White Rock Medical Center

All Charges

Charge

Type

Setting

Price

sponge abs 6x2 gel

Facility

$16.98

Hospital Charge Code	8660510
Hospital Revenue Code	272
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$11.04
Rate for Payer: Aetna Commercial	$9.34
Rate for Payer: Amerigroup CHIP/Medicaid	$1.53
Rate for Payer: BCBS of TX Blue Advantage	$5.09
Rate for Payer: BCBS of TX Blue Essentials	$6.11
Rate for Payer: BCBS of TX PPO	$6.79
Rate for Payer: Cash Price	$14.94
Rate for Payer: Multiplan Auto	$11.04
Rate for Payer: Multiplan Commercial	$11.04
Rate for Payer: Multiplan Workers Comp	$11.04
Rate for Payer: Scott and White EPO/PPO	$8.49
Rate for Payer: Superior Health Plan EPO	$2.31

sponge abs 6x2 gel

Facility

$16.98

Hospital Charge Code	8660510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$14.94

SPPRT WRIST -- DHF

Facility

$360.44

Hospital Charge Code	80341506
Hospital Revenue Code	270
Min. Negotiated Rate	$32.44
Max. Negotiated Rate	$234.29
Rate for Payer: Aetna Commercial	$198.24
Rate for Payer: Amerigroup CHIP/Medicaid	$32.44
Rate for Payer: BCBS of TX Blue Advantage	$108.13
Rate for Payer: BCBS of TX Blue Essentials	$129.76
Rate for Payer: BCBS of TX PPO	$144.18
Rate for Payer: Cash Price	$317.19
Rate for Payer: Multiplan Auto	$234.29
Rate for Payer: Multiplan Commercial	$234.29
Rate for Payer: Multiplan Workers Comp	$234.29
Rate for Payer: Scott and White EPO/PPO	$180.22
Rate for Payer: Superior Health Plan EPO	$49.02

SPPRT WRIST -- DHF

Facility

$360.44

Hospital Charge Code	80341506
Hospital Revenue Code	270
Rate for Payer: Cash Price	$317.19

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC

Facility

$18,373.00

Service Code	MSDRG 537
Min. Negotiated Rate	$7,925.76
Max. Negotiated Rate	$18,373.00
Rate for Payer: Aetna Commercial	$10,878.75
Rate for Payer: Aetna Medicare	$14,633.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,755.35
Rate for Payer: Amerigroup Medicare	$9,755.35
Rate for Payer: BCBS of TX Blue Advantage	$7,925.76
Rate for Payer: BCBS of TX Blue Essentials	$9,395.45
Rate for Payer: BCBS of TX Medicare	$9,755.35
Rate for Payer: BCBS of TX PPO	$10,439.79
Rate for Payer: Cigna Commercial	$12,454.96
Rate for Payer: Cigna Medicare	$9,755.35
Rate for Payer: Employer Direct Commercial	$9,755.35
Rate for Payer: Humana Medicare/TRICARE	$9,755.35
Rate for Payer: Molina Dual Medicare/Medicaid	$9,755.35
Rate for Payer: Molina Medicare	$9,755.35
Rate for Payer: Multiplan Auto	$18,373.00
Rate for Payer: Multiplan Commercial	$18,373.00
Rate for Payer: Multiplan Workers Comp	$18,373.00
Rate for Payer: Scott and White EPO/PPO	$8,461.25
Rate for Payer: Scott and White Medicare	$9,755.35
Rate for Payer: Superior Health Plan EPO	$9,755.35
Rate for Payer: Superior Health Plan Medicare	$9,755.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,755.35
Rate for Payer: Universal American Medicare	$9,755.35
Rate for Payer: Wellcare Medicare	$9,755.35
Rate for Payer: Wellmed Medicare	$9,755.35

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC

Facility

$13,472.90

Service Code	MSDRG 538
Min. Negotiated Rate	$6,026.88
Max. Negotiated Rate	$13,472.90
Rate for Payer: Aetna Commercial	$7,977.38
Rate for Payer: Aetna Medicare	$11,872.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,914.97
Rate for Payer: Amerigroup Medicare	$7,914.97
Rate for Payer: BCBS of TX Blue Advantage	$6,026.88
Rate for Payer: BCBS of TX Blue Essentials	$7,501.91
Rate for Payer: BCBS of TX Medicare	$7,914.97
Rate for Payer: BCBS of TX PPO	$8,335.78
Rate for Payer: Cigna Commercial	$9,133.21
Rate for Payer: Cigna Medicare	$7,914.97
Rate for Payer: Employer Direct Commercial	$7,914.97
Rate for Payer: Humana Medicare/TRICARE	$7,914.97
Rate for Payer: Molina Dual Medicare/Medicaid	$7,914.97
Rate for Payer: Molina Medicare	$7,914.97
Rate for Payer: Multiplan Auto	$13,472.90
Rate for Payer: Multiplan Commercial	$13,472.90
Rate for Payer: Multiplan Workers Comp	$13,472.90
Rate for Payer: Scott and White EPO/PPO	$6,204.62
Rate for Payer: Scott and White Medicare	$7,914.97
Rate for Payer: Superior Health Plan EPO	$7,914.97
Rate for Payer: Superior Health Plan Medicare	$7,914.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,914.97
Rate for Payer: Universal American Medicare	$7,914.97
Rate for Payer: Wellcare Medicare	$7,914.97
Rate for Payer: Wellmed Medicare	$7,914.97

Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions

Facility

$10,000.00

Service Code	CPT 37765
Hospital Charge Code	36037765
Hospital Revenue Code	360
Min. Negotiated Rate	$64.30
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$194.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Amerigroup Medicare	$2,915.10
Rate for Payer: BCBS of TX Blue Advantage	$414.06
Rate for Payer: BCBS of TX Blue Essentials	$495.88
Rate for Payer: BCBS of TX Medicare	$2,915.10
Rate for Payer: BCBS of TX PPO	$624.81
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$194.90
Rate for Payer: Cigna Medicare	$2,915.10
Rate for Payer: Employer Direct Commercial	$2,915.10
Rate for Payer: Humana Medicare/TRICARE	$2,915.10
Rate for Payer: Molina CHIP/Medicaid	$194.90
Rate for Payer: Molina Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Molina Medicare	$2,915.10
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	$194.90
Rate for Payer: Scott and White EPO/PPO	$64.30
Rate for Payer: Scott and White Medicare	$2,915.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$194.90
Rate for Payer: Superior Health Plan EPO	$2,915.10
Rate for Payer: Superior Health Plan Medicare	$2,915.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Universal American Medicare	$2,915.10
Rate for Payer: Wellcare Medicare	$2,915.10
Rate for Payer: Wellmed Medicare	$2,915.10

Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions

Facility

$10,000.00

Service Code	CPT 36475
Hospital Charge Code	36036475
Hospital Revenue Code	360
Min. Negotiated Rate	$64.30
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Amerigroup Medicare	$2,915.10
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$2,915.10
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$1,118.22
Rate for Payer: Cigna Medicare	$2,915.10
Rate for Payer: Employer Direct Commercial	$2,915.10
Rate for Payer: Humana Medicare/TRICARE	$2,915.10
Rate for Payer: Molina CHIP/Medicaid	$1,118.22
Rate for Payer: Molina Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Molina Medicare	$2,915.10
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	$1,118.22
Rate for Payer: Scott and White EPO/PPO	$64.30
Rate for Payer: Scott and White Medicare	$2,915.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,118.22
Rate for Payer: Superior Health Plan EPO	$2,915.10
Rate for Payer: Superior Health Plan Medicare	$2,915.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Universal American Medicare	$2,915.10
Rate for Payer: Wellcare Medicare	$2,915.10
Rate for Payer: Wellmed Medicare	$2,915.10

Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions

Facility

$10,000.00

Service Code	CPT 37766
Hospital Charge Code	36037766
Hospital Revenue Code	360
Min. Negotiated Rate	$64.30
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$212.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Amerigroup Medicare	$2,915.10
Rate for Payer: BCBS of TX Blue Advantage	$456.24
Rate for Payer: BCBS of TX Blue Essentials	$546.40
Rate for Payer: BCBS of TX Medicare	$2,915.10
Rate for Payer: BCBS of TX PPO	$688.46
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$212.90
Rate for Payer: Cigna Medicare	$2,915.10
Rate for Payer: Employer Direct Commercial	$2,915.10
Rate for Payer: Humana Medicare/TRICARE	$2,915.10
Rate for Payer: Molina CHIP/Medicaid	$212.90
Rate for Payer: Molina Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Molina Medicare	$2,915.10
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	$212.90
Rate for Payer: Scott and White EPO/PPO	$64.30
Rate for Payer: Scott and White Medicare	$2,915.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$212.90
Rate for Payer: Superior Health Plan EPO	$2,915.10
Rate for Payer: Superior Health Plan Medicare	$2,915.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Universal American Medicare	$2,915.10
Rate for Payer: Wellcare Medicare	$2,915.10
Rate for Payer: Wellmed Medicare	$2,915.10

ST ADM BLOOD/PMP -- DHF

Facility

$152.70

Hospital Charge Code	54200365
Hospital Revenue Code	270
Rate for Payer: Cash Price	$134.38

ST ADM BLOOD/PMP -- DHF

Facility

$152.70

Hospital Charge Code	54200365
Hospital Revenue Code	270
Min. Negotiated Rate	$13.74
Max. Negotiated Rate	$99.26
Rate for Payer: Aetna Commercial	$83.98
Rate for Payer: Amerigroup CHIP/Medicaid	$13.74
Rate for Payer: BCBS of TX Blue Advantage	$45.81
Rate for Payer: BCBS of TX Blue Essentials	$54.97
Rate for Payer: BCBS of TX PPO	$61.08
Rate for Payer: Cash Price	$134.38
Rate for Payer: Multiplan Auto	$99.26
Rate for Payer: Multiplan Commercial	$99.26
Rate for Payer: Multiplan Workers Comp	$99.26
Rate for Payer: Scott and White EPO/PPO	$76.35
Rate for Payer: Superior Health Plan EPO	$20.77

ST AMBU -- DHF

Facility

$85.35

Hospital Charge Code	82070004
Hospital Revenue Code	270
Min. Negotiated Rate	$7.68
Max. Negotiated Rate	$55.48
Rate for Payer: Aetna Commercial	$46.94
Rate for Payer: Amerigroup CHIP/Medicaid	$7.68
Rate for Payer: BCBS of TX Blue Advantage	$25.60
Rate for Payer: BCBS of TX Blue Essentials	$30.73
Rate for Payer: BCBS of TX PPO	$34.14
Rate for Payer: Cash Price	$75.11
Rate for Payer: Multiplan Auto	$55.48
Rate for Payer: Multiplan Commercial	$55.48
Rate for Payer: Multiplan Workers Comp	$55.48
Rate for Payer: Scott and White EPO/PPO	$42.68
Rate for Payer: Superior Health Plan EPO	$11.61

ST AMBU -- DHF

Facility

$85.35

Hospital Charge Code	82070004
Hospital Revenue Code	270
Rate for Payer: Cash Price	$75.11

Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of for

Facility

$12,223.34

Service Code	CPT 69660
Hospital Charge Code	36069660
Hospital Revenue Code	360
Min. Negotiated Rate	$118.13
Max. Negotiated Rate	$12,223.34
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$8,033.61
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Amerigroup Medicare	$5,355.74
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,355.74
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,132.30
Rate for Payer: Cigna Medicaid	$1,954.22
Rate for Payer: Cigna Medicare	$5,355.74
Rate for Payer: Employer Direct Commercial	$5,355.74
Rate for Payer: Humana Medicare/TRICARE	$5,355.74
Rate for Payer: Molina CHIP/Medicaid	$1,954.22
Rate for Payer: Molina Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Molina Medicare	$5,355.74
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	$1,954.22
Rate for Payer: Scott and White EPO/PPO	$118.13
Rate for Payer: Scott and White Medicare	$5,355.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.22
Rate for Payer: Superior Health Plan EPO	$5,355.74
Rate for Payer: Superior Health Plan Medicare	$5,355.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Universal American Medicare	$5,355.74
Rate for Payer: Wellcare Medicare	$5,355.74
Rate for Payer: Wellmed Medicare	$5,355.74

Staph Latex

Facility

$144.00

Service Code	CPT 87147
Hospital Charge Code	4107148
Hospital Revenue Code	306
Rate for Payer: Cash Price	$126.72

Staph Latex

Facility

$144.00

Service Code	CPT 87147
Hospital Charge Code	4107148
Hospital Revenue Code	306
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna Commercial	$5.44
Rate for Payer: Aetna Medicare	$7.77
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$8.55
Rate for Payer: BCBS of TX Blue Essentials	$10.26
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$11.45
Rate for Payer: Cash Price	$126.72
Rate for Payer: Cash Price	$126.72
Rate for Payer: Cigna Medicaid	$5.18
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$5.18
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$93.60
Rate for Payer: Multiplan Commercial	$93.60
Rate for Payer: Multiplan Workers Comp	$93.60
Rate for Payer: Parkland Medicaid	$5.18
Rate for Payer: Scott and White EPO/PPO	$6.48
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.18
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

STAPLER, ARTICULATING PWRD ECH FLX 45MM 340MM SHAF -- DHF

Facility

$1,735.94

Hospital Charge Code	81911158
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,527.63

STAPLER, ARTICULATING PWRD ECH FLX 45MM 340MM SHAF -- DHF

Facility

$1,735.94

Hospital Charge Code	81911158
Hospital Revenue Code	272
Min. Negotiated Rate	$156.23
Max. Negotiated Rate	$1,128.36
Rate for Payer: Aetna Commercial	$954.77
Rate for Payer: Amerigroup CHIP/Medicaid	$156.23
Rate for Payer: BCBS of TX Blue Advantage	$520.78
Rate for Payer: BCBS of TX Blue Essentials	$624.94
Rate for Payer: BCBS of TX PPO	$694.38
Rate for Payer: Cash Price	$1,527.63
Rate for Payer: Multiplan Auto	$1,128.36
Rate for Payer: Multiplan Commercial	$1,128.36
Rate for Payer: Multiplan Workers Comp	$1,128.36
Rate for Payer: Scott and White EPO/PPO	$867.97
Rate for Payer: Superior Health Plan EPO	$236.09

stapler contour curved cs40b blue

Facility

$1,435.50

Hospital Charge Code	8666510
Hospital Revenue Code	272
Min. Negotiated Rate	$129.20
Max. Negotiated Rate	$933.08
Rate for Payer: Aetna Commercial	$789.52
Rate for Payer: Amerigroup CHIP/Medicaid	$129.20
Rate for Payer: BCBS of TX Blue Advantage	$430.65
Rate for Payer: BCBS of TX Blue Essentials	$516.78
Rate for Payer: BCBS of TX PPO	$574.20
Rate for Payer: Cash Price	$1,263.24
Rate for Payer: Multiplan Auto	$933.08
Rate for Payer: Multiplan Commercial	$933.08
Rate for Payer: Multiplan Workers Comp	$933.08
Rate for Payer: Scott and White EPO/PPO	$717.75
Rate for Payer: Superior Health Plan EPO	$195.23

stapler contour curved cs40b blue

Facility

$1,435.50

Hospital Charge Code	8666510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,263.24

STAPLER INSORB

Facility

$272.36

Hospital Charge Code	144265
Hospital Revenue Code	272
Rate for Payer: Cash Price	$239.68

STAPLER INSORB

Facility

$272.36

Hospital Charge Code	144265
Hospital Revenue Code	272
Min. Negotiated Rate	$24.51
Max. Negotiated Rate	$177.03
Rate for Payer: Aetna Commercial	$149.80
Rate for Payer: Amerigroup CHIP/Medicaid	$24.51
Rate for Payer: BCBS of TX Blue Advantage	$81.71
Rate for Payer: BCBS of TX Blue Essentials	$98.05
Rate for Payer: BCBS of TX PPO	$108.94
Rate for Payer: Cash Price	$239.68
Rate for Payer: Multiplan Auto	$177.03
Rate for Payer: Multiplan Commercial	$177.03
Rate for Payer: Multiplan Workers Comp	$177.03
Rate for Payer: Scott and White EPO/PPO	$136.18
Rate for Payer: Superior Health Plan EPO	$37.04

STAPLER, INTERNAL CURVE EEA-21MM XL SNGL WHT 4.8MM -- DHF

Facility

$6,510.82

Hospital Charge Code	81930935
Hospital Revenue Code	272
Min. Negotiated Rate	$585.97
Max. Negotiated Rate	$4,232.03
Rate for Payer: Aetna Commercial	$3,580.95
Rate for Payer: Amerigroup CHIP/Medicaid	$585.97
Rate for Payer: BCBS of TX Blue Advantage	$1,953.25
Rate for Payer: BCBS of TX Blue Essentials	$2,343.90
Rate for Payer: BCBS of TX PPO	$2,604.33
Rate for Payer: Cash Price	$5,729.52
Rate for Payer: Multiplan Auto	$4,232.03
Rate for Payer: Multiplan Commercial	$4,232.03
Rate for Payer: Multiplan Workers Comp	$4,232.03
Rate for Payer: Scott and White EPO/PPO	$3,255.41
Rate for Payer: Superior Health Plan EPO	$885.47

STAPLER, INTERNAL CURVE EEA-21MM XL SNGL WHT 4.8MM -- DHF

Facility

$6,510.82

Hospital Charge Code	81930935
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,729.52

STAPLER, INTERNAL CURVE ORVIL EEA-21MM XL TIT 35CM -- DHF

Facility

$1,383.59

Hospital Charge Code	81911158
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,217.56

Know your out-of-pocket cost for care.

All Charges