White Rock Medical Center

All Charges

Charge

Type

Setting

Price

COMPLICATED PEPTIC ULCER WITHOUT CC/MCC

Facility

$14,626.20

Service Code	MSDRG 382
Min. Negotiated Rate	$6,603.08
Max. Negotiated Rate	$14,626.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,627.70
Rate for Payer: Amerigroup Medicare	$10,627.70
Rate for Payer: BCBS of TX Medicare	$10,627.70
Rate for Payer: Cigna Commercial	$10,311.73
Rate for Payer: Cigna Medicare	$10,627.70
Rate for Payer: Employer Direct Commercial	$10,627.70
Rate for Payer: Humana Medicare/TRICARE	$10,627.70
Rate for Payer: Molina Dual Medicare/Medicaid	$10,627.70
Rate for Payer: Molina Medicare	$10,627.70
Rate for Payer: Multiplan Auto	$14,626.20
Rate for Payer: Multiplan Commercial	$14,626.20
Rate for Payer: Multiplan Workers Comp	$14,626.20
Rate for Payer: Scott and White EPO/PPO	$6,735.75
Rate for Payer: Scott and White Medicare	$10,627.70
Rate for Payer: Superior Health Plan EPO	$10,627.70
Rate for Payer: Superior Health Plan Medicare	$10,627.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,627.70
Rate for Payer: Universal American Medicare	$10,627.70
Rate for Payer: Wellcare Medicare	$10,627.70
Rate for Payer: Wellmed Medicare	$10,627.70

COMPLICATED PEPTIC ULCER W MCC

Facility

$36,177.90

Service Code	MSDRG 380
Min. Negotiated Rate	$16,660.88
Max. Negotiated Rate	$36,177.90
Rate for Payer: BCBS of TX Blue Advantage	$16,735.60
Rate for Payer: BCBS of TX Blue Essentials	$20,080.77
Rate for Payer: BCBS of TX PPO	$22,312.84

COMPLICATED PEPTIC ULCER W/O CC/MCC

Facility

$14,626.20

Service Code	MSDRG 382
Min. Negotiated Rate	$6,603.08
Max. Negotiated Rate	$14,626.20
Rate for Payer: BCBS of TX Blue Advantage	$6,603.08
Rate for Payer: BCBS of TX Blue Essentials	$7,922.93
Rate for Payer: BCBS of TX PPO	$8,803.59

COMPLICATIONS OF TREATMENT W CC

Facility

$19,414.20

Service Code	MSDRG 920
Min. Negotiated Rate	$8,626.66
Max. Negotiated Rate	$19,414.20
Rate for Payer: BCBS of TX Blue Advantage	$8,626.66
Rate for Payer: BCBS of TX Blue Essentials	$10,350.99
Rate for Payer: BCBS of TX PPO	$11,501.54

COMPLICATIONS OF TREATMENT WITH CC

Facility

$19,414.20

Service Code	MSDRG 920
Min. Negotiated Rate	$8,626.66
Max. Negotiated Rate	$19,414.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,105.96
Rate for Payer: Amerigroup Medicare	$12,105.96
Rate for Payer: BCBS of TX Medicare	$12,105.96
Rate for Payer: Cigna Commercial	$12,909.62
Rate for Payer: Cigna Medicare	$12,105.96
Rate for Payer: Employer Direct Commercial	$12,105.96
Rate for Payer: Humana Medicare/TRICARE	$12,105.96
Rate for Payer: Molina Dual Medicare/Medicaid	$12,105.96
Rate for Payer: Molina Medicare	$12,105.96
Rate for Payer: Multiplan Auto	$19,414.20
Rate for Payer: Multiplan Commercial	$19,414.20
Rate for Payer: Multiplan Workers Comp	$19,414.20
Rate for Payer: Scott and White EPO/PPO	$8,940.75
Rate for Payer: Scott and White Medicare	$12,105.96
Rate for Payer: Superior Health Plan EPO	$12,105.96
Rate for Payer: Superior Health Plan Medicare	$12,105.96
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,105.96
Rate for Payer: Universal American Medicare	$12,105.96
Rate for Payer: Wellcare Medicare	$12,105.96
Rate for Payer: Wellmed Medicare	$12,105.96

COMPLICATIONS OF TREATMENT WITH MCC

Facility

$34,078.40

Service Code	MSDRG 919
Min. Negotiated Rate	$15,688.98
Max. Negotiated Rate	$34,078.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,178.06
Rate for Payer: Amerigroup Medicare	$18,178.06
Rate for Payer: BCBS of TX Medicare	$18,178.06
Rate for Payer: Cigna Commercial	$23,580.70
Rate for Payer: Cigna Medicare	$18,178.06
Rate for Payer: Employer Direct Commercial	$18,178.06
Rate for Payer: Humana Medicare/TRICARE	$18,178.06
Rate for Payer: Molina Dual Medicare/Medicaid	$18,178.06
Rate for Payer: Molina Medicare	$18,178.06
Rate for Payer: Multiplan Auto	$34,078.40
Rate for Payer: Multiplan Commercial	$34,078.40
Rate for Payer: Multiplan Workers Comp	$34,078.40
Rate for Payer: Scott and White EPO/PPO	$15,694.00
Rate for Payer: Scott and White Medicare	$18,178.06
Rate for Payer: Superior Health Plan EPO	$18,178.06
Rate for Payer: Superior Health Plan Medicare	$18,178.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,178.06
Rate for Payer: Universal American Medicare	$18,178.06
Rate for Payer: Wellcare Medicare	$18,178.06
Rate for Payer: Wellmed Medicare	$18,178.06

COMPLICATIONS OF TREATMENT WITHOUT CC/MCC

Facility

$13,830.10

Service Code	MSDRG 921
Min. Negotiated Rate	$6,076.76
Max. Negotiated Rate	$13,830.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,805.38
Rate for Payer: Amerigroup Medicare	$9,805.38
Rate for Payer: BCBS of TX Medicare	$9,805.38
Rate for Payer: Cigna Commercial	$8,866.59
Rate for Payer: Cigna Medicare	$9,805.38
Rate for Payer: Employer Direct Commercial	$9,805.38
Rate for Payer: Humana Medicare/TRICARE	$9,805.38
Rate for Payer: Molina Dual Medicare/Medicaid	$9,805.38
Rate for Payer: Molina Medicare	$9,805.38
Rate for Payer: Multiplan Auto	$13,830.10
Rate for Payer: Multiplan Commercial	$13,830.10
Rate for Payer: Multiplan Workers Comp	$13,830.10
Rate for Payer: Scott and White EPO/PPO	$6,369.12
Rate for Payer: Scott and White Medicare	$9,805.38
Rate for Payer: Superior Health Plan EPO	$9,805.38
Rate for Payer: Superior Health Plan Medicare	$9,805.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,805.38
Rate for Payer: Universal American Medicare	$9,805.38
Rate for Payer: Wellcare Medicare	$9,805.38
Rate for Payer: Wellmed Medicare	$9,805.38

COMPLICATIONS OF TREATMENT W MCC

Facility

$34,078.40

Service Code	MSDRG 919
Min. Negotiated Rate	$15,688.98
Max. Negotiated Rate	$34,078.40
Rate for Payer: BCBS of TX Blue Advantage	$15,688.98
Rate for Payer: BCBS of TX Blue Essentials	$18,824.95
Rate for Payer: BCBS of TX PPO	$20,917.42

COMPLICATIONS OF TREATMENT W/O CC/MCC

Facility

$13,830.10

Service Code	MSDRG 921
Min. Negotiated Rate	$6,076.76
Max. Negotiated Rate	$13,830.10
Rate for Payer: BCBS of TX Blue Advantage	$6,076.76
Rate for Payer: BCBS of TX Blue Essentials	$7,291.41
Rate for Payer: BCBS of TX PPO	$8,101.88

COMPLX CHRON CARE PLANNING Units

Facility

$139.00

Hospital Charge Code	6019903
Hospital Revenue Code	510
Rate for Payer: Cash Price	$94.52

COMPLX CHRON CARE PLANNING Units

Facility

$139.00

Hospital Charge Code	6019903
Hospital Revenue Code	510
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$100.08
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$41.70
Rate for Payer: BCBS of TX Blue Essentials	$50.04
Rate for Payer: BCBS of TX PPO	$55.60
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cigna Medicaid	$100.08
Rate for Payer: Molina CHIP/Medicaid	$100.08
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Parkland Medicaid	$100.08
Rate for Payer: Scott and White EPO/PPO	$69.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100.08

Composite Mesh,Monofilament Polyester with Absorbable

Facility

$2,608.43

Service Code	HCPCS C1781
Hospital Charge Code	992351
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,773.73

Composite Mesh,Monofilament Polyester with Absorbable

Facility

$2,608.43

Service Code	HCPCS C1781
Hospital Charge Code	992351
Hospital Revenue Code	272
Min. Negotiated Rate	$234.76
Max. Negotiated Rate	$1,878.07
Rate for Payer: Amerigroup CHIP/Medicaid	$234.76
Rate for Payer: BCBS of TX Blue Advantage	$782.53
Rate for Payer: BCBS of TX Blue Essentials	$939.03
Rate for Payer: BCBS of TX PPO	$1,043.37
Rate for Payer: Cash Price	$1,773.73
Rate for Payer: Cigna Medicaid	$1,878.07
Rate for Payer: Molina CHIP/Medicaid	$1,878.07
Rate for Payer: Multiplan Auto	$1,695.48
Rate for Payer: Multiplan Commercial	$1,695.48
Rate for Payer: Multiplan Workers Comp	$1,695.48
Rate for Payer: Parkland Medicaid	$1,878.07
Rate for Payer: Scott and White EPO/PPO	$1,304.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,878.07
Rate for Payer: Superior Health Plan EPO	$354.75

Composite Mesh,Monofilament Polyester with Absorbable Collag

Facility

$1,575.60

Service Code	HCPCS C1781
Hospital Charge Code	992342
Hospital Revenue Code	272
Min. Negotiated Rate	$141.80
Max. Negotiated Rate	$1,134.43
Rate for Payer: Amerigroup CHIP/Medicaid	$141.80
Rate for Payer: BCBS of TX Blue Advantage	$472.68
Rate for Payer: BCBS of TX Blue Essentials	$567.22
Rate for Payer: BCBS of TX PPO	$630.24
Rate for Payer: Cash Price	$1,071.41
Rate for Payer: Cigna Medicaid	$1,134.43
Rate for Payer: Molina CHIP/Medicaid	$1,134.43
Rate for Payer: Multiplan Auto	$1,024.14
Rate for Payer: Multiplan Commercial	$1,024.14
Rate for Payer: Multiplan Workers Comp	$1,024.14
Rate for Payer: Parkland Medicaid	$1,134.43
Rate for Payer: Scott and White EPO/PPO	$787.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,134.43
Rate for Payer: Superior Health Plan EPO	$214.28

Composite Mesh,Monofilament Polyester with Absorbable Collag

Facility

$1,575.60

Service Code	HCPCS C1781
Hospital Charge Code	992342
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,071.41

Comprehensive Metabolic Panel

Facility

$661.00

Service Code	HCPCS 80053
Hospital Charge Code	1603190
Hospital Revenue Code	301
Rate for Payer: Cash Price	$449.48

Comprehensive Metabolic Panel

Facility

$661.00

Service Code	HCPCS 80053
Hospital Charge Code	1603190
Hospital Revenue Code	301
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$475.92
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.56
Rate for Payer: Amerigroup Medicare	$10.56
Rate for Payer: BCBS of TX Blue Advantage	$198.30
Rate for Payer: BCBS of TX Blue Essentials	$237.96
Rate for Payer: BCBS of TX Medicare	$10.56
Rate for Payer: BCBS of TX PPO	$264.40
Rate for Payer: Cash Price	$449.48
Rate for Payer: Cash Price	$449.48
Rate for Payer: Cigna Medicaid	$475.92
Rate for Payer: Cigna Medicare	$10.56
Rate for Payer: Employer Direct Commercial	$10.56
Rate for Payer: Humana Medicare/TRICARE	$10.56
Rate for Payer: Molina CHIP/Medicaid	$475.92
Rate for Payer: Molina Dual Medicare/Medicaid	$10.56
Rate for Payer: Molina Medicare	$10.56
Rate for Payer: Multiplan Auto	$429.65
Rate for Payer: Multiplan Commercial	$429.65
Rate for Payer: Multiplan Workers Comp	$429.65
Rate for Payer: Parkland Medicaid	$475.92
Rate for Payer: Scott and White EPO/PPO	$13.20
Rate for Payer: Scott and White Medicare	$10.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$475.92
Rate for Payer: Superior Health Plan EPO	$10.56
Rate for Payer: Superior Health Plan Medicare	$10.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.56
Rate for Payer: Universal American Medicare	$10.56
Rate for Payer: Wellcare Medicare	$10.56
Rate for Payer: Wellmed Medicare	$10.56

COMPRESSION PLATE U-SHAPED - 17X20MM

Facility

$26,459.12

Service Code	HCPCS C1713
Hospital Charge Code	993183
Hospital Revenue Code	278
Min. Negotiated Rate	$6,614.78
Max. Negotiated Rate	$13,229.56
Rate for Payer: Cash Price	$17,992.20
Rate for Payer: Cigna Commercial	$6,614.78
Rate for Payer: Multiplan Auto	$13,229.56
Rate for Payer: Multiplan Commercial	$13,229.56
Rate for Payer: Multiplan Workers Comp	$13,229.56
Rate for Payer: Scott and White EPO/PPO	$13,229.56

COMPRESSION PLATE U-SHAPED - 17X20MM

Facility

$26,459.12

Service Code	HCPCS C1713
Hospital Charge Code	993183
Hospital Revenue Code	278
Min. Negotiated Rate	$2,381.32
Max. Negotiated Rate	$19,050.57
Rate for Payer: Amerigroup CHIP/Medicaid	$2,381.32
Rate for Payer: BCBS of TX Blue Advantage	$7,937.74
Rate for Payer: BCBS of TX Blue Essentials	$9,525.28
Rate for Payer: BCBS of TX PPO	$10,583.65
Rate for Payer: Cash Price	$17,992.20
Rate for Payer: Cigna Medicaid	$19,050.57
Rate for Payer: Molina CHIP/Medicaid	$19,050.57
Rate for Payer: Multiplan Auto	$13,229.56
Rate for Payer: Multiplan Commercial	$13,229.56
Rate for Payer: Multiplan Workers Comp	$13,229.56
Rate for Payer: Parkland Medicaid	$19,050.57
Rate for Payer: Scott and White EPO/PPO	$13,229.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,050.57
Rate for Payer: Superior Health Plan EPO	$3,598.44

Compression Screw

Facility

$8,102.41

Service Code	HCPCS C1713
Hospital Charge Code	993119
Hospital Revenue Code	278
Min. Negotiated Rate	$729.22
Max. Negotiated Rate	$5,833.74
Rate for Payer: Amerigroup CHIP/Medicaid	$729.22
Rate for Payer: BCBS of TX Blue Advantage	$2,430.72
Rate for Payer: BCBS of TX Blue Essentials	$2,916.87
Rate for Payer: BCBS of TX PPO	$3,240.96
Rate for Payer: Cash Price	$5,509.64
Rate for Payer: Cigna Medicaid	$5,833.74
Rate for Payer: Molina CHIP/Medicaid	$5,833.74
Rate for Payer: Multiplan Auto	$4,051.20
Rate for Payer: Multiplan Commercial	$4,051.20
Rate for Payer: Multiplan Workers Comp	$4,051.20
Rate for Payer: Parkland Medicaid	$5,833.74
Rate for Payer: Scott and White EPO/PPO	$4,051.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,833.74
Rate for Payer: Superior Health Plan EPO	$1,101.93

Compression Screw

Facility

$8,102.41

Service Code	HCPCS C1713
Hospital Charge Code	993119
Hospital Revenue Code	278
Min. Negotiated Rate	$2,025.60
Max. Negotiated Rate	$4,051.20
Rate for Payer: Cash Price	$5,509.64
Rate for Payer: Cigna Commercial	$2,025.60
Rate for Payer: Multiplan Auto	$4,051.20
Rate for Payer: Multiplan Commercial	$4,051.20
Rate for Payer: Multiplan Workers Comp	$4,051.20
Rate for Payer: Scott and White EPO/PPO	$4,051.20

Compression Screw 4.0 x 44mm

Facility

$12,439.76

Service Code	HCPCS C1713
Hospital Charge Code	993120
Hospital Revenue Code	278
Min. Negotiated Rate	$1,119.58
Max. Negotiated Rate	$8,956.63
Rate for Payer: Amerigroup CHIP/Medicaid	$1,119.58
Rate for Payer: BCBS of TX Blue Advantage	$3,731.93
Rate for Payer: BCBS of TX Blue Essentials	$4,478.31
Rate for Payer: BCBS of TX PPO	$4,975.90
Rate for Payer: Cash Price	$8,459.04
Rate for Payer: Cigna Medicaid	$8,956.63
Rate for Payer: Molina CHIP/Medicaid	$8,956.63
Rate for Payer: Multiplan Auto	$6,219.88
Rate for Payer: Multiplan Commercial	$6,219.88
Rate for Payer: Multiplan Workers Comp	$6,219.88
Rate for Payer: Parkland Medicaid	$8,956.63
Rate for Payer: Scott and White EPO/PPO	$6,219.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,956.63
Rate for Payer: Superior Health Plan EPO	$1,691.81

Compression Screw 4.0 x 44mm

Facility

$12,439.76

Service Code	HCPCS C1713
Hospital Charge Code	993120
Hospital Revenue Code	278
Min. Negotiated Rate	$3,109.94
Max. Negotiated Rate	$6,219.88
Rate for Payer: Cash Price	$8,459.04
Rate for Payer: Cigna Commercial	$3,109.94
Rate for Payer: Multiplan Auto	$6,219.88
Rate for Payer: Multiplan Commercial	$6,219.88
Rate for Payer: Multiplan Workers Comp	$6,219.88
Rate for Payer: Scott and White EPO/PPO	$6,219.88

COMPRESSION SLEEVE BARIATRIC VP501B

Facility

$62.43

Hospital Charge Code	145255
Hospital Revenue Code	270
Min. Negotiated Rate	$5.62
Max. Negotiated Rate	$44.95
Rate for Payer: Amerigroup CHIP/Medicaid	$5.62
Rate for Payer: BCBS of TX Blue Advantage	$18.73
Rate for Payer: BCBS of TX Blue Essentials	$22.47
Rate for Payer: BCBS of TX PPO	$24.97
Rate for Payer: Cash Price	$42.45
Rate for Payer: Cigna Medicaid	$44.95
Rate for Payer: Molina CHIP/Medicaid	$44.95
Rate for Payer: Multiplan Auto	$40.58
Rate for Payer: Multiplan Commercial	$40.58
Rate for Payer: Multiplan Workers Comp	$40.58
Rate for Payer: Parkland Medicaid	$44.95
Rate for Payer: Scott and White EPO/PPO	$31.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44.95
Rate for Payer: Superior Health Plan EPO	$8.49

COMPRESSION SLEEVE BARIATRIC VP501B

Facility

$62.43

Hospital Charge Code	145255
Hospital Revenue Code	270
Rate for Payer: Cash Price	$42.45

Know your out-of-pocket cost for care.

All Charges