White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DRSSG, TGDRM, TRNSP, FRAME, W/TAB, 4X4.75

Facility

$3.53

Hospital Charge Code	992822
Hospital Revenue Code	272
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$2.54
Rate for Payer: Amerigroup CHIP/Medicaid	$0.32
Rate for Payer: BCBS of TX Blue Advantage	$1.06
Rate for Payer: BCBS of TX Blue Essentials	$1.27
Rate for Payer: BCBS of TX PPO	$1.41
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cigna Medicaid	$2.54
Rate for Payer: Molina CHIP/Medicaid	$2.54
Rate for Payer: Multiplan Auto	$2.29
Rate for Payer: Multiplan Commercial	$2.29
Rate for Payer: Multiplan Workers Comp	$2.29
Rate for Payer: Parkland Medicaid	$2.54
Rate for Payer: Scott and White EPO/PPO	$1.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.54
Rate for Payer: Superior Health Plan EPO	$0.48

DRS SORB 2X2 -- DHF

Facility

$101.36

Hospital Charge Code	80248057
Hospital Revenue Code	270
Min. Negotiated Rate	$9.12
Max. Negotiated Rate	$72.98
Rate for Payer: Amerigroup CHIP/Medicaid	$9.12
Rate for Payer: BCBS of TX Blue Advantage	$30.41
Rate for Payer: BCBS of TX Blue Essentials	$36.49
Rate for Payer: BCBS of TX PPO	$40.54
Rate for Payer: Cash Price	$68.92
Rate for Payer: Cigna Medicaid	$72.98
Rate for Payer: Molina CHIP/Medicaid	$72.98
Rate for Payer: Multiplan Auto	$65.88
Rate for Payer: Multiplan Commercial	$65.88
Rate for Payer: Multiplan Workers Comp	$65.88
Rate for Payer: Parkland Medicaid	$72.98
Rate for Payer: Scott and White EPO/PPO	$50.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$72.98
Rate for Payer: Superior Health Plan EPO	$13.78

DRS SORB 2X2 -- DHF

Facility

$101.36

Hospital Charge Code	80248057
Hospital Revenue Code	270
Rate for Payer: Cash Price	$68.92

DRS SORB 4X4 -- DHF

Facility

$87.80

Hospital Charge Code	80248107
Hospital Revenue Code	270
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$63.22
Rate for Payer: Amerigroup CHIP/Medicaid	$7.90
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.61
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$59.70
Rate for Payer: Cigna Medicaid	$63.22
Rate for Payer: Molina CHIP/Medicaid	$63.22
Rate for Payer: Multiplan Auto	$57.07
Rate for Payer: Multiplan Commercial	$57.07
Rate for Payer: Multiplan Workers Comp	$57.07
Rate for Payer: Parkland Medicaid	$63.22
Rate for Payer: Scott and White EPO/PPO	$43.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.22
Rate for Payer: Superior Health Plan EPO	$11.94

DRS SORB 4X4 -- DHF

Facility

$87.80

Hospital Charge Code	80248107
Hospital Revenue Code	270
Rate for Payer: Cash Price	$59.70

DRS SORB A/S -- DHF

Facility

$96.69

Hospital Charge Code	80248040
Hospital Revenue Code	270
Min. Negotiated Rate	$8.70
Max. Negotiated Rate	$69.62
Rate for Payer: Amerigroup CHIP/Medicaid	$8.70
Rate for Payer: BCBS of TX Blue Advantage	$29.01
Rate for Payer: BCBS of TX Blue Essentials	$34.81
Rate for Payer: BCBS of TX PPO	$38.68
Rate for Payer: Cash Price	$65.75
Rate for Payer: Cigna Medicaid	$69.62
Rate for Payer: Molina CHIP/Medicaid	$69.62
Rate for Payer: Multiplan Auto	$62.85
Rate for Payer: Multiplan Commercial	$62.85
Rate for Payer: Multiplan Workers Comp	$62.85
Rate for Payer: Parkland Medicaid	$69.62
Rate for Payer: Scott and White EPO/PPO	$48.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.62
Rate for Payer: Superior Health Plan EPO	$13.15

DRS SORB A/S -- DHF

Facility

$96.69

Hospital Charge Code	80248040
Hospital Revenue Code	270
Rate for Payer: Cash Price	$65.75

DRS SPEC BURN -- DHF

Facility

$45.82

Hospital Charge Code	80248099
Hospital Revenue Code	272
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$32.99
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$31.16
Rate for Payer: Cigna Medicaid	$32.99
Rate for Payer: Molina CHIP/Medicaid	$32.99
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Parkland Medicaid	$32.99
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.99
Rate for Payer: Superior Health Plan EPO	$6.23

DRS SPEC BURN -- DHF

Facility

$45.82

Hospital Charge Code	80248099
Hospital Revenue Code	272
Rate for Payer: Cash Price	$31.16

DRS SPECIALTY 80248115 -- DHF

Facility

$2,582.77

Hospital Charge Code	80248115
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,756.28

DRS SPECIALTY 80248115 -- DHF

Facility

$2,582.77

Hospital Charge Code	80248115
Hospital Revenue Code	270
Min. Negotiated Rate	$232.45
Max. Negotiated Rate	$1,859.59
Rate for Payer: Amerigroup CHIP/Medicaid	$232.45
Rate for Payer: BCBS of TX Blue Advantage	$774.83
Rate for Payer: BCBS of TX Blue Essentials	$929.80
Rate for Payer: BCBS of TX PPO	$1,033.11
Rate for Payer: Cash Price	$1,756.28
Rate for Payer: Cigna Medicaid	$1,859.59
Rate for Payer: Molina CHIP/Medicaid	$1,859.59
Rate for Payer: Multiplan Auto	$1,678.80
Rate for Payer: Multiplan Commercial	$1,678.80
Rate for Payer: Multiplan Workers Comp	$1,678.80
Rate for Payer: Parkland Medicaid	$1,859.59
Rate for Payer: Scott and White EPO/PPO	$1,291.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,859.59
Rate for Payer: Superior Health Plan EPO	$351.26

DRS SPECIALTY 80248131 -- DHF

Facility

$73.38

Hospital Charge Code	80248131
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.90

DRS SPECIALTY 80248131 -- DHF

Facility

$73.38

Hospital Charge Code	80248131
Hospital Revenue Code	270
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$52.83
Rate for Payer: Amerigroup CHIP/Medicaid	$6.60
Rate for Payer: BCBS of TX Blue Advantage	$22.01
Rate for Payer: BCBS of TX Blue Essentials	$26.42
Rate for Payer: BCBS of TX PPO	$29.35
Rate for Payer: Cash Price	$49.90
Rate for Payer: Cigna Medicaid	$52.83
Rate for Payer: Molina CHIP/Medicaid	$52.83
Rate for Payer: Multiplan Auto	$47.70
Rate for Payer: Multiplan Commercial	$47.70
Rate for Payer: Multiplan Workers Comp	$47.70
Rate for Payer: Parkland Medicaid	$52.83
Rate for Payer: Scott and White EPO/PPO	$36.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.83
Rate for Payer: Superior Health Plan EPO	$9.98

DRS SPECIALTY 80248149 -- DHF

Facility

$62.76

Hospital Charge Code	80248149
Hospital Revenue Code	270
Rate for Payer: Cash Price	$42.68

DRS SPECIALTY 80248149 -- DHF

Facility

$62.76

Hospital Charge Code	80248149
Hospital Revenue Code	270
Min. Negotiated Rate	$5.65
Max. Negotiated Rate	$45.19
Rate for Payer: Amerigroup CHIP/Medicaid	$5.65
Rate for Payer: BCBS of TX Blue Advantage	$18.83
Rate for Payer: BCBS of TX Blue Essentials	$22.59
Rate for Payer: BCBS of TX PPO	$25.10
Rate for Payer: Cash Price	$42.68
Rate for Payer: Cigna Medicaid	$45.19
Rate for Payer: Molina CHIP/Medicaid	$45.19
Rate for Payer: Multiplan Auto	$40.79
Rate for Payer: Multiplan Commercial	$40.79
Rate for Payer: Multiplan Workers Comp	$40.79
Rate for Payer: Parkland Medicaid	$45.19
Rate for Payer: Scott and White EPO/PPO	$31.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$45.19
Rate for Payer: Superior Health Plan EPO	$8.54

DRS ST ADH 4X8 -- DHF

Facility

$82.50

Hospital Charge Code	80248552
Hospital Revenue Code	270
Rate for Payer: Cash Price	$56.10

DRS ST ADH 4X8 -- DHF

Facility

$82.50

Hospital Charge Code	80248552
Hospital Revenue Code	270
Min. Negotiated Rate	$7.42
Max. Negotiated Rate	$59.40
Rate for Payer: Amerigroup CHIP/Medicaid	$7.42
Rate for Payer: BCBS of TX Blue Advantage	$24.75
Rate for Payer: BCBS of TX Blue Essentials	$29.70
Rate for Payer: BCBS of TX PPO	$33.00
Rate for Payer: Cash Price	$56.10
Rate for Payer: Cigna Medicaid	$59.40
Rate for Payer: Molina CHIP/Medicaid	$59.40
Rate for Payer: Multiplan Auto	$53.62
Rate for Payer: Multiplan Commercial	$53.62
Rate for Payer: Multiplan Workers Comp	$53.62
Rate for Payer: Parkland Medicaid	$59.40
Rate for Payer: Scott and White EPO/PPO	$41.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.40
Rate for Payer: Superior Health Plan EPO	$11.22

DRS TEGDRM 15X20 -- DHF

Facility

$49.41

Hospital Charge Code	80248909
Hospital Revenue Code	270
Rate for Payer: Cash Price	$33.60

DRS TEGDRM 15X20 -- DHF

Facility

$49.41

Hospital Charge Code	80248909
Hospital Revenue Code	270
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$35.58
Rate for Payer: Amerigroup CHIP/Medicaid	$4.45
Rate for Payer: BCBS of TX Blue Advantage	$14.82
Rate for Payer: BCBS of TX Blue Essentials	$17.79
Rate for Payer: BCBS of TX PPO	$19.76
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cigna Medicaid	$35.58
Rate for Payer: Molina CHIP/Medicaid	$35.58
Rate for Payer: Multiplan Auto	$32.12
Rate for Payer: Multiplan Commercial	$32.12
Rate for Payer: Multiplan Workers Comp	$32.12
Rate for Payer: Parkland Medicaid	$35.58
Rate for Payer: Scott and White EPO/PPO	$24.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.58
Rate for Payer: Superior Health Plan EPO	$6.72

DRS TEGDRM 5X7 -- DHF

Facility

$23.32

Hospital Charge Code	80249055
Hospital Revenue Code	270
Rate for Payer: Cash Price	$15.86

DRS TEGDRM 5X7 -- DHF

Facility

$23.32

Hospital Charge Code	80249055
Hospital Revenue Code	270
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$16.79
Rate for Payer: Amerigroup CHIP/Medicaid	$2.10
Rate for Payer: BCBS of TX Blue Advantage	$7.00
Rate for Payer: BCBS of TX Blue Essentials	$8.40
Rate for Payer: BCBS of TX PPO	$9.33
Rate for Payer: Cash Price	$15.86
Rate for Payer: Cigna Medicaid	$16.79
Rate for Payer: Molina CHIP/Medicaid	$16.79
Rate for Payer: Multiplan Auto	$15.16
Rate for Payer: Multiplan Commercial	$15.16
Rate for Payer: Multiplan Workers Comp	$15.16
Rate for Payer: Parkland Medicaid	$16.79
Rate for Payer: Scott and White EPO/PPO	$11.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.79
Rate for Payer: Superior Health Plan EPO	$3.17

DRS TEGDRM 6X8 -- DHF

Facility

$174.75

Hospital Charge Code	80249105
Hospital Revenue Code	270
Min. Negotiated Rate	$15.73
Max. Negotiated Rate	$125.82
Rate for Payer: Amerigroup CHIP/Medicaid	$15.73
Rate for Payer: BCBS of TX Blue Advantage	$52.42
Rate for Payer: BCBS of TX Blue Essentials	$62.91
Rate for Payer: BCBS of TX PPO	$69.90
Rate for Payer: Cash Price	$118.83
Rate for Payer: Cigna Medicaid	$125.82
Rate for Payer: Molina CHIP/Medicaid	$125.82
Rate for Payer: Multiplan Auto	$113.59
Rate for Payer: Multiplan Commercial	$113.59
Rate for Payer: Multiplan Workers Comp	$113.59
Rate for Payer: Parkland Medicaid	$125.82
Rate for Payer: Scott and White EPO/PPO	$87.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.82
Rate for Payer: Superior Health Plan EPO	$23.77

DRS TEGDRM 6X8 -- DHF

Facility

$174.75

Hospital Charge Code	80249105
Hospital Revenue Code	270
Rate for Payer: Cash Price	$118.83

DRS TELFA ISLAND -- DHF

Facility

$27.56

Hospital Charge Code	80249287
Hospital Revenue Code	270
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$19.84
Rate for Payer: Amerigroup CHIP/Medicaid	$2.48
Rate for Payer: BCBS of TX Blue Advantage	$8.27
Rate for Payer: BCBS of TX Blue Essentials	$9.92
Rate for Payer: BCBS of TX PPO	$11.02
Rate for Payer: Cash Price	$18.74
Rate for Payer: Cigna Medicaid	$19.84
Rate for Payer: Molina CHIP/Medicaid	$19.84
Rate for Payer: Multiplan Auto	$17.91
Rate for Payer: Multiplan Commercial	$17.91
Rate for Payer: Multiplan Workers Comp	$17.91
Rate for Payer: Parkland Medicaid	$19.84
Rate for Payer: Scott and White EPO/PPO	$13.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.84
Rate for Payer: Superior Health Plan EPO	$3.75

DRS TELFA ISLAND -- DHF

Facility

$27.56

Hospital Charge Code	80249287
Hospital Revenue Code	270
Rate for Payer: Cash Price	$18.74

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