White Rock Medical Center

All Charges

Charge

Type

Setting

Price

RELOAD, STAPLE REINFORCED W/TRI 60MM -- DHF

Facility

$1,880.65

Hospital Charge Code	81911406
Hospital Revenue Code	272
Min. Negotiated Rate	$169.26
Max. Negotiated Rate	$1,354.07
Rate for Payer: Amerigroup CHIP/Medicaid	$169.26
Rate for Payer: BCBS of TX Blue Advantage	$564.20
Rate for Payer: BCBS of TX Blue Essentials	$677.03
Rate for Payer: BCBS of TX PPO	$752.26
Rate for Payer: Cash Price	$1,278.84
Rate for Payer: Cigna Medicaid	$1,354.07
Rate for Payer: Molina CHIP/Medicaid	$1,354.07
Rate for Payer: Multiplan Auto	$1,222.42
Rate for Payer: Multiplan Commercial	$1,222.42
Rate for Payer: Multiplan Workers Comp	$1,222.42
Rate for Payer: Parkland Medicaid	$1,354.07
Rate for Payer: Scott and White EPO/PPO	$940.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,354.07
Rate for Payer: Superior Health Plan EPO	$255.77

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Facility

$1,044.20

Hospital Charge Code	8690515
Hospital Revenue Code	272
Rate for Payer: Cash Price	$710.06

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Facility

$1,044.20

Hospital Charge Code	8690515
Hospital Revenue Code	272
Min. Negotiated Rate	$93.98
Max. Negotiated Rate	$751.82
Rate for Payer: Amerigroup CHIP/Medicaid	$93.98
Rate for Payer: BCBS of TX Blue Advantage	$313.26
Rate for Payer: BCBS of TX Blue Essentials	$375.91
Rate for Payer: BCBS of TX PPO	$417.68
Rate for Payer: Cash Price	$710.06
Rate for Payer: Cigna Medicaid	$751.82
Rate for Payer: Molina CHIP/Medicaid	$751.82
Rate for Payer: Multiplan Auto	$678.73
Rate for Payer: Multiplan Commercial	$678.73
Rate for Payer: Multiplan Workers Comp	$678.73
Rate for Payer: Parkland Medicaid	$751.82
Rate for Payer: Scott and White EPO/PPO	$522.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$751.82
Rate for Payer: Superior Health Plan EPO	$142.01

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Facility

$1,044.20

Hospital Charge Code	8690518
Hospital Revenue Code	272
Rate for Payer: Cash Price	$710.06

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Facility

$1,044.20

Hospital Charge Code	8690518
Hospital Revenue Code	272
Min. Negotiated Rate	$93.98
Max. Negotiated Rate	$751.82
Rate for Payer: Amerigroup CHIP/Medicaid	$93.98
Rate for Payer: BCBS of TX Blue Advantage	$313.26
Rate for Payer: BCBS of TX Blue Essentials	$375.91
Rate for Payer: BCBS of TX PPO	$417.68
Rate for Payer: Cash Price	$710.06
Rate for Payer: Cigna Medicaid	$751.82
Rate for Payer: Molina CHIP/Medicaid	$751.82
Rate for Payer: Multiplan Auto	$678.73
Rate for Payer: Multiplan Commercial	$678.73
Rate for Payer: Multiplan Workers Comp	$678.73
Rate for Payer: Parkland Medicaid	$751.82
Rate for Payer: Scott and White EPO/PPO	$522.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$751.82
Rate for Payer: Superior Health Plan EPO	$142.01

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Facility

$1,044.20

Hospital Charge Code	8690519
Hospital Revenue Code	272
Min. Negotiated Rate	$93.98
Max. Negotiated Rate	$751.82
Rate for Payer: Amerigroup CHIP/Medicaid	$93.98
Rate for Payer: BCBS of TX Blue Advantage	$313.26
Rate for Payer: BCBS of TX Blue Essentials	$375.91
Rate for Payer: BCBS of TX PPO	$417.68
Rate for Payer: Cash Price	$710.06
Rate for Payer: Cigna Medicaid	$751.82
Rate for Payer: Molina CHIP/Medicaid	$751.82
Rate for Payer: Multiplan Auto	$678.73
Rate for Payer: Multiplan Commercial	$678.73
Rate for Payer: Multiplan Workers Comp	$678.73
Rate for Payer: Parkland Medicaid	$751.82
Rate for Payer: Scott and White EPO/PPO	$522.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$751.82
Rate for Payer: Superior Health Plan EPO	$142.01

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Facility

$1,044.20

Hospital Charge Code	8690519
Hospital Revenue Code	272
Rate for Payer: Cash Price	$710.06

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Facility

$1,044.20

Hospital Charge Code	8690517
Hospital Revenue Code	272
Rate for Payer: Cash Price	$710.06

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Facility

$1,044.20

Hospital Charge Code	8690517
Hospital Revenue Code	272
Min. Negotiated Rate	$93.98
Max. Negotiated Rate	$751.82
Rate for Payer: Amerigroup CHIP/Medicaid	$93.98
Rate for Payer: BCBS of TX Blue Advantage	$313.26
Rate for Payer: BCBS of TX Blue Essentials	$375.91
Rate for Payer: BCBS of TX PPO	$417.68
Rate for Payer: Cash Price	$710.06
Rate for Payer: Cigna Medicaid	$751.82
Rate for Payer: Molina CHIP/Medicaid	$751.82
Rate for Payer: Multiplan Auto	$678.73
Rate for Payer: Multiplan Commercial	$678.73
Rate for Payer: Multiplan Workers Comp	$678.73
Rate for Payer: Parkland Medicaid	$751.82
Rate for Payer: Scott and White EPO/PPO	$522.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$751.82
Rate for Payer: Superior Health Plan EPO	$142.01

reload tri staple 60black sig60axt

Facility

$1,358.23

Hospital Charge Code	8634513
Hospital Revenue Code	272
Min. Negotiated Rate	$122.24
Max. Negotiated Rate	$977.93
Rate for Payer: Amerigroup CHIP/Medicaid	$122.24
Rate for Payer: BCBS of TX Blue Advantage	$407.47
Rate for Payer: BCBS of TX Blue Essentials	$488.96
Rate for Payer: BCBS of TX PPO	$543.29
Rate for Payer: Cash Price	$923.60
Rate for Payer: Cigna Medicaid	$977.93
Rate for Payer: Molina CHIP/Medicaid	$977.93
Rate for Payer: Multiplan Auto	$882.85
Rate for Payer: Multiplan Commercial	$882.85
Rate for Payer: Multiplan Workers Comp	$882.85
Rate for Payer: Parkland Medicaid	$977.93
Rate for Payer: Scott and White EPO/PPO	$679.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$977.93
Rate for Payer: Superior Health Plan EPO	$184.72

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Facility

$1,358.23

Hospital Charge Code	8634513
Hospital Revenue Code	272
Rate for Payer: Cash Price	$923.60

RELOAD TRI STPL 45PURPLE EGIA45AMT

Facility

$2,526.83

Hospital Charge Code	8612534
Hospital Revenue Code	272
Min. Negotiated Rate	$227.41
Max. Negotiated Rate	$1,819.32
Rate for Payer: Amerigroup CHIP/Medicaid	$227.41
Rate for Payer: BCBS of TX Blue Advantage	$758.05
Rate for Payer: BCBS of TX Blue Essentials	$909.66
Rate for Payer: BCBS of TX PPO	$1,010.73
Rate for Payer: Cash Price	$1,718.24
Rate for Payer: Cigna Medicaid	$1,819.32
Rate for Payer: Molina CHIP/Medicaid	$1,819.32
Rate for Payer: Multiplan Auto	$1,642.44
Rate for Payer: Multiplan Commercial	$1,642.44
Rate for Payer: Multiplan Workers Comp	$1,642.44
Rate for Payer: Parkland Medicaid	$1,819.32
Rate for Payer: Scott and White EPO/PPO	$1,263.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,819.32
Rate for Payer: Superior Health Plan EPO	$343.65

RELOAD TRI STPL 45PURPLE EGIA45AMT

Facility

$2,526.83

Hospital Charge Code	8612534
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,718.24

RELOAD TRI STPL 60PURPLE EGIA60AMT

Facility

$2,751.42

Hospital Charge Code	8612535
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,870.97

RELOAD TRI STPL 60PURPLE EGIA60AMT

Facility

$2,751.42

Hospital Charge Code	8612535
Hospital Revenue Code	272
Min. Negotiated Rate	$247.63
Max. Negotiated Rate	$1,981.02
Rate for Payer: Amerigroup CHIP/Medicaid	$247.63
Rate for Payer: BCBS of TX Blue Advantage	$825.43
Rate for Payer: BCBS of TX Blue Essentials	$990.51
Rate for Payer: BCBS of TX PPO	$1,100.57
Rate for Payer: Cash Price	$1,870.97
Rate for Payer: Cigna Medicaid	$1,981.02
Rate for Payer: Molina CHIP/Medicaid	$1,981.02
Rate for Payer: Multiplan Auto	$1,788.42
Rate for Payer: Multiplan Commercial	$1,788.42
Rate for Payer: Multiplan Workers Comp	$1,788.42
Rate for Payer: Parkland Medicaid	$1,981.02
Rate for Payer: Scott and White EPO/PPO	$1,375.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,981.02
Rate for Payer: Superior Health Plan EPO	$374.19

RELOAD TRI STPL 60 TAN EGIA60AVM

Facility

$2,655.99

Hospital Charge Code	8612531
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,806.07

RELOAD TRI STPL 60 TAN EGIA60AVM

Facility

$2,655.99

Hospital Charge Code	8612531
Hospital Revenue Code	272
Min. Negotiated Rate	$239.04
Max. Negotiated Rate	$1,912.31
Rate for Payer: Amerigroup CHIP/Medicaid	$239.04
Rate for Payer: BCBS of TX Blue Advantage	$796.80
Rate for Payer: BCBS of TX Blue Essentials	$956.16
Rate for Payer: BCBS of TX PPO	$1,062.40
Rate for Payer: Cash Price	$1,806.07
Rate for Payer: Cigna Medicaid	$1,912.31
Rate for Payer: Molina CHIP/Medicaid	$1,912.31
Rate for Payer: Multiplan Auto	$1,726.39
Rate for Payer: Multiplan Commercial	$1,726.39
Rate for Payer: Multiplan Workers Comp	$1,726.39
Rate for Payer: Parkland Medicaid	$1,912.31
Rate for Payer: Scott and White EPO/PPO	$1,327.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,912.31
Rate for Payer: Superior Health Plan EPO	$361.21

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Facility

$210.00

Hospital Charge Code	8452484
Hospital Revenue Code	272
Rate for Payer: Cash Price	$142.80

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Facility

$210.00

Hospital Charge Code	8452484
Hospital Revenue Code	272
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$151.20
Rate for Payer: Amerigroup CHIP/Medicaid	$18.90
Rate for Payer: BCBS of TX Blue Advantage	$63.00
Rate for Payer: BCBS of TX Blue Essentials	$75.60
Rate for Payer: BCBS of TX PPO	$84.00
Rate for Payer: Cash Price	$142.80
Rate for Payer: Cigna Medicaid	$151.20
Rate for Payer: Molina CHIP/Medicaid	$151.20
Rate for Payer: Multiplan Auto	$136.50
Rate for Payer: Multiplan Commercial	$136.50
Rate for Payer: Multiplan Workers Comp	$136.50
Rate for Payer: Parkland Medicaid	$151.20
Rate for Payer: Scott and White EPO/PPO	$105.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.20
Rate for Payer: Superior Health Plan EPO	$28.56

REM AICD LDS TRANSVEN

Facility

$6,343.00

Service Code	HCPCS 33244
Hospital Charge Code	2302503
Hospital Revenue Code	360
Min. Negotiated Rate	$570.87
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$570.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,753.99
Rate for Payer: Amerigroup Medicare	$3,753.99
Rate for Payer: BCBS of TX Blue Advantage	$4,983.30
Rate for Payer: BCBS of TX Blue Essentials	$5,968.02
Rate for Payer: BCBS of TX Medicare	$3,753.99
Rate for Payer: BCBS of TX PPO	$7,519.71
Rate for Payer: Cash Price	$4,313.24
Rate for Payer: Cash Price	$4,313.24
Rate for Payer: Cash Price	$4,313.24
Rate for Payer: Cigna Commercial	$7,935.26
Rate for Payer: Cigna Medicaid	$4,566.96
Rate for Payer: Cigna Medicare	$3,753.99
Rate for Payer: Employer Direct Commercial	$3,753.99
Rate for Payer: Humana Medicare/TRICARE	$3,753.99
Rate for Payer: Molina CHIP/Medicaid	$4,566.96
Rate for Payer: Molina Dual Medicare/Medicaid	$3,753.99
Rate for Payer: Molina Medicare	$3,753.99
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	$4,566.96
Rate for Payer: Scott and White EPO/PPO	$6,644.15
Rate for Payer: Scott and White Medicare	$3,753.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,566.96
Rate for Payer: Superior Health Plan EPO	$3,753.99
Rate for Payer: Superior Health Plan Medicare	$3,753.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,753.99
Rate for Payer: Universal American Medicare	$3,753.99
Rate for Payer: Wellcare Medicare	$3,753.99
Rate for Payer: Wellmed Medicare	$3,753.99

REM AICD LDS TRANSVEN

Facility

$6,343.00

Service Code	HCPCS 33244
Hospital Charge Code	2302503
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,313.24

REMEDY MODULAR HEAD

Facility

$24,909.64

Service Code	HCPCS C1776
Hospital Charge Code	992265
Hospital Revenue Code	278
Min. Negotiated Rate	$2,241.87
Max. Negotiated Rate	$17,934.94
Rate for Payer: Amerigroup CHIP/Medicaid	$2,241.87
Rate for Payer: BCBS of TX Blue Advantage	$7,472.89
Rate for Payer: BCBS of TX Blue Essentials	$8,967.47
Rate for Payer: BCBS of TX PPO	$9,963.86
Rate for Payer: Cash Price	$16,938.56
Rate for Payer: Cigna Medicaid	$17,934.94
Rate for Payer: Molina CHIP/Medicaid	$17,934.94
Rate for Payer: Multiplan Auto	$12,454.82
Rate for Payer: Multiplan Commercial	$12,454.82
Rate for Payer: Multiplan Workers Comp	$12,454.82
Rate for Payer: Parkland Medicaid	$17,934.94
Rate for Payer: Scott and White EPO/PPO	$12,454.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,934.94
Rate for Payer: Superior Health Plan EPO	$3,387.71

REMEDY MODULAR HEAD

Facility

$24,909.64

Service Code	HCPCS C1776
Hospital Charge Code	992265
Hospital Revenue Code	278
Min. Negotiated Rate	$6,227.41
Max. Negotiated Rate	$12,454.82
Rate for Payer: Cash Price	$16,938.56
Rate for Payer: Cigna Commercial	$6,227.41
Rate for Payer: Multiplan Auto	$12,454.82
Rate for Payer: Multiplan Commercial	$12,454.82
Rate for Payer: Multiplan Workers Comp	$12,454.82
Rate for Payer: Scott and White EPO/PPO	$12,454.82

REMEDY MODULAR STEM

Facility

$34,909.64

Service Code	HCPCS C1776
Hospital Charge Code	992266
Hospital Revenue Code	278
Min. Negotiated Rate	$8,727.41
Max. Negotiated Rate	$17,454.82
Rate for Payer: Cash Price	$23,738.56
Rate for Payer: Cigna Commercial	$8,727.41
Rate for Payer: Multiplan Auto	$17,454.82
Rate for Payer: Multiplan Commercial	$17,454.82
Rate for Payer: Multiplan Workers Comp	$17,454.82
Rate for Payer: Scott and White EPO/PPO	$17,454.82

REMEDY MODULAR STEM

Facility

$34,909.64

Service Code	HCPCS C1776
Hospital Charge Code	992266
Hospital Revenue Code	278
Min. Negotiated Rate	$3,141.87
Max. Negotiated Rate	$25,134.94
Rate for Payer: Amerigroup CHIP/Medicaid	$3,141.87
Rate for Payer: BCBS of TX Blue Advantage	$10,472.89
Rate for Payer: BCBS of TX Blue Essentials	$12,567.47
Rate for Payer: BCBS of TX PPO	$13,963.86
Rate for Payer: Cash Price	$23,738.56
Rate for Payer: Cigna Medicaid	$25,134.94
Rate for Payer: Molina CHIP/Medicaid	$25,134.94
Rate for Payer: Multiplan Auto	$17,454.82
Rate for Payer: Multiplan Commercial	$17,454.82
Rate for Payer: Multiplan Workers Comp	$17,454.82
Rate for Payer: Parkland Medicaid	$25,134.94
Rate for Payer: Scott and White EPO/PPO	$17,454.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,134.94
Rate for Payer: Superior Health Plan EPO	$4,747.71

Know your out-of-pocket cost for care.

All Charges