White Rock Medical Center

All Charges

Charge

Type

Setting

Price

P65ST650P65ST567

Facility

$5,409.63

Service Code	HCPCS C1734
Hospital Charge Code	991210
Hospital Revenue Code	278
Min. Negotiated Rate	$486.87
Max. Negotiated Rate	$3,894.93
Rate for Payer: Amerigroup CHIP/Medicaid	$486.87
Rate for Payer: BCBS of TX Blue Advantage	$1,622.89
Rate for Payer: BCBS of TX Blue Essentials	$1,947.47
Rate for Payer: BCBS of TX PPO	$2,163.85
Rate for Payer: Cash Price	$3,678.55
Rate for Payer: Cigna Medicaid	$3,894.93
Rate for Payer: Molina CHIP/Medicaid	$3,894.93
Rate for Payer: Multiplan Auto	$2,704.82
Rate for Payer: Multiplan Commercial	$2,704.82
Rate for Payer: Multiplan Workers Comp	$2,704.82
Rate for Payer: Parkland Medicaid	$3,894.93
Rate for Payer: Scott and White EPO/PPO	$2,704.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,894.93
Rate for Payer: Superior Health Plan EPO	$735.71

P65ST650P65ST567

Facility

$5,409.63

Service Code	HCPCS C1734
Hospital Charge Code	991210
Hospital Revenue Code	278
Min. Negotiated Rate	$1,352.41
Max. Negotiated Rate	$2,704.82
Rate for Payer: Cash Price	$3,678.55
Rate for Payer: Cigna Commercial	$1,352.41
Rate for Payer: Multiplan Auto	$2,704.82
Rate for Payer: Multiplan Commercial	$2,704.82
Rate for Payer: Multiplan Workers Comp	$2,704.82
Rate for Payer: Scott and White EPO/PPO	$2,704.82

PACE ADAPTER CBL -- DHF

Facility

$495.28

Hospital Charge Code	81760159
Hospital Revenue Code	270
Min. Negotiated Rate	$44.58
Max. Negotiated Rate	$356.60
Rate for Payer: Amerigroup CHIP/Medicaid	$44.58
Rate for Payer: BCBS of TX Blue Advantage	$148.58
Rate for Payer: BCBS of TX Blue Essentials	$178.30
Rate for Payer: BCBS of TX PPO	$198.11
Rate for Payer: Cash Price	$336.79
Rate for Payer: Cigna Medicaid	$356.60
Rate for Payer: Molina CHIP/Medicaid	$356.60
Rate for Payer: Multiplan Auto	$321.93
Rate for Payer: Multiplan Commercial	$321.93
Rate for Payer: Multiplan Workers Comp	$321.93
Rate for Payer: Parkland Medicaid	$356.60
Rate for Payer: Scott and White EPO/PPO	$247.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$356.60
Rate for Payer: Superior Health Plan EPO	$67.36

PACE ADAPTER CBL -- DHF

Facility

$495.28

Hospital Charge Code	81760159
Hospital Revenue Code	270
Rate for Payer: Cash Price	$336.79

Pacemaker, dual chamber, rate-responsive (implantable)

Facility

$22,559.76

Service Code	HCPCS C1785
Hospital Charge Code	990936
Hospital Revenue Code	275
Min. Negotiated Rate	$5,639.94
Max. Negotiated Rate	$11,279.88
Rate for Payer: Cash Price	$15,340.64
Rate for Payer: Cigna Commercial	$5,639.94
Rate for Payer: Multiplan Auto	$11,279.88
Rate for Payer: Multiplan Commercial	$11,279.88
Rate for Payer: Multiplan Workers Comp	$11,279.88
Rate for Payer: Scott and White EPO/PPO	$11,279.88

Pacemaker, dual chamber, rate-responsive (implantable)

Facility

$22,559.76

Service Code	HCPCS C1785
Hospital Charge Code	990936
Hospital Revenue Code	275
Min. Negotiated Rate	$2,030.38
Max. Negotiated Rate	$16,243.03
Rate for Payer: Amerigroup CHIP/Medicaid	$2,030.38
Rate for Payer: BCBS of TX Blue Advantage	$6,767.93
Rate for Payer: BCBS of TX Blue Essentials	$8,121.51
Rate for Payer: BCBS of TX PPO	$9,023.90
Rate for Payer: Cash Price	$15,340.64
Rate for Payer: Cigna Medicaid	$16,243.03
Rate for Payer: Molina CHIP/Medicaid	$16,243.03
Rate for Payer: Multiplan Auto	$11,279.88
Rate for Payer: Multiplan Commercial	$11,279.88
Rate for Payer: Multiplan Workers Comp	$11,279.88
Rate for Payer: Parkland Medicaid	$16,243.03
Rate for Payer: Scott and White EPO/PPO	$11,279.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,243.03
Rate for Payer: Superior Health Plan EPO	$3,068.13

Package 3.2mm x 330mm Steinmann Pin Threaded

Facility

$1,275.74

Hospital Charge Code	993905
Hospital Revenue Code	272
Min. Negotiated Rate	$114.82
Max. Negotiated Rate	$918.53
Rate for Payer: Amerigroup CHIP/Medicaid	$114.82
Rate for Payer: BCBS of TX Blue Advantage	$382.72
Rate for Payer: BCBS of TX Blue Essentials	$459.27
Rate for Payer: BCBS of TX PPO	$510.30
Rate for Payer: Cash Price	$867.50
Rate for Payer: Cigna Medicaid	$918.53
Rate for Payer: Molina CHIP/Medicaid	$918.53
Rate for Payer: Multiplan Auto	$829.23
Rate for Payer: Multiplan Commercial	$829.23
Rate for Payer: Multiplan Workers Comp	$829.23
Rate for Payer: Parkland Medicaid	$918.53
Rate for Payer: Scott and White EPO/PPO	$637.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$918.53
Rate for Payer: Superior Health Plan EPO	$173.50

Package 3.2mm x 330mm Steinmann Pin Threaded

Facility

$1,275.74

Hospital Charge Code	993905
Hospital Revenue Code	272
Rate for Payer: Cash Price	$867.50

PACKAGED 4.3MM DRILL BIT FULLY THREADED, ANKLE SA

Facility

$1,552.68

Hospital Charge Code	993897
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,055.82

PACKAGED 4.3MM DRILL BIT FULLY THREADED, ANKLE SA

Facility

$1,552.68

Hospital Charge Code	993897
Hospital Revenue Code	272
Min. Negotiated Rate	$139.74
Max. Negotiated Rate	$1,117.93
Rate for Payer: Amerigroup CHIP/Medicaid	$139.74
Rate for Payer: BCBS of TX Blue Advantage	$465.80
Rate for Payer: BCBS of TX Blue Essentials	$558.96
Rate for Payer: BCBS of TX PPO	$621.07
Rate for Payer: Cash Price	$1,055.82
Rate for Payer: Cigna Medicaid	$1,117.93
Rate for Payer: Molina CHIP/Medicaid	$1,117.93
Rate for Payer: Multiplan Auto	$1,009.24
Rate for Payer: Multiplan Commercial	$1,009.24
Rate for Payer: Multiplan Workers Comp	$1,009.24
Rate for Payer: Parkland Medicaid	$1,117.93
Rate for Payer: Scott and White EPO/PPO	$776.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,117.93
Rate for Payer: Superior Health Plan EPO	$211.16

PACKAGED 5.0MM STEP DRILL BIT, ANKLE SALVAGE

Facility

$1,983.98

Hospital Charge Code	993900
Hospital Revenue Code	272
Min. Negotiated Rate	$178.56
Max. Negotiated Rate	$1,428.47
Rate for Payer: Amerigroup CHIP/Medicaid	$178.56
Rate for Payer: BCBS of TX Blue Advantage	$595.19
Rate for Payer: BCBS of TX Blue Essentials	$714.23
Rate for Payer: BCBS of TX PPO	$793.59
Rate for Payer: Cash Price	$1,349.11
Rate for Payer: Cigna Medicaid	$1,428.47
Rate for Payer: Molina CHIP/Medicaid	$1,428.47
Rate for Payer: Multiplan Auto	$1,289.59
Rate for Payer: Multiplan Commercial	$1,289.59
Rate for Payer: Multiplan Workers Comp	$1,289.59
Rate for Payer: Parkland Medicaid	$1,428.47
Rate for Payer: Scott and White EPO/PPO	$991.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,428.47
Rate for Payer: Superior Health Plan EPO	$269.82

PACKAGED 5.0MM STEP DRILL BIT, ANKLE SALVAGE

Facility

$1,983.98

Hospital Charge Code	993900
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,349.11

PACKAGED 6.0MM STEP DRILL BIT, ANKLE SALVAGE

Facility

$1,983.98

Hospital Charge Code	993899
Hospital Revenue Code	272
Min. Negotiated Rate	$178.56
Max. Negotiated Rate	$1,428.47
Rate for Payer: Amerigroup CHIP/Medicaid	$178.56
Rate for Payer: BCBS of TX Blue Advantage	$595.19
Rate for Payer: BCBS of TX Blue Essentials	$714.23
Rate for Payer: BCBS of TX PPO	$793.59
Rate for Payer: Cash Price	$1,349.11
Rate for Payer: Cigna Medicaid	$1,428.47
Rate for Payer: Molina CHIP/Medicaid	$1,428.47
Rate for Payer: Multiplan Auto	$1,289.59
Rate for Payer: Multiplan Commercial	$1,289.59
Rate for Payer: Multiplan Workers Comp	$1,289.59
Rate for Payer: Parkland Medicaid	$1,428.47
Rate for Payer: Scott and White EPO/PPO	$991.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,428.47
Rate for Payer: Superior Health Plan EPO	$269.82

PACKAGED 6.0MM STEP DRILL BIT, ANKLE SALVAGE

Facility

$1,983.98

Hospital Charge Code	993899
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,349.11

PACKAGED STARTER DRILL BIT, ANKLE SALVAGE INSTR

Facility

$1,552.68

Hospital Charge Code	993896
Hospital Revenue Code	272
Min. Negotiated Rate	$139.74
Max. Negotiated Rate	$1,117.93
Rate for Payer: Amerigroup CHIP/Medicaid	$139.74
Rate for Payer: BCBS of TX Blue Advantage	$465.80
Rate for Payer: BCBS of TX Blue Essentials	$558.96
Rate for Payer: BCBS of TX PPO	$621.07
Rate for Payer: Cash Price	$1,055.82
Rate for Payer: Cigna Medicaid	$1,117.93
Rate for Payer: Molina CHIP/Medicaid	$1,117.93
Rate for Payer: Multiplan Auto	$1,009.24
Rate for Payer: Multiplan Commercial	$1,009.24
Rate for Payer: Multiplan Workers Comp	$1,009.24
Rate for Payer: Parkland Medicaid	$1,117.93
Rate for Payer: Scott and White EPO/PPO	$776.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,117.93
Rate for Payer: Superior Health Plan EPO	$211.16

PACKAGED STARTER DRILL BIT, ANKLE SALVAGE INSTR

Facility

$1,552.68

Hospital Charge Code	993896
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,055.82

Package Kit, Drills, Plate, Coticol Screws, Locking Screws-Stryker

Facility

$50,269.15

Service Code	HCPCS C1734
Hospital Charge Code	991202
Hospital Revenue Code	278
Min. Negotiated Rate	$4,524.22
Max. Negotiated Rate	$36,193.79
Rate for Payer: Amerigroup CHIP/Medicaid	$4,524.22
Rate for Payer: BCBS of TX Blue Advantage	$15,080.75
Rate for Payer: BCBS of TX Blue Essentials	$18,096.89
Rate for Payer: BCBS of TX PPO	$20,107.66
Rate for Payer: Cash Price	$34,183.02
Rate for Payer: Cigna Medicaid	$36,193.79
Rate for Payer: Molina CHIP/Medicaid	$36,193.79
Rate for Payer: Multiplan Auto	$25,134.58
Rate for Payer: Multiplan Commercial	$25,134.58
Rate for Payer: Multiplan Workers Comp	$25,134.58
Rate for Payer: Parkland Medicaid	$36,193.79
Rate for Payer: Scott and White EPO/PPO	$25,134.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36,193.79
Rate for Payer: Superior Health Plan EPO	$6,836.60

Package Kit, Drills, Plate, Coticol Screws, Locking Screws-Stryker

Facility

$37,927.71

Service Code	HCPCS C1734
Hospital Charge Code	994144
Hospital Revenue Code	278
Min. Negotiated Rate	$3,413.49
Max. Negotiated Rate	$27,307.95
Rate for Payer: Amerigroup CHIP/Medicaid	$3,413.49
Rate for Payer: BCBS of TX Blue Advantage	$11,378.31
Rate for Payer: BCBS of TX Blue Essentials	$13,653.98
Rate for Payer: BCBS of TX PPO	$15,171.08
Rate for Payer: Cash Price	$25,790.84
Rate for Payer: Cigna Medicaid	$27,307.95
Rate for Payer: Molina CHIP/Medicaid	$27,307.95
Rate for Payer: Multiplan Auto	$18,963.85
Rate for Payer: Multiplan Commercial	$18,963.85
Rate for Payer: Multiplan Workers Comp	$18,963.85
Rate for Payer: Parkland Medicaid	$27,307.95
Rate for Payer: Scott and White EPO/PPO	$18,963.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,307.95
Rate for Payer: Superior Health Plan EPO	$5,158.17

Package Kit, Drills, Plate, Coticol Screws, Locking Screws-Stryker

Facility

$37,927.71

Service Code	HCPCS C1734
Hospital Charge Code	994144
Hospital Revenue Code	278
Min. Negotiated Rate	$9,481.93
Max. Negotiated Rate	$18,963.85
Rate for Payer: Cash Price	$25,790.84
Rate for Payer: Cigna Commercial	$9,481.93
Rate for Payer: Multiplan Auto	$18,963.85
Rate for Payer: Multiplan Commercial	$18,963.85
Rate for Payer: Multiplan Workers Comp	$18,963.85
Rate for Payer: Scott and White EPO/PPO	$18,963.85

Package Kit, Drills, Plate, Coticol Screws, Locking Screws-Stryker

Facility

$50,269.15

Service Code	HCPCS C1734
Hospital Charge Code	991202
Hospital Revenue Code	278
Min. Negotiated Rate	$12,567.29
Max. Negotiated Rate	$25,134.58
Rate for Payer: Cash Price	$34,183.02
Rate for Payer: Cigna Commercial	$12,567.29
Rate for Payer: Multiplan Auto	$25,134.58
Rate for Payer: Multiplan Commercial	$25,134.58
Rate for Payer: Multiplan Workers Comp	$25,134.58
Rate for Payer: Scott and White EPO/PPO	$25,134.58

PACK, ARTHROSCOPY I DRAPES,GOWNS,TOWELS 90'X121 -- DHF

Facility

$127.21

Hospital Charge Code	81650152
Hospital Revenue Code	272
Min. Negotiated Rate	$11.45
Max. Negotiated Rate	$91.59
Rate for Payer: Amerigroup CHIP/Medicaid	$11.45
Rate for Payer: BCBS of TX Blue Advantage	$38.16
Rate for Payer: BCBS of TX Blue Essentials	$45.80
Rate for Payer: BCBS of TX PPO	$50.88
Rate for Payer: Cash Price	$86.50
Rate for Payer: Cigna Medicaid	$91.59
Rate for Payer: Molina CHIP/Medicaid	$91.59
Rate for Payer: Multiplan Auto	$82.69
Rate for Payer: Multiplan Commercial	$82.69
Rate for Payer: Multiplan Workers Comp	$82.69
Rate for Payer: Parkland Medicaid	$91.59
Rate for Payer: Scott and White EPO/PPO	$63.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.59
Rate for Payer: Superior Health Plan EPO	$17.30

PACK, ARTHROSCOPY I DRAPES,GOWNS,TOWELS 90'X121 -- DHF

Facility

$127.21

Hospital Charge Code	81650152
Hospital Revenue Code	272
Rate for Payer: Cash Price	$86.50

PACK, ARTHROSCOPY I, SIRUS, 6/CS

Facility

$119.92

Hospital Charge Code	993066
Hospital Revenue Code	272
Min. Negotiated Rate	$10.79
Max. Negotiated Rate	$86.34
Rate for Payer: Amerigroup CHIP/Medicaid	$10.79
Rate for Payer: BCBS of TX Blue Advantage	$35.98
Rate for Payer: BCBS of TX Blue Essentials	$43.17
Rate for Payer: BCBS of TX PPO	$47.97
Rate for Payer: Cash Price	$81.55
Rate for Payer: Cigna Medicaid	$86.34
Rate for Payer: Molina CHIP/Medicaid	$86.34
Rate for Payer: Multiplan Auto	$77.95
Rate for Payer: Multiplan Commercial	$77.95
Rate for Payer: Multiplan Workers Comp	$77.95
Rate for Payer: Parkland Medicaid	$86.34
Rate for Payer: Scott and White EPO/PPO	$59.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.34
Rate for Payer: Superior Health Plan EPO	$16.31

PACK, ARTHROSCOPY I, SIRUS, 6/CS

Facility

$119.92

Hospital Charge Code	993066
Hospital Revenue Code	272
Rate for Payer: Cash Price	$81.55

PACK, BOWIE DICK TYPE TEST, LEAD FREE

Facility

$14.17

Hospital Charge Code	992970
Hospital Revenue Code	270
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$10.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1.28
Rate for Payer: BCBS of TX Blue Advantage	$4.25
Rate for Payer: BCBS of TX Blue Essentials	$5.10
Rate for Payer: BCBS of TX PPO	$5.67
Rate for Payer: Cash Price	$9.64
Rate for Payer: Cigna Medicaid	$10.20
Rate for Payer: Molina CHIP/Medicaid	$10.20
Rate for Payer: Multiplan Auto	$9.21
Rate for Payer: Multiplan Commercial	$9.21
Rate for Payer: Multiplan Workers Comp	$9.21
Rate for Payer: Parkland Medicaid	$10.20
Rate for Payer: Scott and White EPO/PPO	$7.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.20
Rate for Payer: Superior Health Plan EPO	$1.93

Know your out-of-pocket cost for care.

All Charges