White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PIN CERVICAL DISTRACTION 12MM

Facility

$126.00

Service Code	HCPCS C1713
Hospital Charge Code	8504482
Hospital Revenue Code	278
Min. Negotiated Rate	$11.34
Max. Negotiated Rate	$90.72
Rate for Payer: Amerigroup CHIP/Medicaid	$11.34
Rate for Payer: BCBS of TX Blue Advantage	$37.80
Rate for Payer: BCBS of TX Blue Essentials	$45.36
Rate for Payer: BCBS of TX PPO	$50.40
Rate for Payer: Cash Price	$85.68
Rate for Payer: Cigna Medicaid	$90.72
Rate for Payer: Molina CHIP/Medicaid	$90.72
Rate for Payer: Multiplan Auto	$63.00
Rate for Payer: Multiplan Commercial	$63.00
Rate for Payer: Multiplan Workers Comp	$63.00
Rate for Payer: Parkland Medicaid	$90.72
Rate for Payer: Scott and White EPO/PPO	$63.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.72
Rate for Payer: Superior Health Plan EPO	$17.14

PIN CERVICAL DISTRACTION 14MM

Facility

$126.00

Service Code	HCPCS C1713
Hospital Charge Code	8504486
Hospital Revenue Code	278
Min. Negotiated Rate	$11.34
Max. Negotiated Rate	$90.72
Rate for Payer: Amerigroup CHIP/Medicaid	$11.34
Rate for Payer: BCBS of TX Blue Advantage	$37.80
Rate for Payer: BCBS of TX Blue Essentials	$45.36
Rate for Payer: BCBS of TX PPO	$50.40
Rate for Payer: Cash Price	$85.68
Rate for Payer: Cigna Medicaid	$90.72
Rate for Payer: Molina CHIP/Medicaid	$90.72
Rate for Payer: Multiplan Auto	$63.00
Rate for Payer: Multiplan Commercial	$63.00
Rate for Payer: Multiplan Workers Comp	$63.00
Rate for Payer: Parkland Medicaid	$90.72
Rate for Payer: Scott and White EPO/PPO	$63.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.72
Rate for Payer: Superior Health Plan EPO	$17.14

PIN CERVICAL DISTRACTION 14MM

Facility

$126.00

Service Code	HCPCS C1713
Hospital Charge Code	8504486
Hospital Revenue Code	278
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$63.00
Rate for Payer: Cash Price	$85.68
Rate for Payer: Cigna Commercial	$31.50
Rate for Payer: Multiplan Auto	$63.00
Rate for Payer: Multiplan Commercial	$63.00
Rate for Payer: Multiplan Workers Comp	$63.00
Rate for Payer: Scott and White EPO/PPO	$63.00

PIN FIX 1.4MM TEMP SM

Facility

$581.00

Service Code	HCPCS C1713
Hospital Charge Code	126426
Hospital Revenue Code	278
Min. Negotiated Rate	$145.25
Max. Negotiated Rate	$290.50
Rate for Payer: Cash Price	$395.08
Rate for Payer: Cigna Commercial	$145.25
Rate for Payer: Multiplan Auto	$290.50
Rate for Payer: Multiplan Commercial	$290.50
Rate for Payer: Multiplan Workers Comp	$290.50
Rate for Payer: Scott and White EPO/PPO	$290.50

PIN FIX 1.4MM TEMP SM

Facility

$581.00

Service Code	HCPCS C1713
Hospital Charge Code	126426
Hospital Revenue Code	278
Min. Negotiated Rate	$52.29
Max. Negotiated Rate	$418.32
Rate for Payer: Amerigroup CHIP/Medicaid	$52.29
Rate for Payer: BCBS of TX Blue Advantage	$174.30
Rate for Payer: BCBS of TX Blue Essentials	$209.16
Rate for Payer: BCBS of TX PPO	$232.40
Rate for Payer: Cash Price	$395.08
Rate for Payer: Cigna Medicaid	$418.32
Rate for Payer: Molina CHIP/Medicaid	$418.32
Rate for Payer: Multiplan Auto	$290.50
Rate for Payer: Multiplan Commercial	$290.50
Rate for Payer: Multiplan Workers Comp	$290.50
Rate for Payer: Parkland Medicaid	$418.32
Rate for Payer: Scott and White EPO/PPO	$290.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$418.32
Rate for Payer: Superior Health Plan EPO	$79.02

PIN, FIXATION TEMPORARY FOR ACHORAGE SYSTEM

Facility

$953.00

Service Code	HCPCS C1713
Hospital Charge Code	133884
Hospital Revenue Code	278
Min. Negotiated Rate	$85.77
Max. Negotiated Rate	$686.16
Rate for Payer: Amerigroup CHIP/Medicaid	$85.77
Rate for Payer: BCBS of TX Blue Advantage	$285.90
Rate for Payer: BCBS of TX Blue Essentials	$343.08
Rate for Payer: BCBS of TX PPO	$381.20
Rate for Payer: Cash Price	$648.04
Rate for Payer: Cigna Medicaid	$686.16
Rate for Payer: Molina CHIP/Medicaid	$686.16
Rate for Payer: Multiplan Auto	$476.50
Rate for Payer: Multiplan Commercial	$476.50
Rate for Payer: Multiplan Workers Comp	$476.50
Rate for Payer: Parkland Medicaid	$686.16
Rate for Payer: Scott and White EPO/PPO	$476.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$686.16
Rate for Payer: Superior Health Plan EPO	$129.61

PIN, FIXATION TEMPORARY FOR ACHORAGE SYSTEM

Facility

$953.00

Service Code	HCPCS C1713
Hospital Charge Code	133884
Hospital Revenue Code	278
Min. Negotiated Rate	$238.25
Max. Negotiated Rate	$476.50
Rate for Payer: Cash Price	$648.04
Rate for Payer: Cigna Commercial	$238.25
Rate for Payer: Multiplan Auto	$476.50
Rate for Payer: Multiplan Commercial	$476.50
Rate for Payer: Multiplan Workers Comp	$476.50
Rate for Payer: Scott and White EPO/PPO	$476.50

PIN HALF APX 3-5MM 120X20MM SLFDRL

Facility

$961.84

Hospital Charge Code	130857
Hospital Revenue Code	272
Rate for Payer: Cash Price	$654.05

PIN HALF APX 3-5MM 120X20MM SLFDRL

Facility

$961.84

Hospital Charge Code	130857
Hospital Revenue Code	272
Min. Negotiated Rate	$86.57
Max. Negotiated Rate	$692.52
Rate for Payer: Amerigroup CHIP/Medicaid	$86.57
Rate for Payer: BCBS of TX Blue Advantage	$288.55
Rate for Payer: BCBS of TX Blue Essentials	$346.26
Rate for Payer: BCBS of TX PPO	$384.74
Rate for Payer: Cash Price	$654.05
Rate for Payer: Cigna Medicaid	$692.52
Rate for Payer: Molina CHIP/Medicaid	$692.52
Rate for Payer: Multiplan Auto	$625.20
Rate for Payer: Multiplan Commercial	$625.20
Rate for Payer: Multiplan Workers Comp	$625.20
Rate for Payer: Parkland Medicaid	$692.52
Rate for Payer: Scott and White EPO/PPO	$480.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$692.52
Rate for Payer: Superior Health Plan EPO	$130.81

pin headles trocar drill

Facility

$1,389.24

Hospital Charge Code	113721
Hospital Revenue Code	272
Min. Negotiated Rate	$125.03
Max. Negotiated Rate	$1,000.25
Rate for Payer: Amerigroup CHIP/Medicaid	$125.03
Rate for Payer: BCBS of TX Blue Advantage	$416.77
Rate for Payer: BCBS of TX Blue Essentials	$500.13
Rate for Payer: BCBS of TX PPO	$555.70
Rate for Payer: Cash Price	$944.68
Rate for Payer: Cigna Medicaid	$1,000.25
Rate for Payer: Molina CHIP/Medicaid	$1,000.25
Rate for Payer: Multiplan Auto	$903.01
Rate for Payer: Multiplan Commercial	$903.01
Rate for Payer: Multiplan Workers Comp	$903.01
Rate for Payer: Parkland Medicaid	$1,000.25
Rate for Payer: Scott and White EPO/PPO	$694.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,000.25
Rate for Payer: Superior Health Plan EPO	$188.94

pin headles trocar drill

Facility

$1,389.24

Hospital Charge Code	113721
Hospital Revenue Code	272
Rate for Payer: Cash Price	$944.68

PIN HOFMAN TRNFX -- DHF

Facility

$746.00

Service Code	HCPCS C1713
Hospital Charge Code	81335705
Hospital Revenue Code	278
Min. Negotiated Rate	$186.50
Max. Negotiated Rate	$373.00
Rate for Payer: Cash Price	$507.28
Rate for Payer: Cigna Commercial	$186.50
Rate for Payer: Multiplan Auto	$373.00
Rate for Payer: Multiplan Commercial	$373.00
Rate for Payer: Multiplan Workers Comp	$373.00
Rate for Payer: Scott and White EPO/PPO	$373.00

PIN HOFMAN TRNFX -- DHF

Facility

$746.00

Service Code	HCPCS C1713
Hospital Charge Code	81335705
Hospital Revenue Code	278
Min. Negotiated Rate	$67.14
Max. Negotiated Rate	$537.12
Rate for Payer: Amerigroup CHIP/Medicaid	$67.14
Rate for Payer: BCBS of TX Blue Advantage	$223.80
Rate for Payer: BCBS of TX Blue Essentials	$268.56
Rate for Payer: BCBS of TX PPO	$298.40
Rate for Payer: Cash Price	$507.28
Rate for Payer: Cigna Medicaid	$537.12
Rate for Payer: Molina CHIP/Medicaid	$537.12
Rate for Payer: Multiplan Auto	$373.00
Rate for Payer: Multiplan Commercial	$373.00
Rate for Payer: Multiplan Workers Comp	$373.00
Rate for Payer: Parkland Medicaid	$537.12
Rate for Payer: Scott and White EPO/PPO	$373.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$537.12
Rate for Payer: Superior Health Plan EPO	$101.46

Pink Hub 18G x 2.75' (7 cm) Introducer Needle, Extra-Thin Wall, No Wings

Facility

$9.69

Hospital Charge Code	993773
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6.59

Pink Hub 18G x 2.75' (7 cm) Introducer Needle, Extra-Thin Wall, No Wings

Facility

$9.69

Hospital Charge Code	993773
Hospital Revenue Code	272
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$6.98
Rate for Payer: Amerigroup CHIP/Medicaid	$0.87
Rate for Payer: BCBS of TX Blue Advantage	$2.91
Rate for Payer: BCBS of TX Blue Essentials	$3.49
Rate for Payer: BCBS of TX PPO	$3.88
Rate for Payer: Cash Price	$6.59
Rate for Payer: Cigna Medicaid	$6.98
Rate for Payer: Molina CHIP/Medicaid	$6.98
Rate for Payer: Multiplan Auto	$6.30
Rate for Payer: Multiplan Commercial	$6.30
Rate for Payer: Multiplan Workers Comp	$6.30
Rate for Payer: Parkland Medicaid	$6.98
Rate for Payer: Scott and White EPO/PPO	$4.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.98
Rate for Payer: Superior Health Plan EPO	$1.32

PINNACEL STD IK 8FR 10CM .38 MINI GW

Facility

$65.18

Hospital Charge Code	993161
Hospital Revenue Code	270
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$46.93
Rate for Payer: Amerigroup CHIP/Medicaid	$5.87
Rate for Payer: BCBS of TX Blue Advantage	$19.55
Rate for Payer: BCBS of TX Blue Essentials	$23.46
Rate for Payer: BCBS of TX PPO	$26.07
Rate for Payer: Cash Price	$44.32
Rate for Payer: Cigna Medicaid	$46.93
Rate for Payer: Molina CHIP/Medicaid	$46.93
Rate for Payer: Multiplan Auto	$42.37
Rate for Payer: Multiplan Commercial	$42.37
Rate for Payer: Multiplan Workers Comp	$42.37
Rate for Payer: Parkland Medicaid	$46.93
Rate for Payer: Scott and White EPO/PPO	$32.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.93
Rate for Payer: Superior Health Plan EPO	$8.86

PINNACEL STD IK 8FR 10CM .38 MINI GW

Facility

$65.18

Hospital Charge Code	993161
Hospital Revenue Code	270
Rate for Payer: Cash Price	$44.32

PINNACLE ROLL HIFLO 6FR .035 MINI GW 1BX=10EA

Facility

$126.44

Service Code	HCPCS C1893
Hospital Charge Code	993709
Hospital Revenue Code	272
Min. Negotiated Rate	$11.38
Max. Negotiated Rate	$91.04
Rate for Payer: Amerigroup CHIP/Medicaid	$11.38
Rate for Payer: BCBS of TX Blue Advantage	$37.93
Rate for Payer: BCBS of TX Blue Essentials	$45.52
Rate for Payer: BCBS of TX PPO	$50.58
Rate for Payer: Cash Price	$85.98
Rate for Payer: Cigna Medicaid	$91.04
Rate for Payer: Molina CHIP/Medicaid	$91.04
Rate for Payer: Multiplan Auto	$82.19
Rate for Payer: Multiplan Commercial	$82.19
Rate for Payer: Multiplan Workers Comp	$82.19
Rate for Payer: Parkland Medicaid	$91.04
Rate for Payer: Scott and White EPO/PPO	$63.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.04
Rate for Payer: Superior Health Plan EPO	$17.20

PINNACLE ROLL HIFLO 6FR .035 MINI GW 1BX=10EA

Facility

$126.44

Service Code	HCPCS C1893
Hospital Charge Code	993709
Hospital Revenue Code	272
Rate for Payer: Cash Price	$85.98

PINNACLE STD IK 5FR 10 CM .035 MINI GW

Facility

$51.30

Hospital Charge Code	993908
Hospital Revenue Code	272
Rate for Payer: Cash Price	$34.88

PINNACLE STD IK 5FR 10 CM .035 MINI GW

Facility

$51.30

Hospital Charge Code	993908
Hospital Revenue Code	272
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$36.94
Rate for Payer: Amerigroup CHIP/Medicaid	$4.62
Rate for Payer: BCBS of TX Blue Advantage	$15.39
Rate for Payer: BCBS of TX Blue Essentials	$18.47
Rate for Payer: BCBS of TX PPO	$20.52
Rate for Payer: Cash Price	$34.88
Rate for Payer: Cigna Medicaid	$36.94
Rate for Payer: Molina CHIP/Medicaid	$36.94
Rate for Payer: Multiplan Auto	$33.34
Rate for Payer: Multiplan Commercial	$33.34
Rate for Payer: Multiplan Workers Comp	$33.34
Rate for Payer: Parkland Medicaid	$36.94
Rate for Payer: Scott and White EPO/PPO	$25.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.94
Rate for Payer: Superior Health Plan EPO	$6.98

PINNACLE STD IK 6FR 10CM .035 MINI GW

Facility

$51.30

Hospital Charge Code	993907
Hospital Revenue Code	272
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$36.94
Rate for Payer: Amerigroup CHIP/Medicaid	$4.62
Rate for Payer: BCBS of TX Blue Advantage	$15.39
Rate for Payer: BCBS of TX Blue Essentials	$18.47
Rate for Payer: BCBS of TX PPO	$20.52
Rate for Payer: Cash Price	$34.88
Rate for Payer: Cigna Medicaid	$36.94
Rate for Payer: Molina CHIP/Medicaid	$36.94
Rate for Payer: Multiplan Auto	$33.34
Rate for Payer: Multiplan Commercial	$33.34
Rate for Payer: Multiplan Workers Comp	$33.34
Rate for Payer: Parkland Medicaid	$36.94
Rate for Payer: Scott and White EPO/PPO	$25.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.94
Rate for Payer: Superior Health Plan EPO	$6.98

PINNACLE STD IK 6FR 10CM .035 MINI GW

Facility

$51.30

Hospital Charge Code	993907
Hospital Revenue Code	272
Rate for Payer: Cash Price	$34.88

PINNACLE STD IK 6FR 10CM .035 MINI GW 1BX=10EA

Facility

$153.91

Service Code	HCPCS C1893
Hospital Charge Code	993710
Hospital Revenue Code	272
Min. Negotiated Rate	$13.85
Max. Negotiated Rate	$110.82
Rate for Payer: Amerigroup CHIP/Medicaid	$13.85
Rate for Payer: BCBS of TX Blue Advantage	$46.17
Rate for Payer: BCBS of TX Blue Essentials	$55.41
Rate for Payer: BCBS of TX PPO	$61.56
Rate for Payer: Cash Price	$104.66
Rate for Payer: Cigna Medicaid	$110.82
Rate for Payer: Molina CHIP/Medicaid	$110.82
Rate for Payer: Multiplan Auto	$100.04
Rate for Payer: Multiplan Commercial	$100.04
Rate for Payer: Multiplan Workers Comp	$100.04
Rate for Payer: Parkland Medicaid	$110.82
Rate for Payer: Scott and White EPO/PPO	$76.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.82
Rate for Payer: Superior Health Plan EPO	$20.93

PINNACLE STD IK 6FR 10CM .035 MINI GW 1BX=10EA

Facility

$153.91

Service Code	HCPCS C1893
Hospital Charge Code	993710
Hospital Revenue Code	272
Rate for Payer: Cash Price	$104.66

Know your out-of-pocket cost for care.

All Charges