White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SALINE .45% 1000ML BOTTLE

Facility

$22.26

Hospital Charge Code	993515
Hospital Revenue Code	270
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$16.03
Rate for Payer: Amerigroup CHIP/Medicaid	$2.00
Rate for Payer: BCBS of TX Blue Advantage	$6.68
Rate for Payer: BCBS of TX Blue Essentials	$8.01
Rate for Payer: BCBS of TX PPO	$8.90
Rate for Payer: Cash Price	$15.14
Rate for Payer: Cigna Medicaid	$16.03
Rate for Payer: Molina CHIP/Medicaid	$16.03
Rate for Payer: Multiplan Auto	$14.47
Rate for Payer: Multiplan Commercial	$14.47
Rate for Payer: Multiplan Workers Comp	$14.47
Rate for Payer: Parkland Medicaid	$16.03
Rate for Payer: Scott and White EPO/PPO	$11.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.03
Rate for Payer: Superior Health Plan EPO	$3.03

SALINE .45% 1000ML BOTTLE

Facility

$22.26

Hospital Charge Code	993515
Hospital Revenue Code	270
Rate for Payer: Cash Price	$15.14

SALINE, .45 SOLUTION 1 LI

Facility

$27.30

Hospital Charge Code	993539
Hospital Revenue Code	270
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$19.66
Rate for Payer: Amerigroup CHIP/Medicaid	$2.46
Rate for Payer: BCBS of TX Blue Advantage	$8.19
Rate for Payer: BCBS of TX Blue Essentials	$9.83
Rate for Payer: BCBS of TX PPO	$10.92
Rate for Payer: Cash Price	$18.56
Rate for Payer: Cigna Medicaid	$19.66
Rate for Payer: Molina CHIP/Medicaid	$19.66
Rate for Payer: Multiplan Auto	$17.75
Rate for Payer: Multiplan Commercial	$17.75
Rate for Payer: Multiplan Workers Comp	$17.75
Rate for Payer: Parkland Medicaid	$19.66
Rate for Payer: Scott and White EPO/PPO	$13.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.66
Rate for Payer: Superior Health Plan EPO	$3.71

SALINE, .45 SOLUTION 1 LI

Facility

$27.30

Hospital Charge Code	993539
Hospital Revenue Code	270
Rate for Payer: Cash Price	$18.56

SALINE .9% 100ML BOTTLE STERILE

Facility

$3.10

Hospital Charge Code	993291
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.11

SALINE .9% 100ML BOTTLE STERILE

Facility

$3.10

Hospital Charge Code	993291
Hospital Revenue Code	270
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$2.23
Rate for Payer: Amerigroup CHIP/Medicaid	$0.28
Rate for Payer: BCBS of TX Blue Advantage	$0.93
Rate for Payer: BCBS of TX Blue Essentials	$1.12
Rate for Payer: BCBS of TX PPO	$1.24
Rate for Payer: Cash Price	$2.11
Rate for Payer: Cigna Medicaid	$2.23
Rate for Payer: Molina CHIP/Medicaid	$2.23
Rate for Payer: Multiplan Auto	$2.02
Rate for Payer: Multiplan Commercial	$2.02
Rate for Payer: Multiplan Workers Comp	$2.02
Rate for Payer: Parkland Medicaid	$2.23
Rate for Payer: Scott and White EPO/PPO	$1.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.23
Rate for Payer: Superior Health Plan EPO	$0.42

SALIVARY GLAND PROCEDURES

Facility

$23,892.50

Service Code	MSDRG 139
Min. Negotiated Rate	$9,979.44
Max. Negotiated Rate	$23,892.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,816.57
Rate for Payer: Amerigroup Medicare	$13,816.57
Rate for Payer: BCBS of TX Blue Advantage	$9,979.44
Rate for Payer: BCBS of TX Blue Essentials	$11,974.17
Rate for Payer: BCBS of TX Medicare	$13,816.57
Rate for Payer: BCBS of TX PPO	$13,305.15
Rate for Payer: Cigna Commercial	$15,566.77
Rate for Payer: Cigna Medicare	$13,816.57
Rate for Payer: Employer Direct Commercial	$13,816.57
Rate for Payer: Humana Medicare/TRICARE	$13,816.57
Rate for Payer: Molina Dual Medicare/Medicaid	$13,816.57
Rate for Payer: Molina Medicare	$13,816.57
Rate for Payer: Multiplan Auto	$23,892.50
Rate for Payer: Multiplan Commercial	$23,892.50
Rate for Payer: Multiplan Workers Comp	$23,892.50
Rate for Payer: Scott and White EPO/PPO	$11,003.12
Rate for Payer: Scott and White Medicare	$13,816.57
Rate for Payer: Superior Health Plan EPO	$13,816.57
Rate for Payer: Superior Health Plan Medicare	$13,816.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,816.57
Rate for Payer: Universal American Medicare	$13,816.57
Rate for Payer: Wellcare Medicare	$13,816.57
Rate for Payer: Wellmed Medicare	$13,816.57

Salvation 160mm 5/8 ring slotted

Facility

$7,795.18

Service Code	HCPCS C1713
Hospital Charge Code	993396
Hospital Revenue Code	278
Min. Negotiated Rate	$1,948.80
Max. Negotiated Rate	$3,897.59
Rate for Payer: Cash Price	$5,300.72
Rate for Payer: Cigna Commercial	$1,948.80
Rate for Payer: Multiplan Auto	$3,897.59
Rate for Payer: Multiplan Commercial	$3,897.59
Rate for Payer: Multiplan Workers Comp	$3,897.59
Rate for Payer: Scott and White EPO/PPO	$3,897.59

Salvation 160mm 5/8 ring slotted

Facility

$7,795.18

Service Code	HCPCS C1713
Hospital Charge Code	993396
Hospital Revenue Code	278
Min. Negotiated Rate	$701.57
Max. Negotiated Rate	$5,612.53
Rate for Payer: Amerigroup CHIP/Medicaid	$701.57
Rate for Payer: BCBS of TX Blue Advantage	$2,338.55
Rate for Payer: BCBS of TX Blue Essentials	$2,806.26
Rate for Payer: BCBS of TX PPO	$3,118.07
Rate for Payer: Cash Price	$5,300.72
Rate for Payer: Cigna Medicaid	$5,612.53
Rate for Payer: Molina CHIP/Medicaid	$5,612.53
Rate for Payer: Multiplan Auto	$3,897.59
Rate for Payer: Multiplan Commercial	$3,897.59
Rate for Payer: Multiplan Workers Comp	$3,897.59
Rate for Payer: Parkland Medicaid	$5,612.53
Rate for Payer: Scott and White EPO/PPO	$3,897.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,612.53
Rate for Payer: Superior Health Plan EPO	$1,060.14

Salvation 160mm Distal ring slotted

Facility

$8,834.84

Service Code	HCPCS C1713
Hospital Charge Code	993393
Hospital Revenue Code	278
Min. Negotiated Rate	$2,208.71
Max. Negotiated Rate	$4,417.42
Rate for Payer: Cash Price	$6,007.69
Rate for Payer: Cigna Commercial	$2,208.71
Rate for Payer: Multiplan Auto	$4,417.42
Rate for Payer: Multiplan Commercial	$4,417.42
Rate for Payer: Multiplan Workers Comp	$4,417.42
Rate for Payer: Scott and White EPO/PPO	$4,417.42

Salvation 160mm Distal ring slotted

Facility

$8,834.84

Service Code	HCPCS C1713
Hospital Charge Code	993393
Hospital Revenue Code	278
Min. Negotiated Rate	$795.14
Max. Negotiated Rate	$6,361.08
Rate for Payer: Amerigroup CHIP/Medicaid	$795.14
Rate for Payer: BCBS of TX Blue Advantage	$2,650.45
Rate for Payer: BCBS of TX Blue Essentials	$3,180.54
Rate for Payer: BCBS of TX PPO	$3,533.94
Rate for Payer: Cash Price	$6,007.69
Rate for Payer: Cigna Medicaid	$6,361.08
Rate for Payer: Molina CHIP/Medicaid	$6,361.08
Rate for Payer: Multiplan Auto	$4,417.42
Rate for Payer: Multiplan Commercial	$4,417.42
Rate for Payer: Multiplan Workers Comp	$4,417.42
Rate for Payer: Parkland Medicaid	$6,361.08
Rate for Payer: Scott and White EPO/PPO	$4,417.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,361.08
Rate for Payer: Superior Health Plan EPO	$1,201.54

Salvation 160mm foot ring slotted

Facility

$13,965.04

Service Code	HCPCS C1713
Hospital Charge Code	993390
Hospital Revenue Code	278
Min. Negotiated Rate	$3,491.26
Max. Negotiated Rate	$6,982.52
Rate for Payer: Cash Price	$9,496.23
Rate for Payer: Cigna Commercial	$3,491.26
Rate for Payer: Multiplan Auto	$6,982.52
Rate for Payer: Multiplan Commercial	$6,982.52
Rate for Payer: Multiplan Workers Comp	$6,982.52
Rate for Payer: Scott and White EPO/PPO	$6,982.52

Salvation 160mm foot ring slotted

Facility

$13,965.04

Service Code	HCPCS C1713
Hospital Charge Code	993390
Hospital Revenue Code	278
Min. Negotiated Rate	$1,256.85
Max. Negotiated Rate	$10,054.83
Rate for Payer: Amerigroup CHIP/Medicaid	$1,256.85
Rate for Payer: BCBS of TX Blue Advantage	$4,189.51
Rate for Payer: BCBS of TX Blue Essentials	$5,027.41
Rate for Payer: BCBS of TX PPO	$5,586.02
Rate for Payer: Cash Price	$9,496.23
Rate for Payer: Cigna Medicaid	$10,054.83
Rate for Payer: Molina CHIP/Medicaid	$10,054.83
Rate for Payer: Multiplan Auto	$6,982.52
Rate for Payer: Multiplan Commercial	$6,982.52
Rate for Payer: Multiplan Workers Comp	$6,982.52
Rate for Payer: Parkland Medicaid	$10,054.83
Rate for Payer: Scott and White EPO/PPO	$6,982.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,054.83
Rate for Payer: Superior Health Plan EPO	$1,899.25

SALVATION 160MM HF RING HINDFOOT HOLES

Facility

$6,119.92

Service Code	HCPCS C1713
Hospital Charge Code	993469
Hospital Revenue Code	278
Min. Negotiated Rate	$1,529.98
Max. Negotiated Rate	$3,059.96
Rate for Payer: Cash Price	$4,161.55
Rate for Payer: Cigna Commercial	$1,529.98
Rate for Payer: Multiplan Auto	$3,059.96
Rate for Payer: Multiplan Commercial	$3,059.96
Rate for Payer: Multiplan Workers Comp	$3,059.96
Rate for Payer: Scott and White EPO/PPO	$3,059.96

SALVATION 160MM HF RING HINDFOOT HOLES

Facility

$6,119.92

Service Code	HCPCS C1713
Hospital Charge Code	993469
Hospital Revenue Code	278
Min. Negotiated Rate	$550.79
Max. Negotiated Rate	$4,406.34
Rate for Payer: Amerigroup CHIP/Medicaid	$550.79
Rate for Payer: BCBS of TX Blue Advantage	$1,835.98
Rate for Payer: BCBS of TX Blue Essentials	$2,203.17
Rate for Payer: BCBS of TX PPO	$2,447.97
Rate for Payer: Cash Price	$4,161.55
Rate for Payer: Cigna Medicaid	$4,406.34
Rate for Payer: Molina CHIP/Medicaid	$4,406.34
Rate for Payer: Multiplan Auto	$3,059.96
Rate for Payer: Multiplan Commercial	$3,059.96
Rate for Payer: Multiplan Workers Comp	$3,059.96
Rate for Payer: Parkland Medicaid	$4,406.34
Rate for Payer: Scott and White EPO/PPO	$3,059.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,406.34
Rate for Payer: Superior Health Plan EPO	$832.31

Salvation 160mm ring slotted

Facility

$7,686.22

Service Code	HCPCS C1713
Hospital Charge Code	993391
Hospital Revenue Code	278
Min. Negotiated Rate	$1,921.56
Max. Negotiated Rate	$3,843.11
Rate for Payer: Cash Price	$5,226.63
Rate for Payer: Cigna Commercial	$1,921.56
Rate for Payer: Multiplan Auto	$3,843.11
Rate for Payer: Multiplan Commercial	$3,843.11
Rate for Payer: Multiplan Workers Comp	$3,843.11
Rate for Payer: Scott and White EPO/PPO	$3,843.11

Salvation 160mm ring slotted

Facility

$7,686.22

Service Code	HCPCS C1713
Hospital Charge Code	993391
Hospital Revenue Code	278
Min. Negotiated Rate	$691.76
Max. Negotiated Rate	$5,534.08
Rate for Payer: Amerigroup CHIP/Medicaid	$691.76
Rate for Payer: BCBS of TX Blue Advantage	$2,305.87
Rate for Payer: BCBS of TX Blue Essentials	$2,767.04
Rate for Payer: BCBS of TX PPO	$3,074.49
Rate for Payer: Cash Price	$5,226.63
Rate for Payer: Cigna Medicaid	$5,534.08
Rate for Payer: Molina CHIP/Medicaid	$5,534.08
Rate for Payer: Multiplan Auto	$3,843.11
Rate for Payer: Multiplan Commercial	$3,843.11
Rate for Payer: Multiplan Workers Comp	$3,843.11
Rate for Payer: Parkland Medicaid	$5,534.08
Rate for Payer: Scott and White EPO/PPO	$3,843.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,534.08
Rate for Payer: Superior Health Plan EPO	$1,045.33

SALVATION 180MM FOOT RING SLOTTED

Facility

$13,965.04

Service Code	HCPCS C1713
Hospital Charge Code	993163
Hospital Revenue Code	278
Min. Negotiated Rate	$1,256.85
Max. Negotiated Rate	$10,054.83
Rate for Payer: Amerigroup CHIP/Medicaid	$1,256.85
Rate for Payer: BCBS of TX Blue Advantage	$4,189.51
Rate for Payer: BCBS of TX Blue Essentials	$5,027.41
Rate for Payer: BCBS of TX PPO	$5,586.02
Rate for Payer: Cash Price	$9,496.23
Rate for Payer: Cigna Medicaid	$10,054.83
Rate for Payer: Molina CHIP/Medicaid	$10,054.83
Rate for Payer: Multiplan Auto	$6,982.52
Rate for Payer: Multiplan Commercial	$6,982.52
Rate for Payer: Multiplan Workers Comp	$6,982.52
Rate for Payer: Parkland Medicaid	$10,054.83
Rate for Payer: Scott and White EPO/PPO	$6,982.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,054.83
Rate for Payer: Superior Health Plan EPO	$1,899.25

SALVATION 180MM FOOT RING SLOTTED

Facility

$13,965.04

Service Code	HCPCS C1713
Hospital Charge Code	993163
Hospital Revenue Code	278
Min. Negotiated Rate	$3,491.26
Max. Negotiated Rate	$6,982.52
Rate for Payer: Cash Price	$9,496.23
Rate for Payer: Cigna Commercial	$3,491.26
Rate for Payer: Multiplan Auto	$6,982.52
Rate for Payer: Multiplan Commercial	$6,982.52
Rate for Payer: Multiplan Workers Comp	$6,982.52
Rate for Payer: Scott and White EPO/PPO	$6,982.52

Salvation 30mm spacer

Facility

$680.72

Service Code	HCPCS C1776
Hospital Charge Code	992206
Hospital Revenue Code	278
Min. Negotiated Rate	$170.18
Max. Negotiated Rate	$340.36
Rate for Payer: Cash Price	$462.89
Rate for Payer: Cigna Commercial	$170.18
Rate for Payer: Multiplan Auto	$340.36
Rate for Payer: Multiplan Commercial	$340.36
Rate for Payer: Multiplan Workers Comp	$340.36
Rate for Payer: Scott and White EPO/PPO	$340.36

Salvation 30mm spacer

Facility

$680.72

Service Code	HCPCS C1776
Hospital Charge Code	992206
Hospital Revenue Code	278
Min. Negotiated Rate	$61.26
Max. Negotiated Rate	$490.12
Rate for Payer: Amerigroup CHIP/Medicaid	$61.26
Rate for Payer: BCBS of TX Blue Advantage	$204.22
Rate for Payer: BCBS of TX Blue Essentials	$245.06
Rate for Payer: BCBS of TX PPO	$272.29
Rate for Payer: Cash Price	$462.89
Rate for Payer: Cigna Medicaid	$490.12
Rate for Payer: Molina CHIP/Medicaid	$490.12
Rate for Payer: Multiplan Auto	$340.36
Rate for Payer: Multiplan Commercial	$340.36
Rate for Payer: Multiplan Workers Comp	$340.36
Rate for Payer: Parkland Medicaid	$490.12
Rate for Payer: Scott and White EPO/PPO	$340.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$490.12
Rate for Payer: Superior Health Plan EPO	$92.58

Salvation 60mm spacer

Facility

$771.08

Service Code	HCPCS C1776
Hospital Charge Code	992207
Hospital Revenue Code	278
Min. Negotiated Rate	$69.40
Max. Negotiated Rate	$555.18
Rate for Payer: Amerigroup CHIP/Medicaid	$69.40
Rate for Payer: BCBS of TX Blue Advantage	$231.32
Rate for Payer: BCBS of TX Blue Essentials	$277.59
Rate for Payer: BCBS of TX PPO	$308.43
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cigna Medicaid	$555.18
Rate for Payer: Molina CHIP/Medicaid	$555.18
Rate for Payer: Multiplan Auto	$385.54
Rate for Payer: Multiplan Commercial	$385.54
Rate for Payer: Multiplan Workers Comp	$385.54
Rate for Payer: Parkland Medicaid	$555.18
Rate for Payer: Scott and White EPO/PPO	$385.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$555.18
Rate for Payer: Superior Health Plan EPO	$104.87

Salvation 60mm spacer

Facility

$771.08

Service Code	HCPCS C1776
Hospital Charge Code	992207
Hospital Revenue Code	278
Min. Negotiated Rate	$192.77
Max. Negotiated Rate	$385.54
Rate for Payer: Cash Price	$524.33
Rate for Payer: Cigna Commercial	$192.77
Rate for Payer: Multiplan Auto	$385.54
Rate for Payer: Multiplan Commercial	$385.54
Rate for Payer: Multiplan Workers Comp	$385.54
Rate for Payer: Scott and White EPO/PPO	$385.54

Salvation 80mm spacer

Facility

$649.22

Hospital Charge Code	993395
Hospital Revenue Code	272
Min. Negotiated Rate	$58.43
Max. Negotiated Rate	$467.44
Rate for Payer: Amerigroup CHIP/Medicaid	$58.43
Rate for Payer: BCBS of TX Blue Advantage	$194.77
Rate for Payer: BCBS of TX Blue Essentials	$233.72
Rate for Payer: BCBS of TX PPO	$259.69
Rate for Payer: Cash Price	$441.47
Rate for Payer: Cigna Medicaid	$467.44
Rate for Payer: Molina CHIP/Medicaid	$467.44
Rate for Payer: Multiplan Auto	$421.99
Rate for Payer: Multiplan Commercial	$421.99
Rate for Payer: Multiplan Workers Comp	$421.99
Rate for Payer: Parkland Medicaid	$467.44
Rate for Payer: Scott and White EPO/PPO	$324.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$467.44
Rate for Payer: Superior Health Plan EPO	$88.29

Salvation 80mm spacer

Facility

$649.22

Hospital Charge Code	993395
Hospital Revenue Code	272
Rate for Payer: Cash Price	$441.47

Know your out-of-pocket cost for care.

All Charges