White Rock Medical Center

All Charges

Charge

Type

Setting

Price

APPLIER, ENDOSCOPIC M-CLIP W/ROTATE SHAFT 20/LARGE -- DHF

Facility

$624.70

Hospital Charge Code	81910358
Hospital Revenue Code	272
Rate for Payer: Cash Price	$424.80

APPLIER, ENDOSCOPIC M-CLIP W/ROTATE SHAFT 20/LARGE -- DHF

Facility

$624.70

Hospital Charge Code	81910358
Hospital Revenue Code	272
Min. Negotiated Rate	$56.22
Max. Negotiated Rate	$449.78
Rate for Payer: Amerigroup CHIP/Medicaid	$56.22
Rate for Payer: BCBS of TX Blue Advantage	$187.41
Rate for Payer: BCBS of TX Blue Essentials	$224.89
Rate for Payer: BCBS of TX PPO	$249.88
Rate for Payer: Cash Price	$424.80
Rate for Payer: Cigna Medicaid	$449.78
Rate for Payer: Molina CHIP/Medicaid	$449.78
Rate for Payer: Multiplan Auto	$406.06
Rate for Payer: Multiplan Commercial	$406.06
Rate for Payer: Multiplan Workers Comp	$406.06
Rate for Payer: Parkland Medicaid	$449.78
Rate for Payer: Scott and White EPO/PPO	$312.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$449.78
Rate for Payer: Superior Health Plan EPO	$84.96

APPLR, CLIP, LIGACLIP, MLTI, 20MD, 9 3/8'

Facility

$167.75

Hospital Charge Code	993765
Hospital Revenue Code	272
Min. Negotiated Rate	$15.10
Max. Negotiated Rate	$120.78
Rate for Payer: Amerigroup CHIP/Medicaid	$15.10
Rate for Payer: BCBS of TX Blue Advantage	$50.33
Rate for Payer: BCBS of TX Blue Essentials	$60.39
Rate for Payer: BCBS of TX PPO	$67.10
Rate for Payer: Cash Price	$114.07
Rate for Payer: Cigna Medicaid	$120.78
Rate for Payer: Molina CHIP/Medicaid	$120.78
Rate for Payer: Multiplan Auto	$109.04
Rate for Payer: Multiplan Commercial	$109.04
Rate for Payer: Multiplan Workers Comp	$109.04
Rate for Payer: Parkland Medicaid	$120.78
Rate for Payer: Scott and White EPO/PPO	$83.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.78
Rate for Payer: Superior Health Plan EPO	$22.81

APPLR, CLIP, LIGACLIP, MLTI, 20MD, 9 3/8'

Facility

$167.75

Hospital Charge Code	993765
Hospital Revenue Code	272
Rate for Payer: Cash Price	$114.07

APPLY RIGID LEG CAST LT

Facility

$874.00

Service Code	HCPCS 29445
Hospital Charge Code	7150828
Hospital Revenue Code	761
Rate for Payer: Cash Price	$594.32

APPLY RIGID LEG CAST LT

Facility

$874.00

Service Code	HCPCS 29445
Hospital Charge Code	7150828
Hospital Revenue Code	761
Min. Negotiated Rate	$78.66
Max. Negotiated Rate	$629.28
Rate for Payer: Amerigroup CHIP/Medicaid	$78.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$103.66
Rate for Payer: BCBS of TX Blue Essentials	$124.14
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$156.42
Rate for Payer: Cash Price	$594.32
Rate for Payer: Cash Price	$594.32
Rate for Payer: Cash Price	$594.32
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$629.28
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$629.28
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
Rate for Payer: Multiplan Auto	$568.10
Rate for Payer: Multiplan Commercial	$568.10
Rate for Payer: Multiplan Workers Comp	$568.10
Rate for Payer: Parkland Medicaid	$629.28
Rate for Payer: Scott and White EPO/PPO	$120.81
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$629.28
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

APPLY RIGID LEG CAST RT

Facility

$874.00

Service Code	HCPCS 29445
Hospital Charge Code	7150827
Hospital Revenue Code	761
Min. Negotiated Rate	$78.66
Max. Negotiated Rate	$629.28
Rate for Payer: Amerigroup CHIP/Medicaid	$78.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$103.66
Rate for Payer: BCBS of TX Blue Essentials	$124.14
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$156.42
Rate for Payer: Cash Price	$594.32
Rate for Payer: Cash Price	$594.32
Rate for Payer: Cash Price	$594.32
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$629.28
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$629.28
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
Rate for Payer: Multiplan Auto	$568.10
Rate for Payer: Multiplan Commercial	$568.10
Rate for Payer: Multiplan Workers Comp	$568.10
Rate for Payer: Parkland Medicaid	$629.28
Rate for Payer: Scott and White EPO/PPO	$120.81
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$629.28
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

APPLY RIGID LEG CAST RT

Facility

$874.00

Service Code	HCPCS 29445
Hospital Charge Code	7150827
Hospital Revenue Code	761
Rate for Payer: Cash Price	$594.32

AQUACEL AG 3.5 X 4

Facility

$106.69

Hospital Charge Code	138274
Hospital Revenue Code	272
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$76.82
Rate for Payer: Amerigroup CHIP/Medicaid	$9.60
Rate for Payer: BCBS of TX Blue Advantage	$32.01
Rate for Payer: BCBS of TX Blue Essentials	$38.41
Rate for Payer: BCBS of TX PPO	$42.68
Rate for Payer: Cash Price	$72.55
Rate for Payer: Cigna Medicaid	$76.82
Rate for Payer: Molina CHIP/Medicaid	$76.82
Rate for Payer: Multiplan Auto	$69.35
Rate for Payer: Multiplan Commercial	$69.35
Rate for Payer: Multiplan Workers Comp	$69.35
Rate for Payer: Parkland Medicaid	$76.82
Rate for Payer: Scott and White EPO/PPO	$53.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.82
Rate for Payer: Superior Health Plan EPO	$14.51

AQUACEL AG 3.5 X 4

Facility

$106.69

Hospital Charge Code	138274
Hospital Revenue Code	272
Rate for Payer: Cash Price	$72.55

Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft

Facility

$15,998.36

Service Code	HCPCS 66180
Hospital Charge Code	9900863
Hospital Revenue Code	360
Min. Negotiated Rate	$2,064.63
Max. Negotiated Rate	$11,518.82
Rate for Payer: Amerigroup CHIP/Medicaid	$2,064.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,345.55
Rate for Payer: Amerigroup Medicare	$5,345.55
Rate for Payer: BCBS of TX Blue Advantage	$6,376.61
Rate for Payer: BCBS of TX Blue Essentials	$7,636.66
Rate for Payer: BCBS of TX Medicare	$5,345.55
Rate for Payer: BCBS of TX PPO	$9,622.19
Rate for Payer: Cash Price	$10,878.88
Rate for Payer: Cash Price	$10,878.88
Rate for Payer: Cash Price	$10,878.88
Rate for Payer: Cigna Commercial	$11,299.53
Rate for Payer: Cigna Medicaid	$11,518.82
Rate for Payer: Cigna Medicare	$5,345.55
Rate for Payer: Employer Direct Commercial	$5,345.55
Rate for Payer: Humana Medicare/TRICARE	$5,345.55
Rate for Payer: Molina CHIP/Medicaid	$11,518.82
Rate for Payer: Molina Dual Medicare/Medicaid	$5,345.55
Rate for Payer: Molina Medicare	$5,345.55
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$11,518.82
Rate for Payer: Scott and White EPO/PPO	$6,879.04
Rate for Payer: Scott and White Medicare	$5,345.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,518.82
Rate for Payer: Superior Health Plan EPO	$5,345.55
Rate for Payer: Superior Health Plan Medicare	$5,345.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,345.55
Rate for Payer: Universal American Medicare	$5,345.55
Rate for Payer: Wellcare Medicare	$5,345.55
Rate for Payer: Wellmed Medicare	$5,345.55

Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft

Facility

$11,299.53

Service Code	CPT 66180
Hospital Charge Code	36066180
Hospital Revenue Code	360
Min. Negotiated Rate	$2,064.63
Max. Negotiated Rate	$11,299.53
Rate for Payer: Amerigroup CHIP/Medicaid	$2,064.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,345.55
Rate for Payer: Amerigroup Medicare	$5,345.55
Rate for Payer: BCBS of TX Blue Advantage	$6,376.61
Rate for Payer: BCBS of TX Blue Essentials	$7,636.66
Rate for Payer: BCBS of TX Medicare	$5,345.55
Rate for Payer: BCBS of TX PPO	$9,622.19
Rate for Payer: Cigna Commercial	$11,299.53
Rate for Payer: Cigna Medicare	$5,345.55
Rate for Payer: Employer Direct Commercial	$5,345.55
Rate for Payer: Humana Medicare/TRICARE	$5,345.55
Rate for Payer: Molina Dual Medicare/Medicaid	$5,345.55
Rate for Payer: Molina Medicare	$5,345.55
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$6,879.04
Rate for Payer: Scott and White Medicare	$5,345.55
Rate for Payer: Superior Health Plan EPO	$5,345.55
Rate for Payer: Superior Health Plan Medicare	$5,345.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,345.55
Rate for Payer: Universal American Medicare	$5,345.55
Rate for Payer: Wellcare Medicare	$5,345.55
Rate for Payer: Wellmed Medicare	$5,345.55

Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft

Facility

$15,998.36

Service Code	HCPCS 66180
Hospital Charge Code	9900863
Hospital Revenue Code	360
Rate for Payer: Cash Price	$10,878.88

AR-1322BCST

Facility

$4,271.08

Service Code	HCPCS C1713
Hospital Charge Code	991155
Hospital Revenue Code	278
Min. Negotiated Rate	$1,067.77
Max. Negotiated Rate	$2,135.54
Rate for Payer: Cash Price	$2,904.33
Rate for Payer: Cigna Commercial	$1,067.77
Rate for Payer: Multiplan Auto	$2,135.54
Rate for Payer: Multiplan Commercial	$2,135.54
Rate for Payer: Multiplan Workers Comp	$2,135.54
Rate for Payer: Scott and White EPO/PPO	$2,135.54

AR-1322BCST

Facility

$4,271.08

Service Code	HCPCS C1713
Hospital Charge Code	991155
Hospital Revenue Code	278
Min. Negotiated Rate	$384.40
Max. Negotiated Rate	$3,075.18
Rate for Payer: Amerigroup CHIP/Medicaid	$384.40
Rate for Payer: BCBS of TX Blue Advantage	$1,281.32
Rate for Payer: BCBS of TX Blue Essentials	$1,537.59
Rate for Payer: BCBS of TX PPO	$1,708.43
Rate for Payer: Cash Price	$2,904.33
Rate for Payer: Cigna Medicaid	$3,075.18
Rate for Payer: Molina CHIP/Medicaid	$3,075.18
Rate for Payer: Multiplan Auto	$2,135.54
Rate for Payer: Multiplan Commercial	$2,135.54
Rate for Payer: Multiplan Workers Comp	$2,135.54
Rate for Payer: Parkland Medicaid	$3,075.18
Rate for Payer: Scott and White EPO/PPO	$2,135.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,075.18
Rate for Payer: Superior Health Plan EPO	$580.87

AR-1322DSC

Facility

$1,759.03

Hospital Charge Code	991156
Hospital Revenue Code	272
Min. Negotiated Rate	$158.31
Max. Negotiated Rate	$1,266.50
Rate for Payer: Amerigroup CHIP/Medicaid	$158.31
Rate for Payer: BCBS of TX Blue Advantage	$527.71
Rate for Payer: BCBS of TX Blue Essentials	$633.25
Rate for Payer: BCBS of TX PPO	$703.61
Rate for Payer: Cash Price	$1,196.14
Rate for Payer: Cigna Medicaid	$1,266.50
Rate for Payer: Molina CHIP/Medicaid	$1,266.50
Rate for Payer: Multiplan Auto	$1,143.37
Rate for Payer: Multiplan Commercial	$1,143.37
Rate for Payer: Multiplan Workers Comp	$1,143.37
Rate for Payer: Parkland Medicaid	$1,266.50
Rate for Payer: Scott and White EPO/PPO	$879.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,266.50
Rate for Payer: Superior Health Plan EPO	$239.23

AR-1322DSC

Facility

$1,759.03

Hospital Charge Code	991156
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,196.14

AR-1547CDS

Facility

$4,166.00

Service Code	HCPCS C1713
Hospital Charge Code	991313
Hospital Revenue Code	278
Min. Negotiated Rate	$374.94
Max. Negotiated Rate	$2,999.52
Rate for Payer: Amerigroup CHIP/Medicaid	$374.94
Rate for Payer: BCBS of TX Blue Advantage	$1,249.80
Rate for Payer: BCBS of TX Blue Essentials	$1,499.76
Rate for Payer: BCBS of TX PPO	$1,666.40
Rate for Payer: Cash Price	$2,832.88
Rate for Payer: Cigna Medicaid	$2,999.52
Rate for Payer: Molina CHIP/Medicaid	$2,999.52
Rate for Payer: Multiplan Auto	$2,083.00
Rate for Payer: Multiplan Commercial	$2,083.00
Rate for Payer: Multiplan Workers Comp	$2,083.00
Rate for Payer: Parkland Medicaid	$2,999.52
Rate for Payer: Scott and White EPO/PPO	$2,083.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,999.52
Rate for Payer: Superior Health Plan EPO	$566.58

AR-1547CDS

Facility

$4,166.00

Service Code	HCPCS C1713
Hospital Charge Code	991313
Hospital Revenue Code	278
Min. Negotiated Rate	$1,041.50
Max. Negotiated Rate	$2,083.00
Rate for Payer: Cash Price	$2,832.88
Rate for Payer: Cigna Commercial	$1,041.50
Rate for Payer: Multiplan Auto	$2,083.00
Rate for Payer: Multiplan Commercial	$2,083.00
Rate for Payer: Multiplan Workers Comp	$2,083.00
Rate for Payer: Scott and White EPO/PPO	$2,083.00

AR-1555BC

Facility

$4,512.00

Service Code	HCPCS C1776
Hospital Charge Code	991044
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.00
Max. Negotiated Rate	$2,256.00
Rate for Payer: Cash Price	$3,068.16
Rate for Payer: Cigna Commercial	$1,128.00
Rate for Payer: Multiplan Auto	$2,256.00
Rate for Payer: Multiplan Commercial	$2,256.00
Rate for Payer: Multiplan Workers Comp	$2,256.00
Rate for Payer: Scott and White EPO/PPO	$2,256.00

AR-1555BC

Facility

$4,512.00

Service Code	HCPCS C1776
Hospital Charge Code	991044
Hospital Revenue Code	278
Min. Negotiated Rate	$406.08
Max. Negotiated Rate	$3,248.64
Rate for Payer: Amerigroup CHIP/Medicaid	$406.08
Rate for Payer: BCBS of TX Blue Advantage	$1,353.60
Rate for Payer: BCBS of TX Blue Essentials	$1,624.32
Rate for Payer: BCBS of TX PPO	$1,804.80
Rate for Payer: Cash Price	$3,068.16
Rate for Payer: Cigna Medicaid	$3,248.64
Rate for Payer: Molina CHIP/Medicaid	$3,248.64
Rate for Payer: Multiplan Auto	$2,256.00
Rate for Payer: Multiplan Commercial	$2,256.00
Rate for Payer: Multiplan Workers Comp	$2,256.00
Rate for Payer: Parkland Medicaid	$3,248.64
Rate for Payer: Scott and White EPO/PPO	$2,256.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,248.64
Rate for Payer: Superior Health Plan EPO	$613.63

AR-1555CDS

Facility

$4,066.26

Service Code	HCPCS C1713
Hospital Charge Code	991152
Hospital Revenue Code	278
Min. Negotiated Rate	$365.96
Max. Negotiated Rate	$2,927.71
Rate for Payer: Amerigroup CHIP/Medicaid	$365.96
Rate for Payer: BCBS of TX Blue Advantage	$1,219.88
Rate for Payer: BCBS of TX Blue Essentials	$1,463.85
Rate for Payer: BCBS of TX PPO	$1,626.50
Rate for Payer: Cash Price	$2,765.06
Rate for Payer: Cigna Medicaid	$2,927.71
Rate for Payer: Molina CHIP/Medicaid	$2,927.71
Rate for Payer: Multiplan Auto	$2,033.13
Rate for Payer: Multiplan Commercial	$2,033.13
Rate for Payer: Multiplan Workers Comp	$2,033.13
Rate for Payer: Parkland Medicaid	$2,927.71
Rate for Payer: Scott and White EPO/PPO	$2,033.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,927.71
Rate for Payer: Superior Health Plan EPO	$553.01

AR-1555CDS

Facility

$4,066.26

Service Code	HCPCS C1713
Hospital Charge Code	991152
Hospital Revenue Code	278
Min. Negotiated Rate	$1,016.57
Max. Negotiated Rate	$2,033.13
Rate for Payer: Cash Price	$2,765.06
Rate for Payer: Cigna Commercial	$1,016.57
Rate for Payer: Multiplan Auto	$2,033.13
Rate for Payer: Multiplan Commercial	$2,033.13
Rate for Payer: Multiplan Workers Comp	$2,033.13
Rate for Payer: Scott and White EPO/PPO	$2,033.13

AR-1676DS

Facility

$4,512.00

Service Code	HCPCS C1713
Hospital Charge Code	991043
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.00
Max. Negotiated Rate	$2,256.00
Rate for Payer: Cash Price	$3,068.16
Rate for Payer: Cigna Commercial	$1,128.00
Rate for Payer: Multiplan Auto	$2,256.00
Rate for Payer: Multiplan Commercial	$2,256.00
Rate for Payer: Multiplan Workers Comp	$2,256.00
Rate for Payer: Scott and White EPO/PPO	$2,256.00

AR-1676DS

Facility

$4,512.00

Service Code	HCPCS C1713
Hospital Charge Code	991043
Hospital Revenue Code	278
Min. Negotiated Rate	$406.08
Max. Negotiated Rate	$3,248.64
Rate for Payer: Amerigroup CHIP/Medicaid	$406.08
Rate for Payer: BCBS of TX Blue Advantage	$1,353.60
Rate for Payer: BCBS of TX Blue Essentials	$1,624.32
Rate for Payer: BCBS of TX PPO	$1,804.80
Rate for Payer: Cash Price	$3,068.16
Rate for Payer: Cigna Medicaid	$3,248.64
Rate for Payer: Molina CHIP/Medicaid	$3,248.64
Rate for Payer: Multiplan Auto	$2,256.00
Rate for Payer: Multiplan Commercial	$2,256.00
Rate for Payer: Multiplan Workers Comp	$2,256.00
Rate for Payer: Parkland Medicaid	$3,248.64
Rate for Payer: Scott and White EPO/PPO	$2,256.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,248.64
Rate for Payer: Superior Health Plan EPO	$613.63

Know your out-of-pocket cost for care.

All Charges