White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TIP FLEX VISTASEAL 45CM

Facility

$710.96

Service Code	HCPCS A4649
Hospital Charge Code	8494510
Hospital Revenue Code	272
Min. Negotiated Rate	$63.99
Max. Negotiated Rate	$511.89
Rate for Payer: Amerigroup CHIP/Medicaid	$63.99
Rate for Payer: BCBS of TX Blue Advantage	$213.29
Rate for Payer: BCBS of TX Blue Essentials	$255.95
Rate for Payer: BCBS of TX PPO	$284.38
Rate for Payer: Cash Price	$483.45
Rate for Payer: Cigna Medicaid	$511.89
Rate for Payer: Molina CHIP/Medicaid	$511.89
Rate for Payer: Multiplan Auto	$462.12
Rate for Payer: Multiplan Commercial	$462.12
Rate for Payer: Multiplan Workers Comp	$462.12
Rate for Payer: Parkland Medicaid	$511.89
Rate for Payer: Scott and White EPO/PPO	$355.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$511.89
Rate for Payer: Superior Health Plan EPO	$96.69

TIP FLEX VISTASEAL 45CM

Facility

$710.96

Service Code	HCPCS A4649
Hospital Charge Code	8494510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$483.45

TIP, GRASPER MARYLAND DISSECTOR SERRATED 18.8MM -- DHF

Facility

$597.62

Hospital Charge Code	81775736
Hospital Revenue Code	270
Min. Negotiated Rate	$53.79
Max. Negotiated Rate	$430.29
Rate for Payer: Amerigroup CHIP/Medicaid	$53.79
Rate for Payer: BCBS of TX Blue Advantage	$179.29
Rate for Payer: BCBS of TX Blue Essentials	$215.14
Rate for Payer: BCBS of TX PPO	$239.05
Rate for Payer: Cash Price	$406.38
Rate for Payer: Cigna Medicaid	$430.29
Rate for Payer: Molina CHIP/Medicaid	$430.29
Rate for Payer: Multiplan Auto	$388.45
Rate for Payer: Multiplan Commercial	$388.45
Rate for Payer: Multiplan Workers Comp	$388.45
Rate for Payer: Parkland Medicaid	$430.29
Rate for Payer: Scott and White EPO/PPO	$298.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$430.29
Rate for Payer: Superior Health Plan EPO	$81.28

TIP, GRASPER MARYLAND DISSECTOR SERRATED 18.8MM -- DHF

Facility

$597.62

Hospital Charge Code	81775736
Hospital Revenue Code	270
Rate for Payer: Cash Price	$406.38

Ti plasma spray

Facility

$18,072.29

Service Code	HCPCS C1776
Hospital Charge Code	992143
Hospital Revenue Code	278
Min. Negotiated Rate	$1,626.51
Max. Negotiated Rate	$13,012.05
Rate for Payer: Amerigroup CHIP/Medicaid	$1,626.51
Rate for Payer: BCBS of TX Blue Advantage	$5,421.69
Rate for Payer: BCBS of TX Blue Essentials	$6,506.02
Rate for Payer: BCBS of TX PPO	$7,228.92
Rate for Payer: Cash Price	$12,289.16
Rate for Payer: Cigna Medicaid	$13,012.05
Rate for Payer: Molina CHIP/Medicaid	$13,012.05
Rate for Payer: Multiplan Auto	$9,036.15
Rate for Payer: Multiplan Commercial	$9,036.15
Rate for Payer: Multiplan Workers Comp	$9,036.15
Rate for Payer: Parkland Medicaid	$13,012.05
Rate for Payer: Scott and White EPO/PPO	$9,036.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,012.05
Rate for Payer: Superior Health Plan EPO	$2,457.83

Ti plasma spray

Facility

$18,072.29

Service Code	HCPCS C1776
Hospital Charge Code	992143
Hospital Revenue Code	278
Min. Negotiated Rate	$4,518.07
Max. Negotiated Rate	$9,036.15
Rate for Payer: Cash Price	$12,289.16
Rate for Payer: Cigna Commercial	$4,518.07
Rate for Payer: Multiplan Auto	$9,036.15
Rate for Payer: Multiplan Commercial	$9,036.15
Rate for Payer: Multiplan Workers Comp	$9,036.15
Rate for Payer: Scott and White EPO/PPO	$9,036.15

TIP, MANIPULATOR, UTERINE, RUMI, II , WHITE

Facility

$681.90

Hospital Charge Code	992760
Hospital Revenue Code	272
Rate for Payer: Cash Price	$463.69

TIP, MANIPULATOR, UTERINE, RUMI, II , WHITE

Facility

$681.90

Hospital Charge Code	992760
Hospital Revenue Code	272
Min. Negotiated Rate	$61.37
Max. Negotiated Rate	$490.97
Rate for Payer: Amerigroup CHIP/Medicaid	$61.37
Rate for Payer: BCBS of TX Blue Advantage	$204.57
Rate for Payer: BCBS of TX Blue Essentials	$245.48
Rate for Payer: BCBS of TX PPO	$272.76
Rate for Payer: Cash Price	$463.69
Rate for Payer: Cigna Medicaid	$490.97
Rate for Payer: Molina CHIP/Medicaid	$490.97
Rate for Payer: Multiplan Auto	$443.24
Rate for Payer: Multiplan Commercial	$443.24
Rate for Payer: Multiplan Workers Comp	$443.24
Rate for Payer: Parkland Medicaid	$490.97
Rate for Payer: Scott and White EPO/PPO	$340.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$490.97
Rate for Payer: Superior Health Plan EPO	$92.74

TIP RIGID VISTASEAL 35CM

Facility

$710.96

Service Code	HCPCS A4649
Hospital Charge Code	8494507
Hospital Revenue Code	272
Rate for Payer: Cash Price	$483.45

TIP RIGID VISTASEAL 35CM

Facility

$710.96

Service Code	HCPCS A4649
Hospital Charge Code	8494507
Hospital Revenue Code	272
Min. Negotiated Rate	$63.99
Max. Negotiated Rate	$511.89
Rate for Payer: Amerigroup CHIP/Medicaid	$63.99
Rate for Payer: BCBS of TX Blue Advantage	$213.29
Rate for Payer: BCBS of TX Blue Essentials	$255.95
Rate for Payer: BCBS of TX PPO	$284.38
Rate for Payer: Cash Price	$483.45
Rate for Payer: Cigna Medicaid	$511.89
Rate for Payer: Molina CHIP/Medicaid	$511.89
Rate for Payer: Multiplan Auto	$462.12
Rate for Payer: Multiplan Commercial	$462.12
Rate for Payer: Multiplan Workers Comp	$462.12
Rate for Payer: Parkland Medicaid	$511.89
Rate for Payer: Scott and White EPO/PPO	$355.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$511.89
Rate for Payer: Superior Health Plan EPO	$96.69

TIP, RUMI, UTERINE MANIPULATOR, BLUE

Facility

$766.97

Hospital Charge Code	992761
Hospital Revenue Code	272
Rate for Payer: Cash Price	$521.54

TIP, RUMI, UTERINE MANIPULATOR, BLUE

Facility

$766.97

Hospital Charge Code	992761
Hospital Revenue Code	272
Min. Negotiated Rate	$69.03
Max. Negotiated Rate	$552.22
Rate for Payer: Amerigroup CHIP/Medicaid	$69.03
Rate for Payer: BCBS of TX Blue Advantage	$230.09
Rate for Payer: BCBS of TX Blue Essentials	$276.11
Rate for Payer: BCBS of TX PPO	$306.79
Rate for Payer: Cash Price	$521.54
Rate for Payer: Cigna Medicaid	$552.22
Rate for Payer: Molina CHIP/Medicaid	$552.22
Rate for Payer: Multiplan Auto	$498.53
Rate for Payer: Multiplan Commercial	$498.53
Rate for Payer: Multiplan Workers Comp	$498.53
Rate for Payer: Parkland Medicaid	$552.22
Rate for Payer: Scott and White EPO/PPO	$383.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$552.22
Rate for Payer: Superior Health Plan EPO	$104.31

TIP, SUCTION YANKAUER SOFT TIP W/VENT NONSTRL DISP -- DHF

Facility

$41.57

Hospital Charge Code	81855553
Hospital Revenue Code	270
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$29.93
Rate for Payer: Amerigroup CHIP/Medicaid	$3.74
Rate for Payer: BCBS of TX Blue Advantage	$12.47
Rate for Payer: BCBS of TX Blue Essentials	$14.97
Rate for Payer: BCBS of TX PPO	$16.63
Rate for Payer: Cash Price	$28.27
Rate for Payer: Cigna Medicaid	$29.93
Rate for Payer: Molina CHIP/Medicaid	$29.93
Rate for Payer: Multiplan Auto	$27.02
Rate for Payer: Multiplan Commercial	$27.02
Rate for Payer: Multiplan Workers Comp	$27.02
Rate for Payer: Parkland Medicaid	$29.93
Rate for Payer: Scott and White EPO/PPO	$20.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.93
Rate for Payer: Superior Health Plan EPO	$5.65

TIP, SUCTION YANKAUER SOFT TIP W/VENT NONSTRL DISP -- DHF

Facility

$41.57

Hospital Charge Code	81855553
Hospital Revenue Code	270
Rate for Payer: Cash Price	$28.27

TIP, UTERINE MANIPULATOR GRN 6.7MMX10CM STRL DISP -- DHF

Facility

$249.31

Hospital Charge Code	81810152
Hospital Revenue Code	270
Rate for Payer: Cash Price	$169.53

TIP, UTERINE MANIPULATOR GRN 6.7MMX10CM STRL DISP -- DHF

Facility

$249.31

Hospital Charge Code	81810152
Hospital Revenue Code	270
Min. Negotiated Rate	$22.44
Max. Negotiated Rate	$179.50
Rate for Payer: Amerigroup CHIP/Medicaid	$22.44
Rate for Payer: BCBS of TX Blue Advantage	$74.79
Rate for Payer: BCBS of TX Blue Essentials	$89.75
Rate for Payer: BCBS of TX PPO	$99.72
Rate for Payer: Cash Price	$169.53
Rate for Payer: Cigna Medicaid	$179.50
Rate for Payer: Molina CHIP/Medicaid	$179.50
Rate for Payer: Multiplan Auto	$162.05
Rate for Payer: Multiplan Commercial	$162.05
Rate for Payer: Multiplan Workers Comp	$162.05
Rate for Payer: Parkland Medicaid	$179.50
Rate for Payer: Scott and White EPO/PPO	$124.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$179.50
Rate for Payer: Superior Health Plan EPO	$33.91

TISSUE, COMPACT, 2PLY, 1000/36

Facility

$6.25

Hospital Charge Code	993230
Hospital Revenue Code	270
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$4.50
Rate for Payer: Amerigroup CHIP/Medicaid	$0.56
Rate for Payer: BCBS of TX Blue Advantage	$1.88
Rate for Payer: BCBS of TX Blue Essentials	$2.25
Rate for Payer: BCBS of TX PPO	$2.50
Rate for Payer: Cash Price	$4.25
Rate for Payer: Cigna Medicaid	$4.50
Rate for Payer: Molina CHIP/Medicaid	$4.50
Rate for Payer: Multiplan Auto	$4.06
Rate for Payer: Multiplan Commercial	$4.06
Rate for Payer: Multiplan Workers Comp	$4.06
Rate for Payer: Parkland Medicaid	$4.50
Rate for Payer: Scott and White EPO/PPO	$3.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.50
Rate for Payer: Superior Health Plan EPO	$0.85

TISSUE, COMPACT, 2PLY, 1000/36

Facility

$6.25

Hospital Charge Code	993230
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.25

Tissue Culture

Facility

$151.00

Service Code	HCPCS 87252
Hospital Charge Code	1700236
Hospital Revenue Code	306
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$108.72
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.07
Rate for Payer: Amerigroup Medicare	$26.07
Rate for Payer: BCBS of TX Blue Advantage	$45.30
Rate for Payer: BCBS of TX Blue Essentials	$54.36
Rate for Payer: BCBS of TX Medicare	$26.07
Rate for Payer: BCBS of TX PPO	$60.40
Rate for Payer: Cash Price	$102.68
Rate for Payer: Cash Price	$102.68
Rate for Payer: Cigna Medicaid	$108.72
Rate for Payer: Cigna Medicare	$26.07
Rate for Payer: Employer Direct Commercial	$26.07
Rate for Payer: Humana Medicare/TRICARE	$26.07
Rate for Payer: Molina CHIP/Medicaid	$108.72
Rate for Payer: Molina Dual Medicare/Medicaid	$26.07
Rate for Payer: Molina Medicare	$26.07
Rate for Payer: Multiplan Auto	$98.15
Rate for Payer: Multiplan Commercial	$98.15
Rate for Payer: Multiplan Workers Comp	$98.15
Rate for Payer: Parkland Medicaid	$108.72
Rate for Payer: Scott and White EPO/PPO	$32.59
Rate for Payer: Scott and White Medicare	$26.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.72
Rate for Payer: Superior Health Plan EPO	$26.07
Rate for Payer: Superior Health Plan Medicare	$26.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.07
Rate for Payer: Universal American Medicare	$26.07
Rate for Payer: Wellcare Medicare	$26.07
Rate for Payer: Wellmed Medicare	$26.07

Tissue Culture

Facility

$151.00

Service Code	HCPCS 87252
Hospital Charge Code	1700236
Hospital Revenue Code	306
Rate for Payer: Cash Price	$102.68

.Tissue Grind/Digestion/Decon SO

Facility

$46.01

Service Code	HCPCS 87176
Hospital Charge Code	9058996
Hospital Revenue Code	306
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$33.13
Rate for Payer: Amerigroup CHIP/Medicaid	$2.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.88
Rate for Payer: Amerigroup Medicare	$5.88
Rate for Payer: BCBS of TX Blue Advantage	$13.80
Rate for Payer: BCBS of TX Blue Essentials	$16.56
Rate for Payer: BCBS of TX Medicare	$5.88
Rate for Payer: BCBS of TX PPO	$18.40
Rate for Payer: Cash Price	$31.29
Rate for Payer: Cash Price	$31.29
Rate for Payer: Cigna Medicaid	$33.13
Rate for Payer: Cigna Medicare	$5.88
Rate for Payer: Employer Direct Commercial	$5.88
Rate for Payer: Humana Medicare/TRICARE	$5.88
Rate for Payer: Molina CHIP/Medicaid	$33.13
Rate for Payer: Molina Dual Medicare/Medicaid	$5.88
Rate for Payer: Molina Medicare	$5.88
Rate for Payer: Multiplan Auto	$29.91
Rate for Payer: Multiplan Commercial	$29.91
Rate for Payer: Multiplan Workers Comp	$29.91
Rate for Payer: Parkland Medicaid	$33.13
Rate for Payer: Scott and White EPO/PPO	$7.35
Rate for Payer: Scott and White Medicare	$5.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.13
Rate for Payer: Superior Health Plan EPO	$5.88
Rate for Payer: Superior Health Plan Medicare	$5.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.88
Rate for Payer: Universal American Medicare	$5.88
Rate for Payer: Wellcare Medicare	$5.88
Rate for Payer: Wellmed Medicare	$5.88

.Tissue Grind/Digestion/Decon SO

Facility

$46.01

Service Code	HCPCS 87176
Hospital Charge Code	9058996
Hospital Revenue Code	306
Rate for Payer: Cash Price	$31.29

TISSUE GRINDER 50ML CONICAL 10/CA

Facility

$215.16

Hospital Charge Code	993647
Hospital Revenue Code	270
Min. Negotiated Rate	$19.36
Max. Negotiated Rate	$154.92
Rate for Payer: Amerigroup CHIP/Medicaid	$19.36
Rate for Payer: BCBS of TX Blue Advantage	$64.55
Rate for Payer: BCBS of TX Blue Essentials	$77.46
Rate for Payer: BCBS of TX PPO	$86.06
Rate for Payer: Cash Price	$146.31
Rate for Payer: Cigna Medicaid	$154.92
Rate for Payer: Molina CHIP/Medicaid	$154.92
Rate for Payer: Multiplan Auto	$139.85
Rate for Payer: Multiplan Commercial	$139.85
Rate for Payer: Multiplan Workers Comp	$139.85
Rate for Payer: Parkland Medicaid	$154.92
Rate for Payer: Scott and White EPO/PPO	$107.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$154.92
Rate for Payer: Superior Health Plan EPO	$29.26

TISSUE GRINDER 50ML CONICAL 10/CA

Facility

$215.16

Hospital Charge Code	993647
Hospital Revenue Code	270
Rate for Payer: Cash Price	$146.31

.Tissue Grinding SO

Facility

$46.01

Service Code	HCPCS 87176
Hospital Charge Code	9058994
Hospital Revenue Code	306
Rate for Payer: Cash Price	$31.29

Know your out-of-pocket cost for care.

All Charges