White Rock Medical Center

All Charges

Charge

Type

Setting

Price

serfas energy 90-s max

Facility

$839.90

Hospital Charge Code	993257
Hospital Revenue Code	270
Rate for Payer: Cash Price	$571.13

Serial Tonometry Exam -Ishihara (Titmus)

Facility

$330.92

Service Code	HCPCS 92100
Hospital Charge Code	994063
Hospital Revenue Code	920
Min. Negotiated Rate	$29.78
Max. Negotiated Rate	$238.26
Rate for Payer: Amerigroup CHIP/Medicaid	$29.78
Rate for Payer: BCBS of TX Blue Advantage	$99.28
Rate for Payer: BCBS of TX Blue Essentials	$119.13
Rate for Payer: BCBS of TX PPO	$132.37
Rate for Payer: Cash Price	$225.03
Rate for Payer: Cash Price	$225.03
Rate for Payer: Cigna Medicaid	$238.26
Rate for Payer: Molina CHIP/Medicaid	$238.26
Rate for Payer: Multiplan Auto	$215.10
Rate for Payer: Multiplan Commercial	$215.10
Rate for Payer: Multiplan Workers Comp	$215.10
Rate for Payer: Parkland Medicaid	$238.26
Rate for Payer: Scott and White EPO/PPO	$39.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$238.26
Rate for Payer: Superior Health Plan EPO	$45.01

Serial Tonometry Exam -Ishihara (Titmus)

Facility

$330.92

Service Code	HCPCS 92100
Hospital Charge Code	994063
Hospital Revenue Code	920
Rate for Payer: Cash Price	$225.03

Serological Immediate Spin -> Incompatible

Facility

$198.00

Service Code	HCPCS 86920
Hospital Charge Code	2403087
Hospital Revenue Code	302
Rate for Payer: Cash Price	$134.64

Serological Immediate Spin -> Incompatible

Facility

$198.00

Service Code	HCPCS 86920
Hospital Charge Code	2403087
Hospital Revenue Code	302
Min. Negotiated Rate	$17.82
Max. Negotiated Rate	$361.78
Rate for Payer: Amerigroup CHIP/Medicaid	$17.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$171.15
Rate for Payer: Amerigroup Medicare	$171.15
Rate for Payer: BCBS of TX Blue Advantage	$59.40
Rate for Payer: BCBS of TX Blue Essentials	$71.28
Rate for Payer: BCBS of TX Medicare	$171.15
Rate for Payer: BCBS of TX PPO	$79.20
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cigna Commercial	$361.78
Rate for Payer: Cigna Medicaid	$142.56
Rate for Payer: Cigna Medicare	$171.15
Rate for Payer: Employer Direct Commercial	$171.15
Rate for Payer: Humana Medicare/TRICARE	$171.15
Rate for Payer: Molina CHIP/Medicaid	$142.56
Rate for Payer: Molina Dual Medicare/Medicaid	$171.15
Rate for Payer: Molina Medicare	$171.15
Rate for Payer: Multiplan Auto	$128.70
Rate for Payer: Multiplan Commercial	$128.70
Rate for Payer: Multiplan Workers Comp	$128.70
Rate for Payer: Parkland Medicaid	$142.56
Rate for Payer: Scott and White EPO/PPO	$234.31
Rate for Payer: Scott and White Medicare	$171.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$142.56
Rate for Payer: Superior Health Plan EPO	$171.15
Rate for Payer: Superior Health Plan Medicare	$171.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$171.15
Rate for Payer: Universal American Medicare	$171.15
Rate for Payer: Wellcare Medicare	$171.15
Rate for Payer: Wellmed Medicare	$171.15

Serotonin, Serum SO

Facility

$337.46

Service Code	HCPCS 84260
Hospital Charge Code	1701531
Hospital Revenue Code	301
Min. Negotiated Rate	$12.08
Max. Negotiated Rate	$242.97
Rate for Payer: Amerigroup CHIP/Medicaid	$12.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30.98
Rate for Payer: Amerigroup Medicare	$30.98
Rate for Payer: BCBS of TX Blue Advantage	$101.24
Rate for Payer: BCBS of TX Blue Essentials	$121.49
Rate for Payer: BCBS of TX Medicare	$30.98
Rate for Payer: BCBS of TX PPO	$134.98
Rate for Payer: Cash Price	$229.47
Rate for Payer: Cash Price	$229.47
Rate for Payer: Cigna Medicaid	$242.97
Rate for Payer: Cigna Medicare	$30.98
Rate for Payer: Employer Direct Commercial	$30.98
Rate for Payer: Humana Medicare/TRICARE	$30.98
Rate for Payer: Molina CHIP/Medicaid	$242.97
Rate for Payer: Molina Dual Medicare/Medicaid	$30.98
Rate for Payer: Molina Medicare	$30.98
Rate for Payer: Multiplan Auto	$219.35
Rate for Payer: Multiplan Commercial	$219.35
Rate for Payer: Multiplan Workers Comp	$219.35
Rate for Payer: Parkland Medicaid	$242.97
Rate for Payer: Scott and White EPO/PPO	$38.73
Rate for Payer: Scott and White Medicare	$30.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$242.97
Rate for Payer: Superior Health Plan EPO	$30.98
Rate for Payer: Superior Health Plan Medicare	$30.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$30.98
Rate for Payer: Universal American Medicare	$30.98
Rate for Payer: Wellcare Medicare	$30.98
Rate for Payer: Wellmed Medicare	$30.98

Serotonin, Serum SO

Facility

$337.46

Service Code	HCPCS 84260
Hospital Charge Code	1701531
Hospital Revenue Code	301
Rate for Payer: Cash Price	$229.47

sertraline 50 mg Tab

Facility

$21.65

Service Code	HCPCS J3490
Hospital Charge Code	78416965
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.72

sertraline 50 mg Tab

Facility

$21.65

Service Code	HCPCS J3490
Hospital Charge Code	78416965
Hospital Revenue Code	250
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$15.59
Rate for Payer: Amerigroup CHIP/Medicaid	$1.95
Rate for Payer: BCBS of TX Blue Advantage	$6.50
Rate for Payer: BCBS of TX Blue Essentials	$7.79
Rate for Payer: BCBS of TX PPO	$8.66
Rate for Payer: Cash Price	$14.72
Rate for Payer: Cigna Medicaid	$15.59
Rate for Payer: Molina CHIP/Medicaid	$15.59
Rate for Payer: Multiplan Auto	$14.07
Rate for Payer: Multiplan Commercial	$14.07
Rate for Payer: Multiplan Workers Comp	$14.07
Rate for Payer: Parkland Medicaid	$15.59
Rate for Payer: Scott and White EPO/PPO	$10.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.59
Rate for Payer: Superior Health Plan EPO	$2.94

Sesamoidectomy, first toe (separate procedure)

Facility

$9,906.40

Service Code	HCPCS 28315
Hospital Charge Code	9900514
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$6,736.35
Rate for Payer: Cash Price	$6,736.35
Rate for Payer: Cash Price	$6,736.35
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$7,132.61
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$7,132.61
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$7,132.61
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,132.61
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Sesamoidectomy, first toe (separate procedure)

Facility

$10,000.00

Service Code	CPT 28315
Hospital Charge Code	36028315
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Sesamoidectomy, first toe (separate procedure)

Facility

$9,906.40

Service Code	HCPCS 28315
Hospital Charge Code	9900514
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,736.35

SET, ACCESS, MICROPNCTURE, MPIS-501-SS'

Facility

$418.77

Hospital Charge Code	993786
Hospital Revenue Code	272
Rate for Payer: Cash Price	$284.76

SET, ACCESS, MICROPNCTURE, MPIS-501-SS'

Facility

$418.77

Hospital Charge Code	993786
Hospital Revenue Code	272
Min. Negotiated Rate	$37.69
Max. Negotiated Rate	$301.51
Rate for Payer: Amerigroup CHIP/Medicaid	$37.69
Rate for Payer: BCBS of TX Blue Advantage	$125.63
Rate for Payer: BCBS of TX Blue Essentials	$150.76
Rate for Payer: BCBS of TX PPO	$167.51
Rate for Payer: Cash Price	$284.76
Rate for Payer: Cigna Medicaid	$301.51
Rate for Payer: Molina CHIP/Medicaid	$301.51
Rate for Payer: Multiplan Auto	$272.20
Rate for Payer: Multiplan Commercial	$272.20
Rate for Payer: Multiplan Workers Comp	$272.20
Rate for Payer: Parkland Medicaid	$301.51
Rate for Payer: Scott and White EPO/PPO	$209.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$301.51
Rate for Payer: Superior Health Plan EPO	$56.95

SET,ACSS,MICR,MPIS-501-10.0-SC-NTSST

Facility

$150.41

Hospital Charge Code	993363
Hospital Revenue Code	270
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$108.30
Rate for Payer: Amerigroup CHIP/Medicaid	$13.54
Rate for Payer: BCBS of TX Blue Advantage	$45.12
Rate for Payer: BCBS of TX Blue Essentials	$54.15
Rate for Payer: BCBS of TX PPO	$60.16
Rate for Payer: Cash Price	$102.28
Rate for Payer: Cigna Medicaid	$108.30
Rate for Payer: Molina CHIP/Medicaid	$108.30
Rate for Payer: Multiplan Auto	$97.77
Rate for Payer: Multiplan Commercial	$97.77
Rate for Payer: Multiplan Workers Comp	$97.77
Rate for Payer: Parkland Medicaid	$108.30
Rate for Payer: Scott and White EPO/PPO	$75.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.30
Rate for Payer: Superior Health Plan EPO	$20.46

SET,ACSS,MICR,MPIS-501-10.0-SC-NTSST

Facility

$150.41

Hospital Charge Code	993363
Hospital Revenue Code	270
Rate for Payer: Cash Price	$102.28

SET, BLD COLLECTIN, SFTY-LOK, 23GX0.75

Facility

$6.43

Hospital Charge Code	993957
Hospital Revenue Code	272
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$4.63
Rate for Payer: Amerigroup CHIP/Medicaid	$0.58
Rate for Payer: BCBS of TX Blue Advantage	$1.93
Rate for Payer: BCBS of TX Blue Essentials	$2.31
Rate for Payer: BCBS of TX PPO	$2.57
Rate for Payer: Cash Price	$4.37
Rate for Payer: Cigna Medicaid	$4.63
Rate for Payer: Molina CHIP/Medicaid	$4.63
Rate for Payer: Multiplan Auto	$4.18
Rate for Payer: Multiplan Commercial	$4.18
Rate for Payer: Multiplan Workers Comp	$4.18
Rate for Payer: Parkland Medicaid	$4.63
Rate for Payer: Scott and White EPO/PPO	$3.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.63
Rate for Payer: Superior Health Plan EPO	$0.87

SET, BLD COLLECTIN, SFTY-LOK, 23GX0.75

Facility

$6.43

Hospital Charge Code	993957
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.37

SET BLD NON-VNT 1 SMARTSITE DEHP FRE

Facility

$23.46

Hospital Charge Code	993887
Hospital Revenue Code	270
Rate for Payer: Cash Price	$15.95

SET BLD NON-VNT 1 SMARTSITE DEHP FRE

Facility

$23.46

Hospital Charge Code	993887
Hospital Revenue Code	270
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$16.89
Rate for Payer: Amerigroup CHIP/Medicaid	$2.11
Rate for Payer: BCBS of TX Blue Advantage	$7.04
Rate for Payer: BCBS of TX Blue Essentials	$8.45
Rate for Payer: BCBS of TX PPO	$9.38
Rate for Payer: Cash Price	$15.95
Rate for Payer: Cigna Medicaid	$16.89
Rate for Payer: Molina CHIP/Medicaid	$16.89
Rate for Payer: Multiplan Auto	$15.25
Rate for Payer: Multiplan Commercial	$15.25
Rate for Payer: Multiplan Workers Comp	$15.25
Rate for Payer: Parkland Medicaid	$16.89
Rate for Payer: Scott and White EPO/PPO	$11.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.89
Rate for Payer: Superior Health Plan EPO	$3.19

SET, BLOOD/SOLUTION, Y-TYPE, 112, MALE

Facility

$52.49

Hospital Charge Code	993182
Hospital Revenue Code	270
Rate for Payer: Cash Price	$35.69

SET, BLOOD/SOLUTION, Y-TYPE, 112, MALE

Facility

$52.49

Hospital Charge Code	993182
Hospital Revenue Code	270
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$37.79
Rate for Payer: Amerigroup CHIP/Medicaid	$4.72
Rate for Payer: BCBS of TX Blue Advantage	$15.75
Rate for Payer: BCBS of TX Blue Essentials	$18.90
Rate for Payer: BCBS of TX PPO	$21.00
Rate for Payer: Cash Price	$35.69
Rate for Payer: Cigna Medicaid	$37.79
Rate for Payer: Molina CHIP/Medicaid	$37.79
Rate for Payer: Multiplan Auto	$34.12
Rate for Payer: Multiplan Commercial	$34.12
Rate for Payer: Multiplan Workers Comp	$34.12
Rate for Payer: Parkland Medicaid	$37.79
Rate for Payer: Scott and White EPO/PPO	$26.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.79
Rate for Payer: Superior Health Plan EPO	$7.14

SET, CYSTOSCOPY IRRIG NONVENTED -- DHF

Facility

$184.37

Hospital Charge Code	54200605
Hospital Revenue Code	270
Min. Negotiated Rate	$16.59
Max. Negotiated Rate	$132.75
Rate for Payer: Amerigroup CHIP/Medicaid	$16.59
Rate for Payer: BCBS of TX Blue Advantage	$55.31
Rate for Payer: BCBS of TX Blue Essentials	$66.37
Rate for Payer: BCBS of TX PPO	$73.75
Rate for Payer: Cash Price	$125.37
Rate for Payer: Cigna Medicaid	$132.75
Rate for Payer: Molina CHIP/Medicaid	$132.75
Rate for Payer: Multiplan Auto	$119.84
Rate for Payer: Multiplan Commercial	$119.84
Rate for Payer: Multiplan Workers Comp	$119.84
Rate for Payer: Parkland Medicaid	$132.75
Rate for Payer: Scott and White EPO/PPO	$92.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.75
Rate for Payer: Superior Health Plan EPO	$25.07

SET, CYSTOSCOPY IRRIG NONVENTED -- DHF

Facility

$184.37

Hospital Charge Code	54200605
Hospital Revenue Code	270
Rate for Payer: Cash Price	$125.37

SET EPIDURAL NON VENT

Facility

$29.51

Hospital Charge Code	8528471
Hospital Revenue Code	272
Rate for Payer: Cash Price	$20.07

Know your out-of-pocket cost for care.

All Charges