers Comp	$14,445.15
Rate for Payer: Parkland Medicaid	$16,000.78
Rate for Payer: Scott and White EPO/PPO	$11,111.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,000.78
Rate for Payer: Superior Health Plan EPO	$3,022.37

KIT DILATOR VASCLR STIFF MINI W/ECHO NDL 4FX10CM

Facility

$124.85

Hospital Charge Code	993532
Hospital Revenue Code	270
Min. Negotiated Rate	$11.24
Max. Negotiated Rate	$89.89
Rate for Payer: Amerigroup CHIP/Medicaid	$11.24
Rate for Payer: BCBS of TX Blue Advantage	$37.45
Rate for Payer: BCBS of TX Blue Essentials	$44.95
Rate for Payer: BCBS of TX PPO	$49.94
Rate for Payer: Cash Price	$84.90
Rate for Payer: Cigna Medicaid	$89.89
Rate for Payer: Molina CHIP/Medicaid	$89.89
Rate for Payer: Multiplan Auto	$81.15
Rate for Payer: Multiplan Commercial	$81.15
Rate for Payer: Multiplan Workers Comp	$81.15
Rate for Payer: Parkland Medicaid	$89.89
Rate for Payer: Scott and White EPO/PPO	$62.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.89
Rate for Payer: Superior Health Plan EPO	$16.98

KIT DILATOR VASCLR STIFF MINI W/ECHO NDL 4FX10CM

Facility

$124.85

Hospital Charge Code	993532
Hospital Revenue Code	270
Rate for Payer: Cash Price	$84.90

KIT, DRAINAGE PLEUR/PNEUMOPERICARDIAL FUHRMAN 8.5F

Facility

$567.55

Hospital Charge Code	80820053
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.64
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.26
Rate for Payer: BCBS of TX Blue Essentials	$204.32
Rate for Payer: BCBS of TX PPO	$227.02
Rate for Payer: Cash Price	$385.93
Rate for Payer: Cigna Medicaid	$408.64
Rate for Payer: Molina CHIP/Medicaid	$408.64
Rate for Payer: Multiplan Auto	$368.91
Rate for Payer: Multiplan Commercial	$368.91
Rate for Payer: Multiplan Workers Comp	$368.91
Rate for Payer: Parkland Medicaid	$408.64
Rate for Payer: Scott and White EPO/PPO	$283.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.64
Rate for Payer: Superior Health Plan EPO	$77.19

KIT, DRAINAGE PLEUR/PNEUMOPERICARDIAL FUHRMAN 8.5F

Facility

$567.55

Hospital Charge Code	80820053
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.93

KIT E-COIN EXPLANT

Facility

$1,362.00

Hospital Charge Code	145705
Hospital Revenue Code	272
Rate for Payer: Cash Price	$926.16

KIT E-COIN EXPLANT

Facility

$1,362.00

Hospital Charge Code	145705
Hospital Revenue Code	272
Min. Negotiated Rate	$122.58
Max. Negotiated Rate	$980.64
Rate for Payer: Amerigroup CHIP/Medicaid	$122.58
Rate for Payer: BCBS of TX Blue Advantage	$408.60
Rate for Payer: BCBS of TX Blue Essentials	$490.32
Rate for Payer: BCBS of TX PPO	$544.80
Rate for Payer: Cash Price	$926.16
Rate for Payer: Cigna Medicaid	$980.64
Rate for Payer: Molina CHIP/Medicaid	$980.64
Rate for Payer: Multiplan Auto	$885.30
Rate for Payer: Multiplan Commercial	$885.30
Rate for Payer: Multiplan Workers Comp	$885.30
Rate for Payer: Parkland Medicaid	$980.64
Rate for Payer: Scott and White EPO/PPO	$681.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$980.64
Rate for Payer: Superior Health Plan EPO	$185.23

kit emr oblique or straight

Facility

$806.39

Hospital Charge Code	144834
Hospital Revenue Code	272
Min. Negotiated Rate	$72.58
Max. Negotiated Rate	$580.60
Rate for Payer: Amerigroup CHIP/Medicaid	$72.58
Rate for Payer: BCBS of TX Blue Advantage	$241.92
Rate for Payer: BCBS of TX Blue Essentials	$290.30
Rate for Payer: BCBS of TX PPO	$322.56
Rate for Payer: Cash Price	$548.35
Rate for Payer: Cigna Medicaid	$580.60
Rate for Payer: Molina CHIP/Medicaid	$580.60
Rate for Payer: Multiplan Auto	$524.15
Rate for Payer: Multiplan Commercial	$524.15
Rate for Payer: Multiplan Workers Comp	$524.15
Rate for Payer: Parkland Medicaid	$580.60
Rate for Payer: Scott and White EPO/PPO	$403.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$580.60
Rate for Payer: Superior Health Plan EPO	$109.67

kit emr oblique or straight

Facility

$806.39

Hospital Charge Code	144834
Hospital Revenue Code	272
Rate for Payer: Cash Price	$548.35

KIT, ENDO COMPL. DUEL END

Facility

$72.05

Hospital Charge Code	993748
Hospital Revenue Code	272
Rate for Payer: Cash Price	$48.99

KIT, ENDO COMPL. DUEL END

Facility

$72.05

Hospital Charge Code	993748
Hospital Revenue Code	272
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$51.88
Rate for Payer: Amerigroup CHIP/Medicaid	$6.48
Rate for Payer: BCBS of TX Blue Advantage	$21.61
Rate for Payer: BCBS of TX Blue Essentials	$25.94
Rate for Payer: BCBS of TX PPO	$28.82
Rate for Payer: Cash Price	$48.99
Rate for Payer: Cigna Medicaid	$51.88
Rate for Payer: Molina CHIP/Medicaid	$51.88
Rate for Payer: Multiplan Auto	$46.83
Rate for Payer: Multiplan Commercial	$46.83
Rate for Payer: Multiplan Workers Comp	$46.83
Rate for Payer: Parkland Medicaid	$51.88
Rate for Payer: Scott and White EPO/PPO	$36.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.88
Rate for Payer: Superior Health Plan EPO	$9.80

kit endo compliance

Facility

$80.09

Hospital Charge Code	80820400
Hospital Revenue Code	272
Min. Negotiated Rate	$7.21
Max. Negotiated Rate	$57.66
Rate for Payer: Amerigroup CHIP/Medicaid	$7.21
Rate for Payer: BCBS of TX Blue Advantage	$24.03
Rate for Payer: BCBS of TX Blue Essentials	$28.83
Rate for Payer: BCBS of TX PPO	$32.04
Rate for Payer: Cash Price	$54.46
Rate for Payer: Cigna Medicaid	$57.66
Rate for Payer: Molina CHIP/Medicaid	$57.66
Rate for Payer: Multiplan Auto	$52.06
Rate for Payer: Multiplan Commercial	$52.06
Rate for Payer: Multiplan Workers Comp	$52.06
Rate for Payer: Parkland Medicaid	$57.66
Rate for Payer: Scott and White EPO/PPO	$40.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$57.66
Rate for Payer: Superior Health Plan EPO	$10.89

kit endo compliance

Facility

$80.09

Hospital Charge Code	80820400
Hospital Revenue Code	272
Rate for Payer: Cash Price	$54.46

KIT, EXPANSION ON-Q W/2.5' ANTIMICROB SOAKER CATH -- DHF

Facility

$298.12

Hospital Charge Code	80325574
Hospital Revenue Code	272
Min. Negotiated Rate	$26.83
Max. Negotiated Rate	$214.65
Rate for Payer: Amerigroup CHIP/Medicaid	$26.83
Rate for Payer: BCBS of TX Blue Advantage	$89.44
Rate for Payer: BCBS of TX Blue Essentials	$107.32
Rate for Payer: BCBS of TX PPO	$119.25
Rate for Payer: Cash Price	$202.72
Rate for Payer: Cigna Medicaid	$214.65
Rate for Payer: Molina CHIP/Medicaid	$214.65
Rate for Payer: Multiplan Auto	$193.78
Rate for Payer: Multiplan Commercial	$193.78
Rate for Payer: Multiplan Workers Comp	$193.78
Rate for Payer: Parkland Medicaid	$214.65
Rate for Payer: Scott and White EPO/PPO	$149.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$214.65
Rate for Payer: Superior Health Plan EPO	$40.54

KIT, EXPANSION ON-Q W/2.5' ANTIMICROB SOAKER CATH -- DHF

Facility

$298.12

Hospital Charge Code	80325574
Hospital Revenue Code	272
Rate for Payer: Cash Price	$202.72

KIT, FIBRIN SEALANT SURGICAL 5.0ML -- DHF

Facility

$2,678.73

Hospital Charge Code	80325970
Hospital Revenue Code	272
Min. Negotiated Rate	$241.09
Max. Negotiated Rate	$1,928.69
Rate for Payer: Amerigroup CHIP/Medicaid	$241.09
Rate for Payer: BCBS of TX Blue Advantage	$803.62
Rate for Payer: BCBS of TX Blue Essentials	$964.34
Rate for Payer: BCBS of TX PPO	$1,071.49
Rate for Payer: Cash Price	$1,821.54
Rate for Payer: Cigna Medicaid	$1,928.69
Rate for Payer: Molina CHIP/Medicaid	$1,928.69
Rate for Payer: Multiplan Auto	$1,741.17
Rate for Payer: Multiplan Commercial	$1,741.17
Rate for Payer: Multiplan Workers Comp	$1,741.17
Rate for Payer: Parkland Medicaid	$1,928.69
Rate for Payer: Scott and White EPO/PPO	$1,339.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,928.69
Rate for Payer: Superior Health Plan EPO	$364.31

KIT, FIBRIN SEALANT SURGICAL 5.0ML -- DHF

Facility

$2,678.73

Hospital Charge Code	80325970
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,821.54

KIT FOLEY ALL SIL CATH 18F W/VALVE BAG & LUB-SYR

Facility

$31.58

Service Code	HCPCS C1758
Hospital Charge Code	993415
Hospital Revenue Code	272
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$22.74
Rate for Payer: Amerigroup CHIP/Medicaid	$2.84
Rate for Payer: BCBS of TX Blue Advantage	$9.47
Rate for Payer: BCBS of TX Blue Essentials	$11.37
Rate for Payer: BCBS of TX PPO	$12.63
Rate for Payer: Cash Price	$21.47
Rate for Payer: Cigna Medicaid	$22.74
Rate for Payer: Molina CHIP/Medicaid	$22.74
Rate for Payer: Multiplan Auto	$20.53
Rate for Payer: Multiplan Commercial	$20.53
Rate for Payer: Multiplan Workers Comp	$20.53
Rate for Payer: Parkland Medicaid	$22.74
Rate for Payer: Scott and White EPO/PPO	$15.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.74
Rate for Payer: Superior Health Plan EPO	$4.29

Know your out-of-pocket cost for care.

All Charges