White Rock Medical Center

All Charges

Charge

Type

Setting

Price

AR-8724VCL-18AR-8724VCL-20AR-8724VCL-22AR-8724VCL-24

Facility

$816.72

Service Code	HCPCS C1713
Hospital Charge Code	994219
Hospital Revenue Code	278
Min. Negotiated Rate	$204.18
Max. Negotiated Rate	$408.36
Rate for Payer: Cash Price	$555.37
Rate for Payer: Cigna Commercial	$204.18
Rate for Payer: Multiplan Auto	$408.36
Rate for Payer: Multiplan Commercial	$408.36
Rate for Payer: Multiplan Workers Comp	$408.36
Rate for Payer: Scott and White EPO/PPO	$408.36

AR-8724VCL-18AR-8724VCL-20AR-8724VCL-22AR-8724VCL-24

Facility

$816.72

Service Code	HCPCS C1713
Hospital Charge Code	994219
Hospital Revenue Code	278
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$588.04
Rate for Payer: Amerigroup CHIP/Medicaid	$73.50
Rate for Payer: BCBS of TX Blue Advantage	$245.02
Rate for Payer: BCBS of TX Blue Essentials	$294.02
Rate for Payer: BCBS of TX PPO	$326.69
Rate for Payer: Cash Price	$555.37
Rate for Payer: Cigna Medicaid	$588.04
Rate for Payer: Molina CHIP/Medicaid	$588.04
Rate for Payer: Multiplan Auto	$408.36
Rate for Payer: Multiplan Commercial	$408.36
Rate for Payer: Multiplan Workers Comp	$408.36
Rate for Payer: Parkland Medicaid	$588.04
Rate for Payer: Scott and White EPO/PPO	$408.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$588.04
Rate for Payer: Superior Health Plan EPO	$111.07

AR-8827D-01AR-8943-16AR-8943-30

Facility

$512.05

Service Code	HCPCS C1776
Hospital Charge Code	991115
Hospital Revenue Code	278
Min. Negotiated Rate	$46.08
Max. Negotiated Rate	$368.68
Rate for Payer: Amerigroup CHIP/Medicaid	$46.08
Rate for Payer: BCBS of TX Blue Advantage	$153.62
Rate for Payer: BCBS of TX Blue Essentials	$184.34
Rate for Payer: BCBS of TX PPO	$204.82
Rate for Payer: Cash Price	$348.19
Rate for Payer: Cigna Medicaid	$368.68
Rate for Payer: Molina CHIP/Medicaid	$368.68
Rate for Payer: Multiplan Auto	$256.02
Rate for Payer: Multiplan Commercial	$256.02
Rate for Payer: Multiplan Workers Comp	$256.02
Rate for Payer: Parkland Medicaid	$368.68
Rate for Payer: Scott and White EPO/PPO	$256.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.68
Rate for Payer: Superior Health Plan EPO	$69.64

AR-8827D-01AR-8943-16AR-8943-30

Facility

$512.05

Service Code	HCPCS C1776
Hospital Charge Code	991115
Hospital Revenue Code	278
Min. Negotiated Rate	$128.01
Max. Negotiated Rate	$256.02
Rate for Payer: Cash Price	$348.19
Rate for Payer: Cigna Commercial	$128.01
Rate for Payer: Multiplan Auto	$256.02
Rate for Payer: Multiplan Commercial	$256.02
Rate for Payer: Multiplan Workers Comp	$256.02
Rate for Payer: Scott and White EPO/PPO	$256.02

AR-8835-14AR-8840-18

Facility

$352.41

Service Code	HCPCS C1713
Hospital Charge Code	991116
Hospital Revenue Code	278
Min. Negotiated Rate	$88.10
Max. Negotiated Rate	$176.21
Rate for Payer: Cash Price	$239.64
Rate for Payer: Cigna Commercial	$88.10
Rate for Payer: Multiplan Auto	$176.21
Rate for Payer: Multiplan Commercial	$176.21
Rate for Payer: Multiplan Workers Comp	$176.21
Rate for Payer: Scott and White EPO/PPO	$176.21

AR-8835-14AR-8840-18

Facility

$352.41

Service Code	HCPCS C1713
Hospital Charge Code	991116
Hospital Revenue Code	278
Min. Negotiated Rate	$31.72
Max. Negotiated Rate	$253.74
Rate for Payer: Amerigroup CHIP/Medicaid	$31.72
Rate for Payer: BCBS of TX Blue Advantage	$105.72
Rate for Payer: BCBS of TX Blue Essentials	$126.87
Rate for Payer: BCBS of TX PPO	$140.96
Rate for Payer: Cash Price	$239.64
Rate for Payer: Cigna Medicaid	$253.74
Rate for Payer: Molina CHIP/Medicaid	$253.74
Rate for Payer: Multiplan Auto	$176.21
Rate for Payer: Multiplan Commercial	$176.21
Rate for Payer: Multiplan Workers Comp	$176.21
Rate for Payer: Parkland Medicaid	$253.74
Rate for Payer: Scott and White EPO/PPO	$176.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$253.74
Rate for Payer: Superior Health Plan EPO	$47.93

AR-8835CL-16

Facility

$2,963.86

Service Code	HCPCS C1734
Hospital Charge Code	991117
Hospital Revenue Code	278
Min. Negotiated Rate	$266.75
Max. Negotiated Rate	$2,133.98
Rate for Payer: Amerigroup CHIP/Medicaid	$266.75
Rate for Payer: BCBS of TX Blue Advantage	$889.16
Rate for Payer: BCBS of TX Blue Essentials	$1,066.99
Rate for Payer: BCBS of TX PPO	$1,185.54
Rate for Payer: Cash Price	$2,015.42
Rate for Payer: Cigna Medicaid	$2,133.98
Rate for Payer: Molina CHIP/Medicaid	$2,133.98
Rate for Payer: Multiplan Auto	$1,481.93
Rate for Payer: Multiplan Commercial	$1,481.93
Rate for Payer: Multiplan Workers Comp	$1,481.93
Rate for Payer: Parkland Medicaid	$2,133.98
Rate for Payer: Scott and White EPO/PPO	$1,481.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,133.98
Rate for Payer: Superior Health Plan EPO	$403.08

AR-8835CL-16

Facility

$2,963.86

Service Code	HCPCS C1734
Hospital Charge Code	991117
Hospital Revenue Code	278
Min. Negotiated Rate	$740.97
Max. Negotiated Rate	$1,481.93
Rate for Payer: Cash Price	$2,015.42
Rate for Payer: Cigna Commercial	$740.97
Rate for Payer: Multiplan Auto	$1,481.93
Rate for Payer: Multiplan Commercial	$1,481.93
Rate for Payer: Multiplan Workers Comp	$1,481.93
Rate for Payer: Scott and White EPO/PPO	$1,481.93

AR-8916VSL-03

Facility

$2,199.50

Service Code	HCPCS C1776
Hospital Charge Code	994218
Hospital Revenue Code	278
Min. Negotiated Rate	$197.96
Max. Negotiated Rate	$1,583.64
Rate for Payer: Amerigroup CHIP/Medicaid	$197.96
Rate for Payer: BCBS of TX Blue Advantage	$659.85
Rate for Payer: BCBS of TX Blue Essentials	$791.82
Rate for Payer: BCBS of TX PPO	$879.80
Rate for Payer: Cash Price	$1,495.66
Rate for Payer: Cigna Medicaid	$1,583.64
Rate for Payer: Molina CHIP/Medicaid	$1,583.64
Rate for Payer: Multiplan Auto	$1,099.75
Rate for Payer: Multiplan Commercial	$1,099.75
Rate for Payer: Multiplan Workers Comp	$1,099.75
Rate for Payer: Parkland Medicaid	$1,583.64
Rate for Payer: Scott and White EPO/PPO	$1,099.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,583.64
Rate for Payer: Superior Health Plan EPO	$299.13

AR-8916VSL-03

Facility

$2,199.50

Service Code	HCPCS C1776
Hospital Charge Code	994218
Hospital Revenue Code	278
Min. Negotiated Rate	$549.88
Max. Negotiated Rate	$1,099.75
Rate for Payer: Cash Price	$1,495.66
Rate for Payer: Cigna Commercial	$549.88
Rate for Payer: Multiplan Auto	$1,099.75
Rate for Payer: Multiplan Commercial	$1,099.75
Rate for Payer: Multiplan Workers Comp	$1,099.75
Rate for Payer: Scott and White EPO/PPO	$1,099.75

AR-8925-SS

Facility

$15,012.05

Service Code	HCPCS C1734
Hospital Charge Code	991118
Hospital Revenue Code	278
Min. Negotiated Rate	$3,753.01
Max. Negotiated Rate	$7,506.02
Rate for Payer: Cash Price	$10,208.19
Rate for Payer: Cigna Commercial	$3,753.01
Rate for Payer: Multiplan Auto	$7,506.02
Rate for Payer: Multiplan Commercial	$7,506.02
Rate for Payer: Multiplan Workers Comp	$7,506.02
Rate for Payer: Scott and White EPO/PPO	$7,506.02

AR-8925-SS

Facility

$15,012.05

Service Code	HCPCS C1734
Hospital Charge Code	991118
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.08
Max. Negotiated Rate	$10,808.68
Rate for Payer: Amerigroup CHIP/Medicaid	$1,351.08
Rate for Payer: BCBS of TX Blue Advantage	$4,503.61
Rate for Payer: BCBS of TX Blue Essentials	$5,404.34
Rate for Payer: BCBS of TX PPO	$6,004.82
Rate for Payer: Cash Price	$10,208.19
Rate for Payer: Cigna Medicaid	$10,808.68
Rate for Payer: Molina CHIP/Medicaid	$10,808.68
Rate for Payer: Multiplan Auto	$7,506.02
Rate for Payer: Multiplan Commercial	$7,506.02
Rate for Payer: Multiplan Workers Comp	$7,506.02
Rate for Payer: Parkland Medicaid	$10,808.68
Rate for Payer: Scott and White EPO/PPO	$7,506.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,808.68
Rate for Payer: Superior Health Plan EPO	$2,041.64

AR-8935-16AR-8935-18

Facility

$166.00

Service Code	HCPCS C1713
Hospital Charge Code	994222
Hospital Revenue Code	278
Min. Negotiated Rate	$14.94
Max. Negotiated Rate	$119.52
Rate for Payer: Amerigroup CHIP/Medicaid	$14.94
Rate for Payer: BCBS of TX Blue Advantage	$49.80
Rate for Payer: BCBS of TX Blue Essentials	$59.76
Rate for Payer: BCBS of TX PPO	$66.40
Rate for Payer: Cash Price	$112.88
Rate for Payer: Cigna Medicaid	$119.52
Rate for Payer: Molina CHIP/Medicaid	$119.52
Rate for Payer: Multiplan Auto	$83.00
Rate for Payer: Multiplan Commercial	$83.00
Rate for Payer: Multiplan Workers Comp	$83.00
Rate for Payer: Parkland Medicaid	$119.52
Rate for Payer: Scott and White EPO/PPO	$83.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$119.52
Rate for Payer: Superior Health Plan EPO	$22.58

AR-8935-16AR-8935-18

Facility

$166.00

Service Code	HCPCS C1713
Hospital Charge Code	994222
Hospital Revenue Code	278
Min. Negotiated Rate	$41.50
Max. Negotiated Rate	$83.00
Rate for Payer: Cash Price	$112.88
Rate for Payer: Cigna Commercial	$41.50
Rate for Payer: Multiplan Auto	$83.00
Rate for Payer: Multiplan Commercial	$83.00
Rate for Payer: Multiplan Workers Comp	$83.00
Rate for Payer: Scott and White EPO/PPO	$83.00

AR-8935-32AR-8935-34

Facility

$602.41

Service Code	HCPCS C1713
Hospital Charge Code	991073
Hospital Revenue Code	278
Min. Negotiated Rate	$150.60
Max. Negotiated Rate	$301.20
Rate for Payer: Cash Price	$409.64
Rate for Payer: Cigna Commercial	$150.60
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Scott and White EPO/PPO	$301.20

AR-8935-32AR-8935-34

Facility

$602.41

Service Code	HCPCS C1713
Hospital Charge Code	991073
Hospital Revenue Code	278
Min. Negotiated Rate	$54.22
Max. Negotiated Rate	$433.74
Rate for Payer: Amerigroup CHIP/Medicaid	$54.22
Rate for Payer: BCBS of TX Blue Advantage	$180.72
Rate for Payer: BCBS of TX Blue Essentials	$216.87
Rate for Payer: BCBS of TX PPO	$240.96
Rate for Payer: Cash Price	$409.64
Rate for Payer: Cigna Medicaid	$433.74
Rate for Payer: Molina CHIP/Medicaid	$433.74
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Parkland Medicaid	$433.74
Rate for Payer: Scott and White EPO/PPO	$301.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$433.74
Rate for Payer: Superior Health Plan EPO	$81.93

AR-8935CL-30AR-8935CL-38AR-8935-CL-40

Facility

$2,963.85

Service Code	HCPCS C1713
Hospital Charge Code	991074
Hospital Revenue Code	278
Min. Negotiated Rate	$266.75
Max. Negotiated Rate	$2,133.97
Rate for Payer: Amerigroup CHIP/Medicaid	$266.75
Rate for Payer: BCBS of TX Blue Advantage	$889.15
Rate for Payer: BCBS of TX Blue Essentials	$1,066.99
Rate for Payer: BCBS of TX PPO	$1,185.54
Rate for Payer: Cash Price	$2,015.42
Rate for Payer: Cigna Medicaid	$2,133.97
Rate for Payer: Molina CHIP/Medicaid	$2,133.97
Rate for Payer: Multiplan Auto	$1,481.92
Rate for Payer: Multiplan Commercial	$1,481.92
Rate for Payer: Multiplan Workers Comp	$1,481.92
Rate for Payer: Parkland Medicaid	$2,133.97
Rate for Payer: Scott and White EPO/PPO	$1,481.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,133.97
Rate for Payer: Superior Health Plan EPO	$403.08

AR-8935CL-30AR-8935CL-38AR-8935-CL-40

Facility

$2,963.85

Service Code	HCPCS C1713
Hospital Charge Code	991074
Hospital Revenue Code	278
Min. Negotiated Rate	$740.96
Max. Negotiated Rate	$1,481.92
Rate for Payer: Cash Price	$2,015.42
Rate for Payer: Cigna Commercial	$740.96
Rate for Payer: Multiplan Auto	$1,481.92
Rate for Payer: Multiplan Commercial	$1,481.92
Rate for Payer: Multiplan Workers Comp	$1,481.92
Rate for Payer: Scott and White EPO/PPO	$1,481.92

AR-8943-01

Facility

$85.76

Service Code	HCPCS C1769
Hospital Charge Code	994223
Hospital Revenue Code	272
Min. Negotiated Rate	$7.72
Max. Negotiated Rate	$61.75
Rate for Payer: Amerigroup CHIP/Medicaid	$7.72
Rate for Payer: BCBS of TX Blue Advantage	$25.73
Rate for Payer: BCBS of TX Blue Essentials	$30.87
Rate for Payer: BCBS of TX PPO	$34.30
Rate for Payer: Cash Price	$58.32
Rate for Payer: Cigna Medicaid	$61.75
Rate for Payer: Molina CHIP/Medicaid	$61.75
Rate for Payer: Multiplan Auto	$55.74
Rate for Payer: Multiplan Commercial	$55.74
Rate for Payer: Multiplan Workers Comp	$55.74
Rate for Payer: Parkland Medicaid	$61.75
Rate for Payer: Scott and White EPO/PPO	$42.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$61.75
Rate for Payer: Superior Health Plan EPO	$11.66

AR-8943-01

Facility

$85.76

Service Code	HCPCS C1769
Hospital Charge Code	994223
Hospital Revenue Code	272
Rate for Payer: Cash Price	$58.32

AR-8943-16

Facility

$572.29

Service Code	HCPCS C1713
Hospital Charge Code	991119
Hospital Revenue Code	278
Min. Negotiated Rate	$51.51
Max. Negotiated Rate	$412.05
Rate for Payer: Amerigroup CHIP/Medicaid	$51.51
Rate for Payer: BCBS of TX Blue Advantage	$171.69
Rate for Payer: BCBS of TX Blue Essentials	$206.02
Rate for Payer: BCBS of TX PPO	$228.92
Rate for Payer: Cash Price	$389.16
Rate for Payer: Cigna Medicaid	$412.05
Rate for Payer: Molina CHIP/Medicaid	$412.05
Rate for Payer: Multiplan Auto	$286.14
Rate for Payer: Multiplan Commercial	$286.14
Rate for Payer: Multiplan Workers Comp	$286.14
Rate for Payer: Parkland Medicaid	$412.05
Rate for Payer: Scott and White EPO/PPO	$286.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$412.05
Rate for Payer: Superior Health Plan EPO	$77.83

AR-8943-16

Facility

$572.29

Service Code	HCPCS C1713
Hospital Charge Code	991119
Hospital Revenue Code	278
Min. Negotiated Rate	$143.07
Max. Negotiated Rate	$286.14
Rate for Payer: Cash Price	$389.16
Rate for Payer: Cigna Commercial	$143.07
Rate for Payer: Multiplan Auto	$286.14
Rate for Payer: Multiplan Commercial	$286.14
Rate for Payer: Multiplan Workers Comp	$286.14
Rate for Payer: Scott and White EPO/PPO	$286.14

AR-8943-30AR-8943-42

Facility

$512.05

Service Code	HCPCS C1713
Hospital Charge Code	991075
Hospital Revenue Code	278
Min. Negotiated Rate	$128.01
Max. Negotiated Rate	$256.02
Rate for Payer: Cash Price	$348.19
Rate for Payer: Cigna Commercial	$128.01
Rate for Payer: Multiplan Auto	$256.02
Rate for Payer: Multiplan Commercial	$256.02
Rate for Payer: Multiplan Workers Comp	$256.02
Rate for Payer: Scott and White EPO/PPO	$256.02

AR-8943-30AR-8943-42

Facility

$512.05

Service Code	HCPCS C1713
Hospital Charge Code	991075
Hospital Revenue Code	278
Min. Negotiated Rate	$46.08
Max. Negotiated Rate	$368.68
Rate for Payer: Amerigroup CHIP/Medicaid	$46.08
Rate for Payer: BCBS of TX Blue Advantage	$153.62
Rate for Payer: BCBS of TX Blue Essentials	$184.34
Rate for Payer: BCBS of TX PPO	$204.82
Rate for Payer: Cash Price	$348.19
Rate for Payer: Cigna Medicaid	$368.68
Rate for Payer: Molina CHIP/Medicaid	$368.68
Rate for Payer: Multiplan Auto	$256.02
Rate for Payer: Multiplan Commercial	$256.02
Rate for Payer: Multiplan Workers Comp	$256.02
Rate for Payer: Parkland Medicaid	$368.68
Rate for Payer: Scott and White EPO/PPO	$256.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.68
Rate for Payer: Superior Health Plan EPO	$69.64

AR-8943T-07

Facility

$2,560.24

Service Code	HCPCS C1734
Hospital Charge Code	991120
Hospital Revenue Code	278
Min. Negotiated Rate	$230.42
Max. Negotiated Rate	$1,843.37
Rate for Payer: Amerigroup CHIP/Medicaid	$230.42
Rate for Payer: BCBS of TX Blue Advantage	$768.07
Rate for Payer: BCBS of TX Blue Essentials	$921.69
Rate for Payer: BCBS of TX PPO	$1,024.10
Rate for Payer: Cash Price	$1,740.96
Rate for Payer: Cigna Medicaid	$1,843.37
Rate for Payer: Molina CHIP/Medicaid	$1,843.37
Rate for Payer: Multiplan Auto	$1,280.12
Rate for Payer: Multiplan Commercial	$1,280.12
Rate for Payer: Multiplan Workers Comp	$1,280.12
Rate for Payer: Parkland Medicaid	$1,843.37
Rate for Payer: Scott and White EPO/PPO	$1,280.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,843.37
Rate for Payer: Superior Health Plan EPO	$348.19

Know your out-of-pocket cost for care.

All Charges