White Rock Medical Center

All Charges

Charge

Type

Setting

Price

system autoplex w/o needles

Facility

$2,725.69

Hospital Charge Code	8602522
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,398.61

SYSTEM BONE GRAFTING KIT W/3CC AGILON

Facility

$12,650.60

Service Code	HCPCS C1713
Hospital Charge Code	145509
Hospital Revenue Code	278
Min. Negotiated Rate	$1,138.55
Max. Negotiated Rate	$6,325.30
Rate for Payer: Aetna Commercial	$3,795.18
Rate for Payer: Amerigroup CHIP/Medicaid	$1,138.55
Rate for Payer: BCBS of TX Blue Advantage	$3,795.18
Rate for Payer: BCBS of TX Blue Essentials	$4,554.22
Rate for Payer: BCBS of TX PPO	$5,060.24
Rate for Payer: Cash Price	$11,132.53
Rate for Payer: Multiplan Auto	$6,325.30
Rate for Payer: Multiplan Commercial	$6,325.30
Rate for Payer: Multiplan Workers Comp	$6,325.30
Rate for Payer: Scott and White EPO/PPO	$6,325.30
Rate for Payer: Superior Health Plan EPO	$1,720.48

SYSTEM BONE GRAFTING KIT W/3CC AGILON

Facility

$12,650.60

Service Code	HCPCS C1713
Hospital Charge Code	145509
Hospital Revenue Code	278
Min. Negotiated Rate	$3,162.65
Max. Negotiated Rate	$6,325.30
Rate for Payer: Aetna Commercial	$3,795.18
Rate for Payer: Cash Price	$11,132.53
Rate for Payer: Cigna Commercial	$3,162.65
Rate for Payer: Multiplan Auto	$6,325.30
Rate for Payer: Multiplan Commercial	$6,325.30
Rate for Payer: Multiplan Workers Comp	$6,325.30
Rate for Payer: Scott and White EPO/PPO	$6,325.30

SYSTEM CALIBRATION VISIGI 3D W/BLB 32FR

Facility

$966.11

Hospital Charge Code	8598513
Hospital Revenue Code	272
Rate for Payer: Cash Price	$850.18

SYSTEM CALIBRATION VISIGI 3D W/BLB 32FR

Facility

$966.11

Hospital Charge Code	8598513
Hospital Revenue Code	272
Min. Negotiated Rate	$86.95
Max. Negotiated Rate	$627.97
Rate for Payer: Aetna Commercial	$531.36
Rate for Payer: Amerigroup CHIP/Medicaid	$86.95
Rate for Payer: BCBS of TX Blue Advantage	$289.83
Rate for Payer: BCBS of TX Blue Essentials	$347.80
Rate for Payer: BCBS of TX PPO	$386.44
Rate for Payer: Cash Price	$850.18
Rate for Payer: Multiplan Auto	$627.97
Rate for Payer: Multiplan Commercial	$627.97
Rate for Payer: Multiplan Workers Comp	$627.97
Rate for Payer: Scott and White EPO/PPO	$483.06
Rate for Payer: Superior Health Plan EPO	$131.39

SYSTEM CALIBRATION VISIGI 3D W/BLB 40FR

Facility

$1,033.30

Hospital Charge Code	8598511
Hospital Revenue Code	272
Min. Negotiated Rate	$93.00
Max. Negotiated Rate	$671.64
Rate for Payer: Aetna Commercial	$568.32
Rate for Payer: Amerigroup CHIP/Medicaid	$93.00
Rate for Payer: BCBS of TX Blue Advantage	$309.99
Rate for Payer: BCBS of TX Blue Essentials	$371.99
Rate for Payer: BCBS of TX PPO	$413.32
Rate for Payer: Cash Price	$909.30
Rate for Payer: Multiplan Auto	$671.64
Rate for Payer: Multiplan Commercial	$671.64
Rate for Payer: Multiplan Workers Comp	$671.64
Rate for Payer: Scott and White EPO/PPO	$516.65
Rate for Payer: Superior Health Plan EPO	$140.53

SYSTEM CALIBRATION VISIGI 3D W/BLB 40FR

Facility

$1,033.30

Hospital Charge Code	8598511
Hospital Revenue Code	272
Rate for Payer: Cash Price	$909.30

System calibration visigi 3d with bulb 36fr

Facility

$227.60

Hospital Charge Code	8602529
Hospital Revenue Code	272
Rate for Payer: Cash Price	$200.29

System calibration visigi 3d with bulb 36fr

Facility

$227.60

Hospital Charge Code	8602529
Hospital Revenue Code	272
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$147.94
Rate for Payer: Aetna Commercial	$125.18
Rate for Payer: Amerigroup CHIP/Medicaid	$20.48
Rate for Payer: BCBS of TX Blue Advantage	$68.28
Rate for Payer: BCBS of TX Blue Essentials	$81.94
Rate for Payer: BCBS of TX PPO	$91.04
Rate for Payer: Cash Price	$200.29
Rate for Payer: Multiplan Auto	$147.94
Rate for Payer: Multiplan Commercial	$147.94
Rate for Payer: Multiplan Workers Comp	$147.94
Rate for Payer: Scott and White EPO/PPO	$113.80
Rate for Payer: Superior Health Plan EPO	$30.95

SYSTEM CEMENT MIXING VC-1051

Facility

$1,952.20

Hospital Charge Code	144866
Hospital Revenue Code	272
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$1,268.93
Rate for Payer: Aetna Commercial	$1,073.71
Rate for Payer: Amerigroup CHIP/Medicaid	$175.70
Rate for Payer: BCBS of TX Blue Advantage	$585.66
Rate for Payer: BCBS of TX Blue Essentials	$702.79
Rate for Payer: BCBS of TX PPO	$780.88
Rate for Payer: Cash Price	$1,717.94
Rate for Payer: Multiplan Auto	$1,268.93
Rate for Payer: Multiplan Commercial	$1,268.93
Rate for Payer: Multiplan Workers Comp	$1,268.93
Rate for Payer: Scott and White EPO/PPO	$976.10
Rate for Payer: Superior Health Plan EPO	$265.50

SYSTEM CEMENT MIXING VC-1051

Facility

$1,952.20

Hospital Charge Code	144866
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,717.94

SYSTEM FILTER SPIDER EMBL

Facility

$4,317.54

Hospital Charge Code	8470493
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,799.44

SYSTEM FILTER SPIDER EMBL

Facility

$4,317.54

Hospital Charge Code	8470493
Hospital Revenue Code	272
Min. Negotiated Rate	$388.58
Max. Negotiated Rate	$2,806.40
Rate for Payer: Aetna Commercial	$2,374.65
Rate for Payer: Amerigroup CHIP/Medicaid	$388.58
Rate for Payer: BCBS of TX Blue Advantage	$1,295.26
Rate for Payer: BCBS of TX Blue Essentials	$1,554.31
Rate for Payer: BCBS of TX PPO	$1,727.02
Rate for Payer: Cash Price	$3,799.44
Rate for Payer: Multiplan Auto	$2,806.40
Rate for Payer: Multiplan Commercial	$2,806.40
Rate for Payer: Multiplan Workers Comp	$2,806.40
Rate for Payer: Scott and White EPO/PPO	$2,158.77
Rate for Payer: Superior Health Plan EPO	$587.19

SYSTEM GEL PORT LAPAROSCOPIC C8XX2

Facility

$2,951.00

Hospital Charge Code	8556478
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,596.88

SYSTEM GEL PORT LAPAROSCOPIC C8XX2

Facility

$2,951.00

Hospital Charge Code	8556478
Hospital Revenue Code	272
Min. Negotiated Rate	$265.59
Max. Negotiated Rate	$1,918.15
Rate for Payer: Aetna Commercial	$1,623.05
Rate for Payer: Amerigroup CHIP/Medicaid	$265.59
Rate for Payer: BCBS of TX Blue Advantage	$885.30
Rate for Payer: BCBS of TX Blue Essentials	$1,062.36
Rate for Payer: BCBS of TX PPO	$1,180.40
Rate for Payer: Cash Price	$2,596.88
Rate for Payer: Multiplan Auto	$1,918.15
Rate for Payer: Multiplan Commercial	$1,918.15
Rate for Payer: Multiplan Workers Comp	$1,918.15
Rate for Payer: Scott and White EPO/PPO	$1,475.50
Rate for Payer: Superior Health Plan EPO	$401.34

system indigo sep7

Facility

$7,513.70

Hospital Charge Code	8666514
Hospital Revenue Code	272
Min. Negotiated Rate	$676.23
Max. Negotiated Rate	$4,883.90
Rate for Payer: Aetna Commercial	$4,132.54
Rate for Payer: Amerigroup CHIP/Medicaid	$676.23
Rate for Payer: BCBS of TX Blue Advantage	$2,254.11
Rate for Payer: BCBS of TX Blue Essentials	$2,704.93
Rate for Payer: BCBS of TX PPO	$3,005.48
Rate for Payer: Cash Price	$6,612.06
Rate for Payer: Multiplan Auto	$4,883.90
Rate for Payer: Multiplan Commercial	$4,883.90
Rate for Payer: Multiplan Workers Comp	$4,883.90
Rate for Payer: Scott and White EPO/PPO	$3,756.85
Rate for Payer: Superior Health Plan EPO	$1,021.86

system indigo sep7

Facility

$7,513.70

Hospital Charge Code	8666514
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6,612.06

SYSTEM IVC RETRIEVABLE KIT G13287

Facility

$1,384.70

Hospital Charge Code	109371
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,218.54

SYSTEM IVC RETRIEVABLE KIT G13287

Facility

$1,384.70

Hospital Charge Code	109371
Hospital Revenue Code	272
Min. Negotiated Rate	$124.62
Max. Negotiated Rate	$900.06
Rate for Payer: Aetna Commercial	$761.58
Rate for Payer: Amerigroup CHIP/Medicaid	$124.62
Rate for Payer: BCBS of TX Blue Advantage	$415.41
Rate for Payer: BCBS of TX Blue Essentials	$498.49
Rate for Payer: BCBS of TX PPO	$553.88
Rate for Payer: Cash Price	$1,218.54
Rate for Payer: Multiplan Auto	$900.06
Rate for Payer: Multiplan Commercial	$900.06
Rate for Payer: Multiplan Workers Comp	$900.06
Rate for Payer: Scott and White EPO/PPO	$692.35
Rate for Payer: Superior Health Plan EPO	$188.32

SYSTEM, POSITIONING PINK PAD W/ARM PROTCT 29X20X1 -- DHF

Facility

$404.06

Hospital Charge Code	80824055
Hospital Revenue Code	270
Rate for Payer: Cash Price	$355.57

SYSTEM, POSITIONING PINK PAD W/ARM PROTCT 29X20X1 -- DHF

Facility

$404.06

Hospital Charge Code	80824055
Hospital Revenue Code	270
Min. Negotiated Rate	$36.37
Max. Negotiated Rate	$262.64
Rate for Payer: Aetna Commercial	$222.23
Rate for Payer: Amerigroup CHIP/Medicaid	$36.37
Rate for Payer: BCBS of TX Blue Advantage	$121.22
Rate for Payer: BCBS of TX Blue Essentials	$145.46
Rate for Payer: BCBS of TX PPO	$161.62
Rate for Payer: Cash Price	$355.57
Rate for Payer: Multiplan Auto	$262.64
Rate for Payer: Multiplan Commercial	$262.64
Rate for Payer: Multiplan Workers Comp	$262.64
Rate for Payer: Scott and White EPO/PPO	$202.03
Rate for Payer: Superior Health Plan EPO	$54.95

SYSTEM, RETRIEVAL SPECIMEN ENDO 10MM DISP -- DHF

Facility

$363.94

Hospital Charge Code	81744203
Hospital Revenue Code	272
Rate for Payer: Cash Price	$320.27

SYSTEM, RETRIEVAL SPECIMEN ENDO 10MM DISP -- DHF

Facility

$363.94

Hospital Charge Code	81744203
Hospital Revenue Code	272
Min. Negotiated Rate	$32.75
Max. Negotiated Rate	$236.56
Rate for Payer: Aetna Commercial	$200.17
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
Rate for Payer: BCBS of TX Blue Advantage	$109.18
Rate for Payer: BCBS of TX Blue Essentials	$131.02
Rate for Payer: BCBS of TX PPO	$145.58
Rate for Payer: Cash Price	$320.27
Rate for Payer: Multiplan Auto	$236.56
Rate for Payer: Multiplan Commercial	$236.56
Rate for Payer: Multiplan Workers Comp	$236.56
Rate for Payer: Scott and White EPO/PPO	$181.97
Rate for Payer: Superior Health Plan EPO	$49.50

SYSTEM, RETRIEVAL UNIVERSAL INZI 5MM--DHF

Facility

$340.50

Hospital Charge Code	80816978
Hospital Revenue Code	272
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$221.32
Rate for Payer: Aetna Commercial	$187.28
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	$299.64
Rate for Payer: Multiplan Auto	$221.32
Rate for Payer: Multiplan Commercial	$221.32
Rate for Payer: Multiplan Workers Comp	$221.32
Rate for Payer: Scott and White EPO/PPO	$170.25
Rate for Payer: Superior Health Plan EPO	$46.31

SYSTEM, RETRIEVAL UNIVERSAL INZI 5MM--DHF

Facility

$340.50

Hospital Charge Code	80816978
Hospital Revenue Code	272
Rate for Payer: Cash Price	$299.64

Know your out-of-pocket cost for care.

All Charges