White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WIRE BOLT - SHORT - DIA 1.5 TO 2.0mm

Facility

$440.38

Hospital Charge Code	993421
Hospital Revenue Code	272
Rate for Payer: Cash Price	$299.46

WIRE BOLT - SHORT - DIA 1.5 TO 2.0mm

Facility

$440.38

Hospital Charge Code	993421
Hospital Revenue Code	272
Min. Negotiated Rate	$39.63
Max. Negotiated Rate	$317.07
Rate for Payer: Amerigroup CHIP/Medicaid	$39.63
Rate for Payer: BCBS of TX Blue Advantage	$132.11
Rate for Payer: BCBS of TX Blue Essentials	$158.54
Rate for Payer: BCBS of TX PPO	$176.15
Rate for Payer: Cash Price	$299.46
Rate for Payer: Cigna Medicaid	$317.07
Rate for Payer: Molina CHIP/Medicaid	$317.07
Rate for Payer: Multiplan Auto	$286.25
Rate for Payer: Multiplan Commercial	$286.25
Rate for Payer: Multiplan Workers Comp	$286.25
Rate for Payer: Parkland Medicaid	$317.07
Rate for Payer: Scott and White EPO/PPO	$220.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$317.07
Rate for Payer: Superior Health Plan EPO	$59.89

WIRE COMP THREADED 1.6MM

Facility

$385.00

Service Code	HCPCS C1769
Hospital Charge Code	146667
Hospital Revenue Code	278
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$192.50
Rate for Payer: Cash Price	$261.80
Rate for Payer: Cigna Commercial	$96.25
Rate for Payer: Multiplan Auto	$192.50
Rate for Payer: Multiplan Commercial	$192.50
Rate for Payer: Multiplan Workers Comp	$192.50
Rate for Payer: Scott and White EPO/PPO	$192.50

WIRE COMP THREADED 1.6MM

Facility

$385.00

Service Code	HCPCS C1769
Hospital Charge Code	146667
Hospital Revenue Code	278
Min. Negotiated Rate	$34.65
Max. Negotiated Rate	$277.20
Rate for Payer: Amerigroup CHIP/Medicaid	$34.65
Rate for Payer: BCBS of TX Blue Advantage	$115.50
Rate for Payer: BCBS of TX Blue Essentials	$138.60
Rate for Payer: BCBS of TX PPO	$154.00
Rate for Payer: Cash Price	$261.80
Rate for Payer: Cigna Medicaid	$277.20
Rate for Payer: Molina CHIP/Medicaid	$277.20
Rate for Payer: Multiplan Auto	$192.50
Rate for Payer: Multiplan Commercial	$192.50
Rate for Payer: Multiplan Workers Comp	$192.50
Rate for Payer: Parkland Medicaid	$277.20
Rate for Payer: Scott and White EPO/PPO	$192.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$277.20
Rate for Payer: Superior Health Plan EPO	$52.36

WIRE DIAMOND POINT - DIA 1.8 X 450 mm

Facility

$572.04

Hospital Charge Code	993429
Hospital Revenue Code	272
Rate for Payer: Cash Price	$388.99

WIRE DIAMOND POINT - DIA 1.8 X 450 mm

Facility

$572.04

Hospital Charge Code	993429
Hospital Revenue Code	272
Min. Negotiated Rate	$51.48
Max. Negotiated Rate	$411.87
Rate for Payer: Amerigroup CHIP/Medicaid	$51.48
Rate for Payer: BCBS of TX Blue Advantage	$171.61
Rate for Payer: BCBS of TX Blue Essentials	$205.93
Rate for Payer: BCBS of TX PPO	$228.82
Rate for Payer: Cash Price	$388.99
Rate for Payer: Cigna Medicaid	$411.87
Rate for Payer: Molina CHIP/Medicaid	$411.87
Rate for Payer: Multiplan Auto	$371.83
Rate for Payer: Multiplan Commercial	$371.83
Rate for Payer: Multiplan Workers Comp	$371.83
Rate for Payer: Parkland Medicaid	$411.87
Rate for Payer: Scott and White EPO/PPO	$286.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$411.87
Rate for Payer: Superior Health Plan EPO	$77.80

WIRE FIXATION KIRSCHNER 0.9MM DIA 70MML TROCAR TIP MARKED FIXOS SINGLE-USE

Facility

$258.69

Hospital Charge Code	122806
Hospital Revenue Code	272
Min. Negotiated Rate	$23.28
Max. Negotiated Rate	$186.26
Rate for Payer: Amerigroup CHIP/Medicaid	$23.28
Rate for Payer: BCBS of TX Blue Advantage	$77.61
Rate for Payer: BCBS of TX Blue Essentials	$93.13
Rate for Payer: BCBS of TX PPO	$103.48
Rate for Payer: Cash Price	$175.91
Rate for Payer: Cigna Medicaid	$186.26
Rate for Payer: Molina CHIP/Medicaid	$186.26
Rate for Payer: Multiplan Auto	$168.15
Rate for Payer: Multiplan Commercial	$168.15
Rate for Payer: Multiplan Workers Comp	$168.15
Rate for Payer: Parkland Medicaid	$186.26
Rate for Payer: Scott and White EPO/PPO	$129.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$186.26
Rate for Payer: Superior Health Plan EPO	$35.18

WIRE FIXATION KIRSCHNER 0.9MM DIA 70MML TROCAR TIP MARKED FIXOS SINGLE-USE

Facility

$258.69

Hospital Charge Code	122806
Hospital Revenue Code	272
Rate for Payer: Cash Price	$175.91

WIRE FX 1.6X150MM KRSH SS TROC PNT

Facility

$743.65

Hospital Charge Code	122869
Hospital Revenue Code	272
Rate for Payer: Cash Price	$505.68

WIRE FX 1.6X150MM KRSH SS TROC PNT

Facility

$743.65

Hospital Charge Code	122869
Hospital Revenue Code	272
Min. Negotiated Rate	$66.93
Max. Negotiated Rate	$535.43
Rate for Payer: Amerigroup CHIP/Medicaid	$66.93
Rate for Payer: BCBS of TX Blue Advantage	$223.09
Rate for Payer: BCBS of TX Blue Essentials	$267.71
Rate for Payer: BCBS of TX PPO	$297.46
Rate for Payer: Cash Price	$505.68
Rate for Payer: Cigna Medicaid	$535.43
Rate for Payer: Molina CHIP/Medicaid	$535.43
Rate for Payer: Multiplan Auto	$483.37
Rate for Payer: Multiplan Commercial	$483.37
Rate for Payer: Multiplan Workers Comp	$483.37
Rate for Payer: Parkland Medicaid	$535.43
Rate for Payer: Scott and White EPO/PPO	$371.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$535.43
Rate for Payer: Superior Health Plan EPO	$101.14

WIRE FX 3X285MM K T2 SS STRL

Facility

$994.00

Service Code	HCPCS C1769
Hospital Charge Code	122781
Hospital Revenue Code	278
Min. Negotiated Rate	$89.46
Max. Negotiated Rate	$715.68
Rate for Payer: Amerigroup CHIP/Medicaid	$89.46
Rate for Payer: BCBS of TX Blue Advantage	$298.20
Rate for Payer: BCBS of TX Blue Essentials	$357.84
Rate for Payer: BCBS of TX PPO	$397.60
Rate for Payer: Cash Price	$675.92
Rate for Payer: Cigna Medicaid	$715.68
Rate for Payer: Molina CHIP/Medicaid	$715.68
Rate for Payer: Multiplan Auto	$497.00
Rate for Payer: Multiplan Commercial	$497.00
Rate for Payer: Multiplan Workers Comp	$497.00
Rate for Payer: Parkland Medicaid	$715.68
Rate for Payer: Scott and White EPO/PPO	$497.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.68
Rate for Payer: Superior Health Plan EPO	$135.18

WIRE FX 3X285MM K T2 SS STRL

Facility

$994.00

Service Code	HCPCS C1769
Hospital Charge Code	122781
Hospital Revenue Code	278
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$497.00
Rate for Payer: Cash Price	$675.92
Rate for Payer: Cigna Commercial	$248.50
Rate for Payer: Multiplan Auto	$497.00
Rate for Payer: Multiplan Commercial	$497.00
Rate for Payer: Multiplan Workers Comp	$497.00
Rate for Payer: Scott and White EPO/PPO	$497.00

WIRE, GUIDE BENTSON .035'

Facility

$67.30

Service Code	HCPCS C1887
Hospital Charge Code	992457
Hospital Revenue Code	272
Rate for Payer: Cash Price	$45.76

WIRE, GUIDE BENTSON .035'

Facility

$67.30

Service Code	HCPCS C1887
Hospital Charge Code	992457
Hospital Revenue Code	272
Min. Negotiated Rate	$6.06
Max. Negotiated Rate	$48.46
Rate for Payer: Amerigroup CHIP/Medicaid	$6.06
Rate for Payer: BCBS of TX Blue Advantage	$20.19
Rate for Payer: BCBS of TX Blue Essentials	$24.23
Rate for Payer: BCBS of TX PPO	$26.92
Rate for Payer: Cash Price	$45.76
Rate for Payer: Cigna Medicaid	$48.46
Rate for Payer: Molina CHIP/Medicaid	$48.46
Rate for Payer: Multiplan Auto	$43.74
Rate for Payer: Multiplan Commercial	$43.74
Rate for Payer: Multiplan Workers Comp	$43.74
Rate for Payer: Parkland Medicaid	$48.46
Rate for Payer: Scott and White EPO/PPO	$33.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$48.46
Rate for Payer: Superior Health Plan EPO	$9.15

WIRE GUIDE HI-TORQUE FLOPPY VERSACORE 260CM

Facility

$408.60

Hospital Charge Code	131685
Hospital Revenue Code	272
Rate for Payer: Cash Price	$277.85

WIRE GUIDE HI-TORQUE FLOPPY VERSACORE 260CM

Facility

$408.60

Hospital Charge Code	131685
Hospital Revenue Code	272
Min. Negotiated Rate	$36.77
Max. Negotiated Rate	$294.19
Rate for Payer: Amerigroup CHIP/Medicaid	$36.77
Rate for Payer: BCBS of TX Blue Advantage	$122.58
Rate for Payer: BCBS of TX Blue Essentials	$147.10
Rate for Payer: BCBS of TX PPO	$163.44
Rate for Payer: Cash Price	$277.85
Rate for Payer: Cigna Medicaid	$294.19
Rate for Payer: Molina CHIP/Medicaid	$294.19
Rate for Payer: Multiplan Auto	$265.59
Rate for Payer: Multiplan Commercial	$265.59
Rate for Payer: Multiplan Workers Comp	$265.59
Rate for Payer: Parkland Medicaid	$294.19
Rate for Payer: Scott and White EPO/PPO	$204.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$294.19
Rate for Payer: Superior Health Plan EPO	$55.57

WIRE, GUIDE ICE PT XS PLY

Facility

$374.10

Service Code	HCPCS C1887
Hospital Charge Code	992458
Hospital Revenue Code	272
Min. Negotiated Rate	$33.67
Max. Negotiated Rate	$269.35
Rate for Payer: Amerigroup CHIP/Medicaid	$33.67
Rate for Payer: BCBS of TX Blue Advantage	$112.23
Rate for Payer: BCBS of TX Blue Essentials	$134.68
Rate for Payer: BCBS of TX PPO	$149.64
Rate for Payer: Cash Price	$254.39
Rate for Payer: Cigna Medicaid	$269.35
Rate for Payer: Molina CHIP/Medicaid	$269.35
Rate for Payer: Multiplan Auto	$243.16
Rate for Payer: Multiplan Commercial	$243.16
Rate for Payer: Multiplan Workers Comp	$243.16
Rate for Payer: Parkland Medicaid	$269.35
Rate for Payer: Scott and White EPO/PPO	$187.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$269.35
Rate for Payer: Superior Health Plan EPO	$50.88

WIRE, GUIDE ICE PT XS PLY

Facility

$374.10

Service Code	HCPCS C1887
Hospital Charge Code	992458
Hospital Revenue Code	272
Rate for Payer: Cash Price	$254.39

WIRE GUIDEPINCAL -- DHF

Facility

$655.00

Service Code	HCPCS C1713
Hospital Charge Code	81370900
Hospital Revenue Code	278
Min. Negotiated Rate	$163.75
Max. Negotiated Rate	$327.50
Rate for Payer: Cash Price	$445.40
Rate for Payer: Cigna Commercial	$163.75
Rate for Payer: Multiplan Auto	$327.50
Rate for Payer: Multiplan Commercial	$327.50
Rate for Payer: Multiplan Workers Comp	$327.50
Rate for Payer: Scott and White EPO/PPO	$327.50

WIRE GUIDEPINCAL -- DHF

Facility

$655.00

Service Code	HCPCS C1713
Hospital Charge Code	81370900
Hospital Revenue Code	278
Min. Negotiated Rate	$58.95
Max. Negotiated Rate	$471.60
Rate for Payer: Amerigroup CHIP/Medicaid	$58.95
Rate for Payer: BCBS of TX Blue Advantage	$196.50
Rate for Payer: BCBS of TX Blue Essentials	$235.80
Rate for Payer: BCBS of TX PPO	$262.00
Rate for Payer: Cash Price	$445.40
Rate for Payer: Cigna Medicaid	$471.60
Rate for Payer: Molina CHIP/Medicaid	$471.60
Rate for Payer: Multiplan Auto	$327.50
Rate for Payer: Multiplan Commercial	$327.50
Rate for Payer: Multiplan Workers Comp	$327.50
Rate for Payer: Parkland Medicaid	$471.60
Rate for Payer: Scott and White EPO/PPO	$327.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$471.60
Rate for Payer: Superior Health Plan EPO	$89.08

WIRE KIRCHNER I

Facility

$361.00

Service Code	HCPCS C1769
Hospital Charge Code	8514469
Hospital Revenue Code	278
Min. Negotiated Rate	$90.25
Max. Negotiated Rate	$180.50
Rate for Payer: Cash Price	$245.48
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Multiplan Auto	$180.50
Rate for Payer: Multiplan Commercial	$180.50
Rate for Payer: Multiplan Workers Comp	$180.50
Rate for Payer: Scott and White EPO/PPO	$180.50

WIRE KIRCHNER I

Facility

$361.00

Service Code	HCPCS C1769
Hospital Charge Code	8514469
Hospital Revenue Code	278
Min. Negotiated Rate	$32.49
Max. Negotiated Rate	$259.92
Rate for Payer: Amerigroup CHIP/Medicaid	$32.49
Rate for Payer: BCBS of TX Blue Advantage	$108.30
Rate for Payer: BCBS of TX Blue Essentials	$129.96
Rate for Payer: BCBS of TX PPO	$144.40
Rate for Payer: Cash Price	$245.48
Rate for Payer: Cigna Medicaid	$259.92
Rate for Payer: Molina CHIP/Medicaid	$259.92
Rate for Payer: Multiplan Auto	$180.50
Rate for Payer: Multiplan Commercial	$180.50
Rate for Payer: Multiplan Workers Comp	$180.50
Rate for Payer: Parkland Medicaid	$259.92
Rate for Payer: Scott and White EPO/PPO	$180.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$259.92
Rate for Payer: Superior Health Plan EPO	$49.10

WIRE KIRCHNER II

Facility

$116.00

Service Code	HCPCS C1769
Hospital Charge Code	8514476
Hospital Revenue Code	278
Min. Negotiated Rate	$10.44
Max. Negotiated Rate	$83.52
Rate for Payer: Amerigroup CHIP/Medicaid	$10.44
Rate for Payer: BCBS of TX Blue Advantage	$34.80
Rate for Payer: BCBS of TX Blue Essentials	$41.76
Rate for Payer: BCBS of TX PPO	$46.40
Rate for Payer: Cash Price	$78.88
Rate for Payer: Cigna Medicaid	$83.52
Rate for Payer: Molina CHIP/Medicaid	$83.52
Rate for Payer: Multiplan Auto	$58.00
Rate for Payer: Multiplan Commercial	$58.00
Rate for Payer: Multiplan Workers Comp	$58.00
Rate for Payer: Parkland Medicaid	$83.52
Rate for Payer: Scott and White EPO/PPO	$58.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83.52
Rate for Payer: Superior Health Plan EPO	$15.78

WIRE KIRCHNER II

Facility

$116.00

Service Code	HCPCS C1769
Hospital Charge Code	8514476
Hospital Revenue Code	278
Min. Negotiated Rate	$29.00
Max. Negotiated Rate	$58.00
Rate for Payer: Cash Price	$78.88
Rate for Payer: Cigna Commercial	$29.00
Rate for Payer: Multiplan Auto	$58.00
Rate for Payer: Multiplan Commercial	$58.00
Rate for Payer: Multiplan Workers Comp	$58.00
Rate for Payer: Scott and White EPO/PPO	$58.00

WIRE KIRCHNER PL -- DHF

Facility

$261.00

Service Code	HCPCS C1769
Hospital Charge Code	81370959
Hospital Revenue Code	278
Min. Negotiated Rate	$65.25
Max. Negotiated Rate	$130.50
Rate for Payer: Cash Price	$177.48
Rate for Payer: Cigna Commercial	$65.25
Rate for Payer: Multiplan Auto	$130.50
Rate for Payer: Multiplan Commercial	$130.50
Rate for Payer: Multiplan Workers Comp	$130.50
Rate for Payer: Scott and White EPO/PPO	$130.50

Know your out-of-pocket cost for care.

All Charges