White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$1,664.53

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 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

KT CHOLANGIOGRAPHY -- DHF

Facility

$499.40

Hospital Charge Code	80819170
Hospital Revenue Code	272
Rate for Payer: Cash Price	$339.59

KT CHOLANGIOGRAPHY -- DHF

Facility

$499.40

Hospital Charge Code	80819170
Hospital Revenue Code	272
Min. Negotiated Rate	$44.95
Max. Negotiated Rate	$359.57
Rate for Payer: Amerigroup CHIP/Medicaid	$44.95
Rate for Payer: BCBS of TX Blue Advantage	$149.82
Rate for Payer: BCBS of TX Blue Essentials	$179.78
Rate for Payer: BCBS of TX PPO	$199.76
Rate for Payer: Cash Price	$339.59
Rate for Payer: Cigna Medicaid	$359.57
Rate for Payer: Molina CHIP/Medicaid	$359.57
Rate for Payer: Multiplan Auto	$324.61
Rate for Payer: Multiplan Commercial	$324.61
Rate for Payer: Multiplan Workers Comp	$324.61
Rate for Payer: Parkland Medicaid	$359.57
Rate for Payer: Scott and White EPO/PPO	$249.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$359.57
Rate for Payer: Superior Health Plan EPO	$67.92

KT CHST TB INSRT DISP -- DHF

Facility

$272.53

Hospital Charge Code	80819162
Hospital Revenue Code	272
Min. Negotiated Rate	$24.53
Max. Negotiated Rate	$196.22
Rate for Payer: Amerigroup CHIP/Medicaid	$24.53
Rate for Payer: BCBS of TX Blue Advantage	$81.76
Rate for Payer: BCBS of TX Blue Essentials	$98.11
Rate for Payer: BCBS of TX PPO	$109.01
Rate for Payer: Cash Price	$185.32
Rate for Payer: Cigna Medicaid	$196.22
Rate for Payer: Molina CHIP/Medicaid	$196.22
Rate for Payer: Multiplan Auto	$177.14
Rate for Payer: Multiplan Commercial	$177.14
Rate for Payer: Multiplan Workers Comp	$177.14
Rate for Payer: Parkland Medicaid	$196.22
Rate for Payer: Scott and White EPO/PPO	$136.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$196.22
Rate for Payer: Superior Health Plan EPO	$37.06

KT CHST TB INSRT DISP -- DHF

Facility

$272.53

Hospital Charge Code	80819162
Hospital Revenue Code	272
Rate for Payer: Cash Price	$185.32

KT CPM ACCES -- DHF

Facility

$1,038.67

Hospital Charge Code	80819352
Hospital Revenue Code	270
Rate for Payer: Cash Price	$706.30

KT CPM ACCES -- DHF

Facility

$1,038.67

Hospital Charge Code	80819352
Hospital Revenue Code	270
Min. Negotiated Rate	$93.48
Max. Negotiated Rate	$747.84
Rate for Payer: Amerigroup CHIP/Medicaid	$93.48
Rate for Payer: BCBS of TX Blue Advantage	$311.60
Rate for Payer: BCBS of TX Blue Essentials	$373.92
Rate for Payer: BCBS of TX PPO	$415.47
Rate for Payer: Cash Price	$706.30
Rate for Payer: Cigna Medicaid	$747.84
Rate for Payer: Molina CHIP/Medicaid	$747.84
Rate for Payer: Multiplan Auto	$675.14
Rate for Payer: Multiplan Commercial	$675.14
Rate for Payer: Multiplan Workers Comp	$675.14
Rate for Payer: Parkland Medicaid	$747.84
Rate for Payer: Scott and White EPO/PPO	$519.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$747.84
Rate for Payer: Superior Health Plan EPO	$141.26

KT DRS FOAM VAC -- DHF

Facility

$553.43

Hospital Charge Code	80820061
Hospital Revenue Code	272
Rate for Payer: Cash Price	$376.33

KT DRS FOAM VAC -- DHF

Facility

$553.43

Hospital Charge Code	80820061
Hospital Revenue Code	272
Min. Negotiated Rate	$49.81
Max. Negotiated Rate	$398.47
Rate for Payer: Amerigroup CHIP/Medicaid	$49.81
Rate for Payer: BCBS of TX Blue Advantage	$166.03
Rate for Payer: BCBS of TX Blue Essentials	$199.23
Rate for Payer: BCBS of TX PPO	$221.37
Rate for Payer: Cash Price	$376.33
Rate for Payer: Cigna Medicaid	$398.47
Rate for Payer: Molina CHIP/Medicaid	$398.47
Rate for Payer: Multiplan Auto	$359.73
Rate for Payer: Multiplan Commercial	$359.73
Rate for Payer: Multiplan Workers Comp	$359.73
Rate for Payer: Parkland Medicaid	$398.47
Rate for Payer: Scott and White EPO/PPO	$276.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$398.47
Rate for Payer: Superior Health Plan EPO	$75.27

KT EX FX ROCKERRAIL -- DHF

Facility

$6,106.93

Hospital Charge Code	80899016
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,152.71

KT EX FX ROCKERRAIL -- DHF

Facility

$6,106.93

Hospital Charge Code	80899016
Hospital Revenue Code	272
Min. Negotiated Rate	$549.62
Max. Negotiated Rate	$4,396.99
Rate for Payer: Amerigroup CHIP/Medicaid	$549.62
Rate for Payer: BCBS of TX Blue Advantage	$1,832.08
Rate for Payer: BCBS of TX Blue Essentials	$2,198.49
Rate for Payer: BCBS of TX PPO	$2,442.77
Rate for Payer: Cash Price	$4,152.71
Rate for Payer: Cigna Medicaid	$4,396.99
Rate for Payer: Molina CHIP/Medicaid	$4,396.99
Rate for Payer: Multiplan Auto	$3,969.50
Rate for Payer: Multiplan Commercial	$3,969.50
Rate for Payer: Multiplan Workers Comp	$3,969.50
Rate for Payer: Parkland Medicaid	$4,396.99
Rate for Payer: Scott and White EPO/PPO	$3,053.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,396.99
Rate for Payer: Superior Health Plan EPO	$830.54

KT INTRAUTERINE -- DHF

Facility

$1,211.57

Hospital Charge Code	80821556
Hospital Revenue Code	272
Min. Negotiated Rate	$109.04
Max. Negotiated Rate	$872.33
Rate for Payer: Amerigroup CHIP/Medicaid	$109.04
Rate for Payer: BCBS of TX Blue Advantage	$363.47
Rate for Payer: BCBS of TX Blue Essentials	$436.17
Rate for Payer: BCBS of TX PPO	$484.63
Rate for Payer: Cash Price	$823.87
Rate for Payer: Cigna Medicaid	$872.33
Rate for Payer: Molina CHIP/Medicaid	$872.33
Rate for Payer: Multiplan Auto	$787.52
Rate for Payer: Multiplan Commercial	$787.52
Rate for Payer: Multiplan Workers Comp	$787.52
Rate for Payer: Parkland Medicaid	$872.33
Rate for Payer: Scott and White EPO/PPO	$605.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$872.33
Rate for Payer: Superior Health Plan EPO	$164.77

KT INTRAUTERINE -- DHF

Facility

$1,211.57

Hospital Charge Code	80821556
Hospital Revenue Code	272
Rate for Payer: Cash Price	$823.87

KT ISOLATION -- DHF

Facility

$158.44

Hospital Charge Code	80821754
Hospital Revenue Code	270
Rate for Payer: Cash Price	$107.74

KT ISOLATION -- DHF

Facility

$158.44

Hospital Charge Code	80821754
Hospital Revenue Code	270
Min. Negotiated Rate	$14.26
Max. Negotiated Rate	$114.08
Rate for Payer: Amerigroup CHIP/Medicaid	$14.26
Rate for Payer: BCBS of TX Blue Advantage	$47.53
Rate for Payer: BCBS of TX Blue Essentials	$57.04
Rate for Payer: BCBS of TX PPO	$63.38
Rate for Payer: Cash Price	$107.74
Rate for Payer: Cigna Medicaid	$114.08
Rate for Payer: Molina CHIP/Medicaid	$114.08
Rate for Payer: Multiplan Auto	$102.99
Rate for Payer: Multiplan Commercial	$102.99
Rate for Payer: Multiplan Workers Comp	$102.99
Rate for Payer: Parkland Medicaid	$114.08
Rate for Payer: Scott and White EPO/PPO	$79.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$114.08
Rate for Payer: Superior Health Plan EPO	$21.55

KT LIGATR ESOPH -- DHF

Facility

$1,093.80

Hospital Charge Code	82050170
Hospital Revenue Code	270
Rate for Payer: Cash Price	$743.78

KT LIGATR ESOPH -- DHF

Facility

$1,093.80

Hospital Charge Code	82050170
Hospital Revenue Code	270
Min. Negotiated Rate	$98.44
Max. Negotiated Rate	$787.54
Rate for Payer: Amerigroup CHIP/Medicaid	$98.44
Rate for Payer: BCBS of TX Blue Advantage	$328.14
Rate for Payer: BCBS of TX Blue Essentials	$393.77
Rate for Payer: BCBS of TX PPO	$437.52
Rate for Payer: Cash Price	$743.78
Rate for Payer: Cigna Medicaid	$787.54
Rate for Payer: Molina CHIP/Medicaid	$787.54
Rate for Payer: Multiplan Auto	$710.97
Rate for Payer: Multiplan Commercial	$710.97
Rate for Payer: Multiplan Workers Comp	$710.97
Rate for Payer: Parkland Medicaid	$787.54
Rate for Payer: Scott and White EPO/PPO	$546.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$787.54
Rate for Payer: Superior Health Plan EPO	$148.76

KT MANIFLD CUSTM -- DHF

Facility

$163.36

Hospital Charge Code	80326564
Hospital Revenue Code	272
Rate for Payer: Cash Price	$111.08

Know your out-of-pocket cost for care.

All Charges