White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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

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	$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

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

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
Rate for Payer: Cash Price	$438.72

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

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
Min. Negotiated Rate	$579.39
Max. Negotiated Rate	$4,635.16
Rate for Payer: Amerigroup CHIP/Medicaid	$579.39
Rate for Payer: BCBS of TX Blue Advantage	$1,931.32
Rate for Payer: BCBS of TX Blue Essentials	$2,317.58
Rate for Payer: BCBS of TX PPO	$2,575.09
Rate for Payer: Cash Price	$4,377.65
Rate for Payer: Cigna Medicaid	$4,635.16
Rate for Payer: Molina CHIP/Medicaid	$4,635.16
Rate for Payer: Multiplan Auto	$4,184.52
Rate for Payer: Multiplan Commercial	$4,184.52
Rate for Payer: Multiplan Workers Comp	$4,184.52
Rate for Payer: Parkland Medicaid	$4,635.16
Rate for Payer: Scott and White EPO/PPO	$3,218.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,635.16
Rate for Payer: Superior Health Plan EPO	$875.53

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

25-Hydroxyvitamin D LCMS D2+D3 SO

Facility

$521.00

Service Code	HCPCS 82306
Hospital Charge Code	1620104
Hospital Revenue Code	301
Rate for Payer: Cash Price	$354.28

25-Hydroxyvitamin D LCMS D2+D3 SO

Facility

$521.00

Service Code	HCPCS 82306
Hospital Charge Code	1620104
Hospital Revenue Code	301
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$375.12
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29.60
Rate for Payer: Amerigroup Medicare	$29.60
Rate for Payer: BCBS of TX Blue Advantage	$156.30
Rate for Payer: BCBS of TX Blue Essentials	$187.56
Rate for Payer: BCBS of TX Medicare	$29.60
Rate for Payer: BCBS of TX PPO	$208.40
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cigna Medicaid	$375.12
Rate for Payer: Cigna Medicare	$29.60
Rate for Payer: Employer Direct Commercial	$29.60
Rate for Payer: Humana Medicare/TRICARE	$29.60
Rate for Payer: Molina CHIP/Medicaid	$375.12
Rate for Payer: Molina Dual Medicare/Medicaid	$29.60
Rate for Payer: Molina Medicare	$29.60
Rate for Payer: Multiplan Auto	$338.65
Rate for Payer: Multiplan Commercial	$338.65
Rate for Payer: Multiplan Workers Comp	$338.65
Rate for Payer: Parkland Medicaid	$375.12
Rate for Payer: Scott and White EPO/PPO	$37.00
Rate for Payer: Scott and White Medicare	$29.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$375.12
Rate for Payer: Superior Health Plan EPO	$29.60
Rate for Payer: Superior Health Plan Medicare	$29.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$29.60
Rate for Payer: Universal American Medicare	$29.60
Rate for Payer: Wellcare Medicare	$29.60
Rate for Payer: Wellmed Medicare	$29.60

2.5MM DRILL BIT

Facility

$385.90

Hospital Charge Code	992600
Hospital Revenue Code	272
Rate for Payer: Cash Price	$262.41

2.5MM DRILL BIT

Facility

$385.90

Hospital Charge Code	992600
Hospital Revenue Code	272
Min. Negotiated Rate	$34.73
Max. Negotiated Rate	$277.85
Rate for Payer: Amerigroup CHIP/Medicaid	$34.73
Rate for Payer: BCBS of TX Blue Advantage	$115.77
Rate for Payer: BCBS of TX Blue Essentials	$138.92
Rate for Payer: BCBS of TX PPO	$154.36
Rate for Payer: Cash Price	$262.41
Rate for Payer: Cigna Medicaid	$277.85
Rate for Payer: Molina CHIP/Medicaid	$277.85
Rate for Payer: Multiplan Auto	$250.84
Rate for Payer: Multiplan Commercial	$250.84
Rate for Payer: Multiplan Workers Comp	$250.84
Rate for Payer: Parkland Medicaid	$277.85
Rate for Payer: Scott and White EPO/PPO	$192.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$277.85
Rate for Payer: Superior Health Plan EPO	$52.48

2.5MM DRILL BIT, CALIBRATED

Facility

$385.90

Hospital Charge Code	992601
Hospital Revenue Code	272
Rate for Payer: Cash Price	$262.41

2.5MM DRILL BIT, CALIBRATED

Facility

$385.90

Hospital Charge Code	992601
Hospital Revenue Code	272
Min. Negotiated Rate	$34.73
Max. Negotiated Rate	$277.85
Rate for Payer: Amerigroup CHIP/Medicaid	$34.73
Rate for Payer: BCBS of TX Blue Advantage	$115.77
Rate for Payer: BCBS of TX Blue Essentials	$138.92
Rate for Payer: BCBS of TX PPO	$154.36
Rate for Payer: Cash Price	$262.41
Rate for Payer: Cigna Medicaid	$277.85
Rate for Payer: Molina CHIP/Medicaid	$277.85
Rate for Payer: Multiplan Auto	$250.84
Rate for Payer: Multiplan Commercial	$250.84
Rate for Payer: Multiplan Workers Comp	$250.84
Rate for Payer: Parkland Medicaid	$277.85
Rate for Payer: Scott and White EPO/PPO	$192.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$277.85
Rate for Payer: Superior Health Plan EPO	$52.48

2.5 MM K-WIRE

Facility

$1,405.58

Service Code	HCPCS C1769
Hospital Charge Code	993985
Hospital Revenue Code	278
Min. Negotiated Rate	$351.39
Max. Negotiated Rate	$702.79
Rate for Payer: Cash Price	$955.79
Rate for Payer: Cigna Commercial	$351.39
Rate for Payer: Multiplan Auto	$702.79
Rate for Payer: Multiplan Commercial	$702.79
Rate for Payer: Multiplan Workers Comp	$702.79
Rate for Payer: Scott and White EPO/PPO	$702.79

2.5 MM K-WIRE

Facility

$1,405.58

Service Code	HCPCS C1769
Hospital Charge Code	993985
Hospital Revenue Code	278
Min. Negotiated Rate	$126.50
Max. Negotiated Rate	$1,012.02
Rate for Payer: Amerigroup CHIP/Medicaid	$126.50
Rate for Payer: BCBS of TX Blue Advantage	$421.67
Rate for Payer: BCBS of TX Blue Essentials	$506.01
Rate for Payer: BCBS of TX PPO	$562.23
Rate for Payer: Cash Price	$955.79
Rate for Payer: Cigna Medicaid	$1,012.02
Rate for Payer: Molina CHIP/Medicaid	$1,012.02
Rate for Payer: Multiplan Auto	$702.79
Rate for Payer: Multiplan Commercial	$702.79
Rate for Payer: Multiplan Workers Comp	$702.79
Rate for Payer: Parkland Medicaid	$1,012.02
Rate for Payer: Scott and White EPO/PPO	$702.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,012.02
Rate for Payer: Superior Health Plan EPO	$191.16

2.5MM X 285MM K-Wire

Facility

$703.70

Service Code	HCPCS C1769
Hospital Charge Code	993382
Hospital Revenue Code	278
Min. Negotiated Rate	$175.93
Max. Negotiated Rate	$351.85
Rate for Payer: Cash Price	$478.52
Rate for Payer: Cigna Commercial	$175.93
Rate for Payer: Multiplan Auto	$351.85
Rate for Payer: Multiplan Commercial	$351.85
Rate for Payer: Multiplan Workers Comp	$351.85
Rate for Payer: Scott and White EPO/PPO	$351.85

Know your out-of-pocket cost for care.

All Charges