White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Solution Lactated ringers

Facility

$14.98

Hospital Charge Code	992699
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10.19

Solution Lactated ringers

Facility

$14.98

Hospital Charge Code	992699
Hospital Revenue Code	270
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$10.79
Rate for Payer: Amerigroup CHIP/Medicaid	$1.35
Rate for Payer: BCBS of TX Blue Advantage	$4.49
Rate for Payer: BCBS of TX Blue Essentials	$5.39
Rate for Payer: BCBS of TX PPO	$5.99
Rate for Payer: Cash Price	$10.19
Rate for Payer: Cigna Medicaid	$10.79
Rate for Payer: Molina CHIP/Medicaid	$10.79
Rate for Payer: Multiplan Auto	$9.74
Rate for Payer: Multiplan Commercial	$9.74
Rate for Payer: Multiplan Workers Comp	$9.74
Rate for Payer: Parkland Medicaid	$10.79
Rate for Payer: Scott and White EPO/PPO	$7.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.79
Rate for Payer: Superior Health Plan EPO	$2.04

SOLUTION, NACL, 0.9%, IRRG, BAG, 3000ML

Facility

$60.21

Hospital Charge Code	992961
Hospital Revenue Code	270
Rate for Payer: Cash Price	$40.94

SOLUTION, NACL, 0.9%, IRRG, BAG, 3000ML

Facility

$60.21

Hospital Charge Code	992961
Hospital Revenue Code	270
Min. Negotiated Rate	$5.42
Max. Negotiated Rate	$43.35
Rate for Payer: Amerigroup CHIP/Medicaid	$5.42
Rate for Payer: BCBS of TX Blue Advantage	$18.06
Rate for Payer: BCBS of TX Blue Essentials	$21.68
Rate for Payer: BCBS of TX PPO	$24.08
Rate for Payer: Cash Price	$40.94
Rate for Payer: Cigna Medicaid	$43.35
Rate for Payer: Molina CHIP/Medicaid	$43.35
Rate for Payer: Multiplan Auto	$39.14
Rate for Payer: Multiplan Commercial	$39.14
Rate for Payer: Multiplan Workers Comp	$39.14
Rate for Payer: Parkland Medicaid	$43.35
Rate for Payer: Scott and White EPO/PPO	$30.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.35
Rate for Payer: Superior Health Plan EPO	$8.19

SOLUTION, PREP, POVIDNE IODINE, 4OZ BTL

Facility

$7.52

Hospital Charge Code	993178
Hospital Revenue Code	270
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$5.41
Rate for Payer: Amerigroup CHIP/Medicaid	$0.68
Rate for Payer: BCBS of TX Blue Advantage	$2.26
Rate for Payer: BCBS of TX Blue Essentials	$2.71
Rate for Payer: BCBS of TX PPO	$3.01
Rate for Payer: Cash Price	$5.11
Rate for Payer: Cigna Medicaid	$5.41
Rate for Payer: Molina CHIP/Medicaid	$5.41
Rate for Payer: Multiplan Auto	$4.89
Rate for Payer: Multiplan Commercial	$4.89
Rate for Payer: Multiplan Workers Comp	$4.89
Rate for Payer: Parkland Medicaid	$5.41
Rate for Payer: Scott and White EPO/PPO	$3.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.41
Rate for Payer: Superior Health Plan EPO	$1.02

SOLUTION, PREP, POVIDNE IODINE, 4OZ BTL

Facility

$7.52

Hospital Charge Code	993178
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.11

SOLUTION, SODIUM CHL, 0.9, 500ML, INJECT

Facility

$10.88

Hospital Charge Code	992948
Hospital Revenue Code	270
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$7.83
Rate for Payer: Amerigroup CHIP/Medicaid	$0.98
Rate for Payer: BCBS of TX Blue Advantage	$3.26
Rate for Payer: BCBS of TX Blue Essentials	$3.92
Rate for Payer: BCBS of TX PPO	$4.35
Rate for Payer: Cash Price	$7.40
Rate for Payer: Cigna Medicaid	$7.83
Rate for Payer: Molina CHIP/Medicaid	$7.83
Rate for Payer: Multiplan Auto	$7.07
Rate for Payer: Multiplan Commercial	$7.07
Rate for Payer: Multiplan Workers Comp	$7.07
Rate for Payer: Parkland Medicaid	$7.83
Rate for Payer: Scott and White EPO/PPO	$5.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.83
Rate for Payer: Superior Health Plan EPO	$1.48

SOLUTION, SODIUM CHL, 0.9, 500ML, INJECT

Facility

$10.88

Hospital Charge Code	992948
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.40

SOLUTION SRGSCRB CHG 1 PCT AVG 500ML

Facility

$185.62

Hospital Charge Code	992920
Hospital Revenue Code	270
Rate for Payer: Cash Price	$126.22

SOLUTION SRGSCRB CHG 1 PCT AVG 500ML

Facility

$185.62

Hospital Charge Code	992920
Hospital Revenue Code	270
Min. Negotiated Rate	$16.71
Max. Negotiated Rate	$133.65
Rate for Payer: Amerigroup CHIP/Medicaid	$16.71
Rate for Payer: BCBS of TX Blue Advantage	$55.69
Rate for Payer: BCBS of TX Blue Essentials	$66.82
Rate for Payer: BCBS of TX PPO	$74.25
Rate for Payer: Cash Price	$126.22
Rate for Payer: Cigna Medicaid	$133.65
Rate for Payer: Molina CHIP/Medicaid	$133.65
Rate for Payer: Multiplan Auto	$120.65
Rate for Payer: Multiplan Commercial	$120.65
Rate for Payer: Multiplan Workers Comp	$120.65
Rate for Payer: Parkland Medicaid	$133.65
Rate for Payer: Scott and White EPO/PPO	$92.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$133.65
Rate for Payer: Superior Health Plan EPO	$25.24

SOLUTN,SOD CHL,.9 PCNT, 500ML, IRR, BTL

Facility

$11.22

Hospital Charge Code	992952
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.63

SOLUTN,SOD CHL,.9 PCNT, 500ML, IRR, BTL

Facility

$11.22

Hospital Charge Code	992952
Hospital Revenue Code	270
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$8.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1.01
Rate for Payer: BCBS of TX Blue Advantage	$3.37
Rate for Payer: BCBS of TX Blue Essentials	$4.04
Rate for Payer: BCBS of TX PPO	$4.49
Rate for Payer: Cash Price	$7.63
Rate for Payer: Cigna Medicaid	$8.08
Rate for Payer: Molina CHIP/Medicaid	$8.08
Rate for Payer: Multiplan Auto	$7.29
Rate for Payer: Multiplan Commercial	$7.29
Rate for Payer: Multiplan Workers Comp	$7.29
Rate for Payer: Parkland Medicaid	$8.08
Rate for Payer: Scott and White EPO/PPO	$5.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.08
Rate for Payer: Superior Health Plan EPO	$1.53

SONIC ANCHOR KIT

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Charge Code	145759
Hospital Revenue Code	278
Min. Negotiated Rate	$239.76
Max. Negotiated Rate	$1,918.08
Rate for Payer: Amerigroup CHIP/Medicaid	$239.76
Rate for Payer: BCBS of TX Blue Advantage	$799.20
Rate for Payer: BCBS of TX Blue Essentials	$959.04
Rate for Payer: BCBS of TX PPO	$1,065.60
Rate for Payer: Cash Price	$1,811.52
Rate for Payer: Cigna Medicaid	$1,918.08
Rate for Payer: Molina CHIP/Medicaid	$1,918.08
Rate for Payer: Multiplan Auto	$1,332.00
Rate for Payer: Multiplan Commercial	$1,332.00
Rate for Payer: Multiplan Workers Comp	$1,332.00
Rate for Payer: Parkland Medicaid	$1,918.08
Rate for Payer: Scott and White EPO/PPO	$1,332.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,918.08
Rate for Payer: Superior Health Plan EPO	$362.30

SONIC ANCHOR KIT

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Charge Code	145759
Hospital Revenue Code	278
Min. Negotiated Rate	$666.00
Max. Negotiated Rate	$1,332.00
Rate for Payer: Cash Price	$1,811.52
Rate for Payer: Cigna Commercial	$666.00
Rate for Payer: Multiplan Auto	$1,332.00
Rate for Payer: Multiplan Commercial	$1,332.00
Rate for Payer: Multiplan Workers Comp	$1,332.00
Rate for Payer: Scott and White EPO/PPO	$1,332.00

SONIC ANCHOR SYSTEM

Facility

$2,007.59

Hospital Charge Code	114023
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,365.16

SONIC ANCHOR SYSTEM

Facility

$2,007.59

Hospital Charge Code	114023
Hospital Revenue Code	272
Min. Negotiated Rate	$180.68
Max. Negotiated Rate	$1,445.46
Rate for Payer: Amerigroup CHIP/Medicaid	$180.68
Rate for Payer: BCBS of TX Blue Advantage	$602.28
Rate for Payer: BCBS of TX Blue Essentials	$722.73
Rate for Payer: BCBS of TX PPO	$803.04
Rate for Payer: Cash Price	$1,365.16
Rate for Payer: Cigna Medicaid	$1,445.46
Rate for Payer: Molina CHIP/Medicaid	$1,445.46
Rate for Payer: Multiplan Auto	$1,304.93
Rate for Payer: Multiplan Commercial	$1,304.93
Rate for Payer: Multiplan Workers Comp	$1,304.93
Rate for Payer: Parkland Medicaid	$1,445.46
Rate for Payer: Scott and White EPO/PPO	$1,003.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,445.46
Rate for Payer: Superior Health Plan EPO	$273.03

Sp bone algrft morsel add-on

Facility

$10,800.00

Service Code	HCPCS 20930
Hospital Charge Code	9900187
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,344.00

Sp bone algrft morsel add-on

Facility

$10,000.00

Service Code	CPT 20930
Hospital Charge Code	36020930
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$10,000.00
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00

Sp bone algrft morsel add-on

Facility

$10,800.00

Service Code	HCPCS 20930
Hospital Charge Code	9900187
Hospital Revenue Code	360
Min. Negotiated Rate	$972.00
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$972.00
Rate for Payer: BCBS of TX Blue Advantage	$3,240.00
Rate for Payer: BCBS of TX Blue Essentials	$3,888.00
Rate for Payer: BCBS of TX PPO	$4,320.00
Rate for Payer: Cash Price	$7,344.00
Rate for Payer: Cash Price	$7,344.00
Rate for Payer: Cigna Medicaid	$7,776.00
Rate for Payer: Molina CHIP/Medicaid	$7,776.00
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$7,776.00
Rate for Payer: Scott and White EPO/PPO	$5,400.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,776.00
Rate for Payer: Superior Health Plan EPO	$1,468.80

SPECIALIST CAST PADDING 3' X 4 YDA

Facility

$2.32

Hospital Charge Code	992958
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.58

SPECIALIST CAST PADDING 3' X 4 YDA

Facility

$2.32

Hospital Charge Code	992958
Hospital Revenue Code	270
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$1.67
Rate for Payer: Amerigroup CHIP/Medicaid	$0.21
Rate for Payer: BCBS of TX Blue Advantage	$0.70
Rate for Payer: BCBS of TX Blue Essentials	$0.84
Rate for Payer: BCBS of TX PPO	$0.93
Rate for Payer: Cash Price	$1.58
Rate for Payer: Cigna Medicaid	$1.67
Rate for Payer: Molina CHIP/Medicaid	$1.67
Rate for Payer: Multiplan Auto	$1.51
Rate for Payer: Multiplan Commercial	$1.51
Rate for Payer: Multiplan Workers Comp	$1.51
Rate for Payer: Parkland Medicaid	$1.67
Rate for Payer: Scott and White EPO/PPO	$1.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.67
Rate for Payer: Superior Health Plan EPO	$0.32

SPECTRUM SUTURE HOOK

Facility

$280.80

Hospital Charge Code	992652
Hospital Revenue Code	272
Rate for Payer: Cash Price	$190.94

SPECTRUM SUTURE HOOK

Facility

$280.80

Hospital Charge Code	992652
Hospital Revenue Code	272
Min. Negotiated Rate	$25.27
Max. Negotiated Rate	$202.18
Rate for Payer: Amerigroup CHIP/Medicaid	$25.27
Rate for Payer: BCBS of TX Blue Advantage	$84.24
Rate for Payer: BCBS of TX Blue Essentials	$101.09
Rate for Payer: BCBS of TX PPO	$112.32
Rate for Payer: Cash Price	$190.94
Rate for Payer: Cigna Medicaid	$202.18
Rate for Payer: Molina CHIP/Medicaid	$202.18
Rate for Payer: Multiplan Auto	$182.52
Rate for Payer: Multiplan Commercial	$182.52
Rate for Payer: Multiplan Workers Comp	$182.52
Rate for Payer: Parkland Medicaid	$202.18
Rate for Payer: Scott and White EPO/PPO	$140.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$202.18
Rate for Payer: Superior Health Plan EPO	$38.19

SPECTRUM SUTURE HOOK

Facility

$280.80

Hospital Charge Code	992651
Hospital Revenue Code	272
Min. Negotiated Rate	$25.27
Max. Negotiated Rate	$202.18
Rate for Payer: Amerigroup CHIP/Medicaid	$25.27
Rate for Payer: BCBS of TX Blue Advantage	$84.24
Rate for Payer: BCBS of TX Blue Essentials	$101.09
Rate for Payer: BCBS of TX PPO	$112.32
Rate for Payer: Cash Price	$190.94
Rate for Payer: Cigna Medicaid	$202.18
Rate for Payer: Molina CHIP/Medicaid	$202.18
Rate for Payer: Multiplan Auto	$182.52
Rate for Payer: Multiplan Commercial	$182.52
Rate for Payer: Multiplan Workers Comp	$182.52
Rate for Payer: Parkland Medicaid	$202.18
Rate for Payer: Scott and White EPO/PPO	$140.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$202.18
Rate for Payer: Superior Health Plan EPO	$38.19

SPECTRUM SUTURE HOOK

Facility

$280.80

Hospital Charge Code	992651
Hospital Revenue Code	272
Rate for Payer: Cash Price	$190.94

Know your out-of-pocket cost for care.

All Charges