White Rock Medical Center

All Charges

Charge

Type

Setting

Price

5mm x 8cm x 135cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992547
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

604650

Facility

$1,891.56

Service Code	HCPCS C1713
Hospital Charge Code	994042
Hospital Revenue Code	278
Min. Negotiated Rate	$170.24
Max. Negotiated Rate	$1,361.92
Rate for Payer: Amerigroup CHIP/Medicaid	$170.24
Rate for Payer: BCBS of TX Blue Advantage	$567.47
Rate for Payer: BCBS of TX Blue Essentials	$680.96
Rate for Payer: BCBS of TX PPO	$756.62
Rate for Payer: Cash Price	$1,286.26
Rate for Payer: Cigna Medicaid	$1,361.92
Rate for Payer: Molina CHIP/Medicaid	$1,361.92
Rate for Payer: Multiplan Auto	$945.78
Rate for Payer: Multiplan Commercial	$945.78
Rate for Payer: Multiplan Workers Comp	$945.78
Rate for Payer: Parkland Medicaid	$1,361.92
Rate for Payer: Scott and White EPO/PPO	$945.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,361.92
Rate for Payer: Superior Health Plan EPO	$257.25

604650

Facility

$1,891.56

Service Code	HCPCS C1713
Hospital Charge Code	994042
Hospital Revenue Code	278
Min. Negotiated Rate	$472.89
Max. Negotiated Rate	$945.78
Rate for Payer: Cash Price	$1,286.26
Rate for Payer: Cigna Commercial	$472.89
Rate for Payer: Multiplan Auto	$945.78
Rate for Payer: Multiplan Commercial	$945.78
Rate for Payer: Multiplan Workers Comp	$945.78
Rate for Payer: Scott and White EPO/PPO	$945.78

6.0mm x 70mm Screw, Headless, PT, Ti

Facility

$2,819.28

Service Code	HCPCS C1713
Hospital Charge Code	992186
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

6.0mm x 70mm Screw, Headless, PT, Ti

Facility

$2,819.28

Service Code	HCPCS C1713
Hospital Charge Code	992186
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

6197-9-001

Facility

$2,152.00

Service Code	HCPCS C1713
Hospital Charge Code	990973
Hospital Revenue Code	278
Min. Negotiated Rate	$538.00
Max. Negotiated Rate	$1,076.00
Rate for Payer: Cash Price	$1,463.36
Rate for Payer: Cigna Commercial	$538.00
Rate for Payer: Multiplan Auto	$1,076.00
Rate for Payer: Multiplan Commercial	$1,076.00
Rate for Payer: Multiplan Workers Comp	$1,076.00
Rate for Payer: Scott and White EPO/PPO	$1,076.00

6197-9-001

Facility

$2,152.00

Service Code	HCPCS C1713
Hospital Charge Code	990973
Hospital Revenue Code	278
Min. Negotiated Rate	$193.68
Max. Negotiated Rate	$1,549.44
Rate for Payer: Amerigroup CHIP/Medicaid	$193.68
Rate for Payer: BCBS of TX Blue Advantage	$645.60
Rate for Payer: BCBS of TX Blue Essentials	$774.72
Rate for Payer: BCBS of TX PPO	$860.80
Rate for Payer: Cash Price	$1,463.36
Rate for Payer: Cigna Medicaid	$1,549.44
Rate for Payer: Molina CHIP/Medicaid	$1,549.44
Rate for Payer: Multiplan Auto	$1,076.00
Rate for Payer: Multiplan Commercial	$1,076.00
Rate for Payer: Multiplan Workers Comp	$1,076.00
Rate for Payer: Parkland Medicaid	$1,549.44
Rate for Payer: Scott and White EPO/PPO	$1,076.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,549.44
Rate for Payer: Superior Health Plan EPO	$292.67

619905

Facility

$240.96

Hospital Charge Code	994043
Hospital Revenue Code	272
Rate for Payer: Cash Price	$163.85

619905

Facility

$240.96

Hospital Charge Code	994043
Hospital Revenue Code	272
Min. Negotiated Rate	$21.69
Max. Negotiated Rate	$173.49
Rate for Payer: Amerigroup CHIP/Medicaid	$21.69
Rate for Payer: BCBS of TX Blue Advantage	$72.29
Rate for Payer: BCBS of TX Blue Essentials	$86.75
Rate for Payer: BCBS of TX PPO	$96.38
Rate for Payer: Cash Price	$163.85
Rate for Payer: Cigna Medicaid	$173.49
Rate for Payer: Molina CHIP/Medicaid	$173.49
Rate for Payer: Multiplan Auto	$156.62
Rate for Payer: Multiplan Commercial	$156.62
Rate for Payer: Multiplan Workers Comp	$156.62
Rate for Payer: Parkland Medicaid	$173.49
Rate for Payer: Scott and White EPO/PPO	$120.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$173.49
Rate for Payer: Superior Health Plan EPO	$32.77

626-00-38D

Facility

$2,874.96

Service Code	HCPCS C1776
Hospital Charge Code	994000
Hospital Revenue Code	278
Min. Negotiated Rate	$258.75
Max. Negotiated Rate	$2,069.97
Rate for Payer: Amerigroup CHIP/Medicaid	$258.75
Rate for Payer: BCBS of TX Blue Advantage	$862.49
Rate for Payer: BCBS of TX Blue Essentials	$1,034.99
Rate for Payer: BCBS of TX PPO	$1,149.98
Rate for Payer: Cash Price	$1,954.97
Rate for Payer: Cigna Medicaid	$2,069.97
Rate for Payer: Molina CHIP/Medicaid	$2,069.97
Rate for Payer: Multiplan Auto	$1,437.48
Rate for Payer: Multiplan Commercial	$1,437.48
Rate for Payer: Multiplan Workers Comp	$1,437.48
Rate for Payer: Parkland Medicaid	$2,069.97
Rate for Payer: Scott and White EPO/PPO	$1,437.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,069.97
Rate for Payer: Superior Health Plan EPO	$390.99

626-00-38D

Facility

$2,874.96

Service Code	HCPCS C1776
Hospital Charge Code	994000
Hospital Revenue Code	278
Min. Negotiated Rate	$718.74
Max. Negotiated Rate	$1,437.48
Rate for Payer: Cash Price	$1,954.97
Rate for Payer: Cigna Commercial	$718.74
Rate for Payer: Multiplan Auto	$1,437.48
Rate for Payer: Multiplan Commercial	$1,437.48
Rate for Payer: Multiplan Workers Comp	$1,437.48
Rate for Payer: Scott and White EPO/PPO	$1,437.48

6290

Facility

$83,759.03

Service Code	HCPCS C1722
Hospital Charge Code	991206
Hospital Revenue Code	278
Min. Negotiated Rate	$7,538.31
Max. Negotiated Rate	$60,306.50
Rate for Payer: Amerigroup CHIP/Medicaid	$7,538.31
Rate for Payer: BCBS of TX Blue Advantage	$25,127.71
Rate for Payer: BCBS of TX Blue Essentials	$30,153.25
Rate for Payer: BCBS of TX PPO	$33,503.61
Rate for Payer: Cash Price	$56,956.14
Rate for Payer: Cigna Medicaid	$60,306.50
Rate for Payer: Molina CHIP/Medicaid	$60,306.50
Rate for Payer: Multiplan Auto	$41,879.51
Rate for Payer: Multiplan Commercial	$41,879.51
Rate for Payer: Multiplan Workers Comp	$41,879.51
Rate for Payer: Parkland Medicaid	$60,306.50
Rate for Payer: Scott and White EPO/PPO	$41,879.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60,306.50
Rate for Payer: Superior Health Plan EPO	$11,391.23

6290

Facility

$78,313.00

Service Code	HCPCS C1722
Hospital Charge Code	991301
Hospital Revenue Code	278
Min. Negotiated Rate	$19,578.25
Max. Negotiated Rate	$39,156.50
Rate for Payer: Cash Price	$53,252.84
Rate for Payer: Cigna Commercial	$19,578.25
Rate for Payer: Multiplan Auto	$39,156.50
Rate for Payer: Multiplan Commercial	$39,156.50
Rate for Payer: Multiplan Workers Comp	$39,156.50
Rate for Payer: Scott and White EPO/PPO	$39,156.50

6290

Facility

$83,759.03

Service Code	HCPCS C1722
Hospital Charge Code	991206
Hospital Revenue Code	278
Min. Negotiated Rate	$20,939.76
Max. Negotiated Rate	$41,879.51
Rate for Payer: Cash Price	$56,956.14
Rate for Payer: Cigna Commercial	$20,939.76
Rate for Payer: Multiplan Auto	$41,879.51
Rate for Payer: Multiplan Commercial	$41,879.51
Rate for Payer: Multiplan Workers Comp	$41,879.51
Rate for Payer: Scott and White EPO/PPO	$41,879.51

6290

Facility

$78,313.00

Service Code	HCPCS C1722
Hospital Charge Code	991301
Hospital Revenue Code	278
Min. Negotiated Rate	$7,048.17
Max. Negotiated Rate	$56,385.36
Rate for Payer: Amerigroup CHIP/Medicaid	$7,048.17
Rate for Payer: BCBS of TX Blue Advantage	$23,493.90
Rate for Payer: BCBS of TX Blue Essentials	$28,192.68
Rate for Payer: BCBS of TX PPO	$31,325.20
Rate for Payer: Cash Price	$53,252.84
Rate for Payer: Cigna Medicaid	$56,385.36
Rate for Payer: Molina CHIP/Medicaid	$56,385.36
Rate for Payer: Multiplan Auto	$39,156.50
Rate for Payer: Multiplan Commercial	$39,156.50
Rate for Payer: Multiplan Workers Comp	$39,156.50
Rate for Payer: Parkland Medicaid	$56,385.36
Rate for Payer: Scott and White EPO/PPO	$39,156.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56,385.36
Rate for Payer: Superior Health Plan EPO	$10,650.57

656322

Facility

$1,054.22

Service Code	HCPCS C1713
Hospital Charge Code	994077
Hospital Revenue Code	278
Min. Negotiated Rate	$94.88
Max. Negotiated Rate	$759.04
Rate for Payer: Amerigroup CHIP/Medicaid	$94.88
Rate for Payer: BCBS of TX Blue Advantage	$316.27
Rate for Payer: BCBS of TX Blue Essentials	$379.52
Rate for Payer: BCBS of TX PPO	$421.69
Rate for Payer: Cash Price	$716.87
Rate for Payer: Cigna Medicaid	$759.04
Rate for Payer: Molina CHIP/Medicaid	$759.04
Rate for Payer: Multiplan Auto	$527.11
Rate for Payer: Multiplan Commercial	$527.11
Rate for Payer: Multiplan Workers Comp	$527.11
Rate for Payer: Parkland Medicaid	$759.04
Rate for Payer: Scott and White EPO/PPO	$527.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$759.04
Rate for Payer: Superior Health Plan EPO	$143.37

656322

Facility

$1,054.22

Service Code	HCPCS C1713
Hospital Charge Code	994077
Hospital Revenue Code	278
Min. Negotiated Rate	$263.56
Max. Negotiated Rate	$527.11
Rate for Payer: Cash Price	$716.87
Rate for Payer: Cigna Commercial	$263.56
Rate for Payer: Multiplan Auto	$527.11
Rate for Payer: Multiplan Commercial	$527.11
Rate for Payer: Multiplan Workers Comp	$527.11
Rate for Payer: Scott and White EPO/PPO	$527.11

656416

Facility

$614.46

Service Code	HCPCS C1713
Hospital Charge Code	994074
Hospital Revenue Code	278
Min. Negotiated Rate	$153.62
Max. Negotiated Rate	$307.23
Rate for Payer: Cash Price	$417.83
Rate for Payer: Cigna Commercial	$153.62
Rate for Payer: Multiplan Auto	$307.23
Rate for Payer: Multiplan Commercial	$307.23
Rate for Payer: Multiplan Workers Comp	$307.23
Rate for Payer: Scott and White EPO/PPO	$307.23

656416

Facility

$614.46

Service Code	HCPCS C1713
Hospital Charge Code	994074
Hospital Revenue Code	278
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$442.41
Rate for Payer: Amerigroup CHIP/Medicaid	$55.30
Rate for Payer: BCBS of TX Blue Advantage	$184.34
Rate for Payer: BCBS of TX Blue Essentials	$221.21
Rate for Payer: BCBS of TX PPO	$245.78
Rate for Payer: Cash Price	$417.83
Rate for Payer: Cigna Medicaid	$442.41
Rate for Payer: Molina CHIP/Medicaid	$442.41
Rate for Payer: Multiplan Auto	$307.23
Rate for Payer: Multiplan Commercial	$307.23
Rate for Payer: Multiplan Workers Comp	$307.23
Rate for Payer: Parkland Medicaid	$442.41
Rate for Payer: Scott and White EPO/PPO	$307.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$442.41
Rate for Payer: Superior Health Plan EPO	$83.57

656418

Facility

$614.46

Service Code	HCPCS C1713
Hospital Charge Code	994076
Hospital Revenue Code	278
Min. Negotiated Rate	$153.62
Max. Negotiated Rate	$307.23
Rate for Payer: Cash Price	$417.83
Rate for Payer: Cigna Commercial	$153.62
Rate for Payer: Multiplan Auto	$307.23
Rate for Payer: Multiplan Commercial	$307.23
Rate for Payer: Multiplan Workers Comp	$307.23
Rate for Payer: Scott and White EPO/PPO	$307.23

656418

Facility

$614.46

Service Code	HCPCS C1713
Hospital Charge Code	994076
Hospital Revenue Code	278
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$442.41
Rate for Payer: Amerigroup CHIP/Medicaid	$55.30
Rate for Payer: BCBS of TX Blue Advantage	$184.34
Rate for Payer: BCBS of TX Blue Essentials	$221.21
Rate for Payer: BCBS of TX PPO	$245.78
Rate for Payer: Cash Price	$417.83
Rate for Payer: Cigna Medicaid	$442.41
Rate for Payer: Molina CHIP/Medicaid	$442.41
Rate for Payer: Multiplan Auto	$307.23
Rate for Payer: Multiplan Commercial	$307.23
Rate for Payer: Multiplan Workers Comp	$307.23
Rate for Payer: Parkland Medicaid	$442.41
Rate for Payer: Scott and White EPO/PPO	$307.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$442.41
Rate for Payer: Superior Health Plan EPO	$83.57

656422

Facility

$614.46

Service Code	HCPCS C1713
Hospital Charge Code	994075
Hospital Revenue Code	278
Min. Negotiated Rate	$153.62
Max. Negotiated Rate	$307.23
Rate for Payer: Cash Price	$417.83
Rate for Payer: Cigna Commercial	$153.62
Rate for Payer: Multiplan Auto	$307.23
Rate for Payer: Multiplan Commercial	$307.23
Rate for Payer: Multiplan Workers Comp	$307.23
Rate for Payer: Scott and White EPO/PPO	$307.23

656422

Facility

$614.46

Service Code	HCPCS C1713
Hospital Charge Code	994075
Hospital Revenue Code	278
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$442.41
Rate for Payer: Amerigroup CHIP/Medicaid	$55.30
Rate for Payer: BCBS of TX Blue Advantage	$184.34
Rate for Payer: BCBS of TX Blue Essentials	$221.21
Rate for Payer: BCBS of TX PPO	$245.78
Rate for Payer: Cash Price	$417.83
Rate for Payer: Cigna Medicaid	$442.41
Rate for Payer: Molina CHIP/Medicaid	$442.41
Rate for Payer: Multiplan Auto	$307.23
Rate for Payer: Multiplan Commercial	$307.23
Rate for Payer: Multiplan Workers Comp	$307.23
Rate for Payer: Parkland Medicaid	$442.41
Rate for Payer: Scott and White EPO/PPO	$307.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$442.41
Rate for Payer: Superior Health Plan EPO	$83.57

6570-0-328

Facility

$8,474.84

Service Code	HCPCS C1776
Hospital Charge Code	994004
Hospital Revenue Code	278
Min. Negotiated Rate	$2,118.71
Max. Negotiated Rate	$4,237.42
Rate for Payer: Cash Price	$5,762.89
Rate for Payer: Cigna Commercial	$2,118.71
Rate for Payer: Multiplan Auto	$4,237.42
Rate for Payer: Multiplan Commercial	$4,237.42
Rate for Payer: Multiplan Workers Comp	$4,237.42
Rate for Payer: Scott and White EPO/PPO	$4,237.42

6570-0-328

Facility

$8,474.84

Service Code	HCPCS C1776
Hospital Charge Code	994004
Hospital Revenue Code	278
Min. Negotiated Rate	$762.74
Max. Negotiated Rate	$6,101.88
Rate for Payer: Amerigroup CHIP/Medicaid	$762.74
Rate for Payer: BCBS of TX Blue Advantage	$2,542.45
Rate for Payer: BCBS of TX Blue Essentials	$3,050.94
Rate for Payer: BCBS of TX PPO	$3,389.94
Rate for Payer: Cash Price	$5,762.89
Rate for Payer: Cigna Medicaid	$6,101.88
Rate for Payer: Molina CHIP/Medicaid	$6,101.88
Rate for Payer: Multiplan Auto	$4,237.42
Rate for Payer: Multiplan Commercial	$4,237.42
Rate for Payer: Multiplan Workers Comp	$4,237.42
Rate for Payer: Parkland Medicaid	$6,101.88
Rate for Payer: Scott and White EPO/PPO	$4,237.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,101.88
Rate for Payer: Superior Health Plan EPO	$1,152.58

Know your out-of-pocket cost for care.

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