White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SET EPIDURAL NON VENT

Facility

$29.51

Hospital Charge Code	8528471
Hospital Revenue Code	272
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$21.25
Rate for Payer: Amerigroup CHIP/Medicaid	$2.66
Rate for Payer: BCBS of TX Blue Advantage	$8.85
Rate for Payer: BCBS of TX Blue Essentials	$10.62
Rate for Payer: BCBS of TX PPO	$11.80
Rate for Payer: Cash Price	$20.07
Rate for Payer: Cigna Medicaid	$21.25
Rate for Payer: Molina CHIP/Medicaid	$21.25
Rate for Payer: Multiplan Auto	$19.18
Rate for Payer: Multiplan Commercial	$19.18
Rate for Payer: Multiplan Workers Comp	$19.18
Rate for Payer: Parkland Medicaid	$21.25
Rate for Payer: Scott and White EPO/PPO	$14.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.25
Rate for Payer: Superior Health Plan EPO	$4.01

SET EPIDURAL VENTED NV SPIKE

Facility

$40.04

Hospital Charge Code	8528472
Hospital Revenue Code	272
Rate for Payer: Cash Price	$27.23

SET EPIDURAL VENTED NV SPIKE

Facility

$40.04

Hospital Charge Code	8528472
Hospital Revenue Code	272
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$28.83
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.01
Rate for Payer: BCBS of TX Blue Essentials	$14.41
Rate for Payer: BCBS of TX PPO	$16.02
Rate for Payer: Cash Price	$27.23
Rate for Payer: Cigna Medicaid	$28.83
Rate for Payer: Molina CHIP/Medicaid	$28.83
Rate for Payer: Multiplan Auto	$26.03
Rate for Payer: Multiplan Commercial	$26.03
Rate for Payer: Multiplan Workers Comp	$26.03
Rate for Payer: Parkland Medicaid	$28.83
Rate for Payer: Scott and White EPO/PPO	$20.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.83
Rate for Payer: Superior Health Plan EPO	$5.45

SET EXTENSION SMALLBORE LUER LOCK NON-REM 6 L

Facility

$8.11

Hospital Charge Code	993210
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.51

SET EXTENSION SMALLBORE LUER LOCK NON-REM 6 L

Facility

$8.11

Hospital Charge Code	993210
Hospital Revenue Code	270
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$5.84
Rate for Payer: Amerigroup CHIP/Medicaid	$0.73
Rate for Payer: BCBS of TX Blue Advantage	$2.43
Rate for Payer: BCBS of TX Blue Essentials	$2.92
Rate for Payer: BCBS of TX PPO	$3.24
Rate for Payer: Cash Price	$5.51
Rate for Payer: Cigna Medicaid	$5.84
Rate for Payer: Molina CHIP/Medicaid	$5.84
Rate for Payer: Multiplan Auto	$5.27
Rate for Payer: Multiplan Commercial	$5.27
Rate for Payer: Multiplan Workers Comp	$5.27
Rate for Payer: Parkland Medicaid	$5.84
Rate for Payer: Scott and White EPO/PPO	$4.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.84
Rate for Payer: Superior Health Plan EPO	$1.10

SET, EXTENSION SMALL BORE LUER LOCK W/CLAMP 72' L -- DHF

Facility

$59.39

Hospital Charge Code	54200787
Hospital Revenue Code	270
Rate for Payer: Cash Price	$40.39

SET, EXTENSION SMALL BORE LUER LOCK W/CLAMP 72' L -- DHF

Facility

$59.39

Hospital Charge Code	54200787
Hospital Revenue Code	270
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$42.76
Rate for Payer: Amerigroup CHIP/Medicaid	$5.35
Rate for Payer: BCBS of TX Blue Advantage	$17.82
Rate for Payer: BCBS of TX Blue Essentials	$21.38
Rate for Payer: BCBS of TX PPO	$23.76
Rate for Payer: Cash Price	$40.39
Rate for Payer: Cigna Medicaid	$42.76
Rate for Payer: Molina CHIP/Medicaid	$42.76
Rate for Payer: Multiplan Auto	$38.60
Rate for Payer: Multiplan Commercial	$38.60
Rate for Payer: Multiplan Workers Comp	$38.60
Rate for Payer: Parkland Medicaid	$42.76
Rate for Payer: Scott and White EPO/PPO	$29.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.76
Rate for Payer: Superior Health Plan EPO	$8.08

SET, EXTENSION, W/2 CARESITES

Facility

$11.02

Hospital Charge Code	992974
Hospital Revenue Code	270
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$7.93
Rate for Payer: Amerigroup CHIP/Medicaid	$0.99
Rate for Payer: BCBS of TX Blue Advantage	$3.31
Rate for Payer: BCBS of TX Blue Essentials	$3.97
Rate for Payer: BCBS of TX PPO	$4.41
Rate for Payer: Cash Price	$7.49
Rate for Payer: Cigna Medicaid	$7.93
Rate for Payer: Molina CHIP/Medicaid	$7.93
Rate for Payer: Multiplan Auto	$7.16
Rate for Payer: Multiplan Commercial	$7.16
Rate for Payer: Multiplan Workers Comp	$7.16
Rate for Payer: Parkland Medicaid	$7.93
Rate for Payer: Scott and White EPO/PPO	$5.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.93
Rate for Payer: Superior Health Plan EPO	$1.50

SET, EXTENSION, W/2 CARESITES

Facility

$11.02

Hospital Charge Code	992974
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.49

SET, EXTEN TRIPORT NDLSS VALVE

Facility

$14.30

Hospital Charge Code	8592511
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.72

SET, EXTEN TRIPORT NDLSS VALVE

Facility

$14.30

Hospital Charge Code	8592511
Hospital Revenue Code	272
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$10.30
Rate for Payer: Amerigroup CHIP/Medicaid	$1.29
Rate for Payer: BCBS of TX Blue Advantage	$4.29
Rate for Payer: BCBS of TX Blue Essentials	$5.15
Rate for Payer: BCBS of TX PPO	$5.72
Rate for Payer: Cash Price	$9.72
Rate for Payer: Cigna Medicaid	$10.30
Rate for Payer: Molina CHIP/Medicaid	$10.30
Rate for Payer: Multiplan Auto	$9.29
Rate for Payer: Multiplan Commercial	$9.29
Rate for Payer: Multiplan Workers Comp	$9.29
Rate for Payer: Parkland Medicaid	$10.30
Rate for Payer: Scott and White EPO/PPO	$7.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.30
Rate for Payer: Superior Health Plan EPO	$1.94

set ext standard bore

Facility

$9.26

Hospital Charge Code	110771
Hospital Revenue Code	270
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$6.67
Rate for Payer: Amerigroup CHIP/Medicaid	$0.83
Rate for Payer: BCBS of TX Blue Advantage	$2.78
Rate for Payer: BCBS of TX Blue Essentials	$3.33
Rate for Payer: BCBS of TX PPO	$3.70
Rate for Payer: Cash Price	$6.30
Rate for Payer: Cigna Medicaid	$6.67
Rate for Payer: Molina CHIP/Medicaid	$6.67
Rate for Payer: Multiplan Auto	$6.02
Rate for Payer: Multiplan Commercial	$6.02
Rate for Payer: Multiplan Workers Comp	$6.02
Rate for Payer: Parkland Medicaid	$6.67
Rate for Payer: Scott and White EPO/PPO	$4.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.67
Rate for Payer: Superior Health Plan EPO	$1.26

set ext standard bore

Facility

$9.26

Hospital Charge Code	110771
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.30

SET FLUID/BL WARMER

Facility

$267.31

Hospital Charge Code	8570489
Hospital Revenue Code	272
Rate for Payer: Cash Price	$181.77

SET FLUID/BL WARMER

Facility

$267.31

Hospital Charge Code	8570489
Hospital Revenue Code	272
Min. Negotiated Rate	$24.06
Max. Negotiated Rate	$192.46
Rate for Payer: Amerigroup CHIP/Medicaid	$24.06
Rate for Payer: BCBS of TX Blue Advantage	$80.19
Rate for Payer: BCBS of TX Blue Essentials	$96.23
Rate for Payer: BCBS of TX PPO	$106.92
Rate for Payer: Cash Price	$181.77
Rate for Payer: Cigna Medicaid	$192.46
Rate for Payer: Molina CHIP/Medicaid	$192.46
Rate for Payer: Multiplan Auto	$173.75
Rate for Payer: Multiplan Commercial	$173.75
Rate for Payer: Multiplan Workers Comp	$173.75
Rate for Payer: Parkland Medicaid	$192.46
Rate for Payer: Scott and White EPO/PPO	$133.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.46
Rate for Payer: Superior Health Plan EPO	$36.35

SET, HYSTEROSCOPIC OUTFLOW TUBE--DHF

Facility

$689.74

Hospital Charge Code	80347222
Hospital Revenue Code	270
Rate for Payer: Cash Price	$469.02

SET, HYSTEROSCOPIC OUTFLOW TUBE--DHF

Facility

$689.74

Hospital Charge Code	80347222
Hospital Revenue Code	270
Min. Negotiated Rate	$62.08
Max. Negotiated Rate	$496.61
Rate for Payer: Amerigroup CHIP/Medicaid	$62.08
Rate for Payer: BCBS of TX Blue Advantage	$206.92
Rate for Payer: BCBS of TX Blue Essentials	$248.31
Rate for Payer: BCBS of TX PPO	$275.90
Rate for Payer: Cash Price	$469.02
Rate for Payer: Cigna Medicaid	$496.61
Rate for Payer: Molina CHIP/Medicaid	$496.61
Rate for Payer: Multiplan Auto	$448.33
Rate for Payer: Multiplan Commercial	$448.33
Rate for Payer: Multiplan Workers Comp	$448.33
Rate for Payer: Parkland Medicaid	$496.61
Rate for Payer: Scott and White EPO/PPO	$344.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$496.61
Rate for Payer: Superior Health Plan EPO	$93.80

SET INFUSION W/CK VALVE & 3 NDL FREE VALVES 127L

Facility

$28.55

Hospital Charge Code	993180
Hospital Revenue Code	270
Rate for Payer: Cash Price	$19.41

SET INFUSION W/CK VALVE & 3 NDL FREE VALVES 127L

Facility

$28.55

Hospital Charge Code	993180
Hospital Revenue Code	270
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$20.56
Rate for Payer: Amerigroup CHIP/Medicaid	$2.57
Rate for Payer: BCBS of TX Blue Advantage	$8.56
Rate for Payer: BCBS of TX Blue Essentials	$10.28
Rate for Payer: BCBS of TX PPO	$11.42
Rate for Payer: Cash Price	$19.41
Rate for Payer: Cigna Medicaid	$20.56
Rate for Payer: Molina CHIP/Medicaid	$20.56
Rate for Payer: Multiplan Auto	$18.56
Rate for Payer: Multiplan Commercial	$18.56
Rate for Payer: Multiplan Workers Comp	$18.56
Rate for Payer: Parkland Medicaid	$20.56
Rate for Payer: Scott and White EPO/PPO	$14.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.56
Rate for Payer: Superior Health Plan EPO	$3.88

SET, INTRODUCER MICROPUNCTURE 5F GW TRANSITIONLESS -- DHF

Facility

$739.64

Hospital Charge Code	80565559
Hospital Revenue Code	272
Rate for Payer: Cash Price	$502.96

SET, INTRODUCER MICROPUNCTURE 5F GW TRANSITIONLESS -- DHF

Facility

$739.64

Hospital Charge Code	80565559
Hospital Revenue Code	272
Min. Negotiated Rate	$66.57
Max. Negotiated Rate	$532.54
Rate for Payer: Amerigroup CHIP/Medicaid	$66.57
Rate for Payer: BCBS of TX Blue Advantage	$221.89
Rate for Payer: BCBS of TX Blue Essentials	$266.27
Rate for Payer: BCBS of TX PPO	$295.86
Rate for Payer: Cash Price	$502.96
Rate for Payer: Cigna Medicaid	$532.54
Rate for Payer: Molina CHIP/Medicaid	$532.54
Rate for Payer: Multiplan Auto	$480.77
Rate for Payer: Multiplan Commercial	$480.77
Rate for Payer: Multiplan Workers Comp	$480.77
Rate for Payer: Parkland Medicaid	$532.54
Rate for Payer: Scott and White EPO/PPO	$369.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$532.54
Rate for Payer: Superior Health Plan EPO	$100.59

SET, IV, ADMIN, 15DR/ML, W/2 CRSTE INJ

Facility

$11.95

Hospital Charge Code	993942
Hospital Revenue Code	272
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$8.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1.08
Rate for Payer: BCBS of TX Blue Advantage	$3.58
Rate for Payer: BCBS of TX Blue Essentials	$4.30
Rate for Payer: BCBS of TX PPO	$4.78
Rate for Payer: Cash Price	$8.13
Rate for Payer: Cigna Medicaid	$8.60
Rate for Payer: Molina CHIP/Medicaid	$8.60
Rate for Payer: Multiplan Auto	$7.77
Rate for Payer: Multiplan Commercial	$7.77
Rate for Payer: Multiplan Workers Comp	$7.77
Rate for Payer: Parkland Medicaid	$8.60
Rate for Payer: Scott and White EPO/PPO	$5.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.60
Rate for Payer: Superior Health Plan EPO	$1.63

SET, IV, ADMIN, 15DR/ML, W/2 CRSTE INJ

Facility

$11.95

Hospital Charge Code	993942
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8.13

SET, IV, ADMIN, 2ND, 15DR/ML, UNIV SPIK

Facility

$4.52

Hospital Charge Code	993203
Hospital Revenue Code	270
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$3.25
Rate for Payer: Amerigroup CHIP/Medicaid	$0.41
Rate for Payer: BCBS of TX Blue Advantage	$1.36
Rate for Payer: BCBS of TX Blue Essentials	$1.63
Rate for Payer: BCBS of TX PPO	$1.81
Rate for Payer: Cash Price	$3.07
Rate for Payer: Cigna Medicaid	$3.25
Rate for Payer: Molina CHIP/Medicaid	$3.25
Rate for Payer: Multiplan Auto	$2.94
Rate for Payer: Multiplan Commercial	$2.94
Rate for Payer: Multiplan Workers Comp	$2.94
Rate for Payer: Parkland Medicaid	$3.25
Rate for Payer: Scott and White EPO/PPO	$2.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.25
Rate for Payer: Superior Health Plan EPO	$0.61

SET, IV, ADMIN, 2ND, 15DR/ML, UNIV SPIK

Facility

$4.52

Hospital Charge Code	993203
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.07

Know your out-of-pocket cost for care.

All Charges