White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WIRE KIRCHNER PL -- DHF

Facility

$261.00

Service Code	HCPCS C1769
Hospital Charge Code	81370959
Hospital Revenue Code	278
Min. Negotiated Rate	$23.49
Max. Negotiated Rate	$187.92
Rate for Payer: Amerigroup CHIP/Medicaid	$23.49
Rate for Payer: BCBS of TX Blue Advantage	$78.30
Rate for Payer: BCBS of TX Blue Essentials	$93.96
Rate for Payer: BCBS of TX PPO	$104.40
Rate for Payer: Cash Price	$177.48
Rate for Payer: Cigna Medicaid	$187.92
Rate for Payer: Molina CHIP/Medicaid	$187.92
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: Parkland Medicaid	$187.92
Rate for Payer: Scott and White EPO/PPO	$130.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$187.92
Rate for Payer: Superior Health Plan EPO	$35.50

WIRE KIRCHNER TH -- DHF

Facility

$137.00

Service Code	HCPCS C1769
Hospital Charge Code	81371007
Hospital Revenue Code	278
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$98.64
Rate for Payer: Amerigroup CHIP/Medicaid	$12.33
Rate for Payer: BCBS of TX Blue Advantage	$41.10
Rate for Payer: BCBS of TX Blue Essentials	$49.32
Rate for Payer: BCBS of TX PPO	$54.80
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cigna Medicaid	$98.64
Rate for Payer: Molina CHIP/Medicaid	$98.64
Rate for Payer: Multiplan Auto	$68.50
Rate for Payer: Multiplan Commercial	$68.50
Rate for Payer: Multiplan Workers Comp	$68.50
Rate for Payer: Parkland Medicaid	$98.64
Rate for Payer: Scott and White EPO/PPO	$68.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.64
Rate for Payer: Superior Health Plan EPO	$18.63

WIRE KIRCHNER TH -- DHF

Facility

$137.00

Service Code	HCPCS C1769
Hospital Charge Code	81371007
Hospital Revenue Code	278
Min. Negotiated Rate	$34.25
Max. Negotiated Rate	$68.50
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cigna Commercial	$34.25
Rate for Payer: Multiplan Auto	$68.50
Rate for Payer: Multiplan Commercial	$68.50
Rate for Payer: Multiplan Workers Comp	$68.50
Rate for Payer: Scott and White EPO/PPO	$68.50

WIRE, KIRSCHNER 1.6MM DIA 6' L

Facility

$71.57

Hospital Charge Code	140179
Hospital Revenue Code	272
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$51.53
Rate for Payer: Amerigroup CHIP/Medicaid	$6.44
Rate for Payer: BCBS of TX Blue Advantage	$21.47
Rate for Payer: BCBS of TX Blue Essentials	$25.77
Rate for Payer: BCBS of TX PPO	$28.63
Rate for Payer: Cash Price	$48.67
Rate for Payer: Cigna Medicaid	$51.53
Rate for Payer: Molina CHIP/Medicaid	$51.53
Rate for Payer: Multiplan Auto	$46.52
Rate for Payer: Multiplan Commercial	$46.52
Rate for Payer: Multiplan Workers Comp	$46.52
Rate for Payer: Parkland Medicaid	$51.53
Rate for Payer: Scott and White EPO/PPO	$35.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.53
Rate for Payer: Superior Health Plan EPO	$9.73

WIRE, KIRSCHNER 1.6MM DIA 6' L

Facility

$71.57

Hospital Charge Code	140179
Hospital Revenue Code	272
Rate for Payer: Cash Price	$48.67

WIRE, KIRSCHNER DIAMOND POINT 2 END .028 X 4' STRL -- DHF

Facility

$27.00

Service Code	HCPCS C1769
Hospital Charge Code	81371023
Hospital Revenue Code	278
Min. Negotiated Rate	$6.75
Max. Negotiated Rate	$13.50
Rate for Payer: Cash Price	$18.36
Rate for Payer: Cigna Commercial	$6.75
Rate for Payer: Multiplan Auto	$13.50
Rate for Payer: Multiplan Commercial	$13.50
Rate for Payer: Multiplan Workers Comp	$13.50
Rate for Payer: Scott and White EPO/PPO	$13.50

WIRE, KIRSCHNER DIAMOND POINT 2 END .028 X 4' STRL -- DHF

Facility

$27.00

Service Code	HCPCS C1769
Hospital Charge Code	81371023
Hospital Revenue Code	278
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$19.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2.43
Rate for Payer: BCBS of TX Blue Advantage	$8.10
Rate for Payer: BCBS of TX Blue Essentials	$9.72
Rate for Payer: BCBS of TX PPO	$10.80
Rate for Payer: Cash Price	$18.36
Rate for Payer: Cigna Medicaid	$19.44
Rate for Payer: Molina CHIP/Medicaid	$19.44
Rate for Payer: Multiplan Auto	$13.50
Rate for Payer: Multiplan Commercial	$13.50
Rate for Payer: Multiplan Workers Comp	$13.50
Rate for Payer: Parkland Medicaid	$19.44
Rate for Payer: Scott and White EPO/PPO	$13.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.44
Rate for Payer: Superior Health Plan EPO	$3.67

WIRE KIRSCHNER ZEBRA

Facility

$106.00

Service Code	HCPCS C1769
Hospital Charge Code	8576466
Hospital Revenue Code	278
Min. Negotiated Rate	$9.54
Max. Negotiated Rate	$76.32
Rate for Payer: Amerigroup CHIP/Medicaid	$9.54
Rate for Payer: BCBS of TX Blue Advantage	$31.80
Rate for Payer: BCBS of TX Blue Essentials	$38.16
Rate for Payer: BCBS of TX PPO	$42.40
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cigna Medicaid	$76.32
Rate for Payer: Molina CHIP/Medicaid	$76.32
Rate for Payer: Multiplan Auto	$53.00
Rate for Payer: Multiplan Commercial	$53.00
Rate for Payer: Multiplan Workers Comp	$53.00
Rate for Payer: Parkland Medicaid	$76.32
Rate for Payer: Scott and White EPO/PPO	$53.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.32
Rate for Payer: Superior Health Plan EPO	$14.42

WIRE KIRSCHNER ZEBRA

Facility

$106.00

Service Code	HCPCS C1769
Hospital Charge Code	8576466
Hospital Revenue Code	278
Min. Negotiated Rate	$26.50
Max. Negotiated Rate	$53.00
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cigna Commercial	$26.50
Rate for Payer: Multiplan Auto	$53.00
Rate for Payer: Multiplan Commercial	$53.00
Rate for Payer: Multiplan Workers Comp	$53.00
Rate for Payer: Scott and White EPO/PPO	$53.00

WIRE OLIVE SMOOTH 1.4MM R3CON

Facility

$463.08

Hospital Charge Code	146420
Hospital Revenue Code	273
Min. Negotiated Rate	$41.68
Max. Negotiated Rate	$333.42
Rate for Payer: Amerigroup CHIP/Medicaid	$41.68
Rate for Payer: BCBS of TX Blue Advantage	$138.92
Rate for Payer: BCBS of TX Blue Essentials	$166.71
Rate for Payer: BCBS of TX PPO	$185.23
Rate for Payer: Cash Price	$314.89
Rate for Payer: Cigna Medicaid	$333.42
Rate for Payer: Molina CHIP/Medicaid	$333.42
Rate for Payer: Multiplan Auto	$301.00
Rate for Payer: Multiplan Commercial	$301.00
Rate for Payer: Multiplan Workers Comp	$301.00
Rate for Payer: Parkland Medicaid	$333.42
Rate for Payer: Scott and White EPO/PPO	$231.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$333.42
Rate for Payer: Superior Health Plan EPO	$62.98

WIRE OLIVE SMOOTH 1.4MM R3CON

Facility

$463.08

Hospital Charge Code	146420
Hospital Revenue Code	273
Rate for Payer: Cash Price	$314.89

WIRE SHUTTLE LOOP

Facility

$908.00

Hospital Charge Code	8524479
Hospital Revenue Code	272
Rate for Payer: Cash Price	$617.44

WIRE SHUTTLE LOOP

Facility

$908.00

Hospital Charge Code	8524479
Hospital Revenue Code	272
Min. Negotiated Rate	$81.72
Max. Negotiated Rate	$653.76
Rate for Payer: Amerigroup CHIP/Medicaid	$81.72
Rate for Payer: BCBS of TX Blue Advantage	$272.40
Rate for Payer: BCBS of TX Blue Essentials	$326.88
Rate for Payer: BCBS of TX PPO	$363.20
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cigna Medicaid	$653.76
Rate for Payer: Molina CHIP/Medicaid	$653.76
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$653.76
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$653.76
Rate for Payer: Superior Health Plan EPO	$123.49

WIRE SUTURE PASSING

Facility

$340.50

Hospital Charge Code	114787
Hospital Revenue Code	272
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$245.16
Rate for Payer: Amerigroup CHIP/Medicaid	$30.64
Rate for Payer: BCBS of TX Blue Advantage	$102.15
Rate for Payer: BCBS of TX Blue Essentials	$122.58
Rate for Payer: BCBS of TX PPO	$136.20
Rate for Payer: Cash Price	$231.54
Rate for Payer: Cigna Medicaid	$245.16
Rate for Payer: Molina CHIP/Medicaid	$245.16
Rate for Payer: Multiplan Auto	$221.32
Rate for Payer: Multiplan Commercial	$221.32
Rate for Payer: Multiplan Workers Comp	$221.32
Rate for Payer: Parkland Medicaid	$245.16
Rate for Payer: Scott and White EPO/PPO	$170.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$245.16
Rate for Payer: Superior Health Plan EPO	$46.31

WIRE SUTURE PASSING

Facility

$340.50

Hospital Charge Code	114787
Hospital Revenue Code	272
Rate for Payer: Cash Price	$231.54

WIRE WITH OLIVE - DIA 1.8 X 450 mm

Facility

$699.16

Hospital Charge Code	993430
Hospital Revenue Code	272
Min. Negotiated Rate	$62.92
Max. Negotiated Rate	$503.40
Rate for Payer: Amerigroup CHIP/Medicaid	$62.92
Rate for Payer: BCBS of TX Blue Advantage	$209.75
Rate for Payer: BCBS of TX Blue Essentials	$251.70
Rate for Payer: BCBS of TX PPO	$279.66
Rate for Payer: Cash Price	$475.43
Rate for Payer: Cigna Medicaid	$503.40
Rate for Payer: Molina CHIP/Medicaid	$503.40
Rate for Payer: Multiplan Auto	$454.45
Rate for Payer: Multiplan Commercial	$454.45
Rate for Payer: Multiplan Workers Comp	$454.45
Rate for Payer: Parkland Medicaid	$503.40
Rate for Payer: Scott and White EPO/PPO	$349.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$503.40
Rate for Payer: Superior Health Plan EPO	$95.09

WIRE WITH OLIVE - DIA 1.8 X 450 mm

Facility

$699.16

Hospital Charge Code	993430
Hospital Revenue Code	272
Rate for Payer: Cash Price	$475.43

Wire w/stopper 1.8 mm X 400 mm

Facility

$1,747.90

Hospital Charge Code	993386
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,188.57

Wire w/stopper 1.8 mm X 400 mm

Facility

$1,747.90

Hospital Charge Code	993386
Hospital Revenue Code	272
Min. Negotiated Rate	$157.31
Max. Negotiated Rate	$1,258.49
Rate for Payer: Amerigroup CHIP/Medicaid	$157.31
Rate for Payer: BCBS of TX Blue Advantage	$524.37
Rate for Payer: BCBS of TX Blue Essentials	$629.24
Rate for Payer: BCBS of TX PPO	$699.16
Rate for Payer: Cash Price	$1,188.57
Rate for Payer: Cigna Medicaid	$1,258.49
Rate for Payer: Molina CHIP/Medicaid	$1,258.49
Rate for Payer: Multiplan Auto	$1,136.13
Rate for Payer: Multiplan Commercial	$1,136.13
Rate for Payer: Multiplan Workers Comp	$1,136.13
Rate for Payer: Parkland Medicaid	$1,258.49
Rate for Payer: Scott and White EPO/PPO	$873.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,258.49
Rate for Payer: Superior Health Plan EPO	$237.71

WIRE XTRR FXTR OLV XWR STPR 1.8MM TRUE LK

Facility

$789.96

Hospital Charge Code	122772
Hospital Revenue Code	272
Min. Negotiated Rate	$71.10
Max. Negotiated Rate	$568.77
Rate for Payer: Amerigroup CHIP/Medicaid	$71.10
Rate for Payer: BCBS of TX Blue Advantage	$236.99
Rate for Payer: BCBS of TX Blue Essentials	$284.39
Rate for Payer: BCBS of TX PPO	$315.98
Rate for Payer: Cash Price	$537.17
Rate for Payer: Cigna Medicaid	$568.77
Rate for Payer: Molina CHIP/Medicaid	$568.77
Rate for Payer: Multiplan Auto	$513.47
Rate for Payer: Multiplan Commercial	$513.47
Rate for Payer: Multiplan Workers Comp	$513.47
Rate for Payer: Parkland Medicaid	$568.77
Rate for Payer: Scott and White EPO/PPO	$394.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$568.77
Rate for Payer: Superior Health Plan EPO	$107.43

WIRE XTRR FXTR OLV XWR STPR 1.8MM TRUE LK

Facility

$789.96

Hospital Charge Code	122772
Hospital Revenue Code	272
Rate for Payer: Cash Price	$537.17

WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC

Facility

$56,756.80

Service Code	MSDRG 464
Min. Negotiated Rate	$25,318.40
Max. Negotiated Rate	$56,756.80
Rate for Payer: BCBS of TX Blue Advantage	$25,318.40
Rate for Payer: BCBS of TX Blue Essentials	$30,379.14
Rate for Payer: BCBS of TX PPO	$33,755.90

WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W MCC

Facility

$99,590.40

Service Code	MSDRG 463
Min. Negotiated Rate	$44,134.34
Max. Negotiated Rate	$99,590.40
Rate for Payer: BCBS of TX Blue Advantage	$44,134.34
Rate for Payer: BCBS of TX Blue Essentials	$52,956.08
Rate for Payer: BCBS of TX PPO	$58,842.37

WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W/O CC/MCC

Facility

$37,861.30

Service Code	MSDRG 465
Min. Negotiated Rate	$15,801.64
Max. Negotiated Rate	$37,861.30
Rate for Payer: BCBS of TX Blue Advantage	$15,801.64
Rate for Payer: BCBS of TX Blue Essentials	$18,960.13
Rate for Payer: BCBS of TX PPO	$21,067.63

Work hardening/conditioning; initial 2 hours

Facility

$254.10

Service Code	HCPCS 97545
Hospital Charge Code	9381003
Hospital Revenue Code	420
Rate for Payer: Cash Price	$172.79

Know your out-of-pocket cost for care.

All Charges