White Rock Medical Center

All Charges

Charge

Type

Setting

Price

sodium ferric gluconate complex 12.5 mg/mL IV Soln 5 mL

Facility

$128.19

Service Code	HCPCS J2916
Hospital Charge Code	77820216
Hospital Revenue Code	636
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$83.32
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.32
Rate for Payer: BCBS of TX Blue Essentials	$2.78
Rate for Payer: BCBS of TX PPO	$3.09
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cash Price	$87.17
Rate for Payer: Multiplan Auto	$83.32
Rate for Payer: Multiplan Commercial	$83.32
Rate for Payer: Multiplan Workers Comp	$83.32
Rate for Payer: Scott and White EPO/PPO	$64.09
Rate for Payer: Superior Health Plan EPO	$17.43

Sodium Level

Facility

$172.00

Service Code	CPT 84295
Hospital Charge Code	1602234
Hospital Revenue Code	301
Rate for Payer: Cash Price	$151.36

Sodium Level

Facility

$172.00

Service Code	CPT 84295
Hospital Charge Code	1602234
Hospital Revenue Code	301
Min. Negotiated Rate	$1.88
Max. Negotiated Rate	$111.80
Rate for Payer: Aetna Commercial	$5.06
Rate for Payer: Aetna Medicare	$7.21
Rate for Payer: Amerigroup CHIP/Medicaid	$1.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.81
Rate for Payer: Amerigroup Medicare	$4.81
Rate for Payer: BCBS of TX Blue Advantage	$7.94
Rate for Payer: BCBS of TX Blue Essentials	$9.52
Rate for Payer: BCBS of TX Medicare	$4.81
Rate for Payer: BCBS of TX PPO	$10.63
Rate for Payer: Cash Price	$151.36
Rate for Payer: Cash Price	$151.36
Rate for Payer: Cigna Medicaid	$4.81
Rate for Payer: Cigna Medicare	$4.81
Rate for Payer: Employer Direct Commercial	$4.81
Rate for Payer: Humana Medicare/TRICARE	$4.81
Rate for Payer: Molina CHIP/Medicaid	$4.81
Rate for Payer: Molina Dual Medicare/Medicaid	$4.81
Rate for Payer: Molina Medicare	$4.81
Rate for Payer: Multiplan Auto	$111.80
Rate for Payer: Multiplan Commercial	$111.80
Rate for Payer: Multiplan Workers Comp	$111.80
Rate for Payer: Parkland Medicaid	$4.81
Rate for Payer: Scott and White EPO/PPO	$6.01
Rate for Payer: Scott and White Medicare	$4.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.81
Rate for Payer: Superior Health Plan EPO	$4.81
Rate for Payer: Superior Health Plan Medicare	$4.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.81
Rate for Payer: Universal American Medicare	$4.81
Rate for Payer: Wellcare Medicare	$4.81
Rate for Payer: Wellmed Medicare	$4.81

Sodium Level 24 Hour Urine

Facility

$162.00

Service Code	CPT 84300
Hospital Charge Code	1601111
Hospital Revenue Code	301
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$105.30
Rate for Payer: Aetna Commercial	$5.32
Rate for Payer: Aetna Medicare	$7.59
Rate for Payer: Amerigroup CHIP/Medicaid	$1.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.06
Rate for Payer: Amerigroup Medicare	$5.06
Rate for Payer: BCBS of TX Blue Advantage	$8.35
Rate for Payer: BCBS of TX Blue Essentials	$10.02
Rate for Payer: BCBS of TX Medicare	$5.06
Rate for Payer: BCBS of TX PPO	$11.18
Rate for Payer: Cash Price	$142.56
Rate for Payer: Cash Price	$142.56
Rate for Payer: Cigna Medicaid	$5.06
Rate for Payer: Cigna Medicare	$5.06
Rate for Payer: Employer Direct Commercial	$5.06
Rate for Payer: Humana Medicare/TRICARE	$5.06
Rate for Payer: Molina CHIP/Medicaid	$5.06
Rate for Payer: Molina Dual Medicare/Medicaid	$5.06
Rate for Payer: Molina Medicare	$5.06
Rate for Payer: Multiplan Auto	$105.30
Rate for Payer: Multiplan Commercial	$105.30
Rate for Payer: Multiplan Workers Comp	$105.30
Rate for Payer: Parkland Medicaid	$5.06
Rate for Payer: Scott and White EPO/PPO	$6.33
Rate for Payer: Scott and White Medicare	$5.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.06
Rate for Payer: Superior Health Plan EPO	$5.06
Rate for Payer: Superior Health Plan Medicare	$5.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.06
Rate for Payer: Universal American Medicare	$5.06
Rate for Payer: Wellcare Medicare	$5.06
Rate for Payer: Wellmed Medicare	$5.06

Sodium Level Urine

Facility

$162.00

Service Code	CPT 84300
Hospital Charge Code	1601111
Hospital Revenue Code	301
Rate for Payer: Cash Price	$142.56

Sodium Level Urine

Facility

$162.00

Service Code	CPT 84300
Hospital Charge Code	1601111
Hospital Revenue Code	301
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$105.30
Rate for Payer: Aetna Commercial	$5.32
Rate for Payer: Aetna Medicare	$7.59
Rate for Payer: Amerigroup CHIP/Medicaid	$1.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.06
Rate for Payer: Amerigroup Medicare	$5.06
Rate for Payer: BCBS of TX Blue Advantage	$8.35
Rate for Payer: BCBS of TX Blue Essentials	$10.02
Rate for Payer: BCBS of TX Medicare	$5.06
Rate for Payer: BCBS of TX PPO	$11.18
Rate for Payer: Cash Price	$142.56
Rate for Payer: Cash Price	$142.56
Rate for Payer: Cigna Medicaid	$5.06
Rate for Payer: Cigna Medicare	$5.06
Rate for Payer: Employer Direct Commercial	$5.06
Rate for Payer: Humana Medicare/TRICARE	$5.06
Rate for Payer: Molina CHIP/Medicaid	$5.06
Rate for Payer: Molina Dual Medicare/Medicaid	$5.06
Rate for Payer: Molina Medicare	$5.06
Rate for Payer: Multiplan Auto	$105.30
Rate for Payer: Multiplan Commercial	$105.30
Rate for Payer: Multiplan Workers Comp	$105.30
Rate for Payer: Parkland Medicaid	$5.06
Rate for Payer: Scott and White EPO/PPO	$6.33
Rate for Payer: Scott and White Medicare	$5.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.06
Rate for Payer: Superior Health Plan EPO	$5.06
Rate for Payer: Superior Health Plan Medicare	$5.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.06
Rate for Payer: Universal American Medicare	$5.06
Rate for Payer: Wellcare Medicare	$5.06
Rate for Payer: Wellmed Medicare	$5.06

sodium polystyrene sulfonate 15 g/60 mL Oral Susp 60 mL

Facility

$51.60

Service Code	HCPCS J3490
Hospital Charge Code	77823134
Hospital Revenue Code	250
Rate for Payer: Cash Price	$35.09

sodium polystyrene sulfonate 15 g/60 mL Oral Susp 60 mL

Facility

$51.60

Service Code	HCPCS J3490
Hospital Charge Code	77823134
Hospital Revenue Code	250
Min. Negotiated Rate	$4.64
Max. Negotiated Rate	$33.54
Rate for Payer: Amerigroup CHIP/Medicaid	$4.64
Rate for Payer: BCBS of TX Blue Advantage	$15.48
Rate for Payer: BCBS of TX Blue Essentials	$18.58
Rate for Payer: BCBS of TX PPO	$20.64
Rate for Payer: Cash Price	$35.09
Rate for Payer: Multiplan Auto	$33.54
Rate for Payer: Multiplan Commercial	$33.54
Rate for Payer: Multiplan Workers Comp	$33.54
Rate for Payer: Scott and White EPO/PPO	$25.80
Rate for Payer: Superior Health Plan EPO	$7.02

SOFT TISSUE PROCEDURES WITH CC

Facility

$22,861.24

Service Code	MSDRG 501
Min. Negotiated Rate	$14,049.82
Max. Negotiated Rate	$22,861.24
Rate for Payer: Aetna Commercial	$19,526.62
Rate for Payer: Aetna Medicare	$22,861.24
Rate for Payer: BCBS of TX Blue Advantage	$14,049.82
Rate for Payer: BCBS of TX Blue Essentials	$17,412.28
Rate for Payer: BCBS of TX PPO	$19,347.73
Rate for Payer: Cigna Commercial	$22,355.82

SOFT TISSUE PROCEDURES WITH MCC

Facility

$41,767.26

Service Code	MSDRG 500
Min. Negotiated Rate	$26,856.08
Max. Negotiated Rate	$41,767.26
Rate for Payer: Aetna Commercial	$36,481.50
Rate for Payer: Aetna Medicare	$38,993.40
Rate for Payer: BCBS of TX Blue Advantage	$26,856.08
Rate for Payer: BCBS of TX Blue Essentials	$31,658.69
Rate for Payer: BCBS of TX PPO	$35,177.69
Rate for Payer: Cigna Commercial	$41,767.26

SOFT TISSUE PROCEDURES WITHOUT CC/MCC

Facility

$19,082.73

Service Code	MSDRG 502
Min. Negotiated Rate	$10,344.94
Max. Negotiated Rate	$19,082.73
Rate for Payer: Aetna Commercial	$15,555.38
Rate for Payer: Aetna Medicare	$19,082.73
Rate for Payer: BCBS of TX Blue Advantage	$10,344.94
Rate for Payer: BCBS of TX Blue Essentials	$13,322.86
Rate for Payer: BCBS of TX PPO	$14,803.75
Rate for Payer: Cigna Commercial	$17,809.18

SONIC ANCHOR SYSTEM

Facility

$2,007.59

Hospital Charge Code	114023
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,766.68

SONIC ANCHOR SYSTEM

Facility

$2,007.59

Hospital Charge Code	114023
Hospital Revenue Code	272
Min. Negotiated Rate	$180.68
Max. Negotiated Rate	$1,304.93
Rate for Payer: Aetna Commercial	$1,104.17
Rate for Payer: Amerigroup CHIP/Medicaid	$180.68
Rate for Payer: BCBS of TX Blue Advantage	$602.28
Rate for Payer: BCBS of TX Blue Essentials	$722.73
Rate for Payer: BCBS of TX PPO	$803.04
Rate for Payer: Cash Price	$1,766.68
Rate for Payer: Multiplan Auto	$1,304.93
Rate for Payer: Multiplan Commercial	$1,304.93
Rate for Payer: Multiplan Workers Comp	$1,304.93
Rate for Payer: Scott and White EPO/PPO	$1,003.79
Rate for Payer: Superior Health Plan EPO	$273.03

Sp bone algrft morsel add-on

Facility

$10,000.00

Service Code	CPT 20930
Hospital Charge Code	36020930
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$10,000.00
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

Speed trap graft prepkit

Facility

$490.32

Hospital Charge Code	8602528
Hospital Revenue Code	270
Min. Negotiated Rate	$44.13
Max. Negotiated Rate	$318.71
Rate for Payer: Aetna Commercial	$269.68
Rate for Payer: Amerigroup CHIP/Medicaid	$44.13
Rate for Payer: BCBS of TX Blue Advantage	$147.10
Rate for Payer: BCBS of TX Blue Essentials	$176.52
Rate for Payer: BCBS of TX PPO	$196.13
Rate for Payer: Cash Price	$431.48
Rate for Payer: Multiplan Auto	$318.71
Rate for Payer: Multiplan Commercial	$318.71
Rate for Payer: Multiplan Workers Comp	$318.71
Rate for Payer: Scott and White EPO/PPO	$245.16
Rate for Payer: Superior Health Plan EPO	$66.68

Speed trap graft prepkit

Facility

$490.32

Hospital Charge Code	8602528
Hospital Revenue Code	270
Rate for Payer: Cash Price	$431.48

SPHINCTRTOME/HYDRATOME -- DHF

Facility

$1,770.60

Hospital Charge Code	80341126
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,558.13

SPHINCTRTOME/HYDRATOME -- DHF

Facility

$1,770.60

Hospital Charge Code	80341126
Hospital Revenue Code	272
Min. Negotiated Rate	$159.35
Max. Negotiated Rate	$1,150.89
Rate for Payer: Aetna Commercial	$973.83
Rate for Payer: Amerigroup CHIP/Medicaid	$159.35
Rate for Payer: BCBS of TX Blue Advantage	$531.18
Rate for Payer: BCBS of TX Blue Essentials	$637.42
Rate for Payer: BCBS of TX PPO	$708.24
Rate for Payer: Cash Price	$1,558.13
Rate for Payer: Multiplan Auto	$1,150.89
Rate for Payer: Multiplan Commercial	$1,150.89
Rate for Payer: Multiplan Workers Comp	$1,150.89
Rate for Payer: Scott and White EPO/PPO	$885.30
Rate for Payer: Superior Health Plan EPO	$240.80

SPINAL DISORDERS AND INJURIES WITH CC/MCC

Facility

$25,096.26

Service Code	MSDRG 052
Min. Negotiated Rate	$13,629.28
Max. Negotiated Rate	$25,096.26
Rate for Payer: Aetna Commercial	$21,875.62
Rate for Payer: Aetna Medicare	$25,096.26
Rate for Payer: BCBS of TX Blue Advantage	$13,629.28
Rate for Payer: BCBS of TX Blue Essentials	$17,546.43
Rate for Payer: BCBS of TX PPO	$19,496.79
Rate for Payer: Cigna Commercial	$25,045.16

SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC

Facility

$14,812.88

Service Code	MSDRG 053
Min. Negotiated Rate	$7,394.28
Max. Negotiated Rate	$14,812.88
Rate for Payer: Aetna Commercial	$11,067.75
Rate for Payer: Aetna Medicare	$14,812.88
Rate for Payer: BCBS of TX Blue Advantage	$7,394.28
Rate for Payer: BCBS of TX Blue Essentials	$9,432.60
Rate for Payer: BCBS of TX PPO	$10,481.07
Rate for Payer: Cigna Commercial	$12,671.34

SPINAL FUSION EXCEPT CERVICAL WITH MCC

Facility

$85,424.02

Service Code	MSDRG 459
Min. Negotiated Rate	$56,357.52
Max. Negotiated Rate	$85,424.02
Rate for Payer: Aetna Commercial	$74,613.38
Rate for Payer: Aetna Medicare	$75,274.90
Rate for Payer: BCBS of TX Blue Advantage	$56,357.52
Rate for Payer: BCBS of TX Blue Essentials	$65,884.75
Rate for Payer: BCBS of TX PPO	$73,208.12
Rate for Payer: Cigna Commercial	$85,424.02

SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$47,113.75

Service Code	MSDRG 460
Min. Negotiated Rate	$34,308.84
Max. Negotiated Rate	$47,113.75
Rate for Payer: Aetna Commercial	$41,151.38
Rate for Payer: Aetna Medicare	$43,436.68
Rate for Payer: BCBS of TX Blue Advantage	$34,308.84
Rate for Payer: BCBS of TX Blue Essentials	$41,662.96
Rate for Payer: BCBS of TX PPO	$46,293.97
Rate for Payer: Cigna Commercial	$47,113.75

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC

Facility

$78,249.86

Service Code	MSDRG 457
Min. Negotiated Rate	$60,649.78
Max. Negotiated Rate	$78,249.86
Rate for Payer: Aetna Commercial	$68,347.12
Rate for Payer: Aetna Medicare	$69,312.74
Rate for Payer: BCBS of TX Blue Advantage	$60,649.78
Rate for Payer: BCBS of TX Blue Essentials	$67,533.73
Rate for Payer: BCBS of TX PPO	$75,040.38
Rate for Payer: Cigna Commercial	$78,249.86

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC

Facility

$108,570.67

Service Code	MSDRG 456
Min. Negotiated Rate	$85,275.88
Max. Negotiated Rate	$108,570.67
Rate for Payer: Aetna Commercial	$94,830.75
Rate for Payer: Aetna Medicare	$94,511.25
Rate for Payer: BCBS of TX Blue Advantage	$85,275.88
Rate for Payer: BCBS of TX Blue Essentials	$94,162.94
Rate for Payer: BCBS of TX PPO	$104,629.54
Rate for Payer: Cigna Commercial	$108,570.67

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC

Facility

$58,719.68

Service Code	MSDRG 458
Min. Negotiated Rate	$45,914.54
Max. Negotiated Rate	$58,719.68
Rate for Payer: Aetna Commercial	$50,973.75
Rate for Payer: Aetna Medicare	$52,782.40
Rate for Payer: BCBS of TX Blue Advantage	$45,914.54
Rate for Payer: BCBS of TX Blue Essentials	$52,845.66
Rate for Payer: BCBS of TX PPO	$58,719.68
Rate for Payer: Cigna Commercial	$58,359.28

Know your out-of-pocket cost for care.

All Charges