White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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, 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
Rate for Payer: Cash Price	$155.50

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 DYNACLIP PROCEDURE

Facility

$1,589.00

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

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

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

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

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
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, LAPAROSCOPY/PELVISCOPY AURORA SUTURE BAG -- DHF

Facility

$730.83

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

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
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, LITHOTOMY III SIRUS -- DHF

Facility

$501.49

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

PACK MAJOR

Facility

$188.50

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

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 NEEDLE HIP ACCESS

Facility

$342.04

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

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 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
Rate for Payer: Cash Price	$36.95

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

Know your out-of-pocket cost for care.

All Charges