White Rock Medical Center

All Charges

Charge

Type

Setting

Price

2.0MM DRILL BIT, CALIBRATED

Facility

$431.30

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

20mm Speedtrap W

Facility

$620.48

Hospital Charge Code	992192
Hospital Revenue Code	272
Min. Negotiated Rate	$55.84
Max. Negotiated Rate	$446.75
Rate for Payer: Amerigroup CHIP/Medicaid	$55.84
Rate for Payer: BCBS of TX Blue Advantage	$186.14
Rate for Payer: BCBS of TX Blue Essentials	$223.37
Rate for Payer: BCBS of TX PPO	$248.19
Rate for Payer: Cash Price	$421.93
Rate for Payer: Cigna Medicaid	$446.75
Rate for Payer: Molina CHIP/Medicaid	$446.75
Rate for Payer: Multiplan Auto	$403.31
Rate for Payer: Multiplan Commercial	$403.31
Rate for Payer: Multiplan Workers Comp	$403.31
Rate for Payer: Parkland Medicaid	$446.75
Rate for Payer: Scott and White EPO/PPO	$310.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$446.75
Rate for Payer: Superior Health Plan EPO	$84.39

20mm Speedtrap W

Facility

$620.48

Hospital Charge Code	992192
Hospital Revenue Code	272
Rate for Payer: Cash Price	$421.93

21336

Facility

$11,321.00

Service Code	HCPCS 21336
Hospital Charge Code	9900196
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$7,698.28
Rate for Payer: Cash Price	$7,698.28
Rate for Payer: Cash Price	$7,698.28
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$8,151.12
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$8,151.12
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$8,151.12
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,151.12
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

21336

Facility

$11,321.00

Service Code	HCPCS 21336
Hospital Charge Code	9900196
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,698.28

219535ND

Facility

$2,302.41

Service Code	HCPCS C1776
Hospital Charge Code	991179
Hospital Revenue Code	278
Min. Negotiated Rate	$575.60
Max. Negotiated Rate	$1,151.20
Rate for Payer: Cash Price	$1,565.64
Rate for Payer: Cigna Commercial	$575.60
Rate for Payer: Multiplan Auto	$1,151.20
Rate for Payer: Multiplan Commercial	$1,151.20
Rate for Payer: Multiplan Workers Comp	$1,151.20
Rate for Payer: Scott and White EPO/PPO	$1,151.20

219535ND

Facility

$2,302.41

Service Code	HCPCS C1776
Hospital Charge Code	991179
Hospital Revenue Code	278
Min. Negotiated Rate	$207.22
Max. Negotiated Rate	$1,657.74
Rate for Payer: Amerigroup CHIP/Medicaid	$207.22
Rate for Payer: BCBS of TX Blue Advantage	$690.72
Rate for Payer: BCBS of TX Blue Essentials	$828.87
Rate for Payer: BCBS of TX PPO	$920.96
Rate for Payer: Cash Price	$1,565.64
Rate for Payer: Cigna Medicaid	$1,657.74
Rate for Payer: Molina CHIP/Medicaid	$1,657.74
Rate for Payer: Multiplan Auto	$1,151.20
Rate for Payer: Multiplan Commercial	$1,151.20
Rate for Payer: Multiplan Workers Comp	$1,151.20
Rate for Payer: Parkland Medicaid	$1,657.74
Rate for Payer: Scott and White EPO/PPO	$1,151.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,657.74
Rate for Payer: Superior Health Plan EPO	$313.13

21ETC0159

Facility

$1,861.44

Service Code	HCPCS C1734
Hospital Charge Code	994092
Hospital Revenue Code	278
Min. Negotiated Rate	$167.53
Max. Negotiated Rate	$1,340.24
Rate for Payer: Amerigroup CHIP/Medicaid	$167.53
Rate for Payer: BCBS of TX Blue Advantage	$558.43
Rate for Payer: BCBS of TX Blue Essentials	$670.12
Rate for Payer: BCBS of TX PPO	$744.58
Rate for Payer: Cash Price	$1,265.78
Rate for Payer: Cigna Medicaid	$1,340.24
Rate for Payer: Molina CHIP/Medicaid	$1,340.24
Rate for Payer: Multiplan Auto	$930.72
Rate for Payer: Multiplan Commercial	$930.72
Rate for Payer: Multiplan Workers Comp	$930.72
Rate for Payer: Parkland Medicaid	$1,340.24
Rate for Payer: Scott and White EPO/PPO	$930.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,340.24
Rate for Payer: Superior Health Plan EPO	$253.16

21ETC0159

Facility

$1,861.44

Service Code	HCPCS C1734
Hospital Charge Code	994092
Hospital Revenue Code	278
Min. Negotiated Rate	$465.36
Max. Negotiated Rate	$930.72
Rate for Payer: Cash Price	$1,265.78
Rate for Payer: Cigna Commercial	$465.36
Rate for Payer: Multiplan Auto	$930.72
Rate for Payer: Multiplan Commercial	$930.72
Rate for Payer: Multiplan Workers Comp	$930.72
Rate for Payer: Scott and White EPO/PPO	$930.72

220220901

Facility

$32,861.00

Service Code	HCPCS C1776
Hospital Charge Code	990941
Hospital Revenue Code	278
Min. Negotiated Rate	$2,957.49
Max. Negotiated Rate	$23,659.92
Rate for Payer: Amerigroup CHIP/Medicaid	$2,957.49
Rate for Payer: BCBS of TX Blue Advantage	$9,858.30
Rate for Payer: BCBS of TX Blue Essentials	$11,829.96
Rate for Payer: BCBS of TX PPO	$13,144.40
Rate for Payer: Cash Price	$22,345.48
Rate for Payer: Cigna Medicaid	$23,659.92
Rate for Payer: Molina CHIP/Medicaid	$23,659.92
Rate for Payer: Multiplan Auto	$16,430.50
Rate for Payer: Multiplan Commercial	$16,430.50
Rate for Payer: Multiplan Workers Comp	$16,430.50
Rate for Payer: Parkland Medicaid	$23,659.92
Rate for Payer: Scott and White EPO/PPO	$16,430.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,659.92
Rate for Payer: Superior Health Plan EPO	$4,469.10

220220901

Facility

$32,861.00

Service Code	HCPCS C1776
Hospital Charge Code	990941
Hospital Revenue Code	278
Min. Negotiated Rate	$8,215.25
Max. Negotiated Rate	$16,430.50
Rate for Payer: Cash Price	$22,345.48
Rate for Payer: Cigna Commercial	$8,215.25
Rate for Payer: Multiplan Auto	$16,430.50
Rate for Payer: Multiplan Commercial	$16,430.50
Rate for Payer: Multiplan Workers Comp	$16,430.50
Rate for Payer: Scott and White EPO/PPO	$16,430.50

220220902

Facility

$54,733.00

Service Code	HCPCS C1776
Hospital Charge Code	991048
Hospital Revenue Code	278
Min. Negotiated Rate	$4,925.97
Max. Negotiated Rate	$39,407.76
Rate for Payer: Amerigroup CHIP/Medicaid	$4,925.97
Rate for Payer: BCBS of TX Blue Advantage	$16,419.90
Rate for Payer: BCBS of TX Blue Essentials	$19,703.88
Rate for Payer: BCBS of TX PPO	$21,893.20
Rate for Payer: Cash Price	$37,218.44
Rate for Payer: Cigna Medicaid	$39,407.76
Rate for Payer: Molina CHIP/Medicaid	$39,407.76
Rate for Payer: Multiplan Auto	$27,366.50
Rate for Payer: Multiplan Commercial	$27,366.50
Rate for Payer: Multiplan Workers Comp	$27,366.50
Rate for Payer: Parkland Medicaid	$39,407.76
Rate for Payer: Scott and White EPO/PPO	$27,366.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39,407.76
Rate for Payer: Superior Health Plan EPO	$7,443.69

220220902

Facility

$54,733.00

Service Code	HCPCS C1776
Hospital Charge Code	991048
Hospital Revenue Code	278
Min. Negotiated Rate	$13,683.25
Max. Negotiated Rate	$27,366.50
Rate for Payer: Cash Price	$37,218.44
Rate for Payer: Cigna Commercial	$13,683.25
Rate for Payer: Multiplan Auto	$27,366.50
Rate for Payer: Multiplan Commercial	$27,366.50
Rate for Payer: Multiplan Workers Comp	$27,366.50
Rate for Payer: Scott and White EPO/PPO	$27,366.50

220220903

Facility

$13,132.53

Service Code	HCPCS C1776
Hospital Charge Code	991086
Hospital Revenue Code	278
Min. Negotiated Rate	$3,283.13
Max. Negotiated Rate	$6,566.27
Rate for Payer: Cash Price	$8,930.12
Rate for Payer: Cigna Commercial	$3,283.13
Rate for Payer: Multiplan Auto	$6,566.27
Rate for Payer: Multiplan Commercial	$6,566.27
Rate for Payer: Multiplan Workers Comp	$6,566.27
Rate for Payer: Scott and White EPO/PPO	$6,566.27

220220903

Facility

$13,132.53

Service Code	HCPCS C1776
Hospital Charge Code	991086
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.93
Max. Negotiated Rate	$9,455.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1,181.93
Rate for Payer: BCBS of TX Blue Advantage	$3,939.76
Rate for Payer: BCBS of TX Blue Essentials	$4,727.71
Rate for Payer: BCBS of TX PPO	$5,253.01
Rate for Payer: Cash Price	$8,930.12
Rate for Payer: Cigna Medicaid	$9,455.42
Rate for Payer: Molina CHIP/Medicaid	$9,455.42
Rate for Payer: Multiplan Auto	$6,566.27
Rate for Payer: Multiplan Commercial	$6,566.27
Rate for Payer: Multiplan Workers Comp	$6,566.27
Rate for Payer: Parkland Medicaid	$9,455.42
Rate for Payer: Scott and White EPO/PPO	$6,566.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,455.42
Rate for Payer: Superior Health Plan EPO	$1,786.02

22022108

Facility

$23,494.00

Service Code	HCPCS C1713
Hospital Charge Code	990947
Hospital Revenue Code	278
Min. Negotiated Rate	$5,873.50
Max. Negotiated Rate	$11,747.00
Rate for Payer: Cash Price	$15,975.92
Rate for Payer: Cigna Commercial	$5,873.50
Rate for Payer: Multiplan Auto	$11,747.00
Rate for Payer: Multiplan Commercial	$11,747.00
Rate for Payer: Multiplan Workers Comp	$11,747.00
Rate for Payer: Scott and White EPO/PPO	$11,747.00

22022108

Facility

$23,494.00

Service Code	HCPCS C1713
Hospital Charge Code	990947
Hospital Revenue Code	278
Min. Negotiated Rate	$2,114.46
Max. Negotiated Rate	$16,915.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2,114.46
Rate for Payer: BCBS of TX Blue Advantage	$7,048.20
Rate for Payer: BCBS of TX Blue Essentials	$8,457.84
Rate for Payer: BCBS of TX PPO	$9,397.60
Rate for Payer: Cash Price	$15,975.92
Rate for Payer: Cigna Medicaid	$16,915.68
Rate for Payer: Molina CHIP/Medicaid	$16,915.68
Rate for Payer: Multiplan Auto	$11,747.00
Rate for Payer: Multiplan Commercial	$11,747.00
Rate for Payer: Multiplan Workers Comp	$11,747.00
Rate for Payer: Parkland Medicaid	$16,915.68
Rate for Payer: Scott and White EPO/PPO	$11,747.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,915.68
Rate for Payer: Superior Health Plan EPO	$3,195.18

22022208

Facility

$34,246.00

Service Code	HCPCS C1776
Hospital Charge Code	991051
Hospital Revenue Code	278
Min. Negotiated Rate	$3,082.14
Max. Negotiated Rate	$24,657.12
Rate for Payer: Amerigroup CHIP/Medicaid	$3,082.14
Rate for Payer: BCBS of TX Blue Advantage	$10,273.80
Rate for Payer: BCBS of TX Blue Essentials	$12,328.56
Rate for Payer: BCBS of TX PPO	$13,698.40
Rate for Payer: Cash Price	$23,287.28
Rate for Payer: Cigna Medicaid	$24,657.12
Rate for Payer: Molina CHIP/Medicaid	$24,657.12
Rate for Payer: Multiplan Auto	$17,123.00
Rate for Payer: Multiplan Commercial	$17,123.00
Rate for Payer: Multiplan Workers Comp	$17,123.00
Rate for Payer: Parkland Medicaid	$24,657.12
Rate for Payer: Scott and White EPO/PPO	$17,123.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,657.12
Rate for Payer: Superior Health Plan EPO	$4,657.46

22022208

Facility

$34,246.00

Service Code	HCPCS C1776
Hospital Charge Code	991051
Hospital Revenue Code	278
Min. Negotiated Rate	$8,561.50
Max. Negotiated Rate	$17,123.00
Rate for Payer: Cash Price	$23,287.28
Rate for Payer: Cigna Commercial	$8,561.50
Rate for Payer: Multiplan Auto	$17,123.00
Rate for Payer: Multiplan Commercial	$17,123.00
Rate for Payer: Multiplan Workers Comp	$17,123.00
Rate for Payer: Scott and White EPO/PPO	$17,123.00

22022210

Facility

$37,159.77

Service Code	HCPCS C1734
Hospital Charge Code	994019
Hospital Revenue Code	278
Min. Negotiated Rate	$3,344.38
Max. Negotiated Rate	$26,755.03
Rate for Payer: Amerigroup CHIP/Medicaid	$3,344.38
Rate for Payer: BCBS of TX Blue Advantage	$11,147.93
Rate for Payer: BCBS of TX Blue Essentials	$13,377.52
Rate for Payer: BCBS of TX PPO	$14,863.91
Rate for Payer: Cash Price	$25,268.64
Rate for Payer: Cigna Medicaid	$26,755.03
Rate for Payer: Molina CHIP/Medicaid	$26,755.03
Rate for Payer: Multiplan Auto	$18,579.88
Rate for Payer: Multiplan Commercial	$18,579.88
Rate for Payer: Multiplan Workers Comp	$18,579.88
Rate for Payer: Parkland Medicaid	$26,755.03
Rate for Payer: Scott and White EPO/PPO	$18,579.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26,755.03
Rate for Payer: Superior Health Plan EPO	$5,053.73

22022210

Facility

$37,159.77

Service Code	HCPCS C1734
Hospital Charge Code	994019
Hospital Revenue Code	278
Min. Negotiated Rate	$9,289.94
Max. Negotiated Rate	$18,579.88
Rate for Payer: Cash Price	$25,268.64
Rate for Payer: Cigna Commercial	$9,289.94
Rate for Payer: Multiplan Auto	$18,579.88
Rate for Payer: Multiplan Commercial	$18,579.88
Rate for Payer: Multiplan Workers Comp	$18,579.88
Rate for Payer: Scott and White EPO/PPO	$18,579.88

220222206E

Facility

$23,059.16

Service Code	HCPCS C1734
Hospital Charge Code	991091
Hospital Revenue Code	278
Min. Negotiated Rate	$5,764.79
Max. Negotiated Rate	$11,529.58
Rate for Payer: Cash Price	$15,680.23
Rate for Payer: Cigna Commercial	$5,764.79
Rate for Payer: Multiplan Auto	$11,529.58
Rate for Payer: Multiplan Commercial	$11,529.58
Rate for Payer: Multiplan Workers Comp	$11,529.58
Rate for Payer: Scott and White EPO/PPO	$11,529.58

220222206E

Facility

$23,059.16

Service Code	HCPCS C1734
Hospital Charge Code	991091
Hospital Revenue Code	278
Min. Negotiated Rate	$2,075.32
Max. Negotiated Rate	$16,602.60
Rate for Payer: Amerigroup CHIP/Medicaid	$2,075.32
Rate for Payer: BCBS of TX Blue Advantage	$6,917.75
Rate for Payer: BCBS of TX Blue Essentials	$8,301.30
Rate for Payer: BCBS of TX PPO	$9,223.66
Rate for Payer: Cash Price	$15,680.23
Rate for Payer: Cigna Medicaid	$16,602.60
Rate for Payer: Molina CHIP/Medicaid	$16,602.60
Rate for Payer: Multiplan Auto	$11,529.58
Rate for Payer: Multiplan Commercial	$11,529.58
Rate for Payer: Multiplan Workers Comp	$11,529.58
Rate for Payer: Parkland Medicaid	$16,602.60
Rate for Payer: Scott and White EPO/PPO	$11,529.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,602.60
Rate for Payer: Superior Health Plan EPO	$3,136.05

220222902

Facility

$14,530.84

Service Code	HCPCS C1734
Hospital Charge Code	994020
Hospital Revenue Code	278
Min. Negotiated Rate	$1,307.78
Max. Negotiated Rate	$10,462.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1,307.78
Rate for Payer: BCBS of TX Blue Advantage	$4,359.25
Rate for Payer: BCBS of TX Blue Essentials	$5,231.10
Rate for Payer: BCBS of TX PPO	$5,812.34
Rate for Payer: Cash Price	$9,880.97
Rate for Payer: Cigna Medicaid	$10,462.20
Rate for Payer: Molina CHIP/Medicaid	$10,462.20
Rate for Payer: Multiplan Auto	$7,265.42
Rate for Payer: Multiplan Commercial	$7,265.42
Rate for Payer: Multiplan Workers Comp	$7,265.42
Rate for Payer: Parkland Medicaid	$10,462.20
Rate for Payer: Scott and White EPO/PPO	$7,265.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,462.20
Rate for Payer: Superior Health Plan EPO	$1,976.19

220222902

Facility

$14,530.84

Service Code	HCPCS C1734
Hospital Charge Code	994020
Hospital Revenue Code	278
Min. Negotiated Rate	$3,632.71
Max. Negotiated Rate	$7,265.42
Rate for Payer: Cash Price	$9,880.97
Rate for Payer: Cigna Commercial	$3,632.71
Rate for Payer: Multiplan Auto	$7,265.42
Rate for Payer: Multiplan Commercial	$7,265.42
Rate for Payer: Multiplan Workers Comp	$7,265.42
Rate for Payer: Scott and White EPO/PPO	$7,265.42

Know your out-of-pocket cost for care.

All Charges