White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SCRW SOLID 81362600 -- DHF

Facility

$6,435.00

Service Code	HCPCS C1713
Hospital Charge Code	81362600
Hospital Revenue Code	278
Min. Negotiated Rate	$579.15
Max. Negotiated Rate	$4,633.20
Rate for Payer: Amerigroup CHIP/Medicaid	$579.15
Rate for Payer: BCBS of TX Blue Advantage	$1,930.50
Rate for Payer: BCBS of TX Blue Essentials	$2,316.60
Rate for Payer: BCBS of TX PPO	$2,574.00
Rate for Payer: Cash Price	$4,375.80
Rate for Payer: Cigna Medicaid	$4,633.20
Rate for Payer: Molina CHIP/Medicaid	$4,633.20
Rate for Payer: Multiplan Auto	$3,217.50
Rate for Payer: Multiplan Commercial	$3,217.50
Rate for Payer: Multiplan Workers Comp	$3,217.50
Rate for Payer: Parkland Medicaid	$4,633.20
Rate for Payer: Scott and White EPO/PPO	$3,217.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,633.20
Rate for Payer: Superior Health Plan EPO	$875.16

SCRW SOLID 81362600 -- DHF

Facility

$6,435.00

Service Code	HCPCS C1713
Hospital Charge Code	81362600
Hospital Revenue Code	278
Min. Negotiated Rate	$1,608.75
Max. Negotiated Rate	$3,217.50
Rate for Payer: Cash Price	$4,375.80
Rate for Payer: Cigna Commercial	$1,608.75
Rate for Payer: Multiplan Auto	$3,217.50
Rate for Payer: Multiplan Commercial	$3,217.50
Rate for Payer: Multiplan Workers Comp	$3,217.50
Rate for Payer: Scott and White EPO/PPO	$3,217.50

SCRW SOLID 81362659 -- DHF

Facility

$384.00

Service Code	HCPCS C1713
Hospital Charge Code	81362659
Hospital Revenue Code	278
Min. Negotiated Rate	$34.56
Max. Negotiated Rate	$276.48
Rate for Payer: Amerigroup CHIP/Medicaid	$34.56
Rate for Payer: BCBS of TX Blue Advantage	$115.20
Rate for Payer: BCBS of TX Blue Essentials	$138.24
Rate for Payer: BCBS of TX PPO	$153.60
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cigna Medicaid	$276.48
Rate for Payer: Molina CHIP/Medicaid	$276.48
Rate for Payer: Multiplan Auto	$192.00
Rate for Payer: Multiplan Commercial	$192.00
Rate for Payer: Multiplan Workers Comp	$192.00
Rate for Payer: Parkland Medicaid	$276.48
Rate for Payer: Scott and White EPO/PPO	$192.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$276.48
Rate for Payer: Superior Health Plan EPO	$52.22

SCRW SOLID 81362659 -- DHF

Facility

$384.00

Service Code	HCPCS C1713
Hospital Charge Code	81362659
Hospital Revenue Code	278
Min. Negotiated Rate	$96.00
Max. Negotiated Rate	$192.00
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cigna Commercial	$96.00
Rate for Payer: Multiplan Auto	$192.00
Rate for Payer: Multiplan Commercial	$192.00
Rate for Payer: Multiplan Workers Comp	$192.00
Rate for Payer: Scott and White EPO/PPO	$192.00

SCRW WOODRUF -- DHF

Facility

$479.00

Service Code	HCPCS C1713
Hospital Charge Code	81362956
Hospital Revenue Code	278
Min. Negotiated Rate	$119.75
Max. Negotiated Rate	$239.50
Rate for Payer: Cash Price	$325.72
Rate for Payer: Cigna Commercial	$119.75
Rate for Payer: Multiplan Auto	$239.50
Rate for Payer: Multiplan Commercial	$239.50
Rate for Payer: Multiplan Workers Comp	$239.50
Rate for Payer: Scott and White EPO/PPO	$239.50

SCRW WOODRUF -- DHF

Facility

$479.00

Service Code	HCPCS C1713
Hospital Charge Code	81362956
Hospital Revenue Code	278
Min. Negotiated Rate	$43.11
Max. Negotiated Rate	$344.88
Rate for Payer: Amerigroup CHIP/Medicaid	$43.11
Rate for Payer: BCBS of TX Blue Advantage	$143.70
Rate for Payer: BCBS of TX Blue Essentials	$172.44
Rate for Payer: BCBS of TX PPO	$191.60
Rate for Payer: Cash Price	$325.72
Rate for Payer: Cigna Medicaid	$344.88
Rate for Payer: Molina CHIP/Medicaid	$344.88
Rate for Payer: Multiplan Auto	$239.50
Rate for Payer: Multiplan Commercial	$239.50
Rate for Payer: Multiplan Workers Comp	$239.50
Rate for Payer: Parkland Medicaid	$344.88
Rate for Payer: Scott and White EPO/PPO	$239.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$344.88
Rate for Payer: Superior Health Plan EPO	$65.14

SDS Facility Eval, Management Level 1 99211 BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	3603079
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

SDS Facility Eval, Management Level 1 99211 BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	3603079
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$81.36
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$33.90
Rate for Payer: BCBS of TX Blue Essentials	$40.68
Rate for Payer: BCBS of TX PPO	$45.20
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cigna Medicaid	$81.36
Rate for Payer: Molina CHIP/Medicaid	$81.36
Rate for Payer: Multiplan Auto	$73.45
Rate for Payer: Multiplan Commercial	$73.45
Rate for Payer: Multiplan Workers Comp	$73.45
Rate for Payer: Parkland Medicaid	$81.36
Rate for Payer: Scott and White EPO/PPO	$10.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.36

SDS Inf Hydration Initial 31 to 60 Min 96360 BCE

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	610009
Hospital Revenue Code	260
Rate for Payer: Cash Price	$575.96

SDS Inf Hydration Initial 31 to 60 Min 96360 BCE

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	610009
Hospital Revenue Code	260
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$609.84
Rate for Payer: Amerigroup CHIP/Medicaid	$76.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$254.10
Rate for Payer: BCBS of TX Blue Essentials	$304.92
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$338.80
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$609.84
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$609.84
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$550.55
Rate for Payer: Multiplan Commercial	$550.55
Rate for Payer: Multiplan Workers Comp	$550.55
Rate for Payer: Parkland Medicaid	$609.84
Rate for Payer: Scott and White EPO/PPO	$39.95
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$609.84
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

SDS Inf Ther Proph Dx Each Addl Hr 96366 BCE

Facility

$153.00

Hospital Charge Code	600569
Hospital Revenue Code	260
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$110.16
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: BCBS of TX Blue Advantage	$45.90
Rate for Payer: BCBS of TX Blue Essentials	$55.08
Rate for Payer: BCBS of TX PPO	$61.20
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cigna Medicaid	$110.16
Rate for Payer: Molina CHIP/Medicaid	$110.16
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Parkland Medicaid	$110.16
Rate for Payer: Scott and White EPO/PPO	$76.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.16
Rate for Payer: Superior Health Plan EPO	$20.81

SDS Inf Ther Proph Dx Each Addl Hr 96366 BCE

Facility

$153.00

Hospital Charge Code	600569
Hospital Revenue Code	260
Rate for Payer: Cash Price	$104.04

SDS Tx Proph Diag Ea Addl IVP Drug 96375 BCE

Facility

$330.00

Service Code	HCPCS 96375
Hospital Charge Code	610014
Hospital Revenue Code	260
Min. Negotiated Rate	$18.93
Max. Negotiated Rate	$237.60
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47.04
Rate for Payer: Amerigroup Medicare	$47.04
Rate for Payer: BCBS of TX Blue Advantage	$99.00
Rate for Payer: BCBS of TX Blue Essentials	$118.80
Rate for Payer: BCBS of TX Medicare	$47.04
Rate for Payer: BCBS of TX PPO	$132.00
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cigna Commercial	$99.43
Rate for Payer: Cigna Medicaid	$237.60
Rate for Payer: Cigna Medicare	$47.04
Rate for Payer: Employer Direct Commercial	$47.04
Rate for Payer: Humana Medicare/TRICARE	$47.04
Rate for Payer: Molina CHIP/Medicaid	$237.60
Rate for Payer: Molina Dual Medicare/Medicaid	$47.04
Rate for Payer: Molina Medicare	$47.04
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Parkland Medicaid	$237.60
Rate for Payer: Scott and White EPO/PPO	$18.93
Rate for Payer: Scott and White Medicare	$47.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$237.60
Rate for Payer: Superior Health Plan EPO	$47.04
Rate for Payer: Superior Health Plan Medicare	$47.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$47.04
Rate for Payer: Universal American Medicare	$47.04
Rate for Payer: Wellcare Medicare	$47.04
Rate for Payer: Wellmed Medicare	$47.04

SDS Tx Proph Diag Ea Addl IVP Drug 96375 BCE

Facility

$330.00

Service Code	HCPCS 96375
Hospital Charge Code	610014
Hospital Revenue Code	260
Rate for Payer: Cash Price	$224.40

SDS Tx Proph Diag Injection SQ or IM 96372 BCE

Facility

$280.00

Service Code	HCPCS 96372
Hospital Charge Code	600577
Hospital Revenue Code	260
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$201.60
Rate for Payer: Amerigroup CHIP/Medicaid	$25.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$84.00
Rate for Payer: BCBS of TX Blue Essentials	$100.80
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$112.00
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$201.60
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$201.60
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
Rate for Payer: Multiplan Auto	$182.00
Rate for Payer: Multiplan Commercial	$182.00
Rate for Payer: Multiplan Workers Comp	$182.00
Rate for Payer: Parkland Medicaid	$201.60
Rate for Payer: Scott and White EPO/PPO	$17.70
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$201.60
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

SDS Tx Proph Diag Injection SQ or IM 96372 BCE

Facility

$280.00

Service Code	HCPCS 96372
Hospital Charge Code	600577
Hospital Revenue Code	260
Rate for Payer: Cash Price	$190.40

SDS Tx Prophylactic Diag IVP Drug 96374 BCE

Facility

$360.00

Service Code	HCPCS 96374
Hospital Charge Code	610013
Hospital Revenue Code	260
Min. Negotiated Rate	$32.40
Max. Negotiated Rate	$451.67
Rate for Payer: Amerigroup CHIP/Medicaid	$32.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$108.00
Rate for Payer: BCBS of TX Blue Essentials	$129.60
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$144.00
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$259.20
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$259.20
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$234.00
Rate for Payer: Multiplan Commercial	$234.00
Rate for Payer: Multiplan Workers Comp	$234.00
Rate for Payer: Parkland Medicaid	$259.20
Rate for Payer: Scott and White EPO/PPO	$45.26
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$259.20
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

SDS Tx Prophylactic Diag IVP Drug 96374 BCE

Facility

$360.00

Service Code	HCPCS 96374
Hospital Charge Code	610013
Hospital Revenue Code	260
Rate for Payer: Cash Price	$244.80

SEALANT FLOSEAL SURGICAL

Facility

$1,921.42

Hospital Charge Code	8494511
Hospital Revenue Code	272
Min. Negotiated Rate	$172.93
Max. Negotiated Rate	$1,383.42
Rate for Payer: Amerigroup CHIP/Medicaid	$172.93
Rate for Payer: BCBS of TX Blue Advantage	$576.43
Rate for Payer: BCBS of TX Blue Essentials	$691.71
Rate for Payer: BCBS of TX PPO	$768.57
Rate for Payer: Cash Price	$1,306.57
Rate for Payer: Cigna Medicaid	$1,383.42
Rate for Payer: Molina CHIP/Medicaid	$1,383.42
Rate for Payer: Multiplan Auto	$1,248.92
Rate for Payer: Multiplan Commercial	$1,248.92
Rate for Payer: Multiplan Workers Comp	$1,248.92
Rate for Payer: Parkland Medicaid	$1,383.42
Rate for Payer: Scott and White EPO/PPO	$960.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,383.42
Rate for Payer: Superior Health Plan EPO	$261.31

SEALANT FLOSEAL SURGICAL

Facility

$1,921.42

Hospital Charge Code	8494511
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,306.57

SEALANT HEMOSTATIC TISSEEL 10ML FROZEN PRE-FILLED PRIMA SYRI

Facility

$4,124.04

Service Code	HCPCS C9250
Hospital Charge Code	992339
Hospital Revenue Code	278
Min. Negotiated Rate	$142.48
Max. Negotiated Rate	$2,969.31
Rate for Payer: Amerigroup CHIP/Medicaid	$371.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$142.48
Rate for Payer: Amerigroup Medicare	$142.48
Rate for Payer: BCBS of TX Blue Advantage	$1,237.21
Rate for Payer: BCBS of TX Blue Essentials	$1,484.65
Rate for Payer: BCBS of TX Medicare	$142.48
Rate for Payer: BCBS of TX PPO	$1,649.62
Rate for Payer: Cash Price	$2,804.35
Rate for Payer: Cash Price	$2,804.35
Rate for Payer: Cigna Medicaid	$2,969.31
Rate for Payer: Cigna Medicare	$142.48
Rate for Payer: Employer Direct Commercial	$142.48
Rate for Payer: Humana Medicare/TRICARE	$142.48
Rate for Payer: Molina CHIP/Medicaid	$2,969.31
Rate for Payer: Molina Dual Medicare/Medicaid	$142.48
Rate for Payer: Molina Medicare	$142.48
Rate for Payer: Multiplan Auto	$2,062.02
Rate for Payer: Multiplan Commercial	$2,062.02
Rate for Payer: Multiplan Workers Comp	$2,062.02
Rate for Payer: Parkland Medicaid	$2,969.31
Rate for Payer: Scott and White EPO/PPO	$2,062.02
Rate for Payer: Scott and White Medicare	$142.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,969.31
Rate for Payer: Superior Health Plan EPO	$142.48
Rate for Payer: Superior Health Plan Medicare	$142.48
Rate for Payer: Universal American Dual Medicare/Medicaid	$142.48
Rate for Payer: Universal American Medicare	$142.48
Rate for Payer: Wellcare Medicare	$142.48
Rate for Payer: Wellmed Medicare	$142.48

SEALANT HEMOSTATIC TISSEEL 10ML FROZEN PRE-FILLED PRIMA SYRI

Facility

$4,124.04

Service Code	HCPCS C9250
Hospital Charge Code	992339
Hospital Revenue Code	278
Min. Negotiated Rate	$1,031.01
Max. Negotiated Rate	$2,062.02
Rate for Payer: Cash Price	$2,804.35
Rate for Payer: Cigna Commercial	$1,031.01
Rate for Payer: Multiplan Auto	$2,062.02
Rate for Payer: Multiplan Commercial	$2,062.02
Rate for Payer: Multiplan Workers Comp	$2,062.02
Rate for Payer: Scott and White EPO/PPO	$2,062.02

SEALANT HEMOSTATIC TISSEEL 4ML FROZEN PRE-FILLED PRIMA SYRIN

Facility

$1,680.54

Service Code	HCPCS C9250
Hospital Charge Code	992343
Hospital Revenue Code	278
Min. Negotiated Rate	$420.13
Max. Negotiated Rate	$840.27
Rate for Payer: Cash Price	$1,142.77
Rate for Payer: Cigna Commercial	$420.13
Rate for Payer: Multiplan Auto	$840.27
Rate for Payer: Multiplan Commercial	$840.27
Rate for Payer: Multiplan Workers Comp	$840.27
Rate for Payer: Scott and White EPO/PPO	$840.27

SEALANT HEMOSTATIC TISSEEL 4ML FROZEN PRE-FILLED PRIMA SYRIN

Facility

$1,680.54

Service Code	HCPCS C9250
Hospital Charge Code	992343
Hospital Revenue Code	278
Min. Negotiated Rate	$142.48
Max. Negotiated Rate	$1,209.99
Rate for Payer: Amerigroup CHIP/Medicaid	$151.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$142.48
Rate for Payer: Amerigroup Medicare	$142.48
Rate for Payer: BCBS of TX Blue Advantage	$504.16
Rate for Payer: BCBS of TX Blue Essentials	$604.99
Rate for Payer: BCBS of TX Medicare	$142.48
Rate for Payer: BCBS of TX PPO	$672.22
Rate for Payer: Cash Price	$1,142.77
Rate for Payer: Cash Price	$1,142.77
Rate for Payer: Cigna Medicaid	$1,209.99
Rate for Payer: Cigna Medicare	$142.48
Rate for Payer: Employer Direct Commercial	$142.48
Rate for Payer: Humana Medicare/TRICARE	$142.48
Rate for Payer: Molina CHIP/Medicaid	$1,209.99
Rate for Payer: Molina Dual Medicare/Medicaid	$142.48
Rate for Payer: Molina Medicare	$142.48
Rate for Payer: Multiplan Auto	$840.27
Rate for Payer: Multiplan Commercial	$840.27
Rate for Payer: Multiplan Workers Comp	$840.27
Rate for Payer: Parkland Medicaid	$1,209.99
Rate for Payer: Scott and White EPO/PPO	$840.27
Rate for Payer: Scott and White Medicare	$142.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,209.99
Rate for Payer: Superior Health Plan EPO	$142.48
Rate for Payer: Superior Health Plan Medicare	$142.48
Rate for Payer: Universal American Dual Medicare/Medicaid	$142.48
Rate for Payer: Universal American Medicare	$142.48
Rate for Payer: Wellcare Medicare	$142.48
Rate for Payer: Wellmed Medicare	$142.48

SEALANT HEMOSTAT MATRIX -- DHF

Facility

$719.36

Hospital Charge Code	81770182
Hospital Revenue Code	272
Rate for Payer: Cash Price	$489.16

Know your out-of-pocket cost for care.

All Charges