White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC

Facility

$19,442.70

Service Code	MSDRG 872
Min. Negotiated Rate	$8,953.88
Max. Negotiated Rate	$19,442.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,259.87
Rate for Payer: Amerigroup Medicare	$12,259.87
Rate for Payer: BCBS of TX Medicare	$12,259.87
Rate for Payer: Cigna Commercial	$13,180.10
Rate for Payer: Cigna Medicare	$12,259.87
Rate for Payer: Employer Direct Commercial	$12,259.87
Rate for Payer: Humana Medicare/TRICARE	$12,259.87
Rate for Payer: Molina Dual Medicare/Medicaid	$12,259.87
Rate for Payer: Molina Medicare	$12,259.87
Rate for Payer: Multiplan Auto	$19,442.70
Rate for Payer: Multiplan Commercial	$19,442.70
Rate for Payer: Multiplan Workers Comp	$19,442.70
Rate for Payer: Scott and White EPO/PPO	$8,953.88
Rate for Payer: Scott and White Medicare	$12,259.87
Rate for Payer: Superior Health Plan EPO	$12,259.87
Rate for Payer: Superior Health Plan Medicare	$12,259.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,259.87
Rate for Payer: Universal American Medicare	$12,259.87
Rate for Payer: Wellcare Medicare	$12,259.87
Rate for Payer: Wellmed Medicare	$12,259.87

SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS OR PERIPHERAL EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility

$131,324.20

Service Code	MSDRG 870
Min. Negotiated Rate	$54,139.58
Max. Negotiated Rate	$131,324.20
Rate for Payer: BCBS of TX Blue Advantage	$54,139.58
Rate for Payer: BCBS of TX Blue Essentials	$64,961.20
Rate for Payer: BCBS of TX PPO	$72,181.91

SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC

Facility

$36,907.50

Service Code	MSDRG 871
Min. Negotiated Rate	$15,965.04
Max. Negotiated Rate	$36,907.50
Rate for Payer: BCBS of TX Blue Advantage	$15,965.04
Rate for Payer: BCBS of TX Blue Essentials	$19,156.19
Rate for Payer: BCBS of TX PPO	$21,285.48

SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC

Facility

$19,442.70

Service Code	MSDRG 872
Min. Negotiated Rate	$8,953.88
Max. Negotiated Rate	$19,442.70
Rate for Payer: BCBS of TX Blue Advantage	$9,054.94
Rate for Payer: BCBS of TX Blue Essentials	$10,864.88
Rate for Payer: BCBS of TX PPO	$12,072.55

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement wit

Facility

$19,154.73

Service Code	HCPCS 30520
Hospital Charge Code	9900598
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,025.22

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement wit

Facility

$19,154.73

Service Code	HCPCS 30520
Hospital Charge Code	9900598
Hospital Revenue Code	360
Min. Negotiated Rate	$886.62
Max. Negotiated Rate	$13,791.41
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Amerigroup Medicare	$3,330.57
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cash Price	$13,025.22
Rate for Payer: Cash Price	$13,025.22
Rate for Payer: Cash Price	$13,025.22
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicaid	$13,791.41
Rate for Payer: Cigna Medicare	$3,330.57
Rate for Payer: Employer Direct Commercial	$3,330.57
Rate for Payer: Humana Medicare/TRICARE	$3,330.57
Rate for Payer: Molina CHIP/Medicaid	$13,791.41
Rate for Payer: Molina Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Molina Medicare	$3,330.57
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	$13,791.41
Rate for Payer: Scott and White EPO/PPO	$6,161.55
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,791.41
Rate for Payer: Superior Health Plan EPO	$3,330.57
Rate for Payer: Superior Health Plan Medicare	$3,330.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Universal American Medicare	$3,330.57
Rate for Payer: Wellcare Medicare	$3,330.57
Rate for Payer: Wellmed Medicare	$3,330.57

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement wit

Facility

$10,000.00

Service Code	CPT 30520
Hospital Charge Code	36030520
Hospital Revenue Code	360
Min. Negotiated Rate	$886.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Amerigroup Medicare	$3,330.57
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicare	$3,330.57
Rate for Payer: Employer Direct Commercial	$3,330.57
Rate for Payer: Humana Medicare/TRICARE	$3,330.57
Rate for Payer: Molina Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Molina Medicare	$3,330.57
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	$6,161.55
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan EPO	$3,330.57
Rate for Payer: Superior Health Plan Medicare	$3,330.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Universal American Medicare	$3,330.57
Rate for Payer: Wellcare Medicare	$3,330.57
Rate for Payer: Wellmed Medicare	$3,330.57

Serfas energy 90-s cruise

Facility

$893.56

Hospital Charge Code	993581
Hospital Revenue Code	272
Min. Negotiated Rate	$80.42
Max. Negotiated Rate	$643.36
Rate for Payer: Amerigroup CHIP/Medicaid	$80.42
Rate for Payer: BCBS of TX Blue Advantage	$268.07
Rate for Payer: BCBS of TX Blue Essentials	$321.68
Rate for Payer: BCBS of TX PPO	$357.42
Rate for Payer: Cash Price	$607.62
Rate for Payer: Cigna Medicaid	$643.36
Rate for Payer: Molina CHIP/Medicaid	$643.36
Rate for Payer: Multiplan Auto	$580.81
Rate for Payer: Multiplan Commercial	$580.81
Rate for Payer: Multiplan Workers Comp	$580.81
Rate for Payer: Parkland Medicaid	$643.36
Rate for Payer: Scott and White EPO/PPO	$446.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$643.36
Rate for Payer: Superior Health Plan EPO	$121.52

Serfas energy 90-s cruise

Facility

$893.56

Hospital Charge Code	993581
Hospital Revenue Code	272
Rate for Payer: Cash Price	$607.62

serfas energy 90-s max

Facility

$839.90

Hospital Charge Code	993257
Hospital Revenue Code	270
Min. Negotiated Rate	$75.59
Max. Negotiated Rate	$604.73
Rate for Payer: Amerigroup CHIP/Medicaid	$75.59
Rate for Payer: BCBS of TX Blue Advantage	$251.97
Rate for Payer: BCBS of TX Blue Essentials	$302.36
Rate for Payer: BCBS of TX PPO	$335.96
Rate for Payer: Cash Price	$571.13
Rate for Payer: Cigna Medicaid	$604.73
Rate for Payer: Molina CHIP/Medicaid	$604.73
Rate for Payer: Multiplan Auto	$545.93
Rate for Payer: Multiplan Commercial	$545.93
Rate for Payer: Multiplan Workers Comp	$545.93
Rate for Payer: Parkland Medicaid	$604.73
Rate for Payer: Scott and White EPO/PPO	$419.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$604.73
Rate for Payer: Superior Health Plan EPO	$114.23

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
Rate for Payer: Cash Price	$225.03

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: 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	$165.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$238.26
Rate for Payer: Superior Health Plan EPO	$45.01

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	$99.00
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

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

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

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

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

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

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	$6,080.78
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

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	$6,080.78
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

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
Rate for Payer: Cash Price	$102.28

Know your out-of-pocket cost for care.

All Charges