White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PR PRM ST/G7 CP/VE LN/CER

Facility

$27,710.84

Service Code	HCPCS C1734
Hospital Charge Code	992139
Hospital Revenue Code	278
Min. Negotiated Rate	$6,927.71
Max. Negotiated Rate	$13,855.42
Rate for Payer: Cash Price	$18,843.37
Rate for Payer: Cigna Commercial	$6,927.71
Rate for Payer: Multiplan Auto	$13,855.42
Rate for Payer: Multiplan Commercial	$13,855.42
Rate for Payer: Multiplan Workers Comp	$13,855.42
Rate for Payer: Scott and White EPO/PPO	$13,855.42

PRT FM (ALL) -- DHF

Facility

$82.27

Hospital Charge Code	80337553
Hospital Revenue Code	270
Rate for Payer: Cash Price	$55.94

PRT FM (ALL) -- DHF

Facility

$82.27

Hospital Charge Code	80337553
Hospital Revenue Code	270
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$59.23
Rate for Payer: Amerigroup CHIP/Medicaid	$7.40
Rate for Payer: BCBS of TX Blue Advantage	$24.68
Rate for Payer: BCBS of TX Blue Essentials	$29.62
Rate for Payer: BCBS of TX PPO	$32.91
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cigna Medicaid	$59.23
Rate for Payer: Molina CHIP/Medicaid	$59.23
Rate for Payer: Multiplan Auto	$53.48
Rate for Payer: Multiplan Commercial	$53.48
Rate for Payer: Multiplan Workers Comp	$53.48
Rate for Payer: Parkland Medicaid	$59.23
Rate for Payer: Scott and White EPO/PPO	$41.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.23
Rate for Payer: Superior Health Plan EPO	$11.19

PSD VERITAS, 60ECH, 6F GLOBAL

Facility

$1,523.38

Service Code	HCPCS C1781
Hospital Charge Code	992359
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,035.90

PSD VERITAS, 60ECH, 6F GLOBAL

Facility

$1,523.38

Service Code	HCPCS C1781
Hospital Charge Code	992359
Hospital Revenue Code	272
Min. Negotiated Rate	$137.10
Max. Negotiated Rate	$1,096.83
Rate for Payer: Amerigroup CHIP/Medicaid	$137.10
Rate for Payer: BCBS of TX Blue Advantage	$457.01
Rate for Payer: BCBS of TX Blue Essentials	$548.42
Rate for Payer: BCBS of TX PPO	$609.35
Rate for Payer: Cash Price	$1,035.90
Rate for Payer: Cigna Medicaid	$1,096.83
Rate for Payer: Molina CHIP/Medicaid	$1,096.83
Rate for Payer: Multiplan Auto	$990.20
Rate for Payer: Multiplan Commercial	$990.20
Rate for Payer: Multiplan Workers Comp	$990.20
Rate for Payer: Parkland Medicaid	$1,096.83
Rate for Payer: Scott and White EPO/PPO	$761.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,096.83
Rate for Payer: Superior Health Plan EPO	$207.18

PSN 2.5MM FEMALE SCREW 25MM QTY 2 PER PACK

Facility

$780.12

Service Code	HCPCS C1713
Hospital Charge Code	992106
Hospital Revenue Code	278
Min. Negotiated Rate	$70.21
Max. Negotiated Rate	$561.69
Rate for Payer: Amerigroup CHIP/Medicaid	$70.21
Rate for Payer: BCBS of TX Blue Advantage	$234.04
Rate for Payer: BCBS of TX Blue Essentials	$280.84
Rate for Payer: BCBS of TX PPO	$312.05
Rate for Payer: Cash Price	$530.48
Rate for Payer: Cigna Medicaid	$561.69
Rate for Payer: Molina CHIP/Medicaid	$561.69
Rate for Payer: Multiplan Auto	$390.06
Rate for Payer: Multiplan Commercial	$390.06
Rate for Payer: Multiplan Workers Comp	$390.06
Rate for Payer: Parkland Medicaid	$561.69
Rate for Payer: Scott and White EPO/PPO	$390.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$561.69
Rate for Payer: Superior Health Plan EPO	$106.10

PSN 2.5MM FEMALE SCREW 25MM QTY 2 PER PACK

Facility

$780.12

Service Code	HCPCS C1713
Hospital Charge Code	992106
Hospital Revenue Code	278
Min. Negotiated Rate	$195.03
Max. Negotiated Rate	$390.06
Rate for Payer: Cash Price	$530.48
Rate for Payer: Cigna Commercial	$195.03
Rate for Payer: Multiplan Auto	$390.06
Rate for Payer: Multiplan Commercial	$390.06
Rate for Payer: Multiplan Workers Comp	$390.06
Rate for Payer: Scott and White EPO/PPO	$390.06

PSN ASF PS 10MM VE L 10- 11 EF

Facility

$8,447.59

Service Code	HCPCS C1734
Hospital Charge Code	992111
Hospital Revenue Code	278
Min. Negotiated Rate	$760.28
Max. Negotiated Rate	$6,082.26
Rate for Payer: Amerigroup CHIP/Medicaid	$760.28
Rate for Payer: BCBS of TX Blue Advantage	$2,534.28
Rate for Payer: BCBS of TX Blue Essentials	$3,041.13
Rate for Payer: BCBS of TX PPO	$3,379.04
Rate for Payer: Cash Price	$5,744.36
Rate for Payer: Cigna Medicaid	$6,082.26
Rate for Payer: Molina CHIP/Medicaid	$6,082.26
Rate for Payer: Multiplan Auto	$4,223.80
Rate for Payer: Multiplan Commercial	$4,223.80
Rate for Payer: Multiplan Workers Comp	$4,223.80
Rate for Payer: Parkland Medicaid	$6,082.26
Rate for Payer: Scott and White EPO/PPO	$4,223.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,082.26
Rate for Payer: Superior Health Plan EPO	$1,148.87

PSN ASF PS 10MM VE L 10- 11 EF

Facility

$8,447.59

Service Code	HCPCS C1734
Hospital Charge Code	992111
Hospital Revenue Code	278
Min. Negotiated Rate	$2,111.90
Max. Negotiated Rate	$4,223.80
Rate for Payer: Cash Price	$5,744.36
Rate for Payer: Cigna Commercial	$2,111.90
Rate for Payer: Multiplan Auto	$4,223.80
Rate for Payer: Multiplan Commercial	$4,223.80
Rate for Payer: Multiplan Workers Comp	$4,223.80
Rate for Payer: Scott and White EPO/PPO	$4,223.80

PSN CM FM/CM TB/CPS/VE PSN PT

Facility

$25,301.20

Service Code	HCPCS C1734
Hospital Charge Code	992114
Hospital Revenue Code	278
Min. Negotiated Rate	$6,325.30
Max. Negotiated Rate	$12,650.60
Rate for Payer: Cash Price	$17,204.82
Rate for Payer: Cigna Commercial	$6,325.30
Rate for Payer: Multiplan Auto	$12,650.60
Rate for Payer: Multiplan Commercial	$12,650.60
Rate for Payer: Multiplan Workers Comp	$12,650.60
Rate for Payer: Scott and White EPO/PPO	$12,650.60

PSN CM FM/CM TB/CPS/VE PSN PT

Facility

$25,301.20

Service Code	HCPCS C1734
Hospital Charge Code	992114
Hospital Revenue Code	278
Min. Negotiated Rate	$2,277.11
Max. Negotiated Rate	$18,216.86
Rate for Payer: Amerigroup CHIP/Medicaid	$2,277.11
Rate for Payer: BCBS of TX Blue Advantage	$7,590.36
Rate for Payer: BCBS of TX Blue Essentials	$9,108.43
Rate for Payer: BCBS of TX PPO	$10,120.48
Rate for Payer: Cash Price	$17,204.82
Rate for Payer: Cigna Medicaid	$18,216.86
Rate for Payer: Molina CHIP/Medicaid	$18,216.86
Rate for Payer: Multiplan Auto	$12,650.60
Rate for Payer: Multiplan Commercial	$12,650.60
Rate for Payer: Multiplan Workers Comp	$12,650.60
Rate for Payer: Parkland Medicaid	$18,216.86
Rate for Payer: Scott and White EPO/PPO	$12,650.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,216.86
Rate for Payer: Superior Health Plan EPO	$3,440.96

PSN FEM PS CMT COCR STD SZ10

Facility

$19,659.04

Service Code	HCPCS C1734
Hospital Charge Code	992108
Hospital Revenue Code	278
Min. Negotiated Rate	$4,914.76
Max. Negotiated Rate	$9,829.52
Rate for Payer: Cash Price	$13,368.15
Rate for Payer: Cigna Commercial	$4,914.76
Rate for Payer: Multiplan Auto	$9,829.52
Rate for Payer: Multiplan Commercial	$9,829.52
Rate for Payer: Multiplan Workers Comp	$9,829.52
Rate for Payer: Scott and White EPO/PPO	$9,829.52

PSN FEM PS CMT COCR STD SZ10

Facility

$19,659.04

Service Code	HCPCS C1734
Hospital Charge Code	992108
Hospital Revenue Code	278
Min. Negotiated Rate	$1,769.31
Max. Negotiated Rate	$14,154.51
Rate for Payer: Amerigroup CHIP/Medicaid	$1,769.31
Rate for Payer: BCBS of TX Blue Advantage	$5,897.71
Rate for Payer: BCBS of TX Blue Essentials	$7,077.25
Rate for Payer: BCBS of TX PPO	$7,863.62
Rate for Payer: Cash Price	$13,368.15
Rate for Payer: Cigna Medicaid	$14,154.51
Rate for Payer: Molina CHIP/Medicaid	$14,154.51
Rate for Payer: Multiplan Auto	$9,829.52
Rate for Payer: Multiplan Commercial	$9,829.52
Rate for Payer: Multiplan Workers Comp	$9,829.52
Rate for Payer: Parkland Medicaid	$14,154.51
Rate for Payer: Scott and White EPO/PPO	$9,829.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,154.51
Rate for Payer: Superior Health Plan EPO	$2,673.63

PSN REV TAPERED SMOOTH STEM EXT 14X75MM

Facility

$8,090.96

Service Code	HCPCS C1734
Hospital Charge Code	992109
Hospital Revenue Code	278
Min. Negotiated Rate	$728.19
Max. Negotiated Rate	$5,825.49
Rate for Payer: Amerigroup CHIP/Medicaid	$728.19
Rate for Payer: BCBS of TX Blue Advantage	$2,427.29
Rate for Payer: BCBS of TX Blue Essentials	$2,912.75
Rate for Payer: BCBS of TX PPO	$3,236.38
Rate for Payer: Cash Price	$5,501.85
Rate for Payer: Cigna Medicaid	$5,825.49
Rate for Payer: Molina CHIP/Medicaid	$5,825.49
Rate for Payer: Multiplan Auto	$4,045.48
Rate for Payer: Multiplan Commercial	$4,045.48
Rate for Payer: Multiplan Workers Comp	$4,045.48
Rate for Payer: Parkland Medicaid	$5,825.49
Rate for Payer: Scott and White EPO/PPO	$4,045.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,825.49
Rate for Payer: Superior Health Plan EPO	$1,100.37

PSN REV TAPERED SMOOTH STEM EXT 14X75MM

Facility

$8,090.96

Service Code	HCPCS C1734
Hospital Charge Code	992109
Hospital Revenue Code	278
Min. Negotiated Rate	$2,022.74
Max. Negotiated Rate	$4,045.48
Rate for Payer: Cash Price	$5,501.85
Rate for Payer: Cigna Commercial	$2,022.74
Rate for Payer: Multiplan Auto	$4,045.48
Rate for Payer: Multiplan Commercial	$4,045.48
Rate for Payer: Multiplan Workers Comp	$4,045.48
Rate for Payer: Scott and White EPO/PPO	$4,045.48

PSN REV TIB FIXED KEEL CMT SZ F L

Facility

$12,816.27

Service Code	HCPCS C1734
Hospital Charge Code	992107
Hospital Revenue Code	278
Min. Negotiated Rate	$1,153.46
Max. Negotiated Rate	$9,227.71
Rate for Payer: Amerigroup CHIP/Medicaid	$1,153.46
Rate for Payer: BCBS of TX Blue Advantage	$3,844.88
Rate for Payer: BCBS of TX Blue Essentials	$4,613.86
Rate for Payer: BCBS of TX PPO	$5,126.51
Rate for Payer: Cash Price	$8,715.06
Rate for Payer: Cigna Medicaid	$9,227.71
Rate for Payer: Molina CHIP/Medicaid	$9,227.71
Rate for Payer: Multiplan Auto	$6,408.14
Rate for Payer: Multiplan Commercial	$6,408.14
Rate for Payer: Multiplan Workers Comp	$6,408.14
Rate for Payer: Parkland Medicaid	$9,227.71
Rate for Payer: Scott and White EPO/PPO	$6,408.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,227.71
Rate for Payer: Superior Health Plan EPO	$1,743.01

PSN REV TIB FIXED KEEL CMT SZ F L

Facility

$12,816.27

Service Code	HCPCS C1734
Hospital Charge Code	992107
Hospital Revenue Code	278
Min. Negotiated Rate	$3,204.07
Max. Negotiated Rate	$6,408.14
Rate for Payer: Cash Price	$8,715.06
Rate for Payer: Cigna Commercial	$3,204.07
Rate for Payer: Multiplan Auto	$6,408.14
Rate for Payer: Multiplan Commercial	$6,408.14
Rate for Payer: Multiplan Workers Comp	$6,408.14
Rate for Payer: Scott and White EPO/PPO	$6,408.14

PSN REV TIB HALF BLOCK SZEF LM 15MM

Facility

$6,018.07

Service Code	HCPCS C1734
Hospital Charge Code	992110
Hospital Revenue Code	278
Min. Negotiated Rate	$1,504.52
Max. Negotiated Rate	$3,009.03
Rate for Payer: Cash Price	$4,092.29
Rate for Payer: Cigna Commercial	$1,504.52
Rate for Payer: Multiplan Auto	$3,009.03
Rate for Payer: Multiplan Commercial	$3,009.03
Rate for Payer: Multiplan Workers Comp	$3,009.03
Rate for Payer: Scott and White EPO/PPO	$3,009.03

PSN REV TIB HALF BLOCK SZEF LM 15MM

Facility

$6,018.07

Service Code	HCPCS C1734
Hospital Charge Code	992110
Hospital Revenue Code	278
Min. Negotiated Rate	$541.63
Max. Negotiated Rate	$4,333.01
Rate for Payer: Amerigroup CHIP/Medicaid	$541.63
Rate for Payer: BCBS of TX Blue Advantage	$1,805.42
Rate for Payer: BCBS of TX Blue Essentials	$2,166.51
Rate for Payer: BCBS of TX PPO	$2,407.23
Rate for Payer: Cash Price	$4,092.29
Rate for Payer: Cigna Medicaid	$4,333.01
Rate for Payer: Molina CHIP/Medicaid	$4,333.01
Rate for Payer: Multiplan Auto	$3,009.03
Rate for Payer: Multiplan Commercial	$3,009.03
Rate for Payer: Multiplan Workers Comp	$3,009.03
Rate for Payer: Parkland Medicaid	$4,333.01
Rate for Payer: Scott and White EPO/PPO	$3,009.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,333.01
Rate for Payer: Superior Health Plan EPO	$818.46

PSYCH DIAGNOSTIC EVALUATION BCE

Facility

$480.00

Service Code	HCPCS 90791
Hospital Charge Code	100013
Hospital Revenue Code	914
Min. Negotiated Rate	$43.20
Max. Negotiated Rate	$376.90
Rate for Payer: Amerigroup CHIP/Medicaid	$43.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$178.30
Rate for Payer: Amerigroup Medicare	$178.30
Rate for Payer: BCBS of TX Blue Advantage	$144.00
Rate for Payer: BCBS of TX Blue Essentials	$172.80
Rate for Payer: BCBS of TX Medicare	$178.30
Rate for Payer: BCBS of TX PPO	$192.00
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cigna Commercial	$376.90
Rate for Payer: Cigna Medicaid	$345.60
Rate for Payer: Cigna Medicare	$178.30
Rate for Payer: Employer Direct Commercial	$178.30
Rate for Payer: Humana Medicare/TRICARE	$178.30
Rate for Payer: Molina CHIP/Medicaid	$345.60
Rate for Payer: Molina Dual Medicare/Medicaid	$178.30
Rate for Payer: Molina Medicare	$178.30
Rate for Payer: Multiplan Auto	$312.00
Rate for Payer: Multiplan Commercial	$312.00
Rate for Payer: Multiplan Workers Comp	$312.00
Rate for Payer: Parkland Medicaid	$345.60
Rate for Payer: Scott and White EPO/PPO	$182.69
Rate for Payer: Scott and White Medicare	$178.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$345.60
Rate for Payer: Superior Health Plan EPO	$178.30
Rate for Payer: Superior Health Plan Medicare	$178.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$178.30
Rate for Payer: Universal American Medicare	$178.30
Rate for Payer: Wellcare Medicare	$178.30
Rate for Payer: Wellmed Medicare	$178.30

PSYCH DIAGNOSTIC EVALUATION BCE

Facility

$480.00

Service Code	HCPCS 90791
Hospital Charge Code	100013
Hospital Revenue Code	914
Rate for Payer: Cash Price	$326.40

PSYCHOSES

Facility

$24,614.50

Service Code	MSDRG 885
Min. Negotiated Rate	$10,286.46
Max. Negotiated Rate	$24,614.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,997.26
Rate for Payer: Amerigroup Medicare	$14,997.26
Rate for Payer: BCBS of TX Blue Advantage	$10,286.46
Rate for Payer: BCBS of TX Blue Essentials	$12,342.56
Rate for Payer: BCBS of TX Medicare	$14,997.26
Rate for Payer: BCBS of TX PPO	$13,714.48
Rate for Payer: Cigna Commercial	$17,990.78
Rate for Payer: Cigna Medicare	$14,997.26
Rate for Payer: Employer Direct Commercial	$14,997.26
Rate for Payer: Molina Dual Medicare/Medicaid	$14,997.26
Rate for Payer: Molina Medicare	$14,997.26
Rate for Payer: Multiplan Auto	$24,614.50
Rate for Payer: Multiplan Commercial	$24,614.50
Rate for Payer: Multiplan Workers Comp	$24,614.50
Rate for Payer: Scott and White EPO/PPO	$11,335.62
Rate for Payer: Scott and White Medicare	$14,997.26
Rate for Payer: Superior Health Plan EPO	$14,997.26
Rate for Payer: Superior Health Plan Medicare	$14,997.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,997.26
Rate for Payer: Universal American Medicare	$14,997.26
Rate for Payer: Wellcare Medicare	$14,997.26
Rate for Payer: Wellmed Medicare	$14,997.26

psyllium 3.4 g/12 g Oral Powder-Recon

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77785002
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

psyllium 3.4 g/12 g Oral Powder-Recon

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77785002
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

PT Aquatic Assistant Units

Facility

$137.00

Service Code	HCPCS 97113
Hospital Charge Code	5710045
Hospital Revenue Code	420
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.33
Rate for Payer: BCBS of TX Blue Advantage	$41.10
Rate for Payer: BCBS of TX Blue Essentials	$49.32
Rate for Payer: BCBS of TX PPO	$54.80
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$98.64
Rate for Payer: Molina CHIP/Medicaid	$98.64
Rate for Payer: Multiplan Auto	$89.05
Rate for Payer: Multiplan Commercial	$89.05
Rate for Payer: Multiplan Workers Comp	$89.05
Rate for Payer: Parkland Medicaid	$98.64
Rate for Payer: Scott and White EPO/PPO	$45.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.64
Rate for Payer: Superior Health Plan EPO	$18.63

Know your out-of-pocket cost for care.

All Charges