White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC

Facility

$19,568.10

Service Code	MSDRG 872
Min. Negotiated Rate	$8,843.38
Max. Negotiated Rate	$19,568.10
Rate for Payer: Aetna Commercial	$11,586.38
Rate for Payer: Aetna Medicare	$15,306.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,204.21
Rate for Payer: Amerigroup Medicare	$10,204.21
Rate for Payer: BCBS of TX Blue Advantage	$8,843.38
Rate for Payer: BCBS of TX Blue Essentials	$10,864.88
Rate for Payer: BCBS of TX Medicare	$10,204.21
Rate for Payer: BCBS of TX PPO	$12,072.55
Rate for Payer: Cigna Commercial	$13,265.11
Rate for Payer: Cigna Medicare	$10,204.21
Rate for Payer: Employer Direct Commercial	$10,204.21
Rate for Payer: Humana Medicare/TRICARE	$10,204.21
Rate for Payer: Molina Dual Medicare/Medicaid	$10,204.21
Rate for Payer: Molina Medicare	$10,204.21
Rate for Payer: Multiplan Auto	$19,568.10
Rate for Payer: Multiplan Commercial	$19,568.10
Rate for Payer: Multiplan Workers Comp	$19,568.10
Rate for Payer: Scott and White EPO/PPO	$9,011.62
Rate for Payer: Scott and White Medicare	$10,204.21
Rate for Payer: Superior Health Plan EPO	$10,204.21
Rate for Payer: Superior Health Plan Medicare	$10,204.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,204.21
Rate for Payer: Universal American Medicare	$10,204.21
Rate for Payer: Wellcare Medicare	$10,204.21
Rate for Payer: Wellmed Medicare	$10,204.21

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement wit

Facility

$10,000.00

Service Code	CPT 30520
Hospital Charge Code	36030520
Hospital Revenue Code	360
Min. Negotiated Rate	$64.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,416.74
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,944.49
Rate for Payer: Amerigroup Medicare	$2,944.49
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$2,944.49
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cigna Commercial	$6,670.12
Rate for Payer: Cigna Medicaid	$886.62
Rate for Payer: Cigna Medicare	$2,944.49
Rate for Payer: Employer Direct Commercial	$2,944.49
Rate for Payer: Humana Medicare/TRICARE	$2,944.49
Rate for Payer: Molina CHIP/Medicaid	$886.62
Rate for Payer: Molina Dual Medicare/Medicaid	$2,944.49
Rate for Payer: Molina Medicare	$2,944.49
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	$886.62
Rate for Payer: Scott and White EPO/PPO	$64.95
Rate for Payer: Scott and White Medicare	$2,944.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$886.62
Rate for Payer: Superior Health Plan EPO	$2,944.49
Rate for Payer: Superior Health Plan Medicare	$2,944.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,944.49
Rate for Payer: Universal American Medicare	$2,944.49
Rate for Payer: Wellcare Medicare	$2,944.49
Rate for Payer: Wellmed Medicare	$2,944.49

Serological Immediate Spin

Facility

$198.00

Service Code	CPT 86920
Hospital Charge Code	2403087
Hospital Revenue Code	302
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$353.86
Rate for Payer: Aetna Commercial	$38.03
Rate for Payer: Aetna Medicare	$234.32
Rate for Payer: Amerigroup CHIP/Medicaid	$17.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$156.21
Rate for Payer: Amerigroup Medicare	$156.21
Rate for Payer: BCBS of TX Blue Advantage	$236.78
Rate for Payer: BCBS of TX Blue Essentials	$284.13
Rate for Payer: BCBS of TX Medicare	$156.21
Rate for Payer: BCBS of TX PPO	$317.14
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cigna Commercial	$353.86
Rate for Payer: Cigna Medicare	$156.21
Rate for Payer: Employer Direct Commercial	$156.21
Rate for Payer: Humana Medicare/TRICARE	$156.21
Rate for Payer: Molina Dual Medicare/Medicaid	$156.21
Rate for Payer: Molina Medicare	$156.21
Rate for Payer: Multiplan Auto	$128.70
Rate for Payer: Multiplan Commercial	$128.70
Rate for Payer: Multiplan Workers Comp	$128.70
Rate for Payer: Scott and White EPO/PPO	$2.79
Rate for Payer: Scott and White Medicare	$156.21
Rate for Payer: Superior Health Plan EPO	$156.21
Rate for Payer: Superior Health Plan Medicare	$156.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$156.21
Rate for Payer: Universal American Medicare	$156.21
Rate for Payer: Wellcare Medicare	$156.21
Rate for Payer: Wellmed Medicare	$156.21

Serological Immediate Spin BCE

Facility

$198.00

Service Code	CPT 86920
Hospital Charge Code	2403087
Hospital Revenue Code	302
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$353.86
Rate for Payer: Aetna Commercial	$38.03
Rate for Payer: Aetna Medicare	$234.32
Rate for Payer: Amerigroup CHIP/Medicaid	$17.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$156.21
Rate for Payer: Amerigroup Medicare	$156.21
Rate for Payer: BCBS of TX Blue Advantage	$236.78
Rate for Payer: BCBS of TX Blue Essentials	$284.13
Rate for Payer: BCBS of TX Medicare	$156.21
Rate for Payer: BCBS of TX PPO	$317.14
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cigna Commercial	$353.86
Rate for Payer: Cigna Medicare	$156.21
Rate for Payer: Employer Direct Commercial	$156.21
Rate for Payer: Humana Medicare/TRICARE	$156.21
Rate for Payer: Molina Dual Medicare/Medicaid	$156.21
Rate for Payer: Molina Medicare	$156.21
Rate for Payer: Multiplan Auto	$128.70
Rate for Payer: Multiplan Commercial	$128.70
Rate for Payer: Multiplan Workers Comp	$128.70
Rate for Payer: Scott and White EPO/PPO	$2.79
Rate for Payer: Scott and White Medicare	$156.21
Rate for Payer: Superior Health Plan EPO	$156.21
Rate for Payer: Superior Health Plan Medicare	$156.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$156.21
Rate for Payer: Universal American Medicare	$156.21
Rate for Payer: Wellcare Medicare	$156.21
Rate for Payer: Wellmed Medicare	$156.21

Serological Immediate Spin BCE

Facility

$198.00

Service Code	CPT 86920
Hospital Charge Code	2403087
Hospital Revenue Code	302
Rate for Payer: Cash Price	$174.24

Serotonin Release Assay SO

Facility

$314.00

Service Code	CPT 82542
Hospital Charge Code	1708155
Hospital Revenue Code	301
Rate for Payer: Cash Price	$276.32

Serotonin Release Assay SO

Facility

$314.00

Service Code	CPT 82542
Hospital Charge Code	1708155
Hospital Revenue Code	301
Min. Negotiated Rate	$9.40
Max. Negotiated Rate	$204.10
Rate for Payer: Aetna Commercial	$25.29
Rate for Payer: Aetna Medicare	$36.14
Rate for Payer: Amerigroup CHIP/Medicaid	$9.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24.09
Rate for Payer: Amerigroup Medicare	$24.09
Rate for Payer: BCBS of TX Blue Advantage	$39.75
Rate for Payer: BCBS of TX Blue Essentials	$47.70
Rate for Payer: BCBS of TX Medicare	$24.09
Rate for Payer: BCBS of TX PPO	$53.24
Rate for Payer: Cash Price	$276.32
Rate for Payer: Cash Price	$276.32
Rate for Payer: Cigna Medicaid	$24.09
Rate for Payer: Cigna Medicare	$24.09
Rate for Payer: Employer Direct Commercial	$24.09
Rate for Payer: Humana Medicare/TRICARE	$24.09
Rate for Payer: Molina CHIP/Medicaid	$24.09
Rate for Payer: Molina Dual Medicare/Medicaid	$24.09
Rate for Payer: Molina Medicare	$24.09
Rate for Payer: Multiplan Auto	$204.10
Rate for Payer: Multiplan Commercial	$204.10
Rate for Payer: Multiplan Workers Comp	$204.10
Rate for Payer: Parkland Medicaid	$24.09
Rate for Payer: Scott and White EPO/PPO	$30.11
Rate for Payer: Scott and White Medicare	$24.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.09
Rate for Payer: Superior Health Plan EPO	$24.09
Rate for Payer: Superior Health Plan Medicare	$24.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$24.09
Rate for Payer: Universal American Medicare	$24.09
Rate for Payer: Wellcare Medicare	$24.09
Rate for Payer: Wellmed Medicare	$24.09

Serotonin, Serum SO

Facility

$34.00

Service Code	CPT 84260
Hospital Charge Code	1701531
Hospital Revenue Code	301
Rate for Payer: Cash Price	$29.92

Serotonin, Serum SO

Facility

$34.00

Service Code	CPT 84260
Hospital Charge Code	1701531
Hospital Revenue Code	301
Min. Negotiated Rate	$12.08
Max. Negotiated Rate	$68.47
Rate for Payer: Aetna Commercial	$32.53
Rate for Payer: Aetna Medicare	$46.47
Rate for Payer: Amerigroup CHIP/Medicaid	$12.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30.98
Rate for Payer: Amerigroup Medicare	$30.98
Rate for Payer: BCBS of TX Blue Advantage	$51.12
Rate for Payer: BCBS of TX Blue Essentials	$61.34
Rate for Payer: BCBS of TX Medicare	$30.98
Rate for Payer: BCBS of TX PPO	$68.47
Rate for Payer: Cash Price	$29.92
Rate for Payer: Cash Price	$29.92
Rate for Payer: Cigna Medicaid	$30.98
Rate for Payer: Cigna Medicare	$30.98
Rate for Payer: Employer Direct Commercial	$30.98
Rate for Payer: Humana Medicare/TRICARE	$30.98
Rate for Payer: Molina CHIP/Medicaid	$30.98
Rate for Payer: Molina Dual Medicare/Medicaid	$30.98
Rate for Payer: Molina Medicare	$30.98
Rate for Payer: Multiplan Auto	$22.10
Rate for Payer: Multiplan Commercial	$22.10
Rate for Payer: Multiplan Workers Comp	$22.10
Rate for Payer: Parkland Medicaid	$30.98
Rate for Payer: Scott and White EPO/PPO	$38.72
Rate for Payer: Scott and White Medicare	$30.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.98
Rate for Payer: Superior Health Plan EPO	$30.98
Rate for Payer: Superior Health Plan Medicare	$30.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$30.98
Rate for Payer: Universal American Medicare	$30.98
Rate for Payer: Wellcare Medicare	$30.98
Rate for Payer: Wellmed Medicare	$30.98

sertraline 50 mg Tab

Facility

$21.65

Service Code	HCPCS J3490
Hospital Charge Code	78416965
Hospital Revenue Code	250
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$14.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1.95
Rate for Payer: BCBS of TX Blue Advantage	$6.50
Rate for Payer: BCBS of TX Blue Essentials	$7.79
Rate for Payer: BCBS of TX PPO	$8.66
Rate for Payer: Cash Price	$14.72
Rate for Payer: Multiplan Auto	$14.07
Rate for Payer: Multiplan Commercial	$14.07
Rate for Payer: Multiplan Workers Comp	$14.07
Rate for Payer: Scott and White EPO/PPO	$10.82
Rate for Payer: Superior Health Plan EPO	$2.94

sertraline 50 mg Tab

Facility

$21.65

Service Code	HCPCS J3490
Hospital Charge Code	78416965
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.72

Sesamoidectomy, first toe (separate procedure)

Facility

$10,000.00

Service Code	CPT 28315
Hospital Charge Code	36028315
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

SET, CYSTOSCOPY IRRIG NONVENTED -- DHF

Facility

$184.37

Hospital Charge Code	54200605
Hospital Revenue Code	270
Rate for Payer: Cash Price	$162.25

SET, CYSTOSCOPY IRRIG NONVENTED -- DHF

Facility

$184.37

Hospital Charge Code	54200605
Hospital Revenue Code	270
Min. Negotiated Rate	$16.59
Max. Negotiated Rate	$119.84
Rate for Payer: Aetna Commercial	$101.40
Rate for Payer: Amerigroup CHIP/Medicaid	$16.59
Rate for Payer: BCBS of TX Blue Advantage	$55.31
Rate for Payer: BCBS of TX Blue Essentials	$66.37
Rate for Payer: BCBS of TX PPO	$73.75
Rate for Payer: Cash Price	$162.25
Rate for Payer: Multiplan Auto	$119.84
Rate for Payer: Multiplan Commercial	$119.84
Rate for Payer: Multiplan Workers Comp	$119.84
Rate for Payer: Scott and White EPO/PPO	$92.18
Rate for Payer: Superior Health Plan EPO	$25.07

SET EPIDURAL NON VENT

Facility

$29.51

Hospital Charge Code	8528471
Hospital Revenue Code	272
Rate for Payer: Cash Price	$25.97

SET EPIDURAL NON VENT

Facility

$29.51

Hospital Charge Code	8528471
Hospital Revenue Code	272
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$19.18
Rate for Payer: Aetna Commercial	$16.23
Rate for Payer: Amerigroup CHIP/Medicaid	$2.66
Rate for Payer: BCBS of TX Blue Advantage	$8.85
Rate for Payer: BCBS of TX Blue Essentials	$10.62
Rate for Payer: BCBS of TX PPO	$11.80
Rate for Payer: Cash Price	$25.97
Rate for Payer: Multiplan Auto	$19.18
Rate for Payer: Multiplan Commercial	$19.18
Rate for Payer: Multiplan Workers Comp	$19.18
Rate for Payer: Scott and White EPO/PPO	$14.76
Rate for Payer: Superior Health Plan EPO	$4.01

SET EPIDURAL VENTED NV SPIKE

Facility

$40.04

Hospital Charge Code	8528472
Hospital Revenue Code	272
Rate for Payer: Cash Price	$35.24

SET EPIDURAL VENTED NV SPIKE

Facility

$40.04

Hospital Charge Code	8528472
Hospital Revenue Code	272
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$26.03
Rate for Payer: Aetna Commercial	$22.02
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.01
Rate for Payer: BCBS of TX Blue Essentials	$14.41
Rate for Payer: BCBS of TX PPO	$16.02
Rate for Payer: Cash Price	$35.24
Rate for Payer: Multiplan Auto	$26.03
Rate for Payer: Multiplan Commercial	$26.03
Rate for Payer: Multiplan Workers Comp	$26.03
Rate for Payer: Scott and White EPO/PPO	$20.02
Rate for Payer: Superior Health Plan EPO	$5.45

SET, EXTENSION SMALL BORE LUER LOCK W/CLAMP 72'''' L -- DHF

Facility

$59.39

Hospital Charge Code	54200787
Hospital Revenue Code	270
Rate for Payer: Cash Price	$52.26

SET, EXTENSION SMALL BORE LUER LOCK W/CLAMP 72'''' L -- DHF

Facility

$59.39

Hospital Charge Code	54200787
Hospital Revenue Code	270
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$38.60
Rate for Payer: Aetna Commercial	$32.66
Rate for Payer: Amerigroup CHIP/Medicaid	$5.35
Rate for Payer: BCBS of TX Blue Advantage	$17.82
Rate for Payer: BCBS of TX Blue Essentials	$21.38
Rate for Payer: BCBS of TX PPO	$23.76
Rate for Payer: Cash Price	$52.26
Rate for Payer: Multiplan Auto	$38.60
Rate for Payer: Multiplan Commercial	$38.60
Rate for Payer: Multiplan Workers Comp	$38.60
Rate for Payer: Scott and White EPO/PPO	$29.70
Rate for Payer: Superior Health Plan EPO	$8.08

SET, EXTEN TRIPORT NDLSS VALVE

Facility

$14.30

Hospital Charge Code	8592511
Hospital Revenue Code	272
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$9.30
Rate for Payer: Aetna Commercial	$7.86
Rate for Payer: Amerigroup CHIP/Medicaid	$1.29
Rate for Payer: BCBS of TX Blue Advantage	$4.29
Rate for Payer: BCBS of TX Blue Essentials	$5.15
Rate for Payer: BCBS of TX PPO	$5.72
Rate for Payer: Cash Price	$12.58
Rate for Payer: Multiplan Auto	$9.30
Rate for Payer: Multiplan Commercial	$9.30
Rate for Payer: Multiplan Workers Comp	$9.30
Rate for Payer: Scott and White EPO/PPO	$7.15
Rate for Payer: Superior Health Plan EPO	$1.94

SET, EXTEN TRIPORT NDLSS VALVE

Facility

$14.30

Hospital Charge Code	8592511
Hospital Revenue Code	272
Rate for Payer: Cash Price	$12.58

set ext standard bore

Facility

$9.26

Hospital Charge Code	110771
Hospital Revenue Code	270
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$6.02
Rate for Payer: Aetna Commercial	$5.09
Rate for Payer: Amerigroup CHIP/Medicaid	$0.83
Rate for Payer: BCBS of TX Blue Advantage	$2.78
Rate for Payer: BCBS of TX Blue Essentials	$3.33
Rate for Payer: BCBS of TX PPO	$3.70
Rate for Payer: Cash Price	$8.15
Rate for Payer: Multiplan Auto	$6.02
Rate for Payer: Multiplan Commercial	$6.02
Rate for Payer: Multiplan Workers Comp	$6.02
Rate for Payer: Scott and White EPO/PPO	$4.63
Rate for Payer: Superior Health Plan EPO	$1.26

set ext standard bore

Facility

$9.26

Hospital Charge Code	110771
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.15

SET, EXT STD BORE 2 INJ PORT LL SLIDE CLAMP 30'''' L -- DHF

Facility

$59.39

Hospital Charge Code	54200787
Hospital Revenue Code	270
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$38.60
Rate for Payer: Aetna Commercial	$32.66
Rate for Payer: Amerigroup CHIP/Medicaid	$5.35
Rate for Payer: BCBS of TX Blue Advantage	$17.82
Rate for Payer: BCBS of TX Blue Essentials	$21.38
Rate for Payer: BCBS of TX PPO	$23.76
Rate for Payer: Cash Price	$52.26
Rate for Payer: Multiplan Auto	$38.60
Rate for Payer: Multiplan Commercial	$38.60
Rate for Payer: Multiplan Workers Comp	$38.60
Rate for Payer: Scott and White EPO/PPO	$29.70
Rate for Payer: Superior Health Plan EPO	$8.08

Know your out-of-pocket cost for care.

All Charges