White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PACK, LAPAROSCOPY/PELVISCOPY AURORA SUTURE BAG -- DHF

Facility

$730.83

Hospital Charge Code	81651556
Hospital Revenue Code	272
Min. Negotiated Rate	$65.77
Max. Negotiated Rate	$526.20
Rate for Payer: Amerigroup CHIP/Medicaid	$65.77
Rate for Payer: BCBS of TX Blue Advantage	$219.25
Rate for Payer: BCBS of TX Blue Essentials	$263.10
Rate for Payer: BCBS of TX PPO	$292.33
Rate for Payer: Cash Price	$496.96
Rate for Payer: Cigna Medicaid	$526.20
Rate for Payer: Molina CHIP/Medicaid	$526.20
Rate for Payer: Multiplan Auto	$475.04
Rate for Payer: Multiplan Commercial	$475.04
Rate for Payer: Multiplan Workers Comp	$475.04
Rate for Payer: Parkland Medicaid	$526.20
Rate for Payer: Scott and White EPO/PPO	$365.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$526.20
Rate for Payer: Superior Health Plan EPO	$99.39

PACK, LITHOTOMY 1 -- DHF

Facility

$87.56

Hospital Charge Code	80836455
Hospital Revenue Code	272
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$63.04
Rate for Payer: Amerigroup CHIP/Medicaid	$7.88
Rate for Payer: BCBS of TX Blue Advantage	$26.27
Rate for Payer: BCBS of TX Blue Essentials	$31.52
Rate for Payer: BCBS of TX PPO	$35.02
Rate for Payer: Cash Price	$59.54
Rate for Payer: Cigna Medicaid	$63.04
Rate for Payer: Molina CHIP/Medicaid	$63.04
Rate for Payer: Multiplan Auto	$56.91
Rate for Payer: Multiplan Commercial	$56.91
Rate for Payer: Multiplan Workers Comp	$56.91
Rate for Payer: Parkland Medicaid	$63.04
Rate for Payer: Scott and White EPO/PPO	$43.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.04
Rate for Payer: Superior Health Plan EPO	$11.91

PACK, LITHOTOMY 1 -- DHF

Facility

$87.56

Hospital Charge Code	80836455
Hospital Revenue Code	272
Rate for Payer: Cash Price	$59.54

PACK, LITHOTOMY III SIRUS -- DHF

Facility

$501.49

Hospital Charge Code	81651309
Hospital Revenue Code	272
Rate for Payer: Cash Price	$341.01

PACK, LITHOTOMY III SIRUS -- DHF

Facility

$501.49

Hospital Charge Code	81651309
Hospital Revenue Code	272
Min. Negotiated Rate	$45.13
Max. Negotiated Rate	$361.07
Rate for Payer: Amerigroup CHIP/Medicaid	$45.13
Rate for Payer: BCBS of TX Blue Advantage	$150.45
Rate for Payer: BCBS of TX Blue Essentials	$180.54
Rate for Payer: BCBS of TX PPO	$200.60
Rate for Payer: Cash Price	$341.01
Rate for Payer: Cigna Medicaid	$361.07
Rate for Payer: Molina CHIP/Medicaid	$361.07
Rate for Payer: Multiplan Auto	$325.97
Rate for Payer: Multiplan Commercial	$325.97
Rate for Payer: Multiplan Workers Comp	$325.97
Rate for Payer: Parkland Medicaid	$361.07
Rate for Payer: Scott and White EPO/PPO	$250.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$361.07
Rate for Payer: Superior Health Plan EPO	$68.20

PACK MAJOR

Facility

$188.50

Hospital Charge Code	8514474
Hospital Revenue Code	272
Min. Negotiated Rate	$16.96
Max. Negotiated Rate	$135.72
Rate for Payer: Amerigroup CHIP/Medicaid	$16.96
Rate for Payer: BCBS of TX Blue Advantage	$56.55
Rate for Payer: BCBS of TX Blue Essentials	$67.86
Rate for Payer: BCBS of TX PPO	$75.40
Rate for Payer: Cash Price	$128.18
Rate for Payer: Cigna Medicaid	$135.72
Rate for Payer: Molina CHIP/Medicaid	$135.72
Rate for Payer: Multiplan Auto	$122.53
Rate for Payer: Multiplan Commercial	$122.53
Rate for Payer: Multiplan Workers Comp	$122.53
Rate for Payer: Parkland Medicaid	$135.72
Rate for Payer: Scott and White EPO/PPO	$94.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.72
Rate for Payer: Superior Health Plan EPO	$25.64

PACK MAJOR

Facility

$188.50

Hospital Charge Code	8514474
Hospital Revenue Code	272
Rate for Payer: Cash Price	$128.18

PACK NEEDLE HIP ACCESS

Facility

$342.04

Hospital Charge Code	8692541
Hospital Revenue Code	272
Min. Negotiated Rate	$30.78
Max. Negotiated Rate	$246.27
Rate for Payer: Amerigroup CHIP/Medicaid	$30.78
Rate for Payer: BCBS of TX Blue Advantage	$102.61
Rate for Payer: BCBS of TX Blue Essentials	$123.13
Rate for Payer: BCBS of TX PPO	$136.82
Rate for Payer: Cash Price	$232.59
Rate for Payer: Cigna Medicaid	$246.27
Rate for Payer: Molina CHIP/Medicaid	$246.27
Rate for Payer: Multiplan Auto	$222.33
Rate for Payer: Multiplan Commercial	$222.33
Rate for Payer: Multiplan Workers Comp	$222.33
Rate for Payer: Parkland Medicaid	$246.27
Rate for Payer: Scott and White EPO/PPO	$171.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$246.27
Rate for Payer: Superior Health Plan EPO	$46.52

PACK NEEDLE HIP ACCESS

Facility

$342.04

Hospital Charge Code	8692541
Hospital Revenue Code	272
Rate for Payer: Cash Price	$232.59

PACK ORTHOPEDIC IV, SIRUS

Facility

$67.24

Hospital Charge Code	8514473
Hospital Revenue Code	272
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$48.41
Rate for Payer: Amerigroup CHIP/Medicaid	$6.05
Rate for Payer: BCBS of TX Blue Advantage	$20.17
Rate for Payer: BCBS of TX Blue Essentials	$24.21
Rate for Payer: BCBS of TX PPO	$26.90
Rate for Payer: Cash Price	$45.72
Rate for Payer: Cigna Medicaid	$48.41
Rate for Payer: Molina CHIP/Medicaid	$48.41
Rate for Payer: Multiplan Auto	$43.71
Rate for Payer: Multiplan Commercial	$43.71
Rate for Payer: Multiplan Workers Comp	$43.71
Rate for Payer: Parkland Medicaid	$48.41
Rate for Payer: Scott and White EPO/PPO	$33.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$48.41
Rate for Payer: Superior Health Plan EPO	$9.14

PACK ORTHOPEDIC IV, SIRUS

Facility

$67.24

Hospital Charge Code	8514473
Hospital Revenue Code	272
Rate for Payer: Cash Price	$45.72

PACKS, LITHOTOMY PACK III, SIRUS

Facility

$54.34

Hospital Charge Code	993779
Hospital Revenue Code	272
Min. Negotiated Rate	$4.89
Max. Negotiated Rate	$39.12
Rate for Payer: Amerigroup CHIP/Medicaid	$4.89
Rate for Payer: BCBS of TX Blue Advantage	$16.30
Rate for Payer: BCBS of TX Blue Essentials	$19.56
Rate for Payer: BCBS of TX PPO	$21.74
Rate for Payer: Cash Price	$36.95
Rate for Payer: Cigna Medicaid	$39.12
Rate for Payer: Molina CHIP/Medicaid	$39.12
Rate for Payer: Multiplan Auto	$35.32
Rate for Payer: Multiplan Commercial	$35.32
Rate for Payer: Multiplan Workers Comp	$35.32
Rate for Payer: Parkland Medicaid	$39.12
Rate for Payer: Scott and White EPO/PPO	$27.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.12
Rate for Payer: Superior Health Plan EPO	$7.39

PACKS, LITHOTOMY PACK III, SIRUS

Facility

$54.34

Hospital Charge Code	993779
Hospital Revenue Code	272
Rate for Payer: Cash Price	$36.95

PACK UNIVERSAL DRAPE STERILE

Facility

$56.16

Hospital Charge Code	8692537
Hospital Revenue Code	270
Rate for Payer: Cash Price	$38.19

PACK UNIVERSAL DRAPE STERILE

Facility

$56.16

Hospital Charge Code	8692537
Hospital Revenue Code	270
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$40.44
Rate for Payer: Amerigroup CHIP/Medicaid	$5.05
Rate for Payer: BCBS of TX Blue Advantage	$16.85
Rate for Payer: BCBS of TX Blue Essentials	$20.22
Rate for Payer: BCBS of TX PPO	$22.46
Rate for Payer: Cash Price	$38.19
Rate for Payer: Cigna Medicaid	$40.44
Rate for Payer: Molina CHIP/Medicaid	$40.44
Rate for Payer: Multiplan Auto	$36.50
Rate for Payer: Multiplan Commercial	$36.50
Rate for Payer: Multiplan Workers Comp	$36.50
Rate for Payer: Parkland Medicaid	$40.44
Rate for Payer: Scott and White EPO/PPO	$28.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.44
Rate for Payer: Superior Health Plan EPO	$7.64

PAD, ABDOMINAL, 5'X9, STERILE, LF, 1/PK

Facility

$0.56

Hospital Charge Code	992868
Hospital Revenue Code	272
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.40
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.17
Rate for Payer: BCBS of TX Blue Essentials	$0.20
Rate for Payer: BCBS of TX PPO	$0.22
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna Medicaid	$0.40
Rate for Payer: Molina CHIP/Medicaid	$0.40
Rate for Payer: Multiplan Auto	$0.36
Rate for Payer: Multiplan Commercial	$0.36
Rate for Payer: Multiplan Workers Comp	$0.36
Rate for Payer: Parkland Medicaid	$0.40
Rate for Payer: Scott and White EPO/PPO	$0.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.40
Rate for Payer: Superior Health Plan EPO	$0.08

PAD, ABDOMINAL, 5'X9, STERILE, LF, 1/PK

Facility

$0.56

Hospital Charge Code	992868
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.38

pad boot insert

Facility

$935.24

Hospital Charge Code	102867
Hospital Revenue Code	270
Min. Negotiated Rate	$84.17
Max. Negotiated Rate	$673.37
Rate for Payer: Amerigroup CHIP/Medicaid	$84.17
Rate for Payer: BCBS of TX Blue Advantage	$280.57
Rate for Payer: BCBS of TX Blue Essentials	$336.69
Rate for Payer: BCBS of TX PPO	$374.10
Rate for Payer: Cash Price	$635.96
Rate for Payer: Cigna Medicaid	$673.37
Rate for Payer: Molina CHIP/Medicaid	$673.37
Rate for Payer: Multiplan Auto	$607.91
Rate for Payer: Multiplan Commercial	$607.91
Rate for Payer: Multiplan Workers Comp	$607.91
Rate for Payer: Parkland Medicaid	$673.37
Rate for Payer: Scott and White EPO/PPO	$467.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$673.37
Rate for Payer: Superior Health Plan EPO	$127.19

pad boot insert

Facility

$935.24

Hospital Charge Code	102867
Hospital Revenue Code	270
Rate for Payer: Cash Price	$635.96

PAD DEFIB, RADIOLUCENT, ZOLL COMPTBL, ADLT/CHLD 10KG

Facility

$180.77

Hospital Charge Code	993042
Hospital Revenue Code	270
Min. Negotiated Rate	$16.27
Max. Negotiated Rate	$130.15
Rate for Payer: Amerigroup CHIP/Medicaid	$16.27
Rate for Payer: BCBS of TX Blue Advantage	$54.23
Rate for Payer: BCBS of TX Blue Essentials	$65.08
Rate for Payer: BCBS of TX PPO	$72.31
Rate for Payer: Cash Price	$122.92
Rate for Payer: Cigna Medicaid	$130.15
Rate for Payer: Molina CHIP/Medicaid	$130.15
Rate for Payer: Multiplan Auto	$117.50
Rate for Payer: Multiplan Commercial	$117.50
Rate for Payer: Multiplan Workers Comp	$117.50
Rate for Payer: Parkland Medicaid	$130.15
Rate for Payer: Scott and White EPO/PPO	$90.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$130.15
Rate for Payer: Superior Health Plan EPO	$24.58

PAD DEFIB, RADIOLUCENT, ZOLL COMPTBL, ADLT/CHLD 10KG

Facility

$180.77

Hospital Charge Code	993042
Hospital Revenue Code	270
Rate for Payer: Cash Price	$122.92

PADDING, CAST, 4', 12/BG

Facility

$3.33

Hospital Charge Code	992835
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2.26

PADDING, CAST, 4', 12/BG

Facility

$3.33

Hospital Charge Code	992835
Hospital Revenue Code	272
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$2.40
Rate for Payer: Amerigroup CHIP/Medicaid	$0.30
Rate for Payer: BCBS of TX Blue Advantage	$1.00
Rate for Payer: BCBS of TX Blue Essentials	$1.20
Rate for Payer: BCBS of TX PPO	$1.33
Rate for Payer: Cash Price	$2.26
Rate for Payer: Cigna Medicaid	$2.40
Rate for Payer: Molina CHIP/Medicaid	$2.40
Rate for Payer: Multiplan Auto	$2.16
Rate for Payer: Multiplan Commercial	$2.16
Rate for Payer: Multiplan Workers Comp	$2.16
Rate for Payer: Parkland Medicaid	$2.40
Rate for Payer: Scott and White EPO/PPO	$1.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.40
Rate for Payer: Superior Health Plan EPO	$0.45

PADDING, CAST, 6'

Facility

$4.63

Hospital Charge Code	992836
Hospital Revenue Code	272
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$3.33
Rate for Payer: Amerigroup CHIP/Medicaid	$0.42
Rate for Payer: BCBS of TX Blue Advantage	$1.39
Rate for Payer: BCBS of TX Blue Essentials	$1.67
Rate for Payer: BCBS of TX PPO	$1.85
Rate for Payer: Cash Price	$3.15
Rate for Payer: Cigna Medicaid	$3.33
Rate for Payer: Molina CHIP/Medicaid	$3.33
Rate for Payer: Multiplan Auto	$3.01
Rate for Payer: Multiplan Commercial	$3.01
Rate for Payer: Multiplan Workers Comp	$3.01
Rate for Payer: Parkland Medicaid	$3.33
Rate for Payer: Scott and White EPO/PPO	$2.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.33
Rate for Payer: Superior Health Plan EPO	$0.63

PADDING, CAST, 6'

Facility

$4.63

Hospital Charge Code	992836
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.15

Know your out-of-pocket cost for care.

All Charges