White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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

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

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

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

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	$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

5801.0001

Facility

$4,361.17

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

5801.0001

Facility

$4,361.17

Hospital Charge Code	991222
Hospital Revenue Code	272
Min. Negotiated Rate	$392.51
Max. Negotiated Rate	$3,140.04
Rate for Payer: Amerigroup CHIP/Medicaid	$392.51
Rate for Payer: BCBS of TX Blue Advantage	$1,308.35
Rate for Payer: BCBS of TX Blue Essentials	$1,570.02
Rate for Payer: BCBS of TX PPO	$1,744.47
Rate for Payer: Cash Price	$2,965.60
Rate for Payer: Cigna Medicaid	$3,140.04
Rate for Payer: Molina CHIP/Medicaid	$3,140.04
Rate for Payer: Multiplan Auto	$2,834.76
Rate for Payer: Multiplan Commercial	$2,834.76
Rate for Payer: Multiplan Workers Comp	$2,834.76
Rate for Payer: Parkland Medicaid	$3,140.04
Rate for Payer: Scott and White EPO/PPO	$2,180.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,140.04
Rate for Payer: Superior Health Plan EPO	$593.12

5801.00015801-01015801.00925831.90011834.01313832.11.07

Facility

$69,518.07

Service Code	HCPCS C1734
Hospital Charge Code	991211
Hospital Revenue Code	278
Min. Negotiated Rate	$6,256.63
Max. Negotiated Rate	$50,053.01
Rate for Payer: Amerigroup CHIP/Medicaid	$6,256.63
Rate for Payer: BCBS of TX Blue Advantage	$20,855.42
Rate for Payer: BCBS of TX Blue Essentials	$25,026.51
Rate for Payer: BCBS of TX PPO	$27,807.23
Rate for Payer: Cash Price	$47,272.29
Rate for Payer: Cigna Medicaid	$50,053.01
Rate for Payer: Molina CHIP/Medicaid	$50,053.01
Rate for Payer: Multiplan Auto	$34,759.04
Rate for Payer: Multiplan Commercial	$34,759.04
Rate for Payer: Multiplan Workers Comp	$34,759.04
Rate for Payer: Parkland Medicaid	$50,053.01
Rate for Payer: Scott and White EPO/PPO	$34,759.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50,053.01
Rate for Payer: Superior Health Plan EPO	$9,454.46

5801.00015801-01015801.00925831.90011834.01313832.11.07

Facility

$69,518.07

Service Code	HCPCS C1734
Hospital Charge Code	991211
Hospital Revenue Code	278
Min. Negotiated Rate	$17,379.52
Max. Negotiated Rate	$34,759.04
Rate for Payer: Cash Price	$47,272.29
Rate for Payer: Cigna Commercial	$17,379.52
Rate for Payer: Multiplan Auto	$34,759.04
Rate for Payer: Multiplan Commercial	$34,759.04
Rate for Payer: Multiplan Workers Comp	$34,759.04
Rate for Payer: Scott and White EPO/PPO	$34,759.04

5801.0092

Facility

$3,086.42

Service Code	HCPCS C1713
Hospital Charge Code	991219
Hospital Revenue Code	278
Min. Negotiated Rate	$771.61
Max. Negotiated Rate	$1,543.21
Rate for Payer: Cash Price	$2,098.77
Rate for Payer: Cigna Commercial	$771.61
Rate for Payer: Multiplan Auto	$1,543.21
Rate for Payer: Multiplan Commercial	$1,543.21
Rate for Payer: Multiplan Workers Comp	$1,543.21
Rate for Payer: Scott and White EPO/PPO	$1,543.21

5801.0092

Facility

$3,086.42

Service Code	HCPCS C1713
Hospital Charge Code	991219
Hospital Revenue Code	278
Min. Negotiated Rate	$277.78
Max. Negotiated Rate	$2,222.22
Rate for Payer: Amerigroup CHIP/Medicaid	$277.78
Rate for Payer: BCBS of TX Blue Advantage	$925.93
Rate for Payer: BCBS of TX Blue Essentials	$1,111.11
Rate for Payer: BCBS of TX PPO	$1,234.57
Rate for Payer: Cash Price	$2,098.77
Rate for Payer: Cigna Medicaid	$2,222.22
Rate for Payer: Molina CHIP/Medicaid	$2,222.22
Rate for Payer: Multiplan Auto	$1,543.21
Rate for Payer: Multiplan Commercial	$1,543.21
Rate for Payer: Multiplan Workers Comp	$1,543.21
Rate for Payer: Parkland Medicaid	$2,222.22
Rate for Payer: Scott and White EPO/PPO	$1,543.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,222.22
Rate for Payer: Superior Health Plan EPO	$419.75

5831.9001

Facility

$5,208.00

Hospital Charge Code	991223
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,541.44

5831.9001

Facility

$5,208.00

Hospital Charge Code	991223
Hospital Revenue Code	272
Min. Negotiated Rate	$468.72
Max. Negotiated Rate	$3,749.76
Rate for Payer: Amerigroup CHIP/Medicaid	$468.72
Rate for Payer: BCBS of TX Blue Advantage	$1,562.40
Rate for Payer: BCBS of TX Blue Essentials	$1,874.88
Rate for Payer: BCBS of TX PPO	$2,083.20
Rate for Payer: Cash Price	$3,541.44
Rate for Payer: Cigna Medicaid	$3,749.76
Rate for Payer: Molina CHIP/Medicaid	$3,749.76
Rate for Payer: Multiplan Auto	$3,385.20
Rate for Payer: Multiplan Commercial	$3,385.20
Rate for Payer: Multiplan Workers Comp	$3,385.20
Rate for Payer: Parkland Medicaid	$3,749.76
Rate for Payer: Scott and White EPO/PPO	$2,604.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,749.76
Rate for Payer: Superior Health Plan EPO	$708.29

58803510

Facility

$1,476.02

Service Code	HCPCS C1713
Hospital Charge Code	994007
Hospital Revenue Code	278
Min. Negotiated Rate	$132.84
Max. Negotiated Rate	$1,062.73
Rate for Payer: Amerigroup CHIP/Medicaid	$132.84
Rate for Payer: BCBS of TX Blue Advantage	$442.81
Rate for Payer: BCBS of TX Blue Essentials	$531.37
Rate for Payer: BCBS of TX PPO	$590.41
Rate for Payer: Cash Price	$1,003.69
Rate for Payer: Cigna Medicaid	$1,062.73
Rate for Payer: Molina CHIP/Medicaid	$1,062.73
Rate for Payer: Multiplan Auto	$738.01
Rate for Payer: Multiplan Commercial	$738.01
Rate for Payer: Multiplan Workers Comp	$738.01
Rate for Payer: Parkland Medicaid	$1,062.73
Rate for Payer: Scott and White EPO/PPO	$738.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,062.73
Rate for Payer: Superior Health Plan EPO	$200.74

58803510

Facility

$1,476.02

Service Code	HCPCS C1713
Hospital Charge Code	994007
Hospital Revenue Code	278
Min. Negotiated Rate	$369.00
Max. Negotiated Rate	$738.01
Rate for Payer: Cash Price	$1,003.69
Rate for Payer: Cigna Commercial	$369.00
Rate for Payer: Multiplan Auto	$738.01
Rate for Payer: Multiplan Commercial	$738.01
Rate for Payer: Multiplan Workers Comp	$738.01
Rate for Payer: Scott and White EPO/PPO	$738.01

58803512

Facility

$1,837.00

Service Code	HCPCS C1713
Hospital Charge Code	990956
Hospital Revenue Code	278
Min. Negotiated Rate	$165.33
Max. Negotiated Rate	$1,322.64
Rate for Payer: Amerigroup CHIP/Medicaid	$165.33
Rate for Payer: BCBS of TX Blue Advantage	$551.10
Rate for Payer: BCBS of TX Blue Essentials	$661.32
Rate for Payer: BCBS of TX PPO	$734.80
Rate for Payer: Cash Price	$1,249.16
Rate for Payer: Cigna Medicaid	$1,322.64
Rate for Payer: Molina CHIP/Medicaid	$1,322.64
Rate for Payer: Multiplan Auto	$918.50
Rate for Payer: Multiplan Commercial	$918.50
Rate for Payer: Multiplan Workers Comp	$918.50
Rate for Payer: Parkland Medicaid	$1,322.64
Rate for Payer: Scott and White EPO/PPO	$918.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,322.64
Rate for Payer: Superior Health Plan EPO	$249.83

58803512

Facility

$1,837.00

Service Code	HCPCS C1713
Hospital Charge Code	990956
Hospital Revenue Code	278
Min. Negotiated Rate	$459.25
Max. Negotiated Rate	$918.50
Rate for Payer: Cash Price	$1,249.16
Rate for Payer: Cigna Commercial	$459.25
Rate for Payer: Multiplan Auto	$918.50
Rate for Payer: Multiplan Commercial	$918.50
Rate for Payer: Multiplan Workers Comp	$918.50
Rate for Payer: Scott and White EPO/PPO	$918.50

58803514

Facility

$1,837.00

Service Code	HCPCS C1713
Hospital Charge Code	990957
Hospital Revenue Code	278
Min. Negotiated Rate	$459.25
Max. Negotiated Rate	$918.50
Rate for Payer: Cash Price	$1,249.16
Rate for Payer: Cigna Commercial	$459.25
Rate for Payer: Multiplan Auto	$918.50
Rate for Payer: Multiplan Commercial	$918.50
Rate for Payer: Multiplan Workers Comp	$918.50
Rate for Payer: Scott and White EPO/PPO	$918.50

Know your out-of-pocket cost for care.

All Charges