White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SYSTEM, POSITIONING PINK PAD W/ARM PROTCT 29X20X1 -- DHF

Facility

$404.06

Hospital Charge Code	80824055
Hospital Revenue Code	270
Rate for Payer: Cash Price	$274.76

SYSTEM, POSITIONING PINK PAD W/ARM PROTCT 29X20X1 -- DHF

Facility

$404.06

Hospital Charge Code	80824055
Hospital Revenue Code	270
Min. Negotiated Rate	$36.37
Max. Negotiated Rate	$290.92
Rate for Payer: Amerigroup CHIP/Medicaid	$36.37
Rate for Payer: BCBS of TX Blue Advantage	$121.22
Rate for Payer: BCBS of TX Blue Essentials	$145.46
Rate for Payer: BCBS of TX PPO	$161.62
Rate for Payer: Cash Price	$274.76
Rate for Payer: Cigna Medicaid	$290.92
Rate for Payer: Molina CHIP/Medicaid	$290.92
Rate for Payer: Multiplan Auto	$262.64
Rate for Payer: Multiplan Commercial	$262.64
Rate for Payer: Multiplan Workers Comp	$262.64
Rate for Payer: Parkland Medicaid	$290.92
Rate for Payer: Scott and White EPO/PPO	$202.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$290.92
Rate for Payer: Superior Health Plan EPO	$54.95

SYSTEM, RETRIEVAL SPECIMEN ENDO 10MM DISP -- DHF

Facility

$363.94

Hospital Charge Code	81744203
Hospital Revenue Code	272
Min. Negotiated Rate	$32.75
Max. Negotiated Rate	$262.04
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
Rate for Payer: BCBS of TX Blue Advantage	$109.18
Rate for Payer: BCBS of TX Blue Essentials	$131.02
Rate for Payer: BCBS of TX PPO	$145.58
Rate for Payer: Cash Price	$247.48
Rate for Payer: Cigna Medicaid	$262.04
Rate for Payer: Molina CHIP/Medicaid	$262.04
Rate for Payer: Multiplan Auto	$236.56
Rate for Payer: Multiplan Commercial	$236.56
Rate for Payer: Multiplan Workers Comp	$236.56
Rate for Payer: Parkland Medicaid	$262.04
Rate for Payer: Scott and White EPO/PPO	$181.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$262.04
Rate for Payer: Superior Health Plan EPO	$49.50

SYSTEM, RETRIEVAL SPECIMEN ENDO 10MM DISP -- DHF

Facility

$363.94

Hospital Charge Code	81744203
Hospital Revenue Code	272
Rate for Payer: Cash Price	$247.48

SYSTEM, SPEED TRAP GRAFT PREP

Facility

$562.96

Hospital Charge Code	146518
Hospital Revenue Code	272
Min. Negotiated Rate	$50.67
Max. Negotiated Rate	$405.33
Rate for Payer: Amerigroup CHIP/Medicaid	$50.67
Rate for Payer: BCBS of TX Blue Advantage	$168.89
Rate for Payer: BCBS of TX Blue Essentials	$202.67
Rate for Payer: BCBS of TX PPO	$225.18
Rate for Payer: Cash Price	$382.81
Rate for Payer: Cigna Medicaid	$405.33
Rate for Payer: Molina CHIP/Medicaid	$405.33
Rate for Payer: Multiplan Auto	$365.92
Rate for Payer: Multiplan Commercial	$365.92
Rate for Payer: Multiplan Workers Comp	$365.92
Rate for Payer: Parkland Medicaid	$405.33
Rate for Payer: Scott and White EPO/PPO	$281.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$405.33
Rate for Payer: Superior Health Plan EPO	$76.56

SYSTEM, SPEED TRAP GRAFT PREP

Facility

$562.96

Hospital Charge Code	146518
Hospital Revenue Code	272
Rate for Payer: Cash Price	$382.81

SYSTEM, SPLINTING ONE STEP FIBERGLASS & FOAM 3X12 -- DHF

Facility

$258.92

Hospital Charge Code	81035008
Hospital Revenue Code	270
Min. Negotiated Rate	$23.30
Max. Negotiated Rate	$186.42
Rate for Payer: Amerigroup CHIP/Medicaid	$23.30
Rate for Payer: BCBS of TX Blue Advantage	$77.68
Rate for Payer: BCBS of TX Blue Essentials	$93.21
Rate for Payer: BCBS of TX PPO	$103.57
Rate for Payer: Cash Price	$176.07
Rate for Payer: Cigna Medicaid	$186.42
Rate for Payer: Molina CHIP/Medicaid	$186.42
Rate for Payer: Multiplan Auto	$168.30
Rate for Payer: Multiplan Commercial	$168.30
Rate for Payer: Multiplan Workers Comp	$168.30
Rate for Payer: Parkland Medicaid	$186.42
Rate for Payer: Scott and White EPO/PPO	$129.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$186.42
Rate for Payer: Superior Health Plan EPO	$35.21

SYSTEM, SPLINTING ONE STEP FIBERGLASS & FOAM 3X12 -- DHF

Facility

$258.92

Hospital Charge Code	81035008
Hospital Revenue Code	270
Rate for Payer: Cash Price	$176.07

SYSTEM STENT EXPAND OTW 9MMX39MMX135CM

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	991249
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.11
Max. Negotiated Rate	$2,804.22
Rate for Payer: Cash Price	$3,813.73
Rate for Payer: Cigna Commercial	$1,402.11
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Scott and White EPO/PPO	$2,804.22

SYSTEM STENT EXPAND OTW 9MMX39MMX135CM

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	991249
Hospital Revenue Code	278
Min. Negotiated Rate	$504.76
Max. Negotiated Rate	$4,038.07
Rate for Payer: Amerigroup CHIP/Medicaid	$504.76
Rate for Payer: BCBS of TX Blue Advantage	$1,682.53
Rate for Payer: BCBS of TX Blue Essentials	$2,019.03
Rate for Payer: BCBS of TX PPO	$2,243.37
Rate for Payer: Cash Price	$3,813.73
Rate for Payer: Cigna Medicaid	$4,038.07
Rate for Payer: Molina CHIP/Medicaid	$4,038.07
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Parkland Medicaid	$4,038.07
Rate for Payer: Scott and White EPO/PPO	$2,804.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,038.07
Rate for Payer: Superior Health Plan EPO	$762.75

SYSTEM, STENT EXPAND OTW OMNILINK ELITE 6X29X135CM

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	991251
Hospital Revenue Code	278
Min. Negotiated Rate	$504.76
Max. Negotiated Rate	$4,038.07
Rate for Payer: Amerigroup CHIP/Medicaid	$504.76
Rate for Payer: BCBS of TX Blue Advantage	$1,682.53
Rate for Payer: BCBS of TX Blue Essentials	$2,019.03
Rate for Payer: BCBS of TX PPO	$2,243.37
Rate for Payer: Cash Price	$3,813.73
Rate for Payer: Cigna Medicaid	$4,038.07
Rate for Payer: Molina CHIP/Medicaid	$4,038.07
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Parkland Medicaid	$4,038.07
Rate for Payer: Scott and White EPO/PPO	$2,804.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,038.07
Rate for Payer: Superior Health Plan EPO	$762.75

SYSTEM, STENT EXPAND OTW OMNILINK ELITE 6X29X135CM

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	991251
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.11
Max. Negotiated Rate	$2,804.22
Rate for Payer: Cash Price	$3,813.73
Rate for Payer: Cigna Commercial	$1,402.11
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Scott and White EPO/PPO	$2,804.22

SYSTEM STENT SLF EXP 6MMX40MMX135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	991247
Hospital Revenue Code	278
Min. Negotiated Rate	$531.32
Max. Negotiated Rate	$4,250.60
Rate for Payer: Amerigroup CHIP/Medicaid	$531.32
Rate for Payer: BCBS of TX Blue Advantage	$1,771.08
Rate for Payer: BCBS of TX Blue Essentials	$2,125.30
Rate for Payer: BCBS of TX PPO	$2,361.44
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Medicaid	$4,250.60
Rate for Payer: Molina CHIP/Medicaid	$4,250.60
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Parkland Medicaid	$4,250.60
Rate for Payer: Scott and White EPO/PPO	$2,951.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.60
Rate for Payer: Superior Health Plan EPO	$802.89

SYSTEM STENT SLF EXP 6MMX40MMX135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	991247
Hospital Revenue Code	278
Min. Negotiated Rate	$1,475.90
Max. Negotiated Rate	$2,951.80
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Commercial	$1,475.90
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80

SYSTEM STENT SLF EXP 6MMX60MMX135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	991248
Hospital Revenue Code	278
Min. Negotiated Rate	$531.32
Max. Negotiated Rate	$4,250.60
Rate for Payer: Amerigroup CHIP/Medicaid	$531.32
Rate for Payer: BCBS of TX Blue Advantage	$1,771.08
Rate for Payer: BCBS of TX Blue Essentials	$2,125.30
Rate for Payer: BCBS of TX PPO	$2,361.44
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Medicaid	$4,250.60
Rate for Payer: Molina CHIP/Medicaid	$4,250.60
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Parkland Medicaid	$4,250.60
Rate for Payer: Scott and White EPO/PPO	$2,951.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.60
Rate for Payer: Superior Health Plan EPO	$802.89

SYSTEM STENT SLF EXP 6MMX60MMX135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	991248
Hospital Revenue Code	278
Min. Negotiated Rate	$1,475.90
Max. Negotiated Rate	$2,951.80
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Commercial	$1,475.90
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80

SYSTEM, STENT SLF EXP ABS

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	135877
Hospital Revenue Code	278
Min. Negotiated Rate	$531.36
Max. Negotiated Rate	$4,250.88
Rate for Payer: Amerigroup CHIP/Medicaid	$531.36
Rate for Payer: BCBS of TX Blue Advantage	$1,771.20
Rate for Payer: BCBS of TX Blue Essentials	$2,125.44
Rate for Payer: BCBS of TX PPO	$2,361.60
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Medicaid	$4,250.88
Rate for Payer: Molina CHIP/Medicaid	$4,250.88
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Parkland Medicaid	$4,250.88
Rate for Payer: Scott and White EPO/PPO	$2,952.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.88
Rate for Payer: Superior Health Plan EPO	$802.94

SYSTEM, STENT SLF EXP ABS

Facility

$4,367.47

Service Code	HCPCS C1876
Hospital Charge Code	991250
Hospital Revenue Code	278
Min. Negotiated Rate	$393.07
Max. Negotiated Rate	$3,144.58
Rate for Payer: Amerigroup CHIP/Medicaid	$393.07
Rate for Payer: BCBS of TX Blue Advantage	$1,310.24
Rate for Payer: BCBS of TX Blue Essentials	$1,572.29
Rate for Payer: BCBS of TX PPO	$1,746.99
Rate for Payer: Cash Price	$2,969.88
Rate for Payer: Cigna Medicaid	$3,144.58
Rate for Payer: Molina CHIP/Medicaid	$3,144.58
Rate for Payer: Multiplan Auto	$2,183.74
Rate for Payer: Multiplan Commercial	$2,183.74
Rate for Payer: Multiplan Workers Comp	$2,183.74
Rate for Payer: Parkland Medicaid	$3,144.58
Rate for Payer: Scott and White EPO/PPO	$2,183.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,144.58
Rate for Payer: Superior Health Plan EPO	$593.98

SYSTEM, STENT SLF EXP ABS

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	135877
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.00
Max. Negotiated Rate	$2,952.00
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Commercial	$1,476.00
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Scott and White EPO/PPO	$2,952.00

SYSTEM, STENT SLF EXP ABS

Facility

$4,367.47

Service Code	HCPCS C1876
Hospital Charge Code	991250
Hospital Revenue Code	278
Min. Negotiated Rate	$1,091.87
Max. Negotiated Rate	$2,183.74
Rate for Payer: Cash Price	$2,969.88
Rate for Payer: Cigna Commercial	$1,091.87
Rate for Payer: Multiplan Auto	$2,183.74
Rate for Payer: Multiplan Commercial	$2,183.74
Rate for Payer: Multiplan Workers Comp	$2,183.74
Rate for Payer: Scott and White EPO/PPO	$2,183.74

SYSTEM, STENT SLF EXP ABS 136051

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	136051
Hospital Revenue Code	278
Min. Negotiated Rate	$531.36
Max. Negotiated Rate	$4,250.88
Rate for Payer: Amerigroup CHIP/Medicaid	$531.36
Rate for Payer: BCBS of TX Blue Advantage	$1,771.20
Rate for Payer: BCBS of TX Blue Essentials	$2,125.44
Rate for Payer: BCBS of TX PPO	$2,361.60
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Medicaid	$4,250.88
Rate for Payer: Molina CHIP/Medicaid	$4,250.88
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Parkland Medicaid	$4,250.88
Rate for Payer: Scott and White EPO/PPO	$2,952.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.88
Rate for Payer: Superior Health Plan EPO	$802.94

SYSTEM, STENT SLF EXP ABS 136051

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	136051
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.00
Max. Negotiated Rate	$2,952.00
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Commercial	$1,476.00
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Scott and White EPO/PPO	$2,952.00

SYSTEM STENT SLF EXP ABSOLUT PRO OTW 6X100MX135CM

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	9912400
Hospital Revenue Code	278
Min. Negotiated Rate	$1,475.90
Max. Negotiated Rate	$2,951.80
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Commercial	$1,475.90
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80

SYSTEM STENT SLF EXP ABSOLUT PRO OTW 6X100MX135CM

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	131686
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.00
Max. Negotiated Rate	$2,952.00
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Commercial	$1,476.00
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Scott and White EPO/PPO	$2,952.00

SYSTEM STENT SLF EXP ABSOLUT PRO OTW 6X100MX135CM

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	131686
Hospital Revenue Code	278
Min. Negotiated Rate	$531.36
Max. Negotiated Rate	$4,250.88
Rate for Payer: Amerigroup CHIP/Medicaid	$531.36
Rate for Payer: BCBS of TX Blue Advantage	$1,771.20
Rate for Payer: BCBS of TX Blue Essentials	$2,125.44
Rate for Payer: BCBS of TX PPO	$2,361.60
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Medicaid	$4,250.88
Rate for Payer: Molina CHIP/Medicaid	$4,250.88
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Parkland Medicaid	$4,250.88
Rate for Payer: Scott and White EPO/PPO	$2,952.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.88
Rate for Payer: Superior Health Plan EPO	$802.94

Know your out-of-pocket cost for care.

All Charges