White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BN CHIPS -- DHF

Facility

$731.27

Service Code	HCPCS C1713
Hospital Charge Code	81312753
Hospital Revenue Code	278
Min. Negotiated Rate	$182.82
Max. Negotiated Rate	$365.64
Rate for Payer: Aetna Commercial	$219.38
Rate for Payer: Cash Price	$643.52
Rate for Payer: Cigna Commercial	$182.82
Rate for Payer: Multiplan Auto	$365.64
Rate for Payer: Multiplan Commercial	$365.64
Rate for Payer: Multiplan Workers Comp	$365.64
Rate for Payer: Scott and White EPO/PPO	$365.64

BN CHIPS -- DHF

Facility

$731.27

Service Code	HCPCS C1713
Hospital Charge Code	81312753
Hospital Revenue Code	278
Min. Negotiated Rate	$65.81
Max. Negotiated Rate	$365.64
Rate for Payer: Aetna Commercial	$219.38
Rate for Payer: Amerigroup CHIP/Medicaid	$65.81
Rate for Payer: BCBS of TX Blue Advantage	$219.38
Rate for Payer: BCBS of TX Blue Essentials	$263.26
Rate for Payer: BCBS of TX PPO	$292.51
Rate for Payer: Cash Price	$643.52
Rate for Payer: Multiplan Auto	$365.64
Rate for Payer: Multiplan Commercial	$365.64
Rate for Payer: Multiplan Workers Comp	$365.64
Rate for Payer: Scott and White EPO/PPO	$365.64
Rate for Payer: Superior Health Plan EPO	$99.45

BND COBAN 4/5 -- DHF

Facility

$92.25

Hospital Charge Code	80240328
Hospital Revenue Code	270
Rate for Payer: Cash Price	$81.18

BND COBAN 4/5 -- DHF

Facility

$92.25

Hospital Charge Code	80240328
Hospital Revenue Code	270
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$59.96
Rate for Payer: Aetna Commercial	$50.74
Rate for Payer: Amerigroup CHIP/Medicaid	$8.30
Rate for Payer: BCBS of TX Blue Advantage	$27.68
Rate for Payer: BCBS of TX Blue Essentials	$33.21
Rate for Payer: BCBS of TX PPO	$36.90
Rate for Payer: Cash Price	$81.18
Rate for Payer: Multiplan Auto	$59.96
Rate for Payer: Multiplan Commercial	$59.96
Rate for Payer: Multiplan Workers Comp	$59.96
Rate for Payer: Scott and White EPO/PPO	$46.12
Rate for Payer: Superior Health Plan EPO	$12.55

BND ELSTC 2/3 -- DHF

Facility

$37.10

Hospital Charge Code	80240401
Hospital Revenue Code	270
Min. Negotiated Rate	$3.34
Max. Negotiated Rate	$24.12
Rate for Payer: Aetna Commercial	$20.40
Rate for Payer: Amerigroup CHIP/Medicaid	$3.34
Rate for Payer: BCBS of TX Blue Advantage	$11.13
Rate for Payer: BCBS of TX Blue Essentials	$13.36
Rate for Payer: BCBS of TX PPO	$14.84
Rate for Payer: Cash Price	$32.65
Rate for Payer: Multiplan Auto	$24.12
Rate for Payer: Multiplan Commercial	$24.12
Rate for Payer: Multiplan Workers Comp	$24.12
Rate for Payer: Scott and White EPO/PPO	$18.55
Rate for Payer: Superior Health Plan EPO	$5.05

BND ELSTC 2/3 -- DHF

Facility

$37.10

Hospital Charge Code	80240401
Hospital Revenue Code	270
Rate for Payer: Cash Price	$32.65

BND GZ 1/2 -- DHF

Facility

$64.05

Hospital Charge Code	80240609
Hospital Revenue Code	270
Rate for Payer: Cash Price	$56.36

BND GZ 1/2 -- DHF

Facility

$64.05

Hospital Charge Code	80240609
Hospital Revenue Code	270
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$41.63
Rate for Payer: Aetna Commercial	$35.23
Rate for Payer: Amerigroup CHIP/Medicaid	$5.76
Rate for Payer: BCBS of TX Blue Advantage	$19.22
Rate for Payer: BCBS of TX Blue Essentials	$23.06
Rate for Payer: BCBS of TX PPO	$25.62
Rate for Payer: Cash Price	$56.36
Rate for Payer: Multiplan Auto	$41.63
Rate for Payer: Multiplan Commercial	$41.63
Rate for Payer: Multiplan Workers Comp	$41.63
Rate for Payer: Scott and White EPO/PPO	$32.02
Rate for Payer: Superior Health Plan EPO	$8.71

BND KLING 1-3 -- DHF

Facility

$64.05

Hospital Charge Code	80241052
Hospital Revenue Code	270
Rate for Payer: Cash Price	$56.36

BND KLING 1-3 -- DHF

Facility

$64.05

Hospital Charge Code	80241052
Hospital Revenue Code	270
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$41.63
Rate for Payer: Aetna Commercial	$35.23
Rate for Payer: Amerigroup CHIP/Medicaid	$5.76
Rate for Payer: BCBS of TX Blue Advantage	$19.22
Rate for Payer: BCBS of TX Blue Essentials	$23.06
Rate for Payer: BCBS of TX PPO	$25.62
Rate for Payer: Cash Price	$56.36
Rate for Payer: Multiplan Auto	$41.63
Rate for Payer: Multiplan Commercial	$41.63
Rate for Payer: Multiplan Workers Comp	$41.63
Rate for Payer: Scott and White EPO/PPO	$32.02
Rate for Payer: Superior Health Plan EPO	$8.71

BND STKNG KNEE -- DHF

Facility

$128.08

Hospital Charge Code	80241706
Hospital Revenue Code	270
Rate for Payer: Cash Price	$112.71

BND STKNG KNEE -- DHF

Facility

$128.08

Hospital Charge Code	80241706
Hospital Revenue Code	270
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$83.25
Rate for Payer: Aetna Commercial	$70.44
Rate for Payer: Amerigroup CHIP/Medicaid	$11.53
Rate for Payer: BCBS of TX Blue Advantage	$38.42
Rate for Payer: BCBS of TX Blue Essentials	$46.11
Rate for Payer: BCBS of TX PPO	$51.23
Rate for Payer: Cash Price	$112.71
Rate for Payer: Multiplan Auto	$83.25
Rate for Payer: Multiplan Commercial	$83.25
Rate for Payer: Multiplan Workers Comp	$83.25
Rate for Payer: Scott and White EPO/PPO	$64.04
Rate for Payer: Superior Health Plan EPO	$17.42

BND STKNG THGH -- DHF

Facility

$173.39

Hospital Charge Code	80241755
Hospital Revenue Code	270
Min. Negotiated Rate	$15.61
Max. Negotiated Rate	$112.70
Rate for Payer: Aetna Commercial	$95.36
Rate for Payer: Amerigroup CHIP/Medicaid	$15.61
Rate for Payer: BCBS of TX Blue Advantage	$52.02
Rate for Payer: BCBS of TX Blue Essentials	$62.42
Rate for Payer: BCBS of TX PPO	$69.36
Rate for Payer: Cash Price	$152.58
Rate for Payer: Multiplan Auto	$112.70
Rate for Payer: Multiplan Commercial	$112.70
Rate for Payer: Multiplan Workers Comp	$112.70
Rate for Payer: Scott and White EPO/PPO	$86.70
Rate for Payer: Superior Health Plan EPO	$23.58

BND STKNG THGH -- DHF

Facility

$173.39

Hospital Charge Code	80241755
Hospital Revenue Code	270
Rate for Payer: Cash Price	$152.58

BN GRFT 3 -- DHF

Facility

$4,993.43

Service Code	HCPCS C1713
Hospital Charge Code	81312878
Hospital Revenue Code	278
Min. Negotiated Rate	$1,248.36
Max. Negotiated Rate	$2,496.72
Rate for Payer: Aetna Commercial	$1,498.03
Rate for Payer: Cash Price	$4,394.22
Rate for Payer: Cigna Commercial	$1,248.36
Rate for Payer: Multiplan Auto	$2,496.72
Rate for Payer: Multiplan Commercial	$2,496.72
Rate for Payer: Multiplan Workers Comp	$2,496.72
Rate for Payer: Scott and White EPO/PPO	$2,496.72

BN GRFT 3 -- DHF

Facility

$4,993.43

Service Code	HCPCS C1713
Hospital Charge Code	81312878
Hospital Revenue Code	278
Min. Negotiated Rate	$449.41
Max. Negotiated Rate	$2,496.72
Rate for Payer: Aetna Commercial	$1,498.03
Rate for Payer: Amerigroup CHIP/Medicaid	$449.41
Rate for Payer: BCBS of TX Blue Advantage	$1,498.03
Rate for Payer: BCBS of TX Blue Essentials	$1,797.63
Rate for Payer: BCBS of TX PPO	$1,997.37
Rate for Payer: Cash Price	$4,394.22
Rate for Payer: Multiplan Auto	$2,496.72
Rate for Payer: Multiplan Commercial	$2,496.72
Rate for Payer: Multiplan Workers Comp	$2,496.72
Rate for Payer: Scott and White EPO/PPO	$2,496.72
Rate for Payer: Superior Health Plan EPO	$679.11

BN GRFT -- DHF

Facility

$2,358.73

Service Code	HCPCS C1713
Hospital Charge Code	81312852
Hospital Revenue Code	278
Min. Negotiated Rate	$212.29
Max. Negotiated Rate	$1,179.36
Rate for Payer: Aetna Commercial	$707.62
Rate for Payer: Amerigroup CHIP/Medicaid	$212.29
Rate for Payer: BCBS of TX Blue Advantage	$707.62
Rate for Payer: BCBS of TX Blue Essentials	$849.14
Rate for Payer: BCBS of TX PPO	$943.49
Rate for Payer: Cash Price	$2,075.68
Rate for Payer: Multiplan Auto	$1,179.36
Rate for Payer: Multiplan Commercial	$1,179.36
Rate for Payer: Multiplan Workers Comp	$1,179.36
Rate for Payer: Scott and White EPO/PPO	$1,179.36
Rate for Payer: Superior Health Plan EPO	$320.79

BN GRFT -- DHF

Facility

$2,358.73

Service Code	HCPCS C1713
Hospital Charge Code	81312852
Hospital Revenue Code	278
Min. Negotiated Rate	$589.68
Max. Negotiated Rate	$1,179.36
Rate for Payer: Aetna Commercial	$707.62
Rate for Payer: Cash Price	$2,075.68
Rate for Payer: Cigna Commercial	$589.68
Rate for Payer: Multiplan Auto	$1,179.36
Rate for Payer: Multiplan Commercial	$1,179.36
Rate for Payer: Multiplan Workers Comp	$1,179.36
Rate for Payer: Scott and White EPO/PPO	$1,179.36

BN MATRIX 2

Facility

$2,216.75

Service Code	HCPCS L8699
Hospital Charge Code	81329120
Hospital Revenue Code	278
Min. Negotiated Rate	$199.51
Max. Negotiated Rate	$1,108.38
Rate for Payer: Aetna Commercial	$665.02
Rate for Payer: Amerigroup CHIP/Medicaid	$199.51
Rate for Payer: BCBS of TX Blue Advantage	$665.02
Rate for Payer: BCBS of TX Blue Essentials	$798.03
Rate for Payer: BCBS of TX PPO	$886.70
Rate for Payer: Cash Price	$1,950.74
Rate for Payer: Multiplan Auto	$1,108.38
Rate for Payer: Multiplan Commercial	$1,108.38
Rate for Payer: Multiplan Workers Comp	$1,108.38
Rate for Payer: Scott and White EPO/PPO	$1,108.38
Rate for Payer: Superior Health Plan EPO	$301.48

BN MATRIX 2

Facility

$2,216.75

Service Code	HCPCS L8699
Hospital Charge Code	81329120
Hospital Revenue Code	278
Min. Negotiated Rate	$554.19
Max. Negotiated Rate	$1,108.38
Rate for Payer: Aetna Commercial	$665.02
Rate for Payer: Cash Price	$1,950.74
Rate for Payer: Cigna Commercial	$554.19
Rate for Payer: Multiplan Auto	$1,108.38
Rate for Payer: Multiplan Commercial	$1,108.38
Rate for Payer: Multiplan Workers Comp	$1,108.38
Rate for Payer: Scott and White EPO/PPO	$1,108.38

BN SUBST FOAM 10CC

Facility

$10,768.19

Service Code	HCPCS C1713
Hospital Charge Code	40106866
Hospital Revenue Code	278
Min. Negotiated Rate	$2,692.05
Max. Negotiated Rate	$5,384.10
Rate for Payer: Aetna Commercial	$3,230.46
Rate for Payer: Cash Price	$9,476.01
Rate for Payer: Cigna Commercial	$2,692.05
Rate for Payer: Multiplan Auto	$5,384.10
Rate for Payer: Multiplan Commercial	$5,384.10
Rate for Payer: Multiplan Workers Comp	$5,384.10
Rate for Payer: Scott and White EPO/PPO	$5,384.10

BN SUBST FOAM 10CC

Facility

$10,768.19

Service Code	HCPCS C1713
Hospital Charge Code	40106866
Hospital Revenue Code	278
Min. Negotiated Rate	$969.14
Max. Negotiated Rate	$5,384.10
Rate for Payer: Aetna Commercial	$3,230.46
Rate for Payer: Amerigroup CHIP/Medicaid	$969.14
Rate for Payer: BCBS of TX Blue Advantage	$3,230.46
Rate for Payer: BCBS of TX Blue Essentials	$3,876.55
Rate for Payer: BCBS of TX PPO	$4,307.28
Rate for Payer: Cash Price	$9,476.01
Rate for Payer: Multiplan Auto	$5,384.10
Rate for Payer: Multiplan Commercial	$5,384.10
Rate for Payer: Multiplan Workers Comp	$5,384.10
Rate for Payer: Scott and White EPO/PPO	$5,384.10
Rate for Payer: Superior Health Plan EPO	$1,464.47

Body Fluid Culture

Facility

$309.00

Service Code	CPT 87070
Hospital Charge Code	4107074
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$200.85
Rate for Payer: Aetna Commercial	$9.05
Rate for Payer: Aetna Medicare	$12.93
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$14.22
Rate for Payer: BCBS of TX Blue Essentials	$17.07
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$19.05
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cigna Medicaid	$8.62
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$8.62
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$8.62
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.62
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

Body Fluid Culture

Facility

$309.00

Service Code	CPT 87070
Hospital Charge Code	4107074
Hospital Revenue Code	306
Rate for Payer: Cash Price	$271.92

.Body Fluid Differential

Facility

$242.00

Service Code	CPT 89051
Hospital Charge Code	1600295
Hospital Revenue Code	300
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$157.30
Rate for Payer: Aetna Commercial	$5.88
Rate for Payer: Aetna Medicare	$8.40
Rate for Payer: Amerigroup CHIP/Medicaid	$2.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.60
Rate for Payer: Amerigroup Medicare	$5.60
Rate for Payer: BCBS of TX Blue Advantage	$9.24
Rate for Payer: BCBS of TX Blue Essentials	$11.09
Rate for Payer: BCBS of TX Medicare	$5.60
Rate for Payer: BCBS of TX PPO	$12.38
Rate for Payer: Cash Price	$212.96
Rate for Payer: Cash Price	$212.96
Rate for Payer: Cigna Medicaid	$5.60
Rate for Payer: Cigna Medicare	$5.60
Rate for Payer: Employer Direct Commercial	$5.60
Rate for Payer: Humana Medicare/TRICARE	$5.60
Rate for Payer: Molina CHIP/Medicaid	$5.60
Rate for Payer: Molina Dual Medicare/Medicaid	$5.60
Rate for Payer: Molina Medicare	$5.60
Rate for Payer: Multiplan Auto	$157.30
Rate for Payer: Multiplan Commercial	$157.30
Rate for Payer: Multiplan Workers Comp	$157.30
Rate for Payer: Parkland Medicaid	$5.60
Rate for Payer: Scott and White EPO/PPO	$7.00
Rate for Payer: Scott and White Medicare	$5.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.60
Rate for Payer: Superior Health Plan EPO	$5.60
Rate for Payer: Superior Health Plan Medicare	$5.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.60
Rate for Payer: Universal American Medicare	$5.60
Rate for Payer: Wellcare Medicare	$5.60
Rate for Payer: Wellmed Medicare	$5.60

Know your out-of-pocket cost for care.

All Charges