White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PACKAGED 6.0MM STEP DRILL BIT, ANKLE SALVAGE

Facility

$1,983.98

Hospital Charge Code	993899
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,349.11

PACKAGED 6.0MM STEP DRILL BIT, ANKLE SALVAGE

Facility

$1,983.98

Hospital Charge Code	993899
Hospital Revenue Code	272
Min. Negotiated Rate	$178.56
Max. Negotiated Rate	$1,428.47
Rate for Payer: Amerigroup CHIP/Medicaid	$178.56
Rate for Payer: BCBS of TX Blue Advantage	$595.19
Rate for Payer: BCBS of TX Blue Essentials	$714.23
Rate for Payer: BCBS of TX PPO	$793.59
Rate for Payer: Cash Price	$1,349.11
Rate for Payer: Cigna Medicaid	$1,428.47
Rate for Payer: Molina CHIP/Medicaid	$1,428.47
Rate for Payer: Multiplan Auto	$1,289.59
Rate for Payer: Multiplan Commercial	$1,289.59
Rate for Payer: Multiplan Workers Comp	$1,289.59
Rate for Payer: Parkland Medicaid	$1,428.47
Rate for Payer: Scott and White EPO/PPO	$991.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,428.47
Rate for Payer: Superior Health Plan EPO	$269.82

PACKAGED STARTER DRILL BIT, ANKLE SALVAGE INSTR

Facility

$1,552.68

Hospital Charge Code	993896
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,055.82

PACKAGED STARTER DRILL BIT, ANKLE SALVAGE INSTR

Facility

$1,552.68

Hospital Charge Code	993896
Hospital Revenue Code	272
Min. Negotiated Rate	$139.74
Max. Negotiated Rate	$1,117.93
Rate for Payer: Amerigroup CHIP/Medicaid	$139.74
Rate for Payer: BCBS of TX Blue Advantage	$465.80
Rate for Payer: BCBS of TX Blue Essentials	$558.96
Rate for Payer: BCBS of TX PPO	$621.07
Rate for Payer: Cash Price	$1,055.82
Rate for Payer: Cigna Medicaid	$1,117.93
Rate for Payer: Molina CHIP/Medicaid	$1,117.93
Rate for Payer: Multiplan Auto	$1,009.24
Rate for Payer: Multiplan Commercial	$1,009.24
Rate for Payer: Multiplan Workers Comp	$1,009.24
Rate for Payer: Parkland Medicaid	$1,117.93
Rate for Payer: Scott and White EPO/PPO	$776.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,117.93
Rate for Payer: Superior Health Plan EPO	$211.16

Package Kit, Drills, Plate, Coticol Screws, Locking Screws-Stryker

Facility

$37,927.71

Service Code	HCPCS C1734
Hospital Charge Code	994144
Hospital Revenue Code	278
Min. Negotiated Rate	$3,413.49
Max. Negotiated Rate	$27,307.95
Rate for Payer: Amerigroup CHIP/Medicaid	$3,413.49
Rate for Payer: BCBS of TX Blue Advantage	$11,378.31
Rate for Payer: BCBS of TX Blue Essentials	$13,653.98
Rate for Payer: BCBS of TX PPO	$15,171.08
Rate for Payer: Cash Price	$25,790.84
Rate for Payer: Cigna Medicaid	$27,307.95
Rate for Payer: Molina CHIP/Medicaid	$27,307.95
Rate for Payer: Multiplan Auto	$18,963.85
Rate for Payer: Multiplan Commercial	$18,963.85
Rate for Payer: Multiplan Workers Comp	$18,963.85
Rate for Payer: Parkland Medicaid	$27,307.95
Rate for Payer: Scott and White EPO/PPO	$18,963.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,307.95
Rate for Payer: Superior Health Plan EPO	$5,158.17

Package Kit, Drills, Plate, Coticol Screws, Locking Screws-Stryker

Facility

$50,269.15

Service Code	HCPCS C1734
Hospital Charge Code	991202
Hospital Revenue Code	278
Min. Negotiated Rate	$12,567.29
Max. Negotiated Rate	$25,134.58
Rate for Payer: Cash Price	$34,183.02
Rate for Payer: Cigna Commercial	$12,567.29
Rate for Payer: Multiplan Auto	$25,134.58
Rate for Payer: Multiplan Commercial	$25,134.58
Rate for Payer: Multiplan Workers Comp	$25,134.58
Rate for Payer: Scott and White EPO/PPO	$25,134.58

Package Kit, Drills, Plate, Coticol Screws, Locking Screws-Stryker

Facility

$50,269.15

Service Code	HCPCS C1734
Hospital Charge Code	991202
Hospital Revenue Code	278
Min. Negotiated Rate	$4,524.22
Max. Negotiated Rate	$36,193.79
Rate for Payer: Amerigroup CHIP/Medicaid	$4,524.22
Rate for Payer: BCBS of TX Blue Advantage	$15,080.75
Rate for Payer: BCBS of TX Blue Essentials	$18,096.89
Rate for Payer: BCBS of TX PPO	$20,107.66
Rate for Payer: Cash Price	$34,183.02
Rate for Payer: Cigna Medicaid	$36,193.79
Rate for Payer: Molina CHIP/Medicaid	$36,193.79
Rate for Payer: Multiplan Auto	$25,134.58
Rate for Payer: Multiplan Commercial	$25,134.58
Rate for Payer: Multiplan Workers Comp	$25,134.58
Rate for Payer: Parkland Medicaid	$36,193.79
Rate for Payer: Scott and White EPO/PPO	$25,134.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36,193.79
Rate for Payer: Superior Health Plan EPO	$6,836.60

Package Kit, Drills, Plate, Coticol Screws, Locking Screws-Stryker

Facility

$37,927.71

Service Code	HCPCS C1734
Hospital Charge Code	994144
Hospital Revenue Code	278
Min. Negotiated Rate	$9,481.93
Max. Negotiated Rate	$18,963.85
Rate for Payer: Cash Price	$25,790.84
Rate for Payer: Cigna Commercial	$9,481.93
Rate for Payer: Multiplan Auto	$18,963.85
Rate for Payer: Multiplan Commercial	$18,963.85
Rate for Payer: Multiplan Workers Comp	$18,963.85
Rate for Payer: Scott and White EPO/PPO	$18,963.85

PACK, ARTHROSCOPY I DRAPES,GOWNS,TOWELS 90'X121 -- DHF

Facility

$127.21

Hospital Charge Code	81650152
Hospital Revenue Code	272
Min. Negotiated Rate	$11.45
Max. Negotiated Rate	$91.59
Rate for Payer: Amerigroup CHIP/Medicaid	$11.45
Rate for Payer: BCBS of TX Blue Advantage	$38.16
Rate for Payer: BCBS of TX Blue Essentials	$45.80
Rate for Payer: BCBS of TX PPO	$50.88
Rate for Payer: Cash Price	$86.50
Rate for Payer: Cigna Medicaid	$91.59
Rate for Payer: Molina CHIP/Medicaid	$91.59
Rate for Payer: Multiplan Auto	$82.69
Rate for Payer: Multiplan Commercial	$82.69
Rate for Payer: Multiplan Workers Comp	$82.69
Rate for Payer: Parkland Medicaid	$91.59
Rate for Payer: Scott and White EPO/PPO	$63.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.59
Rate for Payer: Superior Health Plan EPO	$17.30

PACK, ARTHROSCOPY I DRAPES,GOWNS,TOWELS 90'X121 -- DHF

Facility

$127.21

Hospital Charge Code	81650152
Hospital Revenue Code	272
Rate for Payer: Cash Price	$86.50

PACK, ARTHROSCOPY I, SIRUS, 6/CS

Facility

$119.92

Hospital Charge Code	993066
Hospital Revenue Code	272
Min. Negotiated Rate	$10.79
Max. Negotiated Rate	$86.34
Rate for Payer: Amerigroup CHIP/Medicaid	$10.79
Rate for Payer: BCBS of TX Blue Advantage	$35.98
Rate for Payer: BCBS of TX Blue Essentials	$43.17
Rate for Payer: BCBS of TX PPO	$47.97
Rate for Payer: Cash Price	$81.55
Rate for Payer: Cigna Medicaid	$86.34
Rate for Payer: Molina CHIP/Medicaid	$86.34
Rate for Payer: Multiplan Auto	$77.95
Rate for Payer: Multiplan Commercial	$77.95
Rate for Payer: Multiplan Workers Comp	$77.95
Rate for Payer: Parkland Medicaid	$86.34
Rate for Payer: Scott and White EPO/PPO	$59.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.34
Rate for Payer: Superior Health Plan EPO	$16.31

PACK, ARTHROSCOPY I, SIRUS, 6/CS

Facility

$119.92

Hospital Charge Code	993066
Hospital Revenue Code	272
Rate for Payer: Cash Price	$81.55

PACK, BOWIE DICK TYPE TEST, LEAD FREE

Facility

$14.17

Hospital Charge Code	992970
Hospital Revenue Code	270
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$10.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1.28
Rate for Payer: BCBS of TX Blue Advantage	$4.25
Rate for Payer: BCBS of TX Blue Essentials	$5.10
Rate for Payer: BCBS of TX PPO	$5.67
Rate for Payer: Cash Price	$9.64
Rate for Payer: Cigna Medicaid	$10.20
Rate for Payer: Molina CHIP/Medicaid	$10.20
Rate for Payer: Multiplan Auto	$9.21
Rate for Payer: Multiplan Commercial	$9.21
Rate for Payer: Multiplan Workers Comp	$9.21
Rate for Payer: Parkland Medicaid	$10.20
Rate for Payer: Scott and White EPO/PPO	$7.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.20
Rate for Payer: Superior Health Plan EPO	$1.93

PACK, BOWIE DICK TYPE TEST, LEAD FREE

Facility

$14.17

Hospital Charge Code	992970
Hospital Revenue Code	270
Rate for Payer: Cash Price	$9.64

PACK, CHLLNGE, BI, ATTST, SUP RAP5, 24MIN

Facility

$36.92

Hospital Charge Code	992922
Hospital Revenue Code	272
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$26.58
Rate for Payer: Amerigroup CHIP/Medicaid	$3.32
Rate for Payer: BCBS of TX Blue Advantage	$11.08
Rate for Payer: BCBS of TX Blue Essentials	$13.29
Rate for Payer: BCBS of TX PPO	$14.77
Rate for Payer: Cash Price	$25.11
Rate for Payer: Cigna Medicaid	$26.58
Rate for Payer: Molina CHIP/Medicaid	$26.58
Rate for Payer: Multiplan Auto	$24.00
Rate for Payer: Multiplan Commercial	$24.00
Rate for Payer: Multiplan Workers Comp	$24.00
Rate for Payer: Parkland Medicaid	$26.58
Rate for Payer: Scott and White EPO/PPO	$18.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.58
Rate for Payer: Superior Health Plan EPO	$5.02

PACK, CHLLNGE, BI, ATTST, SUP RAP5, 24MIN

Facility

$36.92

Hospital Charge Code	992922
Hospital Revenue Code	272
Rate for Payer: Cash Price	$25.11

PACK CUSTOM CARDIAC CATH DOCTORS HOSP AT WHITE RO

Facility

$228.68

Hospital Charge Code	131567
Hospital Revenue Code	272
Min. Negotiated Rate	$20.58
Max. Negotiated Rate	$164.65
Rate for Payer: Amerigroup CHIP/Medicaid	$20.58
Rate for Payer: BCBS of TX Blue Advantage	$68.60
Rate for Payer: BCBS of TX Blue Essentials	$82.32
Rate for Payer: BCBS of TX PPO	$91.47
Rate for Payer: Cash Price	$155.50
Rate for Payer: Cigna Medicaid	$164.65
Rate for Payer: Molina CHIP/Medicaid	$164.65
Rate for Payer: Multiplan Auto	$148.64
Rate for Payer: Multiplan Commercial	$148.64
Rate for Payer: Multiplan Workers Comp	$148.64
Rate for Payer: Parkland Medicaid	$164.65
Rate for Payer: Scott and White EPO/PPO	$114.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$164.65
Rate for Payer: Superior Health Plan EPO	$31.10

PACK CUSTOM CARDIAC CATH DOCTORS HOSP AT WHITE RO

Facility

$228.68

Hospital Charge Code	131567
Hospital Revenue Code	272
Rate for Payer: Cash Price	$155.50

PACK DYNACLIP PROCEDURE

Facility

$1,589.00

Hospital Charge Code	145501
Hospital Revenue Code	272
Min. Negotiated Rate	$143.01
Max. Negotiated Rate	$1,144.08
Rate for Payer: Amerigroup CHIP/Medicaid	$143.01
Rate for Payer: BCBS of TX Blue Advantage	$476.70
Rate for Payer: BCBS of TX Blue Essentials	$572.04
Rate for Payer: BCBS of TX PPO	$635.60
Rate for Payer: Cash Price	$1,080.52
Rate for Payer: Cigna Medicaid	$1,144.08
Rate for Payer: Molina CHIP/Medicaid	$1,144.08
Rate for Payer: Multiplan Auto	$1,032.85
Rate for Payer: Multiplan Commercial	$1,032.85
Rate for Payer: Multiplan Workers Comp	$1,032.85
Rate for Payer: Parkland Medicaid	$1,144.08
Rate for Payer: Scott and White EPO/PPO	$794.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,144.08
Rate for Payer: Superior Health Plan EPO	$216.10

PACK DYNACLIP PROCEDURE

Facility

$1,589.00

Hospital Charge Code	145501
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,080.52

PACKING 5.5CM NSL GEL RP RHN RR551

Facility

$23.25

Hospital Charge Code	993983
Hospital Revenue Code	270
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$16.74
Rate for Payer: Amerigroup CHIP/Medicaid	$2.09
Rate for Payer: BCBS of TX Blue Advantage	$6.97
Rate for Payer: BCBS of TX Blue Essentials	$8.37
Rate for Payer: BCBS of TX PPO	$9.30
Rate for Payer: Cash Price	$15.81
Rate for Payer: Cigna Medicaid	$16.74
Rate for Payer: Molina CHIP/Medicaid	$16.74
Rate for Payer: Multiplan Auto	$15.11
Rate for Payer: Multiplan Commercial	$15.11
Rate for Payer: Multiplan Workers Comp	$15.11
Rate for Payer: Parkland Medicaid	$16.74
Rate for Payer: Scott and White EPO/PPO	$11.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.74
Rate for Payer: Superior Health Plan EPO	$3.16

PACKING 5.5CM NSL GEL RP RHN RR551

Facility

$23.25

Hospital Charge Code	993983
Hospital Revenue Code	270
Rate for Payer: Cash Price	$15.81

PACK INSERTION SONOBLATE

Facility

$8,626.00

Hospital Charge Code	146571
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,865.68

PACK INSERTION SONOBLATE

Facility

$8,626.00

Hospital Charge Code	146571
Hospital Revenue Code	272
Min. Negotiated Rate	$776.34
Max. Negotiated Rate	$6,210.72
Rate for Payer: Amerigroup CHIP/Medicaid	$776.34
Rate for Payer: BCBS of TX Blue Advantage	$2,587.80
Rate for Payer: BCBS of TX Blue Essentials	$3,105.36
Rate for Payer: BCBS of TX PPO	$3,450.40
Rate for Payer: Cash Price	$5,865.68
Rate for Payer: Cigna Medicaid	$6,210.72
Rate for Payer: Molina CHIP/Medicaid	$6,210.72
Rate for Payer: Multiplan Auto	$5,606.90
Rate for Payer: Multiplan Commercial	$5,606.90
Rate for Payer: Multiplan Workers Comp	$5,606.90
Rate for Payer: Parkland Medicaid	$6,210.72
Rate for Payer: Scott and White EPO/PPO	$4,313.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,210.72
Rate for Payer: Superior Health Plan EPO	$1,173.14

PACK, LAPAROSCOPY/PELVISCOPY AURORA SUTURE BAG -- DHF

Facility

$730.83

Hospital Charge Code	81651556
Hospital Revenue Code	272
Rate for Payer: Cash Price	$496.96

Know your out-of-pocket cost for care.

All Charges