White Rock Medical Center

All Charges

Charge

Type

Setting

Price

RETRACTOR DISP -- DHF

Facility

$265.07

Hospital Charge Code	81763062
Hospital Revenue Code	272
Min. Negotiated Rate	$23.86
Max. Negotiated Rate	$190.85
Rate for Payer: Amerigroup CHIP/Medicaid	$23.86
Rate for Payer: BCBS of TX Blue Advantage	$79.52
Rate for Payer: BCBS of TX Blue Essentials	$95.43
Rate for Payer: BCBS of TX PPO	$106.03
Rate for Payer: Cash Price	$180.25
Rate for Payer: Cigna Medicaid	$190.85
Rate for Payer: Molina CHIP/Medicaid	$190.85
Rate for Payer: Multiplan Auto	$172.30
Rate for Payer: Multiplan Commercial	$172.30
Rate for Payer: Multiplan Workers Comp	$172.30
Rate for Payer: Parkland Medicaid	$190.85
Rate for Payer: Scott and White EPO/PPO	$132.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$190.85
Rate for Payer: Superior Health Plan EPO	$36.05

RETRACTOR POSTERIOR

Facility

$5,448.00

Hospital Charge Code	8504493
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,704.64

RETRACTOR POSTERIOR

Facility

$5,448.00

Hospital Charge Code	8504493
Hospital Revenue Code	272
Min. Negotiated Rate	$490.32
Max. Negotiated Rate	$3,922.56
Rate for Payer: Amerigroup CHIP/Medicaid	$490.32
Rate for Payer: BCBS of TX Blue Advantage	$1,634.40
Rate for Payer: BCBS of TX Blue Essentials	$1,961.28
Rate for Payer: BCBS of TX PPO	$2,179.20
Rate for Payer: Cash Price	$3,704.64
Rate for Payer: Cigna Medicaid	$3,922.56
Rate for Payer: Molina CHIP/Medicaid	$3,922.56
Rate for Payer: Multiplan Auto	$3,541.20
Rate for Payer: Multiplan Commercial	$3,541.20
Rate for Payer: Multiplan Workers Comp	$3,541.20
Rate for Payer: Parkland Medicaid	$3,922.56
Rate for Payer: Scott and White EPO/PPO	$2,724.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,922.56
Rate for Payer: Superior Health Plan EPO	$740.93

RETRACTOR WND MEDIUM -- DHF

Facility

$192.50

Hospital Charge Code	81763138
Hospital Revenue Code	272
Rate for Payer: Cash Price	$130.90

RETRACTOR WND MEDIUM -- DHF

Facility

$192.50

Hospital Charge Code	81763138
Hospital Revenue Code	272
Min. Negotiated Rate	$17.32
Max. Negotiated Rate	$138.60
Rate for Payer: Amerigroup CHIP/Medicaid	$17.32
Rate for Payer: BCBS of TX Blue Advantage	$57.75
Rate for Payer: BCBS of TX Blue Essentials	$69.30
Rate for Payer: BCBS of TX PPO	$77.00
Rate for Payer: Cash Price	$130.90
Rate for Payer: Cigna Medicaid	$138.60
Rate for Payer: Molina CHIP/Medicaid	$138.60
Rate for Payer: Multiplan Auto	$125.12
Rate for Payer: Multiplan Commercial	$125.12
Rate for Payer: Multiplan Workers Comp	$125.12
Rate for Payer: Parkland Medicaid	$138.60
Rate for Payer: Scott and White EPO/PPO	$96.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$138.60
Rate for Payer: Superior Health Plan EPO	$26.18

RETRIEVER, SUTURE S/S SHAFT NYLON LOOP HDL DISP -- DHF

Facility

$260.27

Hospital Charge Code	81774101
Hospital Revenue Code	272
Rate for Payer: Cash Price	$176.98

RETRIEVER, SUTURE S/S SHAFT NYLON LOOP HDL DISP -- DHF

Facility

$260.27

Hospital Charge Code	81774101
Hospital Revenue Code	272
Min. Negotiated Rate	$23.42
Max. Negotiated Rate	$187.39
Rate for Payer: Amerigroup CHIP/Medicaid	$23.42
Rate for Payer: BCBS of TX Blue Advantage	$78.08
Rate for Payer: BCBS of TX Blue Essentials	$93.70
Rate for Payer: BCBS of TX PPO	$104.11
Rate for Payer: Cash Price	$176.98
Rate for Payer: Cigna Medicaid	$187.39
Rate for Payer: Molina CHIP/Medicaid	$187.39
Rate for Payer: Multiplan Auto	$169.18
Rate for Payer: Multiplan Commercial	$169.18
Rate for Payer: Multiplan Workers Comp	$169.18
Rate for Payer: Parkland Medicaid	$187.39
Rate for Payer: Scott and White EPO/PPO	$130.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$187.39
Rate for Payer: Superior Health Plan EPO	$35.40

REVASC TIB PER ATH ADD/O

Facility

$15,683.00

Service Code	HCPCS 37233
Hospital Charge Code	2320545
Hospital Revenue Code	360
Min. Negotiated Rate	$1,411.47
Max. Negotiated Rate	$11,291.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1,411.47
Rate for Payer: BCBS of TX Blue Advantage	$4,704.90
Rate for Payer: BCBS of TX Blue Essentials	$5,645.88
Rate for Payer: BCBS of TX PPO	$6,273.20
Rate for Payer: Cash Price	$10,664.44
Rate for Payer: Cash Price	$10,664.44
Rate for Payer: Cigna Medicaid	$11,291.76
Rate for Payer: Molina CHIP/Medicaid	$11,291.76
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	$11,291.76
Rate for Payer: Scott and White EPO/PPO	$7,841.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,291.76
Rate for Payer: Superior Health Plan EPO	$2,132.89

REVASC TIB PER ATH ADD/O

Facility

$15,683.00

Service Code	HCPCS 37233
Hospital Charge Code	2320545
Hospital Revenue Code	360
Rate for Payer: Cash Price	$10,664.44

REVASC TIBPER ST ATH ADD

Facility

$21,816.00

Service Code	HCPCS 37235
Hospital Charge Code	2320547
Hospital Revenue Code	360
Min. Negotiated Rate	$1,963.44
Max. Negotiated Rate	$15,707.52
Rate for Payer: Amerigroup CHIP/Medicaid	$1,963.44
Rate for Payer: BCBS of TX Blue Advantage	$6,544.80
Rate for Payer: BCBS of TX Blue Essentials	$7,853.76
Rate for Payer: BCBS of TX PPO	$8,726.40
Rate for Payer: Cash Price	$14,834.88
Rate for Payer: Cash Price	$14,834.88
Rate for Payer: Cigna Medicaid	$15,707.52
Rate for Payer: Molina CHIP/Medicaid	$15,707.52
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	$15,707.52
Rate for Payer: Scott and White EPO/PPO	$10,908.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,707.52
Rate for Payer: Superior Health Plan EPO	$2,966.98

REVASC TIBPER ST ATH ADD

Facility

$21,816.00

Service Code	HCPCS 37235
Hospital Charge Code	2320547
Hospital Revenue Code	360
Rate for Payer: Cash Price	$14,834.88

REVASC TIBPER W/ATHER

Facility

$37,778.00

Service Code	HCPCS 37229
Hospital Charge Code	2320541
Hospital Revenue Code	360
Rate for Payer: Cash Price	$25,689.04

REVASC TIBPER W/ATHER

Facility

$37,778.00

Service Code	HCPCS 37229
Hospital Charge Code	2320541
Hospital Revenue Code	360
Min. Negotiated Rate	$3,400.02
Max. Negotiated Rate	$40,168.72
Rate for Payer: Amerigroup CHIP/Medicaid	$3,400.02
Rate for Payer: BCBS of TX Blue Advantage	$26,619.75
Rate for Payer: BCBS of TX Blue Essentials	$31,879.94
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cash Price	$25,689.04
Rate for Payer: Cash Price	$25,689.04
Rate for Payer: Cash Price	$25,689.04
Rate for Payer: Cigna Medicaid	$27,200.16
Rate for Payer: Molina CHIP/Medicaid	$27,200.16
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	$27,200.16
Rate for Payer: Scott and White EPO/PPO	$29,667.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,200.16
Rate for Payer: Superior Health Plan EPO	$5,137.81

REVASC TIBPER WSTENTADD

Facility

$13,708.00

Service Code	HCPCS 37234
Hospital Charge Code	4610247
Hospital Revenue Code	360
Min. Negotiated Rate	$1,233.72
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,233.72
Rate for Payer: BCBS of TX Blue Advantage	$4,112.40
Rate for Payer: BCBS of TX Blue Essentials	$4,934.88
Rate for Payer: BCBS of TX PPO	$5,483.20
Rate for Payer: Cash Price	$9,321.44
Rate for Payer: Cash Price	$9,321.44
Rate for Payer: Cigna Medicaid	$9,869.76
Rate for Payer: Molina CHIP/Medicaid	$9,869.76
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	$9,869.76
Rate for Payer: Scott and White EPO/PPO	$6,854.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,869.76
Rate for Payer: Superior Health Plan EPO	$1,864.29

REVASC TIBPER WSTENTADD

Facility

$13,708.00

Service Code	HCPCS 37234
Hospital Charge Code	4610247
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,321.44

Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement

Facility

$47,176.92

Service Code	HCPCS 37269
Hospital Charge Code	994173
Hospital Revenue Code	480
Rate for Payer: Cash Price	$32,080.31

Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement

Facility

$47,176.92

Service Code	HCPCS 37269
Hospital Charge Code	994173
Hospital Revenue Code	480
Min. Negotiated Rate	$4,245.92
Max. Negotiated Rate	$33,967.38
Rate for Payer: Amerigroup CHIP/Medicaid	$4,245.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Amerigroup Medicare	$11,596.79
Rate for Payer: BCBS of TX Blue Advantage	$14,153.08
Rate for Payer: BCBS of TX Blue Essentials	$16,983.69
Rate for Payer: BCBS of TX Medicare	$11,596.79
Rate for Payer: BCBS of TX PPO	$18,870.77
Rate for Payer: Cash Price	$32,080.31
Rate for Payer: Cash Price	$32,080.31
Rate for Payer: Cash Price	$32,080.31
Rate for Payer: Cigna Commercial	$24,513.51
Rate for Payer: Cigna Medicaid	$33,967.38
Rate for Payer: Cigna Medicare	$11,596.79
Rate for Payer: Employer Direct Commercial	$11,596.79
Rate for Payer: Humana Medicare/TRICARE	$11,596.79
Rate for Payer: Molina CHIP/Medicaid	$33,967.38
Rate for Payer: Molina Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Molina Medicare	$11,596.79
Rate for Payer: Multiplan Auto	$30,665.00
Rate for Payer: Multiplan Commercial	$30,665.00
Rate for Payer: Multiplan Workers Comp	$30,665.00
Rate for Payer: Parkland Medicaid	$33,967.38
Rate for Payer: Scott and White EPO/PPO	$23,588.46
Rate for Payer: Scott and White Medicare	$11,596.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33,967.38
Rate for Payer: Superior Health Plan EPO	$11,596.79
Rate for Payer: Superior Health Plan Medicare	$11,596.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Universal American Medicare	$11,596.79
Rate for Payer: Wellcare Medicare	$11,596.79
Rate for Payer: Wellmed Medicare	$11,596.79

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; wit

Facility

$137,420.80

Service Code	HCPCS 37227
Hospital Charge Code	2320539
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$98,942.98
Rate for Payer: Amerigroup CHIP/Medicaid	$12,367.87
Rate for Payer: BCBS of TX Blue Advantage	$26,619.75
Rate for Payer: BCBS of TX Blue Essentials	$31,879.94
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cash Price	$93,446.14
Rate for Payer: Cash Price	$93,446.14
Rate for Payer: Cash Price	$93,446.14
Rate for Payer: Cigna Medicaid	$98,942.98
Rate for Payer: Molina CHIP/Medicaid	$98,942.98
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	$98,942.98
Rate for Payer: Scott and White EPO/PPO	$29,667.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98,942.98
Rate for Payer: Superior Health Plan EPO	$18,689.23

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; wit

Facility

$137,420.80

Service Code	HCPCS 37227
Hospital Charge Code	9900629
Hospital Revenue Code	360
Rate for Payer: Cash Price	$93,446.14

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; wit

Facility

$137,420.80

Service Code	HCPCS 37227
Hospital Charge Code	2320539
Hospital Revenue Code	360
Rate for Payer: Cash Price	$93,446.14

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; wit

Facility

$137,420.80

Service Code	HCPCS 37227
Hospital Charge Code	9900629
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$98,942.98
Rate for Payer: Amerigroup CHIP/Medicaid	$12,367.87
Rate for Payer: BCBS of TX Blue Advantage	$26,619.75
Rate for Payer: BCBS of TX Blue Essentials	$31,879.94
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cash Price	$93,446.14
Rate for Payer: Cash Price	$93,446.14
Rate for Payer: Cash Price	$93,446.14
Rate for Payer: Cigna Medicaid	$98,942.98
Rate for Payer: Molina CHIP/Medicaid	$98,942.98
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	$98,942.98
Rate for Payer: Scott and White EPO/PPO	$29,667.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98,942.98
Rate for Payer: Superior Health Plan EPO	$18,689.23

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; wit

Facility

$40,168.72

Service Code	CPT 37227
Hospital Charge Code	36037227
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$40,168.72
Rate for Payer: BCBS of TX Blue Advantage	$26,619.75
Rate for Payer: BCBS of TX Blue Essentials	$31,879.94
Rate for Payer: BCBS of TX PPO	$40,168.72
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: Scott and White EPO/PPO	$29,667.86

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial

Facility

$137,420.80

Service Code	HCPCS 37231
Hospital Charge Code	2320543
Hospital Revenue Code	360
Rate for Payer: Cash Price	$93,446.14

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial

Facility

$137,420.80

Service Code	HCPCS 37231
Hospital Charge Code	2320543
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$98,942.98
Rate for Payer: Amerigroup CHIP/Medicaid	$12,367.87
Rate for Payer: BCBS of TX Blue Advantage	$26,619.75
Rate for Payer: BCBS of TX Blue Essentials	$31,879.94
Rate for Payer: BCBS of TX PPO	$40,168.72
Rate for Payer: Cash Price	$93,446.14
Rate for Payer: Cash Price	$93,446.14
Rate for Payer: Cash Price	$93,446.14
Rate for Payer: Cigna Medicaid	$98,942.98
Rate for Payer: Molina CHIP/Medicaid	$98,942.98
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	$98,942.98
Rate for Payer: Scott and White EPO/PPO	$29,667.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98,942.98
Rate for Payer: Superior Health Plan EPO	$18,689.23

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial

Facility

$40,168.72

Service Code	CPT 37231
Hospital Charge Code	36037231
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$40,168.72
Rate for Payer: BCBS of TX Blue Advantage	$26,619.75
Rate for Payer: BCBS of TX Blue Essentials	$31,879.94
Rate for Payer: BCBS of TX PPO	$40,168.72
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: Scott and White EPO/PPO	$29,667.86

Know your out-of-pocket cost for care.

All Charges