White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KT BN RESORB BEAD 5CC -- DHF

Facility

$7,130.16

Service Code	HCPCS C1713
Hospital Charge Code	40131005
Hospital Revenue Code	278
Min. Negotiated Rate	$641.71
Max. Negotiated Rate	$3,565.08
Rate for Payer: Aetna Commercial	$2,139.05
Rate for Payer: Amerigroup CHIP/Medicaid	$641.71
Rate for Payer: BCBS of TX Blue Advantage	$2,139.05
Rate for Payer: BCBS of TX Blue Essentials	$2,566.86
Rate for Payer: BCBS of TX PPO	$2,852.06
Rate for Payer: Cash Price	$6,274.54
Rate for Payer: Multiplan Auto	$3,565.08
Rate for Payer: Multiplan Commercial	$3,565.08
Rate for Payer: Multiplan Workers Comp	$3,565.08
Rate for Payer: Scott and White EPO/PPO	$3,565.08
Rate for Payer: Superior Health Plan EPO	$969.70

KT BN RESORB BEAD 5CC -- DHF

Facility

$7,130.16

Service Code	HCPCS C1713
Hospital Charge Code	40131005
Hospital Revenue Code	278
Min. Negotiated Rate	$1,782.54
Max. Negotiated Rate	$3,565.08
Rate for Payer: Aetna Commercial	$2,139.05
Rate for Payer: Cash Price	$6,274.54
Rate for Payer: Cigna Commercial	$1,782.54
Rate for Payer: Multiplan Auto	$3,565.08
Rate for Payer: Multiplan Commercial	$3,565.08
Rate for Payer: Multiplan Workers Comp	$3,565.08
Rate for Payer: Scott and White EPO/PPO	$3,565.08

kt breast pump 67350s

Facility

$110.10

Hospital Charge Code	8618510
Hospital Revenue Code	272
Min. Negotiated Rate	$9.91
Max. Negotiated Rate	$71.56
Rate for Payer: Aetna Commercial	$60.56
Rate for Payer: Amerigroup CHIP/Medicaid	$9.91
Rate for Payer: BCBS of TX Blue Advantage	$33.03
Rate for Payer: BCBS of TX Blue Essentials	$39.64
Rate for Payer: BCBS of TX PPO	$44.04
Rate for Payer: Cash Price	$96.89
Rate for Payer: Multiplan Auto	$71.56
Rate for Payer: Multiplan Commercial	$71.56
Rate for Payer: Multiplan Workers Comp	$71.56
Rate for Payer: Scott and White EPO/PPO	$55.05
Rate for Payer: Superior Health Plan EPO	$14.97

kt breast pump 67350s

Facility

$110.10

Hospital Charge Code	8618510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$96.89

KT CHOLANGIOGRAPHY -- DHF

Facility

$499.40

Hospital Charge Code	80819170
Hospital Revenue Code	272
Rate for Payer: Cash Price	$439.47

KT CHOLANGIOGRAPHY -- DHF

Facility

$499.40

Hospital Charge Code	80819170
Hospital Revenue Code	272
Min. Negotiated Rate	$44.95
Max. Negotiated Rate	$324.61
Rate for Payer: Aetna Commercial	$274.67
Rate for Payer: Amerigroup CHIP/Medicaid	$44.95
Rate for Payer: BCBS of TX Blue Advantage	$149.82
Rate for Payer: BCBS of TX Blue Essentials	$179.78
Rate for Payer: BCBS of TX PPO	$199.76
Rate for Payer: Cash Price	$439.47
Rate for Payer: Multiplan Auto	$324.61
Rate for Payer: Multiplan Commercial	$324.61
Rate for Payer: Multiplan Workers Comp	$324.61
Rate for Payer: Scott and White EPO/PPO	$249.70
Rate for Payer: Superior Health Plan EPO	$67.92

KT CHST TB INSRT DISP -- DHF

Facility

$272.53

Hospital Charge Code	80819162
Hospital Revenue Code	272
Rate for Payer: Cash Price	$239.83

KT CHST TB INSRT DISP -- DHF

Facility

$272.53

Hospital Charge Code	80819162
Hospital Revenue Code	272
Min. Negotiated Rate	$24.53
Max. Negotiated Rate	$177.14
Rate for Payer: Aetna Commercial	$149.89
Rate for Payer: Amerigroup CHIP/Medicaid	$24.53
Rate for Payer: BCBS of TX Blue Advantage	$81.76
Rate for Payer: BCBS of TX Blue Essentials	$98.11
Rate for Payer: BCBS of TX PPO	$109.01
Rate for Payer: Cash Price	$239.83
Rate for Payer: Multiplan Auto	$177.14
Rate for Payer: Multiplan Commercial	$177.14
Rate for Payer: Multiplan Workers Comp	$177.14
Rate for Payer: Scott and White EPO/PPO	$136.26
Rate for Payer: Superior Health Plan EPO	$37.06

KT CPM ACCES -- DHF

Facility

$1,038.67

Hospital Charge Code	80819352
Hospital Revenue Code	270
Rate for Payer: Cash Price	$914.03

KT CPM ACCES -- DHF

Facility

$1,038.67

Hospital Charge Code	80819352
Hospital Revenue Code	270
Min. Negotiated Rate	$93.48
Max. Negotiated Rate	$675.14
Rate for Payer: Aetna Commercial	$571.27
Rate for Payer: Amerigroup CHIP/Medicaid	$93.48
Rate for Payer: BCBS of TX Blue Advantage	$311.60
Rate for Payer: BCBS of TX Blue Essentials	$373.92
Rate for Payer: BCBS of TX PPO	$415.47
Rate for Payer: Cash Price	$914.03
Rate for Payer: Multiplan Auto	$675.14
Rate for Payer: Multiplan Commercial	$675.14
Rate for Payer: Multiplan Workers Comp	$675.14
Rate for Payer: Scott and White EPO/PPO	$519.34
Rate for Payer: Superior Health Plan EPO	$141.26

KT DRN CATH -- DHF

Facility

$279.02

Service Code	HCPCS C1729
Hospital Charge Code	80819907
Hospital Revenue Code	278
Min. Negotiated Rate	$25.11
Max. Negotiated Rate	$139.51
Rate for Payer: Aetna Commercial	$83.71
Rate for Payer: Amerigroup CHIP/Medicaid	$25.11
Rate for Payer: BCBS of TX Blue Advantage	$83.71
Rate for Payer: BCBS of TX Blue Essentials	$100.45
Rate for Payer: BCBS of TX PPO	$111.61
Rate for Payer: Cash Price	$245.54
Rate for Payer: Multiplan Auto	$139.51
Rate for Payer: Multiplan Commercial	$139.51
Rate for Payer: Multiplan Workers Comp	$139.51
Rate for Payer: Scott and White EPO/PPO	$139.51
Rate for Payer: Superior Health Plan EPO	$37.95

KT DRN CATH -- DHF

Facility

$279.02

Service Code	HCPCS C1729
Hospital Charge Code	80819907
Hospital Revenue Code	278
Min. Negotiated Rate	$69.76
Max. Negotiated Rate	$139.51
Rate for Payer: Aetna Commercial	$83.71
Rate for Payer: Cash Price	$245.54
Rate for Payer: Cigna Commercial	$69.76
Rate for Payer: Multiplan Auto	$139.51
Rate for Payer: Multiplan Commercial	$139.51
Rate for Payer: Multiplan Workers Comp	$139.51
Rate for Payer: Scott and White EPO/PPO	$139.51

KT DRN/VAC SYS -- DHF

Facility

$567.55

Hospital Charge Code	80820053
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$368.91
Rate for Payer: Aetna Commercial	$312.15
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.26
Rate for Payer: BCBS of TX Blue Essentials	$204.32
Rate for Payer: BCBS of TX PPO	$227.02
Rate for Payer: Cash Price	$499.44
Rate for Payer: Multiplan Auto	$368.91
Rate for Payer: Multiplan Commercial	$368.91
Rate for Payer: Multiplan Workers Comp	$368.91
Rate for Payer: Scott and White EPO/PPO	$283.78
Rate for Payer: Superior Health Plan EPO	$77.19

KT DRN/VAC SYS -- DHF

Facility

$567.55

Hospital Charge Code	80820053
Hospital Revenue Code	272
Rate for Payer: Cash Price	$499.44

KT DRS FOAM VAC -- DHF

Facility

$553.43

Hospital Charge Code	80820061
Hospital Revenue Code	272
Rate for Payer: Cash Price	$487.02

KT DRS FOAM VAC -- DHF

Facility

$553.43

Hospital Charge Code	80820061
Hospital Revenue Code	272
Min. Negotiated Rate	$49.81
Max. Negotiated Rate	$359.73
Rate for Payer: Aetna Commercial	$304.39
Rate for Payer: Amerigroup CHIP/Medicaid	$49.81
Rate for Payer: BCBS of TX Blue Advantage	$166.03
Rate for Payer: BCBS of TX Blue Essentials	$199.23
Rate for Payer: BCBS of TX PPO	$221.37
Rate for Payer: Cash Price	$487.02
Rate for Payer: Multiplan Auto	$359.73
Rate for Payer: Multiplan Commercial	$359.73
Rate for Payer: Multiplan Workers Comp	$359.73
Rate for Payer: Scott and White EPO/PPO	$276.72
Rate for Payer: Superior Health Plan EPO	$75.27

KT EX FX ROCKERRAIL -- DHF

Facility

$6,106.93

Hospital Charge Code	80899016
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,374.10

KT EX FX ROCKERRAIL -- DHF

Facility

$6,106.93

Hospital Charge Code	80899016
Hospital Revenue Code	272
Min. Negotiated Rate	$549.62
Max. Negotiated Rate	$3,969.50
Rate for Payer: Aetna Commercial	$3,358.81
Rate for Payer: Amerigroup CHIP/Medicaid	$549.62
Rate for Payer: BCBS of TX Blue Advantage	$1,832.08
Rate for Payer: BCBS of TX Blue Essentials	$2,198.49
Rate for Payer: BCBS of TX PPO	$2,442.77
Rate for Payer: Cash Price	$5,374.10
Rate for Payer: Multiplan Auto	$3,969.50
Rate for Payer: Multiplan Commercial	$3,969.50
Rate for Payer: Multiplan Workers Comp	$3,969.50
Rate for Payer: Scott and White EPO/PPO	$3,053.46
Rate for Payer: Superior Health Plan EPO	$830.54

KT GASTROSTOMY -- DHF

Facility

$1,001.57

Hospital Charge Code	80820905
Hospital Revenue Code	272
Rate for Payer: Cash Price	$881.38

KT GASTROSTOMY -- DHF

Facility

$1,001.57

Hospital Charge Code	80820905
Hospital Revenue Code	272
Min. Negotiated Rate	$90.14
Max. Negotiated Rate	$651.02
Rate for Payer: Aetna Commercial	$550.86
Rate for Payer: Amerigroup CHIP/Medicaid	$90.14
Rate for Payer: BCBS of TX Blue Advantage	$300.47
Rate for Payer: BCBS of TX Blue Essentials	$360.57
Rate for Payer: BCBS of TX PPO	$400.63
Rate for Payer: Cash Price	$881.38
Rate for Payer: Multiplan Auto	$651.02
Rate for Payer: Multiplan Commercial	$651.02
Rate for Payer: Multiplan Workers Comp	$651.02
Rate for Payer: Scott and White EPO/PPO	$500.78
Rate for Payer: Superior Health Plan EPO	$136.21

KT INTRAUTERINE -- DHF

Facility

$1,211.57

Hospital Charge Code	80821556
Hospital Revenue Code	272
Min. Negotiated Rate	$109.04
Max. Negotiated Rate	$787.52
Rate for Payer: Aetna Commercial	$666.36
Rate for Payer: Amerigroup CHIP/Medicaid	$109.04
Rate for Payer: BCBS of TX Blue Advantage	$363.47
Rate for Payer: BCBS of TX Blue Essentials	$436.17
Rate for Payer: BCBS of TX PPO	$484.63
Rate for Payer: Cash Price	$1,066.18
Rate for Payer: Multiplan Auto	$787.52
Rate for Payer: Multiplan Commercial	$787.52
Rate for Payer: Multiplan Workers Comp	$787.52
Rate for Payer: Scott and White EPO/PPO	$605.78
Rate for Payer: Superior Health Plan EPO	$164.77

KT INTRAUTERINE -- DHF

Facility

$1,211.57

Hospital Charge Code	80821556
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,066.18

KT ISOLATION -- DHF

Facility

$158.44

Hospital Charge Code	80821754
Hospital Revenue Code	270
Rate for Payer: Cash Price	$139.43

KT ISOLATION -- DHF

Facility

$158.44

Hospital Charge Code	80821754
Hospital Revenue Code	270
Min. Negotiated Rate	$14.26
Max. Negotiated Rate	$102.99
Rate for Payer: Aetna Commercial	$87.14
Rate for Payer: Amerigroup CHIP/Medicaid	$14.26
Rate for Payer: BCBS of TX Blue Advantage	$47.53
Rate for Payer: BCBS of TX Blue Essentials	$57.04
Rate for Payer: BCBS of TX PPO	$63.38
Rate for Payer: Cash Price	$139.43
Rate for Payer: Multiplan Auto	$102.99
Rate for Payer: Multiplan Commercial	$102.99
Rate for Payer: Multiplan Workers Comp	$102.99
Rate for Payer: Scott and White EPO/PPO	$79.22
Rate for Payer: Superior Health Plan EPO	$21.55

KT LIGAMENT REPR AUGMENT -- DHF

Facility

$12,867.46

Service Code	HCPCS C1713
Hospital Charge Code	40131203
Hospital Revenue Code	278
Min. Negotiated Rate	$3,216.86
Max. Negotiated Rate	$6,433.73
Rate for Payer: Aetna Commercial	$3,860.24
Rate for Payer: Cash Price	$11,323.36
Rate for Payer: Cigna Commercial	$3,216.86
Rate for Payer: Multiplan Auto	$6,433.73
Rate for Payer: Multiplan Commercial	$6,433.73
Rate for Payer: Multiplan Workers Comp	$6,433.73
Rate for Payer: Scott and White EPO/PPO	$6,433.73

Know your out-of-pocket cost for care.

All Charges