White Rock Medical Center

All Charges

Charge

Type

Setting

Price

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC

Facility

$45,140.20

Service Code	MSDRG 493
Min. Negotiated Rate	$19,316.46
Max. Negotiated Rate	$45,140.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,347.23
Rate for Payer: Amerigroup Medicare	$23,347.23
Rate for Payer: BCBS of TX Medicare	$23,347.23
Rate for Payer: Cigna Commercial	$32,664.97
Rate for Payer: Cigna Medicare	$23,347.23
Rate for Payer: Employer Direct Commercial	$23,347.23
Rate for Payer: Humana Medicare/TRICARE	$23,347.23
Rate for Payer: Molina Dual Medicare/Medicaid	$23,347.23
Rate for Payer: Molina Medicare	$23,347.23
Rate for Payer: Multiplan Auto	$45,140.20
Rate for Payer: Multiplan Commercial	$45,140.20
Rate for Payer: Multiplan Workers Comp	$45,140.20
Rate for Payer: Scott and White EPO/PPO	$20,788.25
Rate for Payer: Scott and White Medicare	$23,347.23
Rate for Payer: Superior Health Plan EPO	$23,347.23
Rate for Payer: Superior Health Plan Medicare	$23,347.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,347.23
Rate for Payer: Universal American Medicare	$23,347.23
Rate for Payer: Wellcare Medicare	$23,347.23
Rate for Payer: Wellmed Medicare	$23,347.23

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC

Facility

$66,232.10

Service Code	MSDRG 492
Min. Negotiated Rate	$29,158.30
Max. Negotiated Rate	$66,232.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$31,669.33
Rate for Payer: Amerigroup Medicare	$31,669.33
Rate for Payer: BCBS of TX Medicare	$31,669.33
Rate for Payer: Cigna Commercial	$47,290.21
Rate for Payer: Cigna Medicare	$31,669.33
Rate for Payer: Employer Direct Commercial	$31,669.33
Rate for Payer: Humana Medicare/TRICARE	$31,669.33
Rate for Payer: Molina Dual Medicare/Medicaid	$31,669.33
Rate for Payer: Molina Medicare	$31,669.33
Rate for Payer: Multiplan Auto	$66,232.10
Rate for Payer: Multiplan Commercial	$66,232.10
Rate for Payer: Multiplan Workers Comp	$66,232.10
Rate for Payer: Scott and White EPO/PPO	$30,501.62
Rate for Payer: Scott and White Medicare	$31,669.33
Rate for Payer: Superior Health Plan EPO	$31,669.33
Rate for Payer: Superior Health Plan Medicare	$31,669.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$31,669.33
Rate for Payer: Universal American Medicare	$31,669.33
Rate for Payer: Wellcare Medicare	$31,669.33
Rate for Payer: Wellmed Medicare	$31,669.33

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC

Facility

$35,887.20

Service Code	MSDRG 494
Min. Negotiated Rate	$15,083.54
Max. Negotiated Rate	$35,887.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,465.77
Rate for Payer: Amerigroup Medicare	$19,465.77
Rate for Payer: BCBS of TX Medicare	$19,465.77
Rate for Payer: Cigna Commercial	$25,843.72
Rate for Payer: Cigna Medicare	$19,465.77
Rate for Payer: Employer Direct Commercial	$19,465.77
Rate for Payer: Humana Medicare/TRICARE	$19,465.77
Rate for Payer: Molina Dual Medicare/Medicaid	$19,465.77
Rate for Payer: Molina Medicare	$19,465.77
Rate for Payer: Multiplan Auto	$35,887.20
Rate for Payer: Multiplan Commercial	$35,887.20
Rate for Payer: Multiplan Workers Comp	$35,887.20
Rate for Payer: Scott and White EPO/PPO	$16,527.00
Rate for Payer: Scott and White Medicare	$19,465.77
Rate for Payer: Superior Health Plan EPO	$19,465.77
Rate for Payer: Superior Health Plan Medicare	$19,465.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,465.77
Rate for Payer: Universal American Medicare	$19,465.77
Rate for Payer: Wellcare Medicare	$19,465.77
Rate for Payer: Wellmed Medicare	$19,465.77

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$33,067.03

Service Code	APR-DRG 1814
Min. Negotiated Rate	$31,176.75
Max. Negotiated Rate	$33,067.03
Rate for Payer: Amerigroup CHIP/Medicaid	$31,176.75
Rate for Payer: Cigna Medicaid	$31,176.75
Rate for Payer: Molina CHIP/Medicaid	$31,176.75
Rate for Payer: Parkland Medicaid	$31,176.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33,067.03

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$10,531.49

Service Code	APR-DRG 1812
Min. Negotiated Rate	$9,929.46
Max. Negotiated Rate	$10,531.49
Rate for Payer: Amerigroup CHIP/Medicaid	$9,929.46
Rate for Payer: Cigna Medicaid	$9,929.46
Rate for Payer: Molina CHIP/Medicaid	$9,929.46
Rate for Payer: Parkland Medicaid	$9,929.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,531.49

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$17,351.07

Service Code	APR-DRG 1813
Min. Negotiated Rate	$16,359.20
Max. Negotiated Rate	$17,351.07
Rate for Payer: Amerigroup CHIP/Medicaid	$16,359.20
Rate for Payer: Cigna Medicaid	$16,359.20
Rate for Payer: Molina CHIP/Medicaid	$16,359.20
Rate for Payer: Parkland Medicaid	$16,359.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,351.07

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$6,939.52

Service Code	APR-DRG 1811
Min. Negotiated Rate	$6,542.83
Max. Negotiated Rate	$6,939.52
Rate for Payer: Amerigroup CHIP/Medicaid	$6,542.83
Rate for Payer: Cigna Medicaid	$6,542.83
Rate for Payer: Molina CHIP/Medicaid	$6,542.83
Rate for Payer: Parkland Medicaid	$6,542.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,939.52

low fibrinogen control

Facility

$12.23

Hospital Charge Code	993562
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.32

low fibrinogen control

Facility

$12.23

Hospital Charge Code	993562
Hospital Revenue Code	270
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$8.81
Rate for Payer: Amerigroup CHIP/Medicaid	$1.10
Rate for Payer: BCBS of TX Blue Advantage	$3.67
Rate for Payer: BCBS of TX Blue Essentials	$4.40
Rate for Payer: BCBS of TX PPO	$4.89
Rate for Payer: Cash Price	$8.32
Rate for Payer: Cigna Medicaid	$8.81
Rate for Payer: Molina CHIP/Medicaid	$8.81
Rate for Payer: Multiplan Auto	$7.95
Rate for Payer: Multiplan Commercial	$7.95
Rate for Payer: Multiplan Workers Comp	$7.95
Rate for Payer: Parkland Medicaid	$8.81
Rate for Payer: Scott and White EPO/PPO	$6.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.81
Rate for Payer: Superior Health Plan EPO	$1.66

Low frequency, non-contact, non-thermal ultrasound, including topical application(s), wound assess and instructions ongoing care, per day.

Facility

$794.80

Service Code	HCPCS 97610
Hospital Charge Code	994066
Hospital Revenue Code	361
Min. Negotiated Rate	$21.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$71.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$238.44
Rate for Payer: BCBS of TX Blue Essentials	$286.13
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$317.92
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$572.26
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$572.26
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$572.26
Rate for Payer: Scott and White EPO/PPO	$21.86
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$572.26
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

Low frequency, non-contact, non-thermal ultrasound, including topical application(s), wound assess and instructions ongoing care, per day.

Facility

$794.80

Service Code	HCPCS 97610
Hospital Charge Code	994066
Hospital Revenue Code	361
Rate for Payer: Cash Price	$540.46

LOW-PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM

Facility

$939.76

Service Code	HCPCS C1713
Hospital Charge Code	992330
Hospital Revenue Code	278
Min. Negotiated Rate	$84.58
Max. Negotiated Rate	$676.63
Rate for Payer: Amerigroup CHIP/Medicaid	$84.58
Rate for Payer: BCBS of TX Blue Advantage	$281.93
Rate for Payer: BCBS of TX Blue Essentials	$338.31
Rate for Payer: BCBS of TX PPO	$375.90
Rate for Payer: Cash Price	$639.04
Rate for Payer: Cigna Medicaid	$676.63
Rate for Payer: Molina CHIP/Medicaid	$676.63
Rate for Payer: Multiplan Auto	$469.88
Rate for Payer: Multiplan Commercial	$469.88
Rate for Payer: Multiplan Workers Comp	$469.88
Rate for Payer: Parkland Medicaid	$676.63
Rate for Payer: Scott and White EPO/PPO	$469.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$676.63
Rate for Payer: Superior Health Plan EPO	$127.81

LOW-PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM

Facility

$939.76

Service Code	HCPCS C1713
Hospital Charge Code	992330
Hospital Revenue Code	278
Min. Negotiated Rate	$234.94
Max. Negotiated Rate	$469.88
Rate for Payer: Cash Price	$639.04
Rate for Payer: Cigna Commercial	$234.94
Rate for Payer: Multiplan Auto	$469.88
Rate for Payer: Multiplan Commercial	$469.88
Rate for Payer: Multiplan Workers Comp	$469.88
Rate for Payer: Scott and White EPO/PPO	$469.88

LOW-PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM

Facility

$939.76

Service Code	HCPCS C1713
Hospital Charge Code	992381
Hospital Revenue Code	278
Min. Negotiated Rate	$234.94
Max. Negotiated Rate	$469.88
Rate for Payer: Cash Price	$639.04
Rate for Payer: Cigna Commercial	$234.94
Rate for Payer: Multiplan Auto	$469.88
Rate for Payer: Multiplan Commercial	$469.88
Rate for Payer: Multiplan Workers Comp	$469.88
Rate for Payer: Scott and White EPO/PPO	$469.88

LOW-PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM

Facility

$939.76

Service Code	HCPCS C1713
Hospital Charge Code	992381
Hospital Revenue Code	278
Min. Negotiated Rate	$84.58
Max. Negotiated Rate	$676.63
Rate for Payer: Amerigroup CHIP/Medicaid	$84.58
Rate for Payer: BCBS of TX Blue Advantage	$281.93
Rate for Payer: BCBS of TX Blue Essentials	$338.31
Rate for Payer: BCBS of TX PPO	$375.90
Rate for Payer: Cash Price	$639.04
Rate for Payer: Cigna Medicaid	$676.63
Rate for Payer: Molina CHIP/Medicaid	$676.63
Rate for Payer: Multiplan Auto	$469.88
Rate for Payer: Multiplan Commercial	$469.88
Rate for Payer: Multiplan Workers Comp	$469.88
Rate for Payer: Parkland Medicaid	$676.63
Rate for Payer: Scott and White EPO/PPO	$469.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$676.63
Rate for Payer: Superior Health Plan EPO	$127.81

LOW-PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM

Facility

$939.76

Service Code	HCPCS C1713
Hospital Charge Code	993150
Hospital Revenue Code	278
Min. Negotiated Rate	$234.94
Max. Negotiated Rate	$469.88
Rate for Payer: Cash Price	$639.04
Rate for Payer: Cigna Commercial	$234.94
Rate for Payer: Multiplan Auto	$469.88
Rate for Payer: Multiplan Commercial	$469.88
Rate for Payer: Multiplan Workers Comp	$469.88
Rate for Payer: Scott and White EPO/PPO	$469.88

LOW-PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM

Facility

$939.76

Service Code	HCPCS C1713
Hospital Charge Code	993150
Hospital Revenue Code	278
Min. Negotiated Rate	$84.58
Max. Negotiated Rate	$676.63
Rate for Payer: Amerigroup CHIP/Medicaid	$84.58
Rate for Payer: BCBS of TX Blue Advantage	$281.93
Rate for Payer: BCBS of TX Blue Essentials	$338.31
Rate for Payer: BCBS of TX PPO	$375.90
Rate for Payer: Cash Price	$639.04
Rate for Payer: Cigna Medicaid	$676.63
Rate for Payer: Molina CHIP/Medicaid	$676.63
Rate for Payer: Multiplan Auto	$469.88
Rate for Payer: Multiplan Commercial	$469.88
Rate for Payer: Multiplan Workers Comp	$469.88
Rate for Payer: Parkland Medicaid	$676.63
Rate for Payer: Scott and White EPO/PPO	$469.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$676.63
Rate for Payer: Superior Health Plan EPO	$127.81

LOW-PRO CORT SCREW 3.5 X 18MM ORTHOLOC SYSTEM

Facility

$939.76

Service Code	HCPCS C1713
Hospital Charge Code	992382
Hospital Revenue Code	278
Min. Negotiated Rate	$234.94
Max. Negotiated Rate	$469.88
Rate for Payer: Cash Price	$639.04
Rate for Payer: Cigna Commercial	$234.94
Rate for Payer: Multiplan Auto	$469.88
Rate for Payer: Multiplan Commercial	$469.88
Rate for Payer: Multiplan Workers Comp	$469.88
Rate for Payer: Scott and White EPO/PPO	$469.88

LOW-PRO CORT SCREW 3.5 X 18MM ORTHOLOC SYSTEM

Facility

$939.76

Service Code	HCPCS C1713
Hospital Charge Code	992382
Hospital Revenue Code	278
Min. Negotiated Rate	$84.58
Max. Negotiated Rate	$676.63
Rate for Payer: Amerigroup CHIP/Medicaid	$84.58
Rate for Payer: BCBS of TX Blue Advantage	$281.93
Rate for Payer: BCBS of TX Blue Essentials	$338.31
Rate for Payer: BCBS of TX PPO	$375.90
Rate for Payer: Cash Price	$639.04
Rate for Payer: Cigna Medicaid	$676.63
Rate for Payer: Molina CHIP/Medicaid	$676.63
Rate for Payer: Multiplan Auto	$469.88
Rate for Payer: Multiplan Commercial	$469.88
Rate for Payer: Multiplan Workers Comp	$469.88
Rate for Payer: Parkland Medicaid	$676.63
Rate for Payer: Scott and White EPO/PPO	$469.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$676.63
Rate for Payer: Superior Health Plan EPO	$127.81

LOW-PRO CORT SCREW 3.5 X 46MM ORTHOLOC SYSTEM

Facility

$939.76

Service Code	HCPCS C1713
Hospital Charge Code	992389
Hospital Revenue Code	278
Min. Negotiated Rate	$234.94
Max. Negotiated Rate	$469.88
Rate for Payer: Cash Price	$639.04
Rate for Payer: Cigna Commercial	$234.94
Rate for Payer: Multiplan Auto	$469.88
Rate for Payer: Multiplan Commercial	$469.88
Rate for Payer: Multiplan Workers Comp	$469.88
Rate for Payer: Scott and White EPO/PPO	$469.88

LOW-PRO CORT SCREW 3.5 X 46MM ORTHOLOC SYSTEM

Facility

$939.76

Service Code	HCPCS C1713
Hospital Charge Code	992389
Hospital Revenue Code	278
Min. Negotiated Rate	$84.58
Max. Negotiated Rate	$676.63
Rate for Payer: Amerigroup CHIP/Medicaid	$84.58
Rate for Payer: BCBS of TX Blue Advantage	$281.93
Rate for Payer: BCBS of TX Blue Essentials	$338.31
Rate for Payer: BCBS of TX PPO	$375.90
Rate for Payer: Cash Price	$639.04
Rate for Payer: Cigna Medicaid	$676.63
Rate for Payer: Molina CHIP/Medicaid	$676.63
Rate for Payer: Multiplan Auto	$469.88
Rate for Payer: Multiplan Commercial	$469.88
Rate for Payer: Multiplan Workers Comp	$469.88
Rate for Payer: Parkland Medicaid	$676.63
Rate for Payer: Scott and White EPO/PPO	$469.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$676.63
Rate for Payer: Superior Health Plan EPO	$127.81

LOW-PRO CORT SCREW 3.5 X 50MM ORTHOLOC SYSTEM

Facility

$939.76

Service Code	HCPCS C1713
Hospital Charge Code	992390
Hospital Revenue Code	278
Min. Negotiated Rate	$84.58
Max. Negotiated Rate	$676.63
Rate for Payer: Amerigroup CHIP/Medicaid	$84.58
Rate for Payer: BCBS of TX Blue Advantage	$281.93
Rate for Payer: BCBS of TX Blue Essentials	$338.31
Rate for Payer: BCBS of TX PPO	$375.90
Rate for Payer: Cash Price	$639.04
Rate for Payer: Cigna Medicaid	$676.63
Rate for Payer: Molina CHIP/Medicaid	$676.63
Rate for Payer: Multiplan Auto	$469.88
Rate for Payer: Multiplan Commercial	$469.88
Rate for Payer: Multiplan Workers Comp	$469.88
Rate for Payer: Parkland Medicaid	$676.63
Rate for Payer: Scott and White EPO/PPO	$469.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$676.63
Rate for Payer: Superior Health Plan EPO	$127.81

LOW-PRO CORT SCREW 3.5 X 50MM ORTHOLOC SYSTEM

Facility

$939.76

Service Code	HCPCS C1713
Hospital Charge Code	992390
Hospital Revenue Code	278
Min. Negotiated Rate	$234.94
Max. Negotiated Rate	$469.88
Rate for Payer: Cash Price	$639.04
Rate for Payer: Cigna Commercial	$234.94
Rate for Payer: Multiplan Auto	$469.88
Rate for Payer: Multiplan Commercial	$469.88
Rate for Payer: Multiplan Workers Comp	$469.88
Rate for Payer: Scott and White EPO/PPO	$469.88

LOW-PRO CORT SCREW 3.5 X 55MM ORTHOLOC SYSTEM

Facility

$1,879.52

Service Code	HCPCS C1713
Hospital Charge Code	992391
Hospital Revenue Code	278
Min. Negotiated Rate	$169.16
Max. Negotiated Rate	$1,353.25
Rate for Payer: Amerigroup CHIP/Medicaid	$169.16
Rate for Payer: BCBS of TX Blue Advantage	$563.86
Rate for Payer: BCBS of TX Blue Essentials	$676.63
Rate for Payer: BCBS of TX PPO	$751.81
Rate for Payer: Cash Price	$1,278.07
Rate for Payer: Cigna Medicaid	$1,353.25
Rate for Payer: Molina CHIP/Medicaid	$1,353.25
Rate for Payer: Multiplan Auto	$939.76
Rate for Payer: Multiplan Commercial	$939.76
Rate for Payer: Multiplan Workers Comp	$939.76
Rate for Payer: Parkland Medicaid	$1,353.25
Rate for Payer: Scott and White EPO/PPO	$939.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,353.25
Rate for Payer: Superior Health Plan EPO	$255.61

LOW-PRO CORT SCREW 3.5 X 55MM ORTHOLOC SYSTEM

Facility

$1,879.52

Service Code	HCPCS C1713
Hospital Charge Code	992391
Hospital Revenue Code	278
Min. Negotiated Rate	$469.88
Max. Negotiated Rate	$939.76
Rate for Payer: Cash Price	$1,278.07
Rate for Payer: Cigna Commercial	$469.88
Rate for Payer: Multiplan Auto	$939.76
Rate for Payer: Multiplan Commercial	$939.76
Rate for Payer: Multiplan Workers Comp	$939.76
Rate for Payer: Scott and White EPO/PPO	$939.76

Know your out-of-pocket cost for care.

All Charges