White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SYSTEM CALIBRATION VISIGI 3D W/BLB 40FR

Facility

$1,033.30

Hospital Charge Code	8598511
Hospital Revenue Code	272
Rate for Payer: Cash Price	$702.64

System calibration visigi 3d with bulb 36fr

Facility

$227.60

Hospital Charge Code	8602529
Hospital Revenue Code	272
Rate for Payer: Cash Price	$154.77

System calibration visigi 3d with bulb 36fr

Facility

$227.60

Hospital Charge Code	8602529
Hospital Revenue Code	272
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$163.87
Rate for Payer: Amerigroup CHIP/Medicaid	$20.48
Rate for Payer: BCBS of TX Blue Advantage	$68.28
Rate for Payer: BCBS of TX Blue Essentials	$81.94
Rate for Payer: BCBS of TX PPO	$91.04
Rate for Payer: Cash Price	$154.77
Rate for Payer: Cigna Medicaid	$163.87
Rate for Payer: Molina CHIP/Medicaid	$163.87
Rate for Payer: Multiplan Auto	$147.94
Rate for Payer: Multiplan Commercial	$147.94
Rate for Payer: Multiplan Workers Comp	$147.94
Rate for Payer: Parkland Medicaid	$163.87
Rate for Payer: Scott and White EPO/PPO	$113.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.87
Rate for Payer: Superior Health Plan EPO	$30.95

SYSTEM CAST FOOT TOTAL ANKLE

Facility

$516.06

Hospital Charge Code	81020430
Hospital Revenue Code	271
Rate for Payer: Cash Price	$350.92

SYSTEM CAST FOOT TOTAL ANKLE

Facility

$516.06

Hospital Charge Code	81020430
Hospital Revenue Code	271
Min. Negotiated Rate	$46.45
Max. Negotiated Rate	$371.56
Rate for Payer: Amerigroup CHIP/Medicaid	$46.45
Rate for Payer: BCBS of TX Blue Advantage	$154.82
Rate for Payer: BCBS of TX Blue Essentials	$185.78
Rate for Payer: BCBS of TX PPO	$206.42
Rate for Payer: Cash Price	$350.92
Rate for Payer: Cigna Medicaid	$371.56
Rate for Payer: Molina CHIP/Medicaid	$371.56
Rate for Payer: Multiplan Auto	$335.44
Rate for Payer: Multiplan Commercial	$335.44
Rate for Payer: Multiplan Workers Comp	$335.44
Rate for Payer: Parkland Medicaid	$371.56
Rate for Payer: Scott and White EPO/PPO	$258.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$371.56
Rate for Payer: Superior Health Plan EPO	$70.18

SYSTEM CEMENT MIXING VC-1051

Facility

$1,952.20

Hospital Charge Code	144866
Hospital Revenue Code	272
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$1,405.58
Rate for Payer: Amerigroup CHIP/Medicaid	$175.70
Rate for Payer: BCBS of TX Blue Advantage	$585.66
Rate for Payer: BCBS of TX Blue Essentials	$702.79
Rate for Payer: BCBS of TX PPO	$780.88
Rate for Payer: Cash Price	$1,327.50
Rate for Payer: Cigna Medicaid	$1,405.58
Rate for Payer: Molina CHIP/Medicaid	$1,405.58
Rate for Payer: Multiplan Auto	$1,268.93
Rate for Payer: Multiplan Commercial	$1,268.93
Rate for Payer: Multiplan Workers Comp	$1,268.93
Rate for Payer: Parkland Medicaid	$1,405.58
Rate for Payer: Scott and White EPO/PPO	$976.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,405.58
Rate for Payer: Superior Health Plan EPO	$265.50

SYSTEM CEMENT MIXING VC-1051

Facility

$1,952.20

Hospital Charge Code	144866
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,327.50

SYSTEM CONCENTRATION BIOCUE 60ML

Facility

$7,014.30

Hospital Charge Code	145945
Hospital Revenue Code	272
Min. Negotiated Rate	$631.29
Max. Negotiated Rate	$5,050.30
Rate for Payer: Amerigroup CHIP/Medicaid	$631.29
Rate for Payer: BCBS of TX Blue Advantage	$2,104.29
Rate for Payer: BCBS of TX Blue Essentials	$2,525.15
Rate for Payer: BCBS of TX PPO	$2,805.72
Rate for Payer: Cash Price	$4,769.72
Rate for Payer: Cigna Medicaid	$5,050.30
Rate for Payer: Molina CHIP/Medicaid	$5,050.30
Rate for Payer: Multiplan Auto	$4,559.30
Rate for Payer: Multiplan Commercial	$4,559.30
Rate for Payer: Multiplan Workers Comp	$4,559.30
Rate for Payer: Parkland Medicaid	$5,050.30
Rate for Payer: Scott and White EPO/PPO	$3,507.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,050.30
Rate for Payer: Superior Health Plan EPO	$953.94

SYSTEM CONCENTRATION BIOCUE 60ML

Facility

$7,014.30

Hospital Charge Code	145945
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,769.72

SYSTEM EMBL PRTC VC 6.3FR 11FR 80CM 60CM

Facility

$1,384.70

Hospital Charge Code	109371
Hospital Revenue Code	272
Min. Negotiated Rate	$124.62
Max. Negotiated Rate	$996.98
Rate for Payer: Amerigroup CHIP/Medicaid	$124.62
Rate for Payer: BCBS of TX Blue Advantage	$415.41
Rate for Payer: BCBS of TX Blue Essentials	$498.49
Rate for Payer: BCBS of TX PPO	$553.88
Rate for Payer: Cash Price	$941.60
Rate for Payer: Cigna Medicaid	$996.98
Rate for Payer: Molina CHIP/Medicaid	$996.98
Rate for Payer: Multiplan Auto	$900.05
Rate for Payer: Multiplan Commercial	$900.05
Rate for Payer: Multiplan Workers Comp	$900.05
Rate for Payer: Parkland Medicaid	$996.98
Rate for Payer: Scott and White EPO/PPO	$692.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$996.98
Rate for Payer: Superior Health Plan EPO	$188.32

SYSTEM EMBL PRTC VC 6.3FR 11FR 80CM 60CM

Facility

$1,384.70

Hospital Charge Code	109371
Hospital Revenue Code	272
Rate for Payer: Cash Price	$941.60

SYSTEM FILTER EXPIRATORY PB980

Facility

$24.22

Hospital Charge Code	993301
Hospital Revenue Code	270
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$17.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2.18
Rate for Payer: BCBS of TX Blue Advantage	$7.27
Rate for Payer: BCBS of TX Blue Essentials	$8.72
Rate for Payer: BCBS of TX PPO	$9.69
Rate for Payer: Cash Price	$16.47
Rate for Payer: Cigna Medicaid	$17.44
Rate for Payer: Molina CHIP/Medicaid	$17.44
Rate for Payer: Multiplan Auto	$15.74
Rate for Payer: Multiplan Commercial	$15.74
Rate for Payer: Multiplan Workers Comp	$15.74
Rate for Payer: Parkland Medicaid	$17.44
Rate for Payer: Scott and White EPO/PPO	$12.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.44
Rate for Payer: Superior Health Plan EPO	$3.29

SYSTEM FILTER EXPIRATORY PB980

Facility

$24.22

Hospital Charge Code	993301
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.47

SYSTEM FILTER SPIDER EMBL

Facility

$4,317.54

Hospital Charge Code	8470493
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,935.93

SYSTEM FILTER SPIDER EMBL

Facility

$4,317.54

Hospital Charge Code	8470493
Hospital Revenue Code	272
Min. Negotiated Rate	$388.58
Max. Negotiated Rate	$3,108.63
Rate for Payer: Amerigroup CHIP/Medicaid	$388.58
Rate for Payer: BCBS of TX Blue Advantage	$1,295.26
Rate for Payer: BCBS of TX Blue Essentials	$1,554.31
Rate for Payer: BCBS of TX PPO	$1,727.02
Rate for Payer: Cash Price	$2,935.93
Rate for Payer: Cigna Medicaid	$3,108.63
Rate for Payer: Molina CHIP/Medicaid	$3,108.63
Rate for Payer: Multiplan Auto	$2,806.40
Rate for Payer: Multiplan Commercial	$2,806.40
Rate for Payer: Multiplan Workers Comp	$2,806.40
Rate for Payer: Parkland Medicaid	$3,108.63
Rate for Payer: Scott and White EPO/PPO	$2,158.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,108.63
Rate for Payer: Superior Health Plan EPO	$587.19

SYSTEM GEL PORT LAPAROSCOPIC C8XX2

Facility

$2,951.00

Hospital Charge Code	8556478
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,006.68

SYSTEM GEL PORT LAPAROSCOPIC C8XX2

Facility

$2,951.00

Hospital Charge Code	8556478
Hospital Revenue Code	272
Min. Negotiated Rate	$265.59
Max. Negotiated Rate	$2,124.72
Rate for Payer: Amerigroup CHIP/Medicaid	$265.59
Rate for Payer: BCBS of TX Blue Advantage	$885.30
Rate for Payer: BCBS of TX Blue Essentials	$1,062.36
Rate for Payer: BCBS of TX PPO	$1,180.40
Rate for Payer: Cash Price	$2,006.68
Rate for Payer: Cigna Medicaid	$2,124.72
Rate for Payer: Molina CHIP/Medicaid	$2,124.72
Rate for Payer: Multiplan Auto	$1,918.15
Rate for Payer: Multiplan Commercial	$1,918.15
Rate for Payer: Multiplan Workers Comp	$1,918.15
Rate for Payer: Parkland Medicaid	$2,124.72
Rate for Payer: Scott and White EPO/PPO	$1,475.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,124.72
Rate for Payer: Superior Health Plan EPO	$401.34

SYSTEM HARVESTING FASTGRAFTER AUTOGRAFT

Facility

$4,517.30

Hospital Charge Code	145683
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,071.76

SYSTEM HARVESTING FASTGRAFTER AUTOGRAFT

Facility

$4,517.30

Hospital Charge Code	145683
Hospital Revenue Code	272
Min. Negotiated Rate	$406.56
Max. Negotiated Rate	$3,252.46
Rate for Payer: Amerigroup CHIP/Medicaid	$406.56
Rate for Payer: BCBS of TX Blue Advantage	$1,355.19
Rate for Payer: BCBS of TX Blue Essentials	$1,626.23
Rate for Payer: BCBS of TX PPO	$1,806.92
Rate for Payer: Cash Price	$3,071.76
Rate for Payer: Cigna Medicaid	$3,252.46
Rate for Payer: Molina CHIP/Medicaid	$3,252.46
Rate for Payer: Multiplan Auto	$2,936.24
Rate for Payer: Multiplan Commercial	$2,936.24
Rate for Payer: Multiplan Workers Comp	$2,936.24
Rate for Payer: Parkland Medicaid	$3,252.46
Rate for Payer: Scott and White EPO/PPO	$2,258.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,252.46
Rate for Payer: Superior Health Plan EPO	$614.35

system indigo sep7

Facility

$7,513.70

Hospital Charge Code	8666514
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,109.32

system indigo sep7

Facility

$7,513.70

Hospital Charge Code	8666514
Hospital Revenue Code	272
Min. Negotiated Rate	$676.23
Max. Negotiated Rate	$5,409.86
Rate for Payer: Amerigroup CHIP/Medicaid	$676.23
Rate for Payer: BCBS of TX Blue Advantage	$2,254.11
Rate for Payer: BCBS of TX Blue Essentials	$2,704.93
Rate for Payer: BCBS of TX PPO	$3,005.48
Rate for Payer: Cash Price	$5,109.32
Rate for Payer: Cigna Medicaid	$5,409.86
Rate for Payer: Molina CHIP/Medicaid	$5,409.86
Rate for Payer: Multiplan Auto	$4,883.90
Rate for Payer: Multiplan Commercial	$4,883.90
Rate for Payer: Multiplan Workers Comp	$4,883.90
Rate for Payer: Parkland Medicaid	$5,409.86
Rate for Payer: Scott and White EPO/PPO	$3,756.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,409.86
Rate for Payer: Superior Health Plan EPO	$1,021.86

SYSTEM PANNUS RETENTION

Facility

$970.42

Hospital Charge Code	993666
Hospital Revenue Code	270
Rate for Payer: Cash Price	$659.89

SYSTEM PANNUS RETENTION

Facility

$970.42

Hospital Charge Code	993666
Hospital Revenue Code	270
Min. Negotiated Rate	$87.34
Max. Negotiated Rate	$698.70
Rate for Payer: Amerigroup CHIP/Medicaid	$87.34
Rate for Payer: BCBS of TX Blue Advantage	$291.13
Rate for Payer: BCBS of TX Blue Essentials	$349.35
Rate for Payer: BCBS of TX PPO	$388.17
Rate for Payer: Cash Price	$659.89
Rate for Payer: Cigna Medicaid	$698.70
Rate for Payer: Molina CHIP/Medicaid	$698.70
Rate for Payer: Multiplan Auto	$630.77
Rate for Payer: Multiplan Commercial	$630.77
Rate for Payer: Multiplan Workers Comp	$630.77
Rate for Payer: Parkland Medicaid	$698.70
Rate for Payer: Scott and White EPO/PPO	$485.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$698.70
Rate for Payer: Superior Health Plan EPO	$131.98

SYSTEM POSITIONING PINK PAD W/ARM PROTCT 29X20X1

Facility

$486.69

Hospital Charge Code	993754
Hospital Revenue Code	279
Rate for Payer: Cash Price	$330.95

SYSTEM POSITIONING PINK PAD W/ARM PROTCT 29X20X1

Facility

$486.69

Hospital Charge Code	993754
Hospital Revenue Code	279
Min. Negotiated Rate	$43.80
Max. Negotiated Rate	$350.42
Rate for Payer: Amerigroup CHIP/Medicaid	$43.80
Rate for Payer: BCBS of TX Blue Advantage	$146.01
Rate for Payer: BCBS of TX Blue Essentials	$175.21
Rate for Payer: BCBS of TX PPO	$194.68
Rate for Payer: Cash Price	$330.95
Rate for Payer: Cigna Medicaid	$350.42
Rate for Payer: Molina CHIP/Medicaid	$350.42
Rate for Payer: Multiplan Auto	$316.35
Rate for Payer: Multiplan Commercial	$316.35
Rate for Payer: Multiplan Workers Comp	$316.35
Rate for Payer: Parkland Medicaid	$350.42
Rate for Payer: Scott and White EPO/PPO	$243.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$350.42
Rate for Payer: Superior Health Plan EPO	$66.19

Know your out-of-pocket cost for care.

All Charges