White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

4.15115E+29

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

4.15115E+29

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

4.15115E+49

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

4.15115E+49

Facility

$2,180.72

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

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

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

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	$540.75
Max. Negotiated Rate	$1,081.50
Rate for Payer: Cash Price	$1,470.84
Rate for Payer: Cigna Commercial	$540.75
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: Scott and White EPO/PPO	$1,081.50

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
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 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 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
Rate for Payer: Cash Price	$634.94

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

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	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

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

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

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

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

Know your out-of-pocket cost for care.

All Charges