White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MODULE INTBT BLU

Facility

$186.14

Hospital Charge Code	993478
Hospital Revenue Code	270
Rate for Payer: Cash Price	$126.58

MODULE INTBT BLU

Facility

$186.14

Hospital Charge Code	993478
Hospital Revenue Code	270
Min. Negotiated Rate	$16.75
Max. Negotiated Rate	$134.02
Rate for Payer: Amerigroup CHIP/Medicaid	$16.75
Rate for Payer: BCBS of TX Blue Advantage	$55.84
Rate for Payer: BCBS of TX Blue Essentials	$67.01
Rate for Payer: BCBS of TX PPO	$74.46
Rate for Payer: Cash Price	$126.58
Rate for Payer: Cigna Medicaid	$134.02
Rate for Payer: Molina CHIP/Medicaid	$134.02
Rate for Payer: Multiplan Auto	$120.99
Rate for Payer: Multiplan Commercial	$120.99
Rate for Payer: Multiplan Workers Comp	$120.99
Rate for Payer: Parkland Medicaid	$134.02
Rate for Payer: Scott and White EPO/PPO	$93.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.02
Rate for Payer: Superior Health Plan EPO	$25.32

MODULE INTBT GRN

Facility

$186.14

Hospital Charge Code	993476
Hospital Revenue Code	270
Min. Negotiated Rate	$16.75
Max. Negotiated Rate	$134.02
Rate for Payer: Amerigroup CHIP/Medicaid	$16.75
Rate for Payer: BCBS of TX Blue Advantage	$55.84
Rate for Payer: BCBS of TX Blue Essentials	$67.01
Rate for Payer: BCBS of TX PPO	$74.46
Rate for Payer: Cash Price	$126.58
Rate for Payer: Cigna Medicaid	$134.02
Rate for Payer: Molina CHIP/Medicaid	$134.02
Rate for Payer: Multiplan Auto	$120.99
Rate for Payer: Multiplan Commercial	$120.99
Rate for Payer: Multiplan Workers Comp	$120.99
Rate for Payer: Parkland Medicaid	$134.02
Rate for Payer: Scott and White EPO/PPO	$93.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.02
Rate for Payer: Superior Health Plan EPO	$25.32

MODULE INTBT GRN

Facility

$186.14

Hospital Charge Code	993476
Hospital Revenue Code	270
Rate for Payer: Cash Price	$126.58

MODULE INTBT ORNG

Facility

$186.14

Hospital Charge Code	993484
Hospital Revenue Code	270
Min. Negotiated Rate	$16.75
Max. Negotiated Rate	$134.02
Rate for Payer: Amerigroup CHIP/Medicaid	$16.75
Rate for Payer: BCBS of TX Blue Advantage	$55.84
Rate for Payer: BCBS of TX Blue Essentials	$67.01
Rate for Payer: BCBS of TX PPO	$74.46
Rate for Payer: Cash Price	$126.58
Rate for Payer: Cigna Medicaid	$134.02
Rate for Payer: Molina CHIP/Medicaid	$134.02
Rate for Payer: Multiplan Auto	$120.99
Rate for Payer: Multiplan Commercial	$120.99
Rate for Payer: Multiplan Workers Comp	$120.99
Rate for Payer: Parkland Medicaid	$134.02
Rate for Payer: Scott and White EPO/PPO	$93.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.02
Rate for Payer: Superior Health Plan EPO	$25.32

MODULE INTBT ORNG

Facility

$186.14

Hospital Charge Code	993484
Hospital Revenue Code	270
Rate for Payer: Cash Price	$126.58

MODULE INTBT PINK/RED

Facility

$186.14

Hospital Charge Code	993491
Hospital Revenue Code	270
Rate for Payer: Cash Price	$126.58

MODULE INTBT PINK/RED

Facility

$186.14

Hospital Charge Code	993491
Hospital Revenue Code	270
Min. Negotiated Rate	$16.75
Max. Negotiated Rate	$134.02
Rate for Payer: Amerigroup CHIP/Medicaid	$16.75
Rate for Payer: BCBS of TX Blue Advantage	$55.84
Rate for Payer: BCBS of TX Blue Essentials	$67.01
Rate for Payer: BCBS of TX PPO	$74.46
Rate for Payer: Cash Price	$126.58
Rate for Payer: Cigna Medicaid	$134.02
Rate for Payer: Molina CHIP/Medicaid	$134.02
Rate for Payer: Multiplan Auto	$120.99
Rate for Payer: Multiplan Commercial	$120.99
Rate for Payer: Multiplan Workers Comp	$120.99
Rate for Payer: Parkland Medicaid	$134.02
Rate for Payer: Scott and White EPO/PPO	$93.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.02
Rate for Payer: Superior Health Plan EPO	$25.32

MODULE INTBT PUR

Facility

$186.14

Hospital Charge Code	993488
Hospital Revenue Code	270
Rate for Payer: Cash Price	$126.58

MODULE INTBT PUR

Facility

$186.14

Hospital Charge Code	993488
Hospital Revenue Code	270
Min. Negotiated Rate	$16.75
Max. Negotiated Rate	$134.02
Rate for Payer: Amerigroup CHIP/Medicaid	$16.75
Rate for Payer: BCBS of TX Blue Advantage	$55.84
Rate for Payer: BCBS of TX Blue Essentials	$67.01
Rate for Payer: BCBS of TX PPO	$74.46
Rate for Payer: Cash Price	$126.58
Rate for Payer: Cigna Medicaid	$134.02
Rate for Payer: Molina CHIP/Medicaid	$134.02
Rate for Payer: Multiplan Auto	$120.99
Rate for Payer: Multiplan Commercial	$120.99
Rate for Payer: Multiplan Workers Comp	$120.99
Rate for Payer: Parkland Medicaid	$134.02
Rate for Payer: Scott and White EPO/PPO	$93.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.02
Rate for Payer: Superior Health Plan EPO	$25.32

MODULE INTBT YLW

Facility

$186.14

Hospital Charge Code	993497
Hospital Revenue Code	270
Min. Negotiated Rate	$16.75
Max. Negotiated Rate	$134.02
Rate for Payer: Amerigroup CHIP/Medicaid	$16.75
Rate for Payer: BCBS of TX Blue Advantage	$55.84
Rate for Payer: BCBS of TX Blue Essentials	$67.01
Rate for Payer: BCBS of TX PPO	$74.46
Rate for Payer: Cash Price	$126.58
Rate for Payer: Cigna Medicaid	$134.02
Rate for Payer: Molina CHIP/Medicaid	$134.02
Rate for Payer: Multiplan Auto	$120.99
Rate for Payer: Multiplan Commercial	$120.99
Rate for Payer: Multiplan Workers Comp	$120.99
Rate for Payer: Parkland Medicaid	$134.02
Rate for Payer: Scott and White EPO/PPO	$93.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.02
Rate for Payer: Superior Health Plan EPO	$25.32

MODULE INTBT YLW

Facility

$186.14

Hospital Charge Code	993497
Hospital Revenue Code	270
Rate for Payer: Cash Price	$126.58

MODULE INTRAOSSEUS BLU

Facility

$204.30

Hospital Charge Code	993499
Hospital Revenue Code	270
Rate for Payer: Cash Price	$138.92

MODULE INTRAOSSEUS BLU

Facility

$204.30

Hospital Charge Code	993499
Hospital Revenue Code	270
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$147.10
Rate for Payer: Amerigroup CHIP/Medicaid	$18.39
Rate for Payer: BCBS of TX Blue Advantage	$61.29
Rate for Payer: BCBS of TX Blue Essentials	$73.55
Rate for Payer: BCBS of TX PPO	$81.72
Rate for Payer: Cash Price	$138.92
Rate for Payer: Cigna Medicaid	$147.10
Rate for Payer: Molina CHIP/Medicaid	$147.10
Rate for Payer: Multiplan Auto	$132.79
Rate for Payer: Multiplan Commercial	$132.79
Rate for Payer: Multiplan Workers Comp	$132.79
Rate for Payer: Parkland Medicaid	$147.10
Rate for Payer: Scott and White EPO/PPO	$102.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$147.10
Rate for Payer: Superior Health Plan EPO	$27.78

MODULE INTRAOSSEUS GRN

Facility

$249.70

Hospital Charge Code	993481
Hospital Revenue Code	270
Rate for Payer: Cash Price	$169.80

MODULE INTRAOSSEUS GRN

Facility

$249.70

Hospital Charge Code	993481
Hospital Revenue Code	270
Min. Negotiated Rate	$22.47
Max. Negotiated Rate	$179.78
Rate for Payer: Amerigroup CHIP/Medicaid	$22.47
Rate for Payer: BCBS of TX Blue Advantage	$74.91
Rate for Payer: BCBS of TX Blue Essentials	$89.89
Rate for Payer: BCBS of TX PPO	$99.88
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cigna Medicaid	$179.78
Rate for Payer: Molina CHIP/Medicaid	$179.78
Rate for Payer: Multiplan Auto	$162.31
Rate for Payer: Multiplan Commercial	$162.31
Rate for Payer: Multiplan Workers Comp	$162.31
Rate for Payer: Parkland Medicaid	$179.78
Rate for Payer: Scott and White EPO/PPO	$124.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$179.78
Rate for Payer: Superior Health Plan EPO	$33.96

MODULE INTRAOSSEUS ORNG

Facility

$249.70

Hospital Charge Code	993485
Hospital Revenue Code	270
Rate for Payer: Cash Price	$169.80

MODULE INTRAOSSEUS ORNG

Facility

$249.70

Hospital Charge Code	993485
Hospital Revenue Code	270
Min. Negotiated Rate	$22.47
Max. Negotiated Rate	$179.78
Rate for Payer: Amerigroup CHIP/Medicaid	$22.47
Rate for Payer: BCBS of TX Blue Advantage	$74.91
Rate for Payer: BCBS of TX Blue Essentials	$89.89
Rate for Payer: BCBS of TX PPO	$99.88
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cigna Medicaid	$179.78
Rate for Payer: Molina CHIP/Medicaid	$179.78
Rate for Payer: Multiplan Auto	$162.31
Rate for Payer: Multiplan Commercial	$162.31
Rate for Payer: Multiplan Workers Comp	$162.31
Rate for Payer: Parkland Medicaid	$179.78
Rate for Payer: Scott and White EPO/PPO	$124.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$179.78
Rate for Payer: Superior Health Plan EPO	$33.96

MODULE INTRAOSSEUS YLW

Facility

$249.70

Hospital Charge Code	993503
Hospital Revenue Code	270
Rate for Payer: Cash Price	$169.80

MODULE INTRAOSSEUS YLW

Facility

$249.70

Hospital Charge Code	993503
Hospital Revenue Code	270
Min. Negotiated Rate	$22.47
Max. Negotiated Rate	$179.78
Rate for Payer: Amerigroup CHIP/Medicaid	$22.47
Rate for Payer: BCBS of TX Blue Advantage	$74.91
Rate for Payer: BCBS of TX Blue Essentials	$89.89
Rate for Payer: BCBS of TX PPO	$99.88
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cigna Medicaid	$179.78
Rate for Payer: Molina CHIP/Medicaid	$179.78
Rate for Payer: Multiplan Auto	$162.31
Rate for Payer: Multiplan Commercial	$162.31
Rate for Payer: Multiplan Workers Comp	$162.31
Rate for Payer: Parkland Medicaid	$179.78
Rate for Payer: Scott and White EPO/PPO	$124.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$179.78
Rate for Payer: Superior Health Plan EPO	$33.96

MODULE INTUBIATION PED CRT WHT

Facility

$186.14

Hospital Charge Code	993501
Hospital Revenue Code	270
Rate for Payer: Cash Price	$126.58

MODULE INTUBIATION PED CRT WHT

Facility

$186.14

Hospital Charge Code	993501
Hospital Revenue Code	270
Min. Negotiated Rate	$16.75
Max. Negotiated Rate	$134.02
Rate for Payer: Amerigroup CHIP/Medicaid	$16.75
Rate for Payer: BCBS of TX Blue Advantage	$55.84
Rate for Payer: BCBS of TX Blue Essentials	$67.01
Rate for Payer: BCBS of TX PPO	$74.46
Rate for Payer: Cash Price	$126.58
Rate for Payer: Cigna Medicaid	$134.02
Rate for Payer: Molina CHIP/Medicaid	$134.02
Rate for Payer: Multiplan Auto	$120.99
Rate for Payer: Multiplan Commercial	$120.99
Rate for Payer: Multiplan Workers Comp	$120.99
Rate for Payer: Parkland Medicaid	$134.02
Rate for Payer: Scott and White EPO/PPO	$93.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.02
Rate for Payer: Superior Health Plan EPO	$25.32

MODULE IO PED CRT WHT

Facility

$249.70

Hospital Charge Code	993495
Hospital Revenue Code	270
Rate for Payer: Cash Price	$169.80

MODULE IO PED CRT WHT

Facility

$249.70

Hospital Charge Code	993495
Hospital Revenue Code	270
Min. Negotiated Rate	$22.47
Max. Negotiated Rate	$179.78
Rate for Payer: Amerigroup CHIP/Medicaid	$22.47
Rate for Payer: BCBS of TX Blue Advantage	$74.91
Rate for Payer: BCBS of TX Blue Essentials	$89.89
Rate for Payer: BCBS of TX PPO	$99.88
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cigna Medicaid	$179.78
Rate for Payer: Molina CHIP/Medicaid	$179.78
Rate for Payer: Multiplan Auto	$162.31
Rate for Payer: Multiplan Commercial	$162.31
Rate for Payer: Multiplan Workers Comp	$162.31
Rate for Payer: Parkland Medicaid	$179.78
Rate for Payer: Scott and White EPO/PPO	$124.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$179.78
Rate for Payer: Superior Health Plan EPO	$33.96

MODULE IV DLV BLU

Facility

$249.70

Hospital Charge Code	993479
Hospital Revenue Code	270
Rate for Payer: Cash Price	$169.80

Know your out-of-pocket cost for care.

All Charges