White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SET FLUID/BL WARMER

Facility

$267.31

Hospital Charge Code	8570489
Hospital Revenue Code	272
Min. Negotiated Rate	$24.06
Max. Negotiated Rate	$173.75
Rate for Payer: Aetna Commercial	$147.02
Rate for Payer: Amerigroup CHIP/Medicaid	$24.06
Rate for Payer: BCBS of TX Blue Advantage	$80.19
Rate for Payer: BCBS of TX Blue Essentials	$96.23
Rate for Payer: BCBS of TX PPO	$106.92
Rate for Payer: Cash Price	$235.23
Rate for Payer: Multiplan Auto	$173.75
Rate for Payer: Multiplan Commercial	$173.75
Rate for Payer: Multiplan Workers Comp	$173.75
Rate for Payer: Scott and White EPO/PPO	$133.66
Rate for Payer: Superior Health Plan EPO	$36.35

SET FLUID/BL WARMER

Facility

$267.31

Hospital Charge Code	8570489
Hospital Revenue Code	272
Rate for Payer: Cash Price	$235.23

SET, HYSTEROSCOPIC OUTFLOW TUBE--DHF

Facility

$689.74

Hospital Charge Code	80347222
Hospital Revenue Code	270
Min. Negotiated Rate	$62.08
Max. Negotiated Rate	$448.33
Rate for Payer: Aetna Commercial	$379.36
Rate for Payer: Amerigroup CHIP/Medicaid	$62.08
Rate for Payer: BCBS of TX Blue Advantage	$206.92
Rate for Payer: BCBS of TX Blue Essentials	$248.31
Rate for Payer: BCBS of TX PPO	$275.90
Rate for Payer: Cash Price	$606.97
Rate for Payer: Multiplan Auto	$448.33
Rate for Payer: Multiplan Commercial	$448.33
Rate for Payer: Multiplan Workers Comp	$448.33
Rate for Payer: Scott and White EPO/PPO	$344.87
Rate for Payer: Superior Health Plan EPO	$93.80

SET, HYSTEROSCOPIC OUTFLOW TUBE--DHF

Facility

$689.74

Hospital Charge Code	80347222
Hospital Revenue Code	270
Rate for Payer: Cash Price	$606.97

SET, INTRODUCER MICROPUNCTURE 5F GW TRANSITIONLESS -- DHF

Facility

$739.64

Hospital Charge Code	80565559
Hospital Revenue Code	272
Min. Negotiated Rate	$66.57
Max. Negotiated Rate	$480.77
Rate for Payer: Aetna Commercial	$406.80
Rate for Payer: Amerigroup CHIP/Medicaid	$66.57
Rate for Payer: BCBS of TX Blue Advantage	$221.89
Rate for Payer: BCBS of TX Blue Essentials	$266.27
Rate for Payer: BCBS of TX PPO	$295.86
Rate for Payer: Cash Price	$650.88
Rate for Payer: Multiplan Auto	$480.77
Rate for Payer: Multiplan Commercial	$480.77
Rate for Payer: Multiplan Workers Comp	$480.77
Rate for Payer: Scott and White EPO/PPO	$369.82
Rate for Payer: Superior Health Plan EPO	$100.59

SET, INTRODUCER MICROPUNCTURE 5F GW TRANSITIONLESS -- DHF

Facility

$739.64

Hospital Charge Code	80565559
Hospital Revenue Code	272
Rate for Payer: Cash Price	$650.88

SET, MICROINTRODUCER UNIVERSAL

Facility

$359.80

Hospital Charge Code	81749301
Hospital Revenue Code	272
Rate for Payer: Cash Price	$316.62

SET, MICROINTRODUCER UNIVERSAL

Facility

$359.80

Hospital Charge Code	81749301
Hospital Revenue Code	272
Min. Negotiated Rate	$32.38
Max. Negotiated Rate	$233.87
Rate for Payer: Aetna Commercial	$197.89
Rate for Payer: Amerigroup CHIP/Medicaid	$32.38
Rate for Payer: BCBS of TX Blue Advantage	$107.94
Rate for Payer: BCBS of TX Blue Essentials	$129.53
Rate for Payer: BCBS of TX PPO	$143.92
Rate for Payer: Cash Price	$316.62
Rate for Payer: Multiplan Auto	$233.87
Rate for Payer: Multiplan Commercial	$233.87
Rate for Payer: Multiplan Workers Comp	$233.87
Rate for Payer: Scott and White EPO/PPO	$179.90
Rate for Payer: Superior Health Plan EPO	$48.93

SET, PROCEDURE SHEATH CASSETTE DRAINAGE BAG -- DHF

Facility

$7,531.81

Hospital Charge Code	80732654
Hospital Revenue Code	272
Min. Negotiated Rate	$677.86
Max. Negotiated Rate	$4,895.68
Rate for Payer: Aetna Commercial	$4,142.50
Rate for Payer: Amerigroup CHIP/Medicaid	$677.86
Rate for Payer: BCBS of TX Blue Advantage	$2,259.54
Rate for Payer: BCBS of TX Blue Essentials	$2,711.45
Rate for Payer: BCBS of TX PPO	$3,012.72
Rate for Payer: Cash Price	$6,627.99
Rate for Payer: Multiplan Auto	$4,895.68
Rate for Payer: Multiplan Commercial	$4,895.68
Rate for Payer: Multiplan Workers Comp	$4,895.68
Rate for Payer: Scott and White EPO/PPO	$3,765.90
Rate for Payer: Superior Health Plan EPO	$1,024.33

SET, PROCEDURE SHEATH CASSETTE DRAINAGE BAG -- DHF

Facility

$7,531.81

Hospital Charge Code	80732654
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6,627.99

sevelamer carbonate 800 mg Tab

Facility

$28.00

Service Code	HCPCS J3490
Hospital Charge Code	77811505
Hospital Revenue Code	250
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$18.20
Rate for Payer: Amerigroup CHIP/Medicaid	$2.52
Rate for Payer: BCBS of TX Blue Advantage	$8.40
Rate for Payer: BCBS of TX Blue Essentials	$10.08
Rate for Payer: BCBS of TX PPO	$11.20
Rate for Payer: Cash Price	$19.04
Rate for Payer: Multiplan Auto	$18.20
Rate for Payer: Multiplan Commercial	$18.20
Rate for Payer: Multiplan Workers Comp	$18.20
Rate for Payer: Scott and White EPO/PPO	$14.00
Rate for Payer: Superior Health Plan EPO	$3.81

sevelamer carbonate 800 mg Tab

Facility

$28.00

Service Code	HCPCS J3490
Hospital Charge Code	77811505
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.04

sevoflurane Inh Liquid 250 mL

Facility

$242.00

Service Code	HCPCS J3490
Hospital Charge Code	77811660
Hospital Revenue Code	250
Rate for Payer: Cash Price	$164.56

sevoflurane Inh Liquid 250 mL

Facility

$242.00

Service Code	HCPCS J3490
Hospital Charge Code	77811660
Hospital Revenue Code	250
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$157.30
Rate for Payer: Amerigroup CHIP/Medicaid	$21.78
Rate for Payer: BCBS of TX Blue Advantage	$72.60
Rate for Payer: BCBS of TX Blue Essentials	$87.12
Rate for Payer: BCBS of TX PPO	$96.80
Rate for Payer: Cash Price	$164.56
Rate for Payer: Multiplan Auto	$157.30
Rate for Payer: Multiplan Commercial	$157.30
Rate for Payer: Multiplan Workers Comp	$157.30
Rate for Payer: Scott and White EPO/PPO	$121.00
Rate for Payer: Superior Health Plan EPO	$32.91

Sex Horm Binding Glob, Serum SO

Facility

$55.00

Service Code	CPT 84270
Hospital Charge Code	1740703
Hospital Revenue Code	301
Rate for Payer: Cash Price	$48.40

Sex Horm Binding Glob, Serum SO

Facility

$55.00

Service Code	CPT 84270
Hospital Charge Code	1740703
Hospital Revenue Code	301
Min. Negotiated Rate	$8.47
Max. Negotiated Rate	$48.02
Rate for Payer: Aetna Commercial	$22.82
Rate for Payer: Aetna Medicare	$32.60
Rate for Payer: Amerigroup CHIP/Medicaid	$8.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.73
Rate for Payer: Amerigroup Medicare	$21.73
Rate for Payer: BCBS of TX Blue Advantage	$35.85
Rate for Payer: BCBS of TX Blue Essentials	$43.03
Rate for Payer: BCBS of TX Medicare	$21.73
Rate for Payer: BCBS of TX PPO	$48.02
Rate for Payer: Cash Price	$48.40
Rate for Payer: Cash Price	$48.40
Rate for Payer: Cigna Medicaid	$21.73
Rate for Payer: Cigna Medicare	$21.73
Rate for Payer: Employer Direct Commercial	$21.73
Rate for Payer: Humana Medicare/TRICARE	$21.73
Rate for Payer: Molina CHIP/Medicaid	$21.73
Rate for Payer: Molina Dual Medicare/Medicaid	$21.73
Rate for Payer: Molina Medicare	$21.73
Rate for Payer: Multiplan Auto	$35.75
Rate for Payer: Multiplan Commercial	$35.75
Rate for Payer: Multiplan Workers Comp	$35.75
Rate for Payer: Parkland Medicaid	$21.73
Rate for Payer: Scott and White EPO/PPO	$27.16
Rate for Payer: Scott and White Medicare	$21.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.73
Rate for Payer: Superior Health Plan EPO	$21.73
Rate for Payer: Superior Health Plan Medicare	$21.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.73
Rate for Payer: Universal American Medicare	$21.73
Rate for Payer: Wellcare Medicare	$21.73
Rate for Payer: Wellmed Medicare	$21.73

SHAVER 4.2MM 3IN 1

Facility

$1,203.10

Hospital Charge Code	144828
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,058.73

SHAVER 4.2MM 3IN 1

Facility

$1,203.10

Hospital Charge Code	144828
Hospital Revenue Code	272
Min. Negotiated Rate	$108.28
Max. Negotiated Rate	$782.02
Rate for Payer: Aetna Commercial	$661.70
Rate for Payer: Amerigroup CHIP/Medicaid	$108.28
Rate for Payer: BCBS of TX Blue Advantage	$360.93
Rate for Payer: BCBS of TX Blue Essentials	$433.12
Rate for Payer: BCBS of TX PPO	$481.24
Rate for Payer: Cash Price	$1,058.73
Rate for Payer: Multiplan Auto	$782.02
Rate for Payer: Multiplan Commercial	$782.02
Rate for Payer: Multiplan Workers Comp	$782.02
Rate for Payer: Scott and White EPO/PPO	$601.55
Rate for Payer: Superior Health Plan EPO	$163.62

SHAVER BARRELL BURR HOLLOW 12 FLUTES 4.00MM DISP "FORMULA"

Facility

$319.43

Hospital Charge Code	81728883
Hospital Revenue Code	272
Min. Negotiated Rate	$28.75
Max. Negotiated Rate	$207.63
Rate for Payer: Aetna Commercial	$175.69
Rate for Payer: Amerigroup CHIP/Medicaid	$28.75
Rate for Payer: BCBS of TX Blue Advantage	$95.83
Rate for Payer: BCBS of TX Blue Essentials	$114.99
Rate for Payer: BCBS of TX PPO	$127.77
Rate for Payer: Cash Price	$281.10
Rate for Payer: Multiplan Auto	$207.63
Rate for Payer: Multiplan Commercial	$207.63
Rate for Payer: Multiplan Workers Comp	$207.63
Rate for Payer: Scott and White EPO/PPO	$159.72
Rate for Payer: Superior Health Plan EPO	$43.44

SHAVER BARRELL BURR HOLLOW 12 FLUTES 4.00MM DISP "FORMULA"

Facility

$319.43

Hospital Charge Code	81728883
Hospital Revenue Code	272
Rate for Payer: Cash Price	$281.10

SHAVER STANDARD 3.4MM

Facility

$181.60

Hospital Charge Code	144829
Hospital Revenue Code	272
Rate for Payer: Cash Price	$159.81

SHAVER STANDARD 3.4MM

Facility

$181.60

Hospital Charge Code	144829
Hospital Revenue Code	272
Min. Negotiated Rate	$16.34
Max. Negotiated Rate	$118.04
Rate for Payer: Aetna Commercial	$99.88
Rate for Payer: Amerigroup CHIP/Medicaid	$16.34
Rate for Payer: BCBS of TX Blue Advantage	$54.48
Rate for Payer: BCBS of TX Blue Essentials	$65.38
Rate for Payer: BCBS of TX PPO	$72.64
Rate for Payer: Cash Price	$159.81
Rate for Payer: Multiplan Auto	$118.04
Rate for Payer: Multiplan Commercial	$118.04
Rate for Payer: Multiplan Workers Comp	$118.04
Rate for Payer: Scott and White EPO/PPO	$90.80
Rate for Payer: Superior Health Plan EPO	$24.70

SHAVER TOMCAT HC CROSSBLADE 4.0MM "FORMULA"

Facility

$415.11

Hospital Charge Code	8172360
Hospital Revenue Code	272
Rate for Payer: Cash Price	$365.30

SHAVER TOMCAT HC CROSSBLADE 4.0MM "FORMULA"

Facility

$415.11

Hospital Charge Code	8172360
Hospital Revenue Code	272
Min. Negotiated Rate	$37.36
Max. Negotiated Rate	$269.82
Rate for Payer: Aetna Commercial	$228.31
Rate for Payer: Amerigroup CHIP/Medicaid	$37.36
Rate for Payer: BCBS of TX Blue Advantage	$124.53
Rate for Payer: BCBS of TX Blue Essentials	$149.44
Rate for Payer: BCBS of TX PPO	$166.04
Rate for Payer: Cash Price	$365.30
Rate for Payer: Multiplan Auto	$269.82
Rate for Payer: Multiplan Commercial	$269.82
Rate for Payer: Multiplan Workers Comp	$269.82
Rate for Payer: Scott and White EPO/PPO	$207.56
Rate for Payer: Superior Health Plan EPO	$56.45

SHEALTH SYSTEM FORTRESS 6FR 90CM

Facility

$385.90

Hospital Charge Code	145375
Hospital Revenue Code	272
Rate for Payer: Cash Price	$339.59

Know your out-of-pocket cost for care.

All Charges