White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SEALANT FLOSEAL SURGICAL

Facility

$1,921.42

Hospital Charge Code	8494511
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,690.85

SEALANT FLOSEAL SURGICAL

Facility

$1,921.42

Hospital Charge Code	8494511
Hospital Revenue Code	272
Min. Negotiated Rate	$172.93
Max. Negotiated Rate	$1,248.92
Rate for Payer: Aetna Commercial	$1,056.78
Rate for Payer: Amerigroup CHIP/Medicaid	$172.93
Rate for Payer: BCBS of TX Blue Advantage	$576.43
Rate for Payer: BCBS of TX Blue Essentials	$691.71
Rate for Payer: BCBS of TX PPO	$768.57
Rate for Payer: Cash Price	$1,690.85
Rate for Payer: Multiplan Auto	$1,248.92
Rate for Payer: Multiplan Commercial	$1,248.92
Rate for Payer: Multiplan Workers Comp	$1,248.92
Rate for Payer: Scott and White EPO/PPO	$960.71
Rate for Payer: Superior Health Plan EPO	$261.31

SEALANT HEMOSTAT MATRIX -- DHF

Facility

$719.36

Hospital Charge Code	81770182
Hospital Revenue Code	272
Min. Negotiated Rate	$64.74
Max. Negotiated Rate	$467.58
Rate for Payer: Aetna Commercial	$395.65
Rate for Payer: Amerigroup CHIP/Medicaid	$64.74
Rate for Payer: BCBS of TX Blue Advantage	$215.81
Rate for Payer: BCBS of TX Blue Essentials	$258.97
Rate for Payer: BCBS of TX PPO	$287.74
Rate for Payer: Cash Price	$633.04
Rate for Payer: Multiplan Auto	$467.58
Rate for Payer: Multiplan Commercial	$467.58
Rate for Payer: Multiplan Workers Comp	$467.58
Rate for Payer: Scott and White EPO/PPO	$359.68
Rate for Payer: Superior Health Plan EPO	$97.83

SEALANT HEMOSTAT MATRIX -- DHF

Facility

$719.36

Hospital Charge Code	81770182
Hospital Revenue Code	272
Rate for Payer: Cash Price	$633.04

SEALANT VISTA SEAL 10ML

Facility

$2,416.64

Hospital Charge Code	8494509
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,126.64

SEALANT VISTA SEAL 10ML

Facility

$2,416.64

Hospital Charge Code	8494509
Hospital Revenue Code	272
Min. Negotiated Rate	$217.50
Max. Negotiated Rate	$1,570.82
Rate for Payer: Aetna Commercial	$1,329.15
Rate for Payer: Amerigroup CHIP/Medicaid	$217.50
Rate for Payer: BCBS of TX Blue Advantage	$724.99
Rate for Payer: BCBS of TX Blue Essentials	$869.99
Rate for Payer: BCBS of TX PPO	$966.66
Rate for Payer: Cash Price	$2,126.64
Rate for Payer: Multiplan Auto	$1,570.82
Rate for Payer: Multiplan Commercial	$1,570.82
Rate for Payer: Multiplan Workers Comp	$1,570.82
Rate for Payer: Scott and White EPO/PPO	$1,208.32
Rate for Payer: Superior Health Plan EPO	$328.66

SEAL CANNULA STAPLER 12MM

Facility

$90.80

Hospital Charge Code	8690508
Hospital Revenue Code	272
Rate for Payer: Cash Price	$79.90

SEAL CANNULA STAPLER 12MM

Facility

$90.80

Hospital Charge Code	8690508
Hospital Revenue Code	272
Min. Negotiated Rate	$8.17
Max. Negotiated Rate	$59.02
Rate for Payer: Aetna Commercial	$49.94
Rate for Payer: Amerigroup CHIP/Medicaid	$8.17
Rate for Payer: BCBS of TX Blue Advantage	$27.24
Rate for Payer: BCBS of TX Blue Essentials	$32.69
Rate for Payer: BCBS of TX PPO	$36.32
Rate for Payer: Cash Price	$79.90
Rate for Payer: Multiplan Auto	$59.02
Rate for Payer: Multiplan Commercial	$59.02
Rate for Payer: Multiplan Workers Comp	$59.02
Rate for Payer: Scott and White EPO/PPO	$45.40
Rate for Payer: Superior Health Plan EPO	$12.35

seal cannula univ 5-8 mm

Facility

$81.72

Hospital Charge Code	8690513
Hospital Revenue Code	272
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$53.12
Rate for Payer: Aetna Commercial	$44.95
Rate for Payer: Amerigroup CHIP/Medicaid	$7.35
Rate for Payer: BCBS of TX Blue Advantage	$24.52
Rate for Payer: BCBS of TX Blue Essentials	$29.42
Rate for Payer: BCBS of TX PPO	$32.69
Rate for Payer: Cash Price	$71.91
Rate for Payer: Multiplan Auto	$53.12
Rate for Payer: Multiplan Commercial	$53.12
Rate for Payer: Multiplan Workers Comp	$53.12
Rate for Payer: Scott and White EPO/PPO	$40.86
Rate for Payer: Superior Health Plan EPO	$11.11

seal cannula univ 5-8 mm

Facility

$81.72

Hospital Charge Code	8690513
Hospital Revenue Code	272
Rate for Payer: Cash Price	$71.91

SEALER, BIPOLAR TISSUE W/SALINE AQUAMANTYS 6.0 -- DHF

Facility

$2,527.23

Hospital Charge Code	81856353
Hospital Revenue Code	272
Min. Negotiated Rate	$227.45
Max. Negotiated Rate	$1,642.70
Rate for Payer: Aetna Commercial	$1,389.98
Rate for Payer: Amerigroup CHIP/Medicaid	$227.45
Rate for Payer: BCBS of TX Blue Advantage	$758.17
Rate for Payer: BCBS of TX Blue Essentials	$909.80
Rate for Payer: BCBS of TX PPO	$1,010.89
Rate for Payer: Cash Price	$2,223.96
Rate for Payer: Multiplan Auto	$1,642.70
Rate for Payer: Multiplan Commercial	$1,642.70
Rate for Payer: Multiplan Workers Comp	$1,642.70
Rate for Payer: Scott and White EPO/PPO	$1,263.62
Rate for Payer: Superior Health Plan EPO	$343.70

SEALER, BIPOLAR TISSUE W/SALINE AQUAMANTYS 6.0 -- DHF

Facility

$2,527.23

Hospital Charge Code	81856353
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,223.96

SEALER, LAPAROSCOPIC 159 DEG STRT BLUNT 37CM X 5MM--DHF

Facility

$2,457.37

Hospital Charge Code	80811300
Hospital Revenue Code	272
Min. Negotiated Rate	$221.16
Max. Negotiated Rate	$1,597.29
Rate for Payer: Aetna Commercial	$1,351.55
Rate for Payer: Amerigroup CHIP/Medicaid	$221.16
Rate for Payer: BCBS of TX Blue Advantage	$737.21
Rate for Payer: BCBS of TX Blue Essentials	$884.65
Rate for Payer: BCBS of TX PPO	$982.95
Rate for Payer: Cash Price	$2,162.49
Rate for Payer: Multiplan Auto	$1,597.29
Rate for Payer: Multiplan Commercial	$1,597.29
Rate for Payer: Multiplan Workers Comp	$1,597.29
Rate for Payer: Scott and White EPO/PPO	$1,228.68
Rate for Payer: Superior Health Plan EPO	$334.20

SEALER, LAPAROSCOPIC BLUNT HAND OR FOOT 5MM X 37CM -- DHF

Facility

$1,855.73

Hospital Charge Code	80811300
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,633.04

SEALER, LAPAROSCOPIC BLUNT HAND OR FOOT 5MM X 37CM -- DHF

Facility

$1,855.73

Hospital Charge Code	80811300
Hospital Revenue Code	272
Min. Negotiated Rate	$167.02
Max. Negotiated Rate	$1,206.22
Rate for Payer: Aetna Commercial	$1,020.65
Rate for Payer: Amerigroup CHIP/Medicaid	$167.02
Rate for Payer: BCBS of TX Blue Advantage	$556.72
Rate for Payer: BCBS of TX Blue Essentials	$668.06
Rate for Payer: BCBS of TX PPO	$742.29
Rate for Payer: Cash Price	$1,633.04
Rate for Payer: Multiplan Auto	$1,206.22
Rate for Payer: Multiplan Commercial	$1,206.22
Rate for Payer: Multiplan Workers Comp	$1,206.22
Rate for Payer: Scott and White EPO/PPO	$927.86
Rate for Payer: Superior Health Plan EPO	$252.38

sealer vessel extend

Facility

$2,837.50

Hospital Charge Code	8690511
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,497.00

sealer vessel extend

Facility

$2,837.50

Hospital Charge Code	8690511
Hospital Revenue Code	272
Min. Negotiated Rate	$255.38
Max. Negotiated Rate	$1,844.38
Rate for Payer: Aetna Commercial	$1,560.62
Rate for Payer: Amerigroup CHIP/Medicaid	$255.38
Rate for Payer: BCBS of TX Blue Advantage	$851.25
Rate for Payer: BCBS of TX Blue Essentials	$1,021.50
Rate for Payer: BCBS of TX PPO	$1,135.00
Rate for Payer: Cash Price	$2,497.00
Rate for Payer: Multiplan Auto	$1,844.38
Rate for Payer: Multiplan Commercial	$1,844.38
Rate for Payer: Multiplan Workers Comp	$1,844.38
Rate for Payer: Scott and White EPO/PPO	$1,418.75
Rate for Payer: Superior Health Plan EPO	$385.90

SEAMGRAD BIOABSORB STAPLE LINE REINFORCEMENT

Facility

$755.15

Hospital Charge Code	81911604
Hospital Revenue Code	272
Min. Negotiated Rate	$67.96
Max. Negotiated Rate	$490.85
Rate for Payer: Aetna Commercial	$415.33
Rate for Payer: Amerigroup CHIP/Medicaid	$67.96
Rate for Payer: BCBS of TX Blue Advantage	$226.54
Rate for Payer: BCBS of TX Blue Essentials	$271.85
Rate for Payer: BCBS of TX PPO	$302.06
Rate for Payer: Cash Price	$664.53
Rate for Payer: Multiplan Auto	$490.85
Rate for Payer: Multiplan Commercial	$490.85
Rate for Payer: Multiplan Workers Comp	$490.85
Rate for Payer: Scott and White EPO/PPO	$377.58
Rate for Payer: Superior Health Plan EPO	$102.70

SEAMGRAD BIOABSORB STAPLE LINE REINFORCEMENT

Facility

$755.15

Hospital Charge Code	81911604
Hospital Revenue Code	272
Rate for Payer: Cash Price	$664.53

SEC ART M-THROMBECT ADD-ON

Facility

$11,606.00

Service Code	CPT 37186
Hospital Charge Code	2320224
Hospital Revenue Code	481
Min. Negotiated Rate	$1,044.54
Max. Negotiated Rate	$7,543.90
Rate for Payer: Aetna Commercial	$6,383.30
Rate for Payer: Amerigroup CHIP/Medicaid	$1,044.54
Rate for Payer: Cash Price	$10,213.28
Rate for Payer: Multiplan Auto	$7,543.90
Rate for Payer: Multiplan Commercial	$7,543.90
Rate for Payer: Multiplan Workers Comp	$7,543.90
Rate for Payer: Scott and White EPO/PPO	$5,803.00
Rate for Payer: Superior Health Plan EPO	$1,578.42

SEC ART M-THROMBECT ADD-ON

Facility

$11,606.00

Service Code	CPT 37186
Hospital Charge Code	2320224
Hospital Revenue Code	481
Rate for Payer: Cash Price	$10,213.28

Second Dose Moderna 0012A

Facility

$60.00

Service Code	CPT 0012A
Hospital Charge Code	8686558
Hospital Revenue Code	771
Rate for Payer: Cash Price	$52.80

Second Dose Moderna 0012A

Facility

$60.00

Service Code	CPT 0012A
Hospital Charge Code	8686558
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$33.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan EPO	$8.16

Second Dose Pfizer 0002A

Facility

$60.00

Service Code	CPT 0002A
Hospital Charge Code	1500011
Hospital Revenue Code	771
Rate for Payer: Cash Price	$52.80

Second Dose Pfizer 0002A

Facility

$60.00

Service Code	CPT 0002A
Hospital Charge Code	1500011
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$33.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan EPO	$8.16

Know your out-of-pocket cost for care.

All Charges