White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SCRUB, BACTOSHIELD CHG 4% 4OZ

Facility

$10.27

Hospital Charge Code	992953
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.98

SCRW BN 81360059 -- DHF

Facility

$2,829.00

Service Code	HCPCS C1713
Hospital Charge Code	81360059
Hospital Revenue Code	278
Min. Negotiated Rate	$707.25
Max. Negotiated Rate	$1,414.50
Rate for Payer: Cash Price	$1,923.72
Rate for Payer: Cigna Commercial	$707.25
Rate for Payer: Multiplan Auto	$1,414.50
Rate for Payer: Multiplan Commercial	$1,414.50
Rate for Payer: Multiplan Workers Comp	$1,414.50
Rate for Payer: Scott and White EPO/PPO	$1,414.50

SCRW BN 81360059 -- DHF

Facility

$2,829.00

Service Code	HCPCS C1713
Hospital Charge Code	81360059
Hospital Revenue Code	278
Min. Negotiated Rate	$254.61
Max. Negotiated Rate	$2,036.88
Rate for Payer: Amerigroup CHIP/Medicaid	$254.61
Rate for Payer: BCBS of TX Blue Advantage	$848.70
Rate for Payer: BCBS of TX Blue Essentials	$1,018.44
Rate for Payer: BCBS of TX PPO	$1,131.60
Rate for Payer: Cash Price	$1,923.72
Rate for Payer: Cigna Medicaid	$2,036.88
Rate for Payer: Molina CHIP/Medicaid	$2,036.88
Rate for Payer: Multiplan Auto	$1,414.50
Rate for Payer: Multiplan Commercial	$1,414.50
Rate for Payer: Multiplan Workers Comp	$1,414.50
Rate for Payer: Parkland Medicaid	$2,036.88
Rate for Payer: Scott and White EPO/PPO	$1,414.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,036.88
Rate for Payer: Superior Health Plan EPO	$384.74

SCRW BN 81360067 -- DHF

Facility

$274.00

Service Code	HCPCS C1713
Hospital Charge Code	81360067
Hospital Revenue Code	278
Min. Negotiated Rate	$68.50
Max. Negotiated Rate	$137.00
Rate for Payer: Cash Price	$186.32
Rate for Payer: Cigna Commercial	$68.50
Rate for Payer: Multiplan Auto	$137.00
Rate for Payer: Multiplan Commercial	$137.00
Rate for Payer: Multiplan Workers Comp	$137.00
Rate for Payer: Scott and White EPO/PPO	$137.00

SCRW BN 81360067 -- DHF

Facility

$274.00

Service Code	HCPCS C1713
Hospital Charge Code	81360067
Hospital Revenue Code	278
Min. Negotiated Rate	$24.66
Max. Negotiated Rate	$197.28
Rate for Payer: Amerigroup CHIP/Medicaid	$24.66
Rate for Payer: BCBS of TX Blue Advantage	$82.20
Rate for Payer: BCBS of TX Blue Essentials	$98.64
Rate for Payer: BCBS of TX PPO	$109.60
Rate for Payer: Cash Price	$186.32
Rate for Payer: Cigna Medicaid	$197.28
Rate for Payer: Molina CHIP/Medicaid	$197.28
Rate for Payer: Multiplan Auto	$137.00
Rate for Payer: Multiplan Commercial	$137.00
Rate for Payer: Multiplan Workers Comp	$137.00
Rate for Payer: Parkland Medicaid	$197.28
Rate for Payer: Scott and White EPO/PPO	$137.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$197.28
Rate for Payer: Superior Health Plan EPO	$37.26

SCRW CANCL -- DHF

Facility

$3,356.00

Service Code	HCPCS C1713
Hospital Charge Code	81360208
Hospital Revenue Code	278
Min. Negotiated Rate	$839.00
Max. Negotiated Rate	$1,678.00
Rate for Payer: Cash Price	$2,282.08
Rate for Payer: Cigna Commercial	$839.00
Rate for Payer: Multiplan Auto	$1,678.00
Rate for Payer: Multiplan Commercial	$1,678.00
Rate for Payer: Multiplan Workers Comp	$1,678.00
Rate for Payer: Scott and White EPO/PPO	$1,678.00

SCRW CANCL -- DHF

Facility

$3,356.00

Service Code	HCPCS C1713
Hospital Charge Code	81360208
Hospital Revenue Code	278
Min. Negotiated Rate	$302.04
Max. Negotiated Rate	$2,416.32
Rate for Payer: Amerigroup CHIP/Medicaid	$302.04
Rate for Payer: BCBS of TX Blue Advantage	$1,006.80
Rate for Payer: BCBS of TX Blue Essentials	$1,208.16
Rate for Payer: BCBS of TX PPO	$1,342.40
Rate for Payer: Cash Price	$2,282.08
Rate for Payer: Cigna Medicaid	$2,416.32
Rate for Payer: Molina CHIP/Medicaid	$2,416.32
Rate for Payer: Multiplan Auto	$1,678.00
Rate for Payer: Multiplan Commercial	$1,678.00
Rate for Payer: Multiplan Workers Comp	$1,678.00
Rate for Payer: Parkland Medicaid	$2,416.32
Rate for Payer: Scott and White EPO/PPO	$1,678.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,416.32
Rate for Payer: Superior Health Plan EPO	$456.42

SCRW CANN -- DHF

Facility

$3,796.00

Service Code	HCPCS C1713
Hospital Charge Code	81360307
Hospital Revenue Code	278
Min. Negotiated Rate	$949.00
Max. Negotiated Rate	$1,898.00
Rate for Payer: Cash Price	$2,581.28
Rate for Payer: Cigna Commercial	$949.00
Rate for Payer: Multiplan Auto	$1,898.00
Rate for Payer: Multiplan Commercial	$1,898.00
Rate for Payer: Multiplan Workers Comp	$1,898.00
Rate for Payer: Scott and White EPO/PPO	$1,898.00

SCRW CANN -- DHF

Facility

$3,796.00

Service Code	HCPCS C1713
Hospital Charge Code	81360307
Hospital Revenue Code	278
Min. Negotiated Rate	$341.64
Max. Negotiated Rate	$2,733.12
Rate for Payer: Amerigroup CHIP/Medicaid	$341.64
Rate for Payer: BCBS of TX Blue Advantage	$1,138.80
Rate for Payer: BCBS of TX Blue Essentials	$1,366.56
Rate for Payer: BCBS of TX PPO	$1,518.40
Rate for Payer: Cash Price	$2,581.28
Rate for Payer: Cigna Medicaid	$2,733.12
Rate for Payer: Molina CHIP/Medicaid	$2,733.12
Rate for Payer: Multiplan Auto	$1,898.00
Rate for Payer: Multiplan Commercial	$1,898.00
Rate for Payer: Multiplan Workers Comp	$1,898.00
Rate for Payer: Parkland Medicaid	$2,733.12
Rate for Payer: Scott and White EPO/PPO	$1,898.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,733.12
Rate for Payer: Superior Health Plan EPO	$516.26

SCRW COMPRESS 81360505 -- DHF

Facility

$1,540.00

Service Code	HCPCS C1713
Hospital Charge Code	81360505
Hospital Revenue Code	278
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$770.00
Rate for Payer: Cash Price	$1,047.20
Rate for Payer: Cigna Commercial	$385.00
Rate for Payer: Multiplan Auto	$770.00
Rate for Payer: Multiplan Commercial	$770.00
Rate for Payer: Multiplan Workers Comp	$770.00
Rate for Payer: Scott and White EPO/PPO	$770.00

SCRW COMPRESS 81360505 -- DHF

Facility

$1,540.00

Service Code	HCPCS C1713
Hospital Charge Code	81360505
Hospital Revenue Code	278
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$1,108.80
Rate for Payer: Amerigroup CHIP/Medicaid	$138.60
Rate for Payer: BCBS of TX Blue Advantage	$462.00
Rate for Payer: BCBS of TX Blue Essentials	$554.40
Rate for Payer: BCBS of TX PPO	$616.00
Rate for Payer: Cash Price	$1,047.20
Rate for Payer: Cigna Medicaid	$1,108.80
Rate for Payer: Molina CHIP/Medicaid	$1,108.80
Rate for Payer: Multiplan Auto	$770.00
Rate for Payer: Multiplan Commercial	$770.00
Rate for Payer: Multiplan Workers Comp	$770.00
Rate for Payer: Parkland Medicaid	$1,108.80
Rate for Payer: Scott and White EPO/PPO	$770.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,108.80
Rate for Payer: Superior Health Plan EPO	$209.44

SCRW COMPRESS 81360554 -- DHF

Facility

$241.00

Service Code	HCPCS C1713
Hospital Charge Code	81360554
Hospital Revenue Code	278
Min. Negotiated Rate	$60.25
Max. Negotiated Rate	$120.50
Rate for Payer: Cash Price	$163.88
Rate for Payer: Cigna Commercial	$60.25
Rate for Payer: Multiplan Auto	$120.50
Rate for Payer: Multiplan Commercial	$120.50
Rate for Payer: Multiplan Workers Comp	$120.50
Rate for Payer: Scott and White EPO/PPO	$120.50

SCRW COMPRESS 81360554 -- DHF

Facility

$241.00

Service Code	HCPCS C1713
Hospital Charge Code	81360554
Hospital Revenue Code	278
Min. Negotiated Rate	$21.69
Max. Negotiated Rate	$173.52
Rate for Payer: Amerigroup CHIP/Medicaid	$21.69
Rate for Payer: BCBS of TX Blue Advantage	$72.30
Rate for Payer: BCBS of TX Blue Essentials	$86.76
Rate for Payer: BCBS of TX PPO	$96.40
Rate for Payer: Cash Price	$163.88
Rate for Payer: Cigna Medicaid	$173.52
Rate for Payer: Molina CHIP/Medicaid	$173.52
Rate for Payer: Multiplan Auto	$120.50
Rate for Payer: Multiplan Commercial	$120.50
Rate for Payer: Multiplan Workers Comp	$120.50
Rate for Payer: Parkland Medicaid	$173.52
Rate for Payer: Scott and White EPO/PPO	$120.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$173.52
Rate for Payer: Superior Health Plan EPO	$32.78

SCRW CORTICAL -- DHF

Facility

$663.00

Service Code	HCPCS C1713
Hospital Charge Code	81360711
Hospital Revenue Code	278
Min. Negotiated Rate	$59.67
Max. Negotiated Rate	$477.36
Rate for Payer: Amerigroup CHIP/Medicaid	$59.67
Rate for Payer: BCBS of TX Blue Advantage	$198.90
Rate for Payer: BCBS of TX Blue Essentials	$238.68
Rate for Payer: BCBS of TX PPO	$265.20
Rate for Payer: Cash Price	$450.84
Rate for Payer: Cigna Medicaid	$477.36
Rate for Payer: Molina CHIP/Medicaid	$477.36
Rate for Payer: Multiplan Auto	$331.50
Rate for Payer: Multiplan Commercial	$331.50
Rate for Payer: Multiplan Workers Comp	$331.50
Rate for Payer: Parkland Medicaid	$477.36
Rate for Payer: Scott and White EPO/PPO	$331.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$477.36
Rate for Payer: Superior Health Plan EPO	$90.17

SCRW CORTICAL -- DHF

Facility

$663.00

Service Code	HCPCS C1713
Hospital Charge Code	81360711
Hospital Revenue Code	278
Min. Negotiated Rate	$165.75
Max. Negotiated Rate	$331.50
Rate for Payer: Cash Price	$450.84
Rate for Payer: Cigna Commercial	$165.75
Rate for Payer: Multiplan Auto	$331.50
Rate for Payer: Multiplan Commercial	$331.50
Rate for Payer: Multiplan Workers Comp	$331.50
Rate for Payer: Scott and White EPO/PPO	$331.50

SCRW CORTX -- DHF

Facility

$298.00

Service Code	HCPCS C1713
Hospital Charge Code	81360679
Hospital Revenue Code	278
Min. Negotiated Rate	$26.82
Max. Negotiated Rate	$214.56
Rate for Payer: Amerigroup CHIP/Medicaid	$26.82
Rate for Payer: BCBS of TX Blue Advantage	$89.40
Rate for Payer: BCBS of TX Blue Essentials	$107.28
Rate for Payer: BCBS of TX PPO	$119.20
Rate for Payer: Cash Price	$202.64
Rate for Payer: Cigna Medicaid	$214.56
Rate for Payer: Molina CHIP/Medicaid	$214.56
Rate for Payer: Multiplan Auto	$149.00
Rate for Payer: Multiplan Commercial	$149.00
Rate for Payer: Multiplan Workers Comp	$149.00
Rate for Payer: Parkland Medicaid	$214.56
Rate for Payer: Scott and White EPO/PPO	$149.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$214.56
Rate for Payer: Superior Health Plan EPO	$40.53

SCRW CORTX -- DHF

Facility

$298.00

Service Code	HCPCS C1713
Hospital Charge Code	81360679
Hospital Revenue Code	278
Min. Negotiated Rate	$74.50
Max. Negotiated Rate	$149.00
Rate for Payer: Cash Price	$202.64
Rate for Payer: Cigna Commercial	$74.50
Rate for Payer: Multiplan Auto	$149.00
Rate for Payer: Multiplan Commercial	$149.00
Rate for Payer: Multiplan Workers Comp	$149.00
Rate for Payer: Scott and White EPO/PPO	$149.00

SCRW INTRAFIX ADVNC BR SHTH -- DHF

Facility

$7,446.00

Service Code	HCPCS C1713
Hospital Charge Code	81361883
Hospital Revenue Code	278
Min. Negotiated Rate	$1,861.50
Max. Negotiated Rate	$3,723.00
Rate for Payer: Cash Price	$5,063.28
Rate for Payer: Cigna Commercial	$1,861.50
Rate for Payer: Multiplan Auto	$3,723.00
Rate for Payer: Multiplan Commercial	$3,723.00
Rate for Payer: Multiplan Workers Comp	$3,723.00
Rate for Payer: Scott and White EPO/PPO	$3,723.00

SCRW INTRAFIX ADVNC BR SHTH -- DHF

Facility

$7,446.00

Service Code	HCPCS C1713
Hospital Charge Code	81361883
Hospital Revenue Code	278
Min. Negotiated Rate	$670.14
Max. Negotiated Rate	$5,361.12
Rate for Payer: Amerigroup CHIP/Medicaid	$670.14
Rate for Payer: BCBS of TX Blue Advantage	$2,233.80
Rate for Payer: BCBS of TX Blue Essentials	$2,680.56
Rate for Payer: BCBS of TX PPO	$2,978.40
Rate for Payer: Cash Price	$5,063.28
Rate for Payer: Cigna Medicaid	$5,361.12
Rate for Payer: Molina CHIP/Medicaid	$5,361.12
Rate for Payer: Multiplan Auto	$3,723.00
Rate for Payer: Multiplan Commercial	$3,723.00
Rate for Payer: Multiplan Workers Comp	$3,723.00
Rate for Payer: Parkland Medicaid	$5,361.12
Rate for Payer: Scott and White EPO/PPO	$3,723.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,361.12
Rate for Payer: Superior Health Plan EPO	$1,012.66

SCRW LCK SLF TAP -- DHF

Facility

$942.00

Service Code	HCPCS C1713
Hospital Charge Code	81361990
Hospital Revenue Code	278
Min. Negotiated Rate	$235.50
Max. Negotiated Rate	$471.00
Rate for Payer: Cash Price	$640.56
Rate for Payer: Cigna Commercial	$235.50
Rate for Payer: Multiplan Auto	$471.00
Rate for Payer: Multiplan Commercial	$471.00
Rate for Payer: Multiplan Workers Comp	$471.00
Rate for Payer: Scott and White EPO/PPO	$471.00

SCRW LCK SLF TAP -- DHF

Facility

$942.00

Service Code	HCPCS C1713
Hospital Charge Code	81361990
Hospital Revenue Code	278
Min. Negotiated Rate	$84.78
Max. Negotiated Rate	$678.24
Rate for Payer: Amerigroup CHIP/Medicaid	$84.78
Rate for Payer: BCBS of TX Blue Advantage	$282.60
Rate for Payer: BCBS of TX Blue Essentials	$339.12
Rate for Payer: BCBS of TX PPO	$376.80
Rate for Payer: Cash Price	$640.56
Rate for Payer: Cigna Medicaid	$678.24
Rate for Payer: Molina CHIP/Medicaid	$678.24
Rate for Payer: Multiplan Auto	$471.00
Rate for Payer: Multiplan Commercial	$471.00
Rate for Payer: Multiplan Workers Comp	$471.00
Rate for Payer: Parkland Medicaid	$678.24
Rate for Payer: Scott and White EPO/PPO	$471.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$678.24
Rate for Payer: Superior Health Plan EPO	$128.11

SCRW LCK TIT -- DHF

Facility

$845.00

Service Code	HCPCS C1713
Hospital Charge Code	81361941
Hospital Revenue Code	278
Min. Negotiated Rate	$76.05
Max. Negotiated Rate	$608.40
Rate for Payer: Amerigroup CHIP/Medicaid	$76.05
Rate for Payer: BCBS of TX Blue Advantage	$253.50
Rate for Payer: BCBS of TX Blue Essentials	$304.20
Rate for Payer: BCBS of TX PPO	$338.00
Rate for Payer: Cash Price	$574.60
Rate for Payer: Cigna Medicaid	$608.40
Rate for Payer: Molina CHIP/Medicaid	$608.40
Rate for Payer: Multiplan Auto	$422.50
Rate for Payer: Multiplan Commercial	$422.50
Rate for Payer: Multiplan Workers Comp	$422.50
Rate for Payer: Parkland Medicaid	$608.40
Rate for Payer: Scott and White EPO/PPO	$422.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$608.40
Rate for Payer: Superior Health Plan EPO	$114.92

SCRW LCK TIT -- DHF

Facility

$845.00

Service Code	HCPCS C1713
Hospital Charge Code	81361941
Hospital Revenue Code	278
Min. Negotiated Rate	$211.25
Max. Negotiated Rate	$422.50
Rate for Payer: Cash Price	$574.60
Rate for Payer: Cigna Commercial	$211.25
Rate for Payer: Multiplan Auto	$422.50
Rate for Payer: Multiplan Commercial	$422.50
Rate for Payer: Multiplan Workers Comp	$422.50
Rate for Payer: Scott and White EPO/PPO	$422.50

SCRW LOCKING -- DHF

Facility

$802.00

Service Code	HCPCS C1713
Hospital Charge Code	81361966
Hospital Revenue Code	278
Min. Negotiated Rate	$72.18
Max. Negotiated Rate	$577.44
Rate for Payer: Amerigroup CHIP/Medicaid	$72.18
Rate for Payer: BCBS of TX Blue Advantage	$240.60
Rate for Payer: BCBS of TX Blue Essentials	$288.72
Rate for Payer: BCBS of TX PPO	$320.80
Rate for Payer: Cash Price	$545.36
Rate for Payer: Cigna Medicaid	$577.44
Rate for Payer: Molina CHIP/Medicaid	$577.44
Rate for Payer: Multiplan Auto	$401.00
Rate for Payer: Multiplan Commercial	$401.00
Rate for Payer: Multiplan Workers Comp	$401.00
Rate for Payer: Parkland Medicaid	$577.44
Rate for Payer: Scott and White EPO/PPO	$401.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$577.44
Rate for Payer: Superior Health Plan EPO	$109.07

SCRW LOCKING -- DHF

Facility

$802.00

Service Code	HCPCS C1713
Hospital Charge Code	81361966
Hospital Revenue Code	278
Min. Negotiated Rate	$200.50
Max. Negotiated Rate	$401.00
Rate for Payer: Cash Price	$545.36
Rate for Payer: Cigna Commercial	$200.50
Rate for Payer: Multiplan Auto	$401.00
Rate for Payer: Multiplan Commercial	$401.00
Rate for Payer: Multiplan Workers Comp	$401.00
Rate for Payer: Scott and White EPO/PPO	$401.00

Know your out-of-pocket cost for care.

All Charges