White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

SCISSORS DISP. 45CM

Facility

$1,089.15

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

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, 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

scopolamine 1.3 mg TD Film, ER

Facility

$62.35

Service Code	HCPCS J3490
Hospital Charge Code	78876081
Hospital Revenue Code	250
Rate for Payer: Cash Price	$42.40

Screening test of visual acuity, quantitative, bilateral

Facility

$32.30

Service Code	HCPCS 99173
Hospital Charge Code	994128
Hospital Revenue Code	761
Min. Negotiated Rate	$2.91
Max. Negotiated Rate	$50.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2.91
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$21.96
Rate for Payer: Cash Price	$21.96
Rate for Payer: Cigna Medicaid	$23.26
Rate for Payer: Molina CHIP/Medicaid	$23.26
Rate for Payer: Multiplan Auto	$21.00
Rate for Payer: Multiplan Commercial	$21.00
Rate for Payer: Multiplan Workers Comp	$21.00
Rate for Payer: Parkland Medicaid	$23.26
Rate for Payer: Scott and White EPO/PPO	$16.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.26
Rate for Payer: Superior Health Plan EPO	$4.39

Screening test of visual acuity, quantitative, bilateral

Facility

$32.30

Service Code	HCPCS 99173
Hospital Charge Code	994128
Hospital Revenue Code	761
Rate for Payer: Cash Price	$21.96

SCREW

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992136
Hospital Revenue Code	278
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$459.76
Rate for Payer: Amerigroup CHIP/Medicaid	$57.47
Rate for Payer: BCBS of TX Blue Advantage	$191.56
Rate for Payer: BCBS of TX Blue Essentials	$229.88
Rate for Payer: BCBS of TX PPO	$255.42
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Medicaid	$459.76
Rate for Payer: Molina CHIP/Medicaid	$459.76
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Parkland Medicaid	$459.76
Rate for Payer: Scott and White EPO/PPO	$319.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$459.76
Rate for Payer: Superior Health Plan EPO	$86.84

SCREW

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992136
Hospital Revenue Code	278
Min. Negotiated Rate	$159.64
Max. Negotiated Rate	$319.27
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Commercial	$159.64
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Scott and White EPO/PPO	$319.27

SCREW 3.5MM HEX HEAD

Facility

$936.00

Service Code	HCPCS C1713
Hospital Charge Code	144886
Hospital Revenue Code	278
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$468.00
Rate for Payer: Cash Price	$636.48
Rate for Payer: Cigna Commercial	$234.00
Rate for Payer: Multiplan Auto	$468.00
Rate for Payer: Multiplan Commercial	$468.00
Rate for Payer: Multiplan Workers Comp	$468.00
Rate for Payer: Scott and White EPO/PPO	$468.00

SCREW 3.5MM HEX HEAD

Facility

$936.00

Service Code	HCPCS C1713
Hospital Charge Code	144886
Hospital Revenue Code	278
Min. Negotiated Rate	$84.24
Max. Negotiated Rate	$673.92
Rate for Payer: Amerigroup CHIP/Medicaid	$84.24
Rate for Payer: BCBS of TX Blue Advantage	$280.80
Rate for Payer: BCBS of TX Blue Essentials	$336.96
Rate for Payer: BCBS of TX PPO	$374.40
Rate for Payer: Cash Price	$636.48
Rate for Payer: Cigna Medicaid	$673.92
Rate for Payer: Molina CHIP/Medicaid	$673.92
Rate for Payer: Multiplan Auto	$468.00
Rate for Payer: Multiplan Commercial	$468.00
Rate for Payer: Multiplan Workers Comp	$468.00
Rate for Payer: Parkland Medicaid	$673.92
Rate for Payer: Scott and White EPO/PPO	$468.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$673.92
Rate for Payer: Superior Health Plan EPO	$127.30

SCREW 602685 602680 602675

Facility

$2,246.99

Service Code	HCPCS C1713
Hospital Charge Code	994086
Hospital Revenue Code	278
Min. Negotiated Rate	$561.75
Max. Negotiated Rate	$1,123.49
Rate for Payer: Cash Price	$1,527.95
Rate for Payer: Cigna Commercial	$561.75
Rate for Payer: Multiplan Auto	$1,123.49
Rate for Payer: Multiplan Commercial	$1,123.49
Rate for Payer: Multiplan Workers Comp	$1,123.49
Rate for Payer: Scott and White EPO/PPO	$1,123.49

SCREW 602685 602680 602675

Facility

$2,246.99

Service Code	HCPCS C1713
Hospital Charge Code	994086
Hospital Revenue Code	278
Min. Negotiated Rate	$202.23
Max. Negotiated Rate	$1,617.83
Rate for Payer: Amerigroup CHIP/Medicaid	$202.23
Rate for Payer: BCBS of TX Blue Advantage	$674.10
Rate for Payer: BCBS of TX Blue Essentials	$808.92
Rate for Payer: BCBS of TX PPO	$898.80
Rate for Payer: Cash Price	$1,527.95
Rate for Payer: Cigna Medicaid	$1,617.83
Rate for Payer: Molina CHIP/Medicaid	$1,617.83
Rate for Payer: Multiplan Auto	$1,123.49
Rate for Payer: Multiplan Commercial	$1,123.49
Rate for Payer: Multiplan Workers Comp	$1,123.49
Rate for Payer: Parkland Medicaid	$1,617.83
Rate for Payer: Scott and White EPO/PPO	$1,123.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,617.83
Rate for Payer: Superior Health Plan EPO	$305.59

SCREW ACF 4.0 SELF DRILLING SDV40

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8420463
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$1,084.32
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.80
Rate for Payer: BCBS of TX Blue Essentials	$542.16
Rate for Payer: BCBS of TX PPO	$602.40
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Medicaid	$1,084.32
Rate for Payer: Molina CHIP/Medicaid	$1,084.32
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Parkland Medicaid	$1,084.32
Rate for Payer: Scott and White EPO/PPO	$753.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,084.32
Rate for Payer: Superior Health Plan EPO	$204.82

SCREW ACF 4.0 SELF DRILLING SDV40

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8420463
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.00
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Scott and White EPO/PPO	$753.00

SCREW ACIFSLF DRL FXD 4.0X16

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8568969
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$1,084.32
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.80
Rate for Payer: BCBS of TX Blue Essentials	$542.16
Rate for Payer: BCBS of TX PPO	$602.40
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Medicaid	$1,084.32
Rate for Payer: Molina CHIP/Medicaid	$1,084.32
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Parkland Medicaid	$1,084.32
Rate for Payer: Scott and White EPO/PPO	$753.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,084.32
Rate for Payer: Superior Health Plan EPO	$204.82

SCREW ACIFSLF DRL FXD 4.0X16

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8568969
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.00
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Scott and White EPO/PPO	$753.00

SCREW ACIF SLF DRL FXD 4X12

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8568968
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$1,084.32
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.80
Rate for Payer: BCBS of TX Blue Essentials	$542.16
Rate for Payer: BCBS of TX PPO	$602.40
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Medicaid	$1,084.32
Rate for Payer: Molina CHIP/Medicaid	$1,084.32
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Parkland Medicaid	$1,084.32
Rate for Payer: Scott and White EPO/PPO	$753.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,084.32
Rate for Payer: Superior Health Plan EPO	$204.82

SCREW ACIF SLF DRL FXD 4X12

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8568968
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.00
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Scott and White EPO/PPO	$753.00

Know your out-of-pocket cost for care.

All Charges