White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS

Facility

$44,155.22

Service Code	MSDRG 029
Min. Negotiated Rate	$27,418.52
Max. Negotiated Rate	$44,155.22
Rate for Payer: Aetna Commercial	$38,567.25
Rate for Payer: Aetna Medicare	$40,977.93
Rate for Payer: BCBS of TX Blue Advantage	$27,418.52
Rate for Payer: BCBS of TX Blue Essentials	$32,563.67
Rate for Payer: BCBS of TX PPO	$36,183.26
Rate for Payer: Cigna Commercial	$44,155.22

SPINAL PROCEDURES WITH MCC

Facility

$77,616.17

Service Code	MSDRG 028
Min. Negotiated Rate	$47,677.54
Max. Negotiated Rate	$77,616.17
Rate for Payer: Aetna Commercial	$67,793.62
Rate for Payer: Aetna Medicare	$68,786.09
Rate for Payer: BCBS of TX Blue Advantage	$47,677.54
Rate for Payer: BCBS of TX Blue Essentials	$55,462.56
Rate for Payer: BCBS of TX PPO	$61,627.46
Rate for Payer: Cigna Commercial	$77,616.17

SPINAL PROCEDURES WITHOUT CC/MCC

Facility

$29,868.72

Service Code	MSDRG 030
Min. Negotiated Rate	$16,346.88
Max. Negotiated Rate	$29,868.72
Rate for Payer: Aetna Commercial	$26,088.75
Rate for Payer: Aetna Medicare	$29,104.95
Rate for Payer: BCBS of TX Blue Advantage	$16,346.88
Rate for Payer: BCBS of TX Blue Essentials	$22,451.05
Rate for Payer: BCBS of TX PPO	$24,946.58
Rate for Payer: Cigna Commercial	$29,868.72

Spinal puncture, lumbar, diagnostic

Facility

$10,000.00

Service Code	CPT 62270
Hospital Charge Code	36062270
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$948.67
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$632.45
Rate for Payer: Amerigroup Medicare	$632.45
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$632.45
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cigna Commercial	$1,432.68
Rate for Payer: Cigna Medicaid	$262.86
Rate for Payer: Cigna Medicare	$632.45
Rate for Payer: Employer Direct Commercial	$632.45
Rate for Payer: Humana Medicare/TRICARE	$632.45
Rate for Payer: Molina CHIP/Medicaid	$262.86
Rate for Payer: Molina Dual Medicare/Medicaid	$632.45
Rate for Payer: Molina Medicare	$632.45
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	$262.86
Rate for Payer: Scott and White EPO/PPO	$1,170.03
Rate for Payer: Scott and White Medicare	$632.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$262.86
Rate for Payer: Superior Health Plan EPO	$632.45
Rate for Payer: Superior Health Plan Medicare	$632.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$632.45
Rate for Payer: Universal American Medicare	$632.45
Rate for Payer: Wellcare Medicare	$632.45
Rate for Payer: Wellmed Medicare	$632.45

Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)

Facility

$10,000.00

Service Code	CPT 62272
Hospital Charge Code	36062272
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$948.67
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$632.45
Rate for Payer: Amerigroup Medicare	$632.45
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$632.45
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cigna Commercial	$1,432.68
Rate for Payer: Cigna Medicaid	$262.86
Rate for Payer: Cigna Medicare	$632.45
Rate for Payer: Employer Direct Commercial	$632.45
Rate for Payer: Humana Medicare/TRICARE	$632.45
Rate for Payer: Molina CHIP/Medicaid	$262.86
Rate for Payer: Molina Dual Medicare/Medicaid	$632.45
Rate for Payer: Molina Medicare	$632.45
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	$262.86
Rate for Payer: Scott and White EPO/PPO	$1,170.03
Rate for Payer: Scott and White Medicare	$632.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$262.86
Rate for Payer: Superior Health Plan EPO	$632.45
Rate for Payer: Superior Health Plan Medicare	$632.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$632.45
Rate for Payer: Universal American Medicare	$632.45
Rate for Payer: Wellcare Medicare	$632.45
Rate for Payer: Wellmed Medicare	$632.45

SPINAL PUNCTURE THERAPTC

Facility

$1,519.00

Service Code	CPT 62272
Hospital Charge Code	4612272
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,336.72

SPINAL PUNCTURE THERAPTC

Facility

$1,519.00

Service Code	CPT 62272
Hospital Charge Code	4612272
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$948.67
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$632.45
Rate for Payer: Amerigroup Medicare	$632.45
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$632.45
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$1,336.72
Rate for Payer: Cash Price	$1,336.72
Rate for Payer: Cigna Commercial	$1,432.68
Rate for Payer: Cigna Medicaid	$262.86
Rate for Payer: Cigna Medicare	$632.45
Rate for Payer: Employer Direct Commercial	$632.45
Rate for Payer: Humana Medicare/TRICARE	$632.45
Rate for Payer: Molina CHIP/Medicaid	$262.86
Rate for Payer: Molina Dual Medicare/Medicaid	$632.45
Rate for Payer: Molina Medicare	$632.45
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	$262.86
Rate for Payer: Scott and White EPO/PPO	$1,170.03
Rate for Payer: Scott and White Medicare	$632.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$262.86
Rate for Payer: Superior Health Plan EPO	$632.45
Rate for Payer: Superior Health Plan Medicare	$632.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$632.45
Rate for Payer: Universal American Medicare	$632.45
Rate for Payer: Wellcare Medicare	$632.45
Rate for Payer: Wellmed Medicare	$632.45

Spirometry

Facility

$295.00

Service Code	CPT 94010
Hospital Charge Code	4000162
Hospital Revenue Code	460
Min. Negotiated Rate	$26.55
Max. Negotiated Rate	$323.61
Rate for Payer: Aetna Commercial	$162.25
Rate for Payer: Aetna Medicare	$214.29
Rate for Payer: Amerigroup CHIP/Medicaid	$26.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$142.86
Rate for Payer: Amerigroup Medicare	$142.86
Rate for Payer: BCBS of TX Blue Advantage	$240.73
Rate for Payer: BCBS of TX Blue Essentials	$287.77
Rate for Payer: BCBS of TX Medicare	$142.86
Rate for Payer: BCBS of TX PPO	$320.97
Rate for Payer: Cash Price	$259.60
Rate for Payer: Cash Price	$259.60
Rate for Payer: Cash Price	$259.60
Rate for Payer: Cigna Commercial	$323.61
Rate for Payer: Cigna Medicare	$142.86
Rate for Payer: Employer Direct Commercial	$142.86
Rate for Payer: Humana Medicare/TRICARE	$142.86
Rate for Payer: Molina Dual Medicare/Medicaid	$142.86
Rate for Payer: Molina Medicare	$142.86
Rate for Payer: Multiplan Auto	$191.75
Rate for Payer: Multiplan Commercial	$191.75
Rate for Payer: Multiplan Workers Comp	$191.75
Rate for Payer: Scott and White EPO/PPO	$33.73
Rate for Payer: Scott and White Medicare	$142.86
Rate for Payer: Superior Health Plan EPO	$142.86
Rate for Payer: Superior Health Plan Medicare	$142.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$142.86
Rate for Payer: Universal American Medicare	$142.86
Rate for Payer: Wellcare Medicare	$142.86
Rate for Payer: Wellmed Medicare	$142.86

Spirometry

Facility

$295.00

Service Code	CPT 94010
Hospital Charge Code	4000162
Hospital Revenue Code	460
Rate for Payer: Cash Price	$259.60

Spirometry before & after

Facility

$694.00

Service Code	CPT 94060
Hospital Charge Code	4000170
Hospital Revenue Code	460
Min. Negotiated Rate	$48.15
Max. Negotiated Rate	$650.27
Rate for Payer: Aetna Commercial	$381.70
Rate for Payer: Aetna Medicare	$430.59
Rate for Payer: Amerigroup CHIP/Medicaid	$62.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$287.06
Rate for Payer: Amerigroup Medicare	$287.06
Rate for Payer: BCBS of TX Blue Advantage	$82.15
Rate for Payer: BCBS of TX Blue Essentials	$98.20
Rate for Payer: BCBS of TX Medicare	$287.06
Rate for Payer: BCBS of TX PPO	$109.53
Rate for Payer: Cash Price	$610.72
Rate for Payer: Cash Price	$610.72
Rate for Payer: Cash Price	$610.72
Rate for Payer: Cigna Commercial	$650.27
Rate for Payer: Cigna Medicare	$287.06
Rate for Payer: Employer Direct Commercial	$287.06
Rate for Payer: Humana Medicare/TRICARE	$287.06
Rate for Payer: Molina Dual Medicare/Medicaid	$287.06
Rate for Payer: Molina Medicare	$287.06
Rate for Payer: Multiplan Auto	$451.10
Rate for Payer: Multiplan Commercial	$451.10
Rate for Payer: Multiplan Workers Comp	$451.10
Rate for Payer: Scott and White EPO/PPO	$48.15
Rate for Payer: Scott and White Medicare	$287.06
Rate for Payer: Superior Health Plan EPO	$287.06
Rate for Payer: Superior Health Plan Medicare	$287.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$287.06
Rate for Payer: Universal American Medicare	$287.06
Rate for Payer: Wellcare Medicare	$287.06
Rate for Payer: Wellmed Medicare	$287.06

Spirometry before & after

Facility

$694.00

Service Code	CPT 94060
Hospital Charge Code	4000170
Hospital Revenue Code	460
Rate for Payer: Cash Price	$610.72

spironolactone 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77826262
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

spironolactone 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77826262
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

SPLENIC PROCEDURES WITH CC

Facility

$36,291.98

Service Code	MSDRG 800
Min. Negotiated Rate	$24,452.38
Max. Negotiated Rate	$36,291.98
Rate for Payer: Aetna Commercial	$31,699.12
Rate for Payer: Aetna Medicare	$34,443.09
Rate for Payer: BCBS of TX Blue Advantage	$24,452.38
Rate for Payer: BCBS of TX Blue Essentials	$27,105.95
Rate for Payer: BCBS of TX PPO	$30,118.89
Rate for Payer: Cigna Commercial	$36,291.98

SPLENIC PROCEDURES WITH MCC

Facility

$63,815.25

Service Code	MSDRG 799
Min. Negotiated Rate	$43,848.82
Max. Negotiated Rate	$63,815.25
Rate for Payer: Aetna Commercial	$55,739.25
Rate for Payer: Aetna Medicare	$57,316.67
Rate for Payer: BCBS of TX Blue Advantage	$43,848.82
Rate for Payer: BCBS of TX Blue Essentials	$48,515.81
Rate for Payer: BCBS of TX PPO	$53,908.55
Rate for Payer: Cigna Commercial	$63,815.25

SPLENIC PROCEDURES WITHOUT CC/MCC

Facility

$23,439.28

Service Code	MSDRG 801
Min. Negotiated Rate	$14,309.54
Max. Negotiated Rate	$23,439.28
Rate for Payer: Aetna Commercial	$20,134.12
Rate for Payer: Aetna Medicare	$23,439.28
Rate for Payer: BCBS of TX Blue Advantage	$14,309.54
Rate for Payer: BCBS of TX Blue Essentials	$16,059.46
Rate for Payer: BCBS of TX PPO	$17,844.54
Rate for Payer: Cigna Commercial	$23,051.34

SPLIT GRAFT FACE, NECK, FEET

Facility

$10,000.00

Service Code	CPT 15120
Hospital Charge Code	36015120
Hospital Revenue Code	360
Min. Negotiated Rate	$1,457.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,921.57
Rate for Payer: Amerigroup CHIP/Medicaid	$1,457.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Amerigroup Medicare	$3,281.05
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,281.05
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cigna Commercial	$7,432.53
Rate for Payer: Cigna Medicaid	$1,457.62
Rate for Payer: Cigna Medicare	$3,281.05
Rate for Payer: Employer Direct Commercial	$3,281.05
Rate for Payer: Humana Medicare/TRICARE	$3,281.05
Rate for Payer: Molina CHIP/Medicaid	$1,457.62
Rate for Payer: Molina Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Molina Medicare	$3,281.05
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	$1,457.62
Rate for Payer: Scott and White EPO/PPO	$6,069.94
Rate for Payer: Scott and White Medicare	$3,281.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,457.62
Rate for Payer: Superior Health Plan EPO	$3,281.05
Rate for Payer: Superior Health Plan Medicare	$3,281.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Universal American Medicare	$3,281.05
Rate for Payer: Wellcare Medicare	$3,281.05
Rate for Payer: Wellmed Medicare	$3,281.05

SPLNT IMOBL SHLD -- DHF

Facility

$284.49

Hospital Charge Code	81145757
Hospital Revenue Code	270
Min. Negotiated Rate	$25.60
Max. Negotiated Rate	$184.92
Rate for Payer: Aetna Commercial	$156.47
Rate for Payer: Amerigroup CHIP/Medicaid	$25.60
Rate for Payer: BCBS of TX Blue Advantage	$85.35
Rate for Payer: BCBS of TX Blue Essentials	$102.42
Rate for Payer: BCBS of TX PPO	$113.80
Rate for Payer: Cash Price	$250.35
Rate for Payer: Multiplan Auto	$184.92
Rate for Payer: Multiplan Commercial	$184.92
Rate for Payer: Multiplan Workers Comp	$184.92
Rate for Payer: Scott and White EPO/PPO	$142.25
Rate for Payer: Superior Health Plan EPO	$38.69

SPLNT IMOBL SHLD -- DHF

Facility

$284.49

Hospital Charge Code	81145757
Hospital Revenue Code	270
Rate for Payer: Cash Price	$250.35

SPLNT KNEE UNN -- DHF

Facility

$284.49

Hospital Charge Code	81145906
Hospital Revenue Code	270
Min. Negotiated Rate	$25.60
Max. Negotiated Rate	$184.92
Rate for Payer: Aetna Commercial	$156.47
Rate for Payer: Amerigroup CHIP/Medicaid	$25.60
Rate for Payer: BCBS of TX Blue Advantage	$85.35
Rate for Payer: BCBS of TX Blue Essentials	$102.42
Rate for Payer: BCBS of TX PPO	$113.80
Rate for Payer: Cash Price	$250.35
Rate for Payer: Multiplan Auto	$184.92
Rate for Payer: Multiplan Commercial	$184.92
Rate for Payer: Multiplan Workers Comp	$184.92
Rate for Payer: Scott and White EPO/PPO	$142.25
Rate for Payer: Superior Health Plan EPO	$38.69

SPLNT KNEE UNN -- DHF

Facility

$284.49

Hospital Charge Code	81145906
Hospital Revenue Code	270
Rate for Payer: Cash Price	$250.35

SPLNT LEG LONG A -- DHF

Facility

$388.14

Hospital Charge Code	81036055
Hospital Revenue Code	270
Rate for Payer: Cash Price	$341.56

SPLNT LEG LONG A -- DHF

Facility

$388.14

Hospital Charge Code	81036055
Hospital Revenue Code	270
Min. Negotiated Rate	$34.93
Max. Negotiated Rate	$252.29
Rate for Payer: Aetna Commercial	$213.48
Rate for Payer: Amerigroup CHIP/Medicaid	$34.93
Rate for Payer: BCBS of TX Blue Advantage	$116.44
Rate for Payer: BCBS of TX Blue Essentials	$139.73
Rate for Payer: BCBS of TX PPO	$155.26
Rate for Payer: Cash Price	$341.56
Rate for Payer: Multiplan Auto	$252.29
Rate for Payer: Multiplan Commercial	$252.29
Rate for Payer: Multiplan Workers Comp	$252.29
Rate for Payer: Scott and White EPO/PPO	$194.07
Rate for Payer: Superior Health Plan EPO	$52.79

SPLNT NASAL -- DHF

Facility

$248.60

Hospital Charge Code	80341159
Hospital Revenue Code	270
Rate for Payer: Cash Price	$218.77

SPLNT NASAL -- DHF

Facility

$248.60

Hospital Charge Code	80341159
Hospital Revenue Code	270
Min. Negotiated Rate	$22.37
Max. Negotiated Rate	$161.59
Rate for Payer: Aetna Commercial	$136.73
Rate for Payer: Amerigroup CHIP/Medicaid	$22.37
Rate for Payer: BCBS of TX Blue Advantage	$74.58
Rate for Payer: BCBS of TX Blue Essentials	$89.50
Rate for Payer: BCBS of TX PPO	$99.44
Rate for Payer: Cash Price	$218.77
Rate for Payer: Multiplan Auto	$161.59
Rate for Payer: Multiplan Commercial	$161.59
Rate for Payer: Multiplan Workers Comp	$161.59
Rate for Payer: Scott and White EPO/PPO	$124.30
Rate for Payer: Superior Health Plan EPO	$33.81

Know your out-of-pocket cost for care.

All Charges