White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PLT COMP TUBE -- DHF

Facility

$5,163.45

Service Code	HCPCS C1713
Hospital Charge Code	81336950
Hospital Revenue Code	278
Min. Negotiated Rate	$1,290.86
Max. Negotiated Rate	$2,581.72
Rate for Payer: Aetna Commercial	$1,549.04
Rate for Payer: Cash Price	$4,543.84
Rate for Payer: Cigna Commercial	$1,290.86
Rate for Payer: Multiplan Auto	$2,581.72
Rate for Payer: Multiplan Commercial	$2,581.72
Rate for Payer: Multiplan Workers Comp	$2,581.72
Rate for Payer: Scott and White EPO/PPO	$2,581.72

PLT COMP TUBE -- DHF

Facility

$5,163.45

Service Code	HCPCS C1713
Hospital Charge Code	81336950
Hospital Revenue Code	278
Min. Negotiated Rate	$464.71
Max. Negotiated Rate	$2,581.72
Rate for Payer: Aetna Commercial	$1,549.04
Rate for Payer: Amerigroup CHIP/Medicaid	$464.71
Rate for Payer: BCBS of TX Blue Advantage	$1,549.04
Rate for Payer: BCBS of TX Blue Essentials	$1,858.84
Rate for Payer: BCBS of TX PPO	$2,065.38
Rate for Payer: Cash Price	$4,543.84
Rate for Payer: Multiplan Auto	$2,581.72
Rate for Payer: Multiplan Commercial	$2,581.72
Rate for Payer: Multiplan Workers Comp	$2,581.72
Rate for Payer: Scott and White EPO/PPO	$2,581.72
Rate for Payer: Superior Health Plan EPO	$702.23

PLT E 1/3 TUBE -- DHF

Facility

$803.81

Service Code	HCPCS C1713
Hospital Charge Code	81338253
Hospital Revenue Code	278
Min. Negotiated Rate	$72.34
Max. Negotiated Rate	$401.90
Rate for Payer: Aetna Commercial	$241.14
Rate for Payer: Amerigroup CHIP/Medicaid	$72.34
Rate for Payer: BCBS of TX Blue Advantage	$241.14
Rate for Payer: BCBS of TX Blue Essentials	$289.37
Rate for Payer: BCBS of TX PPO	$321.52
Rate for Payer: Cash Price	$707.35
Rate for Payer: Multiplan Auto	$401.90
Rate for Payer: Multiplan Commercial	$401.90
Rate for Payer: Multiplan Workers Comp	$401.90
Rate for Payer: Scott and White EPO/PPO	$401.90
Rate for Payer: Superior Health Plan EPO	$109.32

PLT E 1/3 TUBE -- DHF

Facility

$803.81

Service Code	HCPCS C1713
Hospital Charge Code	81338253
Hospital Revenue Code	278
Min. Negotiated Rate	$200.95
Max. Negotiated Rate	$401.90
Rate for Payer: Aetna Commercial	$241.14
Rate for Payer: Cash Price	$707.35
Rate for Payer: Cigna Commercial	$200.95
Rate for Payer: Multiplan Auto	$401.90
Rate for Payer: Multiplan Commercial	$401.90
Rate for Payer: Multiplan Workers Comp	$401.90
Rate for Payer: Scott and White EPO/PPO	$401.90

PLT E COMP BRD -- DHF

Facility

$1,818.15

Service Code	HCPCS C1713
Hospital Charge Code	81337206
Hospital Revenue Code	278
Min. Negotiated Rate	$163.63
Max. Negotiated Rate	$909.08
Rate for Payer: Aetna Commercial	$545.44
Rate for Payer: Amerigroup CHIP/Medicaid	$163.63
Rate for Payer: BCBS of TX Blue Advantage	$545.44
Rate for Payer: BCBS of TX Blue Essentials	$654.53
Rate for Payer: BCBS of TX PPO	$727.26
Rate for Payer: Cash Price	$1,599.97
Rate for Payer: Multiplan Auto	$909.08
Rate for Payer: Multiplan Commercial	$909.08
Rate for Payer: Multiplan Workers Comp	$909.08
Rate for Payer: Scott and White EPO/PPO	$909.08
Rate for Payer: Superior Health Plan EPO	$247.27

PLT E COMP BRD -- DHF

Facility

$1,818.15

Service Code	HCPCS C1713
Hospital Charge Code	81337206
Hospital Revenue Code	278
Min. Negotiated Rate	$454.54
Max. Negotiated Rate	$909.08
Rate for Payer: Aetna Commercial	$545.44
Rate for Payer: Cash Price	$1,599.97
Rate for Payer: Cigna Commercial	$454.54
Rate for Payer: Multiplan Auto	$909.08
Rate for Payer: Multiplan Commercial	$909.08
Rate for Payer: Multiplan Workers Comp	$909.08
Rate for Payer: Scott and White EPO/PPO	$909.08

PLT E SM STRAT -- DHF

Facility

$14,747.00

Service Code	HCPCS C1713
Hospital Charge Code	81337909
Hospital Revenue Code	278
Min. Negotiated Rate	$1,327.23
Max. Negotiated Rate	$7,373.50
Rate for Payer: Aetna Commercial	$4,424.10
Rate for Payer: Amerigroup CHIP/Medicaid	$1,327.23
Rate for Payer: BCBS of TX Blue Advantage	$4,424.10
Rate for Payer: BCBS of TX Blue Essentials	$5,308.92
Rate for Payer: BCBS of TX PPO	$5,898.80
Rate for Payer: Cash Price	$12,977.36
Rate for Payer: Multiplan Auto	$7,373.50
Rate for Payer: Multiplan Commercial	$7,373.50
Rate for Payer: Multiplan Workers Comp	$7,373.50
Rate for Payer: Scott and White EPO/PPO	$7,373.50
Rate for Payer: Superior Health Plan EPO	$2,005.59

PLT E SM STRAT -- DHF

Facility

$14,747.00

Service Code	HCPCS C1713
Hospital Charge Code	81337909
Hospital Revenue Code	278
Min. Negotiated Rate	$3,686.75
Max. Negotiated Rate	$7,373.50
Rate for Payer: Aetna Commercial	$4,424.10
Rate for Payer: Cash Price	$12,977.36
Rate for Payer: Cigna Commercial	$3,686.75
Rate for Payer: Multiplan Auto	$7,373.50
Rate for Payer: Multiplan Commercial	$7,373.50
Rate for Payer: Multiplan Workers Comp	$7,373.50
Rate for Payer: Scott and White EPO/PPO	$7,373.50

PLT E T -- DHF

Facility

$453.81

Service Code	HCPCS C1713
Hospital Charge Code	81337958
Hospital Revenue Code	278
Min. Negotiated Rate	$113.45
Max. Negotiated Rate	$226.90
Rate for Payer: Aetna Commercial	$136.14
Rate for Payer: Cash Price	$399.35
Rate for Payer: Cigna Commercial	$113.45
Rate for Payer: Multiplan Auto	$226.90
Rate for Payer: Multiplan Commercial	$226.90
Rate for Payer: Multiplan Workers Comp	$226.90
Rate for Payer: Scott and White EPO/PPO	$226.90

PLT E T -- DHF

Facility

$453.81

Service Code	HCPCS C1713
Hospital Charge Code	81337958
Hospital Revenue Code	278
Min. Negotiated Rate	$40.84
Max. Negotiated Rate	$226.90
Rate for Payer: Aetna Commercial	$136.14
Rate for Payer: Amerigroup CHIP/Medicaid	$40.84
Rate for Payer: BCBS of TX Blue Advantage	$136.14
Rate for Payer: BCBS of TX Blue Essentials	$163.37
Rate for Payer: BCBS of TX PPO	$181.52
Rate for Payer: Cash Price	$399.35
Rate for Payer: Multiplan Auto	$226.90
Rate for Payer: Multiplan Commercial	$226.90
Rate for Payer: Multiplan Workers Comp	$226.90
Rate for Payer: Scott and White EPO/PPO	$226.90
Rate for Payer: Superior Health Plan EPO	$61.72

PLT RECONSTRCT II -- DHF

Facility

$6,588.92

Service Code	HCPCS C1713
Hospital Charge Code	81338469
Hospital Revenue Code	278
Min. Negotiated Rate	$1,647.23
Max. Negotiated Rate	$3,294.46
Rate for Payer: Aetna Commercial	$1,976.68
Rate for Payer: Cash Price	$5,798.25
Rate for Payer: Cigna Commercial	$1,647.23
Rate for Payer: Multiplan Auto	$3,294.46
Rate for Payer: Multiplan Commercial	$3,294.46
Rate for Payer: Multiplan Workers Comp	$3,294.46
Rate for Payer: Scott and White EPO/PPO	$3,294.46

PLT RECONSTRCT II -- DHF

Facility

$6,588.92

Service Code	HCPCS C1713
Hospital Charge Code	81338469
Hospital Revenue Code	278
Min. Negotiated Rate	$593.00
Max. Negotiated Rate	$3,294.46
Rate for Payer: Aetna Commercial	$1,976.68
Rate for Payer: Amerigroup CHIP/Medicaid	$593.00
Rate for Payer: BCBS of TX Blue Advantage	$1,976.68
Rate for Payer: BCBS of TX Blue Essentials	$2,372.01
Rate for Payer: BCBS of TX PPO	$2,635.57
Rate for Payer: Cash Price	$5,798.25
Rate for Payer: Multiplan Auto	$3,294.46
Rate for Payer: Multiplan Commercial	$3,294.46
Rate for Payer: Multiplan Workers Comp	$3,294.46
Rate for Payer: Scott and White EPO/PPO	$3,294.46
Rate for Payer: Superior Health Plan EPO	$896.09

PLT RECONTSRCT -- DHF

Facility

$3,828.24

Service Code	HCPCS C1713
Hospital Charge Code	81338451
Hospital Revenue Code	278
Min. Negotiated Rate	$957.06
Max. Negotiated Rate	$1,914.12
Rate for Payer: Aetna Commercial	$1,148.47
Rate for Payer: Cash Price	$3,368.85
Rate for Payer: Cigna Commercial	$957.06
Rate for Payer: Multiplan Auto	$1,914.12
Rate for Payer: Multiplan Commercial	$1,914.12
Rate for Payer: Multiplan Workers Comp	$1,914.12
Rate for Payer: Scott and White EPO/PPO	$1,914.12

PLT RECONTSRCT -- DHF

Facility

$3,828.24

Service Code	HCPCS C1713
Hospital Charge Code	81338451
Hospital Revenue Code	278
Min. Negotiated Rate	$344.54
Max. Negotiated Rate	$1,914.12
Rate for Payer: Aetna Commercial	$1,148.47
Rate for Payer: Amerigroup CHIP/Medicaid	$344.54
Rate for Payer: BCBS of TX Blue Advantage	$1,148.47
Rate for Payer: BCBS of TX Blue Essentials	$1,378.17
Rate for Payer: BCBS of TX PPO	$1,531.30
Rate for Payer: Cash Price	$3,368.85
Rate for Payer: Multiplan Auto	$1,914.12
Rate for Payer: Multiplan Commercial	$1,914.12
Rate for Payer: Multiplan Workers Comp	$1,914.12
Rate for Payer: Scott and White EPO/PPO	$1,914.12
Rate for Payer: Superior Health Plan EPO	$520.64

PLUG AC-IP PHOTON MICRO-ABBOTT

Facility

$120.48

Service Code	HCPCS C1713
Hospital Charge Code	8688553
Hospital Revenue Code	278
Min. Negotiated Rate	$30.12
Max. Negotiated Rate	$60.24
Rate for Payer: Aetna Commercial	$36.14
Rate for Payer: Cash Price	$106.02
Rate for Payer: Cigna Commercial	$30.12
Rate for Payer: Multiplan Auto	$60.24
Rate for Payer: Multiplan Commercial	$60.24
Rate for Payer: Multiplan Workers Comp	$60.24
Rate for Payer: Scott and White EPO/PPO	$60.24

PLUG AC-IP PHOTON MICRO-ABBOTT

Facility

$120.48

Service Code	HCPCS C1713
Hospital Charge Code	8688553
Hospital Revenue Code	278
Min. Negotiated Rate	$10.84
Max. Negotiated Rate	$60.24
Rate for Payer: Aetna Commercial	$36.14
Rate for Payer: Amerigroup CHIP/Medicaid	$10.84
Rate for Payer: BCBS of TX Blue Advantage	$36.14
Rate for Payer: BCBS of TX Blue Essentials	$43.37
Rate for Payer: BCBS of TX PPO	$48.19
Rate for Payer: Cash Price	$106.02
Rate for Payer: Multiplan Auto	$60.24
Rate for Payer: Multiplan Commercial	$60.24
Rate for Payer: Multiplan Workers Comp	$60.24
Rate for Payer: Scott and White EPO/PPO	$60.24
Rate for Payer: Superior Health Plan EPO	$16.39

PM ACCOLADE DR L301 -- DHF

Facility

$45,363.63

Service Code	HCPCS C1785
Hospital Charge Code	40040891
Hospital Revenue Code	275
Min. Negotiated Rate	$11,340.91
Max. Negotiated Rate	$22,681.82
Rate for Payer: Aetna Commercial	$13,609.09
Rate for Payer: Cash Price	$39,919.99
Rate for Payer: Cigna Commercial	$11,340.91
Rate for Payer: Multiplan Auto	$22,681.82
Rate for Payer: Multiplan Commercial	$22,681.82
Rate for Payer: Multiplan Workers Comp	$22,681.82
Rate for Payer: Scott and White EPO/PPO	$22,681.82

PM ACCOLADE DR L301 -- DHF

Facility

$45,363.63

Service Code	HCPCS C1785
Hospital Charge Code	40040891
Hospital Revenue Code	275
Min. Negotiated Rate	$4,082.73
Max. Negotiated Rate	$22,681.82
Rate for Payer: Aetna Commercial	$13,609.09
Rate for Payer: Amerigroup CHIP/Medicaid	$4,082.73
Rate for Payer: BCBS of TX Blue Advantage	$13,609.09
Rate for Payer: BCBS of TX Blue Essentials	$16,330.91
Rate for Payer: BCBS of TX PPO	$18,145.45
Rate for Payer: Cash Price	$39,919.99
Rate for Payer: Multiplan Auto	$22,681.82
Rate for Payer: Multiplan Commercial	$22,681.82
Rate for Payer: Multiplan Workers Comp	$22,681.82
Rate for Payer: Scott and White EPO/PPO	$22,681.82
Rate for Payer: Superior Health Plan EPO	$6,169.45

PM ACCOLADE DR MRI L311 -- DHF

Facility

$36,322.31

Service Code	HCPCS C1785
Hospital Charge Code	40040875
Hospital Revenue Code	275
Min. Negotiated Rate	$3,269.01
Max. Negotiated Rate	$18,161.16
Rate for Payer: Aetna Commercial	$10,896.69
Rate for Payer: Amerigroup CHIP/Medicaid	$3,269.01
Rate for Payer: BCBS of TX Blue Advantage	$10,896.69
Rate for Payer: BCBS of TX Blue Essentials	$13,076.03
Rate for Payer: BCBS of TX PPO	$14,528.92
Rate for Payer: Cash Price	$31,963.63
Rate for Payer: Multiplan Auto	$18,161.16
Rate for Payer: Multiplan Commercial	$18,161.16
Rate for Payer: Multiplan Workers Comp	$18,161.16
Rate for Payer: Scott and White EPO/PPO	$18,161.16
Rate for Payer: Superior Health Plan EPO	$4,939.83

PM ACCOLADE DR MRI L311 -- DHF

Facility

$36,322.31

Service Code	HCPCS C1785
Hospital Charge Code	40040875
Hospital Revenue Code	275
Min. Negotiated Rate	$9,080.58
Max. Negotiated Rate	$18,161.16
Rate for Payer: Aetna Commercial	$10,896.69
Rate for Payer: Cash Price	$31,963.63
Rate for Payer: Cigna Commercial	$9,080.58
Rate for Payer: Multiplan Auto	$18,161.16
Rate for Payer: Multiplan Commercial	$18,161.16
Rate for Payer: Multiplan Workers Comp	$18,161.16
Rate for Payer: Scott and White EPO/PPO	$18,161.16

PM ASSURITY MRI PM2272

Facility

$41,414.16

Service Code	HCPCS C1785
Hospital Charge Code	40004335
Hospital Revenue Code	275
Min. Negotiated Rate	$10,353.54
Max. Negotiated Rate	$20,707.08
Rate for Payer: Aetna Commercial	$12,424.25
Rate for Payer: Cash Price	$36,444.46
Rate for Payer: Cigna Commercial	$10,353.54
Rate for Payer: Multiplan Auto	$20,707.08
Rate for Payer: Multiplan Commercial	$20,707.08
Rate for Payer: Multiplan Workers Comp	$20,707.08
Rate for Payer: Scott and White EPO/PPO	$20,707.08

PM ASSURITY MRI PM2272

Facility

$41,414.16

Service Code	HCPCS C1785
Hospital Charge Code	40004335
Hospital Revenue Code	275
Min. Negotiated Rate	$3,727.27
Max. Negotiated Rate	$20,707.08
Rate for Payer: Aetna Commercial	$12,424.25
Rate for Payer: Amerigroup CHIP/Medicaid	$3,727.27
Rate for Payer: BCBS of TX Blue Advantage	$12,424.25
Rate for Payer: BCBS of TX Blue Essentials	$14,909.10
Rate for Payer: BCBS of TX PPO	$16,565.66
Rate for Payer: Cash Price	$36,444.46
Rate for Payer: Multiplan Auto	$20,707.08
Rate for Payer: Multiplan Commercial	$20,707.08
Rate for Payer: Multiplan Workers Comp	$20,707.08
Rate for Payer: Scott and White EPO/PPO	$20,707.08
Rate for Payer: Superior Health Plan EPO	$5,632.33

PM AZURE XT SR MRI W1SR01 -- DHF

Facility

$27,314.04

Service Code	HCPCS C1786
Hospital Charge Code	40004350
Hospital Revenue Code	275
Min. Negotiated Rate	$2,458.26
Max. Negotiated Rate	$13,657.02
Rate for Payer: Aetna Commercial	$8,194.21
Rate for Payer: Amerigroup CHIP/Medicaid	$2,458.26
Rate for Payer: BCBS of TX Blue Advantage	$8,194.21
Rate for Payer: BCBS of TX Blue Essentials	$9,833.05
Rate for Payer: BCBS of TX PPO	$10,925.62
Rate for Payer: Cash Price	$24,036.36
Rate for Payer: Multiplan Auto	$13,657.02
Rate for Payer: Multiplan Commercial	$13,657.02
Rate for Payer: Multiplan Workers Comp	$13,657.02
Rate for Payer: Scott and White EPO/PPO	$13,657.02
Rate for Payer: Superior Health Plan EPO	$3,714.71

PM AZURE XT SR MRI W1SR01 -- DHF

Facility

$27,314.04

Service Code	HCPCS C1786
Hospital Charge Code	40004350
Hospital Revenue Code	275
Min. Negotiated Rate	$6,828.51
Max. Negotiated Rate	$13,657.02
Rate for Payer: Aetna Commercial	$8,194.21
Rate for Payer: Cash Price	$24,036.36
Rate for Payer: Cigna Commercial	$6,828.51
Rate for Payer: Multiplan Auto	$13,657.02
Rate for Payer: Multiplan Commercial	$13,657.02
Rate for Payer: Multiplan Workers Comp	$13,657.02
Rate for Payer: Scott and White EPO/PPO	$13,657.02

PM AZURE XT W1DR01

Facility

$24,698.80

Service Code	HCPCS C1785
Hospital Charge Code	109967
Hospital Revenue Code	275
Min. Negotiated Rate	$2,222.89
Max. Negotiated Rate	$12,349.40
Rate for Payer: Aetna Commercial	$7,409.64
Rate for Payer: Amerigroup CHIP/Medicaid	$2,222.89
Rate for Payer: BCBS of TX Blue Advantage	$7,409.64
Rate for Payer: BCBS of TX Blue Essentials	$8,891.57
Rate for Payer: BCBS of TX PPO	$9,879.52
Rate for Payer: Cash Price	$21,734.94
Rate for Payer: Multiplan Auto	$12,349.40
Rate for Payer: Multiplan Commercial	$12,349.40
Rate for Payer: Multiplan Workers Comp	$12,349.40
Rate for Payer: Scott and White EPO/PPO	$12,349.40
Rate for Payer: Superior Health Plan EPO	$3,359.04

Know your out-of-pocket cost for care.

All Charges