White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BALLOON EUP4015X EUP

Facility

$354.12

Service Code	HCPCS C1726
Hospital Charge Code	992570
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 EUP4015X EUP

Facility

$354.12

Service Code	HCPCS C1726
Hospital Charge Code	992570
Hospital Revenue Code	272
Rate for Payer: Cash Price	$240.80

BALLOON EUP4020X EUP

Facility

$354.12

Service Code	HCPCS C1726
Hospital Charge Code	992571
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 EUP4020X EUP

Facility

$354.12

Service Code	HCPCS C1726
Hospital Charge Code	992571
Hospital Revenue Code	272
Rate for Payer: Cash Price	$240.80

BALLOON EUP4030X EUP

Facility

$354.12

Service Code	HCPCS C1726
Hospital Charge Code	992572
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 EUP4030X EUP

Facility

$354.12

Service Code	HCPCS C1726
Hospital Charge Code	992572
Hospital Revenue Code	272
Rate for Payer: Cash Price	$240.80

BALLOON RETRIEVAL EXTRACTOR PRO XL ENDOSCOPIC 12-15MM

Facility

$738.98

Hospital Charge Code	116259
Hospital Revenue Code	272
Rate for Payer: Cash Price	$502.51

BALLOON RETRIEVAL EXTRACTOR PRO XL ENDOSCOPIC 12-15MM

Facility

$738.98

Hospital Charge Code	116259
Hospital Revenue Code	272
Min. Negotiated Rate	$66.51
Max. Negotiated Rate	$532.07
Rate for Payer: Amerigroup CHIP/Medicaid	$66.51
Rate for Payer: BCBS of TX Blue Advantage	$221.69
Rate for Payer: BCBS of TX Blue Essentials	$266.03
Rate for Payer: BCBS of TX PPO	$295.59
Rate for Payer: Cash Price	$502.51
Rate for Payer: Cigna Medicaid	$532.07
Rate for Payer: Molina CHIP/Medicaid	$532.07
Rate for Payer: Multiplan Auto	$480.34
Rate for Payer: Multiplan Commercial	$480.34
Rate for Payer: Multiplan Workers Comp	$480.34
Rate for Payer: Parkland Medicaid	$532.07
Rate for Payer: Scott and White EPO/PPO	$369.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$532.07
Rate for Payer: Superior Health Plan EPO	$100.50

BALLOON RETRIEVAL EXTRACTOR PRO XL ENDOSCOPIC 15-18MM

Facility

$738.98

Hospital Charge Code	116250
Hospital Revenue Code	272
Rate for Payer: Cash Price	$502.51

BALLOON RETRIEVAL EXTRACTOR PRO XL ENDOSCOPIC 15-18MM

Facility

$738.98

Hospital Charge Code	116250
Hospital Revenue Code	272
Min. Negotiated Rate	$66.51
Max. Negotiated Rate	$532.07
Rate for Payer: Amerigroup CHIP/Medicaid	$66.51
Rate for Payer: BCBS of TX Blue Advantage	$221.69
Rate for Payer: BCBS of TX Blue Essentials	$266.03
Rate for Payer: BCBS of TX PPO	$295.59
Rate for Payer: Cash Price	$502.51
Rate for Payer: Cigna Medicaid	$532.07
Rate for Payer: Molina CHIP/Medicaid	$532.07
Rate for Payer: Multiplan Auto	$480.34
Rate for Payer: Multiplan Commercial	$480.34
Rate for Payer: Multiplan Workers Comp	$480.34
Rate for Payer: Parkland Medicaid	$532.07
Rate for Payer: Scott and White EPO/PPO	$369.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$532.07
Rate for Payer: Superior Health Plan EPO	$100.50

BALLOON RETRIEVAL EXTRACTOR PRO XL ENDOSCOPIC 9-12MM

Facility

$738.98

Hospital Charge Code	116258
Hospital Revenue Code	272
Min. Negotiated Rate	$66.51
Max. Negotiated Rate	$532.07
Rate for Payer: Amerigroup CHIP/Medicaid	$66.51
Rate for Payer: BCBS of TX Blue Advantage	$221.69
Rate for Payer: BCBS of TX Blue Essentials	$266.03
Rate for Payer: BCBS of TX PPO	$295.59
Rate for Payer: Cash Price	$502.51
Rate for Payer: Cigna Medicaid	$532.07
Rate for Payer: Molina CHIP/Medicaid	$532.07
Rate for Payer: Multiplan Auto	$480.34
Rate for Payer: Multiplan Commercial	$480.34
Rate for Payer: Multiplan Workers Comp	$480.34
Rate for Payer: Parkland Medicaid	$532.07
Rate for Payer: Scott and White EPO/PPO	$369.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$532.07
Rate for Payer: Superior Health Plan EPO	$100.50

BALLOON RETRIEVAL EXTRACTOR PRO XL ENDOSCOPIC 9-12MM

Facility

$738.98

Hospital Charge Code	116258
Hospital Revenue Code	272
Rate for Payer: Cash Price	$502.51

BALO ANGIOP CTR DIALYSIS SEG

Facility

$8,145.00

Service Code	HCPCS 36907
Hospital Charge Code	2351106
Hospital Revenue Code	360
Min. Negotiated Rate	$733.05
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$733.05
Rate for Payer: BCBS of TX Blue Advantage	$2,443.50
Rate for Payer: BCBS of TX Blue Essentials	$2,932.20
Rate for Payer: BCBS of TX PPO	$3,258.00
Rate for Payer: Cash Price	$5,538.60
Rate for Payer: Cash Price	$5,538.60
Rate for Payer: Cigna Medicaid	$5,864.40
Rate for Payer: Molina CHIP/Medicaid	$5,864.40
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$5,864.40
Rate for Payer: Scott and White EPO/PPO	$4,072.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,864.40
Rate for Payer: Superior Health Plan EPO	$1,107.72

BALO ANGIOP CTR DIALYSIS SEG

Facility

$8,145.00

Service Code	HCPCS 36907
Hospital Charge Code	2351106
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,538.60

BANANA SUTURE LASSO

Facility

$844.44

Hospital Charge Code	114792
Hospital Revenue Code	272
Min. Negotiated Rate	$76.00
Max. Negotiated Rate	$608.00
Rate for Payer: Amerigroup CHIP/Medicaid	$76.00
Rate for Payer: BCBS of TX Blue Advantage	$253.33
Rate for Payer: BCBS of TX Blue Essentials	$304.00
Rate for Payer: BCBS of TX PPO	$337.78
Rate for Payer: Cash Price	$574.22
Rate for Payer: Cigna Medicaid	$608.00
Rate for Payer: Molina CHIP/Medicaid	$608.00
Rate for Payer: Multiplan Auto	$548.89
Rate for Payer: Multiplan Commercial	$548.89
Rate for Payer: Multiplan Workers Comp	$548.89
Rate for Payer: Parkland Medicaid	$608.00
Rate for Payer: Scott and White EPO/PPO	$422.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$608.00
Rate for Payer: Superior Health Plan EPO	$114.84

BANANA SUTURE LASSO

Facility

$844.44

Hospital Charge Code	114792
Hospital Revenue Code	272
Rate for Payer: Cash Price	$574.22

BANDAGE, ADHESIVE, MEDTOONS, 3/4'X3', LF

Facility

$0.15

Hospital Charge Code	993207
Hospital Revenue Code	270
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.11
Rate for Payer: Amerigroup CHIP/Medicaid	$0.01
Rate for Payer: BCBS of TX Blue Advantage	$0.05
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	$0.11
Rate for Payer: Molina CHIP/Medicaid	$0.11
Rate for Payer: Multiplan Auto	$0.10
Rate for Payer: Multiplan Commercial	$0.10
Rate for Payer: Multiplan Workers Comp	$0.10
Rate for Payer: Parkland Medicaid	$0.11
Rate for Payer: Scott and White EPO/PPO	$0.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.11
Rate for Payer: Superior Health Plan EPO	$0.02

BANDAGE, ADHESIVE, MEDTOONS, 3/4'X3', LF

Facility

$0.15

Hospital Charge Code	993207
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.10

BANDAGE, ADHESIVE, PLASTIC, 1'X3', STRL, LF

Facility

$0.17

Hospital Charge Code	993003
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.12

BANDAGE, ADHESIVE, PLASTIC, 1'X3', STRL, LF

Facility

$0.17

Hospital Charge Code	993003
Hospital Revenue Code	270
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Amerigroup CHIP/Medicaid	$0.02
Rate for Payer: BCBS of TX Blue Advantage	$0.05
Rate for Payer: BCBS of TX Blue Essentials	$0.06
Rate for Payer: BCBS of TX PPO	$0.07
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna Medicaid	$0.12
Rate for Payer: Molina CHIP/Medicaid	$0.12
Rate for Payer: Multiplan Auto	$0.11
Rate for Payer: Multiplan Commercial	$0.11
Rate for Payer: Multiplan Workers Comp	$0.11
Rate for Payer: Parkland Medicaid	$0.12
Rate for Payer: Scott and White EPO/PPO	$0.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.12
Rate for Payer: Superior Health Plan EPO	$0.02

BANDAGE, ADHESIVE, PLASTIC, 3/4'X3', STRL, LF

Facility

$0.09

Hospital Charge Code	992921
Hospital Revenue Code	272
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.06
Rate for Payer: Amerigroup CHIP/Medicaid	$0.01
Rate for Payer: BCBS of TX Blue Advantage	$0.03
Rate for Payer: BCBS of TX Blue Essentials	$0.03
Rate for Payer: BCBS of TX PPO	$0.04
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna Medicaid	$0.06
Rate for Payer: Molina CHIP/Medicaid	$0.06
Rate for Payer: Multiplan Auto	$0.06
Rate for Payer: Multiplan Commercial	$0.06
Rate for Payer: Multiplan Workers Comp	$0.06
Rate for Payer: Parkland Medicaid	$0.06
Rate for Payer: Scott and White EPO/PPO	$0.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.06
Rate for Payer: Superior Health Plan EPO	$0.01

BANDAGE, ADHESIVE, PLASTIC, 3/4'X3', STRL, LF

Facility

$0.09

Hospital Charge Code	992921
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.06

BANDAGE CBN 5YDX6IN STRL TAN CMPR LF

Facility

$7.40

Hospital Charge Code	993251
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.03

BANDAGE CBN 5YDX6IN STRL TAN CMPR LF

Facility

$7.40

Hospital Charge Code	993251
Hospital Revenue Code	270
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$5.33
Rate for Payer: Amerigroup CHIP/Medicaid	$0.67
Rate for Payer: BCBS of TX Blue Advantage	$2.22
Rate for Payer: BCBS of TX Blue Essentials	$2.66
Rate for Payer: BCBS of TX PPO	$2.96
Rate for Payer: Cash Price	$5.03
Rate for Payer: Cigna Medicaid	$5.33
Rate for Payer: Molina CHIP/Medicaid	$5.33
Rate for Payer: Multiplan Auto	$4.81
Rate for Payer: Multiplan Commercial	$4.81
Rate for Payer: Multiplan Workers Comp	$4.81
Rate for Payer: Parkland Medicaid	$5.33
Rate for Payer: Scott and White EPO/PPO	$3.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.33
Rate for Payer: Superior Health Plan EPO	$1.01

BANDAGE, CONFORMING GAUZE 3-PLY 4'X 4.1 YD STERILE -- DHF

Facility

$78.04

Hospital Charge Code	80241102
Hospital Revenue Code	270
Rate for Payer: Cash Price	$53.07

Know your out-of-pocket cost for care.

All Charges