White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$21.47

KIT GNB ID CARD VITEK II COLORIMETRIC 20 TEST

Facility

$25.21

Hospital Charge Code	993514
Hospital Revenue Code	270
Rate for Payer: Cash Price	$17.14

KIT GNB ID CARD VITEK II COLORIMETRIC 20 TEST

Facility

$25.21

Hospital Charge Code	993514
Hospital Revenue Code	270
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$18.15
Rate for Payer: Amerigroup CHIP/Medicaid	$2.27
Rate for Payer: BCBS of TX Blue Advantage	$7.56
Rate for Payer: BCBS of TX Blue Essentials	$9.08
Rate for Payer: BCBS of TX PPO	$10.08
Rate for Payer: Cash Price	$17.14
Rate for Payer: Cigna Medicaid	$18.15
Rate for Payer: Molina CHIP/Medicaid	$18.15
Rate for Payer: Multiplan Auto	$16.39
Rate for Payer: Multiplan Commercial	$16.39
Rate for Payer: Multiplan Workers Comp	$16.39
Rate for Payer: Parkland Medicaid	$18.15
Rate for Payer: Scott and White EPO/PPO	$12.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.15
Rate for Payer: Superior Health Plan EPO	$3.43

KIT, HIP LONG W/32' REACHER SHOEHORN SOCK AID SPNG

Facility

$73.55

Hospital Charge Code	133980
Hospital Revenue Code	272
Rate for Payer: Cash Price	$50.01

KIT, HIP LONG W/32' REACHER SHOEHORN SOCK AID SPNG

Facility

$73.55

Hospital Charge Code	133980
Hospital Revenue Code	272
Min. Negotiated Rate	$6.62
Max. Negotiated Rate	$52.96
Rate for Payer: Amerigroup CHIP/Medicaid	$6.62
Rate for Payer: BCBS of TX Blue Advantage	$22.07
Rate for Payer: BCBS of TX Blue Essentials	$26.48
Rate for Payer: BCBS of TX PPO	$29.42
Rate for Payer: Cash Price	$50.01
Rate for Payer: Cigna Medicaid	$52.96
Rate for Payer: Molina CHIP/Medicaid	$52.96
Rate for Payer: Multiplan Auto	$47.81
Rate for Payer: Multiplan Commercial	$47.81
Rate for Payer: Multiplan Workers Comp	$47.81
Rate for Payer: Parkland Medicaid	$52.96
Rate for Payer: Scott and White EPO/PPO	$36.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.96
Rate for Payer: Superior Health Plan EPO	$10.00

KIT IL PVP

Facility

$27.12

Hospital Charge Code	993522
Hospital Revenue Code	270
Rate for Payer: Cash Price	$18.44

KIT IL PVP

Facility

$27.12

Hospital Charge Code	993522
Hospital Revenue Code	270
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$19.53
Rate for Payer: Amerigroup CHIP/Medicaid	$2.44
Rate for Payer: BCBS of TX Blue Advantage	$8.14
Rate for Payer: BCBS of TX Blue Essentials	$9.76
Rate for Payer: BCBS of TX PPO	$10.85
Rate for Payer: Cash Price	$18.44
Rate for Payer: Cigna Medicaid	$19.53
Rate for Payer: Molina CHIP/Medicaid	$19.53
Rate for Payer: Multiplan Auto	$17.63
Rate for Payer: Multiplan Commercial	$17.63
Rate for Payer: Multiplan Workers Comp	$17.63
Rate for Payer: Parkland Medicaid	$19.53
Rate for Payer: Scott and White EPO/PPO	$13.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.53
Rate for Payer: Superior Health Plan EPO	$3.69

KIT INFECTIOUS CONTROL TURNOVER CITY HOSPITAL WR

Facility

$522.96

Hospital Charge Code	993036
Hospital Revenue Code	270
Min. Negotiated Rate	$47.07
Max. Negotiated Rate	$376.53
Rate for Payer: Amerigroup CHIP/Medicaid	$47.07
Rate for Payer: BCBS of TX Blue Advantage	$156.89
Rate for Payer: BCBS of TX Blue Essentials	$188.27
Rate for Payer: BCBS of TX PPO	$209.18
Rate for Payer: Cash Price	$355.61
Rate for Payer: Cigna Medicaid	$376.53
Rate for Payer: Molina CHIP/Medicaid	$376.53
Rate for Payer: Multiplan Auto	$339.92
Rate for Payer: Multiplan Commercial	$339.92
Rate for Payer: Multiplan Workers Comp	$339.92
Rate for Payer: Parkland Medicaid	$376.53
Rate for Payer: Scott and White EPO/PPO	$261.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$376.53
Rate for Payer: Superior Health Plan EPO	$71.12

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
Rate for Payer: Cash Price	$80.27

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 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 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, 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
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

Facility

$1,001.57

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

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, 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

Know your out-of-pocket cost for care.

All Charges