White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Shiga Toxin II

Facility

$117.00

Service Code	CPT 87899
Hospital Charge Code	4107909
Hospital Revenue Code	306
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$76.05
Rate for Payer: Aetna Commercial	$16.87
Rate for Payer: Aetna Medicare	$24.11
Rate for Payer: Amerigroup CHIP/Medicaid	$6.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.07
Rate for Payer: Amerigroup Medicare	$16.07
Rate for Payer: BCBS of TX Blue Advantage	$26.52
Rate for Payer: BCBS of TX Blue Essentials	$31.82
Rate for Payer: BCBS of TX Medicare	$16.07
Rate for Payer: BCBS of TX PPO	$35.51
Rate for Payer: Cash Price	$102.96
Rate for Payer: Cash Price	$102.96
Rate for Payer: Cigna Medicaid	$16.07
Rate for Payer: Cigna Medicare	$16.07
Rate for Payer: Employer Direct Commercial	$16.07
Rate for Payer: Humana Medicare/TRICARE	$16.07
Rate for Payer: Molina CHIP/Medicaid	$16.07
Rate for Payer: Molina Dual Medicare/Medicaid	$16.07
Rate for Payer: Molina Medicare	$16.07
Rate for Payer: Multiplan Auto	$76.05
Rate for Payer: Multiplan Commercial	$76.05
Rate for Payer: Multiplan Workers Comp	$76.05
Rate for Payer: Parkland Medicaid	$16.07
Rate for Payer: Scott and White EPO/PPO	$20.09
Rate for Payer: Scott and White Medicare	$16.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.07
Rate for Payer: Superior Health Plan EPO	$16.07
Rate for Payer: Superior Health Plan Medicare	$16.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.07
Rate for Payer: Universal American Medicare	$16.07
Rate for Payer: Wellcare Medicare	$16.07
Rate for Payer: Wellmed Medicare	$16.07

Shiga Toxin II

Facility

$117.00

Service Code	CPT 87899
Hospital Charge Code	4107909
Hospital Revenue Code	306
Rate for Payer: Cash Price	$102.96

SHOE CST WALKNG -- DHF

Facility

$181.91

Hospital Charge Code	81144156
Hospital Revenue Code	270
Rate for Payer: Cash Price	$160.08

SHOE CST WALKNG -- DHF

Facility

$181.91

Hospital Charge Code	81144156
Hospital Revenue Code	270
Min. Negotiated Rate	$16.37
Max. Negotiated Rate	$118.24
Rate for Payer: Aetna Commercial	$100.05
Rate for Payer: Amerigroup CHIP/Medicaid	$16.37
Rate for Payer: BCBS of TX Blue Advantage	$54.57
Rate for Payer: BCBS of TX Blue Essentials	$65.49
Rate for Payer: BCBS of TX PPO	$72.76
Rate for Payer: Cash Price	$160.08
Rate for Payer: Multiplan Auto	$118.24
Rate for Payer: Multiplan Commercial	$118.24
Rate for Payer: Multiplan Workers Comp	$118.24
Rate for Payer: Scott and White EPO/PPO	$90.95
Rate for Payer: Superior Health Plan EPO	$24.74

SHOE ORTHOPEDIC -- DHF

Facility

$689.34

Hospital Charge Code	81144206
Hospital Revenue Code	271
Rate for Payer: Cash Price	$606.62

SHOE ORTHOPEDIC -- DHF

Facility

$689.34

Hospital Charge Code	81144206
Hospital Revenue Code	271
Min. Negotiated Rate	$62.04
Max. Negotiated Rate	$448.07
Rate for Payer: Aetna Commercial	$379.14
Rate for Payer: Amerigroup CHIP/Medicaid	$62.04
Rate for Payer: BCBS of TX Blue Advantage	$206.80
Rate for Payer: BCBS of TX Blue Essentials	$248.16
Rate for Payer: BCBS of TX PPO	$275.74
Rate for Payer: Cash Price	$606.62
Rate for Payer: Multiplan Auto	$448.07
Rate for Payer: Multiplan Commercial	$448.07
Rate for Payer: Multiplan Workers Comp	$448.07
Rate for Payer: Scott and White EPO/PPO	$344.67
Rate for Payer: Superior Health Plan EPO	$93.75

SHOE POST-OP A/S -- DHF

Facility

$46.80

Hospital Charge Code	81144255
Hospital Revenue Code	271
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$30.42
Rate for Payer: Aetna Commercial	$25.74
Rate for Payer: Amerigroup CHIP/Medicaid	$4.21
Rate for Payer: BCBS of TX Blue Advantage	$14.04
Rate for Payer: BCBS of TX Blue Essentials	$16.85
Rate for Payer: BCBS of TX PPO	$18.72
Rate for Payer: Cash Price	$41.18
Rate for Payer: Multiplan Auto	$30.42
Rate for Payer: Multiplan Commercial	$30.42
Rate for Payer: Multiplan Workers Comp	$30.42
Rate for Payer: Scott and White EPO/PPO	$23.40
Rate for Payer: Superior Health Plan EPO	$6.36

SHOE POST-OP A/S -- DHF

Facility

$46.80

Hospital Charge Code	81144255
Hospital Revenue Code	271
Rate for Payer: Cash Price	$41.18

SHOE POST-OP SPEC1 -- DHF

Facility

$116.00

Hospital Charge Code	81144230
Hospital Revenue Code	271
Rate for Payer: Cash Price	$102.08

SHOE POST-OP SPEC1 -- DHF

Facility

$116.00

Hospital Charge Code	81144230
Hospital Revenue Code	271
Min. Negotiated Rate	$10.44
Max. Negotiated Rate	$75.40
Rate for Payer: Aetna Commercial	$63.80
Rate for Payer: Amerigroup CHIP/Medicaid	$10.44
Rate for Payer: BCBS of TX Blue Advantage	$34.80
Rate for Payer: BCBS of TX Blue Essentials	$41.76
Rate for Payer: BCBS of TX PPO	$46.40
Rate for Payer: Cash Price	$102.08
Rate for Payer: Multiplan Auto	$75.40
Rate for Payer: Multiplan Commercial	$75.40
Rate for Payer: Multiplan Workers Comp	$75.40
Rate for Payer: Scott and White EPO/PPO	$58.00
Rate for Payer: Superior Health Plan EPO	$15.78

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC

Facility

$25,680.14

Service Code	MSDRG 511
Min. Negotiated Rate	$15,075.80
Max. Negotiated Rate	$25,680.14
Rate for Payer: Aetna Commercial	$22,430.25
Rate for Payer: Aetna Medicare	$25,623.99
Rate for Payer: BCBS of TX Blue Advantage	$15,075.80
Rate for Payer: BCBS of TX Blue Essentials	$19,062.29
Rate for Payer: BCBS of TX PPO	$21,181.14
Rate for Payer: Cigna Commercial	$25,680.14

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC

Facility

$35,041.33

Service Code	MSDRG 510
Min. Negotiated Rate	$21,100.10
Max. Negotiated Rate	$35,041.33
Rate for Payer: Aetna Commercial	$30,606.75
Rate for Payer: Aetna Medicare	$33,403.71
Rate for Payer: BCBS of TX Blue Advantage	$21,100.10
Rate for Payer: BCBS of TX Blue Essentials	$28,195.64
Rate for Payer: BCBS of TX PPO	$31,329.70
Rate for Payer: Cigna Commercial	$35,041.33

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$21,556.46

Service Code	MSDRG 512
Min. Negotiated Rate	$12,233.50
Max. Negotiated Rate	$21,556.46
Rate for Payer: Aetna Commercial	$18,155.25
Rate for Payer: Aetna Medicare	$21,556.46
Rate for Payer: BCBS of TX Blue Advantage	$12,233.50
Rate for Payer: BCBS of TX Blue Essentials	$15,706.55
Rate for Payer: BCBS of TX PPO	$17,452.40
Rate for Payer: Cigna Commercial	$20,785.74

SHUNT, CAROTID ARTERY STRAIGHT 8,10,12,14FR 6''''LONG -- DHF

Facility

$652.50

Hospital Charge Code	81450108
Hospital Revenue Code	278
Min. Negotiated Rate	$163.12
Max. Negotiated Rate	$326.25
Rate for Payer: Aetna Commercial	$195.75
Rate for Payer: Cash Price	$574.20
Rate for Payer: Cigna Commercial	$163.12
Rate for Payer: Multiplan Auto	$326.25
Rate for Payer: Multiplan Commercial	$326.25
Rate for Payer: Multiplan Workers Comp	$326.25
Rate for Payer: Scott and White EPO/PPO	$326.25

SHUNT, CAROTID ARTERY STRAIGHT 8,10,12,14FR 6''''LONG -- DHF

Facility

$652.50

Hospital Charge Code	81450108
Hospital Revenue Code	278
Min. Negotiated Rate	$58.73
Max. Negotiated Rate	$326.25
Rate for Payer: Aetna Commercial	$195.75
Rate for Payer: Amerigroup CHIP/Medicaid	$58.73
Rate for Payer: BCBS of TX Blue Advantage	$195.75
Rate for Payer: BCBS of TX Blue Essentials	$234.90
Rate for Payer: BCBS of TX PPO	$261.00
Rate for Payer: Cash Price	$574.20
Rate for Payer: Multiplan Auto	$326.25
Rate for Payer: Multiplan Commercial	$326.25
Rate for Payer: Multiplan Workers Comp	$326.25
Rate for Payer: Scott and White EPO/PPO	$326.25
Rate for Payer: Superior Health Plan EPO	$88.74

Shuntogram for investigation of previously placed indwelling nonvascular shunt (eg, LeVeen shunt, ve

Facility

$10,000.00

Service Code	CPT 75809
Hospital Charge Code	36075809
Hospital Revenue Code	360
Min. Negotiated Rate	$68.39
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$68.39
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$100.55
Rate for Payer: Amerigroup Medicare	$100.55
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$100.55
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$82.53
Rate for Payer: Cigna Medicare	$100.55
Rate for Payer: Employer Direct Commercial	$100.55
Rate for Payer: Humana Medicare/TRICARE	$100.55
Rate for Payer: Molina CHIP/Medicaid	$82.53
Rate for Payer: Molina Dual Medicare/Medicaid	$100.55
Rate for Payer: Molina Medicare	$100.55
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	$82.53
Rate for Payer: Scott and White EPO/PPO	$100.85
Rate for Payer: Scott and White Medicare	$100.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$82.53
Rate for Payer: Superior Health Plan EPO	$100.55
Rate for Payer: Superior Health Plan Medicare	$100.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$100.55
Rate for Payer: Universal American Medicare	$100.55
Rate for Payer: Wellcare Medicare	$100.55
Rate for Payer: Wellmed Medicare	$100.55

Sialolithotomy; submandibular (submaxillary), complicated, intraoral

Facility

$10,000.00

Service Code	CPT 42335
Hospital Charge Code	36042335
Hospital Revenue Code	360
Min. Negotiated Rate	$252.76
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,416.73
Rate for Payer: Amerigroup CHIP/Medicaid	$252.76
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	$462.87
Rate for Payer: BCBS of TX Blue Essentials	$554.34
Rate for Payer: BCBS of TX Medicare	$2,944.49
Rate for Payer: BCBS of TX PPO	$698.47
Rate for Payer: Cigna Commercial	$6,670.12
Rate for Payer: Cigna Medicaid	$252.76
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	$252.76
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	$252.76
Rate for Payer: Scott and White EPO/PPO	$5,447.31
Rate for Payer: Scott and White Medicare	$2,944.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$252.76
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

SICKLING OF RBC REDUCTION

Facility

$120.00

Service Code	CPT 85660
Hospital Charge Code	1600568
Hospital Revenue Code	305
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$5.79
Rate for Payer: Aetna Medicare	$8.27
Rate for Payer: Amerigroup CHIP/Medicaid	$2.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.51
Rate for Payer: Amerigroup Medicare	$5.51
Rate for Payer: BCBS of TX Blue Advantage	$9.09
Rate for Payer: BCBS of TX Blue Essentials	$10.91
Rate for Payer: BCBS of TX Medicare	$5.51
Rate for Payer: BCBS of TX PPO	$12.18
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Cigna Medicare	$5.51
Rate for Payer: Employer Direct Commercial	$5.51
Rate for Payer: Humana Medicare/TRICARE	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Molina Dual Medicare/Medicaid	$5.51
Rate for Payer: Molina Medicare	$5.51
Rate for Payer: Multiplan Auto	$78.00
Rate for Payer: Multiplan Commercial	$78.00
Rate for Payer: Multiplan Workers Comp	$78.00
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$6.89
Rate for Payer: Scott and White Medicare	$5.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$5.51
Rate for Payer: Superior Health Plan Medicare	$5.51
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.51
Rate for Payer: Universal American Medicare	$5.51
Rate for Payer: Wellcare Medicare	$5.51
Rate for Payer: Wellmed Medicare	$5.51

SICKLING OF RBC REDUCTION

Facility

$120.00

Service Code	CPT 85660
Hospital Charge Code	1600568
Hospital Revenue Code	305
Rate for Payer: Cash Price	$105.60

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$19,257.19

Service Code	MSDRG 555
Min. Negotiated Rate	$10,912.54
Max. Negotiated Rate	$19,257.19
Rate for Payer: Aetna Commercial	$15,738.75
Rate for Payer: Aetna Medicare	$19,257.19
Rate for Payer: BCBS of TX Blue Advantage	$10,912.54
Rate for Payer: BCBS of TX Blue Essentials	$13,200.06
Rate for Payer: BCBS of TX PPO	$14,667.31
Rate for Payer: Cigna Commercial	$18,019.12

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC

Facility

$13,106.62

Service Code	MSDRG 556
Min. Negotiated Rate	$6,392.38
Max. Negotiated Rate	$13,106.62
Rate for Payer: Aetna Commercial	$9,274.50
Rate for Payer: Aetna Medicare	$13,106.62
Rate for Payer: BCBS of TX Blue Advantage	$6,392.38
Rate for Payer: BCBS of TX Blue Essentials	$7,921.90
Rate for Payer: BCBS of TX PPO	$8,802.45
Rate for Payer: Cigna Commercial	$10,618.27

SIGNS AND SYMPTOMS WITH MCC

Facility

$17,679.40

Service Code	MSDRG 947
Min. Negotiated Rate	$9,773.04
Max. Negotiated Rate	$17,679.40
Rate for Payer: Aetna Commercial	$14,080.50
Rate for Payer: Aetna Medicare	$17,679.40
Rate for Payer: BCBS of TX Blue Advantage	$9,773.04
Rate for Payer: BCBS of TX Blue Essentials	$12,440.59
Rate for Payer: BCBS of TX PPO	$13,823.41
Rate for Payer: Cigna Commercial	$16,120.61

SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$12,856.14

Service Code	MSDRG 948
Min. Negotiated Rate	$6,418.18
Max. Negotiated Rate	$12,856.14
Rate for Payer: Aetna Commercial	$9,011.25
Rate for Payer: Aetna Medicare	$12,856.14
Rate for Payer: BCBS of TX Blue Advantage	$6,418.18
Rate for Payer: BCBS of TX Blue Essentials	$8,050.88
Rate for Payer: BCBS of TX PPO	$8,945.77
Rate for Payer: Cigna Commercial	$10,316.88

silver sulfADIAZINE 1% Cream 50 g

Facility

$29.00

Service Code	HCPCS J3490
Hospital Charge Code	77812704
Hospital Revenue Code	250
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$18.85
Rate for Payer: Amerigroup CHIP/Medicaid	$2.61
Rate for Payer: BCBS of TX Blue Advantage	$8.70
Rate for Payer: BCBS of TX Blue Essentials	$10.44
Rate for Payer: BCBS of TX PPO	$11.60
Rate for Payer: Cash Price	$19.72
Rate for Payer: Multiplan Auto	$18.85
Rate for Payer: Multiplan Commercial	$18.85
Rate for Payer: Multiplan Workers Comp	$18.85
Rate for Payer: Scott and White EPO/PPO	$14.50
Rate for Payer: Superior Health Plan EPO	$3.94

silver sulfADIAZINE 1% Cream 50 g

Facility

$29.00

Service Code	HCPCS J3490
Hospital Charge Code	77812704
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.72

Know your out-of-pocket cost for care.

All Charges