White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Rubella Antibodies, IgM SO

Facility

$149.00

Service Code	HCPCS 86762
Hospital Charge Code	1605377
Hospital Revenue Code	302
Rate for Payer: Cash Price	$101.32

Rubella Antibodies, IgM SO

Facility

$149.00

Service Code	HCPCS 86762
Hospital Charge Code	1605377
Hospital Revenue Code	302
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$107.28
Rate for Payer: Amerigroup CHIP/Medicaid	$5.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.39
Rate for Payer: Amerigroup Medicare	$14.39
Rate for Payer: BCBS of TX Blue Advantage	$44.70
Rate for Payer: BCBS of TX Blue Essentials	$53.64
Rate for Payer: BCBS of TX Medicare	$14.39
Rate for Payer: BCBS of TX PPO	$59.60
Rate for Payer: Cash Price	$101.32
Rate for Payer: Cash Price	$101.32
Rate for Payer: Cigna Medicaid	$107.28
Rate for Payer: Cigna Medicare	$14.39
Rate for Payer: Employer Direct Commercial	$14.39
Rate for Payer: Humana Medicare/TRICARE	$14.39
Rate for Payer: Molina CHIP/Medicaid	$107.28
Rate for Payer: Molina Dual Medicare/Medicaid	$14.39
Rate for Payer: Molina Medicare	$14.39
Rate for Payer: Multiplan Auto	$96.85
Rate for Payer: Multiplan Commercial	$96.85
Rate for Payer: Multiplan Workers Comp	$96.85
Rate for Payer: Parkland Medicaid	$107.28
Rate for Payer: Scott and White EPO/PPO	$17.99
Rate for Payer: Scott and White Medicare	$14.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$107.28
Rate for Payer: Superior Health Plan EPO	$14.39
Rate for Payer: Superior Health Plan Medicare	$14.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.39
Rate for Payer: Universal American Medicare	$14.39
Rate for Payer: Wellcare Medicare	$14.39
Rate for Payer: Wellmed Medicare	$14.39

RUNTHROUGH NS EXTRA FLOPPY 180CM

Facility

$1,253.01

Hospital Charge Code	993162
Hospital Revenue Code	270
Min. Negotiated Rate	$112.77
Max. Negotiated Rate	$902.17
Rate for Payer: Amerigroup CHIP/Medicaid	$112.77
Rate for Payer: BCBS of TX Blue Advantage	$375.90
Rate for Payer: BCBS of TX Blue Essentials	$451.08
Rate for Payer: BCBS of TX PPO	$501.20
Rate for Payer: Cash Price	$852.05
Rate for Payer: Cigna Medicaid	$902.17
Rate for Payer: Molina CHIP/Medicaid	$902.17
Rate for Payer: Multiplan Auto	$814.46
Rate for Payer: Multiplan Commercial	$814.46
Rate for Payer: Multiplan Workers Comp	$814.46
Rate for Payer: Parkland Medicaid	$902.17
Rate for Payer: Scott and White EPO/PPO	$626.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$902.17
Rate for Payer: Superior Health Plan EPO	$170.41

RUNTHROUGH NS EXTRA FLOPPY 180CM

Facility

$1,253.01

Hospital Charge Code	993162
Hospital Revenue Code	270
Rate for Payer: Cash Price	$852.05

Rupture of Membrane

Facility

$540.00

Service Code	HCPCS 84112
Hospital Charge Code	1692010
Hospital Revenue Code	300
Rate for Payer: Cash Price	$367.20

Rupture of Membrane

Facility

$540.00

Service Code	HCPCS 84112
Hospital Charge Code	1692010
Hospital Revenue Code	300
Min. Negotiated Rate	$38.26
Max. Negotiated Rate	$388.80
Rate for Payer: Amerigroup CHIP/Medicaid	$38.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$98.11
Rate for Payer: Amerigroup Medicare	$98.11
Rate for Payer: BCBS of TX Blue Advantage	$162.00
Rate for Payer: BCBS of TX Blue Essentials	$194.40
Rate for Payer: BCBS of TX Medicare	$98.11
Rate for Payer: BCBS of TX PPO	$216.00
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cigna Medicaid	$388.80
Rate for Payer: Cigna Medicare	$98.11
Rate for Payer: Employer Direct Commercial	$98.11
Rate for Payer: Humana Medicare/TRICARE	$98.11
Rate for Payer: Molina CHIP/Medicaid	$388.80
Rate for Payer: Molina Dual Medicare/Medicaid	$98.11
Rate for Payer: Molina Medicare	$98.11
Rate for Payer: Multiplan Auto	$351.00
Rate for Payer: Multiplan Commercial	$351.00
Rate for Payer: Multiplan Workers Comp	$351.00
Rate for Payer: Parkland Medicaid	$388.80
Rate for Payer: Scott and White EPO/PPO	$122.64
Rate for Payer: Scott and White Medicare	$98.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$388.80
Rate for Payer: Superior Health Plan EPO	$98.11
Rate for Payer: Superior Health Plan Medicare	$98.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$98.11
Rate for Payer: Universal American Medicare	$98.11
Rate for Payer: Wellcare Medicare	$98.11
Rate for Payer: Wellmed Medicare	$98.11

Sabar .035 10x40 80cm SL

Facility

$567.50

Service Code	HCPCS C1887
Hospital Charge Code	992455
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

Sabar .035 10x40 80cm SL

Facility

$567.50

Service Code	HCPCS C1887
Hospital Charge Code	992455
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

Sabar .035 5x200 135cm SL

Facility

$612.90

Service Code	HCPCS C1726
Hospital Charge Code	992551
Hospital Revenue Code	272
Min. Negotiated Rate	$55.16
Max. Negotiated Rate	$441.29
Rate for Payer: Amerigroup CHIP/Medicaid	$55.16
Rate for Payer: BCBS of TX Blue Advantage	$183.87
Rate for Payer: BCBS of TX Blue Essentials	$220.64
Rate for Payer: BCBS of TX PPO	$245.16
Rate for Payer: Cash Price	$416.77
Rate for Payer: Cigna Medicaid	$441.29
Rate for Payer: Molina CHIP/Medicaid	$441.29
Rate for Payer: Multiplan Auto	$398.38
Rate for Payer: Multiplan Commercial	$398.38
Rate for Payer: Multiplan Workers Comp	$398.38
Rate for Payer: Parkland Medicaid	$441.29
Rate for Payer: Scott and White EPO/PPO	$306.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$441.29
Rate for Payer: Superior Health Plan EPO	$83.35

Sabar .035 5x200 135cm SL

Facility

$612.90

Service Code	HCPCS C1726
Hospital Charge Code	992551
Hospital Revenue Code	272
Rate for Payer: Cash Price	$416.77

Sabar .035 6x120 135cm SL

Facility

$612.90

Service Code	HCPCS C1887
Hospital Charge Code	992452
Hospital Revenue Code	272
Min. Negotiated Rate	$55.16
Max. Negotiated Rate	$441.29
Rate for Payer: Amerigroup CHIP/Medicaid	$55.16
Rate for Payer: BCBS of TX Blue Advantage	$183.87
Rate for Payer: BCBS of TX Blue Essentials	$220.64
Rate for Payer: BCBS of TX PPO	$245.16
Rate for Payer: Cash Price	$416.77
Rate for Payer: Cigna Medicaid	$441.29
Rate for Payer: Molina CHIP/Medicaid	$441.29
Rate for Payer: Multiplan Auto	$398.38
Rate for Payer: Multiplan Commercial	$398.38
Rate for Payer: Multiplan Workers Comp	$398.38
Rate for Payer: Parkland Medicaid	$441.29
Rate for Payer: Scott and White EPO/PPO	$306.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$441.29
Rate for Payer: Superior Health Plan EPO	$83.35

Sabar .035 6x120 135cm SL

Facility

$612.90

Service Code	HCPCS C1887
Hospital Charge Code	992452
Hospital Revenue Code	272
Rate for Payer: Cash Price	$416.77

Sabar .035 8x40 80cm SL

Facility

$567.50

Service Code	HCPCS C1887
Hospital Charge Code	992453
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

Sabar .035 8x40 80cm SL

Facility

$567.50

Service Code	HCPCS C1887
Hospital Charge Code	992453
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

SABER .014 PTA DILATION CATHETER 2.5MM X 8CM X 150CM

Facility

$867.87

Service Code	HCPCS C1726
Hospital Charge Code	992543
Hospital Revenue Code	272
Rate for Payer: Cash Price	$590.15

SABER .014 PTA DILATION CATHETER 2.5MM X 8CM X 150CM

Facility

$867.87

Service Code	HCPCS C1726
Hospital Charge Code	992543
Hospital Revenue Code	272
Min. Negotiated Rate	$78.11
Max. Negotiated Rate	$624.87
Rate for Payer: Amerigroup CHIP/Medicaid	$78.11
Rate for Payer: BCBS of TX Blue Advantage	$260.36
Rate for Payer: BCBS of TX Blue Essentials	$312.43
Rate for Payer: BCBS of TX PPO	$347.15
Rate for Payer: Cash Price	$590.15
Rate for Payer: Cigna Medicaid	$624.87
Rate for Payer: Molina CHIP/Medicaid	$624.87
Rate for Payer: Multiplan Auto	$564.12
Rate for Payer: Multiplan Commercial	$564.12
Rate for Payer: Multiplan Workers Comp	$564.12
Rate for Payer: Parkland Medicaid	$624.87
Rate for Payer: Scott and White EPO/PPO	$433.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$624.87
Rate for Payer: Superior Health Plan EPO	$118.03

SABER. 035 12X40 80CM SL

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992574
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

SABER. 035 12X40 80CM SL

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992574
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

Saber .035 8x60 80cm SL

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992563
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

Saber .035 8x60 80cm SL

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992563
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

SABER .035 9mm X 6cm

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992565
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

SABER .035 9mm X 6cm

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992565
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

SABER .035 PTA Dilatation Catheter 6x20x135

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992552
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

SABER .035 PTA Dilatation Catheter 6x20x135

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992552
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

SABER .035 PTA DILATION CATHETER 10MM X 6CM X 80CM

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992542
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

Know your out-of-pocket cost for care.

All Charges