White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KT MANIFLD CUSTM -- DHF

Facility

$163.36

Hospital Charge Code	80326564
Hospital Revenue Code	272
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$117.62
Rate for Payer: Amerigroup CHIP/Medicaid	$14.70
Rate for Payer: BCBS of TX Blue Advantage	$49.01
Rate for Payer: BCBS of TX Blue Essentials	$58.81
Rate for Payer: BCBS of TX PPO	$65.34
Rate for Payer: Cash Price	$111.08
Rate for Payer: Cigna Medicaid	$117.62
Rate for Payer: Molina CHIP/Medicaid	$117.62
Rate for Payer: Multiplan Auto	$106.18
Rate for Payer: Multiplan Commercial	$106.18
Rate for Payer: Multiplan Workers Comp	$106.18
Rate for Payer: Parkland Medicaid	$117.62
Rate for Payer: Scott and White EPO/PPO	$81.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$117.62
Rate for Payer: Superior Health Plan EPO	$22.22

KT MENISC REPR PROCEDUR -- DHF

Facility

$3,300.00

Hospital Charge Code	81780835
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,244.00

KT MENISC REPR PROCEDUR -- DHF

Facility

$3,300.00

Hospital Charge Code	81780835
Hospital Revenue Code	272
Min. Negotiated Rate	$297.00
Max. Negotiated Rate	$2,376.00
Rate for Payer: Amerigroup CHIP/Medicaid	$297.00
Rate for Payer: BCBS of TX Blue Advantage	$990.00
Rate for Payer: BCBS of TX Blue Essentials	$1,188.00
Rate for Payer: BCBS of TX PPO	$1,320.00
Rate for Payer: Cash Price	$2,244.00
Rate for Payer: Cigna Medicaid	$2,376.00
Rate for Payer: Molina CHIP/Medicaid	$2,376.00
Rate for Payer: Multiplan Auto	$2,145.00
Rate for Payer: Multiplan Commercial	$2,145.00
Rate for Payer: Multiplan Workers Comp	$2,145.00
Rate for Payer: Parkland Medicaid	$2,376.00
Rate for Payer: Scott and White EPO/PPO	$1,650.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,376.00
Rate for Payer: Superior Health Plan EPO	$448.80

KT NASOPK -- DHF

Facility

$562.96

Hospital Charge Code	80822455
Hospital Revenue Code	270
Min. Negotiated Rate	$50.67
Max. Negotiated Rate	$405.33
Rate for Payer: Amerigroup CHIP/Medicaid	$50.67
Rate for Payer: BCBS of TX Blue Advantage	$168.89
Rate for Payer: BCBS of TX Blue Essentials	$202.67
Rate for Payer: BCBS of TX PPO	$225.18
Rate for Payer: Cash Price	$382.81
Rate for Payer: Cigna Medicaid	$405.33
Rate for Payer: Molina CHIP/Medicaid	$405.33
Rate for Payer: Multiplan Auto	$365.92
Rate for Payer: Multiplan Commercial	$365.92
Rate for Payer: Multiplan Workers Comp	$365.92
Rate for Payer: Parkland Medicaid	$405.33
Rate for Payer: Scott and White EPO/PPO	$281.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$405.33
Rate for Payer: Superior Health Plan EPO	$76.56

KT NASOPK -- DHF

Facility

$562.96

Hospital Charge Code	80822455
Hospital Revenue Code	270
Rate for Payer: Cash Price	$382.81

KT ORTHO -- DHF

Facility

$3,745.37

Hospital Charge Code	80822802
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2,546.85

KT ORTHO -- DHF

Facility

$3,745.37

Hospital Charge Code	80822802
Hospital Revenue Code	270
Min. Negotiated Rate	$337.08
Max. Negotiated Rate	$2,696.67
Rate for Payer: Amerigroup CHIP/Medicaid	$337.08
Rate for Payer: BCBS of TX Blue Advantage	$1,123.61
Rate for Payer: BCBS of TX Blue Essentials	$1,348.33
Rate for Payer: BCBS of TX PPO	$1,498.15
Rate for Payer: Cash Price	$2,546.85
Rate for Payer: Cigna Medicaid	$2,696.67
Rate for Payer: Molina CHIP/Medicaid	$2,696.67
Rate for Payer: Multiplan Auto	$2,434.49
Rate for Payer: Multiplan Commercial	$2,434.49
Rate for Payer: Multiplan Workers Comp	$2,434.49
Rate for Payer: Parkland Medicaid	$2,696.67
Rate for Payer: Scott and White EPO/PPO	$1,872.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,696.67
Rate for Payer: Superior Health Plan EPO	$509.37

KT PAD ARCTICGEL LRG -- DHF

Facility

$4,788.08

Hospital Charge Code	80385289
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,255.89

KT PAD ARCTICGEL LRG -- DHF

Facility

$4,788.08

Hospital Charge Code	80385289
Hospital Revenue Code	272
Min. Negotiated Rate	$430.93
Max. Negotiated Rate	$3,447.42
Rate for Payer: Amerigroup CHIP/Medicaid	$430.93
Rate for Payer: BCBS of TX Blue Advantage	$1,436.42
Rate for Payer: BCBS of TX Blue Essentials	$1,723.71
Rate for Payer: BCBS of TX PPO	$1,915.23
Rate for Payer: Cash Price	$3,255.89
Rate for Payer: Cigna Medicaid	$3,447.42
Rate for Payer: Molina CHIP/Medicaid	$3,447.42
Rate for Payer: Multiplan Auto	$3,112.25
Rate for Payer: Multiplan Commercial	$3,112.25
Rate for Payer: Multiplan Workers Comp	$3,112.25
Rate for Payer: Parkland Medicaid	$3,447.42
Rate for Payer: Scott and White EPO/PPO	$2,394.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,447.42
Rate for Payer: Superior Health Plan EPO	$651.18

KT PRESSURE MONITOR

Facility

$40.09

Hospital Charge Code	80824345
Hospital Revenue Code	272
Rate for Payer: Cash Price	$27.26

KT PRESSURE MONITOR

Facility

$40.09

Hospital Charge Code	80824345
Hospital Revenue Code	272
Min. Negotiated Rate	$3.61
Max. Negotiated Rate	$28.86
Rate for Payer: Amerigroup CHIP/Medicaid	$3.61
Rate for Payer: BCBS of TX Blue Advantage	$12.03
Rate for Payer: BCBS of TX Blue Essentials	$14.43
Rate for Payer: BCBS of TX PPO	$16.04
Rate for Payer: Cash Price	$27.26
Rate for Payer: Cigna Medicaid	$28.86
Rate for Payer: Molina CHIP/Medicaid	$28.86
Rate for Payer: Multiplan Auto	$26.06
Rate for Payer: Multiplan Commercial	$26.06
Rate for Payer: Multiplan Workers Comp	$26.06
Rate for Payer: Parkland Medicaid	$28.86
Rate for Payer: Scott and White EPO/PPO	$20.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.86
Rate for Payer: Superior Health Plan EPO	$5.45

KT PT ADM OB -- DHF

Facility

$179.51

Hospital Charge Code	80325855
Hospital Revenue Code	270
Rate for Payer: Cash Price	$122.07

KT PT ADM OB -- DHF

Facility

$179.51

Hospital Charge Code	80325855
Hospital Revenue Code	270
Min. Negotiated Rate	$16.16
Max. Negotiated Rate	$129.25
Rate for Payer: Amerigroup CHIP/Medicaid	$16.16
Rate for Payer: BCBS of TX Blue Advantage	$53.85
Rate for Payer: BCBS of TX Blue Essentials	$64.62
Rate for Payer: BCBS of TX PPO	$71.80
Rate for Payer: Cash Price	$122.07
Rate for Payer: Cigna Medicaid	$129.25
Rate for Payer: Molina CHIP/Medicaid	$129.25
Rate for Payer: Multiplan Auto	$116.68
Rate for Payer: Multiplan Commercial	$116.68
Rate for Payer: Multiplan Workers Comp	$116.68
Rate for Payer: Parkland Medicaid	$129.25
Rate for Payer: Scott and White EPO/PPO	$89.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$129.25
Rate for Payer: Superior Health Plan EPO	$24.41

KT PT CR NB -- DHF

Facility

$74.65

Hospital Charge Code	80325954
Hospital Revenue Code	270
Rate for Payer: Cash Price	$50.76

KT PT CR NB -- DHF

Facility

$74.65

Hospital Charge Code	80325954
Hospital Revenue Code	270
Min. Negotiated Rate	$6.72
Max. Negotiated Rate	$53.75
Rate for Payer: Amerigroup CHIP/Medicaid	$6.72
Rate for Payer: BCBS of TX Blue Advantage	$22.39
Rate for Payer: BCBS of TX Blue Essentials	$26.87
Rate for Payer: BCBS of TX PPO	$29.86
Rate for Payer: Cash Price	$50.76
Rate for Payer: Cigna Medicaid	$53.75
Rate for Payer: Molina CHIP/Medicaid	$53.75
Rate for Payer: Multiplan Auto	$48.52
Rate for Payer: Multiplan Commercial	$48.52
Rate for Payer: Multiplan Workers Comp	$48.52
Rate for Payer: Parkland Medicaid	$53.75
Rate for Payer: Scott and White EPO/PPO	$37.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53.75
Rate for Payer: Superior Health Plan EPO	$10.15

KT SPINEJACK EXPANSION -- DHF

Facility

$25,090.00

Service Code	HCPCS C1713
Hospital Charge Code	81781122
Hospital Revenue Code	278
Min. Negotiated Rate	$6,272.50
Max. Negotiated Rate	$12,545.00
Rate for Payer: Cash Price	$17,061.20
Rate for Payer: Cigna Commercial	$6,272.50
Rate for Payer: Multiplan Auto	$12,545.00
Rate for Payer: Multiplan Commercial	$12,545.00
Rate for Payer: Multiplan Workers Comp	$12,545.00
Rate for Payer: Scott and White EPO/PPO	$12,545.00

KT SPINEJACK EXPANSION -- DHF

Facility

$25,090.00

Service Code	HCPCS C1713
Hospital Charge Code	81781122
Hospital Revenue Code	278
Min. Negotiated Rate	$2,258.10
Max. Negotiated Rate	$18,064.80
Rate for Payer: Amerigroup CHIP/Medicaid	$2,258.10
Rate for Payer: BCBS of TX Blue Advantage	$7,527.00
Rate for Payer: BCBS of TX Blue Essentials	$9,032.40
Rate for Payer: BCBS of TX PPO	$10,036.00
Rate for Payer: Cash Price	$17,061.20
Rate for Payer: Cigna Medicaid	$18,064.80
Rate for Payer: Molina CHIP/Medicaid	$18,064.80
Rate for Payer: Multiplan Auto	$12,545.00
Rate for Payer: Multiplan Commercial	$12,545.00
Rate for Payer: Multiplan Workers Comp	$12,545.00
Rate for Payer: Parkland Medicaid	$18,064.80
Rate for Payer: Scott and White EPO/PPO	$12,545.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,064.80
Rate for Payer: Superior Health Plan EPO	$3,412.24

KT VERTBRL AUGMNT INFLAT -- DHF

Facility

$4,619.45

Hospital Charge Code	81870776
Hospital Revenue Code	272
Min. Negotiated Rate	$415.75
Max. Negotiated Rate	$3,326.00
Rate for Payer: Amerigroup CHIP/Medicaid	$415.75
Rate for Payer: BCBS of TX Blue Advantage	$1,385.84
Rate for Payer: BCBS of TX Blue Essentials	$1,663.00
Rate for Payer: BCBS of TX PPO	$1,847.78
Rate for Payer: Cash Price	$3,141.23
Rate for Payer: Cigna Medicaid	$3,326.00
Rate for Payer: Molina CHIP/Medicaid	$3,326.00
Rate for Payer: Multiplan Auto	$3,002.64
Rate for Payer: Multiplan Commercial	$3,002.64
Rate for Payer: Multiplan Workers Comp	$3,002.64
Rate for Payer: Parkland Medicaid	$3,326.00
Rate for Payer: Scott and White EPO/PPO	$2,309.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,326.00
Rate for Payer: Superior Health Plan EPO	$628.25

KT VERTBRL AUGMNT INFLAT -- DHF

Facility

$4,619.45

Hospital Charge Code	81870776
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,141.23

KT WRENCH DISP -- DHF

Facility

$216.01

Hospital Charge Code	80325939
Hospital Revenue Code	272
Min. Negotiated Rate	$19.44
Max. Negotiated Rate	$155.53
Rate for Payer: Amerigroup CHIP/Medicaid	$19.44
Rate for Payer: BCBS of TX Blue Advantage	$64.80
Rate for Payer: BCBS of TX Blue Essentials	$77.76
Rate for Payer: BCBS of TX PPO	$86.40
Rate for Payer: Cash Price	$146.89
Rate for Payer: Cigna Medicaid	$155.53
Rate for Payer: Molina CHIP/Medicaid	$155.53
Rate for Payer: Multiplan Auto	$140.41
Rate for Payer: Multiplan Commercial	$140.41
Rate for Payer: Multiplan Workers Comp	$140.41
Rate for Payer: Parkland Medicaid	$155.53
Rate for Payer: Scott and White EPO/PPO	$108.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$155.53
Rate for Payer: Superior Health Plan EPO	$29.38

KT WRENCH DISP -- DHF

Facility

$216.01

Hospital Charge Code	80325939
Hospital Revenue Code	272
Rate for Payer: Cash Price	$146.89

KW062SS

Facility

$227.71

Service Code	HCPCS C1713
Hospital Charge Code	991316
Hospital Revenue Code	278
Min. Negotiated Rate	$56.93
Max. Negotiated Rate	$113.86
Rate for Payer: Cash Price	$154.84
Rate for Payer: Cigna Commercial	$56.93
Rate for Payer: Multiplan Auto	$113.86
Rate for Payer: Multiplan Commercial	$113.86
Rate for Payer: Multiplan Workers Comp	$113.86
Rate for Payer: Scott and White EPO/PPO	$113.86

KW062SS

Facility

$227.71

Service Code	HCPCS C1713
Hospital Charge Code	991316
Hospital Revenue Code	278
Min. Negotiated Rate	$20.49
Max. Negotiated Rate	$163.95
Rate for Payer: Amerigroup CHIP/Medicaid	$20.49
Rate for Payer: BCBS of TX Blue Advantage	$68.31
Rate for Payer: BCBS of TX Blue Essentials	$81.98
Rate for Payer: BCBS of TX PPO	$91.08
Rate for Payer: Cash Price	$154.84
Rate for Payer: Cigna Medicaid	$163.95
Rate for Payer: Molina CHIP/Medicaid	$163.95
Rate for Payer: Multiplan Auto	$113.86
Rate for Payer: Multiplan Commercial	$113.86
Rate for Payer: Multiplan Workers Comp	$113.86
Rate for Payer: Parkland Medicaid	$163.95
Rate for Payer: Scott and White EPO/PPO	$113.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.95
Rate for Payer: Superior Health Plan EPO	$30.97

K-WIRE

Facility

$898.92

Service Code	HCPCS C1769
Hospital Charge Code	993255
Hospital Revenue Code	278
Min. Negotiated Rate	$224.73
Max. Negotiated Rate	$449.46
Rate for Payer: Cash Price	$611.27
Rate for Payer: Cigna Commercial	$224.73
Rate for Payer: Multiplan Auto	$449.46
Rate for Payer: Multiplan Commercial	$449.46
Rate for Payer: Multiplan Workers Comp	$449.46
Rate for Payer: Scott and White EPO/PPO	$449.46

K-WIRE

Facility

$898.92

Service Code	HCPCS C1769
Hospital Charge Code	993255
Hospital Revenue Code	278
Min. Negotiated Rate	$80.90
Max. Negotiated Rate	$647.22
Rate for Payer: Amerigroup CHIP/Medicaid	$80.90
Rate for Payer: BCBS of TX Blue Advantage	$269.68
Rate for Payer: BCBS of TX Blue Essentials	$323.61
Rate for Payer: BCBS of TX PPO	$359.57
Rate for Payer: Cash Price	$611.27
Rate for Payer: Cigna Medicaid	$647.22
Rate for Payer: Molina CHIP/Medicaid	$647.22
Rate for Payer: Multiplan Auto	$449.46
Rate for Payer: Multiplan Commercial	$449.46
Rate for Payer: Multiplan Workers Comp	$449.46
Rate for Payer: Parkland Medicaid	$647.22
Rate for Payer: Scott and White EPO/PPO	$449.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$647.22
Rate for Payer: Superior Health Plan EPO	$122.25

Know your out-of-pocket cost for care.

All Charges