White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BND COBAN 4/5 -- DHF

Facility

$92.25

Hospital Charge Code	80240328
Hospital Revenue Code	270
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$66.42
Rate for Payer: Amerigroup CHIP/Medicaid	$8.30
Rate for Payer: BCBS of TX Blue Advantage	$27.68
Rate for Payer: BCBS of TX Blue Essentials	$33.21
Rate for Payer: BCBS of TX PPO	$36.90
Rate for Payer: Cash Price	$62.73
Rate for Payer: Cigna Medicaid	$66.42
Rate for Payer: Molina CHIP/Medicaid	$66.42
Rate for Payer: Multiplan Auto	$59.96
Rate for Payer: Multiplan Commercial	$59.96
Rate for Payer: Multiplan Workers Comp	$59.96
Rate for Payer: Parkland Medicaid	$66.42
Rate for Payer: Scott and White EPO/PPO	$46.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$66.42
Rate for Payer: Superior Health Plan EPO	$12.55

BND ELSTC 2/3 -- DHF

Facility

$37.10

Hospital Charge Code	80240401
Hospital Revenue Code	270
Rate for Payer: Cash Price	$25.23

BND ELSTC 2/3 -- DHF

Facility

$37.10

Hospital Charge Code	80240401
Hospital Revenue Code	270
Min. Negotiated Rate	$3.34
Max. Negotiated Rate	$26.71
Rate for Payer: Amerigroup CHIP/Medicaid	$3.34
Rate for Payer: BCBS of TX Blue Advantage	$11.13
Rate for Payer: BCBS of TX Blue Essentials	$13.36
Rate for Payer: BCBS of TX PPO	$14.84
Rate for Payer: Cash Price	$25.23
Rate for Payer: Cigna Medicaid	$26.71
Rate for Payer: Molina CHIP/Medicaid	$26.71
Rate for Payer: Multiplan Auto	$24.11
Rate for Payer: Multiplan Commercial	$24.11
Rate for Payer: Multiplan Workers Comp	$24.11
Rate for Payer: Parkland Medicaid	$26.71
Rate for Payer: Scott and White EPO/PPO	$18.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.71
Rate for Payer: Superior Health Plan EPO	$5.05

BNDG, ELSTC, MATRIX, STRL, 4'X5YD, LF, HOOK&LP

Facility

$9.19

Hospital Charge Code	992908
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6.25

BNDG, ELSTC, MATRIX, STRL, 4'X5YD, LF, HOOK&LP

Facility

$9.19

Hospital Charge Code	992908
Hospital Revenue Code	272
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$6.62
Rate for Payer: Amerigroup CHIP/Medicaid	$0.83
Rate for Payer: BCBS of TX Blue Advantage	$2.76
Rate for Payer: BCBS of TX Blue Essentials	$3.31
Rate for Payer: BCBS of TX PPO	$3.68
Rate for Payer: Cash Price	$6.25
Rate for Payer: Cigna Medicaid	$6.62
Rate for Payer: Molina CHIP/Medicaid	$6.62
Rate for Payer: Multiplan Auto	$5.97
Rate for Payer: Multiplan Commercial	$5.97
Rate for Payer: Multiplan Workers Comp	$5.97
Rate for Payer: Parkland Medicaid	$6.62
Rate for Payer: Scott and White EPO/PPO	$4.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.62
Rate for Payer: Superior Health Plan EPO	$1.25

BNDG, ELSTC, MATRIX, STRL, 6'X5YD, LF, HOOK&LP

Facility

$6.89

Hospital Charge Code	992977
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.69

BNDG, ELSTC, MATRIX, STRL, 6'X5YD, LF, HOOK&LP

Facility

$6.89

Hospital Charge Code	992977
Hospital Revenue Code	272
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$4.96
Rate for Payer: Amerigroup CHIP/Medicaid	$0.62
Rate for Payer: BCBS of TX Blue Advantage	$2.07
Rate for Payer: BCBS of TX Blue Essentials	$2.48
Rate for Payer: BCBS of TX PPO	$2.76
Rate for Payer: Cash Price	$4.69
Rate for Payer: Cigna Medicaid	$4.96
Rate for Payer: Molina CHIP/Medicaid	$4.96
Rate for Payer: Multiplan Auto	$4.48
Rate for Payer: Multiplan Commercial	$4.48
Rate for Payer: Multiplan Workers Comp	$4.48
Rate for Payer: Parkland Medicaid	$4.96
Rate for Payer: Scott and White EPO/PPO	$3.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.96
Rate for Payer: Superior Health Plan EPO	$0.94

BNDG, SELF ADHRNT, COBAN, 2'X5, YD, BLU

Facility

$5.07

Hospital Charge Code	992994
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.45

BNDG, SELF ADHRNT, COBAN, 2'X5, YD, BLU

Facility

$5.07

Hospital Charge Code	992994
Hospital Revenue Code	270
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$3.65
Rate for Payer: Amerigroup CHIP/Medicaid	$0.46
Rate for Payer: BCBS of TX Blue Advantage	$1.52
Rate for Payer: BCBS of TX Blue Essentials	$1.83
Rate for Payer: BCBS of TX PPO	$2.03
Rate for Payer: Cash Price	$3.45
Rate for Payer: Cigna Medicaid	$3.65
Rate for Payer: Molina CHIP/Medicaid	$3.65
Rate for Payer: Multiplan Auto	$3.30
Rate for Payer: Multiplan Commercial	$3.30
Rate for Payer: Multiplan Workers Comp	$3.30
Rate for Payer: Parkland Medicaid	$3.65
Rate for Payer: Scott and White EPO/PPO	$2.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.65
Rate for Payer: Superior Health Plan EPO	$0.69

BND GZ 1/2 -- DHF

Facility

$64.05

Hospital Charge Code	80240609
Hospital Revenue Code	270
Rate for Payer: Cash Price	$43.55

BND GZ 1/2 -- DHF

Facility

$64.05

Hospital Charge Code	80240609
Hospital Revenue Code	270
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$46.12
Rate for Payer: Amerigroup CHIP/Medicaid	$5.76
Rate for Payer: BCBS of TX Blue Advantage	$19.21
Rate for Payer: BCBS of TX Blue Essentials	$23.06
Rate for Payer: BCBS of TX PPO	$25.62
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cigna Medicaid	$46.12
Rate for Payer: Molina CHIP/Medicaid	$46.12
Rate for Payer: Multiplan Auto	$41.63
Rate for Payer: Multiplan Commercial	$41.63
Rate for Payer: Multiplan Workers Comp	$41.63
Rate for Payer: Parkland Medicaid	$46.12
Rate for Payer: Scott and White EPO/PPO	$32.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.12
Rate for Payer: Superior Health Plan EPO	$8.71

BND KLING 1-3 -- DHF

Facility

$64.05

Hospital Charge Code	80241052
Hospital Revenue Code	270
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$46.12
Rate for Payer: Amerigroup CHIP/Medicaid	$5.76
Rate for Payer: BCBS of TX Blue Advantage	$19.21
Rate for Payer: BCBS of TX Blue Essentials	$23.06
Rate for Payer: BCBS of TX PPO	$25.62
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cigna Medicaid	$46.12
Rate for Payer: Molina CHIP/Medicaid	$46.12
Rate for Payer: Multiplan Auto	$41.63
Rate for Payer: Multiplan Commercial	$41.63
Rate for Payer: Multiplan Workers Comp	$41.63
Rate for Payer: Parkland Medicaid	$46.12
Rate for Payer: Scott and White EPO/PPO	$32.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.12
Rate for Payer: Superior Health Plan EPO	$8.71

BND KLING 1-3 -- DHF

Facility

$64.05

Hospital Charge Code	80241052
Hospital Revenue Code	270
Rate for Payer: Cash Price	$43.55

BND STKNG KNEE -- DHF

Facility

$128.08

Hospital Charge Code	80241706
Hospital Revenue Code	270
Rate for Payer: Cash Price	$87.09

BND STKNG KNEE -- DHF

Facility

$128.08

Hospital Charge Code	80241706
Hospital Revenue Code	270
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$92.22
Rate for Payer: Amerigroup CHIP/Medicaid	$11.53
Rate for Payer: BCBS of TX Blue Advantage	$38.42
Rate for Payer: BCBS of TX Blue Essentials	$46.11
Rate for Payer: BCBS of TX PPO	$51.23
Rate for Payer: Cash Price	$87.09
Rate for Payer: Cigna Medicaid	$92.22
Rate for Payer: Molina CHIP/Medicaid	$92.22
Rate for Payer: Multiplan Auto	$83.25
Rate for Payer: Multiplan Commercial	$83.25
Rate for Payer: Multiplan Workers Comp	$83.25
Rate for Payer: Parkland Medicaid	$92.22
Rate for Payer: Scott and White EPO/PPO	$64.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.22
Rate for Payer: Superior Health Plan EPO	$17.42

BND STKNG THGH -- DHF

Facility

$173.39

Hospital Charge Code	80241755
Hospital Revenue Code	270
Min. Negotiated Rate	$15.61
Max. Negotiated Rate	$124.84
Rate for Payer: Amerigroup CHIP/Medicaid	$15.61
Rate for Payer: BCBS of TX Blue Advantage	$52.02
Rate for Payer: BCBS of TX Blue Essentials	$62.42
Rate for Payer: BCBS of TX PPO	$69.36
Rate for Payer: Cash Price	$117.91
Rate for Payer: Cigna Medicaid	$124.84
Rate for Payer: Molina CHIP/Medicaid	$124.84
Rate for Payer: Multiplan Auto	$112.70
Rate for Payer: Multiplan Commercial	$112.70
Rate for Payer: Multiplan Workers Comp	$112.70
Rate for Payer: Parkland Medicaid	$124.84
Rate for Payer: Scott and White EPO/PPO	$86.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$124.84
Rate for Payer: Superior Health Plan EPO	$23.58

BND STKNG THGH -- DHF

Facility

$173.39

Hospital Charge Code	80241755
Hospital Revenue Code	270
Rate for Payer: Cash Price	$117.91

BN GRFT 3 -- DHF

Facility

$4,993.00

Service Code	HCPCS C1734
Hospital Charge Code	81312878
Hospital Revenue Code	278
Min. Negotiated Rate	$449.37
Max. Negotiated Rate	$3,594.96
Rate for Payer: Amerigroup CHIP/Medicaid	$449.37
Rate for Payer: BCBS of TX Blue Advantage	$1,497.90
Rate for Payer: BCBS of TX Blue Essentials	$1,797.48
Rate for Payer: BCBS of TX PPO	$1,997.20
Rate for Payer: Cash Price	$3,395.24
Rate for Payer: Cigna Medicaid	$3,594.96
Rate for Payer: Molina CHIP/Medicaid	$3,594.96
Rate for Payer: Multiplan Auto	$2,496.50
Rate for Payer: Multiplan Commercial	$2,496.50
Rate for Payer: Multiplan Workers Comp	$2,496.50
Rate for Payer: Parkland Medicaid	$3,594.96
Rate for Payer: Scott and White EPO/PPO	$2,496.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,594.96
Rate for Payer: Superior Health Plan EPO	$679.05

BN GRFT 3 -- DHF

Facility

$4,993.00

Service Code	HCPCS C1734
Hospital Charge Code	81312878
Hospital Revenue Code	278
Min. Negotiated Rate	$1,248.25
Max. Negotiated Rate	$2,496.50
Rate for Payer: Cash Price	$3,395.24
Rate for Payer: Cigna Commercial	$1,248.25
Rate for Payer: Multiplan Auto	$2,496.50
Rate for Payer: Multiplan Commercial	$2,496.50
Rate for Payer: Multiplan Workers Comp	$2,496.50
Rate for Payer: Scott and White EPO/PPO	$2,496.50

BN GRFT -- DHF

Facility

$2,359.00

Service Code	HCPCS C1734
Hospital Charge Code	81312852
Hospital Revenue Code	278
Min. Negotiated Rate	$589.75
Max. Negotiated Rate	$1,179.50
Rate for Payer: Cash Price	$1,604.12
Rate for Payer: Cigna Commercial	$589.75
Rate for Payer: Multiplan Auto	$1,179.50
Rate for Payer: Multiplan Commercial	$1,179.50
Rate for Payer: Multiplan Workers Comp	$1,179.50
Rate for Payer: Scott and White EPO/PPO	$1,179.50

BN GRFT -- DHF

Facility

$2,359.00

Service Code	HCPCS C1734
Hospital Charge Code	81312852
Hospital Revenue Code	278
Min. Negotiated Rate	$212.31
Max. Negotiated Rate	$1,698.48
Rate for Payer: Amerigroup CHIP/Medicaid	$212.31
Rate for Payer: BCBS of TX Blue Advantage	$707.70
Rate for Payer: BCBS of TX Blue Essentials	$849.24
Rate for Payer: BCBS of TX PPO	$943.60
Rate for Payer: Cash Price	$1,604.12
Rate for Payer: Cigna Medicaid	$1,698.48
Rate for Payer: Molina CHIP/Medicaid	$1,698.48
Rate for Payer: Multiplan Auto	$1,179.50
Rate for Payer: Multiplan Commercial	$1,179.50
Rate for Payer: Multiplan Workers Comp	$1,179.50
Rate for Payer: Parkland Medicaid	$1,698.48
Rate for Payer: Scott and White EPO/PPO	$1,179.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,698.48
Rate for Payer: Superior Health Plan EPO	$320.82

BN MATRIX 2

Facility

$2,217.00

Service Code	HCPCS C1734
Hospital Charge Code	81329120
Hospital Revenue Code	278
Min. Negotiated Rate	$554.25
Max. Negotiated Rate	$1,108.50
Rate for Payer: Cash Price	$1,507.56
Rate for Payer: Cigna Commercial	$554.25
Rate for Payer: Multiplan Auto	$1,108.50
Rate for Payer: Multiplan Commercial	$1,108.50
Rate for Payer: Multiplan Workers Comp	$1,108.50
Rate for Payer: Scott and White EPO/PPO	$1,108.50

BN MATRIX 2

Facility

$2,217.00

Service Code	HCPCS C1734
Hospital Charge Code	81329120
Hospital Revenue Code	278
Min. Negotiated Rate	$199.53
Max. Negotiated Rate	$1,596.24
Rate for Payer: Amerigroup CHIP/Medicaid	$199.53
Rate for Payer: BCBS of TX Blue Advantage	$665.10
Rate for Payer: BCBS of TX Blue Essentials	$798.12
Rate for Payer: BCBS of TX PPO	$886.80
Rate for Payer: Cash Price	$1,507.56
Rate for Payer: Cigna Medicaid	$1,596.24
Rate for Payer: Molina CHIP/Medicaid	$1,596.24
Rate for Payer: Multiplan Auto	$1,108.50
Rate for Payer: Multiplan Commercial	$1,108.50
Rate for Payer: Multiplan Workers Comp	$1,108.50
Rate for Payer: Parkland Medicaid	$1,596.24
Rate for Payer: Scott and White EPO/PPO	$1,108.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,596.24
Rate for Payer: Superior Health Plan EPO	$301.51

BN SUBST FOAM 10CC

Facility

$10,768.00

Service Code	HCPCS C1734
Hospital Charge Code	40106866
Hospital Revenue Code	278
Min. Negotiated Rate	$2,692.00
Max. Negotiated Rate	$5,384.00
Rate for Payer: Cash Price	$7,322.24
Rate for Payer: Cigna Commercial	$2,692.00
Rate for Payer: Multiplan Auto	$5,384.00
Rate for Payer: Multiplan Commercial	$5,384.00
Rate for Payer: Multiplan Workers Comp	$5,384.00
Rate for Payer: Scott and White EPO/PPO	$5,384.00

BN SUBST FOAM 10CC

Facility

$10,768.00

Service Code	HCPCS C1734
Hospital Charge Code	40106866
Hospital Revenue Code	278
Min. Negotiated Rate	$969.12
Max. Negotiated Rate	$7,752.96
Rate for Payer: Amerigroup CHIP/Medicaid	$969.12
Rate for Payer: BCBS of TX Blue Advantage	$3,230.40
Rate for Payer: BCBS of TX Blue Essentials	$3,876.48
Rate for Payer: BCBS of TX PPO	$4,307.20
Rate for Payer: Cash Price	$7,322.24
Rate for Payer: Cigna Medicaid	$7,752.96
Rate for Payer: Molina CHIP/Medicaid	$7,752.96
Rate for Payer: Multiplan Auto	$5,384.00
Rate for Payer: Multiplan Commercial	$5,384.00
Rate for Payer: Multiplan Workers Comp	$5,384.00
Rate for Payer: Parkland Medicaid	$7,752.96
Rate for Payer: Scott and White EPO/PPO	$5,384.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,752.96
Rate for Payer: Superior Health Plan EPO	$1,464.45

Know your out-of-pocket cost for care.

All Charges