White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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, 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

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

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 GZ 1/2 -- DHF

Facility

$64.05

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

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
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 KNEE -- DHF

Facility

$128.08

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

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	$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 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 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

Body Fluid Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107074
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$222.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$92.70
Rate for Payer: BCBS of TX Blue Essentials	$111.24
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$123.60
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cigna Medicaid	$222.48
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$222.48
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$222.48
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.48
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

Body Fluid Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107074
Hospital Revenue Code	306
Rate for Payer: Cash Price	$210.12

Body Fluid Culture Aer/Ana/GS SO

Facility

$239.38

Service Code	HCPCS 87070
Hospital Charge Code	9174976
Hospital Revenue Code	306
Rate for Payer: Cash Price	$162.78

Body Fluid Culture Aer/Ana/GS SO

Facility

$239.38

Service Code	HCPCS 87070
Hospital Charge Code	9174976
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$172.35
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$71.81
Rate for Payer: BCBS of TX Blue Essentials	$86.18
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$95.75
Rate for Payer: Cash Price	$162.78
Rate for Payer: Cash Price	$162.78
Rate for Payer: Cigna Medicaid	$172.35
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$172.35
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$155.60
Rate for Payer: Multiplan Commercial	$155.60
Rate for Payer: Multiplan Workers Comp	$155.60
Rate for Payer: Parkland Medicaid	$172.35
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$172.35
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

Body Fluid Culture Aer/Ana/GS SO

Facility

$239.38

Service Code	HCPCS 87070
Hospital Charge Code	4107043
Hospital Revenue Code	306
Rate for Payer: Cash Price	$162.78

Body Fluid Culture Aer/Ana/GS SO

Facility

$239.38

Service Code	HCPCS 87070
Hospital Charge Code	4107043
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$172.35
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$71.81
Rate for Payer: BCBS of TX Blue Essentials	$86.18
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$95.75
Rate for Payer: Cash Price	$162.78
Rate for Payer: Cash Price	$162.78
Rate for Payer: Cigna Medicaid	$172.35
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$172.35
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$155.60
Rate for Payer: Multiplan Commercial	$155.60
Rate for Payer: Multiplan Workers Comp	$155.60
Rate for Payer: Parkland Medicaid	$172.35
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$172.35
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

Know your out-of-pocket cost for care.

All Charges