White Rock Medical Center

All Charges

Charge

Type

Setting

Price

#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
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

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

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

30-0240

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

30-0249

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

30-0329

Facility

$1,732.72

Service Code	HCPCS C1713
Hospital Charge Code	994027
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

30-0329

Facility

$1,732.72

Service Code	HCPCS C1713
Hospital Charge Code	994027
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

30-0330

Facility

$1,732.72

Service Code	HCPCS C1713
Hospital Charge Code	994028
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

30-0330

Facility

$1,732.72

Service Code	HCPCS C1713
Hospital Charge Code	994028
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

30-2063

Facility

$876.04

Service Code	HCPCS C1713
Hospital Charge Code	994029
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

30-2063

Facility

$876.04

Service Code	HCPCS C1713
Hospital Charge Code	994029
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

3060-0080S

Facility

$5,048.19

Service Code	HCPCS C1734
Hospital Charge Code	991187
Hospital Revenue Code	278
Min. Negotiated Rate	$1,262.05
Max. Negotiated Rate	$2,524.09
Rate for Payer: Cash Price	$3,432.77
Rate for Payer: Cigna Commercial	$1,262.05
Rate for Payer: Multiplan Auto	$2,524.09
Rate for Payer: Multiplan Commercial	$2,524.09
Rate for Payer: Multiplan Workers Comp	$2,524.09
Rate for Payer: Scott and White EPO/PPO	$2,524.09

3060-0080S

Facility

$5,048.19

Service Code	HCPCS C1734
Hospital Charge Code	991187
Hospital Revenue Code	278
Min. Negotiated Rate	$454.34
Max. Negotiated Rate	$3,634.70
Rate for Payer: Amerigroup CHIP/Medicaid	$454.34
Rate for Payer: BCBS of TX Blue Advantage	$1,514.46
Rate for Payer: BCBS of TX Blue Essentials	$1,817.35
Rate for Payer: BCBS of TX PPO	$2,019.28
Rate for Payer: Cash Price	$3,432.77
Rate for Payer: Cigna Medicaid	$3,634.70
Rate for Payer: Molina CHIP/Medicaid	$3,634.70
Rate for Payer: Multiplan Auto	$2,524.09
Rate for Payer: Multiplan Commercial	$2,524.09
Rate for Payer: Multiplan Workers Comp	$2,524.09
Rate for Payer: Parkland Medicaid	$3,634.70
Rate for Payer: Scott and White EPO/PPO	$2,524.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,634.70
Rate for Payer: Superior Health Plan EPO	$686.55

3-0 fiberwire

Facility

$1,724.10

Hospital Charge Code	992166
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,172.39

3-0 fiberwire

Facility

$1,724.10

Hospital Charge Code	992166
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

3-0 FW, 18' W/REVSE CUT NDL, 16.3MM

Facility

$1,198.56

Service Code	HCPCS C1713
Hospital Charge Code	992605
Hospital Revenue Code	278
Min. Negotiated Rate	$107.87
Max. Negotiated Rate	$862.96
Rate for Payer: Amerigroup CHIP/Medicaid	$107.87
Rate for Payer: BCBS of TX Blue Advantage	$359.57
Rate for Payer: BCBS of TX Blue Essentials	$431.48
Rate for Payer: BCBS of TX PPO	$479.42
Rate for Payer: Cash Price	$815.02
Rate for Payer: Cigna Medicaid	$862.96
Rate for Payer: Molina CHIP/Medicaid	$862.96
Rate for Payer: Multiplan Auto	$599.28
Rate for Payer: Multiplan Commercial	$599.28
Rate for Payer: Multiplan Workers Comp	$599.28
Rate for Payer: Parkland Medicaid	$862.96
Rate for Payer: Scott and White EPO/PPO	$599.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$862.96
Rate for Payer: Superior Health Plan EPO	$163.00

3-0 FW, 18' W/REVSE CUT NDL, 16.3MM

Facility

$1,198.56

Service Code	HCPCS C1713
Hospital Charge Code	992605
Hospital Revenue Code	278
Min. Negotiated Rate	$299.64
Max. Negotiated Rate	$599.28
Rate for Payer: Cash Price	$815.02
Rate for Payer: Cigna Commercial	$299.64
Rate for Payer: Multiplan Auto	$599.28
Rate for Payer: Multiplan Commercial	$599.28
Rate for Payer: Multiplan Workers Comp	$599.28
Rate for Payer: Scott and White EPO/PPO	$599.28

30mm Speedtrap 6 / W

Facility

$617.47

Hospital Charge Code	992191
Hospital Revenue Code	272
Rate for Payer: Cash Price	$419.88

30mm Speedtrap 6 / W

Facility

$617.47

Hospital Charge Code	992191
Hospital Revenue Code	272
Min. Negotiated Rate	$55.57
Max. Negotiated Rate	$444.58
Rate for Payer: Amerigroup CHIP/Medicaid	$55.57
Rate for Payer: BCBS of TX Blue Advantage	$185.24
Rate for Payer: BCBS of TX Blue Essentials	$222.29
Rate for Payer: BCBS of TX PPO	$246.99
Rate for Payer: Cash Price	$419.88
Rate for Payer: Cigna Medicaid	$444.58
Rate for Payer: Molina CHIP/Medicaid	$444.58
Rate for Payer: Multiplan Auto	$401.36
Rate for Payer: Multiplan Commercial	$401.36
Rate for Payer: Multiplan Workers Comp	$401.36
Rate for Payer: Parkland Medicaid	$444.58
Rate for Payer: Scott and White EPO/PPO	$308.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$444.58
Rate for Payer: Superior Health Plan EPO	$83.98

30mm Speedtrap W

Facility

$617.47

Hospital Charge Code	992190
Hospital Revenue Code	272
Rate for Payer: Cash Price	$419.88

Know your out-of-pocket cost for care.

All Charges