White Rock Medical Center

All Charges

Charge

Type

Setting

Price

10 x 30mm Intrafix Adv

Facility

$5,439.76

Service Code	HCPCS C1713
Hospital Charge Code	992194
Hospital Revenue Code	278
Min. Negotiated Rate	$1,359.94
Max. Negotiated Rate	$2,719.88
Rate for Payer: Cash Price	$3,699.04
Rate for Payer: Cigna Commercial	$1,359.94
Rate for Payer: Multiplan Auto	$2,719.88
Rate for Payer: Multiplan Commercial	$2,719.88
Rate for Payer: Multiplan Workers Comp	$2,719.88
Rate for Payer: Scott and White EPO/PPO	$2,719.88

11000408

Facility

$14,755.00

Service Code	HCPCS C1889
Hospital Charge Code	993950
Hospital Revenue Code	278
Min. Negotiated Rate	$3,688.75
Max. Negotiated Rate	$7,377.50
Rate for Payer: Cash Price	$10,033.40
Rate for Payer: Cigna Commercial	$3,688.75
Rate for Payer: Multiplan Auto	$7,377.50
Rate for Payer: Multiplan Commercial	$7,377.50
Rate for Payer: Multiplan Workers Comp	$7,377.50
Rate for Payer: Scott and White EPO/PPO	$7,377.50

11000408

Facility

$14,755.00

Service Code	HCPCS C1889
Hospital Charge Code	993950
Hospital Revenue Code	278
Min. Negotiated Rate	$1,327.95
Max. Negotiated Rate	$10,623.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1,327.95
Rate for Payer: BCBS of TX Blue Advantage	$4,426.50
Rate for Payer: BCBS of TX Blue Essentials	$5,311.80
Rate for Payer: BCBS of TX PPO	$5,902.00
Rate for Payer: Cash Price	$10,033.40
Rate for Payer: Cigna Medicaid	$10,623.60
Rate for Payer: Molina CHIP/Medicaid	$10,623.60
Rate for Payer: Multiplan Auto	$7,377.50
Rate for Payer: Multiplan Commercial	$7,377.50
Rate for Payer: Multiplan Workers Comp	$7,377.50
Rate for Payer: Parkland Medicaid	$10,623.60
Rate for Payer: Scott and White EPO/PPO	$7,377.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,623.60
Rate for Payer: Superior Health Plan EPO	$2,006.68

115225ND

Facility

$621.69

Service Code	HCPCS C1769
Hospital Charge Code	991178
Hospital Revenue Code	272
Rate for Payer: Cash Price	$422.75

115225ND

Facility

$621.69

Service Code	HCPCS C1769
Hospital Charge Code	991178
Hospital Revenue Code	272
Min. Negotiated Rate	$55.95
Max. Negotiated Rate	$447.62
Rate for Payer: Amerigroup CHIP/Medicaid	$55.95
Rate for Payer: BCBS of TX Blue Advantage	$186.51
Rate for Payer: BCBS of TX Blue Essentials	$223.81
Rate for Payer: BCBS of TX PPO	$248.68
Rate for Payer: Cash Price	$422.75
Rate for Payer: Cigna Medicaid	$447.62
Rate for Payer: Molina CHIP/Medicaid	$447.62
Rate for Payer: Multiplan Auto	$404.10
Rate for Payer: Multiplan Commercial	$404.10
Rate for Payer: Multiplan Workers Comp	$404.10
Rate for Payer: Parkland Medicaid	$447.62
Rate for Payer: Scott and White EPO/PPO	$310.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$447.62
Rate for Payer: Superior Health Plan EPO	$84.55

11.5MM ANKLE SALVAGE TI, 250MM

Facility

$201,506.02

Service Code	HCPCS C1734
Hospital Charge Code	992185
Hospital Revenue Code	278
Min. Negotiated Rate	$50,376.50
Max. Negotiated Rate	$100,753.01
Rate for Payer: Cash Price	$137,024.09
Rate for Payer: Cigna Commercial	$50,376.50
Rate for Payer: Multiplan Auto	$100,753.01
Rate for Payer: Multiplan Commercial	$100,753.01
Rate for Payer: Multiplan Workers Comp	$100,753.01
Rate for Payer: Scott and White EPO/PPO	$100,753.01

11.5MM ANKLE SALVAGE TI, 250MM

Facility

$201,506.02

Service Code	HCPCS C1734
Hospital Charge Code	992185
Hospital Revenue Code	278
Min. Negotiated Rate	$18,135.54
Max. Negotiated Rate	$145,084.33
Rate for Payer: Amerigroup CHIP/Medicaid	$18,135.54
Rate for Payer: BCBS of TX Blue Advantage	$60,451.81
Rate for Payer: BCBS of TX Blue Essentials	$72,542.17
Rate for Payer: BCBS of TX PPO	$80,602.41
Rate for Payer: Cash Price	$137,024.09
Rate for Payer: Cigna Medicaid	$145,084.33
Rate for Payer: Molina CHIP/Medicaid	$145,084.33
Rate for Payer: Multiplan Auto	$100,753.01
Rate for Payer: Multiplan Commercial	$100,753.01
Rate for Payer: Multiplan Workers Comp	$100,753.01
Rate for Payer: Parkland Medicaid	$145,084.33
Rate for Payer: Scott and White EPO/PPO	$100,753.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145,084.33
Rate for Payer: Superior Health Plan EPO	$27,404.82

11-Desoxycortisol SO

Facility

$122.69

Service Code	HCPCS 82634
Hospital Charge Code	9048978
Hospital Revenue Code	301
Min. Negotiated Rate	$11.42
Max. Negotiated Rate	$88.34
Rate for Payer: Amerigroup CHIP/Medicaid	$11.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29.28
Rate for Payer: Amerigroup Medicare	$29.28
Rate for Payer: BCBS of TX Blue Advantage	$36.81
Rate for Payer: BCBS of TX Blue Essentials	$44.17
Rate for Payer: BCBS of TX Medicare	$29.28
Rate for Payer: BCBS of TX PPO	$49.08
Rate for Payer: Cash Price	$83.43
Rate for Payer: Cash Price	$83.43
Rate for Payer: Cigna Medicaid	$88.34
Rate for Payer: Cigna Medicare	$29.28
Rate for Payer: Employer Direct Commercial	$29.28
Rate for Payer: Humana Medicare/TRICARE	$29.28
Rate for Payer: Molina CHIP/Medicaid	$88.34
Rate for Payer: Molina Dual Medicare/Medicaid	$29.28
Rate for Payer: Molina Medicare	$29.28
Rate for Payer: Multiplan Auto	$79.75
Rate for Payer: Multiplan Commercial	$79.75
Rate for Payer: Multiplan Workers Comp	$79.75
Rate for Payer: Parkland Medicaid	$88.34
Rate for Payer: Scott and White EPO/PPO	$36.60
Rate for Payer: Scott and White Medicare	$29.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$88.34
Rate for Payer: Superior Health Plan EPO	$29.28
Rate for Payer: Superior Health Plan Medicare	$29.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$29.28
Rate for Payer: Universal American Medicare	$29.28
Rate for Payer: Wellcare Medicare	$29.28
Rate for Payer: Wellmed Medicare	$29.28

11-Desoxycortisol SO

Facility

$122.69

Service Code	HCPCS 82634
Hospital Charge Code	9048978
Hospital Revenue Code	301
Rate for Payer: Cash Price	$83.43

1210-6450S

Facility

$1,192.77

Service Code	HCPCS C1769
Hospital Charge Code	991182
Hospital Revenue Code	272
Min. Negotiated Rate	$107.35
Max. Negotiated Rate	$858.79
Rate for Payer: Amerigroup CHIP/Medicaid	$107.35
Rate for Payer: BCBS of TX Blue Advantage	$357.83
Rate for Payer: BCBS of TX Blue Essentials	$429.40
Rate for Payer: BCBS of TX PPO	$477.11
Rate for Payer: Cash Price	$811.08
Rate for Payer: Cigna Medicaid	$858.79
Rate for Payer: Molina CHIP/Medicaid	$858.79
Rate for Payer: Multiplan Auto	$775.30
Rate for Payer: Multiplan Commercial	$775.30
Rate for Payer: Multiplan Workers Comp	$775.30
Rate for Payer: Parkland Medicaid	$858.79
Rate for Payer: Scott and White EPO/PPO	$596.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$858.79
Rate for Payer: Superior Health Plan EPO	$162.22

1210-6450S

Facility

$1,192.77

Service Code	HCPCS C1769
Hospital Charge Code	991182
Hospital Revenue Code	272
Rate for Payer: Cash Price	$811.08

12165991

Facility

$72,959.00

Service Code	HCPCS C1768
Hospital Charge Code	991024
Hospital Revenue Code	278
Min. Negotiated Rate	$18,239.75
Max. Negotiated Rate	$36,479.50
Rate for Payer: Cash Price	$49,612.12
Rate for Payer: Cigna Commercial	$18,239.75
Rate for Payer: Multiplan Auto	$36,479.50
Rate for Payer: Multiplan Commercial	$36,479.50
Rate for Payer: Multiplan Workers Comp	$36,479.50
Rate for Payer: Scott and White EPO/PPO	$36,479.50

12165991

Facility

$72,959.00

Service Code	HCPCS C1768
Hospital Charge Code	991024
Hospital Revenue Code	278
Min. Negotiated Rate	$6,566.31
Max. Negotiated Rate	$52,530.48
Rate for Payer: Amerigroup CHIP/Medicaid	$6,566.31
Rate for Payer: BCBS of TX Blue Advantage	$21,887.70
Rate for Payer: BCBS of TX Blue Essentials	$26,265.24
Rate for Payer: BCBS of TX PPO	$29,183.60
Rate for Payer: Cash Price	$49,612.12
Rate for Payer: Cigna Medicaid	$52,530.48
Rate for Payer: Molina CHIP/Medicaid	$52,530.48
Rate for Payer: Multiplan Auto	$36,479.50
Rate for Payer: Multiplan Commercial	$36,479.50
Rate for Payer: Multiplan Workers Comp	$36,479.50
Rate for Payer: Parkland Medicaid	$52,530.48
Rate for Payer: Scott and White EPO/PPO	$36,479.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52,530.48
Rate for Payer: Superior Health Plan EPO	$9,922.42

12BSGEC60A

Facility

$662.65

Service Code	HCPCS A4649
Hospital Charge Code	991068
Hospital Revenue Code	272
Rate for Payer: Cash Price	$450.60

12BSGEC60A

Facility

$662.65

Service Code	HCPCS A4649
Hospital Charge Code	991068
Hospital Revenue Code	272
Min. Negotiated Rate	$59.64
Max. Negotiated Rate	$477.11
Rate for Payer: Amerigroup CHIP/Medicaid	$59.64
Rate for Payer: BCBS of TX Blue Advantage	$198.79
Rate for Payer: BCBS of TX Blue Essentials	$238.55
Rate for Payer: BCBS of TX PPO	$265.06
Rate for Payer: Cash Price	$450.60
Rate for Payer: Cigna Medicaid	$477.11
Rate for Payer: Molina CHIP/Medicaid	$477.11
Rate for Payer: Multiplan Auto	$430.72
Rate for Payer: Multiplan Commercial	$430.72
Rate for Payer: Multiplan Workers Comp	$430.72
Rate for Payer: Parkland Medicaid	$477.11
Rate for Payer: Scott and White EPO/PPO	$331.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$477.11
Rate for Payer: Superior Health Plan EPO	$90.12

131227114

Facility

$759.03

Service Code	HCPCS C1713
Hospital Charge Code	991322
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$379.51
Rate for Payer: Cash Price	$516.14
Rate for Payer: Cigna Commercial	$189.76
Rate for Payer: Multiplan Auto	$379.51
Rate for Payer: Multiplan Commercial	$379.51
Rate for Payer: Multiplan Workers Comp	$379.51
Rate for Payer: Scott and White EPO/PPO	$379.51

131227114

Facility

$759.03

Service Code	HCPCS C1713
Hospital Charge Code	991322
Hospital Revenue Code	278
Min. Negotiated Rate	$68.31
Max. Negotiated Rate	$546.50
Rate for Payer: Amerigroup CHIP/Medicaid	$68.31
Rate for Payer: BCBS of TX Blue Advantage	$227.71
Rate for Payer: BCBS of TX Blue Essentials	$273.25
Rate for Payer: BCBS of TX PPO	$303.61
Rate for Payer: Cash Price	$516.14
Rate for Payer: Cigna Medicaid	$546.50
Rate for Payer: Molina CHIP/Medicaid	$546.50
Rate for Payer: Multiplan Auto	$379.51
Rate for Payer: Multiplan Commercial	$379.51
Rate for Payer: Multiplan Workers Comp	$379.51
Rate for Payer: Parkland Medicaid	$546.50
Rate for Payer: Scott and White EPO/PPO	$379.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$546.50
Rate for Payer: Superior Health Plan EPO	$103.23

131227115

Facility

$759.03

Service Code	HCPCS C1713
Hospital Charge Code	991323
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$379.51
Rate for Payer: Cash Price	$516.14
Rate for Payer: Cigna Commercial	$189.76
Rate for Payer: Multiplan Auto	$379.51
Rate for Payer: Multiplan Commercial	$379.51
Rate for Payer: Multiplan Workers Comp	$379.51
Rate for Payer: Scott and White EPO/PPO	$379.51

131227115

Facility

$759.03

Service Code	HCPCS C1713
Hospital Charge Code	991323
Hospital Revenue Code	278
Min. Negotiated Rate	$68.31
Max. Negotiated Rate	$546.50
Rate for Payer: Amerigroup CHIP/Medicaid	$68.31
Rate for Payer: BCBS of TX Blue Advantage	$227.71
Rate for Payer: BCBS of TX Blue Essentials	$273.25
Rate for Payer: BCBS of TX PPO	$303.61
Rate for Payer: Cash Price	$516.14
Rate for Payer: Cigna Medicaid	$546.50
Rate for Payer: Molina CHIP/Medicaid	$546.50
Rate for Payer: Multiplan Auto	$379.51
Rate for Payer: Multiplan Commercial	$379.51
Rate for Payer: Multiplan Workers Comp	$379.51
Rate for Payer: Parkland Medicaid	$546.50
Rate for Payer: Scott and White EPO/PPO	$379.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$546.50
Rate for Payer: Superior Health Plan EPO	$103.23

131227116

Facility

$759.03

Service Code	HCPCS C1713
Hospital Charge Code	991324
Hospital Revenue Code	278
Min. Negotiated Rate	$68.31
Max. Negotiated Rate	$546.50
Rate for Payer: Amerigroup CHIP/Medicaid	$68.31
Rate for Payer: BCBS of TX Blue Advantage	$227.71
Rate for Payer: BCBS of TX Blue Essentials	$273.25
Rate for Payer: BCBS of TX PPO	$303.61
Rate for Payer: Cash Price	$516.14
Rate for Payer: Cigna Medicaid	$546.50
Rate for Payer: Molina CHIP/Medicaid	$546.50
Rate for Payer: Multiplan Auto	$379.51
Rate for Payer: Multiplan Commercial	$379.51
Rate for Payer: Multiplan Workers Comp	$379.51
Rate for Payer: Parkland Medicaid	$546.50
Rate for Payer: Scott and White EPO/PPO	$379.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$546.50
Rate for Payer: Superior Health Plan EPO	$103.23

131227116

Facility

$759.03

Service Code	HCPCS C1713
Hospital Charge Code	991324
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$379.51
Rate for Payer: Cash Price	$516.14
Rate for Payer: Cigna Commercial	$189.76
Rate for Payer: Multiplan Auto	$379.51
Rate for Payer: Multiplan Commercial	$379.51
Rate for Payer: Multiplan Workers Comp	$379.51
Rate for Payer: Scott and White EPO/PPO	$379.51

131227118

Facility

$759.03

Service Code	HCPCS C1713
Hospital Charge Code	991325
Hospital Revenue Code	278
Min. Negotiated Rate	$68.31
Max. Negotiated Rate	$546.50
Rate for Payer: Amerigroup CHIP/Medicaid	$68.31
Rate for Payer: BCBS of TX Blue Advantage	$227.71
Rate for Payer: BCBS of TX Blue Essentials	$273.25
Rate for Payer: BCBS of TX PPO	$303.61
Rate for Payer: Cash Price	$516.14
Rate for Payer: Cigna Medicaid	$546.50
Rate for Payer: Molina CHIP/Medicaid	$546.50
Rate for Payer: Multiplan Auto	$379.51
Rate for Payer: Multiplan Commercial	$379.51
Rate for Payer: Multiplan Workers Comp	$379.51
Rate for Payer: Parkland Medicaid	$546.50
Rate for Payer: Scott and White EPO/PPO	$379.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$546.50
Rate for Payer: Superior Health Plan EPO	$103.23

131227118

Facility

$759.03

Service Code	HCPCS C1713
Hospital Charge Code	991325
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$379.51
Rate for Payer: Cash Price	$516.14
Rate for Payer: Cigna Commercial	$189.76
Rate for Payer: Multiplan Auto	$379.51
Rate for Payer: Multiplan Commercial	$379.51
Rate for Payer: Multiplan Workers Comp	$379.51
Rate for Payer: Scott and White EPO/PPO	$379.51

131227120

Facility

$759.03

Service Code	HCPCS C1713
Hospital Charge Code	991326
Hospital Revenue Code	278
Min. Negotiated Rate	$68.31
Max. Negotiated Rate	$546.50
Rate for Payer: Amerigroup CHIP/Medicaid	$68.31
Rate for Payer: BCBS of TX Blue Advantage	$227.71
Rate for Payer: BCBS of TX Blue Essentials	$273.25
Rate for Payer: BCBS of TX PPO	$303.61
Rate for Payer: Cash Price	$516.14
Rate for Payer: Cigna Medicaid	$546.50
Rate for Payer: Molina CHIP/Medicaid	$546.50
Rate for Payer: Multiplan Auto	$379.51
Rate for Payer: Multiplan Commercial	$379.51
Rate for Payer: Multiplan Workers Comp	$379.51
Rate for Payer: Parkland Medicaid	$546.50
Rate for Payer: Scott and White EPO/PPO	$379.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$546.50
Rate for Payer: Superior Health Plan EPO	$103.23

131227120

Facility

$759.03

Service Code	HCPCS C1713
Hospital Charge Code	991326
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$379.51
Rate for Payer: Cash Price	$516.14
Rate for Payer: Cigna Commercial	$189.76
Rate for Payer: Multiplan Auto	$379.51
Rate for Payer: Multiplan Commercial	$379.51
Rate for Payer: Multiplan Workers Comp	$379.51
Rate for Payer: Scott and White EPO/PPO	$379.51

Know your out-of-pocket cost for care.

All Charges