White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIT TACTILE ACCESS PARADIGM

Facility

$3,291.50

Hospital Charge Code	8428500
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 TACTILE ACCESS PARADIGM

Facility

$3,291.50

Hospital Charge Code	8428500
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,238.22

KIT TENDODESIS SIZER W/ FIBERLOOP

Facility

$1,915.88

Hospital Charge Code	145620
Hospital Revenue Code	272
Min. Negotiated Rate	$172.43
Max. Negotiated Rate	$1,379.43
Rate for Payer: Amerigroup CHIP/Medicaid	$172.43
Rate for Payer: BCBS of TX Blue Advantage	$574.76
Rate for Payer: BCBS of TX Blue Essentials	$689.72
Rate for Payer: BCBS of TX PPO	$766.35
Rate for Payer: Cash Price	$1,302.80
Rate for Payer: Cigna Medicaid	$1,379.43
Rate for Payer: Molina CHIP/Medicaid	$1,379.43
Rate for Payer: Multiplan Auto	$1,245.32
Rate for Payer: Multiplan Commercial	$1,245.32
Rate for Payer: Multiplan Workers Comp	$1,245.32
Rate for Payer: Parkland Medicaid	$1,379.43
Rate for Payer: Scott and White EPO/PPO	$957.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,379.43
Rate for Payer: Superior Health Plan EPO	$260.56

KIT TENDODESIS SIZER W/ FIBERLOOP

Facility

$1,915.88

Hospital Charge Code	145620
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,302.80

KITTNER, ENDOSCOPIC SINGLE TIP -- DHF

Facility

$100.00

Hospital Charge Code	81750002
Hospital Revenue Code	272
Rate for Payer: Cash Price	$68.00

KITTNER, ENDOSCOPIC SINGLE TIP -- DHF

Facility

$100.00

Hospital Charge Code	81750002
Hospital Revenue Code	272
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$72.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.00
Rate for Payer: BCBS of TX Blue Advantage	$30.00
Rate for Payer: BCBS of TX Blue Essentials	$36.00
Rate for Payer: BCBS of TX PPO	$40.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cigna Medicaid	$72.00
Rate for Payer: Molina CHIP/Medicaid	$72.00
Rate for Payer: Multiplan Auto	$65.00
Rate for Payer: Multiplan Commercial	$65.00
Rate for Payer: Multiplan Workers Comp	$65.00
Rate for Payer: Parkland Medicaid	$72.00
Rate for Payer: Scott and White EPO/PPO	$50.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$72.00
Rate for Payer: Superior Health Plan EPO	$13.60

KIT, TRACHEOSTOMY INTRODU

Facility

$2,023.98

Hospital Charge Code	82050253
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,376.31

KIT, TRACHEOSTOMY INTRODU

Facility

$2,023.98

Hospital Charge Code	82050253
Hospital Revenue Code	270
Min. Negotiated Rate	$182.16
Max. Negotiated Rate	$1,457.27
Rate for Payer: Amerigroup CHIP/Medicaid	$182.16
Rate for Payer: BCBS of TX Blue Advantage	$607.19
Rate for Payer: BCBS of TX Blue Essentials	$728.63
Rate for Payer: BCBS of TX PPO	$809.59
Rate for Payer: Cash Price	$1,376.31
Rate for Payer: Cigna Medicaid	$1,457.27
Rate for Payer: Molina CHIP/Medicaid	$1,457.27
Rate for Payer: Multiplan Auto	$1,315.59
Rate for Payer: Multiplan Commercial	$1,315.59
Rate for Payer: Multiplan Workers Comp	$1,315.59
Rate for Payer: Parkland Medicaid	$1,457.27
Rate for Payer: Scott and White EPO/PPO	$1,011.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,457.27
Rate for Payer: Superior Health Plan EPO	$275.26

KIT UNIVERSAL ARTERIAL

Facility

$299.14

Hospital Charge Code	145162
Hospital Revenue Code	272
Min. Negotiated Rate	$26.92
Max. Negotiated Rate	$215.38
Rate for Payer: Amerigroup CHIP/Medicaid	$26.92
Rate for Payer: BCBS of TX Blue Advantage	$89.74
Rate for Payer: BCBS of TX Blue Essentials	$107.69
Rate for Payer: BCBS of TX PPO	$119.66
Rate for Payer: Cash Price	$203.42
Rate for Payer: Cigna Medicaid	$215.38
Rate for Payer: Molina CHIP/Medicaid	$215.38
Rate for Payer: Multiplan Auto	$194.44
Rate for Payer: Multiplan Commercial	$194.44
Rate for Payer: Multiplan Workers Comp	$194.44
Rate for Payer: Parkland Medicaid	$215.38
Rate for Payer: Scott and White EPO/PPO	$149.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$215.38
Rate for Payer: Superior Health Plan EPO	$40.68

KIT UNIVERSAL ARTERIAL

Facility

$299.14

Hospital Charge Code	145162
Hospital Revenue Code	272
Rate for Payer: Cash Price	$203.42

KIT VASC ACC LTRM HMDIAL CV CATH INS

Facility

$10,896.00

Service Code	HCPCS C1752
Hospital Charge Code	993789
Hospital Revenue Code	272
Min. Negotiated Rate	$980.64
Max. Negotiated Rate	$7,845.12
Rate for Payer: Amerigroup CHIP/Medicaid	$980.64
Rate for Payer: BCBS of TX Blue Advantage	$3,268.80
Rate for Payer: BCBS of TX Blue Essentials	$3,922.56
Rate for Payer: BCBS of TX PPO	$4,358.40
Rate for Payer: Cash Price	$7,409.28
Rate for Payer: Cigna Medicaid	$7,845.12
Rate for Payer: Molina CHIP/Medicaid	$7,845.12
Rate for Payer: Multiplan Auto	$7,082.40
Rate for Payer: Multiplan Commercial	$7,082.40
Rate for Payer: Multiplan Workers Comp	$7,082.40
Rate for Payer: Parkland Medicaid	$7,845.12
Rate for Payer: Scott and White EPO/PPO	$5,448.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,845.12
Rate for Payer: Superior Health Plan EPO	$1,481.86

KIT VASC ACC LTRM HMDIAL CV CATH INS

Facility

$10,896.00

Service Code	HCPCS C1752
Hospital Charge Code	993789
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7,409.28

kit verteport mainfold 11g

Facility

$1,663.27

Hospital Charge Code	8634508
Hospital Revenue Code	272
Min. Negotiated Rate	$149.69
Max. Negotiated Rate	$1,197.55
Rate for Payer: Amerigroup CHIP/Medicaid	$149.69
Rate for Payer: BCBS of TX Blue Advantage	$498.98
Rate for Payer: BCBS of TX Blue Essentials	$598.78
Rate for Payer: BCBS of TX PPO	$665.31
Rate for Payer: Cash Price	$1,131.02
Rate for Payer: Cigna Medicaid	$1,197.55
Rate for Payer: Molina CHIP/Medicaid	$1,197.55
Rate for Payer: Multiplan Auto	$1,081.13
Rate for Payer: Multiplan Commercial	$1,081.13
Rate for Payer: Multiplan Workers Comp	$1,081.13
Rate for Payer: Parkland Medicaid	$1,197.55
Rate for Payer: Scott and White EPO/PPO	$831.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,197.55
Rate for Payer: Superior Health Plan EPO	$226.20

kit verteport mainfold 11g

Facility

$1,663.27

Hospital Charge Code	8634508
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,131.02

KIT VERTIPORT MANIFOLD 11G

Facility

$5,921.57

Hospital Charge Code	992347
Hospital Revenue Code	272
Min. Negotiated Rate	$532.94
Max. Negotiated Rate	$4,263.53
Rate for Payer: Amerigroup CHIP/Medicaid	$532.94
Rate for Payer: BCBS of TX Blue Advantage	$1,776.47
Rate for Payer: BCBS of TX Blue Essentials	$2,131.77
Rate for Payer: BCBS of TX PPO	$2,368.63
Rate for Payer: Cash Price	$4,026.67
Rate for Payer: Cigna Medicaid	$4,263.53
Rate for Payer: Molina CHIP/Medicaid	$4,263.53
Rate for Payer: Multiplan Auto	$3,849.02
Rate for Payer: Multiplan Commercial	$3,849.02
Rate for Payer: Multiplan Workers Comp	$3,849.02
Rate for Payer: Parkland Medicaid	$4,263.53
Rate for Payer: Scott and White EPO/PPO	$2,960.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,263.53
Rate for Payer: Superior Health Plan EPO	$805.33

KIT VERTIPORT MANIFOLD 11G

Facility

$5,921.57

Hospital Charge Code	992347
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,026.67

K-LESS T-ROPE W/DRV, SYN REPR, SS

Facility

$11,313.68

Service Code	HCPCS C1713
Hospital Charge Code	992598
Hospital Revenue Code	278
Min. Negotiated Rate	$2,828.42
Max. Negotiated Rate	$5,656.84
Rate for Payer: Cash Price	$7,693.30
Rate for Payer: Cigna Commercial	$2,828.42
Rate for Payer: Multiplan Auto	$5,656.84
Rate for Payer: Multiplan Commercial	$5,656.84
Rate for Payer: Multiplan Workers Comp	$5,656.84
Rate for Payer: Scott and White EPO/PPO	$5,656.84

K-LESS T-ROPE W/DRV, SYN REPR, SS

Facility

$11,313.68

Service Code	HCPCS C1713
Hospital Charge Code	992598
Hospital Revenue Code	278
Min. Negotiated Rate	$1,018.23
Max. Negotiated Rate	$8,145.85
Rate for Payer: Amerigroup CHIP/Medicaid	$1,018.23
Rate for Payer: BCBS of TX Blue Advantage	$3,394.10
Rate for Payer: BCBS of TX Blue Essentials	$4,072.92
Rate for Payer: BCBS of TX PPO	$4,525.47
Rate for Payer: Cash Price	$7,693.30
Rate for Payer: Cigna Medicaid	$8,145.85
Rate for Payer: Molina CHIP/Medicaid	$8,145.85
Rate for Payer: Multiplan Auto	$5,656.84
Rate for Payer: Multiplan Commercial	$5,656.84
Rate for Payer: Multiplan Workers Comp	$5,656.84
Rate for Payer: Parkland Medicaid	$8,145.85
Rate for Payer: Scott and White EPO/PPO	$5,656.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,145.85
Rate for Payer: Superior Health Plan EPO	$1,538.66

KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT

Facility

$14,342.23

Service Code	APR-DRG 3133
Min. Negotiated Rate	$13,522.36
Max. Negotiated Rate	$14,342.23
Rate for Payer: Amerigroup CHIP/Medicaid	$13,522.36
Rate for Payer: Cigna Medicaid	$13,522.36
Rate for Payer: Molina CHIP/Medicaid	$13,522.36
Rate for Payer: Parkland Medicaid	$13,522.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,342.23

KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT

Facility

$6,280.20

Service Code	APR-DRG 3131
Min. Negotiated Rate	$5,921.19
Max. Negotiated Rate	$6,280.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5,921.19
Rate for Payer: Cigna Medicaid	$5,921.19
Rate for Payer: Molina CHIP/Medicaid	$5,921.19
Rate for Payer: Parkland Medicaid	$5,921.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,280.20

KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT

Facility

$8,604.06

Service Code	APR-DRG 3132
Min. Negotiated Rate	$8,112.21
Max. Negotiated Rate	$8,604.06
Rate for Payer: Amerigroup CHIP/Medicaid	$8,112.21
Rate for Payer: Cigna Medicaid	$8,112.21
Rate for Payer: Molina CHIP/Medicaid	$8,112.21
Rate for Payer: Parkland Medicaid	$8,112.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,604.06

KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT

Facility

$24,778.30

Service Code	APR-DRG 3134
Min. Negotiated Rate	$23,361.85
Max. Negotiated Rate	$24,778.30
Rate for Payer: Amerigroup CHIP/Medicaid	$23,361.85
Rate for Payer: Cigna Medicaid	$23,361.85
Rate for Payer: Molina CHIP/Medicaid	$23,361.85
Rate for Payer: Parkland Medicaid	$23,361.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,778.30

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC

Facility

$28,948.40

Service Code	MSDRG 488
Min. Negotiated Rate	$13,331.50
Max. Negotiated Rate	$28,948.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,724.39
Rate for Payer: Amerigroup Medicare	$17,724.39
Rate for Payer: BCBS of TX Medicare	$17,724.39
Rate for Payer: Cigna Commercial	$19,623.97
Rate for Payer: Cigna Medicare	$17,724.39
Rate for Payer: Employer Direct Commercial	$17,724.39
Rate for Payer: Humana Medicare/TRICARE	$17,724.39
Rate for Payer: Molina Dual Medicare/Medicaid	$17,724.39
Rate for Payer: Molina Medicare	$17,724.39
Rate for Payer: Multiplan Auto	$28,948.40
Rate for Payer: Multiplan Commercial	$28,948.40
Rate for Payer: Multiplan Workers Comp	$28,948.40
Rate for Payer: Scott and White EPO/PPO	$13,331.50
Rate for Payer: Scott and White Medicare	$17,724.39
Rate for Payer: Superior Health Plan EPO	$17,724.39
Rate for Payer: Superior Health Plan Medicare	$17,724.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,724.39
Rate for Payer: Universal American Medicare	$17,724.39
Rate for Payer: Wellcare Medicare	$17,724.39
Rate for Payer: Wellmed Medicare	$17,724.39

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$21,219.20

Service Code	MSDRG 489
Min. Negotiated Rate	$9,772.00
Max. Negotiated Rate	$21,219.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,945.14
Rate for Payer: Amerigroup Medicare	$12,945.14
Rate for Payer: BCBS of TX Medicare	$12,945.14
Rate for Payer: Cigna Commercial	$14,384.38
Rate for Payer: Cigna Medicare	$12,945.14
Rate for Payer: Employer Direct Commercial	$12,945.14
Rate for Payer: Humana Medicare/TRICARE	$12,945.14
Rate for Payer: Molina Dual Medicare/Medicaid	$12,945.14
Rate for Payer: Molina Medicare	$12,945.14
Rate for Payer: Multiplan Auto	$21,219.20
Rate for Payer: Multiplan Commercial	$21,219.20
Rate for Payer: Multiplan Workers Comp	$21,219.20
Rate for Payer: Scott and White EPO/PPO	$9,772.00
Rate for Payer: Scott and White Medicare	$12,945.14
Rate for Payer: Superior Health Plan EPO	$12,945.14
Rate for Payer: Superior Health Plan Medicare	$12,945.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,945.14
Rate for Payer: Universal American Medicare	$12,945.14
Rate for Payer: Wellcare Medicare	$12,945.14
Rate for Payer: Wellmed Medicare	$12,945.14

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC

Facility

$39,730.90

Service Code	MSDRG 486
Min. Negotiated Rate	$18,297.12
Max. Negotiated Rate	$39,730.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,085.80
Rate for Payer: Amerigroup Medicare	$20,085.80
Rate for Payer: BCBS of TX Medicare	$20,085.80
Rate for Payer: Cigna Commercial	$26,933.37
Rate for Payer: Cigna Medicare	$20,085.80
Rate for Payer: Employer Direct Commercial	$20,085.80
Rate for Payer: Humana Medicare/TRICARE	$20,085.80
Rate for Payer: Molina Dual Medicare/Medicaid	$20,085.80
Rate for Payer: Molina Medicare	$20,085.80
Rate for Payer: Multiplan Auto	$39,730.90
Rate for Payer: Multiplan Commercial	$39,730.90
Rate for Payer: Multiplan Workers Comp	$39,730.90
Rate for Payer: Scott and White EPO/PPO	$18,297.12
Rate for Payer: Scott and White Medicare	$20,085.80
Rate for Payer: Superior Health Plan EPO	$20,085.80
Rate for Payer: Superior Health Plan Medicare	$20,085.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,085.80
Rate for Payer: Universal American Medicare	$20,085.80
Rate for Payer: Wellcare Medicare	$20,085.80
Rate for Payer: Wellmed Medicare	$20,085.80

Know your out-of-pocket cost for care.

All Charges