White Rock Medical Center

All Charges

Charge

Type

Setting

Price

44112008

Facility

$228.91

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

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

$164.92

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

4.411E+15

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

4.411E+15

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

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

44cm Laparoscopic L-Hook

Facility

$93.64

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

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

4.5mm x 27.5mm Screw, Fully Threaded

Facility

$2,204.82

Service Code	HCPCS C1713
Hospital Charge Code	992188
Hospital Revenue Code	278
Min. Negotiated Rate	$198.43
Max. Negotiated Rate	$1,587.47
Rate for Payer: Amerigroup CHIP/Medicaid	$198.43
Rate for Payer: BCBS of TX Blue Advantage	$661.45
Rate for Payer: BCBS of TX Blue Essentials	$793.74
Rate for Payer: BCBS of TX PPO	$881.93
Rate for Payer: Cash Price	$1,499.28
Rate for Payer: Cigna Medicaid	$1,587.47
Rate for Payer: Molina CHIP/Medicaid	$1,587.47
Rate for Payer: Multiplan Auto	$1,102.41
Rate for Payer: Multiplan Commercial	$1,102.41
Rate for Payer: Multiplan Workers Comp	$1,102.41
Rate for Payer: Parkland Medicaid	$1,587.47
Rate for Payer: Scott and White EPO/PPO	$1,102.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,587.47
Rate for Payer: Superior Health Plan EPO	$299.86

4.5mm x 27.5mm Screw, Fully Threaded

Facility

$2,204.82

Service Code	HCPCS C1713
Hospital Charge Code	992188
Hospital Revenue Code	278
Min. Negotiated Rate	$551.21
Max. Negotiated Rate	$1,102.41
Rate for Payer: Cash Price	$1,499.28
Rate for Payer: Cigna Commercial	$551.21
Rate for Payer: Multiplan Auto	$1,102.41
Rate for Payer: Multiplan Commercial	$1,102.41
Rate for Payer: Multiplan Workers Comp	$1,102.41
Rate for Payer: Scott and White EPO/PPO	$1,102.41

4.5mm x 30mm Screw, Fully Threaded

Facility

$2,204.82

Service Code	HCPCS C1713
Hospital Charge Code	992187
Hospital Revenue Code	278
Min. Negotiated Rate	$551.21
Max. Negotiated Rate	$1,102.41
Rate for Payer: Cash Price	$1,499.28
Rate for Payer: Cigna Commercial	$551.21
Rate for Payer: Multiplan Auto	$1,102.41
Rate for Payer: Multiplan Commercial	$1,102.41
Rate for Payer: Multiplan Workers Comp	$1,102.41
Rate for Payer: Scott and White EPO/PPO	$1,102.41

4.5mm x 30mm Screw, Fully Threaded

Facility

$2,204.82

Service Code	HCPCS C1713
Hospital Charge Code	992187
Hospital Revenue Code	278
Min. Negotiated Rate	$198.43
Max. Negotiated Rate	$1,587.47
Rate for Payer: Amerigroup CHIP/Medicaid	$198.43
Rate for Payer: BCBS of TX Blue Advantage	$661.45
Rate for Payer: BCBS of TX Blue Essentials	$793.74
Rate for Payer: BCBS of TX PPO	$881.93
Rate for Payer: Cash Price	$1,499.28
Rate for Payer: Cigna Medicaid	$1,587.47
Rate for Payer: Molina CHIP/Medicaid	$1,587.47
Rate for Payer: Multiplan Auto	$1,102.41
Rate for Payer: Multiplan Commercial	$1,102.41
Rate for Payer: Multiplan Workers Comp	$1,102.41
Rate for Payer: Parkland Medicaid	$1,587.47
Rate for Payer: Scott and White EPO/PPO	$1,102.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,587.47
Rate for Payer: Superior Health Plan EPO	$299.86

4.5 X 35 SCREW

Facility

$11,371.08

Service Code	HCPCS C1713
Hospital Charge Code	992385
Hospital Revenue Code	278
Min. Negotiated Rate	$2,842.77
Max. Negotiated Rate	$5,685.54
Rate for Payer: Cash Price	$7,732.33
Rate for Payer: Cigna Commercial	$2,842.77
Rate for Payer: Multiplan Auto	$5,685.54
Rate for Payer: Multiplan Commercial	$5,685.54
Rate for Payer: Multiplan Workers Comp	$5,685.54
Rate for Payer: Scott and White EPO/PPO	$5,685.54

4.5 X 35 SCREW

Facility

$11,371.08

Service Code	HCPCS C1713
Hospital Charge Code	992385
Hospital Revenue Code	278
Min. Negotiated Rate	$1,023.40
Max. Negotiated Rate	$8,187.18
Rate for Payer: Amerigroup CHIP/Medicaid	$1,023.40
Rate for Payer: BCBS of TX Blue Advantage	$3,411.32
Rate for Payer: BCBS of TX Blue Essentials	$4,093.59
Rate for Payer: BCBS of TX PPO	$4,548.43
Rate for Payer: Cash Price	$7,732.33
Rate for Payer: Cigna Medicaid	$8,187.18
Rate for Payer: Molina CHIP/Medicaid	$8,187.18
Rate for Payer: Multiplan Auto	$5,685.54
Rate for Payer: Multiplan Commercial	$5,685.54
Rate for Payer: Multiplan Workers Comp	$5,685.54
Rate for Payer: Parkland Medicaid	$8,187.18
Rate for Payer: Scott and White EPO/PPO	$5,685.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,187.18
Rate for Payer: Superior Health Plan EPO	$1,546.47

46S01645

Facility

$18,971.69

Service Code	HCPCS C1776
Hospital Charge Code	991133
Hospital Revenue Code	278
Min. Negotiated Rate	$1,707.45
Max. Negotiated Rate	$13,659.62
Rate for Payer: Amerigroup CHIP/Medicaid	$1,707.45
Rate for Payer: BCBS of TX Blue Advantage	$5,691.51
Rate for Payer: BCBS of TX Blue Essentials	$6,829.81
Rate for Payer: BCBS of TX PPO	$7,588.68
Rate for Payer: Cash Price	$12,900.75
Rate for Payer: Cigna Medicaid	$13,659.62
Rate for Payer: Molina CHIP/Medicaid	$13,659.62
Rate for Payer: Multiplan Auto	$9,485.84
Rate for Payer: Multiplan Commercial	$9,485.84
Rate for Payer: Multiplan Workers Comp	$9,485.84
Rate for Payer: Parkland Medicaid	$13,659.62
Rate for Payer: Scott and White EPO/PPO	$9,485.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,659.62
Rate for Payer: Superior Health Plan EPO	$2,580.15

46S01645

Facility

$18,971.69

Service Code	HCPCS C1734
Hospital Charge Code	991070
Hospital Revenue Code	278
Min. Negotiated Rate	$1,707.45
Max. Negotiated Rate	$13,659.62
Rate for Payer: Amerigroup CHIP/Medicaid	$1,707.45
Rate for Payer: BCBS of TX Blue Advantage	$5,691.51
Rate for Payer: BCBS of TX Blue Essentials	$6,829.81
Rate for Payer: BCBS of TX PPO	$7,588.68
Rate for Payer: Cash Price	$12,900.75
Rate for Payer: Cigna Medicaid	$13,659.62
Rate for Payer: Molina CHIP/Medicaid	$13,659.62
Rate for Payer: Multiplan Auto	$9,485.84
Rate for Payer: Multiplan Commercial	$9,485.84
Rate for Payer: Multiplan Workers Comp	$9,485.84
Rate for Payer: Parkland Medicaid	$13,659.62
Rate for Payer: Scott and White EPO/PPO	$9,485.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,659.62
Rate for Payer: Superior Health Plan EPO	$2,580.15

46S01645

Facility

$18,971.69

Service Code	HCPCS C1776
Hospital Charge Code	991133
Hospital Revenue Code	278
Min. Negotiated Rate	$4,742.92
Max. Negotiated Rate	$9,485.84
Rate for Payer: Cash Price	$12,900.75
Rate for Payer: Cigna Commercial	$4,742.92
Rate for Payer: Multiplan Auto	$9,485.84
Rate for Payer: Multiplan Commercial	$9,485.84
Rate for Payer: Multiplan Workers Comp	$9,485.84
Rate for Payer: Scott and White EPO/PPO	$9,485.84

46S01645

Facility

$18,971.69

Service Code	HCPCS C1734
Hospital Charge Code	991070
Hospital Revenue Code	278
Min. Negotiated Rate	$4,742.92
Max. Negotiated Rate	$9,485.84
Rate for Payer: Cash Price	$12,900.75
Rate for Payer: Cigna Commercial	$4,742.92
Rate for Payer: Multiplan Auto	$9,485.84
Rate for Payer: Multiplan Commercial	$9,485.84
Rate for Payer: Multiplan Workers Comp	$9,485.84
Rate for Payer: Scott and White EPO/PPO	$9,485.84

46S02055

Facility

$28,246.99

Service Code	HCPCS C1734
Hospital Charge Code	991196
Hospital Revenue Code	278
Min. Negotiated Rate	$7,061.75
Max. Negotiated Rate	$14,123.50
Rate for Payer: Cash Price	$19,207.95
Rate for Payer: Cigna Commercial	$7,061.75
Rate for Payer: Multiplan Auto	$14,123.50
Rate for Payer: Multiplan Commercial	$14,123.50
Rate for Payer: Multiplan Workers Comp	$14,123.50
Rate for Payer: Scott and White EPO/PPO	$14,123.50

46S02055

Facility

$28,246.99

Service Code	HCPCS C1734
Hospital Charge Code	991196
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.23
Max. Negotiated Rate	$20,337.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2,542.23
Rate for Payer: BCBS of TX Blue Advantage	$8,474.10
Rate for Payer: BCBS of TX Blue Essentials	$10,168.92
Rate for Payer: BCBS of TX PPO	$11,298.80
Rate for Payer: Cash Price	$19,207.95
Rate for Payer: Cigna Medicaid	$20,337.83
Rate for Payer: Molina CHIP/Medicaid	$20,337.83
Rate for Payer: Multiplan Auto	$14,123.50
Rate for Payer: Multiplan Commercial	$14,123.50
Rate for Payer: Multiplan Workers Comp	$14,123.50
Rate for Payer: Parkland Medicaid	$20,337.83
Rate for Payer: Scott and White EPO/PPO	$14,123.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,337.83
Rate for Payer: Superior Health Plan EPO	$3,841.59

47S01645 BIOFOAM

Facility

$1,500.00

Service Code	HCPCS C1734
Hospital Charge Code	991153
Hospital Revenue Code	278
Min. Negotiated Rate	$135.00
Max. Negotiated Rate	$1,080.00
Rate for Payer: Amerigroup CHIP/Medicaid	$135.00
Rate for Payer: BCBS of TX Blue Advantage	$450.00
Rate for Payer: BCBS of TX Blue Essentials	$540.00
Rate for Payer: BCBS of TX PPO	$600.00
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Cigna Medicaid	$1,080.00
Rate for Payer: Molina CHIP/Medicaid	$1,080.00
Rate for Payer: Multiplan Auto	$750.00
Rate for Payer: Multiplan Commercial	$750.00
Rate for Payer: Multiplan Workers Comp	$750.00
Rate for Payer: Parkland Medicaid	$1,080.00
Rate for Payer: Scott and White EPO/PPO	$750.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,080.00
Rate for Payer: Superior Health Plan EPO	$204.00

47S01645 BIOFOAM

Facility

$1,500.00

Service Code	HCPCS C1734
Hospital Charge Code	991153
Hospital Revenue Code	278
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$750.00
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Cigna Commercial	$375.00
Rate for Payer: Multiplan Auto	$750.00
Rate for Payer: Multiplan Commercial	$750.00
Rate for Payer: Multiplan Workers Comp	$750.00
Rate for Payer: Scott and White EPO/PPO	$750.00

4933-1-0014933-1-1004933-1-200

Facility

$584.33

Service Code	HCPCS C1776
Hospital Charge Code	991098
Hospital Revenue Code	278
Min. Negotiated Rate	$146.08
Max. Negotiated Rate	$292.17
Rate for Payer: Cash Price	$397.34
Rate for Payer: Cigna Commercial	$146.08
Rate for Payer: Multiplan Auto	$292.17
Rate for Payer: Multiplan Commercial	$292.17
Rate for Payer: Multiplan Workers Comp	$292.17
Rate for Payer: Scott and White EPO/PPO	$292.17

Know your out-of-pocket cost for care.

All Charges