White Rock Medical Center

All Charges

Charge

Type

Setting

Price

200347901

Facility

$9,633.00

Service Code	HCPCS C1776
Hospital Charge Code	990943
Hospital Revenue Code	278
Min. Negotiated Rate	$2,408.25
Max. Negotiated Rate	$4,816.50
Rate for Payer: Cash Price	$6,550.44
Rate for Payer: Cigna Commercial	$2,408.25
Rate for Payer: Multiplan Auto	$4,816.50
Rate for Payer: Multiplan Commercial	$4,816.50
Rate for Payer: Multiplan Workers Comp	$4,816.50
Rate for Payer: Scott and White EPO/PPO	$4,816.50

200424010

Facility

$1,536.14

Service Code	HCPCS A4649
Hospital Charge Code	991085
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,044.58

200424010

Facility

$1,536.14

Service Code	HCPCS A4649
Hospital Charge Code	991085
Hospital Revenue Code	272
Min. Negotiated Rate	$138.25
Max. Negotiated Rate	$1,106.02
Rate for Payer: Amerigroup CHIP/Medicaid	$138.25
Rate for Payer: BCBS of TX Blue Advantage	$460.84
Rate for Payer: BCBS of TX Blue Essentials	$553.01
Rate for Payer: BCBS of TX PPO	$614.46
Rate for Payer: Cash Price	$1,044.58
Rate for Payer: Cigna Medicaid	$1,106.02
Rate for Payer: Molina CHIP/Medicaid	$1,106.02
Rate for Payer: Multiplan Auto	$998.49
Rate for Payer: Multiplan Commercial	$998.49
Rate for Payer: Multiplan Workers Comp	$998.49
Rate for Payer: Parkland Medicaid	$1,106.02
Rate for Payer: Scott and White EPO/PPO	$768.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,106.02
Rate for Payer: Superior Health Plan EPO	$208.92

200432010

Facility

$1,536.00

Service Code	HCPCS C1713
Hospital Charge Code	991053
Hospital Revenue Code	278
Min. Negotiated Rate	$384.00
Max. Negotiated Rate	$768.00
Rate for Payer: Cash Price	$1,044.48
Rate for Payer: Cigna Commercial	$384.00
Rate for Payer: Multiplan Auto	$768.00
Rate for Payer: Multiplan Commercial	$768.00
Rate for Payer: Multiplan Workers Comp	$768.00
Rate for Payer: Scott and White EPO/PPO	$768.00

200432010

Facility

$1,536.00

Service Code	HCPCS C1713
Hospital Charge Code	991053
Hospital Revenue Code	278
Min. Negotiated Rate	$138.24
Max. Negotiated Rate	$1,105.92
Rate for Payer: Amerigroup CHIP/Medicaid	$138.24
Rate for Payer: BCBS of TX Blue Advantage	$460.80
Rate for Payer: BCBS of TX Blue Essentials	$552.96
Rate for Payer: BCBS of TX PPO	$614.40
Rate for Payer: Cash Price	$1,044.48
Rate for Payer: Cigna Medicaid	$1,105.92
Rate for Payer: Molina CHIP/Medicaid	$1,105.92
Rate for Payer: Multiplan Auto	$768.00
Rate for Payer: Multiplan Commercial	$768.00
Rate for Payer: Multiplan Workers Comp	$768.00
Rate for Payer: Parkland Medicaid	$1,105.92
Rate for Payer: Scott and White EPO/PPO	$768.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,105.92
Rate for Payer: Superior Health Plan EPO	$208.90

2-0 Fiberwire

Facility

$862.05

Hospital Charge Code	992360
Hospital Revenue Code	272
Rate for Payer: Cash Price	$586.19

2-0 Fiberwire

Facility

$862.05

Hospital Charge Code	992360
Hospital Revenue Code	272
Min. Negotiated Rate	$77.58
Max. Negotiated Rate	$620.68
Rate for Payer: Amerigroup CHIP/Medicaid	$77.58
Rate for Payer: BCBS of TX Blue Advantage	$258.62
Rate for Payer: BCBS of TX Blue Essentials	$310.34
Rate for Payer: BCBS of TX PPO	$344.82
Rate for Payer: Cash Price	$586.19
Rate for Payer: Cigna Medicaid	$620.68
Rate for Payer: Molina CHIP/Medicaid	$620.68
Rate for Payer: Multiplan Auto	$560.33
Rate for Payer: Multiplan Commercial	$560.33
Rate for Payer: Multiplan Workers Comp	$560.33
Rate for Payer: Parkland Medicaid	$620.68
Rate for Payer: Scott and White EPO/PPO	$431.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$620.68
Rate for Payer: Superior Health Plan EPO	$117.24

20MM 2 HOLE PLATE

Facility

$32,868.67

Service Code	HCPCS C1734
Hospital Charge Code	992387
Hospital Revenue Code	278
Min. Negotiated Rate	$8,217.17
Max. Negotiated Rate	$16,434.33
Rate for Payer: Cash Price	$22,350.70
Rate for Payer: Cigna Commercial	$8,217.17
Rate for Payer: Multiplan Auto	$16,434.33
Rate for Payer: Multiplan Commercial	$16,434.33
Rate for Payer: Multiplan Workers Comp	$16,434.33
Rate for Payer: Scott and White EPO/PPO	$16,434.33

20MM 2 HOLE PLATE

Facility

$32,868.67

Service Code	HCPCS C1734
Hospital Charge Code	992387
Hospital Revenue Code	278
Min. Negotiated Rate	$2,958.18
Max. Negotiated Rate	$23,665.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2,958.18
Rate for Payer: BCBS of TX Blue Advantage	$9,860.60
Rate for Payer: BCBS of TX Blue Essentials	$11,832.72
Rate for Payer: BCBS of TX PPO	$13,147.47
Rate for Payer: Cash Price	$22,350.70
Rate for Payer: Cigna Medicaid	$23,665.44
Rate for Payer: Molina CHIP/Medicaid	$23,665.44
Rate for Payer: Multiplan Auto	$16,434.33
Rate for Payer: Multiplan Commercial	$16,434.33
Rate for Payer: Multiplan Workers Comp	$16,434.33
Rate for Payer: Parkland Medicaid	$23,665.44
Rate for Payer: Scott and White EPO/PPO	$16,434.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,665.44
Rate for Payer: Superior Health Plan EPO	$4,470.14

2.0MM DRILL BIT, CALIBRATED

Facility

$431.30

Hospital Charge Code	992606
Hospital Revenue Code	272
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$310.54
Rate for Payer: Amerigroup CHIP/Medicaid	$38.82
Rate for Payer: BCBS of TX Blue Advantage	$129.39
Rate for Payer: BCBS of TX Blue Essentials	$155.27
Rate for Payer: BCBS of TX PPO	$172.52
Rate for Payer: Cash Price	$293.28
Rate for Payer: Cigna Medicaid	$310.54
Rate for Payer: Molina CHIP/Medicaid	$310.54
Rate for Payer: Multiplan Auto	$280.35
Rate for Payer: Multiplan Commercial	$280.35
Rate for Payer: Multiplan Workers Comp	$280.35
Rate for Payer: Parkland Medicaid	$310.54
Rate for Payer: Scott and White EPO/PPO	$215.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$310.54
Rate for Payer: Superior Health Plan EPO	$58.66

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
Rate for Payer: Cash Price	$421.93

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

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

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	$5,476.44
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

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	$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

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

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	$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

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

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

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

Know your out-of-pocket cost for care.

All Charges