White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PK HEAD+NECK -- DHF

Facility

$753.76

Hospital Charge Code	81651358
Hospital Revenue Code	272
Rate for Payer: Cash Price	$663.31

PK HEAD+NECK -- DHF

Facility

$753.76

Hospital Charge Code	81651358
Hospital Revenue Code	272
Min. Negotiated Rate	$67.84
Max. Negotiated Rate	$489.94
Rate for Payer: Aetna Commercial	$414.57
Rate for Payer: Amerigroup CHIP/Medicaid	$67.84
Rate for Payer: BCBS of TX Blue Advantage	$226.13
Rate for Payer: BCBS of TX Blue Essentials	$271.35
Rate for Payer: BCBS of TX PPO	$301.50
Rate for Payer: Cash Price	$663.31
Rate for Payer: Multiplan Auto	$489.94
Rate for Payer: Multiplan Commercial	$489.94
Rate for Payer: Multiplan Workers Comp	$489.94
Rate for Payer: Scott and White EPO/PPO	$376.88
Rate for Payer: Superior Health Plan EPO	$102.51

PK OB CEASARA -- DHF

Facility

$2,610.97

Hospital Charge Code	81652000
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,297.65

PK OB CEASARA -- DHF

Facility

$2,610.97

Hospital Charge Code	81652000
Hospital Revenue Code	272
Min. Negotiated Rate	$234.99
Max. Negotiated Rate	$1,697.13
Rate for Payer: Aetna Commercial	$1,436.03
Rate for Payer: Amerigroup CHIP/Medicaid	$234.99
Rate for Payer: BCBS of TX Blue Advantage	$783.29
Rate for Payer: BCBS of TX Blue Essentials	$939.95
Rate for Payer: BCBS of TX PPO	$1,044.39
Rate for Payer: Cash Price	$2,297.65
Rate for Payer: Multiplan Auto	$1,697.13
Rate for Payer: Multiplan Commercial	$1,697.13
Rate for Payer: Multiplan Workers Comp	$1,697.13
Rate for Payer: Scott and White EPO/PPO	$1,305.48
Rate for Payer: Superior Health Plan EPO	$355.09

PK OB -- DHF

Facility

$351.20

Hospital Charge Code	81651952
Hospital Revenue Code	272
Min. Negotiated Rate	$31.61
Max. Negotiated Rate	$228.28
Rate for Payer: Aetna Commercial	$193.16
Rate for Payer: Amerigroup CHIP/Medicaid	$31.61
Rate for Payer: BCBS of TX Blue Advantage	$105.36
Rate for Payer: BCBS of TX Blue Essentials	$126.43
Rate for Payer: BCBS of TX PPO	$140.48
Rate for Payer: Cash Price	$309.06
Rate for Payer: Multiplan Auto	$228.28
Rate for Payer: Multiplan Commercial	$228.28
Rate for Payer: Multiplan Workers Comp	$228.28
Rate for Payer: Scott and White EPO/PPO	$175.60
Rate for Payer: Superior Health Plan EPO	$47.76

PK OB -- DHF

Facility

$351.20

Hospital Charge Code	81651952
Hospital Revenue Code	272
Rate for Payer: Cash Price	$309.06

PK PACEMAKER -- DHF

Facility

$213.94

Hospital Charge Code	81846073
Hospital Revenue Code	272
Rate for Payer: Cash Price	$188.27

PK PACEMAKER -- DHF

Facility

$213.94

Hospital Charge Code	81846073
Hospital Revenue Code	272
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$139.06
Rate for Payer: Aetna Commercial	$117.67
Rate for Payer: Amerigroup CHIP/Medicaid	$19.25
Rate for Payer: BCBS of TX Blue Advantage	$64.18
Rate for Payer: BCBS of TX Blue Essentials	$77.02
Rate for Payer: BCBS of TX PPO	$85.58
Rate for Payer: Cash Price	$188.27
Rate for Payer: Multiplan Auto	$139.06
Rate for Payer: Multiplan Commercial	$139.06
Rate for Payer: Multiplan Workers Comp	$139.06
Rate for Payer: Scott and White EPO/PPO	$106.97
Rate for Payer: Superior Health Plan EPO	$29.10

PK TOTAL HIP -- DHF

Facility

$198.05

Hospital Charge Code	81653008
Hospital Revenue Code	272
Min. Negotiated Rate	$17.82
Max. Negotiated Rate	$128.73
Rate for Payer: Aetna Commercial	$108.93
Rate for Payer: Amerigroup CHIP/Medicaid	$17.82
Rate for Payer: BCBS of TX Blue Advantage	$59.42
Rate for Payer: BCBS of TX Blue Essentials	$71.30
Rate for Payer: BCBS of TX PPO	$79.22
Rate for Payer: Cash Price	$174.28
Rate for Payer: Multiplan Auto	$128.73
Rate for Payer: Multiplan Commercial	$128.73
Rate for Payer: Multiplan Workers Comp	$128.73
Rate for Payer: Scott and White EPO/PPO	$99.02
Rate for Payer: Superior Health Plan EPO	$26.93

PK TOTAL HIP -- DHF

Facility

$198.05

Hospital Charge Code	81653008
Hospital Revenue Code	272
Rate for Payer: Cash Price	$174.28

PLACE CATH THOR/BRAC 3RD

Facility

$3,918.00

Service Code	CPT 36217
Hospital Charge Code	2301703
Hospital Revenue Code	361
Min. Negotiated Rate	$352.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,154.90
Rate for Payer: Amerigroup CHIP/Medicaid	$352.62
Rate for Payer: Cash Price	$3,447.84
Rate for Payer: Cash Price	$3,447.84
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	$1,959.00
Rate for Payer: Superior Health Plan EPO	$532.85

PLACE CATH THOR/BRAC 3RD

Facility

$3,918.00

Service Code	CPT 36217
Hospital Charge Code	2301703
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,447.84

Placement of amniotic membrane on the ocular surface; single layer, sutured

Facility

$10,000.00

Service Code	CPT 65779
Hospital Charge Code	36065779
Hospital Revenue Code	360
Min. Negotiated Rate	$77.99
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$5,303.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,535.99
Rate for Payer: Amerigroup Medicare	$3,535.99
Rate for Payer: BCBS of TX Blue Advantage	$5,222.19
Rate for Payer: BCBS of TX Blue Essentials	$6,254.12
Rate for Payer: BCBS of TX Medicare	$3,535.99
Rate for Payer: BCBS of TX PPO	$7,880.19
Rate for Payer: Cigna Commercial	$8,010.04
Rate for Payer: Cigna Medicare	$3,535.99
Rate for Payer: Employer Direct Commercial	$3,535.99
Rate for Payer: Humana Medicare/TRICARE	$3,535.99
Rate for Payer: Molina Dual Medicare/Medicaid	$3,535.99
Rate for Payer: Molina Medicare	$3,535.99
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	$77.99
Rate for Payer: Scott and White Medicare	$3,535.99
Rate for Payer: Superior Health Plan EPO	$3,535.99
Rate for Payer: Superior Health Plan Medicare	$3,535.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,535.99
Rate for Payer: Universal American Medicare	$3,535.99
Rate for Payer: Wellcare Medicare	$3,535.99
Rate for Payer: Wellmed Medicare	$3,535.99

Plastic repair of salivary duct, sialodochoplasty; primary or simple

Facility

$12,223.34

Service Code	CPT 42500
Hospital Charge Code	36042500
Hospital Revenue Code	360
Min. Negotiated Rate	$118.13
Max. Negotiated Rate	$12,223.34
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$8,033.61
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Amerigroup Medicare	$5,355.74
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,355.74
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,132.30
Rate for Payer: Cigna Medicaid	$1,954.22
Rate for Payer: Cigna Medicare	$5,355.74
Rate for Payer: Employer Direct Commercial	$5,355.74
Rate for Payer: Humana Medicare/TRICARE	$5,355.74
Rate for Payer: Molina CHIP/Medicaid	$1,954.22
Rate for Payer: Molina Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Molina Medicare	$5,355.74
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	$1,954.22
Rate for Payer: Scott and White EPO/PPO	$118.13
Rate for Payer: Scott and White Medicare	$5,355.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.22
Rate for Payer: Superior Health Plan EPO	$5,355.74
Rate for Payer: Superior Health Plan Medicare	$5,355.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Universal American Medicare	$5,355.74
Rate for Payer: Wellcare Medicare	$5,355.74
Rate for Payer: Wellmed Medicare	$5,355.74

PLATE 7 HOLE RIGHT

Facility

$19,578.31

Service Code	HCPCS C1713
Hospital Charge Code	8428493
Hospital Revenue Code	278
Min. Negotiated Rate	$4,894.58
Max. Negotiated Rate	$9,789.16
Rate for Payer: Aetna Commercial	$5,873.49
Rate for Payer: Cash Price	$17,228.91
Rate for Payer: Cigna Commercial	$4,894.58
Rate for Payer: Multiplan Auto	$9,789.16
Rate for Payer: Multiplan Commercial	$9,789.16
Rate for Payer: Multiplan Workers Comp	$9,789.16
Rate for Payer: Scott and White EPO/PPO	$9,789.16

PLATE 7 HOLE RIGHT

Facility

$19,578.31

Service Code	HCPCS C1713
Hospital Charge Code	8428493
Hospital Revenue Code	278
Min. Negotiated Rate	$1,762.05
Max. Negotiated Rate	$9,789.16
Rate for Payer: Aetna Commercial	$5,873.49
Rate for Payer: Amerigroup CHIP/Medicaid	$1,762.05
Rate for Payer: BCBS of TX Blue Advantage	$5,873.49
Rate for Payer: BCBS of TX Blue Essentials	$7,048.19
Rate for Payer: BCBS of TX PPO	$7,831.32
Rate for Payer: Cash Price	$17,228.91
Rate for Payer: Multiplan Auto	$9,789.16
Rate for Payer: Multiplan Commercial	$9,789.16
Rate for Payer: Multiplan Workers Comp	$9,789.16
Rate for Payer: Scott and White EPO/PPO	$9,789.16
Rate for Payer: Superior Health Plan EPO	$2,662.65

plate acdf all levels

Facility

$6,024.10

Service Code	HCPCS C1713
Hospital Charge Code	8672535
Hospital Revenue Code	278
Min. Negotiated Rate	$1,506.02
Max. Negotiated Rate	$3,012.05
Rate for Payer: Aetna Commercial	$1,807.23
Rate for Payer: Cash Price	$5,301.21
Rate for Payer: Cigna Commercial	$1,506.02
Rate for Payer: Multiplan Auto	$3,012.05
Rate for Payer: Multiplan Commercial	$3,012.05
Rate for Payer: Multiplan Workers Comp	$3,012.05
Rate for Payer: Scott and White EPO/PPO	$3,012.05

plate acdf all levels

Facility

$6,024.10

Service Code	HCPCS C1713
Hospital Charge Code	8672535
Hospital Revenue Code	278
Min. Negotiated Rate	$542.17
Max. Negotiated Rate	$3,012.05
Rate for Payer: Aetna Commercial	$1,807.23
Rate for Payer: Amerigroup CHIP/Medicaid	$542.17
Rate for Payer: BCBS of TX Blue Advantage	$1,807.23
Rate for Payer: BCBS of TX Blue Essentials	$2,168.68
Rate for Payer: BCBS of TX PPO	$2,409.64
Rate for Payer: Cash Price	$5,301.21
Rate for Payer: Multiplan Auto	$3,012.05
Rate for Payer: Multiplan Commercial	$3,012.05
Rate for Payer: Multiplan Workers Comp	$3,012.05
Rate for Payer: Scott and White EPO/PPO	$3,012.05
Rate for Payer: Superior Health Plan EPO	$819.28

PLATE ACF 2 LEVEL

Facility

$14,457.83

Service Code	HCPCS C1713
Hospital Charge Code	8568967
Hospital Revenue Code	278
Min. Negotiated Rate	$1,301.20
Max. Negotiated Rate	$7,228.92
Rate for Payer: Aetna Commercial	$4,337.35
Rate for Payer: Amerigroup CHIP/Medicaid	$1,301.20
Rate for Payer: BCBS of TX Blue Advantage	$4,337.35
Rate for Payer: BCBS of TX Blue Essentials	$5,204.82
Rate for Payer: BCBS of TX PPO	$5,783.13
Rate for Payer: Cash Price	$12,722.89
Rate for Payer: Multiplan Auto	$7,228.92
Rate for Payer: Multiplan Commercial	$7,228.92
Rate for Payer: Multiplan Workers Comp	$7,228.92
Rate for Payer: Scott and White EPO/PPO	$7,228.92
Rate for Payer: Superior Health Plan EPO	$1,966.26

PLATE ACF 2 LEVEL

Facility

$14,457.83

Service Code	HCPCS C1713
Hospital Charge Code	8568967
Hospital Revenue Code	278
Min. Negotiated Rate	$3,614.46
Max. Negotiated Rate	$7,228.92
Rate for Payer: Aetna Commercial	$4,337.35
Rate for Payer: Cash Price	$12,722.89
Rate for Payer: Cigna Commercial	$3,614.46
Rate for Payer: Multiplan Auto	$7,228.92
Rate for Payer: Multiplan Commercial	$7,228.92
Rate for Payer: Multiplan Workers Comp	$7,228.92
Rate for Payer: Scott and White EPO/PPO	$7,228.92

plate acf cover

Facility

$1,325.30

Service Code	HCPCS C1713
Hospital Charge Code	8666512
Hospital Revenue Code	278
Min. Negotiated Rate	$331.32
Max. Negotiated Rate	$662.65
Rate for Payer: Aetna Commercial	$397.59
Rate for Payer: Cash Price	$1,166.26
Rate for Payer: Cigna Commercial	$331.32
Rate for Payer: Multiplan Auto	$662.65
Rate for Payer: Multiplan Commercial	$662.65
Rate for Payer: Multiplan Workers Comp	$662.65
Rate for Payer: Scott and White EPO/PPO	$662.65

plate acf cover

Facility

$1,325.30

Service Code	HCPCS C1713
Hospital Charge Code	8666512
Hospital Revenue Code	278
Min. Negotiated Rate	$119.28
Max. Negotiated Rate	$662.65
Rate for Payer: Aetna Commercial	$397.59
Rate for Payer: Amerigroup CHIP/Medicaid	$119.28
Rate for Payer: BCBS of TX Blue Advantage	$397.59
Rate for Payer: BCBS of TX Blue Essentials	$477.11
Rate for Payer: BCBS of TX PPO	$530.12
Rate for Payer: Cash Price	$1,166.26
Rate for Payer: Multiplan Auto	$662.65
Rate for Payer: Multiplan Commercial	$662.65
Rate for Payer: Multiplan Workers Comp	$662.65
Rate for Payer: Scott and White EPO/PPO	$662.65
Rate for Payer: Superior Health Plan EPO	$180.24

PLATE ACIF LEVEL 2 40MM

Facility

$14,457.83

Service Code	HCPCS C1713
Hospital Charge Code	8569067
Hospital Revenue Code	278
Min. Negotiated Rate	$1,301.20
Max. Negotiated Rate	$7,228.92
Rate for Payer: Aetna Commercial	$4,337.35
Rate for Payer: Amerigroup CHIP/Medicaid	$1,301.20
Rate for Payer: BCBS of TX Blue Advantage	$4,337.35
Rate for Payer: BCBS of TX Blue Essentials	$5,204.82
Rate for Payer: BCBS of TX PPO	$5,783.13
Rate for Payer: Cash Price	$12,722.89
Rate for Payer: Multiplan Auto	$7,228.92
Rate for Payer: Multiplan Commercial	$7,228.92
Rate for Payer: Multiplan Workers Comp	$7,228.92
Rate for Payer: Scott and White EPO/PPO	$7,228.92
Rate for Payer: Superior Health Plan EPO	$1,966.26

PLATE ACIF LEVEL 2 40MM

Facility

$14,457.83

Service Code	HCPCS C1713
Hospital Charge Code	8569067
Hospital Revenue Code	278
Min. Negotiated Rate	$3,614.46
Max. Negotiated Rate	$7,228.92
Rate for Payer: Aetna Commercial	$4,337.35
Rate for Payer: Cash Price	$12,722.89
Rate for Payer: Cigna Commercial	$3,614.46
Rate for Payer: Multiplan Auto	$7,228.92
Rate for Payer: Multiplan Commercial	$7,228.92
Rate for Payer: Multiplan Workers Comp	$7,228.92
Rate for Payer: Scott and White EPO/PPO	$7,228.92

PLATE ACP

Facility

$12,048.19

Service Code	HCPCS C1713
Hospital Charge Code	8452479
Hospital Revenue Code	278
Min. Negotiated Rate	$1,084.34
Max. Negotiated Rate	$6,024.10
Rate for Payer: Aetna Commercial	$3,614.46
Rate for Payer: Amerigroup CHIP/Medicaid	$1,084.34
Rate for Payer: BCBS of TX Blue Advantage	$3,614.46
Rate for Payer: BCBS of TX Blue Essentials	$4,337.35
Rate for Payer: BCBS of TX PPO	$4,819.28
Rate for Payer: Cash Price	$10,602.41
Rate for Payer: Multiplan Auto	$6,024.10
Rate for Payer: Multiplan Commercial	$6,024.10
Rate for Payer: Multiplan Workers Comp	$6,024.10
Rate for Payer: Scott and White EPO/PPO	$6,024.10
Rate for Payer: Superior Health Plan EPO	$1,638.55

Know your out-of-pocket cost for care.

All Charges