White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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 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

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

*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

*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	$29.85
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: 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	$29.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$252.72
Rate for Payer: Superior Health Plan EPO	$47.74

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
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

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

SENSOR DISP BIS -- DHF

Facility

$117.50

Hospital Charge Code	80340177
Hospital Revenue Code	271
Rate for Payer: Cash Price	$79.90

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

SENSOR, FINGER PULSE OXIMETRY ADULT REUSABLE

Facility

$624.20

Hospital Charge Code	993536
Hospital Revenue Code	270
Rate for Payer: Cash Price	$424.46

SENSOR, FINGER PULSE OXIMETRY ADULT REUSABLE

Facility

$624.20

Hospital Charge Code	993536
Hospital Revenue Code	270
Min. Negotiated Rate	$56.18
Max. Negotiated Rate	$449.42
Rate for Payer: Amerigroup CHIP/Medicaid	$56.18
Rate for Payer: BCBS of TX Blue Advantage	$187.26
Rate for Payer: BCBS of TX Blue Essentials	$224.71
Rate for Payer: BCBS of TX PPO	$249.68
Rate for Payer: Cash Price	$424.46
Rate for Payer: Cigna Medicaid	$449.42
Rate for Payer: Molina CHIP/Medicaid	$449.42
Rate for Payer: Multiplan Auto	$405.73
Rate for Payer: Multiplan Commercial	$405.73
Rate for Payer: Multiplan Workers Comp	$405.73
Rate for Payer: Parkland Medicaid	$449.42
Rate for Payer: Scott and White EPO/PPO	$312.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$449.42
Rate for Payer: Superior Health Plan EPO	$84.89

SENSOR, LNCS, ADULT

Facility

$26.15

Hospital Charge Code	993370
Hospital Revenue Code	270
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$18.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2.35
Rate for Payer: BCBS of TX Blue Advantage	$7.84
Rate for Payer: BCBS of TX Blue Essentials	$9.41
Rate for Payer: BCBS of TX PPO	$10.46
Rate for Payer: Cash Price	$17.78
Rate for Payer: Cigna Medicaid	$18.83
Rate for Payer: Molina CHIP/Medicaid	$18.83
Rate for Payer: Multiplan Auto	$17.00
Rate for Payer: Multiplan Commercial	$17.00
Rate for Payer: Multiplan Workers Comp	$17.00
Rate for Payer: Parkland Medicaid	$18.83
Rate for Payer: Scott and White EPO/PPO	$13.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.83
Rate for Payer: Superior Health Plan EPO	$3.56

SENSOR, LNCS, ADULT

Facility

$26.15

Hospital Charge Code	993370
Hospital Revenue Code	270
Rate for Payer: Cash Price	$17.78

SENSOR, LNCS, PEDIATRIC

Facility

$27.83

Hospital Charge Code	993087
Hospital Revenue Code	270
Rate for Payer: Cash Price	$18.92

SENSOR, LNCS, PEDIATRIC

Facility

$27.83

Hospital Charge Code	993087
Hospital Revenue Code	270
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$20.04
Rate for Payer: Amerigroup CHIP/Medicaid	$2.50
Rate for Payer: BCBS of TX Blue Advantage	$8.35
Rate for Payer: BCBS of TX Blue Essentials	$10.02
Rate for Payer: BCBS of TX PPO	$11.13
Rate for Payer: Cash Price	$18.92
Rate for Payer: Cigna Medicaid	$20.04
Rate for Payer: Molina CHIP/Medicaid	$20.04
Rate for Payer: Multiplan Auto	$18.09
Rate for Payer: Multiplan Commercial	$18.09
Rate for Payer: Multiplan Workers Comp	$18.09
Rate for Payer: Parkland Medicaid	$20.04
Rate for Payer: Scott and White EPO/PPO	$13.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.04
Rate for Payer: Superior Health Plan EPO	$3.78

SENSOR MONITOR BRAIN BIS QUATRO

Facility

$105.06

Hospital Charge Code	993002
Hospital Revenue Code	270
Rate for Payer: Cash Price	$71.44

SENSOR MONITOR BRAIN BIS QUATRO

Facility

$105.06

Hospital Charge Code	993002
Hospital Revenue Code	270
Min. Negotiated Rate	$9.46
Max. Negotiated Rate	$75.64
Rate for Payer: Amerigroup CHIP/Medicaid	$9.46
Rate for Payer: BCBS of TX Blue Advantage	$31.52
Rate for Payer: BCBS of TX Blue Essentials	$37.82
Rate for Payer: BCBS of TX PPO	$42.02
Rate for Payer: Cash Price	$71.44
Rate for Payer: Cigna Medicaid	$75.64
Rate for Payer: Molina CHIP/Medicaid	$75.64
Rate for Payer: Multiplan Auto	$68.29
Rate for Payer: Multiplan Commercial	$68.29
Rate for Payer: Multiplan Workers Comp	$68.29
Rate for Payer: Parkland Medicaid	$75.64
Rate for Payer: Scott and White EPO/PPO	$52.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$75.64
Rate for Payer: Superior Health Plan EPO	$14.29

SENSOR, SPO2, SHORT, NELLCOR COMPAT

Facility

$327.06

Hospital Charge Code	993197
Hospital Revenue Code	270
Rate for Payer: Cash Price	$222.40

Know your out-of-pocket cost for care.

All Charges