White Rock Medical Center

All Charges

Charge

Type

Setting

Price

D142: INOGEN EL ICD DF4 - DR

Facility

$63,124.16

Service Code	HCPCS C1882
Hospital Charge Code	991303
Hospital Revenue Code	278
Min. Negotiated Rate	$15,781.04
Max. Negotiated Rate	$31,562.08
Rate for Payer: Cash Price	$42,924.43
Rate for Payer: Cigna Commercial	$15,781.04
Rate for Payer: Multiplan Auto	$31,562.08
Rate for Payer: Multiplan Commercial	$31,562.08
Rate for Payer: Multiplan Workers Comp	$31,562.08
Rate for Payer: Scott and White EPO/PPO	$31,562.08

D142: INOGEN EL ICD DF4 - DR

Facility

$63,124.16

Service Code	HCPCS C1882
Hospital Charge Code	991303
Hospital Revenue Code	278
Min. Negotiated Rate	$5,681.17
Max. Negotiated Rate	$45,449.40
Rate for Payer: Amerigroup CHIP/Medicaid	$5,681.17
Rate for Payer: BCBS of TX Blue Advantage	$18,937.25
Rate for Payer: BCBS of TX Blue Essentials	$22,724.70
Rate for Payer: BCBS of TX PPO	$25,249.66
Rate for Payer: Cash Price	$42,924.43
Rate for Payer: Cigna Medicaid	$45,449.40
Rate for Payer: Molina CHIP/Medicaid	$45,449.40
Rate for Payer: Multiplan Auto	$31,562.08
Rate for Payer: Multiplan Commercial	$31,562.08
Rate for Payer: Multiplan Workers Comp	$31,562.08
Rate for Payer: Parkland Medicaid	$45,449.40
Rate for Payer: Scott and White EPO/PPO	$31,562.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$45,449.40
Rate for Payer: Superior Health Plan EPO	$8,584.89

D142: INOGEN EL ICD DF4 - DR

Facility

$63,124.16

Service Code	HCPCS C1882
Hospital Charge Code	992635
Hospital Revenue Code	278
Min. Negotiated Rate	$5,681.17
Max. Negotiated Rate	$45,449.40
Rate for Payer: Amerigroup CHIP/Medicaid	$5,681.17
Rate for Payer: BCBS of TX Blue Advantage	$18,937.25
Rate for Payer: BCBS of TX Blue Essentials	$22,724.70
Rate for Payer: BCBS of TX PPO	$25,249.66
Rate for Payer: Cash Price	$42,924.43
Rate for Payer: Cigna Medicaid	$45,449.40
Rate for Payer: Molina CHIP/Medicaid	$45,449.40
Rate for Payer: Multiplan Auto	$31,562.08
Rate for Payer: Multiplan Commercial	$31,562.08
Rate for Payer: Multiplan Workers Comp	$31,562.08
Rate for Payer: Parkland Medicaid	$45,449.40
Rate for Payer: Scott and White EPO/PPO	$31,562.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$45,449.40
Rate for Payer: Superior Health Plan EPO	$8,584.89

D1N20012S

Facility

$1,188.27

Service Code	HCPCS C1713
Hospital Charge Code	991225
Hospital Revenue Code	278
Min. Negotiated Rate	$297.07
Max. Negotiated Rate	$594.13
Rate for Payer: Cash Price	$808.02
Rate for Payer: Cigna Commercial	$297.07
Rate for Payer: Multiplan Auto	$594.13
Rate for Payer: Multiplan Commercial	$594.13
Rate for Payer: Multiplan Workers Comp	$594.13
Rate for Payer: Scott and White EPO/PPO	$594.13

D1N20012S

Facility

$1,188.27

Service Code	HCPCS C1713
Hospital Charge Code	991225
Hospital Revenue Code	278
Min. Negotiated Rate	$106.94
Max. Negotiated Rate	$855.55
Rate for Payer: Amerigroup CHIP/Medicaid	$106.94
Rate for Payer: BCBS of TX Blue Advantage	$356.48
Rate for Payer: BCBS of TX Blue Essentials	$427.78
Rate for Payer: BCBS of TX PPO	$475.31
Rate for Payer: Cash Price	$808.02
Rate for Payer: Cigna Medicaid	$855.55
Rate for Payer: Molina CHIP/Medicaid	$855.55
Rate for Payer: Multiplan Auto	$594.13
Rate for Payer: Multiplan Commercial	$594.13
Rate for Payer: Multiplan Workers Comp	$594.13
Rate for Payer: Parkland Medicaid	$855.55
Rate for Payer: Scott and White EPO/PPO	$594.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$855.55
Rate for Payer: Superior Health Plan EPO	$161.60

D1N30022SD1N30034SD1N30036S

Facility

$1,199.39

Service Code	HCPCS C1713
Hospital Charge Code	991171
Hospital Revenue Code	278
Min. Negotiated Rate	$299.85
Max. Negotiated Rate	$599.70
Rate for Payer: Cash Price	$815.59
Rate for Payer: Cigna Commercial	$299.85
Rate for Payer: Multiplan Auto	$599.70
Rate for Payer: Multiplan Commercial	$599.70
Rate for Payer: Multiplan Workers Comp	$599.70
Rate for Payer: Scott and White EPO/PPO	$599.70

D1N30022SD1N30034SD1N30036S

Facility

$1,199.39

Service Code	HCPCS C1713
Hospital Charge Code	991171
Hospital Revenue Code	278
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$863.56
Rate for Payer: Amerigroup CHIP/Medicaid	$107.95
Rate for Payer: BCBS of TX Blue Advantage	$359.82
Rate for Payer: BCBS of TX Blue Essentials	$431.78
Rate for Payer: BCBS of TX PPO	$479.76
Rate for Payer: Cash Price	$815.59
Rate for Payer: Cigna Medicaid	$863.56
Rate for Payer: Molina CHIP/Medicaid	$863.56
Rate for Payer: Multiplan Auto	$599.70
Rate for Payer: Multiplan Commercial	$599.70
Rate for Payer: Multiplan Workers Comp	$599.70
Rate for Payer: Parkland Medicaid	$863.56
Rate for Payer: Scott and White EPO/PPO	$599.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$863.56
Rate for Payer: Superior Health Plan EPO	$163.12

D2N25024

Facility

$1,636.42

Service Code	HCPCS C1713
Hospital Charge Code	991226
Hospital Revenue Code	278
Min. Negotiated Rate	$409.11
Max. Negotiated Rate	$818.21
Rate for Payer: Cash Price	$1,112.77
Rate for Payer: Cigna Commercial	$409.11
Rate for Payer: Multiplan Auto	$818.21
Rate for Payer: Multiplan Commercial	$818.21
Rate for Payer: Multiplan Workers Comp	$818.21
Rate for Payer: Scott and White EPO/PPO	$818.21

D2N25024

Facility

$1,636.42

Service Code	HCPCS C1713
Hospital Charge Code	991226
Hospital Revenue Code	278
Min. Negotiated Rate	$147.28
Max. Negotiated Rate	$1,178.22
Rate for Payer: Amerigroup CHIP/Medicaid	$147.28
Rate for Payer: BCBS of TX Blue Advantage	$490.93
Rate for Payer: BCBS of TX Blue Essentials	$589.11
Rate for Payer: BCBS of TX PPO	$654.57
Rate for Payer: Cash Price	$1,112.77
Rate for Payer: Cigna Medicaid	$1,178.22
Rate for Payer: Molina CHIP/Medicaid	$1,178.22
Rate for Payer: Multiplan Auto	$818.21
Rate for Payer: Multiplan Commercial	$818.21
Rate for Payer: Multiplan Workers Comp	$818.21
Rate for Payer: Parkland Medicaid	$1,178.22
Rate for Payer: Scott and White EPO/PPO	$818.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,178.22
Rate for Payer: Superior Health Plan EPO	$222.55

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

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

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	$0.05
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	$0.05
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	$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 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 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 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 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 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 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 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 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 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

Know your out-of-pocket cost for care.

All Charges