White Rock Medical Center

All Charges

Charge

Type

Setting

Price

succinylcholine 20 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J0330
Hospital Charge Code	77828712
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

sucralfate 1 g/10 mL Oral Susp 10 mL

Facility

$52.00

Service Code	HCPCS J3490
Hospital Charge Code	77828881
Hospital Revenue Code	250
Rate for Payer: Cash Price	$35.36

sucralfate 1 g/10 mL Oral Susp 10 mL

Facility

$52.00

Service Code	HCPCS J3490
Hospital Charge Code	77828881
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$33.80
Rate for Payer: Amerigroup CHIP/Medicaid	$4.68
Rate for Payer: BCBS of TX Blue Advantage	$15.60
Rate for Payer: BCBS of TX Blue Essentials	$18.72
Rate for Payer: BCBS of TX PPO	$20.80
Rate for Payer: Cash Price	$35.36
Rate for Payer: Multiplan Auto	$33.80
Rate for Payer: Multiplan Commercial	$33.80
Rate for Payer: Multiplan Workers Comp	$33.80
Rate for Payer: Scott and White EPO/PPO	$26.00
Rate for Payer: Superior Health Plan EPO	$7.07

sucralfate 1 g Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77828828
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	$2.30
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	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

sucralfate 1 g Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77828828
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Suction assisted lipectomy head and neck

Facility

$10,000.00

Service Code	CPT 15876
Hospital Charge Code	36015876
Hospital Revenue Code	360
Min. Negotiated Rate	$72.37
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,921.58
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 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 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: Scott and White EPO/PPO	$72.37
Rate for Payer: Scott and White Medicare	$3,281.05
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

Suction assisted lipectomy lower extremity

Facility

$10,000.00

Service Code	CPT 15879
Hospital Charge Code	36015879
Hospital Revenue Code	360
Min. Negotiated Rate	$72.37
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,921.58
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 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 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: Scott and White EPO/PPO	$72.37
Rate for Payer: Scott and White Medicare	$3,281.05
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

Suction assisted lipectomy trunk

Facility

$10,000.00

Service Code	CPT 15877
Hospital Charge Code	36015877
Hospital Revenue Code	360
Min. Negotiated Rate	$72.37
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,921.58
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 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 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: Scott and White EPO/PPO	$72.37
Rate for Payer: Scott and White Medicare	$3,281.05
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

Suction assisted lipectomy upper extremity

Facility

$10,000.00

Service Code	CPT 15878
Hospital Charge Code	36015878
Hospital Revenue Code	360
Min. Negotiated Rate	$36.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,501.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Amerigroup Medicare	$1,667.79
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$1,667.79
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$3,778.02
Rate for Payer: Cigna Medicare	$1,667.79
Rate for Payer: Employer Direct Commercial	$1,667.79
Rate for Payer: Humana Medicare/TRICARE	$1,667.79
Rate for Payer: Molina Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Molina Medicare	$1,667.79
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: Scott and White EPO/PPO	$36.79
Rate for Payer: Scott and White Medicare	$1,667.79
Rate for Payer: Superior Health Plan EPO	$1,667.79
Rate for Payer: Superior Health Plan Medicare	$1,667.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Universal American Medicare	$1,667.79
Rate for Payer: Wellcare Medicare	$1,667.79
Rate for Payer: Wellmed Medicare	$1,667.79

sugammadex 100mg/2ml

Facility

$280.90

Service Code	HCPCS J3490
Hospital Charge Code	78353651
Hospital Revenue Code	250
Min. Negotiated Rate	$25.28
Max. Negotiated Rate	$182.58
Rate for Payer: Amerigroup CHIP/Medicaid	$25.28
Rate for Payer: BCBS of TX Blue Advantage	$84.27
Rate for Payer: BCBS of TX Blue Essentials	$101.12
Rate for Payer: BCBS of TX PPO	$112.36
Rate for Payer: Cash Price	$191.01
Rate for Payer: Multiplan Auto	$182.58
Rate for Payer: Multiplan Commercial	$182.58
Rate for Payer: Multiplan Workers Comp	$182.58
Rate for Payer: Scott and White EPO/PPO	$140.45
Rate for Payer: Superior Health Plan EPO	$38.20

sugammadex 100mg/2ml

Facility

$280.90

Service Code	HCPCS J3490
Hospital Charge Code	78353651
Hospital Revenue Code	250
Rate for Payer: Cash Price	$191.01

sulfamethoxazole-trimethoprim 400 mg-80 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77833565
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	$2.30
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	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

sulfamethoxazole-trimethoprim 400 mg-80 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77833565
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

sulfamethoxazole-trimethoprim 800 mg-160 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77833777
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

sulfamethoxazole-trimethoprim 800 mg-160 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77833777
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	$2.30
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	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

Sulfonamides Undiff., Urine SO

Facility

$334.00

Service Code	CPT 84311
Hospital Charge Code	1708650
Hospital Revenue Code	301
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$217.10
Rate for Payer: Aetna Commercial	$8.50
Rate for Payer: Aetna Medicare	$12.15
Rate for Payer: Amerigroup CHIP/Medicaid	$3.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.10
Rate for Payer: Amerigroup Medicare	$8.10
Rate for Payer: BCBS of TX Blue Advantage	$13.36
Rate for Payer: BCBS of TX Blue Essentials	$16.04
Rate for Payer: BCBS of TX Medicare	$8.10
Rate for Payer: BCBS of TX PPO	$17.90
Rate for Payer: Cash Price	$293.92
Rate for Payer: Cash Price	$293.92
Rate for Payer: Cigna Medicaid	$8.10
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Employer Direct Commercial	$8.10
Rate for Payer: Humana Medicare/TRICARE	$8.10
Rate for Payer: Molina CHIP/Medicaid	$8.10
Rate for Payer: Molina Dual Medicare/Medicaid	$8.10
Rate for Payer: Molina Medicare	$8.10
Rate for Payer: Multiplan Auto	$217.10
Rate for Payer: Multiplan Commercial	$217.10
Rate for Payer: Multiplan Workers Comp	$217.10
Rate for Payer: Parkland Medicaid	$8.10
Rate for Payer: Scott and White EPO/PPO	$10.12
Rate for Payer: Scott and White Medicare	$8.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.10
Rate for Payer: Superior Health Plan EPO	$8.10
Rate for Payer: Superior Health Plan Medicare	$8.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.10
Rate for Payer: Universal American Medicare	$8.10
Rate for Payer: Wellcare Medicare	$8.10
Rate for Payer: Wellmed Medicare	$8.10

Sulfonamides Undiff., Urine SO

Facility

$334.00

Service Code	CPT 84311
Hospital Charge Code	1708650
Hospital Revenue Code	301
Rate for Payer: Cash Price	$293.92

Sulfonylurea Screen, QT SO

Facility

$281.00

Service Code	CPT 80377
Hospital Charge Code	1700005
Hospital Revenue Code	300
Rate for Payer: Cash Price	$247.28

Sulfonylurea Screen, QT SO

Facility

$281.00

Service Code	CPT 80377
Hospital Charge Code	1700005
Hospital Revenue Code	300
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$182.65
Rate for Payer: Aetna Commercial	$0.02
Rate for Payer: Amerigroup CHIP/Medicaid	$3.03
Rate for Payer: Cash Price	$247.28
Rate for Payer: Cash Price	$247.28
Rate for Payer: Cigna Medicaid	$7.77
Rate for Payer: Molina CHIP/Medicaid	$7.77
Rate for Payer: Multiplan Auto	$182.65
Rate for Payer: Multiplan Commercial	$182.65
Rate for Payer: Multiplan Workers Comp	$182.65
Rate for Payer: Parkland Medicaid	$7.77
Rate for Payer: Scott and White EPO/PPO	$140.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.77
Rate for Payer: Superior Health Plan EPO	$38.22

SUMAtriptan 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77834401
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

SUMAtriptan 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77834401
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	$2.30
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	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

SUMAtriptan 6 mg/0.5 mL Subcut Soln 0.5 mL

Facility

$128.00

Service Code	HCPCS J3030
Hospital Charge Code	77834607
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

SUMAtriptan 6 mg/0.5 mL Subcut Soln 0.5 mL

Facility

$128.00

Service Code	HCPCS J3030
Hospital Charge Code	77834607
Hospital Revenue Code	636
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$35.08
Rate for Payer: BCBS of TX Blue Essentials	$42.09
Rate for Payer: BCBS of TX PPO	$46.69
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

SUPERBAG SPECIMEN RETRIEVAL 7MMX140ML PNI0140

Facility

$165.66

Hospital Charge Code	8538535
Hospital Revenue Code	272
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$107.68
Rate for Payer: Aetna Commercial	$91.11
Rate for Payer: Amerigroup CHIP/Medicaid	$14.91
Rate for Payer: BCBS of TX Blue Advantage	$49.70
Rate for Payer: BCBS of TX Blue Essentials	$59.64
Rate for Payer: BCBS of TX PPO	$66.26
Rate for Payer: Cash Price	$145.78
Rate for Payer: Multiplan Auto	$107.68
Rate for Payer: Multiplan Commercial	$107.68
Rate for Payer: Multiplan Workers Comp	$107.68
Rate for Payer: Scott and White EPO/PPO	$82.83
Rate for Payer: Superior Health Plan EPO	$22.53

SUPERBAG SPECIMEN RETRIEVAL 7MMX140ML PNI0140

Facility

$165.66

Hospital Charge Code	8538535
Hospital Revenue Code	272
Rate for Payer: Cash Price	$145.78

Know your out-of-pocket cost for care.

All Charges