White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SEALANT HEMOSTAT MATRIX -- DHF

Facility

$719.36

Hospital Charge Code	81770182
Hospital Revenue Code	272
Min. Negotiated Rate	$64.74
Max. Negotiated Rate	$517.94
Rate for Payer: Amerigroup CHIP/Medicaid	$64.74
Rate for Payer: BCBS of TX Blue Advantage	$215.81
Rate for Payer: BCBS of TX Blue Essentials	$258.97
Rate for Payer: BCBS of TX PPO	$287.74
Rate for Payer: Cash Price	$489.16
Rate for Payer: Cigna Medicaid	$517.94
Rate for Payer: Molina CHIP/Medicaid	$517.94
Rate for Payer: Multiplan Auto	$467.58
Rate for Payer: Multiplan Commercial	$467.58
Rate for Payer: Multiplan Workers Comp	$467.58
Rate for Payer: Parkland Medicaid	$517.94
Rate for Payer: Scott and White EPO/PPO	$359.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$517.94
Rate for Payer: Superior Health Plan EPO	$97.83

SEALANT VISTA SEAL 10ML

Facility

$2,416.64

Hospital Charge Code	8494509
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,643.32

SEALANT VISTA SEAL 10ML

Facility

$2,416.64

Hospital Charge Code	8494509
Hospital Revenue Code	272
Min. Negotiated Rate	$217.50
Max. Negotiated Rate	$1,739.98
Rate for Payer: Amerigroup CHIP/Medicaid	$217.50
Rate for Payer: BCBS of TX Blue Advantage	$724.99
Rate for Payer: BCBS of TX Blue Essentials	$869.99
Rate for Payer: BCBS of TX PPO	$966.66
Rate for Payer: Cash Price	$1,643.32
Rate for Payer: Cigna Medicaid	$1,739.98
Rate for Payer: Molina CHIP/Medicaid	$1,739.98
Rate for Payer: Multiplan Auto	$1,570.82
Rate for Payer: Multiplan Commercial	$1,570.82
Rate for Payer: Multiplan Workers Comp	$1,570.82
Rate for Payer: Parkland Medicaid	$1,739.98
Rate for Payer: Scott and White EPO/PPO	$1,208.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,739.98
Rate for Payer: Superior Health Plan EPO	$328.66

SEAL CANNULA DAVINCI UNIVERSAL 5-12

Facility

$908.00

Hospital Charge Code	992734
Hospital Revenue Code	270
Min. Negotiated Rate	$81.72
Max. Negotiated Rate	$653.76
Rate for Payer: Amerigroup CHIP/Medicaid	$81.72
Rate for Payer: BCBS of TX Blue Advantage	$272.40
Rate for Payer: BCBS of TX Blue Essentials	$326.88
Rate for Payer: BCBS of TX PPO	$363.20
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cigna Medicaid	$653.76
Rate for Payer: Molina CHIP/Medicaid	$653.76
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$653.76
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$653.76
Rate for Payer: Superior Health Plan EPO	$123.49

SEAL CANNULA DAVINCI UNIVERSAL 5-12

Facility

$908.00

Hospital Charge Code	992734
Hospital Revenue Code	270
Rate for Payer: Cash Price	$617.44

SEAL CANNULA STAPLER 12MM

Facility

$90.80

Hospital Charge Code	8690508
Hospital Revenue Code	272
Rate for Payer: Cash Price	$61.74

SEAL CANNULA STAPLER 12MM

Facility

$90.80

Hospital Charge Code	8690508
Hospital Revenue Code	272
Min. Negotiated Rate	$8.17
Max. Negotiated Rate	$65.38
Rate for Payer: Amerigroup CHIP/Medicaid	$8.17
Rate for Payer: BCBS of TX Blue Advantage	$27.24
Rate for Payer: BCBS of TX Blue Essentials	$32.69
Rate for Payer: BCBS of TX PPO	$36.32
Rate for Payer: Cash Price	$61.74
Rate for Payer: Cigna Medicaid	$65.38
Rate for Payer: Molina CHIP/Medicaid	$65.38
Rate for Payer: Multiplan Auto	$59.02
Rate for Payer: Multiplan Commercial	$59.02
Rate for Payer: Multiplan Workers Comp	$59.02
Rate for Payer: Parkland Medicaid	$65.38
Rate for Payer: Scott and White EPO/PPO	$45.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.38
Rate for Payer: Superior Health Plan EPO	$12.35

seal cannula univ 5-8 mm

Facility

$81.72

Hospital Charge Code	8690513
Hospital Revenue Code	272
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$58.84
Rate for Payer: Amerigroup CHIP/Medicaid	$7.35
Rate for Payer: BCBS of TX Blue Advantage	$24.52
Rate for Payer: BCBS of TX Blue Essentials	$29.42
Rate for Payer: BCBS of TX PPO	$32.69
Rate for Payer: Cash Price	$55.57
Rate for Payer: Cigna Medicaid	$58.84
Rate for Payer: Molina CHIP/Medicaid	$58.84
Rate for Payer: Multiplan Auto	$53.12
Rate for Payer: Multiplan Commercial	$53.12
Rate for Payer: Multiplan Workers Comp	$53.12
Rate for Payer: Parkland Medicaid	$58.84
Rate for Payer: Scott and White EPO/PPO	$40.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$58.84
Rate for Payer: Superior Health Plan EPO	$11.11

seal cannula univ 5-8 mm

Facility

$81.72

Hospital Charge Code	8690513
Hospital Revenue Code	272
Rate for Payer: Cash Price	$55.57

SEAL DAVINCI UNIVERSAL 5-12

Facility

$908.00

Hospital Charge Code	992735
Hospital Revenue Code	270
Rate for Payer: Cash Price	$617.44

SEAL DAVINCI UNIVERSAL 5-12

Facility

$908.00

Hospital Charge Code	992735
Hospital Revenue Code	270
Min. Negotiated Rate	$81.72
Max. Negotiated Rate	$653.76
Rate for Payer: Amerigroup CHIP/Medicaid	$81.72
Rate for Payer: BCBS of TX Blue Advantage	$272.40
Rate for Payer: BCBS of TX Blue Essentials	$326.88
Rate for Payer: BCBS of TX PPO	$363.20
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cigna Medicaid	$653.76
Rate for Payer: Molina CHIP/Medicaid	$653.76
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$653.76
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$653.76
Rate for Payer: Superior Health Plan EPO	$123.49

SEALER, BIPOLAR TISSUE W/SALINE AQUAMANTYS 6.0 -- DHF

Facility

$2,527.23

Hospital Charge Code	81856353
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,718.52

SEALER, BIPOLAR TISSUE W/SALINE AQUAMANTYS 6.0 -- DHF

Facility

$2,527.23

Hospital Charge Code	81856353
Hospital Revenue Code	272
Min. Negotiated Rate	$227.45
Max. Negotiated Rate	$1,819.61
Rate for Payer: Amerigroup CHIP/Medicaid	$227.45
Rate for Payer: BCBS of TX Blue Advantage	$758.17
Rate for Payer: BCBS of TX Blue Essentials	$909.80
Rate for Payer: BCBS of TX PPO	$1,010.89
Rate for Payer: Cash Price	$1,718.52
Rate for Payer: Cigna Medicaid	$1,819.61
Rate for Payer: Molina CHIP/Medicaid	$1,819.61
Rate for Payer: Multiplan Auto	$1,642.70
Rate for Payer: Multiplan Commercial	$1,642.70
Rate for Payer: Multiplan Workers Comp	$1,642.70
Rate for Payer: Parkland Medicaid	$1,819.61
Rate for Payer: Scott and White EPO/PPO	$1,263.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,819.61
Rate for Payer: Superior Health Plan EPO	$343.70

sealer vessel extend

Facility

$2,837.50

Hospital Charge Code	8690511
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,929.50

sealer vessel extend

Facility

$2,837.50

Hospital Charge Code	8690511
Hospital Revenue Code	272
Min. Negotiated Rate	$255.38
Max. Negotiated Rate	$2,043.00
Rate for Payer: Amerigroup CHIP/Medicaid	$255.38
Rate for Payer: BCBS of TX Blue Advantage	$851.25
Rate for Payer: BCBS of TX Blue Essentials	$1,021.50
Rate for Payer: BCBS of TX PPO	$1,135.00
Rate for Payer: Cash Price	$1,929.50
Rate for Payer: Cigna Medicaid	$2,043.00
Rate for Payer: Molina CHIP/Medicaid	$2,043.00
Rate for Payer: Multiplan Auto	$1,844.38
Rate for Payer: Multiplan Commercial	$1,844.38
Rate for Payer: Multiplan Workers Comp	$1,844.38
Rate for Payer: Parkland Medicaid	$2,043.00
Rate for Payer: Scott and White EPO/PPO	$1,418.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,043.00
Rate for Payer: Superior Health Plan EPO	$385.90

SEAL, PULL-TITE II, GREEN, NO NMBRS

Facility

$1.28

Hospital Charge Code	993244
Hospital Revenue Code	270
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.92
Rate for Payer: Amerigroup CHIP/Medicaid	$0.12
Rate for Payer: BCBS of TX Blue Advantage	$0.38
Rate for Payer: BCBS of TX Blue Essentials	$0.46
Rate for Payer: BCBS of TX PPO	$0.51
Rate for Payer: Cash Price	$0.87
Rate for Payer: Cigna Medicaid	$0.92
Rate for Payer: Molina CHIP/Medicaid	$0.92
Rate for Payer: Multiplan Auto	$0.83
Rate for Payer: Multiplan Commercial	$0.83
Rate for Payer: Multiplan Workers Comp	$0.83
Rate for Payer: Parkland Medicaid	$0.92
Rate for Payer: Scott and White EPO/PPO	$0.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.92
Rate for Payer: Superior Health Plan EPO	$0.17

SEAL, PULL-TITE II, GREEN, NO NMBRS

Facility

$1.28

Hospital Charge Code	993244
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.87

SEAL SHEARS HOT MCS

Facility

$15,254.40

Hospital Charge Code	992729
Hospital Revenue Code	270
Min. Negotiated Rate	$1,372.90
Max. Negotiated Rate	$10,983.17
Rate for Payer: Amerigroup CHIP/Medicaid	$1,372.90
Rate for Payer: BCBS of TX Blue Advantage	$4,576.32
Rate for Payer: BCBS of TX Blue Essentials	$5,491.58
Rate for Payer: BCBS of TX PPO	$6,101.76
Rate for Payer: Cash Price	$10,372.99
Rate for Payer: Cigna Medicaid	$10,983.17
Rate for Payer: Molina CHIP/Medicaid	$10,983.17
Rate for Payer: Multiplan Auto	$9,915.36
Rate for Payer: Multiplan Commercial	$9,915.36
Rate for Payer: Multiplan Workers Comp	$9,915.36
Rate for Payer: Parkland Medicaid	$10,983.17
Rate for Payer: Scott and White EPO/PPO	$7,627.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,983.17
Rate for Payer: Superior Health Plan EPO	$2,074.60

SEAL SHEARS HOT MCS

Facility

$15,254.40

Hospital Charge Code	992729
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10,372.99

SEAMGARD

Facility

$1,032.83

Hospital Charge Code	992367
Hospital Revenue Code	272
Rate for Payer: Cash Price	$702.32

SEAMGARD

Facility

$1,032.83

Hospital Charge Code	992367
Hospital Revenue Code	272
Min. Negotiated Rate	$92.95
Max. Negotiated Rate	$743.64
Rate for Payer: Amerigroup CHIP/Medicaid	$92.95
Rate for Payer: BCBS of TX Blue Advantage	$309.85
Rate for Payer: BCBS of TX Blue Essentials	$371.82
Rate for Payer: BCBS of TX PPO	$413.13
Rate for Payer: Cash Price	$702.32
Rate for Payer: Cigna Medicaid	$743.64
Rate for Payer: Molina CHIP/Medicaid	$743.64
Rate for Payer: Multiplan Auto	$671.34
Rate for Payer: Multiplan Commercial	$671.34
Rate for Payer: Multiplan Workers Comp	$671.34
Rate for Payer: Parkland Medicaid	$743.64
Rate for Payer: Scott and White EPO/PPO	$516.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$743.64
Rate for Payer: Superior Health Plan EPO	$140.46

Seamguard

Facility

$873.49

Hospital Charge Code	992303
Hospital Revenue Code	272
Rate for Payer: Cash Price	$593.97

Seamguard

Facility

$873.49

Hospital Charge Code	992303
Hospital Revenue Code	272
Min. Negotiated Rate	$78.61
Max. Negotiated Rate	$628.91
Rate for Payer: Amerigroup CHIP/Medicaid	$78.61
Rate for Payer: BCBS of TX Blue Advantage	$262.05
Rate for Payer: BCBS of TX Blue Essentials	$314.46
Rate for Payer: BCBS of TX PPO	$349.40
Rate for Payer: Cash Price	$593.97
Rate for Payer: Cigna Medicaid	$628.91
Rate for Payer: Molina CHIP/Medicaid	$628.91
Rate for Payer: Multiplan Auto	$567.77
Rate for Payer: Multiplan Commercial	$567.77
Rate for Payer: Multiplan Workers Comp	$567.77
Rate for Payer: Parkland Medicaid	$628.91
Rate for Payer: Scott and White EPO/PPO	$436.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$628.91
Rate for Payer: Superior Health Plan EPO	$118.79

SEATTLE PAP PLUS

Facility

$249.43

Hospital Charge Code	993558
Hospital Revenue Code	270
Min. Negotiated Rate	$22.45
Max. Negotiated Rate	$179.59
Rate for Payer: Amerigroup CHIP/Medicaid	$22.45
Rate for Payer: BCBS of TX Blue Advantage	$74.83
Rate for Payer: BCBS of TX Blue Essentials	$89.79
Rate for Payer: BCBS of TX PPO	$99.77
Rate for Payer: Cash Price	$169.61
Rate for Payer: Cigna Medicaid	$179.59
Rate for Payer: Molina CHIP/Medicaid	$179.59
Rate for Payer: Multiplan Auto	$162.13
Rate for Payer: Multiplan Commercial	$162.13
Rate for Payer: Multiplan Workers Comp	$162.13
Rate for Payer: Parkland Medicaid	$179.59
Rate for Payer: Scott and White EPO/PPO	$124.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$179.59
Rate for Payer: Superior Health Plan EPO	$33.92

SEATTLE PAP PLUS

Facility

$249.43

Hospital Charge Code	993558
Hospital Revenue Code	270
Rate for Payer: Cash Price	$169.61

Know your out-of-pocket cost for care.

All Charges