White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KT LIGAMENT REPR AUGMENT -- DHF

Facility

$12,867.46

Service Code	HCPCS C1713
Hospital Charge Code	40131203
Hospital Revenue Code	278
Min. Negotiated Rate	$1,158.07
Max. Negotiated Rate	$6,433.73
Rate for Payer: Aetna Commercial	$3,860.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,158.07
Rate for Payer: BCBS of TX Blue Advantage	$3,860.24
Rate for Payer: BCBS of TX Blue Essentials	$4,632.29
Rate for Payer: BCBS of TX PPO	$5,146.98
Rate for Payer: Cash Price	$11,323.36
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
Rate for Payer: Superior Health Plan EPO	$1,749.97

KT LIGATR ESOPH -- DHF

Facility

$1,093.80

Hospital Charge Code	82050170
Hospital Revenue Code	270
Rate for Payer: Cash Price	$962.54

KT LIGATR ESOPH -- DHF

Facility

$1,093.80

Hospital Charge Code	82050170
Hospital Revenue Code	270
Min. Negotiated Rate	$98.44
Max. Negotiated Rate	$710.97
Rate for Payer: Aetna Commercial	$601.59
Rate for Payer: Amerigroup CHIP/Medicaid	$98.44
Rate for Payer: BCBS of TX Blue Advantage	$328.14
Rate for Payer: BCBS of TX Blue Essentials	$393.77
Rate for Payer: BCBS of TX PPO	$437.52
Rate for Payer: Cash Price	$962.54
Rate for Payer: Multiplan Auto	$710.97
Rate for Payer: Multiplan Commercial	$710.97
Rate for Payer: Multiplan Workers Comp	$710.97
Rate for Payer: Scott and White EPO/PPO	$546.90
Rate for Payer: Superior Health Plan EPO	$148.76

KT MANIFLD CUSTM -- DHF

Facility

$163.36

Hospital Charge Code	80326564
Hospital Revenue Code	272
Rate for Payer: Cash Price	$143.76

KT MANIFLD CUSTM -- DHF

Facility

$163.36

Hospital Charge Code	80326564
Hospital Revenue Code	272
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$106.18
Rate for Payer: Aetna Commercial	$89.85
Rate for Payer: Amerigroup CHIP/Medicaid	$14.70
Rate for Payer: BCBS of TX Blue Advantage	$49.01
Rate for Payer: BCBS of TX Blue Essentials	$58.81
Rate for Payer: BCBS of TX PPO	$65.34
Rate for Payer: Cash Price	$143.76
Rate for Payer: Multiplan Auto	$106.18
Rate for Payer: Multiplan Commercial	$106.18
Rate for Payer: Multiplan Workers Comp	$106.18
Rate for Payer: Scott and White EPO/PPO	$81.68
Rate for Payer: Superior Health Plan EPO	$22.22

KT MENISC REPR PROCEDUR -- DHF

Facility

$3,300.00

Hospital Charge Code	81780835
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,904.00

KT MENISC REPR PROCEDUR -- DHF

Facility

$3,300.00

Hospital Charge Code	81780835
Hospital Revenue Code	272
Min. Negotiated Rate	$297.00
Max. Negotiated Rate	$2,145.00
Rate for Payer: Aetna Commercial	$1,815.00
Rate for Payer: Amerigroup CHIP/Medicaid	$297.00
Rate for Payer: BCBS of TX Blue Advantage	$990.00
Rate for Payer: BCBS of TX Blue Essentials	$1,188.00
Rate for Payer: BCBS of TX PPO	$1,320.00
Rate for Payer: Cash Price	$2,904.00
Rate for Payer: Multiplan Auto	$2,145.00
Rate for Payer: Multiplan Commercial	$2,145.00
Rate for Payer: Multiplan Workers Comp	$2,145.00
Rate for Payer: Scott and White EPO/PPO	$1,650.00
Rate for Payer: Superior Health Plan EPO	$448.80

KT MULTILMR CTH

Facility

$348.60

Service Code	HCPCS C1751
Hospital Charge Code	80822307
Hospital Revenue Code	278
Min. Negotiated Rate	$31.37
Max. Negotiated Rate	$174.30
Rate for Payer: Aetna Commercial	$104.58
Rate for Payer: Amerigroup CHIP/Medicaid	$31.37
Rate for Payer: BCBS of TX Blue Advantage	$104.58
Rate for Payer: BCBS of TX Blue Essentials	$125.50
Rate for Payer: BCBS of TX PPO	$139.44
Rate for Payer: Cash Price	$306.77
Rate for Payer: Multiplan Auto	$174.30
Rate for Payer: Multiplan Commercial	$174.30
Rate for Payer: Multiplan Workers Comp	$174.30
Rate for Payer: Scott and White EPO/PPO	$174.30
Rate for Payer: Superior Health Plan EPO	$47.41

KT MULTILMR CTH

Facility

$348.60

Service Code	HCPCS C1751
Hospital Charge Code	80822307
Hospital Revenue Code	278
Min. Negotiated Rate	$87.15
Max. Negotiated Rate	$174.30
Rate for Payer: Aetna Commercial	$104.58
Rate for Payer: Cash Price	$306.77
Rate for Payer: Cigna Commercial	$87.15
Rate for Payer: Multiplan Auto	$174.30
Rate for Payer: Multiplan Commercial	$174.30
Rate for Payer: Multiplan Workers Comp	$174.30
Rate for Payer: Scott and White EPO/PPO	$174.30

KT NASOPK -- DHF

Facility

$562.96

Hospital Charge Code	80822455
Hospital Revenue Code	270
Rate for Payer: Cash Price	$495.40

KT NASOPK -- DHF

Facility

$562.96

Hospital Charge Code	80822455
Hospital Revenue Code	270
Min. Negotiated Rate	$50.67
Max. Negotiated Rate	$365.92
Rate for Payer: Aetna Commercial	$309.63
Rate for Payer: Amerigroup CHIP/Medicaid	$50.67
Rate for Payer: BCBS of TX Blue Advantage	$168.89
Rate for Payer: BCBS of TX Blue Essentials	$202.67
Rate for Payer: BCBS of TX PPO	$225.18
Rate for Payer: Cash Price	$495.40
Rate for Payer: Multiplan Auto	$365.92
Rate for Payer: Multiplan Commercial	$365.92
Rate for Payer: Multiplan Workers Comp	$365.92
Rate for Payer: Scott and White EPO/PPO	$281.48
Rate for Payer: Superior Health Plan EPO	$76.56

KT NDL GUIDE DISP -- DHF

Facility

$122.17

Hospital Charge Code	80822539
Hospital Revenue Code	272
Rate for Payer: Cash Price	$107.51

KT NDL GUIDE DISP -- DHF

Facility

$122.17

Hospital Charge Code	80822539
Hospital Revenue Code	272
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$79.41
Rate for Payer: Aetna Commercial	$67.19
Rate for Payer: Amerigroup CHIP/Medicaid	$11.00
Rate for Payer: BCBS of TX Blue Advantage	$36.65
Rate for Payer: BCBS of TX Blue Essentials	$43.98
Rate for Payer: BCBS of TX PPO	$48.87
Rate for Payer: Cash Price	$107.51
Rate for Payer: Multiplan Auto	$79.41
Rate for Payer: Multiplan Commercial	$79.41
Rate for Payer: Multiplan Workers Comp	$79.41
Rate for Payer: Scott and White EPO/PPO	$61.08
Rate for Payer: Superior Health Plan EPO	$16.62

KT ORTHO -- DHF

Facility

$3,745.37

Hospital Charge Code	80822802
Hospital Revenue Code	270
Min. Negotiated Rate	$337.08
Max. Negotiated Rate	$2,434.49
Rate for Payer: Aetna Commercial	$2,059.95
Rate for Payer: Amerigroup CHIP/Medicaid	$337.08
Rate for Payer: BCBS of TX Blue Advantage	$1,123.61
Rate for Payer: BCBS of TX Blue Essentials	$1,348.33
Rate for Payer: BCBS of TX PPO	$1,498.15
Rate for Payer: Cash Price	$3,295.93
Rate for Payer: Multiplan Auto	$2,434.49
Rate for Payer: Multiplan Commercial	$2,434.49
Rate for Payer: Multiplan Workers Comp	$2,434.49
Rate for Payer: Scott and White EPO/PPO	$1,872.68
Rate for Payer: Superior Health Plan EPO	$509.37

KT ORTHO -- DHF

Facility

$3,745.37

Hospital Charge Code	80822802
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3,295.93

KT PAD ARCTICGEL LRG -- DHF

Facility

$4,788.08

Hospital Charge Code	80385289
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,213.51

KT PAD ARCTICGEL LRG -- DHF

Facility

$4,788.08

Hospital Charge Code	80385289
Hospital Revenue Code	272
Min. Negotiated Rate	$430.93
Max. Negotiated Rate	$3,112.25
Rate for Payer: Aetna Commercial	$2,633.44
Rate for Payer: Amerigroup CHIP/Medicaid	$430.93
Rate for Payer: BCBS of TX Blue Advantage	$1,436.42
Rate for Payer: BCBS of TX Blue Essentials	$1,723.71
Rate for Payer: BCBS of TX PPO	$1,915.23
Rate for Payer: Cash Price	$4,213.51
Rate for Payer: Multiplan Auto	$3,112.25
Rate for Payer: Multiplan Commercial	$3,112.25
Rate for Payer: Multiplan Workers Comp	$3,112.25
Rate for Payer: Scott and White EPO/PPO	$2,394.04
Rate for Payer: Superior Health Plan EPO	$651.18

KT PRESSURE MONITOR -- DHF

Facility

$40.09

Hospital Charge Code	80824345
Hospital Revenue Code	272
Min. Negotiated Rate	$3.61
Max. Negotiated Rate	$26.06
Rate for Payer: Aetna Commercial	$22.05
Rate for Payer: Amerigroup CHIP/Medicaid	$3.61
Rate for Payer: BCBS of TX Blue Advantage	$12.03
Rate for Payer: BCBS of TX Blue Essentials	$14.43
Rate for Payer: BCBS of TX PPO	$16.04
Rate for Payer: Cash Price	$35.28
Rate for Payer: Multiplan Auto	$26.06
Rate for Payer: Multiplan Commercial	$26.06
Rate for Payer: Multiplan Workers Comp	$26.06
Rate for Payer: Scott and White EPO/PPO	$20.04
Rate for Payer: Superior Health Plan EPO	$5.45

KT PRESSURE MONITOR -- DHF

Facility

$40.09

Hospital Charge Code	80824345
Hospital Revenue Code	272
Rate for Payer: Cash Price	$35.28

KT PT ADM OB -- DHF

Facility

$179.51

Hospital Charge Code	80325855
Hospital Revenue Code	270
Min. Negotiated Rate	$16.16
Max. Negotiated Rate	$116.68
Rate for Payer: Aetna Commercial	$98.73
Rate for Payer: Amerigroup CHIP/Medicaid	$16.16
Rate for Payer: BCBS of TX Blue Advantage	$53.85
Rate for Payer: BCBS of TX Blue Essentials	$64.62
Rate for Payer: BCBS of TX PPO	$71.80
Rate for Payer: Cash Price	$157.97
Rate for Payer: Multiplan Auto	$116.68
Rate for Payer: Multiplan Commercial	$116.68
Rate for Payer: Multiplan Workers Comp	$116.68
Rate for Payer: Scott and White EPO/PPO	$89.76
Rate for Payer: Superior Health Plan EPO	$24.41

KT PT ADM OB -- DHF

Facility

$179.51

Hospital Charge Code	80325855
Hospital Revenue Code	270
Rate for Payer: Cash Price	$157.97

KT PT CR NB -- DHF

Facility

$74.65

Hospital Charge Code	80325954
Hospital Revenue Code	270
Rate for Payer: Cash Price	$65.69

KT PT CR NB -- DHF

Facility

$74.65

Hospital Charge Code	80325954
Hospital Revenue Code	270
Min. Negotiated Rate	$6.72
Max. Negotiated Rate	$48.52
Rate for Payer: Aetna Commercial	$41.06
Rate for Payer: Amerigroup CHIP/Medicaid	$6.72
Rate for Payer: BCBS of TX Blue Advantage	$22.40
Rate for Payer: BCBS of TX Blue Essentials	$26.87
Rate for Payer: BCBS of TX PPO	$29.86
Rate for Payer: Cash Price	$65.69
Rate for Payer: Multiplan Auto	$48.52
Rate for Payer: Multiplan Commercial	$48.52
Rate for Payer: Multiplan Workers Comp	$48.52
Rate for Payer: Scott and White EPO/PPO	$37.32
Rate for Payer: Superior Health Plan EPO	$10.15

KT SPINEJACK EXPANSION -- DHF

Facility

$25,090.36

Service Code	HCPCS C1889
Hospital Charge Code	81781122
Hospital Revenue Code	278
Min. Negotiated Rate	$2,258.13
Max. Negotiated Rate	$12,545.18
Rate for Payer: Aetna Commercial	$7,527.11
Rate for Payer: Amerigroup CHIP/Medicaid	$2,258.13
Rate for Payer: BCBS of TX Blue Advantage	$7,527.11
Rate for Payer: BCBS of TX Blue Essentials	$9,032.53
Rate for Payer: BCBS of TX PPO	$10,036.14
Rate for Payer: Cash Price	$22,079.52
Rate for Payer: Multiplan Auto	$12,545.18
Rate for Payer: Multiplan Commercial	$12,545.18
Rate for Payer: Multiplan Workers Comp	$12,545.18
Rate for Payer: Scott and White EPO/PPO	$12,545.18
Rate for Payer: Superior Health Plan EPO	$3,412.29

KT SPINEJACK EXPANSION -- DHF

Facility

$25,090.36

Service Code	HCPCS C1889
Hospital Charge Code	81781122
Hospital Revenue Code	278
Min. Negotiated Rate	$6,272.59
Max. Negotiated Rate	$12,545.18
Rate for Payer: Aetna Commercial	$7,527.11
Rate for Payer: Cash Price	$22,079.52
Rate for Payer: Cigna Commercial	$6,272.59
Rate for Payer: Multiplan Auto	$12,545.18
Rate for Payer: Multiplan Commercial	$12,545.18
Rate for Payer: Multiplan Workers Comp	$12,545.18
Rate for Payer: Scott and White EPO/PPO	$12,545.18

Know your out-of-pocket cost for care.

All Charges