White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

4.2MM X 19CM HPS PREBENT GREAT WHITE CONCAV

Facility

$806.63

Hospital Charge Code	992133
Hospital Revenue Code	272
Rate for Payer: Cash Price	$548.51

4.2MM X 19CM HPS PREBENT GREAT WHITE CONCAV

Facility

$806.63

Hospital Charge Code	992133
Hospital Revenue Code	272
Min. Negotiated Rate	$72.60
Max. Negotiated Rate	$580.77
Rate for Payer: Amerigroup CHIP/Medicaid	$72.60
Rate for Payer: BCBS of TX Blue Advantage	$241.99
Rate for Payer: BCBS of TX Blue Essentials	$290.39
Rate for Payer: BCBS of TX PPO	$322.65
Rate for Payer: Cash Price	$548.51
Rate for Payer: Cigna Medicaid	$580.77
Rate for Payer: Molina CHIP/Medicaid	$580.77
Rate for Payer: Multiplan Auto	$524.31
Rate for Payer: Multiplan Commercial	$524.31
Rate for Payer: Multiplan Workers Comp	$524.31
Rate for Payer: Parkland Medicaid	$580.77
Rate for Payer: Scott and White EPO/PPO	$403.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$580.77
Rate for Payer: Superior Health Plan EPO	$109.70

4.2MM X 19CM HPS STERLING GREAT WHITE

Facility

$806.63

Hospital Charge Code	992132
Hospital Revenue Code	272
Rate for Payer: Cash Price	$548.51

4.2MM X 19CM HPS STERLING GREAT WHITE

Facility

$806.63

Hospital Charge Code	992132
Hospital Revenue Code	272
Min. Negotiated Rate	$72.60
Max. Negotiated Rate	$580.77
Rate for Payer: Amerigroup CHIP/Medicaid	$72.60
Rate for Payer: BCBS of TX Blue Advantage	$241.99
Rate for Payer: BCBS of TX Blue Essentials	$290.39
Rate for Payer: BCBS of TX PPO	$322.65
Rate for Payer: Cash Price	$548.51
Rate for Payer: Cigna Medicaid	$580.77
Rate for Payer: Molina CHIP/Medicaid	$580.77
Rate for Payer: Multiplan Auto	$524.31
Rate for Payer: Multiplan Commercial	$524.31
Rate for Payer: Multiplan Workers Comp	$524.31
Rate for Payer: Parkland Medicaid	$580.77
Rate for Payer: Scott and White EPO/PPO	$403.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$580.77
Rate for Payer: Superior Health Plan EPO	$109.70

4313BA

Facility

$933.73

Service Code	HCPCS C1769
Hospital Charge Code	991123
Hospital Revenue Code	272
Min. Negotiated Rate	$84.04
Max. Negotiated Rate	$672.29
Rate for Payer: Amerigroup CHIP/Medicaid	$84.04
Rate for Payer: BCBS of TX Blue Advantage	$280.12
Rate for Payer: BCBS of TX Blue Essentials	$336.14
Rate for Payer: BCBS of TX PPO	$373.49
Rate for Payer: Cash Price	$634.94
Rate for Payer: Cigna Medicaid	$672.29
Rate for Payer: Molina CHIP/Medicaid	$672.29
Rate for Payer: Multiplan Auto	$606.92
Rate for Payer: Multiplan Commercial	$606.92
Rate for Payer: Multiplan Workers Comp	$606.92
Rate for Payer: Parkland Medicaid	$672.29
Rate for Payer: Scott and White EPO/PPO	$466.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$672.29
Rate for Payer: Superior Health Plan EPO	$126.99

4313BA

Facility

$933.73

Service Code	HCPCS C1769
Hospital Charge Code	991123
Hospital Revenue Code	272
Rate for Payer: Cash Price	$634.94

44110010

Facility

$2,233.13

Service Code	HCPCS C1713
Hospital Charge Code	991092
Hospital Revenue Code	278
Min. Negotiated Rate	$200.98
Max. Negotiated Rate	$1,607.85
Rate for Payer: Amerigroup CHIP/Medicaid	$200.98
Rate for Payer: BCBS of TX Blue Advantage	$669.94
Rate for Payer: BCBS of TX Blue Essentials	$803.93
Rate for Payer: BCBS of TX PPO	$893.25
Rate for Payer: Cash Price	$1,518.53
Rate for Payer: Cigna Medicaid	$1,607.85
Rate for Payer: Molina CHIP/Medicaid	$1,607.85
Rate for Payer: Multiplan Auto	$1,116.57
Rate for Payer: Multiplan Commercial	$1,116.57
Rate for Payer: Multiplan Workers Comp	$1,116.57
Rate for Payer: Parkland Medicaid	$1,607.85
Rate for Payer: Scott and White EPO/PPO	$1,116.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,607.85
Rate for Payer: Superior Health Plan EPO	$303.71

44110010

Facility

$2,233.13

Service Code	HCPCS C1713
Hospital Charge Code	991092
Hospital Revenue Code	278
Min. Negotiated Rate	$558.28
Max. Negotiated Rate	$1,116.57
Rate for Payer: Cash Price	$1,518.53
Rate for Payer: Cigna Commercial	$558.28
Rate for Payer: Multiplan Auto	$1,116.57
Rate for Payer: Multiplan Commercial	$1,116.57
Rate for Payer: Multiplan Workers Comp	$1,116.57
Rate for Payer: Scott and White EPO/PPO	$1,116.57

44110010

Facility

$2,233.13

Service Code	HCPCS C1713
Hospital Charge Code	991071
Hospital Revenue Code	278
Min. Negotiated Rate	$558.28
Max. Negotiated Rate	$1,116.57
Rate for Payer: Cash Price	$1,518.53
Rate for Payer: Cigna Commercial	$558.28
Rate for Payer: Multiplan Auto	$1,116.57
Rate for Payer: Multiplan Commercial	$1,116.57
Rate for Payer: Multiplan Workers Comp	$1,116.57
Rate for Payer: Scott and White EPO/PPO	$1,116.57

44110010

Facility

$2,233.13

Service Code	HCPCS C1713
Hospital Charge Code	991071
Hospital Revenue Code	278
Min. Negotiated Rate	$200.98
Max. Negotiated Rate	$1,607.85
Rate for Payer: Amerigroup CHIP/Medicaid	$200.98
Rate for Payer: BCBS of TX Blue Advantage	$669.94
Rate for Payer: BCBS of TX Blue Essentials	$803.93
Rate for Payer: BCBS of TX PPO	$893.25
Rate for Payer: Cash Price	$1,518.53
Rate for Payer: Cigna Medicaid	$1,607.85
Rate for Payer: Molina CHIP/Medicaid	$1,607.85
Rate for Payer: Multiplan Auto	$1,116.57
Rate for Payer: Multiplan Commercial	$1,116.57
Rate for Payer: Multiplan Workers Comp	$1,116.57
Rate for Payer: Parkland Medicaid	$1,607.85
Rate for Payer: Scott and White EPO/PPO	$1,116.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,607.85
Rate for Payer: Superior Health Plan EPO	$303.71

44110033

Facility

$2,743.37

Service Code	HCPCS C1734
Hospital Charge Code	991194
Hospital Revenue Code	278
Min. Negotiated Rate	$685.84
Max. Negotiated Rate	$1,371.68
Rate for Payer: Cash Price	$1,865.49
Rate for Payer: Cigna Commercial	$685.84
Rate for Payer: Multiplan Auto	$1,371.68
Rate for Payer: Multiplan Commercial	$1,371.68
Rate for Payer: Multiplan Workers Comp	$1,371.68
Rate for Payer: Scott and White EPO/PPO	$1,371.68

44110033

Facility

$2,743.37

Service Code	HCPCS C1734
Hospital Charge Code	991194
Hospital Revenue Code	278
Min. Negotiated Rate	$246.90
Max. Negotiated Rate	$1,975.23
Rate for Payer: Amerigroup CHIP/Medicaid	$246.90
Rate for Payer: BCBS of TX Blue Advantage	$823.01
Rate for Payer: BCBS of TX Blue Essentials	$987.61
Rate for Payer: BCBS of TX PPO	$1,097.35
Rate for Payer: Cash Price	$1,865.49
Rate for Payer: Cigna Medicaid	$1,975.23
Rate for Payer: Molina CHIP/Medicaid	$1,975.23
Rate for Payer: Multiplan Auto	$1,371.68
Rate for Payer: Multiplan Commercial	$1,371.68
Rate for Payer: Multiplan Workers Comp	$1,371.68
Rate for Payer: Parkland Medicaid	$1,975.23
Rate for Payer: Scott and White EPO/PPO	$1,371.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,975.23
Rate for Payer: Superior Health Plan EPO	$373.10

4411003344110040

Facility

$2,743.37

Service Code	HCPCS C1734
Hospital Charge Code	991193
Hospital Revenue Code	278
Min. Negotiated Rate	$685.84
Max. Negotiated Rate	$1,371.68
Rate for Payer: Cash Price	$1,865.49
Rate for Payer: Cigna Commercial	$685.84
Rate for Payer: Multiplan Auto	$1,371.68
Rate for Payer: Multiplan Commercial	$1,371.68
Rate for Payer: Multiplan Workers Comp	$1,371.68
Rate for Payer: Scott and White EPO/PPO	$1,371.68

4411003344110040

Facility

$2,743.37

Service Code	HCPCS C1734
Hospital Charge Code	991193
Hospital Revenue Code	278
Min. Negotiated Rate	$246.90
Max. Negotiated Rate	$1,975.23
Rate for Payer: Amerigroup CHIP/Medicaid	$246.90
Rate for Payer: BCBS of TX Blue Advantage	$823.01
Rate for Payer: BCBS of TX Blue Essentials	$987.61
Rate for Payer: BCBS of TX PPO	$1,097.35
Rate for Payer: Cash Price	$1,865.49
Rate for Payer: Cigna Medicaid	$1,975.23
Rate for Payer: Molina CHIP/Medicaid	$1,975.23
Rate for Payer: Multiplan Auto	$1,371.68
Rate for Payer: Multiplan Commercial	$1,371.68
Rate for Payer: Multiplan Workers Comp	$1,371.68
Rate for Payer: Parkland Medicaid	$1,975.23
Rate for Payer: Scott and White EPO/PPO	$1,371.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,975.23
Rate for Payer: Superior Health Plan EPO	$373.10

44112000

Facility

$234.94

Service Code	HCPCS C1713
Hospital Charge Code	991093
Hospital Revenue Code	278
Min. Negotiated Rate	$58.73
Max. Negotiated Rate	$117.47
Rate for Payer: Cash Price	$159.76
Rate for Payer: Cigna Commercial	$58.73
Rate for Payer: Multiplan Auto	$117.47
Rate for Payer: Multiplan Commercial	$117.47
Rate for Payer: Multiplan Workers Comp	$117.47
Rate for Payer: Scott and White EPO/PPO	$117.47

44112000

Facility

$234.94

Service Code	HCPCS C1713
Hospital Charge Code	991093
Hospital Revenue Code	278
Min. Negotiated Rate	$21.14
Max. Negotiated Rate	$169.16
Rate for Payer: Amerigroup CHIP/Medicaid	$21.14
Rate for Payer: BCBS of TX Blue Advantage	$70.48
Rate for Payer: BCBS of TX Blue Essentials	$84.58
Rate for Payer: BCBS of TX PPO	$93.98
Rate for Payer: Cash Price	$159.76
Rate for Payer: Cigna Medicaid	$169.16
Rate for Payer: Molina CHIP/Medicaid	$169.16
Rate for Payer: Multiplan Auto	$117.47
Rate for Payer: Multiplan Commercial	$117.47
Rate for Payer: Multiplan Workers Comp	$117.47
Rate for Payer: Parkland Medicaid	$169.16
Rate for Payer: Scott and White EPO/PPO	$117.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$169.16
Rate for Payer: Superior Health Plan EPO	$31.95

44112008

Facility

$164.92

Service Code	HCPCS C1769
Hospital Charge Code	991224
Hospital Revenue Code	272
Rate for Payer: Cash Price	$112.15

44112008

Facility

$164.92

Service Code	HCPCS C1769
Hospital Charge Code	991224
Hospital Revenue Code	272
Min. Negotiated Rate	$14.84
Max. Negotiated Rate	$118.74
Rate for Payer: Amerigroup CHIP/Medicaid	$14.84
Rate for Payer: BCBS of TX Blue Advantage	$49.48
Rate for Payer: BCBS of TX Blue Essentials	$59.37
Rate for Payer: BCBS of TX PPO	$65.97
Rate for Payer: Cash Price	$112.15
Rate for Payer: Cigna Medicaid	$118.74
Rate for Payer: Molina CHIP/Medicaid	$118.74
Rate for Payer: Multiplan Auto	$107.20
Rate for Payer: Multiplan Commercial	$107.20
Rate for Payer: Multiplan Workers Comp	$107.20
Rate for Payer: Parkland Medicaid	$118.74
Rate for Payer: Scott and White EPO/PPO	$82.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.74
Rate for Payer: Superior Health Plan EPO	$22.43

44112008

Facility

$228.91

Service Code	HCPCS C1769
Hospital Charge Code	991195
Hospital Revenue Code	272
Min. Negotiated Rate	$20.60
Max. Negotiated Rate	$164.82
Rate for Payer: Amerigroup CHIP/Medicaid	$20.60
Rate for Payer: BCBS of TX Blue Advantage	$68.67
Rate for Payer: BCBS of TX Blue Essentials	$82.41
Rate for Payer: BCBS of TX PPO	$91.56
Rate for Payer: Cash Price	$155.66
Rate for Payer: Cigna Medicaid	$164.82
Rate for Payer: Molina CHIP/Medicaid	$164.82
Rate for Payer: Multiplan Auto	$148.79
Rate for Payer: Multiplan Commercial	$148.79
Rate for Payer: Multiplan Workers Comp	$148.79
Rate for Payer: Parkland Medicaid	$164.82
Rate for Payer: Scott and White EPO/PPO	$114.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$164.82
Rate for Payer: Superior Health Plan EPO	$31.13

44112008

Facility

$228.91

Service Code	HCPCS C1769
Hospital Charge Code	991195
Hospital Revenue Code	272
Rate for Payer: Cash Price	$155.66

44cm Laparoscopic L-Hook

Facility

$93.64

Hospital Charge Code	993962
Hospital Revenue Code	279
Rate for Payer: Cash Price	$63.68

44cm Laparoscopic L-Hook

Facility

$93.64

Hospital Charge Code	993962
Hospital Revenue Code	279
Min. Negotiated Rate	$8.43
Max. Negotiated Rate	$67.42
Rate for Payer: Amerigroup CHIP/Medicaid	$8.43
Rate for Payer: BCBS of TX Blue Advantage	$28.09
Rate for Payer: BCBS of TX Blue Essentials	$33.71
Rate for Payer: BCBS of TX PPO	$37.46
Rate for Payer: Cash Price	$63.68
Rate for Payer: Cigna Medicaid	$67.42
Rate for Payer: Molina CHIP/Medicaid	$67.42
Rate for Payer: Multiplan Auto	$60.87
Rate for Payer: Multiplan Commercial	$60.87
Rate for Payer: Multiplan Workers Comp	$60.87
Rate for Payer: Parkland Medicaid	$67.42
Rate for Payer: Scott and White EPO/PPO	$46.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$67.42
Rate for Payer: Superior Health Plan EPO	$12.74

4.5 MM TAP

Facility

$989.72

Hospital Charge Code	993167
Hospital Revenue Code	272
Min. Negotiated Rate	$89.07
Max. Negotiated Rate	$712.60
Rate for Payer: Amerigroup CHIP/Medicaid	$89.07
Rate for Payer: BCBS of TX Blue Advantage	$296.92
Rate for Payer: BCBS of TX Blue Essentials	$356.30
Rate for Payer: BCBS of TX PPO	$395.89
Rate for Payer: Cash Price	$673.01
Rate for Payer: Cigna Medicaid	$712.60
Rate for Payer: Molina CHIP/Medicaid	$712.60
Rate for Payer: Multiplan Auto	$643.32
Rate for Payer: Multiplan Commercial	$643.32
Rate for Payer: Multiplan Workers Comp	$643.32
Rate for Payer: Parkland Medicaid	$712.60
Rate for Payer: Scott and White EPO/PPO	$494.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$712.60
Rate for Payer: Superior Health Plan EPO	$134.60

4.5 MM TAP

Facility

$989.72

Hospital Charge Code	993167
Hospital Revenue Code	272
Rate for Payer: Cash Price	$673.01

Know your out-of-pocket cost for care.

All Charges