White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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 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 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 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 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 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	$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

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 SOLID 81362600 -- DHF

Facility

$6,435.00

Service Code	HCPCS C1713
Hospital Charge Code	81362600
Hospital Revenue Code	278
Min. Negotiated Rate	$579.15
Max. Negotiated Rate	$4,633.20
Rate for Payer: Amerigroup CHIP/Medicaid	$579.15
Rate for Payer: BCBS of TX Blue Advantage	$1,930.50
Rate for Payer: BCBS of TX Blue Essentials	$2,316.60
Rate for Payer: BCBS of TX PPO	$2,574.00
Rate for Payer: Cash Price	$4,375.80
Rate for Payer: Cigna Medicaid	$4,633.20
Rate for Payer: Molina CHIP/Medicaid	$4,633.20
Rate for Payer: Multiplan Auto	$3,217.50
Rate for Payer: Multiplan Commercial	$3,217.50
Rate for Payer: Multiplan Workers Comp	$3,217.50
Rate for Payer: Parkland Medicaid	$4,633.20
Rate for Payer: Scott and White EPO/PPO	$3,217.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,633.20
Rate for Payer: Superior Health Plan EPO	$875.16

SCRW SOLID 81362600 -- DHF

Facility

$6,435.00

Service Code	HCPCS C1713
Hospital Charge Code	81362600
Hospital Revenue Code	278
Min. Negotiated Rate	$1,608.75
Max. Negotiated Rate	$3,217.50
Rate for Payer: Cash Price	$4,375.80
Rate for Payer: Cigna Commercial	$1,608.75
Rate for Payer: Multiplan Auto	$3,217.50
Rate for Payer: Multiplan Commercial	$3,217.50
Rate for Payer: Multiplan Workers Comp	$3,217.50
Rate for Payer: Scott and White EPO/PPO	$3,217.50

SCRW SOLID 81362659 -- DHF

Facility

$384.00

Service Code	HCPCS C1713
Hospital Charge Code	81362659
Hospital Revenue Code	278
Min. Negotiated Rate	$34.56
Max. Negotiated Rate	$276.48
Rate for Payer: Amerigroup CHIP/Medicaid	$34.56
Rate for Payer: BCBS of TX Blue Advantage	$115.20
Rate for Payer: BCBS of TX Blue Essentials	$138.24
Rate for Payer: BCBS of TX PPO	$153.60
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cigna Medicaid	$276.48
Rate for Payer: Molina CHIP/Medicaid	$276.48
Rate for Payer: Multiplan Auto	$192.00
Rate for Payer: Multiplan Commercial	$192.00
Rate for Payer: Multiplan Workers Comp	$192.00
Rate for Payer: Parkland Medicaid	$276.48
Rate for Payer: Scott and White EPO/PPO	$192.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$276.48
Rate for Payer: Superior Health Plan EPO	$52.22

SCRW SOLID 81362659 -- DHF

Facility

$384.00

Service Code	HCPCS C1713
Hospital Charge Code	81362659
Hospital Revenue Code	278
Min. Negotiated Rate	$96.00
Max. Negotiated Rate	$192.00
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cigna Commercial	$96.00
Rate for Payer: Multiplan Auto	$192.00
Rate for Payer: Multiplan Commercial	$192.00
Rate for Payer: Multiplan Workers Comp	$192.00
Rate for Payer: Scott and White EPO/PPO	$192.00

SCRW WOODRUF -- DHF

Facility

$479.00

Service Code	HCPCS C1713
Hospital Charge Code	81362956
Hospital Revenue Code	278
Min. Negotiated Rate	$43.11
Max. Negotiated Rate	$344.88
Rate for Payer: Amerigroup CHIP/Medicaid	$43.11
Rate for Payer: BCBS of TX Blue Advantage	$143.70
Rate for Payer: BCBS of TX Blue Essentials	$172.44
Rate for Payer: BCBS of TX PPO	$191.60
Rate for Payer: Cash Price	$325.72
Rate for Payer: Cigna Medicaid	$344.88
Rate for Payer: Molina CHIP/Medicaid	$344.88
Rate for Payer: Multiplan Auto	$239.50
Rate for Payer: Multiplan Commercial	$239.50
Rate for Payer: Multiplan Workers Comp	$239.50
Rate for Payer: Parkland Medicaid	$344.88
Rate for Payer: Scott and White EPO/PPO	$239.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$344.88
Rate for Payer: Superior Health Plan EPO	$65.14

SCRW WOODRUF -- DHF

Facility

$479.00

Service Code	HCPCS C1713
Hospital Charge Code	81362956
Hospital Revenue Code	278
Min. Negotiated Rate	$119.75
Max. Negotiated Rate	$239.50
Rate for Payer: Cash Price	$325.72
Rate for Payer: Cigna Commercial	$119.75
Rate for Payer: Multiplan Auto	$239.50
Rate for Payer: Multiplan Commercial	$239.50
Rate for Payer: Multiplan Workers Comp	$239.50
Rate for Payer: Scott and White EPO/PPO	$239.50

SDS Facility Eval, Management Level 1 99211 BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	3603079
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$81.36
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$33.90
Rate for Payer: BCBS of TX Blue Essentials	$40.68
Rate for Payer: BCBS of TX PPO	$45.20
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cigna Medicaid	$81.36
Rate for Payer: Molina CHIP/Medicaid	$81.36
Rate for Payer: Multiplan Auto	$73.45
Rate for Payer: Multiplan Commercial	$73.45
Rate for Payer: Multiplan Workers Comp	$73.45
Rate for Payer: Parkland Medicaid	$81.36
Rate for Payer: Scott and White EPO/PPO	$56.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.36

SDS Facility Eval, Management Level 1 99211 BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	3603079
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

SDS Inf Hydration Initial 31 to 60 Min 96360 BCE

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	610009
Hospital Revenue Code	260
Min. Negotiated Rate	$76.23
Max. Negotiated Rate	$609.84
Rate for Payer: Amerigroup CHIP/Medicaid	$76.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$254.10
Rate for Payer: BCBS of TX Blue Essentials	$304.92
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$338.80
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$609.84
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$609.84
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$550.55
Rate for Payer: Multiplan Commercial	$550.55
Rate for Payer: Multiplan Workers Comp	$550.55
Rate for Payer: Parkland Medicaid	$609.84
Rate for Payer: Scott and White EPO/PPO	$423.50
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$609.84
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

SDS Inf Hydration Initial 31 to 60 Min 96360 BCE

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	610009
Hospital Revenue Code	260
Rate for Payer: Cash Price	$575.96

SDS Inf Ther Proph Dx Each Addl Hr 96366 BCE

Facility

$153.00

Hospital Charge Code	600569
Hospital Revenue Code	260
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$110.16
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: BCBS of TX Blue Advantage	$45.90
Rate for Payer: BCBS of TX Blue Essentials	$55.08
Rate for Payer: BCBS of TX PPO	$61.20
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cigna Medicaid	$110.16
Rate for Payer: Molina CHIP/Medicaid	$110.16
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Parkland Medicaid	$110.16
Rate for Payer: Scott and White EPO/PPO	$76.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.16
Rate for Payer: Superior Health Plan EPO	$20.81

SDS Inf Ther Proph Dx Each Addl Hr 96366 BCE

Facility

$153.00

Hospital Charge Code	600569
Hospital Revenue Code	260
Rate for Payer: Cash Price	$104.04

SDS Tx Proph Diag Ea Addl IVP Drug 96375 BCE

Facility

$330.00

Service Code	HCPCS 96375
Hospital Charge Code	610014
Hospital Revenue Code	260
Rate for Payer: Cash Price	$224.40

SDS Tx Proph Diag Ea Addl IVP Drug 96375 BCE

Facility

$330.00

Service Code	HCPCS 96375
Hospital Charge Code	610014
Hospital Revenue Code	260
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$237.60
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47.04
Rate for Payer: Amerigroup Medicare	$47.04
Rate for Payer: BCBS of TX Blue Advantage	$99.00
Rate for Payer: BCBS of TX Blue Essentials	$118.80
Rate for Payer: BCBS of TX Medicare	$47.04
Rate for Payer: BCBS of TX PPO	$132.00
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cigna Commercial	$99.43
Rate for Payer: Cigna Medicaid	$237.60
Rate for Payer: Cigna Medicare	$47.04
Rate for Payer: Employer Direct Commercial	$47.04
Rate for Payer: Humana Medicare/TRICARE	$47.04
Rate for Payer: Molina CHIP/Medicaid	$237.60
Rate for Payer: Molina Dual Medicare/Medicaid	$47.04
Rate for Payer: Molina Medicare	$47.04
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Parkland Medicaid	$237.60
Rate for Payer: Scott and White EPO/PPO	$165.00
Rate for Payer: Scott and White Medicare	$47.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$237.60
Rate for Payer: Superior Health Plan EPO	$47.04
Rate for Payer: Superior Health Plan Medicare	$47.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$47.04
Rate for Payer: Universal American Medicare	$47.04
Rate for Payer: Wellcare Medicare	$47.04
Rate for Payer: Wellmed Medicare	$47.04

SDS Tx Proph Diag Injection SQ or IM 96372 BCE

Facility

$280.00

Service Code	HCPCS 96372
Hospital Charge Code	600577
Hospital Revenue Code	260
Rate for Payer: Cash Price	$190.40

Know your out-of-pocket cost for care.

All Charges