White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SEIZURES W MCC

Facility

$36,799.20

Service Code	MSDRG 100
Min. Negotiated Rate	$15,586.64
Max. Negotiated Rate	$36,799.20
Rate for Payer: BCBS of TX Blue Advantage	$15,586.64
Rate for Payer: BCBS of TX Blue Essentials	$18,702.16
Rate for Payer: BCBS of TX PPO	$20,780.98

SEIZURES W/O MCC

Facility

$17,149.40

Service Code	MSDRG 101
Min. Negotiated Rate	$7,475.98
Max. Negotiated Rate	$17,149.40
Rate for Payer: BCBS of TX Blue Advantage	$7,475.98
Rate for Payer: BCBS of TX Blue Essentials	$8,970.31
Rate for Payer: BCBS of TX PPO	$9,967.39

Select-A-Vent Adult Mask Kit, Universal Tubing Connector

Facility

$8.54

Hospital Charge Code	993374
Hospital Revenue Code	270
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$6.15
Rate for Payer: Amerigroup CHIP/Medicaid	$0.77
Rate for Payer: BCBS of TX Blue Advantage	$2.56
Rate for Payer: BCBS of TX Blue Essentials	$3.07
Rate for Payer: BCBS of TX PPO	$3.42
Rate for Payer: Cash Price	$5.81
Rate for Payer: Cigna Medicaid	$6.15
Rate for Payer: Molina CHIP/Medicaid	$6.15
Rate for Payer: Multiplan Auto	$5.55
Rate for Payer: Multiplan Commercial	$5.55
Rate for Payer: Multiplan Workers Comp	$5.55
Rate for Payer: Parkland Medicaid	$6.15
Rate for Payer: Scott and White EPO/PPO	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.15
Rate for Payer: Superior Health Plan EPO	$1.16

Select-A-Vent Adult Mask Kit, Universal Tubing Connector

Facility

$8.54

Hospital Charge Code	993374
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.81

SELECT CATH PLCMNT, 1ST ORD, ART AB

Facility

$3,394.00

Service Code	HCPCS 36245
Hospital Charge Code	2301802
Hospital Revenue Code	361
Min. Negotiated Rate	$305.46
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$305.46
Rate for Payer: BCBS of TX Blue Advantage	$1,018.20
Rate for Payer: BCBS of TX Blue Essentials	$1,221.84
Rate for Payer: BCBS of TX PPO	$1,357.60
Rate for Payer: Cash Price	$2,307.92
Rate for Payer: Cash Price	$2,307.92
Rate for Payer: Cigna Medicaid	$2,443.68
Rate for Payer: Molina CHIP/Medicaid	$2,443.68
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$2,443.68
Rate for Payer: Scott and White EPO/PPO	$1,697.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,443.68
Rate for Payer: Superior Health Plan EPO	$461.58

SELECT CATH PLCMNT, 1ST ORD, ART AB

Facility

$3,394.00

Service Code	HCPCS 36245
Hospital Charge Code	2301802
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,307.92

SELECT CATH PLCMNT, 2ND ORD, ART AB

Facility

$3,747.00

Service Code	HCPCS 36246
Hospital Charge Code	2301810
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,547.96

SELECT CATH PLCMNT, 2ND ORD, ART AB

Facility

$3,747.00

Service Code	HCPCS 36246
Hospital Charge Code	2301810
Hospital Revenue Code	361
Min. Negotiated Rate	$337.23
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$337.23
Rate for Payer: BCBS of TX Blue Advantage	$1,124.10
Rate for Payer: BCBS of TX Blue Essentials	$1,348.92
Rate for Payer: BCBS of TX PPO	$1,498.80
Rate for Payer: Cash Price	$2,547.96
Rate for Payer: Cash Price	$2,547.96
Rate for Payer: Cigna Medicaid	$2,697.84
Rate for Payer: Molina CHIP/Medicaid	$2,697.84
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$2,697.84
Rate for Payer: Scott and White EPO/PPO	$1,873.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,697.84
Rate for Payer: Superior Health Plan EPO	$509.59

SELECT CATH PLCMNT, 2ND ORD, ART TH

Facility

$3,236.00

Service Code	HCPCS 36216
Hospital Charge Code	2301794
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,200.48

SELECT CATH PLCMNT, 2ND ORD, ART TH

Facility

$3,236.00

Service Code	HCPCS 36216
Hospital Charge Code	2301794
Hospital Revenue Code	361
Min. Negotiated Rate	$291.24
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$291.24
Rate for Payer: BCBS of TX Blue Advantage	$970.80
Rate for Payer: BCBS of TX Blue Essentials	$1,164.96
Rate for Payer: BCBS of TX PPO	$1,294.40
Rate for Payer: Cash Price	$2,200.48
Rate for Payer: Cash Price	$2,200.48
Rate for Payer: Cigna Medicaid	$2,329.92
Rate for Payer: Molina CHIP/Medicaid	$2,329.92
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$2,329.92
Rate for Payer: Scott and White EPO/PPO	$1,618.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,329.92
Rate for Payer: Superior Health Plan EPO	$440.10

Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch,

Facility

$130.68

Service Code	HCPCS 36248
Hospital Charge Code	993996
Hospital Revenue Code	361
Rate for Payer: Cash Price	$88.86

Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch,

Facility

$130.68

Service Code	HCPCS 36248
Hospital Charge Code	993996
Hospital Revenue Code	361
Min. Negotiated Rate	$11.76
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.76
Rate for Payer: BCBS of TX Blue Advantage	$39.20
Rate for Payer: BCBS of TX Blue Essentials	$47.04
Rate for Payer: BCBS of TX PPO	$52.27
Rate for Payer: Cash Price	$88.86
Rate for Payer: Cash Price	$88.86
Rate for Payer: Cigna Medicaid	$94.09
Rate for Payer: Molina CHIP/Medicaid	$94.09
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$94.09
Rate for Payer: Scott and White EPO/PPO	$65.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$94.09
Rate for Payer: Superior Health Plan EPO	$17.77

Self Drilling Variable Screw, 4.0x16mm

Facility

$903.61

Service Code	HCPCS C1713
Hospital Charge Code	992220
Hospital Revenue Code	278
Min. Negotiated Rate	$81.32
Max. Negotiated Rate	$650.60
Rate for Payer: Amerigroup CHIP/Medicaid	$81.32
Rate for Payer: BCBS of TX Blue Advantage	$271.08
Rate for Payer: BCBS of TX Blue Essentials	$325.30
Rate for Payer: BCBS of TX PPO	$361.44
Rate for Payer: Cash Price	$614.45
Rate for Payer: Cigna Medicaid	$650.60
Rate for Payer: Molina CHIP/Medicaid	$650.60
Rate for Payer: Multiplan Auto	$451.81
Rate for Payer: Multiplan Commercial	$451.81
Rate for Payer: Multiplan Workers Comp	$451.81
Rate for Payer: Parkland Medicaid	$650.60
Rate for Payer: Scott and White EPO/PPO	$451.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$650.60
Rate for Payer: Superior Health Plan EPO	$122.89

Self Drilling Variable Screw, 4.0x16mm

Facility

$903.61

Service Code	HCPCS C1713
Hospital Charge Code	992220
Hospital Revenue Code	278
Min. Negotiated Rate	$225.90
Max. Negotiated Rate	$451.81
Rate for Payer: Cash Price	$614.45
Rate for Payer: Cigna Commercial	$225.90
Rate for Payer: Multiplan Auto	$451.81
Rate for Payer: Multiplan Commercial	$451.81
Rate for Payer: Multiplan Workers Comp	$451.81
Rate for Payer: Scott and White EPO/PPO	$451.81

Self Seal Sterilization Pouch, 3.5' x 22'

Facility

$0.59

Hospital Charge Code	992987
Hospital Revenue Code	270
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.42
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.18
Rate for Payer: BCBS of TX Blue Essentials	$0.21
Rate for Payer: BCBS of TX PPO	$0.24
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cigna Medicaid	$0.42
Rate for Payer: Molina CHIP/Medicaid	$0.42
Rate for Payer: Multiplan Auto	$0.38
Rate for Payer: Multiplan Commercial	$0.38
Rate for Payer: Multiplan Workers Comp	$0.38
Rate for Payer: Parkland Medicaid	$0.42
Rate for Payer: Scott and White EPO/PPO	$0.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.42
Rate for Payer: Superior Health Plan EPO	$0.08

Self Seal Sterilization Pouch, 3.5' x 22'

Facility

$0.59

Hospital Charge Code	992987
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.40

*Sel Sharp Deb Each Addl 20 cm

Facility

$351.00

Service Code	HCPCS 97598
Hospital Charge Code	7150667
Hospital Revenue Code	361
Min. Negotiated Rate	$31.59
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$31.59
Rate for Payer: BCBS of TX Blue Advantage	$105.30
Rate for Payer: BCBS of TX Blue Essentials	$126.36
Rate for Payer: BCBS of TX PPO	$140.40
Rate for Payer: Cash Price	$238.68
Rate for Payer: Cash Price	$238.68
Rate for Payer: Cigna Medicaid	$252.72
Rate for Payer: Molina CHIP/Medicaid	$252.72
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$252.72
Rate for Payer: Scott and White EPO/PPO	$175.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$252.72
Rate for Payer: Superior Health Plan EPO	$47.74

*Sel Sharp Deb Each Addl 20 cm

Facility

$351.00

Service Code	HCPCS 97598
Hospital Charge Code	7150667
Hospital Revenue Code	361
Rate for Payer: Cash Price	$238.68

SEMITENDINOSIS TENDON ALLOGRAFT

Facility

$12,345.68

Hospital Charge Code	146502
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8,395.06

SEMITENDINOSIS TENDON ALLOGRAFT

Facility

$12,345.68

Hospital Charge Code	146502
Hospital Revenue Code	272
Min. Negotiated Rate	$1,111.11
Max. Negotiated Rate	$8,888.89
Rate for Payer: Amerigroup CHIP/Medicaid	$1,111.11
Rate for Payer: BCBS of TX Blue Advantage	$3,703.70
Rate for Payer: BCBS of TX Blue Essentials	$4,444.44
Rate for Payer: BCBS of TX PPO	$4,938.27
Rate for Payer: Cash Price	$8,395.06
Rate for Payer: Cigna Medicaid	$8,888.89
Rate for Payer: Molina CHIP/Medicaid	$8,888.89
Rate for Payer: Multiplan Auto	$8,024.69
Rate for Payer: Multiplan Commercial	$8,024.69
Rate for Payer: Multiplan Workers Comp	$8,024.69
Rate for Payer: Parkland Medicaid	$8,888.89
Rate for Payer: Scott and White EPO/PPO	$6,172.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,888.89
Rate for Payer: Superior Health Plan EPO	$1,679.01

senna 8.6 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78419863
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

senna 8.6 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78419863
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

Sensicare Nitrile Exam Gloves Small Blue Non-sterile, 10 BX / CA

Facility

$47.17

Hospital Charge Code	992698
Hospital Revenue Code	270
Rate for Payer: Cash Price	$32.08

Sensicare Nitrile Exam Gloves Small Blue Non-sterile, 10 BX / CA

Facility

$47.17

Hospital Charge Code	992698
Hospital Revenue Code	270
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$33.96
Rate for Payer: Amerigroup CHIP/Medicaid	$4.25
Rate for Payer: BCBS of TX Blue Advantage	$14.15
Rate for Payer: BCBS of TX Blue Essentials	$16.98
Rate for Payer: BCBS of TX PPO	$18.87
Rate for Payer: Cash Price	$32.08
Rate for Payer: Cigna Medicaid	$33.96
Rate for Payer: Molina CHIP/Medicaid	$33.96
Rate for Payer: Multiplan Auto	$30.66
Rate for Payer: Multiplan Commercial	$30.66
Rate for Payer: Multiplan Workers Comp	$30.66
Rate for Payer: Parkland Medicaid	$33.96
Rate for Payer: Scott and White EPO/PPO	$23.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.96
Rate for Payer: Superior Health Plan EPO	$6.42

SENSOR DISP BIS -- DHF

Facility

$117.50

Hospital Charge Code	80340177
Hospital Revenue Code	271
Min. Negotiated Rate	$10.57
Max. Negotiated Rate	$84.60
Rate for Payer: Amerigroup CHIP/Medicaid	$10.57
Rate for Payer: BCBS of TX Blue Advantage	$35.25
Rate for Payer: BCBS of TX Blue Essentials	$42.30
Rate for Payer: BCBS of TX PPO	$47.00
Rate for Payer: Cash Price	$79.90
Rate for Payer: Cigna Medicaid	$84.60
Rate for Payer: Molina CHIP/Medicaid	$84.60
Rate for Payer: Multiplan Auto	$76.38
Rate for Payer: Multiplan Commercial	$76.38
Rate for Payer: Multiplan Workers Comp	$76.38
Rate for Payer: Parkland Medicaid	$84.60
Rate for Payer: Scott and White EPO/PPO	$58.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.60
Rate for Payer: Superior Health Plan EPO	$15.98

Know your out-of-pocket cost for care.

All Charges