White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 THROM SOLENT DISTA

Facility

$15,147.53

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

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	$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 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 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 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 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	$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 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 HUMERAL NAIL 9MM X 260MM

Facility

$13,759.04

Service Code	HCPCS C1776
Hospital Charge Code	992160
Hospital Revenue Code	278
Min. Negotiated Rate	$1,238.31
Max. Negotiated Rate	$9,906.51
Rate for Payer: Amerigroup CHIP/Medicaid	$1,238.31
Rate for Payer: BCBS of TX Blue Advantage	$4,127.71
Rate for Payer: BCBS of TX Blue Essentials	$4,953.25
Rate for Payer: BCBS of TX PPO	$5,503.62
Rate for Payer: Cash Price	$9,356.15
Rate for Payer: Cigna Medicaid	$9,906.51
Rate for Payer: Molina CHIP/Medicaid	$9,906.51
Rate for Payer: Multiplan Auto	$6,879.52
Rate for Payer: Multiplan Commercial	$6,879.52
Rate for Payer: Multiplan Workers Comp	$6,879.52
Rate for Payer: Parkland Medicaid	$9,906.51
Rate for Payer: Scott and White EPO/PPO	$6,879.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,906.51
Rate for Payer: Superior Health Plan EPO	$1,871.23

T2 HUMERAL NAIL 9MM X 260MM

Facility

$13,759.04

Service Code	HCPCS C1776
Hospital Charge Code	992160
Hospital Revenue Code	278
Min. Negotiated Rate	$3,439.76
Max. Negotiated Rate	$6,879.52
Rate for Payer: Cash Price	$9,356.15
Rate for Payer: Cigna Commercial	$3,439.76
Rate for Payer: Multiplan Auto	$6,879.52
Rate for Payer: Multiplan Commercial	$6,879.52
Rate for Payer: Multiplan Workers Comp	$6,879.52
Rate for Payer: Scott and White EPO/PPO	$6,879.52

T2 SCN FULLY THREADED END CAP

Facility

$1,771.08

Service Code	HCPCS C1713
Hospital Charge Code	992233
Hospital Revenue Code	278
Min. Negotiated Rate	$159.40
Max. Negotiated Rate	$1,275.18
Rate for Payer: Amerigroup CHIP/Medicaid	$159.40
Rate for Payer: BCBS of TX Blue Advantage	$531.32
Rate for Payer: BCBS of TX Blue Essentials	$637.59
Rate for Payer: BCBS of TX PPO	$708.43
Rate for Payer: Cash Price	$1,204.33
Rate for Payer: Cigna Medicaid	$1,275.18
Rate for Payer: Molina CHIP/Medicaid	$1,275.18
Rate for Payer: Multiplan Auto	$885.54
Rate for Payer: Multiplan Commercial	$885.54
Rate for Payer: Multiplan Workers Comp	$885.54
Rate for Payer: Parkland Medicaid	$1,275.18
Rate for Payer: Scott and White EPO/PPO	$885.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,275.18
Rate for Payer: Superior Health Plan EPO	$240.87

T2 SCN FULLY THREADED END CAP

Facility

$1,771.08

Service Code	HCPCS C1713
Hospital Charge Code	992233
Hospital Revenue Code	278
Min. Negotiated Rate	$442.77
Max. Negotiated Rate	$885.54
Rate for Payer: Cash Price	$1,204.33
Rate for Payer: Cigna Commercial	$442.77
Rate for Payer: Multiplan Auto	$885.54
Rate for Payer: Multiplan Commercial	$885.54
Rate for Payer: Multiplan Workers Comp	$885.54
Rate for Payer: Scott and White EPO/PPO	$885.54

T2 STD Tibial Nail 9mmx315mm

Facility

$9,462.00

Service Code	HCPCS C1776
Hospital Charge Code	145894
Hospital Revenue Code	278
Min. Negotiated Rate	$851.58
Max. Negotiated Rate	$6,812.64
Rate for Payer: Amerigroup CHIP/Medicaid	$851.58
Rate for Payer: BCBS of TX Blue Advantage	$2,838.60
Rate for Payer: BCBS of TX Blue Essentials	$3,406.32
Rate for Payer: BCBS of TX PPO	$3,784.80
Rate for Payer: Cash Price	$6,434.16
Rate for Payer: Cigna Medicaid	$6,812.64
Rate for Payer: Molina CHIP/Medicaid	$6,812.64
Rate for Payer: Multiplan Auto	$4,731.00
Rate for Payer: Multiplan Commercial	$4,731.00
Rate for Payer: Multiplan Workers Comp	$4,731.00
Rate for Payer: Parkland Medicaid	$6,812.64
Rate for Payer: Scott and White EPO/PPO	$4,731.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,812.64
Rate for Payer: Superior Health Plan EPO	$1,286.83

T2 STD Tibial Nail 9mmx315mm

Facility

$9,462.00

Service Code	HCPCS C1776
Hospital Charge Code	145894
Hospital Revenue Code	278
Min. Negotiated Rate	$2,365.50
Max. Negotiated Rate	$4,731.00
Rate for Payer: Cash Price	$6,434.16
Rate for Payer: Cigna Commercial	$2,365.50
Rate for Payer: Multiplan Auto	$4,731.00
Rate for Payer: Multiplan Commercial	$4,731.00
Rate for Payer: Multiplan Workers Comp	$4,731.00
Rate for Payer: Scott and White EPO/PPO	$4,731.00

T3 Uptake

Facility

$199.00

Service Code	HCPCS 84479
Hospital Charge Code	1602267
Hospital Revenue Code	301
Rate for Payer: Cash Price	$135.32

Know your out-of-pocket cost for care.

All Charges