White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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- Misc Supply

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

415004030- Misc Supply

Facility

$1,861.45

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

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

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

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	$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

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

41511500304151150045

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

41511500304151150045

Facility

$2,398.80

Service Code	HCPCS C1713
Hospital Charge Code	9911311
Hospital Revenue Code	278
Min. Negotiated Rate	$599.70
Max. Negotiated Rate	$1,199.40
Rate for Payer: Cash Price	$1,631.18
Rate for Payer: Cigna Commercial	$599.70
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: Scott and White EPO/PPO	$1,199.40

41511500304151150045415115002541511500654151150070

Facility

$2,180.72

Service Code	HCPCS C1769
Hospital Charge Code	991000
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,482.89

41511500304151150045415115002541511500654151150070

Facility

$2,180.72

Service Code	HCPCS C1769
Hospital Charge Code	991000
Hospital Revenue Code	272
Min. Negotiated Rate	$196.26
Max. Negotiated Rate	$1,570.12
Rate for Payer: Amerigroup CHIP/Medicaid	$196.26
Rate for Payer: BCBS of TX Blue Advantage	$654.22
Rate for Payer: BCBS of TX Blue Essentials	$785.06
Rate for Payer: BCBS of TX PPO	$872.29
Rate for Payer: Cash Price	$1,482.89
Rate for Payer: Cigna Medicaid	$1,570.12
Rate for Payer: Molina CHIP/Medicaid	$1,570.12
Rate for Payer: Multiplan Auto	$1,417.47
Rate for Payer: Multiplan Commercial	$1,417.47
Rate for Payer: Multiplan Workers Comp	$1,417.47
Rate for Payer: Parkland Medicaid	$1,570.12
Rate for Payer: Scott and White EPO/PPO	$1,090.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,570.12
Rate for Payer: Superior Health Plan EPO	$296.58

415115003541511500454151150085

Facility

$2,180.72

Service Code	HCPCS C1713
Hospital Charge Code	991063
Hospital Revenue Code	278
Min. Negotiated Rate	$545.18
Max. Negotiated Rate	$1,090.36
Rate for Payer: Cash Price	$1,482.89
Rate for Payer: Cigna Commercial	$545.18
Rate for Payer: Multiplan Auto	$1,090.36
Rate for Payer: Multiplan Commercial	$1,090.36
Rate for Payer: Multiplan Workers Comp	$1,090.36
Rate for Payer: Scott and White EPO/PPO	$1,090.36

415115003541511500454151150085

Facility

$2,180.72

Service Code	HCPCS C1713
Hospital Charge Code	991063
Hospital Revenue Code	278
Min. Negotiated Rate	$196.26
Max. Negotiated Rate	$1,570.12
Rate for Payer: Amerigroup CHIP/Medicaid	$196.26
Rate for Payer: BCBS of TX Blue Advantage	$654.22
Rate for Payer: BCBS of TX Blue Essentials	$785.06
Rate for Payer: BCBS of TX PPO	$872.29
Rate for Payer: Cash Price	$1,482.89
Rate for Payer: Cigna Medicaid	$1,570.12
Rate for Payer: Molina CHIP/Medicaid	$1,570.12
Rate for Payer: Multiplan Auto	$1,090.36
Rate for Payer: Multiplan Commercial	$1,090.36
Rate for Payer: Multiplan Workers Comp	$1,090.36
Rate for Payer: Parkland Medicaid	$1,570.12
Rate for Payer: Scott and White EPO/PPO	$1,090.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,570.12
Rate for Payer: Superior Health Plan EPO	$296.58

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

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

4151200003

Facility

$1,804.83

Service Code	HCPCS C1713
Hospital Charge Code	994015
Hospital Revenue Code	278
Min. Negotiated Rate	$162.43
Max. Negotiated Rate	$1,299.48
Rate for Payer: Amerigroup CHIP/Medicaid	$162.43
Rate for Payer: BCBS of TX Blue Advantage	$541.45
Rate for Payer: BCBS of TX Blue Essentials	$649.74
Rate for Payer: BCBS of TX PPO	$721.93
Rate for Payer: Cash Price	$1,227.28
Rate for Payer: Cigna Medicaid	$1,299.48
Rate for Payer: Molina CHIP/Medicaid	$1,299.48
Rate for Payer: Multiplan Auto	$902.41
Rate for Payer: Multiplan Commercial	$902.41
Rate for Payer: Multiplan Workers Comp	$902.41
Rate for Payer: Parkland Medicaid	$1,299.48
Rate for Payer: Scott and White EPO/PPO	$902.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,299.48
Rate for Payer: Superior Health Plan EPO	$245.46

4151200003

Facility

$1,804.83

Service Code	HCPCS C1713
Hospital Charge Code	994015
Hospital Revenue Code	278
Min. Negotiated Rate	$451.21
Max. Negotiated Rate	$902.41
Rate for Payer: Cash Price	$1,227.28
Rate for Payer: Cigna Commercial	$451.21
Rate for Payer: Multiplan Auto	$902.41
Rate for Payer: Multiplan Commercial	$902.41
Rate for Payer: Multiplan Workers Comp	$902.41
Rate for Payer: Scott and White EPO/PPO	$902.41

415S002351415S002352

Facility

$2,162.65

Service Code	HCPCS C1776
Hospital Charge Code	991065
Hospital Revenue Code	278
Min. Negotiated Rate	$540.66
Max. Negotiated Rate	$1,081.33
Rate for Payer: Cash Price	$1,470.60
Rate for Payer: Cigna Commercial	$540.66
Rate for Payer: Multiplan Auto	$1,081.33
Rate for Payer: Multiplan Commercial	$1,081.33
Rate for Payer: Multiplan Workers Comp	$1,081.33
Rate for Payer: Scott and White EPO/PPO	$1,081.33

415S002351415S002352

Facility

$2,162.65

Service Code	HCPCS C1776
Hospital Charge Code	991065
Hospital Revenue Code	278
Min. Negotiated Rate	$194.64
Max. Negotiated Rate	$1,557.11
Rate for Payer: Amerigroup CHIP/Medicaid	$194.64
Rate for Payer: BCBS of TX Blue Advantage	$648.79
Rate for Payer: BCBS of TX Blue Essentials	$778.55
Rate for Payer: BCBS of TX PPO	$865.06
Rate for Payer: Cash Price	$1,470.60
Rate for Payer: Cigna Medicaid	$1,557.11
Rate for Payer: Molina CHIP/Medicaid	$1,557.11
Rate for Payer: Multiplan Auto	$1,081.33
Rate for Payer: Multiplan Commercial	$1,081.33
Rate for Payer: Multiplan Workers Comp	$1,081.33
Rate for Payer: Parkland Medicaid	$1,557.11
Rate for Payer: Scott and White EPO/PPO	$1,081.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,557.11
Rate for Payer: Superior Health Plan EPO	$294.12

415S002352415S002351

Facility

$2,163.00

Service Code	HCPCS C1713
Hospital Charge Code	991037
Hospital Revenue Code	278
Min. Negotiated Rate	$194.67
Max. Negotiated Rate	$1,557.36
Rate for Payer: Amerigroup CHIP/Medicaid	$194.67
Rate for Payer: BCBS of TX Blue Advantage	$648.90
Rate for Payer: BCBS of TX Blue Essentials	$778.68
Rate for Payer: BCBS of TX PPO	$865.20
Rate for Payer: Cash Price	$1,470.84
Rate for Payer: Cigna Medicaid	$1,557.36
Rate for Payer: Molina CHIP/Medicaid	$1,557.36
Rate for Payer: Multiplan Auto	$1,081.50
Rate for Payer: Multiplan Commercial	$1,081.50
Rate for Payer: Multiplan Workers Comp	$1,081.50
Rate for Payer: Parkland Medicaid	$1,557.36
Rate for Payer: Scott and White EPO/PPO	$1,081.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,557.36
Rate for Payer: Superior Health Plan EPO	$294.17

Know your out-of-pocket cost for care.

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