White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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

4934-1-008

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

4934-1-060

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	$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

4934-6-155

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

4934-8-140

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

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

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

500ML, PRESSURE INFUSER W/STOPCOCK

Facility

$51.35

Hospital Charge Code	993184
Hospital Revenue Code	270
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$36.97
Rate for Payer: Amerigroup CHIP/Medicaid	$4.62
Rate for Payer: BCBS of TX Blue Advantage	$15.40
Rate for Payer: BCBS of TX Blue Essentials	$18.49
Rate for Payer: BCBS of TX PPO	$20.54
Rate for Payer: Cash Price	$34.92
Rate for Payer: Cigna Medicaid	$36.97
Rate for Payer: Molina CHIP/Medicaid	$36.97
Rate for Payer: Multiplan Auto	$33.38
Rate for Payer: Multiplan Commercial	$33.38
Rate for Payer: Multiplan Workers Comp	$33.38
Rate for Payer: Parkland Medicaid	$36.97
Rate for Payer: Scott and White EPO/PPO	$25.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.97
Rate for Payer: Superior Health Plan EPO	$6.98

500ML, PRESSURE INFUSER W/STOPCOCK

Facility

$51.35

Hospital Charge Code	993184
Hospital Revenue Code	270
Rate for Payer: Cash Price	$34.92

5.0mm x 40mm Screw, Partially Threaded, Ti

Facility

$2,819.28

Service Code	HCPCS C1713
Hospital Charge Code	992189
Hospital Revenue Code	278
Min. Negotiated Rate	$253.74
Max. Negotiated Rate	$2,029.88
Rate for Payer: Amerigroup CHIP/Medicaid	$253.74
Rate for Payer: BCBS of TX Blue Advantage	$845.78
Rate for Payer: BCBS of TX Blue Essentials	$1,014.94
Rate for Payer: BCBS of TX PPO	$1,127.71
Rate for Payer: Cash Price	$1,917.11
Rate for Payer: Cigna Medicaid	$2,029.88
Rate for Payer: Molina CHIP/Medicaid	$2,029.88
Rate for Payer: Multiplan Auto	$1,409.64
Rate for Payer: Multiplan Commercial	$1,409.64
Rate for Payer: Multiplan Workers Comp	$1,409.64
Rate for Payer: Parkland Medicaid	$2,029.88
Rate for Payer: Scott and White EPO/PPO	$1,409.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,029.88
Rate for Payer: Superior Health Plan EPO	$383.42

5.0mm x 40mm Screw, Partially Threaded, Ti

Facility

$2,819.28

Service Code	HCPCS C1713
Hospital Charge Code	992189
Hospital Revenue Code	278
Min. Negotiated Rate	$704.82
Max. Negotiated Rate	$1,409.64
Rate for Payer: Cash Price	$1,917.11
Rate for Payer: Cigna Commercial	$704.82
Rate for Payer: Multiplan Auto	$1,409.64
Rate for Payer: Multiplan Commercial	$1,409.64
Rate for Payer: Multiplan Workers Comp	$1,409.64
Rate for Payer: Scott and White EPO/PPO	$1,409.64

54-25674

Facility

$9,048.19

Service Code	HCPCS C1776
Hospital Charge Code	994073
Hospital Revenue Code	278
Min. Negotiated Rate	$2,262.05
Max. Negotiated Rate	$4,524.10
Rate for Payer: Cash Price	$6,152.77
Rate for Payer: Cigna Commercial	$2,262.05
Rate for Payer: Multiplan Auto	$4,524.10
Rate for Payer: Multiplan Commercial	$4,524.10
Rate for Payer: Multiplan Workers Comp	$4,524.10
Rate for Payer: Scott and White EPO/PPO	$4,524.10

54-25674

Facility

$9,048.19

Service Code	HCPCS C1776
Hospital Charge Code	994073
Hospital Revenue Code	278
Min. Negotiated Rate	$814.34
Max. Negotiated Rate	$6,514.70
Rate for Payer: Amerigroup CHIP/Medicaid	$814.34
Rate for Payer: BCBS of TX Blue Advantage	$2,714.46
Rate for Payer: BCBS of TX Blue Essentials	$3,257.35
Rate for Payer: BCBS of TX PPO	$3,619.28
Rate for Payer: Cash Price	$6,152.77
Rate for Payer: Cigna Medicaid	$6,514.70
Rate for Payer: Molina CHIP/Medicaid	$6,514.70
Rate for Payer: Multiplan Auto	$4,524.10
Rate for Payer: Multiplan Commercial	$4,524.10
Rate for Payer: Multiplan Workers Comp	$4,524.10
Rate for Payer: Parkland Medicaid	$6,514.70
Rate for Payer: Scott and White EPO/PPO	$4,524.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,514.70
Rate for Payer: Superior Health Plan EPO	$1,230.55

56010228560132005601550056025540

Facility

$13,488.00

Service Code	HCPCS C1776
Hospital Charge Code	990930
Hospital Revenue Code	278
Min. Negotiated Rate	$1,213.92
Max. Negotiated Rate	$9,711.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,213.92
Rate for Payer: BCBS of TX Blue Advantage	$4,046.40
Rate for Payer: BCBS of TX Blue Essentials	$4,855.68
Rate for Payer: BCBS of TX PPO	$5,395.20
Rate for Payer: Cash Price	$9,171.84
Rate for Payer: Cigna Medicaid	$9,711.36
Rate for Payer: Molina CHIP/Medicaid	$9,711.36
Rate for Payer: Multiplan Auto	$6,744.00
Rate for Payer: Multiplan Commercial	$6,744.00
Rate for Payer: Multiplan Workers Comp	$6,744.00
Rate for Payer: Parkland Medicaid	$9,711.36
Rate for Payer: Scott and White EPO/PPO	$6,744.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,711.36
Rate for Payer: Superior Health Plan EPO	$1,834.37

56010228560132005601550056025540

Facility

$13,488.00

Service Code	HCPCS C1776
Hospital Charge Code	990930
Hospital Revenue Code	278
Min. Negotiated Rate	$3,372.00
Max. Negotiated Rate	$6,744.00
Rate for Payer: Cash Price	$9,171.84
Rate for Payer: Cigna Commercial	$3,372.00
Rate for Payer: Multiplan Auto	$6,744.00
Rate for Payer: Multiplan Commercial	$6,744.00
Rate for Payer: Multiplan Workers Comp	$6,744.00
Rate for Payer: Scott and White EPO/PPO	$6,744.00

57S00030

Facility

$1,873.50

Service Code	HCPCS C1713
Hospital Charge Code	991163
Hospital Revenue Code	278
Min. Negotiated Rate	$468.38
Max. Negotiated Rate	$936.75
Rate for Payer: Cash Price	$1,273.98
Rate for Payer: Cigna Commercial	$468.38
Rate for Payer: Multiplan Auto	$936.75
Rate for Payer: Multiplan Commercial	$936.75
Rate for Payer: Multiplan Workers Comp	$936.75
Rate for Payer: Scott and White EPO/PPO	$936.75

57S00030

Facility

$1,873.50

Service Code	HCPCS C1713
Hospital Charge Code	991163
Hospital Revenue Code	278
Min. Negotiated Rate	$168.62
Max. Negotiated Rate	$1,348.92
Rate for Payer: Amerigroup CHIP/Medicaid	$168.62
Rate for Payer: BCBS of TX Blue Advantage	$562.05
Rate for Payer: BCBS of TX Blue Essentials	$674.46
Rate for Payer: BCBS of TX PPO	$749.40
Rate for Payer: Cash Price	$1,273.98
Rate for Payer: Cigna Medicaid	$1,348.92
Rate for Payer: Molina CHIP/Medicaid	$1,348.92
Rate for Payer: Multiplan Auto	$936.75
Rate for Payer: Multiplan Commercial	$936.75
Rate for Payer: Multiplan Workers Comp	$936.75
Rate for Payer: Parkland Medicaid	$1,348.92
Rate for Payer: Scott and White EPO/PPO	$936.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,348.92
Rate for Payer: Superior Health Plan EPO	$254.80

57S02025

Facility

$5,254.82

Service Code	HCPCS C1734
Hospital Charge Code	991164
Hospital Revenue Code	278
Min. Negotiated Rate	$1,313.70
Max. Negotiated Rate	$2,627.41
Rate for Payer: Cash Price	$3,573.28
Rate for Payer: Cigna Commercial	$1,313.70
Rate for Payer: Multiplan Auto	$2,627.41
Rate for Payer: Multiplan Commercial	$2,627.41
Rate for Payer: Multiplan Workers Comp	$2,627.41
Rate for Payer: Scott and White EPO/PPO	$2,627.41

57S02025

Facility

$5,254.82

Service Code	HCPCS C1734
Hospital Charge Code	991164
Hospital Revenue Code	278
Min. Negotiated Rate	$472.93
Max. Negotiated Rate	$3,783.47
Rate for Payer: Amerigroup CHIP/Medicaid	$472.93
Rate for Payer: BCBS of TX Blue Advantage	$1,576.45
Rate for Payer: BCBS of TX Blue Essentials	$1,891.74
Rate for Payer: BCBS of TX PPO	$2,101.93
Rate for Payer: Cash Price	$3,573.28
Rate for Payer: Cigna Medicaid	$3,783.47
Rate for Payer: Molina CHIP/Medicaid	$3,783.47
Rate for Payer: Multiplan Auto	$2,627.41
Rate for Payer: Multiplan Commercial	$2,627.41
Rate for Payer: Multiplan Workers Comp	$2,627.41
Rate for Payer: Parkland Medicaid	$3,783.47
Rate for Payer: Scott and White EPO/PPO	$2,627.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,783.47
Rate for Payer: Superior Health Plan EPO	$714.66

Know your out-of-pocket cost for care.

All Charges