White Rock Medical Center

All Charges

Charge

Type

Setting

Price

30-0329

Facility

$1,732.72

Service Code	HCPCS C1713
Hospital Charge Code	994027
Hospital Revenue Code	278
Min. Negotiated Rate	$433.18
Max. Negotiated Rate	$866.36
Rate for Payer: Cash Price	$1,178.25
Rate for Payer: Cigna Commercial	$433.18
Rate for Payer: Multiplan Auto	$866.36
Rate for Payer: Multiplan Commercial	$866.36
Rate for Payer: Multiplan Workers Comp	$866.36
Rate for Payer: Scott and White EPO/PPO	$866.36

30-0329

Facility

$1,732.72

Service Code	HCPCS C1713
Hospital Charge Code	994027
Hospital Revenue Code	278
Min. Negotiated Rate	$155.94
Max. Negotiated Rate	$1,247.56
Rate for Payer: Amerigroup CHIP/Medicaid	$155.94
Rate for Payer: BCBS of TX Blue Advantage	$519.82
Rate for Payer: BCBS of TX Blue Essentials	$623.78
Rate for Payer: BCBS of TX PPO	$693.09
Rate for Payer: Cash Price	$1,178.25
Rate for Payer: Cigna Medicaid	$1,247.56
Rate for Payer: Molina CHIP/Medicaid	$1,247.56
Rate for Payer: Multiplan Auto	$866.36
Rate for Payer: Multiplan Commercial	$866.36
Rate for Payer: Multiplan Workers Comp	$866.36
Rate for Payer: Parkland Medicaid	$1,247.56
Rate for Payer: Scott and White EPO/PPO	$866.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,247.56
Rate for Payer: Superior Health Plan EPO	$235.65

30-0330

Facility

$1,732.72

Service Code	HCPCS C1713
Hospital Charge Code	994028
Hospital Revenue Code	278
Min. Negotiated Rate	$155.94
Max. Negotiated Rate	$1,247.56
Rate for Payer: Amerigroup CHIP/Medicaid	$155.94
Rate for Payer: BCBS of TX Blue Advantage	$519.82
Rate for Payer: BCBS of TX Blue Essentials	$623.78
Rate for Payer: BCBS of TX PPO	$693.09
Rate for Payer: Cash Price	$1,178.25
Rate for Payer: Cigna Medicaid	$1,247.56
Rate for Payer: Molina CHIP/Medicaid	$1,247.56
Rate for Payer: Multiplan Auto	$866.36
Rate for Payer: Multiplan Commercial	$866.36
Rate for Payer: Multiplan Workers Comp	$866.36
Rate for Payer: Parkland Medicaid	$1,247.56
Rate for Payer: Scott and White EPO/PPO	$866.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,247.56
Rate for Payer: Superior Health Plan EPO	$235.65

30-0330

Facility

$1,732.72

Service Code	HCPCS C1713
Hospital Charge Code	994028
Hospital Revenue Code	278
Min. Negotiated Rate	$433.18
Max. Negotiated Rate	$866.36
Rate for Payer: Cash Price	$1,178.25
Rate for Payer: Cigna Commercial	$433.18
Rate for Payer: Multiplan Auto	$866.36
Rate for Payer: Multiplan Commercial	$866.36
Rate for Payer: Multiplan Workers Comp	$866.36
Rate for Payer: Scott and White EPO/PPO	$866.36

30-2063

Facility

$876.04

Service Code	HCPCS C1713
Hospital Charge Code	994029
Hospital Revenue Code	278
Min. Negotiated Rate	$219.01
Max. Negotiated Rate	$438.02
Rate for Payer: Cash Price	$595.71
Rate for Payer: Cigna Commercial	$219.01
Rate for Payer: Multiplan Auto	$438.02
Rate for Payer: Multiplan Commercial	$438.02
Rate for Payer: Multiplan Workers Comp	$438.02
Rate for Payer: Scott and White EPO/PPO	$438.02

30-2063

Facility

$876.04

Service Code	HCPCS C1713
Hospital Charge Code	994029
Hospital Revenue Code	278
Min. Negotiated Rate	$78.84
Max. Negotiated Rate	$630.75
Rate for Payer: Amerigroup CHIP/Medicaid	$78.84
Rate for Payer: BCBS of TX Blue Advantage	$262.81
Rate for Payer: BCBS of TX Blue Essentials	$315.37
Rate for Payer: BCBS of TX PPO	$350.42
Rate for Payer: Cash Price	$595.71
Rate for Payer: Cigna Medicaid	$630.75
Rate for Payer: Molina CHIP/Medicaid	$630.75
Rate for Payer: Multiplan Auto	$438.02
Rate for Payer: Multiplan Commercial	$438.02
Rate for Payer: Multiplan Workers Comp	$438.02
Rate for Payer: Parkland Medicaid	$630.75
Rate for Payer: Scott and White EPO/PPO	$438.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$630.75
Rate for Payer: Superior Health Plan EPO	$119.14

3060-0080S

Facility

$5,048.19

Service Code	HCPCS C1734
Hospital Charge Code	991187
Hospital Revenue Code	278
Min. Negotiated Rate	$1,262.05
Max. Negotiated Rate	$2,524.09
Rate for Payer: Cash Price	$3,432.77
Rate for Payer: Cigna Commercial	$1,262.05
Rate for Payer: Multiplan Auto	$2,524.09
Rate for Payer: Multiplan Commercial	$2,524.09
Rate for Payer: Multiplan Workers Comp	$2,524.09
Rate for Payer: Scott and White EPO/PPO	$2,524.09

3060-0080S

Facility

$5,048.19

Service Code	HCPCS C1734
Hospital Charge Code	991187
Hospital Revenue Code	278
Min. Negotiated Rate	$454.34
Max. Negotiated Rate	$3,634.70
Rate for Payer: Amerigroup CHIP/Medicaid	$454.34
Rate for Payer: BCBS of TX Blue Advantage	$1,514.46
Rate for Payer: BCBS of TX Blue Essentials	$1,817.35
Rate for Payer: BCBS of TX PPO	$2,019.28
Rate for Payer: Cash Price	$3,432.77
Rate for Payer: Cigna Medicaid	$3,634.70
Rate for Payer: Molina CHIP/Medicaid	$3,634.70
Rate for Payer: Multiplan Auto	$2,524.09
Rate for Payer: Multiplan Commercial	$2,524.09
Rate for Payer: Multiplan Workers Comp	$2,524.09
Rate for Payer: Parkland Medicaid	$3,634.70
Rate for Payer: Scott and White EPO/PPO	$2,524.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,634.70
Rate for Payer: Superior Health Plan EPO	$686.55

3-0 fiberwire

Facility

$1,724.10

Hospital Charge Code	992166
Hospital Revenue Code	272
Min. Negotiated Rate	$155.17
Max. Negotiated Rate	$1,241.35
Rate for Payer: Amerigroup CHIP/Medicaid	$155.17
Rate for Payer: BCBS of TX Blue Advantage	$517.23
Rate for Payer: BCBS of TX Blue Essentials	$620.68
Rate for Payer: BCBS of TX PPO	$689.64
Rate for Payer: Cash Price	$1,172.39
Rate for Payer: Cigna Medicaid	$1,241.35
Rate for Payer: Molina CHIP/Medicaid	$1,241.35
Rate for Payer: Multiplan Auto	$1,120.66
Rate for Payer: Multiplan Commercial	$1,120.66
Rate for Payer: Multiplan Workers Comp	$1,120.66
Rate for Payer: Parkland Medicaid	$1,241.35
Rate for Payer: Scott and White EPO/PPO	$862.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,241.35
Rate for Payer: Superior Health Plan EPO	$234.48

3-0 fiberwire

Facility

$1,724.10

Hospital Charge Code	992166
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,172.39

3-0 FW, 18' W/REVSE CUT NDL, 16.3MM

Facility

$1,198.56

Service Code	HCPCS C1713
Hospital Charge Code	992605
Hospital Revenue Code	278
Min. Negotiated Rate	$107.87
Max. Negotiated Rate	$862.96
Rate for Payer: Amerigroup CHIP/Medicaid	$107.87
Rate for Payer: BCBS of TX Blue Advantage	$359.57
Rate for Payer: BCBS of TX Blue Essentials	$431.48
Rate for Payer: BCBS of TX PPO	$479.42
Rate for Payer: Cash Price	$815.02
Rate for Payer: Cigna Medicaid	$862.96
Rate for Payer: Molina CHIP/Medicaid	$862.96
Rate for Payer: Multiplan Auto	$599.28
Rate for Payer: Multiplan Commercial	$599.28
Rate for Payer: Multiplan Workers Comp	$599.28
Rate for Payer: Parkland Medicaid	$862.96
Rate for Payer: Scott and White EPO/PPO	$599.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$862.96
Rate for Payer: Superior Health Plan EPO	$163.00

3-0 FW, 18' W/REVSE CUT NDL, 16.3MM

Facility

$1,198.56

Service Code	HCPCS C1713
Hospital Charge Code	992605
Hospital Revenue Code	278
Min. Negotiated Rate	$299.64
Max. Negotiated Rate	$599.28
Rate for Payer: Cash Price	$815.02
Rate for Payer: Cigna Commercial	$299.64
Rate for Payer: Multiplan Auto	$599.28
Rate for Payer: Multiplan Commercial	$599.28
Rate for Payer: Multiplan Workers Comp	$599.28
Rate for Payer: Scott and White EPO/PPO	$599.28

30mm Speedtrap 6 / W

Facility

$617.47

Hospital Charge Code	992191
Hospital Revenue Code	272
Min. Negotiated Rate	$55.57
Max. Negotiated Rate	$444.58
Rate for Payer: Amerigroup CHIP/Medicaid	$55.57
Rate for Payer: BCBS of TX Blue Advantage	$185.24
Rate for Payer: BCBS of TX Blue Essentials	$222.29
Rate for Payer: BCBS of TX PPO	$246.99
Rate for Payer: Cash Price	$419.88
Rate for Payer: Cigna Medicaid	$444.58
Rate for Payer: Molina CHIP/Medicaid	$444.58
Rate for Payer: Multiplan Auto	$401.36
Rate for Payer: Multiplan Commercial	$401.36
Rate for Payer: Multiplan Workers Comp	$401.36
Rate for Payer: Parkland Medicaid	$444.58
Rate for Payer: Scott and White EPO/PPO	$308.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$444.58
Rate for Payer: Superior Health Plan EPO	$83.98

30mm Speedtrap 6 / W

Facility

$617.47

Hospital Charge Code	992191
Hospital Revenue Code	272
Rate for Payer: Cash Price	$419.88

30mm Speedtrap W

Facility

$617.47

Hospital Charge Code	992190
Hospital Revenue Code	272
Min. Negotiated Rate	$55.57
Max. Negotiated Rate	$444.58
Rate for Payer: Amerigroup CHIP/Medicaid	$55.57
Rate for Payer: BCBS of TX Blue Advantage	$185.24
Rate for Payer: BCBS of TX Blue Essentials	$222.29
Rate for Payer: BCBS of TX PPO	$246.99
Rate for Payer: Cash Price	$419.88
Rate for Payer: Cigna Medicaid	$444.58
Rate for Payer: Molina CHIP/Medicaid	$444.58
Rate for Payer: Multiplan Auto	$401.36
Rate for Payer: Multiplan Commercial	$401.36
Rate for Payer: Multiplan Workers Comp	$401.36
Rate for Payer: Parkland Medicaid	$444.58
Rate for Payer: Scott and White EPO/PPO	$308.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$444.58
Rate for Payer: Superior Health Plan EPO	$83.98

30mm Speedtrap W

Facility

$617.47

Hospital Charge Code	992190
Hospital Revenue Code	272
Rate for Payer: Cash Price	$419.88

3.0mm x 900mm Ball Nose Guide Wire - Sterile Pkg

Facility

$2,347.18

Hospital Charge Code	993894
Hospital Revenue Code	272
Min. Negotiated Rate	$211.25
Max. Negotiated Rate	$1,689.97
Rate for Payer: Amerigroup CHIP/Medicaid	$211.25
Rate for Payer: BCBS of TX Blue Advantage	$704.15
Rate for Payer: BCBS of TX Blue Essentials	$844.98
Rate for Payer: BCBS of TX PPO	$938.87
Rate for Payer: Cash Price	$1,596.08
Rate for Payer: Cigna Medicaid	$1,689.97
Rate for Payer: Molina CHIP/Medicaid	$1,689.97
Rate for Payer: Multiplan Auto	$1,525.67
Rate for Payer: Multiplan Commercial	$1,525.67
Rate for Payer: Multiplan Workers Comp	$1,525.67
Rate for Payer: Parkland Medicaid	$1,689.97
Rate for Payer: Scott and White EPO/PPO	$1,173.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,689.97
Rate for Payer: Superior Health Plan EPO	$319.22

3.0mm x 900mm Ball Nose Guide Wire - Sterile Pkg

Facility

$2,347.18

Hospital Charge Code	993894
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,596.08

3.0 SINGLE LOADED SUTURETAPE S-TAKASSY

Facility

$3,218.86

Hospital Charge Code	992607
Hospital Revenue Code	272
Min. Negotiated Rate	$289.70
Max. Negotiated Rate	$2,317.58
Rate for Payer: Amerigroup CHIP/Medicaid	$289.70
Rate for Payer: BCBS of TX Blue Advantage	$965.66
Rate for Payer: BCBS of TX Blue Essentials	$1,158.79
Rate for Payer: BCBS of TX PPO	$1,287.54
Rate for Payer: Cash Price	$2,188.82
Rate for Payer: Cigna Medicaid	$2,317.58
Rate for Payer: Molina CHIP/Medicaid	$2,317.58
Rate for Payer: Multiplan Auto	$2,092.26
Rate for Payer: Multiplan Commercial	$2,092.26
Rate for Payer: Multiplan Workers Comp	$2,092.26
Rate for Payer: Parkland Medicaid	$2,317.58
Rate for Payer: Scott and White EPO/PPO	$1,609.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,317.58
Rate for Payer: Superior Health Plan EPO	$437.76

3.0 SINGLE LOADED SUTURETAPE S-TAKASSY

Facility

$3,218.86

Hospital Charge Code	992607
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,188.82

326260S

Facility

$2,343.38

Service Code	HCPCS C1713
Hospital Charge Code	992003
Hospital Revenue Code	278
Min. Negotiated Rate	$585.85
Max. Negotiated Rate	$1,171.69
Rate for Payer: Cash Price	$1,593.50
Rate for Payer: Cigna Commercial	$585.85
Rate for Payer: Multiplan Auto	$1,171.69
Rate for Payer: Multiplan Commercial	$1,171.69
Rate for Payer: Multiplan Workers Comp	$1,171.69
Rate for Payer: Scott and White EPO/PPO	$1,171.69

326260S

Facility

$2,343.38

Service Code	HCPCS C1713
Hospital Charge Code	992003
Hospital Revenue Code	278
Min. Negotiated Rate	$210.90
Max. Negotiated Rate	$1,687.23
Rate for Payer: Amerigroup CHIP/Medicaid	$210.90
Rate for Payer: BCBS of TX Blue Advantage	$703.01
Rate for Payer: BCBS of TX Blue Essentials	$843.62
Rate for Payer: BCBS of TX PPO	$937.35
Rate for Payer: Cash Price	$1,593.50
Rate for Payer: Cigna Medicaid	$1,687.23
Rate for Payer: Molina CHIP/Medicaid	$1,687.23
Rate for Payer: Multiplan Auto	$1,171.69
Rate for Payer: Multiplan Commercial	$1,171.69
Rate for Payer: Multiplan Workers Comp	$1,171.69
Rate for Payer: Parkland Medicaid	$1,687.23
Rate for Payer: Scott and White EPO/PPO	$1,171.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,687.23
Rate for Payer: Superior Health Plan EPO	$318.70

326265S

Facility

$2,343.37

Service Code	HCPCS C1713
Hospital Charge Code	992006
Hospital Revenue Code	278
Min. Negotiated Rate	$210.90
Max. Negotiated Rate	$1,687.23
Rate for Payer: Amerigroup CHIP/Medicaid	$210.90
Rate for Payer: BCBS of TX Blue Advantage	$703.01
Rate for Payer: BCBS of TX Blue Essentials	$843.61
Rate for Payer: BCBS of TX PPO	$937.35
Rate for Payer: Cash Price	$1,593.49
Rate for Payer: Cigna Medicaid	$1,687.23
Rate for Payer: Molina CHIP/Medicaid	$1,687.23
Rate for Payer: Multiplan Auto	$1,171.68
Rate for Payer: Multiplan Commercial	$1,171.68
Rate for Payer: Multiplan Workers Comp	$1,171.68
Rate for Payer: Parkland Medicaid	$1,687.23
Rate for Payer: Scott and White EPO/PPO	$1,171.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,687.23
Rate for Payer: Superior Health Plan EPO	$318.70

326265S

Facility

$2,343.37

Service Code	HCPCS C1713
Hospital Charge Code	992006
Hospital Revenue Code	278
Min. Negotiated Rate	$585.84
Max. Negotiated Rate	$1,171.68
Rate for Payer: Cash Price	$1,593.49
Rate for Payer: Cigna Commercial	$585.84
Rate for Payer: Multiplan Auto	$1,171.68
Rate for Payer: Multiplan Commercial	$1,171.68
Rate for Payer: Multiplan Workers Comp	$1,171.68
Rate for Payer: Scott and White EPO/PPO	$1,171.68

326465

Facility

$2,343.37

Service Code	HCPCS C1713
Hospital Charge Code	992007
Hospital Revenue Code	278
Min. Negotiated Rate	$585.84
Max. Negotiated Rate	$1,171.68
Rate for Payer: Cash Price	$1,593.49
Rate for Payer: Cigna Commercial	$585.84
Rate for Payer: Multiplan Auto	$1,171.68
Rate for Payer: Multiplan Commercial	$1,171.68
Rate for Payer: Multiplan Workers Comp	$1,171.68
Rate for Payer: Scott and White EPO/PPO	$1,171.68

Know your out-of-pocket cost for care.

All Charges