White Rock Medical Center

All Charges

Charge

Type

Setting

Price

131227215

Facility

$455.42

Service Code	HCPCS C1713
Hospital Charge Code	991319
Hospital Revenue Code	278
Min. Negotiated Rate	$113.86
Max. Negotiated Rate	$227.71
Rate for Payer: Cash Price	$309.69
Rate for Payer: Cigna Commercial	$113.86
Rate for Payer: Multiplan Auto	$227.71
Rate for Payer: Multiplan Commercial	$227.71
Rate for Payer: Multiplan Workers Comp	$227.71
Rate for Payer: Scott and White EPO/PPO	$227.71

131227215

Facility

$455.42

Service Code	HCPCS C1713
Hospital Charge Code	991319
Hospital Revenue Code	278
Min. Negotiated Rate	$40.99
Max. Negotiated Rate	$327.90
Rate for Payer: Amerigroup CHIP/Medicaid	$40.99
Rate for Payer: BCBS of TX Blue Advantage	$136.63
Rate for Payer: BCBS of TX Blue Essentials	$163.95
Rate for Payer: BCBS of TX PPO	$182.17
Rate for Payer: Cash Price	$309.69
Rate for Payer: Cigna Medicaid	$327.90
Rate for Payer: Molina CHIP/Medicaid	$327.90
Rate for Payer: Multiplan Auto	$227.71
Rate for Payer: Multiplan Commercial	$227.71
Rate for Payer: Multiplan Workers Comp	$227.71
Rate for Payer: Parkland Medicaid	$327.90
Rate for Payer: Scott and White EPO/PPO	$227.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$327.90
Rate for Payer: Superior Health Plan EPO	$61.94

131227222

Facility

$455.42

Service Code	HCPCS C1713
Hospital Charge Code	991320
Hospital Revenue Code	278
Min. Negotiated Rate	$40.99
Max. Negotiated Rate	$327.90
Rate for Payer: Amerigroup CHIP/Medicaid	$40.99
Rate for Payer: BCBS of TX Blue Advantage	$136.63
Rate for Payer: BCBS of TX Blue Essentials	$163.95
Rate for Payer: BCBS of TX PPO	$182.17
Rate for Payer: Cash Price	$309.69
Rate for Payer: Cigna Medicaid	$327.90
Rate for Payer: Molina CHIP/Medicaid	$327.90
Rate for Payer: Multiplan Auto	$227.71
Rate for Payer: Multiplan Commercial	$227.71
Rate for Payer: Multiplan Workers Comp	$227.71
Rate for Payer: Parkland Medicaid	$327.90
Rate for Payer: Scott and White EPO/PPO	$227.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$327.90
Rate for Payer: Superior Health Plan EPO	$61.94

131227222

Facility

$455.42

Service Code	HCPCS C1713
Hospital Charge Code	991320
Hospital Revenue Code	278
Min. Negotiated Rate	$113.86
Max. Negotiated Rate	$227.71
Rate for Payer: Cash Price	$309.69
Rate for Payer: Cigna Commercial	$113.86
Rate for Payer: Multiplan Auto	$227.71
Rate for Payer: Multiplan Commercial	$227.71
Rate for Payer: Multiplan Workers Comp	$227.71
Rate for Payer: Scott and White EPO/PPO	$227.71

131227224

Facility

$455.42

Service Code	HCPCS C1713
Hospital Charge Code	991321
Hospital Revenue Code	278
Min. Negotiated Rate	$113.86
Max. Negotiated Rate	$227.71
Rate for Payer: Cash Price	$309.69
Rate for Payer: Cigna Commercial	$113.86
Rate for Payer: Multiplan Auto	$227.71
Rate for Payer: Multiplan Commercial	$227.71
Rate for Payer: Multiplan Workers Comp	$227.71
Rate for Payer: Scott and White EPO/PPO	$227.71

131227224

Facility

$455.42

Service Code	HCPCS C1713
Hospital Charge Code	991321
Hospital Revenue Code	278
Min. Negotiated Rate	$40.99
Max. Negotiated Rate	$327.90
Rate for Payer: Amerigroup CHIP/Medicaid	$40.99
Rate for Payer: BCBS of TX Blue Advantage	$136.63
Rate for Payer: BCBS of TX Blue Essentials	$163.95
Rate for Payer: BCBS of TX PPO	$182.17
Rate for Payer: Cash Price	$309.69
Rate for Payer: Cigna Medicaid	$327.90
Rate for Payer: Molina CHIP/Medicaid	$327.90
Rate for Payer: Multiplan Auto	$227.71
Rate for Payer: Multiplan Commercial	$227.71
Rate for Payer: Multiplan Workers Comp	$227.71
Rate for Payer: Parkland Medicaid	$327.90
Rate for Payer: Scott and White EPO/PPO	$227.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$327.90
Rate for Payer: Superior Health Plan EPO	$61.94

131812060

Facility

$633.13

Service Code	HCPCS C1713
Hospital Charge Code	991318
Hospital Revenue Code	278
Min. Negotiated Rate	$56.98
Max. Negotiated Rate	$455.85
Rate for Payer: Amerigroup CHIP/Medicaid	$56.98
Rate for Payer: BCBS of TX Blue Advantage	$189.94
Rate for Payer: BCBS of TX Blue Essentials	$227.93
Rate for Payer: BCBS of TX PPO	$253.25
Rate for Payer: Cash Price	$430.53
Rate for Payer: Cigna Medicaid	$455.85
Rate for Payer: Molina CHIP/Medicaid	$455.85
Rate for Payer: Multiplan Auto	$316.56
Rate for Payer: Multiplan Commercial	$316.56
Rate for Payer: Multiplan Workers Comp	$316.56
Rate for Payer: Parkland Medicaid	$455.85
Rate for Payer: Scott and White EPO/PPO	$316.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$455.85
Rate for Payer: Superior Health Plan EPO	$86.11

131812060

Facility

$633.13

Service Code	HCPCS C1713
Hospital Charge Code	991318
Hospital Revenue Code	278
Min. Negotiated Rate	$158.28
Max. Negotiated Rate	$316.56
Rate for Payer: Cash Price	$430.53
Rate for Payer: Cigna Commercial	$158.28
Rate for Payer: Multiplan Auto	$316.56
Rate for Payer: Multiplan Commercial	$316.56
Rate for Payer: Multiplan Workers Comp	$316.56
Rate for Payer: Scott and White EPO/PPO	$316.56

1320-0191

Facility

$15,879.52

Service Code	HCPCS C1713
Hospital Charge Code	991183
Hospital Revenue Code	278
Min. Negotiated Rate	$3,969.88
Max. Negotiated Rate	$7,939.76
Rate for Payer: Cash Price	$10,798.07
Rate for Payer: Cigna Commercial	$3,969.88
Rate for Payer: Multiplan Auto	$7,939.76
Rate for Payer: Multiplan Commercial	$7,939.76
Rate for Payer: Multiplan Workers Comp	$7,939.76
Rate for Payer: Scott and White EPO/PPO	$7,939.76

1320-0191

Facility

$15,879.52

Service Code	HCPCS C1713
Hospital Charge Code	991183
Hospital Revenue Code	278
Min. Negotiated Rate	$1,429.16
Max. Negotiated Rate	$11,433.25
Rate for Payer: Amerigroup CHIP/Medicaid	$1,429.16
Rate for Payer: BCBS of TX Blue Advantage	$4,763.86
Rate for Payer: BCBS of TX Blue Essentials	$5,716.63
Rate for Payer: BCBS of TX PPO	$6,351.81
Rate for Payer: Cash Price	$10,798.07
Rate for Payer: Cigna Medicaid	$11,433.25
Rate for Payer: Molina CHIP/Medicaid	$11,433.25
Rate for Payer: Multiplan Auto	$7,939.76
Rate for Payer: Multiplan Commercial	$7,939.76
Rate for Payer: Multiplan Workers Comp	$7,939.76
Rate for Payer: Parkland Medicaid	$11,433.25
Rate for Payer: Scott and White EPO/PPO	$7,939.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,433.25
Rate for Payer: Superior Health Plan EPO	$2,159.61

14x12x7mm 3D Titanium Implant

Facility

$12,650.60

Service Code	HCPCS C1734
Hospital Charge Code	992218
Hospital Revenue Code	278
Min. Negotiated Rate	$1,138.55
Max. Negotiated Rate	$9,108.43
Rate for Payer: Amerigroup CHIP/Medicaid	$1,138.55
Rate for Payer: BCBS of TX Blue Advantage	$3,795.18
Rate for Payer: BCBS of TX Blue Essentials	$4,554.22
Rate for Payer: BCBS of TX PPO	$5,060.24
Rate for Payer: Cash Price	$8,602.41
Rate for Payer: Cigna Medicaid	$9,108.43
Rate for Payer: Molina CHIP/Medicaid	$9,108.43
Rate for Payer: Multiplan Auto	$6,325.30
Rate for Payer: Multiplan Commercial	$6,325.30
Rate for Payer: Multiplan Workers Comp	$6,325.30
Rate for Payer: Parkland Medicaid	$9,108.43
Rate for Payer: Scott and White EPO/PPO	$6,325.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,108.43
Rate for Payer: Superior Health Plan EPO	$1,720.48

14x12x7mm 3D Titanium Implant

Facility

$12,650.60

Service Code	HCPCS C1734
Hospital Charge Code	992218
Hospital Revenue Code	278
Min. Negotiated Rate	$3,162.65
Max. Negotiated Rate	$6,325.30
Rate for Payer: Cash Price	$8,602.41
Rate for Payer: Cigna Commercial	$3,162.65
Rate for Payer: Multiplan Auto	$6,325.30
Rate for Payer: Multiplan Commercial	$6,325.30
Rate for Payer: Multiplan Workers Comp	$6,325.30
Rate for Payer: Scott and White EPO/PPO	$6,325.30

1792502

Facility

$9,307.22

Service Code	HCPCS C1713
Hospital Charge Code	994142
Hospital Revenue Code	278
Min. Negotiated Rate	$837.65
Max. Negotiated Rate	$6,701.20
Rate for Payer: Amerigroup CHIP/Medicaid	$837.65
Rate for Payer: BCBS of TX Blue Advantage	$2,792.17
Rate for Payer: BCBS of TX Blue Essentials	$3,350.60
Rate for Payer: BCBS of TX PPO	$3,722.89
Rate for Payer: Cash Price	$6,328.91
Rate for Payer: Cigna Medicaid	$6,701.20
Rate for Payer: Molina CHIP/Medicaid	$6,701.20
Rate for Payer: Multiplan Auto	$4,653.61
Rate for Payer: Multiplan Commercial	$4,653.61
Rate for Payer: Multiplan Workers Comp	$4,653.61
Rate for Payer: Parkland Medicaid	$6,701.20
Rate for Payer: Scott and White EPO/PPO	$4,653.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,701.20
Rate for Payer: Superior Health Plan EPO	$1,265.78

1792502

Facility

$2,047.54

Service Code	HCPCS C1713
Hospital Charge Code	993133
Hospital Revenue Code	278
Min. Negotiated Rate	$511.88
Max. Negotiated Rate	$1,023.77
Rate for Payer: Cash Price	$1,392.33
Rate for Payer: Cigna Commercial	$511.88
Rate for Payer: Multiplan Auto	$1,023.77
Rate for Payer: Multiplan Commercial	$1,023.77
Rate for Payer: Multiplan Workers Comp	$1,023.77
Rate for Payer: Scott and White EPO/PPO	$1,023.77

1792502

Facility

$9,307.22

Service Code	HCPCS C1713
Hospital Charge Code	994142
Hospital Revenue Code	278
Min. Negotiated Rate	$2,326.80
Max. Negotiated Rate	$4,653.61
Rate for Payer: Cash Price	$6,328.91
Rate for Payer: Cigna Commercial	$2,326.80
Rate for Payer: Multiplan Auto	$4,653.61
Rate for Payer: Multiplan Commercial	$4,653.61
Rate for Payer: Multiplan Workers Comp	$4,653.61
Rate for Payer: Scott and White EPO/PPO	$4,653.61

1792502

Facility

$2,047.54

Service Code	HCPCS C1713
Hospital Charge Code	993133
Hospital Revenue Code	278
Min. Negotiated Rate	$184.28
Max. Negotiated Rate	$1,474.23
Rate for Payer: Amerigroup CHIP/Medicaid	$184.28
Rate for Payer: BCBS of TX Blue Advantage	$614.26
Rate for Payer: BCBS of TX Blue Essentials	$737.11
Rate for Payer: BCBS of TX PPO	$819.02
Rate for Payer: Cash Price	$1,392.33
Rate for Payer: Cigna Medicaid	$1,474.23
Rate for Payer: Molina CHIP/Medicaid	$1,474.23
Rate for Payer: Multiplan Auto	$1,023.77
Rate for Payer: Multiplan Commercial	$1,023.77
Rate for Payer: Multiplan Workers Comp	$1,023.77
Rate for Payer: Parkland Medicaid	$1,474.23
Rate for Payer: Scott and White EPO/PPO	$1,023.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,474.23
Rate for Payer: Superior Health Plan EPO	$278.47

1806-0050S

Facility

$1,620.48

Service Code	HCPCS C1776
Hospital Charge Code	991062
Hospital Revenue Code	278
Min. Negotiated Rate	$145.84
Max. Negotiated Rate	$1,166.75
Rate for Payer: Amerigroup CHIP/Medicaid	$145.84
Rate for Payer: BCBS of TX Blue Advantage	$486.14
Rate for Payer: BCBS of TX Blue Essentials	$583.37
Rate for Payer: BCBS of TX PPO	$648.19
Rate for Payer: Cash Price	$1,101.93
Rate for Payer: Cigna Medicaid	$1,166.75
Rate for Payer: Molina CHIP/Medicaid	$1,166.75
Rate for Payer: Multiplan Auto	$810.24
Rate for Payer: Multiplan Commercial	$810.24
Rate for Payer: Multiplan Workers Comp	$810.24
Rate for Payer: Parkland Medicaid	$1,166.75
Rate for Payer: Scott and White EPO/PPO	$810.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,166.75
Rate for Payer: Superior Health Plan EPO	$220.39

1806-0050S

Facility

$1,620.48

Service Code	HCPCS C1776
Hospital Charge Code	991062
Hospital Revenue Code	278
Min. Negotiated Rate	$405.12
Max. Negotiated Rate	$810.24
Rate for Payer: Cash Price	$1,101.93
Rate for Payer: Cigna Commercial	$405.12
Rate for Payer: Multiplan Auto	$810.24
Rate for Payer: Multiplan Commercial	$810.24
Rate for Payer: Multiplan Workers Comp	$810.24
Rate for Payer: Scott and White EPO/PPO	$810.24

1806-0050S1806-4280S1806-3550S

Facility

$1,663.00

Service Code	HCPCS C1776
Hospital Charge Code	991041
Hospital Revenue Code	278
Min. Negotiated Rate	$149.67
Max. Negotiated Rate	$1,197.36
Rate for Payer: Amerigroup CHIP/Medicaid	$149.67
Rate for Payer: BCBS of TX Blue Advantage	$498.90
Rate for Payer: BCBS of TX Blue Essentials	$598.68
Rate for Payer: BCBS of TX PPO	$665.20
Rate for Payer: Cash Price	$1,130.84
Rate for Payer: Cigna Medicaid	$1,197.36
Rate for Payer: Molina CHIP/Medicaid	$1,197.36
Rate for Payer: Multiplan Auto	$831.50
Rate for Payer: Multiplan Commercial	$831.50
Rate for Payer: Multiplan Workers Comp	$831.50
Rate for Payer: Parkland Medicaid	$1,197.36
Rate for Payer: Scott and White EPO/PPO	$831.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,197.36
Rate for Payer: Superior Health Plan EPO	$226.17

1806-0050S1806-4280S1806-3550S

Facility

$1,663.00

Service Code	HCPCS C1776
Hospital Charge Code	991041
Hospital Revenue Code	278
Min. Negotiated Rate	$415.75
Max. Negotiated Rate	$831.50
Rate for Payer: Cash Price	$1,130.84
Rate for Payer: Cigna Commercial	$415.75
Rate for Payer: Multiplan Auto	$831.50
Rate for Payer: Multiplan Commercial	$831.50
Rate for Payer: Multiplan Workers Comp	$831.50
Rate for Payer: Scott and White EPO/PPO	$831.50

1806-0080S

Facility

$1,753.01

Service Code	HCPCS C1734
Hospital Charge Code	991203
Hospital Revenue Code	278
Min. Negotiated Rate	$157.77
Max. Negotiated Rate	$1,262.17
Rate for Payer: Amerigroup CHIP/Medicaid	$157.77
Rate for Payer: BCBS of TX Blue Advantage	$525.90
Rate for Payer: BCBS of TX Blue Essentials	$631.08
Rate for Payer: BCBS of TX PPO	$701.20
Rate for Payer: Cash Price	$1,192.05
Rate for Payer: Cigna Medicaid	$1,262.17
Rate for Payer: Molina CHIP/Medicaid	$1,262.17
Rate for Payer: Multiplan Auto	$876.50
Rate for Payer: Multiplan Commercial	$876.50
Rate for Payer: Multiplan Workers Comp	$876.50
Rate for Payer: Parkland Medicaid	$1,262.17
Rate for Payer: Scott and White EPO/PPO	$876.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,262.17
Rate for Payer: Superior Health Plan EPO	$238.41

1806-0080S

Facility

$1,753.01

Service Code	HCPCS C1734
Hospital Charge Code	991203
Hospital Revenue Code	278
Min. Negotiated Rate	$438.25
Max. Negotiated Rate	$876.50
Rate for Payer: Cash Price	$1,192.05
Rate for Payer: Cigna Commercial	$438.25
Rate for Payer: Multiplan Auto	$876.50
Rate for Payer: Multiplan Commercial	$876.50
Rate for Payer: Multiplan Workers Comp	$876.50
Rate for Payer: Scott and White EPO/PPO	$876.50

1806-0085S

Facility

$1,831.32

Service Code	HCPCS C1776
Hospital Charge Code	991184
Hospital Revenue Code	278
Min. Negotiated Rate	$457.83
Max. Negotiated Rate	$915.66
Rate for Payer: Cash Price	$1,245.30
Rate for Payer: Cigna Commercial	$457.83
Rate for Payer: Multiplan Auto	$915.66
Rate for Payer: Multiplan Commercial	$915.66
Rate for Payer: Multiplan Workers Comp	$915.66
Rate for Payer: Scott and White EPO/PPO	$915.66

1806-0085S

Facility

$1,831.32

Service Code	HCPCS C1776
Hospital Charge Code	991184
Hospital Revenue Code	278
Min. Negotiated Rate	$164.82
Max. Negotiated Rate	$1,318.55
Rate for Payer: Amerigroup CHIP/Medicaid	$164.82
Rate for Payer: BCBS of TX Blue Advantage	$549.40
Rate for Payer: BCBS of TX Blue Essentials	$659.28
Rate for Payer: BCBS of TX PPO	$732.53
Rate for Payer: Cash Price	$1,245.30
Rate for Payer: Cigna Medicaid	$1,318.55
Rate for Payer: Molina CHIP/Medicaid	$1,318.55
Rate for Payer: Multiplan Auto	$915.66
Rate for Payer: Multiplan Commercial	$915.66
Rate for Payer: Multiplan Workers Comp	$915.66
Rate for Payer: Parkland Medicaid	$1,318.55
Rate for Payer: Scott and White EPO/PPO	$915.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,318.55
Rate for Payer: Superior Health Plan EPO	$249.06

1806-3550S

Facility

$1,144.58

Service Code	HCPCS C1776
Hospital Charge Code	991060
Hospital Revenue Code	278
Min. Negotiated Rate	$286.14
Max. Negotiated Rate	$572.29
Rate for Payer: Cash Price	$778.31
Rate for Payer: Cigna Commercial	$286.14
Rate for Payer: Multiplan Auto	$572.29
Rate for Payer: Multiplan Commercial	$572.29
Rate for Payer: Multiplan Workers Comp	$572.29
Rate for Payer: Scott and White EPO/PPO	$572.29

Know your out-of-pocket cost for care.

All Charges