White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIT SONIC ANCHOR

Facility

$2,971.00

Service Code	HCPCS C1713
Hospital Charge Code	139445
Hospital Revenue Code	278
Min. Negotiated Rate	$267.39
Max. Negotiated Rate	$2,139.12
Rate for Payer: Amerigroup CHIP/Medicaid	$267.39
Rate for Payer: BCBS of TX Blue Advantage	$891.30
Rate for Payer: BCBS of TX Blue Essentials	$1,069.56
Rate for Payer: BCBS of TX PPO	$1,188.40
Rate for Payer: Cash Price	$2,020.28
Rate for Payer: Cigna Medicaid	$2,139.12
Rate for Payer: Molina CHIP/Medicaid	$2,139.12
Rate for Payer: Multiplan Auto	$1,485.50
Rate for Payer: Multiplan Commercial	$1,485.50
Rate for Payer: Multiplan Workers Comp	$1,485.50
Rate for Payer: Parkland Medicaid	$2,139.12
Rate for Payer: Scott and White EPO/PPO	$1,485.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,139.12
Rate for Payer: Superior Health Plan EPO	$404.06

KIT SONIC ANCHOR

Facility

$2,971.00

Service Code	HCPCS C1713
Hospital Charge Code	139445
Hospital Revenue Code	278
Min. Negotiated Rate	$742.75
Max. Negotiated Rate	$1,485.50
Rate for Payer: Cash Price	$2,020.28
Rate for Payer: Cigna Commercial	$742.75
Rate for Payer: Multiplan Auto	$1,485.50
Rate for Payer: Multiplan Commercial	$1,485.50
Rate for Payer: Multiplan Workers Comp	$1,485.50
Rate for Payer: Scott and White EPO/PPO	$1,485.50

KIT, SUBCHONDROPLASTY KNEE W/SIDE OPENING UPGRADE

Facility

$19,068.00

Hospital Charge Code	993172
Hospital Revenue Code	272
Rate for Payer: Cash Price	$12,966.24

KIT, SUBCHONDROPLASTY KNEE W/SIDE OPENING UPGRADE

Facility

$19,068.00

Hospital Charge Code	993172
Hospital Revenue Code	272
Min. Negotiated Rate	$1,716.12
Max. Negotiated Rate	$13,728.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1,716.12
Rate for Payer: BCBS of TX Blue Advantage	$5,720.40
Rate for Payer: BCBS of TX Blue Essentials	$6,864.48
Rate for Payer: BCBS of TX PPO	$7,627.20
Rate for Payer: Cash Price	$12,966.24
Rate for Payer: Cigna Medicaid	$13,728.96
Rate for Payer: Molina CHIP/Medicaid	$13,728.96
Rate for Payer: Multiplan Auto	$12,394.20
Rate for Payer: Multiplan Commercial	$12,394.20
Rate for Payer: Multiplan Workers Comp	$12,394.20
Rate for Payer: Parkland Medicaid	$13,728.96
Rate for Payer: Scott and White EPO/PPO	$9,534.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,728.96
Rate for Payer: Superior Health Plan EPO	$2,593.25

KIT, SUCT WOUND CLSED 3-SPRING 400ML MD W/NDL 1/8' -- DHF

Facility

$41.57

Hospital Charge Code	81821159
Hospital Revenue Code	272
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$29.93
Rate for Payer: Amerigroup CHIP/Medicaid	$3.74
Rate for Payer: BCBS of TX Blue Advantage	$12.47
Rate for Payer: BCBS of TX Blue Essentials	$14.97
Rate for Payer: BCBS of TX PPO	$16.63
Rate for Payer: Cash Price	$28.27
Rate for Payer: Cigna Medicaid	$29.93
Rate for Payer: Molina CHIP/Medicaid	$29.93
Rate for Payer: Multiplan Auto	$27.02
Rate for Payer: Multiplan Commercial	$27.02
Rate for Payer: Multiplan Workers Comp	$27.02
Rate for Payer: Parkland Medicaid	$29.93
Rate for Payer: Scott and White EPO/PPO	$20.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.93
Rate for Payer: Superior Health Plan EPO	$5.65

KIT, SUCT WOUND CLSED 3-SPRING 400ML MD W/NDL 1/8' -- DHF

Facility

$41.57

Hospital Charge Code	81821159
Hospital Revenue Code	272
Rate for Payer: Cash Price	$28.27

KIT SUTURE IMPLANT W/SUTURE TAPE

Facility

$12,867.00

Service Code	HCPCS C1713
Hospital Charge Code	130280
Hospital Revenue Code	278
Min. Negotiated Rate	$3,216.75
Max. Negotiated Rate	$6,433.50
Rate for Payer: Cash Price	$8,749.56
Rate for Payer: Cigna Commercial	$3,216.75
Rate for Payer: Multiplan Auto	$6,433.50
Rate for Payer: Multiplan Commercial	$6,433.50
Rate for Payer: Multiplan Workers Comp	$6,433.50
Rate for Payer: Scott and White EPO/PPO	$6,433.50

KIT SUTURE IMPLANT W/SUTURE TAPE

Facility

$12,867.00

Service Code	HCPCS C1713
Hospital Charge Code	130280
Hospital Revenue Code	278
Min. Negotiated Rate	$1,158.03
Max. Negotiated Rate	$9,264.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,158.03
Rate for Payer: BCBS of TX Blue Advantage	$3,860.10
Rate for Payer: BCBS of TX Blue Essentials	$4,632.12
Rate for Payer: BCBS of TX PPO	$5,146.80
Rate for Payer: Cash Price	$8,749.56
Rate for Payer: Cigna Medicaid	$9,264.24
Rate for Payer: Molina CHIP/Medicaid	$9,264.24
Rate for Payer: Multiplan Auto	$6,433.50
Rate for Payer: Multiplan Commercial	$6,433.50
Rate for Payer: Multiplan Workers Comp	$6,433.50
Rate for Payer: Parkland Medicaid	$9,264.24
Rate for Payer: Scott and White EPO/PPO	$6,433.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,264.24
Rate for Payer: Superior Health Plan EPO	$1,749.91

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 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 TENDODESIS SIZER W/ FIBERLOOP

Facility

$1,915.88

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

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

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

KITTNER, ENDOSCOPIC SINGLE TIP -- DHF

Facility

$100.00

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

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
Rate for Payer: Cash Price	$203.42

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 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
Rate for Payer: Cash Price	$1,131.02

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 VERTIPORT MANIFOLD 11G

Facility

$5,921.57

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

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

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

Know your out-of-pocket cost for care.

All Charges