White Rock Medical Center

All Charges

Charge

Type

Setting

Price

200010901

Facility

$4,892.00

Service Code	HCPCS C1776
Hospital Charge Code	990946
Hospital Revenue Code	278
Min. Negotiated Rate	$440.28
Max. Negotiated Rate	$3,522.24
Rate for Payer: Amerigroup CHIP/Medicaid	$440.28
Rate for Payer: BCBS of TX Blue Advantage	$1,467.60
Rate for Payer: BCBS of TX Blue Essentials	$1,761.12
Rate for Payer: BCBS of TX PPO	$1,956.80
Rate for Payer: Cash Price	$3,326.56
Rate for Payer: Cigna Medicaid	$3,522.24
Rate for Payer: Molina CHIP/Medicaid	$3,522.24
Rate for Payer: Multiplan Auto	$2,446.00
Rate for Payer: Multiplan Commercial	$2,446.00
Rate for Payer: Multiplan Workers Comp	$2,446.00
Rate for Payer: Parkland Medicaid	$3,522.24
Rate for Payer: Scott and White EPO/PPO	$2,446.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,522.24
Rate for Payer: Superior Health Plan EPO	$665.31

200010901

Facility

$4,892.00

Service Code	HCPCS C1776
Hospital Charge Code	990946
Hospital Revenue Code	278
Min. Negotiated Rate	$1,223.00
Max. Negotiated Rate	$2,446.00
Rate for Payer: Cash Price	$3,326.56
Rate for Payer: Cigna Commercial	$1,223.00
Rate for Payer: Multiplan Auto	$2,446.00
Rate for Payer: Multiplan Commercial	$2,446.00
Rate for Payer: Multiplan Workers Comp	$2,446.00
Rate for Payer: Scott and White EPO/PPO	$2,446.00

200011904

Facility

$5,012.00

Service Code	HCPCS C1776
Hospital Charge Code	990942
Hospital Revenue Code	278
Min. Negotiated Rate	$1,253.00
Max. Negotiated Rate	$2,506.00
Rate for Payer: Cash Price	$3,408.16
Rate for Payer: Cigna Commercial	$1,253.00
Rate for Payer: Multiplan Auto	$2,506.00
Rate for Payer: Multiplan Commercial	$2,506.00
Rate for Payer: Multiplan Workers Comp	$2,506.00
Rate for Payer: Scott and White EPO/PPO	$2,506.00

200011904

Facility

$5,012.00

Service Code	HCPCS C1776
Hospital Charge Code	990942
Hospital Revenue Code	278
Min. Negotiated Rate	$451.08
Max. Negotiated Rate	$3,608.64
Rate for Payer: Amerigroup CHIP/Medicaid	$451.08
Rate for Payer: BCBS of TX Blue Advantage	$1,503.60
Rate for Payer: BCBS of TX Blue Essentials	$1,804.32
Rate for Payer: BCBS of TX PPO	$2,004.80
Rate for Payer: Cash Price	$3,408.16
Rate for Payer: Cigna Medicaid	$3,608.64
Rate for Payer: Molina CHIP/Medicaid	$3,608.64
Rate for Payer: Multiplan Auto	$2,506.00
Rate for Payer: Multiplan Commercial	$2,506.00
Rate for Payer: Multiplan Workers Comp	$2,506.00
Rate for Payer: Parkland Medicaid	$3,608.64
Rate for Payer: Scott and White EPO/PPO	$2,506.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,608.64
Rate for Payer: Superior Health Plan EPO	$681.63

200011904200011901

Facility

$6,738.00

Service Code	HCPCS C1776
Hospital Charge Code	991047
Hospital Revenue Code	278
Min. Negotiated Rate	$606.42
Max. Negotiated Rate	$4,851.36
Rate for Payer: Amerigroup CHIP/Medicaid	$606.42
Rate for Payer: BCBS of TX Blue Advantage	$2,021.40
Rate for Payer: BCBS of TX Blue Essentials	$2,425.68
Rate for Payer: BCBS of TX PPO	$2,695.20
Rate for Payer: Cash Price	$4,581.84
Rate for Payer: Cigna Medicaid	$4,851.36
Rate for Payer: Molina CHIP/Medicaid	$4,851.36
Rate for Payer: Multiplan Auto	$3,369.00
Rate for Payer: Multiplan Commercial	$3,369.00
Rate for Payer: Multiplan Workers Comp	$3,369.00
Rate for Payer: Parkland Medicaid	$4,851.36
Rate for Payer: Scott and White EPO/PPO	$3,369.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,851.36
Rate for Payer: Superior Health Plan EPO	$916.37

200011904200011901

Facility

$6,738.00

Service Code	HCPCS C1776
Hospital Charge Code	991047
Hospital Revenue Code	278
Min. Negotiated Rate	$1,684.50
Max. Negotiated Rate	$3,369.00
Rate for Payer: Cash Price	$4,581.84
Rate for Payer: Cigna Commercial	$1,684.50
Rate for Payer: Multiplan Auto	$3,369.00
Rate for Payer: Multiplan Commercial	$3,369.00
Rate for Payer: Multiplan Workers Comp	$3,369.00
Rate for Payer: Scott and White EPO/PPO	$3,369.00

200072

Facility

$530.12

Service Code	HCPCS C1769
Hospital Charge Code	990989
Hospital Revenue Code	272
Rate for Payer: Cash Price	$360.48

200072

Facility

$204.81

Service Code	HCPCS C1713
Hospital Charge Code	991080
Hospital Revenue Code	278
Min. Negotiated Rate	$51.20
Max. Negotiated Rate	$102.41
Rate for Payer: Cash Price	$139.27
Rate for Payer: Cigna Commercial	$51.20
Rate for Payer: Multiplan Auto	$102.41
Rate for Payer: Multiplan Commercial	$102.41
Rate for Payer: Multiplan Workers Comp	$102.41
Rate for Payer: Scott and White EPO/PPO	$102.41

200072

Facility

$530.12

Service Code	HCPCS C1769
Hospital Charge Code	990989
Hospital Revenue Code	272
Min. Negotiated Rate	$47.71
Max. Negotiated Rate	$381.69
Rate for Payer: Amerigroup CHIP/Medicaid	$47.71
Rate for Payer: BCBS of TX Blue Advantage	$159.04
Rate for Payer: BCBS of TX Blue Essentials	$190.84
Rate for Payer: BCBS of TX PPO	$212.05
Rate for Payer: Cash Price	$360.48
Rate for Payer: Cigna Medicaid	$381.69
Rate for Payer: Molina CHIP/Medicaid	$381.69
Rate for Payer: Multiplan Auto	$344.58
Rate for Payer: Multiplan Commercial	$344.58
Rate for Payer: Multiplan Workers Comp	$344.58
Rate for Payer: Parkland Medicaid	$381.69
Rate for Payer: Scott and White EPO/PPO	$265.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$381.69
Rate for Payer: Superior Health Plan EPO	$72.10

200072

Facility

$204.81

Service Code	HCPCS C1713
Hospital Charge Code	991080
Hospital Revenue Code	278
Min. Negotiated Rate	$18.43
Max. Negotiated Rate	$147.46
Rate for Payer: Amerigroup CHIP/Medicaid	$18.43
Rate for Payer: BCBS of TX Blue Advantage	$61.44
Rate for Payer: BCBS of TX Blue Essentials	$73.73
Rate for Payer: BCBS of TX PPO	$81.92
Rate for Payer: Cash Price	$139.27
Rate for Payer: Cigna Medicaid	$147.46
Rate for Payer: Molina CHIP/Medicaid	$147.46
Rate for Payer: Multiplan Auto	$102.41
Rate for Payer: Multiplan Commercial	$102.41
Rate for Payer: Multiplan Workers Comp	$102.41
Rate for Payer: Parkland Medicaid	$147.46
Rate for Payer: Scott and White EPO/PPO	$102.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$147.46
Rate for Payer: Superior Health Plan EPO	$27.85

200134

Facility

$1,987.95

Service Code	HCPCS C1776
Hospital Charge Code	991081
Hospital Revenue Code	278
Min. Negotiated Rate	$496.99
Max. Negotiated Rate	$993.98
Rate for Payer: Cash Price	$1,351.81
Rate for Payer: Cigna Commercial	$496.99
Rate for Payer: Multiplan Auto	$993.98
Rate for Payer: Multiplan Commercial	$993.98
Rate for Payer: Multiplan Workers Comp	$993.98
Rate for Payer: Scott and White EPO/PPO	$993.98

200134

Facility

$1,987.95

Service Code	HCPCS C1776
Hospital Charge Code	991081
Hospital Revenue Code	278
Min. Negotiated Rate	$178.92
Max. Negotiated Rate	$1,431.32
Rate for Payer: Amerigroup CHIP/Medicaid	$178.92
Rate for Payer: BCBS of TX Blue Advantage	$596.38
Rate for Payer: BCBS of TX Blue Essentials	$715.66
Rate for Payer: BCBS of TX PPO	$795.18
Rate for Payer: Cash Price	$1,351.81
Rate for Payer: Cigna Medicaid	$1,431.32
Rate for Payer: Molina CHIP/Medicaid	$1,431.32
Rate for Payer: Multiplan Auto	$993.98
Rate for Payer: Multiplan Commercial	$993.98
Rate for Payer: Multiplan Workers Comp	$993.98
Rate for Payer: Parkland Medicaid	$1,431.32
Rate for Payer: Scott and White EPO/PPO	$993.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,431.32
Rate for Payer: Superior Health Plan EPO	$270.36

200134200178002IB20020

Facility

$4,233.61

Service Code	HCPCS A9270
Hospital Charge Code	991046
Hospital Revenue Code	272
Min. Negotiated Rate	$381.02
Max. Negotiated Rate	$3,048.20
Rate for Payer: Amerigroup CHIP/Medicaid	$381.02
Rate for Payer: BCBS of TX Blue Advantage	$1,270.08
Rate for Payer: BCBS of TX Blue Essentials	$1,524.10
Rate for Payer: BCBS of TX PPO	$1,693.44
Rate for Payer: Cash Price	$2,878.85
Rate for Payer: Cigna Medicaid	$3,048.20
Rate for Payer: Molina CHIP/Medicaid	$3,048.20
Rate for Payer: Multiplan Auto	$2,751.85
Rate for Payer: Multiplan Commercial	$2,751.85
Rate for Payer: Multiplan Workers Comp	$2,751.85
Rate for Payer: Parkland Medicaid	$3,048.20
Rate for Payer: Scott and White EPO/PPO	$2,116.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,048.20
Rate for Payer: Superior Health Plan EPO	$575.77

200134200178002IB20020

Facility

$4,233.61

Service Code	HCPCS A9270
Hospital Charge Code	991046
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,878.85

200347901

Facility

$9,632.53

Service Code	HCPCS C1776
Hospital Charge Code	991084
Hospital Revenue Code	278
Min. Negotiated Rate	$866.93
Max. Negotiated Rate	$6,935.42
Rate for Payer: Amerigroup CHIP/Medicaid	$866.93
Rate for Payer: BCBS of TX Blue Advantage	$2,889.76
Rate for Payer: BCBS of TX Blue Essentials	$3,467.71
Rate for Payer: BCBS of TX PPO	$3,853.01
Rate for Payer: Cash Price	$6,550.12
Rate for Payer: Cigna Medicaid	$6,935.42
Rate for Payer: Molina CHIP/Medicaid	$6,935.42
Rate for Payer: Multiplan Auto	$4,816.27
Rate for Payer: Multiplan Commercial	$4,816.27
Rate for Payer: Multiplan Workers Comp	$4,816.27
Rate for Payer: Parkland Medicaid	$6,935.42
Rate for Payer: Scott and White EPO/PPO	$4,816.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,935.42
Rate for Payer: Superior Health Plan EPO	$1,310.02

200347901

Facility

$9,632.53

Service Code	HCPCS C1776
Hospital Charge Code	991084
Hospital Revenue Code	278
Min. Negotiated Rate	$2,408.13
Max. Negotiated Rate	$4,816.27
Rate for Payer: Cash Price	$6,550.12
Rate for Payer: Cigna Commercial	$2,408.13
Rate for Payer: Multiplan Auto	$4,816.27
Rate for Payer: Multiplan Commercial	$4,816.27
Rate for Payer: Multiplan Workers Comp	$4,816.27
Rate for Payer: Scott and White EPO/PPO	$4,816.27

200347901

Facility

$9,633.00

Service Code	HCPCS C1776
Hospital Charge Code	990943
Hospital Revenue Code	278
Min. Negotiated Rate	$866.97
Max. Negotiated Rate	$6,935.76
Rate for Payer: Amerigroup CHIP/Medicaid	$866.97
Rate for Payer: BCBS of TX Blue Advantage	$2,889.90
Rate for Payer: BCBS of TX Blue Essentials	$3,467.88
Rate for Payer: BCBS of TX PPO	$3,853.20
Rate for Payer: Cash Price	$6,550.44
Rate for Payer: Cigna Medicaid	$6,935.76
Rate for Payer: Molina CHIP/Medicaid	$6,935.76
Rate for Payer: Multiplan Auto	$4,816.50
Rate for Payer: Multiplan Commercial	$4,816.50
Rate for Payer: Multiplan Workers Comp	$4,816.50
Rate for Payer: Parkland Medicaid	$6,935.76
Rate for Payer: Scott and White EPO/PPO	$4,816.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,935.76
Rate for Payer: Superior Health Plan EPO	$1,310.09

200347901

Facility

$9,633.00

Service Code	HCPCS C1776
Hospital Charge Code	990943
Hospital Revenue Code	278
Min. Negotiated Rate	$2,408.25
Max. Negotiated Rate	$4,816.50
Rate for Payer: Cash Price	$6,550.44
Rate for Payer: Cigna Commercial	$2,408.25
Rate for Payer: Multiplan Auto	$4,816.50
Rate for Payer: Multiplan Commercial	$4,816.50
Rate for Payer: Multiplan Workers Comp	$4,816.50
Rate for Payer: Scott and White EPO/PPO	$4,816.50

200432010

Facility

$1,536.00

Service Code	HCPCS C1713
Hospital Charge Code	991053
Hospital Revenue Code	278
Min. Negotiated Rate	$138.24
Max. Negotiated Rate	$1,105.92
Rate for Payer: Amerigroup CHIP/Medicaid	$138.24
Rate for Payer: BCBS of TX Blue Advantage	$460.80
Rate for Payer: BCBS of TX Blue Essentials	$552.96
Rate for Payer: BCBS of TX PPO	$614.40
Rate for Payer: Cash Price	$1,044.48
Rate for Payer: Cigna Medicaid	$1,105.92
Rate for Payer: Molina CHIP/Medicaid	$1,105.92
Rate for Payer: Multiplan Auto	$768.00
Rate for Payer: Multiplan Commercial	$768.00
Rate for Payer: Multiplan Workers Comp	$768.00
Rate for Payer: Parkland Medicaid	$1,105.92
Rate for Payer: Scott and White EPO/PPO	$768.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,105.92
Rate for Payer: Superior Health Plan EPO	$208.90

200432010

Facility

$1,536.00

Service Code	HCPCS C1713
Hospital Charge Code	991053
Hospital Revenue Code	278
Min. Negotiated Rate	$384.00
Max. Negotiated Rate	$768.00
Rate for Payer: Cash Price	$1,044.48
Rate for Payer: Cigna Commercial	$384.00
Rate for Payer: Multiplan Auto	$768.00
Rate for Payer: Multiplan Commercial	$768.00
Rate for Payer: Multiplan Workers Comp	$768.00
Rate for Payer: Scott and White EPO/PPO	$768.00

2-0 Fiberwire

Facility

$862.05

Hospital Charge Code	992360
Hospital Revenue Code	272
Min. Negotiated Rate	$77.58
Max. Negotiated Rate	$620.68
Rate for Payer: Amerigroup CHIP/Medicaid	$77.58
Rate for Payer: BCBS of TX Blue Advantage	$258.62
Rate for Payer: BCBS of TX Blue Essentials	$310.34
Rate for Payer: BCBS of TX PPO	$344.82
Rate for Payer: Cash Price	$586.19
Rate for Payer: Cigna Medicaid	$620.68
Rate for Payer: Molina CHIP/Medicaid	$620.68
Rate for Payer: Multiplan Auto	$560.33
Rate for Payer: Multiplan Commercial	$560.33
Rate for Payer: Multiplan Workers Comp	$560.33
Rate for Payer: Parkland Medicaid	$620.68
Rate for Payer: Scott and White EPO/PPO	$431.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$620.68
Rate for Payer: Superior Health Plan EPO	$117.24

2-0 Fiberwire

Facility

$862.05

Hospital Charge Code	992360
Hospital Revenue Code	272
Rate for Payer: Cash Price	$586.19

20MM 2 HOLE PLATE

Facility

$32,868.67

Service Code	HCPCS C1734
Hospital Charge Code	992387
Hospital Revenue Code	278
Min. Negotiated Rate	$2,958.18
Max. Negotiated Rate	$23,665.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2,958.18
Rate for Payer: BCBS of TX Blue Advantage	$9,860.60
Rate for Payer: BCBS of TX Blue Essentials	$11,832.72
Rate for Payer: BCBS of TX PPO	$13,147.47
Rate for Payer: Cash Price	$22,350.70
Rate for Payer: Cigna Medicaid	$23,665.44
Rate for Payer: Molina CHIP/Medicaid	$23,665.44
Rate for Payer: Multiplan Auto	$16,434.33
Rate for Payer: Multiplan Commercial	$16,434.33
Rate for Payer: Multiplan Workers Comp	$16,434.33
Rate for Payer: Parkland Medicaid	$23,665.44
Rate for Payer: Scott and White EPO/PPO	$16,434.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,665.44
Rate for Payer: Superior Health Plan EPO	$4,470.14

20MM 2 HOLE PLATE

Facility

$32,868.67

Service Code	HCPCS C1734
Hospital Charge Code	992387
Hospital Revenue Code	278
Min. Negotiated Rate	$8,217.17
Max. Negotiated Rate	$16,434.33
Rate for Payer: Cash Price	$22,350.70
Rate for Payer: Cigna Commercial	$8,217.17
Rate for Payer: Multiplan Auto	$16,434.33
Rate for Payer: Multiplan Commercial	$16,434.33
Rate for Payer: Multiplan Workers Comp	$16,434.33
Rate for Payer: Scott and White EPO/PPO	$16,434.33

2.0MM DRILL BIT, CALIBRATED

Facility

$431.30

Hospital Charge Code	992606
Hospital Revenue Code	272
Rate for Payer: Cash Price	$293.28

Know your out-of-pocket cost for care.

All Charges