White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BURR, CUTTING OVAL STERLING HI SPEED REDUCD HOOD 4M

Facility

$199.76

Hospital Charge Code	140409
Hospital Revenue Code	272
Rate for Payer: Cash Price	$135.84

burr hip prebent

Facility

$754.78

Hospital Charge Code	8692517
Hospital Revenue Code	272
Rate for Payer: Cash Price	$513.25

burr hip prebent

Facility

$754.78

Hospital Charge Code	8692517
Hospital Revenue Code	272
Min. Negotiated Rate	$67.93
Max. Negotiated Rate	$543.44
Rate for Payer: Amerigroup CHIP/Medicaid	$67.93
Rate for Payer: BCBS of TX Blue Advantage	$226.43
Rate for Payer: BCBS of TX Blue Essentials	$271.72
Rate for Payer: BCBS of TX PPO	$301.91
Rate for Payer: Cash Price	$513.25
Rate for Payer: Cigna Medicaid	$543.44
Rate for Payer: Molina CHIP/Medicaid	$543.44
Rate for Payer: Multiplan Auto	$490.61
Rate for Payer: Multiplan Commercial	$490.61
Rate for Payer: Multiplan Workers Comp	$490.61
Rate for Payer: Parkland Medicaid	$543.44
Rate for Payer: Scott and White EPO/PPO	$377.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$543.44
Rate for Payer: Superior Health Plan EPO	$102.65

BURR METAL CUTTING WHEEL MC254

Facility

$823.73

Hospital Charge Code	8528500
Hospital Revenue Code	272
Rate for Payer: Cash Price	$560.14

BURR METAL CUTTING WHEEL MC254

Facility

$823.73

Hospital Charge Code	8528500
Hospital Revenue Code	272
Min. Negotiated Rate	$74.14
Max. Negotiated Rate	$593.09
Rate for Payer: Amerigroup CHIP/Medicaid	$74.14
Rate for Payer: BCBS of TX Blue Advantage	$247.12
Rate for Payer: BCBS of TX Blue Essentials	$296.54
Rate for Payer: BCBS of TX PPO	$329.49
Rate for Payer: Cash Price	$560.14
Rate for Payer: Cigna Medicaid	$593.09
Rate for Payer: Molina CHIP/Medicaid	$593.09
Rate for Payer: Multiplan Auto	$535.42
Rate for Payer: Multiplan Commercial	$535.42
Rate for Payer: Multiplan Workers Comp	$535.42
Rate for Payer: Parkland Medicaid	$593.09
Rate for Payer: Scott and White EPO/PPO	$411.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$593.09
Rate for Payer: Superior Health Plan EPO	$112.03

burr oval 4.0

Facility

$204.30

Hospital Charge Code	8688551
Hospital Revenue Code	272
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$147.10
Rate for Payer: Amerigroup CHIP/Medicaid	$18.39
Rate for Payer: BCBS of TX Blue Advantage	$61.29
Rate for Payer: BCBS of TX Blue Essentials	$73.55
Rate for Payer: BCBS of TX PPO	$81.72
Rate for Payer: Cash Price	$138.92
Rate for Payer: Cigna Medicaid	$147.10
Rate for Payer: Molina CHIP/Medicaid	$147.10
Rate for Payer: Multiplan Auto	$132.79
Rate for Payer: Multiplan Commercial	$132.79
Rate for Payer: Multiplan Workers Comp	$132.79
Rate for Payer: Parkland Medicaid	$147.10
Rate for Payer: Scott and White EPO/PPO	$102.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$147.10
Rate for Payer: Superior Health Plan EPO	$27.78

burr oval 4.0

Facility

$204.30

Hospital Charge Code	8688551
Hospital Revenue Code	272
Rate for Payer: Cash Price	$138.92

BURR STERLING SPHERICAL 4.5MM

Facility

$183.87

Hospital Charge Code	146145
Hospital Revenue Code	272
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$132.39
Rate for Payer: Amerigroup CHIP/Medicaid	$16.55
Rate for Payer: BCBS of TX Blue Advantage	$55.16
Rate for Payer: BCBS of TX Blue Essentials	$66.19
Rate for Payer: BCBS of TX PPO	$73.55
Rate for Payer: Cash Price	$125.03
Rate for Payer: Cigna Medicaid	$132.39
Rate for Payer: Molina CHIP/Medicaid	$132.39
Rate for Payer: Multiplan Auto	$119.52
Rate for Payer: Multiplan Commercial	$119.52
Rate for Payer: Multiplan Workers Comp	$119.52
Rate for Payer: Parkland Medicaid	$132.39
Rate for Payer: Scott and White EPO/PPO	$91.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.39
Rate for Payer: Superior Health Plan EPO	$25.01

BURR STERLING SPHERICAL 4.5MM

Facility

$183.87

Hospital Charge Code	146145
Hospital Revenue Code	272
Rate for Payer: Cash Price	$125.03

BURR STND 5.0MM

Facility

$249.70

Hospital Charge Code	144830
Hospital Revenue Code	272
Rate for Payer: Cash Price	$169.80

BURR STND 5.0MM

Facility

$249.70

Hospital Charge Code	144830
Hospital Revenue Code	272
Min. Negotiated Rate	$22.47
Max. Negotiated Rate	$179.78
Rate for Payer: Amerigroup CHIP/Medicaid	$22.47
Rate for Payer: BCBS of TX Blue Advantage	$74.91
Rate for Payer: BCBS of TX Blue Essentials	$89.89
Rate for Payer: BCBS of TX PPO	$99.88
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cigna Medicaid	$179.78
Rate for Payer: Molina CHIP/Medicaid	$179.78
Rate for Payer: Multiplan Auto	$162.31
Rate for Payer: Multiplan Commercial	$162.31
Rate for Payer: Multiplan Workers Comp	$162.31
Rate for Payer: Parkland Medicaid	$179.78
Rate for Payer: Scott and White EPO/PPO	$124.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$179.78
Rate for Payer: Superior Health Plan EPO	$33.96

BURR STRYKER 4MM

Facility

$480.19

Hospital Charge Code	8470498
Hospital Revenue Code	272
Min. Negotiated Rate	$43.22
Max. Negotiated Rate	$345.74
Rate for Payer: Amerigroup CHIP/Medicaid	$43.22
Rate for Payer: BCBS of TX Blue Advantage	$144.06
Rate for Payer: BCBS of TX Blue Essentials	$172.87
Rate for Payer: BCBS of TX PPO	$192.08
Rate for Payer: Cash Price	$326.53
Rate for Payer: Cigna Medicaid	$345.74
Rate for Payer: Molina CHIP/Medicaid	$345.74
Rate for Payer: Multiplan Auto	$312.12
Rate for Payer: Multiplan Commercial	$312.12
Rate for Payer: Multiplan Workers Comp	$312.12
Rate for Payer: Parkland Medicaid	$345.74
Rate for Payer: Scott and White EPO/PPO	$240.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$345.74
Rate for Payer: Superior Health Plan EPO	$65.31

BURR STRYKER 4MM

Facility

$480.19

Hospital Charge Code	8470498
Hospital Revenue Code	272
Rate for Payer: Cash Price	$326.53

BURR SURG 4MM BRL 12 FLUT SHVR

Facility

$159.71

Hospital Charge Code	993205
Hospital Revenue Code	272
Min. Negotiated Rate	$14.37
Max. Negotiated Rate	$114.99
Rate for Payer: Amerigroup CHIP/Medicaid	$14.37
Rate for Payer: BCBS of TX Blue Advantage	$47.91
Rate for Payer: BCBS of TX Blue Essentials	$57.50
Rate for Payer: BCBS of TX PPO	$63.88
Rate for Payer: Cash Price	$108.60
Rate for Payer: Cigna Medicaid	$114.99
Rate for Payer: Molina CHIP/Medicaid	$114.99
Rate for Payer: Multiplan Auto	$103.81
Rate for Payer: Multiplan Commercial	$103.81
Rate for Payer: Multiplan Workers Comp	$103.81
Rate for Payer: Parkland Medicaid	$114.99
Rate for Payer: Scott and White EPO/PPO	$79.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$114.99
Rate for Payer: Superior Health Plan EPO	$21.72

BURR SURG 4MM BRL 12 FLUT SHVR

Facility

$159.71

Hospital Charge Code	993205
Hospital Revenue Code	272
Rate for Payer: Cash Price	$108.60

BURR TYPE 2 -- DHF

Facility

$108.86

Hospital Charge Code	81728909
Hospital Revenue Code	272
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$78.38
Rate for Payer: Amerigroup CHIP/Medicaid	$9.80
Rate for Payer: BCBS of TX Blue Advantage	$32.66
Rate for Payer: BCBS of TX Blue Essentials	$39.19
Rate for Payer: BCBS of TX PPO	$43.54
Rate for Payer: Cash Price	$74.02
Rate for Payer: Cigna Medicaid	$78.38
Rate for Payer: Molina CHIP/Medicaid	$78.38
Rate for Payer: Multiplan Auto	$70.76
Rate for Payer: Multiplan Commercial	$70.76
Rate for Payer: Multiplan Workers Comp	$70.76
Rate for Payer: Parkland Medicaid	$78.38
Rate for Payer: Scott and White EPO/PPO	$54.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$78.38
Rate for Payer: Superior Health Plan EPO	$14.80

BURR TYPE 2 -- DHF

Facility

$108.86

Hospital Charge Code	81728909
Hospital Revenue Code	272
Rate for Payer: Cash Price	$74.02

BUR SPHERICAL HPS 5.5MMx19CM

Facility

$590.20

Hospital Charge Code	145898
Hospital Revenue Code	272
Min. Negotiated Rate	$53.12
Max. Negotiated Rate	$424.94
Rate for Payer: Amerigroup CHIP/Medicaid	$53.12
Rate for Payer: BCBS of TX Blue Advantage	$177.06
Rate for Payer: BCBS of TX Blue Essentials	$212.47
Rate for Payer: BCBS of TX PPO	$236.08
Rate for Payer: Cash Price	$401.34
Rate for Payer: Cigna Medicaid	$424.94
Rate for Payer: Molina CHIP/Medicaid	$424.94
Rate for Payer: Multiplan Auto	$383.63
Rate for Payer: Multiplan Commercial	$383.63
Rate for Payer: Multiplan Workers Comp	$383.63
Rate for Payer: Parkland Medicaid	$424.94
Rate for Payer: Scott and White EPO/PPO	$295.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$424.94
Rate for Payer: Superior Health Plan EPO	$80.27

BUR SPHERICAL HPS 5.5MMx19CM

Facility

$590.20

Hospital Charge Code	145898
Hospital Revenue Code	272
Rate for Payer: Cash Price	$401.34

BUSHING

Facility

$730.94

Hospital Charge Code	993166
Hospital Revenue Code	272
Min. Negotiated Rate	$65.78
Max. Negotiated Rate	$526.28
Rate for Payer: Amerigroup CHIP/Medicaid	$65.78
Rate for Payer: BCBS of TX Blue Advantage	$219.28
Rate for Payer: BCBS of TX Blue Essentials	$263.14
Rate for Payer: BCBS of TX PPO	$292.38
Rate for Payer: Cash Price	$497.04
Rate for Payer: Cigna Medicaid	$526.28
Rate for Payer: Molina CHIP/Medicaid	$526.28
Rate for Payer: Multiplan Auto	$475.11
Rate for Payer: Multiplan Commercial	$475.11
Rate for Payer: Multiplan Workers Comp	$475.11
Rate for Payer: Parkland Medicaid	$526.28
Rate for Payer: Scott and White EPO/PPO	$365.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$526.28
Rate for Payer: Superior Health Plan EPO	$99.41

BUSHING

Facility

$730.94

Hospital Charge Code	993166
Hospital Revenue Code	272
Rate for Payer: Cash Price	$497.04

busPIRone 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77428639
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

busPIRone 10 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77428639
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

busPIRone 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77428802
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

busPIRone 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77428802
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

Know your out-of-pocket cost for care.

All Charges