White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DARCO HEADED SCR 3.5X38 FULL

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992326
Hospital Revenue Code	278
Min. Negotiated Rate	$326.81
Max. Negotiated Rate	$653.62
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Commercial	$326.81
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Scott and White EPO/PPO	$653.62

DARCO HEADED SCR 3.5X38 LONG

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992279
Hospital Revenue Code	278
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$941.21
Rate for Payer: Amerigroup CHIP/Medicaid	$117.65
Rate for Payer: BCBS of TX Blue Advantage	$392.17
Rate for Payer: BCBS of TX Blue Essentials	$470.60
Rate for Payer: BCBS of TX PPO	$522.89
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Medicaid	$941.21
Rate for Payer: Molina CHIP/Medicaid	$941.21
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Parkland Medicaid	$941.21
Rate for Payer: Scott and White EPO/PPO	$653.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.21
Rate for Payer: Superior Health Plan EPO	$177.78

DARCO HEADED SCR 3.5X38 LONG

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992279
Hospital Revenue Code	278
Min. Negotiated Rate	$326.81
Max. Negotiated Rate	$653.62
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Commercial	$326.81
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Scott and White EPO/PPO	$653.62

DARCO HEADED SCR 3.5 X 40 FULL

Facility

$2,875.90

Service Code	HCPCS C1713
Hospital Charge Code	992371
Hospital Revenue Code	278
Min. Negotiated Rate	$718.98
Max. Negotiated Rate	$1,437.95
Rate for Payer: Cash Price	$1,955.61
Rate for Payer: Cigna Commercial	$718.98
Rate for Payer: Multiplan Auto	$1,437.95
Rate for Payer: Multiplan Commercial	$1,437.95
Rate for Payer: Multiplan Workers Comp	$1,437.95
Rate for Payer: Scott and White EPO/PPO	$1,437.95

DARCO HEADED SCR 3.5 X 40 FULL

Facility

$2,875.90

Service Code	HCPCS C1713
Hospital Charge Code	992371
Hospital Revenue Code	278
Min. Negotiated Rate	$258.83
Max. Negotiated Rate	$2,070.65
Rate for Payer: Amerigroup CHIP/Medicaid	$258.83
Rate for Payer: BCBS of TX Blue Advantage	$862.77
Rate for Payer: BCBS of TX Blue Essentials	$1,035.32
Rate for Payer: BCBS of TX PPO	$1,150.36
Rate for Payer: Cash Price	$1,955.61
Rate for Payer: Cigna Medicaid	$2,070.65
Rate for Payer: Molina CHIP/Medicaid	$2,070.65
Rate for Payer: Multiplan Auto	$1,437.95
Rate for Payer: Multiplan Commercial	$1,437.95
Rate for Payer: Multiplan Workers Comp	$1,437.95
Rate for Payer: Parkland Medicaid	$2,070.65
Rate for Payer: Scott and White EPO/PPO	$1,437.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,070.65
Rate for Payer: Superior Health Plan EPO	$391.12

DARCO HEADED SCR 3.5 X 40 LONG

Facility

$1,437.95

Service Code	HCPCS C1713
Hospital Charge Code	992372
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

DARCO HEADED SCR 3.5 X 40 LONG

Facility

$1,437.95

Service Code	HCPCS C1713
Hospital Charge Code	992372
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

DARCO HEADED SCR 3.5 X 40 SHORT

Facility

$2,875.90

Service Code	HCPCS C1713
Hospital Charge Code	992383
Hospital Revenue Code	278
Min. Negotiated Rate	$718.98
Max. Negotiated Rate	$1,437.95
Rate for Payer: Cash Price	$1,955.61
Rate for Payer: Cigna Commercial	$718.98
Rate for Payer: Multiplan Auto	$1,437.95
Rate for Payer: Multiplan Commercial	$1,437.95
Rate for Payer: Multiplan Workers Comp	$1,437.95
Rate for Payer: Scott and White EPO/PPO	$1,437.95

DARCO HEADED SCR 3.5 X 40 SHORT

Facility

$2,875.90

Service Code	HCPCS C1713
Hospital Charge Code	992383
Hospital Revenue Code	278
Min. Negotiated Rate	$258.83
Max. Negotiated Rate	$2,070.65
Rate for Payer: Amerigroup CHIP/Medicaid	$258.83
Rate for Payer: BCBS of TX Blue Advantage	$862.77
Rate for Payer: BCBS of TX Blue Essentials	$1,035.32
Rate for Payer: BCBS of TX PPO	$1,150.36
Rate for Payer: Cash Price	$1,955.61
Rate for Payer: Cigna Medicaid	$2,070.65
Rate for Payer: Molina CHIP/Medicaid	$2,070.65
Rate for Payer: Multiplan Auto	$1,437.95
Rate for Payer: Multiplan Commercial	$1,437.95
Rate for Payer: Multiplan Workers Comp	$1,437.95
Rate for Payer: Parkland Medicaid	$2,070.65
Rate for Payer: Scott and White EPO/PPO	$1,437.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,070.65
Rate for Payer: Superior Health Plan EPO	$391.12

DARCO HEADED SCR 3.5X42 FULL

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992327
Hospital Revenue Code	278
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$941.21
Rate for Payer: Amerigroup CHIP/Medicaid	$117.65
Rate for Payer: BCBS of TX Blue Advantage	$392.17
Rate for Payer: BCBS of TX Blue Essentials	$470.60
Rate for Payer: BCBS of TX PPO	$522.89
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Medicaid	$941.21
Rate for Payer: Molina CHIP/Medicaid	$941.21
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Parkland Medicaid	$941.21
Rate for Payer: Scott and White EPO/PPO	$653.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.21
Rate for Payer: Superior Health Plan EPO	$177.78

DARCO HEADED SCR 3.5X42 FULL

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992327
Hospital Revenue Code	278
Min. Negotiated Rate	$326.81
Max. Negotiated Rate	$653.62
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Commercial	$326.81
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Scott and White EPO/PPO	$653.62

DARCO HEADED SCR 3.5X48 LONG

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992280
Hospital Revenue Code	278
Min. Negotiated Rate	$326.81
Max. Negotiated Rate	$653.62
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Commercial	$326.81
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Scott and White EPO/PPO	$653.62

DARCO HEADED SCR 3.5X48 LONG

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992280
Hospital Revenue Code	278
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$941.21
Rate for Payer: Amerigroup CHIP/Medicaid	$117.65
Rate for Payer: BCBS of TX Blue Advantage	$392.17
Rate for Payer: BCBS of TX Blue Essentials	$470.60
Rate for Payer: BCBS of TX PPO	$522.89
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Medicaid	$941.21
Rate for Payer: Molina CHIP/Medicaid	$941.21
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Parkland Medicaid	$941.21
Rate for Payer: Scott and White EPO/PPO	$653.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.21
Rate for Payer: Superior Health Plan EPO	$177.78

DARCO HEADED SCR 3.5X50 LONG

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992273
Hospital Revenue Code	278
Min. Negotiated Rate	$326.81
Max. Negotiated Rate	$653.62
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Commercial	$326.81
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Scott and White EPO/PPO	$653.62

DARCO HEADED SCR 3.5X50 LONG

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992273
Hospital Revenue Code	278
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$941.21
Rate for Payer: Amerigroup CHIP/Medicaid	$117.65
Rate for Payer: BCBS of TX Blue Advantage	$392.17
Rate for Payer: BCBS of TX Blue Essentials	$470.60
Rate for Payer: BCBS of TX PPO	$522.89
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Medicaid	$941.21
Rate for Payer: Molina CHIP/Medicaid	$941.21
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Parkland Medicaid	$941.21
Rate for Payer: Scott and White EPO/PPO	$653.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.21
Rate for Payer: Superior Health Plan EPO	$177.78

DARCO HEADED SCR 4.5X55 LONG

Facility

$1,560.24

Service Code	HCPCS C1713
Hospital Charge Code	992301
Hospital Revenue Code	278
Min. Negotiated Rate	$390.06
Max. Negotiated Rate	$780.12
Rate for Payer: Cash Price	$1,060.96
Rate for Payer: Cigna Commercial	$390.06
Rate for Payer: Multiplan Auto	$780.12
Rate for Payer: Multiplan Commercial	$780.12
Rate for Payer: Multiplan Workers Comp	$780.12
Rate for Payer: Scott and White EPO/PPO	$780.12

DARCO HEADED SCR 4.5X55 LONG

Facility

$1,560.24

Service Code	HCPCS C1713
Hospital Charge Code	992301
Hospital Revenue Code	278
Min. Negotiated Rate	$140.42
Max. Negotiated Rate	$1,123.37
Rate for Payer: Amerigroup CHIP/Medicaid	$140.42
Rate for Payer: BCBS of TX Blue Advantage	$468.07
Rate for Payer: BCBS of TX Blue Essentials	$561.69
Rate for Payer: BCBS of TX PPO	$624.10
Rate for Payer: Cash Price	$1,060.96
Rate for Payer: Cigna Medicaid	$1,123.37
Rate for Payer: Molina CHIP/Medicaid	$1,123.37
Rate for Payer: Multiplan Auto	$780.12
Rate for Payer: Multiplan Commercial	$780.12
Rate for Payer: Multiplan Workers Comp	$780.12
Rate for Payer: Parkland Medicaid	$1,123.37
Rate for Payer: Scott and White EPO/PPO	$780.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,123.37
Rate for Payer: Superior Health Plan EPO	$212.19

DARCO HEADED SCR 6.5X55 16MM

Facility

$2,584.34

Service Code	HCPCS C1713
Hospital Charge Code	992375
Hospital Revenue Code	278
Min. Negotiated Rate	$232.59
Max. Negotiated Rate	$1,860.72
Rate for Payer: Amerigroup CHIP/Medicaid	$232.59
Rate for Payer: BCBS of TX Blue Advantage	$775.30
Rate for Payer: BCBS of TX Blue Essentials	$930.36
Rate for Payer: BCBS of TX PPO	$1,033.74
Rate for Payer: Cash Price	$1,757.35
Rate for Payer: Cigna Medicaid	$1,860.72
Rate for Payer: Molina CHIP/Medicaid	$1,860.72
Rate for Payer: Multiplan Auto	$1,292.17
Rate for Payer: Multiplan Commercial	$1,292.17
Rate for Payer: Multiplan Workers Comp	$1,292.17
Rate for Payer: Parkland Medicaid	$1,860.72
Rate for Payer: Scott and White EPO/PPO	$1,292.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,860.72
Rate for Payer: Superior Health Plan EPO	$351.47

DARCO HEADED SCR 6.5X55 16MM

Facility

$2,584.34

Service Code	HCPCS C1713
Hospital Charge Code	992375
Hospital Revenue Code	278
Min. Negotiated Rate	$646.09
Max. Negotiated Rate	$1,292.17
Rate for Payer: Cash Price	$1,757.35
Rate for Payer: Cigna Commercial	$646.09
Rate for Payer: Multiplan Auto	$1,292.17
Rate for Payer: Multiplan Commercial	$1,292.17
Rate for Payer: Multiplan Workers Comp	$1,292.17
Rate for Payer: Scott and White EPO/PPO	$1,292.17

DARCO HEADED SCR 6.5 X 65 16 MM

Facility

$2,584.34

Service Code	HCPCS C1713
Hospital Charge Code	993139
Hospital Revenue Code	278
Min. Negotiated Rate	$232.59
Max. Negotiated Rate	$1,860.72
Rate for Payer: Amerigroup CHIP/Medicaid	$232.59
Rate for Payer: BCBS of TX Blue Advantage	$775.30
Rate for Payer: BCBS of TX Blue Essentials	$930.36
Rate for Payer: BCBS of TX PPO	$1,033.74
Rate for Payer: Cash Price	$1,757.35
Rate for Payer: Cigna Medicaid	$1,860.72
Rate for Payer: Molina CHIP/Medicaid	$1,860.72
Rate for Payer: Multiplan Auto	$1,292.17
Rate for Payer: Multiplan Commercial	$1,292.17
Rate for Payer: Multiplan Workers Comp	$1,292.17
Rate for Payer: Parkland Medicaid	$1,860.72
Rate for Payer: Scott and White EPO/PPO	$1,292.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,860.72
Rate for Payer: Superior Health Plan EPO	$351.47

DARCO HEADED SCR 6.5 X 65 16 MM

Facility

$2,584.34

Service Code	HCPCS C1713
Hospital Charge Code	993139
Hospital Revenue Code	278
Min. Negotiated Rate	$646.09
Max. Negotiated Rate	$1,292.17
Rate for Payer: Cash Price	$1,757.35
Rate for Payer: Cigna Commercial	$646.09
Rate for Payer: Multiplan Auto	$1,292.17
Rate for Payer: Multiplan Commercial	$1,292.17
Rate for Payer: Multiplan Workers Comp	$1,292.17
Rate for Payer: Scott and White EPO/PPO	$1,292.17

Datascope 3 Lead Set

Facility

$308.72

Hospital Charge Code	993892
Hospital Revenue Code	270
Min. Negotiated Rate	$27.78
Max. Negotiated Rate	$222.28
Rate for Payer: Amerigroup CHIP/Medicaid	$27.78
Rate for Payer: BCBS of TX Blue Advantage	$92.62
Rate for Payer: BCBS of TX Blue Essentials	$111.14
Rate for Payer: BCBS of TX PPO	$123.49
Rate for Payer: Cash Price	$209.93
Rate for Payer: Cigna Medicaid	$222.28
Rate for Payer: Molina CHIP/Medicaid	$222.28
Rate for Payer: Multiplan Auto	$200.67
Rate for Payer: Multiplan Commercial	$200.67
Rate for Payer: Multiplan Workers Comp	$200.67
Rate for Payer: Parkland Medicaid	$222.28
Rate for Payer: Scott and White EPO/PPO	$154.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.28
Rate for Payer: Superior Health Plan EPO	$41.99

Datascope 3 Lead Set

Facility

$308.72

Hospital Charge Code	993892
Hospital Revenue Code	270
Rate for Payer: Cash Price	$209.93

Datascope 5 Lead Set

Facility

$340.50

Hospital Charge Code	993893
Hospital Revenue Code	270
Rate for Payer: Cash Price	$231.54

Datascope 5 Lead Set

Facility

$340.50

Hospital Charge Code	993893
Hospital Revenue Code	270
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$245.16
Rate for Payer: Amerigroup CHIP/Medicaid	$30.64
Rate for Payer: BCBS of TX Blue Advantage	$102.15
Rate for Payer: BCBS of TX Blue Essentials	$122.58
Rate for Payer: BCBS of TX PPO	$136.20
Rate for Payer: Cash Price	$231.54
Rate for Payer: Cigna Medicaid	$245.16
Rate for Payer: Molina CHIP/Medicaid	$245.16
Rate for Payer: Multiplan Auto	$221.32
Rate for Payer: Multiplan Commercial	$221.32
Rate for Payer: Multiplan Workers Comp	$221.32
Rate for Payer: Parkland Medicaid	$245.16
Rate for Payer: Scott and White EPO/PPO	$170.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$245.16
Rate for Payer: Superior Health Plan EPO	$46.31

Know your out-of-pocket cost for care.

All Charges