White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIT OSTEOSET RESORBABLE BEAD 5CC

Facility

$4,505.24

Hospital Charge Code	133606
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,063.56

KIT PARADIGMACCESS EZ SWITCH

Facility

$8,172.00

Hospital Charge Code	144851
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,556.96

KIT PARADIGMACCESS EZ SWITCH

Facility

$8,172.00

Hospital Charge Code	144851
Hospital Revenue Code	272
Min. Negotiated Rate	$735.48
Max. Negotiated Rate	$5,883.84
Rate for Payer: Amerigroup CHIP/Medicaid	$735.48
Rate for Payer: BCBS of TX Blue Advantage	$2,451.60
Rate for Payer: BCBS of TX Blue Essentials	$2,941.92
Rate for Payer: BCBS of TX PPO	$3,268.80
Rate for Payer: Cash Price	$5,556.96
Rate for Payer: Cigna Medicaid	$5,883.84
Rate for Payer: Molina CHIP/Medicaid	$5,883.84
Rate for Payer: Multiplan Auto	$5,311.80
Rate for Payer: Multiplan Commercial	$5,311.80
Rate for Payer: Multiplan Workers Comp	$5,311.80
Rate for Payer: Parkland Medicaid	$5,883.84
Rate for Payer: Scott and White EPO/PPO	$4,086.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,883.84
Rate for Payer: Superior Health Plan EPO	$1,111.39

KIT PEG FLOW 20 PUSH

Facility

$431.30

Hospital Charge Code	8568963
Hospital Revenue Code	272
Rate for Payer: Cash Price	$293.28

KIT PEG FLOW 20 PUSH

Facility

$431.30

Hospital Charge Code	8568963
Hospital Revenue Code	272
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$310.54
Rate for Payer: Amerigroup CHIP/Medicaid	$38.82
Rate for Payer: BCBS of TX Blue Advantage	$129.39
Rate for Payer: BCBS of TX Blue Essentials	$155.27
Rate for Payer: BCBS of TX PPO	$172.52
Rate for Payer: Cash Price	$293.28
Rate for Payer: Cigna Medicaid	$310.54
Rate for Payer: Molina CHIP/Medicaid	$310.54
Rate for Payer: Multiplan Auto	$280.35
Rate for Payer: Multiplan Commercial	$280.35
Rate for Payer: Multiplan Workers Comp	$280.35
Rate for Payer: Parkland Medicaid	$310.54
Rate for Payer: Scott and White EPO/PPO	$215.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$310.54
Rate for Payer: Superior Health Plan EPO	$58.66

KIT, PERICARDIOCENTESIS W

Facility

$452.87

Hospital Charge Code	133128
Hospital Revenue Code	272
Rate for Payer: Cash Price	$307.95

KIT, PERICARDIOCENTESIS W

Facility

$452.87

Hospital Charge Code	133128
Hospital Revenue Code	272
Min. Negotiated Rate	$40.76
Max. Negotiated Rate	$326.07
Rate for Payer: Amerigroup CHIP/Medicaid	$40.76
Rate for Payer: BCBS of TX Blue Advantage	$135.86
Rate for Payer: BCBS of TX Blue Essentials	$163.03
Rate for Payer: BCBS of TX PPO	$181.15
Rate for Payer: Cash Price	$307.95
Rate for Payer: Cigna Medicaid	$326.07
Rate for Payer: Molina CHIP/Medicaid	$326.07
Rate for Payer: Multiplan Auto	$294.37
Rate for Payer: Multiplan Commercial	$294.37
Rate for Payer: Multiplan Workers Comp	$294.37
Rate for Payer: Parkland Medicaid	$326.07
Rate for Payer: Scott and White EPO/PPO	$226.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$326.07
Rate for Payer: Superior Health Plan EPO	$61.59

KIT, PICO 14, 10X40CM

Facility

$1,869.32

Hospital Charge Code	993098
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,271.14

KIT, PICO 14, 10X40CM

Facility

$1,869.32

Hospital Charge Code	993098
Hospital Revenue Code	270
Min. Negotiated Rate	$168.24
Max. Negotiated Rate	$1,345.91
Rate for Payer: Amerigroup CHIP/Medicaid	$168.24
Rate for Payer: BCBS of TX Blue Advantage	$560.80
Rate for Payer: BCBS of TX Blue Essentials	$672.96
Rate for Payer: BCBS of TX PPO	$747.73
Rate for Payer: Cash Price	$1,271.14
Rate for Payer: Cigna Medicaid	$1,345.91
Rate for Payer: Molina CHIP/Medicaid	$1,345.91
Rate for Payer: Multiplan Auto	$1,215.06
Rate for Payer: Multiplan Commercial	$1,215.06
Rate for Payer: Multiplan Workers Comp	$1,215.06
Rate for Payer: Parkland Medicaid	$1,345.91
Rate for Payer: Scott and White EPO/PPO	$934.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,345.91
Rate for Payer: Superior Health Plan EPO	$254.23

KIT, PIV SECUREMENT-CUSTOM

Facility

$26.17

Hospital Charge Code	993596
Hospital Revenue Code	270
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$18.84
Rate for Payer: Amerigroup CHIP/Medicaid	$2.36
Rate for Payer: BCBS of TX Blue Advantage	$7.85
Rate for Payer: BCBS of TX Blue Essentials	$9.42
Rate for Payer: BCBS of TX PPO	$10.47
Rate for Payer: Cash Price	$17.80
Rate for Payer: Cigna Medicaid	$18.84
Rate for Payer: Molina CHIP/Medicaid	$18.84
Rate for Payer: Multiplan Auto	$17.01
Rate for Payer: Multiplan Commercial	$17.01
Rate for Payer: Multiplan Workers Comp	$17.01
Rate for Payer: Parkland Medicaid	$18.84
Rate for Payer: Scott and White EPO/PPO	$13.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.84
Rate for Payer: Superior Health Plan EPO	$3.56

KIT, PIV SECUREMENT-CUSTOM

Facility

$26.17

Hospital Charge Code	993596
Hospital Revenue Code	270
Rate for Payer: Cash Price	$17.80

KIT PLEURX CATHETER

Facility

$2,682.27

Hospital Charge Code	8422509
Hospital Revenue Code	272
Min. Negotiated Rate	$241.40
Max. Negotiated Rate	$1,931.23
Rate for Payer: Amerigroup CHIP/Medicaid	$241.40
Rate for Payer: BCBS of TX Blue Advantage	$804.68
Rate for Payer: BCBS of TX Blue Essentials	$965.62
Rate for Payer: BCBS of TX PPO	$1,072.91
Rate for Payer: Cash Price	$1,823.94
Rate for Payer: Cigna Medicaid	$1,931.23
Rate for Payer: Molina CHIP/Medicaid	$1,931.23
Rate for Payer: Multiplan Auto	$1,743.48
Rate for Payer: Multiplan Commercial	$1,743.48
Rate for Payer: Multiplan Workers Comp	$1,743.48
Rate for Payer: Parkland Medicaid	$1,931.23
Rate for Payer: Scott and White EPO/PPO	$1,341.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,931.23
Rate for Payer: Superior Health Plan EPO	$364.79

KIT PLEURX CATHETER

Facility

$2,682.27

Hospital Charge Code	8422509
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,823.94

KIT, PLEURX DRAINAGE 500 ML

Facility

$240.71

Hospital Charge Code	992767
Hospital Revenue Code	272
Rate for Payer: Cash Price	$163.68

KIT, PLEURX DRAINAGE 500 ML

Facility

$240.71

Hospital Charge Code	992767
Hospital Revenue Code	272
Min. Negotiated Rate	$21.66
Max. Negotiated Rate	$173.31
Rate for Payer: Amerigroup CHIP/Medicaid	$21.66
Rate for Payer: BCBS of TX Blue Advantage	$72.21
Rate for Payer: BCBS of TX Blue Essentials	$86.66
Rate for Payer: BCBS of TX PPO	$96.28
Rate for Payer: Cash Price	$163.68
Rate for Payer: Cigna Medicaid	$173.31
Rate for Payer: Molina CHIP/Medicaid	$173.31
Rate for Payer: Multiplan Auto	$156.46
Rate for Payer: Multiplan Commercial	$156.46
Rate for Payer: Multiplan Workers Comp	$156.46
Rate for Payer: Parkland Medicaid	$173.31
Rate for Payer: Scott and White EPO/PPO	$120.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$173.31
Rate for Payer: Superior Health Plan EPO	$32.74

KIT RADIOFREQUENCY COOLIEF COOLED

Facility

$3,291.50

Hospital Charge Code	8568957
Hospital Revenue Code	272
Min. Negotiated Rate	$296.24
Max. Negotiated Rate	$2,369.88
Rate for Payer: Amerigroup CHIP/Medicaid	$296.24
Rate for Payer: BCBS of TX Blue Advantage	$987.45
Rate for Payer: BCBS of TX Blue Essentials	$1,184.94
Rate for Payer: BCBS of TX PPO	$1,316.60
Rate for Payer: Cash Price	$2,238.22
Rate for Payer: Cigna Medicaid	$2,369.88
Rate for Payer: Molina CHIP/Medicaid	$2,369.88
Rate for Payer: Multiplan Auto	$2,139.47
Rate for Payer: Multiplan Commercial	$2,139.47
Rate for Payer: Multiplan Workers Comp	$2,139.47
Rate for Payer: Parkland Medicaid	$2,369.88
Rate for Payer: Scott and White EPO/PPO	$1,645.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,369.88
Rate for Payer: Superior Health Plan EPO	$447.64

KIT RADIOFREQUENCY COOLIEF COOLED

Facility

$3,291.50

Hospital Charge Code	8568957
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,238.22

KIT, RETRACTOR W/SCREW & 13G ASPIRATION NEEDLE SET -- DHF

Facility

$1,398.11

Hospital Charge Code	80811250
Hospital Revenue Code	272
Min. Negotiated Rate	$125.83
Max. Negotiated Rate	$1,006.64
Rate for Payer: Amerigroup CHIP/Medicaid	$125.83
Rate for Payer: BCBS of TX Blue Advantage	$419.43
Rate for Payer: BCBS of TX Blue Essentials	$503.32
Rate for Payer: BCBS of TX PPO	$559.24
Rate for Payer: Cash Price	$950.71
Rate for Payer: Cigna Medicaid	$1,006.64
Rate for Payer: Molina CHIP/Medicaid	$1,006.64
Rate for Payer: Multiplan Auto	$908.77
Rate for Payer: Multiplan Commercial	$908.77
Rate for Payer: Multiplan Workers Comp	$908.77
Rate for Payer: Parkland Medicaid	$1,006.64
Rate for Payer: Scott and White EPO/PPO	$699.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,006.64
Rate for Payer: Superior Health Plan EPO	$190.14

KIT, RETRACTOR W/SCREW & 13G ASPIRATION NEEDLE SET -- DHF

Facility

$1,398.11

Hospital Charge Code	80811250
Hospital Revenue Code	272
Rate for Payer: Cash Price	$950.71

kit rigidloop

Facility

$3,777.28

Hospital Charge Code	8612545
Hospital Revenue Code	272
Min. Negotiated Rate	$339.96
Max. Negotiated Rate	$2,719.64
Rate for Payer: Amerigroup CHIP/Medicaid	$339.96
Rate for Payer: BCBS of TX Blue Advantage	$1,133.18
Rate for Payer: BCBS of TX Blue Essentials	$1,359.82
Rate for Payer: BCBS of TX PPO	$1,510.91
Rate for Payer: Cash Price	$2,568.55
Rate for Payer: Cigna Medicaid	$2,719.64
Rate for Payer: Molina CHIP/Medicaid	$2,719.64
Rate for Payer: Multiplan Auto	$2,455.23
Rate for Payer: Multiplan Commercial	$2,455.23
Rate for Payer: Multiplan Workers Comp	$2,455.23
Rate for Payer: Parkland Medicaid	$2,719.64
Rate for Payer: Scott and White EPO/PPO	$1,888.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,719.64
Rate for Payer: Superior Health Plan EPO	$513.71

kit rigidloop

Facility

$3,777.28

Hospital Charge Code	8612545
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,568.55

kit scp knee

Facility

$27,651.00

Service Code	HCPCS C1776
Hospital Charge Code	8720610
Hospital Revenue Code	278
Min. Negotiated Rate	$2,488.59
Max. Negotiated Rate	$19,908.72
Rate for Payer: Amerigroup CHIP/Medicaid	$2,488.59
Rate for Payer: BCBS of TX Blue Advantage	$8,295.30
Rate for Payer: BCBS of TX Blue Essentials	$9,954.36
Rate for Payer: BCBS of TX PPO	$11,060.40
Rate for Payer: Cash Price	$18,802.68
Rate for Payer: Cigna Medicaid	$19,908.72
Rate for Payer: Molina CHIP/Medicaid	$19,908.72
Rate for Payer: Multiplan Auto	$13,825.50
Rate for Payer: Multiplan Commercial	$13,825.50
Rate for Payer: Multiplan Workers Comp	$13,825.50
Rate for Payer: Parkland Medicaid	$19,908.72
Rate for Payer: Scott and White EPO/PPO	$13,825.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,908.72
Rate for Payer: Superior Health Plan EPO	$3,760.54

kit scp knee

Facility

$27,651.00

Service Code	HCPCS C1776
Hospital Charge Code	8720610
Hospital Revenue Code	278
Min. Negotiated Rate	$6,912.75
Max. Negotiated Rate	$13,825.50
Rate for Payer: Cash Price	$18,802.68
Rate for Payer: Cigna Commercial	$6,912.75
Rate for Payer: Multiplan Auto	$13,825.50
Rate for Payer: Multiplan Commercial	$13,825.50
Rate for Payer: Multiplan Workers Comp	$13,825.50
Rate for Payer: Scott and White EPO/PPO	$13,825.50

KIT SIZERS INSTAFIX -- DHF

Facility

$794.50

Hospital Charge Code	80899065
Hospital Revenue Code	272
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$572.04
Rate for Payer: Amerigroup CHIP/Medicaid	$71.50
Rate for Payer: BCBS of TX Blue Advantage	$238.35
Rate for Payer: BCBS of TX Blue Essentials	$286.02
Rate for Payer: BCBS of TX PPO	$317.80
Rate for Payer: Cash Price	$540.26
Rate for Payer: Cigna Medicaid	$572.04
Rate for Payer: Molina CHIP/Medicaid	$572.04
Rate for Payer: Multiplan Auto	$516.42
Rate for Payer: Multiplan Commercial	$516.42
Rate for Payer: Multiplan Workers Comp	$516.42
Rate for Payer: Parkland Medicaid	$572.04
Rate for Payer: Scott and White EPO/PPO	$397.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$572.04
Rate for Payer: Superior Health Plan EPO	$108.05

KIT SIZERS INSTAFIX -- DHF

Facility

$794.50

Hospital Charge Code	80899065
Hospital Revenue Code	272
Rate for Payer: Cash Price	$540.26

Know your out-of-pocket cost for care.

All Charges