White Rock Medical Center

All Charges

Charge

Type

Setting

Price

simethicone 40 mg/0.6 mL Oral Liquid 30 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77813459
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

simethicone 40 mg/0.6 mL Oral Liquid 30 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77813459
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

simethicone 80 mg Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77813565
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan EPO	$1.04

simethicone 80 mg Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77813565
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$13,083.09

Service Code	MSDRG 194
Min. Negotiated Rate	$8,143.34
Max. Negotiated Rate	$13,083.09
Rate for Payer: Aetna Commercial	$9,249.75
Rate for Payer: Aetna Medicare	$13,083.09
Rate for Payer: BCBS of TX Blue Advantage	$8,143.34
Rate for Payer: BCBS of TX Blue Essentials	$9,289.16
Rate for Payer: BCBS of TX PPO	$10,321.69
Rate for Payer: Cigna Commercial	$10,589.94

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$18,482.21

Service Code	MSDRG 193
Min. Negotiated Rate	$11,919.60
Max. Negotiated Rate	$18,482.21
Rate for Payer: Aetna Commercial	$14,924.25
Rate for Payer: Aetna Medicare	$18,482.21
Rate for Payer: BCBS of TX Blue Advantage	$11,919.60
Rate for Payer: BCBS of TX Blue Essentials	$13,587.03
Rate for Payer: BCBS of TX PPO	$15,097.28
Rate for Payer: Cigna Commercial	$17,086.61

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$10,978.65

Service Code	MSDRG 195
Min. Negotiated Rate	$6,044.08
Max. Negotiated Rate	$10,978.65
Rate for Payer: Aetna Commercial	$7,038.00
Rate for Payer: Aetna Medicare	$10,978.65
Rate for Payer: BCBS of TX Blue Advantage	$6,044.08
Rate for Payer: BCBS of TX Blue Essentials	$7,087.09
Rate for Payer: BCBS of TX PPO	$7,874.85
Rate for Payer: Cigna Commercial	$8,057.73

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$67,770.70

Service Code	MSDRG 008
Min. Negotiated Rate	$47,183.04
Max. Negotiated Rate	$67,770.70
Rate for Payer: Aetna Commercial	$59,194.12
Rate for Payer: Aetna Medicare	$60,603.89
Rate for Payer: BCBS of TX Blue Advantage	$47,183.04
Rate for Payer: BCBS of TX Blue Essentials	$54,164.43
Rate for Payer: BCBS of TX PPO	$60,185.03
Rate for Payer: Cigna Commercial	$67,770.70

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS

Facility

$102,956.28

Service Code	MSDRG 019
Min. Negotiated Rate	$89,845.32
Max. Negotiated Rate	$102,956.28
Rate for Payer: Aetna Commercial	$89,926.88
Rate for Payer: Aetna Medicare	$89,845.32
Rate for Payer: Cigna Commercial	$102,956.28

SINUS AND MASTOID PROCEDURES WITH CC/MCC

Facility

$34,159.05

Service Code	MSDRG 135
Min. Negotiated Rate	$17,322.12
Max. Negotiated Rate	$34,159.05
Rate for Payer: Aetna Commercial	$29,836.12
Rate for Payer: Aetna Medicare	$32,670.48
Rate for Payer: BCBS of TX Blue Advantage	$17,322.12
Rate for Payer: BCBS of TX Blue Essentials	$23,715.13
Rate for Payer: BCBS of TX PPO	$26,351.16
Rate for Payer: Cigna Commercial	$34,159.05

SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC

Facility

$15,460.47

Service Code	MSDRG 136
Min. Negotiated Rate	$9,529.66
Max. Negotiated Rate	$15,460.47
Rate for Payer: Aetna Commercial	$10,564.88
Rate for Payer: Aetna Medicare	$15,460.47
Rate for Payer: BCBS of TX Blue Advantage	$9,529.66
Rate for Payer: BCBS of TX Blue Essentials	$12,511.79
Rate for Payer: BCBS of TX PPO	$13,902.52
Rate for Payer: Cigna Commercial	$12,095.61

SIZER BREAST IMPLANT

Facility

$1,265.06

Hospital Charge Code	8592512
Hospital Revenue Code	278
Min. Negotiated Rate	$316.26
Max. Negotiated Rate	$632.53
Rate for Payer: Aetna Commercial	$379.52
Rate for Payer: Cash Price	$1,113.25
Rate for Payer: Cigna Commercial	$316.26
Rate for Payer: Multiplan Auto	$632.53
Rate for Payer: Multiplan Commercial	$632.53
Rate for Payer: Multiplan Workers Comp	$632.53
Rate for Payer: Scott and White EPO/PPO	$632.53

SIZER BREAST IMPLANT

Facility

$1,265.06

Hospital Charge Code	8592512
Hospital Revenue Code	278
Min. Negotiated Rate	$113.86
Max. Negotiated Rate	$632.53
Rate for Payer: Aetna Commercial	$379.52
Rate for Payer: Amerigroup CHIP/Medicaid	$113.86
Rate for Payer: BCBS of TX Blue Advantage	$379.52
Rate for Payer: BCBS of TX Blue Essentials	$455.42
Rate for Payer: BCBS of TX PPO	$506.02
Rate for Payer: Cash Price	$1,113.25
Rate for Payer: Multiplan Auto	$632.53
Rate for Payer: Multiplan Commercial	$632.53
Rate for Payer: Multiplan Workers Comp	$632.53
Rate for Payer: Scott and White EPO/PPO	$632.53
Rate for Payer: Superior Health Plan EPO	$172.05

Sjogren's Anti-SS-A SO

Facility

$230.00

Service Code	CPT 86235
Hospital Charge Code	1701143
Hospital Revenue Code	302
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$149.50
Rate for Payer: Aetna Commercial	$18.83
Rate for Payer: Aetna Medicare	$26.89
Rate for Payer: Amerigroup CHIP/Medicaid	$6.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.93
Rate for Payer: Amerigroup Medicare	$17.93
Rate for Payer: BCBS of TX Blue Advantage	$29.58
Rate for Payer: BCBS of TX Blue Essentials	$35.50
Rate for Payer: BCBS of TX Medicare	$17.93
Rate for Payer: BCBS of TX PPO	$39.63
Rate for Payer: Cash Price	$202.40
Rate for Payer: Cash Price	$202.40
Rate for Payer: Cigna Medicaid	$17.93
Rate for Payer: Cigna Medicare	$17.93
Rate for Payer: Employer Direct Commercial	$17.93
Rate for Payer: Humana Medicare/TRICARE	$17.93
Rate for Payer: Molina CHIP/Medicaid	$17.93
Rate for Payer: Molina Dual Medicare/Medicaid	$17.93
Rate for Payer: Molina Medicare	$17.93
Rate for Payer: Multiplan Auto	$149.50
Rate for Payer: Multiplan Commercial	$149.50
Rate for Payer: Multiplan Workers Comp	$149.50
Rate for Payer: Parkland Medicaid	$17.93
Rate for Payer: Scott and White EPO/PPO	$22.41
Rate for Payer: Scott and White Medicare	$17.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.93
Rate for Payer: Superior Health Plan EPO	$17.93
Rate for Payer: Superior Health Plan Medicare	$17.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.93
Rate for Payer: Universal American Medicare	$17.93
Rate for Payer: Wellcare Medicare	$17.93
Rate for Payer: Wellmed Medicare	$17.93

Sjogren's Anti-SS-B SO

Facility

$230.00

Service Code	CPT 86235
Hospital Charge Code	1701143
Hospital Revenue Code	302
Rate for Payer: Cash Price	$202.40

Sjogren's Anti-SS-B SO

Facility

$230.00

Service Code	CPT 86235
Hospital Charge Code	1701143
Hospital Revenue Code	302
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$149.50
Rate for Payer: Aetna Commercial	$18.83
Rate for Payer: Aetna Medicare	$26.89
Rate for Payer: Amerigroup CHIP/Medicaid	$6.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.93
Rate for Payer: Amerigroup Medicare	$17.93
Rate for Payer: BCBS of TX Blue Advantage	$29.58
Rate for Payer: BCBS of TX Blue Essentials	$35.50
Rate for Payer: BCBS of TX Medicare	$17.93
Rate for Payer: BCBS of TX PPO	$39.63
Rate for Payer: Cash Price	$202.40
Rate for Payer: Cash Price	$202.40
Rate for Payer: Cigna Medicaid	$17.93
Rate for Payer: Cigna Medicare	$17.93
Rate for Payer: Employer Direct Commercial	$17.93
Rate for Payer: Humana Medicare/TRICARE	$17.93
Rate for Payer: Molina CHIP/Medicaid	$17.93
Rate for Payer: Molina Dual Medicare/Medicaid	$17.93
Rate for Payer: Molina Medicare	$17.93
Rate for Payer: Multiplan Auto	$149.50
Rate for Payer: Multiplan Commercial	$149.50
Rate for Payer: Multiplan Workers Comp	$149.50
Rate for Payer: Parkland Medicaid	$17.93
Rate for Payer: Scott and White EPO/PPO	$22.41
Rate for Payer: Scott and White Medicare	$17.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.93
Rate for Payer: Superior Health Plan EPO	$17.93
Rate for Payer: Superior Health Plan Medicare	$17.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.93
Rate for Payer: Universal American Medicare	$17.93
Rate for Payer: Wellcare Medicare	$17.93
Rate for Payer: Wellmed Medicare	$17.93

SKIN CLOS 1/4 -- DHF

Facility

$55.15

Hospital Charge Code	81850653
Hospital Revenue Code	272
Rate for Payer: Cash Price	$48.53

SKIN CLOS 1/4 -- DHF

Facility

$55.15

Hospital Charge Code	81850653
Hospital Revenue Code	272
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$35.85
Rate for Payer: Aetna Commercial	$30.33
Rate for Payer: Amerigroup CHIP/Medicaid	$4.96
Rate for Payer: BCBS of TX Blue Advantage	$16.55
Rate for Payer: BCBS of TX Blue Essentials	$19.85
Rate for Payer: BCBS of TX PPO	$22.06
Rate for Payer: Cash Price	$48.53
Rate for Payer: Multiplan Auto	$35.85
Rate for Payer: Multiplan Commercial	$35.85
Rate for Payer: Multiplan Workers Comp	$35.85
Rate for Payer: Scott and White EPO/PPO	$27.57
Rate for Payer: Superior Health Plan EPO	$7.50

SKIN DEBRIDEMENT WITH CC

Facility

$22,392.42

Service Code	MSDRG 571
Min. Negotiated Rate	$12,376.26
Max. Negotiated Rate	$22,392.42
Rate for Payer: Aetna Commercial	$19,033.88
Rate for Payer: Aetna Medicare	$22,392.42
Rate for Payer: BCBS of TX Blue Advantage	$12,376.26
Rate for Payer: BCBS of TX Blue Essentials	$17,572.23
Rate for Payer: BCBS of TX PPO	$19,525.45
Rate for Payer: Cigna Commercial	$21,791.67

SKIN DEBRIDEMENT WITH MCC

Facility

$37,637.94

Service Code	MSDRG 570
Min. Negotiated Rate	$20,391.46
Max. Negotiated Rate	$37,637.94
Rate for Payer: Aetna Commercial	$32,874.75
Rate for Payer: Aetna Medicare	$35,561.67
Rate for Payer: BCBS of TX Blue Advantage	$20,391.46
Rate for Payer: BCBS of TX Blue Essentials	$31,315.07
Rate for Payer: BCBS of TX PPO	$34,795.87
Rate for Payer: Cigna Commercial	$37,637.94

SKIN DEBRIDEMENT WITHOUT CC/MCC

Facility

$16,480.56

Service Code	MSDRG 572
Min. Negotiated Rate	$9,024.84
Max. Negotiated Rate	$16,480.56
Rate for Payer: Aetna Commercial	$12,820.50
Rate for Payer: Aetna Medicare	$16,480.56
Rate for Payer: BCBS of TX Blue Advantage	$9,024.84
Rate for Payer: BCBS of TX Blue Essentials	$12,161.97
Rate for Payer: BCBS of TX PPO	$13,513.83
Rate for Payer: Cigna Commercial	$14,678.05

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$34,120.41

Service Code	MSDRG 577
Min. Negotiated Rate	$19,684.54
Max. Negotiated Rate	$34,120.41
Rate for Payer: Aetna Commercial	$29,802.38
Rate for Payer: Aetna Medicare	$32,638.37
Rate for Payer: BCBS of TX Blue Advantage	$19,684.54
Rate for Payer: BCBS of TX Blue Essentials	$25,892.43
Rate for Payer: BCBS of TX PPO	$28,770.49
Rate for Payer: Cigna Commercial	$34,120.41

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$73,198.33

Service Code	MSDRG 576
Min. Negotiated Rate	$37,149.42
Max. Negotiated Rate	$73,198.33
Rate for Payer: Aetna Commercial	$63,934.88
Rate for Payer: Aetna Medicare	$65,114.60
Rate for Payer: BCBS of TX Blue Advantage	$37,149.42
Rate for Payer: BCBS of TX Blue Essentials	$50,363.94
Rate for Payer: BCBS of TX PPO	$55,962.11
Rate for Payer: Cigna Commercial	$73,198.33

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$21,521.12

Service Code	MSDRG 578
Min. Negotiated Rate	$11,896.38
Max. Negotiated Rate	$21,521.12
Rate for Payer: Aetna Commercial	$18,118.12
Rate for Payer: Aetna Medicare	$21,521.12
Rate for Payer: BCBS of TX Blue Advantage	$11,896.38
Rate for Payer: BCBS of TX Blue Essentials	$15,784.97
Rate for Payer: BCBS of TX PPO	$17,539.54
Rate for Payer: Cigna Commercial	$20,743.24

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$43,866.70

Service Code	MSDRG 574
Min. Negotiated Rate	$24,569.34
Max. Negotiated Rate	$43,866.70
Rate for Payer: Aetna Commercial	$38,315.25
Rate for Payer: Aetna Medicare	$40,738.15
Rate for Payer: BCBS of TX Blue Advantage	$24,569.34
Rate for Payer: BCBS of TX Blue Essentials	$31,430.64
Rate for Payer: BCBS of TX PPO	$34,924.29
Rate for Payer: Cigna Commercial	$43,866.70

Know your out-of-pocket cost for care.

All Charges