White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MBO-CANISTER 2000CCGUARDIAN, W/LOCKINGLID

Facility

$9.41

Hospital Charge Code	992906
Hospital Revenue Code	270
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$6.78
Rate for Payer: Amerigroup CHIP/Medicaid	$0.85
Rate for Payer: BCBS of TX Blue Advantage	$2.82
Rate for Payer: BCBS of TX Blue Essentials	$3.39
Rate for Payer: BCBS of TX PPO	$3.76
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna Medicaid	$6.78
Rate for Payer: Molina CHIP/Medicaid	$6.78
Rate for Payer: Multiplan Auto	$6.12
Rate for Payer: Multiplan Commercial	$6.12
Rate for Payer: Multiplan Workers Comp	$6.12
Rate for Payer: Parkland Medicaid	$6.78
Rate for Payer: Scott and White EPO/PPO	$4.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.78
Rate for Payer: Superior Health Plan EPO	$1.28

MBO-CANISTER 2000CCGUARDIAN, W/LOCKINGLID

Facility

$9.41

Hospital Charge Code	992906
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.40

MBO-CATHETER, SAFETY, VIAVALVE, IV, 20

Facility

$9.28

Service Code	HCPCS C1751
Hospital Charge Code	993968
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.31

MBO-CATHETER, SAFETY, VIAVALVE, IV, 20

Facility

$9.28

Service Code	HCPCS C1751
Hospital Charge Code	82457557
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.68
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.78
Rate for Payer: BCBS of TX Blue Essentials	$3.34
Rate for Payer: BCBS of TX PPO	$3.71
Rate for Payer: Cash Price	$6.31
Rate for Payer: Cigna Medicaid	$6.68
Rate for Payer: Molina CHIP/Medicaid	$6.68
Rate for Payer: Multiplan Auto	$6.03
Rate for Payer: Multiplan Commercial	$6.03
Rate for Payer: Multiplan Workers Comp	$6.03
Rate for Payer: Parkland Medicaid	$6.68
Rate for Payer: Scott and White EPO/PPO	$4.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.68
Rate for Payer: Superior Health Plan EPO	$1.26

MBO-CATHETER, SAFETY, VIAVALVE, IV, 20

Facility

$9.28

Service Code	HCPCS C1751
Hospital Charge Code	82457557
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.31

MBO-CATHETER, SAFETY, VIAVALVE, IV, 20

Facility

$9.28

Service Code	HCPCS C1751
Hospital Charge Code	993968
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.68
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.78
Rate for Payer: BCBS of TX Blue Essentials	$3.34
Rate for Payer: BCBS of TX PPO	$3.71
Rate for Payer: Cash Price	$6.31
Rate for Payer: Cigna Medicaid	$6.68
Rate for Payer: Molina CHIP/Medicaid	$6.68
Rate for Payer: Multiplan Auto	$6.03
Rate for Payer: Multiplan Commercial	$6.03
Rate for Payer: Multiplan Workers Comp	$6.03
Rate for Payer: Parkland Medicaid	$6.68
Rate for Payer: Scott and White EPO/PPO	$4.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.68
Rate for Payer: Superior Health Plan EPO	$1.26

MBO-CATHETER,SAFETY,VIAVALVE,IV,22'X1'

Facility

$9.28

Service Code	HCPCS C1751
Hospital Charge Code	992520
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.68
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.78
Rate for Payer: BCBS of TX Blue Essentials	$3.34
Rate for Payer: BCBS of TX PPO	$3.71
Rate for Payer: Cash Price	$6.31
Rate for Payer: Cigna Medicaid	$6.68
Rate for Payer: Molina CHIP/Medicaid	$6.68
Rate for Payer: Multiplan Auto	$6.03
Rate for Payer: Multiplan Commercial	$6.03
Rate for Payer: Multiplan Workers Comp	$6.03
Rate for Payer: Parkland Medicaid	$6.68
Rate for Payer: Scott and White EPO/PPO	$4.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.68
Rate for Payer: Superior Health Plan EPO	$1.26

MBO-CATHETER,SAFETY,VIAVALVE,IV,22'X1'

Facility

$9.28

Service Code	HCPCS C1751
Hospital Charge Code	992520
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.31

MBO-ELECTRODE, ECG, MEDITRACE 450, FOAM, SNP

Facility

$0.29

Hospital Charge Code	993953
Hospital Revenue Code	271
Rate for Payer: Cash Price	$0.20

MBO-ELECTRODE, ECG, MEDITRACE 450, FOAM, SNP

Facility

$0.29

Hospital Charge Code	993953
Hospital Revenue Code	271
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.21
Rate for Payer: Amerigroup CHIP/Medicaid	$0.03
Rate for Payer: BCBS of TX Blue Advantage	$0.09
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.12
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna Medicaid	$0.21
Rate for Payer: Molina CHIP/Medicaid	$0.21
Rate for Payer: Multiplan Auto	$0.19
Rate for Payer: Multiplan Commercial	$0.19
Rate for Payer: Multiplan Workers Comp	$0.19
Rate for Payer: Parkland Medicaid	$0.21
Rate for Payer: Scott and White EPO/PPO	$0.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.21
Rate for Payer: Superior Health Plan EPO	$0.04

MBO-GLOVE SRGCL BIOGEL ULTRATOUCH, PF,6.5

Facility

$8.40

Hospital Charge Code	992756
Hospital Revenue Code	272
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$6.05
Rate for Payer: Amerigroup CHIP/Medicaid	$0.76
Rate for Payer: BCBS of TX Blue Advantage	$2.52
Rate for Payer: BCBS of TX Blue Essentials	$3.02
Rate for Payer: BCBS of TX PPO	$3.36
Rate for Payer: Cash Price	$5.71
Rate for Payer: Cigna Medicaid	$6.05
Rate for Payer: Molina CHIP/Medicaid	$6.05
Rate for Payer: Multiplan Auto	$5.46
Rate for Payer: Multiplan Commercial	$5.46
Rate for Payer: Multiplan Workers Comp	$5.46
Rate for Payer: Parkland Medicaid	$6.05
Rate for Payer: Scott and White EPO/PPO	$4.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.05
Rate for Payer: Superior Health Plan EPO	$1.14

MBO-GLOVE SRGCL BIOGEL ULTRATOUCH, PF,6.5

Facility

$8.40

Hospital Charge Code	992756
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.71

MBO-KIT, GRAM STAIN STABILIZED

Facility

$136.84

Hospital Charge Code	993357
Hospital Revenue Code	270
Rate for Payer: Cash Price	$93.05

MBO-KIT, GRAM STAIN STABILIZED

Facility

$136.84

Hospital Charge Code	993357
Hospital Revenue Code	270
Min. Negotiated Rate	$12.32
Max. Negotiated Rate	$98.52
Rate for Payer: Amerigroup CHIP/Medicaid	$12.32
Rate for Payer: BCBS of TX Blue Advantage	$41.05
Rate for Payer: BCBS of TX Blue Essentials	$49.26
Rate for Payer: BCBS of TX PPO	$54.74
Rate for Payer: Cash Price	$93.05
Rate for Payer: Cigna Medicaid	$98.52
Rate for Payer: Molina CHIP/Medicaid	$98.52
Rate for Payer: Multiplan Auto	$88.95
Rate for Payer: Multiplan Commercial	$88.95
Rate for Payer: Multiplan Workers Comp	$88.95
Rate for Payer: Parkland Medicaid	$98.52
Rate for Payer: Scott and White EPO/PPO	$68.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.52
Rate for Payer: Superior Health Plan EPO	$18.61

MBO-KIT,SLIDE HEMOCCULT SINGLE

Facility

$12.03

Hospital Charge Code	993112
Hospital Revenue Code	270
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$8.66
Rate for Payer: Amerigroup CHIP/Medicaid	$1.08
Rate for Payer: BCBS of TX Blue Advantage	$3.61
Rate for Payer: BCBS of TX Blue Essentials	$4.33
Rate for Payer: BCBS of TX PPO	$4.81
Rate for Payer: Cash Price	$8.18
Rate for Payer: Cigna Medicaid	$8.66
Rate for Payer: Molina CHIP/Medicaid	$8.66
Rate for Payer: Multiplan Auto	$7.82
Rate for Payer: Multiplan Commercial	$7.82
Rate for Payer: Multiplan Workers Comp	$7.82
Rate for Payer: Parkland Medicaid	$8.66
Rate for Payer: Scott and White EPO/PPO	$6.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.66
Rate for Payer: Superior Health Plan EPO	$1.64

MBO-KIT,SLIDE HEMOCCULT SINGLE

Facility

$12.03

Hospital Charge Code	993112
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.18

MBO-NDL, 25G X 1, ECLIPSE, USE WITH LURE-LOK

Facility

$9.24

Hospital Charge Code	993081
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.28

MBO-NDL, 25G X 1, ECLIPSE, USE WITH LURE-LOK

Facility

$9.24

Hospital Charge Code	993081
Hospital Revenue Code	270
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$6.65
Rate for Payer: Amerigroup CHIP/Medicaid	$0.83
Rate for Payer: BCBS of TX Blue Advantage	$2.77
Rate for Payer: BCBS of TX Blue Essentials	$3.33
Rate for Payer: BCBS of TX PPO	$3.70
Rate for Payer: Cash Price	$6.28
Rate for Payer: Cigna Medicaid	$6.65
Rate for Payer: Molina CHIP/Medicaid	$6.65
Rate for Payer: Multiplan Auto	$6.01
Rate for Payer: Multiplan Commercial	$6.01
Rate for Payer: Multiplan Workers Comp	$6.01
Rate for Payer: Parkland Medicaid	$6.65
Rate for Payer: Scott and White EPO/PPO	$4.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.65
Rate for Payer: Superior Health Plan EPO	$1.26

MBO-NEEDLE, SAFETY, 18G X 1.5, MAGELLAN

Facility

$1.19

Hospital Charge Code	993921
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.81

MBO-NEEDLE, SAFETY, 18G X 1.5, MAGELLAN

Facility

$1.19

Hospital Charge Code	993921
Hospital Revenue Code	272
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.86
Rate for Payer: Amerigroup CHIP/Medicaid	$0.11
Rate for Payer: BCBS of TX Blue Advantage	$0.36
Rate for Payer: BCBS of TX Blue Essentials	$0.43
Rate for Payer: BCBS of TX PPO	$0.48
Rate for Payer: Cash Price	$0.81
Rate for Payer: Cigna Medicaid	$0.86
Rate for Payer: Molina CHIP/Medicaid	$0.86
Rate for Payer: Multiplan Auto	$0.77
Rate for Payer: Multiplan Commercial	$0.77
Rate for Payer: Multiplan Workers Comp	$0.77
Rate for Payer: Parkland Medicaid	$0.86
Rate for Payer: Scott and White EPO/PPO	$0.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.86
Rate for Payer: Superior Health Plan EPO	$0.16

MBO-SENSOR, ADULT, LNCS-ADTX, SPO2

Facility

$16.75

Hospital Charge Code	993941
Hospital Revenue Code	279
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$12.06
Rate for Payer: Amerigroup CHIP/Medicaid	$1.51
Rate for Payer: BCBS of TX Blue Advantage	$5.03
Rate for Payer: BCBS of TX Blue Essentials	$6.03
Rate for Payer: BCBS of TX PPO	$6.70
Rate for Payer: Cash Price	$11.39
Rate for Payer: Cigna Medicaid	$12.06
Rate for Payer: Molina CHIP/Medicaid	$12.06
Rate for Payer: Multiplan Auto	$10.89
Rate for Payer: Multiplan Commercial	$10.89
Rate for Payer: Multiplan Workers Comp	$10.89
Rate for Payer: Parkland Medicaid	$12.06
Rate for Payer: Scott and White EPO/PPO	$8.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.06
Rate for Payer: Superior Health Plan EPO	$2.28

MBO-SENSOR, ADULT, LNCS-ADTX, SPO2

Facility

$16.75

Hospital Charge Code	993941
Hospital Revenue Code	279
Rate for Payer: Cash Price	$11.39

MBO-SET, BLD COLLECTIN, SFTY-LOK, 23G X 0.75

Facility

$25.98

Hospital Charge Code	993717
Hospital Revenue Code	270
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$18.71
Rate for Payer: Amerigroup CHIP/Medicaid	$2.34
Rate for Payer: BCBS of TX Blue Advantage	$7.79
Rate for Payer: BCBS of TX Blue Essentials	$9.35
Rate for Payer: BCBS of TX PPO	$10.39
Rate for Payer: Cash Price	$17.67
Rate for Payer: Cigna Medicaid	$18.71
Rate for Payer: Molina CHIP/Medicaid	$18.71
Rate for Payer: Multiplan Auto	$16.89
Rate for Payer: Multiplan Commercial	$16.89
Rate for Payer: Multiplan Workers Comp	$16.89
Rate for Payer: Parkland Medicaid	$18.71
Rate for Payer: Scott and White EPO/PPO	$12.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.71
Rate for Payer: Superior Health Plan EPO	$3.53

MBO-SET, BLD COLLECTIN, SFTY-LOK, 23G X 0.75

Facility

$25.98

Hospital Charge Code	993717
Hospital Revenue Code	270
Rate for Payer: Cash Price	$17.67

MBO-SET, IRRIGATION, TWO-BAG, 94

Facility

$39.56

Hospital Charge Code	992969
Hospital Revenue Code	270
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$28.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3.56
Rate for Payer: BCBS of TX Blue Advantage	$11.87
Rate for Payer: BCBS of TX Blue Essentials	$14.24
Rate for Payer: BCBS of TX PPO	$15.82
Rate for Payer: Cash Price	$26.90
Rate for Payer: Cigna Medicaid	$28.48
Rate for Payer: Molina CHIP/Medicaid	$28.48
Rate for Payer: Multiplan Auto	$25.71
Rate for Payer: Multiplan Commercial	$25.71
Rate for Payer: Multiplan Workers Comp	$25.71
Rate for Payer: Parkland Medicaid	$28.48
Rate for Payer: Scott and White EPO/PPO	$19.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.48
Rate for Payer: Superior Health Plan EPO	$5.38

Know your out-of-pocket cost for care.

All Charges