White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SABER. 035 12X40 80CM SL

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992574
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

Saber .035 8x60 80cm SL

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992563
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

Saber .035 8x60 80cm SL

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992563
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

SABER .035 9mm X 6cm

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992565
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

SABER .035 9mm X 6cm

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992565
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

SABER .035 PTA Dilatation Catheter 6x20x135

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992552
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

SABER .035 PTA Dilatation Catheter 6x20x135

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992552
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

SABER .035 PTA DILATION CATHETER 10MM X 6CM X 80CM

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992542
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

SABER .035 PTA DILATION CATHETER 10MM X 6CM X 80CM

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992542
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

SABER .035 PTA Dilation Catheter 5x15x135

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992550
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

SABER .035 PTA Dilation Catheter 5x15x135

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992550
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

SABER .035 PTA Dilation Catheter 6x15x135

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992557
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

SABER .035 PTA Dilation Catheter 6x15x135

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992557
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

SABER 4MM8cm 150

Facility

$977.24

Service Code	HCPCS C1726
Hospital Charge Code	992544
Hospital Revenue Code	272
Min. Negotiated Rate	$87.95
Max. Negotiated Rate	$703.61
Rate for Payer: Amerigroup CHIP/Medicaid	$87.95
Rate for Payer: BCBS of TX Blue Advantage	$293.17
Rate for Payer: BCBS of TX Blue Essentials	$351.81
Rate for Payer: BCBS of TX PPO	$390.90
Rate for Payer: Cash Price	$664.52
Rate for Payer: Cigna Medicaid	$703.61
Rate for Payer: Molina CHIP/Medicaid	$703.61
Rate for Payer: Multiplan Auto	$635.21
Rate for Payer: Multiplan Commercial	$635.21
Rate for Payer: Multiplan Workers Comp	$635.21
Rate for Payer: Parkland Medicaid	$703.61
Rate for Payer: Scott and White EPO/PPO	$488.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$703.61
Rate for Payer: Superior Health Plan EPO	$132.90

SABER 4MM8cm 150

Facility

$977.24

Service Code	HCPCS C1726
Hospital Charge Code	992544
Hospital Revenue Code	272
Rate for Payer: Cash Price	$664.52

Saccharomyces cerevisiae Panel SO

Facility

$142.85

Service Code	HCPCS 86671
Hospital Charge Code	1709757
Hospital Revenue Code	302
Min. Negotiated Rate	$4.78
Max. Negotiated Rate	$102.85
Rate for Payer: Amerigroup CHIP/Medicaid	$4.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.25
Rate for Payer: Amerigroup Medicare	$12.25
Rate for Payer: BCBS of TX Blue Advantage	$42.85
Rate for Payer: BCBS of TX Blue Essentials	$51.43
Rate for Payer: BCBS of TX Medicare	$12.25
Rate for Payer: BCBS of TX PPO	$57.14
Rate for Payer: Cash Price	$97.14
Rate for Payer: Cash Price	$97.14
Rate for Payer: Cigna Medicaid	$102.85
Rate for Payer: Cigna Medicare	$12.25
Rate for Payer: Employer Direct Commercial	$12.25
Rate for Payer: Humana Medicare/TRICARE	$12.25
Rate for Payer: Molina CHIP/Medicaid	$102.85
Rate for Payer: Molina Dual Medicare/Medicaid	$12.25
Rate for Payer: Molina Medicare	$12.25
Rate for Payer: Multiplan Auto	$92.85
Rate for Payer: Multiplan Commercial	$92.85
Rate for Payer: Multiplan Workers Comp	$92.85
Rate for Payer: Parkland Medicaid	$102.85
Rate for Payer: Scott and White EPO/PPO	$15.31
Rate for Payer: Scott and White Medicare	$12.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.85
Rate for Payer: Superior Health Plan EPO	$12.25
Rate for Payer: Superior Health Plan Medicare	$12.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.25
Rate for Payer: Universal American Medicare	$12.25
Rate for Payer: Wellcare Medicare	$12.25
Rate for Payer: Wellmed Medicare	$12.25

Saccharomyces cerevisiae Panel SO

Facility

$142.85

Service Code	HCPCS 86671
Hospital Charge Code	1709757
Hospital Revenue Code	302
Rate for Payer: Cash Price	$97.14

sacubitril-valsartan 24 mg-26 mg Tab

Facility

$40.19

Service Code	HCPCS J3490
Hospital Charge Code	78351957
Hospital Revenue Code	250
Rate for Payer: Cash Price	$27.33

sacubitril-valsartan 24 mg-26 mg Tab

Facility

$40.19

Service Code	HCPCS J3490
Hospital Charge Code	78351957
Hospital Revenue Code	250
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$28.94
Rate for Payer: Amerigroup CHIP/Medicaid	$3.62
Rate for Payer: BCBS of TX Blue Advantage	$12.06
Rate for Payer: BCBS of TX Blue Essentials	$14.47
Rate for Payer: BCBS of TX PPO	$16.08
Rate for Payer: Cash Price	$27.33
Rate for Payer: Cigna Medicaid	$28.94
Rate for Payer: Molina CHIP/Medicaid	$28.94
Rate for Payer: Multiplan Auto	$26.12
Rate for Payer: Multiplan Commercial	$26.12
Rate for Payer: Multiplan Workers Comp	$26.12
Rate for Payer: Parkland Medicaid	$28.94
Rate for Payer: Scott and White EPO/PPO	$20.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.94
Rate for Payer: Superior Health Plan EPO	$5.47

sacubitril-valsartan Tab

Facility

$40.19

Service Code	HCPCS J3490
Hospital Charge Code	1.43478E+11
Hospital Revenue Code	250
Rate for Payer: Cash Price	$27.33

sacubitril-valsartan Tab

Facility

$40.19

Service Code	HCPCS J3490
Hospital Charge Code	1.43478E+11
Hospital Revenue Code	250
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$28.94
Rate for Payer: Amerigroup CHIP/Medicaid	$3.62
Rate for Payer: BCBS of TX Blue Advantage	$12.06
Rate for Payer: BCBS of TX Blue Essentials	$14.47
Rate for Payer: BCBS of TX PPO	$16.08
Rate for Payer: Cash Price	$27.33
Rate for Payer: Cigna Medicaid	$28.94
Rate for Payer: Molina CHIP/Medicaid	$28.94
Rate for Payer: Multiplan Auto	$26.12
Rate for Payer: Multiplan Commercial	$26.12
Rate for Payer: Multiplan Workers Comp	$26.12
Rate for Payer: Parkland Medicaid	$28.94
Rate for Payer: Scott and White EPO/PPO	$20.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.94
Rate for Payer: Superior Health Plan EPO	$5.47

sacubitril-valsartan Tab

Facility

$40.19

Service Code	HCPCS J3490
Hospital Charge Code	78349105
Hospital Revenue Code	250
Rate for Payer: Cash Price	$27.33

sacubitril-valsartan Tab

Facility

$40.19

Service Code	HCPCS J3490
Hospital Charge Code	78349105
Hospital Revenue Code	250
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$28.94
Rate for Payer: Amerigroup CHIP/Medicaid	$3.62
Rate for Payer: BCBS of TX Blue Advantage	$12.06
Rate for Payer: BCBS of TX Blue Essentials	$14.47
Rate for Payer: BCBS of TX PPO	$16.08
Rate for Payer: Cash Price	$27.33
Rate for Payer: Cigna Medicaid	$28.94
Rate for Payer: Molina CHIP/Medicaid	$28.94
Rate for Payer: Multiplan Auto	$26.12
Rate for Payer: Multiplan Commercial	$26.12
Rate for Payer: Multiplan Workers Comp	$26.12
Rate for Payer: Parkland Medicaid	$28.94
Rate for Payer: Scott and White EPO/PPO	$20.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.94
Rate for Payer: Superior Health Plan EPO	$5.47

Safeday administration set with 3 ports, 15 drops / ml

Facility

$12.25

Hospital Charge Code	993935
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8.33

Safeday administration set with 3 ports, 15 drops / ml

Facility

$12.25

Hospital Charge Code	993935
Hospital Revenue Code	272
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$8.82
Rate for Payer: Amerigroup CHIP/Medicaid	$1.10
Rate for Payer: BCBS of TX Blue Advantage	$3.67
Rate for Payer: BCBS of TX Blue Essentials	$4.41
Rate for Payer: BCBS of TX PPO	$4.90
Rate for Payer: Cash Price	$8.33
Rate for Payer: Cigna Medicaid	$8.82
Rate for Payer: Molina CHIP/Medicaid	$8.82
Rate for Payer: Multiplan Auto	$7.96
Rate for Payer: Multiplan Commercial	$7.96
Rate for Payer: Multiplan Workers Comp	$7.96
Rate for Payer: Parkland Medicaid	$8.82
Rate for Payer: Scott and White EPO/PPO	$6.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.82
Rate for Payer: Superior Health Plan EPO	$1.67

Know your out-of-pocket cost for care.

All Charges