White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SUPERIOR VENACAVAGRAM

Facility

$2,529.00

Service Code	CPT 75827
Hospital Charge Code	4615828
Hospital Revenue Code	323
Min. Negotiated Rate	$26.19
Max. Negotiated Rate	$3,317.93
Rate for Payer: Aetna Commercial	$77.24
Rate for Payer: Aetna Medicare	$2,197.02
Rate for Payer: Amerigroup CHIP/Medicaid	$119.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,464.68
Rate for Payer: Amerigroup Medicare	$1,464.68
Rate for Payer: BCBS of TX Blue Advantage	$1,040.34
Rate for Payer: BCBS of TX Blue Essentials	$1,248.41
Rate for Payer: BCBS of TX Medicare	$1,464.68
Rate for Payer: BCBS of TX PPO	$1,393.43
Rate for Payer: Cash Price	$2,225.52
Rate for Payer: Cash Price	$2,225.52
Rate for Payer: Cash Price	$2,225.52
Rate for Payer: Cigna Commercial	$3,317.93
Rate for Payer: Cigna Medicaid	$119.63
Rate for Payer: Cigna Medicare	$1,464.68
Rate for Payer: Employer Direct Commercial	$1,464.68
Rate for Payer: Humana Medicare/TRICARE	$1,464.68
Rate for Payer: Molina CHIP/Medicaid	$119.63
Rate for Payer: Molina Dual Medicare/Medicaid	$1,464.68
Rate for Payer: Molina Medicare	$1,464.68
Rate for Payer: Multiplan Auto	$1,643.85
Rate for Payer: Multiplan Commercial	$1,643.85
Rate for Payer: Multiplan Workers Comp	$1,643.85
Rate for Payer: Parkland Medicaid	$119.63
Rate for Payer: Scott and White EPO/PPO	$26.19
Rate for Payer: Scott and White Medicare	$1,464.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$119.63
Rate for Payer: Superior Health Plan EPO	$1,464.68
Rate for Payer: Superior Health Plan Medicare	$1,464.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,464.68
Rate for Payer: Universal American Medicare	$1,464.68
Rate for Payer: Wellcare Medicare	$1,464.68
Rate for Payer: Wellmed Medicare	$1,464.68

SUPERIOR VENACAVAGRAM

Facility

$2,529.00

Service Code	CPT 75827
Hospital Charge Code	4615828
Hospital Revenue Code	323
Rate for Payer: Cash Price	$2,225.52

SUPPORT, ABDOMINAL ELASTIC 12'''' W 26-50'''' UNIVERSAL -- DHF

Facility

$53.51

Hospital Charge Code	80240104
Hospital Revenue Code	270
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$34.78
Rate for Payer: Aetna Commercial	$29.43
Rate for Payer: Amerigroup CHIP/Medicaid	$4.82
Rate for Payer: BCBS of TX Blue Advantage	$16.05
Rate for Payer: BCBS of TX Blue Essentials	$19.26
Rate for Payer: BCBS of TX PPO	$21.40
Rate for Payer: Cash Price	$47.09
Rate for Payer: Multiplan Auto	$34.78
Rate for Payer: Multiplan Commercial	$34.78
Rate for Payer: Multiplan Workers Comp	$34.78
Rate for Payer: Scott and White EPO/PPO	$26.76
Rate for Payer: Superior Health Plan EPO	$7.28

SUPPORT, ABDOMINAL ELASTIC 12'''' W 26-50'''' UNIVERSAL -- DHF

Facility

$53.51

Hospital Charge Code	80240104
Hospital Revenue Code	270
Rate for Payer: Cash Price	$47.09

support breast

Facility

$174.52

Service Code	HCPCS L8020
Hospital Charge Code	80931702
Hospital Revenue Code	274
Min. Negotiated Rate	$15.71
Max. Negotiated Rate	$87.26
Rate for Payer: Aetna Commercial	$52.36
Rate for Payer: Amerigroup CHIP/Medicaid	$15.71
Rate for Payer: BCBS of TX Blue Advantage	$52.36
Rate for Payer: BCBS of TX Blue Essentials	$62.83
Rate for Payer: BCBS of TX PPO	$69.81
Rate for Payer: Cash Price	$153.58
Rate for Payer: Multiplan Auto	$87.26
Rate for Payer: Multiplan Commercial	$87.26
Rate for Payer: Multiplan Workers Comp	$87.26
Rate for Payer: Scott and White EPO/PPO	$87.26
Rate for Payer: Superior Health Plan EPO	$23.73

support breast

Facility

$174.52

Service Code	HCPCS L8020
Hospital Charge Code	80931702
Hospital Revenue Code	274
Min. Negotiated Rate	$43.63
Max. Negotiated Rate	$87.26
Rate for Payer: Aetna Commercial	$52.36
Rate for Payer: Cash Price	$153.58
Rate for Payer: Cigna Commercial	$43.63
Rate for Payer: Multiplan Auto	$87.26
Rate for Payer: Multiplan Commercial	$87.26
Rate for Payer: Multiplan Workers Comp	$87.26
Rate for Payer: Scott and White EPO/PPO	$87.26

SUPPORT, HEAD SLOTTED POSITIONER ADULT -- DHF

Facility

$17.58

Hospital Charge Code	80319650
Hospital Revenue Code	270
Rate for Payer: Cash Price	$15.47

SUPPORT, HEAD SLOTTED POSITIONER ADULT -- DHF

Facility

$17.58

Hospital Charge Code	80319650
Hospital Revenue Code	270
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$11.43
Rate for Payer: Aetna Commercial	$9.67
Rate for Payer: Amerigroup CHIP/Medicaid	$1.58
Rate for Payer: BCBS of TX Blue Advantage	$5.27
Rate for Payer: BCBS of TX Blue Essentials	$6.33
Rate for Payer: BCBS of TX PPO	$7.03
Rate for Payer: Cash Price	$15.47
Rate for Payer: Multiplan Auto	$11.43
Rate for Payer: Multiplan Commercial	$11.43
Rate for Payer: Multiplan Workers Comp	$11.43
Rate for Payer: Scott and White EPO/PPO	$8.79
Rate for Payer: Superior Health Plan EPO	$2.39

support scrotal

Facility

$43.77

Hospital Charge Code	80341456
Hospital Revenue Code	270
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$28.45
Rate for Payer: Aetna Commercial	$24.07
Rate for Payer: Amerigroup CHIP/Medicaid	$3.94
Rate for Payer: BCBS of TX Blue Advantage	$13.13
Rate for Payer: BCBS of TX Blue Essentials	$15.76
Rate for Payer: BCBS of TX PPO	$17.51
Rate for Payer: Cash Price	$38.52
Rate for Payer: Multiplan Auto	$28.45
Rate for Payer: Multiplan Commercial	$28.45
Rate for Payer: Multiplan Workers Comp	$28.45
Rate for Payer: Scott and White EPO/PPO	$21.88
Rate for Payer: Superior Health Plan EPO	$5.95

support scrotal

Facility

$43.77

Hospital Charge Code	80341456
Hospital Revenue Code	270
Rate for Payer: Cash Price	$38.52

Surfactant Administration Units

Facility

$176.00

Service Code	CPT 94610
Hospital Charge Code	5504610
Hospital Revenue Code	460
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$441.88
Rate for Payer: Aetna Commercial	$96.80
Rate for Payer: Aetna Medicare	$292.59
Rate for Payer: Amerigroup CHIP/Medicaid	$15.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$195.06
Rate for Payer: Amerigroup Medicare	$195.06
Rate for Payer: BCBS of TX Blue Advantage	$320.09
Rate for Payer: BCBS of TX Blue Essentials	$382.64
Rate for Payer: BCBS of TX Medicare	$195.06
Rate for Payer: BCBS of TX PPO	$426.79
Rate for Payer: Cash Price	$154.88
Rate for Payer: Cash Price	$154.88
Rate for Payer: Cash Price	$154.88
Rate for Payer: Cigna Commercial	$441.88
Rate for Payer: Cigna Medicare	$195.06
Rate for Payer: Employer Direct Commercial	$195.06
Rate for Payer: Humana Medicare/TRICARE	$195.06
Rate for Payer: Molina Dual Medicare/Medicaid	$195.06
Rate for Payer: Molina Medicare	$195.06
Rate for Payer: Multiplan Auto	$114.40
Rate for Payer: Multiplan Commercial	$114.40
Rate for Payer: Multiplan Workers Comp	$114.40
Rate for Payer: Scott and White EPO/PPO	$3.49
Rate for Payer: Scott and White Medicare	$195.06
Rate for Payer: Superior Health Plan EPO	$195.06
Rate for Payer: Superior Health Plan Medicare	$195.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$195.06
Rate for Payer: Universal American Medicare	$195.06
Rate for Payer: Wellcare Medicare	$195.06
Rate for Payer: Wellmed Medicare	$195.06

Surfactant Administration Units BCE

Facility

$176.00

Service Code	CPT 94610
Hospital Charge Code	5504610
Hospital Revenue Code	460
Rate for Payer: Cash Price	$154.88

Surfactant Administration Units BCE

Facility

$176.00

Service Code	CPT 94610
Hospital Charge Code	5504610
Hospital Revenue Code	460
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$441.88
Rate for Payer: Aetna Commercial	$96.80
Rate for Payer: Aetna Medicare	$292.59
Rate for Payer: Amerigroup CHIP/Medicaid	$15.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$195.06
Rate for Payer: Amerigroup Medicare	$195.06
Rate for Payer: BCBS of TX Blue Advantage	$320.09
Rate for Payer: BCBS of TX Blue Essentials	$382.64
Rate for Payer: BCBS of TX Medicare	$195.06
Rate for Payer: BCBS of TX PPO	$426.79
Rate for Payer: Cash Price	$154.88
Rate for Payer: Cash Price	$154.88
Rate for Payer: Cash Price	$154.88
Rate for Payer: Cigna Commercial	$441.88
Rate for Payer: Cigna Medicare	$195.06
Rate for Payer: Employer Direct Commercial	$195.06
Rate for Payer: Humana Medicare/TRICARE	$195.06
Rate for Payer: Molina Dual Medicare/Medicaid	$195.06
Rate for Payer: Molina Medicare	$195.06
Rate for Payer: Multiplan Auto	$114.40
Rate for Payer: Multiplan Commercial	$114.40
Rate for Payer: Multiplan Workers Comp	$114.40
Rate for Payer: Scott and White EPO/PPO	$3.49
Rate for Payer: Scott and White Medicare	$195.06
Rate for Payer: Superior Health Plan EPO	$195.06
Rate for Payer: Superior Health Plan Medicare	$195.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$195.06
Rate for Payer: Universal American Medicare	$195.06
Rate for Payer: Wellcare Medicare	$195.06
Rate for Payer: Wellmed Medicare	$195.06

SURGICAL FIBRILLAR 2X4

Facility

$485.00

Hospital Charge Code	8568494
Hospital Revenue Code	272
Rate for Payer: Cash Price	$426.80

SURGICAL FIBRILLAR 2X4

Facility

$485.00

Hospital Charge Code	8568494
Hospital Revenue Code	272
Min. Negotiated Rate	$43.65
Max. Negotiated Rate	$315.25
Rate for Payer: Aetna Commercial	$266.75
Rate for Payer: Amerigroup CHIP/Medicaid	$43.65
Rate for Payer: BCBS of TX Blue Advantage	$145.50
Rate for Payer: BCBS of TX Blue Essentials	$174.60
Rate for Payer: BCBS of TX PPO	$194.00
Rate for Payer: Cash Price	$426.80
Rate for Payer: Multiplan Auto	$315.25
Rate for Payer: Multiplan Commercial	$315.25
Rate for Payer: Multiplan Workers Comp	$315.25
Rate for Payer: Scott and White EPO/PPO	$242.50
Rate for Payer: Superior Health Plan EPO	$65.96

SURGICAL HOOD TS2 00992040112

Facility

$124.85

Hospital Charge Code	144892
Hospital Revenue Code	270
Rate for Payer: Cash Price	$109.87

SURGICAL HOOD TS2 00992040112

Facility

$124.85

Hospital Charge Code	144892
Hospital Revenue Code	270
Min. Negotiated Rate	$11.24
Max. Negotiated Rate	$81.15
Rate for Payer: Aetna Commercial	$68.67
Rate for Payer: Amerigroup CHIP/Medicaid	$11.24
Rate for Payer: BCBS of TX Blue Advantage	$37.46
Rate for Payer: BCBS of TX Blue Essentials	$44.95
Rate for Payer: BCBS of TX PPO	$49.94
Rate for Payer: Cash Price	$109.87
Rate for Payer: Multiplan Auto	$81.15
Rate for Payer: Multiplan Commercial	$81.15
Rate for Payer: Multiplan Workers Comp	$81.15
Rate for Payer: Scott and White EPO/PPO	$62.42
Rate for Payer: Superior Health Plan EPO	$16.98

SURGICAL SNOW 2X4

Facility

$398.24

Hospital Charge Code	8568493
Hospital Revenue Code	272
Min. Negotiated Rate	$35.84
Max. Negotiated Rate	$258.86
Rate for Payer: Aetna Commercial	$219.03
Rate for Payer: Amerigroup CHIP/Medicaid	$35.84
Rate for Payer: BCBS of TX Blue Advantage	$119.47
Rate for Payer: BCBS of TX Blue Essentials	$143.37
Rate for Payer: BCBS of TX PPO	$159.30
Rate for Payer: Cash Price	$350.45
Rate for Payer: Multiplan Auto	$258.86
Rate for Payer: Multiplan Commercial	$258.86
Rate for Payer: Multiplan Workers Comp	$258.86
Rate for Payer: Scott and White EPO/PPO	$199.12
Rate for Payer: Superior Health Plan EPO	$54.16

SURGICAL SNOW 2X4

Facility

$398.24

Hospital Charge Code	8568493
Hospital Revenue Code	272
Rate for Payer: Cash Price	$350.45

Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous

Facility

$10,000.00

Service Code	CPT 46270
Hospital Charge Code	36046270
Hospital Revenue Code	360
Min. Negotiated Rate	$56.64
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$3,851.79
Rate for Payer: Amerigroup CHIP/Medicaid	$939.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,567.86
Rate for Payer: Amerigroup Medicare	$2,567.86
Rate for Payer: BCBS of TX Blue Advantage	$3,914.78
Rate for Payer: BCBS of TX Blue Essentials	$4,688.36
Rate for Payer: BCBS of TX Medicare	$2,567.86
Rate for Payer: BCBS of TX PPO	$5,907.33
Rate for Payer: Cigna Commercial	$5,816.94
Rate for Payer: Cigna Medicaid	$939.93
Rate for Payer: Cigna Medicare	$2,567.86
Rate for Payer: Employer Direct Commercial	$2,567.86
Rate for Payer: Humana Medicare/TRICARE	$2,567.86
Rate for Payer: Molina CHIP/Medicaid	$939.93
Rate for Payer: Molina Dual Medicare/Medicaid	$2,567.86
Rate for Payer: Molina Medicare	$2,567.86
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	$939.93
Rate for Payer: Scott and White EPO/PPO	$56.64
Rate for Payer: Scott and White Medicare	$2,567.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$939.93
Rate for Payer: Superior Health Plan EPO	$2,567.86
Rate for Payer: Superior Health Plan Medicare	$2,567.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,567.86
Rate for Payer: Universal American Medicare	$2,567.86
Rate for Payer: Wellcare Medicare	$2,567.86
Rate for Payer: Wellmed Medicare	$2,567.86

surgicel hemostat 4 X 8 pad

Facility

$69.76

Service Code	HCPCS A9270
Hospital Charge Code	78921545
Hospital Revenue Code	636
Min. Negotiated Rate	$17.44
Max. Negotiated Rate	$34.88
Rate for Payer: Cash Price	$47.44
Rate for Payer: Cigna Commercial	$17.44
Rate for Payer: Scott and White EPO/PPO	$34.88

surgicel hemostat 4 X 8 pad

Facility

$69.76

Service Code	HCPCS A9270
Hospital Charge Code	78921545
Hospital Revenue Code	636
Min. Negotiated Rate	$6.28
Max. Negotiated Rate	$45.34
Rate for Payer: Aetna Commercial	$38.37
Rate for Payer: Amerigroup CHIP/Medicaid	$6.28
Rate for Payer: BCBS of TX Blue Advantage	$20.93
Rate for Payer: BCBS of TX Blue Essentials	$25.11
Rate for Payer: BCBS of TX PPO	$27.90
Rate for Payer: Cash Price	$47.44
Rate for Payer: Multiplan Auto	$45.34
Rate for Payer: Multiplan Commercial	$45.34
Rate for Payer: Multiplan Workers Comp	$45.34
Rate for Payer: Scott and White EPO/PPO	$34.88
Rate for Payer: Superior Health Plan EPO	$9.49

SURG PROC I CHARGE

Facility

$107.00

Hospital Charge Code	6296000
Hospital Revenue Code	361
Min. Negotiated Rate	$9.63
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$58.85
Rate for Payer: Amerigroup CHIP/Medicaid	$9.63
Rate for Payer: BCBS of TX Blue Advantage	$32.10
Rate for Payer: BCBS of TX Blue Essentials	$38.52
Rate for Payer: BCBS of TX PPO	$42.80
Rate for Payer: Cash Price	$94.16
Rate for Payer: Cash Price	$94.16
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	$53.50
Rate for Payer: Superior Health Plan EPO	$14.55

SURG PROC I CHARGE

Facility

$107.00

Hospital Charge Code	6296000
Hospital Revenue Code	361
Rate for Payer: Cash Price	$94.16

Surg Proc I Charge BCE

Facility

$107.00

Hospital Charge Code	6296000
Hospital Revenue Code	361
Min. Negotiated Rate	$9.63
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$58.85
Rate for Payer: Amerigroup CHIP/Medicaid	$9.63
Rate for Payer: BCBS of TX Blue Advantage	$32.10
Rate for Payer: BCBS of TX Blue Essentials	$38.52
Rate for Payer: BCBS of TX PPO	$42.80
Rate for Payer: Cash Price	$94.16
Rate for Payer: Cash Price	$94.16
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	$53.50
Rate for Payer: Superior Health Plan EPO	$14.55

Know your out-of-pocket cost for care.

All Charges