White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Salvation Nut 10mm

Facility

$195.22

Hospital Charge Code	993394
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

Salvation Nut 10mm

Facility

$195.22

Hospital Charge Code	993394
Hospital Revenue Code	272
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$140.56
Rate for Payer: Amerigroup CHIP/Medicaid	$17.57
Rate for Payer: BCBS of TX Blue Advantage	$58.57
Rate for Payer: BCBS of TX Blue Essentials	$70.28
Rate for Payer: BCBS of TX PPO	$78.09
Rate for Payer: Cash Price	$132.75
Rate for Payer: Cigna Medicaid	$140.56
Rate for Payer: Molina CHIP/Medicaid	$140.56
Rate for Payer: Multiplan Auto	$126.89
Rate for Payer: Multiplan Commercial	$126.89
Rate for Payer: Multiplan Workers Comp	$126.89
Rate for Payer: Parkland Medicaid	$140.56
Rate for Payer: Scott and White EPO/PPO	$97.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.56
Rate for Payer: Superior Health Plan EPO	$26.55

Salvation open rocker plate

Facility

$13,374.84

Service Code	HCPCS C1713
Hospital Charge Code	993389
Hospital Revenue Code	278
Min. Negotiated Rate	$1,203.74
Max. Negotiated Rate	$9,629.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1,203.74
Rate for Payer: BCBS of TX Blue Advantage	$4,012.45
Rate for Payer: BCBS of TX Blue Essentials	$4,814.94
Rate for Payer: BCBS of TX PPO	$5,349.94
Rate for Payer: Cash Price	$9,094.89
Rate for Payer: Cigna Medicaid	$9,629.88
Rate for Payer: Molina CHIP/Medicaid	$9,629.88
Rate for Payer: Multiplan Auto	$6,687.42
Rate for Payer: Multiplan Commercial	$6,687.42
Rate for Payer: Multiplan Workers Comp	$6,687.42
Rate for Payer: Parkland Medicaid	$9,629.88
Rate for Payer: Scott and White EPO/PPO	$6,687.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,629.88
Rate for Payer: Superior Health Plan EPO	$1,818.98

Salvation open rocker plate

Facility

$13,374.84

Service Code	HCPCS C1713
Hospital Charge Code	993389
Hospital Revenue Code	278
Min. Negotiated Rate	$3,343.71
Max. Negotiated Rate	$6,687.42
Rate for Payer: Cash Price	$9,094.89
Rate for Payer: Cigna Commercial	$3,343.71
Rate for Payer: Multiplan Auto	$6,687.42
Rate for Payer: Multiplan Commercial	$6,687.42
Rate for Payer: Multiplan Workers Comp	$6,687.42
Rate for Payer: Scott and White EPO/PPO	$6,687.42

SALVATION T25 DRIVER CANNULATED

Facility

$2,238.22

Hospital Charge Code	993517
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,521.99

SALVATION T25 DRIVER CANNULATED

Facility

$2,238.22

Hospital Charge Code	993517
Hospital Revenue Code	272
Min. Negotiated Rate	$201.44
Max. Negotiated Rate	$1,611.52
Rate for Payer: Amerigroup CHIP/Medicaid	$201.44
Rate for Payer: BCBS of TX Blue Advantage	$671.47
Rate for Payer: BCBS of TX Blue Essentials	$805.76
Rate for Payer: BCBS of TX PPO	$895.29
Rate for Payer: Cash Price	$1,521.99
Rate for Payer: Cigna Medicaid	$1,611.52
Rate for Payer: Molina CHIP/Medicaid	$1,611.52
Rate for Payer: Multiplan Auto	$1,454.84
Rate for Payer: Multiplan Commercial	$1,454.84
Rate for Payer: Multiplan Workers Comp	$1,454.84
Rate for Payer: Parkland Medicaid	$1,611.52
Rate for Payer: Scott and White EPO/PPO	$1,119.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,611.52
Rate for Payer: Superior Health Plan EPO	$304.40

SALVATION WIRE BOLT 2 MM PREASSEMBLED

Facility

$1,489.12

Hospital Charge Code	993445
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,012.60

SALVATION WIRE BOLT 2 MM PREASSEMBLED

Facility

$1,489.12

Hospital Charge Code	993445
Hospital Revenue Code	272
Min. Negotiated Rate	$134.02
Max. Negotiated Rate	$1,072.17
Rate for Payer: Amerigroup CHIP/Medicaid	$134.02
Rate for Payer: BCBS of TX Blue Advantage	$446.74
Rate for Payer: BCBS of TX Blue Essentials	$536.08
Rate for Payer: BCBS of TX PPO	$595.65
Rate for Payer: Cash Price	$1,012.60
Rate for Payer: Cigna Medicaid	$1,072.17
Rate for Payer: Molina CHIP/Medicaid	$1,072.17
Rate for Payer: Multiplan Auto	$967.93
Rate for Payer: Multiplan Commercial	$967.93
Rate for Payer: Multiplan Workers Comp	$967.93
Rate for Payer: Parkland Medicaid	$1,072.17
Rate for Payer: Scott and White EPO/PPO	$744.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,072.17
Rate for Payer: Superior Health Plan EPO	$202.52

Salvation wire bolt 2mm preassembled washerless

Facility

$1,507.28

Hospital Charge Code	993392
Hospital Revenue Code	272
Min. Negotiated Rate	$135.66
Max. Negotiated Rate	$1,085.24
Rate for Payer: Amerigroup CHIP/Medicaid	$135.66
Rate for Payer: BCBS of TX Blue Advantage	$452.18
Rate for Payer: BCBS of TX Blue Essentials	$542.62
Rate for Payer: BCBS of TX PPO	$602.91
Rate for Payer: Cash Price	$1,024.95
Rate for Payer: Cigna Medicaid	$1,085.24
Rate for Payer: Molina CHIP/Medicaid	$1,085.24
Rate for Payer: Multiplan Auto	$979.73
Rate for Payer: Multiplan Commercial	$979.73
Rate for Payer: Multiplan Workers Comp	$979.73
Rate for Payer: Parkland Medicaid	$1,085.24
Rate for Payer: Scott and White EPO/PPO	$753.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,085.24
Rate for Payer: Superior Health Plan EPO	$204.99

Salvation wire bolt 2mm preassembled washerless

Facility

$1,507.28

Hospital Charge Code	993392
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,024.95

SANITIZER HAND FOAM SPECTRUM DISP 1000ML

Facility

$56.26

Hospital Charge Code	993273
Hospital Revenue Code	270
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$40.51
Rate for Payer: Amerigroup CHIP/Medicaid	$5.06
Rate for Payer: BCBS of TX Blue Advantage	$16.88
Rate for Payer: BCBS of TX Blue Essentials	$20.25
Rate for Payer: BCBS of TX PPO	$22.50
Rate for Payer: Cash Price	$38.26
Rate for Payer: Cigna Medicaid	$40.51
Rate for Payer: Molina CHIP/Medicaid	$40.51
Rate for Payer: Multiplan Auto	$36.57
Rate for Payer: Multiplan Commercial	$36.57
Rate for Payer: Multiplan Workers Comp	$36.57
Rate for Payer: Parkland Medicaid	$40.51
Rate for Payer: Scott and White EPO/PPO	$28.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.51
Rate for Payer: Superior Health Plan EPO	$7.65

SANITIZER HAND FOAM SPECTRUM DISP 1000ML

Facility

$56.26

Hospital Charge Code	993273
Hospital Revenue Code	270
Rate for Payer: Cash Price	$38.26

Saphenous vein

Facility

$66,114.46

Service Code	HCPCS C1768
Hospital Charge Code	992352
Hospital Revenue Code	278
Min. Negotiated Rate	$16,528.62
Max. Negotiated Rate	$33,057.23
Rate for Payer: Cash Price	$44,957.83
Rate for Payer: Cigna Commercial	$16,528.62
Rate for Payer: Multiplan Auto	$33,057.23
Rate for Payer: Multiplan Commercial	$33,057.23
Rate for Payer: Multiplan Workers Comp	$33,057.23
Rate for Payer: Scott and White EPO/PPO	$33,057.23

Saphenous vein

Facility

$66,114.46

Service Code	HCPCS C1768
Hospital Charge Code	992352
Hospital Revenue Code	278
Min. Negotiated Rate	$5,950.30
Max. Negotiated Rate	$47,602.41
Rate for Payer: Amerigroup CHIP/Medicaid	$5,950.30
Rate for Payer: BCBS of TX Blue Advantage	$19,834.34
Rate for Payer: BCBS of TX Blue Essentials	$23,801.21
Rate for Payer: BCBS of TX PPO	$26,445.78
Rate for Payer: Cash Price	$44,957.83
Rate for Payer: Cigna Medicaid	$47,602.41
Rate for Payer: Molina CHIP/Medicaid	$47,602.41
Rate for Payer: Multiplan Auto	$33,057.23
Rate for Payer: Multiplan Commercial	$33,057.23
Rate for Payer: Multiplan Workers Comp	$33,057.23
Rate for Payer: Parkland Medicaid	$47,602.41
Rate for Payer: Scott and White EPO/PPO	$33,057.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47,602.41
Rate for Payer: Superior Health Plan EPO	$8,991.57

SARS-CoV-2

Facility

$165.52

Service Code	HCPCS 87811
Hospital Charge Code	994062
Hospital Revenue Code	301
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$119.17
Rate for Payer: Amerigroup CHIP/Medicaid	$13.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$41.38
Rate for Payer: Amerigroup Medicare	$41.38
Rate for Payer: BCBS of TX Blue Advantage	$49.66
Rate for Payer: BCBS of TX Blue Essentials	$59.59
Rate for Payer: BCBS of TX Medicare	$41.38
Rate for Payer: BCBS of TX PPO	$66.21
Rate for Payer: Cash Price	$112.55
Rate for Payer: Cash Price	$112.55
Rate for Payer: Cigna Medicaid	$119.17
Rate for Payer: Cigna Medicare	$41.38
Rate for Payer: Employer Direct Commercial	$41.38
Rate for Payer: Humana Medicare/TRICARE	$41.38
Rate for Payer: Molina CHIP/Medicaid	$119.17
Rate for Payer: Molina Dual Medicare/Medicaid	$41.38
Rate for Payer: Molina Medicare	$41.38
Rate for Payer: Multiplan Auto	$107.59
Rate for Payer: Multiplan Commercial	$107.59
Rate for Payer: Multiplan Workers Comp	$107.59
Rate for Payer: Parkland Medicaid	$119.17
Rate for Payer: Scott and White EPO/PPO	$51.73
Rate for Payer: Scott and White Medicare	$41.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$119.17
Rate for Payer: Superior Health Plan EPO	$41.38
Rate for Payer: Superior Health Plan Medicare	$41.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$41.38
Rate for Payer: Universal American Medicare	$41.38
Rate for Payer: Wellcare Medicare	$41.38
Rate for Payer: Wellmed Medicare	$41.38

SARS-CoV-2

Facility

$165.52

Service Code	HCPCS 87811
Hospital Charge Code	994062
Hospital Revenue Code	301
Rate for Payer: Cash Price	$112.55

SARS-CoV-2 Ab, Nucleocapsid SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8660505
Hospital Revenue Code	302
Rate for Payer: Cash Price	$72.08

SARS-CoV-2 Ab, Nucleocapsid SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8660505
Hospital Revenue Code	302
Min. Negotiated Rate	$31.80
Max. Negotiated Rate	$76.32
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$31.80
Rate for Payer: BCBS of TX Blue Essentials	$38.16
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$42.40
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cigna Medicaid	$76.32
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$76.32
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$76.32
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.32
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV-2 Antibody, IgG SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8628549
Hospital Revenue Code	302
Rate for Payer: Cash Price	$72.08

SARS-CoV-2 Antibody, IgG SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8628549
Hospital Revenue Code	302
Min. Negotiated Rate	$31.80
Max. Negotiated Rate	$76.32
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$31.80
Rate for Payer: BCBS of TX Blue Essentials	$38.16
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$42.40
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cigna Medicaid	$76.32
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$76.32
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$76.32
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.32
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV-2 Antibody, IgM SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8660506
Hospital Revenue Code	302
Min. Negotiated Rate	$31.80
Max. Negotiated Rate	$76.32
Rate for Payer: Amerigroup CHIP/Medicaid	$42.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$42.13
Rate for Payer: Amerigroup Medicare	$42.13
Rate for Payer: BCBS of TX Blue Advantage	$31.80
Rate for Payer: BCBS of TX Blue Essentials	$38.16
Rate for Payer: BCBS of TX Medicare	$42.13
Rate for Payer: BCBS of TX PPO	$42.40
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cigna Medicaid	$76.32
Rate for Payer: Cigna Medicare	$42.13
Rate for Payer: Employer Direct Commercial	$42.13
Rate for Payer: Humana Medicare/TRICARE	$42.13
Rate for Payer: Molina CHIP/Medicaid	$76.32
Rate for Payer: Molina Dual Medicare/Medicaid	$42.13
Rate for Payer: Molina Medicare	$42.13
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$76.32
Rate for Payer: Scott and White EPO/PPO	$52.66
Rate for Payer: Scott and White Medicare	$42.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.32
Rate for Payer: Superior Health Plan EPO	$42.13
Rate for Payer: Superior Health Plan Medicare	$42.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$42.13
Rate for Payer: Universal American Medicare	$42.13
Rate for Payer: Wellcare Medicare	$42.13
Rate for Payer: Wellmed Medicare	$42.13

SARS-CoV-2 Antibody, IgM SO

Facility

$106.00

Service Code	HCPCS 86769
Hospital Charge Code	8660506
Hospital Revenue Code	302
Rate for Payer: Cash Price	$72.08

SARS-CoV-2/Flu/RSV PCR

Facility

$282.00

Service Code	HCPCS 0241U
Hospital Charge Code	8484529
Hospital Revenue Code	300
Rate for Payer: Cash Price	$191.76

SARS-CoV-2/Flu/RSV PCR

Facility

$282.00

Service Code	HCPCS 0241U
Hospital Charge Code	8484529
Hospital Revenue Code	300
Min. Negotiated Rate	$38.35
Max. Negotiated Rate	$203.04
Rate for Payer: Amerigroup CHIP/Medicaid	$142.63
Rate for Payer: BCBS of TX Blue Advantage	$84.60
Rate for Payer: BCBS of TX Blue Essentials	$101.52
Rate for Payer: BCBS of TX PPO	$112.80
Rate for Payer: Cash Price	$191.76
Rate for Payer: Cash Price	$191.76
Rate for Payer: Cigna Medicaid	$203.04
Rate for Payer: Molina CHIP/Medicaid	$203.04
Rate for Payer: Multiplan Auto	$183.30
Rate for Payer: Multiplan Commercial	$183.30
Rate for Payer: Multiplan Workers Comp	$183.30
Rate for Payer: Parkland Medicaid	$203.04
Rate for Payer: Scott and White EPO/PPO	$178.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$203.04
Rate for Payer: Superior Health Plan EPO	$38.35

SARS-CoV-2, NAA SO

Facility

$189.00

Hospital Charge Code	1700027
Hospital Revenue Code	300
Min. Negotiated Rate	$17.01
Max. Negotiated Rate	$136.08
Rate for Payer: Amerigroup CHIP/Medicaid	$17.01
Rate for Payer: BCBS of TX Blue Advantage	$56.70
Rate for Payer: BCBS of TX Blue Essentials	$68.04
Rate for Payer: BCBS of TX PPO	$75.60
Rate for Payer: Cash Price	$128.52
Rate for Payer: Cigna Medicaid	$136.08
Rate for Payer: Molina CHIP/Medicaid	$136.08
Rate for Payer: Multiplan Auto	$122.85
Rate for Payer: Multiplan Commercial	$122.85
Rate for Payer: Multiplan Workers Comp	$122.85
Rate for Payer: Parkland Medicaid	$136.08
Rate for Payer: Scott and White EPO/PPO	$94.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$136.08
Rate for Payer: Superior Health Plan EPO	$25.70

Know your out-of-pocket cost for care.

All Charges