White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$52.59
Max. Negotiated Rate	$420.72
Rate for Payer: Amerigroup CHIP/Medicaid	$52.59
Rate for Payer: BCBS of TX Blue Advantage	$175.30
Rate for Payer: BCBS of TX Blue Essentials	$210.36
Rate for Payer: BCBS of TX PPO	$233.73
Rate for Payer: Cash Price	$397.34
Rate for Payer: Cigna Medicaid	$420.72
Rate for Payer: Molina CHIP/Medicaid	$420.72
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: Parkland Medicaid	$420.72
Rate for Payer: Scott and White EPO/PPO	$292.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$420.72
Rate for Payer: Superior Health Plan EPO	$79.47

4933-1-010

Facility

$162.65

Service Code	HCPCS A4649
Hospital Charge Code	991099
Hospital Revenue Code	272
Min. Negotiated Rate	$14.64
Max. Negotiated Rate	$117.11
Rate for Payer: Amerigroup CHIP/Medicaid	$14.64
Rate for Payer: BCBS of TX Blue Advantage	$48.80
Rate for Payer: BCBS of TX Blue Essentials	$58.55
Rate for Payer: BCBS of TX PPO	$65.06
Rate for Payer: Cash Price	$110.60
Rate for Payer: Cigna Medicaid	$117.11
Rate for Payer: Molina CHIP/Medicaid	$117.11
Rate for Payer: Multiplan Auto	$105.72
Rate for Payer: Multiplan Commercial	$105.72
Rate for Payer: Multiplan Workers Comp	$105.72
Rate for Payer: Parkland Medicaid	$117.11
Rate for Payer: Scott and White EPO/PPO	$81.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$117.11
Rate for Payer: Superior Health Plan EPO	$22.12

4933-1-010

Facility

$162.65

Service Code	HCPCS A4649
Hospital Charge Code	991099
Hospital Revenue Code	272
Rate for Payer: Cash Price	$110.60

4933-1-520

Facility

$403.61

Service Code	HCPCS C1734
Hospital Charge Code	991100
Hospital Revenue Code	278
Min. Negotiated Rate	$100.90
Max. Negotiated Rate	$201.81
Rate for Payer: Cash Price	$274.45
Rate for Payer: Cigna Commercial	$100.90
Rate for Payer: Multiplan Auto	$201.81
Rate for Payer: Multiplan Commercial	$201.81
Rate for Payer: Multiplan Workers Comp	$201.81
Rate for Payer: Scott and White EPO/PPO	$201.81

4933-1-520

Facility

$403.61

Service Code	HCPCS C1734
Hospital Charge Code	991100
Hospital Revenue Code	278
Min. Negotiated Rate	$36.32
Max. Negotiated Rate	$290.60
Rate for Payer: Amerigroup CHIP/Medicaid	$36.32
Rate for Payer: BCBS of TX Blue Advantage	$121.08
Rate for Payer: BCBS of TX Blue Essentials	$145.30
Rate for Payer: BCBS of TX PPO	$161.44
Rate for Payer: Cash Price	$274.45
Rate for Payer: Cigna Medicaid	$290.60
Rate for Payer: Molina CHIP/Medicaid	$290.60
Rate for Payer: Multiplan Auto	$201.81
Rate for Payer: Multiplan Commercial	$201.81
Rate for Payer: Multiplan Workers Comp	$201.81
Rate for Payer: Parkland Medicaid	$290.60
Rate for Payer: Scott and White EPO/PPO	$201.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$290.60
Rate for Payer: Superior Health Plan EPO	$54.89

4933-1-560

Facility

$512.04

Service Code	HCPCS C1776
Hospital Charge Code	991101
Hospital Revenue Code	278
Min. Negotiated Rate	$128.01
Max. Negotiated Rate	$256.02
Rate for Payer: Cash Price	$348.19
Rate for Payer: Cigna Commercial	$128.01
Rate for Payer: Multiplan Auto	$256.02
Rate for Payer: Multiplan Commercial	$256.02
Rate for Payer: Multiplan Workers Comp	$256.02
Rate for Payer: Scott and White EPO/PPO	$256.02

4933-1-560

Facility

$512.04

Service Code	HCPCS C1776
Hospital Charge Code	991101
Hospital Revenue Code	278
Min. Negotiated Rate	$46.08
Max. Negotiated Rate	$368.67
Rate for Payer: Amerigroup CHIP/Medicaid	$46.08
Rate for Payer: BCBS of TX Blue Advantage	$153.61
Rate for Payer: BCBS of TX Blue Essentials	$184.33
Rate for Payer: BCBS of TX PPO	$204.82
Rate for Payer: Cash Price	$348.19
Rate for Payer: Cigna Medicaid	$368.67
Rate for Payer: Molina CHIP/Medicaid	$368.67
Rate for Payer: Multiplan Auto	$256.02
Rate for Payer: Multiplan Commercial	$256.02
Rate for Payer: Multiplan Workers Comp	$256.02
Rate for Payer: Parkland Medicaid	$368.67
Rate for Payer: Scott and White EPO/PPO	$256.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.67
Rate for Payer: Superior Health Plan EPO	$69.64

4933-1-701

Facility

$162.65

Service Code	HCPCS C1776
Hospital Charge Code	991102
Hospital Revenue Code	278
Min. Negotiated Rate	$40.66
Max. Negotiated Rate	$81.33
Rate for Payer: Cash Price	$110.60
Rate for Payer: Cigna Commercial	$40.66
Rate for Payer: Multiplan Auto	$81.33
Rate for Payer: Multiplan Commercial	$81.33
Rate for Payer: Multiplan Workers Comp	$81.33
Rate for Payer: Scott and White EPO/PPO	$81.33

4933-1-701

Facility

$162.65

Service Code	HCPCS C1776
Hospital Charge Code	991102
Hospital Revenue Code	278
Min. Negotiated Rate	$14.64
Max. Negotiated Rate	$117.11
Rate for Payer: Amerigroup CHIP/Medicaid	$14.64
Rate for Payer: BCBS of TX Blue Advantage	$48.80
Rate for Payer: BCBS of TX Blue Essentials	$58.55
Rate for Payer: BCBS of TX PPO	$65.06
Rate for Payer: Cash Price	$110.60
Rate for Payer: Cigna Medicaid	$117.11
Rate for Payer: Molina CHIP/Medicaid	$117.11
Rate for Payer: Multiplan Auto	$81.33
Rate for Payer: Multiplan Commercial	$81.33
Rate for Payer: Multiplan Workers Comp	$81.33
Rate for Payer: Parkland Medicaid	$117.11
Rate for Payer: Scott and White EPO/PPO	$81.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$117.11
Rate for Payer: Superior Health Plan EPO	$22.12

4933-2-1554933-3-155

Facility

$12,132.53

Service Code	HCPCS C1776
Hospital Charge Code	991103
Hospital Revenue Code	278
Min. Negotiated Rate	$3,033.13
Max. Negotiated Rate	$6,066.27
Rate for Payer: Cash Price	$8,250.12
Rate for Payer: Cigna Commercial	$3,033.13
Rate for Payer: Multiplan Auto	$6,066.27
Rate for Payer: Multiplan Commercial	$6,066.27
Rate for Payer: Multiplan Workers Comp	$6,066.27
Rate for Payer: Scott and White EPO/PPO	$6,066.27

4933-2-1554933-3-155

Facility

$12,132.53

Service Code	HCPCS C1776
Hospital Charge Code	991103
Hospital Revenue Code	278
Min. Negotiated Rate	$1,091.93
Max. Negotiated Rate	$8,735.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1,091.93
Rate for Payer: BCBS of TX Blue Advantage	$3,639.76
Rate for Payer: BCBS of TX Blue Essentials	$4,367.71
Rate for Payer: BCBS of TX PPO	$4,853.01
Rate for Payer: Cash Price	$8,250.12
Rate for Payer: Cigna Medicaid	$8,735.42
Rate for Payer: Molina CHIP/Medicaid	$8,735.42
Rate for Payer: Multiplan Auto	$6,066.27
Rate for Payer: Multiplan Commercial	$6,066.27
Rate for Payer: Multiplan Workers Comp	$6,066.27
Rate for Payer: Parkland Medicaid	$8,735.42
Rate for Payer: Scott and White EPO/PPO	$6,066.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,735.42
Rate for Payer: Superior Health Plan EPO	$1,650.02

4933-8-0104933-8-030

Facility

$1,686.75

Service Code	HCPCS C1734
Hospital Charge Code	991104
Hospital Revenue Code	278
Min. Negotiated Rate	$151.81
Max. Negotiated Rate	$1,214.46
Rate for Payer: Amerigroup CHIP/Medicaid	$151.81
Rate for Payer: BCBS of TX Blue Advantage	$506.02
Rate for Payer: BCBS of TX Blue Essentials	$607.23
Rate for Payer: BCBS of TX PPO	$674.70
Rate for Payer: Cash Price	$1,146.99
Rate for Payer: Cigna Medicaid	$1,214.46
Rate for Payer: Molina CHIP/Medicaid	$1,214.46
Rate for Payer: Multiplan Auto	$843.38
Rate for Payer: Multiplan Commercial	$843.38
Rate for Payer: Multiplan Workers Comp	$843.38
Rate for Payer: Parkland Medicaid	$1,214.46
Rate for Payer: Scott and White EPO/PPO	$843.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,214.46
Rate for Payer: Superior Health Plan EPO	$229.40

4933-8-0104933-8-030

Facility

$1,686.75

Service Code	HCPCS C1734
Hospital Charge Code	991104
Hospital Revenue Code	278
Min. Negotiated Rate	$421.69
Max. Negotiated Rate	$843.38
Rate for Payer: Cash Price	$1,146.99
Rate for Payer: Cigna Commercial	$421.69
Rate for Payer: Multiplan Auto	$843.38
Rate for Payer: Multiplan Commercial	$843.38
Rate for Payer: Multiplan Workers Comp	$843.38
Rate for Payer: Scott and White EPO/PPO	$843.38

4934-1-008

Facility

$542.17

Service Code	HCPCS C1713
Hospital Charge Code	991105
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$271.08
Rate for Payer: Cash Price	$368.68
Rate for Payer: Cigna Commercial	$135.54
Rate for Payer: Multiplan Auto	$271.08
Rate for Payer: Multiplan Commercial	$271.08
Rate for Payer: Multiplan Workers Comp	$271.08
Rate for Payer: Scott and White EPO/PPO	$271.08

4934-1-008

Facility

$542.17

Service Code	HCPCS C1713
Hospital Charge Code	991105
Hospital Revenue Code	278
Min. Negotiated Rate	$48.80
Max. Negotiated Rate	$390.36
Rate for Payer: Amerigroup CHIP/Medicaid	$48.80
Rate for Payer: BCBS of TX Blue Advantage	$162.65
Rate for Payer: BCBS of TX Blue Essentials	$195.18
Rate for Payer: BCBS of TX PPO	$216.87
Rate for Payer: Cash Price	$368.68
Rate for Payer: Cigna Medicaid	$390.36
Rate for Payer: Molina CHIP/Medicaid	$390.36
Rate for Payer: Multiplan Auto	$271.08
Rate for Payer: Multiplan Commercial	$271.08
Rate for Payer: Multiplan Workers Comp	$271.08
Rate for Payer: Parkland Medicaid	$390.36
Rate for Payer: Scott and White EPO/PPO	$271.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$390.36
Rate for Payer: Superior Health Plan EPO	$73.74

4934-1-060

Facility

$879.52

Service Code	HCPCS C1734
Hospital Charge Code	991106
Hospital Revenue Code	278
Min. Negotiated Rate	$219.88
Max. Negotiated Rate	$439.76
Rate for Payer: Cash Price	$598.07
Rate for Payer: Cigna Commercial	$219.88
Rate for Payer: Multiplan Auto	$439.76
Rate for Payer: Multiplan Commercial	$439.76
Rate for Payer: Multiplan Workers Comp	$439.76
Rate for Payer: Scott and White EPO/PPO	$439.76

4934-1-060

Facility

$879.52

Service Code	HCPCS C1734
Hospital Charge Code	991106
Hospital Revenue Code	278
Min. Negotiated Rate	$79.16
Max. Negotiated Rate	$633.25
Rate for Payer: Amerigroup CHIP/Medicaid	$79.16
Rate for Payer: BCBS of TX Blue Advantage	$263.86
Rate for Payer: BCBS of TX Blue Essentials	$316.63
Rate for Payer: BCBS of TX PPO	$351.81
Rate for Payer: Cash Price	$598.07
Rate for Payer: Cigna Medicaid	$633.25
Rate for Payer: Molina CHIP/Medicaid	$633.25
Rate for Payer: Multiplan Auto	$439.76
Rate for Payer: Multiplan Commercial	$439.76
Rate for Payer: Multiplan Workers Comp	$439.76
Rate for Payer: Parkland Medicaid	$633.25
Rate for Payer: Scott and White EPO/PPO	$439.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$633.25
Rate for Payer: Superior Health Plan EPO	$119.61

4934-2-155

Facility

$14,024.09

Service Code	HCPCS C1776
Hospital Charge Code	991107
Hospital Revenue Code	278
Min. Negotiated Rate	$1,262.17
Max. Negotiated Rate	$10,097.34
Rate for Payer: Amerigroup CHIP/Medicaid	$1,262.17
Rate for Payer: BCBS of TX Blue Advantage	$4,207.23
Rate for Payer: BCBS of TX Blue Essentials	$5,048.67
Rate for Payer: BCBS of TX PPO	$5,609.64
Rate for Payer: Cash Price	$9,536.38
Rate for Payer: Cigna Medicaid	$10,097.34
Rate for Payer: Molina CHIP/Medicaid	$10,097.34
Rate for Payer: Multiplan Auto	$7,012.05
Rate for Payer: Multiplan Commercial	$7,012.05
Rate for Payer: Multiplan Workers Comp	$7,012.05
Rate for Payer: Parkland Medicaid	$10,097.34
Rate for Payer: Scott and White EPO/PPO	$7,012.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,097.34
Rate for Payer: Superior Health Plan EPO	$1,907.28

4934-2-155

Facility

$14,024.09

Service Code	HCPCS C1776
Hospital Charge Code	991107
Hospital Revenue Code	278
Min. Negotiated Rate	$3,506.02
Max. Negotiated Rate	$7,012.05
Rate for Payer: Cash Price	$9,536.38
Rate for Payer: Cigna Commercial	$3,506.02
Rate for Payer: Multiplan Auto	$7,012.05
Rate for Payer: Multiplan Commercial	$7,012.05
Rate for Payer: Multiplan Workers Comp	$7,012.05
Rate for Payer: Scott and White EPO/PPO	$7,012.05

4934-6-155

Facility

$15,843.37

Service Code	HCPCS C1734
Hospital Charge Code	991108
Hospital Revenue Code	278
Min. Negotiated Rate	$1,425.90
Max. Negotiated Rate	$11,407.23
Rate for Payer: Amerigroup CHIP/Medicaid	$1,425.90
Rate for Payer: BCBS of TX Blue Advantage	$4,753.01
Rate for Payer: BCBS of TX Blue Essentials	$5,703.61
Rate for Payer: BCBS of TX PPO	$6,337.35
Rate for Payer: Cash Price	$10,773.49
Rate for Payer: Cigna Medicaid	$11,407.23
Rate for Payer: Molina CHIP/Medicaid	$11,407.23
Rate for Payer: Multiplan Auto	$7,921.69
Rate for Payer: Multiplan Commercial	$7,921.69
Rate for Payer: Multiplan Workers Comp	$7,921.69
Rate for Payer: Parkland Medicaid	$11,407.23
Rate for Payer: Scott and White EPO/PPO	$7,921.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,407.23
Rate for Payer: Superior Health Plan EPO	$2,154.70

4934-6-155

Facility

$15,843.37

Service Code	HCPCS C1734
Hospital Charge Code	991108
Hospital Revenue Code	278
Min. Negotiated Rate	$3,960.84
Max. Negotiated Rate	$7,921.69
Rate for Payer: Cash Price	$10,773.49
Rate for Payer: Cigna Commercial	$3,960.84
Rate for Payer: Multiplan Auto	$7,921.69
Rate for Payer: Multiplan Commercial	$7,921.69
Rate for Payer: Multiplan Workers Comp	$7,921.69
Rate for Payer: Scott and White EPO/PPO	$7,921.69

4934-8-140

Facility

$17,662.65

Service Code	HCPCS C1734
Hospital Charge Code	991109
Hospital Revenue Code	278
Min. Negotiated Rate	$1,589.64
Max. Negotiated Rate	$12,717.11
Rate for Payer: Amerigroup CHIP/Medicaid	$1,589.64
Rate for Payer: BCBS of TX Blue Advantage	$5,298.80
Rate for Payer: BCBS of TX Blue Essentials	$6,358.55
Rate for Payer: BCBS of TX PPO	$7,065.06
Rate for Payer: Cash Price	$12,010.60
Rate for Payer: Cigna Medicaid	$12,717.11
Rate for Payer: Molina CHIP/Medicaid	$12,717.11
Rate for Payer: Multiplan Auto	$8,831.33
Rate for Payer: Multiplan Commercial	$8,831.33
Rate for Payer: Multiplan Workers Comp	$8,831.33
Rate for Payer: Parkland Medicaid	$12,717.11
Rate for Payer: Scott and White EPO/PPO	$8,831.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,717.11
Rate for Payer: Superior Health Plan EPO	$2,402.12

4934-8-140

Facility

$17,662.65

Service Code	HCPCS C1734
Hospital Charge Code	991109
Hospital Revenue Code	278
Min. Negotiated Rate	$4,415.66
Max. Negotiated Rate	$8,831.33
Rate for Payer: Cash Price	$12,010.60
Rate for Payer: Cigna Commercial	$4,415.66
Rate for Payer: Multiplan Auto	$8,831.33
Rate for Payer: Multiplan Commercial	$8,831.33
Rate for Payer: Multiplan Workers Comp	$8,831.33
Rate for Payer: Scott and White EPO/PPO	$8,831.33

500036

Facility

$215.06

Service Code	HCPCS C1769
Hospital Charge Code	991045
Hospital Revenue Code	272
Min. Negotiated Rate	$19.36
Max. Negotiated Rate	$154.84
Rate for Payer: Amerigroup CHIP/Medicaid	$19.36
Rate for Payer: BCBS of TX Blue Advantage	$64.52
Rate for Payer: BCBS of TX Blue Essentials	$77.42
Rate for Payer: BCBS of TX PPO	$86.02
Rate for Payer: Cash Price	$146.24
Rate for Payer: Cigna Medicaid	$154.84
Rate for Payer: Molina CHIP/Medicaid	$154.84
Rate for Payer: Multiplan Auto	$139.79
Rate for Payer: Multiplan Commercial	$139.79
Rate for Payer: Multiplan Workers Comp	$139.79
Rate for Payer: Parkland Medicaid	$154.84
Rate for Payer: Scott and White EPO/PPO	$107.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$154.84
Rate for Payer: Superior Health Plan EPO	$29.25

500036

Facility

$215.06

Service Code	HCPCS C1769
Hospital Charge Code	991045
Hospital Revenue Code	272
Rate for Payer: Cash Price	$146.24

Know your out-of-pocket cost for care.

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