White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SEAL, PULL-TITE II, GREEN, NO NMBRS

Facility

$1.28

Hospital Charge Code	993244
Hospital Revenue Code	270
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.92
Rate for Payer: Amerigroup CHIP/Medicaid	$0.12
Rate for Payer: BCBS of TX Blue Advantage	$0.38
Rate for Payer: BCBS of TX Blue Essentials	$0.46
Rate for Payer: BCBS of TX PPO	$0.51
Rate for Payer: Cash Price	$0.87
Rate for Payer: Cigna Medicaid	$0.92
Rate for Payer: Molina CHIP/Medicaid	$0.92
Rate for Payer: Multiplan Auto	$0.83
Rate for Payer: Multiplan Commercial	$0.83
Rate for Payer: Multiplan Workers Comp	$0.83
Rate for Payer: Parkland Medicaid	$0.92
Rate for Payer: Scott and White EPO/PPO	$0.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.92
Rate for Payer: Superior Health Plan EPO	$0.17

SEAL, PULL-TITE II, GREEN, NO NMBRS

Facility

$1.28

Hospital Charge Code	993244
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.87

SEAL SHEARS HOT MCS

Facility

$15,254.40

Hospital Charge Code	992729
Hospital Revenue Code	270
Min. Negotiated Rate	$1,372.90
Max. Negotiated Rate	$10,983.17
Rate for Payer: Amerigroup CHIP/Medicaid	$1,372.90
Rate for Payer: BCBS of TX Blue Advantage	$4,576.32
Rate for Payer: BCBS of TX Blue Essentials	$5,491.58
Rate for Payer: BCBS of TX PPO	$6,101.76
Rate for Payer: Cash Price	$10,372.99
Rate for Payer: Cigna Medicaid	$10,983.17
Rate for Payer: Molina CHIP/Medicaid	$10,983.17
Rate for Payer: Multiplan Auto	$9,915.36
Rate for Payer: Multiplan Commercial	$9,915.36
Rate for Payer: Multiplan Workers Comp	$9,915.36
Rate for Payer: Parkland Medicaid	$10,983.17
Rate for Payer: Scott and White EPO/PPO	$7,627.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,983.17
Rate for Payer: Superior Health Plan EPO	$2,074.60

SEAL SHEARS HOT MCS

Facility

$15,254.40

Hospital Charge Code	992729
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10,372.99

SEAMGARD

Facility

$1,032.83

Hospital Charge Code	992367
Hospital Revenue Code	272
Rate for Payer: Cash Price	$702.32

SEAMGARD

Facility

$1,032.83

Hospital Charge Code	992367
Hospital Revenue Code	272
Min. Negotiated Rate	$92.95
Max. Negotiated Rate	$743.64
Rate for Payer: Amerigroup CHIP/Medicaid	$92.95
Rate for Payer: BCBS of TX Blue Advantage	$309.85
Rate for Payer: BCBS of TX Blue Essentials	$371.82
Rate for Payer: BCBS of TX PPO	$413.13
Rate for Payer: Cash Price	$702.32
Rate for Payer: Cigna Medicaid	$743.64
Rate for Payer: Molina CHIP/Medicaid	$743.64
Rate for Payer: Multiplan Auto	$671.34
Rate for Payer: Multiplan Commercial	$671.34
Rate for Payer: Multiplan Workers Comp	$671.34
Rate for Payer: Parkland Medicaid	$743.64
Rate for Payer: Scott and White EPO/PPO	$516.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$743.64
Rate for Payer: Superior Health Plan EPO	$140.46

Seamguard

Facility

$873.49

Hospital Charge Code	992303
Hospital Revenue Code	272
Rate for Payer: Cash Price	$593.97

Seamguard

Facility

$873.49

Hospital Charge Code	992303
Hospital Revenue Code	272
Min. Negotiated Rate	$78.61
Max. Negotiated Rate	$628.91
Rate for Payer: Amerigroup CHIP/Medicaid	$78.61
Rate for Payer: BCBS of TX Blue Advantage	$262.05
Rate for Payer: BCBS of TX Blue Essentials	$314.46
Rate for Payer: BCBS of TX PPO	$349.40
Rate for Payer: Cash Price	$593.97
Rate for Payer: Cigna Medicaid	$628.91
Rate for Payer: Molina CHIP/Medicaid	$628.91
Rate for Payer: Multiplan Auto	$567.77
Rate for Payer: Multiplan Commercial	$567.77
Rate for Payer: Multiplan Workers Comp	$567.77
Rate for Payer: Parkland Medicaid	$628.91
Rate for Payer: Scott and White EPO/PPO	$436.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$628.91
Rate for Payer: Superior Health Plan EPO	$118.79

SEATTLE PAP PLUS

Facility

$249.43

Hospital Charge Code	993558
Hospital Revenue Code	270
Min. Negotiated Rate	$22.45
Max. Negotiated Rate	$179.59
Rate for Payer: Amerigroup CHIP/Medicaid	$22.45
Rate for Payer: BCBS of TX Blue Advantage	$74.83
Rate for Payer: BCBS of TX Blue Essentials	$89.79
Rate for Payer: BCBS of TX PPO	$99.77
Rate for Payer: Cash Price	$169.61
Rate for Payer: Cigna Medicaid	$179.59
Rate for Payer: Molina CHIP/Medicaid	$179.59
Rate for Payer: Multiplan Auto	$162.13
Rate for Payer: Multiplan Commercial	$162.13
Rate for Payer: Multiplan Workers Comp	$162.13
Rate for Payer: Parkland Medicaid	$179.59
Rate for Payer: Scott and White EPO/PPO	$124.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$179.59
Rate for Payer: Superior Health Plan EPO	$33.92

SEATTLE PAP PLUS

Facility

$249.43

Hospital Charge Code	993558
Hospital Revenue Code	270
Rate for Payer: Cash Price	$169.61

SEC ART M-THROMBECT ADD-ON

Facility

$11,606.00

Service Code	HCPCS 37186
Hospital Charge Code	2320224
Hospital Revenue Code	481
Min. Negotiated Rate	$1,044.54
Max. Negotiated Rate	$8,356.32
Rate for Payer: Amerigroup CHIP/Medicaid	$1,044.54
Rate for Payer: BCBS of TX Blue Advantage	$3,481.80
Rate for Payer: BCBS of TX Blue Essentials	$4,178.16
Rate for Payer: BCBS of TX PPO	$4,642.40
Rate for Payer: Cash Price	$7,892.08
Rate for Payer: Cigna Medicaid	$8,356.32
Rate for Payer: Molina CHIP/Medicaid	$8,356.32
Rate for Payer: Multiplan Auto	$7,543.90
Rate for Payer: Multiplan Commercial	$7,543.90
Rate for Payer: Multiplan Workers Comp	$7,543.90
Rate for Payer: Parkland Medicaid	$8,356.32
Rate for Payer: Scott and White EPO/PPO	$5,803.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,356.32
Rate for Payer: Superior Health Plan EPO	$1,578.42

SEC ART M-THROMBECT ADD-ON

Facility

$11,606.00

Service Code	HCPCS 37186
Hospital Charge Code	2320224
Hospital Revenue Code	481
Rate for Payer: Cash Price	$7,892.08

Sedimentation Rate

Facility

$191.00

Service Code	HCPCS 85652
Hospital Charge Code	1630019
Hospital Revenue Code	305
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$137.52
Rate for Payer: Amerigroup CHIP/Medicaid	$1.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.70
Rate for Payer: Amerigroup Medicare	$2.70
Rate for Payer: BCBS of TX Blue Advantage	$57.30
Rate for Payer: BCBS of TX Blue Essentials	$68.76
Rate for Payer: BCBS of TX Medicare	$2.70
Rate for Payer: BCBS of TX PPO	$76.40
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cigna Medicaid	$137.52
Rate for Payer: Cigna Medicare	$2.70
Rate for Payer: Employer Direct Commercial	$2.70
Rate for Payer: Humana Medicare/TRICARE	$2.70
Rate for Payer: Molina CHIP/Medicaid	$137.52
Rate for Payer: Molina Dual Medicare/Medicaid	$2.70
Rate for Payer: Molina Medicare	$2.70
Rate for Payer: Multiplan Auto	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Parkland Medicaid	$137.52
Rate for Payer: Scott and White EPO/PPO	$3.38
Rate for Payer: Scott and White Medicare	$2.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$2.70
Rate for Payer: Superior Health Plan Medicare	$2.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.70
Rate for Payer: Universal American Medicare	$2.70
Rate for Payer: Wellcare Medicare	$2.70
Rate for Payer: Wellmed Medicare	$2.70

Sedimentation Rate

Facility

$191.00

Service Code	HCPCS 85652
Hospital Charge Code	1630019
Hospital Revenue Code	305
Rate for Payer: Cash Price	$129.88

Sedimentation rate, erythrocyte; non-automated

Facility

$38.72

Service Code	HCPCS 85651 QW
Hospital Charge Code	993989
Hospital Revenue Code	300
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$27.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: BCBS of TX Blue Advantage	$11.62
Rate for Payer: BCBS of TX Blue Essentials	$13.94
Rate for Payer: BCBS of TX PPO	$15.49
Rate for Payer: Cash Price	$26.33
Rate for Payer: Cash Price	$26.33
Rate for Payer: Cigna Medicaid	$27.88
Rate for Payer: Molina CHIP/Medicaid	$27.88
Rate for Payer: Multiplan Auto	$25.17
Rate for Payer: Multiplan Commercial	$25.17
Rate for Payer: Multiplan Workers Comp	$25.17
Rate for Payer: Parkland Medicaid	$27.88
Rate for Payer: Scott and White EPO/PPO	$19.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.88
Rate for Payer: Superior Health Plan EPO	$5.27

Sedimentation rate, erythrocyte; non-automated

Facility

$38.72

Service Code	HCPCS 85651 QW
Hospital Charge Code	993989
Hospital Revenue Code	300
Rate for Payer: Cash Price	$26.33

SEE CLEAR LAPARSCOPIC SMOKE EVAC

Facility

$133.93

Hospital Charge Code	117227
Hospital Revenue Code	270
Rate for Payer: Cash Price	$91.07

SEE CLEAR LAPARSCOPIC SMOKE EVAC

Facility

$133.93

Hospital Charge Code	117227
Hospital Revenue Code	270
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$96.43
Rate for Payer: Amerigroup CHIP/Medicaid	$12.05
Rate for Payer: BCBS of TX Blue Advantage	$40.18
Rate for Payer: BCBS of TX Blue Essentials	$48.21
Rate for Payer: BCBS of TX PPO	$53.57
Rate for Payer: Cash Price	$91.07
Rate for Payer: Cigna Medicaid	$96.43
Rate for Payer: Molina CHIP/Medicaid	$96.43
Rate for Payer: Multiplan Auto	$87.05
Rate for Payer: Multiplan Commercial	$87.05
Rate for Payer: Multiplan Workers Comp	$87.05
Rate for Payer: Parkland Medicaid	$96.43
Rate for Payer: Scott and White EPO/PPO	$66.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96.43
Rate for Payer: Superior Health Plan EPO	$18.21

see sharp

Facility

$254.24

Hospital Charge Code	993169
Hospital Revenue Code	270
Min. Negotiated Rate	$22.88
Max. Negotiated Rate	$183.05
Rate for Payer: Amerigroup CHIP/Medicaid	$22.88
Rate for Payer: BCBS of TX Blue Advantage	$76.27
Rate for Payer: BCBS of TX Blue Essentials	$91.53
Rate for Payer: BCBS of TX PPO	$101.70
Rate for Payer: Cash Price	$172.88
Rate for Payer: Cigna Medicaid	$183.05
Rate for Payer: Molina CHIP/Medicaid	$183.05
Rate for Payer: Multiplan Auto	$165.26
Rate for Payer: Multiplan Commercial	$165.26
Rate for Payer: Multiplan Workers Comp	$165.26
Rate for Payer: Parkland Medicaid	$183.05
Rate for Payer: Scott and White EPO/PPO	$127.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$183.05
Rate for Payer: Superior Health Plan EPO	$34.58

see sharp

Facility

$254.24

Hospital Charge Code	993169
Hospital Revenue Code	270
Rate for Payer: Cash Price	$172.88

SEF02401

Facility

$17,746.99

Hospital Charge Code	991003
Hospital Revenue Code	272
Min. Negotiated Rate	$1,597.23
Max. Negotiated Rate	$12,777.83
Rate for Payer: Amerigroup CHIP/Medicaid	$1,597.23
Rate for Payer: BCBS of TX Blue Advantage	$5,324.10
Rate for Payer: BCBS of TX Blue Essentials	$6,388.92
Rate for Payer: BCBS of TX PPO	$7,098.80
Rate for Payer: Cash Price	$12,067.95
Rate for Payer: Cigna Medicaid	$12,777.83
Rate for Payer: Molina CHIP/Medicaid	$12,777.83
Rate for Payer: Multiplan Auto	$11,535.54
Rate for Payer: Multiplan Commercial	$11,535.54
Rate for Payer: Multiplan Workers Comp	$11,535.54
Rate for Payer: Parkland Medicaid	$12,777.83
Rate for Payer: Scott and White EPO/PPO	$8,873.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,777.83
Rate for Payer: Superior Health Plan EPO	$2,413.59

SEF02401

Facility

$17,746.99

Hospital Charge Code	991003
Hospital Revenue Code	272
Rate for Payer: Cash Price	$12,067.95

SEF05160

Facility

$18,530.00

Service Code	HCPCS C1713
Hospital Charge Code	990995
Hospital Revenue Code	278
Min. Negotiated Rate	$1,667.70
Max. Negotiated Rate	$13,341.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1,667.70
Rate for Payer: BCBS of TX Blue Advantage	$5,559.00
Rate for Payer: BCBS of TX Blue Essentials	$6,670.80
Rate for Payer: BCBS of TX PPO	$7,412.00
Rate for Payer: Cash Price	$12,600.40
Rate for Payer: Cigna Medicaid	$13,341.60
Rate for Payer: Molina CHIP/Medicaid	$13,341.60
Rate for Payer: Multiplan Auto	$9,265.00
Rate for Payer: Multiplan Commercial	$9,265.00
Rate for Payer: Multiplan Workers Comp	$9,265.00
Rate for Payer: Parkland Medicaid	$13,341.60
Rate for Payer: Scott and White EPO/PPO	$9,265.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,341.60
Rate for Payer: Superior Health Plan EPO	$2,520.08

SEF05160

Facility

$18,530.00

Service Code	HCPCS C1713
Hospital Charge Code	990995
Hospital Revenue Code	278
Min. Negotiated Rate	$4,632.50
Max. Negotiated Rate	$9,265.00
Rate for Payer: Cash Price	$12,600.40
Rate for Payer: Cigna Commercial	$4,632.50
Rate for Payer: Multiplan Auto	$9,265.00
Rate for Payer: Multiplan Commercial	$9,265.00
Rate for Payer: Multiplan Workers Comp	$9,265.00
Rate for Payer: Scott and White EPO/PPO	$9,265.00

SEF08160

Facility

$10,199.00

Service Code	HCPCS C1713
Hospital Charge Code	990993
Hospital Revenue Code	278
Min. Negotiated Rate	$2,549.75
Max. Negotiated Rate	$5,099.50
Rate for Payer: Cash Price	$6,935.32
Rate for Payer: Cigna Commercial	$2,549.75
Rate for Payer: Multiplan Auto	$5,099.50
Rate for Payer: Multiplan Commercial	$5,099.50
Rate for Payer: Multiplan Workers Comp	$5,099.50
Rate for Payer: Scott and White EPO/PPO	$5,099.50

Know your out-of-pocket cost for care.

All Charges