White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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

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

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

58850025

Facility

$1,403.62

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

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

58850035

Facility

$1,011.22

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

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

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

58862515

Facility

$216.87

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

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

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

58884010

Facility

$3,783.00

Service Code	HCPCS C1776
Hospital Charge Code	991022
Hospital Revenue Code	278
Min. Negotiated Rate	$340.47
Max. Negotiated Rate	$2,723.76
Rate for Payer: Amerigroup CHIP/Medicaid	$340.47
Rate for Payer: BCBS of TX Blue Advantage	$1,134.90
Rate for Payer: BCBS of TX Blue Essentials	$1,361.88
Rate for Payer: BCBS of TX PPO	$1,513.20
Rate for Payer: Cash Price	$2,572.44
Rate for Payer: Cigna Medicaid	$2,723.76
Rate for Payer: Molina CHIP/Medicaid	$2,723.76
Rate for Payer: Multiplan Auto	$1,891.50
Rate for Payer: Multiplan Commercial	$1,891.50
Rate for Payer: Multiplan Workers Comp	$1,891.50
Rate for Payer: Parkland Medicaid	$2,723.76
Rate for Payer: Scott and White EPO/PPO	$1,891.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,723.76
Rate for Payer: Superior Health Plan EPO	$514.49

58884010

Facility

$3,783.00

Service Code	HCPCS C1776
Hospital Charge Code	991022
Hospital Revenue Code	278
Min. Negotiated Rate	$945.75
Max. Negotiated Rate	$1,891.50
Rate for Payer: Cash Price	$2,572.44
Rate for Payer: Cigna Commercial	$945.75
Rate for Payer: Multiplan Auto	$1,891.50
Rate for Payer: Multiplan Commercial	$1,891.50
Rate for Payer: Multiplan Workers Comp	$1,891.50
Rate for Payer: Scott and White EPO/PPO	$1,891.50

5888402L

Facility

$13,000.00

Service Code	HCPCS C1713
Hospital Charge Code	991314
Hospital Revenue Code	278
Min. Negotiated Rate	$3,250.00
Max. Negotiated Rate	$6,500.00
Rate for Payer: Cash Price	$8,840.00
Rate for Payer: Cigna Commercial	$3,250.00
Rate for Payer: Multiplan Auto	$6,500.00
Rate for Payer: Multiplan Commercial	$6,500.00
Rate for Payer: Multiplan Workers Comp	$6,500.00
Rate for Payer: Scott and White EPO/PPO	$6,500.00

5888402L

Facility

$13,000.00

Service Code	HCPCS C1713
Hospital Charge Code	991314
Hospital Revenue Code	278
Min. Negotiated Rate	$1,170.00
Max. Negotiated Rate	$9,360.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,170.00
Rate for Payer: BCBS of TX Blue Advantage	$3,900.00
Rate for Payer: BCBS of TX Blue Essentials	$4,680.00
Rate for Payer: BCBS of TX PPO	$5,200.00
Rate for Payer: Cash Price	$8,840.00
Rate for Payer: Cigna Medicaid	$9,360.00
Rate for Payer: Molina CHIP/Medicaid	$9,360.00
Rate for Payer: Multiplan Auto	$6,500.00
Rate for Payer: Multiplan Commercial	$6,500.00
Rate for Payer: Multiplan Workers Comp	$6,500.00
Rate for Payer: Parkland Medicaid	$9,360.00
Rate for Payer: Scott and White EPO/PPO	$6,500.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,360.00
Rate for Payer: Superior Health Plan EPO	$1,768.00

5888403R

Facility

$13,277.00

Service Code	HCPCS C1776
Hospital Charge Code	990954
Hospital Revenue Code	278
Min. Negotiated Rate	$1,194.93
Max. Negotiated Rate	$9,559.44
Rate for Payer: Amerigroup CHIP/Medicaid	$1,194.93
Rate for Payer: BCBS of TX Blue Advantage	$3,983.10
Rate for Payer: BCBS of TX Blue Essentials	$4,779.72
Rate for Payer: BCBS of TX PPO	$5,310.80
Rate for Payer: Cash Price	$9,028.36
Rate for Payer: Cigna Medicaid	$9,559.44
Rate for Payer: Molina CHIP/Medicaid	$9,559.44
Rate for Payer: Multiplan Auto	$6,638.50
Rate for Payer: Multiplan Commercial	$6,638.50
Rate for Payer: Multiplan Workers Comp	$6,638.50
Rate for Payer: Parkland Medicaid	$9,559.44
Rate for Payer: Scott and White EPO/PPO	$6,638.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,559.44
Rate for Payer: Superior Health Plan EPO	$1,805.67

5888403R

Facility

$13,277.00

Service Code	HCPCS C1776
Hospital Charge Code	990954
Hospital Revenue Code	278
Min. Negotiated Rate	$3,319.25
Max. Negotiated Rate	$6,638.50
Rate for Payer: Cash Price	$9,028.36
Rate for Payer: Cigna Commercial	$3,319.25
Rate for Payer: Multiplan Auto	$6,638.50
Rate for Payer: Multiplan Commercial	$6,638.50
Rate for Payer: Multiplan Workers Comp	$6,638.50
Rate for Payer: Scott and White EPO/PPO	$6,638.50

5888404R

Facility

$13,907.40

Service Code	HCPCS C1776
Hospital Charge Code	991234
Hospital Revenue Code	278
Min. Negotiated Rate	$3,476.85
Max. Negotiated Rate	$6,953.70
Rate for Payer: Cash Price	$9,457.03
Rate for Payer: Cigna Commercial	$3,476.85
Rate for Payer: Multiplan Auto	$6,953.70
Rate for Payer: Multiplan Commercial	$6,953.70
Rate for Payer: Multiplan Workers Comp	$6,953.70
Rate for Payer: Scott and White EPO/PPO	$6,953.70

5888404R

Facility

$13,907.40

Service Code	HCPCS C1776
Hospital Charge Code	991234
Hospital Revenue Code	278
Min. Negotiated Rate	$1,251.67
Max. Negotiated Rate	$10,013.33
Rate for Payer: Amerigroup CHIP/Medicaid	$1,251.67
Rate for Payer: BCBS of TX Blue Advantage	$4,172.22
Rate for Payer: BCBS of TX Blue Essentials	$5,006.66
Rate for Payer: BCBS of TX PPO	$5,562.96
Rate for Payer: Cash Price	$9,457.03
Rate for Payer: Cigna Medicaid	$10,013.33
Rate for Payer: Molina CHIP/Medicaid	$10,013.33
Rate for Payer: Multiplan Auto	$6,953.70
Rate for Payer: Multiplan Commercial	$6,953.70
Rate for Payer: Multiplan Workers Comp	$6,953.70
Rate for Payer: Parkland Medicaid	$10,013.33
Rate for Payer: Scott and White EPO/PPO	$6,953.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,013.33
Rate for Payer: Superior Health Plan EPO	$1,891.41

5% Dextrose Solution, 0.45%, 1000 mL, Bag

Facility

$12.62

Hospital Charge Code	992982
Hospital Revenue Code	270
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$9.09
Rate for Payer: Amerigroup CHIP/Medicaid	$1.14
Rate for Payer: BCBS of TX Blue Advantage	$3.79
Rate for Payer: BCBS of TX Blue Essentials	$4.54
Rate for Payer: BCBS of TX PPO	$5.05
Rate for Payer: Cash Price	$8.58
Rate for Payer: Cigna Medicaid	$9.09
Rate for Payer: Molina CHIP/Medicaid	$9.09
Rate for Payer: Multiplan Auto	$8.20
Rate for Payer: Multiplan Commercial	$8.20
Rate for Payer: Multiplan Workers Comp	$8.20
Rate for Payer: Parkland Medicaid	$9.09
Rate for Payer: Scott and White EPO/PPO	$6.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.09
Rate for Payer: Superior Health Plan EPO	$1.72

5% Dextrose Solution, 0.45%, 1000 mL, Bag

Facility

$12.62

Hospital Charge Code	992982
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.58

5F CELT Arterial Closure Device Individual Units

Facility

$1,135.00

Hospital Charge Code	993890
Hospital Revenue Code	279
Rate for Payer: Cash Price	$771.80

5F CELT Arterial Closure Device Individual Units

Facility

$1,135.00

Hospital Charge Code	993890
Hospital Revenue Code	279
Min. Negotiated Rate	$102.15
Max. Negotiated Rate	$817.20
Rate for Payer: Amerigroup CHIP/Medicaid	$102.15
Rate for Payer: BCBS of TX Blue Advantage	$340.50
Rate for Payer: BCBS of TX Blue Essentials	$408.60
Rate for Payer: BCBS of TX PPO	$454.00
Rate for Payer: Cash Price	$771.80
Rate for Payer: Cigna Medicaid	$817.20
Rate for Payer: Molina CHIP/Medicaid	$817.20
Rate for Payer: Multiplan Auto	$737.75
Rate for Payer: Multiplan Commercial	$737.75
Rate for Payer: Multiplan Workers Comp	$737.75
Rate for Payer: Parkland Medicaid	$817.20
Rate for Payer: Scott and White EPO/PPO	$567.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$817.20
Rate for Payer: Superior Health Plan EPO	$154.36

5-HIAA,Quant.,24 Hr Urine SO

Facility

$80.00

Service Code	HCPCS 83497
Hospital Charge Code	1702067
Hospital Revenue Code	301
Rate for Payer: Cash Price	$54.40

Know your out-of-pocket cost for care.

All Charges