White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Critical Care Ill/Injured Patient Init 30-74 Min 99291

Facility

$3,605.00

Service Code	HCPCS 99291
Hospital Charge Code	5201678
Hospital Revenue Code	450
Min. Negotiated Rate	$258.57
Max. Negotiated Rate	$4,117.38
Rate for Payer: Amerigroup CHIP/Medicaid	$324.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$829.79
Rate for Payer: Amerigroup Medicare	$829.79
Rate for Payer: BCBS of TX Blue Advantage	$2,640.00
Rate for Payer: BCBS of TX Blue Essentials	$3,168.00
Rate for Payer: BCBS of TX Medicare	$829.79
Rate for Payer: BCBS of TX PPO	$3,520.00
Rate for Payer: Cash Price	$2,451.40
Rate for Payer: Cash Price	$2,451.40
Rate for Payer: Cash Price	$2,451.40
Rate for Payer: Cigna Commercial	$4,117.38
Rate for Payer: Cigna Medicaid	$2,595.60
Rate for Payer: Cigna Medicare	$829.79
Rate for Payer: Employer Direct Commercial	$829.79
Rate for Payer: Humana Medicare/TRICARE	$829.79
Rate for Payer: Molina CHIP/Medicaid	$2,595.60
Rate for Payer: Molina Dual Medicare/Medicaid	$829.79
Rate for Payer: Molina Medicare	$829.79
Rate for Payer: Multiplan Auto	$2,343.25
Rate for Payer: Multiplan Commercial	$2,343.25
Rate for Payer: Multiplan Workers Comp	$2,343.25
Rate for Payer: Parkland Medicaid	$2,595.60
Rate for Payer: Scott and White EPO/PPO	$258.57
Rate for Payer: Scott and White Medicare	$829.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,595.60
Rate for Payer: Superior Health Plan EPO	$829.79
Rate for Payer: Superior Health Plan Medicare	$829.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$829.79
Rate for Payer: Universal American Medicare	$829.79
Rate for Payer: Wellcare Medicare	$829.79
Rate for Payer: Wellmed Medicare	$829.79

Crossflow inflow caseette tubing

Facility

$335.10

Hospital Charge Code	993575
Hospital Revenue Code	272
Min. Negotiated Rate	$30.16
Max. Negotiated Rate	$241.27
Rate for Payer: Amerigroup CHIP/Medicaid	$30.16
Rate for Payer: BCBS of TX Blue Advantage	$100.53
Rate for Payer: BCBS of TX Blue Essentials	$120.64
Rate for Payer: BCBS of TX PPO	$134.04
Rate for Payer: Cash Price	$227.87
Rate for Payer: Cigna Medicaid	$241.27
Rate for Payer: Molina CHIP/Medicaid	$241.27
Rate for Payer: Multiplan Auto	$217.81
Rate for Payer: Multiplan Commercial	$217.81
Rate for Payer: Multiplan Workers Comp	$217.81
Rate for Payer: Parkland Medicaid	$241.27
Rate for Payer: Scott and White EPO/PPO	$167.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$241.27
Rate for Payer: Superior Health Plan EPO	$45.57

Crossflow inflow caseette tubing

Facility

$335.10

Hospital Charge Code	993575
Hospital Revenue Code	272
Rate for Payer: Cash Price	$227.87

CROSSFLOW TUBING

Facility

$335.12

Hospital Charge Code	993591
Hospital Revenue Code	272
Min. Negotiated Rate	$30.16
Max. Negotiated Rate	$241.29
Rate for Payer: Amerigroup CHIP/Medicaid	$30.16
Rate for Payer: BCBS of TX Blue Advantage	$100.54
Rate for Payer: BCBS of TX Blue Essentials	$120.64
Rate for Payer: BCBS of TX PPO	$134.05
Rate for Payer: Cash Price	$227.88
Rate for Payer: Cigna Medicaid	$241.29
Rate for Payer: Molina CHIP/Medicaid	$241.29
Rate for Payer: Multiplan Auto	$217.83
Rate for Payer: Multiplan Commercial	$217.83
Rate for Payer: Multiplan Workers Comp	$217.83
Rate for Payer: Parkland Medicaid	$241.29
Rate for Payer: Scott and White EPO/PPO	$167.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$241.29
Rate for Payer: Superior Health Plan EPO	$45.58

CROSSFLOW TUBING

Facility

$335.12

Hospital Charge Code	993591
Hospital Revenue Code	272
Rate for Payer: Cash Price	$227.88

CROSSLINK CONNECTOR 42MM

Facility

$4,012.00

Service Code	HCPCS C1713
Hospital Charge Code	146438
Hospital Revenue Code	278
Min. Negotiated Rate	$361.08
Max. Negotiated Rate	$2,888.64
Rate for Payer: Amerigroup CHIP/Medicaid	$361.08
Rate for Payer: BCBS of TX Blue Advantage	$1,203.60
Rate for Payer: BCBS of TX Blue Essentials	$1,444.32
Rate for Payer: BCBS of TX PPO	$1,604.80
Rate for Payer: Cash Price	$2,728.16
Rate for Payer: Cigna Medicaid	$2,888.64
Rate for Payer: Molina CHIP/Medicaid	$2,888.64
Rate for Payer: Multiplan Auto	$2,006.00
Rate for Payer: Multiplan Commercial	$2,006.00
Rate for Payer: Multiplan Workers Comp	$2,006.00
Rate for Payer: Parkland Medicaid	$2,888.64
Rate for Payer: Scott and White EPO/PPO	$2,006.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,888.64
Rate for Payer: Superior Health Plan EPO	$545.63

CROSSLINK CONNECTOR 42MM

Facility

$4,012.00

Service Code	HCPCS C1713
Hospital Charge Code	146438
Hospital Revenue Code	278
Min. Negotiated Rate	$1,003.00
Max. Negotiated Rate	$2,006.00
Rate for Payer: Cash Price	$2,728.16
Rate for Payer: Cigna Commercial	$1,003.00
Rate for Payer: Multiplan Auto	$2,006.00
Rate for Payer: Multiplan Commercial	$2,006.00
Rate for Payer: Multiplan Workers Comp	$2,006.00
Rate for Payer: Scott and White EPO/PPO	$2,006.00

CROSSLINK CONNECTOR 50MM

Facility

$4,012.00

Service Code	HCPCS C1713
Hospital Charge Code	146439
Hospital Revenue Code	278
Min. Negotiated Rate	$361.08
Max. Negotiated Rate	$2,888.64
Rate for Payer: Amerigroup CHIP/Medicaid	$361.08
Rate for Payer: BCBS of TX Blue Advantage	$1,203.60
Rate for Payer: BCBS of TX Blue Essentials	$1,444.32
Rate for Payer: BCBS of TX PPO	$1,604.80
Rate for Payer: Cash Price	$2,728.16
Rate for Payer: Cigna Medicaid	$2,888.64
Rate for Payer: Molina CHIP/Medicaid	$2,888.64
Rate for Payer: Multiplan Auto	$2,006.00
Rate for Payer: Multiplan Commercial	$2,006.00
Rate for Payer: Multiplan Workers Comp	$2,006.00
Rate for Payer: Parkland Medicaid	$2,888.64
Rate for Payer: Scott and White EPO/PPO	$2,006.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,888.64
Rate for Payer: Superior Health Plan EPO	$545.63

CROSSLINK CONNECTOR 50MM

Facility

$4,012.00

Service Code	HCPCS C1713
Hospital Charge Code	146439
Hospital Revenue Code	278
Min. Negotiated Rate	$1,003.00
Max. Negotiated Rate	$2,006.00
Rate for Payer: Cash Price	$2,728.16
Rate for Payer: Cigna Commercial	$1,003.00
Rate for Payer: Multiplan Auto	$2,006.00
Rate for Payer: Multiplan Commercial	$2,006.00
Rate for Payer: Multiplan Workers Comp	$2,006.00
Rate for Payer: Scott and White EPO/PPO	$2,006.00

Crossmatch Extended Interpretation -> Least Incompatible

Facility

$297.00

Service Code	HCPCS 86922
Hospital Charge Code	2400158
Hospital Revenue Code	300
Min. Negotiated Rate	$26.73
Max. Negotiated Rate	$361.78
Rate for Payer: Amerigroup CHIP/Medicaid	$26.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$171.15
Rate for Payer: Amerigroup Medicare	$171.15
Rate for Payer: BCBS of TX Blue Advantage	$89.10
Rate for Payer: BCBS of TX Blue Essentials	$106.92
Rate for Payer: BCBS of TX Medicare	$171.15
Rate for Payer: BCBS of TX PPO	$118.80
Rate for Payer: Cash Price	$201.96
Rate for Payer: Cash Price	$201.96
Rate for Payer: Cash Price	$201.96
Rate for Payer: Cigna Commercial	$361.78
Rate for Payer: Cigna Medicaid	$213.84
Rate for Payer: Cigna Medicare	$171.15
Rate for Payer: Employer Direct Commercial	$171.15
Rate for Payer: Humana Medicare/TRICARE	$171.15
Rate for Payer: Molina CHIP/Medicaid	$213.84
Rate for Payer: Molina Dual Medicare/Medicaid	$171.15
Rate for Payer: Molina Medicare	$171.15
Rate for Payer: Multiplan Auto	$193.05
Rate for Payer: Multiplan Commercial	$193.05
Rate for Payer: Multiplan Workers Comp	$193.05
Rate for Payer: Parkland Medicaid	$213.84
Rate for Payer: Scott and White EPO/PPO	$234.31
Rate for Payer: Scott and White Medicare	$171.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$213.84
Rate for Payer: Superior Health Plan EPO	$171.15
Rate for Payer: Superior Health Plan Medicare	$171.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$171.15
Rate for Payer: Universal American Medicare	$171.15
Rate for Payer: Wellcare Medicare	$171.15
Rate for Payer: Wellmed Medicare	$171.15

Crossmatch Extended Interpretation -> Least Incompatible

Facility

$297.00

Service Code	HCPCS 86922
Hospital Charge Code	2400158
Hospital Revenue Code	300
Rate for Payer: Cash Price	$201.96

CRTD COBALT XT HF QUAD MRI IS4 DF4

Facility

$96,686.75

Service Code	HCPCS C1882
Hospital Charge Code	991305
Hospital Revenue Code	278
Min. Negotiated Rate	$24,171.69
Max. Negotiated Rate	$48,343.38
Rate for Payer: Cash Price	$65,746.99
Rate for Payer: Cigna Commercial	$24,171.69
Rate for Payer: Multiplan Auto	$48,343.38
Rate for Payer: Multiplan Commercial	$48,343.38
Rate for Payer: Multiplan Workers Comp	$48,343.38
Rate for Payer: Scott and White EPO/PPO	$48,343.38

CRTD COBALT XT HF QUAD MRI IS4 DF4

Facility

$96,686.75

Service Code	HCPCS C1882
Hospital Charge Code	991305
Hospital Revenue Code	278
Min. Negotiated Rate	$8,701.81
Max. Negotiated Rate	$69,614.46
Rate for Payer: Amerigroup CHIP/Medicaid	$8,701.81
Rate for Payer: BCBS of TX Blue Advantage	$29,006.03
Rate for Payer: BCBS of TX Blue Essentials	$34,807.23
Rate for Payer: BCBS of TX PPO	$38,674.70
Rate for Payer: Cash Price	$65,746.99
Rate for Payer: Cigna Medicaid	$69,614.46
Rate for Payer: Molina CHIP/Medicaid	$69,614.46
Rate for Payer: Multiplan Auto	$48,343.38
Rate for Payer: Multiplan Commercial	$48,343.38
Rate for Payer: Multiplan Workers Comp	$48,343.38
Rate for Payer: Parkland Medicaid	$69,614.46
Rate for Payer: Scott and White EPO/PPO	$48,343.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69,614.46
Rate for Payer: Superior Health Plan EPO	$13,149.40

Cruciate retaining femoral

Facility

$14,457.83

Service Code	HCPCS C1734
Hospital Charge Code	992213
Hospital Revenue Code	278
Min. Negotiated Rate	$3,614.46
Max. Negotiated Rate	$7,228.91
Rate for Payer: Cash Price	$9,831.32
Rate for Payer: Cigna Commercial	$3,614.46
Rate for Payer: Multiplan Auto	$7,228.91
Rate for Payer: Multiplan Commercial	$7,228.91
Rate for Payer: Multiplan Workers Comp	$7,228.91
Rate for Payer: Scott and White EPO/PPO	$7,228.91

Cruciate retaining femoral

Facility

$14,457.83

Service Code	HCPCS C1734
Hospital Charge Code	992213
Hospital Revenue Code	278
Min. Negotiated Rate	$1,301.20
Max. Negotiated Rate	$10,409.64
Rate for Payer: Amerigroup CHIP/Medicaid	$1,301.20
Rate for Payer: BCBS of TX Blue Advantage	$4,337.35
Rate for Payer: BCBS of TX Blue Essentials	$5,204.82
Rate for Payer: BCBS of TX PPO	$5,783.13
Rate for Payer: Cash Price	$9,831.32
Rate for Payer: Cigna Medicaid	$10,409.64
Rate for Payer: Molina CHIP/Medicaid	$10,409.64
Rate for Payer: Multiplan Auto	$7,228.91
Rate for Payer: Multiplan Commercial	$7,228.91
Rate for Payer: Multiplan Workers Comp	$7,228.91
Rate for Payer: Parkland Medicaid	$10,409.64
Rate for Payer: Scott and White EPO/PPO	$7,228.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,409.64
Rate for Payer: Superior Health Plan EPO	$1,966.26

CRUTCH, ALUMINUM, ADULT, MED, LF, 300LB

Facility

$72.41

Hospital Charge Code	993946
Hospital Revenue Code	274
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$52.14
Rate for Payer: Amerigroup CHIP/Medicaid	$6.52
Rate for Payer: BCBS of TX Blue Advantage	$21.72
Rate for Payer: BCBS of TX Blue Essentials	$26.07
Rate for Payer: BCBS of TX PPO	$28.96
Rate for Payer: Cash Price	$49.24
Rate for Payer: Cigna Medicaid	$52.14
Rate for Payer: Molina CHIP/Medicaid	$52.14
Rate for Payer: Multiplan Auto	$36.20
Rate for Payer: Multiplan Commercial	$36.20
Rate for Payer: Multiplan Workers Comp	$36.20
Rate for Payer: Parkland Medicaid	$52.14
Rate for Payer: Scott and White EPO/PPO	$36.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.14
Rate for Payer: Superior Health Plan EPO	$9.85

CRUTCH, ALUMINUM, ADULT, MED, LF, 300LB

Facility

$72.41

Hospital Charge Code	993946
Hospital Revenue Code	274
Min. Negotiated Rate	$18.10
Max. Negotiated Rate	$36.20
Rate for Payer: Cash Price	$49.24
Rate for Payer: Cigna Commercial	$18.10
Rate for Payer: Multiplan Auto	$36.20
Rate for Payer: Multiplan Commercial	$36.20
Rate for Payer: Multiplan Workers Comp	$36.20
Rate for Payer: Scott and White EPO/PPO	$36.20

CRUTCH, ALUMINUM, YOUTH, LF, 300LB

Facility

$56.11

Hospital Charge Code	993945
Hospital Revenue Code	274
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$40.40
Rate for Payer: Amerigroup CHIP/Medicaid	$5.05
Rate for Payer: BCBS of TX Blue Advantage	$16.83
Rate for Payer: BCBS of TX Blue Essentials	$20.20
Rate for Payer: BCBS of TX PPO	$22.44
Rate for Payer: Cash Price	$38.15
Rate for Payer: Cigna Medicaid	$40.40
Rate for Payer: Molina CHIP/Medicaid	$40.40
Rate for Payer: Multiplan Auto	$28.05
Rate for Payer: Multiplan Commercial	$28.05
Rate for Payer: Multiplan Workers Comp	$28.05
Rate for Payer: Parkland Medicaid	$40.40
Rate for Payer: Scott and White EPO/PPO	$28.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.40
Rate for Payer: Superior Health Plan EPO	$7.63

CRUTCH, ALUMINUM, YOUTH, LF, 300LB

Facility

$56.11

Hospital Charge Code	993945
Hospital Revenue Code	274
Min. Negotiated Rate	$14.03
Max. Negotiated Rate	$28.05
Rate for Payer: Cash Price	$38.15
Rate for Payer: Cigna Commercial	$14.03
Rate for Payer: Multiplan Auto	$28.05
Rate for Payer: Multiplan Commercial	$28.05
Rate for Payer: Multiplan Workers Comp	$28.05
Rate for Payer: Scott and White EPO/PPO	$28.05

CRUTCHES, ADULT, 45-53

Facility

$48.62

Hospital Charge Code	993919
Hospital Revenue Code	274
Min. Negotiated Rate	$4.38
Max. Negotiated Rate	$35.01
Rate for Payer: Amerigroup CHIP/Medicaid	$4.38
Rate for Payer: BCBS of TX Blue Advantage	$14.59
Rate for Payer: BCBS of TX Blue Essentials	$17.50
Rate for Payer: BCBS of TX PPO	$19.45
Rate for Payer: Cash Price	$33.06
Rate for Payer: Cigna Medicaid	$35.01
Rate for Payer: Molina CHIP/Medicaid	$35.01
Rate for Payer: Multiplan Auto	$24.31
Rate for Payer: Multiplan Commercial	$24.31
Rate for Payer: Multiplan Workers Comp	$24.31
Rate for Payer: Parkland Medicaid	$35.01
Rate for Payer: Scott and White EPO/PPO	$24.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.01
Rate for Payer: Superior Health Plan EPO	$6.61

CRUTCHES, ADULT, 45-53

Facility

$48.62

Hospital Charge Code	993919
Hospital Revenue Code	274
Min. Negotiated Rate	$12.15
Max. Negotiated Rate	$24.31
Rate for Payer: Cash Price	$33.06
Rate for Payer: Cigna Commercial	$12.15
Rate for Payer: Multiplan Auto	$24.31
Rate for Payer: Multiplan Commercial	$24.31
Rate for Payer: Multiplan Workers Comp	$24.31
Rate for Payer: Scott and White EPO/PPO	$24.31

CRUTCHES, TALL ADULT,53-61

Facility

$53.53

Hospital Charge Code	993965
Hospital Revenue Code	274
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$38.54
Rate for Payer: Amerigroup CHIP/Medicaid	$4.82
Rate for Payer: BCBS of TX Blue Advantage	$16.06
Rate for Payer: BCBS of TX Blue Essentials	$19.27
Rate for Payer: BCBS of TX PPO	$21.41
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cigna Medicaid	$38.54
Rate for Payer: Molina CHIP/Medicaid	$38.54
Rate for Payer: Multiplan Auto	$26.77
Rate for Payer: Multiplan Commercial	$26.77
Rate for Payer: Multiplan Workers Comp	$26.77
Rate for Payer: Parkland Medicaid	$38.54
Rate for Payer: Scott and White EPO/PPO	$26.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.54
Rate for Payer: Superior Health Plan EPO	$7.28

CRUTCHES, TALL ADULT,53-61

Facility

$53.53

Hospital Charge Code	993965
Hospital Revenue Code	274
Min. Negotiated Rate	$13.38
Max. Negotiated Rate	$26.77
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cigna Commercial	$13.38
Rate for Payer: Multiplan Auto	$26.77
Rate for Payer: Multiplan Commercial	$26.77
Rate for Payer: Multiplan Workers Comp	$26.77
Rate for Payer: Scott and White EPO/PPO	$26.77

Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips

Facility

$39.00

Service Code	HCPCS E0114
Hospital Charge Code	131433
Hospital Revenue Code	270
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$92.33
Rate for Payer: Amerigroup CHIP/Medicaid	$3.51
Rate for Payer: BCBS of TX Blue Advantage	$69.37
Rate for Payer: BCBS of TX Blue Essentials	$83.24
Rate for Payer: BCBS of TX PPO	$92.33
Rate for Payer: Cash Price	$26.52
Rate for Payer: Cash Price	$26.52
Rate for Payer: Cigna Medicaid	$28.08
Rate for Payer: Molina CHIP/Medicaid	$28.08
Rate for Payer: Multiplan Auto	$25.35
Rate for Payer: Multiplan Commercial	$25.35
Rate for Payer: Multiplan Workers Comp	$25.35
Rate for Payer: Parkland Medicaid	$28.08
Rate for Payer: Scott and White EPO/PPO	$19.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.08
Rate for Payer: Superior Health Plan EPO	$5.30

Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips

Facility

$250.00

Service Code	HCPCS E0114
Hospital Charge Code	990952
Hospital Revenue Code	270
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$180.00
Rate for Payer: Amerigroup CHIP/Medicaid	$22.50
Rate for Payer: BCBS of TX Blue Advantage	$69.37
Rate for Payer: BCBS of TX Blue Essentials	$83.24
Rate for Payer: BCBS of TX PPO	$92.33
Rate for Payer: Cash Price	$170.00
Rate for Payer: Cash Price	$170.00
Rate for Payer: Cigna Medicaid	$180.00
Rate for Payer: Molina CHIP/Medicaid	$180.00
Rate for Payer: Multiplan Auto	$162.50
Rate for Payer: Multiplan Commercial	$162.50
Rate for Payer: Multiplan Workers Comp	$162.50
Rate for Payer: Parkland Medicaid	$180.00
Rate for Payer: Scott and White EPO/PPO	$125.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.00
Rate for Payer: Superior Health Plan EPO	$34.00

Know your out-of-pocket cost for care.

All Charges