White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$25.20
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	$140.00
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 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

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	$180.00
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

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	$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 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	$145.67
Max. Negotiated Rate	$2,969.31
Rate for Payer: Amerigroup CHIP/Medicaid	$371.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$145.67
Rate for Payer: Amerigroup Medicare	$145.67
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	$145.67
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	$145.67
Rate for Payer: Employer Direct Commercial	$145.67
Rate for Payer: Humana Medicare/TRICARE	$145.67
Rate for Payer: Molina CHIP/Medicaid	$2,969.31
Rate for Payer: Molina Dual Medicare/Medicaid	$145.67
Rate for Payer: Molina Medicare	$145.67
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	$145.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,969.31
Rate for Payer: Superior Health Plan EPO	$145.67
Rate for Payer: Superior Health Plan Medicare	$145.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$145.67
Rate for Payer: Universal American Medicare	$145.67
Rate for Payer: Wellcare Medicare	$145.67
Rate for Payer: Wellmed Medicare	$145.67

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	$145.67
Max. Negotiated Rate	$1,209.99
Rate for Payer: Amerigroup CHIP/Medicaid	$151.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$145.67
Rate for Payer: Amerigroup Medicare	$145.67
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	$145.67
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	$145.67
Rate for Payer: Employer Direct Commercial	$145.67
Rate for Payer: Humana Medicare/TRICARE	$145.67
Rate for Payer: Molina CHIP/Medicaid	$1,209.99
Rate for Payer: Molina Dual Medicare/Medicaid	$145.67
Rate for Payer: Molina Medicare	$145.67
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	$145.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,209.99
Rate for Payer: Superior Health Plan EPO	$145.67
Rate for Payer: Superior Health Plan Medicare	$145.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$145.67
Rate for Payer: Universal American Medicare	$145.67
Rate for Payer: Wellcare Medicare	$145.67
Rate for Payer: Wellmed Medicare	$145.67

SEALANT HEMOSTAT MATRIX -- DHF

Facility

$719.36

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

SEALANT HEMOSTAT MATRIX -- DHF

Facility

$719.36

Hospital Charge Code	81770182
Hospital Revenue Code	272
Min. Negotiated Rate	$64.74
Max. Negotiated Rate	$517.94
Rate for Payer: Amerigroup CHIP/Medicaid	$64.74
Rate for Payer: BCBS of TX Blue Advantage	$215.81
Rate for Payer: BCBS of TX Blue Essentials	$258.97
Rate for Payer: BCBS of TX PPO	$287.74
Rate for Payer: Cash Price	$489.16
Rate for Payer: Cigna Medicaid	$517.94
Rate for Payer: Molina CHIP/Medicaid	$517.94
Rate for Payer: Multiplan Auto	$467.58
Rate for Payer: Multiplan Commercial	$467.58
Rate for Payer: Multiplan Workers Comp	$467.58
Rate for Payer: Parkland Medicaid	$517.94
Rate for Payer: Scott and White EPO/PPO	$359.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$517.94
Rate for Payer: Superior Health Plan EPO	$97.83

SEALANT VISTA SEAL 10ML

Facility

$2,416.64

Hospital Charge Code	8494509
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,643.32

SEALANT VISTA SEAL 10ML

Facility

$2,416.64

Hospital Charge Code	8494509
Hospital Revenue Code	272
Min. Negotiated Rate	$217.50
Max. Negotiated Rate	$1,739.98
Rate for Payer: Amerigroup CHIP/Medicaid	$217.50
Rate for Payer: BCBS of TX Blue Advantage	$724.99
Rate for Payer: BCBS of TX Blue Essentials	$869.99
Rate for Payer: BCBS of TX PPO	$966.66
Rate for Payer: Cash Price	$1,643.32
Rate for Payer: Cigna Medicaid	$1,739.98
Rate for Payer: Molina CHIP/Medicaid	$1,739.98
Rate for Payer: Multiplan Auto	$1,570.82
Rate for Payer: Multiplan Commercial	$1,570.82
Rate for Payer: Multiplan Workers Comp	$1,570.82
Rate for Payer: Parkland Medicaid	$1,739.98
Rate for Payer: Scott and White EPO/PPO	$1,208.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,739.98
Rate for Payer: Superior Health Plan EPO	$328.66

SEAL CANNULA DAVINCI UNIVERSAL 5-12

Facility

$908.00

Hospital Charge Code	992734
Hospital Revenue Code	270
Rate for Payer: Cash Price	$617.44

SEAL CANNULA DAVINCI UNIVERSAL 5-12

Facility

$908.00

Hospital Charge Code	992734
Hospital Revenue Code	270
Min. Negotiated Rate	$81.72
Max. Negotiated Rate	$653.76
Rate for Payer: Amerigroup CHIP/Medicaid	$81.72
Rate for Payer: BCBS of TX Blue Advantage	$272.40
Rate for Payer: BCBS of TX Blue Essentials	$326.88
Rate for Payer: BCBS of TX PPO	$363.20
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cigna Medicaid	$653.76
Rate for Payer: Molina CHIP/Medicaid	$653.76
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$653.76
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$653.76
Rate for Payer: Superior Health Plan EPO	$123.49

SEAL CANNULA STAPLER 12MM

Facility

$90.80

Hospital Charge Code	8690508
Hospital Revenue Code	272
Min. Negotiated Rate	$8.17
Max. Negotiated Rate	$65.38
Rate for Payer: Amerigroup CHIP/Medicaid	$8.17
Rate for Payer: BCBS of TX Blue Advantage	$27.24
Rate for Payer: BCBS of TX Blue Essentials	$32.69
Rate for Payer: BCBS of TX PPO	$36.32
Rate for Payer: Cash Price	$61.74
Rate for Payer: Cigna Medicaid	$65.38
Rate for Payer: Molina CHIP/Medicaid	$65.38
Rate for Payer: Multiplan Auto	$59.02
Rate for Payer: Multiplan Commercial	$59.02
Rate for Payer: Multiplan Workers Comp	$59.02
Rate for Payer: Parkland Medicaid	$65.38
Rate for Payer: Scott and White EPO/PPO	$45.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.38
Rate for Payer: Superior Health Plan EPO	$12.35

SEAL CANNULA STAPLER 12MM

Facility

$90.80

Hospital Charge Code	8690508
Hospital Revenue Code	272
Rate for Payer: Cash Price	$61.74

seal cannula univ 5-8 mm

Facility

$81.72

Hospital Charge Code	8690513
Hospital Revenue Code	272
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$58.84
Rate for Payer: Amerigroup CHIP/Medicaid	$7.35
Rate for Payer: BCBS of TX Blue Advantage	$24.52
Rate for Payer: BCBS of TX Blue Essentials	$29.42
Rate for Payer: BCBS of TX PPO	$32.69
Rate for Payer: Cash Price	$55.57
Rate for Payer: Cigna Medicaid	$58.84
Rate for Payer: Molina CHIP/Medicaid	$58.84
Rate for Payer: Multiplan Auto	$53.12
Rate for Payer: Multiplan Commercial	$53.12
Rate for Payer: Multiplan Workers Comp	$53.12
Rate for Payer: Parkland Medicaid	$58.84
Rate for Payer: Scott and White EPO/PPO	$40.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$58.84
Rate for Payer: Superior Health Plan EPO	$11.11

seal cannula univ 5-8 mm

Facility

$81.72

Hospital Charge Code	8690513
Hospital Revenue Code	272
Rate for Payer: Cash Price	$55.57

SEAL DAVINCI UNIVERSAL 5-12

Facility

$908.00

Hospital Charge Code	992735
Hospital Revenue Code	270
Min. Negotiated Rate	$81.72
Max. Negotiated Rate	$653.76
Rate for Payer: Amerigroup CHIP/Medicaid	$81.72
Rate for Payer: BCBS of TX Blue Advantage	$272.40
Rate for Payer: BCBS of TX Blue Essentials	$326.88
Rate for Payer: BCBS of TX PPO	$363.20
Rate for Payer: Cash Price	$617.44
Rate for Payer: Cigna Medicaid	$653.76
Rate for Payer: Molina CHIP/Medicaid	$653.76
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Parkland Medicaid	$653.76
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$653.76
Rate for Payer: Superior Health Plan EPO	$123.49

SEAL DAVINCI UNIVERSAL 5-12

Facility

$908.00

Hospital Charge Code	992735
Hospital Revenue Code	270
Rate for Payer: Cash Price	$617.44

SEALER, BIPOLAR TISSUE W/SALINE AQUAMANTYS 6.0 -- DHF

Facility

$2,527.23

Hospital Charge Code	81856353
Hospital Revenue Code	272
Min. Negotiated Rate	$227.45
Max. Negotiated Rate	$1,819.61
Rate for Payer: Amerigroup CHIP/Medicaid	$227.45
Rate for Payer: BCBS of TX Blue Advantage	$758.17
Rate for Payer: BCBS of TX Blue Essentials	$909.80
Rate for Payer: BCBS of TX PPO	$1,010.89
Rate for Payer: Cash Price	$1,718.52
Rate for Payer: Cigna Medicaid	$1,819.61
Rate for Payer: Molina CHIP/Medicaid	$1,819.61
Rate for Payer: Multiplan Auto	$1,642.70
Rate for Payer: Multiplan Commercial	$1,642.70
Rate for Payer: Multiplan Workers Comp	$1,642.70
Rate for Payer: Parkland Medicaid	$1,819.61
Rate for Payer: Scott and White EPO/PPO	$1,263.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,819.61
Rate for Payer: Superior Health Plan EPO	$343.70

SEALER, BIPOLAR TISSUE W/SALINE AQUAMANTYS 6.0 -- DHF

Facility

$2,527.23

Hospital Charge Code	81856353
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,718.52

sealer vessel extend

Facility

$2,837.50

Hospital Charge Code	8690511
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,929.50

sealer vessel extend

Facility

$2,837.50

Hospital Charge Code	8690511
Hospital Revenue Code	272
Min. Negotiated Rate	$255.38
Max. Negotiated Rate	$2,043.00
Rate for Payer: Amerigroup CHIP/Medicaid	$255.38
Rate for Payer: BCBS of TX Blue Advantage	$851.25
Rate for Payer: BCBS of TX Blue Essentials	$1,021.50
Rate for Payer: BCBS of TX PPO	$1,135.00
Rate for Payer: Cash Price	$1,929.50
Rate for Payer: Cigna Medicaid	$2,043.00
Rate for Payer: Molina CHIP/Medicaid	$2,043.00
Rate for Payer: Multiplan Auto	$1,844.38
Rate for Payer: Multiplan Commercial	$1,844.38
Rate for Payer: Multiplan Workers Comp	$1,844.38
Rate for Payer: Parkland Medicaid	$2,043.00
Rate for Payer: Scott and White EPO/PPO	$1,418.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,043.00
Rate for Payer: Superior Health Plan EPO	$385.90

Know your out-of-pocket cost for care.

All Charges