White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

326470

Facility

$2,343.37

Service Code	HCPCS C1713
Hospital Charge Code	992004
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

326470

Facility

$2,343.37

Service Code	HCPCS C1713
Hospital Charge Code	992004
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

3.2 MM DRILL

Facility

$1,157.70

Hospital Charge Code	993067
Hospital Revenue Code	272
Min. Negotiated Rate	$104.19
Max. Negotiated Rate	$833.54
Rate for Payer: Amerigroup CHIP/Medicaid	$104.19
Rate for Payer: BCBS of TX Blue Advantage	$347.31
Rate for Payer: BCBS of TX Blue Essentials	$416.77
Rate for Payer: BCBS of TX PPO	$463.08
Rate for Payer: Cash Price	$787.24
Rate for Payer: Cigna Medicaid	$833.54
Rate for Payer: Molina CHIP/Medicaid	$833.54
Rate for Payer: Multiplan Auto	$752.50
Rate for Payer: Multiplan Commercial	$752.50
Rate for Payer: Multiplan Workers Comp	$752.50
Rate for Payer: Parkland Medicaid	$833.54
Rate for Payer: Scott and White EPO/PPO	$578.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$833.54
Rate for Payer: Superior Health Plan EPO	$157.45

3.2 MM DRILL

Facility

$1,157.70

Hospital Charge Code	993067
Hospital Revenue Code	272
Rate for Payer: Cash Price	$787.24

330021SND

Facility

$35,108.43

Service Code	HCPCS C1734
Hospital Charge Code	991176
Hospital Revenue Code	278
Min. Negotiated Rate	$8,777.11
Max. Negotiated Rate	$17,554.22
Rate for Payer: Cash Price	$23,873.73
Rate for Payer: Cigna Commercial	$8,777.11
Rate for Payer: Multiplan Auto	$17,554.22
Rate for Payer: Multiplan Commercial	$17,554.22
Rate for Payer: Multiplan Workers Comp	$17,554.22
Rate for Payer: Scott and White EPO/PPO	$17,554.22

330021SND

Facility

$35,108.43

Service Code	HCPCS C1734
Hospital Charge Code	991176
Hospital Revenue Code	278
Min. Negotiated Rate	$3,159.76
Max. Negotiated Rate	$25,278.07
Rate for Payer: Amerigroup CHIP/Medicaid	$3,159.76
Rate for Payer: BCBS of TX Blue Advantage	$10,532.53
Rate for Payer: BCBS of TX Blue Essentials	$12,639.03
Rate for Payer: BCBS of TX PPO	$14,043.37
Rate for Payer: Cash Price	$23,873.73
Rate for Payer: Cigna Medicaid	$25,278.07
Rate for Payer: Molina CHIP/Medicaid	$25,278.07
Rate for Payer: Multiplan Auto	$17,554.22
Rate for Payer: Multiplan Commercial	$17,554.22
Rate for Payer: Multiplan Workers Comp	$17,554.22
Rate for Payer: Parkland Medicaid	$25,278.07
Rate for Payer: Scott and White EPO/PPO	$17,554.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,278.07
Rate for Payer: Superior Health Plan EPO	$4,774.75

330220SND

Facility

$16,433.73

Service Code	HCPCS C1776
Hospital Charge Code	991095
Hospital Revenue Code	278
Min. Negotiated Rate	$1,479.04
Max. Negotiated Rate	$11,832.29
Rate for Payer: Amerigroup CHIP/Medicaid	$1,479.04
Rate for Payer: BCBS of TX Blue Advantage	$4,930.12
Rate for Payer: BCBS of TX Blue Essentials	$5,916.14
Rate for Payer: BCBS of TX PPO	$6,573.49
Rate for Payer: Cash Price	$11,174.94
Rate for Payer: Cigna Medicaid	$11,832.29
Rate for Payer: Molina CHIP/Medicaid	$11,832.29
Rate for Payer: Multiplan Auto	$8,216.86
Rate for Payer: Multiplan Commercial	$8,216.86
Rate for Payer: Multiplan Workers Comp	$8,216.86
Rate for Payer: Parkland Medicaid	$11,832.29
Rate for Payer: Scott and White EPO/PPO	$8,216.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,832.29
Rate for Payer: Superior Health Plan EPO	$2,234.99

330220SND

Facility

$16,433.73

Service Code	HCPCS C1776
Hospital Charge Code	991095
Hospital Revenue Code	278
Min. Negotiated Rate	$4,108.43
Max. Negotiated Rate	$8,216.86
Rate for Payer: Cash Price	$11,174.94
Rate for Payer: Cigna Commercial	$4,108.43
Rate for Payer: Multiplan Auto	$8,216.86
Rate for Payer: Multiplan Commercial	$8,216.86
Rate for Payer: Multiplan Workers Comp	$8,216.86
Rate for Payer: Scott and White EPO/PPO	$8,216.86

3425-0360S

Facility

$21,240.96

Service Code	HCPCS C1734
Hospital Charge Code	991188
Hospital Revenue Code	278
Min. Negotiated Rate	$5,310.24
Max. Negotiated Rate	$10,620.48
Rate for Payer: Cash Price	$14,443.85
Rate for Payer: Cigna Commercial	$5,310.24
Rate for Payer: Multiplan Auto	$10,620.48
Rate for Payer: Multiplan Commercial	$10,620.48
Rate for Payer: Multiplan Workers Comp	$10,620.48
Rate for Payer: Scott and White EPO/PPO	$10,620.48

3425-0360S

Facility

$21,240.96

Service Code	HCPCS C1734
Hospital Charge Code	991188
Hospital Revenue Code	278
Min. Negotiated Rate	$1,911.69
Max. Negotiated Rate	$15,293.49
Rate for Payer: Amerigroup CHIP/Medicaid	$1,911.69
Rate for Payer: BCBS of TX Blue Advantage	$6,372.29
Rate for Payer: BCBS of TX Blue Essentials	$7,646.75
Rate for Payer: BCBS of TX PPO	$8,496.38
Rate for Payer: Cash Price	$14,443.85
Rate for Payer: Cigna Medicaid	$15,293.49
Rate for Payer: Molina CHIP/Medicaid	$15,293.49
Rate for Payer: Multiplan Auto	$10,620.48
Rate for Payer: Multiplan Commercial	$10,620.48
Rate for Payer: Multiplan Workers Comp	$10,620.48
Rate for Payer: Parkland Medicaid	$15,293.49
Rate for Payer: Scott and White EPO/PPO	$10,620.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,293.49
Rate for Payer: Superior Health Plan EPO	$2,888.77

3.5 X 24 MM SCREW

Facility

$11,084.34

Service Code	HCPCS C1713
Hospital Charge Code	992386
Hospital Revenue Code	278
Min. Negotiated Rate	$997.59
Max. Negotiated Rate	$7,980.72
Rate for Payer: Amerigroup CHIP/Medicaid	$997.59
Rate for Payer: BCBS of TX Blue Advantage	$3,325.30
Rate for Payer: BCBS of TX Blue Essentials	$3,990.36
Rate for Payer: BCBS of TX PPO	$4,433.74
Rate for Payer: Cash Price	$7,537.35
Rate for Payer: Cigna Medicaid	$7,980.72
Rate for Payer: Molina CHIP/Medicaid	$7,980.72
Rate for Payer: Multiplan Auto	$5,542.17
Rate for Payer: Multiplan Commercial	$5,542.17
Rate for Payer: Multiplan Workers Comp	$5,542.17
Rate for Payer: Parkland Medicaid	$7,980.72
Rate for Payer: Scott and White EPO/PPO	$5,542.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,980.72
Rate for Payer: Superior Health Plan EPO	$1,507.47

3.5 X 24 MM SCREW

Facility

$11,084.34

Service Code	HCPCS C1713
Hospital Charge Code	992386
Hospital Revenue Code	278
Min. Negotiated Rate	$2,771.09
Max. Negotiated Rate	$5,542.17
Rate for Payer: Cash Price	$7,537.35
Rate for Payer: Cigna Commercial	$2,771.09
Rate for Payer: Multiplan Auto	$5,542.17
Rate for Payer: Multiplan Commercial	$5,542.17
Rate for Payer: Multiplan Workers Comp	$5,542.17
Rate for Payer: Scott and White EPO/PPO	$5,542.17

3832-1107

Facility

$8,240.75

Service Code	HCPCS C1776
Hospital Charge Code	991220
Hospital Revenue Code	278
Min. Negotiated Rate	$741.67
Max. Negotiated Rate	$5,933.34
Rate for Payer: Amerigroup CHIP/Medicaid	$741.67
Rate for Payer: BCBS of TX Blue Advantage	$2,472.22
Rate for Payer: BCBS of TX Blue Essentials	$2,966.67
Rate for Payer: BCBS of TX PPO	$3,296.30
Rate for Payer: Cash Price	$5,603.71
Rate for Payer: Cigna Medicaid	$5,933.34
Rate for Payer: Molina CHIP/Medicaid	$5,933.34
Rate for Payer: Multiplan Auto	$4,120.38
Rate for Payer: Multiplan Commercial	$4,120.38
Rate for Payer: Multiplan Workers Comp	$4,120.38
Rate for Payer: Parkland Medicaid	$5,933.34
Rate for Payer: Scott and White EPO/PPO	$4,120.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,933.34
Rate for Payer: Superior Health Plan EPO	$1,120.74

3832-1107

Facility

$8,240.75

Service Code	HCPCS C1776
Hospital Charge Code	991220
Hospital Revenue Code	278
Min. Negotiated Rate	$2,060.19
Max. Negotiated Rate	$4,120.38
Rate for Payer: Cash Price	$5,603.71
Rate for Payer: Cigna Commercial	$2,060.19
Rate for Payer: Multiplan Auto	$4,120.38
Rate for Payer: Multiplan Commercial	$4,120.38
Rate for Payer: Multiplan Workers Comp	$4,120.38
Rate for Payer: Scott and White EPO/PPO	$4,120.38

3RD ORDER SELEC ABDOMEN/PELVIS

Facility

$4,484.00

Service Code	HCPCS 36247
Hospital Charge Code	2300176
Hospital Revenue Code	361
Min. Negotiated Rate	$403.56
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$403.56
Rate for Payer: BCBS of TX Blue Advantage	$1,345.20
Rate for Payer: BCBS of TX Blue Essentials	$1,614.24
Rate for Payer: BCBS of TX PPO	$1,793.60
Rate for Payer: Cash Price	$3,049.12
Rate for Payer: Cash Price	$3,049.12
Rate for Payer: Cigna Medicaid	$3,228.48
Rate for Payer: Molina CHIP/Medicaid	$3,228.48
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	$3,228.48
Rate for Payer: Scott and White EPO/PPO	$2,242.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,228.48
Rate for Payer: Superior Health Plan EPO	$609.82

3RD ORDER SELEC ABDOMEN/PELVIS

Facility

$4,484.00

Service Code	HCPCS 36247
Hospital Charge Code	2300176
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,049.12

4.0x14mm Self-Drilling Variable Screw, 4.0x16mm

Facility

$903.61

Service Code	HCPCS C1713
Hospital Charge Code	992219
Hospital Revenue Code	278
Min. Negotiated Rate	$225.90
Max. Negotiated Rate	$451.81
Rate for Payer: Cash Price	$614.45
Rate for Payer: Cigna Commercial	$225.90
Rate for Payer: Multiplan Auto	$451.81
Rate for Payer: Multiplan Commercial	$451.81
Rate for Payer: Multiplan Workers Comp	$451.81
Rate for Payer: Scott and White EPO/PPO	$451.81

4.0x14mm Self-Drilling Variable Screw, 4.0x16mm

Facility

$903.61

Service Code	HCPCS C1713
Hospital Charge Code	992219
Hospital Revenue Code	278
Min. Negotiated Rate	$81.32
Max. Negotiated Rate	$650.60
Rate for Payer: Amerigroup CHIP/Medicaid	$81.32
Rate for Payer: BCBS of TX Blue Advantage	$271.08
Rate for Payer: BCBS of TX Blue Essentials	$325.30
Rate for Payer: BCBS of TX PPO	$361.44
Rate for Payer: Cash Price	$614.45
Rate for Payer: Cigna Medicaid	$650.60
Rate for Payer: Molina CHIP/Medicaid	$650.60
Rate for Payer: Multiplan Auto	$451.81
Rate for Payer: Multiplan Commercial	$451.81
Rate for Payer: Multiplan Workers Comp	$451.81
Rate for Payer: Parkland Medicaid	$650.60
Rate for Payer: Scott and White EPO/PPO	$451.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$650.60
Rate for Payer: Superior Health Plan EPO	$122.89

4150002090

Facility

$2,512.04

Hospital Charge Code	991005
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,708.19

4150002090

Facility

$2,512.04

Service Code	HCPCS C1776
Hospital Charge Code	991097
Hospital Revenue Code	278
Min. Negotiated Rate	$628.01
Max. Negotiated Rate	$1,256.02
Rate for Payer: Cash Price	$1,708.19
Rate for Payer: Cigna Commercial	$628.01
Rate for Payer: Multiplan Auto	$1,256.02
Rate for Payer: Multiplan Commercial	$1,256.02
Rate for Payer: Multiplan Workers Comp	$1,256.02
Rate for Payer: Scott and White EPO/PPO	$1,256.02

4150002090

Facility

$2,512.04

Hospital Charge Code	991005
Hospital Revenue Code	272
Min. Negotiated Rate	$226.08
Max. Negotiated Rate	$1,808.67
Rate for Payer: Amerigroup CHIP/Medicaid	$226.08
Rate for Payer: BCBS of TX Blue Advantage	$753.61
Rate for Payer: BCBS of TX Blue Essentials	$904.33
Rate for Payer: BCBS of TX PPO	$1,004.82
Rate for Payer: Cash Price	$1,708.19
Rate for Payer: Cigna Medicaid	$1,808.67
Rate for Payer: Molina CHIP/Medicaid	$1,808.67
Rate for Payer: Multiplan Auto	$1,632.83
Rate for Payer: Multiplan Commercial	$1,632.83
Rate for Payer: Multiplan Workers Comp	$1,632.83
Rate for Payer: Parkland Medicaid	$1,808.67
Rate for Payer: Scott and White EPO/PPO	$1,256.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,808.67
Rate for Payer: Superior Health Plan EPO	$341.64

4150002090

Facility

$2,512.04

Service Code	HCPCS C1776
Hospital Charge Code	991097
Hospital Revenue Code	278
Min. Negotiated Rate	$226.08
Max. Negotiated Rate	$1,808.67
Rate for Payer: Amerigroup CHIP/Medicaid	$226.08
Rate for Payer: BCBS of TX Blue Advantage	$753.61
Rate for Payer: BCBS of TX Blue Essentials	$904.33
Rate for Payer: BCBS of TX PPO	$1,004.82
Rate for Payer: Cash Price	$1,708.19
Rate for Payer: Cigna Medicaid	$1,808.67
Rate for Payer: Molina CHIP/Medicaid	$1,808.67
Rate for Payer: Multiplan Auto	$1,256.02
Rate for Payer: Multiplan Commercial	$1,256.02
Rate for Payer: Multiplan Workers Comp	$1,256.02
Rate for Payer: Parkland Medicaid	$1,808.67
Rate for Payer: Scott and White EPO/PPO	$1,256.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,808.67
Rate for Payer: Superior Health Plan EPO	$341.64

4150003000

Facility

$2,228.91

Hospital Charge Code	991033
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,515.66

4150003000

Facility

$2,228.91

Hospital Charge Code	991033
Hospital Revenue Code	270
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$1,604.82
Rate for Payer: Amerigroup CHIP/Medicaid	$200.60
Rate for Payer: BCBS of TX Blue Advantage	$668.67
Rate for Payer: BCBS of TX Blue Essentials	$802.41
Rate for Payer: BCBS of TX PPO	$891.56
Rate for Payer: Cash Price	$1,515.66
Rate for Payer: Cigna Medicaid	$1,604.82
Rate for Payer: Molina CHIP/Medicaid	$1,604.82
Rate for Payer: Multiplan Auto	$1,448.79
Rate for Payer: Multiplan Commercial	$1,448.79
Rate for Payer: Multiplan Workers Comp	$1,448.79
Rate for Payer: Parkland Medicaid	$1,604.82
Rate for Payer: Scott and White EPO/PPO	$1,114.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,604.82
Rate for Payer: Superior Health Plan EPO	$303.13

Know your out-of-pocket cost for care.

All Charges