White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIT INFECTIOUS CONTROL TURNOVER CITY HOSPITAL WR

Facility

$522.96

Hospital Charge Code	993036
Hospital Revenue Code	270
Rate for Payer: Cash Price	$355.61

KIT INFLATION DEVICE 30 PSI

Facility

$118.04

Hospital Charge Code	993574
Hospital Revenue Code	270
Min. Negotiated Rate	$10.62
Max. Negotiated Rate	$84.99
Rate for Payer: Amerigroup CHIP/Medicaid	$10.62
Rate for Payer: BCBS of TX Blue Advantage	$35.41
Rate for Payer: BCBS of TX Blue Essentials	$42.49
Rate for Payer: BCBS of TX PPO	$47.22
Rate for Payer: Cash Price	$80.27
Rate for Payer: Cigna Medicaid	$84.99
Rate for Payer: Molina CHIP/Medicaid	$84.99
Rate for Payer: Multiplan Auto	$76.73
Rate for Payer: Multiplan Commercial	$76.73
Rate for Payer: Multiplan Workers Comp	$76.73
Rate for Payer: Parkland Medicaid	$84.99
Rate for Payer: Scott and White EPO/PPO	$59.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.99
Rate for Payer: Superior Health Plan EPO	$16.05

KIT INFLATION DEVICE 30 PSI

Facility

$118.04

Hospital Charge Code	993574
Hospital Revenue Code	270
Rate for Payer: Cash Price	$80.27

KIT INFLATION DEVICE 30 PSI W/14 TB W/HEMO VALVE

Facility

$118.04

Hospital Charge Code	993531
Hospital Revenue Code	270
Min. Negotiated Rate	$10.62
Max. Negotiated Rate	$84.99
Rate for Payer: Amerigroup CHIP/Medicaid	$10.62
Rate for Payer: BCBS of TX Blue Advantage	$35.41
Rate for Payer: BCBS of TX Blue Essentials	$42.49
Rate for Payer: BCBS of TX PPO	$47.22
Rate for Payer: Cash Price	$80.27
Rate for Payer: Cigna Medicaid	$84.99
Rate for Payer: Molina CHIP/Medicaid	$84.99
Rate for Payer: Multiplan Auto	$76.73
Rate for Payer: Multiplan Commercial	$76.73
Rate for Payer: Multiplan Workers Comp	$76.73
Rate for Payer: Parkland Medicaid	$84.99
Rate for Payer: Scott and White EPO/PPO	$59.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.99
Rate for Payer: Superior Health Plan EPO	$16.05

KIT INFLATION DEVICE 30 PSI W/14 TB W/HEMO VALVE

Facility

$118.04

Hospital Charge Code	993531
Hospital Revenue Code	270
Rate for Payer: Cash Price	$80.27

KIT, INFLATION, DEVICE, GTWY, Y, ADAPTER

Facility

$226.43

Hospital Charge Code	993321
Hospital Revenue Code	270
Min. Negotiated Rate	$20.38
Max. Negotiated Rate	$163.03
Rate for Payer: Amerigroup CHIP/Medicaid	$20.38
Rate for Payer: BCBS of TX Blue Advantage	$67.93
Rate for Payer: BCBS of TX Blue Essentials	$81.51
Rate for Payer: BCBS of TX PPO	$90.57
Rate for Payer: Cash Price	$153.97
Rate for Payer: Cigna Medicaid	$163.03
Rate for Payer: Molina CHIP/Medicaid	$163.03
Rate for Payer: Multiplan Auto	$147.18
Rate for Payer: Multiplan Commercial	$147.18
Rate for Payer: Multiplan Workers Comp	$147.18
Rate for Payer: Parkland Medicaid	$163.03
Rate for Payer: Scott and White EPO/PPO	$113.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.03
Rate for Payer: Superior Health Plan EPO	$30.79

KIT, INFLATION, DEVICE, GTWY, Y, ADAPTER

Facility

$226.43

Hospital Charge Code	993321
Hospital Revenue Code	270
Rate for Payer: Cash Price	$153.97

KIT INFLATION ELITE FRACTURE 15MM

Facility

$16,512.59

Hospital Charge Code	992348
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11,228.56

KIT INFLATION ELITE FRACTURE 15MM

Facility

$16,512.59

Hospital Charge Code	992348
Hospital Revenue Code	272
Min. Negotiated Rate	$1,486.13
Max. Negotiated Rate	$11,889.06
Rate for Payer: Amerigroup CHIP/Medicaid	$1,486.13
Rate for Payer: BCBS of TX Blue Advantage	$4,953.78
Rate for Payer: BCBS of TX Blue Essentials	$5,944.53
Rate for Payer: BCBS of TX PPO	$6,605.04
Rate for Payer: Cash Price	$11,228.56
Rate for Payer: Cigna Medicaid	$11,889.06
Rate for Payer: Molina CHIP/Medicaid	$11,889.06
Rate for Payer: Multiplan Auto	$10,733.18
Rate for Payer: Multiplan Commercial	$10,733.18
Rate for Payer: Multiplan Workers Comp	$10,733.18
Rate for Payer: Parkland Medicaid	$11,889.06
Rate for Payer: Scott and White EPO/PPO	$8,256.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,889.06
Rate for Payer: Superior Health Plan EPO	$2,245.71

kit insertion central line

Facility

$97.39

Hospital Charge Code	8660704
Hospital Revenue Code	272
Min. Negotiated Rate	$8.77
Max. Negotiated Rate	$70.12
Rate for Payer: Amerigroup CHIP/Medicaid	$8.77
Rate for Payer: BCBS of TX Blue Advantage	$29.22
Rate for Payer: BCBS of TX Blue Essentials	$35.06
Rate for Payer: BCBS of TX PPO	$38.96
Rate for Payer: Cash Price	$66.23
Rate for Payer: Cigna Medicaid	$70.12
Rate for Payer: Molina CHIP/Medicaid	$70.12
Rate for Payer: Multiplan Auto	$63.30
Rate for Payer: Multiplan Commercial	$63.30
Rate for Payer: Multiplan Workers Comp	$63.30
Rate for Payer: Parkland Medicaid	$70.12
Rate for Payer: Scott and White EPO/PPO	$48.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$70.12
Rate for Payer: Superior Health Plan EPO	$13.25

kit insertion central line

Facility

$97.39

Hospital Charge Code	8660704
Hospital Revenue Code	272
Rate for Payer: Cash Price	$66.23

KIT, INTRODUCER 16FR PTFE .038' 50CM L DBL FLX TIP -- DHF

Facility

$598.48

Hospital Charge Code	80620404
Hospital Revenue Code	272
Rate for Payer: Cash Price	$406.97

KIT, INTRODUCER 16FR PTFE .038' 50CM L DBL FLX TIP -- DHF

Facility

$598.48

Hospital Charge Code	80620404
Hospital Revenue Code	272
Min. Negotiated Rate	$53.86
Max. Negotiated Rate	$430.91
Rate for Payer: Amerigroup CHIP/Medicaid	$53.86
Rate for Payer: BCBS of TX Blue Advantage	$179.54
Rate for Payer: BCBS of TX Blue Essentials	$215.45
Rate for Payer: BCBS of TX PPO	$239.39
Rate for Payer: Cash Price	$406.97
Rate for Payer: Cigna Medicaid	$430.91
Rate for Payer: Molina CHIP/Medicaid	$430.91
Rate for Payer: Multiplan Auto	$389.01
Rate for Payer: Multiplan Commercial	$389.01
Rate for Payer: Multiplan Workers Comp	$389.01
Rate for Payer: Parkland Medicaid	$430.91
Rate for Payer: Scott and White EPO/PPO	$299.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$430.91
Rate for Payer: Superior Health Plan EPO	$81.39

KIT, INTRODUCER FOR MIC-K

Facility

$1,001.57

Hospital Charge Code	80820905
Hospital Revenue Code	272
Rate for Payer: Cash Price	$681.07

KIT, INTRODUCER FOR MIC-K

Facility

$1,001.57

Hospital Charge Code	80820905
Hospital Revenue Code	272
Min. Negotiated Rate	$90.14
Max. Negotiated Rate	$721.13
Rate for Payer: Amerigroup CHIP/Medicaid	$90.14
Rate for Payer: BCBS of TX Blue Advantage	$300.47
Rate for Payer: BCBS of TX Blue Essentials	$360.57
Rate for Payer: BCBS of TX PPO	$400.63
Rate for Payer: Cash Price	$681.07
Rate for Payer: Cigna Medicaid	$721.13
Rate for Payer: Molina CHIP/Medicaid	$721.13
Rate for Payer: Multiplan Auto	$651.02
Rate for Payer: Multiplan Commercial	$651.02
Rate for Payer: Multiplan Workers Comp	$651.02
Rate for Payer: Parkland Medicaid	$721.13
Rate for Payer: Scott and White EPO/PPO	$500.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$721.13
Rate for Payer: Superior Health Plan EPO	$136.21

KIT, INTRODUCER FOR MIC-K 98433

Facility

$1,001.57

Hospital Charge Code	993303
Hospital Revenue Code	270
Min. Negotiated Rate	$90.14
Max. Negotiated Rate	$721.13
Rate for Payer: Amerigroup CHIP/Medicaid	$90.14
Rate for Payer: BCBS of TX Blue Advantage	$300.47
Rate for Payer: BCBS of TX Blue Essentials	$360.57
Rate for Payer: BCBS of TX PPO	$400.63
Rate for Payer: Cash Price	$681.07
Rate for Payer: Cigna Medicaid	$721.13
Rate for Payer: Molina CHIP/Medicaid	$721.13
Rate for Payer: Multiplan Auto	$651.02
Rate for Payer: Multiplan Commercial	$651.02
Rate for Payer: Multiplan Workers Comp	$651.02
Rate for Payer: Parkland Medicaid	$721.13
Rate for Payer: Scott and White EPO/PPO	$500.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$721.13
Rate for Payer: Superior Health Plan EPO	$136.21

KIT, INTRODUCER FOR MIC-K 98433

Facility

$1,001.57

Hospital Charge Code	993303
Hospital Revenue Code	270
Rate for Payer: Cash Price	$681.07

KIT IV START 1ML DISP

Facility

$5.37

Hospital Charge Code	993819
Hospital Revenue Code	272
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$3.87
Rate for Payer: Amerigroup CHIP/Medicaid	$0.48
Rate for Payer: BCBS of TX Blue Advantage	$1.61
Rate for Payer: BCBS of TX Blue Essentials	$1.93
Rate for Payer: BCBS of TX PPO	$2.15
Rate for Payer: Cash Price	$3.65
Rate for Payer: Cigna Medicaid	$3.87
Rate for Payer: Molina CHIP/Medicaid	$3.87
Rate for Payer: Multiplan Auto	$3.49
Rate for Payer: Multiplan Commercial	$3.49
Rate for Payer: Multiplan Workers Comp	$3.49
Rate for Payer: Parkland Medicaid	$3.87
Rate for Payer: Scott and White EPO/PPO	$2.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.87
Rate for Payer: Superior Health Plan EPO	$0.73

KIT IV START 1ML DISP

Facility

$5.37

Hospital Charge Code	993819
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.65

KIT, IV START, CHLORAPREP APPLICATOR

Facility

$32.24

Hospital Charge Code	993064
Hospital Revenue Code	270
Min. Negotiated Rate	$2.90
Max. Negotiated Rate	$23.21
Rate for Payer: Amerigroup CHIP/Medicaid	$2.90
Rate for Payer: BCBS of TX Blue Advantage	$9.67
Rate for Payer: BCBS of TX Blue Essentials	$11.61
Rate for Payer: BCBS of TX PPO	$12.90
Rate for Payer: Cash Price	$21.92
Rate for Payer: Cigna Medicaid	$23.21
Rate for Payer: Molina CHIP/Medicaid	$23.21
Rate for Payer: Multiplan Auto	$20.96
Rate for Payer: Multiplan Commercial	$20.96
Rate for Payer: Multiplan Workers Comp	$20.96
Rate for Payer: Parkland Medicaid	$23.21
Rate for Payer: Scott and White EPO/PPO	$16.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.21
Rate for Payer: Superior Health Plan EPO	$4.38

KIT, IV START, CHLORAPREP APPLICATOR

Facility

$32.24

Hospital Charge Code	993064
Hospital Revenue Code	270
Rate for Payer: Cash Price	$21.92

kit jackson table post

Facility

$82.90

Hospital Charge Code	144755
Hospital Revenue Code	270
Min. Negotiated Rate	$7.46
Max. Negotiated Rate	$59.69
Rate for Payer: Amerigroup CHIP/Medicaid	$7.46
Rate for Payer: BCBS of TX Blue Advantage	$24.87
Rate for Payer: BCBS of TX Blue Essentials	$29.84
Rate for Payer: BCBS of TX PPO	$33.16
Rate for Payer: Cash Price	$56.37
Rate for Payer: Cigna Medicaid	$59.69
Rate for Payer: Molina CHIP/Medicaid	$59.69
Rate for Payer: Multiplan Auto	$53.88
Rate for Payer: Multiplan Commercial	$53.88
Rate for Payer: Multiplan Workers Comp	$53.88
Rate for Payer: Parkland Medicaid	$59.69
Rate for Payer: Scott and White EPO/PPO	$41.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.69
Rate for Payer: Superior Health Plan EPO	$11.27

kit jackson table post

Facility

$82.90

Hospital Charge Code	144755
Hospital Revenue Code	270
Rate for Payer: Cash Price	$56.37

KIT KYPHOPAK EXPRESS FIRST FIX KEX152EB-A

Facility

$21,565.00

Hospital Charge Code	145217
Hospital Revenue Code	272
Min. Negotiated Rate	$1,940.85
Max. Negotiated Rate	$15,526.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1,940.85
Rate for Payer: BCBS of TX Blue Advantage	$6,469.50
Rate for Payer: BCBS of TX Blue Essentials	$7,763.40
Rate for Payer: BCBS of TX PPO	$8,626.00
Rate for Payer: Cash Price	$14,664.20
Rate for Payer: Cigna Medicaid	$15,526.80
Rate for Payer: Molina CHIP/Medicaid	$15,526.80
Rate for Payer: Multiplan Auto	$14,017.25
Rate for Payer: Multiplan Commercial	$14,017.25
Rate for Payer: Multiplan Workers Comp	$14,017.25
Rate for Payer: Parkland Medicaid	$15,526.80
Rate for Payer: Scott and White EPO/PPO	$10,782.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,526.80
Rate for Payer: Superior Health Plan EPO	$2,932.84

KIT KYPHOPAK EXPRESS FIRST FIX KEX152EB-A

Facility

$21,565.00

Hospital Charge Code	145217
Hospital Revenue Code	272
Rate for Payer: Cash Price	$14,664.20

Know your out-of-pocket cost for care.

All Charges