White Rock Medical Center

All Charges

Charge

Type

Setting

Price

K-WIRE SS 1.6 X 127MM NS

Facility

$171.61

Service Code	HCPCS C1769
Hospital Charge Code	993173
Hospital Revenue Code	278
Min. Negotiated Rate	$42.90
Max. Negotiated Rate	$85.81
Rate for Payer: Cash Price	$116.69
Rate for Payer: Cigna Commercial	$42.90
Rate for Payer: Multiplan Auto	$85.81
Rate for Payer: Multiplan Commercial	$85.81
Rate for Payer: Multiplan Workers Comp	$85.81
Rate for Payer: Scott and White EPO/PPO	$85.81

K-WIRE, VARIES

Facility

$340.50

Service Code	HCPCS C1769
Hospital Charge Code	993665
Hospital Revenue Code	278
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$245.16
Rate for Payer: Amerigroup CHIP/Medicaid	$30.64
Rate for Payer: BCBS of TX Blue Advantage	$102.15
Rate for Payer: BCBS of TX Blue Essentials	$122.58
Rate for Payer: BCBS of TX PPO	$136.20
Rate for Payer: Cash Price	$231.54
Rate for Payer: Cigna Medicaid	$245.16
Rate for Payer: Molina CHIP/Medicaid	$245.16
Rate for Payer: Multiplan Auto	$170.25
Rate for Payer: Multiplan Commercial	$170.25
Rate for Payer: Multiplan Workers Comp	$170.25
Rate for Payer: Parkland Medicaid	$245.16
Rate for Payer: Scott and White EPO/PPO	$170.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$245.16
Rate for Payer: Superior Health Plan EPO	$46.31

K-WIRE, VARIES

Facility

$340.50

Service Code	HCPCS C1769
Hospital Charge Code	993665
Hospital Revenue Code	278
Min. Negotiated Rate	$85.12
Max. Negotiated Rate	$170.25
Rate for Payer: Cash Price	$231.54
Rate for Payer: Cigna Commercial	$85.12
Rate for Payer: Multiplan Auto	$170.25
Rate for Payer: Multiplan Commercial	$170.25
Rate for Payer: Multiplan Workers Comp	$170.25
Rate for Payer: Scott and White EPO/PPO	$170.25

KYPHON ADDITIONAL FIX KIT

Facility

$8,802.19

Hospital Charge Code	8576624
Hospital Revenue Code	272
Min. Negotiated Rate	$792.20
Max. Negotiated Rate	$6,337.58
Rate for Payer: Amerigroup CHIP/Medicaid	$792.20
Rate for Payer: BCBS of TX Blue Advantage	$2,640.66
Rate for Payer: BCBS of TX Blue Essentials	$3,168.79
Rate for Payer: BCBS of TX PPO	$3,520.88
Rate for Payer: Cash Price	$5,985.49
Rate for Payer: Cigna Medicaid	$6,337.58
Rate for Payer: Molina CHIP/Medicaid	$6,337.58
Rate for Payer: Multiplan Auto	$5,721.42
Rate for Payer: Multiplan Commercial	$5,721.42
Rate for Payer: Multiplan Workers Comp	$5,721.42
Rate for Payer: Parkland Medicaid	$6,337.58
Rate for Payer: Scott and White EPO/PPO	$4,401.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,337.58
Rate for Payer: Superior Health Plan EPO	$1,197.10

KYPHON ADDITIONAL FIX KIT

Facility

$8,802.19

Hospital Charge Code	8576624
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,985.49

KYPHON CEMENT WITH MIXER

Facility

$2,223.00

Service Code	HCPCS C1763
Hospital Charge Code	8484501
Hospital Revenue Code	278
Min. Negotiated Rate	$555.75
Max. Negotiated Rate	$1,111.50
Rate for Payer: Cash Price	$1,511.64
Rate for Payer: Cigna Commercial	$555.75
Rate for Payer: Multiplan Auto	$1,111.50
Rate for Payer: Multiplan Commercial	$1,111.50
Rate for Payer: Multiplan Workers Comp	$1,111.50
Rate for Payer: Scott and White EPO/PPO	$1,111.50

KYPHON CEMENT WITH MIXER

Facility

$2,223.00

Service Code	HCPCS C1763
Hospital Charge Code	8484501
Hospital Revenue Code	278
Min. Negotiated Rate	$200.07
Max. Negotiated Rate	$1,600.56
Rate for Payer: Amerigroup CHIP/Medicaid	$200.07
Rate for Payer: BCBS of TX Blue Advantage	$666.90
Rate for Payer: BCBS of TX Blue Essentials	$800.28
Rate for Payer: BCBS of TX PPO	$889.20
Rate for Payer: Cash Price	$1,511.64
Rate for Payer: Cigna Medicaid	$1,600.56
Rate for Payer: Molina CHIP/Medicaid	$1,600.56
Rate for Payer: Multiplan Auto	$1,111.50
Rate for Payer: Multiplan Commercial	$1,111.50
Rate for Payer: Multiplan Workers Comp	$1,111.50
Rate for Payer: Parkland Medicaid	$1,600.56
Rate for Payer: Scott and White EPO/PPO	$1,111.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,600.56
Rate for Payer: Superior Health Plan EPO	$302.33

KYPHON FIRST FIX KIT

Facility

$21,565.00

Hospital Charge Code	8484496
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

KYPHON FIRST FIX KIT

Facility

$21,565.00

Hospital Charge Code	8484496
Hospital Revenue Code	272
Rate for Payer: Cash Price	$14,664.20

LABEL 3-1/2'x1-3/32 WHITE THERMAL DYMO

Facility

$38.73

Hospital Charge Code	993552
Hospital Revenue Code	270
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$27.89
Rate for Payer: Amerigroup CHIP/Medicaid	$3.49
Rate for Payer: BCBS of TX Blue Advantage	$11.62
Rate for Payer: BCBS of TX Blue Essentials	$13.94
Rate for Payer: BCBS of TX PPO	$15.49
Rate for Payer: Cash Price	$26.34
Rate for Payer: Cigna Medicaid	$27.89
Rate for Payer: Molina CHIP/Medicaid	$27.89
Rate for Payer: Multiplan Auto	$25.17
Rate for Payer: Multiplan Commercial	$25.17
Rate for Payer: Multiplan Workers Comp	$25.17
Rate for Payer: Parkland Medicaid	$27.89
Rate for Payer: Scott and White EPO/PPO	$19.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.89
Rate for Payer: Superior Health Plan EPO	$5.27

LABEL 3-1/2'x1-3/32 WHITE THERMAL DYMO

Facility

$38.73

Hospital Charge Code	993552
Hospital Revenue Code	270
Rate for Payer: Cash Price	$26.34

LABEL FLO GRN CLEAN 2 5/16X1.5

Facility

$54.57

Hospital Charge Code	993553
Hospital Revenue Code	270
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$39.29
Rate for Payer: Amerigroup CHIP/Medicaid	$4.91
Rate for Payer: BCBS of TX Blue Advantage	$16.37
Rate for Payer: BCBS of TX Blue Essentials	$19.65
Rate for Payer: BCBS of TX PPO	$21.83
Rate for Payer: Cash Price	$37.11
Rate for Payer: Cigna Medicaid	$39.29
Rate for Payer: Molina CHIP/Medicaid	$39.29
Rate for Payer: Multiplan Auto	$35.47
Rate for Payer: Multiplan Commercial	$35.47
Rate for Payer: Multiplan Workers Comp	$35.47
Rate for Payer: Parkland Medicaid	$39.29
Rate for Payer: Scott and White EPO/PPO	$27.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.29
Rate for Payer: Superior Health Plan EPO	$7.42

LABEL FLO GRN CLEAN 2 5/16X1.5

Facility

$54.57

Hospital Charge Code	993553
Hospital Revenue Code	270
Rate for Payer: Cash Price	$37.11

LABEL, PIGGYBACK COATED THERMAL BLUE .9' X 1.6'

Facility

$20.21

Hospital Charge Code	993297
Hospital Revenue Code	270
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$14.55
Rate for Payer: Amerigroup CHIP/Medicaid	$1.82
Rate for Payer: BCBS of TX Blue Advantage	$6.06
Rate for Payer: BCBS of TX Blue Essentials	$7.28
Rate for Payer: BCBS of TX PPO	$8.08
Rate for Payer: Cash Price	$13.74
Rate for Payer: Cigna Medicaid	$14.55
Rate for Payer: Molina CHIP/Medicaid	$14.55
Rate for Payer: Multiplan Auto	$13.14
Rate for Payer: Multiplan Commercial	$13.14
Rate for Payer: Multiplan Workers Comp	$13.14
Rate for Payer: Parkland Medicaid	$14.55
Rate for Payer: Scott and White EPO/PPO	$10.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.55
Rate for Payer: Superior Health Plan EPO	$2.75

LABEL, PIGGYBACK COATED THERMAL BLUE .9' X 1.6'

Facility

$20.21

Hospital Charge Code	993297
Hospital Revenue Code	270
Rate for Payer: Cash Price	$13.74

LABELS, PRO-FILE CHART, WHITE

Facility

$24.06

Hospital Charge Code	993236
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.36

LABELS, PRO-FILE CHART, WHITE

Facility

$24.06

Hospital Charge Code	993236
Hospital Revenue Code	270
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$17.32
Rate for Payer: Amerigroup CHIP/Medicaid	$2.17
Rate for Payer: BCBS of TX Blue Advantage	$7.22
Rate for Payer: BCBS of TX Blue Essentials	$8.66
Rate for Payer: BCBS of TX PPO	$9.62
Rate for Payer: Cash Price	$16.36
Rate for Payer: Cigna Medicaid	$17.32
Rate for Payer: Molina CHIP/Medicaid	$17.32
Rate for Payer: Multiplan Auto	$15.64
Rate for Payer: Multiplan Commercial	$15.64
Rate for Payer: Multiplan Workers Comp	$15.64
Rate for Payer: Parkland Medicaid	$17.32
Rate for Payer: Scott and White EPO/PPO	$12.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.32
Rate for Payer: Superior Health Plan EPO	$3.27

labetalol 200 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77649925
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

labetalol 200 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77649925
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

labetalol 5 mg/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J1920
Hospital Charge Code	77650245
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

labetalol 5 mg/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J1920
Hospital Charge Code	77650245
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.39
Rate for Payer: BCBS of TX Blue Essentials	$0.47
Rate for Payer: BCBS of TX PPO	$0.52
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

labetalol 5 mg/mL IV Soln 4 mL

Facility

$128.17

Service Code	HCPCS J1920
Hospital Charge Code	77650190
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

labetalol 5 mg/mL IV Soln 4 mL

Facility

$128.17

Service Code	HCPCS J1920
Hospital Charge Code	77650190
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.39
Rate for Payer: BCBS of TX Blue Essentials	$0.47
Rate for Payer: BCBS of TX PPO	$0.52
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Labor Level Complex 1st Hour -> Yes

Facility

$2,345.00

Hospital Charge Code	300038
Hospital Revenue Code	720
Min. Negotiated Rate	$211.05
Max. Negotiated Rate	$1,688.40
Rate for Payer: Amerigroup CHIP/Medicaid	$211.05
Rate for Payer: BCBS of TX Blue Advantage	$703.50
Rate for Payer: BCBS of TX Blue Essentials	$844.20
Rate for Payer: BCBS of TX PPO	$938.00
Rate for Payer: Cash Price	$1,594.60
Rate for Payer: Cigna Medicaid	$1,688.40
Rate for Payer: Molina CHIP/Medicaid	$1,688.40
Rate for Payer: Multiplan Auto	$1,524.25
Rate for Payer: Multiplan Commercial	$1,524.25
Rate for Payer: Multiplan Workers Comp	$1,524.25
Rate for Payer: Parkland Medicaid	$1,688.40
Rate for Payer: Scott and White EPO/PPO	$1,172.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,688.40
Rate for Payer: Superior Health Plan EPO	$318.92

Labor Level Complex 1st Hour -> Yes

Facility

$2,345.00

Hospital Charge Code	300038
Hospital Revenue Code	720
Rate for Payer: Cash Price	$1,594.60

Know your out-of-pocket cost for care.

All Charges