White Rock Medical Center

All Charges

Charge

Type

Setting

Price

500ML, PRESSURE INFUSER W/STOPCOCK

Facility

$51.35

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

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

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

5.60102E+31

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

5.60102E+31

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	$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

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

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

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

57S04056

Facility

$5,254.82

Service Code	HCPCS C1734
Hospital Charge Code	991189
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

57S04056

Facility

$5,254.82

Service Code	HCPCS C1734
Hospital Charge Code	991189
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

57S100MT

Facility

$1,048.19

Service Code	HCPCS C1734
Hospital Charge Code	991190
Hospital Revenue Code	278
Min. Negotiated Rate	$262.05
Max. Negotiated Rate	$524.10
Rate for Payer: Cash Price	$712.77
Rate for Payer: Cigna Commercial	$262.05
Rate for Payer: Multiplan Auto	$524.10
Rate for Payer: Multiplan Commercial	$524.10
Rate for Payer: Multiplan Workers Comp	$524.10
Rate for Payer: Scott and White EPO/PPO	$524.10

57S100MT

Facility

$1,048.19

Service Code	HCPCS C1734
Hospital Charge Code	991190
Hospital Revenue Code	278
Min. Negotiated Rate	$94.34
Max. Negotiated Rate	$754.70
Rate for Payer: Amerigroup CHIP/Medicaid	$94.34
Rate for Payer: BCBS of TX Blue Advantage	$314.46
Rate for Payer: BCBS of TX Blue Essentials	$377.35
Rate for Payer: BCBS of TX PPO	$419.28
Rate for Payer: Cash Price	$712.77
Rate for Payer: Cigna Medicaid	$754.70
Rate for Payer: Molina CHIP/Medicaid	$754.70
Rate for Payer: Multiplan Auto	$524.10
Rate for Payer: Multiplan Commercial	$524.10
Rate for Payer: Multiplan Workers Comp	$524.10
Rate for Payer: Parkland Medicaid	$754.70
Rate for Payer: Scott and White EPO/PPO	$524.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$754.70
Rate for Payer: Superior Health Plan EPO	$142.55

57SR0212

Facility

$2,969.88

Service Code	HCPCS C1713
Hospital Charge Code	991159
Hospital Revenue Code	278
Min. Negotiated Rate	$267.29
Max. Negotiated Rate	$2,138.31
Rate for Payer: Amerigroup CHIP/Medicaid	$267.29
Rate for Payer: BCBS of TX Blue Advantage	$890.96
Rate for Payer: BCBS of TX Blue Essentials	$1,069.16
Rate for Payer: BCBS of TX PPO	$1,187.95
Rate for Payer: Cash Price	$2,019.52
Rate for Payer: Cigna Medicaid	$2,138.31
Rate for Payer: Molina CHIP/Medicaid	$2,138.31
Rate for Payer: Multiplan Auto	$1,484.94
Rate for Payer: Multiplan Commercial	$1,484.94
Rate for Payer: Multiplan Workers Comp	$1,484.94
Rate for Payer: Parkland Medicaid	$2,138.31
Rate for Payer: Scott and White EPO/PPO	$1,484.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,138.31
Rate for Payer: Superior Health Plan EPO	$403.90

57SR0212

Facility

$2,969.88

Service Code	HCPCS C1713
Hospital Charge Code	991159
Hospital Revenue Code	278
Min. Negotiated Rate	$742.47
Max. Negotiated Rate	$1,484.94
Rate for Payer: Cash Price	$2,019.52
Rate for Payer: Cigna Commercial	$742.47
Rate for Payer: Multiplan Auto	$1,484.94
Rate for Payer: Multiplan Commercial	$1,484.94
Rate for Payer: Multiplan Workers Comp	$1,484.94
Rate for Payer: Scott and White EPO/PPO	$1,484.94

57SR021257R0220

Facility

$2,969.88

Service Code	HCPCS C1734
Hospital Charge Code	991165
Hospital Revenue Code	278
Min. Negotiated Rate	$742.47
Max. Negotiated Rate	$1,484.94
Rate for Payer: Cash Price	$2,019.52
Rate for Payer: Cigna Commercial	$742.47
Rate for Payer: Multiplan Auto	$1,484.94
Rate for Payer: Multiplan Commercial	$1,484.94
Rate for Payer: Multiplan Workers Comp	$1,484.94
Rate for Payer: Scott and White EPO/PPO	$1,484.94

57SR021257R0220

Facility

$2,969.88

Service Code	HCPCS C1734
Hospital Charge Code	991165
Hospital Revenue Code	278
Min. Negotiated Rate	$267.29
Max. Negotiated Rate	$2,138.31
Rate for Payer: Amerigroup CHIP/Medicaid	$267.29
Rate for Payer: BCBS of TX Blue Advantage	$890.96
Rate for Payer: BCBS of TX Blue Essentials	$1,069.16
Rate for Payer: BCBS of TX PPO	$1,187.95
Rate for Payer: Cash Price	$2,019.52
Rate for Payer: Cigna Medicaid	$2,138.31
Rate for Payer: Molina CHIP/Medicaid	$2,138.31
Rate for Payer: Multiplan Auto	$1,484.94
Rate for Payer: Multiplan Commercial	$1,484.94
Rate for Payer: Multiplan Workers Comp	$1,484.94
Rate for Payer: Parkland Medicaid	$2,138.31
Rate for Payer: Scott and White EPO/PPO	$1,484.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,138.31
Rate for Payer: Superior Health Plan EPO	$403.90

57SR0220

Facility

$2,969.88

Service Code	HCPCS C1734
Hospital Charge Code	991191
Hospital Revenue Code	278
Min. Negotiated Rate	$742.47
Max. Negotiated Rate	$1,484.94
Rate for Payer: Cash Price	$2,019.52
Rate for Payer: Cigna Commercial	$742.47
Rate for Payer: Multiplan Auto	$1,484.94
Rate for Payer: Multiplan Commercial	$1,484.94
Rate for Payer: Multiplan Workers Comp	$1,484.94
Rate for Payer: Scott and White EPO/PPO	$1,484.94

57SR0220

Facility

$2,969.88

Service Code	HCPCS C1734
Hospital Charge Code	991191
Hospital Revenue Code	278
Min. Negotiated Rate	$267.29
Max. Negotiated Rate	$2,138.31
Rate for Payer: Amerigroup CHIP/Medicaid	$267.29
Rate for Payer: BCBS of TX Blue Advantage	$890.96
Rate for Payer: BCBS of TX Blue Essentials	$1,069.16
Rate for Payer: BCBS of TX PPO	$1,187.95
Rate for Payer: Cash Price	$2,019.52
Rate for Payer: Cigna Medicaid	$2,138.31
Rate for Payer: Molina CHIP/Medicaid	$2,138.31
Rate for Payer: Multiplan Auto	$1,484.94
Rate for Payer: Multiplan Commercial	$1,484.94
Rate for Payer: Multiplan Workers Comp	$1,484.94
Rate for Payer: Parkland Medicaid	$2,138.31
Rate for Payer: Scott and White EPO/PPO	$1,484.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,138.31
Rate for Payer: Superior Health Plan EPO	$403.90

57SW3113

Facility

$2,969.88

Service Code	HCPCS C1734
Hospital Charge Code	991192
Hospital Revenue Code	278
Min. Negotiated Rate	$742.47
Max. Negotiated Rate	$1,484.94
Rate for Payer: Cash Price	$2,019.52
Rate for Payer: Cigna Commercial	$742.47
Rate for Payer: Multiplan Auto	$1,484.94
Rate for Payer: Multiplan Commercial	$1,484.94
Rate for Payer: Multiplan Workers Comp	$1,484.94
Rate for Payer: Scott and White EPO/PPO	$1,484.94

57SW3113

Facility

$2,969.88

Service Code	HCPCS C1734
Hospital Charge Code	991192
Hospital Revenue Code	278
Min. Negotiated Rate	$267.29
Max. Negotiated Rate	$2,138.31
Rate for Payer: Amerigroup CHIP/Medicaid	$267.29
Rate for Payer: BCBS of TX Blue Advantage	$890.96
Rate for Payer: BCBS of TX Blue Essentials	$1,069.16
Rate for Payer: BCBS of TX PPO	$1,187.95
Rate for Payer: Cash Price	$2,019.52
Rate for Payer: Cigna Medicaid	$2,138.31
Rate for Payer: Molina CHIP/Medicaid	$2,138.31
Rate for Payer: Multiplan Auto	$1,484.94
Rate for Payer: Multiplan Commercial	$1,484.94
Rate for Payer: Multiplan Workers Comp	$1,484.94
Rate for Payer: Parkland Medicaid	$2,138.31
Rate for Payer: Scott and White EPO/PPO	$1,484.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,138.31
Rate for Payer: Superior Health Plan EPO	$403.90

5801.0001

Facility

$4,361.17

Hospital Charge Code	991222
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,965.60

Know your out-of-pocket cost for care.

All Charges