White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$87.20

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

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

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

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

SHAMPOO BODY BATH DAWNMIST 2OZ

Facility

$2.01

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

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

SHAVER BLADE 3-IN-1 4.2MM

Facility

$1,203.10

Hospital Charge Code	144828
Hospital Revenue Code	272
Rate for Payer: Cash Price	$818.11

SHAVER BLADE STND 3.4MM

Facility

$181.60

Hospital Charge Code	144829
Hospital Revenue Code	272
Rate for Payer: Cash Price	$123.49

SHAVER BLADE STND 3.4MM

Facility

$181.60

Hospital Charge Code	144829
Hospital Revenue Code	272
Min. Negotiated Rate	$16.34
Max. Negotiated Rate	$130.75
Rate for Payer: Amerigroup CHIP/Medicaid	$16.34
Rate for Payer: BCBS of TX Blue Advantage	$54.48
Rate for Payer: BCBS of TX Blue Essentials	$65.38
Rate for Payer: BCBS of TX PPO	$72.64
Rate for Payer: Cash Price	$123.49
Rate for Payer: Cigna Medicaid	$130.75
Rate for Payer: Molina CHIP/Medicaid	$130.75
Rate for Payer: Multiplan Auto	$118.04
Rate for Payer: Multiplan Commercial	$118.04
Rate for Payer: Multiplan Workers Comp	$118.04
Rate for Payer: Parkland Medicaid	$130.75
Rate for Payer: Scott and White EPO/PPO	$90.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$130.75
Rate for Payer: Superior Health Plan EPO	$24.70

SHAVER BURR MIMIX CUDA 3.5 X 8CM 35 DEGREE STEALTH

Facility

$830.14

Hospital Charge Code	146207
Hospital Revenue Code	272
Min. Negotiated Rate	$74.71
Max. Negotiated Rate	$597.70
Rate for Payer: Amerigroup CHIP/Medicaid	$74.71
Rate for Payer: BCBS of TX Blue Advantage	$249.04
Rate for Payer: BCBS of TX Blue Essentials	$298.85
Rate for Payer: BCBS of TX PPO	$332.06
Rate for Payer: Cash Price	$564.50
Rate for Payer: Cigna Medicaid	$597.70
Rate for Payer: Molina CHIP/Medicaid	$597.70
Rate for Payer: Multiplan Auto	$539.59
Rate for Payer: Multiplan Commercial	$539.59
Rate for Payer: Multiplan Workers Comp	$539.59
Rate for Payer: Parkland Medicaid	$597.70
Rate for Payer: Scott and White EPO/PPO	$415.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$597.70
Rate for Payer: Superior Health Plan EPO	$112.90

SHAVER BURR MIMIX CUDA 3.5 X 8CM 35 DEGREE STEALTH

Facility

$830.14

Hospital Charge Code	146207
Hospital Revenue Code	272
Rate for Payer: Cash Price	$564.50

SHAVER RESECTOR MIMIX FULL RADIUS 2.9 X 8CM 35 DEGREE STEALTH

Facility

$830.14

Hospital Charge Code	146205
Hospital Revenue Code	272
Rate for Payer: Cash Price	$564.50

SHAVER RESECTOR MIMIX FULL RADIUS 2.9 X 8CM 35 DEGREE STEALTH

Facility

$830.14

Hospital Charge Code	146205
Hospital Revenue Code	272
Min. Negotiated Rate	$74.71
Max. Negotiated Rate	$597.70
Rate for Payer: Amerigroup CHIP/Medicaid	$74.71
Rate for Payer: BCBS of TX Blue Advantage	$249.04
Rate for Payer: BCBS of TX Blue Essentials	$298.85
Rate for Payer: BCBS of TX PPO	$332.06
Rate for Payer: Cash Price	$564.50
Rate for Payer: Cigna Medicaid	$597.70
Rate for Payer: Molina CHIP/Medicaid	$597.70
Rate for Payer: Multiplan Auto	$539.59
Rate for Payer: Multiplan Commercial	$539.59
Rate for Payer: Multiplan Workers Comp	$539.59
Rate for Payer: Parkland Medicaid	$597.70
Rate for Payer: Scott and White EPO/PPO	$415.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$597.70
Rate for Payer: Superior Health Plan EPO	$112.90

SHAVER TOMCAT HC CROSSBLADE 4.0MM 'FORMULA

Facility

$415.11

Hospital Charge Code	8172360
Hospital Revenue Code	272
Min. Negotiated Rate	$37.36
Max. Negotiated Rate	$298.88
Rate for Payer: Amerigroup CHIP/Medicaid	$37.36
Rate for Payer: BCBS of TX Blue Advantage	$124.53
Rate for Payer: BCBS of TX Blue Essentials	$149.44
Rate for Payer: BCBS of TX PPO	$166.04
Rate for Payer: Cash Price	$282.27
Rate for Payer: Cigna Medicaid	$298.88
Rate for Payer: Molina CHIP/Medicaid	$298.88
Rate for Payer: Multiplan Auto	$269.82
Rate for Payer: Multiplan Commercial	$269.82
Rate for Payer: Multiplan Workers Comp	$269.82
Rate for Payer: Parkland Medicaid	$298.88
Rate for Payer: Scott and White EPO/PPO	$207.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$298.88
Rate for Payer: Superior Health Plan EPO	$56.45

SHAVER TOMCAT HC CROSSBLADE 4.0MM 'FORMULA

Facility

$415.11

Hospital Charge Code	8172360
Hospital Revenue Code	272
Rate for Payer: Cash Price	$282.27

SHEALTH SYSTEM FORTRESS 6FR 90CM

Facility

$385.90

Hospital Charge Code	145375
Hospital Revenue Code	272
Rate for Payer: Cash Price	$262.41

SHEALTH SYSTEM FORTRESS 6FR 90CM

Facility

$385.90

Hospital Charge Code	145375
Hospital Revenue Code	272
Min. Negotiated Rate	$34.73
Max. Negotiated Rate	$277.85
Rate for Payer: Amerigroup CHIP/Medicaid	$34.73
Rate for Payer: BCBS of TX Blue Advantage	$115.77
Rate for Payer: BCBS of TX Blue Essentials	$138.92
Rate for Payer: BCBS of TX PPO	$154.36
Rate for Payer: Cash Price	$262.41
Rate for Payer: Cigna Medicaid	$277.85
Rate for Payer: Molina CHIP/Medicaid	$277.85
Rate for Payer: Multiplan Auto	$250.84
Rate for Payer: Multiplan Commercial	$250.84
Rate for Payer: Multiplan Workers Comp	$250.84
Rate for Payer: Parkland Medicaid	$277.85
Rate for Payer: Scott and White EPO/PPO	$192.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$277.85
Rate for Payer: Superior Health Plan EPO	$52.48

SHEARS, HARMONIC CRVD W/ERGNMC HANDLE 5.5MM X 23CM -- DHF

Facility

$2,457.37

Hospital Charge Code	80811300
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,671.01

SHEARS, HARMONIC CRVD W/ERGNMC HANDLE 5.5MM X 23CM -- DHF

Facility

$2,457.37

Hospital Charge Code	80811300
Hospital Revenue Code	272
Min. Negotiated Rate	$221.16
Max. Negotiated Rate	$1,769.31
Rate for Payer: Amerigroup CHIP/Medicaid	$221.16
Rate for Payer: BCBS of TX Blue Advantage	$737.21
Rate for Payer: BCBS of TX Blue Essentials	$884.65
Rate for Payer: BCBS of TX PPO	$982.95
Rate for Payer: Cash Price	$1,671.01
Rate for Payer: Cigna Medicaid	$1,769.31
Rate for Payer: Molina CHIP/Medicaid	$1,769.31
Rate for Payer: Multiplan Auto	$1,597.29
Rate for Payer: Multiplan Commercial	$1,597.29
Rate for Payer: Multiplan Workers Comp	$1,597.29
Rate for Payer: Parkland Medicaid	$1,769.31
Rate for Payer: Scott and White EPO/PPO	$1,228.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,769.31
Rate for Payer: Superior Health Plan EPO	$334.20

SHEARS HARMONIC CRVD W/ERGNMC HANDLE 5MM X 23CM

Facility

$1,194.93

Hospital Charge Code	993685
Hospital Revenue Code	270
Min. Negotiated Rate	$107.54
Max. Negotiated Rate	$860.35
Rate for Payer: Amerigroup CHIP/Medicaid	$107.54
Rate for Payer: BCBS of TX Blue Advantage	$358.48
Rate for Payer: BCBS of TX Blue Essentials	$430.17
Rate for Payer: BCBS of TX PPO	$477.97
Rate for Payer: Cash Price	$812.55
Rate for Payer: Cigna Medicaid	$860.35
Rate for Payer: Molina CHIP/Medicaid	$860.35
Rate for Payer: Multiplan Auto	$776.70
Rate for Payer: Multiplan Commercial	$776.70
Rate for Payer: Multiplan Workers Comp	$776.70
Rate for Payer: Parkland Medicaid	$860.35
Rate for Payer: Scott and White EPO/PPO	$597.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$860.35
Rate for Payer: Superior Health Plan EPO	$162.51

SHEARS HARMONIC CRVD W/ERGNMC HANDLE 5MM X 23CM

Facility

$1,194.93

Hospital Charge Code	993685
Hospital Revenue Code	270
Rate for Payer: Cash Price	$812.55

Know your out-of-pocket cost for care.

All Charges