White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DWF510

Facility

$34,469.88

Service Code	HCPCS C1776
Hospital Charge Code	991241
Hospital Revenue Code	278
Min. Negotiated Rate	$8,617.47
Max. Negotiated Rate	$17,234.94
Rate for Payer: Cash Price	$23,439.52
Rate for Payer: Cigna Commercial	$8,617.47
Rate for Payer: Multiplan Auto	$17,234.94
Rate for Payer: Multiplan Commercial	$17,234.94
Rate for Payer: Multiplan Workers Comp	$17,234.94
Rate for Payer: Scott and White EPO/PPO	$17,234.94

DX BONE MARROW ASP/BX MULTI

Facility

$4,639.00

Service Code	HCPCS 38222
Hospital Charge Code	4613822
Hospital Revenue Code	360
Min. Negotiated Rate	$815.20
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$815.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Amerigroup Medicare	$2,917.95
Rate for Payer: BCBS of TX Blue Advantage	$3,872.55
Rate for Payer: BCBS of TX Blue Essentials	$4,637.78
Rate for Payer: BCBS of TX Medicare	$2,917.95
Rate for Payer: BCBS of TX PPO	$5,843.60
Rate for Payer: Cash Price	$3,154.52
Rate for Payer: Cash Price	$3,154.52
Rate for Payer: Cash Price	$3,154.52
Rate for Payer: Cigna Commercial	$6,168.03
Rate for Payer: Cigna Medicaid	$3,340.08
Rate for Payer: Cigna Medicare	$2,917.95
Rate for Payer: Employer Direct Commercial	$2,917.95
Rate for Payer: Humana Medicare/TRICARE	$2,917.95
Rate for Payer: Molina CHIP/Medicaid	$3,340.08
Rate for Payer: Molina Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Molina Medicare	$2,917.95
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$3,340.08
Rate for Payer: Scott and White EPO/PPO	$5,398.21
Rate for Payer: Scott and White Medicare	$2,917.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,340.08
Rate for Payer: Superior Health Plan EPO	$2,917.95
Rate for Payer: Superior Health Plan Medicare	$2,917.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Universal American Medicare	$2,917.95
Rate for Payer: Wellcare Medicare	$2,917.95
Rate for Payer: Wellmed Medicare	$2,917.95

DX BONE MARROW ASP/BX MULTI

Facility

$4,639.00

Service Code	HCPCS 38222
Hospital Charge Code	4613822
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,154.52

DX FIBERTAX SUTURE ANCHOR, #2 MTS W/ NDL

Facility

$5,975.90

Service Code	HCPCS C1713
Hospital Charge Code	992311
Hospital Revenue Code	278
Min. Negotiated Rate	$1,493.97
Max. Negotiated Rate	$2,987.95
Rate for Payer: Cash Price	$4,063.61
Rate for Payer: Cigna Commercial	$1,493.97
Rate for Payer: Multiplan Auto	$2,987.95
Rate for Payer: Multiplan Commercial	$2,987.95
Rate for Payer: Multiplan Workers Comp	$2,987.95
Rate for Payer: Scott and White EPO/PPO	$2,987.95

DX FIBERTAX SUTURE ANCHOR, #2 MTS W/ NDL

Facility

$5,975.90

Service Code	HCPCS C1713
Hospital Charge Code	992311
Hospital Revenue Code	278
Min. Negotiated Rate	$537.83
Max. Negotiated Rate	$4,302.65
Rate for Payer: Amerigroup CHIP/Medicaid	$537.83
Rate for Payer: BCBS of TX Blue Advantage	$1,792.77
Rate for Payer: BCBS of TX Blue Essentials	$2,151.32
Rate for Payer: BCBS of TX PPO	$2,390.36
Rate for Payer: Cash Price	$4,063.61
Rate for Payer: Cigna Medicaid	$4,302.65
Rate for Payer: Molina CHIP/Medicaid	$4,302.65
Rate for Payer: Multiplan Auto	$2,987.95
Rate for Payer: Multiplan Commercial	$2,987.95
Rate for Payer: Multiplan Workers Comp	$2,987.95
Rate for Payer: Parkland Medicaid	$4,302.65
Rate for Payer: Scott and White EPO/PPO	$2,987.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,302.65
Rate for Payer: Superior Health Plan EPO	$812.72

DxH 800 Sample Diluent

Facility

$4,520.48

Hospital Charge Code	992713
Hospital Revenue Code	270
Min. Negotiated Rate	$406.84
Max. Negotiated Rate	$3,254.75
Rate for Payer: Amerigroup CHIP/Medicaid	$406.84
Rate for Payer: BCBS of TX Blue Advantage	$1,356.14
Rate for Payer: BCBS of TX Blue Essentials	$1,627.37
Rate for Payer: BCBS of TX PPO	$1,808.19
Rate for Payer: Cash Price	$3,073.93
Rate for Payer: Cigna Medicaid	$3,254.75
Rate for Payer: Molina CHIP/Medicaid	$3,254.75
Rate for Payer: Multiplan Auto	$2,938.31
Rate for Payer: Multiplan Commercial	$2,938.31
Rate for Payer: Multiplan Workers Comp	$2,938.31
Rate for Payer: Parkland Medicaid	$3,254.75
Rate for Payer: Scott and White EPO/PPO	$2,260.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,254.75
Rate for Payer: Superior Health Plan EPO	$614.79

DxH 800 Sample Diluent

Facility

$4,520.48

Hospital Charge Code	992713
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3,073.93

DYNACLIP FIXATION SYSTEM

Facility

$5,970.10

Hospital Charge Code	145502
Hospital Revenue Code	272
Min. Negotiated Rate	$537.31
Max. Negotiated Rate	$4,298.47
Rate for Payer: Amerigroup CHIP/Medicaid	$537.31
Rate for Payer: BCBS of TX Blue Advantage	$1,791.03
Rate for Payer: BCBS of TX Blue Essentials	$2,149.24
Rate for Payer: BCBS of TX PPO	$2,388.04
Rate for Payer: Cash Price	$4,059.67
Rate for Payer: Cigna Medicaid	$4,298.47
Rate for Payer: Molina CHIP/Medicaid	$4,298.47
Rate for Payer: Multiplan Auto	$3,880.57
Rate for Payer: Multiplan Commercial	$3,880.57
Rate for Payer: Multiplan Workers Comp	$3,880.57
Rate for Payer: Parkland Medicaid	$4,298.47
Rate for Payer: Scott and White EPO/PPO	$2,985.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,298.47
Rate for Payer: Superior Health Plan EPO	$811.93

DYNACLIP FIXATION SYSTEM

Facility

$5,970.10

Hospital Charge Code	145502
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,059.67

DYNACORD

Facility

$754.78

Service Code	HCPCS C1713
Hospital Charge Code	992669
Hospital Revenue Code	278
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$377.39
Rate for Payer: Cash Price	$513.25
Rate for Payer: Cigna Commercial	$188.69
Rate for Payer: Multiplan Auto	$377.39
Rate for Payer: Multiplan Commercial	$377.39
Rate for Payer: Multiplan Workers Comp	$377.39
Rate for Payer: Scott and White EPO/PPO	$377.39

DYNACORD

Facility

$754.78

Service Code	HCPCS C1713
Hospital Charge Code	992669
Hospital Revenue Code	278
Min. Negotiated Rate	$67.93
Max. Negotiated Rate	$543.44
Rate for Payer: Amerigroup CHIP/Medicaid	$67.93
Rate for Payer: BCBS of TX Blue Advantage	$226.43
Rate for Payer: BCBS of TX Blue Essentials	$271.72
Rate for Payer: BCBS of TX PPO	$301.91
Rate for Payer: Cash Price	$513.25
Rate for Payer: Cigna Medicaid	$543.44
Rate for Payer: Molina CHIP/Medicaid	$543.44
Rate for Payer: Multiplan Auto	$377.39
Rate for Payer: Multiplan Commercial	$377.39
Rate for Payer: Multiplan Workers Comp	$377.39
Rate for Payer: Parkland Medicaid	$543.44
Rate for Payer: Scott and White EPO/PPO	$377.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$543.44
Rate for Payer: Superior Health Plan EPO	$102.65

DYSEQUILIBRIUM

Facility

$14,280.40

Service Code	MSDRG 149
Min. Negotiated Rate	$6,115.46
Max. Negotiated Rate	$14,280.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,268.57
Rate for Payer: Amerigroup Medicare	$10,268.57
Rate for Payer: BCBS of TX Blue Advantage	$6,115.46
Rate for Payer: BCBS of TX Blue Essentials	$7,337.84
Rate for Payer: BCBS of TX Medicare	$10,268.57
Rate for Payer: BCBS of TX PPO	$8,153.47
Rate for Payer: Cigna Commercial	$9,680.61
Rate for Payer: Cigna Medicare	$10,268.57
Rate for Payer: Employer Direct Commercial	$10,268.57
Rate for Payer: Humana Medicare/TRICARE	$10,268.57
Rate for Payer: Molina Dual Medicare/Medicaid	$10,268.57
Rate for Payer: Molina Medicare	$10,268.57
Rate for Payer: Multiplan Auto	$14,280.40
Rate for Payer: Multiplan Commercial	$14,280.40
Rate for Payer: Multiplan Workers Comp	$14,280.40
Rate for Payer: Scott and White EPO/PPO	$6,576.50
Rate for Payer: Scott and White Medicare	$10,268.57
Rate for Payer: Superior Health Plan EPO	$10,268.57
Rate for Payer: Superior Health Plan Medicare	$10,268.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,268.57
Rate for Payer: Universal American Medicare	$10,268.57
Rate for Payer: Wellcare Medicare	$10,268.57
Rate for Payer: Wellmed Medicare	$10,268.57

E0033 Whole Blood CPD 500 LR

Facility

$818.00

Hospital Charge Code	2404036
Hospital Revenue Code	390
Min. Negotiated Rate	$73.62
Max. Negotiated Rate	$588.96
Rate for Payer: Amerigroup CHIP/Medicaid	$73.62
Rate for Payer: BCBS of TX Blue Advantage	$245.40
Rate for Payer: BCBS of TX Blue Essentials	$294.48
Rate for Payer: BCBS of TX PPO	$327.20
Rate for Payer: Cash Price	$556.24
Rate for Payer: Cigna Medicaid	$588.96
Rate for Payer: Molina CHIP/Medicaid	$588.96
Rate for Payer: Multiplan Auto	$531.70
Rate for Payer: Multiplan Commercial	$531.70
Rate for Payer: Multiplan Workers Comp	$531.70
Rate for Payer: Parkland Medicaid	$588.96
Rate for Payer: Scott and White EPO/PPO	$409.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$588.96
Rate for Payer: Superior Health Plan EPO	$111.25

E0033 Whole Blood CPD 500 LR

Facility

$818.00

Hospital Charge Code	2404036
Hospital Revenue Code	390
Rate for Payer: Cash Price	$556.24

E0162 DRBC CPD 450 LR Irr

Facility

$695.00

Hospital Charge Code	7266926
Hospital Revenue Code	390
Rate for Payer: Cash Price	$472.60

E0162 DRBC CPD 450 LR Irr

Facility

$695.00

Hospital Charge Code	7266926
Hospital Revenue Code	390
Min. Negotiated Rate	$62.55
Max. Negotiated Rate	$500.40
Rate for Payer: Amerigroup CHIP/Medicaid	$62.55
Rate for Payer: BCBS of TX Blue Advantage	$208.50
Rate for Payer: BCBS of TX Blue Essentials	$250.20
Rate for Payer: BCBS of TX PPO	$278.00
Rate for Payer: Cash Price	$472.60
Rate for Payer: Cigna Medicaid	$500.40
Rate for Payer: Molina CHIP/Medicaid	$500.40
Rate for Payer: Multiplan Auto	$451.75
Rate for Payer: Multiplan Commercial	$451.75
Rate for Payer: Multiplan Workers Comp	$451.75
Rate for Payer: Parkland Medicaid	$500.40
Rate for Payer: Scott and White EPO/PPO	$347.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$500.40
Rate for Payer: Superior Health Plan EPO	$94.52

E0164 DRBC CPD 450 LR

Facility

$590.00

Service Code	HCPCS P9016
Hospital Charge Code	7266927
Hospital Revenue Code	390
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$424.80
Rate for Payer: Amerigroup CHIP/Medicaid	$53.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$181.81
Rate for Payer: Amerigroup Medicare	$181.81
Rate for Payer: BCBS of TX Blue Advantage	$177.00
Rate for Payer: BCBS of TX Blue Essentials	$212.40
Rate for Payer: BCBS of TX Medicare	$181.81
Rate for Payer: BCBS of TX PPO	$236.00
Rate for Payer: Cash Price	$401.20
Rate for Payer: Cash Price	$401.20
Rate for Payer: Cash Price	$401.20
Rate for Payer: Cigna Commercial	$384.33
Rate for Payer: Cigna Medicaid	$424.80
Rate for Payer: Cigna Medicare	$181.81
Rate for Payer: Employer Direct Commercial	$181.81
Rate for Payer: Humana Medicare/TRICARE	$181.81
Rate for Payer: Molina CHIP/Medicaid	$424.80
Rate for Payer: Molina Dual Medicare/Medicaid	$181.81
Rate for Payer: Molina Medicare	$181.81
Rate for Payer: Multiplan Auto	$383.50
Rate for Payer: Multiplan Commercial	$383.50
Rate for Payer: Multiplan Workers Comp	$383.50
Rate for Payer: Parkland Medicaid	$424.80
Rate for Payer: Scott and White EPO/PPO	$295.00
Rate for Payer: Scott and White Medicare	$181.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$424.80
Rate for Payer: Superior Health Plan EPO	$181.81
Rate for Payer: Superior Health Plan Medicare	$181.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$181.81
Rate for Payer: Universal American Medicare	$181.81
Rate for Payer: Wellcare Medicare	$181.81
Rate for Payer: Wellmed Medicare	$181.81

E0164 DRBC CPD 450 LR

Facility

$590.00

Service Code	HCPCS P9016
Hospital Charge Code	7266927
Hospital Revenue Code	390
Rate for Payer: Cash Price	$401.20

E0404 DRBC CPD AS5

Facility

$401.91

Hospital Charge Code	2401040
Hospital Revenue Code	390
Rate for Payer: Cash Price	$273.30

E0404 DRBC CPD AS5

Facility

$401.91

Hospital Charge Code	2401040
Hospital Revenue Code	390
Min. Negotiated Rate	$36.17
Max. Negotiated Rate	$289.38
Rate for Payer: Amerigroup CHIP/Medicaid	$36.17
Rate for Payer: BCBS of TX Blue Advantage	$120.57
Rate for Payer: BCBS of TX Blue Essentials	$144.69
Rate for Payer: BCBS of TX PPO	$160.76
Rate for Payer: Cash Price	$273.30
Rate for Payer: Cigna Medicaid	$289.38
Rate for Payer: Molina CHIP/Medicaid	$289.38
Rate for Payer: Multiplan Auto	$261.24
Rate for Payer: Multiplan Commercial	$261.24
Rate for Payer: Multiplan Workers Comp	$261.24
Rate for Payer: Parkland Medicaid	$289.38
Rate for Payer: Scott and White EPO/PPO	$200.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$289.38
Rate for Payer: Superior Health Plan EPO	$54.66

E0487 ARBC Washed Open

Facility

$589.81

Hospital Charge Code	2403673
Hospital Revenue Code	390
Min. Negotiated Rate	$53.08
Max. Negotiated Rate	$424.66
Rate for Payer: Amerigroup CHIP/Medicaid	$53.08
Rate for Payer: BCBS of TX Blue Advantage	$176.94
Rate for Payer: BCBS of TX Blue Essentials	$212.33
Rate for Payer: BCBS of TX PPO	$235.92
Rate for Payer: Cash Price	$401.07
Rate for Payer: Cigna Medicaid	$424.66
Rate for Payer: Molina CHIP/Medicaid	$424.66
Rate for Payer: Multiplan Auto	$383.38
Rate for Payer: Multiplan Commercial	$383.38
Rate for Payer: Multiplan Workers Comp	$383.38
Rate for Payer: Parkland Medicaid	$424.66
Rate for Payer: Scott and White EPO/PPO	$294.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$424.66
Rate for Payer: Superior Health Plan EPO	$80.21

E0487 ARBC Washed Open

Facility

$589.81

Hospital Charge Code	2403673
Hospital Revenue Code	390
Rate for Payer: Cash Price	$401.07

E0634 Aph Dv RBC CP2D AS3 LR Irr 2 Open

Facility

$538.30

Hospital Charge Code	2408722
Hospital Revenue Code	390
Min. Negotiated Rate	$48.45
Max. Negotiated Rate	$387.58
Rate for Payer: Amerigroup CHIP/Medicaid	$48.45
Rate for Payer: BCBS of TX Blue Advantage	$161.49
Rate for Payer: BCBS of TX Blue Essentials	$193.79
Rate for Payer: BCBS of TX PPO	$215.32
Rate for Payer: Cash Price	$366.04
Rate for Payer: Cigna Medicaid	$387.58
Rate for Payer: Molina CHIP/Medicaid	$387.58
Rate for Payer: Multiplan Auto	$349.89
Rate for Payer: Multiplan Commercial	$349.89
Rate for Payer: Multiplan Workers Comp	$349.89
Rate for Payer: Parkland Medicaid	$387.58
Rate for Payer: Scott and White EPO/PPO	$269.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$387.58
Rate for Payer: Superior Health Plan EPO	$73.21

E0634 Aph Dv RBC CP2D AS3 LR Irr 2 Open

Facility

$538.30

Hospital Charge Code	2408722
Hospital Revenue Code	390
Rate for Payer: Cash Price	$366.04

E0685 Aph DRBC CP2D AS3 LR 1

Facility

$590.00

Hospital Charge Code	2401479
Hospital Revenue Code	390
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$424.80
Rate for Payer: Amerigroup CHIP/Medicaid	$53.10
Rate for Payer: BCBS of TX Blue Advantage	$177.00
Rate for Payer: BCBS of TX Blue Essentials	$212.40
Rate for Payer: BCBS of TX PPO	$236.00
Rate for Payer: Cash Price	$401.20
Rate for Payer: Cigna Medicaid	$424.80
Rate for Payer: Molina CHIP/Medicaid	$424.80
Rate for Payer: Multiplan Auto	$383.50
Rate for Payer: Multiplan Commercial	$383.50
Rate for Payer: Multiplan Workers Comp	$383.50
Rate for Payer: Parkland Medicaid	$424.80
Rate for Payer: Scott and White EPO/PPO	$295.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$424.80
Rate for Payer: Superior Health Plan EPO	$80.24

Know your out-of-pocket cost for care.

All Charges