White Rock Medical Center

All Charges

Charge

Type

Setting

Price

EXFX STRUT -- DHF

Facility

$4,409.11

Hospital Charge Code	81321770
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,998.19

EXFX STRUT -- DHF

Facility

$4,409.11

Hospital Charge Code	81321770
Hospital Revenue Code	272
Min. Negotiated Rate	$396.82
Max. Negotiated Rate	$3,174.56
Rate for Payer: Amerigroup CHIP/Medicaid	$396.82
Rate for Payer: BCBS of TX Blue Advantage	$1,322.73
Rate for Payer: BCBS of TX Blue Essentials	$1,587.28
Rate for Payer: BCBS of TX PPO	$1,763.64
Rate for Payer: Cash Price	$2,998.19
Rate for Payer: Cigna Medicaid	$3,174.56
Rate for Payer: Molina CHIP/Medicaid	$3,174.56
Rate for Payer: Multiplan Auto	$2,865.92
Rate for Payer: Multiplan Commercial	$2,865.92
Rate for Payer: Multiplan Workers Comp	$2,865.92
Rate for Payer: Parkland Medicaid	$3,174.56
Rate for Payer: Scott and White EPO/PPO	$2,204.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,174.56
Rate for Payer: Superior Health Plan EPO	$599.64

EXFX STRUT QUICK ADJUST

Facility

$4,409.11

Hospital Charge Code	145133
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,998.19

EXFX STRUT QUICK ADJUST

Facility

$4,409.11

Hospital Charge Code	145133
Hospital Revenue Code	272
Min. Negotiated Rate	$396.82
Max. Negotiated Rate	$3,174.56
Rate for Payer: Amerigroup CHIP/Medicaid	$396.82
Rate for Payer: BCBS of TX Blue Advantage	$1,322.73
Rate for Payer: BCBS of TX Blue Essentials	$1,587.28
Rate for Payer: BCBS of TX PPO	$1,763.64
Rate for Payer: Cash Price	$2,998.19
Rate for Payer: Cigna Medicaid	$3,174.56
Rate for Payer: Molina CHIP/Medicaid	$3,174.56
Rate for Payer: Multiplan Auto	$2,865.92
Rate for Payer: Multiplan Commercial	$2,865.92
Rate for Payer: Multiplan Workers Comp	$2,865.92
Rate for Payer: Parkland Medicaid	$3,174.56
Rate for Payer: Scott and White EPO/PPO	$2,204.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,174.56
Rate for Payer: Superior Health Plan EPO	$599.64

EXFX TL RING

Facility

$4,698.90

Hospital Charge Code	81321663
Hospital Revenue Code	272
Min. Negotiated Rate	$422.90
Max. Negotiated Rate	$3,383.21
Rate for Payer: Amerigroup CHIP/Medicaid	$422.90
Rate for Payer: BCBS of TX Blue Advantage	$1,409.67
Rate for Payer: BCBS of TX Blue Essentials	$1,691.60
Rate for Payer: BCBS of TX PPO	$1,879.56
Rate for Payer: Cash Price	$3,195.25
Rate for Payer: Cigna Medicaid	$3,383.21
Rate for Payer: Molina CHIP/Medicaid	$3,383.21
Rate for Payer: Multiplan Auto	$3,054.28
Rate for Payer: Multiplan Commercial	$3,054.28
Rate for Payer: Multiplan Workers Comp	$3,054.28
Rate for Payer: Parkland Medicaid	$3,383.21
Rate for Payer: Scott and White EPO/PPO	$2,349.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,383.21
Rate for Payer: Superior Health Plan EPO	$639.05

EXFX TL RING

Facility

$4,698.90

Hospital Charge Code	81321663
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,195.25

EXFX TL ROCKER RAIL KIT

Facility

$6,106.94

Hospital Charge Code	139392
Hospital Revenue Code	272
Min. Negotiated Rate	$549.62
Max. Negotiated Rate	$4,397.00
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	$2,198.50
Rate for Payer: BCBS of TX PPO	$2,442.78
Rate for Payer: Cash Price	$4,152.72
Rate for Payer: Cigna Medicaid	$4,397.00
Rate for Payer: Molina CHIP/Medicaid	$4,397.00
Rate for Payer: Multiplan Auto	$3,969.51
Rate for Payer: Multiplan Commercial	$3,969.51
Rate for Payer: Multiplan Workers Comp	$3,969.51
Rate for Payer: Parkland Medicaid	$4,397.00
Rate for Payer: Scott and White EPO/PPO	$3,053.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,397.00
Rate for Payer: Superior Health Plan EPO	$830.54

EXFX TL ROCKER RAIL KIT

Facility

$6,106.94

Hospital Charge Code	139392
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,152.72

EXFX WASHER -- DHF

Facility

$36.00

Hospital Charge Code	81321887
Hospital Revenue Code	272
Min. Negotiated Rate	$3.24
Max. Negotiated Rate	$25.92
Rate for Payer: Amerigroup CHIP/Medicaid	$3.24
Rate for Payer: BCBS of TX Blue Advantage	$10.80
Rate for Payer: BCBS of TX Blue Essentials	$12.96
Rate for Payer: BCBS of TX PPO	$14.40
Rate for Payer: Cash Price	$24.48
Rate for Payer: Cigna Medicaid	$25.92
Rate for Payer: Molina CHIP/Medicaid	$25.92
Rate for Payer: Multiplan Auto	$23.40
Rate for Payer: Multiplan Commercial	$23.40
Rate for Payer: Multiplan Workers Comp	$23.40
Rate for Payer: Parkland Medicaid	$25.92
Rate for Payer: Scott and White EPO/PPO	$18.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25.92
Rate for Payer: Superior Health Plan EPO	$4.90

EXFX WASHER -- DHF

Facility

$36.00

Hospital Charge Code	81321887
Hospital Revenue Code	272
Rate for Payer: Cash Price	$24.48

EXFX WIRE BOLT ADAPTER

Facility

$1,325.91

Hospital Charge Code	115246
Hospital Revenue Code	272
Rate for Payer: Cash Price	$901.62

EXFX WIRE BOLT ADAPTER

Facility

$1,325.91

Hospital Charge Code	115246
Hospital Revenue Code	272
Min. Negotiated Rate	$119.33
Max. Negotiated Rate	$954.66
Rate for Payer: Amerigroup CHIP/Medicaid	$119.33
Rate for Payer: BCBS of TX Blue Advantage	$397.77
Rate for Payer: BCBS of TX Blue Essentials	$477.33
Rate for Payer: BCBS of TX PPO	$530.36
Rate for Payer: Cash Price	$901.62
Rate for Payer: Cigna Medicaid	$954.66
Rate for Payer: Molina CHIP/Medicaid	$954.66
Rate for Payer: Multiplan Auto	$861.84
Rate for Payer: Multiplan Commercial	$861.84
Rate for Payer: Multiplan Workers Comp	$861.84
Rate for Payer: Parkland Medicaid	$954.66
Rate for Payer: Scott and White EPO/PPO	$662.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$954.66
Rate for Payer: Superior Health Plan EPO	$180.32

EX FX WIRE BOLT SHORT DIA 1.5-2.0MM

Facility

$440.38

Hospital Charge Code	993243
Hospital Revenue Code	272
Min. Negotiated Rate	$39.63
Max. Negotiated Rate	$317.07
Rate for Payer: Amerigroup CHIP/Medicaid	$39.63
Rate for Payer: BCBS of TX Blue Advantage	$132.11
Rate for Payer: BCBS of TX Blue Essentials	$158.54
Rate for Payer: BCBS of TX PPO	$176.15
Rate for Payer: Cash Price	$299.46
Rate for Payer: Cigna Medicaid	$317.07
Rate for Payer: Molina CHIP/Medicaid	$317.07
Rate for Payer: Multiplan Auto	$286.25
Rate for Payer: Multiplan Commercial	$286.25
Rate for Payer: Multiplan Workers Comp	$286.25
Rate for Payer: Parkland Medicaid	$317.07
Rate for Payer: Scott and White EPO/PPO	$220.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$317.07
Rate for Payer: Superior Health Plan EPO	$59.89

EX FX WIRE BOLT SHORT DIA 1.5-2.0MM

Facility

$440.38

Hospital Charge Code	993243
Hospital Revenue Code	272
Rate for Payer: Cash Price	$299.46

EXFX WIRE FIXATION BOLT

Facility

$430.21

Hospital Charge Code	130819
Hospital Revenue Code	272
Min. Negotiated Rate	$38.72
Max. Negotiated Rate	$309.75
Rate for Payer: Amerigroup CHIP/Medicaid	$38.72
Rate for Payer: BCBS of TX Blue Advantage	$129.06
Rate for Payer: BCBS of TX Blue Essentials	$154.88
Rate for Payer: BCBS of TX PPO	$172.08
Rate for Payer: Cash Price	$292.54
Rate for Payer: Cigna Medicaid	$309.75
Rate for Payer: Molina CHIP/Medicaid	$309.75
Rate for Payer: Multiplan Auto	$279.64
Rate for Payer: Multiplan Commercial	$279.64
Rate for Payer: Multiplan Workers Comp	$279.64
Rate for Payer: Parkland Medicaid	$309.75
Rate for Payer: Scott and White EPO/PPO	$215.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$309.75
Rate for Payer: Superior Health Plan EPO	$58.51

EXFX WIRE FIXATION BOLT

Facility

$430.21

Hospital Charge Code	130819
Hospital Revenue Code	272
Rate for Payer: Cash Price	$292.54

Exploration for postoperative hemorrhage, thrombosis or infection; extremity

Facility

$12,590.00

Service Code	HCPCS 35860
Hospital Charge Code	994070
Hospital Revenue Code	360
Min. Negotiated Rate	$1,133.10
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,133.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$8,561.20
Rate for Payer: Cash Price	$8,561.20
Rate for Payer: Cash Price	$8,561.20
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$9,064.80
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$9,064.80
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$9,064.80
Rate for Payer: Scott and White EPO/PPO	$5,867.96
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,064.80
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

Exploration for postoperative hemorrhage, thrombosis or infection; extremity

Facility

$12,590.00

Service Code	HCPCS 35860
Hospital Charge Code	994070
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,561.20

Exploration of penetrating wound (separate procedure) extremity

Facility

$10,000.00

Service Code	CPT 20103
Hospital Charge Code	36020103
Hospital Revenue Code	360
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$257.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$1,018.72
Rate for Payer: BCBS of TX Blue Essentials	$1,220.02
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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: Scott and White EPO/PPO	$3,069.37
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

Exploration of penetrating wound (separate procedure) extremity

Facility

$3,731.82

Service Code	HCPCS 20103
Hospital Charge Code	9900166
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,537.64

Exploration of penetrating wound (separate procedure) extremity

Facility

$3,731.82

Service Code	HCPCS 20103
Hospital Charge Code	9900166
Hospital Revenue Code	360
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$257.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$1,018.72
Rate for Payer: BCBS of TX Blue Essentials	$1,220.02
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$2,537.64
Rate for Payer: Cash Price	$2,537.64
Rate for Payer: Cash Price	$2,537.64
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$2,686.91
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$2,686.91
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$2,686.91
Rate for Payer: Scott and White EPO/PPO	$3,069.37
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,686.91
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

Exploration, retroperitoneal area with or without biopsy

Facility

$7,221.44

Service Code	HCPCS 49010
Hospital Charge Code	994110
Hospital Revenue Code	360
Min. Negotiated Rate	$649.93
Max. Negotiated Rate	$13,746.84
Rate for Payer: Amerigroup CHIP/Medicaid	$649.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Amerigroup Medicare	$6,503.32
Rate for Payer: BCBS of TX Blue Advantage	$1,618.98
Rate for Payer: BCBS of TX Blue Essentials	$1,938.90
Rate for Payer: BCBS of TX Medicare	$6,503.32
Rate for Payer: BCBS of TX PPO	$2,443.01
Rate for Payer: Cash Price	$4,910.58
Rate for Payer: Cash Price	$4,910.58
Rate for Payer: Cash Price	$4,910.58
Rate for Payer: Cigna Commercial	$13,746.84
Rate for Payer: Cigna Medicaid	$5,199.44
Rate for Payer: Cigna Medicare	$6,503.32
Rate for Payer: Employer Direct Commercial	$6,503.32
Rate for Payer: Humana Medicare/TRICARE	$6,503.32
Rate for Payer: Molina CHIP/Medicaid	$5,199.44
Rate for Payer: Molina Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Molina Medicare	$6,503.32
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	$5,199.44
Rate for Payer: Scott and White EPO/PPO	$12,031.14
Rate for Payer: Scott and White Medicare	$6,503.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,199.44
Rate for Payer: Superior Health Plan EPO	$6,503.32
Rate for Payer: Superior Health Plan Medicare	$6,503.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Universal American Medicare	$6,503.32
Rate for Payer: Wellcare Medicare	$6,503.32
Rate for Payer: Wellmed Medicare	$6,503.32

Exploration, retroperitoneal area with or without biopsy

Facility

$7,221.44

Service Code	HCPCS 49010
Hospital Charge Code	994110
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,910.58

expressbraid graft manipulator

Facility

$267.41

Hospital Charge Code	8720588
Hospital Revenue Code	272
Min. Negotiated Rate	$24.07
Max. Negotiated Rate	$192.54
Rate for Payer: Amerigroup CHIP/Medicaid	$24.07
Rate for Payer: BCBS of TX Blue Advantage	$80.22
Rate for Payer: BCBS of TX Blue Essentials	$96.27
Rate for Payer: BCBS of TX PPO	$106.96
Rate for Payer: Cash Price	$181.84
Rate for Payer: Cigna Medicaid	$192.54
Rate for Payer: Molina CHIP/Medicaid	$192.54
Rate for Payer: Multiplan Auto	$173.82
Rate for Payer: Multiplan Commercial	$173.82
Rate for Payer: Multiplan Workers Comp	$173.82
Rate for Payer: Parkland Medicaid	$192.54
Rate for Payer: Scott and White EPO/PPO	$133.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.54
Rate for Payer: Superior Health Plan EPO	$36.37

expressbraid graft manipulator

Facility

$267.41

Hospital Charge Code	8720588
Hospital Revenue Code	272
Rate for Payer: Cash Price	$181.84

Know your out-of-pocket cost for care.

All Charges