White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
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 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, 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
Rate for Payer: Cash Price	$3.07

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, MICROINTRODUCER UNIV

Facility

$359.80

Hospital Charge Code	81749301
Hospital Revenue Code	272
Min. Negotiated Rate	$32.38
Max. Negotiated Rate	$259.06
Rate for Payer: Amerigroup CHIP/Medicaid	$32.38
Rate for Payer: BCBS of TX Blue Advantage	$107.94
Rate for Payer: BCBS of TX Blue Essentials	$129.53
Rate for Payer: BCBS of TX PPO	$143.92
Rate for Payer: Cash Price	$244.66
Rate for Payer: Cigna Medicaid	$259.06
Rate for Payer: Molina CHIP/Medicaid	$259.06
Rate for Payer: Multiplan Auto	$233.87
Rate for Payer: Multiplan Commercial	$233.87
Rate for Payer: Multiplan Workers Comp	$233.87
Rate for Payer: Parkland Medicaid	$259.06
Rate for Payer: Scott and White EPO/PPO	$179.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$259.06
Rate for Payer: Superior Health Plan EPO	$48.93

SET, MICROINTRODUCER UNIV

Facility

$359.80

Hospital Charge Code	81749301
Hospital Revenue Code	272
Rate for Payer: Cash Price	$244.66

SET, PROCEDURE SHEATH CASSETTE DRAINAGE BAG -- DHF

Facility

$7,531.81

Hospital Charge Code	80732654
Hospital Revenue Code	272
Min. Negotiated Rate	$677.86
Max. Negotiated Rate	$5,422.90
Rate for Payer: Amerigroup CHIP/Medicaid	$677.86
Rate for Payer: BCBS of TX Blue Advantage	$2,259.54
Rate for Payer: BCBS of TX Blue Essentials	$2,711.45
Rate for Payer: BCBS of TX PPO	$3,012.72
Rate for Payer: Cash Price	$5,121.63
Rate for Payer: Cigna Medicaid	$5,422.90
Rate for Payer: Molina CHIP/Medicaid	$5,422.90
Rate for Payer: Multiplan Auto	$4,895.68
Rate for Payer: Multiplan Commercial	$4,895.68
Rate for Payer: Multiplan Workers Comp	$4,895.68
Rate for Payer: Parkland Medicaid	$5,422.90
Rate for Payer: Scott and White EPO/PPO	$3,765.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,422.90
Rate for Payer: Superior Health Plan EPO	$1,024.33

SET, PROCEDURE SHEATH CASSETTE DRAINAGE BAG -- DHF

Facility

$7,531.81

Hospital Charge Code	80732654
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,121.63

Set Screw

Facility

$602.41

Service Code	HCPCS C1713
Hospital Charge Code	992227
Hospital Revenue Code	278
Min. Negotiated Rate	$54.22
Max. Negotiated Rate	$433.74
Rate for Payer: Amerigroup CHIP/Medicaid	$54.22
Rate for Payer: BCBS of TX Blue Advantage	$180.72
Rate for Payer: BCBS of TX Blue Essentials	$216.87
Rate for Payer: BCBS of TX PPO	$240.96
Rate for Payer: Cash Price	$409.64
Rate for Payer: Cigna Medicaid	$433.74
Rate for Payer: Molina CHIP/Medicaid	$433.74
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Parkland Medicaid	$433.74
Rate for Payer: Scott and White EPO/PPO	$301.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$433.74
Rate for Payer: Superior Health Plan EPO	$81.93

Set Screw

Facility

$602.41

Service Code	HCPCS C1713
Hospital Charge Code	992227
Hospital Revenue Code	278
Min. Negotiated Rate	$150.60
Max. Negotiated Rate	$301.20
Rate for Payer: Cash Price	$409.64
Rate for Payer: Cigna Commercial	$150.60
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Scott and White EPO/PPO	$301.20

SET, STD EXT W/SPIN-LOCK CONNECTION 6

Facility

$48.66

Hospital Charge Code	993718
Hospital Revenue Code	270
Rate for Payer: Cash Price	$33.09

SET, STD EXT W/SPIN-LOCK CONNECTION 6

Facility

$48.66

Hospital Charge Code	993718
Hospital Revenue Code	270
Min. Negotiated Rate	$4.38
Max. Negotiated Rate	$35.04
Rate for Payer: Amerigroup CHIP/Medicaid	$4.38
Rate for Payer: BCBS of TX Blue Advantage	$14.60
Rate for Payer: BCBS of TX Blue Essentials	$17.52
Rate for Payer: BCBS of TX PPO	$19.46
Rate for Payer: Cash Price	$33.09
Rate for Payer: Cigna Medicaid	$35.04
Rate for Payer: Molina CHIP/Medicaid	$35.04
Rate for Payer: Multiplan Auto	$31.63
Rate for Payer: Multiplan Commercial	$31.63
Rate for Payer: Multiplan Workers Comp	$31.63
Rate for Payer: Parkland Medicaid	$35.04
Rate for Payer: Scott and White EPO/PPO	$24.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.04
Rate for Payer: Superior Health Plan EPO	$6.62

SET, TUBE, HIGH-FLOW, PNEUMOCLEAR

Facility

$213.33

Hospital Charge Code	992811
Hospital Revenue Code	272
Rate for Payer: Cash Price	$145.06

SET, TUBE, HIGH-FLOW, PNEUMOCLEAR

Facility

$213.33

Hospital Charge Code	992811
Hospital Revenue Code	272
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$153.60
Rate for Payer: Amerigroup CHIP/Medicaid	$19.20
Rate for Payer: BCBS of TX Blue Advantage	$64.00
Rate for Payer: BCBS of TX Blue Essentials	$76.80
Rate for Payer: BCBS of TX PPO	$85.33
Rate for Payer: Cash Price	$145.06
Rate for Payer: Cigna Medicaid	$153.60
Rate for Payer: Molina CHIP/Medicaid	$153.60
Rate for Payer: Multiplan Auto	$138.66
Rate for Payer: Multiplan Commercial	$138.66
Rate for Payer: Multiplan Workers Comp	$138.66
Rate for Payer: Parkland Medicaid	$153.60
Rate for Payer: Scott and White EPO/PPO	$106.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$153.60
Rate for Payer: Superior Health Plan EPO	$29.01

SET TUBING SUCTION/IRRIGATION LAPAROSCOPIC 33CML HANDPIECE A

Facility

$25.64

Hospital Charge Code	993593
Hospital Revenue Code	272
Rate for Payer: Cash Price	$17.44

SET TUBING SUCTION/IRRIGATION LAPAROSCOPIC 33CML HANDPIECE A

Facility

$25.64

Hospital Charge Code	993593
Hospital Revenue Code	272
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$18.46
Rate for Payer: Amerigroup CHIP/Medicaid	$2.31
Rate for Payer: BCBS of TX Blue Advantage	$7.69
Rate for Payer: BCBS of TX Blue Essentials	$9.23
Rate for Payer: BCBS of TX PPO	$10.26
Rate for Payer: Cash Price	$17.44
Rate for Payer: Cigna Medicaid	$18.46
Rate for Payer: Molina CHIP/Medicaid	$18.46
Rate for Payer: Multiplan Auto	$16.67
Rate for Payer: Multiplan Commercial	$16.67
Rate for Payer: Multiplan Workers Comp	$16.67
Rate for Payer: Parkland Medicaid	$18.46
Rate for Payer: Scott and White EPO/PPO	$12.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.46
Rate for Payer: Superior Health Plan EPO	$3.49

sevelamer carbonate 800 mg Tab

Facility

$28.00

Service Code	HCPCS J3490
Hospital Charge Code	77811505
Hospital Revenue Code	636
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$20.16
Rate for Payer: Amerigroup CHIP/Medicaid	$2.52
Rate for Payer: BCBS of TX Blue Advantage	$8.40
Rate for Payer: BCBS of TX Blue Essentials	$10.08
Rate for Payer: BCBS of TX PPO	$11.20
Rate for Payer: Cash Price	$19.04
Rate for Payer: Cigna Medicaid	$20.16
Rate for Payer: Molina CHIP/Medicaid	$20.16
Rate for Payer: Multiplan Auto	$18.20
Rate for Payer: Multiplan Commercial	$18.20
Rate for Payer: Multiplan Workers Comp	$18.20
Rate for Payer: Parkland Medicaid	$20.16
Rate for Payer: Scott and White EPO/PPO	$14.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.16
Rate for Payer: Superior Health Plan EPO	$3.81

sevelamer carbonate 800 mg Tab

Facility

$28.00

Service Code	HCPCS J3490
Hospital Charge Code	77811505
Hospital Revenue Code	636
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$14.00
Rate for Payer: Cash Price	$19.04
Rate for Payer: Cigna Commercial	$7.00
Rate for Payer: Scott and White EPO/PPO	$14.00

sevoflurane Inh Liquid 250 mL

Facility

$242.00

Service Code	HCPCS J3490
Hospital Charge Code	77811660
Hospital Revenue Code	250
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$174.24
Rate for Payer: Amerigroup CHIP/Medicaid	$21.78
Rate for Payer: BCBS of TX Blue Advantage	$72.60
Rate for Payer: BCBS of TX Blue Essentials	$87.12
Rate for Payer: BCBS of TX PPO	$96.80
Rate for Payer: Cash Price	$164.56
Rate for Payer: Cigna Medicaid	$174.24
Rate for Payer: Molina CHIP/Medicaid	$174.24
Rate for Payer: Multiplan Auto	$157.30
Rate for Payer: Multiplan Commercial	$157.30
Rate for Payer: Multiplan Workers Comp	$157.30
Rate for Payer: Parkland Medicaid	$174.24
Rate for Payer: Scott and White EPO/PPO	$121.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$174.24
Rate for Payer: Superior Health Plan EPO	$32.91

Know your out-of-pocket cost for care.

All Charges