White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ST IV START -- DHF

Facility

$110.27

Hospital Charge Code	54201017
Hospital Revenue Code	270
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$79.39
Rate for Payer: Amerigroup CHIP/Medicaid	$9.92
Rate for Payer: BCBS of TX Blue Advantage	$33.08
Rate for Payer: BCBS of TX Blue Essentials	$39.70
Rate for Payer: BCBS of TX PPO	$44.11
Rate for Payer: Cash Price	$74.98
Rate for Payer: Cigna Medicaid	$79.39
Rate for Payer: Molina CHIP/Medicaid	$79.39
Rate for Payer: Multiplan Auto	$71.68
Rate for Payer: Multiplan Commercial	$71.68
Rate for Payer: Multiplan Workers Comp	$71.68
Rate for Payer: Parkland Medicaid	$79.39
Rate for Payer: Scott and White EPO/PPO	$55.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.39
Rate for Payer: Superior Health Plan EPO	$15.00

ST IV START -- DHF

Facility

$110.27

Hospital Charge Code	54201017
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.98

ST NDL BX -- DHF

Facility

$176.60

Hospital Charge Code	80827413
Hospital Revenue Code	272
Rate for Payer: Cash Price	$120.09

ST NDL BX -- DHF

Facility

$176.60

Hospital Charge Code	80827413
Hospital Revenue Code	272
Min. Negotiated Rate	$15.89
Max. Negotiated Rate	$127.15
Rate for Payer: Amerigroup CHIP/Medicaid	$15.89
Rate for Payer: BCBS of TX Blue Advantage	$52.98
Rate for Payer: BCBS of TX Blue Essentials	$63.58
Rate for Payer: BCBS of TX PPO	$70.64
Rate for Payer: Cash Price	$120.09
Rate for Payer: Cigna Medicaid	$127.15
Rate for Payer: Molina CHIP/Medicaid	$127.15
Rate for Payer: Multiplan Auto	$114.79
Rate for Payer: Multiplan Commercial	$114.79
Rate for Payer: Multiplan Workers Comp	$114.79
Rate for Payer: Parkland Medicaid	$127.15
Rate for Payer: Scott and White EPO/PPO	$88.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$127.15
Rate for Payer: Superior Health Plan EPO	$24.02

ST NDL INTRAOSS ADLT -- DHF

Facility

$577.49

Hospital Charge Code	81786501
Hospital Revenue Code	272
Min. Negotiated Rate	$51.97
Max. Negotiated Rate	$415.79
Rate for Payer: Amerigroup CHIP/Medicaid	$51.97
Rate for Payer: BCBS of TX Blue Advantage	$173.25
Rate for Payer: BCBS of TX Blue Essentials	$207.90
Rate for Payer: BCBS of TX PPO	$231.00
Rate for Payer: Cash Price	$392.69
Rate for Payer: Cigna Medicaid	$415.79
Rate for Payer: Molina CHIP/Medicaid	$415.79
Rate for Payer: Multiplan Auto	$375.37
Rate for Payer: Multiplan Commercial	$375.37
Rate for Payer: Multiplan Workers Comp	$375.37
Rate for Payer: Parkland Medicaid	$415.79
Rate for Payer: Scott and White EPO/PPO	$288.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$415.79
Rate for Payer: Superior Health Plan EPO	$78.54

ST NDL INTRAOSS ADLT -- DHF

Facility

$577.49

Hospital Charge Code	81786501
Hospital Revenue Code	272
Rate for Payer: Cash Price	$392.69

STNT C XIENCE ALPINE RX -- DHF

Facility

$10,331.00

Service Code	HCPCS C1713
Hospital Charge Code	80622103
Hospital Revenue Code	278
Min. Negotiated Rate	$929.79
Max. Negotiated Rate	$7,438.32
Rate for Payer: Amerigroup CHIP/Medicaid	$929.79
Rate for Payer: BCBS of TX Blue Advantage	$3,099.30
Rate for Payer: BCBS of TX Blue Essentials	$3,719.16
Rate for Payer: BCBS of TX PPO	$4,132.40
Rate for Payer: Cash Price	$7,025.08
Rate for Payer: Cigna Medicaid	$7,438.32
Rate for Payer: Molina CHIP/Medicaid	$7,438.32
Rate for Payer: Multiplan Auto	$5,165.50
Rate for Payer: Multiplan Commercial	$5,165.50
Rate for Payer: Multiplan Workers Comp	$5,165.50
Rate for Payer: Parkland Medicaid	$7,438.32
Rate for Payer: Scott and White EPO/PPO	$5,165.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,438.32
Rate for Payer: Superior Health Plan EPO	$1,405.02

STNT C XIENCE ALPINE RX -- DHF

Facility

$10,331.00

Service Code	HCPCS C1713
Hospital Charge Code	80622103
Hospital Revenue Code	278
Min. Negotiated Rate	$2,582.75
Max. Negotiated Rate	$5,165.50
Rate for Payer: Cash Price	$7,025.08
Rate for Payer: Cigna Commercial	$2,582.75
Rate for Payer: Multiplan Auto	$5,165.50
Rate for Payer: Multiplan Commercial	$5,165.50
Rate for Payer: Multiplan Workers Comp	$5,165.50
Rate for Payer: Scott and White EPO/PPO	$5,165.50

STNT ENDOPROS VIABAHN SX 7X120

Facility

$22,633.00

Service Code	HCPCS C1874
Hospital Charge Code	119940
Hospital Revenue Code	278
Min. Negotiated Rate	$2,036.97
Max. Negotiated Rate	$16,295.76
Rate for Payer: Amerigroup CHIP/Medicaid	$2,036.97
Rate for Payer: BCBS of TX Blue Advantage	$6,789.90
Rate for Payer: BCBS of TX Blue Essentials	$8,147.88
Rate for Payer: BCBS of TX PPO	$9,053.20
Rate for Payer: Cash Price	$15,390.44
Rate for Payer: Cigna Medicaid	$16,295.76
Rate for Payer: Molina CHIP/Medicaid	$16,295.76
Rate for Payer: Multiplan Auto	$11,316.50
Rate for Payer: Multiplan Commercial	$11,316.50
Rate for Payer: Multiplan Workers Comp	$11,316.50
Rate for Payer: Parkland Medicaid	$16,295.76
Rate for Payer: Scott and White EPO/PPO	$11,316.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,295.76
Rate for Payer: Superior Health Plan EPO	$3,078.09

STNT ENDOPROS VIABAHN SX 7X120

Facility

$22,633.00

Service Code	HCPCS C1874
Hospital Charge Code	119940
Hospital Revenue Code	278
Min. Negotiated Rate	$5,658.25
Max. Negotiated Rate	$11,316.50
Rate for Payer: Cash Price	$15,390.44
Rate for Payer: Cigna Commercial	$5,658.25
Rate for Payer: Multiplan Auto	$11,316.50
Rate for Payer: Multiplan Commercial	$11,316.50
Rate for Payer: Multiplan Workers Comp	$11,316.50
Rate for Payer: Scott and White EPO/PPO	$11,316.50

STNT OMNILINK ELITE 101262-29

Facility

$5,608.00

Service Code	HCPCS C1874
Hospital Charge Code	138719
Hospital Revenue Code	278
Min. Negotiated Rate	$504.72
Max. Negotiated Rate	$4,037.76
Rate for Payer: Amerigroup CHIP/Medicaid	$504.72
Rate for Payer: BCBS of TX Blue Advantage	$1,682.40
Rate for Payer: BCBS of TX Blue Essentials	$2,018.88
Rate for Payer: BCBS of TX PPO	$2,243.20
Rate for Payer: Cash Price	$3,813.44
Rate for Payer: Cigna Medicaid	$4,037.76
Rate for Payer: Molina CHIP/Medicaid	$4,037.76
Rate for Payer: Multiplan Auto	$2,804.00
Rate for Payer: Multiplan Commercial	$2,804.00
Rate for Payer: Multiplan Workers Comp	$2,804.00
Rate for Payer: Parkland Medicaid	$4,037.76
Rate for Payer: Scott and White EPO/PPO	$2,804.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,037.76
Rate for Payer: Superior Health Plan EPO	$762.69

STNT OMNILINK ELITE 101262-29

Facility

$5,608.00

Service Code	HCPCS C1874
Hospital Charge Code	138719
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.00
Max. Negotiated Rate	$2,804.00
Rate for Payer: Cash Price	$3,813.44
Rate for Payer: Cigna Commercial	$1,402.00
Rate for Payer: Multiplan Auto	$2,804.00
Rate for Payer: Multiplan Commercial	$2,804.00
Rate for Payer: Multiplan Workers Comp	$2,804.00
Rate for Payer: Scott and White EPO/PPO	$2,804.00

STNT OMNILINK ELITE 1012632-39

Facility

$5,608.00

Service Code	HCPCS C1874
Hospital Charge Code	136038
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.00
Max. Negotiated Rate	$2,804.00
Rate for Payer: Cash Price	$3,813.44
Rate for Payer: Cigna Commercial	$1,402.00
Rate for Payer: Multiplan Auto	$2,804.00
Rate for Payer: Multiplan Commercial	$2,804.00
Rate for Payer: Multiplan Workers Comp	$2,804.00
Rate for Payer: Scott and White EPO/PPO	$2,804.00

STNT OMNILINK ELITE 1012632-39

Facility

$5,608.00

Service Code	HCPCS C1874
Hospital Charge Code	136038
Hospital Revenue Code	278
Min. Negotiated Rate	$504.72
Max. Negotiated Rate	$4,037.76
Rate for Payer: Amerigroup CHIP/Medicaid	$504.72
Rate for Payer: BCBS of TX Blue Advantage	$1,682.40
Rate for Payer: BCBS of TX Blue Essentials	$2,018.88
Rate for Payer: BCBS of TX PPO	$2,243.20
Rate for Payer: Cash Price	$3,813.44
Rate for Payer: Cigna Medicaid	$4,037.76
Rate for Payer: Molina CHIP/Medicaid	$4,037.76
Rate for Payer: Multiplan Auto	$2,804.00
Rate for Payer: Multiplan Commercial	$2,804.00
Rate for Payer: Multiplan Workers Comp	$2,804.00
Rate for Payer: Parkland Medicaid	$4,037.76
Rate for Payer: Scott and White EPO/PPO	$2,804.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,037.76
Rate for Payer: Superior Health Plan EPO	$762.69

STNT OMNILINK ELITE 101263-29

Facility

$5,608.00

Service Code	HCPCS C1874
Hospital Charge Code	82431321
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.00
Max. Negotiated Rate	$2,804.00
Rate for Payer: Cash Price	$3,813.44
Rate for Payer: Cigna Commercial	$1,402.00
Rate for Payer: Multiplan Auto	$2,804.00
Rate for Payer: Multiplan Commercial	$2,804.00
Rate for Payer: Multiplan Workers Comp	$2,804.00
Rate for Payer: Scott and White EPO/PPO	$2,804.00

STNT OMNILINK ELITE 101263-29

Facility

$5,608.00

Service Code	HCPCS C1874
Hospital Charge Code	82431321
Hospital Revenue Code	278
Min. Negotiated Rate	$504.72
Max. Negotiated Rate	$4,037.76
Rate for Payer: Amerigroup CHIP/Medicaid	$504.72
Rate for Payer: BCBS of TX Blue Advantage	$1,682.40
Rate for Payer: BCBS of TX Blue Essentials	$2,018.88
Rate for Payer: BCBS of TX PPO	$2,243.20
Rate for Payer: Cash Price	$3,813.44
Rate for Payer: Cigna Medicaid	$4,037.76
Rate for Payer: Molina CHIP/Medicaid	$4,037.76
Rate for Payer: Multiplan Auto	$2,804.00
Rate for Payer: Multiplan Commercial	$2,804.00
Rate for Payer: Multiplan Workers Comp	$2,804.00
Rate for Payer: Parkland Medicaid	$4,037.76
Rate for Payer: Scott and White EPO/PPO	$2,804.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,037.76
Rate for Payer: Superior Health Plan EPO	$762.69

STOCKINET, IMPERVIOUS, 6X30

Facility

$17.51

Hospital Charge Code	992758
Hospital Revenue Code	272
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$12.61
Rate for Payer: Amerigroup CHIP/Medicaid	$1.58
Rate for Payer: BCBS of TX Blue Advantage	$5.25
Rate for Payer: BCBS of TX Blue Essentials	$6.30
Rate for Payer: BCBS of TX PPO	$7.00
Rate for Payer: Cash Price	$11.91
Rate for Payer: Cigna Medicaid	$12.61
Rate for Payer: Molina CHIP/Medicaid	$12.61
Rate for Payer: Multiplan Auto	$11.38
Rate for Payer: Multiplan Commercial	$11.38
Rate for Payer: Multiplan Workers Comp	$11.38
Rate for Payer: Parkland Medicaid	$12.61
Rate for Payer: Scott and White EPO/PPO	$8.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.61
Rate for Payer: Superior Health Plan EPO	$2.38

STOCKINET, IMPERVIOUS, 6X30

Facility

$17.51

Hospital Charge Code	992758
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11.91

STOCKINETTE ORTH 48X12IN IMPRV FLP FLD

Facility

$7.39

Hospital Charge Code	993732
Hospital Revenue Code	272
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$5.32
Rate for Payer: Amerigroup CHIP/Medicaid	$0.67
Rate for Payer: BCBS of TX Blue Advantage	$2.22
Rate for Payer: BCBS of TX Blue Essentials	$2.66
Rate for Payer: BCBS of TX PPO	$2.96
Rate for Payer: Cash Price	$5.03
Rate for Payer: Cigna Medicaid	$5.32
Rate for Payer: Molina CHIP/Medicaid	$5.32
Rate for Payer: Multiplan Auto	$4.80
Rate for Payer: Multiplan Commercial	$4.80
Rate for Payer: Multiplan Workers Comp	$4.80
Rate for Payer: Parkland Medicaid	$5.32
Rate for Payer: Scott and White EPO/PPO	$3.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.32
Rate for Payer: Superior Health Plan EPO	$1.01

STOCKINETTE ORTH 48X12IN IMPRV FLP FLD

Facility

$7.39

Hospital Charge Code	993732
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.03

STOCKINETTE, TUBULAR 100% COTTN 2-PLY 6'X48 STERL -- DHF

Facility

$354.16

Hospital Charge Code	80241557
Hospital Revenue Code	270
Rate for Payer: Cash Price	$240.83

STOCKINETTE, TUBULAR 100% COTTN 2-PLY 6'X48 STERL -- DHF

Facility

$354.16

Hospital Charge Code	80241557
Hospital Revenue Code	270
Min. Negotiated Rate	$31.87
Max. Negotiated Rate	$255.00
Rate for Payer: Amerigroup CHIP/Medicaid	$31.87
Rate for Payer: BCBS of TX Blue Advantage	$106.25
Rate for Payer: BCBS of TX Blue Essentials	$127.50
Rate for Payer: BCBS of TX PPO	$141.66
Rate for Payer: Cash Price	$240.83
Rate for Payer: Cigna Medicaid	$255.00
Rate for Payer: Molina CHIP/Medicaid	$255.00
Rate for Payer: Multiplan Auto	$230.20
Rate for Payer: Multiplan Commercial	$230.20
Rate for Payer: Multiplan Workers Comp	$230.20
Rate for Payer: Parkland Medicaid	$255.00
Rate for Payer: Scott and White EPO/PPO	$177.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$255.00
Rate for Payer: Superior Health Plan EPO	$48.17

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC

Facility

$46,439.80

Service Code	MSDRG 327
Min. Negotiated Rate	$21,364.98
Max. Negotiated Rate	$46,439.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,673.69
Rate for Payer: Amerigroup Medicare	$22,673.69
Rate for Payer: BCBS of TX Medicare	$22,673.69
Rate for Payer: Cigna Commercial	$31,481.30
Rate for Payer: Cigna Medicare	$22,673.69
Rate for Payer: Employer Direct Commercial	$22,673.69
Rate for Payer: Humana Medicare/TRICARE	$22,673.69
Rate for Payer: Molina Dual Medicare/Medicaid	$22,673.69
Rate for Payer: Molina Medicare	$22,673.69
Rate for Payer: Multiplan Auto	$46,439.80
Rate for Payer: Multiplan Commercial	$46,439.80
Rate for Payer: Multiplan Workers Comp	$46,439.80
Rate for Payer: Scott and White EPO/PPO	$21,386.75
Rate for Payer: Scott and White Medicare	$22,673.69
Rate for Payer: Superior Health Plan EPO	$22,673.69
Rate for Payer: Superior Health Plan Medicare	$22,673.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,673.69
Rate for Payer: Universal American Medicare	$22,673.69
Rate for Payer: Wellcare Medicare	$22,673.69
Rate for Payer: Wellmed Medicare	$22,673.69

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC

Facility

$94,760.60

Service Code	MSDRG 326
Min. Negotiated Rate	$41,312.86
Max. Negotiated Rate	$94,760.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$41,312.86
Rate for Payer: Amerigroup Medicare	$41,312.86
Rate for Payer: BCBS of TX Medicare	$41,312.86
Rate for Payer: Cigna Commercial	$64,237.71
Rate for Payer: Cigna Medicare	$41,312.86
Rate for Payer: Employer Direct Commercial	$41,312.86
Rate for Payer: Humana Medicare/TRICARE	$41,312.86
Rate for Payer: Molina Dual Medicare/Medicaid	$41,312.86
Rate for Payer: Molina Medicare	$41,312.86
Rate for Payer: Multiplan Auto	$94,760.60
Rate for Payer: Multiplan Commercial	$94,760.60
Rate for Payer: Multiplan Workers Comp	$94,760.60
Rate for Payer: Scott and White EPO/PPO	$43,639.75
Rate for Payer: Scott and White Medicare	$41,312.86
Rate for Payer: Superior Health Plan EPO	$41,312.86
Rate for Payer: Superior Health Plan Medicare	$41,312.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$41,312.86
Rate for Payer: Universal American Medicare	$41,312.86
Rate for Payer: Wellcare Medicare	$41,312.86
Rate for Payer: Wellmed Medicare	$41,312.86

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC

Facility

$30,443.70

Service Code	MSDRG 328
Min. Negotiated Rate	$13,262.06
Max. Negotiated Rate	$30,443.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,503.39
Rate for Payer: Amerigroup Medicare	$16,503.39
Rate for Payer: BCBS of TX Medicare	$16,503.39
Rate for Payer: Cigna Commercial	$20,637.62
Rate for Payer: Cigna Medicare	$16,503.39
Rate for Payer: Employer Direct Commercial	$16,503.39
Rate for Payer: Humana Medicare/TRICARE	$16,503.39
Rate for Payer: Molina Dual Medicare/Medicaid	$16,503.39
Rate for Payer: Molina Medicare	$16,503.39
Rate for Payer: Multiplan Auto	$30,443.70
Rate for Payer: Multiplan Commercial	$30,443.70
Rate for Payer: Multiplan Workers Comp	$30,443.70
Rate for Payer: Scott and White EPO/PPO	$14,020.12
Rate for Payer: Scott and White Medicare	$16,503.39
Rate for Payer: Superior Health Plan EPO	$16,503.39
Rate for Payer: Superior Health Plan Medicare	$16,503.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,503.39
Rate for Payer: Universal American Medicare	$16,503.39
Rate for Payer: Wellcare Medicare	$16,503.39
Rate for Payer: Wellmed Medicare	$16,503.39

Know your out-of-pocket cost for care.

All Charges