White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SYSTEM, SPLINTING ONE STEP FIBERGLASS & FOAM 3X12 -- DHF

Facility

$258.92

Hospital Charge Code	81035008
Hospital Revenue Code	270
Min. Negotiated Rate	$23.30
Max. Negotiated Rate	$186.42
Rate for Payer: Amerigroup CHIP/Medicaid	$23.30
Rate for Payer: BCBS of TX Blue Advantage	$77.68
Rate for Payer: BCBS of TX Blue Essentials	$93.21
Rate for Payer: BCBS of TX PPO	$103.57
Rate for Payer: Cash Price	$176.07
Rate for Payer: Cigna Medicaid	$186.42
Rate for Payer: Molina CHIP/Medicaid	$186.42
Rate for Payer: Multiplan Auto	$168.30
Rate for Payer: Multiplan Commercial	$168.30
Rate for Payer: Multiplan Workers Comp	$168.30
Rate for Payer: Parkland Medicaid	$186.42
Rate for Payer: Scott and White EPO/PPO	$129.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$186.42
Rate for Payer: Superior Health Plan EPO	$35.21

SYSTEM STENT EXPAND OTW 9MMX39MMX135CM

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	991249
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.11
Max. Negotiated Rate	$2,804.22
Rate for Payer: Cash Price	$3,813.73
Rate for Payer: Cigna Commercial	$1,402.11
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Scott and White EPO/PPO	$2,804.22

SYSTEM STENT EXPAND OTW 9MMX39MMX135CM

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	991249
Hospital Revenue Code	278
Min. Negotiated Rate	$504.76
Max. Negotiated Rate	$4,038.07
Rate for Payer: Amerigroup CHIP/Medicaid	$504.76
Rate for Payer: BCBS of TX Blue Advantage	$1,682.53
Rate for Payer: BCBS of TX Blue Essentials	$2,019.03
Rate for Payer: BCBS of TX PPO	$2,243.37
Rate for Payer: Cash Price	$3,813.73
Rate for Payer: Cigna Medicaid	$4,038.07
Rate for Payer: Molina CHIP/Medicaid	$4,038.07
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Parkland Medicaid	$4,038.07
Rate for Payer: Scott and White EPO/PPO	$2,804.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,038.07
Rate for Payer: Superior Health Plan EPO	$762.75

SYSTEM, STENT EXPAND OTW OMNILINK ELITE 6X29X135CM

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	991251
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.11
Max. Negotiated Rate	$2,804.22
Rate for Payer: Cash Price	$3,813.73
Rate for Payer: Cigna Commercial	$1,402.11
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Scott and White EPO/PPO	$2,804.22

SYSTEM, STENT EXPAND OTW OMNILINK ELITE 6X29X135CM

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	991251
Hospital Revenue Code	278
Min. Negotiated Rate	$504.76
Max. Negotiated Rate	$4,038.07
Rate for Payer: Amerigroup CHIP/Medicaid	$504.76
Rate for Payer: BCBS of TX Blue Advantage	$1,682.53
Rate for Payer: BCBS of TX Blue Essentials	$2,019.03
Rate for Payer: BCBS of TX PPO	$2,243.37
Rate for Payer: Cash Price	$3,813.73
Rate for Payer: Cigna Medicaid	$4,038.07
Rate for Payer: Molina CHIP/Medicaid	$4,038.07
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Parkland Medicaid	$4,038.07
Rate for Payer: Scott and White EPO/PPO	$2,804.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,038.07
Rate for Payer: Superior Health Plan EPO	$762.75

SYSTEM STENT SLF EXP 6MMX40MMX135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	991247
Hospital Revenue Code	278
Min. Negotiated Rate	$531.32
Max. Negotiated Rate	$4,250.60
Rate for Payer: Amerigroup CHIP/Medicaid	$531.32
Rate for Payer: BCBS of TX Blue Advantage	$1,771.08
Rate for Payer: BCBS of TX Blue Essentials	$2,125.30
Rate for Payer: BCBS of TX PPO	$2,361.44
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Medicaid	$4,250.60
Rate for Payer: Molina CHIP/Medicaid	$4,250.60
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Parkland Medicaid	$4,250.60
Rate for Payer: Scott and White EPO/PPO	$2,951.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.60
Rate for Payer: Superior Health Plan EPO	$802.89

SYSTEM STENT SLF EXP 6MMX40MMX135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	991247
Hospital Revenue Code	278
Min. Negotiated Rate	$1,475.90
Max. Negotiated Rate	$2,951.80
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Commercial	$1,475.90
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80

SYSTEM STENT SLF EXP 6MMX60MMX135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	991248
Hospital Revenue Code	278
Min. Negotiated Rate	$531.32
Max. Negotiated Rate	$4,250.60
Rate for Payer: Amerigroup CHIP/Medicaid	$531.32
Rate for Payer: BCBS of TX Blue Advantage	$1,771.08
Rate for Payer: BCBS of TX Blue Essentials	$2,125.30
Rate for Payer: BCBS of TX PPO	$2,361.44
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Medicaid	$4,250.60
Rate for Payer: Molina CHIP/Medicaid	$4,250.60
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Parkland Medicaid	$4,250.60
Rate for Payer: Scott and White EPO/PPO	$2,951.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.60
Rate for Payer: Superior Health Plan EPO	$802.89

SYSTEM STENT SLF EXP 6MMX60MMX135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	991248
Hospital Revenue Code	278
Min. Negotiated Rate	$1,475.90
Max. Negotiated Rate	$2,951.80
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Commercial	$1,475.90
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80

SYSTEM, STENT SLF EXP ABS

Facility

$4,367.47

Service Code	HCPCS C1876
Hospital Charge Code	991250
Hospital Revenue Code	278
Min. Negotiated Rate	$393.07
Max. Negotiated Rate	$3,144.58
Rate for Payer: Amerigroup CHIP/Medicaid	$393.07
Rate for Payer: BCBS of TX Blue Advantage	$1,310.24
Rate for Payer: BCBS of TX Blue Essentials	$1,572.29
Rate for Payer: BCBS of TX PPO	$1,746.99
Rate for Payer: Cash Price	$2,969.88
Rate for Payer: Cigna Medicaid	$3,144.58
Rate for Payer: Molina CHIP/Medicaid	$3,144.58
Rate for Payer: Multiplan Auto	$2,183.74
Rate for Payer: Multiplan Commercial	$2,183.74
Rate for Payer: Multiplan Workers Comp	$2,183.74
Rate for Payer: Parkland Medicaid	$3,144.58
Rate for Payer: Scott and White EPO/PPO	$2,183.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,144.58
Rate for Payer: Superior Health Plan EPO	$593.98

SYSTEM, STENT SLF EXP ABS

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	135877
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.00
Max. Negotiated Rate	$2,952.00
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Commercial	$1,476.00
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Scott and White EPO/PPO	$2,952.00

SYSTEM, STENT SLF EXP ABS

Facility

$4,367.47

Service Code	HCPCS C1876
Hospital Charge Code	991250
Hospital Revenue Code	278
Min. Negotiated Rate	$1,091.87
Max. Negotiated Rate	$2,183.74
Rate for Payer: Cash Price	$2,969.88
Rate for Payer: Cigna Commercial	$1,091.87
Rate for Payer: Multiplan Auto	$2,183.74
Rate for Payer: Multiplan Commercial	$2,183.74
Rate for Payer: Multiplan Workers Comp	$2,183.74
Rate for Payer: Scott and White EPO/PPO	$2,183.74

SYSTEM, STENT SLF EXP ABS

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	135877
Hospital Revenue Code	278
Min. Negotiated Rate	$531.36
Max. Negotiated Rate	$4,250.88
Rate for Payer: Amerigroup CHIP/Medicaid	$531.36
Rate for Payer: BCBS of TX Blue Advantage	$1,771.20
Rate for Payer: BCBS of TX Blue Essentials	$2,125.44
Rate for Payer: BCBS of TX PPO	$2,361.60
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Medicaid	$4,250.88
Rate for Payer: Molina CHIP/Medicaid	$4,250.88
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Parkland Medicaid	$4,250.88
Rate for Payer: Scott and White EPO/PPO	$2,952.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.88
Rate for Payer: Superior Health Plan EPO	$802.94

SYSTEM, STENT SLF EXP ABS 136051

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	136051
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.00
Max. Negotiated Rate	$2,952.00
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Commercial	$1,476.00
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Scott and White EPO/PPO	$2,952.00

SYSTEM, STENT SLF EXP ABS 136051

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	136051
Hospital Revenue Code	278
Min. Negotiated Rate	$531.36
Max. Negotiated Rate	$4,250.88
Rate for Payer: Amerigroup CHIP/Medicaid	$531.36
Rate for Payer: BCBS of TX Blue Advantage	$1,771.20
Rate for Payer: BCBS of TX Blue Essentials	$2,125.44
Rate for Payer: BCBS of TX PPO	$2,361.60
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Medicaid	$4,250.88
Rate for Payer: Molina CHIP/Medicaid	$4,250.88
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Parkland Medicaid	$4,250.88
Rate for Payer: Scott and White EPO/PPO	$2,952.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.88
Rate for Payer: Superior Health Plan EPO	$802.94

SYSTEM STENT SLF EXP ABSOLUT PRO OTW 6X100MX135CM

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	131686
Hospital Revenue Code	278
Min. Negotiated Rate	$531.36
Max. Negotiated Rate	$4,250.88
Rate for Payer: Amerigroup CHIP/Medicaid	$531.36
Rate for Payer: BCBS of TX Blue Advantage	$1,771.20
Rate for Payer: BCBS of TX Blue Essentials	$2,125.44
Rate for Payer: BCBS of TX PPO	$2,361.60
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Medicaid	$4,250.88
Rate for Payer: Molina CHIP/Medicaid	$4,250.88
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Parkland Medicaid	$4,250.88
Rate for Payer: Scott and White EPO/PPO	$2,952.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.88
Rate for Payer: Superior Health Plan EPO	$802.94

SYSTEM STENT SLF EXP ABSOLUT PRO OTW 6X100MX135CM

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	131686
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.00
Max. Negotiated Rate	$2,952.00
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Commercial	$1,476.00
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Scott and White EPO/PPO	$2,952.00

SYSTEM STENT SLF EXP ABSOLUT PRO OTW 6X100MX135CM

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	9912400
Hospital Revenue Code	278
Min. Negotiated Rate	$1,475.90
Max. Negotiated Rate	$2,951.80
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Commercial	$1,475.90
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80

SYSTEM STENT SLF EXP ABSOLUT PRO OTW 6X100MX135CM

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	9912400
Hospital Revenue Code	278
Min. Negotiated Rate	$531.32
Max. Negotiated Rate	$4,250.60
Rate for Payer: Amerigroup CHIP/Medicaid	$531.32
Rate for Payer: BCBS of TX Blue Advantage	$1,771.08
Rate for Payer: BCBS of TX Blue Essentials	$2,125.30
Rate for Payer: BCBS of TX PPO	$2,361.44
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Medicaid	$4,250.60
Rate for Payer: Molina CHIP/Medicaid	$4,250.60
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Parkland Medicaid	$4,250.60
Rate for Payer: Scott and White EPO/PPO	$2,951.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.60
Rate for Payer: Superior Health Plan EPO	$802.89

SYSTEM STENT SLF EXP ABSOLUT PRO OTW 6X80MMX135CM

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	131687
Hospital Revenue Code	278
Min. Negotiated Rate	$531.36
Max. Negotiated Rate	$4,250.88
Rate for Payer: Amerigroup CHIP/Medicaid	$531.36
Rate for Payer: BCBS of TX Blue Advantage	$1,771.20
Rate for Payer: BCBS of TX Blue Essentials	$2,125.44
Rate for Payer: BCBS of TX PPO	$2,361.60
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Medicaid	$4,250.88
Rate for Payer: Molina CHIP/Medicaid	$4,250.88
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Parkland Medicaid	$4,250.88
Rate for Payer: Scott and White EPO/PPO	$2,952.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.88
Rate for Payer: Superior Health Plan EPO	$802.94

SYSTEM STENT SLF EXP ABSOLUT PRO OTW 6X80MMX135CM

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	131687
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.00
Max. Negotiated Rate	$2,952.00
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Commercial	$1,476.00
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Scott and White EPO/PPO	$2,952.00

SYSTEM STENT SLF EXP ABSOLUT PRO OTW 6X80MMX135CM

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	991246
Hospital Revenue Code	278
Min. Negotiated Rate	$531.32
Max. Negotiated Rate	$4,250.60
Rate for Payer: Amerigroup CHIP/Medicaid	$531.32
Rate for Payer: BCBS of TX Blue Advantage	$1,771.08
Rate for Payer: BCBS of TX Blue Essentials	$2,125.30
Rate for Payer: BCBS of TX PPO	$2,361.44
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Medicaid	$4,250.60
Rate for Payer: Molina CHIP/Medicaid	$4,250.60
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Parkland Medicaid	$4,250.60
Rate for Payer: Scott and White EPO/PPO	$2,951.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.60
Rate for Payer: Superior Health Plan EPO	$802.89

SYSTEM STENT SLF EXP ABSOLUT PRO OTW 6X80MMX135CM

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	991246
Hospital Revenue Code	278
Min. Negotiated Rate	$1,475.90
Max. Negotiated Rate	$2,951.80
Rate for Payer: Cash Price	$4,014.45
Rate for Payer: Cigna Commercial	$1,475.90
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80

SYSTEM, SUTURE ENDOSCOPIC OVERSTITCH -- DHF

Facility

$4,838.12

Hospital Charge Code	82499013
Hospital Revenue Code	272
Min. Negotiated Rate	$435.43
Max. Negotiated Rate	$3,483.45
Rate for Payer: Amerigroup CHIP/Medicaid	$435.43
Rate for Payer: BCBS of TX Blue Advantage	$1,451.44
Rate for Payer: BCBS of TX Blue Essentials	$1,741.72
Rate for Payer: BCBS of TX PPO	$1,935.25
Rate for Payer: Cash Price	$3,289.92
Rate for Payer: Cigna Medicaid	$3,483.45
Rate for Payer: Molina CHIP/Medicaid	$3,483.45
Rate for Payer: Multiplan Auto	$3,144.78
Rate for Payer: Multiplan Commercial	$3,144.78
Rate for Payer: Multiplan Workers Comp	$3,144.78
Rate for Payer: Parkland Medicaid	$3,483.45
Rate for Payer: Scott and White EPO/PPO	$2,419.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,483.45
Rate for Payer: Superior Health Plan EPO	$657.98

SYSTEM, SUTURE ENDOSCOPIC OVERSTITCH -- DHF

Facility

$4,838.12

Hospital Charge Code	82499013
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,289.92

Know your out-of-pocket cost for care.

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