White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ANAL AND STOMAL PROCEDURES WITH MCC

Facility

$48,225.80

Service Code	MSDRG 347
Min. Negotiated Rate	$20,735.46
Max. Negotiated Rate	$48,225.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,584.60
Rate for Payer: Amerigroup Medicare	$21,584.60
Rate for Payer: BCBS of TX Medicare	$21,584.60
Rate for Payer: Cigna Commercial	$29,567.33
Rate for Payer: Cigna Medicare	$21,584.60
Rate for Payer: Employer Direct Commercial	$21,584.60
Rate for Payer: Humana Medicare/TRICARE	$21,584.60
Rate for Payer: Molina Dual Medicare/Medicaid	$21,584.60
Rate for Payer: Molina Medicare	$21,584.60
Rate for Payer: Multiplan Auto	$48,225.80
Rate for Payer: Multiplan Commercial	$48,225.80
Rate for Payer: Multiplan Workers Comp	$48,225.80
Rate for Payer: Scott and White EPO/PPO	$22,209.25
Rate for Payer: Scott and White Medicare	$21,584.60
Rate for Payer: Superior Health Plan EPO	$21,584.60
Rate for Payer: Superior Health Plan Medicare	$21,584.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,584.60
Rate for Payer: Universal American Medicare	$21,584.60
Rate for Payer: Wellcare Medicare	$21,584.60
Rate for Payer: Wellmed Medicare	$21,584.60

ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC

Facility

$18,946.80

Service Code	MSDRG 349
Min. Negotiated Rate	$8,167.42
Max. Negotiated Rate	$18,946.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,140.73
Rate for Payer: Amerigroup Medicare	$11,140.73
Rate for Payer: BCBS of TX Medicare	$11,140.73
Rate for Payer: Cigna Commercial	$11,213.33
Rate for Payer: Cigna Medicare	$11,140.73
Rate for Payer: Employer Direct Commercial	$11,140.73
Rate for Payer: Humana Medicare/TRICARE	$11,140.73
Rate for Payer: Molina Dual Medicare/Medicaid	$11,140.73
Rate for Payer: Molina Medicare	$11,140.73
Rate for Payer: Multiplan Auto	$18,946.80
Rate for Payer: Multiplan Commercial	$18,946.80
Rate for Payer: Multiplan Workers Comp	$18,946.80
Rate for Payer: Scott and White EPO/PPO	$8,725.50
Rate for Payer: Scott and White Medicare	$11,140.73
Rate for Payer: Superior Health Plan EPO	$11,140.73
Rate for Payer: Superior Health Plan Medicare	$11,140.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,140.73
Rate for Payer: Universal American Medicare	$11,140.73
Rate for Payer: Wellcare Medicare	$11,140.73
Rate for Payer: Wellmed Medicare	$11,140.73

ANAL & STOMAL PROCEDURES W CC

Facility

$26,239.00

Service Code	MSDRG 348
Min. Negotiated Rate	$12,040.00
Max. Negotiated Rate	$26,239.00
Rate for Payer: BCBS of TX Blue Advantage	$12,040.00
Rate for Payer: BCBS of TX Blue Essentials	$14,446.60
Rate for Payer: BCBS of TX PPO	$16,052.40

ANAL & STOMAL PROCEDURES W MCC

Facility

$48,225.80

Service Code	MSDRG 347
Min. Negotiated Rate	$20,735.46
Max. Negotiated Rate	$48,225.80
Rate for Payer: BCBS of TX Blue Advantage	$20,735.46
Rate for Payer: BCBS of TX Blue Essentials	$24,880.14
Rate for Payer: BCBS of TX PPO	$27,645.67

ANAL & STOMAL PROCEDURES W/O CC/MCC

Facility

$18,946.80

Service Code	MSDRG 349
Min. Negotiated Rate	$8,167.42
Max. Negotiated Rate	$18,946.80
Rate for Payer: BCBS of TX Blue Advantage	$8,167.42
Rate for Payer: BCBS of TX Blue Essentials	$9,799.95
Rate for Payer: BCBS of TX PPO	$10,889.26

ANA Screen, IFA, w/REFL TITER AND PATTERN

Facility

$44.64

Service Code	HCPCS 86039
Hospital Charge Code	994045
Hospital Revenue Code	302
Min. Negotiated Rate	$4.35
Max. Negotiated Rate	$32.14
Rate for Payer: Amerigroup CHIP/Medicaid	$4.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.16
Rate for Payer: Amerigroup Medicare	$11.16
Rate for Payer: BCBS of TX Blue Advantage	$13.39
Rate for Payer: BCBS of TX Blue Essentials	$16.07
Rate for Payer: BCBS of TX Medicare	$11.16
Rate for Payer: BCBS of TX PPO	$17.86
Rate for Payer: Cash Price	$30.36
Rate for Payer: Cash Price	$30.36
Rate for Payer: Cigna Medicaid	$32.14
Rate for Payer: Cigna Medicare	$11.16
Rate for Payer: Employer Direct Commercial	$11.16
Rate for Payer: Humana Medicare/TRICARE	$11.16
Rate for Payer: Molina CHIP/Medicaid	$32.14
Rate for Payer: Molina Dual Medicare/Medicaid	$11.16
Rate for Payer: Molina Medicare	$11.16
Rate for Payer: Multiplan Auto	$29.02
Rate for Payer: Multiplan Commercial	$29.02
Rate for Payer: Multiplan Workers Comp	$29.02
Rate for Payer: Parkland Medicaid	$32.14
Rate for Payer: Scott and White EPO/PPO	$13.95
Rate for Payer: Scott and White Medicare	$11.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.14
Rate for Payer: Superior Health Plan EPO	$11.16
Rate for Payer: Superior Health Plan Medicare	$11.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.16
Rate for Payer: Universal American Medicare	$11.16
Rate for Payer: Wellcare Medicare	$11.16
Rate for Payer: Wellmed Medicare	$11.16

ANA Screen, IFA, w/REFL TITER AND PATTERN

Facility

$44.64

Service Code	HCPCS 86039
Hospital Charge Code	994045
Hospital Revenue Code	302
Rate for Payer: Cash Price	$30.36

ANATOMIC ACL DISPOSABLE KIT

Facility

$628.84

Hospital Charge Code	992649
Hospital Revenue Code	272
Min. Negotiated Rate	$56.60
Max. Negotiated Rate	$452.76
Rate for Payer: Amerigroup CHIP/Medicaid	$56.60
Rate for Payer: BCBS of TX Blue Advantage	$188.65
Rate for Payer: BCBS of TX Blue Essentials	$226.38
Rate for Payer: BCBS of TX PPO	$251.54
Rate for Payer: Cash Price	$427.61
Rate for Payer: Cigna Medicaid	$452.76
Rate for Payer: Molina CHIP/Medicaid	$452.76
Rate for Payer: Multiplan Auto	$408.75
Rate for Payer: Multiplan Commercial	$408.75
Rate for Payer: Multiplan Workers Comp	$408.75
Rate for Payer: Parkland Medicaid	$452.76
Rate for Payer: Scott and White EPO/PPO	$314.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$452.76
Rate for Payer: Superior Health Plan EPO	$85.52

ANATOMIC ACL DISPOSABLE KIT

Facility

$628.84

Hospital Charge Code	992649
Hospital Revenue Code	272
Rate for Payer: Cash Price	$427.61

ANCH BIO-SWIVELOCK -- DHF

Facility

$2,892.00

Service Code	HCPCS C1713
Hospital Charge Code	40205981
Hospital Revenue Code	278
Min. Negotiated Rate	$723.00
Max. Negotiated Rate	$1,446.00
Rate for Payer: Cash Price	$1,966.56
Rate for Payer: Cigna Commercial	$723.00
Rate for Payer: Multiplan Auto	$1,446.00
Rate for Payer: Multiplan Commercial	$1,446.00
Rate for Payer: Multiplan Workers Comp	$1,446.00
Rate for Payer: Scott and White EPO/PPO	$1,446.00

ANCH BIO-SWIVELOCK -- DHF

Facility

$2,892.00

Service Code	HCPCS C1713
Hospital Charge Code	40205981
Hospital Revenue Code	278
Min. Negotiated Rate	$260.28
Max. Negotiated Rate	$2,082.24
Rate for Payer: Amerigroup CHIP/Medicaid	$260.28
Rate for Payer: BCBS of TX Blue Advantage	$867.60
Rate for Payer: BCBS of TX Blue Essentials	$1,041.12
Rate for Payer: BCBS of TX PPO	$1,156.80
Rate for Payer: Cash Price	$1,966.56
Rate for Payer: Cigna Medicaid	$2,082.24
Rate for Payer: Molina CHIP/Medicaid	$2,082.24
Rate for Payer: Multiplan Auto	$1,446.00
Rate for Payer: Multiplan Commercial	$1,446.00
Rate for Payer: Multiplan Workers Comp	$1,446.00
Rate for Payer: Parkland Medicaid	$2,082.24
Rate for Payer: Scott and White EPO/PPO	$1,446.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,082.24
Rate for Payer: Superior Health Plan EPO	$393.31

ANCH HEALIX PEEK -- DHF

Facility

$1,512.00

Service Code	HCPCS C1713
Hospital Charge Code	40206401
Hospital Revenue Code	278
Min. Negotiated Rate	$378.00
Max. Negotiated Rate	$756.00
Rate for Payer: Cash Price	$1,028.16
Rate for Payer: Cigna Commercial	$378.00
Rate for Payer: Multiplan Auto	$756.00
Rate for Payer: Multiplan Commercial	$756.00
Rate for Payer: Multiplan Workers Comp	$756.00
Rate for Payer: Scott and White EPO/PPO	$756.00

ANCH HEALIX PEEK -- DHF

Facility

$1,512.00

Service Code	HCPCS C1713
Hospital Charge Code	40206401
Hospital Revenue Code	278
Min. Negotiated Rate	$136.08
Max. Negotiated Rate	$1,088.64
Rate for Payer: Amerigroup CHIP/Medicaid	$136.08
Rate for Payer: BCBS of TX Blue Advantage	$453.60
Rate for Payer: BCBS of TX Blue Essentials	$544.32
Rate for Payer: BCBS of TX PPO	$604.80
Rate for Payer: Cash Price	$1,028.16
Rate for Payer: Cigna Medicaid	$1,088.64
Rate for Payer: Molina CHIP/Medicaid	$1,088.64
Rate for Payer: Multiplan Auto	$756.00
Rate for Payer: Multiplan Commercial	$756.00
Rate for Payer: Multiplan Workers Comp	$756.00
Rate for Payer: Parkland Medicaid	$1,088.64
Rate for Payer: Scott and White EPO/PPO	$756.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.64
Rate for Payer: Superior Health Plan EPO	$205.63

ANCHOR HEALIX 4.5 TI

Facility

$3,180.72

Service Code	HCPCS C1713
Hospital Charge Code	992100
Hospital Revenue Code	278
Min. Negotiated Rate	$795.18
Max. Negotiated Rate	$1,590.36
Rate for Payer: Cash Price	$2,162.89
Rate for Payer: Cigna Commercial	$795.18
Rate for Payer: Multiplan Auto	$1,590.36
Rate for Payer: Multiplan Commercial	$1,590.36
Rate for Payer: Multiplan Workers Comp	$1,590.36
Rate for Payer: Scott and White EPO/PPO	$1,590.36

ANCHOR HEALIX 4.5 TI

Facility

$3,180.72

Service Code	HCPCS C1713
Hospital Charge Code	992100
Hospital Revenue Code	278
Min. Negotiated Rate	$286.26
Max. Negotiated Rate	$2,290.12
Rate for Payer: Amerigroup CHIP/Medicaid	$286.26
Rate for Payer: BCBS of TX Blue Advantage	$954.22
Rate for Payer: BCBS of TX Blue Essentials	$1,145.06
Rate for Payer: BCBS of TX PPO	$1,272.29
Rate for Payer: Cash Price	$2,162.89
Rate for Payer: Cigna Medicaid	$2,290.12
Rate for Payer: Molina CHIP/Medicaid	$2,290.12
Rate for Payer: Multiplan Auto	$1,590.36
Rate for Payer: Multiplan Commercial	$1,590.36
Rate for Payer: Multiplan Workers Comp	$1,590.36
Rate for Payer: Parkland Medicaid	$2,290.12
Rate for Payer: Scott and White EPO/PPO	$1,590.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,290.12
Rate for Payer: Superior Health Plan EPO	$432.58

ANCHOR HEALIX WITH DYNACORD

Facility

$3,506.02

Service Code	HCPCS C1713
Hospital Charge Code	992121
Hospital Revenue Code	278
Min. Negotiated Rate	$315.54
Max. Negotiated Rate	$2,524.33
Rate for Payer: Amerigroup CHIP/Medicaid	$315.54
Rate for Payer: BCBS of TX Blue Advantage	$1,051.81
Rate for Payer: BCBS of TX Blue Essentials	$1,262.17
Rate for Payer: BCBS of TX PPO	$1,402.41
Rate for Payer: Cash Price	$2,384.09
Rate for Payer: Cigna Medicaid	$2,524.33
Rate for Payer: Molina CHIP/Medicaid	$2,524.33
Rate for Payer: Multiplan Auto	$1,753.01
Rate for Payer: Multiplan Commercial	$1,753.01
Rate for Payer: Multiplan Workers Comp	$1,753.01
Rate for Payer: Parkland Medicaid	$2,524.33
Rate for Payer: Scott and White EPO/PPO	$1,753.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,524.33
Rate for Payer: Superior Health Plan EPO	$476.82

ANCHOR HEALIX WITH DYNACORD

Facility

$3,506.02

Service Code	HCPCS C1713
Hospital Charge Code	992121
Hospital Revenue Code	278
Min. Negotiated Rate	$876.50
Max. Negotiated Rate	$1,753.01
Rate for Payer: Cash Price	$2,384.09
Rate for Payer: Cigna Commercial	$876.50
Rate for Payer: Multiplan Auto	$1,753.01
Rate for Payer: Multiplan Commercial	$1,753.01
Rate for Payer: Multiplan Workers Comp	$1,753.01
Rate for Payer: Scott and White EPO/PPO	$1,753.01

ANCHOR PUNCHTAK THREADED

Facility

$2,196.00

Service Code	HCPCS C1713
Hospital Charge Code	8524480
Hospital Revenue Code	278
Min. Negotiated Rate	$549.00
Max. Negotiated Rate	$1,098.00
Rate for Payer: Cash Price	$1,493.28
Rate for Payer: Cigna Commercial	$549.00
Rate for Payer: Multiplan Auto	$1,098.00
Rate for Payer: Multiplan Commercial	$1,098.00
Rate for Payer: Multiplan Workers Comp	$1,098.00
Rate for Payer: Scott and White EPO/PPO	$1,098.00

ANCHOR PUNCHTAK THREADED

Facility

$2,196.00

Service Code	HCPCS C1713
Hospital Charge Code	8524480
Hospital Revenue Code	278
Min. Negotiated Rate	$197.64
Max. Negotiated Rate	$1,581.12
Rate for Payer: Amerigroup CHIP/Medicaid	$197.64
Rate for Payer: BCBS of TX Blue Advantage	$658.80
Rate for Payer: BCBS of TX Blue Essentials	$790.56
Rate for Payer: BCBS of TX PPO	$878.40
Rate for Payer: Cash Price	$1,493.28
Rate for Payer: Cigna Medicaid	$1,581.12
Rate for Payer: Molina CHIP/Medicaid	$1,581.12
Rate for Payer: Multiplan Auto	$1,098.00
Rate for Payer: Multiplan Commercial	$1,098.00
Rate for Payer: Multiplan Workers Comp	$1,098.00
Rate for Payer: Parkland Medicaid	$1,581.12
Rate for Payer: Scott and White EPO/PPO	$1,098.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,581.12
Rate for Payer: Superior Health Plan EPO	$298.66

ANCHOR QUICK ANCHOR PLUS SUPER

Facility

$3,669.00

Service Code	HCPCS C1713
Hospital Charge Code	8512491
Hospital Revenue Code	278
Min. Negotiated Rate	$330.21
Max. Negotiated Rate	$2,641.68
Rate for Payer: Amerigroup CHIP/Medicaid	$330.21
Rate for Payer: BCBS of TX Blue Advantage	$1,100.70
Rate for Payer: BCBS of TX Blue Essentials	$1,320.84
Rate for Payer: BCBS of TX PPO	$1,467.60
Rate for Payer: Cash Price	$2,494.92
Rate for Payer: Cigna Medicaid	$2,641.68
Rate for Payer: Molina CHIP/Medicaid	$2,641.68
Rate for Payer: Multiplan Auto	$1,834.50
Rate for Payer: Multiplan Commercial	$1,834.50
Rate for Payer: Multiplan Workers Comp	$1,834.50
Rate for Payer: Parkland Medicaid	$2,641.68
Rate for Payer: Scott and White EPO/PPO	$1,834.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,641.68
Rate for Payer: Superior Health Plan EPO	$498.98

ANCHOR QUICK ANCHOR PLUS SUPER

Facility

$3,669.00

Service Code	HCPCS C1713
Hospital Charge Code	8512491
Hospital Revenue Code	278
Min. Negotiated Rate	$917.25
Max. Negotiated Rate	$1,834.50
Rate for Payer: Cash Price	$2,494.92
Rate for Payer: Cigna Commercial	$917.25
Rate for Payer: Multiplan Auto	$1,834.50
Rate for Payer: Multiplan Commercial	$1,834.50
Rate for Payer: Multiplan Workers Comp	$1,834.50
Rate for Payer: Scott and White EPO/PPO	$1,834.50

Anchor/screw bn/bn,tis/bn

Facility

$138,889.00

Service Code	HCPCS C1713
Hospital Charge Code	146706
Hospital Revenue Code	278
Min. Negotiated Rate	$12,500.01
Max. Negotiated Rate	$100,000.08
Rate for Payer: Amerigroup CHIP/Medicaid	$12,500.01
Rate for Payer: BCBS of TX Blue Advantage	$41,666.70
Rate for Payer: BCBS of TX Blue Essentials	$50,000.04
Rate for Payer: BCBS of TX PPO	$55,555.60
Rate for Payer: Cash Price	$94,444.52
Rate for Payer: Cigna Medicaid	$100,000.08
Rate for Payer: Molina CHIP/Medicaid	$100,000.08
Rate for Payer: Multiplan Auto	$69,444.50
Rate for Payer: Multiplan Commercial	$69,444.50
Rate for Payer: Multiplan Workers Comp	$69,444.50
Rate for Payer: Parkland Medicaid	$100,000.08
Rate for Payer: Scott and White EPO/PPO	$69,444.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100,000.08
Rate for Payer: Superior Health Plan EPO	$18,888.90

Anchor/screw bn/bn,tis/bn

Facility

$138,889.00

Service Code	HCPCS C1713
Hospital Charge Code	146706
Hospital Revenue Code	278
Min. Negotiated Rate	$34,722.25
Max. Negotiated Rate	$69,444.50
Rate for Payer: Cash Price	$94,444.52
Rate for Payer: Cigna Commercial	$34,722.25
Rate for Payer: Multiplan Auto	$69,444.50
Rate for Payer: Multiplan Commercial	$69,444.50
Rate for Payer: Multiplan Workers Comp	$69,444.50
Rate for Payer: Scott and White EPO/PPO	$69,444.50

Anchor/screw for opposing bone-to-bone

Facility

$10,000.00

Service Code	CPT 11012
Hospital Charge Code	36011012
Hospital Revenue Code	360
Min. Negotiated Rate	$815.20
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$815.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Amerigroup Medicare	$2,917.95
Rate for Payer: BCBS of TX Blue Advantage	$3,872.55
Rate for Payer: BCBS of TX Blue Essentials	$4,637.78
Rate for Payer: BCBS of TX Medicare	$2,917.95
Rate for Payer: BCBS of TX PPO	$5,843.60
Rate for Payer: Cigna Commercial	$6,168.03
Rate for Payer: Cigna Medicare	$2,917.95
Rate for Payer: Employer Direct Commercial	$2,917.95
Rate for Payer: Humana Medicare/TRICARE	$2,917.95
Rate for Payer: Molina Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Molina Medicare	$2,917.95
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: Scott and White EPO/PPO	$4,807.56
Rate for Payer: Scott and White Medicare	$2,917.95
Rate for Payer: Superior Health Plan EPO	$2,917.95
Rate for Payer: Superior Health Plan Medicare	$2,917.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,917.95
Rate for Payer: Universal American Medicare	$2,917.95
Rate for Payer: Wellcare Medicare	$2,917.95
Rate for Payer: Wellmed Medicare	$2,917.95

Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)

Facility

$1,687.00

Service Code	HCPCS C1713
Hospital Charge Code	146479
Hospital Revenue Code	278
Min. Negotiated Rate	$421.75
Max. Negotiated Rate	$843.50
Rate for Payer: Cash Price	$1,147.16
Rate for Payer: Cigna Commercial	$421.75
Rate for Payer: Multiplan Auto	$843.50
Rate for Payer: Multiplan Commercial	$843.50
Rate for Payer: Multiplan Workers Comp	$843.50
Rate for Payer: Scott and White EPO/PPO	$843.50

Know your out-of-pocket cost for care.

All Charges