White Rock Medical Center

All Charges

Charge

Type

Setting

Price

LC Skin Sub App Face/Nck/HF to 25 sqcm

Facility

$2,804.00

Hospital Charge Code	7150905
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$2,018.88
Rate for Payer: Amerigroup CHIP/Medicaid	$252.36
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$1,906.72
Rate for Payer: Cash Price	$1,906.72
Rate for Payer: Cigna Medicaid	$2,018.88
Rate for Payer: Molina CHIP/Medicaid	$2,018.88
Rate for Payer: Multiplan Auto	$1,822.60
Rate for Payer: Multiplan Commercial	$1,822.60
Rate for Payer: Multiplan Workers Comp	$1,822.60
Rate for Payer: Parkland Medicaid	$2,018.88
Rate for Payer: Scott and White EPO/PPO	$1,402.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,018.88
Rate for Payer: Superior Health Plan EPO	$381.34

LC Skin Sub App Face/Nck/HF to 25 sqcm

Facility

$2,804.00

Hospital Charge Code	7150905
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,906.72

LC Skin Sub App Trnk/Arm/Leg ad 100sqcm

Facility

$1,623.00

Hospital Charge Code	7150904
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,103.64

LC Skin Sub App Trnk/Arm/Leg ad 100sqcm

Facility

$1,623.00

Hospital Charge Code	7150904
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$1,168.56
Rate for Payer: Amerigroup CHIP/Medicaid	$146.07
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$1,103.64
Rate for Payer: Cash Price	$1,103.64
Rate for Payer: Cigna Medicaid	$1,168.56
Rate for Payer: Molina CHIP/Medicaid	$1,168.56
Rate for Payer: Multiplan Auto	$1,054.95
Rate for Payer: Multiplan Commercial	$1,054.95
Rate for Payer: Multiplan Workers Comp	$1,054.95
Rate for Payer: Parkland Medicaid	$1,168.56
Rate for Payer: Scott and White EPO/PPO	$811.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,168.56
Rate for Payer: Superior Health Plan EPO	$220.73

LC Skin Sub App Trnk/Arm/Leg ad 25 sqcm

Facility

$1,037.00

Hospital Charge Code	7150902
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$746.64
Rate for Payer: Amerigroup CHIP/Medicaid	$93.33
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$705.16
Rate for Payer: Cash Price	$705.16
Rate for Payer: Cigna Medicaid	$746.64
Rate for Payer: Molina CHIP/Medicaid	$746.64
Rate for Payer: Multiplan Auto	$674.05
Rate for Payer: Multiplan Commercial	$674.05
Rate for Payer: Multiplan Workers Comp	$674.05
Rate for Payer: Parkland Medicaid	$746.64
Rate for Payer: Scott and White EPO/PPO	$518.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$746.64
Rate for Payer: Superior Health Plan EPO	$141.03

LC Skin Sub App Trnk/Arm/Leg ad 25 sqcm

Facility

$1,037.00

Hospital Charge Code	7150902
Hospital Revenue Code	761
Rate for Payer: Cash Price	$705.16

LC Skin Sub App Trnk/Arm/Leg to 25 sqcm

Facility

$1,845.00

Hospital Charge Code	7150901
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$1,328.40
Rate for Payer: Amerigroup CHIP/Medicaid	$166.05
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$1,254.60
Rate for Payer: Cash Price	$1,254.60
Rate for Payer: Cigna Medicaid	$1,328.40
Rate for Payer: Molina CHIP/Medicaid	$1,328.40
Rate for Payer: Multiplan Auto	$1,199.25
Rate for Payer: Multiplan Commercial	$1,199.25
Rate for Payer: Multiplan Workers Comp	$1,199.25
Rate for Payer: Parkland Medicaid	$1,328.40
Rate for Payer: Scott and White EPO/PPO	$922.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,328.40
Rate for Payer: Superior Health Plan EPO	$250.92

LC Skin Sub App Trnk/Arm/Leg to 25 sqcm

Facility

$1,845.00

Hospital Charge Code	7150901
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,254.60

LC Skin Sub App Trnk/Arm/Leg up 100sqcm

Facility

$3,676.00

Hospital Charge Code	7150903
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$2,646.72
Rate for Payer: Amerigroup CHIP/Medicaid	$330.84
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$2,499.68
Rate for Payer: Cash Price	$2,499.68
Rate for Payer: Cigna Medicaid	$2,646.72
Rate for Payer: Molina CHIP/Medicaid	$2,646.72
Rate for Payer: Multiplan Auto	$2,389.40
Rate for Payer: Multiplan Commercial	$2,389.40
Rate for Payer: Multiplan Workers Comp	$2,389.40
Rate for Payer: Parkland Medicaid	$2,646.72
Rate for Payer: Scott and White EPO/PPO	$1,838.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,646.72
Rate for Payer: Superior Health Plan EPO	$499.94

LC Skin Sub App Trnk/Arm/Leg up 100sqcm

Facility

$3,676.00

Hospital Charge Code	7150903
Hospital Revenue Code	761
Rate for Payer: Cash Price	$2,499.68

LD ATTAIN PERFORMA 4298 -- DHF

Facility

$13,158.00

Service Code	HCPCS C1898
Hospital Charge Code	40003683
Hospital Revenue Code	278
Min. Negotiated Rate	$1,184.22
Max. Negotiated Rate	$9,473.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1,184.22
Rate for Payer: BCBS of TX Blue Advantage	$3,947.40
Rate for Payer: BCBS of TX Blue Essentials	$4,736.88
Rate for Payer: BCBS of TX PPO	$5,263.20
Rate for Payer: Cash Price	$8,947.44
Rate for Payer: Cigna Medicaid	$9,473.76
Rate for Payer: Molina CHIP/Medicaid	$9,473.76
Rate for Payer: Multiplan Auto	$6,579.00
Rate for Payer: Multiplan Commercial	$6,579.00
Rate for Payer: Multiplan Workers Comp	$6,579.00
Rate for Payer: Parkland Medicaid	$9,473.76
Rate for Payer: Scott and White EPO/PPO	$6,579.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,473.76
Rate for Payer: Superior Health Plan EPO	$1,789.49

LD ATTAIN PERFORMA 4298 -- DHF

Facility

$13,158.00

Service Code	HCPCS C1898
Hospital Charge Code	40003683
Hospital Revenue Code	278
Min. Negotiated Rate	$3,289.50
Max. Negotiated Rate	$6,579.00
Rate for Payer: Cash Price	$8,947.44
Rate for Payer: Cigna Commercial	$3,289.50
Rate for Payer: Multiplan Auto	$6,579.00
Rate for Payer: Multiplan Commercial	$6,579.00
Rate for Payer: Multiplan Workers Comp	$6,579.00
Rate for Payer: Scott and White EPO/PPO	$6,579.00

LD ATTAIN PERFORMA 4598 -- DHF

Facility

$15,289.00

Service Code	HCPCS C1898
Hospital Charge Code	40085680
Hospital Revenue Code	278
Min. Negotiated Rate	$3,822.25
Max. Negotiated Rate	$7,644.50
Rate for Payer: Cash Price	$10,396.52
Rate for Payer: Cigna Commercial	$3,822.25
Rate for Payer: Multiplan Auto	$7,644.50
Rate for Payer: Multiplan Commercial	$7,644.50
Rate for Payer: Multiplan Workers Comp	$7,644.50
Rate for Payer: Scott and White EPO/PPO	$7,644.50

LD ATTAIN PERFORMA 4598 -- DHF

Facility

$15,289.00

Service Code	HCPCS C1898
Hospital Charge Code	40085680
Hospital Revenue Code	278
Min. Negotiated Rate	$1,376.01
Max. Negotiated Rate	$11,008.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1,376.01
Rate for Payer: BCBS of TX Blue Advantage	$4,586.70
Rate for Payer: BCBS of TX Blue Essentials	$5,504.04
Rate for Payer: BCBS of TX PPO	$6,115.60
Rate for Payer: Cash Price	$10,396.52
Rate for Payer: Cigna Medicaid	$11,008.08
Rate for Payer: Molina CHIP/Medicaid	$11,008.08
Rate for Payer: Multiplan Auto	$7,644.50
Rate for Payer: Multiplan Commercial	$7,644.50
Rate for Payer: Multiplan Workers Comp	$7,644.50
Rate for Payer: Parkland Medicaid	$11,008.08
Rate for Payer: Scott and White EPO/PPO	$7,644.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,008.08
Rate for Payer: Superior Health Plan EPO	$2,079.30

LD DFB SPRNT QUATR 6947M -- DHF

Facility

$21,084.00

Service Code	HCPCS C1899
Hospital Charge Code	40085904
Hospital Revenue Code	278
Min. Negotiated Rate	$5,271.00
Max. Negotiated Rate	$10,542.00
Rate for Payer: Cash Price	$14,337.12
Rate for Payer: Cigna Commercial	$5,271.00
Rate for Payer: Multiplan Auto	$10,542.00
Rate for Payer: Multiplan Commercial	$10,542.00
Rate for Payer: Multiplan Workers Comp	$10,542.00
Rate for Payer: Scott and White EPO/PPO	$10,542.00

LD DFB SPRNT QUATR 6947M -- DHF

Facility

$21,084.00

Service Code	HCPCS C1899
Hospital Charge Code	40085904
Hospital Revenue Code	278
Min. Negotiated Rate	$1,897.56
Max. Negotiated Rate	$15,180.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,897.56
Rate for Payer: BCBS of TX Blue Advantage	$6,325.20
Rate for Payer: BCBS of TX Blue Essentials	$7,590.24
Rate for Payer: BCBS of TX PPO	$8,433.60
Rate for Payer: Cash Price	$14,337.12
Rate for Payer: Cigna Medicaid	$15,180.48
Rate for Payer: Molina CHIP/Medicaid	$15,180.48
Rate for Payer: Multiplan Auto	$10,542.00
Rate for Payer: Multiplan Commercial	$10,542.00
Rate for Payer: Multiplan Workers Comp	$10,542.00
Rate for Payer: Parkland Medicaid	$15,180.48
Rate for Payer: Scott and White EPO/PPO	$10,542.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,180.48
Rate for Payer: Superior Health Plan EPO	$2,867.42

LD DFIB DURATA 7122Q SJ4 -- DHF

Facility

$23,025.00

Service Code	HCPCS C1899
Hospital Charge Code	40085912
Hospital Revenue Code	278
Min. Negotiated Rate	$2,072.25
Max. Negotiated Rate	$16,578.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2,072.25
Rate for Payer: BCBS of TX Blue Advantage	$6,907.50
Rate for Payer: BCBS of TX Blue Essentials	$8,289.00
Rate for Payer: BCBS of TX PPO	$9,210.00
Rate for Payer: Cash Price	$15,657.00
Rate for Payer: Cigna Medicaid	$16,578.00
Rate for Payer: Molina CHIP/Medicaid	$16,578.00
Rate for Payer: Multiplan Auto	$11,512.50
Rate for Payer: Multiplan Commercial	$11,512.50
Rate for Payer: Multiplan Workers Comp	$11,512.50
Rate for Payer: Parkland Medicaid	$16,578.00
Rate for Payer: Scott and White EPO/PPO	$11,512.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,578.00
Rate for Payer: Superior Health Plan EPO	$3,131.40

LD DFIB DURATA 7122Q SJ4 -- DHF

Facility

$23,025.00

Service Code	HCPCS C1899
Hospital Charge Code	40086225
Hospital Revenue Code	278
Min. Negotiated Rate	$5,756.25
Max. Negotiated Rate	$11,512.50
Rate for Payer: Cash Price	$15,657.00
Rate for Payer: Cigna Commercial	$5,756.25
Rate for Payer: Multiplan Auto	$11,512.50
Rate for Payer: Multiplan Commercial	$11,512.50
Rate for Payer: Multiplan Workers Comp	$11,512.50
Rate for Payer: Scott and White EPO/PPO	$11,512.50

LD DFIB DURATA 7122Q SJ4 -- DHF

Facility

$23,025.00

Service Code	HCPCS C1899
Hospital Charge Code	40085912
Hospital Revenue Code	278
Min. Negotiated Rate	$5,756.25
Max. Negotiated Rate	$11,512.50
Rate for Payer: Cash Price	$15,657.00
Rate for Payer: Cigna Commercial	$5,756.25
Rate for Payer: Multiplan Auto	$11,512.50
Rate for Payer: Multiplan Commercial	$11,512.50
Rate for Payer: Multiplan Workers Comp	$11,512.50
Rate for Payer: Scott and White EPO/PPO	$11,512.50

LD DFIB DURATA 7122Q SJ4 -- DHF

Facility

$23,025.00

Service Code	HCPCS C1899
Hospital Charge Code	40086225
Hospital Revenue Code	278
Min. Negotiated Rate	$2,072.25
Max. Negotiated Rate	$16,578.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2,072.25
Rate for Payer: BCBS of TX Blue Advantage	$6,907.50
Rate for Payer: BCBS of TX Blue Essentials	$8,289.00
Rate for Payer: BCBS of TX PPO	$9,210.00
Rate for Payer: Cash Price	$15,657.00
Rate for Payer: Cigna Medicaid	$16,578.00
Rate for Payer: Molina CHIP/Medicaid	$16,578.00
Rate for Payer: Multiplan Auto	$11,512.50
Rate for Payer: Multiplan Commercial	$11,512.50
Rate for Payer: Multiplan Workers Comp	$11,512.50
Rate for Payer: Parkland Medicaid	$16,578.00
Rate for Payer: Scott and White EPO/PPO	$11,512.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,578.00
Rate for Payer: Superior Health Plan EPO	$3,131.40

LD PACE/SENS DFB SGL COIL 0672 -- DHF

Facility

$21,687.00

Service Code	HCPCS C1899
Hospital Charge Code	40087496
Hospital Revenue Code	278
Min. Negotiated Rate	$5,421.75
Max. Negotiated Rate	$10,843.50
Rate for Payer: Cash Price	$14,747.16
Rate for Payer: Cigna Commercial	$5,421.75
Rate for Payer: Multiplan Auto	$10,843.50
Rate for Payer: Multiplan Commercial	$10,843.50
Rate for Payer: Multiplan Workers Comp	$10,843.50
Rate for Payer: Scott and White EPO/PPO	$10,843.50

LD PACE/SENS DFB SGL COIL 0672 -- DHF

Facility

$21,687.00

Service Code	HCPCS C1899
Hospital Charge Code	40085789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,951.83
Max. Negotiated Rate	$15,614.64
Rate for Payer: Amerigroup CHIP/Medicaid	$1,951.83
Rate for Payer: BCBS of TX Blue Advantage	$6,506.10
Rate for Payer: BCBS of TX Blue Essentials	$7,807.32
Rate for Payer: BCBS of TX PPO	$8,674.80
Rate for Payer: Cash Price	$14,747.16
Rate for Payer: Cigna Medicaid	$15,614.64
Rate for Payer: Molina CHIP/Medicaid	$15,614.64
Rate for Payer: Multiplan Auto	$10,843.50
Rate for Payer: Multiplan Commercial	$10,843.50
Rate for Payer: Multiplan Workers Comp	$10,843.50
Rate for Payer: Parkland Medicaid	$15,614.64
Rate for Payer: Scott and White EPO/PPO	$10,843.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,614.64
Rate for Payer: Superior Health Plan EPO	$2,949.43

LD PACE/SENS DFB SGL COIL 0672 -- DHF

Facility

$21,687.00

Service Code	HCPCS C1899
Hospital Charge Code	40087496
Hospital Revenue Code	278
Min. Negotiated Rate	$1,951.83
Max. Negotiated Rate	$15,614.64
Rate for Payer: Amerigroup CHIP/Medicaid	$1,951.83
Rate for Payer: BCBS of TX Blue Advantage	$6,506.10
Rate for Payer: BCBS of TX Blue Essentials	$7,807.32
Rate for Payer: BCBS of TX PPO	$8,674.80
Rate for Payer: Cash Price	$14,747.16
Rate for Payer: Cigna Medicaid	$15,614.64
Rate for Payer: Molina CHIP/Medicaid	$15,614.64
Rate for Payer: Multiplan Auto	$10,843.50
Rate for Payer: Multiplan Commercial	$10,843.50
Rate for Payer: Multiplan Workers Comp	$10,843.50
Rate for Payer: Parkland Medicaid	$15,614.64
Rate for Payer: Scott and White EPO/PPO	$10,843.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,614.64
Rate for Payer: Superior Health Plan EPO	$2,949.43

LD PACE/SENS DFB SGL COIL 0672 -- DHF

Facility

$21,687.00

Service Code	HCPCS C1899
Hospital Charge Code	40085789
Hospital Revenue Code	278
Min. Negotiated Rate	$5,421.75
Max. Negotiated Rate	$10,843.50
Rate for Payer: Cash Price	$14,747.16
Rate for Payer: Cigna Commercial	$5,421.75
Rate for Payer: Multiplan Auto	$10,843.50
Rate for Payer: Multiplan Commercial	$10,843.50
Rate for Payer: Multiplan Workers Comp	$10,843.50
Rate for Payer: Scott and White EPO/PPO	$10,843.50

LD PM TENDRIL STS 2088TC

Facility

$3,409.00

Service Code	HCPCS C1898
Hospital Charge Code	40087421
Hospital Revenue Code	278
Min. Negotiated Rate	$852.25
Max. Negotiated Rate	$1,704.50
Rate for Payer: Cash Price	$2,318.12
Rate for Payer: Cigna Commercial	$852.25
Rate for Payer: Multiplan Auto	$1,704.50
Rate for Payer: Multiplan Commercial	$1,704.50
Rate for Payer: Multiplan Workers Comp	$1,704.50
Rate for Payer: Scott and White EPO/PPO	$1,704.50

Know your out-of-pocket cost for care.

All Charges