White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Under Sacroiliac Joint Arthrodesis Procedure

Facility

$175,181.04

Service Code	HCPCS 0775T
Hospital Charge Code	9900916
Hospital Revenue Code	360
Rate for Payer: Cash Price	$119,123.11

Under Sacroiliac Joint Arthrodesis Procedure

Facility

$175,181.04

Service Code	HCPCS 0775T
Hospital Charge Code	9900916
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$126,130.35
Rate for Payer: Amerigroup CHIP/Medicaid	$15,766.29
Rate for Payer: BCBS of TX Blue Advantage	$36,569.04
Rate for Payer: BCBS of TX Blue Essentials	$43,795.26
Rate for Payer: BCBS of TX PPO	$55,182.03
Rate for Payer: Cash Price	$119,123.11
Rate for Payer: Cash Price	$119,123.11
Rate for Payer: Cash Price	$119,123.11
Rate for Payer: Cigna Medicaid	$126,130.35
Rate for Payer: Molina CHIP/Medicaid	$126,130.35
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	$126,130.35
Rate for Payer: Scott and White EPO/PPO	$87,590.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126,130.35
Rate for Payer: Superior Health Plan EPO	$23,824.62

Under Sacroiliac Joint Arthrodesis Procedure

Facility

$55,182.03

Service Code	CPT 0775T
Hospital Charge Code	3600775T
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$55,182.03
Rate for Payer: BCBS of TX Blue Advantage	$36,569.04
Rate for Payer: BCBS of TX Blue Essentials	$43,795.26
Rate for Payer: BCBS of TX PPO	$55,182.03
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

Under Transpedicular or Costovertebral Approach for Posterolateral Extradural Exploration/Decompress

Facility

$10,000.00

Service Code	CPT 63057
Hospital Charge Code	36063057
Hospital Revenue Code	360
Min. Negotiated Rate	$387.84
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
Rate for Payer: Scott and White EPO/PPO	$387.84

Under Transpedicular or Costovertebral Approach for Posterolateral Extradural Exploration/Decompress

Facility

$50,400.00

Service Code	HCPCS 63057
Hospital Charge Code	9900767
Hospital Revenue Code	360
Min. Negotiated Rate	$4,536.00
Max. Negotiated Rate	$36,288.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4,536.00
Rate for Payer: BCBS of TX Blue Advantage	$15,120.00
Rate for Payer: BCBS of TX Blue Essentials	$18,144.00
Rate for Payer: BCBS of TX PPO	$20,160.00
Rate for Payer: Cash Price	$34,272.00
Rate for Payer: Cash Price	$34,272.00
Rate for Payer: Cigna Medicaid	$36,288.00
Rate for Payer: Molina CHIP/Medicaid	$36,288.00
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	$36,288.00
Rate for Payer: Scott and White EPO/PPO	$25,200.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36,288.00
Rate for Payer: Superior Health Plan EPO	$6,854.40

Under Transpedicular or Costovertebral Approach for Posterolateral Extradural Exploration/Decompress

Facility

$50,400.00

Service Code	HCPCS 63057
Hospital Charge Code	9900767
Hospital Revenue Code	360
Rate for Payer: Cash Price	$34,272.00

UNDERWEAR, PROTECTIVE, LG, 40-56

Facility

$1.88

Hospital Charge Code	993216
Hospital Revenue Code	270
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$1.35
Rate for Payer: Amerigroup CHIP/Medicaid	$0.17
Rate for Payer: BCBS of TX Blue Advantage	$0.56
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
Rate for Payer: Cash Price	$1.28
Rate for Payer: Cigna Medicaid	$1.35
Rate for Payer: Molina CHIP/Medicaid	$1.35
Rate for Payer: Multiplan Auto	$1.22
Rate for Payer: Multiplan Commercial	$1.22
Rate for Payer: Multiplan Workers Comp	$1.22
Rate for Payer: Parkland Medicaid	$1.35
Rate for Payer: Scott and White EPO/PPO	$0.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.35
Rate for Payer: Superior Health Plan EPO	$0.26

UNDERWEAR, PROTECTIVE, LG, 40-56

Facility

$1.88

Hospital Charge Code	993216
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.28

UNDERWEAR, PROTECTIVE, MD, 28-40

Facility

$1.76

Hospital Charge Code	993217
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.20

UNDERWEAR, PROTECTIVE, MD, 28-40

Facility

$1.76

Hospital Charge Code	993217
Hospital Revenue Code	270
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$1.27
Rate for Payer: Amerigroup CHIP/Medicaid	$0.16
Rate for Payer: BCBS of TX Blue Advantage	$0.53
Rate for Payer: BCBS of TX Blue Essentials	$0.63
Rate for Payer: BCBS of TX PPO	$0.70
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cigna Medicaid	$1.27
Rate for Payer: Molina CHIP/Medicaid	$1.27
Rate for Payer: Multiplan Auto	$1.14
Rate for Payer: Multiplan Commercial	$1.14
Rate for Payer: Multiplan Workers Comp	$1.14
Rate for Payer: Parkland Medicaid	$1.27
Rate for Payer: Scott and White EPO/PPO	$0.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.27
Rate for Payer: Superior Health Plan EPO	$0.24

UNDERWEAR, PROTECTIVE, XL, 56-68

Facility

$2.42

Hospital Charge Code	993218
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.65

UNDERWEAR, PROTECTIVE, XL, 56-68

Facility

$2.42

Hospital Charge Code	993218
Hospital Revenue Code	270
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$1.74
Rate for Payer: Amerigroup CHIP/Medicaid	$0.22
Rate for Payer: BCBS of TX Blue Advantage	$0.73
Rate for Payer: BCBS of TX Blue Essentials	$0.87
Rate for Payer: BCBS of TX PPO	$0.97
Rate for Payer: Cash Price	$1.65
Rate for Payer: Cigna Medicaid	$1.74
Rate for Payer: Molina CHIP/Medicaid	$1.74
Rate for Payer: Multiplan Auto	$1.57
Rate for Payer: Multiplan Commercial	$1.57
Rate for Payer: Multiplan Workers Comp	$1.57
Rate for Payer: Parkland Medicaid	$1.74
Rate for Payer: Scott and White EPO/PPO	$1.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.74
Rate for Payer: Superior Health Plan EPO	$0.33

Undyed coated Vicryl 0 CT-1 27' Suture

Facility

$5.00

Hospital Charge Code	992862
Hospital Revenue Code	272
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$3.60
Rate for Payer: Amerigroup CHIP/Medicaid	$0.45
Rate for Payer: BCBS of TX Blue Advantage	$1.50
Rate for Payer: BCBS of TX Blue Essentials	$1.80
Rate for Payer: BCBS of TX PPO	$2.00
Rate for Payer: Cash Price	$3.40
Rate for Payer: Cigna Medicaid	$3.60
Rate for Payer: Molina CHIP/Medicaid	$3.60
Rate for Payer: Multiplan Auto	$3.25
Rate for Payer: Multiplan Commercial	$3.25
Rate for Payer: Multiplan Workers Comp	$3.25
Rate for Payer: Parkland Medicaid	$3.60
Rate for Payer: Scott and White EPO/PPO	$2.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.60
Rate for Payer: Superior Health Plan EPO	$0.68

Undyed coated Vicryl 0 CT-1 27' Suture

Facility

$5.00

Hospital Charge Code	992862
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.40

Undyed coated Vicryl 2-0 SH 27' Suture

Facility

$4.97

Hospital Charge Code	992863
Hospital Revenue Code	272
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$3.58
Rate for Payer: Amerigroup CHIP/Medicaid	$0.45
Rate for Payer: BCBS of TX Blue Advantage	$1.49
Rate for Payer: BCBS of TX Blue Essentials	$1.79
Rate for Payer: BCBS of TX PPO	$1.99
Rate for Payer: Cash Price	$3.38
Rate for Payer: Cigna Medicaid	$3.58
Rate for Payer: Molina CHIP/Medicaid	$3.58
Rate for Payer: Multiplan Auto	$3.23
Rate for Payer: Multiplan Commercial	$3.23
Rate for Payer: Multiplan Workers Comp	$3.23
Rate for Payer: Parkland Medicaid	$3.58
Rate for Payer: Scott and White EPO/PPO	$2.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.58
Rate for Payer: Superior Health Plan EPO	$0.68

Undyed coated Vicryl 2-0 SH 27' Suture

Facility

$4.97

Hospital Charge Code	992863
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.38

Undyed coated Vicryl 3-0 PS-2 18' Suture

Facility

$13.08

Hospital Charge Code	992864
Hospital Revenue Code	272
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$9.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1.18
Rate for Payer: BCBS of TX Blue Advantage	$3.92
Rate for Payer: BCBS of TX Blue Essentials	$4.71
Rate for Payer: BCBS of TX PPO	$5.23
Rate for Payer: Cash Price	$8.89
Rate for Payer: Cigna Medicaid	$9.42
Rate for Payer: Molina CHIP/Medicaid	$9.42
Rate for Payer: Multiplan Auto	$8.50
Rate for Payer: Multiplan Commercial	$8.50
Rate for Payer: Multiplan Workers Comp	$8.50
Rate for Payer: Parkland Medicaid	$9.42
Rate for Payer: Scott and White EPO/PPO	$6.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.42
Rate for Payer: Superior Health Plan EPO	$1.78

Undyed coated Vicryl 3-0 PS-2 18' Suture

Facility

$13.08

Hospital Charge Code	992864
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8.89

Undyed Ethicon Monocryl Monofilament Absorbable Prime Reverse Cutting 3/8C 4-0 PS-2 18'Suture

Facility

$18.91

Hospital Charge Code	992865
Hospital Revenue Code	272
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$13.62
Rate for Payer: Amerigroup CHIP/Medicaid	$1.70
Rate for Payer: BCBS of TX Blue Advantage	$5.67
Rate for Payer: BCBS of TX Blue Essentials	$6.81
Rate for Payer: BCBS of TX PPO	$7.56
Rate for Payer: Cash Price	$12.86
Rate for Payer: Cigna Medicaid	$13.62
Rate for Payer: Molina CHIP/Medicaid	$13.62
Rate for Payer: Multiplan Auto	$12.29
Rate for Payer: Multiplan Commercial	$12.29
Rate for Payer: Multiplan Workers Comp	$12.29
Rate for Payer: Parkland Medicaid	$13.62
Rate for Payer: Scott and White EPO/PPO	$9.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.62
Rate for Payer: Superior Health Plan EPO	$2.57

Undyed Ethicon Monocryl Monofilament Absorbable Prime Reverse Cutting 3/8C 4-0 PS-2 18'Suture

Facility

$18.91

Hospital Charge Code	992865
Hospital Revenue Code	272
Rate for Payer: Cash Price	$12.86

UNIT, COLD THERAPY, COOLJET

Facility

$420.17

Hospital Charge Code	146230
Hospital Revenue Code	272
Min. Negotiated Rate	$37.82
Max. Negotiated Rate	$302.52
Rate for Payer: Amerigroup CHIP/Medicaid	$37.82
Rate for Payer: BCBS of TX Blue Advantage	$126.05
Rate for Payer: BCBS of TX Blue Essentials	$151.26
Rate for Payer: BCBS of TX PPO	$168.07
Rate for Payer: Cash Price	$285.72
Rate for Payer: Cigna Medicaid	$302.52
Rate for Payer: Molina CHIP/Medicaid	$302.52
Rate for Payer: Multiplan Auto	$273.11
Rate for Payer: Multiplan Commercial	$273.11
Rate for Payer: Multiplan Workers Comp	$273.11
Rate for Payer: Parkland Medicaid	$302.52
Rate for Payer: Scott and White EPO/PPO	$210.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$302.52
Rate for Payer: Superior Health Plan EPO	$57.14

UNIT, COLD THERAPY, COOLJET

Facility

$420.17

Hospital Charge Code	146230
Hospital Revenue Code	272
Rate for Payer: Cash Price	$285.72

UNITE 'AB Bone Cement

Facility

$5,180.72

Service Code	HCPCS C1734
Hospital Charge Code	992264
Hospital Revenue Code	278
Min. Negotiated Rate	$1,295.18
Max. Negotiated Rate	$2,590.36
Rate for Payer: Cash Price	$3,522.89
Rate for Payer: Cigna Commercial	$1,295.18
Rate for Payer: Multiplan Auto	$2,590.36
Rate for Payer: Multiplan Commercial	$2,590.36
Rate for Payer: Multiplan Workers Comp	$2,590.36
Rate for Payer: Scott and White EPO/PPO	$2,590.36

UNITE 'AB Bone Cement

Facility

$5,180.72

Service Code	HCPCS C1734
Hospital Charge Code	992264
Hospital Revenue Code	278
Min. Negotiated Rate	$466.26
Max. Negotiated Rate	$3,730.12
Rate for Payer: Amerigroup CHIP/Medicaid	$466.26
Rate for Payer: BCBS of TX Blue Advantage	$1,554.22
Rate for Payer: BCBS of TX Blue Essentials	$1,865.06
Rate for Payer: BCBS of TX PPO	$2,072.29
Rate for Payer: Cash Price	$3,522.89
Rate for Payer: Cigna Medicaid	$3,730.12
Rate for Payer: Molina CHIP/Medicaid	$3,730.12
Rate for Payer: Multiplan Auto	$2,590.36
Rate for Payer: Multiplan Commercial	$2,590.36
Rate for Payer: Multiplan Workers Comp	$2,590.36
Rate for Payer: Parkland Medicaid	$3,730.12
Rate for Payer: Scott and White EPO/PPO	$2,590.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,730.12
Rate for Payer: Superior Health Plan EPO	$704.58

Universal Pack I without Gowns

Facility

$52.93

Hospital Charge Code	992783
Hospital Revenue Code	272
Rate for Payer: Cash Price	$35.99

Know your out-of-pocket cost for care.

All Charges