White Rock Medical Center

All Charges

Charge

Type

Setting

Price

FOOT ARCH 155mm

Facility

$11,940.20

Service Code	HCPCS C1713
Hospital Charge Code	993433
Hospital Revenue Code	278
Min. Negotiated Rate	$2,985.05
Max. Negotiated Rate	$5,970.10
Rate for Payer: Cash Price	$8,119.34
Rate for Payer: Cigna Commercial	$2,985.05
Rate for Payer: Multiplan Auto	$5,970.10
Rate for Payer: Multiplan Commercial	$5,970.10
Rate for Payer: Multiplan Workers Comp	$5,970.10
Rate for Payer: Scott and White EPO/PPO	$5,970.10

FOOT ARCH 155mm

Facility

$11,940.20

Service Code	HCPCS C1713
Hospital Charge Code	993433
Hospital Revenue Code	278
Min. Negotiated Rate	$1,074.62
Max. Negotiated Rate	$8,596.94
Rate for Payer: Amerigroup CHIP/Medicaid	$1,074.62
Rate for Payer: BCBS of TX Blue Advantage	$3,582.06
Rate for Payer: BCBS of TX Blue Essentials	$4,298.47
Rate for Payer: BCBS of TX PPO	$4,776.08
Rate for Payer: Cash Price	$8,119.34
Rate for Payer: Cigna Medicaid	$8,596.94
Rate for Payer: Molina CHIP/Medicaid	$8,596.94
Rate for Payer: Multiplan Auto	$5,970.10
Rate for Payer: Multiplan Commercial	$5,970.10
Rate for Payer: Multiplan Workers Comp	$5,970.10
Rate for Payer: Parkland Medicaid	$8,596.94
Rate for Payer: Scott and White EPO/PPO	$5,970.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,596.94
Rate for Payer: Superior Health Plan EPO	$1,623.87

FOOT PROCEDURES W CC

Facility

$35,514.80

Service Code	MSDRG 504
Min. Negotiated Rate	$14,873.70
Max. Negotiated Rate	$35,514.80
Rate for Payer: BCBS of TX Blue Advantage	$14,873.70
Rate for Payer: BCBS of TX Blue Essentials	$17,846.71
Rate for Payer: BCBS of TX PPO	$19,830.45

FOOT PROCEDURES WITH CC

Facility

$35,514.80

Service Code	MSDRG 504
Min. Negotiated Rate	$14,873.70
Max. Negotiated Rate	$35,514.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,459.49
Rate for Payer: Amerigroup Medicare	$18,459.49
Rate for Payer: BCBS of TX Medicare	$18,459.49
Rate for Payer: Cigna Commercial	$24,075.30
Rate for Payer: Cigna Medicare	$18,459.49
Rate for Payer: Employer Direct Commercial	$18,459.49
Rate for Payer: Humana Medicare/TRICARE	$18,459.49
Rate for Payer: Molina Dual Medicare/Medicaid	$18,459.49
Rate for Payer: Molina Medicare	$18,459.49
Rate for Payer: Multiplan Auto	$35,514.80
Rate for Payer: Multiplan Commercial	$35,514.80
Rate for Payer: Multiplan Workers Comp	$35,514.80
Rate for Payer: Scott and White EPO/PPO	$16,355.50
Rate for Payer: Scott and White Medicare	$18,459.49
Rate for Payer: Superior Health Plan EPO	$18,459.49
Rate for Payer: Superior Health Plan Medicare	$18,459.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,459.49
Rate for Payer: Universal American Medicare	$18,459.49
Rate for Payer: Wellcare Medicare	$18,459.49
Rate for Payer: Wellmed Medicare	$18,459.49

FOOT PROCEDURES WITH MCC

Facility

$53,030.90

Service Code	MSDRG 503
Min. Negotiated Rate	$22,034.92
Max. Negotiated Rate	$53,030.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25,216.12
Rate for Payer: Amerigroup Medicare	$25,216.12
Rate for Payer: BCBS of TX Medicare	$25,216.12
Rate for Payer: Cigna Commercial	$35,949.37
Rate for Payer: Cigna Medicare	$25,216.12
Rate for Payer: Employer Direct Commercial	$25,216.12
Rate for Payer: Humana Medicare/TRICARE	$25,216.12
Rate for Payer: Molina Dual Medicare/Medicaid	$25,216.12
Rate for Payer: Molina Medicare	$25,216.12
Rate for Payer: Multiplan Auto	$53,030.90
Rate for Payer: Multiplan Commercial	$53,030.90
Rate for Payer: Multiplan Workers Comp	$53,030.90
Rate for Payer: Scott and White EPO/PPO	$24,422.12
Rate for Payer: Scott and White Medicare	$25,216.12
Rate for Payer: Superior Health Plan EPO	$25,216.12
Rate for Payer: Superior Health Plan Medicare	$25,216.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$25,216.12
Rate for Payer: Universal American Medicare	$25,216.12
Rate for Payer: Wellcare Medicare	$25,216.12
Rate for Payer: Wellmed Medicare	$25,216.12

FOOT PROCEDURES WITHOUT CC/MCC

Facility

$34,063.20

Service Code	MSDRG 505
Min. Negotiated Rate	$13,586.28
Max. Negotiated Rate	$34,063.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,899.55
Rate for Payer: Amerigroup Medicare	$17,899.55
Rate for Payer: BCBS of TX Medicare	$17,899.55
Rate for Payer: Cigna Commercial	$23,091.26
Rate for Payer: Cigna Medicare	$17,899.55
Rate for Payer: Employer Direct Commercial	$17,899.55
Rate for Payer: Humana Medicare/TRICARE	$17,899.55
Rate for Payer: Molina Dual Medicare/Medicaid	$17,899.55
Rate for Payer: Molina Medicare	$17,899.55
Rate for Payer: Multiplan Auto	$34,063.20
Rate for Payer: Multiplan Commercial	$34,063.20
Rate for Payer: Multiplan Workers Comp	$34,063.20
Rate for Payer: Scott and White EPO/PPO	$15,687.00
Rate for Payer: Scott and White Medicare	$17,899.55
Rate for Payer: Superior Health Plan EPO	$17,899.55
Rate for Payer: Superior Health Plan Medicare	$17,899.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,899.55
Rate for Payer: Universal American Medicare	$17,899.55
Rate for Payer: Wellcare Medicare	$17,899.55
Rate for Payer: Wellmed Medicare	$17,899.55

FOOT PROCEDURES W MCC

Facility

$53,030.90

Service Code	MSDRG 503
Min. Negotiated Rate	$22,034.92
Max. Negotiated Rate	$53,030.90
Rate for Payer: BCBS of TX Blue Advantage	$22,034.92
Rate for Payer: BCBS of TX Blue Essentials	$26,439.34
Rate for Payer: BCBS of TX PPO	$29,378.19

FOOT PROCEDURES W/O CC/MCC

Facility

$34,063.20

Service Code	MSDRG 505
Min. Negotiated Rate	$13,586.28
Max. Negotiated Rate	$34,063.20
Rate for Payer: BCBS of TX Blue Advantage	$13,586.28
Rate for Payer: BCBS of TX Blue Essentials	$16,301.96
Rate for Payer: BCBS of TX PPO	$18,113.99

FOOT RING LONG DIA 155 mm - ALUMINIUM

Facility

$10,569.12

Service Code	HCPCS C1713
Hospital Charge Code	993432
Hospital Revenue Code	278
Min. Negotiated Rate	$951.22
Max. Negotiated Rate	$7,609.77
Rate for Payer: Amerigroup CHIP/Medicaid	$951.22
Rate for Payer: BCBS of TX Blue Advantage	$3,170.74
Rate for Payer: BCBS of TX Blue Essentials	$3,804.88
Rate for Payer: BCBS of TX PPO	$4,227.65
Rate for Payer: Cash Price	$7,187.00
Rate for Payer: Cigna Medicaid	$7,609.77
Rate for Payer: Molina CHIP/Medicaid	$7,609.77
Rate for Payer: Multiplan Auto	$5,284.56
Rate for Payer: Multiplan Commercial	$5,284.56
Rate for Payer: Multiplan Workers Comp	$5,284.56
Rate for Payer: Parkland Medicaid	$7,609.77
Rate for Payer: Scott and White EPO/PPO	$5,284.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,609.77
Rate for Payer: Superior Health Plan EPO	$1,437.40

FOOT RING LONG DIA 155 mm - ALUMINIUM

Facility

$10,569.12

Service Code	HCPCS C1713
Hospital Charge Code	993432
Hospital Revenue Code	278
Min. Negotiated Rate	$2,642.28
Max. Negotiated Rate	$5,284.56
Rate for Payer: Cash Price	$7,187.00
Rate for Payer: Cigna Commercial	$2,642.28
Rate for Payer: Multiplan Auto	$5,284.56
Rate for Payer: Multiplan Commercial	$5,284.56
Rate for Payer: Multiplan Workers Comp	$5,284.56
Rate for Payer: Scott and White EPO/PPO	$5,284.56

FORCEP, BIPOLAR BAYONET W

Facility

$180.37

Hospital Charge Code	133208
Hospital Revenue Code	272
Min. Negotiated Rate	$16.23
Max. Negotiated Rate	$129.87
Rate for Payer: Amerigroup CHIP/Medicaid	$16.23
Rate for Payer: BCBS of TX Blue Advantage	$54.11
Rate for Payer: BCBS of TX Blue Essentials	$64.93
Rate for Payer: BCBS of TX PPO	$72.15
Rate for Payer: Cash Price	$122.65
Rate for Payer: Cigna Medicaid	$129.87
Rate for Payer: Molina CHIP/Medicaid	$129.87
Rate for Payer: Multiplan Auto	$117.24
Rate for Payer: Multiplan Commercial	$117.24
Rate for Payer: Multiplan Workers Comp	$117.24
Rate for Payer: Parkland Medicaid	$129.87
Rate for Payer: Scott and White EPO/PPO	$90.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$129.87
Rate for Payer: Superior Health Plan EPO	$24.53

FORCEP, BIPOLAR BAYONET W

Facility

$180.37

Hospital Charge Code	133208
Hospital Revenue Code	272
Rate for Payer: Cash Price	$122.65

forcep bronch bx 1.8mmx100cm

Facility

$131.66

Hospital Charge Code	8626514
Hospital Revenue Code	272
Min. Negotiated Rate	$11.85
Max. Negotiated Rate	$94.80
Rate for Payer: Amerigroup CHIP/Medicaid	$11.85
Rate for Payer: BCBS of TX Blue Advantage	$39.50
Rate for Payer: BCBS of TX Blue Essentials	$47.40
Rate for Payer: BCBS of TX PPO	$52.66
Rate for Payer: Cash Price	$89.53
Rate for Payer: Cigna Medicaid	$94.80
Rate for Payer: Molina CHIP/Medicaid	$94.80
Rate for Payer: Multiplan Auto	$85.58
Rate for Payer: Multiplan Commercial	$85.58
Rate for Payer: Multiplan Workers Comp	$85.58
Rate for Payer: Parkland Medicaid	$94.80
Rate for Payer: Scott and White EPO/PPO	$65.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$94.80
Rate for Payer: Superior Health Plan EPO	$17.91

forcep bronch bx 1.8mmx100cm

Facility

$131.66

Hospital Charge Code	8626514
Hospital Revenue Code	272
Rate for Payer: Cash Price	$89.53

FORCEP DRESSING ADSON STANDARD TIP 1.2MM 5

Facility

$33.19

Hospital Charge Code	992728
Hospital Revenue Code	272
Rate for Payer: Cash Price	$22.57

FORCEP DRESSING ADSON STANDARD TIP 1.2MM 5

Facility

$33.19

Hospital Charge Code	992728
Hospital Revenue Code	272
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$23.90
Rate for Payer: Amerigroup CHIP/Medicaid	$2.99
Rate for Payer: BCBS of TX Blue Advantage	$9.96
Rate for Payer: BCBS of TX Blue Essentials	$11.95
Rate for Payer: BCBS of TX PPO	$13.28
Rate for Payer: Cash Price	$22.57
Rate for Payer: Cigna Medicaid	$23.90
Rate for Payer: Molina CHIP/Medicaid	$23.90
Rate for Payer: Multiplan Auto	$21.57
Rate for Payer: Multiplan Commercial	$21.57
Rate for Payer: Multiplan Workers Comp	$21.57
Rate for Payer: Parkland Medicaid	$23.90
Rate for Payer: Scott and White EPO/PPO	$16.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.90
Rate for Payer: Superior Health Plan EPO	$4.51

FORCEP HEMOSTATIC 107-171

Facility

$42.22

Hospital Charge Code	992725
Hospital Revenue Code	272
Rate for Payer: Cash Price	$28.71

FORCEP HEMOSTATIC 107-171

Facility

$42.22

Hospital Charge Code	992725
Hospital Revenue Code	272
Min. Negotiated Rate	$3.80
Max. Negotiated Rate	$30.40
Rate for Payer: Amerigroup CHIP/Medicaid	$3.80
Rate for Payer: BCBS of TX Blue Advantage	$12.67
Rate for Payer: BCBS of TX Blue Essentials	$15.20
Rate for Payer: BCBS of TX PPO	$16.89
Rate for Payer: Cash Price	$28.71
Rate for Payer: Cigna Medicaid	$30.40
Rate for Payer: Molina CHIP/Medicaid	$30.40
Rate for Payer: Multiplan Auto	$27.44
Rate for Payer: Multiplan Commercial	$27.44
Rate for Payer: Multiplan Workers Comp	$27.44
Rate for Payer: Parkland Medicaid	$30.40
Rate for Payer: Scott and White EPO/PPO	$21.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.40
Rate for Payer: Superior Health Plan EPO	$5.74

FORCEPS, BIOPSY, 2.8MM, ALLIGATOR, JAW

Facility

$308.07

Hospital Charge Code	993760
Hospital Revenue Code	272
Rate for Payer: Cash Price	$209.49

FORCEPS, BIOPSY, 2.8MM, ALLIGATOR, JAW

Facility

$308.07

Hospital Charge Code	993760
Hospital Revenue Code	272
Min. Negotiated Rate	$27.73
Max. Negotiated Rate	$221.81
Rate for Payer: Amerigroup CHIP/Medicaid	$27.73
Rate for Payer: BCBS of TX Blue Advantage	$92.42
Rate for Payer: BCBS of TX Blue Essentials	$110.91
Rate for Payer: BCBS of TX PPO	$123.23
Rate for Payer: Cash Price	$209.49
Rate for Payer: Cigna Medicaid	$221.81
Rate for Payer: Molina CHIP/Medicaid	$221.81
Rate for Payer: Multiplan Auto	$200.25
Rate for Payer: Multiplan Commercial	$200.25
Rate for Payer: Multiplan Workers Comp	$200.25
Rate for Payer: Parkland Medicaid	$221.81
Rate for Payer: Scott and White EPO/PPO	$154.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$221.81
Rate for Payer: Superior Health Plan EPO	$41.90

FORCEP, TISSUE ADSON S/S 1X2 TEETH TP 4 3/4' REUSE

Facility

$42.54

Hospital Charge Code	992726
Hospital Revenue Code	272
Rate for Payer: Cash Price	$28.93

FORCEP, TISSUE ADSON S/S 1X2 TEETH TP 4 3/4' REUSE

Facility

$42.54

Hospital Charge Code	992726
Hospital Revenue Code	272
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$30.63
Rate for Payer: Amerigroup CHIP/Medicaid	$3.83
Rate for Payer: BCBS of TX Blue Advantage	$12.76
Rate for Payer: BCBS of TX Blue Essentials	$15.31
Rate for Payer: BCBS of TX PPO	$17.02
Rate for Payer: Cash Price	$28.93
Rate for Payer: Cigna Medicaid	$30.63
Rate for Payer: Molina CHIP/Medicaid	$30.63
Rate for Payer: Multiplan Auto	$27.65
Rate for Payer: Multiplan Commercial	$27.65
Rate for Payer: Multiplan Workers Comp	$27.65
Rate for Payer: Parkland Medicaid	$30.63
Rate for Payer: Scott and White EPO/PPO	$21.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.63
Rate for Payer: Superior Health Plan EPO	$5.79

FORCEP, TISSUE ADSON STD PATTERN 2X3 BRN TEETH 5'

Facility

$84.17

Hospital Charge Code	992720
Hospital Revenue Code	272
Rate for Payer: Cash Price	$57.24

FORCEP, TISSUE ADSON STD PATTERN 2X3 BRN TEETH 5'

Facility

$84.17

Hospital Charge Code	992720
Hospital Revenue Code	272
Min. Negotiated Rate	$7.58
Max. Negotiated Rate	$60.60
Rate for Payer: Amerigroup CHIP/Medicaid	$7.58
Rate for Payer: BCBS of TX Blue Advantage	$25.25
Rate for Payer: BCBS of TX Blue Essentials	$30.30
Rate for Payer: BCBS of TX PPO	$33.67
Rate for Payer: Cash Price	$57.24
Rate for Payer: Cigna Medicaid	$60.60
Rate for Payer: Molina CHIP/Medicaid	$60.60
Rate for Payer: Multiplan Auto	$54.71
Rate for Payer: Multiplan Commercial	$54.71
Rate for Payer: Multiplan Workers Comp	$54.71
Rate for Payer: Parkland Medicaid	$60.60
Rate for Payer: Scott and White EPO/PPO	$42.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60.60
Rate for Payer: Superior Health Plan EPO	$11.45

FORCEP, VANGUARD CRILE CURVED 5 1/2'

Facility

$36.14

Hospital Charge Code	992722
Hospital Revenue Code	272
Rate for Payer: Cash Price	$24.58

Know your out-of-pocket cost for care.

All Charges