White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SONIC ANCHOR KIT

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Charge Code	145759
Hospital Revenue Code	278
Min. Negotiated Rate	$239.76
Max. Negotiated Rate	$1,918.08
Rate for Payer: Amerigroup CHIP/Medicaid	$239.76
Rate for Payer: BCBS of TX Blue Advantage	$799.20
Rate for Payer: BCBS of TX Blue Essentials	$959.04
Rate for Payer: BCBS of TX PPO	$1,065.60
Rate for Payer: Cash Price	$1,811.52
Rate for Payer: Cigna Medicaid	$1,918.08
Rate for Payer: Molina CHIP/Medicaid	$1,918.08
Rate for Payer: Multiplan Auto	$1,332.00
Rate for Payer: Multiplan Commercial	$1,332.00
Rate for Payer: Multiplan Workers Comp	$1,332.00
Rate for Payer: Parkland Medicaid	$1,918.08
Rate for Payer: Scott and White EPO/PPO	$1,332.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,918.08
Rate for Payer: Superior Health Plan EPO	$362.30

SONIC ANCHOR KIT

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Charge Code	145759
Hospital Revenue Code	278
Min. Negotiated Rate	$666.00
Max. Negotiated Rate	$1,332.00
Rate for Payer: Cash Price	$1,811.52
Rate for Payer: Cigna Commercial	$666.00
Rate for Payer: Multiplan Auto	$1,332.00
Rate for Payer: Multiplan Commercial	$1,332.00
Rate for Payer: Multiplan Workers Comp	$1,332.00
Rate for Payer: Scott and White EPO/PPO	$1,332.00

SONIC ANCHOR SYSTEM

Facility

$2,007.59

Hospital Charge Code	114023
Hospital Revenue Code	272
Min. Negotiated Rate	$180.68
Max. Negotiated Rate	$1,445.46
Rate for Payer: Amerigroup CHIP/Medicaid	$180.68
Rate for Payer: BCBS of TX Blue Advantage	$602.28
Rate for Payer: BCBS of TX Blue Essentials	$722.73
Rate for Payer: BCBS of TX PPO	$803.04
Rate for Payer: Cash Price	$1,365.16
Rate for Payer: Cigna Medicaid	$1,445.46
Rate for Payer: Molina CHIP/Medicaid	$1,445.46
Rate for Payer: Multiplan Auto	$1,304.93
Rate for Payer: Multiplan Commercial	$1,304.93
Rate for Payer: Multiplan Workers Comp	$1,304.93
Rate for Payer: Parkland Medicaid	$1,445.46
Rate for Payer: Scott and White EPO/PPO	$1,003.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,445.46
Rate for Payer: Superior Health Plan EPO	$273.03

SONIC ANCHOR SYSTEM

Facility

$2,007.59

Hospital Charge Code	114023
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,365.16

Sp bone algrft morsel add-on

Facility

$10,800.00

Service Code	HCPCS 20930
Hospital Charge Code	9900187
Hospital Revenue Code	360
Min. Negotiated Rate	$972.00
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$972.00
Rate for Payer: BCBS of TX Blue Advantage	$3,240.00
Rate for Payer: BCBS of TX Blue Essentials	$3,888.00
Rate for Payer: BCBS of TX PPO	$4,320.00
Rate for Payer: Cash Price	$7,344.00
Rate for Payer: Cash Price	$7,344.00
Rate for Payer: Cigna Medicaid	$7,776.00
Rate for Payer: Molina CHIP/Medicaid	$7,776.00
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	$7,776.00
Rate for Payer: Scott and White EPO/PPO	$5,400.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,776.00
Rate for Payer: Superior Health Plan EPO	$1,468.80

Sp bone algrft morsel add-on

Facility

$10,800.00

Service Code	HCPCS 20930
Hospital Charge Code	9900187
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,344.00

Sp bone algrft morsel add-on

Facility

$10,000.00

Service Code	CPT 20930
Hospital Charge Code	36020930
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$10,000.00
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

SPECIALIST CAST PADDING 3' X 4 YDA

Facility

$2.32

Hospital Charge Code	992958
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.58

SPECIALIST CAST PADDING 3' X 4 YDA

Facility

$2.32

Hospital Charge Code	992958
Hospital Revenue Code	270
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$1.67
Rate for Payer: Amerigroup CHIP/Medicaid	$0.21
Rate for Payer: BCBS of TX Blue Advantage	$0.70
Rate for Payer: BCBS of TX Blue Essentials	$0.84
Rate for Payer: BCBS of TX PPO	$0.93
Rate for Payer: Cash Price	$1.58
Rate for Payer: Cigna Medicaid	$1.67
Rate for Payer: Molina CHIP/Medicaid	$1.67
Rate for Payer: Multiplan Auto	$1.51
Rate for Payer: Multiplan Commercial	$1.51
Rate for Payer: Multiplan Workers Comp	$1.51
Rate for Payer: Parkland Medicaid	$1.67
Rate for Payer: Scott and White EPO/PPO	$1.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.67
Rate for Payer: Superior Health Plan EPO	$0.32

SPECTRUM SUTURE HOOK

Facility

$280.80

Hospital Charge Code	992652
Hospital Revenue Code	272
Rate for Payer: Cash Price	$190.94

SPECTRUM SUTURE HOOK

Facility

$280.80

Hospital Charge Code	992652
Hospital Revenue Code	272
Min. Negotiated Rate	$25.27
Max. Negotiated Rate	$202.18
Rate for Payer: Amerigroup CHIP/Medicaid	$25.27
Rate for Payer: BCBS of TX Blue Advantage	$84.24
Rate for Payer: BCBS of TX Blue Essentials	$101.09
Rate for Payer: BCBS of TX PPO	$112.32
Rate for Payer: Cash Price	$190.94
Rate for Payer: Cigna Medicaid	$202.18
Rate for Payer: Molina CHIP/Medicaid	$202.18
Rate for Payer: Multiplan Auto	$182.52
Rate for Payer: Multiplan Commercial	$182.52
Rate for Payer: Multiplan Workers Comp	$182.52
Rate for Payer: Parkland Medicaid	$202.18
Rate for Payer: Scott and White EPO/PPO	$140.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$202.18
Rate for Payer: Superior Health Plan EPO	$38.19

SPECTRUM SUTURE HOOK

Facility

$280.80

Hospital Charge Code	992651
Hospital Revenue Code	272
Min. Negotiated Rate	$25.27
Max. Negotiated Rate	$202.18
Rate for Payer: Amerigroup CHIP/Medicaid	$25.27
Rate for Payer: BCBS of TX Blue Advantage	$84.24
Rate for Payer: BCBS of TX Blue Essentials	$101.09
Rate for Payer: BCBS of TX PPO	$112.32
Rate for Payer: Cash Price	$190.94
Rate for Payer: Cigna Medicaid	$202.18
Rate for Payer: Molina CHIP/Medicaid	$202.18
Rate for Payer: Multiplan Auto	$182.52
Rate for Payer: Multiplan Commercial	$182.52
Rate for Payer: Multiplan Workers Comp	$182.52
Rate for Payer: Parkland Medicaid	$202.18
Rate for Payer: Scott and White EPO/PPO	$140.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$202.18
Rate for Payer: Superior Health Plan EPO	$38.19

SPECTRUM SUTURE HOOK

Facility

$280.80

Hospital Charge Code	992651
Hospital Revenue Code	272
Rate for Payer: Cash Price	$190.94

Speed trap graft prepkit

Facility

$490.32

Hospital Charge Code	8602528
Hospital Revenue Code	270
Min. Negotiated Rate	$44.13
Max. Negotiated Rate	$353.03
Rate for Payer: Amerigroup CHIP/Medicaid	$44.13
Rate for Payer: BCBS of TX Blue Advantage	$147.10
Rate for Payer: BCBS of TX Blue Essentials	$176.52
Rate for Payer: BCBS of TX PPO	$196.13
Rate for Payer: Cash Price	$333.42
Rate for Payer: Cigna Medicaid	$353.03
Rate for Payer: Molina CHIP/Medicaid	$353.03
Rate for Payer: Multiplan Auto	$318.71
Rate for Payer: Multiplan Commercial	$318.71
Rate for Payer: Multiplan Workers Comp	$318.71
Rate for Payer: Parkland Medicaid	$353.03
Rate for Payer: Scott and White EPO/PPO	$245.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$353.03
Rate for Payer: Superior Health Plan EPO	$66.68

Speed trap graft prepkit

Facility

$490.32

Hospital Charge Code	8602528
Hospital Revenue Code	270
Rate for Payer: Cash Price	$333.42

SPEEDTRAP GRAFT PREP SYSTEM

Facility

$562.96

Hospital Charge Code	131971
Hospital Revenue Code	272
Rate for Payer: Cash Price	$382.81

SPEEDTRAP GRAFT PREP SYSTEM

Facility

$562.96

Hospital Charge Code	131971
Hospital Revenue Code	272
Min. Negotiated Rate	$50.67
Max. Negotiated Rate	$405.33
Rate for Payer: Amerigroup CHIP/Medicaid	$50.67
Rate for Payer: BCBS of TX Blue Advantage	$168.89
Rate for Payer: BCBS of TX Blue Essentials	$202.67
Rate for Payer: BCBS of TX PPO	$225.18
Rate for Payer: Cash Price	$382.81
Rate for Payer: Cigna Medicaid	$405.33
Rate for Payer: Molina CHIP/Medicaid	$405.33
Rate for Payer: Multiplan Auto	$365.92
Rate for Payer: Multiplan Commercial	$365.92
Rate for Payer: Multiplan Workers Comp	$365.92
Rate for Payer: Parkland Medicaid	$405.33
Rate for Payer: Scott and White EPO/PPO	$281.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$405.33
Rate for Payer: Superior Health Plan EPO	$76.56

SPHINCTRTOME/HYDRATOME -- DHF

Facility

$1,770.60

Hospital Charge Code	80341126
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,204.01

SPHINCTRTOME/HYDRATOME -- DHF

Facility

$1,770.60

Hospital Charge Code	80341126
Hospital Revenue Code	272
Min. Negotiated Rate	$159.35
Max. Negotiated Rate	$1,274.83
Rate for Payer: Amerigroup CHIP/Medicaid	$159.35
Rate for Payer: BCBS of TX Blue Advantage	$531.18
Rate for Payer: BCBS of TX Blue Essentials	$637.42
Rate for Payer: BCBS of TX PPO	$708.24
Rate for Payer: Cash Price	$1,204.01
Rate for Payer: Cigna Medicaid	$1,274.83
Rate for Payer: Molina CHIP/Medicaid	$1,274.83
Rate for Payer: Multiplan Auto	$1,150.89
Rate for Payer: Multiplan Commercial	$1,150.89
Rate for Payer: Multiplan Workers Comp	$1,150.89
Rate for Payer: Parkland Medicaid	$1,274.83
Rate for Payer: Scott and White EPO/PPO	$885.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,274.83
Rate for Payer: Superior Health Plan EPO	$240.80

SPINAL DISORDERS AND INJURIES

Facility

$22,134.58

Service Code	APR-DRG 0404
Min. Negotiated Rate	$20,869.26
Max. Negotiated Rate	$22,134.58
Rate for Payer: Amerigroup CHIP/Medicaid	$20,869.26
Rate for Payer: Cigna Medicaid	$20,869.26
Rate for Payer: Molina CHIP/Medicaid	$20,869.26
Rate for Payer: Parkland Medicaid	$20,869.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,134.58

SPINAL DISORDERS AND INJURIES

Facility

$11,084.45

Service Code	APR-DRG 0402
Min. Negotiated Rate	$10,450.81
Max. Negotiated Rate	$11,084.45
Rate for Payer: Amerigroup CHIP/Medicaid	$10,450.81
Rate for Payer: Cigna Medicaid	$10,450.81
Rate for Payer: Molina CHIP/Medicaid	$10,450.81
Rate for Payer: Parkland Medicaid	$10,450.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,084.45

SPINAL DISORDERS AND INJURIES

Facility

$5,139.95

Service Code	APR-DRG 0401
Min. Negotiated Rate	$4,846.13
Max. Negotiated Rate	$5,139.95
Rate for Payer: Amerigroup CHIP/Medicaid	$4,846.13
Rate for Payer: Cigna Medicaid	$4,846.13
Rate for Payer: Molina CHIP/Medicaid	$4,846.13
Rate for Payer: Parkland Medicaid	$4,846.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,139.95

SPINAL DISORDERS AND INJURIES

Facility

$14,349.40

Service Code	APR-DRG 0403
Min. Negotiated Rate	$13,529.12
Max. Negotiated Rate	$14,349.40
Rate for Payer: Amerigroup CHIP/Medicaid	$13,529.12
Rate for Payer: Cigna Medicaid	$13,529.12
Rate for Payer: Molina CHIP/Medicaid	$13,529.12
Rate for Payer: Parkland Medicaid	$13,529.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,349.40

SPINAL DISORDERS AND INJURIES WITH CC/MCC

Facility

$33,825.70

Service Code	MSDRG 052
Min. Negotiated Rate	$14,623.44
Max. Negotiated Rate	$33,825.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,035.15
Rate for Payer: Amerigroup Medicare	$18,035.15
Rate for Payer: BCBS of TX Medicare	$18,035.15
Rate for Payer: Cigna Commercial	$22,936.70
Rate for Payer: Cigna Medicare	$18,035.15
Rate for Payer: Employer Direct Commercial	$18,035.15
Rate for Payer: Humana Medicare/TRICARE	$18,035.15
Rate for Payer: Molina Dual Medicare/Medicaid	$18,035.15
Rate for Payer: Molina Medicare	$18,035.15
Rate for Payer: Multiplan Auto	$33,825.70
Rate for Payer: Multiplan Commercial	$33,825.70
Rate for Payer: Multiplan Workers Comp	$33,825.70
Rate for Payer: Scott and White EPO/PPO	$15,577.62
Rate for Payer: Scott and White Medicare	$18,035.15
Rate for Payer: Superior Health Plan EPO	$18,035.15
Rate for Payer: Superior Health Plan Medicare	$18,035.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,035.15
Rate for Payer: Universal American Medicare	$18,035.15
Rate for Payer: Wellcare Medicare	$18,035.15
Rate for Payer: Wellmed Medicare	$18,035.15

SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC

Facility

$19,433.20

Service Code	MSDRG 053
Min. Negotiated Rate	$7,861.26
Max. Negotiated Rate	$19,433.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,936.66
Rate for Payer: Amerigroup Medicare	$11,936.66
Rate for Payer: BCBS of TX Medicare	$11,936.66
Rate for Payer: Cigna Commercial	$12,612.10
Rate for Payer: Cigna Medicare	$11,936.66
Rate for Payer: Employer Direct Commercial	$11,936.66
Rate for Payer: Humana Medicare/TRICARE	$11,936.66
Rate for Payer: Molina Dual Medicare/Medicaid	$11,936.66
Rate for Payer: Molina Medicare	$11,936.66
Rate for Payer: Multiplan Auto	$19,433.20
Rate for Payer: Multiplan Commercial	$19,433.20
Rate for Payer: Multiplan Workers Comp	$19,433.20
Rate for Payer: Scott and White EPO/PPO	$8,949.50
Rate for Payer: Scott and White Medicare	$11,936.66
Rate for Payer: Superior Health Plan EPO	$11,936.66
Rate for Payer: Superior Health Plan Medicare	$11,936.66
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,936.66
Rate for Payer: Universal American Medicare	$11,936.66
Rate for Payer: Wellcare Medicare	$11,936.66
Rate for Payer: Wellmed Medicare	$11,936.66

Know your out-of-pocket cost for care.

All Charges