White Rock Medical Center

All Charges

Charge

Type

Setting

Price

LOCK SCREW SQUARE 2.7MM X 14MM

Facility

$759.04

Service Code	HCPCS C1713
Hospital Charge Code	992316
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$379.52
Rate for Payer: Cash Price	$516.15
Rate for Payer: Cigna Commercial	$189.76
Rate for Payer: Multiplan Auto	$379.52
Rate for Payer: Multiplan Commercial	$379.52
Rate for Payer: Multiplan Workers Comp	$379.52
Rate for Payer: Scott and White EPO/PPO	$379.52

LOCK SCREW SQUARE 2.7MM X 16MM

Facility

$759.04

Service Code	HCPCS C1713
Hospital Charge Code	992317
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$379.52
Rate for Payer: Cash Price	$516.15
Rate for Payer: Cigna Commercial	$189.76
Rate for Payer: Multiplan Auto	$379.52
Rate for Payer: Multiplan Commercial	$379.52
Rate for Payer: Multiplan Workers Comp	$379.52
Rate for Payer: Scott and White EPO/PPO	$379.52

LOCK SCREW SQUARE 2.7MM X 16MM

Facility

$759.04

Service Code	HCPCS C1713
Hospital Charge Code	992317
Hospital Revenue Code	278
Min. Negotiated Rate	$68.31
Max. Negotiated Rate	$546.51
Rate for Payer: Amerigroup CHIP/Medicaid	$68.31
Rate for Payer: BCBS of TX Blue Advantage	$227.71
Rate for Payer: BCBS of TX Blue Essentials	$273.25
Rate for Payer: BCBS of TX PPO	$303.62
Rate for Payer: Cash Price	$516.15
Rate for Payer: Cigna Medicaid	$546.51
Rate for Payer: Molina CHIP/Medicaid	$546.51
Rate for Payer: Multiplan Auto	$379.52
Rate for Payer: Multiplan Commercial	$379.52
Rate for Payer: Multiplan Workers Comp	$379.52
Rate for Payer: Parkland Medicaid	$546.51
Rate for Payer: Scott and White EPO/PPO	$379.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$546.51
Rate for Payer: Superior Health Plan EPO	$103.23

LOCK SCREW SQUARE 2.7MM X 18MM

Facility

$759.04

Service Code	HCPCS C1713
Hospital Charge Code	992318
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$379.52
Rate for Payer: Cash Price	$516.15
Rate for Payer: Cigna Commercial	$189.76
Rate for Payer: Multiplan Auto	$379.52
Rate for Payer: Multiplan Commercial	$379.52
Rate for Payer: Multiplan Workers Comp	$379.52
Rate for Payer: Scott and White EPO/PPO	$379.52

LOCK SCREW SQUARE 2.7MM X 18MM

Facility

$759.04

Service Code	HCPCS C1713
Hospital Charge Code	992318
Hospital Revenue Code	278
Min. Negotiated Rate	$68.31
Max. Negotiated Rate	$546.51
Rate for Payer: Amerigroup CHIP/Medicaid	$68.31
Rate for Payer: BCBS of TX Blue Advantage	$227.71
Rate for Payer: BCBS of TX Blue Essentials	$273.25
Rate for Payer: BCBS of TX PPO	$303.62
Rate for Payer: Cash Price	$516.15
Rate for Payer: Cigna Medicaid	$546.51
Rate for Payer: Molina CHIP/Medicaid	$546.51
Rate for Payer: Multiplan Auto	$379.52
Rate for Payer: Multiplan Commercial	$379.52
Rate for Payer: Multiplan Workers Comp	$379.52
Rate for Payer: Parkland Medicaid	$546.51
Rate for Payer: Scott and White EPO/PPO	$379.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$546.51
Rate for Payer: Superior Health Plan EPO	$103.23

LOCK SCREW SQUARE 2.7MM X 20MM

Facility

$759.04

Service Code	HCPCS C1713
Hospital Charge Code	992319
Hospital Revenue Code	278
Min. Negotiated Rate	$68.31
Max. Negotiated Rate	$546.51
Rate for Payer: Amerigroup CHIP/Medicaid	$68.31
Rate for Payer: BCBS of TX Blue Advantage	$227.71
Rate for Payer: BCBS of TX Blue Essentials	$273.25
Rate for Payer: BCBS of TX PPO	$303.62
Rate for Payer: Cash Price	$516.15
Rate for Payer: Cigna Medicaid	$546.51
Rate for Payer: Molina CHIP/Medicaid	$546.51
Rate for Payer: Multiplan Auto	$379.52
Rate for Payer: Multiplan Commercial	$379.52
Rate for Payer: Multiplan Workers Comp	$379.52
Rate for Payer: Parkland Medicaid	$546.51
Rate for Payer: Scott and White EPO/PPO	$379.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$546.51
Rate for Payer: Superior Health Plan EPO	$103.23

LOCK SCREW SQUARE 2.7MM X 20MM

Facility

$759.04

Service Code	HCPCS C1713
Hospital Charge Code	992319
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$379.52
Rate for Payer: Cash Price	$516.15
Rate for Payer: Cigna Commercial	$189.76
Rate for Payer: Multiplan Auto	$379.52
Rate for Payer: Multiplan Commercial	$379.52
Rate for Payer: Multiplan Workers Comp	$379.52
Rate for Payer: Scott and White EPO/PPO	$379.52

LOGIO E9, TRACKBALL (Removable) - see new PN: 5737554

Facility

$3,405.00

Hospital Charge Code	992621
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,315.40

LOGIO E9, TRACKBALL (Removable) - see new PN: 5737554

Facility

$3,405.00

Hospital Charge Code	992621
Hospital Revenue Code	272
Min. Negotiated Rate	$306.45
Max. Negotiated Rate	$2,451.60
Rate for Payer: Amerigroup CHIP/Medicaid	$306.45
Rate for Payer: BCBS of TX Blue Advantage	$1,021.50
Rate for Payer: BCBS of TX Blue Essentials	$1,225.80
Rate for Payer: BCBS of TX PPO	$1,362.00
Rate for Payer: Cash Price	$2,315.40
Rate for Payer: Cigna Medicaid	$2,451.60
Rate for Payer: Molina CHIP/Medicaid	$2,451.60
Rate for Payer: Multiplan Auto	$2,213.25
Rate for Payer: Multiplan Commercial	$2,213.25
Rate for Payer: Multiplan Workers Comp	$2,213.25
Rate for Payer: Parkland Medicaid	$2,451.60
Rate for Payer: Scott and White EPO/PPO	$1,702.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,451.60
Rate for Payer: Superior Health Plan EPO	$463.08

LONG MED BL (31.0MM X9.0MM)S

Facility

$757.95

Hospital Charge Code	993855
Hospital Revenue Code	270
Rate for Payer: Cash Price	$515.41

LONG MED BL (31.0MM X9.0MM)S

Facility

$757.95

Hospital Charge Code	993855
Hospital Revenue Code	270
Min. Negotiated Rate	$68.22
Max. Negotiated Rate	$545.72
Rate for Payer: Amerigroup CHIP/Medicaid	$68.22
Rate for Payer: BCBS of TX Blue Advantage	$227.38
Rate for Payer: BCBS of TX Blue Essentials	$272.86
Rate for Payer: BCBS of TX PPO	$303.18
Rate for Payer: Cash Price	$515.41
Rate for Payer: Cigna Medicaid	$545.72
Rate for Payer: Molina CHIP/Medicaid	$545.72
Rate for Payer: Multiplan Auto	$492.67
Rate for Payer: Multiplan Commercial	$492.67
Rate for Payer: Multiplan Workers Comp	$492.67
Rate for Payer: Parkland Medicaid	$545.72
Rate for Payer: Scott and White EPO/PPO	$378.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$545.72
Rate for Payer: Superior Health Plan EPO	$103.08

LOOP VESSEL AS -- DHF

Facility

$170.09

Hospital Charge Code	81751653
Hospital Revenue Code	272
Min. Negotiated Rate	$15.31
Max. Negotiated Rate	$122.46
Rate for Payer: Amerigroup CHIP/Medicaid	$15.31
Rate for Payer: BCBS of TX Blue Advantage	$51.03
Rate for Payer: BCBS of TX Blue Essentials	$61.23
Rate for Payer: BCBS of TX PPO	$68.04
Rate for Payer: Cash Price	$115.66
Rate for Payer: Cigna Medicaid	$122.46
Rate for Payer: Molina CHIP/Medicaid	$122.46
Rate for Payer: Multiplan Auto	$110.56
Rate for Payer: Multiplan Commercial	$110.56
Rate for Payer: Multiplan Workers Comp	$110.56
Rate for Payer: Parkland Medicaid	$122.46
Rate for Payer: Scott and White EPO/PPO	$85.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$122.46
Rate for Payer: Superior Health Plan EPO	$23.13

LOOP VESSEL AS -- DHF

Facility

$170.09

Hospital Charge Code	81751653
Hospital Revenue Code	272
Rate for Payer: Cash Price	$115.66

LOOP, VESSEL, MAXI, RED, 2/PK

Facility

$7.16

Hospital Charge Code	992853
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.87

LOOP, VESSEL, MAXI, RED, 2/PK

Facility

$7.16

Hospital Charge Code	992853
Hospital Revenue Code	272
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$5.16
Rate for Payer: Amerigroup CHIP/Medicaid	$0.64
Rate for Payer: BCBS of TX Blue Advantage	$2.15
Rate for Payer: BCBS of TX Blue Essentials	$2.58
Rate for Payer: BCBS of TX PPO	$2.86
Rate for Payer: Cash Price	$4.87
Rate for Payer: Cigna Medicaid	$5.16
Rate for Payer: Molina CHIP/Medicaid	$5.16
Rate for Payer: Multiplan Auto	$4.65
Rate for Payer: Multiplan Commercial	$4.65
Rate for Payer: Multiplan Workers Comp	$4.65
Rate for Payer: Parkland Medicaid	$5.16
Rate for Payer: Scott and White EPO/PPO	$3.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.16
Rate for Payer: Superior Health Plan EPO	$0.97

loperamide 2mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	1.30978E+11
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

loperamide 2mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78438367
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

loperamide 2mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78438367
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

loperamide 2mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	1.30978E+11
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

LO-PRO SCRW, SS 4.0X 18MM CANCLUS

Facility

$352.41

Service Code	HCPCS C1713
Hospital Charge Code	992251
Hospital Revenue Code	278
Min. Negotiated Rate	$88.10
Max. Negotiated Rate	$176.21
Rate for Payer: Cash Price	$239.64
Rate for Payer: Cigna Commercial	$88.10
Rate for Payer: Multiplan Auto	$176.21
Rate for Payer: Multiplan Commercial	$176.21
Rate for Payer: Multiplan Workers Comp	$176.21
Rate for Payer: Scott and White EPO/PPO	$176.21

LO-PRO SCRW, SS 4.0X 18MM CANCLUS

Facility

$352.41

Service Code	HCPCS C1713
Hospital Charge Code	992251
Hospital Revenue Code	278
Min. Negotiated Rate	$31.72
Max. Negotiated Rate	$253.74
Rate for Payer: Amerigroup CHIP/Medicaid	$31.72
Rate for Payer: BCBS of TX Blue Advantage	$105.72
Rate for Payer: BCBS of TX Blue Essentials	$126.87
Rate for Payer: BCBS of TX PPO	$140.96
Rate for Payer: Cash Price	$239.64
Rate for Payer: Cigna Medicaid	$253.74
Rate for Payer: Molina CHIP/Medicaid	$253.74
Rate for Payer: Multiplan Auto	$176.21
Rate for Payer: Multiplan Commercial	$176.21
Rate for Payer: Multiplan Workers Comp	$176.21
Rate for Payer: Parkland Medicaid	$253.74
Rate for Payer: Scott and White EPO/PPO	$176.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$253.74
Rate for Payer: Superior Health Plan EPO	$47.93

LO-PRO SCRW, TI,3.5MM X 32MM

Facility

$602.41

Service Code	HCPCS C1713
Hospital Charge Code	992242
Hospital Revenue Code	278
Min. Negotiated Rate	$54.22
Max. Negotiated Rate	$433.74
Rate for Payer: Amerigroup CHIP/Medicaid	$54.22
Rate for Payer: BCBS of TX Blue Advantage	$180.72
Rate for Payer: BCBS of TX Blue Essentials	$216.87
Rate for Payer: BCBS of TX PPO	$240.96
Rate for Payer: Cash Price	$409.64
Rate for Payer: Cigna Medicaid	$433.74
Rate for Payer: Molina CHIP/Medicaid	$433.74
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Parkland Medicaid	$433.74
Rate for Payer: Scott and White EPO/PPO	$301.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$433.74
Rate for Payer: Superior Health Plan EPO	$81.93

LO-PRO SCRW, TI,3.5MM X 32MM

Facility

$602.41

Service Code	HCPCS C1713
Hospital Charge Code	992242
Hospital Revenue Code	278
Min. Negotiated Rate	$150.60
Max. Negotiated Rate	$301.20
Rate for Payer: Cash Price	$409.64
Rate for Payer: Cigna Commercial	$150.60
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Scott and White EPO/PPO	$301.20

LO-PRO SCRW, TI,3.5MM X 34MM

Facility

$602.41

Service Code	HCPCS C1713
Hospital Charge Code	992243
Hospital Revenue Code	278
Min. Negotiated Rate	$54.22
Max. Negotiated Rate	$433.74
Rate for Payer: Amerigroup CHIP/Medicaid	$54.22
Rate for Payer: BCBS of TX Blue Advantage	$180.72
Rate for Payer: BCBS of TX Blue Essentials	$216.87
Rate for Payer: BCBS of TX PPO	$240.96
Rate for Payer: Cash Price	$409.64
Rate for Payer: Cigna Medicaid	$433.74
Rate for Payer: Molina CHIP/Medicaid	$433.74
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Parkland Medicaid	$433.74
Rate for Payer: Scott and White EPO/PPO	$301.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$433.74
Rate for Payer: Superior Health Plan EPO	$81.93

LO-PRO SCRW, TI,3.5MM X 34MM

Facility

$602.41

Service Code	HCPCS C1713
Hospital Charge Code	992243
Hospital Revenue Code	278
Min. Negotiated Rate	$150.60
Max. Negotiated Rate	$301.20
Rate for Payer: Cash Price	$409.64
Rate for Payer: Cigna Commercial	$150.60
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Scott and White EPO/PPO	$301.20

Know your out-of-pocket cost for care.

All Charges