White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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

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

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

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

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

4150004030

Facility

$1,861.45

Service Code	HCPCS C1713
Hospital Charge Code	991064
Hospital Revenue Code	278
Min. Negotiated Rate	$465.36
Max. Negotiated Rate	$930.73
Rate for Payer: Cash Price	$1,265.79
Rate for Payer: Cigna Commercial	$465.36
Rate for Payer: Multiplan Auto	$930.73
Rate for Payer: Multiplan Commercial	$930.73
Rate for Payer: Multiplan Workers Comp	$930.73
Rate for Payer: Scott and White EPO/PPO	$930.73

4150004030

Facility

$1,861.45

Service Code	HCPCS C1713
Hospital Charge Code	991064
Hospital Revenue Code	278
Min. Negotiated Rate	$167.53
Max. Negotiated Rate	$1,340.24
Rate for Payer: Amerigroup CHIP/Medicaid	$167.53
Rate for Payer: BCBS of TX Blue Advantage	$558.43
Rate for Payer: BCBS of TX Blue Essentials	$670.12
Rate for Payer: BCBS of TX PPO	$744.58
Rate for Payer: Cash Price	$1,265.79
Rate for Payer: Cigna Medicaid	$1,340.24
Rate for Payer: Molina CHIP/Medicaid	$1,340.24
Rate for Payer: Multiplan Auto	$930.73
Rate for Payer: Multiplan Commercial	$930.73
Rate for Payer: Multiplan Workers Comp	$930.73
Rate for Payer: Parkland Medicaid	$1,340.24
Rate for Payer: Scott and White EPO/PPO	$930.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,340.24
Rate for Payer: Superior Health Plan EPO	$253.16

415004030

Facility

$1,861.45

Service Code	HCPCS A4649
Hospital Charge Code	991038
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,265.79

415004030

Facility

$1,861.45

Service Code	HCPCS A4649
Hospital Charge Code	991038
Hospital Revenue Code	272
Min. Negotiated Rate	$167.53
Max. Negotiated Rate	$1,340.24
Rate for Payer: Amerigroup CHIP/Medicaid	$167.53
Rate for Payer: BCBS of TX Blue Advantage	$558.43
Rate for Payer: BCBS of TX Blue Essentials	$670.12
Rate for Payer: BCBS of TX PPO	$744.58
Rate for Payer: Cash Price	$1,265.79
Rate for Payer: Cigna Medicaid	$1,340.24
Rate for Payer: Molina CHIP/Medicaid	$1,340.24
Rate for Payer: Multiplan Auto	$1,209.94
Rate for Payer: Multiplan Commercial	$1,209.94
Rate for Payer: Multiplan Workers Comp	$1,209.94
Rate for Payer: Parkland Medicaid	$1,340.24
Rate for Payer: Scott and White EPO/PPO	$930.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,340.24
Rate for Payer: Superior Health Plan EPO	$253.16

415101020L 415101020R

Facility

$26,440.74

Service Code	HCPCS C1734
Hospital Charge Code	991228
Hospital Revenue Code	278
Min. Negotiated Rate	$2,379.67
Max. Negotiated Rate	$19,037.33
Rate for Payer: Amerigroup CHIP/Medicaid	$2,379.67
Rate for Payer: BCBS of TX Blue Advantage	$7,932.22
Rate for Payer: BCBS of TX Blue Essentials	$9,518.67
Rate for Payer: BCBS of TX PPO	$10,576.30
Rate for Payer: Cash Price	$17,979.70
Rate for Payer: Cigna Medicaid	$19,037.33
Rate for Payer: Molina CHIP/Medicaid	$19,037.33
Rate for Payer: Multiplan Auto	$13,220.37
Rate for Payer: Multiplan Commercial	$13,220.37
Rate for Payer: Multiplan Workers Comp	$13,220.37
Rate for Payer: Parkland Medicaid	$19,037.33
Rate for Payer: Scott and White EPO/PPO	$13,220.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,037.33
Rate for Payer: Superior Health Plan EPO	$3,595.94

415101020L 415101020R

Facility

$26,440.74

Service Code	HCPCS C1734
Hospital Charge Code	991228
Hospital Revenue Code	278
Min. Negotiated Rate	$6,610.19
Max. Negotiated Rate	$13,220.37
Rate for Payer: Cash Price	$17,979.70
Rate for Payer: Cigna Commercial	$6,610.19
Rate for Payer: Multiplan Auto	$13,220.37
Rate for Payer: Multiplan Commercial	$13,220.37
Rate for Payer: Multiplan Workers Comp	$13,220.37
Rate for Payer: Scott and White EPO/PPO	$13,220.37

415101025L 415101025R

Facility

$25,803.62

Service Code	HCPCS C1734
Hospital Charge Code	991204
Hospital Revenue Code	278
Min. Negotiated Rate	$6,450.90
Max. Negotiated Rate	$12,901.81
Rate for Payer: Cash Price	$17,546.46
Rate for Payer: Cigna Commercial	$6,450.90
Rate for Payer: Multiplan Auto	$12,901.81
Rate for Payer: Multiplan Commercial	$12,901.81
Rate for Payer: Multiplan Workers Comp	$12,901.81
Rate for Payer: Scott and White EPO/PPO	$12,901.81

415101025L 415101025R

Facility

$25,803.62

Service Code	HCPCS C1734
Hospital Charge Code	991204
Hospital Revenue Code	278
Min. Negotiated Rate	$2,322.33
Max. Negotiated Rate	$18,578.61
Rate for Payer: Amerigroup CHIP/Medicaid	$2,322.33
Rate for Payer: BCBS of TX Blue Advantage	$7,741.09
Rate for Payer: BCBS of TX Blue Essentials	$9,289.30
Rate for Payer: BCBS of TX PPO	$10,321.45
Rate for Payer: Cash Price	$17,546.46
Rate for Payer: Cigna Medicaid	$18,578.61
Rate for Payer: Molina CHIP/Medicaid	$18,578.61
Rate for Payer: Multiplan Auto	$12,901.81
Rate for Payer: Multiplan Commercial	$12,901.81
Rate for Payer: Multiplan Workers Comp	$12,901.81
Rate for Payer: Parkland Medicaid	$18,578.61
Rate for Payer: Scott and White EPO/PPO	$12,901.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,578.61
Rate for Payer: Superior Health Plan EPO	$3,509.29

415101120L

Facility

$23,458.00

Service Code	HCPCS C1713
Hospital Charge Code	991039
Hospital Revenue Code	278
Min. Negotiated Rate	$2,111.22
Max. Negotiated Rate	$16,889.76
Rate for Payer: Amerigroup CHIP/Medicaid	$2,111.22
Rate for Payer: BCBS of TX Blue Advantage	$7,037.40
Rate for Payer: BCBS of TX Blue Essentials	$8,444.88
Rate for Payer: BCBS of TX PPO	$9,383.20
Rate for Payer: Cash Price	$15,951.44
Rate for Payer: Cigna Medicaid	$16,889.76
Rate for Payer: Molina CHIP/Medicaid	$16,889.76
Rate for Payer: Multiplan Auto	$11,729.00
Rate for Payer: Multiplan Commercial	$11,729.00
Rate for Payer: Multiplan Workers Comp	$11,729.00
Rate for Payer: Parkland Medicaid	$16,889.76
Rate for Payer: Scott and White EPO/PPO	$11,729.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,889.76
Rate for Payer: Superior Health Plan EPO	$3,190.29

415101120L

Facility

$23,458.00

Service Code	HCPCS C1713
Hospital Charge Code	991039
Hospital Revenue Code	278
Min. Negotiated Rate	$5,864.50
Max. Negotiated Rate	$11,729.00
Rate for Payer: Cash Price	$15,951.44
Rate for Payer: Cigna Commercial	$5,864.50
Rate for Payer: Multiplan Auto	$11,729.00
Rate for Payer: Multiplan Commercial	$11,729.00
Rate for Payer: Multiplan Workers Comp	$11,729.00
Rate for Payer: Scott and White EPO/PPO	$11,729.00

415101125L 415101125R

Facility

$23,457.83

Service Code	HCPCS C1776
Hospital Charge Code	991066
Hospital Revenue Code	278
Min. Negotiated Rate	$5,864.46
Max. Negotiated Rate	$11,728.92
Rate for Payer: Cash Price	$15,951.32
Rate for Payer: Cigna Commercial	$5,864.46
Rate for Payer: Multiplan Auto	$11,728.92
Rate for Payer: Multiplan Commercial	$11,728.92
Rate for Payer: Multiplan Workers Comp	$11,728.92
Rate for Payer: Scott and White EPO/PPO	$11,728.92

415101125L 415101125R

Facility

$23,457.83

Service Code	HCPCS C1776
Hospital Charge Code	991066
Hospital Revenue Code	278
Min. Negotiated Rate	$2,111.20
Max. Negotiated Rate	$16,889.64
Rate for Payer: Amerigroup CHIP/Medicaid	$2,111.20
Rate for Payer: BCBS of TX Blue Advantage	$7,037.35
Rate for Payer: BCBS of TX Blue Essentials	$8,444.82
Rate for Payer: BCBS of TX PPO	$9,383.13
Rate for Payer: Cash Price	$15,951.32
Rate for Payer: Cigna Medicaid	$16,889.64
Rate for Payer: Molina CHIP/Medicaid	$16,889.64
Rate for Payer: Multiplan Auto	$11,728.92
Rate for Payer: Multiplan Commercial	$11,728.92
Rate for Payer: Multiplan Workers Comp	$11,728.92
Rate for Payer: Parkland Medicaid	$16,889.64
Rate for Payer: Scott and White EPO/PPO	$11,728.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,889.64
Rate for Payer: Superior Health Plan EPO	$3,190.26

4151150075

Facility

$1,927.28

Service Code	HCPCS C1713
Hospital Charge Code	994014
Hospital Revenue Code	278
Min. Negotiated Rate	$481.82
Max. Negotiated Rate	$963.64
Rate for Payer: Cash Price	$1,310.55
Rate for Payer: Cigna Commercial	$481.82
Rate for Payer: Multiplan Auto	$963.64
Rate for Payer: Multiplan Commercial	$963.64
Rate for Payer: Multiplan Workers Comp	$963.64
Rate for Payer: Scott and White EPO/PPO	$963.64

4151150075

Facility

$1,927.28

Service Code	HCPCS C1713
Hospital Charge Code	994014
Hospital Revenue Code	278
Min. Negotiated Rate	$173.46
Max. Negotiated Rate	$1,387.64
Rate for Payer: Amerigroup CHIP/Medicaid	$173.46
Rate for Payer: BCBS of TX Blue Advantage	$578.18
Rate for Payer: BCBS of TX Blue Essentials	$693.82
Rate for Payer: BCBS of TX PPO	$770.91
Rate for Payer: Cash Price	$1,310.55
Rate for Payer: Cigna Medicaid	$1,387.64
Rate for Payer: Molina CHIP/Medicaid	$1,387.64
Rate for Payer: Multiplan Auto	$963.64
Rate for Payer: Multiplan Commercial	$963.64
Rate for Payer: Multiplan Workers Comp	$963.64
Rate for Payer: Parkland Medicaid	$1,387.64
Rate for Payer: Scott and White EPO/PPO	$963.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,387.64
Rate for Payer: Superior Health Plan EPO	$262.11

4.15115E+19

Facility

$2,398.80

Service Code	HCPCS C1713
Hospital Charge Code	9911311
Hospital Revenue Code	278
Min. Negotiated Rate	$215.89
Max. Negotiated Rate	$1,727.14
Rate for Payer: Amerigroup CHIP/Medicaid	$215.89
Rate for Payer: BCBS of TX Blue Advantage	$719.64
Rate for Payer: BCBS of TX Blue Essentials	$863.57
Rate for Payer: BCBS of TX PPO	$959.52
Rate for Payer: Cash Price	$1,631.18
Rate for Payer: Cigna Medicaid	$1,727.14
Rate for Payer: Molina CHIP/Medicaid	$1,727.14
Rate for Payer: Multiplan Auto	$1,199.40
Rate for Payer: Multiplan Commercial	$1,199.40
Rate for Payer: Multiplan Workers Comp	$1,199.40
Rate for Payer: Parkland Medicaid	$1,727.14
Rate for Payer: Scott and White EPO/PPO	$1,199.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,727.14
Rate for Payer: Superior Health Plan EPO	$326.24

Know your out-of-pocket cost for care.

All Charges