White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SET,ACSS,MICR,MPIS-501-10.0-SC-NTSST

Facility

$150.41

Hospital Charge Code	993363
Hospital Revenue Code	270
Rate for Payer: Cash Price	$102.28

SET, BLD COLLECTIN, SFTY-LOK, 23GX0.75

Facility

$6.43

Hospital Charge Code	993957
Hospital Revenue Code	272
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$4.63
Rate for Payer: Amerigroup CHIP/Medicaid	$0.58
Rate for Payer: BCBS of TX Blue Advantage	$1.93
Rate for Payer: BCBS of TX Blue Essentials	$2.31
Rate for Payer: BCBS of TX PPO	$2.57
Rate for Payer: Cash Price	$4.37
Rate for Payer: Cigna Medicaid	$4.63
Rate for Payer: Molina CHIP/Medicaid	$4.63
Rate for Payer: Multiplan Auto	$4.18
Rate for Payer: Multiplan Commercial	$4.18
Rate for Payer: Multiplan Workers Comp	$4.18
Rate for Payer: Parkland Medicaid	$4.63
Rate for Payer: Scott and White EPO/PPO	$3.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.63
Rate for Payer: Superior Health Plan EPO	$0.87

SET, BLD COLLECTIN, SFTY-LOK, 23GX0.75

Facility

$6.43

Hospital Charge Code	993957
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.37

SET BLD NON-VNT 1 SMARTSITE DEHP FRE

Facility

$23.46

Hospital Charge Code	993887
Hospital Revenue Code	270
Rate for Payer: Cash Price	$15.95

SET BLD NON-VNT 1 SMARTSITE DEHP FRE

Facility

$23.46

Hospital Charge Code	993887
Hospital Revenue Code	270
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$16.89
Rate for Payer: Amerigroup CHIP/Medicaid	$2.11
Rate for Payer: BCBS of TX Blue Advantage	$7.04
Rate for Payer: BCBS of TX Blue Essentials	$8.45
Rate for Payer: BCBS of TX PPO	$9.38
Rate for Payer: Cash Price	$15.95
Rate for Payer: Cigna Medicaid	$16.89
Rate for Payer: Molina CHIP/Medicaid	$16.89
Rate for Payer: Multiplan Auto	$15.25
Rate for Payer: Multiplan Commercial	$15.25
Rate for Payer: Multiplan Workers Comp	$15.25
Rate for Payer: Parkland Medicaid	$16.89
Rate for Payer: Scott and White EPO/PPO	$11.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.89
Rate for Payer: Superior Health Plan EPO	$3.19

SET, BLOOD/SOLUTION, Y-TYPE, 112, MALE

Facility

$52.49

Hospital Charge Code	993182
Hospital Revenue Code	270
Rate for Payer: Cash Price	$35.69

SET, BLOOD/SOLUTION, Y-TYPE, 112, MALE

Facility

$52.49

Hospital Charge Code	993182
Hospital Revenue Code	270
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$37.79
Rate for Payer: Amerigroup CHIP/Medicaid	$4.72
Rate for Payer: BCBS of TX Blue Advantage	$15.75
Rate for Payer: BCBS of TX Blue Essentials	$18.90
Rate for Payer: BCBS of TX PPO	$21.00
Rate for Payer: Cash Price	$35.69
Rate for Payer: Cigna Medicaid	$37.79
Rate for Payer: Molina CHIP/Medicaid	$37.79
Rate for Payer: Multiplan Auto	$34.12
Rate for Payer: Multiplan Commercial	$34.12
Rate for Payer: Multiplan Workers Comp	$34.12
Rate for Payer: Parkland Medicaid	$37.79
Rate for Payer: Scott and White EPO/PPO	$26.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.79
Rate for Payer: Superior Health Plan EPO	$7.14

SET, CYSTOSCOPY IRRIG NONVENTED -- DHF

Facility

$184.37

Hospital Charge Code	54200605
Hospital Revenue Code	270
Min. Negotiated Rate	$16.59
Max. Negotiated Rate	$132.75
Rate for Payer: Amerigroup CHIP/Medicaid	$16.59
Rate for Payer: BCBS of TX Blue Advantage	$55.31
Rate for Payer: BCBS of TX Blue Essentials	$66.37
Rate for Payer: BCBS of TX PPO	$73.75
Rate for Payer: Cash Price	$125.37
Rate for Payer: Cigna Medicaid	$132.75
Rate for Payer: Molina CHIP/Medicaid	$132.75
Rate for Payer: Multiplan Auto	$119.84
Rate for Payer: Multiplan Commercial	$119.84
Rate for Payer: Multiplan Workers Comp	$119.84
Rate for Payer: Parkland Medicaid	$132.75
Rate for Payer: Scott and White EPO/PPO	$92.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.75
Rate for Payer: Superior Health Plan EPO	$25.07

SET, CYSTOSCOPY IRRIG NONVENTED -- DHF

Facility

$184.37

Hospital Charge Code	54200605
Hospital Revenue Code	270
Rate for Payer: Cash Price	$125.37

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 NON VENT

Facility

$29.51

Hospital Charge Code	8528471
Hospital Revenue Code	272
Rate for Payer: Cash Price	$20.07

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 EPIDURAL VENTED NV SPIKE

Facility

$40.04

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

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 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 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 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, 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
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, EXTEN TRIPORT NDLSS VALVE

Facility

$14.30

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

set ext standard bore

Facility

$9.26

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

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 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 FLUID/BL WARMER

Facility

$267.31

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

Know your out-of-pocket cost for care.

All Charges