White Rock Medical Center

All Charges

Charge

Type

Setting

Price

71342803 ; 71322046; 75018402

Facility

$19,277.11

Service Code	HCPCS C1734
Hospital Charge Code	994098
Hospital Revenue Code	278
Min. Negotiated Rate	$1,734.94
Max. Negotiated Rate	$13,879.52
Rate for Payer: Amerigroup CHIP/Medicaid	$1,734.94
Rate for Payer: BCBS of TX Blue Advantage	$5,783.13
Rate for Payer: BCBS of TX Blue Essentials	$6,939.76
Rate for Payer: BCBS of TX PPO	$7,710.84
Rate for Payer: Cash Price	$13,108.43
Rate for Payer: Cigna Medicaid	$13,879.52
Rate for Payer: Molina CHIP/Medicaid	$13,879.52
Rate for Payer: Multiplan Auto	$9,638.56
Rate for Payer: Multiplan Commercial	$9,638.56
Rate for Payer: Multiplan Workers Comp	$9,638.56
Rate for Payer: Parkland Medicaid	$13,879.52
Rate for Payer: Scott and White EPO/PPO	$9,638.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,879.52
Rate for Payer: Superior Health Plan EPO	$2,621.69

71421215 71424003 71424223 71424202 71452315

Facility

$17,702.41

Service Code	HCPCS C1776
Hospital Charge Code	994083
Hospital Revenue Code	278
Min. Negotiated Rate	$1,593.22
Max. Negotiated Rate	$12,745.74
Rate for Payer: Amerigroup CHIP/Medicaid	$1,593.22
Rate for Payer: BCBS of TX Blue Advantage	$5,310.72
Rate for Payer: BCBS of TX Blue Essentials	$6,372.87
Rate for Payer: BCBS of TX PPO	$7,080.96
Rate for Payer: Cash Price	$12,037.64
Rate for Payer: Cigna Medicaid	$12,745.74
Rate for Payer: Molina CHIP/Medicaid	$12,745.74
Rate for Payer: Multiplan Auto	$8,851.20
Rate for Payer: Multiplan Commercial	$8,851.20
Rate for Payer: Multiplan Workers Comp	$8,851.20
Rate for Payer: Parkland Medicaid	$12,745.74
Rate for Payer: Scott and White EPO/PPO	$8,851.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,745.74
Rate for Payer: Superior Health Plan EPO	$2,407.53

71421215 71424003 71424223 71424202 71452315

Facility

$17,702.41

Service Code	HCPCS C1776
Hospital Charge Code	994083
Hospital Revenue Code	278
Min. Negotiated Rate	$4,425.60
Max. Negotiated Rate	$8,851.20
Rate for Payer: Cash Price	$12,037.64
Rate for Payer: Cigna Commercial	$4,425.60
Rate for Payer: Multiplan Auto	$8,851.20
Rate for Payer: Multiplan Commercial	$8,851.20
Rate for Payer: Multiplan Workers Comp	$8,851.20
Rate for Payer: Scott and White EPO/PPO	$8,851.20

71631121

Facility

$5,012.04

Service Code	HCPCS A4649
Hospital Charge Code	994137
Hospital Revenue Code	272
Min. Negotiated Rate	$451.08
Max. Negotiated Rate	$3,608.67
Rate for Payer: Amerigroup CHIP/Medicaid	$451.08
Rate for Payer: BCBS of TX Blue Advantage	$1,503.61
Rate for Payer: BCBS of TX Blue Essentials	$1,804.33
Rate for Payer: BCBS of TX PPO	$2,004.82
Rate for Payer: Cash Price	$3,408.19
Rate for Payer: Cigna Medicaid	$3,608.67
Rate for Payer: Molina CHIP/Medicaid	$3,608.67
Rate for Payer: Multiplan Auto	$3,257.83
Rate for Payer: Multiplan Commercial	$3,257.83
Rate for Payer: Multiplan Workers Comp	$3,257.83
Rate for Payer: Parkland Medicaid	$3,608.67
Rate for Payer: Scott and White EPO/PPO	$2,506.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,608.67
Rate for Payer: Superior Health Plan EPO	$681.64

71631121

Facility

$5,012.04

Service Code	HCPCS A4649
Hospital Charge Code	994137
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,408.19

71631121-2

Facility

$3,632.53

Service Code	HCPCS A4649
Hospital Charge Code	994138
Hospital Revenue Code	272
Min. Negotiated Rate	$326.93
Max. Negotiated Rate	$2,615.42
Rate for Payer: Amerigroup CHIP/Medicaid	$326.93
Rate for Payer: BCBS of TX Blue Advantage	$1,089.76
Rate for Payer: BCBS of TX Blue Essentials	$1,307.71
Rate for Payer: BCBS of TX PPO	$1,453.01
Rate for Payer: Cash Price	$2,470.12
Rate for Payer: Cigna Medicaid	$2,615.42
Rate for Payer: Molina CHIP/Medicaid	$2,615.42
Rate for Payer: Multiplan Auto	$2,361.14
Rate for Payer: Multiplan Commercial	$2,361.14
Rate for Payer: Multiplan Workers Comp	$2,361.14
Rate for Payer: Parkland Medicaid	$2,615.42
Rate for Payer: Scott and White EPO/PPO	$1,816.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,615.42
Rate for Payer: Superior Health Plan EPO	$494.02

71631121-2

Facility

$3,632.53

Service Code	HCPCS A4649
Hospital Charge Code	994138
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,470.12

71631436

Facility

$2,933.73

Service Code	HCPCS A4649
Hospital Charge Code	994136
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,994.94

71631436

Facility

$2,933.73

Service Code	HCPCS A4649
Hospital Charge Code	994136
Hospital Revenue Code	272
Min. Negotiated Rate	$264.04
Max. Negotiated Rate	$2,112.29
Rate for Payer: Amerigroup CHIP/Medicaid	$264.04
Rate for Payer: BCBS of TX Blue Advantage	$880.12
Rate for Payer: BCBS of TX Blue Essentials	$1,056.14
Rate for Payer: BCBS of TX PPO	$1,173.49
Rate for Payer: Cash Price	$1,994.94
Rate for Payer: Cigna Medicaid	$2,112.29
Rate for Payer: Molina CHIP/Medicaid	$2,112.29
Rate for Payer: Multiplan Auto	$1,906.92
Rate for Payer: Multiplan Commercial	$1,906.92
Rate for Payer: Multiplan Workers Comp	$1,906.92
Rate for Payer: Parkland Medicaid	$2,112.29
Rate for Payer: Scott and White EPO/PPO	$1,466.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,112.29
Rate for Payer: Superior Health Plan EPO	$398.99

71631626

Facility

$4,427.71

Service Code	HCPCS C1713
Hospital Charge Code	994135
Hospital Revenue Code	278
Min. Negotiated Rate	$1,106.93
Max. Negotiated Rate	$2,213.86
Rate for Payer: Cash Price	$3,010.84
Rate for Payer: Cigna Commercial	$1,106.93
Rate for Payer: Multiplan Auto	$2,213.86
Rate for Payer: Multiplan Commercial	$2,213.86
Rate for Payer: Multiplan Workers Comp	$2,213.86
Rate for Payer: Scott and White EPO/PPO	$2,213.86

71631626

Facility

$4,427.71

Service Code	HCPCS C1713
Hospital Charge Code	994135
Hospital Revenue Code	278
Min. Negotiated Rate	$398.49
Max. Negotiated Rate	$3,187.95
Rate for Payer: Amerigroup CHIP/Medicaid	$398.49
Rate for Payer: BCBS of TX Blue Advantage	$1,328.31
Rate for Payer: BCBS of TX Blue Essentials	$1,593.98
Rate for Payer: BCBS of TX PPO	$1,771.08
Rate for Payer: Cash Price	$3,010.84
Rate for Payer: Cigna Medicaid	$3,187.95
Rate for Payer: Molina CHIP/Medicaid	$3,187.95
Rate for Payer: Multiplan Auto	$2,213.86
Rate for Payer: Multiplan Commercial	$2,213.86
Rate for Payer: Multiplan Workers Comp	$2,213.86
Rate for Payer: Parkland Medicaid	$3,187.95
Rate for Payer: Scott and White EPO/PPO	$2,213.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,187.95
Rate for Payer: Superior Health Plan EPO	$602.17

7.1645E+23

Facility

$4,626.51

Service Code	HCPCS C1713
Hospital Charge Code	994140
Hospital Revenue Code	278
Min. Negotiated Rate	$1,156.63
Max. Negotiated Rate	$2,313.26
Rate for Payer: Cash Price	$3,146.03
Rate for Payer: Cigna Commercial	$1,156.63
Rate for Payer: Multiplan Auto	$2,313.26
Rate for Payer: Multiplan Commercial	$2,313.26
Rate for Payer: Multiplan Workers Comp	$2,313.26
Rate for Payer: Scott and White EPO/PPO	$2,313.26

7.1645E+23

Facility

$4,626.51

Service Code	HCPCS C1713
Hospital Charge Code	994140
Hospital Revenue Code	278
Min. Negotiated Rate	$416.39
Max. Negotiated Rate	$3,331.09
Rate for Payer: Amerigroup CHIP/Medicaid	$416.39
Rate for Payer: BCBS of TX Blue Advantage	$1,387.95
Rate for Payer: BCBS of TX Blue Essentials	$1,665.54
Rate for Payer: BCBS of TX PPO	$1,850.60
Rate for Payer: Cash Price	$3,146.03
Rate for Payer: Cigna Medicaid	$3,331.09
Rate for Payer: Molina CHIP/Medicaid	$3,331.09
Rate for Payer: Multiplan Auto	$2,313.26
Rate for Payer: Multiplan Commercial	$2,313.26
Rate for Payer: Multiplan Workers Comp	$2,313.26
Rate for Payer: Parkland Medicaid	$3,331.09
Rate for Payer: Scott and White EPO/PPO	$2,313.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,331.09
Rate for Payer: Superior Health Plan EPO	$629.21

71653032

Facility

$38,644.57

Service Code	HCPCS C1734
Hospital Charge Code	994139
Hospital Revenue Code	278
Min. Negotiated Rate	$3,478.01
Max. Negotiated Rate	$27,824.09
Rate for Payer: Amerigroup CHIP/Medicaid	$3,478.01
Rate for Payer: BCBS of TX Blue Advantage	$11,593.37
Rate for Payer: BCBS of TX Blue Essentials	$13,912.05
Rate for Payer: BCBS of TX PPO	$15,457.83
Rate for Payer: Cash Price	$26,278.31
Rate for Payer: Cigna Medicaid	$27,824.09
Rate for Payer: Molina CHIP/Medicaid	$27,824.09
Rate for Payer: Multiplan Auto	$19,322.28
Rate for Payer: Multiplan Commercial	$19,322.28
Rate for Payer: Multiplan Workers Comp	$19,322.28
Rate for Payer: Parkland Medicaid	$27,824.09
Rate for Payer: Scott and White EPO/PPO	$19,322.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,824.09
Rate for Payer: Superior Health Plan EPO	$5,255.66

71653032

Facility

$38,644.57

Service Code	HCPCS C1734
Hospital Charge Code	994139
Hospital Revenue Code	278
Min. Negotiated Rate	$9,661.14
Max. Negotiated Rate	$19,322.28
Rate for Payer: Cash Price	$26,278.31
Rate for Payer: Cigna Commercial	$9,661.14
Rate for Payer: Multiplan Auto	$19,322.28
Rate for Payer: Multiplan Commercial	$19,322.28
Rate for Payer: Multiplan Workers Comp	$19,322.28
Rate for Payer: Scott and White EPO/PPO	$19,322.28

7236-2-844

Facility

$4,993.48

Service Code	HCPCS C1776
Hospital Charge Code	994001
Hospital Revenue Code	278
Min. Negotiated Rate	$1,248.37
Max. Negotiated Rate	$2,496.74
Rate for Payer: Cash Price	$3,395.57
Rate for Payer: Cigna Commercial	$1,248.37
Rate for Payer: Multiplan Auto	$2,496.74
Rate for Payer: Multiplan Commercial	$2,496.74
Rate for Payer: Multiplan Workers Comp	$2,496.74
Rate for Payer: Scott and White EPO/PPO	$2,496.74

7236-2-844

Facility

$4,993.48

Service Code	HCPCS C1776
Hospital Charge Code	994001
Hospital Revenue Code	278
Min. Negotiated Rate	$449.41
Max. Negotiated Rate	$3,595.31
Rate for Payer: Amerigroup CHIP/Medicaid	$449.41
Rate for Payer: BCBS of TX Blue Advantage	$1,498.04
Rate for Payer: BCBS of TX Blue Essentials	$1,797.65
Rate for Payer: BCBS of TX PPO	$1,997.39
Rate for Payer: Cash Price	$3,395.57
Rate for Payer: Cigna Medicaid	$3,595.31
Rate for Payer: Molina CHIP/Medicaid	$3,595.31
Rate for Payer: Multiplan Auto	$2,496.74
Rate for Payer: Multiplan Commercial	$2,496.74
Rate for Payer: Multiplan Workers Comp	$2,496.74
Rate for Payer: Parkland Medicaid	$3,595.31
Rate for Payer: Scott and White EPO/PPO	$2,496.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,595.31
Rate for Payer: Superior Health Plan EPO	$679.11

74177 CT ABDOMEN+PELVIS WITH CONTRAST

Facility

$7,920.00

Service Code	HCPCS 74177
Hospital Charge Code	3890211
Hospital Revenue Code	352
Min. Negotiated Rate	$312.08
Max. Negotiated Rate	$5,702.40
Rate for Payer: Amerigroup CHIP/Medicaid	$312.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX Medicare	$350.46
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$5,385.60
Rate for Payer: Cash Price	$5,385.60
Rate for Payer: Cash Price	$5,385.60
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$5,702.40
Rate for Payer: Cigna Medicare	$350.46
Rate for Payer: Employer Direct Commercial	$350.46
Rate for Payer: Humana Medicare/TRICARE	$350.46
Rate for Payer: Molina CHIP/Medicaid	$5,702.40
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$5,148.00
Rate for Payer: Multiplan Commercial	$5,148.00
Rate for Payer: Multiplan Workers Comp	$5,148.00
Rate for Payer: Parkland Medicaid	$5,702.40
Rate for Payer: Scott and White EPO/PPO	$384.68
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,702.40
Rate for Payer: Superior Health Plan EPO	$350.46
Rate for Payer: Superior Health Plan Medicare	$350.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$350.46
Rate for Payer: Universal American Medicare	$350.46
Rate for Payer: Wellcare Medicare	$350.46
Rate for Payer: Wellmed Medicare	$350.46

74177 CT ABDOMEN+PELVIS WITH CONTRAST

Facility

$7,920.00

Service Code	HCPCS 74177
Hospital Charge Code	3890211
Hospital Revenue Code	352
Rate for Payer: Cash Price	$5,385.60

777353402

Facility

$1,155.30

Service Code	HCPCS C1713
Hospital Charge Code	994021
Hospital Revenue Code	278
Min. Negotiated Rate	$288.82
Max. Negotiated Rate	$577.65
Rate for Payer: Cash Price	$785.60
Rate for Payer: Cigna Commercial	$288.82
Rate for Payer: Multiplan Auto	$577.65
Rate for Payer: Multiplan Commercial	$577.65
Rate for Payer: Multiplan Workers Comp	$577.65
Rate for Payer: Scott and White EPO/PPO	$577.65

777353402

Facility

$1,155.30

Service Code	HCPCS C1713
Hospital Charge Code	994021
Hospital Revenue Code	278
Min. Negotiated Rate	$103.98
Max. Negotiated Rate	$831.82
Rate for Payer: Amerigroup CHIP/Medicaid	$103.98
Rate for Payer: BCBS of TX Blue Advantage	$346.59
Rate for Payer: BCBS of TX Blue Essentials	$415.91
Rate for Payer: BCBS of TX PPO	$462.12
Rate for Payer: Cash Price	$785.60
Rate for Payer: Cigna Medicaid	$831.82
Rate for Payer: Molina CHIP/Medicaid	$831.82
Rate for Payer: Multiplan Auto	$577.65
Rate for Payer: Multiplan Commercial	$577.65
Rate for Payer: Multiplan Workers Comp	$577.65
Rate for Payer: Parkland Medicaid	$831.82
Rate for Payer: Scott and White EPO/PPO	$577.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$831.82
Rate for Payer: Superior Health Plan EPO	$157.12

777353422

Facility

$1,437.95

Service Code	HCPCS C1713
Hospital Charge Code	991315
Hospital Revenue Code	278
Min. Negotiated Rate	$359.49
Max. Negotiated Rate	$718.98
Rate for Payer: Cash Price	$977.81
Rate for Payer: Cigna Commercial	$359.49
Rate for Payer: Multiplan Auto	$718.98
Rate for Payer: Multiplan Commercial	$718.98
Rate for Payer: Multiplan Workers Comp	$718.98
Rate for Payer: Scott and White EPO/PPO	$718.98

777353422

Facility

$1,437.95

Service Code	HCPCS C1713
Hospital Charge Code	991315
Hospital Revenue Code	278
Min. Negotiated Rate	$129.42
Max. Negotiated Rate	$1,035.32
Rate for Payer: Amerigroup CHIP/Medicaid	$129.42
Rate for Payer: BCBS of TX Blue Advantage	$431.38
Rate for Payer: BCBS of TX Blue Essentials	$517.66
Rate for Payer: BCBS of TX PPO	$575.18
Rate for Payer: Cash Price	$977.81
Rate for Payer: Cigna Medicaid	$1,035.32
Rate for Payer: Molina CHIP/Medicaid	$1,035.32
Rate for Payer: Multiplan Auto	$718.98
Rate for Payer: Multiplan Commercial	$718.98
Rate for Payer: Multiplan Workers Comp	$718.98
Rate for Payer: Parkland Medicaid	$1,035.32
Rate for Payer: Scott and White EPO/PPO	$718.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,035.32
Rate for Payer: Superior Health Plan EPO	$195.56

777353622

Facility

$1,307.00

Service Code	HCPCS C1713
Hospital Charge Code	991020
Hospital Revenue Code	278
Min. Negotiated Rate	$117.63
Max. Negotiated Rate	$941.04
Rate for Payer: Amerigroup CHIP/Medicaid	$117.63
Rate for Payer: BCBS of TX Blue Advantage	$392.10
Rate for Payer: BCBS of TX Blue Essentials	$470.52
Rate for Payer: BCBS of TX PPO	$522.80
Rate for Payer: Cash Price	$888.76
Rate for Payer: Cigna Medicaid	$941.04
Rate for Payer: Molina CHIP/Medicaid	$941.04
Rate for Payer: Multiplan Auto	$653.50
Rate for Payer: Multiplan Commercial	$653.50
Rate for Payer: Multiplan Workers Comp	$653.50
Rate for Payer: Parkland Medicaid	$941.04
Rate for Payer: Scott and White EPO/PPO	$653.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.04
Rate for Payer: Superior Health Plan EPO	$177.75

777353622

Facility

$1,307.00

Service Code	HCPCS C1713
Hospital Charge Code	991020
Hospital Revenue Code	278
Min. Negotiated Rate	$326.75
Max. Negotiated Rate	$653.50
Rate for Payer: Cash Price	$888.76
Rate for Payer: Cigna Commercial	$326.75
Rate for Payer: Multiplan Auto	$653.50
Rate for Payer: Multiplan Commercial	$653.50
Rate for Payer: Multiplan Workers Comp	$653.50
Rate for Payer: Scott and White EPO/PPO	$653.50

Know your out-of-pocket cost for care.

All Charges