White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$385.90

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 6x15x135

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992557
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 4MM8cm 150

Facility

$977.24

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

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

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

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

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 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 Tab

Facility

$32.05

Service Code	HCPCS J3490
Hospital Charge Code	78349105
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.79

sacubitril-valsartan Tab

Facility

$32.05

Service Code	HCPCS J3490
Hospital Charge Code	78349105
Hospital Revenue Code	250
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$23.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2.88
Rate for Payer: BCBS of TX Blue Advantage	$9.62
Rate for Payer: BCBS of TX Blue Essentials	$11.54
Rate for Payer: BCBS of TX PPO	$12.82
Rate for Payer: Cash Price	$21.79
Rate for Payer: Cigna Medicaid	$23.08
Rate for Payer: Molina CHIP/Medicaid	$23.08
Rate for Payer: Multiplan Auto	$20.83
Rate for Payer: Multiplan Commercial	$20.83
Rate for Payer: Multiplan Workers Comp	$20.83
Rate for Payer: Parkland Medicaid	$23.08
Rate for Payer: Scott and White EPO/PPO	$16.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.08
Rate for Payer: Superior Health Plan EPO	$4.36

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

Safety Valve

Facility

$1,516.36

Hospital Charge Code	993841
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,031.12

Safety Valve

Facility

$1,516.36

Hospital Charge Code	993841
Hospital Revenue Code	270
Min. Negotiated Rate	$136.47
Max. Negotiated Rate	$1,091.78
Rate for Payer: Amerigroup CHIP/Medicaid	$136.47
Rate for Payer: BCBS of TX Blue Advantage	$454.91
Rate for Payer: BCBS of TX Blue Essentials	$545.89
Rate for Payer: BCBS of TX PPO	$606.54
Rate for Payer: Cash Price	$1,031.12
Rate for Payer: Cigna Medicaid	$1,091.78
Rate for Payer: Molina CHIP/Medicaid	$1,091.78
Rate for Payer: Multiplan Auto	$985.63
Rate for Payer: Multiplan Commercial	$985.63
Rate for Payer: Multiplan Workers Comp	$985.63
Rate for Payer: Parkland Medicaid	$1,091.78
Rate for Payer: Scott and White EPO/PPO	$758.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,091.78
Rate for Payer: Superior Health Plan EPO	$206.22

S. AGALACTIAE, ATCC 12386, KWIK-S,2/PK

Facility

$201.96

Hospital Charge Code	993239
Hospital Revenue Code	270
Rate for Payer: Cash Price	$137.33

S. AGALACTIAE, ATCC 12386, KWIK-S,2/PK

Facility

$201.96

Hospital Charge Code	993239
Hospital Revenue Code	270
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$145.41
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: BCBS of TX Blue Advantage	$60.59
Rate for Payer: BCBS of TX Blue Essentials	$72.71
Rate for Payer: BCBS of TX PPO	$80.78
Rate for Payer: Cash Price	$137.33
Rate for Payer: Cigna Medicaid	$145.41
Rate for Payer: Molina CHIP/Medicaid	$145.41
Rate for Payer: Multiplan Auto	$131.27
Rate for Payer: Multiplan Commercial	$131.27
Rate for Payer: Multiplan Workers Comp	$131.27
Rate for Payer: Parkland Medicaid	$145.41
Rate for Payer: Scott and White EPO/PPO	$100.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.41
Rate for Payer: Superior Health Plan EPO	$27.47

sagital blade 25x 90

Facility

$190.68

Hospital Charge Code	992675
Hospital Revenue Code	270
Rate for Payer: Cash Price	$129.66

sagital blade 25x 90

Facility

$190.68

Hospital Charge Code	992675
Hospital Revenue Code	270
Min. Negotiated Rate	$17.16
Max. Negotiated Rate	$137.29
Rate for Payer: Amerigroup CHIP/Medicaid	$17.16
Rate for Payer: BCBS of TX Blue Advantage	$57.20
Rate for Payer: BCBS of TX Blue Essentials	$68.64
Rate for Payer: BCBS of TX PPO	$76.27
Rate for Payer: Cash Price	$129.66
Rate for Payer: Cigna Medicaid	$137.29
Rate for Payer: Molina CHIP/Medicaid	$137.29
Rate for Payer: Multiplan Auto	$123.94
Rate for Payer: Multiplan Commercial	$123.94
Rate for Payer: Multiplan Workers Comp	$123.94
Rate for Payer: Parkland Medicaid	$137.29
Rate for Payer: Scott and White EPO/PPO	$95.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.29
Rate for Payer: Superior Health Plan EPO	$25.93

sagittal blade 25x100

Facility

$190.68

Hospital Charge Code	992676
Hospital Revenue Code	270
Rate for Payer: Cash Price	$129.66

sagittal blade 25x100

Facility

$190.68

Hospital Charge Code	992676
Hospital Revenue Code	270
Min. Negotiated Rate	$17.16
Max. Negotiated Rate	$137.29
Rate for Payer: Amerigroup CHIP/Medicaid	$17.16
Rate for Payer: BCBS of TX Blue Advantage	$57.20
Rate for Payer: BCBS of TX Blue Essentials	$68.64
Rate for Payer: BCBS of TX PPO	$76.27
Rate for Payer: Cash Price	$129.66
Rate for Payer: Cigna Medicaid	$137.29
Rate for Payer: Molina CHIP/Medicaid	$137.29
Rate for Payer: Multiplan Auto	$123.94
Rate for Payer: Multiplan Commercial	$123.94
Rate for Payer: Multiplan Workers Comp	$123.94
Rate for Payer: Parkland Medicaid	$137.29
Rate for Payer: Scott and White EPO/PPO	$95.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.29
Rate for Payer: Superior Health Plan EPO	$25.93

Salicylate Level

Facility

$164.76

Service Code	HCPCS 80179
Hospital Charge Code	993988
Hospital Revenue Code	300
Rate for Payer: Cash Price	$112.04

Salicylate Level

Facility

$164.76

Service Code	HCPCS 80179
Hospital Charge Code	993988
Hospital Revenue Code	300
Min. Negotiated Rate	$7.27
Max. Negotiated Rate	$118.63
Rate for Payer: Amerigroup CHIP/Medicaid	$7.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.64
Rate for Payer: Amerigroup Medicare	$18.64
Rate for Payer: BCBS of TX Blue Advantage	$49.43
Rate for Payer: BCBS of TX Blue Essentials	$59.31
Rate for Payer: BCBS of TX Medicare	$18.64
Rate for Payer: BCBS of TX PPO	$65.90
Rate for Payer: Cash Price	$112.04
Rate for Payer: Cash Price	$112.04
Rate for Payer: Cigna Medicaid	$118.63
Rate for Payer: Cigna Medicare	$18.64
Rate for Payer: Employer Direct Commercial	$18.64
Rate for Payer: Humana Medicare/TRICARE	$18.64
Rate for Payer: Molina CHIP/Medicaid	$118.63
Rate for Payer: Molina Dual Medicare/Medicaid	$18.64
Rate for Payer: Molina Medicare	$18.64
Rate for Payer: Multiplan Auto	$107.09
Rate for Payer: Multiplan Commercial	$107.09
Rate for Payer: Multiplan Workers Comp	$107.09
Rate for Payer: Parkland Medicaid	$118.63
Rate for Payer: Scott and White EPO/PPO	$23.30
Rate for Payer: Scott and White Medicare	$18.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.63
Rate for Payer: Superior Health Plan EPO	$18.64
Rate for Payer: Superior Health Plan Medicare	$18.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.64
Rate for Payer: Universal American Medicare	$18.64
Rate for Payer: Wellcare Medicare	$18.64
Rate for Payer: Wellmed Medicare	$18.64

Know your out-of-pocket cost for care.

All Charges