White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CANNULA, ARTHROSCOPIC THREADED 7.0MM X 75MM DISP -- DHF

Facility

$190.68

Hospital Charge Code	81730608
Hospital Revenue Code	272
Min. Negotiated Rate	$17.16
Max. Negotiated Rate	$123.94
Rate for Payer: Aetna Commercial	$104.87
Rate for Payer: Amerigroup CHIP/Medicaid	$17.16
Rate for Payer: BCBS of TX Blue Advantage	$57.20
Rate for Payer: BCBS of TX Blue Essentials	$68.64
Rate for Payer: BCBS of TX PPO	$76.27
Rate for Payer: Cash Price	$167.80
Rate for Payer: Multiplan Auto	$123.94
Rate for Payer: Multiplan Commercial	$123.94
Rate for Payer: Multiplan Workers Comp	$123.94
Rate for Payer: Scott and White EPO/PPO	$95.34
Rate for Payer: Superior Health Plan EPO	$25.93

cannula co2 microfilter

Facility

$45.85

Hospital Charge Code	144832
Hospital Revenue Code	272
Min. Negotiated Rate	$4.13
Max. Negotiated Rate	$29.80
Rate for Payer: Aetna Commercial	$25.22
Rate for Payer: Amerigroup CHIP/Medicaid	$4.13
Rate for Payer: BCBS of TX Blue Advantage	$13.76
Rate for Payer: BCBS of TX Blue Essentials	$16.51
Rate for Payer: BCBS of TX PPO	$18.34
Rate for Payer: Cash Price	$40.35
Rate for Payer: Multiplan Auto	$29.80
Rate for Payer: Multiplan Commercial	$29.80
Rate for Payer: Multiplan Workers Comp	$29.80
Rate for Payer: Scott and White EPO/PPO	$22.92
Rate for Payer: Superior Health Plan EPO	$6.24

cannula co2 microfilter

Facility

$45.85

Hospital Charge Code	144832
Hospital Revenue Code	272
Rate for Payer: Cash Price	$40.35

cannula dry doc 2/obtuarator

Facility

$124.76

Hospital Charge Code	140711
Hospital Revenue Code	272
Rate for Payer: Cash Price	$109.79

cannula dry doc 2/obtuarator

Facility

$124.76

Hospital Charge Code	140711
Hospital Revenue Code	272
Min. Negotiated Rate	$11.23
Max. Negotiated Rate	$81.09
Rate for Payer: Aetna Commercial	$68.62
Rate for Payer: Amerigroup CHIP/Medicaid	$11.23
Rate for Payer: BCBS of TX Blue Advantage	$37.43
Rate for Payer: BCBS of TX Blue Essentials	$44.91
Rate for Payer: BCBS of TX PPO	$49.90
Rate for Payer: Cash Price	$109.79
Rate for Payer: Multiplan Auto	$81.09
Rate for Payer: Multiplan Commercial	$81.09
Rate for Payer: Multiplan Workers Comp	$81.09
Rate for Payer: Scott and White EPO/PPO	$62.38
Rate for Payer: Superior Health Plan EPO	$16.97

CANNULA DRY DOC W/OB 8.0 X75

Facility

$161.71

Hospital Charge Code	145531
Hospital Revenue Code	272
Rate for Payer: Cash Price	$142.30

CANNULA DRY DOC W/OB 8.0 X75

Facility

$161.71

Hospital Charge Code	145531
Hospital Revenue Code	272
Min. Negotiated Rate	$14.55
Max. Negotiated Rate	$105.11
Rate for Payer: Aetna Commercial	$88.94
Rate for Payer: Amerigroup CHIP/Medicaid	$14.55
Rate for Payer: BCBS of TX Blue Advantage	$48.51
Rate for Payer: BCBS of TX Blue Essentials	$58.22
Rate for Payer: BCBS of TX PPO	$64.68
Rate for Payer: Cash Price	$142.30
Rate for Payer: Multiplan Auto	$105.11
Rate for Payer: Multiplan Commercial	$105.11
Rate for Payer: Multiplan Workers Comp	$105.11
Rate for Payer: Scott and White EPO/PPO	$80.86
Rate for Payer: Superior Health Plan EPO	$21.99

cannula ivas 11g bn bx

Facility

$336.41

Hospital Charge Code	8634510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$296.04

cannula ivas 11g bn bx

Facility

$336.41

Hospital Charge Code	8634510
Hospital Revenue Code	272
Min. Negotiated Rate	$30.28
Max. Negotiated Rate	$218.67
Rate for Payer: Aetna Commercial	$185.03
Rate for Payer: Amerigroup CHIP/Medicaid	$30.28
Rate for Payer: BCBS of TX Blue Advantage	$100.92
Rate for Payer: BCBS of TX Blue Essentials	$121.11
Rate for Payer: BCBS of TX PPO	$134.56
Rate for Payer: Cash Price	$296.04
Rate for Payer: Multiplan Auto	$218.67
Rate for Payer: Multiplan Commercial	$218.67
Rate for Payer: Multiplan Workers Comp	$218.67
Rate for Payer: Scott and White EPO/PPO	$168.20
Rate for Payer: Superior Health Plan EPO	$45.75

Cannula ivas access 11g

Facility

$321.66

Hospital Charge Code	8602530
Hospital Revenue Code	272
Min. Negotiated Rate	$28.95
Max. Negotiated Rate	$209.08
Rate for Payer: Aetna Commercial	$176.91
Rate for Payer: Amerigroup CHIP/Medicaid	$28.95
Rate for Payer: BCBS of TX Blue Advantage	$96.50
Rate for Payer: BCBS of TX Blue Essentials	$115.80
Rate for Payer: BCBS of TX PPO	$128.66
Rate for Payer: Cash Price	$283.06
Rate for Payer: Multiplan Auto	$209.08
Rate for Payer: Multiplan Commercial	$209.08
Rate for Payer: Multiplan Workers Comp	$209.08
Rate for Payer: Scott and White EPO/PPO	$160.83
Rate for Payer: Superior Health Plan EPO	$43.75

Cannula ivas access 11g

Facility

$321.66

Hospital Charge Code	8602530
Hospital Revenue Code	272
Rate for Payer: Cash Price	$283.06

CANNULA MICROFILTER CO2 SAMPL/DEL

Facility

$52.52

Hospital Charge Code	145097
Hospital Revenue Code	272
Rate for Payer: Cash Price	$46.22

CANNULA MICROFILTER CO2 SAMPL/DEL

Facility

$52.52

Hospital Charge Code	145097
Hospital Revenue Code	272
Min. Negotiated Rate	$4.73
Max. Negotiated Rate	$34.14
Rate for Payer: Aetna Commercial	$28.89
Rate for Payer: Amerigroup CHIP/Medicaid	$4.73
Rate for Payer: BCBS of TX Blue Advantage	$15.76
Rate for Payer: BCBS of TX Blue Essentials	$18.91
Rate for Payer: BCBS of TX PPO	$21.01
Rate for Payer: Cash Price	$46.22
Rate for Payer: Multiplan Auto	$34.14
Rate for Payer: Multiplan Commercial	$34.14
Rate for Payer: Multiplan Workers Comp	$34.14
Rate for Payer: Scott and White EPO/PPO	$26.26
Rate for Payer: Superior Health Plan EPO	$7.14

cannula reducer endowrist 12-8mm

Facility

$113.50

Hospital Charge Code	8690516
Hospital Revenue Code	272
Rate for Payer: Cash Price	$99.88

cannula reducer endowrist 12-8mm

Facility

$113.50

Hospital Charge Code	8690516
Hospital Revenue Code	272
Min. Negotiated Rate	$10.22
Max. Negotiated Rate	$73.78
Rate for Payer: Aetna Commercial	$62.42
Rate for Payer: Amerigroup CHIP/Medicaid	$10.22
Rate for Payer: BCBS of TX Blue Advantage	$34.05
Rate for Payer: BCBS of TX Blue Essentials	$40.86
Rate for Payer: BCBS of TX PPO	$45.40
Rate for Payer: Cash Price	$99.88
Rate for Payer: Multiplan Auto	$73.78
Rate for Payer: Multiplan Commercial	$73.78
Rate for Payer: Multiplan Workers Comp	$73.78
Rate for Payer: Scott and White EPO/PPO	$56.75
Rate for Payer: Superior Health Plan EPO	$15.44

CANNULA, SEAL 8MM FOR DAVINCI SURGICAL SYSTEM -- DHF

Facility

$939.78

Hospital Charge Code	81813875
Hospital Revenue Code	270
Rate for Payer: Cash Price	$827.01

CANNULA, SEAL 8MM FOR DAVINCI SURGICAL SYSTEM -- DHF

Facility

$939.78

Hospital Charge Code	81813875
Hospital Revenue Code	270
Min. Negotiated Rate	$84.58
Max. Negotiated Rate	$610.86
Rate for Payer: Aetna Commercial	$516.88
Rate for Payer: Amerigroup CHIP/Medicaid	$84.58
Rate for Payer: BCBS of TX Blue Advantage	$281.93
Rate for Payer: BCBS of TX Blue Essentials	$338.32
Rate for Payer: BCBS of TX PPO	$375.91
Rate for Payer: Cash Price	$827.01
Rate for Payer: Multiplan Auto	$610.86
Rate for Payer: Multiplan Commercial	$610.86
Rate for Payer: Multiplan Workers Comp	$610.86
Rate for Payer: Scott and White EPO/PPO	$469.89
Rate for Payer: Superior Health Plan EPO	$127.81

CANNULATED DRIVER

Facility

$2,156.50

Hospital Charge Code	145138
Hospital Revenue Code	272
Min. Negotiated Rate	$194.08
Max. Negotiated Rate	$1,401.72
Rate for Payer: Aetna Commercial	$1,186.08
Rate for Payer: Amerigroup CHIP/Medicaid	$194.08
Rate for Payer: BCBS of TX Blue Advantage	$646.95
Rate for Payer: BCBS of TX Blue Essentials	$776.34
Rate for Payer: BCBS of TX PPO	$862.60
Rate for Payer: Cash Price	$1,897.72
Rate for Payer: Multiplan Auto	$1,401.72
Rate for Payer: Multiplan Commercial	$1,401.72
Rate for Payer: Multiplan Workers Comp	$1,401.72
Rate for Payer: Scott and White EPO/PPO	$1,078.25
Rate for Payer: Superior Health Plan EPO	$293.28

CANNULATED DRIVER

Facility

$2,156.50

Hospital Charge Code	145138
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,897.72

CAP END

Facility

$753.00

Service Code	HCPCS C1713
Hospital Charge Code	145476
Hospital Revenue Code	278
Min. Negotiated Rate	$67.77
Max. Negotiated Rate	$376.50
Rate for Payer: Aetna Commercial	$225.90
Rate for Payer: Amerigroup CHIP/Medicaid	$67.77
Rate for Payer: BCBS of TX Blue Advantage	$225.90
Rate for Payer: BCBS of TX Blue Essentials	$271.08
Rate for Payer: BCBS of TX PPO	$301.20
Rate for Payer: Cash Price	$662.64
Rate for Payer: Multiplan Auto	$376.50
Rate for Payer: Multiplan Commercial	$376.50
Rate for Payer: Multiplan Workers Comp	$376.50
Rate for Payer: Scott and White EPO/PPO	$376.50
Rate for Payer: Superior Health Plan EPO	$102.41

CAP END

Facility

$753.00

Service Code	HCPCS C1713
Hospital Charge Code	145476
Hospital Revenue Code	278
Min. Negotiated Rate	$188.25
Max. Negotiated Rate	$376.50
Rate for Payer: Aetna Commercial	$225.90
Rate for Payer: Cash Price	$662.64
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Multiplan Auto	$376.50
Rate for Payer: Multiplan Commercial	$376.50
Rate for Payer: Multiplan Workers Comp	$376.50
Rate for Payer: Scott and White EPO/PPO	$376.50

Capsulectomy or capsulotomy; interphalangeal joint, each joint

Facility

$10,000.00

Service Code	CPT 26525
Hospital Charge Code	36026525
Hospital Revenue Code	360
Min. Negotiated Rate	$32.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,204.79
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,469.86
Rate for Payer: Amerigroup Medicare	$1,469.86
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,469.86
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cigna Commercial	$3,329.66
Rate for Payer: Cigna Medicaid	$593.04
Rate for Payer: Cigna Medicare	$1,469.86
Rate for Payer: Employer Direct Commercial	$1,469.86
Rate for Payer: Humana Medicare/TRICARE	$1,469.86
Rate for Payer: Molina CHIP/Medicaid	$593.04
Rate for Payer: Molina Dual Medicare/Medicaid	$1,469.86
Rate for Payer: Molina Medicare	$1,469.86
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$593.04
Rate for Payer: Scott and White EPO/PPO	$32.42
Rate for Payer: Scott and White Medicare	$1,469.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$593.04
Rate for Payer: Superior Health Plan EPO	$1,469.86
Rate for Payer: Superior Health Plan Medicare	$1,469.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,469.86
Rate for Payer: Universal American Medicare	$1,469.86
Rate for Payer: Wellcare Medicare	$1,469.86
Rate for Payer: Wellmed Medicare	$1,469.86

Capsulectomy or capsulotomy metacarpophalangeal joint, each joint

Facility

$10,000.00

Service Code	CPT 26520
Hospital Charge Code	36026520
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block

Facility

$15,074.51

Service Code	CPT 23465
Hospital Charge Code	36023465
Hospital Revenue Code	360
Min. Negotiated Rate	$144.31
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Amerigroup Medicare	$6,542.72
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$6,542.72
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$14,821.16
Rate for Payer: Cigna Medicaid	$2,398.52
Rate for Payer: Cigna Medicare	$6,542.72
Rate for Payer: Employer Direct Commercial	$6,542.72
Rate for Payer: Humana Medicare/TRICARE	$6,542.72
Rate for Payer: Molina CHIP/Medicaid	$2,398.52
Rate for Payer: Molina Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Molina Medicare	$6,542.72
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$2,398.52
Rate for Payer: Scott and White EPO/PPO	$144.31
Rate for Payer: Scott and White Medicare	$6,542.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,398.52
Rate for Payer: Superior Health Plan EPO	$6,542.72
Rate for Payer: Superior Health Plan Medicare	$6,542.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Universal American Medicare	$6,542.72
Rate for Payer: Wellcare Medicare	$6,542.72
Rate for Payer: Wellmed Medicare	$6,542.72

Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or

Facility

$15,074.51

Service Code	CPT 25320
Hospital Charge Code	36025320
Hospital Revenue Code	360
Min. Negotiated Rate	$144.31
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Amerigroup Medicare	$6,542.72
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$6,542.72
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$14,821.16
Rate for Payer: Cigna Medicaid	$2,398.52
Rate for Payer: Cigna Medicare	$6,542.72
Rate for Payer: Employer Direct Commercial	$6,542.72
Rate for Payer: Humana Medicare/TRICARE	$6,542.72
Rate for Payer: Molina CHIP/Medicaid	$2,398.52
Rate for Payer: Molina Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Molina Medicare	$6,542.72
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$2,398.52
Rate for Payer: Scott and White EPO/PPO	$144.31
Rate for Payer: Scott and White Medicare	$6,542.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,398.52
Rate for Payer: Superior Health Plan EPO	$6,542.72
Rate for Payer: Superior Health Plan Medicare	$6,542.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Universal American Medicare	$6,542.72
Rate for Payer: Wellcare Medicare	$6,542.72
Rate for Payer: Wellmed Medicare	$6,542.72

Know your out-of-pocket cost for care.

All Charges