White Rock Medical Center

All Charges

Charge

Type

Setting

Price

22022108

Facility

$23,494.00

Service Code	HCPCS C1713
Hospital Charge Code	990947
Hospital Revenue Code	278
Min. Negotiated Rate	$5,873.50
Max. Negotiated Rate	$11,747.00
Rate for Payer: Cash Price	$15,975.92
Rate for Payer: Cigna Commercial	$5,873.50
Rate for Payer: Multiplan Auto	$11,747.00
Rate for Payer: Multiplan Commercial	$11,747.00
Rate for Payer: Multiplan Workers Comp	$11,747.00
Rate for Payer: Scott and White EPO/PPO	$11,747.00

22022108

Facility

$23,494.00

Service Code	HCPCS C1713
Hospital Charge Code	990947
Hospital Revenue Code	278
Min. Negotiated Rate	$2,114.46
Max. Negotiated Rate	$16,915.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2,114.46
Rate for Payer: BCBS of TX Blue Advantage	$7,048.20
Rate for Payer: BCBS of TX Blue Essentials	$8,457.84
Rate for Payer: BCBS of TX PPO	$9,397.60
Rate for Payer: Cash Price	$15,975.92
Rate for Payer: Cigna Medicaid	$16,915.68
Rate for Payer: Molina CHIP/Medicaid	$16,915.68
Rate for Payer: Multiplan Auto	$11,747.00
Rate for Payer: Multiplan Commercial	$11,747.00
Rate for Payer: Multiplan Workers Comp	$11,747.00
Rate for Payer: Parkland Medicaid	$16,915.68
Rate for Payer: Scott and White EPO/PPO	$11,747.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,915.68
Rate for Payer: Superior Health Plan EPO	$3,195.18

22022208

Facility

$34,246.00

Service Code	HCPCS C1776
Hospital Charge Code	991051
Hospital Revenue Code	278
Min. Negotiated Rate	$3,082.14
Max. Negotiated Rate	$24,657.12
Rate for Payer: Amerigroup CHIP/Medicaid	$3,082.14
Rate for Payer: BCBS of TX Blue Advantage	$10,273.80
Rate for Payer: BCBS of TX Blue Essentials	$12,328.56
Rate for Payer: BCBS of TX PPO	$13,698.40
Rate for Payer: Cash Price	$23,287.28
Rate for Payer: Cigna Medicaid	$24,657.12
Rate for Payer: Molina CHIP/Medicaid	$24,657.12
Rate for Payer: Multiplan Auto	$17,123.00
Rate for Payer: Multiplan Commercial	$17,123.00
Rate for Payer: Multiplan Workers Comp	$17,123.00
Rate for Payer: Parkland Medicaid	$24,657.12
Rate for Payer: Scott and White EPO/PPO	$17,123.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,657.12
Rate for Payer: Superior Health Plan EPO	$4,657.46

22022208

Facility

$34,246.00

Service Code	HCPCS C1776
Hospital Charge Code	991051
Hospital Revenue Code	278
Min. Negotiated Rate	$8,561.50
Max. Negotiated Rate	$17,123.00
Rate for Payer: Cash Price	$23,287.28
Rate for Payer: Cigna Commercial	$8,561.50
Rate for Payer: Multiplan Auto	$17,123.00
Rate for Payer: Multiplan Commercial	$17,123.00
Rate for Payer: Multiplan Workers Comp	$17,123.00
Rate for Payer: Scott and White EPO/PPO	$17,123.00

22022210

Facility

$37,159.77

Service Code	HCPCS C1734
Hospital Charge Code	994019
Hospital Revenue Code	278
Min. Negotiated Rate	$9,289.94
Max. Negotiated Rate	$18,579.88
Rate for Payer: Cash Price	$25,268.64
Rate for Payer: Cigna Commercial	$9,289.94
Rate for Payer: Multiplan Auto	$18,579.88
Rate for Payer: Multiplan Commercial	$18,579.88
Rate for Payer: Multiplan Workers Comp	$18,579.88
Rate for Payer: Scott and White EPO/PPO	$18,579.88

22022210

Facility

$37,159.77

Service Code	HCPCS C1734
Hospital Charge Code	994019
Hospital Revenue Code	278
Min. Negotiated Rate	$3,344.38
Max. Negotiated Rate	$26,755.03
Rate for Payer: Amerigroup CHIP/Medicaid	$3,344.38
Rate for Payer: BCBS of TX Blue Advantage	$11,147.93
Rate for Payer: BCBS of TX Blue Essentials	$13,377.52
Rate for Payer: BCBS of TX PPO	$14,863.91
Rate for Payer: Cash Price	$25,268.64
Rate for Payer: Cigna Medicaid	$26,755.03
Rate for Payer: Molina CHIP/Medicaid	$26,755.03
Rate for Payer: Multiplan Auto	$18,579.88
Rate for Payer: Multiplan Commercial	$18,579.88
Rate for Payer: Multiplan Workers Comp	$18,579.88
Rate for Payer: Parkland Medicaid	$26,755.03
Rate for Payer: Scott and White EPO/PPO	$18,579.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26,755.03
Rate for Payer: Superior Health Plan EPO	$5,053.73

220222206E

Facility

$23,059.16

Service Code	HCPCS C1734
Hospital Charge Code	991091
Hospital Revenue Code	278
Min. Negotiated Rate	$2,075.32
Max. Negotiated Rate	$16,602.60
Rate for Payer: Amerigroup CHIP/Medicaid	$2,075.32
Rate for Payer: BCBS of TX Blue Advantage	$6,917.75
Rate for Payer: BCBS of TX Blue Essentials	$8,301.30
Rate for Payer: BCBS of TX PPO	$9,223.66
Rate for Payer: Cash Price	$15,680.23
Rate for Payer: Cigna Medicaid	$16,602.60
Rate for Payer: Molina CHIP/Medicaid	$16,602.60
Rate for Payer: Multiplan Auto	$11,529.58
Rate for Payer: Multiplan Commercial	$11,529.58
Rate for Payer: Multiplan Workers Comp	$11,529.58
Rate for Payer: Parkland Medicaid	$16,602.60
Rate for Payer: Scott and White EPO/PPO	$11,529.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,602.60
Rate for Payer: Superior Health Plan EPO	$3,136.05

220222206E

Facility

$23,059.16

Service Code	HCPCS C1734
Hospital Charge Code	991091
Hospital Revenue Code	278
Min. Negotiated Rate	$5,764.79
Max. Negotiated Rate	$11,529.58
Rate for Payer: Cash Price	$15,680.23
Rate for Payer: Cigna Commercial	$5,764.79
Rate for Payer: Multiplan Auto	$11,529.58
Rate for Payer: Multiplan Commercial	$11,529.58
Rate for Payer: Multiplan Workers Comp	$11,529.58
Rate for Payer: Scott and White EPO/PPO	$11,529.58

220222902

Facility

$14,530.84

Service Code	HCPCS C1734
Hospital Charge Code	994020
Hospital Revenue Code	278
Min. Negotiated Rate	$3,632.71
Max. Negotiated Rate	$7,265.42
Rate for Payer: Cash Price	$9,880.97
Rate for Payer: Cigna Commercial	$3,632.71
Rate for Payer: Multiplan Auto	$7,265.42
Rate for Payer: Multiplan Commercial	$7,265.42
Rate for Payer: Multiplan Workers Comp	$7,265.42
Rate for Payer: Scott and White EPO/PPO	$7,265.42

220222902

Facility

$14,530.84

Service Code	HCPCS C1734
Hospital Charge Code	994020
Hospital Revenue Code	278
Min. Negotiated Rate	$1,307.78
Max. Negotiated Rate	$10,462.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1,307.78
Rate for Payer: BCBS of TX Blue Advantage	$4,359.25
Rate for Payer: BCBS of TX Blue Essentials	$5,231.10
Rate for Payer: BCBS of TX PPO	$5,812.34
Rate for Payer: Cash Price	$9,880.97
Rate for Payer: Cigna Medicaid	$10,462.20
Rate for Payer: Molina CHIP/Medicaid	$10,462.20
Rate for Payer: Multiplan Auto	$7,265.42
Rate for Payer: Multiplan Commercial	$7,265.42
Rate for Payer: Multiplan Workers Comp	$7,265.42
Rate for Payer: Parkland Medicaid	$10,462.20
Rate for Payer: Scott and White EPO/PPO	$7,265.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,462.20
Rate for Payer: Superior Health Plan EPO	$1,976.19

220222903

Facility

$5,078.31

Service Code	HCPCS C1776
Hospital Charge Code	991077
Hospital Revenue Code	278
Min. Negotiated Rate	$1,269.58
Max. Negotiated Rate	$2,539.16
Rate for Payer: Cash Price	$3,453.25
Rate for Payer: Cigna Commercial	$1,269.58
Rate for Payer: Multiplan Auto	$2,539.16
Rate for Payer: Multiplan Commercial	$2,539.16
Rate for Payer: Multiplan Workers Comp	$2,539.16
Rate for Payer: Scott and White EPO/PPO	$2,539.16

220222903

Facility

$5,078.31

Service Code	HCPCS C1776
Hospital Charge Code	991077
Hospital Revenue Code	278
Min. Negotiated Rate	$457.05
Max. Negotiated Rate	$3,656.38
Rate for Payer: Amerigroup CHIP/Medicaid	$457.05
Rate for Payer: BCBS of TX Blue Advantage	$1,523.49
Rate for Payer: BCBS of TX Blue Essentials	$1,828.19
Rate for Payer: BCBS of TX PPO	$2,031.32
Rate for Payer: Cash Price	$3,453.25
Rate for Payer: Cigna Medicaid	$3,656.38
Rate for Payer: Molina CHIP/Medicaid	$3,656.38
Rate for Payer: Multiplan Auto	$2,539.16
Rate for Payer: Multiplan Commercial	$2,539.16
Rate for Payer: Multiplan Workers Comp	$2,539.16
Rate for Payer: Parkland Medicaid	$3,656.38
Rate for Payer: Scott and White EPO/PPO	$2,539.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,656.38
Rate for Payer: Superior Health Plan EPO	$690.65

22022902

Facility

$13,133.00

Service Code	HCPCS C1776
Hospital Charge Code	990944
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.97
Max. Negotiated Rate	$9,455.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1,181.97
Rate for Payer: BCBS of TX Blue Advantage	$3,939.90
Rate for Payer: BCBS of TX Blue Essentials	$4,727.88
Rate for Payer: BCBS of TX PPO	$5,253.20
Rate for Payer: Cash Price	$8,930.44
Rate for Payer: Cigna Medicaid	$9,455.76
Rate for Payer: Molina CHIP/Medicaid	$9,455.76
Rate for Payer: Multiplan Auto	$6,566.50
Rate for Payer: Multiplan Commercial	$6,566.50
Rate for Payer: Multiplan Workers Comp	$6,566.50
Rate for Payer: Parkland Medicaid	$9,455.76
Rate for Payer: Scott and White EPO/PPO	$6,566.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,455.76
Rate for Payer: Superior Health Plan EPO	$1,786.09

22022902

Facility

$13,133.00

Service Code	HCPCS C1776
Hospital Charge Code	990944
Hospital Revenue Code	278
Min. Negotiated Rate	$3,283.25
Max. Negotiated Rate	$6,566.50
Rate for Payer: Cash Price	$8,930.44
Rate for Payer: Cigna Commercial	$3,283.25
Rate for Payer: Multiplan Auto	$6,566.50
Rate for Payer: Multiplan Commercial	$6,566.50
Rate for Payer: Multiplan Workers Comp	$6,566.50
Rate for Payer: Scott and White EPO/PPO	$6,566.50

22023308

Facility

$34,245.96

Service Code	HCPCS C1734
Hospital Charge Code	991087
Hospital Revenue Code	278
Min. Negotiated Rate	$8,561.49
Max. Negotiated Rate	$17,122.98
Rate for Payer: Cash Price	$23,287.25
Rate for Payer: Cigna Commercial	$8,561.49
Rate for Payer: Multiplan Auto	$17,122.98
Rate for Payer: Multiplan Commercial	$17,122.98
Rate for Payer: Multiplan Workers Comp	$17,122.98
Rate for Payer: Scott and White EPO/PPO	$17,122.98

22023308

Facility

$34,245.96

Service Code	HCPCS C1734
Hospital Charge Code	991087
Hospital Revenue Code	278
Min. Negotiated Rate	$3,082.14
Max. Negotiated Rate	$24,657.09
Rate for Payer: Amerigroup CHIP/Medicaid	$3,082.14
Rate for Payer: BCBS of TX Blue Advantage	$10,273.79
Rate for Payer: BCBS of TX Blue Essentials	$12,328.55
Rate for Payer: BCBS of TX PPO	$13,698.38
Rate for Payer: Cash Price	$23,287.25
Rate for Payer: Cigna Medicaid	$24,657.09
Rate for Payer: Molina CHIP/Medicaid	$24,657.09
Rate for Payer: Multiplan Auto	$17,122.98
Rate for Payer: Multiplan Commercial	$17,122.98
Rate for Payer: Multiplan Workers Comp	$17,122.98
Rate for Payer: Parkland Medicaid	$24,657.09
Rate for Payer: Scott and White EPO/PPO	$17,122.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,657.09
Rate for Payer: Superior Health Plan EPO	$4,657.45

220252902

Facility

$18,085.73

Service Code	HCPCS C1734
Hospital Charge Code	991049
Hospital Revenue Code	278
Min. Negotiated Rate	$4,521.43
Max. Negotiated Rate	$9,042.86
Rate for Payer: Cash Price	$12,298.30
Rate for Payer: Cigna Commercial	$4,521.43
Rate for Payer: Multiplan Auto	$9,042.86
Rate for Payer: Multiplan Commercial	$9,042.86
Rate for Payer: Multiplan Workers Comp	$9,042.86
Rate for Payer: Scott and White EPO/PPO	$9,042.86

220252902

Facility

$18,085.73

Service Code	HCPCS C1734
Hospital Charge Code	991049
Hospital Revenue Code	278
Min. Negotiated Rate	$1,627.72
Max. Negotiated Rate	$13,021.73
Rate for Payer: Amerigroup CHIP/Medicaid	$1,627.72
Rate for Payer: BCBS of TX Blue Advantage	$5,425.72
Rate for Payer: BCBS of TX Blue Essentials	$6,510.86
Rate for Payer: BCBS of TX PPO	$7,234.29
Rate for Payer: Cash Price	$12,298.30
Rate for Payer: Cigna Medicaid	$13,021.73
Rate for Payer: Molina CHIP/Medicaid	$13,021.73
Rate for Payer: Multiplan Auto	$9,042.86
Rate for Payer: Multiplan Commercial	$9,042.86
Rate for Payer: Multiplan Workers Comp	$9,042.86
Rate for Payer: Parkland Medicaid	$13,021.73
Rate for Payer: Scott and White EPO/PPO	$9,042.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,021.73
Rate for Payer: Superior Health Plan EPO	$2,459.66

220252903

Facility

$18,085.78

Service Code	HCPCS C1776
Hospital Charge Code	991088
Hospital Revenue Code	278
Min. Negotiated Rate	$1,627.72
Max. Negotiated Rate	$13,021.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1,627.72
Rate for Payer: BCBS of TX Blue Advantage	$5,425.73
Rate for Payer: BCBS of TX Blue Essentials	$6,510.88
Rate for Payer: BCBS of TX PPO	$7,234.31
Rate for Payer: Cash Price	$12,298.33
Rate for Payer: Cigna Medicaid	$13,021.76
Rate for Payer: Molina CHIP/Medicaid	$13,021.76
Rate for Payer: Multiplan Auto	$9,042.89
Rate for Payer: Multiplan Commercial	$9,042.89
Rate for Payer: Multiplan Workers Comp	$9,042.89
Rate for Payer: Parkland Medicaid	$13,021.76
Rate for Payer: Scott and White EPO/PPO	$9,042.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,021.76
Rate for Payer: Superior Health Plan EPO	$2,459.67

220252903

Facility

$18,085.78

Service Code	HCPCS C1776
Hospital Charge Code	991088
Hospital Revenue Code	278
Min. Negotiated Rate	$4,521.44
Max. Negotiated Rate	$9,042.89
Rate for Payer: Cash Price	$12,298.33
Rate for Payer: Cigna Commercial	$4,521.44
Rate for Payer: Multiplan Auto	$9,042.89
Rate for Payer: Multiplan Commercial	$9,042.89
Rate for Payer: Multiplan Workers Comp	$9,042.89
Rate for Payer: Scott and White EPO/PPO	$9,042.89

231200200

Facility

$645.18

Hospital Charge Code	991317
Hospital Revenue Code	272
Min. Negotiated Rate	$58.07
Max. Negotiated Rate	$464.53
Rate for Payer: Amerigroup CHIP/Medicaid	$58.07
Rate for Payer: BCBS of TX Blue Advantage	$193.55
Rate for Payer: BCBS of TX Blue Essentials	$232.26
Rate for Payer: BCBS of TX PPO	$258.07
Rate for Payer: Cash Price	$438.72
Rate for Payer: Cigna Medicaid	$464.53
Rate for Payer: Molina CHIP/Medicaid	$464.53
Rate for Payer: Multiplan Auto	$419.37
Rate for Payer: Multiplan Commercial	$419.37
Rate for Payer: Multiplan Workers Comp	$419.37
Rate for Payer: Parkland Medicaid	$464.53
Rate for Payer: Scott and White EPO/PPO	$322.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$464.53
Rate for Payer: Superior Health Plan EPO	$87.74

231200200

Facility

$645.18

Hospital Charge Code	991317
Hospital Revenue Code	272
Rate for Payer: Cash Price	$438.72

23FTC0236

Facility

$40,512.04

Service Code	HCPCS C1734
Hospital Charge Code	994120
Hospital Revenue Code	278
Min. Negotiated Rate	$10,128.01
Max. Negotiated Rate	$20,256.02
Rate for Payer: Cash Price	$27,548.19
Rate for Payer: Cigna Commercial	$10,128.01
Rate for Payer: Multiplan Auto	$20,256.02
Rate for Payer: Multiplan Commercial	$20,256.02
Rate for Payer: Multiplan Workers Comp	$20,256.02
Rate for Payer: Scott and White EPO/PPO	$20,256.02

23FTC0236

Facility

$40,512.04

Service Code	HCPCS C1734
Hospital Charge Code	994120
Hospital Revenue Code	278
Min. Negotiated Rate	$3,646.08
Max. Negotiated Rate	$29,168.67
Rate for Payer: Amerigroup CHIP/Medicaid	$3,646.08
Rate for Payer: BCBS of TX Blue Advantage	$12,153.61
Rate for Payer: BCBS of TX Blue Essentials	$14,584.33
Rate for Payer: BCBS of TX PPO	$16,204.82
Rate for Payer: Cash Price	$27,548.19
Rate for Payer: Cigna Medicaid	$29,168.67
Rate for Payer: Molina CHIP/Medicaid	$29,168.67
Rate for Payer: Multiplan Auto	$20,256.02
Rate for Payer: Multiplan Commercial	$20,256.02
Rate for Payer: Multiplan Workers Comp	$20,256.02
Rate for Payer: Parkland Medicaid	$29,168.67
Rate for Payer: Scott and White EPO/PPO	$20,256.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,168.67
Rate for Payer: Superior Health Plan EPO	$5,509.64

2.4 SINGLE LOADED SUTURE TAPE S-TAK ASSY

Facility

$6,437.72

Hospital Charge Code	992610
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,377.65

Know your out-of-pocket cost for care.

All Charges