White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MODULE IV DLV BLU

Facility

$249.70

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

MODULE IV DLV GRN

Facility

$204.30

Hospital Charge Code	993482
Hospital Revenue Code	270
Rate for Payer: Cash Price	$138.92

MODULE IV DLV GRN

Facility

$204.30

Hospital Charge Code	993482
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 IV DLV ORNG

Facility

$204.30

Hospital Charge Code	993486
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 IV DLV ORNG

Facility

$204.30

Hospital Charge Code	993486
Hospital Revenue Code	270
Rate for Payer: Cash Price	$138.92

MODULE IV DLV PINK/RED

Facility

$204.30

Hospital Charge Code	993493
Hospital Revenue Code	270
Rate for Payer: Cash Price	$138.92

MODULE IV DLV PINK/RED

Facility

$204.30

Hospital Charge Code	993493
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 IV DLV PUR

Facility

$204.30

Hospital Charge Code	993489
Hospital Revenue Code	270
Rate for Payer: Cash Price	$138.92

MODULE IV DLV PUR

Facility

$204.30

Hospital Charge Code	993489
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 IV DLV WHT

Facility

$204.30

Hospital Charge Code	993502
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 IV DLV WHT

Facility

$204.30

Hospital Charge Code	993502
Hospital Revenue Code	270
Rate for Payer: Cash Price	$138.92

MODULE IV DLV YLW

Facility

$204.30

Hospital Charge Code	993498
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 IV DLV YLW

Facility

$204.30

Hospital Charge Code	993498
Hospital Revenue Code	270
Rate for Payer: Cash Price	$138.92

MODULE O2 BRSL WHT

Facility

$72.64

Hospital Charge Code	993494
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.40

MODULE O2 BRSL WHT

Facility

$72.64

Hospital Charge Code	993494
Hospital Revenue Code	270
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$52.30
Rate for Payer: Amerigroup CHIP/Medicaid	$6.54
Rate for Payer: BCBS of TX Blue Advantage	$21.79
Rate for Payer: BCBS of TX Blue Essentials	$26.15
Rate for Payer: BCBS of TX PPO	$29.06
Rate for Payer: Cash Price	$49.40
Rate for Payer: Cigna Medicaid	$52.30
Rate for Payer: Molina CHIP/Medicaid	$52.30
Rate for Payer: Multiplan Auto	$47.22
Rate for Payer: Multiplan Commercial	$47.22
Rate for Payer: Multiplan Workers Comp	$47.22
Rate for Payer: Parkland Medicaid	$52.30
Rate for Payer: Scott and White EPO/PPO	$36.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.30
Rate for Payer: Superior Health Plan EPO	$9.88

MODULE O2DEL BLU

Facility

$72.64

Hospital Charge Code	993477
Hospital Revenue Code	270
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$52.30
Rate for Payer: Amerigroup CHIP/Medicaid	$6.54
Rate for Payer: BCBS of TX Blue Advantage	$21.79
Rate for Payer: BCBS of TX Blue Essentials	$26.15
Rate for Payer: BCBS of TX PPO	$29.06
Rate for Payer: Cash Price	$49.40
Rate for Payer: Cigna Medicaid	$52.30
Rate for Payer: Molina CHIP/Medicaid	$52.30
Rate for Payer: Multiplan Auto	$47.22
Rate for Payer: Multiplan Commercial	$47.22
Rate for Payer: Multiplan Workers Comp	$47.22
Rate for Payer: Parkland Medicaid	$52.30
Rate for Payer: Scott and White EPO/PPO	$36.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.30
Rate for Payer: Superior Health Plan EPO	$9.88

MODULE O2DEL BLU

Facility

$72.64

Hospital Charge Code	993477
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.40

MODULE O2DEL GRN

Facility

$72.64

Hospital Charge Code	993480
Hospital Revenue Code	270
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$52.30
Rate for Payer: Amerigroup CHIP/Medicaid	$6.54
Rate for Payer: BCBS of TX Blue Advantage	$21.79
Rate for Payer: BCBS of TX Blue Essentials	$26.15
Rate for Payer: BCBS of TX PPO	$29.06
Rate for Payer: Cash Price	$49.40
Rate for Payer: Cigna Medicaid	$52.30
Rate for Payer: Molina CHIP/Medicaid	$52.30
Rate for Payer: Multiplan Auto	$47.22
Rate for Payer: Multiplan Commercial	$47.22
Rate for Payer: Multiplan Workers Comp	$47.22
Rate for Payer: Parkland Medicaid	$52.30
Rate for Payer: Scott and White EPO/PPO	$36.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.30
Rate for Payer: Superior Health Plan EPO	$9.88

MODULE O2DEL GRN

Facility

$72.64

Hospital Charge Code	993480
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.40

MODULE O2DEL ORNG

Facility

$72.64

Hospital Charge Code	993483
Hospital Revenue Code	270
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$52.30
Rate for Payer: Amerigroup CHIP/Medicaid	$6.54
Rate for Payer: BCBS of TX Blue Advantage	$21.79
Rate for Payer: BCBS of TX Blue Essentials	$26.15
Rate for Payer: BCBS of TX PPO	$29.06
Rate for Payer: Cash Price	$49.40
Rate for Payer: Cigna Medicaid	$52.30
Rate for Payer: Molina CHIP/Medicaid	$52.30
Rate for Payer: Multiplan Auto	$47.22
Rate for Payer: Multiplan Commercial	$47.22
Rate for Payer: Multiplan Workers Comp	$47.22
Rate for Payer: Parkland Medicaid	$52.30
Rate for Payer: Scott and White EPO/PPO	$36.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.30
Rate for Payer: Superior Health Plan EPO	$9.88

MODULE O2DEL ORNG

Facility

$72.64

Hospital Charge Code	993483
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.40

MODULE O2DEL PINK/RED

Facility

$72.64

Hospital Charge Code	993490
Hospital Revenue Code	270
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$52.30
Rate for Payer: Amerigroup CHIP/Medicaid	$6.54
Rate for Payer: BCBS of TX Blue Advantage	$21.79
Rate for Payer: BCBS of TX Blue Essentials	$26.15
Rate for Payer: BCBS of TX PPO	$29.06
Rate for Payer: Cash Price	$49.40
Rate for Payer: Cigna Medicaid	$52.30
Rate for Payer: Molina CHIP/Medicaid	$52.30
Rate for Payer: Multiplan Auto	$47.22
Rate for Payer: Multiplan Commercial	$47.22
Rate for Payer: Multiplan Workers Comp	$47.22
Rate for Payer: Parkland Medicaid	$52.30
Rate for Payer: Scott and White EPO/PPO	$36.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.30
Rate for Payer: Superior Health Plan EPO	$9.88

MODULE O2DEL PINK/RED

Facility

$72.64

Hospital Charge Code	993490
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.40

MODULE O2DEL PUR

Facility

$72.64

Hospital Charge Code	993487
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.40

MODULE O2DEL PUR

Facility

$72.64

Hospital Charge Code	993487
Hospital Revenue Code	270
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$52.30
Rate for Payer: Amerigroup CHIP/Medicaid	$6.54
Rate for Payer: BCBS of TX Blue Advantage	$21.79
Rate for Payer: BCBS of TX Blue Essentials	$26.15
Rate for Payer: BCBS of TX PPO	$29.06
Rate for Payer: Cash Price	$49.40
Rate for Payer: Cigna Medicaid	$52.30
Rate for Payer: Molina CHIP/Medicaid	$52.30
Rate for Payer: Multiplan Auto	$47.22
Rate for Payer: Multiplan Commercial	$47.22
Rate for Payer: Multiplan Workers Comp	$47.22
Rate for Payer: Parkland Medicaid	$52.30
Rate for Payer: Scott and White EPO/PPO	$36.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.30
Rate for Payer: Superior Health Plan EPO	$9.88

Know your out-of-pocket cost for care.

All Charges