White Rock Medical Center

All Charges

Charge

Type

Setting

Price

K-LESS T-ROPE W/DRV, SYN REPR, SS

Facility

$11,313.68

Service Code	HCPCS C1713
Hospital Charge Code	992598
Hospital Revenue Code	278
Min. Negotiated Rate	$1,018.23
Max. Negotiated Rate	$8,145.85
Rate for Payer: Amerigroup CHIP/Medicaid	$1,018.23
Rate for Payer: BCBS of TX Blue Advantage	$3,394.10
Rate for Payer: BCBS of TX Blue Essentials	$4,072.92
Rate for Payer: BCBS of TX PPO	$4,525.47
Rate for Payer: Cash Price	$7,693.30
Rate for Payer: Cigna Medicaid	$8,145.85
Rate for Payer: Molina CHIP/Medicaid	$8,145.85
Rate for Payer: Multiplan Auto	$5,656.84
Rate for Payer: Multiplan Commercial	$5,656.84
Rate for Payer: Multiplan Workers Comp	$5,656.84
Rate for Payer: Parkland Medicaid	$8,145.85
Rate for Payer: Scott and White EPO/PPO	$5,656.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,145.85
Rate for Payer: Superior Health Plan EPO	$1,538.66

KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT

Facility

$6,280.20

Service Code	APR-DRG 3131
Min. Negotiated Rate	$5,921.19
Max. Negotiated Rate	$6,280.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5,921.19
Rate for Payer: Cigna Medicaid	$5,921.19
Rate for Payer: Molina CHIP/Medicaid	$5,921.19
Rate for Payer: Parkland Medicaid	$5,921.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,280.20

KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT

Facility

$14,342.23

Service Code	APR-DRG 3133
Min. Negotiated Rate	$13,522.36
Max. Negotiated Rate	$14,342.23
Rate for Payer: Amerigroup CHIP/Medicaid	$13,522.36
Rate for Payer: Cigna Medicaid	$13,522.36
Rate for Payer: Molina CHIP/Medicaid	$13,522.36
Rate for Payer: Parkland Medicaid	$13,522.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,342.23

KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT

Facility

$24,778.30

Service Code	APR-DRG 3134
Min. Negotiated Rate	$23,361.85
Max. Negotiated Rate	$24,778.30
Rate for Payer: Amerigroup CHIP/Medicaid	$23,361.85
Rate for Payer: Cigna Medicaid	$23,361.85
Rate for Payer: Molina CHIP/Medicaid	$23,361.85
Rate for Payer: Parkland Medicaid	$23,361.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,778.30

KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT

Facility

$8,604.06

Service Code	APR-DRG 3132
Min. Negotiated Rate	$8,112.21
Max. Negotiated Rate	$8,604.06
Rate for Payer: Amerigroup CHIP/Medicaid	$8,112.21
Rate for Payer: Cigna Medicaid	$8,112.21
Rate for Payer: Molina CHIP/Medicaid	$8,112.21
Rate for Payer: Parkland Medicaid	$8,112.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,604.06

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC

Facility

$43,114.80

Service Code	MSDRG 488
Min. Negotiated Rate	$17,724.39
Max. Negotiated Rate	$43,114.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,724.39
Rate for Payer: Amerigroup Medicare	$17,724.39
Rate for Payer: BCBS of TX Medicare	$17,724.39
Rate for Payer: Cigna Commercial	$19,623.97
Rate for Payer: Cigna Medicare	$17,724.39
Rate for Payer: Employer Direct Commercial	$17,724.39
Rate for Payer: Humana Medicare/TRICARE	$17,724.39
Rate for Payer: Molina Dual Medicare/Medicaid	$17,724.39
Rate for Payer: Molina Medicare	$17,724.39
Rate for Payer: Multiplan Auto	$43,114.80
Rate for Payer: Multiplan Commercial	$43,114.80
Rate for Payer: Multiplan Workers Comp	$43,114.80
Rate for Payer: Scott and White EPO/PPO	$19,855.50
Rate for Payer: Scott and White Medicare	$17,724.39
Rate for Payer: Superior Health Plan EPO	$17,724.39
Rate for Payer: Superior Health Plan Medicare	$17,724.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,724.39
Rate for Payer: Universal American Medicare	$17,724.39
Rate for Payer: Wellcare Medicare	$17,724.39
Rate for Payer: Wellmed Medicare	$17,724.39

KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC

Facility

$25,260.50

Service Code	MSDRG 489
Min. Negotiated Rate	$11,157.64
Max. Negotiated Rate	$25,260.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,945.14
Rate for Payer: Amerigroup Medicare	$12,945.14
Rate for Payer: BCBS of TX Medicare	$12,945.14
Rate for Payer: Cigna Commercial	$14,384.38
Rate for Payer: Cigna Medicare	$12,945.14
Rate for Payer: Employer Direct Commercial	$12,945.14
Rate for Payer: Humana Medicare/TRICARE	$12,945.14
Rate for Payer: Molina Dual Medicare/Medicaid	$12,945.14
Rate for Payer: Molina Medicare	$12,945.14
Rate for Payer: Multiplan Auto	$25,260.50
Rate for Payer: Multiplan Commercial	$25,260.50
Rate for Payer: Multiplan Workers Comp	$25,260.50
Rate for Payer: Scott and White EPO/PPO	$11,633.12
Rate for Payer: Scott and White Medicare	$12,945.14
Rate for Payer: Superior Health Plan EPO	$12,945.14
Rate for Payer: Superior Health Plan Medicare	$12,945.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,945.14
Rate for Payer: Universal American Medicare	$12,945.14
Rate for Payer: Wellcare Medicare	$12,945.14
Rate for Payer: Wellmed Medicare	$12,945.14

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC

Facility

$39,634.00

Service Code	MSDRG 486
Min. Negotiated Rate	$18,252.50
Max. Negotiated Rate	$39,634.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,085.80
Rate for Payer: Amerigroup Medicare	$20,085.80
Rate for Payer: BCBS of TX Medicare	$20,085.80
Rate for Payer: Cigna Commercial	$26,933.37
Rate for Payer: Cigna Medicare	$20,085.80
Rate for Payer: Employer Direct Commercial	$20,085.80
Rate for Payer: Humana Medicare/TRICARE	$20,085.80
Rate for Payer: Molina Dual Medicare/Medicaid	$20,085.80
Rate for Payer: Molina Medicare	$20,085.80
Rate for Payer: Multiplan Auto	$39,634.00
Rate for Payer: Multiplan Commercial	$39,634.00
Rate for Payer: Multiplan Workers Comp	$39,634.00
Rate for Payer: Scott and White EPO/PPO	$18,252.50
Rate for Payer: Scott and White Medicare	$20,085.80
Rate for Payer: Superior Health Plan EPO	$20,085.80
Rate for Payer: Superior Health Plan Medicare	$20,085.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,085.80
Rate for Payer: Universal American Medicare	$20,085.80
Rate for Payer: Wellcare Medicare	$20,085.80
Rate for Payer: Wellmed Medicare	$20,085.80

KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC

Facility

$61,769.00

Service Code	MSDRG 485
Min. Negotiated Rate	$28,411.58
Max. Negotiated Rate	$61,769.00
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	$61,769.00
Rate for Payer: Multiplan Commercial	$61,769.00
Rate for Payer: Multiplan Workers Comp	$61,769.00
Rate for Payer: Scott and White EPO/PPO	$28,446.25
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

$30,476.00

Service Code	MSDRG 487
Min. Negotiated Rate	$14,035.00
Max. Negotiated Rate	$30,476.00
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	$30,476.00
Rate for Payer: Multiplan Commercial	$30,476.00
Rate for Payer: Multiplan Workers Comp	$30,476.00
Rate for Payer: Scott and White EPO/PPO	$14,035.00
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

$43,114.80

Service Code	MSDRG 488
Min. Negotiated Rate	$17,724.39
Max. Negotiated Rate	$43,114.80
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

$25,260.50

Service Code	MSDRG 489
Min. Negotiated Rate	$11,157.64
Max. Negotiated Rate	$25,260.50
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

$39,634.00

Service Code	MSDRG 486
Min. Negotiated Rate	$18,252.50
Max. Negotiated Rate	$39,634.00
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

$61,769.00

Service Code	MSDRG 485
Min. Negotiated Rate	$28,411.58
Max. Negotiated Rate	$61,769.00
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

$30,476.00

Service Code	MSDRG 487
Min. Negotiated Rate	$14,035.00
Max. Negotiated Rate	$30,476.00
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
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

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

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	$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

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

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

Know your out-of-pocket cost for care.

All Charges