White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SC-8336-50SC-5572-1

Facility

$145,783.13

Service Code	HCPCS C1820
Hospital Charge Code	13522732
Hospital Revenue Code	278
Min. Negotiated Rate	$36,445.78
Max. Negotiated Rate	$72,891.57
Rate for Payer: Cash Price	$99,132.53
Rate for Payer: Cigna Commercial	$36,445.78
Rate for Payer: Multiplan Auto	$72,891.57
Rate for Payer: Multiplan Commercial	$72,891.57
Rate for Payer: Multiplan Workers Comp	$72,891.57
Rate for Payer: Scott and White EPO/PPO	$72,891.57

SC-8336-50SC-5572-1

Facility

$145,783.13

Service Code	HCPCS C1820
Hospital Charge Code	994125
Hospital Revenue Code	278
Min. Negotiated Rate	$13,120.48
Max. Negotiated Rate	$104,963.85
Rate for Payer: Amerigroup CHIP/Medicaid	$13,120.48
Rate for Payer: BCBS of TX Blue Advantage	$43,734.94
Rate for Payer: BCBS of TX Blue Essentials	$52,481.93
Rate for Payer: BCBS of TX PPO	$58,313.25
Rate for Payer: Cash Price	$99,132.53
Rate for Payer: Cigna Medicaid	$104,963.85
Rate for Payer: Molina CHIP/Medicaid	$104,963.85
Rate for Payer: Multiplan Auto	$72,891.57
Rate for Payer: Multiplan Commercial	$72,891.57
Rate for Payer: Multiplan Workers Comp	$72,891.57
Rate for Payer: Parkland Medicaid	$104,963.85
Rate for Payer: Scott and White EPO/PPO	$72,891.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$104,963.85
Rate for Payer: Superior Health Plan EPO	$19,826.51

Scaled Drill Bit AO FIT DIA 2.6 X 220MM

Facility

$2,973.70

Hospital Charge Code	993380
Hospital Revenue Code	272
Min. Negotiated Rate	$267.63
Max. Negotiated Rate	$2,141.06
Rate for Payer: Amerigroup CHIP/Medicaid	$267.63
Rate for Payer: BCBS of TX Blue Advantage	$892.11
Rate for Payer: BCBS of TX Blue Essentials	$1,070.53
Rate for Payer: BCBS of TX PPO	$1,189.48
Rate for Payer: Cash Price	$2,022.12
Rate for Payer: Cigna Medicaid	$2,141.06
Rate for Payer: Molina CHIP/Medicaid	$2,141.06
Rate for Payer: Multiplan Auto	$1,932.90
Rate for Payer: Multiplan Commercial	$1,932.90
Rate for Payer: Multiplan Workers Comp	$1,932.90
Rate for Payer: Parkland Medicaid	$2,141.06
Rate for Payer: Scott and White EPO/PPO	$1,486.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,141.06
Rate for Payer: Superior Health Plan EPO	$404.42

Scaled Drill Bit AO FIT DIA 2.6 X 220MM

Facility

$2,973.70

Hospital Charge Code	993380
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,022.12

SCALPEL HARMONIC FOCUS HAR9F

Facility

$1,631.99

Hospital Charge Code	134451
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,109.75

SCALPEL HARMONIC FOCUS HAR9F

Facility

$1,631.99

Hospital Charge Code	134451
Hospital Revenue Code	272
Min. Negotiated Rate	$146.88
Max. Negotiated Rate	$1,175.03
Rate for Payer: Amerigroup CHIP/Medicaid	$146.88
Rate for Payer: BCBS of TX Blue Advantage	$489.60
Rate for Payer: BCBS of TX Blue Essentials	$587.52
Rate for Payer: BCBS of TX PPO	$652.80
Rate for Payer: Cash Price	$1,109.75
Rate for Payer: Cigna Medicaid	$1,175.03
Rate for Payer: Molina CHIP/Medicaid	$1,175.03
Rate for Payer: Multiplan Auto	$1,060.79
Rate for Payer: Multiplan Commercial	$1,060.79
Rate for Payer: Multiplan Workers Comp	$1,060.79
Rate for Payer: Parkland Medicaid	$1,175.03
Rate for Payer: Scott and White EPO/PPO	$816.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,175.03
Rate for Payer: Superior Health Plan EPO	$221.95

SCHIZOPHRENIA

Facility

$3,710.03

Service Code	APR-DRG 7503
Min. Negotiated Rate	$3,497.95
Max. Negotiated Rate	$3,710.03
Rate for Payer: Amerigroup CHIP/Medicaid	$3,497.95
Rate for Payer: Cigna Medicaid	$3,497.95
Rate for Payer: Molina CHIP/Medicaid	$3,497.95
Rate for Payer: Parkland Medicaid	$3,497.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,710.03

SCHIZOPHRENIA

Facility

$13,106.19

Service Code	APR-DRG 7504
Min. Negotiated Rate	$12,356.97
Max. Negotiated Rate	$13,106.19
Rate for Payer: Amerigroup CHIP/Medicaid	$12,356.97
Rate for Payer: Cigna Medicaid	$12,356.97
Rate for Payer: Molina CHIP/Medicaid	$12,356.97
Rate for Payer: Parkland Medicaid	$12,356.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,106.19

SCHIZOPHRENIA

Facility

$2,422.68

Service Code	APR-DRG 7502
Min. Negotiated Rate	$2,284.19
Max. Negotiated Rate	$2,422.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2,284.19
Rate for Payer: Cigna Medicaid	$2,284.19
Rate for Payer: Molina CHIP/Medicaid	$2,284.19
Rate for Payer: Parkland Medicaid	$2,284.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,422.68

SCHIZOPHRENIA

Facility

$2,086.23

Service Code	APR-DRG 7501
Min. Negotiated Rate	$1,966.97
Max. Negotiated Rate	$2,086.23
Rate for Payer: Amerigroup CHIP/Medicaid	$1,966.97
Rate for Payer: Cigna Medicaid	$1,966.97
Rate for Payer: Molina CHIP/Medicaid	$1,966.97
Rate for Payer: Parkland Medicaid	$1,966.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,086.23

SCISSOR DISP. LAP 45CM

Facility

$172.52

Hospital Charge Code	145301
Hospital Revenue Code	270
Rate for Payer: Cash Price	$117.31

SCISSOR DISP. LAP 45CM

Facility

$172.52

Hospital Charge Code	145301
Hospital Revenue Code	270
Min. Negotiated Rate	$15.53
Max. Negotiated Rate	$124.21
Rate for Payer: Amerigroup CHIP/Medicaid	$15.53
Rate for Payer: BCBS of TX Blue Advantage	$51.76
Rate for Payer: BCBS of TX Blue Essentials	$62.11
Rate for Payer: BCBS of TX PPO	$69.01
Rate for Payer: Cash Price	$117.31
Rate for Payer: Cigna Medicaid	$124.21
Rate for Payer: Molina CHIP/Medicaid	$124.21
Rate for Payer: Multiplan Auto	$112.14
Rate for Payer: Multiplan Commercial	$112.14
Rate for Payer: Multiplan Workers Comp	$112.14
Rate for Payer: Parkland Medicaid	$124.21
Rate for Payer: Scott and White EPO/PPO	$86.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$124.21
Rate for Payer: Superior Health Plan EPO	$23.46

SCISSOR FULL DISPOSIBLE 5MM/35CM

Facility

$136.14

Hospital Charge Code	993669
Hospital Revenue Code	272
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$98.02
Rate for Payer: Amerigroup CHIP/Medicaid	$12.25
Rate for Payer: BCBS of TX Blue Advantage	$40.84
Rate for Payer: BCBS of TX Blue Essentials	$49.01
Rate for Payer: BCBS of TX PPO	$54.46
Rate for Payer: Cash Price	$92.58
Rate for Payer: Cigna Medicaid	$98.02
Rate for Payer: Molina CHIP/Medicaid	$98.02
Rate for Payer: Multiplan Auto	$88.49
Rate for Payer: Multiplan Commercial	$88.49
Rate for Payer: Multiplan Workers Comp	$88.49
Rate for Payer: Parkland Medicaid	$98.02
Rate for Payer: Scott and White EPO/PPO	$68.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.02
Rate for Payer: Superior Health Plan EPO	$18.52

SCISSOR FULL DISPOSIBLE 5MM/35CM

Facility

$136.14

Hospital Charge Code	993669
Hospital Revenue Code	272
Rate for Payer: Cash Price	$92.58

SCISSOR MINI FULL DISPOSIBLE 5MM/35CM

Facility

$136.14

Hospital Charge Code	993668
Hospital Revenue Code	272
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$98.02
Rate for Payer: Amerigroup CHIP/Medicaid	$12.25
Rate for Payer: BCBS of TX Blue Advantage	$40.84
Rate for Payer: BCBS of TX Blue Essentials	$49.01
Rate for Payer: BCBS of TX PPO	$54.46
Rate for Payer: Cash Price	$92.58
Rate for Payer: Cigna Medicaid	$98.02
Rate for Payer: Molina CHIP/Medicaid	$98.02
Rate for Payer: Multiplan Auto	$88.49
Rate for Payer: Multiplan Commercial	$88.49
Rate for Payer: Multiplan Workers Comp	$88.49
Rate for Payer: Parkland Medicaid	$98.02
Rate for Payer: Scott and White EPO/PPO	$68.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.02
Rate for Payer: Superior Health Plan EPO	$18.52

SCISSOR MINI FULL DISPOSIBLE 5MM/35CM

Facility

$136.14

Hospital Charge Code	993668
Hospital Revenue Code	272
Rate for Payer: Cash Price	$92.58

SCISSORS DISP. 45CM

Facility

$1,089.15

Hospital Charge Code	993667
Hospital Revenue Code	272
Min. Negotiated Rate	$98.02
Max. Negotiated Rate	$784.19
Rate for Payer: Amerigroup CHIP/Medicaid	$98.02
Rate for Payer: BCBS of TX Blue Advantage	$326.75
Rate for Payer: BCBS of TX Blue Essentials	$392.09
Rate for Payer: BCBS of TX PPO	$435.66
Rate for Payer: Cash Price	$740.62
Rate for Payer: Cigna Medicaid	$784.19
Rate for Payer: Molina CHIP/Medicaid	$784.19
Rate for Payer: Multiplan Auto	$707.95
Rate for Payer: Multiplan Commercial	$707.95
Rate for Payer: Multiplan Workers Comp	$707.95
Rate for Payer: Parkland Medicaid	$784.19
Rate for Payer: Scott and White EPO/PPO	$544.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$784.19
Rate for Payer: Superior Health Plan EPO	$148.12

SCISSORS DISP. 45CM

Facility

$1,089.15

Hospital Charge Code	993667
Hospital Revenue Code	272
Rate for Payer: Cash Price	$740.62

SCISSORS, TENOTOMY STEVENS CURVED 4 1/4'

Facility

$137.47

Hospital Charge Code	992721
Hospital Revenue Code	272
Min. Negotiated Rate	$12.37
Max. Negotiated Rate	$98.98
Rate for Payer: Amerigroup CHIP/Medicaid	$12.37
Rate for Payer: BCBS of TX Blue Advantage	$41.24
Rate for Payer: BCBS of TX Blue Essentials	$49.49
Rate for Payer: BCBS of TX PPO	$54.99
Rate for Payer: Cash Price	$93.48
Rate for Payer: Cigna Medicaid	$98.98
Rate for Payer: Molina CHIP/Medicaid	$98.98
Rate for Payer: Multiplan Auto	$89.36
Rate for Payer: Multiplan Commercial	$89.36
Rate for Payer: Multiplan Workers Comp	$89.36
Rate for Payer: Parkland Medicaid	$98.98
Rate for Payer: Scott and White EPO/PPO	$68.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.98
Rate for Payer: Superior Health Plan EPO	$18.70

SCISSORS, TENOTOMY STEVENS CURVED 4 1/4'

Facility

$137.47

Hospital Charge Code	992721
Hospital Revenue Code	272
Rate for Payer: Cash Price	$93.48

SCOPE, INTUBATION VIDEO 5.0/2.2 SINGLE-USE STERILE

Facility

$396.12

Hospital Charge Code	992593
Hospital Revenue Code	270
Rate for Payer: Cash Price	$269.36

SCOPE, INTUBATION VIDEO 5.0/2.2 SINGLE-USE STERILE

Facility

$396.12

Hospital Charge Code	992593
Hospital Revenue Code	270
Min. Negotiated Rate	$35.65
Max. Negotiated Rate	$285.21
Rate for Payer: Amerigroup CHIP/Medicaid	$35.65
Rate for Payer: BCBS of TX Blue Advantage	$118.84
Rate for Payer: BCBS of TX Blue Essentials	$142.60
Rate for Payer: BCBS of TX PPO	$158.45
Rate for Payer: Cash Price	$269.36
Rate for Payer: Cigna Medicaid	$285.21
Rate for Payer: Molina CHIP/Medicaid	$285.21
Rate for Payer: Multiplan Auto	$257.48
Rate for Payer: Multiplan Commercial	$257.48
Rate for Payer: Multiplan Workers Comp	$257.48
Rate for Payer: Parkland Medicaid	$285.21
Rate for Payer: Scott and White EPO/PPO	$198.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$285.21
Rate for Payer: Superior Health Plan EPO	$53.87

SCOPE, INTUBATION VIDEO 5.8/2.8 SGL-USE STRL LARGE

Facility

$1,484.72

Hospital Charge Code	80870603
Hospital Revenue Code	272
Min. Negotiated Rate	$133.62
Max. Negotiated Rate	$1,069.00
Rate for Payer: Amerigroup CHIP/Medicaid	$133.62
Rate for Payer: BCBS of TX Blue Advantage	$445.42
Rate for Payer: BCBS of TX Blue Essentials	$534.50
Rate for Payer: BCBS of TX PPO	$593.89
Rate for Payer: Cash Price	$1,009.61
Rate for Payer: Cigna Medicaid	$1,069.00
Rate for Payer: Molina CHIP/Medicaid	$1,069.00
Rate for Payer: Multiplan Auto	$965.07
Rate for Payer: Multiplan Commercial	$965.07
Rate for Payer: Multiplan Workers Comp	$965.07
Rate for Payer: Parkland Medicaid	$1,069.00
Rate for Payer: Scott and White EPO/PPO	$742.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,069.00
Rate for Payer: Superior Health Plan EPO	$201.92

SCOPE, INTUBATION VIDEO 5.8/2.8 SGL-USE STRL LARGE

Facility

$1,484.72

Hospital Charge Code	80870603
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,009.61

scopolamine 1.3 mg TD Film, ER

Facility

$62.35

Service Code	HCPCS J3490
Hospital Charge Code	78876081
Hospital Revenue Code	250
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$44.89
Rate for Payer: Amerigroup CHIP/Medicaid	$5.61
Rate for Payer: BCBS of TX Blue Advantage	$18.70
Rate for Payer: BCBS of TX Blue Essentials	$22.45
Rate for Payer: BCBS of TX PPO	$24.94
Rate for Payer: Cash Price	$42.40
Rate for Payer: Cigna Medicaid	$44.89
Rate for Payer: Molina CHIP/Medicaid	$44.89
Rate for Payer: Multiplan Auto	$40.53
Rate for Payer: Multiplan Commercial	$40.53
Rate for Payer: Multiplan Workers Comp	$40.53
Rate for Payer: Parkland Medicaid	$44.89
Rate for Payer: Scott and White EPO/PPO	$31.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44.89
Rate for Payer: Superior Health Plan EPO	$8.48

Know your out-of-pocket cost for care.

All Charges