White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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

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

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

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

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

2CB5LTR ENDPH XCEL INTEGRATED STABILITY

Facility

$134.62

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

#2 fiberwire

Facility

$1,724.10

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

#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-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

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 Orthocord Suture

Facility

$365.48

Hospital Charge Code	992193
Hospital Revenue Code	272
Rate for Payer: Cash Price	$248.53

#2 Orthocord Suture

Facility

$365.48

Hospital Charge Code	992193
Hospital Revenue Code	272
Min. Negotiated Rate	$32.89
Max. Negotiated Rate	$263.15
Rate for Payer: Amerigroup CHIP/Medicaid	$32.89
Rate for Payer: BCBS of TX Blue Advantage	$109.64
Rate for Payer: BCBS of TX Blue Essentials	$131.57
Rate for Payer: BCBS of TX PPO	$146.19
Rate for Payer: Cash Price	$248.53
Rate for Payer: Cigna Medicaid	$263.15
Rate for Payer: Molina CHIP/Medicaid	$263.15
Rate for Payer: Multiplan Auto	$237.56
Rate for Payer: Multiplan Commercial	$237.56
Rate for Payer: Multiplan Workers Comp	$237.56
Rate for Payer: Parkland Medicaid	$263.15
Rate for Payer: Scott and White EPO/PPO	$182.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$263.15
Rate for Payer: Superior Health Plan EPO	$49.71

2 Piece Beach Chair Head Restraint with DermaProx Layer

Facility

$233.02

Hospital Charge Code	993171
Hospital Revenue Code	270
Rate for Payer: Cash Price	$158.45

2 Piece Beach Chair Head Restraint with DermaProx Layer

Facility

$233.02

Hospital Charge Code	993171
Hospital Revenue Code	270
Min. Negotiated Rate	$20.97
Max. Negotiated Rate	$167.77
Rate for Payer: Amerigroup CHIP/Medicaid	$20.97
Rate for Payer: BCBS of TX Blue Advantage	$69.91
Rate for Payer: BCBS of TX Blue Essentials	$83.89
Rate for Payer: BCBS of TX PPO	$93.21
Rate for Payer: Cash Price	$158.45
Rate for Payer: Cigna Medicaid	$167.77
Rate for Payer: Molina CHIP/Medicaid	$167.77
Rate for Payer: Multiplan Auto	$151.46
Rate for Payer: Multiplan Commercial	$151.46
Rate for Payer: Multiplan Workers Comp	$151.46
Rate for Payer: Parkland Medicaid	$167.77
Rate for Payer: Scott and White EPO/PPO	$116.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$167.77
Rate for Payer: Superior Health Plan EPO	$31.69

30-0240

Facility

$1,732.72

Service Code	HCPCS C1713
Hospital Charge Code	994031
Hospital Revenue Code	278
Min. Negotiated Rate	$155.94
Max. Negotiated Rate	$1,247.56
Rate for Payer: Amerigroup CHIP/Medicaid	$155.94
Rate for Payer: BCBS of TX Blue Advantage	$519.82
Rate for Payer: BCBS of TX Blue Essentials	$623.78
Rate for Payer: BCBS of TX PPO	$693.09
Rate for Payer: Cash Price	$1,178.25
Rate for Payer: Cigna Medicaid	$1,247.56
Rate for Payer: Molina CHIP/Medicaid	$1,247.56
Rate for Payer: Multiplan Auto	$866.36
Rate for Payer: Multiplan Commercial	$866.36
Rate for Payer: Multiplan Workers Comp	$866.36
Rate for Payer: Parkland Medicaid	$1,247.56
Rate for Payer: Scott and White EPO/PPO	$866.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,247.56
Rate for Payer: Superior Health Plan EPO	$235.65

30-0240

Facility

$1,732.72

Service Code	HCPCS C1713
Hospital Charge Code	994031
Hospital Revenue Code	278
Min. Negotiated Rate	$433.18
Max. Negotiated Rate	$866.36
Rate for Payer: Cash Price	$1,178.25
Rate for Payer: Cigna Commercial	$433.18
Rate for Payer: Multiplan Auto	$866.36
Rate for Payer: Multiplan Commercial	$866.36
Rate for Payer: Multiplan Workers Comp	$866.36
Rate for Payer: Scott and White EPO/PPO	$866.36

30-0249

Facility

$1,732.72

Service Code	HCPCS C1713
Hospital Charge Code	994032
Hospital Revenue Code	278
Min. Negotiated Rate	$155.94
Max. Negotiated Rate	$1,247.56
Rate for Payer: Amerigroup CHIP/Medicaid	$155.94
Rate for Payer: BCBS of TX Blue Advantage	$519.82
Rate for Payer: BCBS of TX Blue Essentials	$623.78
Rate for Payer: BCBS of TX PPO	$693.09
Rate for Payer: Cash Price	$1,178.25
Rate for Payer: Cigna Medicaid	$1,247.56
Rate for Payer: Molina CHIP/Medicaid	$1,247.56
Rate for Payer: Multiplan Auto	$866.36
Rate for Payer: Multiplan Commercial	$866.36
Rate for Payer: Multiplan Workers Comp	$866.36
Rate for Payer: Parkland Medicaid	$1,247.56
Rate for Payer: Scott and White EPO/PPO	$866.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,247.56
Rate for Payer: Superior Health Plan EPO	$235.65

30-0249

Facility

$1,732.72

Service Code	HCPCS C1713
Hospital Charge Code	994032
Hospital Revenue Code	278
Min. Negotiated Rate	$433.18
Max. Negotiated Rate	$866.36
Rate for Payer: Cash Price	$1,178.25
Rate for Payer: Cigna Commercial	$433.18
Rate for Payer: Multiplan Auto	$866.36
Rate for Payer: Multiplan Commercial	$866.36
Rate for Payer: Multiplan Workers Comp	$866.36
Rate for Payer: Scott and White EPO/PPO	$866.36

30-0263

Facility

$876.04

Service Code	HCPCS C1713
Hospital Charge Code	994030
Hospital Revenue Code	278
Min. Negotiated Rate	$219.01
Max. Negotiated Rate	$438.02
Rate for Payer: Cash Price	$595.71
Rate for Payer: Cigna Commercial	$219.01
Rate for Payer: Multiplan Auto	$438.02
Rate for Payer: Multiplan Commercial	$438.02
Rate for Payer: Multiplan Workers Comp	$438.02
Rate for Payer: Scott and White EPO/PPO	$438.02

30-0263

Facility

$876.04

Service Code	HCPCS C1713
Hospital Charge Code	994030
Hospital Revenue Code	278
Min. Negotiated Rate	$78.84
Max. Negotiated Rate	$630.75
Rate for Payer: Amerigroup CHIP/Medicaid	$78.84
Rate for Payer: BCBS of TX Blue Advantage	$262.81
Rate for Payer: BCBS of TX Blue Essentials	$315.37
Rate for Payer: BCBS of TX PPO	$350.42
Rate for Payer: Cash Price	$595.71
Rate for Payer: Cigna Medicaid	$630.75
Rate for Payer: Molina CHIP/Medicaid	$630.75
Rate for Payer: Multiplan Auto	$438.02
Rate for Payer: Multiplan Commercial	$438.02
Rate for Payer: Multiplan Workers Comp	$438.02
Rate for Payer: Parkland Medicaid	$630.75
Rate for Payer: Scott and White EPO/PPO	$438.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$630.75
Rate for Payer: Superior Health Plan EPO	$119.14

Know your out-of-pocket cost for care.

All Charges