White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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, SUTURE ENDOSCOPIC OVERSTITCH -- DHF

Facility

$4,838.12

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

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 THROM SOLENT DISTA

Facility

$15,147.53

Hospital Charge Code	135989
Hospital Revenue Code	272
Rate for Payer: Cash Price	$10,300.32

SYSTEM THROM SOLENT DISTA

Facility

$15,147.53

Hospital Charge Code	135989
Hospital Revenue Code	272
Min. Negotiated Rate	$1,363.28
Max. Negotiated Rate	$10,906.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,363.28
Rate for Payer: BCBS of TX Blue Advantage	$4,544.26
Rate for Payer: BCBS of TX Blue Essentials	$5,453.11
Rate for Payer: BCBS of TX PPO	$6,059.01
Rate for Payer: Cash Price	$10,300.32
Rate for Payer: Cigna Medicaid	$10,906.22
Rate for Payer: Molina CHIP/Medicaid	$10,906.22
Rate for Payer: Multiplan Auto	$9,845.89
Rate for Payer: Multiplan Commercial	$9,845.89
Rate for Payer: Multiplan Workers Comp	$9,845.89
Rate for Payer: Parkland Medicaid	$10,906.22
Rate for Payer: Scott and White EPO/PPO	$7,573.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,906.22
Rate for Payer: Superior Health Plan EPO	$2,060.06

SYSTEM TIS RETRVL BAG SUPERBAG SMALL

Facility

$138.05

Hospital Charge Code	993952
Hospital Revenue Code	270
Rate for Payer: Cash Price	$93.87

SYSTEM TIS RETRVL BAG SUPERBAG SMALL

Facility

$138.05

Hospital Charge Code	993952
Hospital Revenue Code	270
Min. Negotiated Rate	$12.42
Max. Negotiated Rate	$99.40
Rate for Payer: Amerigroup CHIP/Medicaid	$12.42
Rate for Payer: BCBS of TX Blue Advantage	$41.41
Rate for Payer: BCBS of TX Blue Essentials	$49.70
Rate for Payer: BCBS of TX PPO	$55.22
Rate for Payer: Cash Price	$93.87
Rate for Payer: Cigna Medicaid	$99.40
Rate for Payer: Molina CHIP/Medicaid	$99.40
Rate for Payer: Multiplan Auto	$89.73
Rate for Payer: Multiplan Commercial	$89.73
Rate for Payer: Multiplan Workers Comp	$89.73
Rate for Payer: Parkland Medicaid	$99.40
Rate for Payer: Scott and White EPO/PPO	$69.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$99.40
Rate for Payer: Superior Health Plan EPO	$18.77

SYS THROMB SOLENT PROXI -- DHF

Facility

$12,411.20

Hospital Charge Code	81787467
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8,439.62

SYS THROMB SOLENT PROXI -- DHF

Facility

$12,411.20

Hospital Charge Code	81787467
Hospital Revenue Code	272
Min. Negotiated Rate	$1,117.01
Max. Negotiated Rate	$8,936.06
Rate for Payer: Amerigroup CHIP/Medicaid	$1,117.01
Rate for Payer: BCBS of TX Blue Advantage	$3,723.36
Rate for Payer: BCBS of TX Blue Essentials	$4,468.03
Rate for Payer: BCBS of TX PPO	$4,964.48
Rate for Payer: Cash Price	$8,439.62
Rate for Payer: Cigna Medicaid	$8,936.06
Rate for Payer: Molina CHIP/Medicaid	$8,936.06
Rate for Payer: Multiplan Auto	$8,067.28
Rate for Payer: Multiplan Commercial	$8,067.28
Rate for Payer: Multiplan Workers Comp	$8,067.28
Rate for Payer: Parkland Medicaid	$8,936.06
Rate for Payer: Scott and White EPO/PPO	$6,205.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,936.06
Rate for Payer: Superior Health Plan EPO	$1,687.92

T2 ANKLE ARTHRODESIS NAIL LEFT

Facility

$22,788.55

Service Code	HCPCS C1734
Hospital Charge Code	992232
Hospital Revenue Code	278
Min. Negotiated Rate	$2,050.97
Max. Negotiated Rate	$16,407.76
Rate for Payer: Amerigroup CHIP/Medicaid	$2,050.97
Rate for Payer: BCBS of TX Blue Advantage	$6,836.56
Rate for Payer: BCBS of TX Blue Essentials	$8,203.88
Rate for Payer: BCBS of TX PPO	$9,115.42
Rate for Payer: Cash Price	$15,496.21
Rate for Payer: Cigna Medicaid	$16,407.76
Rate for Payer: Molina CHIP/Medicaid	$16,407.76
Rate for Payer: Multiplan Auto	$11,394.27
Rate for Payer: Multiplan Commercial	$11,394.27
Rate for Payer: Multiplan Workers Comp	$11,394.27
Rate for Payer: Parkland Medicaid	$16,407.76
Rate for Payer: Scott and White EPO/PPO	$11,394.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,407.76
Rate for Payer: Superior Health Plan EPO	$3,099.24

T2 ANKLE ARTHRODESIS NAIL LEFT

Facility

$22,788.55

Service Code	HCPCS C1734
Hospital Charge Code	992232
Hospital Revenue Code	278
Min. Negotiated Rate	$5,697.14
Max. Negotiated Rate	$11,394.27
Rate for Payer: Cash Price	$15,496.21
Rate for Payer: Cigna Commercial	$5,697.14
Rate for Payer: Multiplan Auto	$11,394.27
Rate for Payer: Multiplan Commercial	$11,394.27
Rate for Payer: Multiplan Workers Comp	$11,394.27
Rate for Payer: Scott and White EPO/PPO	$11,394.27

T2 ANKLE COMPRESSION SCREW

Facility

$1,795.18

Service Code	HCPCS C1713
Hospital Charge Code	992231
Hospital Revenue Code	278
Min. Negotiated Rate	$161.57
Max. Negotiated Rate	$1,292.53
Rate for Payer: Amerigroup CHIP/Medicaid	$161.57
Rate for Payer: BCBS of TX Blue Advantage	$538.55
Rate for Payer: BCBS of TX Blue Essentials	$646.26
Rate for Payer: BCBS of TX PPO	$718.07
Rate for Payer: Cash Price	$1,220.72
Rate for Payer: Cigna Medicaid	$1,292.53
Rate for Payer: Molina CHIP/Medicaid	$1,292.53
Rate for Payer: Multiplan Auto	$897.59
Rate for Payer: Multiplan Commercial	$897.59
Rate for Payer: Multiplan Workers Comp	$897.59
Rate for Payer: Parkland Medicaid	$1,292.53
Rate for Payer: Scott and White EPO/PPO	$897.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,292.53
Rate for Payer: Superior Health Plan EPO	$244.14

T2 ANKLE COMPRESSION SCREW

Facility

$1,795.18

Service Code	HCPCS C1713
Hospital Charge Code	992231
Hospital Revenue Code	278
Min. Negotiated Rate	$448.80
Max. Negotiated Rate	$897.59
Rate for Payer: Cash Price	$1,220.72
Rate for Payer: Cigna Commercial	$448.80
Rate for Payer: Multiplan Auto	$897.59
Rate for Payer: Multiplan Commercial	$897.59
Rate for Payer: Multiplan Workers Comp	$897.59
Rate for Payer: Scott and White EPO/PPO	$897.59

T2 F/T LOCKING SCREW 5mmX105mm

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992236
Hospital Revenue Code	278
Min. Negotiated Rate	$158.86
Max. Negotiated Rate	$1,270.84
Rate for Payer: Amerigroup CHIP/Medicaid	$158.86
Rate for Payer: BCBS of TX Blue Advantage	$529.52
Rate for Payer: BCBS of TX Blue Essentials	$635.42
Rate for Payer: BCBS of TX PPO	$706.02
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Medicaid	$1,270.84
Rate for Payer: Molina CHIP/Medicaid	$1,270.84
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Parkland Medicaid	$1,270.84
Rate for Payer: Scott and White EPO/PPO	$882.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,270.84
Rate for Payer: Superior Health Plan EPO	$240.05

T2 F/T LOCKING SCREW 5mmX105mm

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992236
Hospital Revenue Code	278
Min. Negotiated Rate	$441.26
Max. Negotiated Rate	$882.53
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Commercial	$441.26
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Scott and White EPO/PPO	$882.53

T2 F/T LOCKING SCREW 5mmX27.5mm

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992234
Hospital Revenue Code	278
Min. Negotiated Rate	$441.26
Max. Negotiated Rate	$882.53
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Commercial	$441.26
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Scott and White EPO/PPO	$882.53

T2 F/T LOCKING SCREW 5mmX27.5mm

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992234
Hospital Revenue Code	278
Min. Negotiated Rate	$158.86
Max. Negotiated Rate	$1,270.84
Rate for Payer: Amerigroup CHIP/Medicaid	$158.86
Rate for Payer: BCBS of TX Blue Advantage	$529.52
Rate for Payer: BCBS of TX Blue Essentials	$635.42
Rate for Payer: BCBS of TX PPO	$706.02
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Medicaid	$1,270.84
Rate for Payer: Molina CHIP/Medicaid	$1,270.84
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Parkland Medicaid	$1,270.84
Rate for Payer: Scott and White EPO/PPO	$882.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,270.84
Rate for Payer: Superior Health Plan EPO	$240.05

T2 F/T LOCKING SCREW 5MM X 40MM

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	993142
Hospital Revenue Code	278
Min. Negotiated Rate	$441.26
Max. Negotiated Rate	$882.53
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Commercial	$441.26
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Scott and White EPO/PPO	$882.53

T2 F/T LOCKING SCREW 5MM X 40MM

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	993142
Hospital Revenue Code	278
Min. Negotiated Rate	$158.86
Max. Negotiated Rate	$1,270.84
Rate for Payer: Amerigroup CHIP/Medicaid	$158.86
Rate for Payer: BCBS of TX Blue Advantage	$529.52
Rate for Payer: BCBS of TX Blue Essentials	$635.42
Rate for Payer: BCBS of TX PPO	$706.02
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Medicaid	$1,270.84
Rate for Payer: Molina CHIP/Medicaid	$1,270.84
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Parkland Medicaid	$1,270.84
Rate for Payer: Scott and White EPO/PPO	$882.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,270.84
Rate for Payer: Superior Health Plan EPO	$240.05

T2 F/T LOCKING SCREW 5mmX60mm

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992235
Hospital Revenue Code	278
Min. Negotiated Rate	$158.86
Max. Negotiated Rate	$1,270.84
Rate for Payer: Amerigroup CHIP/Medicaid	$158.86
Rate for Payer: BCBS of TX Blue Advantage	$529.52
Rate for Payer: BCBS of TX Blue Essentials	$635.42
Rate for Payer: BCBS of TX PPO	$706.02
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Medicaid	$1,270.84
Rate for Payer: Molina CHIP/Medicaid	$1,270.84
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Parkland Medicaid	$1,270.84
Rate for Payer: Scott and White EPO/PPO	$882.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,270.84
Rate for Payer: Superior Health Plan EPO	$240.05

T2 F/T LOCKING SCREW 5mmX60mm

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992235
Hospital Revenue Code	278
Min. Negotiated Rate	$441.26
Max. Negotiated Rate	$882.53
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Commercial	$441.26
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Scott and White EPO/PPO	$882.53

Know your out-of-pocket cost for care.

All Charges