White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Myxredlin insulin regular in 0.9 % NaCl 100

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	7746921
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

Myxredlin insulin regular in 0.9 % NaCl 100

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	7746921
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

MYXREDLIN SOD CHL 0.9% BAG 12X100ML

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	7446921
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

MYXREDLIN SOD CHL 0.9% BAG 12X100ML

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	7446921
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

NAIL FEMORAL RETROGRADE EVO AUTOBAHN 12MM

Facility

$14,568.00

Service Code	HCPCS C1776
Hospital Charge Code	146676
Hospital Revenue Code	278
Min. Negotiated Rate	$3,642.00
Max. Negotiated Rate	$7,284.00
Rate for Payer: Cash Price	$9,906.24
Rate for Payer: Cigna Commercial	$3,642.00
Rate for Payer: Multiplan Auto	$7,284.00
Rate for Payer: Multiplan Commercial	$7,284.00
Rate for Payer: Multiplan Workers Comp	$7,284.00
Rate for Payer: Scott and White EPO/PPO	$7,284.00

NAIL FEMORAL RETROGRADE EVO AUTOBAHN 12MM

Facility

$14,568.00

Service Code	HCPCS C1776
Hospital Charge Code	146676
Hospital Revenue Code	278
Min. Negotiated Rate	$1,311.12
Max. Negotiated Rate	$10,488.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1,311.12
Rate for Payer: BCBS of TX Blue Advantage	$4,370.40
Rate for Payer: BCBS of TX Blue Essentials	$5,244.48
Rate for Payer: BCBS of TX PPO	$5,827.20
Rate for Payer: Cash Price	$9,906.24
Rate for Payer: Cigna Medicaid	$10,488.96
Rate for Payer: Molina CHIP/Medicaid	$10,488.96
Rate for Payer: Multiplan Auto	$7,284.00
Rate for Payer: Multiplan Commercial	$7,284.00
Rate for Payer: Multiplan Workers Comp	$7,284.00
Rate for Payer: Parkland Medicaid	$10,488.96
Rate for Payer: Scott and White EPO/PPO	$7,284.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,488.96
Rate for Payer: Superior Health Plan EPO	$1,981.25

NAIL FEMORAL ZIMMER NATURAL NAIL 11.5MM

Facility

$9,842.00

Service Code	HCPCS C1776
Hospital Charge Code	146541
Hospital Revenue Code	278
Min. Negotiated Rate	$885.78
Max. Negotiated Rate	$7,086.24
Rate for Payer: Amerigroup CHIP/Medicaid	$885.78
Rate for Payer: BCBS of TX Blue Advantage	$2,952.60
Rate for Payer: BCBS of TX Blue Essentials	$3,543.12
Rate for Payer: BCBS of TX PPO	$3,936.80
Rate for Payer: Cash Price	$6,692.56
Rate for Payer: Cigna Medicaid	$7,086.24
Rate for Payer: Molina CHIP/Medicaid	$7,086.24
Rate for Payer: Multiplan Auto	$4,921.00
Rate for Payer: Multiplan Commercial	$4,921.00
Rate for Payer: Multiplan Workers Comp	$4,921.00
Rate for Payer: Parkland Medicaid	$7,086.24
Rate for Payer: Scott and White EPO/PPO	$4,921.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,086.24
Rate for Payer: Superior Health Plan EPO	$1,338.51

NAIL FEMORAL ZIMMER NATURAL NAIL 11.5MM

Facility

$9,842.00

Service Code	HCPCS C1776
Hospital Charge Code	146541
Hospital Revenue Code	278
Min. Negotiated Rate	$2,460.50
Max. Negotiated Rate	$4,921.00
Rate for Payer: Cash Price	$6,692.56
Rate for Payer: Cigna Commercial	$2,460.50
Rate for Payer: Multiplan Auto	$4,921.00
Rate for Payer: Multiplan Commercial	$4,921.00
Rate for Payer: Multiplan Workers Comp	$4,921.00
Rate for Payer: Scott and White EPO/PPO	$4,921.00

NAIL FIBULA

Facility

$25,777.00

Service Code	HCPCS C1776
Hospital Charge Code	145500
Hospital Revenue Code	278
Min. Negotiated Rate	$6,444.25
Max. Negotiated Rate	$12,888.50
Rate for Payer: Cash Price	$17,528.36
Rate for Payer: Cigna Commercial	$6,444.25
Rate for Payer: Multiplan Auto	$12,888.50
Rate for Payer: Multiplan Commercial	$12,888.50
Rate for Payer: Multiplan Workers Comp	$12,888.50
Rate for Payer: Scott and White EPO/PPO	$12,888.50

NAIL FIBULA

Facility

$25,777.00

Service Code	HCPCS C1776
Hospital Charge Code	145500
Hospital Revenue Code	278
Min. Negotiated Rate	$2,319.93
Max. Negotiated Rate	$18,559.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2,319.93
Rate for Payer: BCBS of TX Blue Advantage	$7,733.10
Rate for Payer: BCBS of TX Blue Essentials	$9,279.72
Rate for Payer: BCBS of TX PPO	$10,310.80
Rate for Payer: Cash Price	$17,528.36
Rate for Payer: Cigna Medicaid	$18,559.44
Rate for Payer: Molina CHIP/Medicaid	$18,559.44
Rate for Payer: Multiplan Auto	$12,888.50
Rate for Payer: Multiplan Commercial	$12,888.50
Rate for Payer: Multiplan Workers Comp	$12,888.50
Rate for Payer: Parkland Medicaid	$18,559.44
Rate for Payer: Scott and White EPO/PPO	$12,888.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,559.44
Rate for Payer: Superior Health Plan EPO	$3,505.67

NAIL GAMMA LONG

Facility

$14,439.00

Service Code	HCPCS C1776
Hospital Charge Code	145506
Hospital Revenue Code	278
Min. Negotiated Rate	$1,299.51
Max. Negotiated Rate	$10,396.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1,299.51
Rate for Payer: BCBS of TX Blue Advantage	$4,331.70
Rate for Payer: BCBS of TX Blue Essentials	$5,198.04
Rate for Payer: BCBS of TX PPO	$5,775.60
Rate for Payer: Cash Price	$9,818.52
Rate for Payer: Cigna Medicaid	$10,396.08
Rate for Payer: Molina CHIP/Medicaid	$10,396.08
Rate for Payer: Multiplan Auto	$7,219.50
Rate for Payer: Multiplan Commercial	$7,219.50
Rate for Payer: Multiplan Workers Comp	$7,219.50
Rate for Payer: Parkland Medicaid	$10,396.08
Rate for Payer: Scott and White EPO/PPO	$7,219.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,396.08
Rate for Payer: Superior Health Plan EPO	$1,963.70

NAIL GAMMA LONG

Facility

$14,439.00

Service Code	HCPCS C1776
Hospital Charge Code	145506
Hospital Revenue Code	278
Min. Negotiated Rate	$3,609.75
Max. Negotiated Rate	$7,219.50
Rate for Payer: Cash Price	$9,818.52
Rate for Payer: Cigna Commercial	$3,609.75
Rate for Payer: Multiplan Auto	$7,219.50
Rate for Payer: Multiplan Commercial	$7,219.50
Rate for Payer: Multiplan Workers Comp	$7,219.50
Rate for Payer: Scott and White EPO/PPO	$7,219.50

NAIL HIP AFFIXUS 11MM X 180MM

Facility

$10,593.00

Service Code	HCPCS C1776
Hospital Charge Code	146545
Hospital Revenue Code	278
Min. Negotiated Rate	$953.37
Max. Negotiated Rate	$7,626.96
Rate for Payer: Amerigroup CHIP/Medicaid	$953.37
Rate for Payer: BCBS of TX Blue Advantage	$3,177.90
Rate for Payer: BCBS of TX Blue Essentials	$3,813.48
Rate for Payer: BCBS of TX PPO	$4,237.20
Rate for Payer: Cash Price	$7,203.24
Rate for Payer: Cigna Medicaid	$7,626.96
Rate for Payer: Molina CHIP/Medicaid	$7,626.96
Rate for Payer: Multiplan Auto	$5,296.50
Rate for Payer: Multiplan Commercial	$5,296.50
Rate for Payer: Multiplan Workers Comp	$5,296.50
Rate for Payer: Parkland Medicaid	$7,626.96
Rate for Payer: Scott and White EPO/PPO	$5,296.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,626.96
Rate for Payer: Superior Health Plan EPO	$1,440.65

NAIL HIP AFFIXUS 11MM X 180MM

Facility

$10,593.00

Service Code	HCPCS C1776
Hospital Charge Code	146545
Hospital Revenue Code	278
Min. Negotiated Rate	$2,648.25
Max. Negotiated Rate	$5,296.50
Rate for Payer: Cash Price	$7,203.24
Rate for Payer: Cigna Commercial	$2,648.25
Rate for Payer: Multiplan Auto	$5,296.50
Rate for Payer: Multiplan Commercial	$5,296.50
Rate for Payer: Multiplan Workers Comp	$5,296.50
Rate for Payer: Scott and White EPO/PPO	$5,296.50

NAIL HUMERAL

Facility

$9,353.00

Service Code	HCPCS C1776
Hospital Charge Code	145143
Hospital Revenue Code	278
Min. Negotiated Rate	$2,338.25
Max. Negotiated Rate	$4,676.50
Rate for Payer: Cash Price	$6,360.04
Rate for Payer: Cigna Commercial	$2,338.25
Rate for Payer: Multiplan Auto	$4,676.50
Rate for Payer: Multiplan Commercial	$4,676.50
Rate for Payer: Multiplan Workers Comp	$4,676.50
Rate for Payer: Scott and White EPO/PPO	$4,676.50

NAIL HUMERAL

Facility

$9,353.00

Service Code	HCPCS C1776
Hospital Charge Code	145143
Hospital Revenue Code	278
Min. Negotiated Rate	$841.77
Max. Negotiated Rate	$6,734.16
Rate for Payer: Amerigroup CHIP/Medicaid	$841.77
Rate for Payer: BCBS of TX Blue Advantage	$2,805.90
Rate for Payer: BCBS of TX Blue Essentials	$3,367.08
Rate for Payer: BCBS of TX PPO	$3,741.20
Rate for Payer: Cash Price	$6,360.04
Rate for Payer: Cigna Medicaid	$6,734.16
Rate for Payer: Molina CHIP/Medicaid	$6,734.16
Rate for Payer: Multiplan Auto	$4,676.50
Rate for Payer: Multiplan Commercial	$4,676.50
Rate for Payer: Multiplan Workers Comp	$4,676.50
Rate for Payer: Parkland Medicaid	$6,734.16
Rate for Payer: Scott and White EPO/PPO	$4,676.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,734.16
Rate for Payer: Superior Health Plan EPO	$1,272.01

NAIL HUMERAL 8V22.5

Facility

$22,018.00

Service Code	HCPCS C1776
Hospital Charge Code	8428490
Hospital Revenue Code	278
Min. Negotiated Rate	$5,504.50
Max. Negotiated Rate	$11,009.00
Rate for Payer: Cash Price	$14,972.24
Rate for Payer: Cigna Commercial	$5,504.50
Rate for Payer: Multiplan Auto	$11,009.00
Rate for Payer: Multiplan Commercial	$11,009.00
Rate for Payer: Multiplan Workers Comp	$11,009.00
Rate for Payer: Scott and White EPO/PPO	$11,009.00

NAIL HUMERAL 8V22.5

Facility

$22,018.00

Service Code	HCPCS C1776
Hospital Charge Code	8428490
Hospital Revenue Code	278
Min. Negotiated Rate	$1,981.62
Max. Negotiated Rate	$15,852.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1,981.62
Rate for Payer: BCBS of TX Blue Advantage	$6,605.40
Rate for Payer: BCBS of TX Blue Essentials	$7,926.48
Rate for Payer: BCBS of TX PPO	$8,807.20
Rate for Payer: Cash Price	$14,972.24
Rate for Payer: Cigna Medicaid	$15,852.96
Rate for Payer: Molina CHIP/Medicaid	$15,852.96
Rate for Payer: Multiplan Auto	$11,009.00
Rate for Payer: Multiplan Commercial	$11,009.00
Rate for Payer: Multiplan Workers Comp	$11,009.00
Rate for Payer: Parkland Medicaid	$15,852.96
Rate for Payer: Scott and White EPO/PPO	$11,009.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,852.96
Rate for Payer: Superior Health Plan EPO	$2,994.45

NAIL IM 10X170MM 125 DEG TFN-ADV SHRT STRL

Facility

$23,673.00

Service Code	HCPCS C1776
Hospital Charge Code	123142
Hospital Revenue Code	278
Min. Negotiated Rate	$2,130.57
Max. Negotiated Rate	$17,044.56
Rate for Payer: Amerigroup CHIP/Medicaid	$2,130.57
Rate for Payer: BCBS of TX Blue Advantage	$7,101.90
Rate for Payer: BCBS of TX Blue Essentials	$8,522.28
Rate for Payer: BCBS of TX PPO	$9,469.20
Rate for Payer: Cash Price	$16,097.64
Rate for Payer: Cigna Medicaid	$17,044.56
Rate for Payer: Molina CHIP/Medicaid	$17,044.56
Rate for Payer: Multiplan Auto	$11,836.50
Rate for Payer: Multiplan Commercial	$11,836.50
Rate for Payer: Multiplan Workers Comp	$11,836.50
Rate for Payer: Parkland Medicaid	$17,044.56
Rate for Payer: Scott and White EPO/PPO	$11,836.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,044.56
Rate for Payer: Superior Health Plan EPO	$3,219.53

NAIL IM 10X170MM 125 DEG TFN-ADV SHRT STRL

Facility

$23,673.00

Service Code	HCPCS C1776
Hospital Charge Code	123142
Hospital Revenue Code	278
Min. Negotiated Rate	$5,918.25
Max. Negotiated Rate	$11,836.50
Rate for Payer: Cash Price	$16,097.64
Rate for Payer: Cigna Commercial	$5,918.25
Rate for Payer: Multiplan Auto	$11,836.50
Rate for Payer: Multiplan Commercial	$11,836.50
Rate for Payer: Multiplan Workers Comp	$11,836.50
Rate for Payer: Scott and White EPO/PPO	$11,836.50

NAIL INTRAMEDULLARY TYP1 -- DHF

Facility

$11,221.00

Service Code	HCPCS C1776
Hospital Charge Code	81330011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,805.25
Max. Negotiated Rate	$5,610.50
Rate for Payer: Cash Price	$7,630.28
Rate for Payer: Cigna Commercial	$2,805.25
Rate for Payer: Multiplan Auto	$5,610.50
Rate for Payer: Multiplan Commercial	$5,610.50
Rate for Payer: Multiplan Workers Comp	$5,610.50
Rate for Payer: Scott and White EPO/PPO	$5,610.50

NAIL INTRAMEDULLARY TYP1 -- DHF

Facility

$11,221.00

Service Code	HCPCS C1776
Hospital Charge Code	81330011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,009.89
Max. Negotiated Rate	$8,079.12
Rate for Payer: Amerigroup CHIP/Medicaid	$1,009.89
Rate for Payer: BCBS of TX Blue Advantage	$3,366.30
Rate for Payer: BCBS of TX Blue Essentials	$4,039.56
Rate for Payer: BCBS of TX PPO	$4,488.40
Rate for Payer: Cash Price	$7,630.28
Rate for Payer: Cigna Medicaid	$8,079.12
Rate for Payer: Molina CHIP/Medicaid	$8,079.12
Rate for Payer: Multiplan Auto	$5,610.50
Rate for Payer: Multiplan Commercial	$5,610.50
Rate for Payer: Multiplan Workers Comp	$5,610.50
Rate for Payer: Parkland Medicaid	$8,079.12
Rate for Payer: Scott and White EPO/PPO	$5,610.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,079.12
Rate for Payer: Superior Health Plan EPO	$1,526.06

NAIL INTRAMEDULLARY TYP4 -- DHF

Facility

$15,528.00

Service Code	HCPCS C1776
Hospital Charge Code	81330045
Hospital Revenue Code	278
Min. Negotiated Rate	$1,397.52
Max. Negotiated Rate	$11,180.16
Rate for Payer: Amerigroup CHIP/Medicaid	$1,397.52
Rate for Payer: BCBS of TX Blue Advantage	$4,658.40
Rate for Payer: BCBS of TX Blue Essentials	$5,590.08
Rate for Payer: BCBS of TX PPO	$6,211.20
Rate for Payer: Cash Price	$10,559.04
Rate for Payer: Cigna Medicaid	$11,180.16
Rate for Payer: Molina CHIP/Medicaid	$11,180.16
Rate for Payer: Multiplan Auto	$7,764.00
Rate for Payer: Multiplan Commercial	$7,764.00
Rate for Payer: Multiplan Workers Comp	$7,764.00
Rate for Payer: Parkland Medicaid	$11,180.16
Rate for Payer: Scott and White EPO/PPO	$7,764.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,180.16
Rate for Payer: Superior Health Plan EPO	$2,111.81

NAIL INTRAMEDULLARY TYP4 -- DHF

Facility

$15,528.00

Service Code	HCPCS C1776
Hospital Charge Code	81330045
Hospital Revenue Code	278
Min. Negotiated Rate	$3,882.00
Max. Negotiated Rate	$7,764.00
Rate for Payer: Cash Price	$10,559.04
Rate for Payer: Cigna Commercial	$3,882.00
Rate for Payer: Multiplan Auto	$7,764.00
Rate for Payer: Multiplan Commercial	$7,764.00
Rate for Payer: Multiplan Workers Comp	$7,764.00
Rate for Payer: Scott and White EPO/PPO	$7,764.00

NAIL INTRAMEDULLARY TYP5 -- DHF

Facility

$13,362.00

Service Code	HCPCS C1776
Hospital Charge Code	81330060
Hospital Revenue Code	278
Min. Negotiated Rate	$3,340.50
Max. Negotiated Rate	$6,681.00
Rate for Payer: Cash Price	$9,086.16
Rate for Payer: Cigna Commercial	$3,340.50
Rate for Payer: Multiplan Auto	$6,681.00
Rate for Payer: Multiplan Commercial	$6,681.00
Rate for Payer: Multiplan Workers Comp	$6,681.00
Rate for Payer: Scott and White EPO/PPO	$6,681.00

Know your out-of-pocket cost for care.

All Charges