White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Salvation 160mm ring slotted

Facility

$7,686.22

Service Code	HCPCS C1713
Hospital Charge Code	993391
Hospital Revenue Code	278
Min. Negotiated Rate	$691.76
Max. Negotiated Rate	$5,534.08
Rate for Payer: Amerigroup CHIP/Medicaid	$691.76
Rate for Payer: BCBS of TX Blue Advantage	$2,305.87
Rate for Payer: BCBS of TX Blue Essentials	$2,767.04
Rate for Payer: BCBS of TX PPO	$3,074.49
Rate for Payer: Cash Price	$5,226.63
Rate for Payer: Cigna Medicaid	$5,534.08
Rate for Payer: Molina CHIP/Medicaid	$5,534.08
Rate for Payer: Multiplan Auto	$3,843.11
Rate for Payer: Multiplan Commercial	$3,843.11
Rate for Payer: Multiplan Workers Comp	$3,843.11
Rate for Payer: Parkland Medicaid	$5,534.08
Rate for Payer: Scott and White EPO/PPO	$3,843.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,534.08
Rate for Payer: Superior Health Plan EPO	$1,045.33

Salvation 160mm ring slotted

Facility

$7,686.22

Service Code	HCPCS C1713
Hospital Charge Code	993391
Hospital Revenue Code	278
Min. Negotiated Rate	$1,921.56
Max. Negotiated Rate	$3,843.11
Rate for Payer: Cash Price	$5,226.63
Rate for Payer: Cigna Commercial	$1,921.56
Rate for Payer: Multiplan Auto	$3,843.11
Rate for Payer: Multiplan Commercial	$3,843.11
Rate for Payer: Multiplan Workers Comp	$3,843.11
Rate for Payer: Scott and White EPO/PPO	$3,843.11

SALVATION 180MM FOOT RING SLOTTED

Facility

$13,965.04

Service Code	HCPCS C1713
Hospital Charge Code	993163
Hospital Revenue Code	278
Min. Negotiated Rate	$1,256.85
Max. Negotiated Rate	$10,054.83
Rate for Payer: Amerigroup CHIP/Medicaid	$1,256.85
Rate for Payer: BCBS of TX Blue Advantage	$4,189.51
Rate for Payer: BCBS of TX Blue Essentials	$5,027.41
Rate for Payer: BCBS of TX PPO	$5,586.02
Rate for Payer: Cash Price	$9,496.23
Rate for Payer: Cigna Medicaid	$10,054.83
Rate for Payer: Molina CHIP/Medicaid	$10,054.83
Rate for Payer: Multiplan Auto	$6,982.52
Rate for Payer: Multiplan Commercial	$6,982.52
Rate for Payer: Multiplan Workers Comp	$6,982.52
Rate for Payer: Parkland Medicaid	$10,054.83
Rate for Payer: Scott and White EPO/PPO	$6,982.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,054.83
Rate for Payer: Superior Health Plan EPO	$1,899.25

SALVATION 180MM FOOT RING SLOTTED

Facility

$13,965.04

Service Code	HCPCS C1713
Hospital Charge Code	993163
Hospital Revenue Code	278
Min. Negotiated Rate	$3,491.26
Max. Negotiated Rate	$6,982.52
Rate for Payer: Cash Price	$9,496.23
Rate for Payer: Cigna Commercial	$3,491.26
Rate for Payer: Multiplan Auto	$6,982.52
Rate for Payer: Multiplan Commercial	$6,982.52
Rate for Payer: Multiplan Workers Comp	$6,982.52
Rate for Payer: Scott and White EPO/PPO	$6,982.52

Salvation 30mm spacer

Facility

$680.72

Service Code	HCPCS C1776
Hospital Charge Code	992206
Hospital Revenue Code	278
Min. Negotiated Rate	$61.26
Max. Negotiated Rate	$490.12
Rate for Payer: Amerigroup CHIP/Medicaid	$61.26
Rate for Payer: BCBS of TX Blue Advantage	$204.22
Rate for Payer: BCBS of TX Blue Essentials	$245.06
Rate for Payer: BCBS of TX PPO	$272.29
Rate for Payer: Cash Price	$462.89
Rate for Payer: Cigna Medicaid	$490.12
Rate for Payer: Molina CHIP/Medicaid	$490.12
Rate for Payer: Multiplan Auto	$340.36
Rate for Payer: Multiplan Commercial	$340.36
Rate for Payer: Multiplan Workers Comp	$340.36
Rate for Payer: Parkland Medicaid	$490.12
Rate for Payer: Scott and White EPO/PPO	$340.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$490.12
Rate for Payer: Superior Health Plan EPO	$92.58

Salvation 30mm spacer

Facility

$680.72

Service Code	HCPCS C1776
Hospital Charge Code	992206
Hospital Revenue Code	278
Min. Negotiated Rate	$170.18
Max. Negotiated Rate	$340.36
Rate for Payer: Cash Price	$462.89
Rate for Payer: Cigna Commercial	$170.18
Rate for Payer: Multiplan Auto	$340.36
Rate for Payer: Multiplan Commercial	$340.36
Rate for Payer: Multiplan Workers Comp	$340.36
Rate for Payer: Scott and White EPO/PPO	$340.36

Salvation 60mm spacer

Facility

$771.08

Service Code	HCPCS C1776
Hospital Charge Code	992207
Hospital Revenue Code	278
Min. Negotiated Rate	$192.77
Max. Negotiated Rate	$385.54
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cigna Commercial	$192.77
Rate for Payer: Multiplan Auto	$385.54
Rate for Payer: Multiplan Commercial	$385.54
Rate for Payer: Multiplan Workers Comp	$385.54
Rate for Payer: Scott and White EPO/PPO	$385.54

Salvation 60mm spacer

Facility

$771.08

Service Code	HCPCS C1776
Hospital Charge Code	992207
Hospital Revenue Code	278
Min. Negotiated Rate	$69.40
Max. Negotiated Rate	$555.18
Rate for Payer: Amerigroup CHIP/Medicaid	$69.40
Rate for Payer: BCBS of TX Blue Advantage	$231.32
Rate for Payer: BCBS of TX Blue Essentials	$277.59
Rate for Payer: BCBS of TX PPO	$308.43
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cigna Medicaid	$555.18
Rate for Payer: Molina CHIP/Medicaid	$555.18
Rate for Payer: Multiplan Auto	$385.54
Rate for Payer: Multiplan Commercial	$385.54
Rate for Payer: Multiplan Workers Comp	$385.54
Rate for Payer: Parkland Medicaid	$555.18
Rate for Payer: Scott and White EPO/PPO	$385.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$555.18
Rate for Payer: Superior Health Plan EPO	$104.87

Salvation 80mm spacer

Facility

$649.22

Hospital Charge Code	993395
Hospital Revenue Code	272
Rate for Payer: Cash Price	$441.47

Salvation 80mm spacer

Facility

$649.22

Hospital Charge Code	993395
Hospital Revenue Code	272
Min. Negotiated Rate	$58.43
Max. Negotiated Rate	$467.44
Rate for Payer: Amerigroup CHIP/Medicaid	$58.43
Rate for Payer: BCBS of TX Blue Advantage	$194.77
Rate for Payer: BCBS of TX Blue Essentials	$233.72
Rate for Payer: BCBS of TX PPO	$259.69
Rate for Payer: Cash Price	$441.47
Rate for Payer: Cigna Medicaid	$467.44
Rate for Payer: Molina CHIP/Medicaid	$467.44
Rate for Payer: Multiplan Auto	$421.99
Rate for Payer: Multiplan Commercial	$421.99
Rate for Payer: Multiplan Workers Comp	$421.99
Rate for Payer: Parkland Medicaid	$467.44
Rate for Payer: Scott and White EPO/PPO	$324.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$467.44
Rate for Payer: Superior Health Plan EPO	$88.29

Salvation Nut 10mm

Facility

$195.22

Hospital Charge Code	993394
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

Salvation Nut 10mm

Facility

$195.22

Hospital Charge Code	993394
Hospital Revenue Code	272
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$140.56
Rate for Payer: Amerigroup CHIP/Medicaid	$17.57
Rate for Payer: BCBS of TX Blue Advantage	$58.57
Rate for Payer: BCBS of TX Blue Essentials	$70.28
Rate for Payer: BCBS of TX PPO	$78.09
Rate for Payer: Cash Price	$132.75
Rate for Payer: Cigna Medicaid	$140.56
Rate for Payer: Molina CHIP/Medicaid	$140.56
Rate for Payer: Multiplan Auto	$126.89
Rate for Payer: Multiplan Commercial	$126.89
Rate for Payer: Multiplan Workers Comp	$126.89
Rate for Payer: Parkland Medicaid	$140.56
Rate for Payer: Scott and White EPO/PPO	$97.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.56
Rate for Payer: Superior Health Plan EPO	$26.55

Salvation open rocker plate

Facility

$13,374.84

Service Code	HCPCS C1713
Hospital Charge Code	993389
Hospital Revenue Code	278
Min. Negotiated Rate	$1,203.74
Max. Negotiated Rate	$9,629.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1,203.74
Rate for Payer: BCBS of TX Blue Advantage	$4,012.45
Rate for Payer: BCBS of TX Blue Essentials	$4,814.94
Rate for Payer: BCBS of TX PPO	$5,349.94
Rate for Payer: Cash Price	$9,094.89
Rate for Payer: Cigna Medicaid	$9,629.88
Rate for Payer: Molina CHIP/Medicaid	$9,629.88
Rate for Payer: Multiplan Auto	$6,687.42
Rate for Payer: Multiplan Commercial	$6,687.42
Rate for Payer: Multiplan Workers Comp	$6,687.42
Rate for Payer: Parkland Medicaid	$9,629.88
Rate for Payer: Scott and White EPO/PPO	$6,687.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,629.88
Rate for Payer: Superior Health Plan EPO	$1,818.98

Salvation open rocker plate

Facility

$13,374.84

Service Code	HCPCS C1713
Hospital Charge Code	993389
Hospital Revenue Code	278
Min. Negotiated Rate	$3,343.71
Max. Negotiated Rate	$6,687.42
Rate for Payer: Cash Price	$9,094.89
Rate for Payer: Cigna Commercial	$3,343.71
Rate for Payer: Multiplan Auto	$6,687.42
Rate for Payer: Multiplan Commercial	$6,687.42
Rate for Payer: Multiplan Workers Comp	$6,687.42
Rate for Payer: Scott and White EPO/PPO	$6,687.42

SALVATION T25 DRIVER CANNULATED

Facility

$2,238.22

Hospital Charge Code	993517
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,521.99

SALVATION T25 DRIVER CANNULATED

Facility

$2,238.22

Hospital Charge Code	993517
Hospital Revenue Code	272
Min. Negotiated Rate	$201.44
Max. Negotiated Rate	$1,611.52
Rate for Payer: Amerigroup CHIP/Medicaid	$201.44
Rate for Payer: BCBS of TX Blue Advantage	$671.47
Rate for Payer: BCBS of TX Blue Essentials	$805.76
Rate for Payer: BCBS of TX PPO	$895.29
Rate for Payer: Cash Price	$1,521.99
Rate for Payer: Cigna Medicaid	$1,611.52
Rate for Payer: Molina CHIP/Medicaid	$1,611.52
Rate for Payer: Multiplan Auto	$1,454.84
Rate for Payer: Multiplan Commercial	$1,454.84
Rate for Payer: Multiplan Workers Comp	$1,454.84
Rate for Payer: Parkland Medicaid	$1,611.52
Rate for Payer: Scott and White EPO/PPO	$1,119.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,611.52
Rate for Payer: Superior Health Plan EPO	$304.40

SALVATION WIRE BOLT 2 MM PREASSEMBLED

Facility

$1,489.12

Hospital Charge Code	993445
Hospital Revenue Code	272
Min. Negotiated Rate	$134.02
Max. Negotiated Rate	$1,072.17
Rate for Payer: Amerigroup CHIP/Medicaid	$134.02
Rate for Payer: BCBS of TX Blue Advantage	$446.74
Rate for Payer: BCBS of TX Blue Essentials	$536.08
Rate for Payer: BCBS of TX PPO	$595.65
Rate for Payer: Cash Price	$1,012.60
Rate for Payer: Cigna Medicaid	$1,072.17
Rate for Payer: Molina CHIP/Medicaid	$1,072.17
Rate for Payer: Multiplan Auto	$967.93
Rate for Payer: Multiplan Commercial	$967.93
Rate for Payer: Multiplan Workers Comp	$967.93
Rate for Payer: Parkland Medicaid	$1,072.17
Rate for Payer: Scott and White EPO/PPO	$744.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,072.17
Rate for Payer: Superior Health Plan EPO	$202.52

SALVATION WIRE BOLT 2 MM PREASSEMBLED

Facility

$1,489.12

Hospital Charge Code	993445
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,012.60

Salvation wire bolt 2mm preassembled washerless

Facility

$1,507.28

Hospital Charge Code	993392
Hospital Revenue Code	272
Min. Negotiated Rate	$135.66
Max. Negotiated Rate	$1,085.24
Rate for Payer: Amerigroup CHIP/Medicaid	$135.66
Rate for Payer: BCBS of TX Blue Advantage	$452.18
Rate for Payer: BCBS of TX Blue Essentials	$542.62
Rate for Payer: BCBS of TX PPO	$602.91
Rate for Payer: Cash Price	$1,024.95
Rate for Payer: Cigna Medicaid	$1,085.24
Rate for Payer: Molina CHIP/Medicaid	$1,085.24
Rate for Payer: Multiplan Auto	$979.73
Rate for Payer: Multiplan Commercial	$979.73
Rate for Payer: Multiplan Workers Comp	$979.73
Rate for Payer: Parkland Medicaid	$1,085.24
Rate for Payer: Scott and White EPO/PPO	$753.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,085.24
Rate for Payer: Superior Health Plan EPO	$204.99

Salvation wire bolt 2mm preassembled washerless

Facility

$1,507.28

Hospital Charge Code	993392
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,024.95

SANITIZER HAND FOAM SPECTRUM DISP 1000ML

Facility

$56.26

Hospital Charge Code	993273
Hospital Revenue Code	270
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$40.51
Rate for Payer: Amerigroup CHIP/Medicaid	$5.06
Rate for Payer: BCBS of TX Blue Advantage	$16.88
Rate for Payer: BCBS of TX Blue Essentials	$20.25
Rate for Payer: BCBS of TX PPO	$22.50
Rate for Payer: Cash Price	$38.26
Rate for Payer: Cigna Medicaid	$40.51
Rate for Payer: Molina CHIP/Medicaid	$40.51
Rate for Payer: Multiplan Auto	$36.57
Rate for Payer: Multiplan Commercial	$36.57
Rate for Payer: Multiplan Workers Comp	$36.57
Rate for Payer: Parkland Medicaid	$40.51
Rate for Payer: Scott and White EPO/PPO	$28.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.51
Rate for Payer: Superior Health Plan EPO	$7.65

SANITIZER HAND FOAM SPECTRUM DISP 1000ML

Facility

$56.26

Hospital Charge Code	993273
Hospital Revenue Code	270
Rate for Payer: Cash Price	$38.26

Saphenous vein

Facility

$66,114.46

Service Code	HCPCS C1768
Hospital Charge Code	992352
Hospital Revenue Code	278
Min. Negotiated Rate	$5,950.30
Max. Negotiated Rate	$47,602.41
Rate for Payer: Amerigroup CHIP/Medicaid	$5,950.30
Rate for Payer: BCBS of TX Blue Advantage	$19,834.34
Rate for Payer: BCBS of TX Blue Essentials	$23,801.21
Rate for Payer: BCBS of TX PPO	$26,445.78
Rate for Payer: Cash Price	$44,957.83
Rate for Payer: Cigna Medicaid	$47,602.41
Rate for Payer: Molina CHIP/Medicaid	$47,602.41
Rate for Payer: Multiplan Auto	$33,057.23
Rate for Payer: Multiplan Commercial	$33,057.23
Rate for Payer: Multiplan Workers Comp	$33,057.23
Rate for Payer: Parkland Medicaid	$47,602.41
Rate for Payer: Scott and White EPO/PPO	$33,057.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47,602.41
Rate for Payer: Superior Health Plan EPO	$8,991.57

Saphenous vein

Facility

$66,114.46

Service Code	HCPCS C1768
Hospital Charge Code	992352
Hospital Revenue Code	278
Min. Negotiated Rate	$16,528.62
Max. Negotiated Rate	$33,057.23
Rate for Payer: Cash Price	$44,957.83
Rate for Payer: Cigna Commercial	$16,528.62
Rate for Payer: Multiplan Auto	$33,057.23
Rate for Payer: Multiplan Commercial	$33,057.23
Rate for Payer: Multiplan Workers Comp	$33,057.23
Rate for Payer: Scott and White EPO/PPO	$33,057.23

SARS-CoV-2

Facility

$165.52

Service Code	HCPCS 87811
Hospital Charge Code	994062
Hospital Revenue Code	301
Rate for Payer: Cash Price	$112.55

Know your out-of-pocket cost for care.

All Charges