White Rock Medical Center

All Charges

Charge

Type

Setting

Price

D2N25030D2N25036DSDS0020

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	991160
Hospital Revenue Code	278
Min. Negotiated Rate	$143.73
Max. Negotiated Rate	$1,149.83
Rate for Payer: Amerigroup CHIP/Medicaid	$143.73
Rate for Payer: BCBS of TX Blue Advantage	$479.10
Rate for Payer: BCBS of TX Blue Essentials	$574.92
Rate for Payer: BCBS of TX PPO	$638.80
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Medicaid	$1,149.83
Rate for Payer: Molina CHIP/Medicaid	$1,149.83
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Parkland Medicaid	$1,149.83
Rate for Payer: Scott and White EPO/PPO	$798.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,149.83
Rate for Payer: Superior Health Plan EPO	$217.19

D2N25030D2N25036DSDS0020

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	991160
Hospital Revenue Code	278
Min. Negotiated Rate	$399.25
Max. Negotiated Rate	$798.50
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Commercial	$399.25
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Scott and White EPO/PPO	$798.50

dall miles cable

Facility

$1,457.34

Hospital Charge Code	8666515
Hospital Revenue Code	272
Rate for Payer: Cash Price	$990.99

dall miles cable

Facility

$1,457.34

Hospital Charge Code	8666515
Hospital Revenue Code	272
Min. Negotiated Rate	$131.16
Max. Negotiated Rate	$1,049.28
Rate for Payer: Amerigroup CHIP/Medicaid	$131.16
Rate for Payer: BCBS of TX Blue Advantage	$437.20
Rate for Payer: BCBS of TX Blue Essentials	$524.64
Rate for Payer: BCBS of TX PPO	$582.94
Rate for Payer: Cash Price	$990.99
Rate for Payer: Cigna Medicaid	$1,049.28
Rate for Payer: Molina CHIP/Medicaid	$1,049.28
Rate for Payer: Multiplan Auto	$947.27
Rate for Payer: Multiplan Commercial	$947.27
Rate for Payer: Multiplan Workers Comp	$947.27
Rate for Payer: Parkland Medicaid	$1,049.28
Rate for Payer: Scott and White EPO/PPO	$728.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,049.28
Rate for Payer: Superior Health Plan EPO	$198.20

DAPTOmycin 500 mg IV Inj

Facility

$128.17

Service Code	HCPCS J0878
Hospital Charge Code	77492294
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

DAPTOmycin 500 mg IV Inj

Facility

$128.17

Service Code	HCPCS J0878
Hospital Charge Code	77492294
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.81
Rate for Payer: BCBS of TX Blue Essentials	$0.97
Rate for Payer: BCBS of TX PPO	$1.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

DARCO 7.0 HEADLESS SCREW 16X40 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	992289
Hospital Revenue Code	278
Min. Negotiated Rate	$446.69
Max. Negotiated Rate	$3,573.54
Rate for Payer: Amerigroup CHIP/Medicaid	$446.69
Rate for Payer: BCBS of TX Blue Advantage	$1,488.97
Rate for Payer: BCBS of TX Blue Essentials	$1,786.77
Rate for Payer: BCBS of TX PPO	$1,985.30
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Medicaid	$3,573.54
Rate for Payer: Molina CHIP/Medicaid	$3,573.54
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Parkland Medicaid	$3,573.54
Rate for Payer: Scott and White EPO/PPO	$2,481.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,573.54
Rate for Payer: Superior Health Plan EPO	$675.00

DARCO 7.0 HEADLESS SCREW 16X40 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	992289
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.81
Max. Negotiated Rate	$2,481.62
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Commercial	$1,240.81
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Scott and White EPO/PPO	$2,481.62

DARCO 7.0 HEADLESS SCREW 16X45 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	992290
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.81
Max. Negotiated Rate	$2,481.62
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Commercial	$1,240.81
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Scott and White EPO/PPO	$2,481.62

DARCO 7.0 HEADLESS SCREW 16X45 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	992290
Hospital Revenue Code	278
Min. Negotiated Rate	$446.69
Max. Negotiated Rate	$3,573.54
Rate for Payer: Amerigroup CHIP/Medicaid	$446.69
Rate for Payer: BCBS of TX Blue Advantage	$1,488.97
Rate for Payer: BCBS of TX Blue Essentials	$1,786.77
Rate for Payer: BCBS of TX PPO	$1,985.30
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Medicaid	$3,573.54
Rate for Payer: Molina CHIP/Medicaid	$3,573.54
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Parkland Medicaid	$3,573.54
Rate for Payer: Scott and White EPO/PPO	$2,481.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,573.54
Rate for Payer: Superior Health Plan EPO	$675.00

Darco 7.0 headless screw 16X75 Darco system

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992201
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.01
Max. Negotiated Rate	$2,256.03
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Commercial	$1,128.01
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Scott and White EPO/PPO	$2,256.03

Darco 7.0 headless screw 16X75 Darco system

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992201
Hospital Revenue Code	278
Min. Negotiated Rate	$406.08
Max. Negotiated Rate	$3,248.68
Rate for Payer: Amerigroup CHIP/Medicaid	$406.08
Rate for Payer: BCBS of TX Blue Advantage	$1,353.62
Rate for Payer: BCBS of TX Blue Essentials	$1,624.34
Rate for Payer: BCBS of TX PPO	$1,804.82
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Medicaid	$3,248.68
Rate for Payer: Molina CHIP/Medicaid	$3,248.68
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Parkland Medicaid	$3,248.68
Rate for Payer: Scott and White EPO/PPO	$2,256.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,248.68
Rate for Payer: Superior Health Plan EPO	$613.64

DARCO 7.0 HEADLESS SCREW 16X90 DARCO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992322
Hospital Revenue Code	278
Min. Negotiated Rate	$406.08
Max. Negotiated Rate	$3,248.68
Rate for Payer: Amerigroup CHIP/Medicaid	$406.08
Rate for Payer: BCBS of TX Blue Advantage	$1,353.62
Rate for Payer: BCBS of TX Blue Essentials	$1,624.34
Rate for Payer: BCBS of TX PPO	$1,804.82
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Medicaid	$3,248.68
Rate for Payer: Molina CHIP/Medicaid	$3,248.68
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Parkland Medicaid	$3,248.68
Rate for Payer: Scott and White EPO/PPO	$2,256.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,248.68
Rate for Payer: Superior Health Plan EPO	$613.64

DARCO 7.0 HEADLESS SCREW 16X90 DARCO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992322
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.01
Max. Negotiated Rate	$2,256.03
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Commercial	$1,128.01
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Scott and White EPO/PPO	$2,256.03

DARCO 7.0 HEADLESS SCREW 32X100 DARCO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992269
Hospital Revenue Code	278
Min. Negotiated Rate	$406.08
Max. Negotiated Rate	$3,248.68
Rate for Payer: Amerigroup CHIP/Medicaid	$406.08
Rate for Payer: BCBS of TX Blue Advantage	$1,353.62
Rate for Payer: BCBS of TX Blue Essentials	$1,624.34
Rate for Payer: BCBS of TX PPO	$1,804.82
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Medicaid	$3,248.68
Rate for Payer: Molina CHIP/Medicaid	$3,248.68
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Parkland Medicaid	$3,248.68
Rate for Payer: Scott and White EPO/PPO	$2,256.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,248.68
Rate for Payer: Superior Health Plan EPO	$613.64

DARCO 7.0 HEADLESS SCREW 32X100 DARCO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992269
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.01
Max. Negotiated Rate	$2,256.03
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Commercial	$1,128.01
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Scott and White EPO/PPO	$2,256.03

DARCO 7.0 HEADLESS SCREW 32X110 DARCO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992270
Hospital Revenue Code	278
Min. Negotiated Rate	$406.08
Max. Negotiated Rate	$3,248.68
Rate for Payer: Amerigroup CHIP/Medicaid	$406.08
Rate for Payer: BCBS of TX Blue Advantage	$1,353.62
Rate for Payer: BCBS of TX Blue Essentials	$1,624.34
Rate for Payer: BCBS of TX PPO	$1,804.82
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Medicaid	$3,248.68
Rate for Payer: Molina CHIP/Medicaid	$3,248.68
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Parkland Medicaid	$3,248.68
Rate for Payer: Scott and White EPO/PPO	$2,256.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,248.68
Rate for Payer: Superior Health Plan EPO	$613.64

DARCO 7.0 HEADLESS SCREW 32X110 DARCO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992270
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.01
Max. Negotiated Rate	$2,256.03
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Commercial	$1,128.01
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Scott and White EPO/PPO	$2,256.03

DARCO 7.0 HEADLESS SCREW 32X75 DARGO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992304
Hospital Revenue Code	278
Min. Negotiated Rate	$406.08
Max. Negotiated Rate	$3,248.68
Rate for Payer: Amerigroup CHIP/Medicaid	$406.08
Rate for Payer: BCBS of TX Blue Advantage	$1,353.62
Rate for Payer: BCBS of TX Blue Essentials	$1,624.34
Rate for Payer: BCBS of TX PPO	$1,804.82
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Medicaid	$3,248.68
Rate for Payer: Molina CHIP/Medicaid	$3,248.68
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Parkland Medicaid	$3,248.68
Rate for Payer: Scott and White EPO/PPO	$2,256.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,248.68
Rate for Payer: Superior Health Plan EPO	$613.64

DARCO 7.0 HEADLESS SCREW 32X75 DARGO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992304
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.01
Max. Negotiated Rate	$2,256.03
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Commercial	$1,128.01
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Scott and White EPO/PPO	$2,256.03

DARCO 7.0 HEADLESS SCREW 32X80 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	992388
Hospital Revenue Code	278
Min. Negotiated Rate	$446.69
Max. Negotiated Rate	$3,573.54
Rate for Payer: Amerigroup CHIP/Medicaid	$446.69
Rate for Payer: BCBS of TX Blue Advantage	$1,488.97
Rate for Payer: BCBS of TX Blue Essentials	$1,786.77
Rate for Payer: BCBS of TX PPO	$1,985.30
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Medicaid	$3,573.54
Rate for Payer: Molina CHIP/Medicaid	$3,573.54
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Parkland Medicaid	$3,573.54
Rate for Payer: Scott and White EPO/PPO	$2,481.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,573.54
Rate for Payer: Superior Health Plan EPO	$675.00

DARCO 7.0 HEADLESS SCREW 32X80 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	992388
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.81
Max. Negotiated Rate	$2,481.62
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Commercial	$1,240.81
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Scott and White EPO/PPO	$2,481.62

DARCO 7.0 HEADLESS SCREW 32 X 85 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	993147
Hospital Revenue Code	278
Min. Negotiated Rate	$446.69
Max. Negotiated Rate	$3,573.54
Rate for Payer: Amerigroup CHIP/Medicaid	$446.69
Rate for Payer: BCBS of TX Blue Advantage	$1,488.97
Rate for Payer: BCBS of TX Blue Essentials	$1,786.77
Rate for Payer: BCBS of TX PPO	$1,985.30
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Medicaid	$3,573.54
Rate for Payer: Molina CHIP/Medicaid	$3,573.54
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Parkland Medicaid	$3,573.54
Rate for Payer: Scott and White EPO/PPO	$2,481.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,573.54
Rate for Payer: Superior Health Plan EPO	$675.00

DARCO 7.0 HEADLESS SCREW 32 X 85 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	993147
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.81
Max. Negotiated Rate	$2,481.62
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Commercial	$1,240.81
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Scott and White EPO/PPO	$2,481.62

DARCO 7.0 HEADLESS SCREW 32X85 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	992376
Hospital Revenue Code	278
Min. Negotiated Rate	$446.69
Max. Negotiated Rate	$3,573.54
Rate for Payer: Amerigroup CHIP/Medicaid	$446.69
Rate for Payer: BCBS of TX Blue Advantage	$1,488.97
Rate for Payer: BCBS of TX Blue Essentials	$1,786.77
Rate for Payer: BCBS of TX PPO	$1,985.30
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Medicaid	$3,573.54
Rate for Payer: Molina CHIP/Medicaid	$3,573.54
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Parkland Medicaid	$3,573.54
Rate for Payer: Scott and White EPO/PPO	$2,481.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,573.54
Rate for Payer: Superior Health Plan EPO	$675.00

Know your out-of-pocket cost for care.

All Charges