White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SYS ORBT ARTHRCM 1.50 SOLID 145CM

Facility

$16,775.30

Hospital Charge Code	8582477
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11,407.20

SYS ORBT ARTHRCM 2.0 SOLID 145CM

Facility

$16,775.30

Hospital Charge Code	8582475
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11,407.20

SYS ORBT ARTHRCM 2.0 SOLID 145CM

Facility

$16,775.30

Hospital Charge Code	8582475
Hospital Revenue Code	272
Min. Negotiated Rate	$1,509.78
Max. Negotiated Rate	$12,078.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,509.78
Rate for Payer: BCBS of TX Blue Advantage	$5,032.59
Rate for Payer: BCBS of TX Blue Essentials	$6,039.11
Rate for Payer: BCBS of TX PPO	$6,710.12
Rate for Payer: Cash Price	$11,407.20
Rate for Payer: Cigna Medicaid	$12,078.22
Rate for Payer: Molina CHIP/Medicaid	$12,078.22
Rate for Payer: Multiplan Auto	$10,903.94
Rate for Payer: Multiplan Commercial	$10,903.94
Rate for Payer: Multiplan Workers Comp	$10,903.94
Rate for Payer: Parkland Medicaid	$12,078.22
Rate for Payer: Scott and White EPO/PPO	$8,387.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,078.22
Rate for Payer: Superior Health Plan EPO	$2,281.44

SYS PANNUS RETENTION

Facility

$187.68

Hospital Charge Code	81147522
Hospital Revenue Code	272
Rate for Payer: Cash Price	$127.62

SYS PANNUS RETENTION

Facility

$187.68

Hospital Charge Code	81147522
Hospital Revenue Code	272
Min. Negotiated Rate	$16.89
Max. Negotiated Rate	$135.13
Rate for Payer: Amerigroup CHIP/Medicaid	$16.89
Rate for Payer: BCBS of TX Blue Advantage	$56.30
Rate for Payer: BCBS of TX Blue Essentials	$67.56
Rate for Payer: BCBS of TX PPO	$75.07
Rate for Payer: Cash Price	$127.62
Rate for Payer: Cigna Medicaid	$135.13
Rate for Payer: Molina CHIP/Medicaid	$135.13
Rate for Payer: Multiplan Auto	$121.99
Rate for Payer: Multiplan Commercial	$121.99
Rate for Payer: Multiplan Workers Comp	$121.99
Rate for Payer: Parkland Medicaid	$135.13
Rate for Payer: Scott and White EPO/PPO	$93.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.13
Rate for Payer: Superior Health Plan EPO	$25.52

SYS PORT CLOSURE -- DHF

Facility

$529.36

Hospital Charge Code	80869860
Hospital Revenue Code	272
Rate for Payer: Cash Price	$359.96

SYS PORT CLOSURE -- DHF

Facility

$529.36

Hospital Charge Code	80869860
Hospital Revenue Code	272
Min. Negotiated Rate	$47.64
Max. Negotiated Rate	$381.14
Rate for Payer: Amerigroup CHIP/Medicaid	$47.64
Rate for Payer: BCBS of TX Blue Advantage	$158.81
Rate for Payer: BCBS of TX Blue Essentials	$190.57
Rate for Payer: BCBS of TX PPO	$211.74
Rate for Payer: Cash Price	$359.96
Rate for Payer: Cigna Medicaid	$381.14
Rate for Payer: Molina CHIP/Medicaid	$381.14
Rate for Payer: Multiplan Auto	$344.08
Rate for Payer: Multiplan Commercial	$344.08
Rate for Payer: Multiplan Workers Comp	$344.08
Rate for Payer: Parkland Medicaid	$381.14
Rate for Payer: Scott and White EPO/PPO	$264.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$381.14
Rate for Payer: Superior Health Plan EPO	$71.99

system autoplex w/o needles

Facility

$2,725.69

Hospital Charge Code	8602522
Hospital Revenue Code	272
Min. Negotiated Rate	$245.31
Max. Negotiated Rate	$1,962.50
Rate for Payer: Amerigroup CHIP/Medicaid	$245.31
Rate for Payer: BCBS of TX Blue Advantage	$817.71
Rate for Payer: BCBS of TX Blue Essentials	$981.25
Rate for Payer: BCBS of TX PPO	$1,090.28
Rate for Payer: Cash Price	$1,853.47
Rate for Payer: Cigna Medicaid	$1,962.50
Rate for Payer: Molina CHIP/Medicaid	$1,962.50
Rate for Payer: Multiplan Auto	$1,771.70
Rate for Payer: Multiplan Commercial	$1,771.70
Rate for Payer: Multiplan Workers Comp	$1,771.70
Rate for Payer: Parkland Medicaid	$1,962.50
Rate for Payer: Scott and White EPO/PPO	$1,362.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,962.50
Rate for Payer: Superior Health Plan EPO	$370.69

system autoplex w/o needles

Facility

$2,725.69

Hospital Charge Code	8602522
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,853.47

SYSTEM BLD WRM NRMTH 800ML/MIN L1

Facility

$356.82

Hospital Charge Code	993758
Hospital Revenue Code	279
Rate for Payer: Cash Price	$242.64

SYSTEM BLD WRM NRMTH 800ML/MIN L1

Facility

$356.82

Hospital Charge Code	993758
Hospital Revenue Code	279
Min. Negotiated Rate	$32.11
Max. Negotiated Rate	$256.91
Rate for Payer: Amerigroup CHIP/Medicaid	$32.11
Rate for Payer: BCBS of TX Blue Advantage	$107.05
Rate for Payer: BCBS of TX Blue Essentials	$128.46
Rate for Payer: BCBS of TX PPO	$142.73
Rate for Payer: Cash Price	$242.64
Rate for Payer: Cigna Medicaid	$256.91
Rate for Payer: Molina CHIP/Medicaid	$256.91
Rate for Payer: Multiplan Auto	$231.93
Rate for Payer: Multiplan Commercial	$231.93
Rate for Payer: Multiplan Workers Comp	$231.93
Rate for Payer: Parkland Medicaid	$256.91
Rate for Payer: Scott and White EPO/PPO	$178.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$256.91
Rate for Payer: Superior Health Plan EPO	$48.53

SYSTEM BONE GRAFTING KIT W/3CC AGILON

Facility

$12,651.00

Service Code	HCPCS C9362
Hospital Charge Code	8720611
Hospital Revenue Code	278
Min. Negotiated Rate	$1,138.59
Max. Negotiated Rate	$9,108.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1,138.59
Rate for Payer: BCBS of TX Blue Advantage	$3,795.30
Rate for Payer: BCBS of TX Blue Essentials	$4,554.36
Rate for Payer: BCBS of TX PPO	$5,060.40
Rate for Payer: Cash Price	$8,602.68
Rate for Payer: Cigna Medicaid	$9,108.72
Rate for Payer: Molina CHIP/Medicaid	$9,108.72
Rate for Payer: Multiplan Auto	$6,325.50
Rate for Payer: Multiplan Commercial	$6,325.50
Rate for Payer: Multiplan Workers Comp	$6,325.50
Rate for Payer: Parkland Medicaid	$9,108.72
Rate for Payer: Scott and White EPO/PPO	$6,325.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,108.72
Rate for Payer: Superior Health Plan EPO	$1,720.54

SYSTEM BONE GRAFTING KIT W/3CC AGILON

Facility

$12,651.00

Service Code	HCPCS C9362
Hospital Charge Code	145509
Hospital Revenue Code	278
Min. Negotiated Rate	$3,162.75
Max. Negotiated Rate	$6,325.50
Rate for Payer: Cash Price	$8,602.68
Rate for Payer: Cigna Commercial	$3,162.75
Rate for Payer: Multiplan Auto	$6,325.50
Rate for Payer: Multiplan Commercial	$6,325.50
Rate for Payer: Multiplan Workers Comp	$6,325.50
Rate for Payer: Scott and White EPO/PPO	$6,325.50

SYSTEM BONE GRAFTING KIT W/3CC AGILON

Facility

$12,651.00

Service Code	HCPCS C9362
Hospital Charge Code	8720611
Hospital Revenue Code	278
Min. Negotiated Rate	$3,162.75
Max. Negotiated Rate	$6,325.50
Rate for Payer: Cash Price	$8,602.68
Rate for Payer: Cigna Commercial	$3,162.75
Rate for Payer: Multiplan Auto	$6,325.50
Rate for Payer: Multiplan Commercial	$6,325.50
Rate for Payer: Multiplan Workers Comp	$6,325.50
Rate for Payer: Scott and White EPO/PPO	$6,325.50

SYSTEM BONE GRAFTING KIT W/3CC AGILON

Facility

$12,651.00

Service Code	HCPCS C9362
Hospital Charge Code	145509
Hospital Revenue Code	278
Min. Negotiated Rate	$1,138.59
Max. Negotiated Rate	$9,108.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1,138.59
Rate for Payer: BCBS of TX Blue Advantage	$3,795.30
Rate for Payer: BCBS of TX Blue Essentials	$4,554.36
Rate for Payer: BCBS of TX PPO	$5,060.40
Rate for Payer: Cash Price	$8,602.68
Rate for Payer: Cigna Medicaid	$9,108.72
Rate for Payer: Molina CHIP/Medicaid	$9,108.72
Rate for Payer: Multiplan Auto	$6,325.50
Rate for Payer: Multiplan Commercial	$6,325.50
Rate for Payer: Multiplan Workers Comp	$6,325.50
Rate for Payer: Parkland Medicaid	$9,108.72
Rate for Payer: Scott and White EPO/PPO	$6,325.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,108.72
Rate for Payer: Superior Health Plan EPO	$1,720.54

SYSTEM CALIBRATION VISIGI 3D W/BLB 32FR

Facility

$966.11

Hospital Charge Code	8598513
Hospital Revenue Code	272
Min. Negotiated Rate	$86.95
Max. Negotiated Rate	$695.60
Rate for Payer: Amerigroup CHIP/Medicaid	$86.95
Rate for Payer: BCBS of TX Blue Advantage	$289.83
Rate for Payer: BCBS of TX Blue Essentials	$347.80
Rate for Payer: BCBS of TX PPO	$386.44
Rate for Payer: Cash Price	$656.95
Rate for Payer: Cigna Medicaid	$695.60
Rate for Payer: Molina CHIP/Medicaid	$695.60
Rate for Payer: Multiplan Auto	$627.97
Rate for Payer: Multiplan Commercial	$627.97
Rate for Payer: Multiplan Workers Comp	$627.97
Rate for Payer: Parkland Medicaid	$695.60
Rate for Payer: Scott and White EPO/PPO	$483.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$695.60
Rate for Payer: Superior Health Plan EPO	$131.39

SYSTEM CALIBRATION VISIGI 3D W/BLB 32FR

Facility

$966.11

Hospital Charge Code	8598513
Hospital Revenue Code	272
Rate for Payer: Cash Price	$656.95

SYSTEM CALIBRATION VISIGI 3D W/BLB 40FR

Facility

$1,033.30

Hospital Charge Code	8598511
Hospital Revenue Code	272
Min. Negotiated Rate	$93.00
Max. Negotiated Rate	$743.98
Rate for Payer: Amerigroup CHIP/Medicaid	$93.00
Rate for Payer: BCBS of TX Blue Advantage	$309.99
Rate for Payer: BCBS of TX Blue Essentials	$371.99
Rate for Payer: BCBS of TX PPO	$413.32
Rate for Payer: Cash Price	$702.64
Rate for Payer: Cigna Medicaid	$743.98
Rate for Payer: Molina CHIP/Medicaid	$743.98
Rate for Payer: Multiplan Auto	$671.64
Rate for Payer: Multiplan Commercial	$671.64
Rate for Payer: Multiplan Workers Comp	$671.64
Rate for Payer: Parkland Medicaid	$743.98
Rate for Payer: Scott and White EPO/PPO	$516.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$743.98
Rate for Payer: Superior Health Plan EPO	$140.53

SYSTEM CALIBRATION VISIGI 3D W/BLB 40FR

Facility

$1,033.30

Hospital Charge Code	8598511
Hospital Revenue Code	272
Rate for Payer: Cash Price	$702.64

System calibration visigi 3d with bulb 36fr

Facility

$227.60

Hospital Charge Code	8602529
Hospital Revenue Code	272
Rate for Payer: Cash Price	$154.77

System calibration visigi 3d with bulb 36fr

Facility

$227.60

Hospital Charge Code	8602529
Hospital Revenue Code	272
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$163.87
Rate for Payer: Amerigroup CHIP/Medicaid	$20.48
Rate for Payer: BCBS of TX Blue Advantage	$68.28
Rate for Payer: BCBS of TX Blue Essentials	$81.94
Rate for Payer: BCBS of TX PPO	$91.04
Rate for Payer: Cash Price	$154.77
Rate for Payer: Cigna Medicaid	$163.87
Rate for Payer: Molina CHIP/Medicaid	$163.87
Rate for Payer: Multiplan Auto	$147.94
Rate for Payer: Multiplan Commercial	$147.94
Rate for Payer: Multiplan Workers Comp	$147.94
Rate for Payer: Parkland Medicaid	$163.87
Rate for Payer: Scott and White EPO/PPO	$113.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.87
Rate for Payer: Superior Health Plan EPO	$30.95

SYSTEM CAST FOOT TOTAL ANKLE

Facility

$516.06

Hospital Charge Code	81020430
Hospital Revenue Code	271
Rate for Payer: Cash Price	$350.92

SYSTEM CAST FOOT TOTAL ANKLE

Facility

$516.06

Hospital Charge Code	81020430
Hospital Revenue Code	271
Min. Negotiated Rate	$46.45
Max. Negotiated Rate	$371.56
Rate for Payer: Amerigroup CHIP/Medicaid	$46.45
Rate for Payer: BCBS of TX Blue Advantage	$154.82
Rate for Payer: BCBS of TX Blue Essentials	$185.78
Rate for Payer: BCBS of TX PPO	$206.42
Rate for Payer: Cash Price	$350.92
Rate for Payer: Cigna Medicaid	$371.56
Rate for Payer: Molina CHIP/Medicaid	$371.56
Rate for Payer: Multiplan Auto	$335.44
Rate for Payer: Multiplan Commercial	$335.44
Rate for Payer: Multiplan Workers Comp	$335.44
Rate for Payer: Parkland Medicaid	$371.56
Rate for Payer: Scott and White EPO/PPO	$258.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$371.56
Rate for Payer: Superior Health Plan EPO	$70.18

SYSTEM CEMENT MIXING VC-1051

Facility

$1,952.20

Hospital Charge Code	144866
Hospital Revenue Code	272
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$1,405.58
Rate for Payer: Amerigroup CHIP/Medicaid	$175.70
Rate for Payer: BCBS of TX Blue Advantage	$585.66
Rate for Payer: BCBS of TX Blue Essentials	$702.79
Rate for Payer: BCBS of TX PPO	$780.88
Rate for Payer: Cash Price	$1,327.50
Rate for Payer: Cigna Medicaid	$1,405.58
Rate for Payer: Molina CHIP/Medicaid	$1,405.58
Rate for Payer: Multiplan Auto	$1,268.93
Rate for Payer: Multiplan Commercial	$1,268.93
Rate for Payer: Multiplan Workers Comp	$1,268.93
Rate for Payer: Parkland Medicaid	$1,405.58
Rate for Payer: Scott and White EPO/PPO	$976.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,405.58
Rate for Payer: Superior Health Plan EPO	$265.50

SYSTEM CEMENT MIXING VC-1051

Facility

$1,952.20

Hospital Charge Code	144866
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,327.50

Know your out-of-pocket cost for care.

All Charges