White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SYS CEMT MIX & DEL WO -- DHF

Facility

$4,443.50

Hospital Charge Code	81786956
Hospital Revenue Code	272
Min. Negotiated Rate	$399.92
Max. Negotiated Rate	$2,888.28
Rate for Payer: Aetna Commercial	$2,443.92
Rate for Payer: Amerigroup CHIP/Medicaid	$399.92
Rate for Payer: BCBS of TX Blue Advantage	$1,333.05
Rate for Payer: BCBS of TX Blue Essentials	$1,599.66
Rate for Payer: BCBS of TX PPO	$1,777.40
Rate for Payer: Cash Price	$3,910.28
Rate for Payer: Multiplan Auto	$2,888.28
Rate for Payer: Multiplan Commercial	$2,888.28
Rate for Payer: Multiplan Workers Comp	$2,888.28
Rate for Payer: Scott and White EPO/PPO	$2,221.75
Rate for Payer: Superior Health Plan EPO	$604.32

SYS CEMT MIX & DEL WO -- DHF

Facility

$4,443.50

Hospital Charge Code	81786956
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,910.28

SYS COR TEC INTRVN TECH -- DHF

Facility

$18,758.14

Service Code	HCPCS C1724
Hospital Charge Code	82489006
Hospital Revenue Code	278
Min. Negotiated Rate	$4,689.54
Max. Negotiated Rate	$9,379.07
Rate for Payer: Aetna Commercial	$5,627.44
Rate for Payer: Cash Price	$16,507.16
Rate for Payer: Cigna Commercial	$4,689.54
Rate for Payer: Multiplan Auto	$9,379.07
Rate for Payer: Multiplan Commercial	$9,379.07
Rate for Payer: Multiplan Workers Comp	$9,379.07
Rate for Payer: Scott and White EPO/PPO	$9,379.07

SYS COR TEC INTRVN TECH -- DHF

Facility

$18,758.14

Service Code	HCPCS C1724
Hospital Charge Code	82489006
Hospital Revenue Code	278
Min. Negotiated Rate	$1,688.23
Max. Negotiated Rate	$9,379.07
Rate for Payer: Aetna Commercial	$5,627.44
Rate for Payer: Amerigroup CHIP/Medicaid	$1,688.23
Rate for Payer: BCBS of TX Blue Advantage	$5,627.44
Rate for Payer: BCBS of TX Blue Essentials	$6,752.93
Rate for Payer: BCBS of TX PPO	$7,503.26
Rate for Payer: Cash Price	$16,507.16
Rate for Payer: Multiplan Auto	$9,379.07
Rate for Payer: Multiplan Commercial	$9,379.07
Rate for Payer: Multiplan Workers Comp	$9,379.07
Rate for Payer: Scott and White EPO/PPO	$9,379.07
Rate for Payer: Superior Health Plan EPO	$2,551.11

SYS CORTICAL ADJUSTABL -- DHF

Facility

$4,842.97

Service Code	HCPCS C1713
Hospital Charge Code	40180770
Hospital Revenue Code	278
Min. Negotiated Rate	$435.87
Max. Negotiated Rate	$2,421.48
Rate for Payer: Aetna Commercial	$1,452.89
Rate for Payer: Amerigroup CHIP/Medicaid	$435.87
Rate for Payer: BCBS of TX Blue Advantage	$1,452.89
Rate for Payer: BCBS of TX Blue Essentials	$1,743.47
Rate for Payer: BCBS of TX PPO	$1,937.19
Rate for Payer: Cash Price	$4,261.81
Rate for Payer: Multiplan Auto	$2,421.48
Rate for Payer: Multiplan Commercial	$2,421.48
Rate for Payer: Multiplan Workers Comp	$2,421.48
Rate for Payer: Scott and White EPO/PPO	$2,421.48
Rate for Payer: Superior Health Plan EPO	$658.64

SYS CORTICAL ADJUSTABL -- DHF

Facility

$4,842.97

Service Code	HCPCS C1713
Hospital Charge Code	40180770
Hospital Revenue Code	278
Min. Negotiated Rate	$1,210.74
Max. Negotiated Rate	$2,421.48
Rate for Payer: Aetna Commercial	$1,452.89
Rate for Payer: Cash Price	$4,261.81
Rate for Payer: Cigna Commercial	$1,210.74
Rate for Payer: Multiplan Auto	$2,421.48
Rate for Payer: Multiplan Commercial	$2,421.48
Rate for Payer: Multiplan Workers Comp	$2,421.48
Rate for Payer: Scott and White EPO/PPO	$2,421.48

SYS GASTRIC POSITIONING -- DHF

Facility

$1,248.50

Hospital Charge Code	81877912
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,098.68

SYS GASTRIC POSITIONING -- DHF

Facility

$1,248.50

Hospital Charge Code	81877912
Hospital Revenue Code	272
Min. Negotiated Rate	$112.36
Max. Negotiated Rate	$811.52
Rate for Payer: Aetna Commercial	$686.68
Rate for Payer: Amerigroup CHIP/Medicaid	$112.36
Rate for Payer: BCBS of TX Blue Advantage	$374.55
Rate for Payer: BCBS of TX Blue Essentials	$449.46
Rate for Payer: BCBS of TX PPO	$499.40
Rate for Payer: Cash Price	$1,098.68
Rate for Payer: Multiplan Auto	$811.52
Rate for Payer: Multiplan Commercial	$811.52
Rate for Payer: Multiplan Workers Comp	$811.52
Rate for Payer: Scott and White EPO/PPO	$624.25
Rate for Payer: Superior Health Plan EPO	$169.80

SYS GRAFT PREP SPEEDTRAP -- DHF

Facility

$454.00

Hospital Charge Code	81949307
Hospital Revenue Code	272
Min. Negotiated Rate	$40.86
Max. Negotiated Rate	$295.10
Rate for Payer: Aetna Commercial	$249.70
Rate for Payer: Amerigroup CHIP/Medicaid	$40.86
Rate for Payer: BCBS of TX Blue Advantage	$136.20
Rate for Payer: BCBS of TX Blue Essentials	$163.44
Rate for Payer: BCBS of TX PPO	$181.60
Rate for Payer: Cash Price	$399.52
Rate for Payer: Multiplan Auto	$295.10
Rate for Payer: Multiplan Commercial	$295.10
Rate for Payer: Multiplan Workers Comp	$295.10
Rate for Payer: Scott and White EPO/PPO	$227.00
Rate for Payer: Superior Health Plan EPO	$61.74

SYS GRAFT PREP SPEEDTRAP -- DHF

Facility

$454.00

Hospital Charge Code	81949307
Hospital Revenue Code	272
Rate for Payer: Cash Price	$399.52

SYS LARYNGOSCOPE -- DHF

Facility

$54.79

Hospital Charge Code	80899073
Hospital Revenue Code	272
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$35.61
Rate for Payer: Aetna Commercial	$30.13
Rate for Payer: Amerigroup CHIP/Medicaid	$4.93
Rate for Payer: BCBS of TX Blue Advantage	$16.44
Rate for Payer: BCBS of TX Blue Essentials	$19.72
Rate for Payer: BCBS of TX PPO	$21.92
Rate for Payer: Cash Price	$48.22
Rate for Payer: Multiplan Auto	$35.61
Rate for Payer: Multiplan Commercial	$35.61
Rate for Payer: Multiplan Workers Comp	$35.61
Rate for Payer: Scott and White EPO/PPO	$27.40
Rate for Payer: Superior Health Plan EPO	$7.45

SYS LARYNGOSCOPE -- DHF

Facility

$54.79

Hospital Charge Code	80899073
Hospital Revenue Code	272
Rate for Payer: Cash Price	$48.22

SYS LARYNGOSCOPE TRULITE

Facility

$60.97

Hospital Charge Code	8556474
Hospital Revenue Code	272
Min. Negotiated Rate	$5.49
Max. Negotiated Rate	$39.63
Rate for Payer: Aetna Commercial	$33.53
Rate for Payer: Amerigroup CHIP/Medicaid	$5.49
Rate for Payer: BCBS of TX Blue Advantage	$18.29
Rate for Payer: BCBS of TX Blue Essentials	$21.95
Rate for Payer: BCBS of TX PPO	$24.39
Rate for Payer: Cash Price	$53.65
Rate for Payer: Multiplan Auto	$39.63
Rate for Payer: Multiplan Commercial	$39.63
Rate for Payer: Multiplan Workers Comp	$39.63
Rate for Payer: Scott and White EPO/PPO	$30.48
Rate for Payer: Superior Health Plan EPO	$8.29

SYS LARYNGOSCOPE TRULITE

Facility

$60.97

Hospital Charge Code	8556474
Hospital Revenue Code	272
Rate for Payer: Cash Price	$53.65

SYS MAXILLARY SINUS BLN -- DHF

Facility

$16,115.70

Service Code	HCPCS C1726
Hospital Charge Code	81774648
Hospital Revenue Code	278
Min. Negotiated Rate	$4,028.92
Max. Negotiated Rate	$8,057.85
Rate for Payer: Aetna Commercial	$4,834.71
Rate for Payer: Cash Price	$14,181.82
Rate for Payer: Cigna Commercial	$4,028.92
Rate for Payer: Multiplan Auto	$8,057.85
Rate for Payer: Multiplan Commercial	$8,057.85
Rate for Payer: Multiplan Workers Comp	$8,057.85
Rate for Payer: Scott and White EPO/PPO	$8,057.85

SYS MAXILLARY SINUS BLN -- DHF

Facility

$16,115.70

Service Code	HCPCS C1726
Hospital Charge Code	81774648
Hospital Revenue Code	278
Min. Negotiated Rate	$1,450.41
Max. Negotiated Rate	$8,057.85
Rate for Payer: Aetna Commercial	$4,834.71
Rate for Payer: Amerigroup CHIP/Medicaid	$1,450.41
Rate for Payer: BCBS of TX Blue Advantage	$4,834.71
Rate for Payer: BCBS of TX Blue Essentials	$5,801.65
Rate for Payer: BCBS of TX PPO	$6,446.28
Rate for Payer: Cash Price	$14,181.82
Rate for Payer: Multiplan Auto	$8,057.85
Rate for Payer: Multiplan Commercial	$8,057.85
Rate for Payer: Multiplan Workers Comp	$8,057.85
Rate for Payer: Scott and White EPO/PPO	$8,057.85
Rate for Payer: Superior Health Plan EPO	$2,191.74

SYS ORBT ARTHRCM 1.50 SOLID 145CM

Facility

$16,775.30

Hospital Charge Code	8582477
Hospital Revenue Code	272
Min. Negotiated Rate	$1,509.78
Max. Negotiated Rate	$10,903.94
Rate for Payer: Aetna Commercial	$9,226.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1,509.78
Rate for Payer: BCBS of TX Blue Advantage	$5,032.59
Rate for Payer: BCBS of TX Blue Essentials	$6,039.11
Rate for Payer: BCBS of TX PPO	$6,710.12
Rate for Payer: Cash Price	$14,762.26
Rate for Payer: Multiplan Auto	$10,903.94
Rate for Payer: Multiplan Commercial	$10,903.94
Rate for Payer: Multiplan Workers Comp	$10,903.94
Rate for Payer: Scott and White EPO/PPO	$8,387.65
Rate for Payer: Superior Health Plan EPO	$2,281.44

SYS ORBT ARTHRCM 1.50 SOLID 145CM

Facility

$16,775.30

Hospital Charge Code	8582477
Hospital Revenue Code	272
Rate for Payer: Cash Price	$14,762.26

SYS ORBT ARTHRCM 2.0 SOLID 145CM

Facility

$16,775.30

Service Code	HCPCS C1724
Hospital Charge Code	8582475
Hospital Revenue Code	272
Rate for Payer: Cash Price	$14,762.26

SYS ORBT ARTHRCM 2.0 SOLID 145CM

Facility

$16,775.30

Service Code	HCPCS C1724
Hospital Charge Code	8582475
Hospital Revenue Code	272
Min. Negotiated Rate	$1,509.78
Max. Negotiated Rate	$10,903.94
Rate for Payer: Aetna Commercial	$9,226.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1,509.78
Rate for Payer: BCBS of TX Blue Advantage	$5,032.59
Rate for Payer: BCBS of TX Blue Essentials	$6,039.11
Rate for Payer: BCBS of TX PPO	$6,710.12
Rate for Payer: Cash Price	$14,762.26
Rate for Payer: Multiplan Auto	$10,903.94
Rate for Payer: Multiplan Commercial	$10,903.94
Rate for Payer: Multiplan Workers Comp	$10,903.94
Rate for Payer: Scott and White EPO/PPO	$8,387.65
Rate for Payer: Superior Health Plan EPO	$2,281.44

SYS PANNUS RETENTION

Facility

$187.68

Hospital Charge Code	81147522
Hospital Revenue Code	272
Min. Negotiated Rate	$16.89
Max. Negotiated Rate	$121.99
Rate for Payer: Aetna Commercial	$103.22
Rate for Payer: Amerigroup CHIP/Medicaid	$16.89
Rate for Payer: BCBS of TX Blue Advantage	$56.30
Rate for Payer: BCBS of TX Blue Essentials	$67.56
Rate for Payer: BCBS of TX PPO	$75.07
Rate for Payer: Cash Price	$165.16
Rate for Payer: Multiplan Auto	$121.99
Rate for Payer: Multiplan Commercial	$121.99
Rate for Payer: Multiplan Workers Comp	$121.99
Rate for Payer: Scott and White EPO/PPO	$93.84
Rate for Payer: Superior Health Plan EPO	$25.52

SYS PANNUS RETENTION

Facility

$187.68

Hospital Charge Code	81147522
Hospital Revenue Code	272
Rate for Payer: Cash Price	$165.16

SYS PORT CLOSURE -- DHF

Facility

$529.36

Hospital Charge Code	80869860
Hospital Revenue Code	272
Min. Negotiated Rate	$47.64
Max. Negotiated Rate	$344.08
Rate for Payer: Aetna Commercial	$291.15
Rate for Payer: Amerigroup CHIP/Medicaid	$47.64
Rate for Payer: BCBS of TX Blue Advantage	$158.81
Rate for Payer: BCBS of TX Blue Essentials	$190.57
Rate for Payer: BCBS of TX PPO	$211.74
Rate for Payer: Cash Price	$465.84
Rate for Payer: Multiplan Auto	$344.08
Rate for Payer: Multiplan Commercial	$344.08
Rate for Payer: Multiplan Workers Comp	$344.08
Rate for Payer: Scott and White EPO/PPO	$264.68
Rate for Payer: Superior Health Plan EPO	$71.99

SYS PORT CLOSURE -- DHF

Facility

$529.36

Hospital Charge Code	80869860
Hospital Revenue Code	272
Rate for Payer: Cash Price	$465.84

system autoplex w/o needles

Facility

$2,725.69

Hospital Charge Code	8602522
Hospital Revenue Code	272
Min. Negotiated Rate	$245.31
Max. Negotiated Rate	$1,771.70
Rate for Payer: Aetna Commercial	$1,499.13
Rate for Payer: Amerigroup CHIP/Medicaid	$245.31
Rate for Payer: BCBS of TX Blue Advantage	$817.71
Rate for Payer: BCBS of TX Blue Essentials	$981.25
Rate for Payer: BCBS of TX PPO	$1,090.28
Rate for Payer: Cash Price	$2,398.61
Rate for Payer: Multiplan Auto	$1,771.70
Rate for Payer: Multiplan Commercial	$1,771.70
Rate for Payer: Multiplan Workers Comp	$1,771.70
Rate for Payer: Scott and White EPO/PPO	$1,362.84
Rate for Payer: Superior Health Plan EPO	$370.69

Know your out-of-pocket cost for care.

All Charges