White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

58803522

Facility

$1,476.02

Service Code	HCPCS C1713
Hospital Charge Code	994008
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

58803522

Facility

$1,476.02

Service Code	HCPCS C1713
Hospital Charge Code	994008
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

58803528

Facility

$1,476.02

Service Code	HCPCS C1713
Hospital Charge Code	994009
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

58803528

Facility

$1,476.02

Service Code	HCPCS C1713
Hospital Charge Code	994009
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

58813512

Facility

$940.00

Service Code	HCPCS C1713
Hospital Charge Code	990955
Hospital Revenue Code	278
Min. Negotiated Rate	$84.60
Max. Negotiated Rate	$676.80
Rate for Payer: Amerigroup CHIP/Medicaid	$84.60
Rate for Payer: BCBS of TX Blue Advantage	$282.00
Rate for Payer: BCBS of TX Blue Essentials	$338.40
Rate for Payer: BCBS of TX PPO	$376.00
Rate for Payer: Cash Price	$639.20
Rate for Payer: Cigna Medicaid	$676.80
Rate for Payer: Molina CHIP/Medicaid	$676.80
Rate for Payer: Multiplan Auto	$470.00
Rate for Payer: Multiplan Commercial	$470.00
Rate for Payer: Multiplan Workers Comp	$470.00
Rate for Payer: Parkland Medicaid	$676.80
Rate for Payer: Scott and White EPO/PPO	$470.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$676.80
Rate for Payer: Superior Health Plan EPO	$127.84

58813512

Facility

$940.00

Service Code	HCPCS C1713
Hospital Charge Code	990955
Hospital Revenue Code	278
Min. Negotiated Rate	$235.00
Max. Negotiated Rate	$470.00
Rate for Payer: Cash Price	$639.20
Rate for Payer: Cigna Commercial	$235.00
Rate for Payer: Multiplan Auto	$470.00
Rate for Payer: Multiplan Commercial	$470.00
Rate for Payer: Multiplan Workers Comp	$470.00
Rate for Payer: Scott and White EPO/PPO	$470.00

58813514

Facility

$1,127.72

Service Code	HCPCS C1713
Hospital Charge Code	994006
Hospital Revenue Code	278
Min. Negotiated Rate	$101.49
Max. Negotiated Rate	$811.96
Rate for Payer: Amerigroup CHIP/Medicaid	$101.49
Rate for Payer: BCBS of TX Blue Advantage	$338.32
Rate for Payer: BCBS of TX Blue Essentials	$405.98
Rate for Payer: BCBS of TX PPO	$451.09
Rate for Payer: Cash Price	$766.85
Rate for Payer: Cigna Medicaid	$811.96
Rate for Payer: Molina CHIP/Medicaid	$811.96
Rate for Payer: Multiplan Auto	$563.86
Rate for Payer: Multiplan Commercial	$563.86
Rate for Payer: Multiplan Workers Comp	$563.86
Rate for Payer: Parkland Medicaid	$811.96
Rate for Payer: Scott and White EPO/PPO	$563.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$811.96
Rate for Payer: Superior Health Plan EPO	$153.37

58813514

Facility

$1,127.72

Service Code	HCPCS C1713
Hospital Charge Code	994006
Hospital Revenue Code	278
Min. Negotiated Rate	$281.93
Max. Negotiated Rate	$563.86
Rate for Payer: Cash Price	$766.85
Rate for Payer: Cigna Commercial	$281.93
Rate for Payer: Multiplan Auto	$563.86
Rate for Payer: Multiplan Commercial	$563.86
Rate for Payer: Multiplan Workers Comp	$563.86
Rate for Payer: Scott and White EPO/PPO	$563.86

58813516

Facility

$923.00

Service Code	HCPCS C1713
Hospital Charge Code	991229
Hospital Revenue Code	278
Min. Negotiated Rate	$230.75
Max. Negotiated Rate	$461.50
Rate for Payer: Cash Price	$627.64
Rate for Payer: Cigna Commercial	$230.75
Rate for Payer: Multiplan Auto	$461.50
Rate for Payer: Multiplan Commercial	$461.50
Rate for Payer: Multiplan Workers Comp	$461.50
Rate for Payer: Scott and White EPO/PPO	$461.50

58813516

Facility

$923.00

Service Code	HCPCS C1713
Hospital Charge Code	991229
Hospital Revenue Code	278
Min. Negotiated Rate	$83.07
Max. Negotiated Rate	$664.56
Rate for Payer: Amerigroup CHIP/Medicaid	$83.07
Rate for Payer: BCBS of TX Blue Advantage	$276.90
Rate for Payer: BCBS of TX Blue Essentials	$332.28
Rate for Payer: BCBS of TX PPO	$369.20
Rate for Payer: Cash Price	$627.64
Rate for Payer: Cigna Medicaid	$664.56
Rate for Payer: Molina CHIP/Medicaid	$664.56
Rate for Payer: Multiplan Auto	$461.50
Rate for Payer: Multiplan Commercial	$461.50
Rate for Payer: Multiplan Workers Comp	$461.50
Rate for Payer: Parkland Medicaid	$664.56
Rate for Payer: Scott and White EPO/PPO	$461.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$664.56
Rate for Payer: Superior Health Plan EPO	$125.53

58813518

Facility

$963.00

Service Code	HCPCS C1713
Hospital Charge Code	991230
Hospital Revenue Code	278
Min. Negotiated Rate	$240.75
Max. Negotiated Rate	$481.50
Rate for Payer: Cash Price	$654.84
Rate for Payer: Cigna Commercial	$240.75
Rate for Payer: Multiplan Auto	$481.50
Rate for Payer: Multiplan Commercial	$481.50
Rate for Payer: Multiplan Workers Comp	$481.50
Rate for Payer: Scott and White EPO/PPO	$481.50

58813518

Facility

$963.00

Service Code	HCPCS C1713
Hospital Charge Code	991230
Hospital Revenue Code	278
Min. Negotiated Rate	$86.67
Max. Negotiated Rate	$693.36
Rate for Payer: Amerigroup CHIP/Medicaid	$86.67
Rate for Payer: BCBS of TX Blue Advantage	$288.90
Rate for Payer: BCBS of TX Blue Essentials	$346.68
Rate for Payer: BCBS of TX PPO	$385.20
Rate for Payer: Cash Price	$654.84
Rate for Payer: Cigna Medicaid	$693.36
Rate for Payer: Molina CHIP/Medicaid	$693.36
Rate for Payer: Multiplan Auto	$481.50
Rate for Payer: Multiplan Commercial	$481.50
Rate for Payer: Multiplan Workers Comp	$481.50
Rate for Payer: Parkland Medicaid	$693.36
Rate for Payer: Scott and White EPO/PPO	$481.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$693.36
Rate for Payer: Superior Health Plan EPO	$130.97

58813550

Facility

$963.00

Service Code	HCPCS C1713
Hospital Charge Code	991231
Hospital Revenue Code	278
Min. Negotiated Rate	$240.75
Max. Negotiated Rate	$481.50
Rate for Payer: Cash Price	$654.84
Rate for Payer: Cigna Commercial	$240.75
Rate for Payer: Multiplan Auto	$481.50
Rate for Payer: Multiplan Commercial	$481.50
Rate for Payer: Multiplan Workers Comp	$481.50
Rate for Payer: Scott and White EPO/PPO	$481.50

58813550

Facility

$963.00

Service Code	HCPCS C1713
Hospital Charge Code	991231
Hospital Revenue Code	278
Min. Negotiated Rate	$86.67
Max. Negotiated Rate	$693.36
Rate for Payer: Amerigroup CHIP/Medicaid	$86.67
Rate for Payer: BCBS of TX Blue Advantage	$288.90
Rate for Payer: BCBS of TX Blue Essentials	$346.68
Rate for Payer: BCBS of TX PPO	$385.20
Rate for Payer: Cash Price	$654.84
Rate for Payer: Cigna Medicaid	$693.36
Rate for Payer: Molina CHIP/Medicaid	$693.36
Rate for Payer: Multiplan Auto	$481.50
Rate for Payer: Multiplan Commercial	$481.50
Rate for Payer: Multiplan Workers Comp	$481.50
Rate for Payer: Parkland Medicaid	$693.36
Rate for Payer: Scott and White EPO/PPO	$481.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$693.36
Rate for Payer: Superior Health Plan EPO	$130.97

58813555

Facility

$963.00

Service Code	HCPCS C1713
Hospital Charge Code	991232
Hospital Revenue Code	278
Min. Negotiated Rate	$240.75
Max. Negotiated Rate	$481.50
Rate for Payer: Cash Price	$654.84
Rate for Payer: Cigna Commercial	$240.75
Rate for Payer: Multiplan Auto	$481.50
Rate for Payer: Multiplan Commercial	$481.50
Rate for Payer: Multiplan Workers Comp	$481.50
Rate for Payer: Scott and White EPO/PPO	$481.50

58813555

Facility

$963.00

Service Code	HCPCS C1713
Hospital Charge Code	991232
Hospital Revenue Code	278
Min. Negotiated Rate	$86.67
Max. Negotiated Rate	$693.36
Rate for Payer: Amerigroup CHIP/Medicaid	$86.67
Rate for Payer: BCBS of TX Blue Advantage	$288.90
Rate for Payer: BCBS of TX Blue Essentials	$346.68
Rate for Payer: BCBS of TX PPO	$385.20
Rate for Payer: Cash Price	$654.84
Rate for Payer: Cigna Medicaid	$693.36
Rate for Payer: Molina CHIP/Medicaid	$693.36
Rate for Payer: Multiplan Auto	$481.50
Rate for Payer: Multiplan Commercial	$481.50
Rate for Payer: Multiplan Workers Comp	$481.50
Rate for Payer: Parkland Medicaid	$693.36
Rate for Payer: Scott and White EPO/PPO	$481.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$693.36
Rate for Payer: Superior Health Plan EPO	$130.97

58850025

Facility

$1,403.62

Hospital Charge Code	990953
Hospital Revenue Code	272
Min. Negotiated Rate	$126.33
Max. Negotiated Rate	$1,010.61
Rate for Payer: Amerigroup CHIP/Medicaid	$126.33
Rate for Payer: BCBS of TX Blue Advantage	$421.09
Rate for Payer: BCBS of TX Blue Essentials	$505.30
Rate for Payer: BCBS of TX PPO	$561.45
Rate for Payer: Cash Price	$954.46
Rate for Payer: Cigna Medicaid	$1,010.61
Rate for Payer: Molina CHIP/Medicaid	$1,010.61
Rate for Payer: Multiplan Auto	$912.35
Rate for Payer: Multiplan Commercial	$912.35
Rate for Payer: Multiplan Workers Comp	$912.35
Rate for Payer: Parkland Medicaid	$1,010.61
Rate for Payer: Scott and White EPO/PPO	$701.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,010.61
Rate for Payer: Superior Health Plan EPO	$190.89

58850025

Facility

$1,403.62

Hospital Charge Code	990953
Hospital Revenue Code	272
Rate for Payer: Cash Price	$954.46

58850035

Facility

$1,011.22

Hospital Charge Code	991233
Hospital Revenue Code	272
Min. Negotiated Rate	$91.01
Max. Negotiated Rate	$728.08
Rate for Payer: Amerigroup CHIP/Medicaid	$91.01
Rate for Payer: BCBS of TX Blue Advantage	$303.37
Rate for Payer: BCBS of TX Blue Essentials	$364.04
Rate for Payer: BCBS of TX PPO	$404.49
Rate for Payer: Cash Price	$687.63
Rate for Payer: Cigna Medicaid	$728.08
Rate for Payer: Molina CHIP/Medicaid	$728.08
Rate for Payer: Multiplan Auto	$657.29
Rate for Payer: Multiplan Commercial	$657.29
Rate for Payer: Multiplan Workers Comp	$657.29
Rate for Payer: Parkland Medicaid	$728.08
Rate for Payer: Scott and White EPO/PPO	$505.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$728.08
Rate for Payer: Superior Health Plan EPO	$137.53

58850035

Facility

$1,011.22

Hospital Charge Code	991233
Hospital Revenue Code	272
Rate for Payer: Cash Price	$687.63

58862515

Facility

$216.87

Service Code	HCPCS C1769
Hospital Charge Code	991170
Hospital Revenue Code	272
Rate for Payer: Cash Price	$147.47

58862515

Facility

$216.87

Service Code	HCPCS C1769
Hospital Charge Code	991170
Hospital Revenue Code	272
Min. Negotiated Rate	$19.52
Max. Negotiated Rate	$156.15
Rate for Payer: Amerigroup CHIP/Medicaid	$19.52
Rate for Payer: BCBS of TX Blue Advantage	$65.06
Rate for Payer: BCBS of TX Blue Essentials	$78.07
Rate for Payer: BCBS of TX PPO	$86.75
Rate for Payer: Cash Price	$147.47
Rate for Payer: Cigna Medicaid	$156.15
Rate for Payer: Molina CHIP/Medicaid	$156.15
Rate for Payer: Multiplan Auto	$140.97
Rate for Payer: Multiplan Commercial	$140.97
Rate for Payer: Multiplan Workers Comp	$140.97
Rate for Payer: Parkland Medicaid	$156.15
Rate for Payer: Scott and White EPO/PPO	$108.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$156.15
Rate for Payer: Superior Health Plan EPO	$29.49

58880105

Facility

$2,763.64

Service Code	HCPCS C1776
Hospital Charge Code	994005
Hospital Revenue Code	278
Min. Negotiated Rate	$690.91
Max. Negotiated Rate	$1,381.82
Rate for Payer: Cash Price	$1,879.28
Rate for Payer: Cigna Commercial	$690.91
Rate for Payer: Multiplan Auto	$1,381.82
Rate for Payer: Multiplan Commercial	$1,381.82
Rate for Payer: Multiplan Workers Comp	$1,381.82
Rate for Payer: Scott and White EPO/PPO	$1,381.82

58880105

Facility

$2,763.64

Service Code	HCPCS C1776
Hospital Charge Code	994005
Hospital Revenue Code	278
Min. Negotiated Rate	$248.73
Max. Negotiated Rate	$1,989.82
Rate for Payer: Amerigroup CHIP/Medicaid	$248.73
Rate for Payer: BCBS of TX Blue Advantage	$829.09
Rate for Payer: BCBS of TX Blue Essentials	$994.91
Rate for Payer: BCBS of TX PPO	$1,105.46
Rate for Payer: Cash Price	$1,879.28
Rate for Payer: Cigna Medicaid	$1,989.82
Rate for Payer: Molina CHIP/Medicaid	$1,989.82
Rate for Payer: Multiplan Auto	$1,381.82
Rate for Payer: Multiplan Commercial	$1,381.82
Rate for Payer: Multiplan Workers Comp	$1,381.82
Rate for Payer: Parkland Medicaid	$1,989.82
Rate for Payer: Scott and White EPO/PPO	$1,381.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,989.82
Rate for Payer: Superior Health Plan EPO	$375.86

Know your out-of-pocket cost for care.

All Charges