White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CABLE PACING 4051I

Facility

$127.71

Hospital Charge Code	8478522
Hospital Revenue Code	272
Min. Negotiated Rate	$11.49
Max. Negotiated Rate	$83.01
Rate for Payer: Aetna Commercial	$70.24
Rate for Payer: Amerigroup CHIP/Medicaid	$11.49
Rate for Payer: BCBS of TX Blue Advantage	$38.31
Rate for Payer: BCBS of TX Blue Essentials	$45.98
Rate for Payer: BCBS of TX PPO	$51.08
Rate for Payer: Cash Price	$112.38
Rate for Payer: Multiplan Auto	$83.01
Rate for Payer: Multiplan Commercial	$83.01
Rate for Payer: Multiplan Workers Comp	$83.01
Rate for Payer: Scott and White EPO/PPO	$63.86
Rate for Payer: Superior Health Plan EPO	$17.37

CABLE PACING 4051I

Facility

$127.71

Hospital Charge Code	8478522
Hospital Revenue Code	272
Rate for Payer: Cash Price	$112.38

CABLE PLUG 5.0MM

Facility

$1,148.92

Service Code	HCPCS C1713
Hospital Charge Code	8428495
Hospital Revenue Code	278
Min. Negotiated Rate	$287.23
Max. Negotiated Rate	$574.46
Rate for Payer: Aetna Commercial	$344.68
Rate for Payer: Cash Price	$1,011.05
Rate for Payer: Cigna Commercial	$287.23
Rate for Payer: Multiplan Auto	$574.46
Rate for Payer: Multiplan Commercial	$574.46
Rate for Payer: Multiplan Workers Comp	$574.46
Rate for Payer: Scott and White EPO/PPO	$574.46

CABLE PLUG 5.0MM

Facility

$1,148.92

Service Code	HCPCS C1713
Hospital Charge Code	8428495
Hospital Revenue Code	278
Min. Negotiated Rate	$103.40
Max. Negotiated Rate	$574.46
Rate for Payer: Aetna Commercial	$344.68
Rate for Payer: Amerigroup CHIP/Medicaid	$103.40
Rate for Payer: BCBS of TX Blue Advantage	$344.68
Rate for Payer: BCBS of TX Blue Essentials	$413.61
Rate for Payer: BCBS of TX PPO	$459.57
Rate for Payer: Cash Price	$1,011.05
Rate for Payer: Multiplan Auto	$574.46
Rate for Payer: Multiplan Commercial	$574.46
Rate for Payer: Multiplan Workers Comp	$574.46
Rate for Payer: Scott and White EPO/PPO	$574.46
Rate for Payer: Superior Health Plan EPO	$156.25

CABLE THRESHOLD PM SJ4 -- DHF

Facility

$136.20

Hospital Charge Code	40082505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$119.86

CABLE THRESHOLD PM SJ4 -- DHF

Facility

$136.20

Hospital Charge Code	40082505
Hospital Revenue Code	272
Min. Negotiated Rate	$12.26
Max. Negotiated Rate	$88.53
Rate for Payer: Aetna Commercial	$74.91
Rate for Payer: Amerigroup CHIP/Medicaid	$12.26
Rate for Payer: BCBS of TX Blue Advantage	$40.86
Rate for Payer: BCBS of TX Blue Essentials	$49.03
Rate for Payer: BCBS of TX PPO	$54.48
Rate for Payer: Cash Price	$119.86
Rate for Payer: Multiplan Auto	$88.53
Rate for Payer: Multiplan Commercial	$88.53
Rate for Payer: Multiplan Workers Comp	$88.53
Rate for Payer: Scott and White EPO/PPO	$68.10
Rate for Payer: Superior Health Plan EPO	$18.52

CAGE ACIF

Facility

$10,240.96

Service Code	HCPCS C1713
Hospital Charge Code	8420465
Hospital Revenue Code	278
Min. Negotiated Rate	$921.69
Max. Negotiated Rate	$5,120.48
Rate for Payer: Aetna Commercial	$3,072.29
Rate for Payer: Amerigroup CHIP/Medicaid	$921.69
Rate for Payer: BCBS of TX Blue Advantage	$3,072.29
Rate for Payer: BCBS of TX Blue Essentials	$3,686.75
Rate for Payer: BCBS of TX PPO	$4,096.38
Rate for Payer: Cash Price	$9,012.04
Rate for Payer: Multiplan Auto	$5,120.48
Rate for Payer: Multiplan Commercial	$5,120.48
Rate for Payer: Multiplan Workers Comp	$5,120.48
Rate for Payer: Scott and White EPO/PPO	$5,120.48
Rate for Payer: Superior Health Plan EPO	$1,392.77

CAGE ACIF

Facility

$10,240.96

Service Code	HCPCS C1713
Hospital Charge Code	8420465
Hospital Revenue Code	278
Min. Negotiated Rate	$2,560.24
Max. Negotiated Rate	$5,120.48
Rate for Payer: Aetna Commercial	$3,072.29
Rate for Payer: Cash Price	$9,012.04
Rate for Payer: Cigna Commercial	$2,560.24
Rate for Payer: Multiplan Auto	$5,120.48
Rate for Payer: Multiplan Commercial	$5,120.48
Rate for Payer: Multiplan Workers Comp	$5,120.48
Rate for Payer: Scott and White EPO/PPO	$5,120.48

cage interbody acif

Facility

$7,831.33

Service Code	HCPCS C1713
Hospital Charge Code	8672536
Hospital Revenue Code	278
Min. Negotiated Rate	$704.82
Max. Negotiated Rate	$3,915.66
Rate for Payer: Aetna Commercial	$2,349.40
Rate for Payer: Amerigroup CHIP/Medicaid	$704.82
Rate for Payer: BCBS of TX Blue Advantage	$2,349.40
Rate for Payer: BCBS of TX Blue Essentials	$2,819.28
Rate for Payer: BCBS of TX PPO	$3,132.53
Rate for Payer: Cash Price	$6,891.57
Rate for Payer: Multiplan Auto	$3,915.66
Rate for Payer: Multiplan Commercial	$3,915.66
Rate for Payer: Multiplan Workers Comp	$3,915.66
Rate for Payer: Scott and White EPO/PPO	$3,915.66
Rate for Payer: Superior Health Plan EPO	$1,065.06

cage interbody acif

Facility

$7,831.33

Service Code	HCPCS C1713
Hospital Charge Code	8672536
Hospital Revenue Code	278
Min. Negotiated Rate	$1,957.83
Max. Negotiated Rate	$3,915.66
Rate for Payer: Aetna Commercial	$2,349.40
Rate for Payer: Cash Price	$6,891.57
Rate for Payer: Cigna Commercial	$1,957.83
Rate for Payer: Multiplan Auto	$3,915.66
Rate for Payer: Multiplan Commercial	$3,915.66
Rate for Payer: Multiplan Workers Comp	$3,915.66
Rate for Payer: Scott and White EPO/PPO	$3,915.66

CAGE PEEK VAULT 32MMX8X15MM

Facility

$36,144.58

Service Code	HCPCS C1713
Hospital Charge Code	8394470
Hospital Revenue Code	278
Min. Negotiated Rate	$9,036.14
Max. Negotiated Rate	$18,072.29
Rate for Payer: Aetna Commercial	$10,843.37
Rate for Payer: Cash Price	$31,807.23
Rate for Payer: Cigna Commercial	$9,036.14
Rate for Payer: Multiplan Auto	$18,072.29
Rate for Payer: Multiplan Commercial	$18,072.29
Rate for Payer: Multiplan Workers Comp	$18,072.29
Rate for Payer: Scott and White EPO/PPO	$18,072.29

CAGE PEEK VAULT 32MMX8X15MM

Facility

$36,144.58

Service Code	HCPCS C1713
Hospital Charge Code	8394470
Hospital Revenue Code	278
Min. Negotiated Rate	$3,253.01
Max. Negotiated Rate	$18,072.29
Rate for Payer: Aetna Commercial	$10,843.37
Rate for Payer: Amerigroup CHIP/Medicaid	$3,253.01
Rate for Payer: BCBS of TX Blue Advantage	$10,843.37
Rate for Payer: BCBS of TX Blue Essentials	$13,012.05
Rate for Payer: BCBS of TX PPO	$14,457.83
Rate for Payer: Cash Price	$31,807.23
Rate for Payer: Multiplan Auto	$18,072.29
Rate for Payer: Multiplan Commercial	$18,072.29
Rate for Payer: Multiplan Workers Comp	$18,072.29
Rate for Payer: Scott and White EPO/PPO	$18,072.29
Rate for Payer: Superior Health Plan EPO	$4,915.66

cage vault peek 32mmx15x15mm

Facility

$36,144.58

Service Code	HCPCS C1713
Hospital Charge Code	8394463
Hospital Revenue Code	278
Min. Negotiated Rate	$9,036.14
Max. Negotiated Rate	$18,072.29
Rate for Payer: Aetna Commercial	$10,843.37
Rate for Payer: Cash Price	$31,807.23
Rate for Payer: Cigna Commercial	$9,036.14
Rate for Payer: Multiplan Auto	$18,072.29
Rate for Payer: Multiplan Commercial	$18,072.29
Rate for Payer: Multiplan Workers Comp	$18,072.29
Rate for Payer: Scott and White EPO/PPO	$18,072.29

cage vault peek 32mmx15x15mm

Facility

$36,144.58

Service Code	HCPCS C1713
Hospital Charge Code	8394463
Hospital Revenue Code	278
Min. Negotiated Rate	$3,253.01
Max. Negotiated Rate	$18,072.29
Rate for Payer: Aetna Commercial	$10,843.37
Rate for Payer: Amerigroup CHIP/Medicaid	$3,253.01
Rate for Payer: BCBS of TX Blue Advantage	$10,843.37
Rate for Payer: BCBS of TX Blue Essentials	$13,012.05
Rate for Payer: BCBS of TX PPO	$14,457.83
Rate for Payer: Cash Price	$31,807.23
Rate for Payer: Multiplan Auto	$18,072.29
Rate for Payer: Multiplan Commercial	$18,072.29
Rate for Payer: Multiplan Workers Comp	$18,072.29
Rate for Payer: Scott and White EPO/PPO	$18,072.29
Rate for Payer: Superior Health Plan EPO	$4,915.66

Calcitonin, Serum SO

Facility

$419.00

Service Code	CPT 82308
Hospital Charge Code	1701564
Hospital Revenue Code	301
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$272.35
Rate for Payer: Aetna Commercial	$28.12
Rate for Payer: Aetna Medicare	$40.18
Rate for Payer: Amerigroup CHIP/Medicaid	$10.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.79
Rate for Payer: Amerigroup Medicare	$26.79
Rate for Payer: BCBS of TX Blue Advantage	$44.20
Rate for Payer: BCBS of TX Blue Essentials	$53.04
Rate for Payer: BCBS of TX Medicare	$26.79
Rate for Payer: BCBS of TX PPO	$59.21
Rate for Payer: Cash Price	$368.72
Rate for Payer: Cash Price	$368.72
Rate for Payer: Cigna Medicaid	$26.79
Rate for Payer: Cigna Medicare	$26.79
Rate for Payer: Employer Direct Commercial	$26.79
Rate for Payer: Humana Medicare/TRICARE	$26.79
Rate for Payer: Molina CHIP/Medicaid	$26.79
Rate for Payer: Molina Dual Medicare/Medicaid	$26.79
Rate for Payer: Molina Medicare	$26.79
Rate for Payer: Multiplan Auto	$272.35
Rate for Payer: Multiplan Commercial	$272.35
Rate for Payer: Multiplan Workers Comp	$272.35
Rate for Payer: Parkland Medicaid	$26.79
Rate for Payer: Scott and White EPO/PPO	$33.49
Rate for Payer: Scott and White Medicare	$26.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.79
Rate for Payer: Superior Health Plan EPO	$26.79
Rate for Payer: Superior Health Plan Medicare	$26.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.79
Rate for Payer: Universal American Medicare	$26.79
Rate for Payer: Wellcare Medicare	$26.79
Rate for Payer: Wellmed Medicare	$26.79

Calcitonin, Serum SO

Facility

$419.00

Service Code	CPT 82308
Hospital Charge Code	1701564
Hospital Revenue Code	301
Rate for Payer: Cash Price	$368.72

calcitriol 0.25 mcg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77431842
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

calcitriol 0.25 mcg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77431842
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Calcitriol(1,25 di-OH Vit D) SO

Facility

$454.00

Service Code	CPT 82652
Hospital Charge Code	1706910
Hospital Revenue Code	301
Min. Negotiated Rate	$15.02
Max. Negotiated Rate	$295.10
Rate for Payer: Aetna Commercial	$40.42
Rate for Payer: Aetna Medicare	$57.75
Rate for Payer: Amerigroup CHIP/Medicaid	$15.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$38.50
Rate for Payer: Amerigroup Medicare	$38.50
Rate for Payer: BCBS of TX Blue Advantage	$63.52
Rate for Payer: BCBS of TX Blue Essentials	$76.23
Rate for Payer: BCBS of TX Medicare	$38.50
Rate for Payer: BCBS of TX PPO	$85.08
Rate for Payer: Cash Price	$399.52
Rate for Payer: Cash Price	$399.52
Rate for Payer: Cigna Medicaid	$38.50
Rate for Payer: Cigna Medicare	$38.50
Rate for Payer: Employer Direct Commercial	$38.50
Rate for Payer: Humana Medicare/TRICARE	$38.50
Rate for Payer: Molina CHIP/Medicaid	$38.50
Rate for Payer: Molina Dual Medicare/Medicaid	$38.50
Rate for Payer: Molina Medicare	$38.50
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: Parkland Medicaid	$38.50
Rate for Payer: Scott and White EPO/PPO	$48.12
Rate for Payer: Scott and White Medicare	$38.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.50
Rate for Payer: Superior Health Plan EPO	$38.50
Rate for Payer: Superior Health Plan Medicare	$38.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$38.50
Rate for Payer: Universal American Medicare	$38.50
Rate for Payer: Wellcare Medicare	$38.50
Rate for Payer: Wellmed Medicare	$38.50

Calcitriol(1,25 di-OH Vit D) SO

Facility

$454.00

Service Code	CPT 82652
Hospital Charge Code	1706910
Hospital Revenue Code	301
Rate for Payer: Cash Price	$399.52

Calcium, 24Hr Urine SO

Facility

$213.00

Service Code	CPT 82340
Hospital Charge Code	1601269
Hospital Revenue Code	301
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$138.45
Rate for Payer: Aetna Commercial	$6.34
Rate for Payer: Aetna Medicare	$9.04
Rate for Payer: Amerigroup CHIP/Medicaid	$2.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.03
Rate for Payer: Amerigroup Medicare	$6.03
Rate for Payer: BCBS of TX Blue Advantage	$9.95
Rate for Payer: BCBS of TX Blue Essentials	$11.94
Rate for Payer: BCBS of TX Medicare	$6.03
Rate for Payer: BCBS of TX PPO	$13.33
Rate for Payer: Cash Price	$187.44
Rate for Payer: Cash Price	$187.44
Rate for Payer: Cigna Medicaid	$6.03
Rate for Payer: Cigna Medicare	$6.03
Rate for Payer: Employer Direct Commercial	$6.03
Rate for Payer: Humana Medicare/TRICARE	$6.03
Rate for Payer: Molina CHIP/Medicaid	$6.03
Rate for Payer: Molina Dual Medicare/Medicaid	$6.03
Rate for Payer: Molina Medicare	$6.03
Rate for Payer: Multiplan Auto	$138.45
Rate for Payer: Multiplan Commercial	$138.45
Rate for Payer: Multiplan Workers Comp	$138.45
Rate for Payer: Parkland Medicaid	$6.03
Rate for Payer: Scott and White EPO/PPO	$7.54
Rate for Payer: Scott and White Medicare	$6.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.03
Rate for Payer: Superior Health Plan EPO	$6.03
Rate for Payer: Superior Health Plan Medicare	$6.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.03
Rate for Payer: Universal American Medicare	$6.03
Rate for Payer: Wellcare Medicare	$6.03
Rate for Payer: Wellmed Medicare	$6.03

calcium acetate 667 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77433217
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

calcium acetate 667 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77433217
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

calcium acetate 667 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77433268
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

calcium acetate 667 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77433268
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

Know your out-of-pocket cost for care.

All Charges