White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC

Facility

$61,314.90

Service Code	MSDRG 485
Min. Negotiated Rate	$28,237.12
Max. Negotiated Rate	$61,314.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,411.58
Rate for Payer: Amerigroup Medicare	$28,411.58
Rate for Payer: BCBS of TX Medicare	$28,411.58
Rate for Payer: Cigna Commercial	$41,565.05
Rate for Payer: Cigna Medicare	$28,411.58
Rate for Payer: Employer Direct Commercial	$28,411.58
Rate for Payer: Humana Medicare/TRICARE	$28,411.58
Rate for Payer: Molina Dual Medicare/Medicaid	$28,411.58
Rate for Payer: Molina Medicare	$28,411.58
Rate for Payer: Multiplan Auto	$61,314.90
Rate for Payer: Multiplan Commercial	$61,314.90
Rate for Payer: Multiplan Workers Comp	$61,314.90
Rate for Payer: Scott and White EPO/PPO	$28,237.12
Rate for Payer: Scott and White Medicare	$28,411.58
Rate for Payer: Superior Health Plan EPO	$28,411.58
Rate for Payer: Superior Health Plan Medicare	$28,411.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,411.58
Rate for Payer: Universal American Medicare	$28,411.58
Rate for Payer: Wellcare Medicare	$28,411.58
Rate for Payer: Wellmed Medicare	$28,411.58

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$29,757.80

Service Code	MSDRG 487
Min. Negotiated Rate	$13,704.25
Max. Negotiated Rate	$29,757.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,238.80
Rate for Payer: Amerigroup Medicare	$16,238.80
Rate for Payer: BCBS of TX Medicare	$16,238.80
Rate for Payer: Cigna Commercial	$20,172.66
Rate for Payer: Cigna Medicare	$16,238.80
Rate for Payer: Employer Direct Commercial	$16,238.80
Rate for Payer: Humana Medicare/TRICARE	$16,238.80
Rate for Payer: Molina Dual Medicare/Medicaid	$16,238.80
Rate for Payer: Molina Medicare	$16,238.80
Rate for Payer: Multiplan Auto	$29,757.80
Rate for Payer: Multiplan Commercial	$29,757.80
Rate for Payer: Multiplan Workers Comp	$29,757.80
Rate for Payer: Scott and White EPO/PPO	$13,704.25
Rate for Payer: Scott and White Medicare	$16,238.80
Rate for Payer: Superior Health Plan EPO	$16,238.80
Rate for Payer: Superior Health Plan Medicare	$16,238.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,238.80
Rate for Payer: Universal American Medicare	$16,238.80
Rate for Payer: Wellcare Medicare	$16,238.80
Rate for Payer: Wellmed Medicare	$16,238.80

KNEE PROCEDURES W/O PDX OF INFECTION W CC/MCC

Facility

$28,948.40

Service Code	MSDRG 488
Min. Negotiated Rate	$13,331.50
Max. Negotiated Rate	$28,948.40
Rate for Payer: BCBS of TX Blue Advantage	$18,167.50
Rate for Payer: BCBS of TX Blue Essentials	$21,798.89
Rate for Payer: BCBS of TX PPO	$24,221.92

KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC

Facility

$21,219.20

Service Code	MSDRG 489
Min. Negotiated Rate	$9,772.00
Max. Negotiated Rate	$21,219.20
Rate for Payer: BCBS of TX Blue Advantage	$11,157.64
Rate for Payer: BCBS of TX Blue Essentials	$13,387.87
Rate for Payer: BCBS of TX PPO	$14,875.99

KNEE PROCEDURES W PDX OF INFECTION W CC

Facility

$39,730.90

Service Code	MSDRG 486
Min. Negotiated Rate	$18,297.12
Max. Negotiated Rate	$39,730.90
Rate for Payer: BCBS of TX Blue Advantage	$19,078.24
Rate for Payer: BCBS of TX Blue Essentials	$22,891.67
Rate for Payer: BCBS of TX PPO	$25,436.17

KNEE PROCEDURES W PDX OF INFECTION W MCC

Facility

$61,314.90

Service Code	MSDRG 485
Min. Negotiated Rate	$28,237.12
Max. Negotiated Rate	$61,314.90
Rate for Payer: BCBS of TX Blue Advantage	$28,415.26
Rate for Payer: BCBS of TX Blue Essentials	$34,095.01
Rate for Payer: BCBS of TX PPO	$37,884.81

KNEE PROCEDURES W PDX OF INFECTION W/O CC/MCC

Facility

$29,757.80

Service Code	MSDRG 487
Min. Negotiated Rate	$13,704.25
Max. Negotiated Rate	$29,757.80
Rate for Payer: BCBS of TX Blue Advantage	$14,191.72
Rate for Payer: BCBS of TX Blue Essentials	$17,028.41
Rate for Payer: BCBS of TX PPO	$18,921.19

KNIFE, RETROGRADE LIGAMENT DISPOSABLE STERILE -- DHF

Facility

$1,362.00

Hospital Charge Code	81828014
Hospital Revenue Code	272
Rate for Payer: Cash Price	$926.16

KNIFE, RETROGRADE LIGAMENT DISPOSABLE STERILE -- DHF

Facility

$1,362.00

Hospital Charge Code	81828014
Hospital Revenue Code	272
Min. Negotiated Rate	$122.58
Max. Negotiated Rate	$980.64
Rate for Payer: Amerigroup CHIP/Medicaid	$122.58
Rate for Payer: BCBS of TX Blue Advantage	$408.60
Rate for Payer: BCBS of TX Blue Essentials	$490.32
Rate for Payer: BCBS of TX PPO	$544.80
Rate for Payer: Cash Price	$926.16
Rate for Payer: Cigna Medicaid	$980.64
Rate for Payer: Molina CHIP/Medicaid	$980.64
Rate for Payer: Multiplan Auto	$885.30
Rate for Payer: Multiplan Commercial	$885.30
Rate for Payer: Multiplan Workers Comp	$885.30
Rate for Payer: Parkland Medicaid	$980.64
Rate for Payer: Scott and White EPO/PPO	$681.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$980.64
Rate for Payer: Superior Health Plan EPO	$185.23

KOB3BB3

Facility

$1,753.01

Hospital Charge Code	991010
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,192.05

KOB3BB3

Facility

$1,753.01

Hospital Charge Code	991010
Hospital Revenue Code	272
Min. Negotiated Rate	$157.77
Max. Negotiated Rate	$1,262.17
Rate for Payer: Amerigroup CHIP/Medicaid	$157.77
Rate for Payer: BCBS of TX Blue Advantage	$525.90
Rate for Payer: BCBS of TX Blue Essentials	$631.08
Rate for Payer: BCBS of TX PPO	$701.20
Rate for Payer: Cash Price	$1,192.05
Rate for Payer: Cigna Medicaid	$1,262.17
Rate for Payer: Molina CHIP/Medicaid	$1,262.17
Rate for Payer: Multiplan Auto	$1,139.46
Rate for Payer: Multiplan Commercial	$1,139.46
Rate for Payer: Multiplan Workers Comp	$1,139.46
Rate for Payer: Parkland Medicaid	$1,262.17
Rate for Payer: Scott and White EPO/PPO	$876.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,262.17
Rate for Payer: Superior Health Plan EPO	$238.41

KORE FIBER 5CC

Facility

$6,283.00

Service Code	HCPCS C9359
Hospital Charge Code	145101
Hospital Revenue Code	278
Min. Negotiated Rate	$565.47
Max. Negotiated Rate	$4,523.76
Rate for Payer: Amerigroup CHIP/Medicaid	$565.47
Rate for Payer: BCBS of TX Blue Advantage	$1,884.90
Rate for Payer: BCBS of TX Blue Essentials	$2,261.88
Rate for Payer: BCBS of TX PPO	$2,513.20
Rate for Payer: Cash Price	$4,272.44
Rate for Payer: Cigna Medicaid	$4,523.76
Rate for Payer: Molina CHIP/Medicaid	$4,523.76
Rate for Payer: Multiplan Auto	$3,141.50
Rate for Payer: Multiplan Commercial	$3,141.50
Rate for Payer: Multiplan Workers Comp	$3,141.50
Rate for Payer: Parkland Medicaid	$4,523.76
Rate for Payer: Scott and White EPO/PPO	$3,141.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,523.76
Rate for Payer: Superior Health Plan EPO	$854.49

KORE FIBER 5CC

Facility

$6,283.00

Service Code	HCPCS C9359
Hospital Charge Code	145101
Hospital Revenue Code	278
Min. Negotiated Rate	$1,570.75
Max. Negotiated Rate	$3,141.50
Rate for Payer: Cash Price	$4,272.44
Rate for Payer: Cigna Commercial	$1,570.75
Rate for Payer: Multiplan Auto	$3,141.50
Rate for Payer: Multiplan Commercial	$3,141.50
Rate for Payer: Multiplan Workers Comp	$3,141.50
Rate for Payer: Scott and White EPO/PPO	$3,141.50

KREULOCK COMPRESSION SCREW, SS, 3.5X16MM

Facility

$2,963.86

Service Code	HCPCS C1713
Hospital Charge Code	992250
Hospital Revenue Code	278
Min. Negotiated Rate	$740.97
Max. Negotiated Rate	$1,481.93
Rate for Payer: Cash Price	$2,015.42
Rate for Payer: Cigna Commercial	$740.97
Rate for Payer: Multiplan Auto	$1,481.93
Rate for Payer: Multiplan Commercial	$1,481.93
Rate for Payer: Multiplan Workers Comp	$1,481.93
Rate for Payer: Scott and White EPO/PPO	$1,481.93

KREULOCK COMPRESSION SCREW, SS, 3.5X16MM

Facility

$2,963.86

Service Code	HCPCS C1713
Hospital Charge Code	992250
Hospital Revenue Code	278
Min. Negotiated Rate	$266.75
Max. Negotiated Rate	$2,133.98
Rate for Payer: Amerigroup CHIP/Medicaid	$266.75
Rate for Payer: BCBS of TX Blue Advantage	$889.16
Rate for Payer: BCBS of TX Blue Essentials	$1,066.99
Rate for Payer: BCBS of TX PPO	$1,185.54
Rate for Payer: Cash Price	$2,015.42
Rate for Payer: Cigna Medicaid	$2,133.98
Rate for Payer: Molina CHIP/Medicaid	$2,133.98
Rate for Payer: Multiplan Auto	$1,481.93
Rate for Payer: Multiplan Commercial	$1,481.93
Rate for Payer: Multiplan Workers Comp	$1,481.93
Rate for Payer: Parkland Medicaid	$2,133.98
Rate for Payer: Scott and White EPO/PPO	$1,481.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,133.98
Rate for Payer: Superior Health Plan EPO	$403.08

KREULOCK SCREW, TI, 3.5X30

Facility

$2,963.86

Service Code	HCPCS C1713
Hospital Charge Code	992244
Hospital Revenue Code	278
Min. Negotiated Rate	$740.97
Max. Negotiated Rate	$1,481.93
Rate for Payer: Cash Price	$2,015.42
Rate for Payer: Cigna Commercial	$740.97
Rate for Payer: Multiplan Auto	$1,481.93
Rate for Payer: Multiplan Commercial	$1,481.93
Rate for Payer: Multiplan Workers Comp	$1,481.93
Rate for Payer: Scott and White EPO/PPO	$1,481.93

KREULOCK SCREW, TI, 3.5X30

Facility

$2,963.86

Service Code	HCPCS C1713
Hospital Charge Code	992244
Hospital Revenue Code	278
Min. Negotiated Rate	$266.75
Max. Negotiated Rate	$2,133.98
Rate for Payer: Amerigroup CHIP/Medicaid	$266.75
Rate for Payer: BCBS of TX Blue Advantage	$889.16
Rate for Payer: BCBS of TX Blue Essentials	$1,066.99
Rate for Payer: BCBS of TX PPO	$1,185.54
Rate for Payer: Cash Price	$2,015.42
Rate for Payer: Cigna Medicaid	$2,133.98
Rate for Payer: Molina CHIP/Medicaid	$2,133.98
Rate for Payer: Multiplan Auto	$1,481.93
Rate for Payer: Multiplan Commercial	$1,481.93
Rate for Payer: Multiplan Workers Comp	$1,481.93
Rate for Payer: Parkland Medicaid	$2,133.98
Rate for Payer: Scott and White EPO/PPO	$1,481.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,133.98
Rate for Payer: Superior Health Plan EPO	$403.08

KREULOCK SCREW, TI, 3.5X38

Facility

$2,963.86

Service Code	HCPCS C1713
Hospital Charge Code	992245
Hospital Revenue Code	278
Min. Negotiated Rate	$266.75
Max. Negotiated Rate	$2,133.98
Rate for Payer: Amerigroup CHIP/Medicaid	$266.75
Rate for Payer: BCBS of TX Blue Advantage	$889.16
Rate for Payer: BCBS of TX Blue Essentials	$1,066.99
Rate for Payer: BCBS of TX PPO	$1,185.54
Rate for Payer: Cash Price	$2,015.42
Rate for Payer: Cigna Medicaid	$2,133.98
Rate for Payer: Molina CHIP/Medicaid	$2,133.98
Rate for Payer: Multiplan Auto	$1,481.93
Rate for Payer: Multiplan Commercial	$1,481.93
Rate for Payer: Multiplan Workers Comp	$1,481.93
Rate for Payer: Parkland Medicaid	$2,133.98
Rate for Payer: Scott and White EPO/PPO	$1,481.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,133.98
Rate for Payer: Superior Health Plan EPO	$403.08

KREULOCK SCREW, TI, 3.5X38

Facility

$2,963.86

Service Code	HCPCS C1713
Hospital Charge Code	992245
Hospital Revenue Code	278
Min. Negotiated Rate	$740.97
Max. Negotiated Rate	$1,481.93
Rate for Payer: Cash Price	$2,015.42
Rate for Payer: Cigna Commercial	$740.97
Rate for Payer: Multiplan Auto	$1,481.93
Rate for Payer: Multiplan Commercial	$1,481.93
Rate for Payer: Multiplan Workers Comp	$1,481.93
Rate for Payer: Scott and White EPO/PPO	$1,481.93

KREULOCK SCREW, TI, 3.5X40

Facility

$2,963.86

Service Code	HCPCS C1713
Hospital Charge Code	992246
Hospital Revenue Code	278
Min. Negotiated Rate	$266.75
Max. Negotiated Rate	$2,133.98
Rate for Payer: Amerigroup CHIP/Medicaid	$266.75
Rate for Payer: BCBS of TX Blue Advantage	$889.16
Rate for Payer: BCBS of TX Blue Essentials	$1,066.99
Rate for Payer: BCBS of TX PPO	$1,185.54
Rate for Payer: Cash Price	$2,015.42
Rate for Payer: Cigna Medicaid	$2,133.98
Rate for Payer: Molina CHIP/Medicaid	$2,133.98
Rate for Payer: Multiplan Auto	$1,481.93
Rate for Payer: Multiplan Commercial	$1,481.93
Rate for Payer: Multiplan Workers Comp	$1,481.93
Rate for Payer: Parkland Medicaid	$2,133.98
Rate for Payer: Scott and White EPO/PPO	$1,481.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,133.98
Rate for Payer: Superior Health Plan EPO	$403.08

KREULOCK SCREW, TI, 3.5X40

Facility

$2,963.86

Service Code	HCPCS C1713
Hospital Charge Code	992246
Hospital Revenue Code	278
Min. Negotiated Rate	$740.97
Max. Negotiated Rate	$1,481.93
Rate for Payer: Cash Price	$2,015.42
Rate for Payer: Cigna Commercial	$740.97
Rate for Payer: Multiplan Auto	$1,481.93
Rate for Payer: Multiplan Commercial	$1,481.93
Rate for Payer: Multiplan Workers Comp	$1,481.93
Rate for Payer: Scott and White EPO/PPO	$1,481.93

KT ACCESS COMP HERO -- DHF

Facility

$2,447.84

Hospital Charge Code	81741233
Hospital Revenue Code	272
Min. Negotiated Rate	$220.31
Max. Negotiated Rate	$1,762.44
Rate for Payer: Amerigroup CHIP/Medicaid	$220.31
Rate for Payer: BCBS of TX Blue Advantage	$734.35
Rate for Payer: BCBS of TX Blue Essentials	$881.22
Rate for Payer: BCBS of TX PPO	$979.14
Rate for Payer: Cash Price	$1,664.53
Rate for Payer: Cigna Medicaid	$1,762.44
Rate for Payer: Molina CHIP/Medicaid	$1,762.44
Rate for Payer: Multiplan Auto	$1,591.10
Rate for Payer: Multiplan Commercial	$1,591.10
Rate for Payer: Multiplan Workers Comp	$1,591.10
Rate for Payer: Parkland Medicaid	$1,762.44
Rate for Payer: Scott and White EPO/PPO	$1,223.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,762.44
Rate for Payer: Superior Health Plan EPO	$332.91

KT ACCESS COMP HERO -- DHF

Facility

$2,447.84

Hospital Charge Code	81741233
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,664.53

kt breast pump 67350s

Facility

$110.10

Hospital Charge Code	8618510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$74.87

kt breast pump 67350s

Facility

$110.10

Hospital Charge Code	8618510
Hospital Revenue Code	272
Min. Negotiated Rate	$9.91
Max. Negotiated Rate	$79.27
Rate for Payer: Amerigroup CHIP/Medicaid	$9.91
Rate for Payer: BCBS of TX Blue Advantage	$33.03
Rate for Payer: BCBS of TX Blue Essentials	$39.64
Rate for Payer: BCBS of TX PPO	$44.04
Rate for Payer: Cash Price	$74.87
Rate for Payer: Cigna Medicaid	$79.27
Rate for Payer: Molina CHIP/Medicaid	$79.27
Rate for Payer: Multiplan Auto	$71.56
Rate for Payer: Multiplan Commercial	$71.56
Rate for Payer: Multiplan Workers Comp	$71.56
Rate for Payer: Parkland Medicaid	$79.27
Rate for Payer: Scott and White EPO/PPO	$55.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.27
Rate for Payer: Superior Health Plan EPO	$14.97

Know your out-of-pocket cost for care.

All Charges