White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BAG, ICE, CLAMP-CLOSE, 4TIES, WHITE, 6.5X14

Facility

$5.68

Hospital Charge Code	993982
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.86

BAG, INFUSION, PRESSURE, 500ML, MESH BACK

Facility

$28.90

Hospital Charge Code	993722
Hospital Revenue Code	272
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$20.81
Rate for Payer: Amerigroup CHIP/Medicaid	$2.60
Rate for Payer: BCBS of TX Blue Advantage	$8.67
Rate for Payer: BCBS of TX Blue Essentials	$10.40
Rate for Payer: BCBS of TX PPO	$11.56
Rate for Payer: Cash Price	$19.65
Rate for Payer: Cigna Medicaid	$20.81
Rate for Payer: Molina CHIP/Medicaid	$20.81
Rate for Payer: Multiplan Auto	$18.79
Rate for Payer: Multiplan Commercial	$18.79
Rate for Payer: Multiplan Workers Comp	$18.79
Rate for Payer: Parkland Medicaid	$20.81
Rate for Payer: Scott and White EPO/PPO	$14.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.81
Rate for Payer: Superior Health Plan EPO	$3.93

BAG, INFUSION, PRESSURE, 500ML, MESH BACK

Facility

$28.90

Hospital Charge Code	993722
Hospital Revenue Code	272
Rate for Payer: Cash Price	$19.65

BAG, LEG, TWIST-VALVE, STRAPS, LARGE, 320OZ

Facility

$6.08

Hospital Charge Code	993077
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.13

BAG, LEG, TWIST-VALVE, STRAPS, LARGE, 320OZ

Facility

$6.08

Hospital Charge Code	993077
Hospital Revenue Code	270
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$4.38
Rate for Payer: Amerigroup CHIP/Medicaid	$0.55
Rate for Payer: BCBS of TX Blue Advantage	$1.82
Rate for Payer: BCBS of TX Blue Essentials	$2.19
Rate for Payer: BCBS of TX PPO	$2.43
Rate for Payer: Cash Price	$4.13
Rate for Payer: Cigna Medicaid	$4.38
Rate for Payer: Molina CHIP/Medicaid	$4.38
Rate for Payer: Multiplan Auto	$3.95
Rate for Payer: Multiplan Commercial	$3.95
Rate for Payer: Multiplan Workers Comp	$3.95
Rate for Payer: Parkland Medicaid	$4.38
Rate for Payer: Scott and White EPO/PPO	$3.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.38
Rate for Payer: Superior Health Plan EPO	$0.83

BAG PLASTIC POLY CLEAR 2 MIL 32 X 22 X 60 XL

Facility

$870.32

Hospital Charge Code	993533
Hospital Revenue Code	270
Rate for Payer: Cash Price	$591.82

BAG PLASTIC POLY CLEAR 2 MIL 32 X 22 X 60 XL

Facility

$870.32

Hospital Charge Code	993533
Hospital Revenue Code	270
Min. Negotiated Rate	$78.33
Max. Negotiated Rate	$626.63
Rate for Payer: Amerigroup CHIP/Medicaid	$78.33
Rate for Payer: BCBS of TX Blue Advantage	$261.10
Rate for Payer: BCBS of TX Blue Essentials	$313.32
Rate for Payer: BCBS of TX PPO	$348.13
Rate for Payer: Cash Price	$591.82
Rate for Payer: Cigna Medicaid	$626.63
Rate for Payer: Molina CHIP/Medicaid	$626.63
Rate for Payer: Multiplan Auto	$565.71
Rate for Payer: Multiplan Commercial	$565.71
Rate for Payer: Multiplan Workers Comp	$565.71
Rate for Payer: Parkland Medicaid	$626.63
Rate for Payer: Scott and White EPO/PPO	$435.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$626.63
Rate for Payer: Superior Health Plan EPO	$118.36

BAG, PLASTIC POLY CLEAR 4 MIL 20' X 10' X 36' XL

Facility

$866.00

Hospital Charge Code	993544
Hospital Revenue Code	270
Rate for Payer: Cash Price	$588.88

BAG, PLASTIC POLY CLEAR 4 MIL 20' X 10' X 36' XL

Facility

$866.00

Hospital Charge Code	993544
Hospital Revenue Code	270
Min. Negotiated Rate	$77.94
Max. Negotiated Rate	$623.52
Rate for Payer: Amerigroup CHIP/Medicaid	$77.94
Rate for Payer: BCBS of TX Blue Advantage	$259.80
Rate for Payer: BCBS of TX Blue Essentials	$311.76
Rate for Payer: BCBS of TX PPO	$346.40
Rate for Payer: Cash Price	$588.88
Rate for Payer: Cigna Medicaid	$623.52
Rate for Payer: Molina CHIP/Medicaid	$623.52
Rate for Payer: Multiplan Auto	$562.90
Rate for Payer: Multiplan Commercial	$562.90
Rate for Payer: Multiplan Workers Comp	$562.90
Rate for Payer: Parkland Medicaid	$623.52
Rate for Payer: Scott and White EPO/PPO	$433.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$623.52
Rate for Payer: Superior Health Plan EPO	$117.78

BAG PPR 4.75X2X10IN AUTOCL

Facility

$27.42

Hospital Charge Code	992697
Hospital Revenue Code	270
Rate for Payer: Cash Price	$18.65

BAG PPR 4.75X2X10IN AUTOCL

Facility

$27.42

Hospital Charge Code	992697
Hospital Revenue Code	270
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$19.74
Rate for Payer: Amerigroup CHIP/Medicaid	$2.47
Rate for Payer: BCBS of TX Blue Advantage	$8.23
Rate for Payer: BCBS of TX Blue Essentials	$9.87
Rate for Payer: BCBS of TX PPO	$10.97
Rate for Payer: Cash Price	$18.65
Rate for Payer: Cigna Medicaid	$19.74
Rate for Payer: Molina CHIP/Medicaid	$19.74
Rate for Payer: Multiplan Auto	$17.82
Rate for Payer: Multiplan Commercial	$17.82
Rate for Payer: Multiplan Workers Comp	$17.82
Rate for Payer: Parkland Medicaid	$19.74
Rate for Payer: Scott and White EPO/PPO	$13.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.74
Rate for Payer: Superior Health Plan EPO	$3.73

BAG SET UP RESP THERAPY 12 X 15 W/VENT HOLES

Facility

$8.35

Hospital Charge Code	993524
Hospital Revenue Code	270
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$6.01
Rate for Payer: Amerigroup CHIP/Medicaid	$0.75
Rate for Payer: BCBS of TX Blue Advantage	$2.50
Rate for Payer: BCBS of TX Blue Essentials	$3.01
Rate for Payer: BCBS of TX PPO	$3.34
Rate for Payer: Cash Price	$5.68
Rate for Payer: Cigna Medicaid	$6.01
Rate for Payer: Molina CHIP/Medicaid	$6.01
Rate for Payer: Multiplan Auto	$5.43
Rate for Payer: Multiplan Commercial	$5.43
Rate for Payer: Multiplan Workers Comp	$5.43
Rate for Payer: Parkland Medicaid	$6.01
Rate for Payer: Scott and White EPO/PPO	$4.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.01
Rate for Payer: Superior Health Plan EPO	$1.14

BAG SET UP RESP THERAPY 12 X 15 W/VENT HOLES

Facility

$8.35

Hospital Charge Code	993524
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.68

BAG, SPECIMEN L6'XW9' RED BIOHAZARD

Facility

$0.14

Hospital Charge Code	992925
Hospital Revenue Code	270
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.10
Rate for Payer: Amerigroup CHIP/Medicaid	$0.01
Rate for Payer: BCBS of TX Blue Advantage	$0.04
Rate for Payer: BCBS of TX Blue Essentials	$0.05
Rate for Payer: BCBS of TX PPO	$0.06
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna Medicaid	$0.10
Rate for Payer: Molina CHIP/Medicaid	$0.10
Rate for Payer: Multiplan Auto	$0.09
Rate for Payer: Multiplan Commercial	$0.09
Rate for Payer: Multiplan Workers Comp	$0.09
Rate for Payer: Parkland Medicaid	$0.10
Rate for Payer: Scott and White EPO/PPO	$0.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.10
Rate for Payer: Superior Health Plan EPO	$0.02

BAG, SPECIMEN L6'XW9' RED BIOHAZARD

Facility

$0.14

Hospital Charge Code	992925
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.10

BAG, SPECIMEN RETREVL,224 ML, DISP, STRL

Facility

$233.24

Hospital Charge Code	992819
Hospital Revenue Code	272
Min. Negotiated Rate	$20.99
Max. Negotiated Rate	$167.93
Rate for Payer: Amerigroup CHIP/Medicaid	$20.99
Rate for Payer: BCBS of TX Blue Advantage	$69.97
Rate for Payer: BCBS of TX Blue Essentials	$83.97
Rate for Payer: BCBS of TX PPO	$93.30
Rate for Payer: Cash Price	$158.60
Rate for Payer: Cigna Medicaid	$167.93
Rate for Payer: Molina CHIP/Medicaid	$167.93
Rate for Payer: Multiplan Auto	$151.61
Rate for Payer: Multiplan Commercial	$151.61
Rate for Payer: Multiplan Workers Comp	$151.61
Rate for Payer: Parkland Medicaid	$167.93
Rate for Payer: Scott and White EPO/PPO	$116.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$167.93
Rate for Payer: Superior Health Plan EPO	$31.72

BAG, SPECIMEN RETREVL,224 ML, DISP, STRL

Facility

$233.24

Hospital Charge Code	992819
Hospital Revenue Code	272
Rate for Payer: Cash Price	$158.60

BAG, SPECIMEN RETRIEVAL MED 7.3CMX17CMX10MM, 240ML -- DHF

Facility

$340.50

Hospital Charge Code	80816978
Hospital Revenue Code	272
Rate for Payer: Cash Price	$231.54

BAG, SPECIMEN RETRIEVAL MED 7.3CMX17CMX10MM, 240ML -- DHF

Facility

$340.50

Hospital Charge Code	80816978
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

BALLOON EUP2025X EUP

Facility

$354.12

Service Code	HCPCS C1726
Hospital Charge Code	992566
Hospital Revenue Code	272
Min. Negotiated Rate	$31.87
Max. Negotiated Rate	$254.97
Rate for Payer: Amerigroup CHIP/Medicaid	$31.87
Rate for Payer: BCBS of TX Blue Advantage	$106.24
Rate for Payer: BCBS of TX Blue Essentials	$127.48
Rate for Payer: BCBS of TX PPO	$141.65
Rate for Payer: Cash Price	$240.80
Rate for Payer: Cigna Medicaid	$254.97
Rate for Payer: Molina CHIP/Medicaid	$254.97
Rate for Payer: Multiplan Auto	$230.18
Rate for Payer: Multiplan Commercial	$230.18
Rate for Payer: Multiplan Workers Comp	$230.18
Rate for Payer: Parkland Medicaid	$254.97
Rate for Payer: Scott and White EPO/PPO	$177.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$254.97
Rate for Payer: Superior Health Plan EPO	$48.16

BALLOON EUP2025X EUP

Facility

$354.12

Service Code	HCPCS C1726
Hospital Charge Code	992566
Hospital Revenue Code	272
Rate for Payer: Cash Price	$240.80

BALLOON EUP2525X EUP

Facility

$354.12

Service Code	HCPCS C1726
Hospital Charge Code	992567
Hospital Revenue Code	272
Min. Negotiated Rate	$31.87
Max. Negotiated Rate	$254.97
Rate for Payer: Amerigroup CHIP/Medicaid	$31.87
Rate for Payer: BCBS of TX Blue Advantage	$106.24
Rate for Payer: BCBS of TX Blue Essentials	$127.48
Rate for Payer: BCBS of TX PPO	$141.65
Rate for Payer: Cash Price	$240.80
Rate for Payer: Cigna Medicaid	$254.97
Rate for Payer: Molina CHIP/Medicaid	$254.97
Rate for Payer: Multiplan Auto	$230.18
Rate for Payer: Multiplan Commercial	$230.18
Rate for Payer: Multiplan Workers Comp	$230.18
Rate for Payer: Parkland Medicaid	$254.97
Rate for Payer: Scott and White EPO/PPO	$177.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$254.97
Rate for Payer: Superior Health Plan EPO	$48.16

BALLOON EUP2525X EUP

Facility

$354.12

Service Code	HCPCS C1726
Hospital Charge Code	992567
Hospital Revenue Code	272
Rate for Payer: Cash Price	$240.80

BALLOON EUP3530X EUP

Facility

$354.12

Service Code	HCPCS C1726
Hospital Charge Code	992569
Hospital Revenue Code	272
Rate for Payer: Cash Price	$240.80

BALLOON EUP3530X EUP

Facility

$354.12

Service Code	HCPCS C1726
Hospital Charge Code	992569
Hospital Revenue Code	272
Min. Negotiated Rate	$31.87
Max. Negotiated Rate	$254.97
Rate for Payer: Amerigroup CHIP/Medicaid	$31.87
Rate for Payer: BCBS of TX Blue Advantage	$106.24
Rate for Payer: BCBS of TX Blue Essentials	$127.48
Rate for Payer: BCBS of TX PPO	$141.65
Rate for Payer: Cash Price	$240.80
Rate for Payer: Cigna Medicaid	$254.97
Rate for Payer: Molina CHIP/Medicaid	$254.97
Rate for Payer: Multiplan Auto	$230.18
Rate for Payer: Multiplan Commercial	$230.18
Rate for Payer: Multiplan Workers Comp	$230.18
Rate for Payer: Parkland Medicaid	$254.97
Rate for Payer: Scott and White EPO/PPO	$177.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$254.97
Rate for Payer: Superior Health Plan EPO	$48.16

Know your out-of-pocket cost for care.

All Charges