White Rock Medical Center

All Charges

Charge

Type

Setting

Price

2.4 SINGLE LOADED SUTURE TAPE S-TAK ASSY

Facility

$6,437.72

Hospital Charge Code	992610
Hospital Revenue Code	272
Min. Negotiated Rate	$579.39
Max. Negotiated Rate	$4,635.16
Rate for Payer: Amerigroup CHIP/Medicaid	$579.39
Rate for Payer: BCBS of TX Blue Advantage	$1,931.32
Rate for Payer: BCBS of TX Blue Essentials	$2,317.58
Rate for Payer: BCBS of TX PPO	$2,575.09
Rate for Payer: Cash Price	$4,377.65
Rate for Payer: Cigna Medicaid	$4,635.16
Rate for Payer: Molina CHIP/Medicaid	$4,635.16
Rate for Payer: Multiplan Auto	$4,184.52
Rate for Payer: Multiplan Commercial	$4,184.52
Rate for Payer: Multiplan Workers Comp	$4,184.52
Rate for Payer: Parkland Medicaid	$4,635.16
Rate for Payer: Scott and White EPO/PPO	$3,218.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,635.16
Rate for Payer: Superior Health Plan EPO	$875.53

25-Hydroxyvitamin D LCMS D2+D3 SO

Facility

$521.00

Service Code	HCPCS 82306
Hospital Charge Code	1620104
Hospital Revenue Code	301
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$375.12
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29.60
Rate for Payer: Amerigroup Medicare	$29.60
Rate for Payer: BCBS of TX Blue Advantage	$156.30
Rate for Payer: BCBS of TX Blue Essentials	$187.56
Rate for Payer: BCBS of TX Medicare	$29.60
Rate for Payer: BCBS of TX PPO	$208.40
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cigna Medicaid	$375.12
Rate for Payer: Cigna Medicare	$29.60
Rate for Payer: Employer Direct Commercial	$29.60
Rate for Payer: Humana Medicare/TRICARE	$29.60
Rate for Payer: Molina CHIP/Medicaid	$375.12
Rate for Payer: Molina Dual Medicare/Medicaid	$29.60
Rate for Payer: Molina Medicare	$29.60
Rate for Payer: Multiplan Auto	$338.65
Rate for Payer: Multiplan Commercial	$338.65
Rate for Payer: Multiplan Workers Comp	$338.65
Rate for Payer: Parkland Medicaid	$375.12
Rate for Payer: Scott and White EPO/PPO	$37.00
Rate for Payer: Scott and White Medicare	$29.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$375.12
Rate for Payer: Superior Health Plan EPO	$29.60
Rate for Payer: Superior Health Plan Medicare	$29.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$29.60
Rate for Payer: Universal American Medicare	$29.60
Rate for Payer: Wellcare Medicare	$29.60
Rate for Payer: Wellmed Medicare	$29.60

25-Hydroxyvitamin D LCMS D2+D3 SO

Facility

$521.00

Service Code	HCPCS 82306
Hospital Charge Code	1620104
Hospital Revenue Code	301
Rate for Payer: Cash Price	$354.28

2.5MM DRILL BIT

Facility

$385.90

Hospital Charge Code	992600
Hospital Revenue Code	272
Rate for Payer: Cash Price	$262.41

2.5MM DRILL BIT

Facility

$385.90

Hospital Charge Code	992600
Hospital Revenue Code	272
Min. Negotiated Rate	$34.73
Max. Negotiated Rate	$277.85
Rate for Payer: Amerigroup CHIP/Medicaid	$34.73
Rate for Payer: BCBS of TX Blue Advantage	$115.77
Rate for Payer: BCBS of TX Blue Essentials	$138.92
Rate for Payer: BCBS of TX PPO	$154.36
Rate for Payer: Cash Price	$262.41
Rate for Payer: Cigna Medicaid	$277.85
Rate for Payer: Molina CHIP/Medicaid	$277.85
Rate for Payer: Multiplan Auto	$250.84
Rate for Payer: Multiplan Commercial	$250.84
Rate for Payer: Multiplan Workers Comp	$250.84
Rate for Payer: Parkland Medicaid	$277.85
Rate for Payer: Scott and White EPO/PPO	$192.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$277.85
Rate for Payer: Superior Health Plan EPO	$52.48

2.5MM DRILL BIT, CALIBRATED

Facility

$385.90

Hospital Charge Code	992601
Hospital Revenue Code	272
Min. Negotiated Rate	$34.73
Max. Negotiated Rate	$277.85
Rate for Payer: Amerigroup CHIP/Medicaid	$34.73
Rate for Payer: BCBS of TX Blue Advantage	$115.77
Rate for Payer: BCBS of TX Blue Essentials	$138.92
Rate for Payer: BCBS of TX PPO	$154.36
Rate for Payer: Cash Price	$262.41
Rate for Payer: Cigna Medicaid	$277.85
Rate for Payer: Molina CHIP/Medicaid	$277.85
Rate for Payer: Multiplan Auto	$250.84
Rate for Payer: Multiplan Commercial	$250.84
Rate for Payer: Multiplan Workers Comp	$250.84
Rate for Payer: Parkland Medicaid	$277.85
Rate for Payer: Scott and White EPO/PPO	$192.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$277.85
Rate for Payer: Superior Health Plan EPO	$52.48

2.5MM DRILL BIT, CALIBRATED

Facility

$385.90

Hospital Charge Code	992601
Hospital Revenue Code	272
Rate for Payer: Cash Price	$262.41

2.5 MM K-WIRE

Facility

$1,405.58

Service Code	HCPCS C1769
Hospital Charge Code	993985
Hospital Revenue Code	278
Min. Negotiated Rate	$126.50
Max. Negotiated Rate	$1,012.02
Rate for Payer: Amerigroup CHIP/Medicaid	$126.50
Rate for Payer: BCBS of TX Blue Advantage	$421.67
Rate for Payer: BCBS of TX Blue Essentials	$506.01
Rate for Payer: BCBS of TX PPO	$562.23
Rate for Payer: Cash Price	$955.79
Rate for Payer: Cigna Medicaid	$1,012.02
Rate for Payer: Molina CHIP/Medicaid	$1,012.02
Rate for Payer: Multiplan Auto	$702.79
Rate for Payer: Multiplan Commercial	$702.79
Rate for Payer: Multiplan Workers Comp	$702.79
Rate for Payer: Parkland Medicaid	$1,012.02
Rate for Payer: Scott and White EPO/PPO	$702.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,012.02
Rate for Payer: Superior Health Plan EPO	$191.16

2.5 MM K-WIRE

Facility

$1,405.58

Service Code	HCPCS C1769
Hospital Charge Code	993985
Hospital Revenue Code	278
Min. Negotiated Rate	$351.39
Max. Negotiated Rate	$702.79
Rate for Payer: Cash Price	$955.79
Rate for Payer: Cigna Commercial	$351.39
Rate for Payer: Multiplan Auto	$702.79
Rate for Payer: Multiplan Commercial	$702.79
Rate for Payer: Multiplan Workers Comp	$702.79
Rate for Payer: Scott and White EPO/PPO	$702.79

2.5MM X 285MM K-Wire

Facility

$703.70

Service Code	HCPCS C1769
Hospital Charge Code	993382
Hospital Revenue Code	278
Min. Negotiated Rate	$63.33
Max. Negotiated Rate	$506.66
Rate for Payer: Amerigroup CHIP/Medicaid	$63.33
Rate for Payer: BCBS of TX Blue Advantage	$211.11
Rate for Payer: BCBS of TX Blue Essentials	$253.33
Rate for Payer: BCBS of TX PPO	$281.48
Rate for Payer: Cash Price	$478.52
Rate for Payer: Cigna Medicaid	$506.66
Rate for Payer: Molina CHIP/Medicaid	$506.66
Rate for Payer: Multiplan Auto	$351.85
Rate for Payer: Multiplan Commercial	$351.85
Rate for Payer: Multiplan Workers Comp	$351.85
Rate for Payer: Parkland Medicaid	$506.66
Rate for Payer: Scott and White EPO/PPO	$351.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$506.66
Rate for Payer: Superior Health Plan EPO	$95.70

2.5MM X 285MM K-Wire

Facility

$703.70

Service Code	HCPCS C1769
Hospital Charge Code	993382
Hospital Revenue Code	278
Min. Negotiated Rate	$175.93
Max. Negotiated Rate	$351.85
Rate for Payer: Cash Price	$478.52
Rate for Payer: Cigna Commercial	$175.93
Rate for Payer: Multiplan Auto	$351.85
Rate for Payer: Multiplan Commercial	$351.85
Rate for Payer: Multiplan Workers Comp	$351.85
Rate for Payer: Scott and White EPO/PPO	$351.85

2.7 MM DRILL

Facility

$1,739.73

Hospital Charge Code	993984
Hospital Revenue Code	272
Min. Negotiated Rate	$156.58
Max. Negotiated Rate	$1,252.61
Rate for Payer: Amerigroup CHIP/Medicaid	$156.58
Rate for Payer: BCBS of TX Blue Advantage	$521.92
Rate for Payer: BCBS of TX Blue Essentials	$626.30
Rate for Payer: BCBS of TX PPO	$695.89
Rate for Payer: Cash Price	$1,183.02
Rate for Payer: Cigna Medicaid	$1,252.61
Rate for Payer: Molina CHIP/Medicaid	$1,252.61
Rate for Payer: Multiplan Auto	$1,130.82
Rate for Payer: Multiplan Commercial	$1,130.82
Rate for Payer: Multiplan Workers Comp	$1,130.82
Rate for Payer: Parkland Medicaid	$1,252.61
Rate for Payer: Scott and White EPO/PPO	$869.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,252.61
Rate for Payer: Superior Health Plan EPO	$236.60

2.7 MM DRILL

Facility

$1,739.73

Hospital Charge Code	993984
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,183.02

286316ND286320ND286322ND283324ND

Facility

$2,771.08

Service Code	HCPCS C1713
Hospital Charge Code	991177
Hospital Revenue Code	278
Min. Negotiated Rate	$692.77
Max. Negotiated Rate	$1,385.54
Rate for Payer: Cash Price	$1,884.33
Rate for Payer: Cigna Commercial	$692.77
Rate for Payer: Multiplan Auto	$1,385.54
Rate for Payer: Multiplan Commercial	$1,385.54
Rate for Payer: Multiplan Workers Comp	$1,385.54
Rate for Payer: Scott and White EPO/PPO	$1,385.54

286316ND286320ND286322ND283324ND

Facility

$2,771.08

Service Code	HCPCS C1713
Hospital Charge Code	991177
Hospital Revenue Code	278
Min. Negotiated Rate	$249.40
Max. Negotiated Rate	$1,995.18
Rate for Payer: Amerigroup CHIP/Medicaid	$249.40
Rate for Payer: BCBS of TX Blue Advantage	$831.32
Rate for Payer: BCBS of TX Blue Essentials	$997.59
Rate for Payer: BCBS of TX PPO	$1,108.43
Rate for Payer: Cash Price	$1,884.33
Rate for Payer: Cigna Medicaid	$1,995.18
Rate for Payer: Molina CHIP/Medicaid	$1,995.18
Rate for Payer: Multiplan Auto	$1,385.54
Rate for Payer: Multiplan Commercial	$1,385.54
Rate for Payer: Multiplan Workers Comp	$1,385.54
Rate for Payer: Parkland Medicaid	$1,995.18
Rate for Payer: Scott and White EPO/PPO	$1,385.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,995.18
Rate for Payer: Superior Health Plan EPO	$376.87

286324ND

Facility

$2,771.08

Service Code	HCPCS C1713
Hospital Charge Code	991094
Hospital Revenue Code	278
Min. Negotiated Rate	$249.40
Max. Negotiated Rate	$1,995.18
Rate for Payer: Amerigroup CHIP/Medicaid	$249.40
Rate for Payer: BCBS of TX Blue Advantage	$831.32
Rate for Payer: BCBS of TX Blue Essentials	$997.59
Rate for Payer: BCBS of TX PPO	$1,108.43
Rate for Payer: Cash Price	$1,884.33
Rate for Payer: Cigna Medicaid	$1,995.18
Rate for Payer: Molina CHIP/Medicaid	$1,995.18
Rate for Payer: Multiplan Auto	$1,385.54
Rate for Payer: Multiplan Commercial	$1,385.54
Rate for Payer: Multiplan Workers Comp	$1,385.54
Rate for Payer: Parkland Medicaid	$1,995.18
Rate for Payer: Scott and White EPO/PPO	$1,385.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,995.18
Rate for Payer: Superior Health Plan EPO	$376.87

286324ND

Facility

$2,771.08

Service Code	HCPCS C1713
Hospital Charge Code	991094
Hospital Revenue Code	278
Min. Negotiated Rate	$692.77
Max. Negotiated Rate	$1,385.54
Rate for Payer: Cash Price	$1,884.33
Rate for Payer: Cigna Commercial	$692.77
Rate for Payer: Multiplan Auto	$1,385.54
Rate for Payer: Multiplan Commercial	$1,385.54
Rate for Payer: Multiplan Workers Comp	$1,385.54
Rate for Payer: Scott and White EPO/PPO	$1,385.54

2B5LT ENDPH XCEL BLADELESS TROCAR.W/ST

Facility

$209.99

Hospital Charge Code	993851
Hospital Revenue Code	272
Rate for Payer: Cash Price	$142.79

2B5LT ENDPH XCEL BLADELESS TROCAR.W/ST

Facility

$209.99

Hospital Charge Code	993851
Hospital Revenue Code	272
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$151.19
Rate for Payer: Amerigroup CHIP/Medicaid	$18.90
Rate for Payer: BCBS of TX Blue Advantage	$63.00
Rate for Payer: BCBS of TX Blue Essentials	$75.60
Rate for Payer: BCBS of TX PPO	$84.00
Rate for Payer: Cash Price	$142.79
Rate for Payer: Cigna Medicaid	$151.19
Rate for Payer: Molina CHIP/Medicaid	$151.19
Rate for Payer: Multiplan Auto	$136.49
Rate for Payer: Multiplan Commercial	$136.49
Rate for Payer: Multiplan Workers Comp	$136.49
Rate for Payer: Parkland Medicaid	$151.19
Rate for Payer: Scott and White EPO/PPO	$105.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.19
Rate for Payer: Superior Health Plan EPO	$28.56

2CB5LTR ENDPH XCEL INTEGRATED STABILITY

Facility

$134.62

Hospital Charge Code	992846
Hospital Revenue Code	272
Rate for Payer: Cash Price	$91.54

2CB5LTR ENDPH XCEL INTEGRATED STABILITY

Facility

$134.62

Hospital Charge Code	992846
Hospital Revenue Code	272
Min. Negotiated Rate	$12.12
Max. Negotiated Rate	$96.93
Rate for Payer: Amerigroup CHIP/Medicaid	$12.12
Rate for Payer: BCBS of TX Blue Advantage	$40.39
Rate for Payer: BCBS of TX Blue Essentials	$48.46
Rate for Payer: BCBS of TX PPO	$53.85
Rate for Payer: Cash Price	$91.54
Rate for Payer: Cigna Medicaid	$96.93
Rate for Payer: Molina CHIP/Medicaid	$96.93
Rate for Payer: Multiplan Auto	$87.50
Rate for Payer: Multiplan Commercial	$87.50
Rate for Payer: Multiplan Workers Comp	$87.50
Rate for Payer: Parkland Medicaid	$96.93
Rate for Payer: Scott and White EPO/PPO	$67.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96.93
Rate for Payer: Superior Health Plan EPO	$18.31

#2 fiberwire

Facility

$1,724.10

Hospital Charge Code	992164
Hospital Revenue Code	272
Min. Negotiated Rate	$155.17
Max. Negotiated Rate	$1,241.35
Rate for Payer: Amerigroup CHIP/Medicaid	$155.17
Rate for Payer: BCBS of TX Blue Advantage	$517.23
Rate for Payer: BCBS of TX Blue Essentials	$620.68
Rate for Payer: BCBS of TX PPO	$689.64
Rate for Payer: Cash Price	$1,172.39
Rate for Payer: Cigna Medicaid	$1,241.35
Rate for Payer: Molina CHIP/Medicaid	$1,241.35
Rate for Payer: Multiplan Auto	$1,120.66
Rate for Payer: Multiplan Commercial	$1,120.66
Rate for Payer: Multiplan Workers Comp	$1,120.66
Rate for Payer: Parkland Medicaid	$1,241.35
Rate for Payer: Scott and White EPO/PPO	$862.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,241.35
Rate for Payer: Superior Health Plan EPO	$234.48

#2 fiberwire

Facility

$1,724.10

Hospital Charge Code	992164
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,172.39

2-Level, 34 mm Midline Carvical Plate

Facility

$6,024.10

Service Code	HCPCS C1734
Hospital Charge Code	992222
Hospital Revenue Code	278
Min. Negotiated Rate	$542.17
Max. Negotiated Rate	$4,337.35
Rate for Payer: Amerigroup CHIP/Medicaid	$542.17
Rate for Payer: BCBS of TX Blue Advantage	$1,807.23
Rate for Payer: BCBS of TX Blue Essentials	$2,168.68
Rate for Payer: BCBS of TX PPO	$2,409.64
Rate for Payer: Cash Price	$4,096.39
Rate for Payer: Cigna Medicaid	$4,337.35
Rate for Payer: Molina CHIP/Medicaid	$4,337.35
Rate for Payer: Multiplan Auto	$3,012.05
Rate for Payer: Multiplan Commercial	$3,012.05
Rate for Payer: Multiplan Workers Comp	$3,012.05
Rate for Payer: Parkland Medicaid	$4,337.35
Rate for Payer: Scott and White EPO/PPO	$3,012.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,337.35
Rate for Payer: Superior Health Plan EPO	$819.28

2-Level, 34 mm Midline Carvical Plate

Facility

$6,024.10

Service Code	HCPCS C1734
Hospital Charge Code	992222
Hospital Revenue Code	278
Min. Negotiated Rate	$1,506.03
Max. Negotiated Rate	$3,012.05
Rate for Payer: Cash Price	$4,096.39
Rate for Payer: Cigna Commercial	$1,506.03
Rate for Payer: Multiplan Auto	$3,012.05
Rate for Payer: Multiplan Commercial	$3,012.05
Rate for Payer: Multiplan Workers Comp	$3,012.05
Rate for Payer: Scott and White EPO/PPO	$3,012.05

Know your out-of-pocket cost for care.

All Charges