White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PILLOW, ABDUCTION FOAM MEDIUM -- DHF

Facility

$977.36

Hospital Charge Code	80335250
Hospital Revenue Code	270
Min. Negotiated Rate	$87.96
Max. Negotiated Rate	$635.28
Rate for Payer: Aetna Commercial	$537.55
Rate for Payer: Amerigroup CHIP/Medicaid	$87.96
Rate for Payer: BCBS of TX Blue Advantage	$293.21
Rate for Payer: BCBS of TX Blue Essentials	$351.85
Rate for Payer: BCBS of TX PPO	$390.94
Rate for Payer: Cash Price	$860.08
Rate for Payer: Multiplan Auto	$635.28
Rate for Payer: Multiplan Commercial	$635.28
Rate for Payer: Multiplan Workers Comp	$635.28
Rate for Payer: Scott and White EPO/PPO	$488.68
Rate for Payer: Superior Health Plan EPO	$132.92

PILLOW, ABDUCTION FOAM SMALL -- DHF

Facility

$977.36

Hospital Charge Code	80335250
Hospital Revenue Code	270
Min. Negotiated Rate	$87.96
Max. Negotiated Rate	$635.28
Rate for Payer: Aetna Commercial	$537.55
Rate for Payer: Amerigroup CHIP/Medicaid	$87.96
Rate for Payer: BCBS of TX Blue Advantage	$293.21
Rate for Payer: BCBS of TX Blue Essentials	$351.85
Rate for Payer: BCBS of TX PPO	$390.94
Rate for Payer: Cash Price	$860.08
Rate for Payer: Multiplan Auto	$635.28
Rate for Payer: Multiplan Commercial	$635.28
Rate for Payer: Multiplan Workers Comp	$635.28
Rate for Payer: Scott and White EPO/PPO	$488.68
Rate for Payer: Superior Health Plan EPO	$132.92

PILLOW, ABDUCTION FOAM SMALL -- DHF

Facility

$977.36

Hospital Charge Code	80335250
Hospital Revenue Code	270
Rate for Payer: Cash Price	$860.08

PIN CAP A/S -- DHF

Facility

$59.39

Hospital Charge Code	81033466
Hospital Revenue Code	272
Rate for Payer: Cash Price	$52.26

PIN CAP A/S -- DHF

Facility

$59.39

Hospital Charge Code	81033466
Hospital Revenue Code	272
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$38.60
Rate for Payer: Aetna Commercial	$32.66
Rate for Payer: Amerigroup CHIP/Medicaid	$5.35
Rate for Payer: BCBS of TX Blue Advantage	$17.82
Rate for Payer: BCBS of TX Blue Essentials	$21.38
Rate for Payer: BCBS of TX PPO	$23.76
Rate for Payer: Cash Price	$52.26
Rate for Payer: Multiplan Auto	$38.60
Rate for Payer: Multiplan Commercial	$38.60
Rate for Payer: Multiplan Workers Comp	$38.60
Rate for Payer: Scott and White EPO/PPO	$29.70
Rate for Payer: Superior Health Plan EPO	$8.08

PIN CERVICAL DISTRACTION 12MM

Facility

$125.90

Service Code	HCPCS C1713
Hospital Charge Code	8504482
Hospital Revenue Code	278
Min. Negotiated Rate	$11.33
Max. Negotiated Rate	$62.95
Rate for Payer: Aetna Commercial	$37.77
Rate for Payer: Amerigroup CHIP/Medicaid	$11.33
Rate for Payer: BCBS of TX Blue Advantage	$37.77
Rate for Payer: BCBS of TX Blue Essentials	$45.32
Rate for Payer: BCBS of TX PPO	$50.36
Rate for Payer: Cash Price	$110.79
Rate for Payer: Multiplan Auto	$62.95
Rate for Payer: Multiplan Commercial	$62.95
Rate for Payer: Multiplan Workers Comp	$62.95
Rate for Payer: Scott and White EPO/PPO	$62.95
Rate for Payer: Superior Health Plan EPO	$17.12

PIN CERVICAL DISTRACTION 12MM

Facility

$125.90

Service Code	HCPCS C1713
Hospital Charge Code	8504482
Hospital Revenue Code	278
Min. Negotiated Rate	$31.48
Max. Negotiated Rate	$62.95
Rate for Payer: Aetna Commercial	$37.77
Rate for Payer: Cash Price	$110.79
Rate for Payer: Cigna Commercial	$31.48
Rate for Payer: Multiplan Auto	$62.95
Rate for Payer: Multiplan Commercial	$62.95
Rate for Payer: Multiplan Workers Comp	$62.95
Rate for Payer: Scott and White EPO/PPO	$62.95

PIN CERVICAL DISTRACTION 14MM

Facility

$125.90

Service Code	HCPCS C1713
Hospital Charge Code	8504486
Hospital Revenue Code	278
Min. Negotiated Rate	$31.48
Max. Negotiated Rate	$62.95
Rate for Payer: Aetna Commercial	$37.77
Rate for Payer: Cash Price	$110.79
Rate for Payer: Cigna Commercial	$31.48
Rate for Payer: Multiplan Auto	$62.95
Rate for Payer: Multiplan Commercial	$62.95
Rate for Payer: Multiplan Workers Comp	$62.95
Rate for Payer: Scott and White EPO/PPO	$62.95

PIN CERVICAL DISTRACTION 14MM

Facility

$125.90

Service Code	HCPCS C1713
Hospital Charge Code	8504486
Hospital Revenue Code	278
Min. Negotiated Rate	$11.33
Max. Negotiated Rate	$62.95
Rate for Payer: Aetna Commercial	$37.77
Rate for Payer: Amerigroup CHIP/Medicaid	$11.33
Rate for Payer: BCBS of TX Blue Advantage	$37.77
Rate for Payer: BCBS of TX Blue Essentials	$45.32
Rate for Payer: BCBS of TX PPO	$50.36
Rate for Payer: Cash Price	$110.79
Rate for Payer: Multiplan Auto	$62.95
Rate for Payer: Multiplan Commercial	$62.95
Rate for Payer: Multiplan Workers Comp	$62.95
Rate for Payer: Scott and White EPO/PPO	$62.95
Rate for Payer: Superior Health Plan EPO	$17.12

pin headles trocar drill

Facility

$1,389.24

Hospital Charge Code	113721
Hospital Revenue Code	272
Min. Negotiated Rate	$125.03
Max. Negotiated Rate	$903.01
Rate for Payer: Aetna Commercial	$764.08
Rate for Payer: Amerigroup CHIP/Medicaid	$125.03
Rate for Payer: BCBS of TX Blue Advantage	$416.77
Rate for Payer: BCBS of TX Blue Essentials	$500.13
Rate for Payer: BCBS of TX PPO	$555.70
Rate for Payer: Cash Price	$1,222.53
Rate for Payer: Multiplan Auto	$903.01
Rate for Payer: Multiplan Commercial	$903.01
Rate for Payer: Multiplan Workers Comp	$903.01
Rate for Payer: Scott and White EPO/PPO	$694.62
Rate for Payer: Superior Health Plan EPO	$188.94

pin headles trocar drill

Facility

$1,389.24

Hospital Charge Code	113721
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,222.53

PIN HOFMAN TRNFX -- DHF

Facility

$745.78

Service Code	HCPCS C1713
Hospital Charge Code	81335705
Hospital Revenue Code	278
Min. Negotiated Rate	$186.44
Max. Negotiated Rate	$372.89
Rate for Payer: Aetna Commercial	$223.73
Rate for Payer: Cash Price	$656.29
Rate for Payer: Cigna Commercial	$186.44
Rate for Payer: Multiplan Auto	$372.89
Rate for Payer: Multiplan Commercial	$372.89
Rate for Payer: Multiplan Workers Comp	$372.89
Rate for Payer: Scott and White EPO/PPO	$372.89

PIN HOFMAN TRNFX -- DHF

Facility

$745.78

Service Code	HCPCS C1713
Hospital Charge Code	81335705
Hospital Revenue Code	278
Min. Negotiated Rate	$67.12
Max. Negotiated Rate	$372.89
Rate for Payer: Aetna Commercial	$223.73
Rate for Payer: Amerigroup CHIP/Medicaid	$67.12
Rate for Payer: BCBS of TX Blue Advantage	$223.73
Rate for Payer: BCBS of TX Blue Essentials	$268.48
Rate for Payer: BCBS of TX PPO	$298.31
Rate for Payer: Cash Price	$656.29
Rate for Payer: Multiplan Auto	$372.89
Rate for Payer: Multiplan Commercial	$372.89
Rate for Payer: Multiplan Workers Comp	$372.89
Rate for Payer: Scott and White EPO/PPO	$372.89
Rate for Payer: Superior Health Plan EPO	$101.43

PIN OLIVE FIX 1.4

Facility

$581.33

Service Code	HCPCS C1713
Hospital Charge Code	126426
Hospital Revenue Code	278
Min. Negotiated Rate	$52.32
Max. Negotiated Rate	$290.67
Rate for Payer: Aetna Commercial	$174.40
Rate for Payer: Amerigroup CHIP/Medicaid	$52.32
Rate for Payer: BCBS of TX Blue Advantage	$174.40
Rate for Payer: BCBS of TX Blue Essentials	$209.28
Rate for Payer: BCBS of TX PPO	$232.53
Rate for Payer: Cash Price	$511.57
Rate for Payer: Multiplan Auto	$290.67
Rate for Payer: Multiplan Commercial	$290.67
Rate for Payer: Multiplan Workers Comp	$290.67
Rate for Payer: Scott and White EPO/PPO	$290.67
Rate for Payer: Superior Health Plan EPO	$79.06

PIN OLIVE FIX 1.4

Facility

$581.33

Service Code	HCPCS C1713
Hospital Charge Code	126426
Hospital Revenue Code	278
Min. Negotiated Rate	$145.33
Max. Negotiated Rate	$290.67
Rate for Payer: Aetna Commercial	$174.40
Rate for Payer: Cash Price	$511.57
Rate for Payer: Cigna Commercial	$145.33
Rate for Payer: Multiplan Auto	$290.67
Rate for Payer: Multiplan Commercial	$290.67
Rate for Payer: Multiplan Workers Comp	$290.67
Rate for Payer: Scott and White EPO/PPO	$290.67

PIN STEINMAN THRD TIP

Facility

$1,156.63

Service Code	HCPCS C1713
Hospital Charge Code	144858
Hospital Revenue Code	278
Min. Negotiated Rate	$289.16
Max. Negotiated Rate	$578.32
Rate for Payer: Aetna Commercial	$346.99
Rate for Payer: Cash Price	$1,017.83
Rate for Payer: Cigna Commercial	$289.16
Rate for Payer: Multiplan Auto	$578.32
Rate for Payer: Multiplan Commercial	$578.32
Rate for Payer: Multiplan Workers Comp	$578.32
Rate for Payer: Scott and White EPO/PPO	$578.32

PIN STEINMAN THRD TIP

Facility

$1,156.63

Service Code	HCPCS C1713
Hospital Charge Code	144858
Hospital Revenue Code	278
Min. Negotiated Rate	$104.10
Max. Negotiated Rate	$578.32
Rate for Payer: Aetna Commercial	$346.99
Rate for Payer: Amerigroup CHIP/Medicaid	$104.10
Rate for Payer: BCBS of TX Blue Advantage	$346.99
Rate for Payer: BCBS of TX Blue Essentials	$416.39
Rate for Payer: BCBS of TX PPO	$462.65
Rate for Payer: Cash Price	$1,017.83
Rate for Payer: Multiplan Auto	$578.32
Rate for Payer: Multiplan Commercial	$578.32
Rate for Payer: Multiplan Workers Comp	$578.32
Rate for Payer: Scott and White EPO/PPO	$578.32
Rate for Payer: Superior Health Plan EPO	$157.30

PIN TEMP FIX ACF 300-1005

Facility

$602.40

Service Code	HCPCS C1713
Hospital Charge Code	8556473
Hospital Revenue Code	278
Min. Negotiated Rate	$150.60
Max. Negotiated Rate	$301.20
Rate for Payer: Aetna Commercial	$180.72
Rate for Payer: Cash Price	$530.11
Rate for Payer: Cigna Commercial	$150.60
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Scott and White EPO/PPO	$301.20

PIN TEMP FIX ACF 300-1005

Facility

$602.40

Service Code	HCPCS C1713
Hospital Charge Code	8556473
Hospital Revenue Code	278
Min. Negotiated Rate	$54.22
Max. Negotiated Rate	$301.20
Rate for Payer: Aetna Commercial	$180.72
Rate for Payer: Amerigroup CHIP/Medicaid	$54.22
Rate for Payer: BCBS of TX Blue Advantage	$180.72
Rate for Payer: BCBS of TX Blue Essentials	$216.86
Rate for Payer: BCBS of TX PPO	$240.96
Rate for Payer: Cash Price	$530.11
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Scott and White EPO/PPO	$301.20
Rate for Payer: Superior Health Plan EPO	$81.93

PIN TYPE II -- DHF

Facility

$4,574.08

Service Code	HCPCS C1713
Hospital Charge Code	81336364
Hospital Revenue Code	278
Min. Negotiated Rate	$1,143.52
Max. Negotiated Rate	$2,287.04
Rate for Payer: Aetna Commercial	$1,372.22
Rate for Payer: Cash Price	$4,025.19
Rate for Payer: Cigna Commercial	$1,143.52
Rate for Payer: Multiplan Auto	$2,287.04
Rate for Payer: Multiplan Commercial	$2,287.04
Rate for Payer: Multiplan Workers Comp	$2,287.04
Rate for Payer: Scott and White EPO/PPO	$2,287.04

PIN TYPE II -- DHF

Facility

$4,574.08

Service Code	HCPCS C1713
Hospital Charge Code	81336364
Hospital Revenue Code	278
Min. Negotiated Rate	$411.67
Max. Negotiated Rate	$2,287.04
Rate for Payer: Aetna Commercial	$1,372.22
Rate for Payer: Amerigroup CHIP/Medicaid	$411.67
Rate for Payer: BCBS of TX Blue Advantage	$1,372.22
Rate for Payer: BCBS of TX Blue Essentials	$1,646.67
Rate for Payer: BCBS of TX PPO	$1,829.63
Rate for Payer: Cash Price	$4,025.19
Rate for Payer: Multiplan Auto	$2,287.04
Rate for Payer: Multiplan Commercial	$2,287.04
Rate for Payer: Multiplan Workers Comp	$2,287.04
Rate for Payer: Scott and White EPO/PPO	$2,287.04
Rate for Payer: Superior Health Plan EPO	$622.07

Piperacillin-tazobactam 3.375gm

Facility

$128.17

Service Code	HCPCS J2543
Hospital Charge Code	79488971
Hospital Revenue Code	636
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.35
Rate for Payer: BCBS of TX Blue Essentials	$4.02
Rate for Payer: BCBS of TX PPO	$4.46
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

Piperacillin-tazobactam 3.375gm

Facility

$128.17

Service Code	HCPCS J2543
Hospital Charge Code	79488971
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

piperacillin-tazobactam 4 g-0.5 g Pow

Facility

$128.17

Service Code	HCPCS J2543
Hospital Charge Code	78398949
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

piperacillin-tazobactam 4 g-0.5 g Pow

Facility

$128.17

Service Code	HCPCS J2543
Hospital Charge Code	78398949
Hospital Revenue Code	636
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$3.35
Rate for Payer: BCBS of TX Blue Essentials	$4.02
Rate for Payer: BCBS of TX PPO	$4.46
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

Know your out-of-pocket cost for care.

All Charges