White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SEF08160

Facility

$10,199.00

Service Code	HCPCS C1713
Hospital Charge Code	990993
Hospital Revenue Code	278
Min. Negotiated Rate	$917.91
Max. Negotiated Rate	$7,343.28
Rate for Payer: Amerigroup CHIP/Medicaid	$917.91
Rate for Payer: BCBS of TX Blue Advantage	$3,059.70
Rate for Payer: BCBS of TX Blue Essentials	$3,671.64
Rate for Payer: BCBS of TX PPO	$4,079.60
Rate for Payer: Cash Price	$6,935.32
Rate for Payer: Cigna Medicaid	$7,343.28
Rate for Payer: Molina CHIP/Medicaid	$7,343.28
Rate for Payer: Multiplan Auto	$5,099.50
Rate for Payer: Multiplan Commercial	$5,099.50
Rate for Payer: Multiplan Workers Comp	$5,099.50
Rate for Payer: Parkland Medicaid	$7,343.28
Rate for Payer: Scott and White EPO/PPO	$5,099.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,343.28
Rate for Payer: Superior Health Plan EPO	$1,387.06

SEF10011

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Charge Code	990982
Hospital Revenue Code	278
Min. Negotiated Rate	$500.00
Max. Negotiated Rate	$1,000.00
Rate for Payer: Cash Price	$1,360.00
Rate for Payer: Cigna Commercial	$500.00
Rate for Payer: Multiplan Auto	$1,000.00
Rate for Payer: Multiplan Commercial	$1,000.00
Rate for Payer: Multiplan Workers Comp	$1,000.00
Rate for Payer: Scott and White EPO/PPO	$1,000.00

SEF10011

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Charge Code	990982
Hospital Revenue Code	278
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$1,440.00
Rate for Payer: Amerigroup CHIP/Medicaid	$180.00
Rate for Payer: BCBS of TX Blue Advantage	$600.00
Rate for Payer: BCBS of TX Blue Essentials	$720.00
Rate for Payer: BCBS of TX PPO	$800.00
Rate for Payer: Cash Price	$1,360.00
Rate for Payer: Cigna Medicaid	$1,440.00
Rate for Payer: Molina CHIP/Medicaid	$1,440.00
Rate for Payer: Multiplan Auto	$1,000.00
Rate for Payer: Multiplan Commercial	$1,000.00
Rate for Payer: Multiplan Workers Comp	$1,000.00
Rate for Payer: Parkland Medicaid	$1,440.00
Rate for Payer: Scott and White EPO/PPO	$1,000.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,440.00
Rate for Payer: Superior Health Plan EPO	$272.00

SEF11160

Facility

$8,127.00

Service Code	HCPCS C1713
Hospital Charge Code	990996
Hospital Revenue Code	278
Min. Negotiated Rate	$731.43
Max. Negotiated Rate	$5,851.44
Rate for Payer: Amerigroup CHIP/Medicaid	$731.43
Rate for Payer: BCBS of TX Blue Advantage	$2,438.10
Rate for Payer: BCBS of TX Blue Essentials	$2,925.72
Rate for Payer: BCBS of TX PPO	$3,250.80
Rate for Payer: Cash Price	$5,526.36
Rate for Payer: Cigna Medicaid	$5,851.44
Rate for Payer: Molina CHIP/Medicaid	$5,851.44
Rate for Payer: Multiplan Auto	$4,063.50
Rate for Payer: Multiplan Commercial	$4,063.50
Rate for Payer: Multiplan Workers Comp	$4,063.50
Rate for Payer: Parkland Medicaid	$5,851.44
Rate for Payer: Scott and White EPO/PPO	$4,063.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,851.44
Rate for Payer: Superior Health Plan EPO	$1,105.27

SEF11160

Facility

$8,127.00

Service Code	HCPCS C1713
Hospital Charge Code	990996
Hospital Revenue Code	278
Min. Negotiated Rate	$2,031.75
Max. Negotiated Rate	$4,063.50
Rate for Payer: Cash Price	$5,526.36
Rate for Payer: Cigna Commercial	$2,031.75
Rate for Payer: Multiplan Auto	$4,063.50
Rate for Payer: Multiplan Commercial	$4,063.50
Rate for Payer: Multiplan Workers Comp	$4,063.50
Rate for Payer: Scott and White EPO/PPO	$4,063.50

SEF16160

Facility

$11,723.00

Service Code	HCPCS C1713
Hospital Charge Code	990994
Hospital Revenue Code	278
Min. Negotiated Rate	$2,930.75
Max. Negotiated Rate	$5,861.50
Rate for Payer: Cash Price	$7,971.64
Rate for Payer: Cigna Commercial	$2,930.75
Rate for Payer: Multiplan Auto	$5,861.50
Rate for Payer: Multiplan Commercial	$5,861.50
Rate for Payer: Multiplan Workers Comp	$5,861.50
Rate for Payer: Scott and White EPO/PPO	$5,861.50

SEF16160

Facility

$11,723.00

Service Code	HCPCS C1713
Hospital Charge Code	990994
Hospital Revenue Code	278
Min. Negotiated Rate	$1,055.07
Max. Negotiated Rate	$8,440.56
Rate for Payer: Amerigroup CHIP/Medicaid	$1,055.07
Rate for Payer: BCBS of TX Blue Advantage	$3,516.90
Rate for Payer: BCBS of TX Blue Essentials	$4,220.28
Rate for Payer: BCBS of TX PPO	$4,689.20
Rate for Payer: Cash Price	$7,971.64
Rate for Payer: Cigna Medicaid	$8,440.56
Rate for Payer: Molina CHIP/Medicaid	$8,440.56
Rate for Payer: Multiplan Auto	$5,861.50
Rate for Payer: Multiplan Commercial	$5,861.50
Rate for Payer: Multiplan Workers Comp	$5,861.50
Rate for Payer: Parkland Medicaid	$8,440.56
Rate for Payer: Scott and White EPO/PPO	$5,861.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,440.56
Rate for Payer: Superior Health Plan EPO	$1,594.33

SEF33010

Facility

$259.03

Hospital Charge Code	991001
Hospital Revenue Code	272
Min. Negotiated Rate	$23.31
Max. Negotiated Rate	$186.50
Rate for Payer: Amerigroup CHIP/Medicaid	$23.31
Rate for Payer: BCBS of TX Blue Advantage	$77.71
Rate for Payer: BCBS of TX Blue Essentials	$93.25
Rate for Payer: BCBS of TX PPO	$103.61
Rate for Payer: Cash Price	$176.14
Rate for Payer: Cigna Medicaid	$186.50
Rate for Payer: Molina CHIP/Medicaid	$186.50
Rate for Payer: Multiplan Auto	$168.37
Rate for Payer: Multiplan Commercial	$168.37
Rate for Payer: Multiplan Workers Comp	$168.37
Rate for Payer: Parkland Medicaid	$186.50
Rate for Payer: Scott and White EPO/PPO	$129.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$186.50
Rate for Payer: Superior Health Plan EPO	$35.23

SEF33010

Facility

$259.00

Service Code	HCPCS C1713
Hospital Charge Code	990987
Hospital Revenue Code	278
Min. Negotiated Rate	$23.31
Max. Negotiated Rate	$186.48
Rate for Payer: Amerigroup CHIP/Medicaid	$23.31
Rate for Payer: BCBS of TX Blue Advantage	$77.70
Rate for Payer: BCBS of TX Blue Essentials	$93.24
Rate for Payer: BCBS of TX PPO	$103.60
Rate for Payer: Cash Price	$176.12
Rate for Payer: Cigna Medicaid	$186.48
Rate for Payer: Molina CHIP/Medicaid	$186.48
Rate for Payer: Multiplan Auto	$129.50
Rate for Payer: Multiplan Commercial	$129.50
Rate for Payer: Multiplan Workers Comp	$129.50
Rate for Payer: Parkland Medicaid	$186.48
Rate for Payer: Scott and White EPO/PPO	$129.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$186.48
Rate for Payer: Superior Health Plan EPO	$35.22

SEF33010

Facility

$259.00

Service Code	HCPCS C1713
Hospital Charge Code	990987
Hospital Revenue Code	278
Min. Negotiated Rate	$64.75
Max. Negotiated Rate	$129.50
Rate for Payer: Cash Price	$176.12
Rate for Payer: Cigna Commercial	$64.75
Rate for Payer: Multiplan Auto	$129.50
Rate for Payer: Multiplan Commercial	$129.50
Rate for Payer: Multiplan Workers Comp	$129.50
Rate for Payer: Scott and White EPO/PPO	$129.50

SEF33010

Facility

$259.03

Hospital Charge Code	991001
Hospital Revenue Code	272
Rate for Payer: Cash Price	$176.14

SEF33400

Facility

$2,975.90

Hospital Charge Code	991007
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,023.61

SEF33400

Facility

$2,975.90

Hospital Charge Code	991007
Hospital Revenue Code	272
Min. Negotiated Rate	$267.83
Max. Negotiated Rate	$2,142.65
Rate for Payer: Amerigroup CHIP/Medicaid	$267.83
Rate for Payer: BCBS of TX Blue Advantage	$892.77
Rate for Payer: BCBS of TX Blue Essentials	$1,071.32
Rate for Payer: BCBS of TX PPO	$1,190.36
Rate for Payer: Cash Price	$2,023.61
Rate for Payer: Cigna Medicaid	$2,142.65
Rate for Payer: Molina CHIP/Medicaid	$2,142.65
Rate for Payer: Multiplan Auto	$1,934.34
Rate for Payer: Multiplan Commercial	$1,934.34
Rate for Payer: Multiplan Workers Comp	$1,934.34
Rate for Payer: Parkland Medicaid	$2,142.65
Rate for Payer: Scott and White EPO/PPO	$1,487.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,142.65
Rate for Payer: Superior Health Plan EPO	$404.72

SEF40080

Facility

$861.00

Service Code	HCPCS C1776
Hospital Charge Code	990998
Hospital Revenue Code	278
Min. Negotiated Rate	$77.49
Max. Negotiated Rate	$619.92
Rate for Payer: Amerigroup CHIP/Medicaid	$77.49
Rate for Payer: BCBS of TX Blue Advantage	$258.30
Rate for Payer: BCBS of TX Blue Essentials	$309.96
Rate for Payer: BCBS of TX PPO	$344.40
Rate for Payer: Cash Price	$585.48
Rate for Payer: Cigna Medicaid	$619.92
Rate for Payer: Molina CHIP/Medicaid	$619.92
Rate for Payer: Multiplan Auto	$430.50
Rate for Payer: Multiplan Commercial	$430.50
Rate for Payer: Multiplan Workers Comp	$430.50
Rate for Payer: Parkland Medicaid	$619.92
Rate for Payer: Scott and White EPO/PPO	$430.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$619.92
Rate for Payer: Superior Health Plan EPO	$117.10

SEF40080

Facility

$861.00

Service Code	HCPCS C1776
Hospital Charge Code	990998
Hospital Revenue Code	278
Min. Negotiated Rate	$215.25
Max. Negotiated Rate	$430.50
Rate for Payer: Cash Price	$585.48
Rate for Payer: Cigna Commercial	$215.25
Rate for Payer: Multiplan Auto	$430.50
Rate for Payer: Multiplan Commercial	$430.50
Rate for Payer: Multiplan Workers Comp	$430.50
Rate for Payer: Scott and White EPO/PPO	$430.50

SEF58016

Facility

$10,343.00

Service Code	HCPCS C1713
Hospital Charge Code	991006
Hospital Revenue Code	278
Min. Negotiated Rate	$2,585.75
Max. Negotiated Rate	$5,171.50
Rate for Payer: Cash Price	$7,033.24
Rate for Payer: Cigna Commercial	$2,585.75
Rate for Payer: Multiplan Auto	$5,171.50
Rate for Payer: Multiplan Commercial	$5,171.50
Rate for Payer: Multiplan Workers Comp	$5,171.50
Rate for Payer: Scott and White EPO/PPO	$5,171.50

SEF58016

Facility

$10,343.00

Service Code	HCPCS C1713
Hospital Charge Code	991006
Hospital Revenue Code	278
Min. Negotiated Rate	$930.87
Max. Negotiated Rate	$7,446.96
Rate for Payer: Amerigroup CHIP/Medicaid	$930.87
Rate for Payer: BCBS of TX Blue Advantage	$3,102.90
Rate for Payer: BCBS of TX Blue Essentials	$3,723.48
Rate for Payer: BCBS of TX PPO	$4,137.20
Rate for Payer: Cash Price	$7,033.24
Rate for Payer: Cigna Medicaid	$7,446.96
Rate for Payer: Molina CHIP/Medicaid	$7,446.96
Rate for Payer: Multiplan Auto	$5,171.50
Rate for Payer: Multiplan Commercial	$5,171.50
Rate for Payer: Multiplan Workers Comp	$5,171.50
Rate for Payer: Parkland Medicaid	$7,446.96
Rate for Payer: Scott and White EPO/PPO	$5,171.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,446.96
Rate for Payer: Superior Health Plan EPO	$1,406.65

SEF8016

Facility

$10,343.00

Service Code	HCPCS C1713
Hospital Charge Code	990992
Hospital Revenue Code	278
Min. Negotiated Rate	$930.87
Max. Negotiated Rate	$7,446.96
Rate for Payer: Amerigroup CHIP/Medicaid	$930.87
Rate for Payer: BCBS of TX Blue Advantage	$3,102.90
Rate for Payer: BCBS of TX Blue Essentials	$3,723.48
Rate for Payer: BCBS of TX PPO	$4,137.20
Rate for Payer: Cash Price	$7,033.24
Rate for Payer: Cigna Medicaid	$7,446.96
Rate for Payer: Molina CHIP/Medicaid	$7,446.96
Rate for Payer: Multiplan Auto	$5,171.50
Rate for Payer: Multiplan Commercial	$5,171.50
Rate for Payer: Multiplan Workers Comp	$5,171.50
Rate for Payer: Parkland Medicaid	$7,446.96
Rate for Payer: Scott and White EPO/PPO	$5,171.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,446.96
Rate for Payer: Superior Health Plan EPO	$1,406.65

SEF8016

Facility

$10,343.00

Service Code	HCPCS C1713
Hospital Charge Code	990992
Hospital Revenue Code	278
Min. Negotiated Rate	$2,585.75
Max. Negotiated Rate	$5,171.50
Rate for Payer: Cash Price	$7,033.24
Rate for Payer: Cigna Commercial	$2,585.75
Rate for Payer: Multiplan Auto	$5,171.50
Rate for Payer: Multiplan Commercial	$5,171.50
Rate for Payer: Multiplan Workers Comp	$5,171.50
Rate for Payer: Scott and White EPO/PPO	$5,171.50

SEIZURE

Facility

$3,188.76

Service Code	APR-DRG 0532
Min. Negotiated Rate	$3,006.47
Max. Negotiated Rate	$3,188.76
Rate for Payer: Amerigroup CHIP/Medicaid	$3,006.47
Rate for Payer: Cigna Medicaid	$3,006.47
Rate for Payer: Molina CHIP/Medicaid	$3,006.47
Rate for Payer: Parkland Medicaid	$3,006.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,188.76

SEIZURE

Facility

$2,371.39

Service Code	APR-DRG 0531
Min. Negotiated Rate	$2,235.83
Max. Negotiated Rate	$2,371.39
Rate for Payer: Amerigroup CHIP/Medicaid	$2,235.83
Rate for Payer: Cigna Medicaid	$2,235.83
Rate for Payer: Molina CHIP/Medicaid	$2,235.83
Rate for Payer: Parkland Medicaid	$2,235.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,371.39

SEIZURE

Facility

$10,748.38

Service Code	APR-DRG 0534
Min. Negotiated Rate	$10,133.95
Max. Negotiated Rate	$10,748.38
Rate for Payer: Amerigroup CHIP/Medicaid	$10,133.95
Rate for Payer: Cigna Medicaid	$10,133.95
Rate for Payer: Molina CHIP/Medicaid	$10,133.95
Rate for Payer: Parkland Medicaid	$10,133.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,748.38

SEIZURE

Facility

$4,615.28

Service Code	APR-DRG 0533
Min. Negotiated Rate	$4,351.45
Max. Negotiated Rate	$4,615.28
Rate for Payer: Amerigroup CHIP/Medicaid	$4,351.45
Rate for Payer: Cigna Medicaid	$4,351.45
Rate for Payer: Molina CHIP/Medicaid	$4,351.45
Rate for Payer: Parkland Medicaid	$4,351.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,615.28

SEIZURES WITH MCC

Facility

$36,799.20

Service Code	MSDRG 100
Min. Negotiated Rate	$15,586.64
Max. Negotiated Rate	$36,799.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,954.95
Rate for Payer: Amerigroup Medicare	$18,954.95
Rate for Payer: BCBS of TX Medicare	$18,954.95
Rate for Payer: Cigna Commercial	$24,945.98
Rate for Payer: Cigna Medicare	$18,954.95
Rate for Payer: Employer Direct Commercial	$18,954.95
Rate for Payer: Humana Medicare/TRICARE	$18,954.95
Rate for Payer: Molina Dual Medicare/Medicaid	$18,954.95
Rate for Payer: Molina Medicare	$18,954.95
Rate for Payer: Multiplan Auto	$36,799.20
Rate for Payer: Multiplan Commercial	$36,799.20
Rate for Payer: Multiplan Workers Comp	$36,799.20
Rate for Payer: Scott and White EPO/PPO	$16,947.00
Rate for Payer: Scott and White Medicare	$18,954.95
Rate for Payer: Superior Health Plan EPO	$18,954.95
Rate for Payer: Superior Health Plan Medicare	$18,954.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,954.95
Rate for Payer: Universal American Medicare	$18,954.95
Rate for Payer: Wellcare Medicare	$18,954.95
Rate for Payer: Wellmed Medicare	$18,954.95

SEIZURES WITHOUT MCC

Facility

$17,149.40

Service Code	MSDRG 101
Min. Negotiated Rate	$7,475.98
Max. Negotiated Rate	$17,149.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,375.26
Rate for Payer: Amerigroup Medicare	$11,375.26
Rate for Payer: BCBS of TX Medicare	$11,375.26
Rate for Payer: Cigna Commercial	$11,625.49
Rate for Payer: Cigna Medicare	$11,375.26
Rate for Payer: Employer Direct Commercial	$11,375.26
Rate for Payer: Humana Medicare/TRICARE	$11,375.26
Rate for Payer: Molina Dual Medicare/Medicaid	$11,375.26
Rate for Payer: Molina Medicare	$11,375.26
Rate for Payer: Multiplan Auto	$17,149.40
Rate for Payer: Multiplan Commercial	$17,149.40
Rate for Payer: Multiplan Workers Comp	$17,149.40
Rate for Payer: Scott and White EPO/PPO	$7,897.75
Rate for Payer: Scott and White Medicare	$11,375.26
Rate for Payer: Superior Health Plan EPO	$11,375.26
Rate for Payer: Superior Health Plan Medicare	$11,375.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,375.26
Rate for Payer: Universal American Medicare	$11,375.26
Rate for Payer: Wellcare Medicare	$11,375.26
Rate for Payer: Wellmed Medicare	$11,375.26

Know your out-of-pocket cost for care.

All Charges