White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SET, MICROINTRODUCER UNIV

Facility

$359.80

Hospital Charge Code	81749301
Hospital Revenue Code	272
Min. Negotiated Rate	$32.38
Max. Negotiated Rate	$259.06
Rate for Payer: Amerigroup CHIP/Medicaid	$32.38
Rate for Payer: BCBS of TX Blue Advantage	$107.94
Rate for Payer: BCBS of TX Blue Essentials	$129.53
Rate for Payer: BCBS of TX PPO	$143.92
Rate for Payer: Cash Price	$244.66
Rate for Payer: Cigna Medicaid	$259.06
Rate for Payer: Molina CHIP/Medicaid	$259.06
Rate for Payer: Multiplan Auto	$233.87
Rate for Payer: Multiplan Commercial	$233.87
Rate for Payer: Multiplan Workers Comp	$233.87
Rate for Payer: Parkland Medicaid	$259.06
Rate for Payer: Scott and White EPO/PPO	$179.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$259.06
Rate for Payer: Superior Health Plan EPO	$48.93

SET, MICROINTRODUCER UNIV

Facility

$359.80

Hospital Charge Code	81749301
Hospital Revenue Code	272
Rate for Payer: Cash Price	$244.66

SET, PROCEDURE SHEATH CASSETTE DRAINAGE BAG -- DHF

Facility

$7,531.81

Hospital Charge Code	80732654
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,121.63

SET, PROCEDURE SHEATH CASSETTE DRAINAGE BAG -- DHF

Facility

$7,531.81

Hospital Charge Code	80732654
Hospital Revenue Code	272
Min. Negotiated Rate	$677.86
Max. Negotiated Rate	$5,422.90
Rate for Payer: Amerigroup CHIP/Medicaid	$677.86
Rate for Payer: BCBS of TX Blue Advantage	$2,259.54
Rate for Payer: BCBS of TX Blue Essentials	$2,711.45
Rate for Payer: BCBS of TX PPO	$3,012.72
Rate for Payer: Cash Price	$5,121.63
Rate for Payer: Cigna Medicaid	$5,422.90
Rate for Payer: Molina CHIP/Medicaid	$5,422.90
Rate for Payer: Multiplan Auto	$4,895.68
Rate for Payer: Multiplan Commercial	$4,895.68
Rate for Payer: Multiplan Workers Comp	$4,895.68
Rate for Payer: Parkland Medicaid	$5,422.90
Rate for Payer: Scott and White EPO/PPO	$3,765.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,422.90
Rate for Payer: Superior Health Plan EPO	$1,024.33

Set Screw

Facility

$602.41

Service Code	HCPCS C1713
Hospital Charge Code	992227
Hospital Revenue Code	278
Min. Negotiated Rate	$54.22
Max. Negotiated Rate	$433.74
Rate for Payer: Amerigroup CHIP/Medicaid	$54.22
Rate for Payer: BCBS of TX Blue Advantage	$180.72
Rate for Payer: BCBS of TX Blue Essentials	$216.87
Rate for Payer: BCBS of TX PPO	$240.96
Rate for Payer: Cash Price	$409.64
Rate for Payer: Cigna Medicaid	$433.74
Rate for Payer: Molina CHIP/Medicaid	$433.74
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Parkland Medicaid	$433.74
Rate for Payer: Scott and White EPO/PPO	$301.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$433.74
Rate for Payer: Superior Health Plan EPO	$81.93

Set Screw

Facility

$602.41

Service Code	HCPCS C1713
Hospital Charge Code	992227
Hospital Revenue Code	278
Min. Negotiated Rate	$150.60
Max. Negotiated Rate	$301.20
Rate for Payer: Cash Price	$409.64
Rate for Payer: Cigna Commercial	$150.60
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Scott and White EPO/PPO	$301.20

SET, STD EXT W/SPIN-LOCK CONNECTION 6

Facility

$48.66

Hospital Charge Code	993718
Hospital Revenue Code	270
Min. Negotiated Rate	$4.38
Max. Negotiated Rate	$35.04
Rate for Payer: Amerigroup CHIP/Medicaid	$4.38
Rate for Payer: BCBS of TX Blue Advantage	$14.60
Rate for Payer: BCBS of TX Blue Essentials	$17.52
Rate for Payer: BCBS of TX PPO	$19.46
Rate for Payer: Cash Price	$33.09
Rate for Payer: Cigna Medicaid	$35.04
Rate for Payer: Molina CHIP/Medicaid	$35.04
Rate for Payer: Multiplan Auto	$31.63
Rate for Payer: Multiplan Commercial	$31.63
Rate for Payer: Multiplan Workers Comp	$31.63
Rate for Payer: Parkland Medicaid	$35.04
Rate for Payer: Scott and White EPO/PPO	$24.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.04
Rate for Payer: Superior Health Plan EPO	$6.62

SET, STD EXT W/SPIN-LOCK CONNECTION 6

Facility

$48.66

Hospital Charge Code	993718
Hospital Revenue Code	270
Rate for Payer: Cash Price	$33.09

SET, TUBE, HIGH-FLOW, PNEUMOCLEAR

Facility

$213.33

Hospital Charge Code	992811
Hospital Revenue Code	272
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$153.60
Rate for Payer: Amerigroup CHIP/Medicaid	$19.20
Rate for Payer: BCBS of TX Blue Advantage	$64.00
Rate for Payer: BCBS of TX Blue Essentials	$76.80
Rate for Payer: BCBS of TX PPO	$85.33
Rate for Payer: Cash Price	$145.06
Rate for Payer: Cigna Medicaid	$153.60
Rate for Payer: Molina CHIP/Medicaid	$153.60
Rate for Payer: Multiplan Auto	$138.66
Rate for Payer: Multiplan Commercial	$138.66
Rate for Payer: Multiplan Workers Comp	$138.66
Rate for Payer: Parkland Medicaid	$153.60
Rate for Payer: Scott and White EPO/PPO	$106.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$153.60
Rate for Payer: Superior Health Plan EPO	$29.01

SET, TUBE, HIGH-FLOW, PNEUMOCLEAR

Facility

$213.33

Hospital Charge Code	992811
Hospital Revenue Code	272
Rate for Payer: Cash Price	$145.06

SET TUBING SUCTION/IRRIGATION LAPAROSCOPIC 33CML HANDPIECE A

Facility

$25.64

Hospital Charge Code	993593
Hospital Revenue Code	272
Rate for Payer: Cash Price	$17.44

SET TUBING SUCTION/IRRIGATION LAPAROSCOPIC 33CML HANDPIECE A

Facility

$25.64

Hospital Charge Code	993593
Hospital Revenue Code	272
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$18.46
Rate for Payer: Amerigroup CHIP/Medicaid	$2.31
Rate for Payer: BCBS of TX Blue Advantage	$7.69
Rate for Payer: BCBS of TX Blue Essentials	$9.23
Rate for Payer: BCBS of TX PPO	$10.26
Rate for Payer: Cash Price	$17.44
Rate for Payer: Cigna Medicaid	$18.46
Rate for Payer: Molina CHIP/Medicaid	$18.46
Rate for Payer: Multiplan Auto	$16.67
Rate for Payer: Multiplan Commercial	$16.67
Rate for Payer: Multiplan Workers Comp	$16.67
Rate for Payer: Parkland Medicaid	$18.46
Rate for Payer: Scott and White EPO/PPO	$12.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.46
Rate for Payer: Superior Health Plan EPO	$3.49

sevelamer carbonate 800 mg Tab

Facility

$28.00

Service Code	HCPCS J3490
Hospital Charge Code	77811505
Hospital Revenue Code	636
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$14.00
Rate for Payer: Cash Price	$19.04
Rate for Payer: Cigna Commercial	$7.00
Rate for Payer: Scott and White EPO/PPO	$14.00

sevelamer carbonate 800 mg Tab

Facility

$28.00

Service Code	HCPCS J3490
Hospital Charge Code	77811505
Hospital Revenue Code	636
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$20.16
Rate for Payer: Amerigroup CHIP/Medicaid	$2.52
Rate for Payer: BCBS of TX Blue Advantage	$8.40
Rate for Payer: BCBS of TX Blue Essentials	$10.08
Rate for Payer: BCBS of TX PPO	$11.20
Rate for Payer: Cash Price	$19.04
Rate for Payer: Cigna Medicaid	$20.16
Rate for Payer: Molina CHIP/Medicaid	$20.16
Rate for Payer: Multiplan Auto	$18.20
Rate for Payer: Multiplan Commercial	$18.20
Rate for Payer: Multiplan Workers Comp	$18.20
Rate for Payer: Parkland Medicaid	$20.16
Rate for Payer: Scott and White EPO/PPO	$14.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.16
Rate for Payer: Superior Health Plan EPO	$3.81

sevoflurane Inh Liquid 250 mL

Facility

$242.00

Service Code	HCPCS J3490
Hospital Charge Code	77811660
Hospital Revenue Code	250
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$174.24
Rate for Payer: Amerigroup CHIP/Medicaid	$21.78
Rate for Payer: BCBS of TX Blue Advantage	$72.60
Rate for Payer: BCBS of TX Blue Essentials	$87.12
Rate for Payer: BCBS of TX PPO	$96.80
Rate for Payer: Cash Price	$164.56
Rate for Payer: Cigna Medicaid	$174.24
Rate for Payer: Molina CHIP/Medicaid	$174.24
Rate for Payer: Multiplan Auto	$157.30
Rate for Payer: Multiplan Commercial	$157.30
Rate for Payer: Multiplan Workers Comp	$157.30
Rate for Payer: Parkland Medicaid	$174.24
Rate for Payer: Scott and White EPO/PPO	$121.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$174.24
Rate for Payer: Superior Health Plan EPO	$32.91

sevoflurane Inh Liquid 250 mL

Facility

$242.00

Service Code	HCPCS J3490
Hospital Charge Code	77811660
Hospital Revenue Code	250
Rate for Payer: Cash Price	$164.56

Sex Horm Binding Glob, Serum SO

Facility

$128.23

Service Code	HCPCS 84270
Hospital Charge Code	1740703
Hospital Revenue Code	301
Min. Negotiated Rate	$8.47
Max. Negotiated Rate	$92.33
Rate for Payer: Amerigroup CHIP/Medicaid	$8.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.73
Rate for Payer: Amerigroup Medicare	$21.73
Rate for Payer: BCBS of TX Blue Advantage	$38.47
Rate for Payer: BCBS of TX Blue Essentials	$46.16
Rate for Payer: BCBS of TX Medicare	$21.73
Rate for Payer: BCBS of TX PPO	$51.29
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna Medicaid	$92.33
Rate for Payer: Cigna Medicare	$21.73
Rate for Payer: Employer Direct Commercial	$21.73
Rate for Payer: Humana Medicare/TRICARE	$21.73
Rate for Payer: Molina CHIP/Medicaid	$92.33
Rate for Payer: Molina Dual Medicare/Medicaid	$21.73
Rate for Payer: Molina Medicare	$21.73
Rate for Payer: Multiplan Auto	$83.35
Rate for Payer: Multiplan Commercial	$83.35
Rate for Payer: Multiplan Workers Comp	$83.35
Rate for Payer: Parkland Medicaid	$92.33
Rate for Payer: Scott and White EPO/PPO	$27.16
Rate for Payer: Scott and White Medicare	$21.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.33
Rate for Payer: Superior Health Plan EPO	$21.73
Rate for Payer: Superior Health Plan Medicare	$21.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.73
Rate for Payer: Universal American Medicare	$21.73
Rate for Payer: Wellcare Medicare	$21.73
Rate for Payer: Wellmed Medicare	$21.73

Sex Horm Binding Glob, Serum SO

Facility

$128.23

Service Code	HCPCS 84270
Hospital Charge Code	1740703
Hospital Revenue Code	301
Rate for Payer: Cash Price	$87.20

SF CELT Arterial Closure Device Individual Units

Facility

$5,675.00

Hospital Charge Code	993926
Hospital Revenue Code	272
Min. Negotiated Rate	$510.75
Max. Negotiated Rate	$4,086.00
Rate for Payer: Amerigroup CHIP/Medicaid	$510.75
Rate for Payer: BCBS of TX Blue Advantage	$1,702.50
Rate for Payer: BCBS of TX Blue Essentials	$2,043.00
Rate for Payer: BCBS of TX PPO	$2,270.00
Rate for Payer: Cash Price	$3,859.00
Rate for Payer: Cigna Medicaid	$4,086.00
Rate for Payer: Molina CHIP/Medicaid	$4,086.00
Rate for Payer: Multiplan Auto	$3,688.75
Rate for Payer: Multiplan Commercial	$3,688.75
Rate for Payer: Multiplan Workers Comp	$3,688.75
Rate for Payer: Parkland Medicaid	$4,086.00
Rate for Payer: Scott and White EPO/PPO	$2,837.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,086.00
Rate for Payer: Superior Health Plan EPO	$771.80

SF CELT Arterial Closure Device Individual Units

Facility

$5,675.00

Hospital Charge Code	993926
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,859.00

SHAMPOO BODY BATH DAWNMIST 2OZ

Facility

$2.01

Hospital Charge Code	993587
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.37

SHAMPOO BODY BATH DAWNMIST 2OZ

Facility

$2.01

Hospital Charge Code	993587
Hospital Revenue Code	270
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$1.45
Rate for Payer: Amerigroup CHIP/Medicaid	$0.18
Rate for Payer: BCBS of TX Blue Advantage	$0.60
Rate for Payer: BCBS of TX Blue Essentials	$0.72
Rate for Payer: BCBS of TX PPO	$0.80
Rate for Payer: Cash Price	$1.37
Rate for Payer: Cigna Medicaid	$1.45
Rate for Payer: Molina CHIP/Medicaid	$1.45
Rate for Payer: Multiplan Auto	$1.31
Rate for Payer: Multiplan Commercial	$1.31
Rate for Payer: Multiplan Workers Comp	$1.31
Rate for Payer: Parkland Medicaid	$1.45
Rate for Payer: Scott and White EPO/PPO	$1.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.45
Rate for Payer: Superior Health Plan EPO	$0.27

SHAVER BARRELL BURR HOLLOW 12 FLUTES 4.00MM DISP 'FORMULA

Facility

$319.43

Hospital Charge Code	81728883
Hospital Revenue Code	272
Rate for Payer: Cash Price	$217.21

SHAVER BARRELL BURR HOLLOW 12 FLUTES 4.00MM DISP 'FORMULA

Facility

$319.43

Hospital Charge Code	81728883
Hospital Revenue Code	272
Min. Negotiated Rate	$28.75
Max. Negotiated Rate	$229.99
Rate for Payer: Amerigroup CHIP/Medicaid	$28.75
Rate for Payer: BCBS of TX Blue Advantage	$95.83
Rate for Payer: BCBS of TX Blue Essentials	$114.99
Rate for Payer: BCBS of TX PPO	$127.77
Rate for Payer: Cash Price	$217.21
Rate for Payer: Cigna Medicaid	$229.99
Rate for Payer: Molina CHIP/Medicaid	$229.99
Rate for Payer: Multiplan Auto	$207.63
Rate for Payer: Multiplan Commercial	$207.63
Rate for Payer: Multiplan Workers Comp	$207.63
Rate for Payer: Parkland Medicaid	$229.99
Rate for Payer: Scott and White EPO/PPO	$159.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$229.99
Rate for Payer: Superior Health Plan EPO	$43.44

SHAVER BLADE 3-IN-1 4.2MM

Facility

$1,203.10

Hospital Charge Code	144828
Hospital Revenue Code	272
Min. Negotiated Rate	$108.28
Max. Negotiated Rate	$866.23
Rate for Payer: Amerigroup CHIP/Medicaid	$108.28
Rate for Payer: BCBS of TX Blue Advantage	$360.93
Rate for Payer: BCBS of TX Blue Essentials	$433.12
Rate for Payer: BCBS of TX PPO	$481.24
Rate for Payer: Cash Price	$818.11
Rate for Payer: Cigna Medicaid	$866.23
Rate for Payer: Molina CHIP/Medicaid	$866.23
Rate for Payer: Multiplan Auto	$782.01
Rate for Payer: Multiplan Commercial	$782.01
Rate for Payer: Multiplan Workers Comp	$782.01
Rate for Payer: Parkland Medicaid	$866.23
Rate for Payer: Scott and White EPO/PPO	$601.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$866.23
Rate for Payer: Superior Health Plan EPO	$163.62

Know your out-of-pocket cost for care.

All Charges