White Rock Medical Center

All Charges

Charge

Type

Setting

Price

1806-3550S

Facility

$1,620.48

Service Code	HCPCS A9270
Hospital Charge Code	991009
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,101.93

1806-3550S

Facility

$1,620.48

Service Code	HCPCS A9270
Hospital Charge Code	991009
Hospital Revenue Code	272
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	$1,053.31
Rate for Payer: Multiplan Commercial	$1,053.31
Rate for Payer: Multiplan Workers Comp	$1,053.31
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

1806-3550S

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

1806-4270S

Facility

$1,777.10

Hospital Charge Code	991185
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,208.43

1806-4270S

Facility

$1,777.10

Hospital Charge Code	991185
Hospital Revenue Code	272
Min. Negotiated Rate	$159.94
Max. Negotiated Rate	$1,279.51
Rate for Payer: Amerigroup CHIP/Medicaid	$159.94
Rate for Payer: BCBS of TX Blue Advantage	$533.13
Rate for Payer: BCBS of TX Blue Essentials	$639.76
Rate for Payer: BCBS of TX PPO	$710.84
Rate for Payer: Cash Price	$1,208.43
Rate for Payer: Cigna Medicaid	$1,279.51
Rate for Payer: Molina CHIP/Medicaid	$1,279.51
Rate for Payer: Multiplan Auto	$1,155.12
Rate for Payer: Multiplan Commercial	$1,155.12
Rate for Payer: Multiplan Workers Comp	$1,155.12
Rate for Payer: Parkland Medicaid	$1,279.51
Rate for Payer: Scott and White EPO/PPO	$888.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,279.51
Rate for Payer: Superior Health Plan EPO	$241.69

1806-4280S

Facility

$1,662.65

Service Code	HCPCS C1776
Hospital Charge Code	991061
Hospital Revenue Code	278
Min. Negotiated Rate	$415.66
Max. Negotiated Rate	$831.33
Rate for Payer: Cash Price	$1,130.60
Rate for Payer: Cigna Commercial	$415.66
Rate for Payer: Multiplan Auto	$831.33
Rate for Payer: Multiplan Commercial	$831.33
Rate for Payer: Multiplan Workers Comp	$831.33
Rate for Payer: Scott and White EPO/PPO	$831.33

1806-4280S

Facility

$1,662.65

Service Code	HCPCS C1776
Hospital Charge Code	991061
Hospital Revenue Code	278
Min. Negotiated Rate	$149.64
Max. Negotiated Rate	$1,197.11
Rate for Payer: Amerigroup CHIP/Medicaid	$149.64
Rate for Payer: BCBS of TX Blue Advantage	$498.80
Rate for Payer: BCBS of TX Blue Essentials	$598.55
Rate for Payer: BCBS of TX PPO	$665.06
Rate for Payer: Cash Price	$1,130.60
Rate for Payer: Cigna Medicaid	$1,197.11
Rate for Payer: Molina CHIP/Medicaid	$1,197.11
Rate for Payer: Multiplan Auto	$831.33
Rate for Payer: Multiplan Commercial	$831.33
Rate for Payer: Multiplan Workers Comp	$831.33
Rate for Payer: Parkland Medicaid	$1,197.11
Rate for Payer: Scott and White EPO/PPO	$831.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,197.11
Rate for Payer: Superior Health Plan EPO	$226.12

1809-0050S

Facility

$1,144.58

Service Code	HCPCS C1769
Hospital Charge Code	990988
Hospital Revenue Code	272
Rate for Payer: Cash Price	$778.31

1809-0050S

Facility

$1,144.58

Service Code	HCPCS C1769
Hospital Charge Code	990988
Hospital Revenue Code	272
Min. Negotiated Rate	$103.01
Max. Negotiated Rate	$824.10
Rate for Payer: Amerigroup CHIP/Medicaid	$103.01
Rate for Payer: BCBS of TX Blue Advantage	$343.37
Rate for Payer: BCBS of TX Blue Essentials	$412.05
Rate for Payer: BCBS of TX PPO	$457.83
Rate for Payer: Cash Price	$778.31
Rate for Payer: Cigna Medicaid	$824.10
Rate for Payer: Molina CHIP/Medicaid	$824.10
Rate for Payer: Multiplan Auto	$743.98
Rate for Payer: Multiplan Commercial	$743.98
Rate for Payer: Multiplan Workers Comp	$743.98
Rate for Payer: Parkland Medicaid	$824.10
Rate for Payer: Scott and White EPO/PPO	$572.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$824.10
Rate for Payer: Superior Health Plan EPO	$155.66

1834-0131

Facility

$46,296.30

Service Code	HCPCS C1734
Hospital Charge Code	991221
Hospital Revenue Code	278
Min. Negotiated Rate	$11,574.08
Max. Negotiated Rate	$23,148.15
Rate for Payer: Cash Price	$31,481.48
Rate for Payer: Cigna Commercial	$11,574.08
Rate for Payer: Multiplan Auto	$23,148.15
Rate for Payer: Multiplan Commercial	$23,148.15
Rate for Payer: Multiplan Workers Comp	$23,148.15
Rate for Payer: Scott and White EPO/PPO	$23,148.15

1834-0131

Facility

$46,296.30

Service Code	HCPCS C1734
Hospital Charge Code	991221
Hospital Revenue Code	278
Min. Negotiated Rate	$4,166.67
Max. Negotiated Rate	$33,333.34
Rate for Payer: Amerigroup CHIP/Medicaid	$4,166.67
Rate for Payer: BCBS of TX Blue Advantage	$13,888.89
Rate for Payer: BCBS of TX Blue Essentials	$16,666.67
Rate for Payer: BCBS of TX PPO	$18,518.52
Rate for Payer: Cash Price	$31,481.48
Rate for Payer: Cigna Medicaid	$33,333.34
Rate for Payer: Molina CHIP/Medicaid	$33,333.34
Rate for Payer: Multiplan Auto	$23,148.15
Rate for Payer: Multiplan Commercial	$23,148.15
Rate for Payer: Multiplan Workers Comp	$23,148.15
Rate for Payer: Parkland Medicaid	$33,333.34
Rate for Payer: Scott and White EPO/PPO	$23,148.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33,333.34
Rate for Payer: Superior Health Plan EPO	$6,296.30

186300SND

Facility

$1,267.47

Service Code	HCPCS C1776
Hospital Charge Code	991096
Hospital Revenue Code	278
Min. Negotiated Rate	$114.07
Max. Negotiated Rate	$912.58
Rate for Payer: Amerigroup CHIP/Medicaid	$114.07
Rate for Payer: BCBS of TX Blue Advantage	$380.24
Rate for Payer: BCBS of TX Blue Essentials	$456.29
Rate for Payer: BCBS of TX PPO	$506.99
Rate for Payer: Cash Price	$861.88
Rate for Payer: Cigna Medicaid	$912.58
Rate for Payer: Molina CHIP/Medicaid	$912.58
Rate for Payer: Multiplan Auto	$633.74
Rate for Payer: Multiplan Commercial	$633.74
Rate for Payer: Multiplan Workers Comp	$633.74
Rate for Payer: Parkland Medicaid	$912.58
Rate for Payer: Scott and White EPO/PPO	$633.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$912.58
Rate for Payer: Superior Health Plan EPO	$172.38

186300SND

Facility

$1,267.47

Service Code	HCPCS C1776
Hospital Charge Code	991096
Hospital Revenue Code	278
Min. Negotiated Rate	$316.87
Max. Negotiated Rate	$633.74
Rate for Payer: Cash Price	$861.88
Rate for Payer: Cigna Commercial	$316.87
Rate for Payer: Multiplan Auto	$633.74
Rate for Payer: Multiplan Commercial	$633.74
Rate for Payer: Multiplan Workers Comp	$633.74
Rate for Payer: Scott and White EPO/PPO	$633.74

186300SND

Facility

$1,267.47

Service Code	HCPCS C1713
Hospital Charge Code	991175
Hospital Revenue Code	278
Min. Negotiated Rate	$316.87
Max. Negotiated Rate	$633.74
Rate for Payer: Cash Price	$861.88
Rate for Payer: Cigna Commercial	$316.87
Rate for Payer: Multiplan Auto	$633.74
Rate for Payer: Multiplan Commercial	$633.74
Rate for Payer: Multiplan Workers Comp	$633.74
Rate for Payer: Scott and White EPO/PPO	$633.74

186300SND

Facility

$1,267.47

Service Code	HCPCS C1713
Hospital Charge Code	991175
Hospital Revenue Code	278
Min. Negotiated Rate	$114.07
Max. Negotiated Rate	$912.58
Rate for Payer: Amerigroup CHIP/Medicaid	$114.07
Rate for Payer: BCBS of TX Blue Advantage	$380.24
Rate for Payer: BCBS of TX Blue Essentials	$456.29
Rate for Payer: BCBS of TX PPO	$506.99
Rate for Payer: Cash Price	$861.88
Rate for Payer: Cigna Medicaid	$912.58
Rate for Payer: Molina CHIP/Medicaid	$912.58
Rate for Payer: Multiplan Auto	$633.74
Rate for Payer: Multiplan Commercial	$633.74
Rate for Payer: Multiplan Workers Comp	$633.74
Rate for Payer: Parkland Medicaid	$912.58
Rate for Payer: Scott and White EPO/PPO	$633.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$912.58
Rate for Payer: Superior Health Plan EPO	$172.38

1896-5040S

Facility

$1,765.06

Service Code	HCPCS C1734
Hospital Charge Code	991186
Hospital Revenue Code	278
Min. Negotiated Rate	$158.86
Max. Negotiated Rate	$1,270.84
Rate for Payer: Amerigroup CHIP/Medicaid	$158.86
Rate for Payer: BCBS of TX Blue Advantage	$529.52
Rate for Payer: BCBS of TX Blue Essentials	$635.42
Rate for Payer: BCBS of TX PPO	$706.02
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Medicaid	$1,270.84
Rate for Payer: Molina CHIP/Medicaid	$1,270.84
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Parkland Medicaid	$1,270.84
Rate for Payer: Scott and White EPO/PPO	$882.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,270.84
Rate for Payer: Superior Health Plan EPO	$240.05

1896-5040S

Facility

$1,765.06

Service Code	HCPCS C1734
Hospital Charge Code	991186
Hospital Revenue Code	278
Min. Negotiated Rate	$441.26
Max. Negotiated Rate	$882.53
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Commercial	$441.26
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Scott and White EPO/PPO	$882.53

18FR, ESOPHAGEAL STETHOSCOPE W/400

Facility

$12.18

Hospital Charge Code	992763
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8.28

18FR, ESOPHAGEAL STETHOSCOPE W/400

Facility

$12.18

Hospital Charge Code	992763
Hospital Revenue Code	272
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$8.77
Rate for Payer: Amerigroup CHIP/Medicaid	$1.10
Rate for Payer: BCBS of TX Blue Advantage	$3.65
Rate for Payer: BCBS of TX Blue Essentials	$4.38
Rate for Payer: BCBS of TX PPO	$4.87
Rate for Payer: Cash Price	$8.28
Rate for Payer: Cigna Medicaid	$8.77
Rate for Payer: Molina CHIP/Medicaid	$8.77
Rate for Payer: Multiplan Auto	$7.92
Rate for Payer: Multiplan Commercial	$7.92
Rate for Payer: Multiplan Workers Comp	$7.92
Rate for Payer: Parkland Medicaid	$8.77
Rate for Payer: Scott and White EPO/PPO	$6.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.77
Rate for Payer: Superior Health Plan EPO	$1.66

2000010901

Facility

$4,891.57

Service Code	HCPCS C1734
Hospital Charge Code	991078
Hospital Revenue Code	278
Min. Negotiated Rate	$1,222.89
Max. Negotiated Rate	$2,445.78
Rate for Payer: Cash Price	$3,326.27
Rate for Payer: Cigna Commercial	$1,222.89
Rate for Payer: Multiplan Auto	$2,445.78
Rate for Payer: Multiplan Commercial	$2,445.78
Rate for Payer: Multiplan Workers Comp	$2,445.78
Rate for Payer: Scott and White EPO/PPO	$2,445.78

2000010901

Facility

$4,891.57

Service Code	HCPCS C1734
Hospital Charge Code	991078
Hospital Revenue Code	278
Min. Negotiated Rate	$440.24
Max. Negotiated Rate	$3,521.93
Rate for Payer: Amerigroup CHIP/Medicaid	$440.24
Rate for Payer: BCBS of TX Blue Advantage	$1,467.47
Rate for Payer: BCBS of TX Blue Essentials	$1,760.97
Rate for Payer: BCBS of TX PPO	$1,956.63
Rate for Payer: Cash Price	$3,326.27
Rate for Payer: Cigna Medicaid	$3,521.93
Rate for Payer: Molina CHIP/Medicaid	$3,521.93
Rate for Payer: Multiplan Auto	$2,445.78
Rate for Payer: Multiplan Commercial	$2,445.78
Rate for Payer: Multiplan Workers Comp	$2,445.78
Rate for Payer: Parkland Medicaid	$3,521.93
Rate for Payer: Scott and White EPO/PPO	$2,445.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,521.93
Rate for Payer: Superior Health Plan EPO	$665.25

2000011901

Facility

$4,819.27

Service Code	HCPCS C1734
Hospital Charge Code	991079
Hospital Revenue Code	278
Min. Negotiated Rate	$1,204.82
Max. Negotiated Rate	$2,409.64
Rate for Payer: Cash Price	$3,277.10
Rate for Payer: Cigna Commercial	$1,204.82
Rate for Payer: Multiplan Auto	$2,409.64
Rate for Payer: Multiplan Commercial	$2,409.64
Rate for Payer: Multiplan Workers Comp	$2,409.64
Rate for Payer: Scott and White EPO/PPO	$2,409.64

2000011901

Facility

$4,819.27

Service Code	HCPCS C1734
Hospital Charge Code	991079
Hospital Revenue Code	278
Min. Negotiated Rate	$433.73
Max. Negotiated Rate	$3,469.87
Rate for Payer: Amerigroup CHIP/Medicaid	$433.73
Rate for Payer: BCBS of TX Blue Advantage	$1,445.78
Rate for Payer: BCBS of TX Blue Essentials	$1,734.94
Rate for Payer: BCBS of TX PPO	$1,927.71
Rate for Payer: Cash Price	$3,277.10
Rate for Payer: Cigna Medicaid	$3,469.87
Rate for Payer: Molina CHIP/Medicaid	$3,469.87
Rate for Payer: Multiplan Auto	$2,409.64
Rate for Payer: Multiplan Commercial	$2,409.64
Rate for Payer: Multiplan Workers Comp	$2,409.64
Rate for Payer: Parkland Medicaid	$3,469.87
Rate for Payer: Scott and White EPO/PPO	$2,409.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,469.87
Rate for Payer: Superior Health Plan EPO	$655.42

200009901

Facility

$5,078.00

Service Code	HCPCS C1713
Hospital Charge Code	990945
Hospital Revenue Code	278
Min. Negotiated Rate	$457.02
Max. Negotiated Rate	$3,656.16
Rate for Payer: Amerigroup CHIP/Medicaid	$457.02
Rate for Payer: BCBS of TX Blue Advantage	$1,523.40
Rate for Payer: BCBS of TX Blue Essentials	$1,828.08
Rate for Payer: BCBS of TX PPO	$2,031.20
Rate for Payer: Cash Price	$3,453.04
Rate for Payer: Cigna Medicaid	$3,656.16
Rate for Payer: Molina CHIP/Medicaid	$3,656.16
Rate for Payer: Multiplan Auto	$2,539.00
Rate for Payer: Multiplan Commercial	$2,539.00
Rate for Payer: Multiplan Workers Comp	$2,539.00
Rate for Payer: Parkland Medicaid	$3,656.16
Rate for Payer: Scott and White EPO/PPO	$2,539.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,656.16
Rate for Payer: Superior Health Plan EPO	$690.61

200009901

Facility

$5,078.00

Service Code	HCPCS C1713
Hospital Charge Code	990945
Hospital Revenue Code	278
Min. Negotiated Rate	$1,269.50
Max. Negotiated Rate	$2,539.00
Rate for Payer: Cash Price	$3,453.04
Rate for Payer: Cigna Commercial	$1,269.50
Rate for Payer: Multiplan Auto	$2,539.00
Rate for Payer: Multiplan Commercial	$2,539.00
Rate for Payer: Multiplan Workers Comp	$2,539.00
Rate for Payer: Scott and White EPO/PPO	$2,539.00

Know your out-of-pocket cost for care.

All Charges