White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$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	$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

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

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

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

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

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

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

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

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

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

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

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

6720-0330

Facility

$5,077.16

Service Code	HCPCS C1734
Hospital Charge Code	994003
Hospital Revenue Code	278
Min. Negotiated Rate	$1,269.29
Max. Negotiated Rate	$2,538.58
Rate for Payer: Cash Price	$3,452.47
Rate for Payer: Cigna Commercial	$1,269.29
Rate for Payer: Multiplan Auto	$2,538.58
Rate for Payer: Multiplan Commercial	$2,538.58
Rate for Payer: Multiplan Workers Comp	$2,538.58
Rate for Payer: Scott and White EPO/PPO	$2,538.58

6720-0330

Facility

$5,077.16

Service Code	HCPCS C1734
Hospital Charge Code	994003
Hospital Revenue Code	278
Min. Negotiated Rate	$456.94
Max. Negotiated Rate	$3,655.56
Rate for Payer: Amerigroup CHIP/Medicaid	$456.94
Rate for Payer: BCBS of TX Blue Advantage	$1,523.15
Rate for Payer: BCBS of TX Blue Essentials	$1,827.78
Rate for Payer: BCBS of TX PPO	$2,030.86
Rate for Payer: Cash Price	$3,452.47
Rate for Payer: Cigna Medicaid	$3,655.56
Rate for Payer: Molina CHIP/Medicaid	$3,655.56
Rate for Payer: Multiplan Auto	$2,538.58
Rate for Payer: Multiplan Commercial	$2,538.58
Rate for Payer: Multiplan Workers Comp	$2,538.58
Rate for Payer: Parkland Medicaid	$3,655.56
Rate for Payer: Scott and White EPO/PPO	$2,538.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,655.56
Rate for Payer: Superior Health Plan EPO	$690.49

6C PLUS CELL CONTROL

Facility

$1,539.06

Hospital Charge Code	993857
Hospital Revenue Code	279
Min. Negotiated Rate	$138.52
Max. Negotiated Rate	$1,108.12
Rate for Payer: Amerigroup CHIP/Medicaid	$138.52
Rate for Payer: BCBS of TX Blue Advantage	$461.72
Rate for Payer: BCBS of TX Blue Essentials	$554.06
Rate for Payer: BCBS of TX PPO	$615.62
Rate for Payer: Cash Price	$1,046.56
Rate for Payer: Cigna Medicaid	$1,108.12
Rate for Payer: Molina CHIP/Medicaid	$1,108.12
Rate for Payer: Multiplan Auto	$1,000.39
Rate for Payer: Multiplan Commercial	$1,000.39
Rate for Payer: Multiplan Workers Comp	$1,000.39
Rate for Payer: Parkland Medicaid	$1,108.12
Rate for Payer: Scott and White EPO/PPO	$769.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,108.12
Rate for Payer: Superior Health Plan EPO	$209.31

6C PLUS CELL CONTROL

Facility

$1,539.06

Hospital Charge Code	993857
Hospital Revenue Code	279
Rate for Payer: Cash Price	$1,046.56

6F CELT Arterial Closure Device Individual Units

Facility

$1,135.00

Hospital Charge Code	993891
Hospital Revenue Code	279
Rate for Payer: Cash Price	$771.80

6F CELT Arterial Closure Device Individual Units

Facility

$1,135.00

Hospital Charge Code	993891
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

6mm x 100mm .035 Saber PTA balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992559
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

6mm x 100mm .035 Saber PTA balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992559
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

6mm x 10xm x 135cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992556
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

6mm x 10xm x 135cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992556
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

6mm x 20cm x 135cm Saber Balloon

Facility

$612.90

Service Code	HCPCS C1726
Hospital Charge Code	992558
Hospital Revenue Code	272
Rate for Payer: Cash Price	$416.77

Know your out-of-pocket cost for care.

All Charges