White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SHEATH INTRODUCER RADIOPQ MRKER 6F 4CM .038

Facility

$632.20

Service Code	HCPCS C1766
Hospital Charge Code	992495
Hospital Revenue Code	272
Min. Negotiated Rate	$56.90
Max. Negotiated Rate	$455.18
Rate for Payer: Amerigroup CHIP/Medicaid	$56.90
Rate for Payer: BCBS of TX Blue Advantage	$189.66
Rate for Payer: BCBS of TX Blue Essentials	$227.59
Rate for Payer: BCBS of TX PPO	$252.88
Rate for Payer: Cash Price	$429.90
Rate for Payer: Cigna Medicaid	$455.18
Rate for Payer: Molina CHIP/Medicaid	$455.18
Rate for Payer: Multiplan Auto	$410.93
Rate for Payer: Multiplan Commercial	$410.93
Rate for Payer: Multiplan Workers Comp	$410.93
Rate for Payer: Parkland Medicaid	$455.18
Rate for Payer: Scott and White EPO/PPO	$316.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$455.18
Rate for Payer: Superior Health Plan EPO	$85.98

SHEATH INTRODUCER RADIOPQ MRKER 6F 4CM .038

Facility

$632.20

Service Code	HCPCS C1766
Hospital Charge Code	992495
Hospital Revenue Code	272
Rate for Payer: Cash Price	$429.90

SHEET AIR LACTERAL COMFT GLIDE

Facility

$271.26

Hospital Charge Code	8514467
Hospital Revenue Code	272
Min. Negotiated Rate	$24.41
Max. Negotiated Rate	$195.31
Rate for Payer: Amerigroup CHIP/Medicaid	$24.41
Rate for Payer: BCBS of TX Blue Advantage	$81.38
Rate for Payer: BCBS of TX Blue Essentials	$97.65
Rate for Payer: BCBS of TX PPO	$108.50
Rate for Payer: Cash Price	$184.46
Rate for Payer: Cigna Medicaid	$195.31
Rate for Payer: Molina CHIP/Medicaid	$195.31
Rate for Payer: Multiplan Auto	$176.32
Rate for Payer: Multiplan Commercial	$176.32
Rate for Payer: Multiplan Workers Comp	$176.32
Rate for Payer: Parkland Medicaid	$195.31
Rate for Payer: Scott and White EPO/PPO	$135.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.31
Rate for Payer: Superior Health Plan EPO	$36.89

SHEET AIR LACTERAL COMFT GLIDE

Facility

$271.26

Hospital Charge Code	8514467
Hospital Revenue Code	272
Rate for Payer: Cash Price	$184.46

SHEET GLIDE TURN & POSIT

Facility

$250.99

Hospital Charge Code	80386808
Hospital Revenue Code	272
Rate for Payer: Cash Price	$170.67

SHEET GLIDE TURN & POSIT

Facility

$250.99

Hospital Charge Code	80386808
Hospital Revenue Code	272
Min. Negotiated Rate	$22.59
Max. Negotiated Rate	$180.71
Rate for Payer: Amerigroup CHIP/Medicaid	$22.59
Rate for Payer: BCBS of TX Blue Advantage	$75.30
Rate for Payer: BCBS of TX Blue Essentials	$90.36
Rate for Payer: BCBS of TX PPO	$100.40
Rate for Payer: Cash Price	$170.67
Rate for Payer: Cigna Medicaid	$180.71
Rate for Payer: Molina CHIP/Medicaid	$180.71
Rate for Payer: Multiplan Auto	$163.14
Rate for Payer: Multiplan Commercial	$163.14
Rate for Payer: Multiplan Workers Comp	$163.14
Rate for Payer: Parkland Medicaid	$180.71
Rate for Payer: Scott and White EPO/PPO	$125.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.71
Rate for Payer: Superior Health Plan EPO	$34.13

SHEET, LAPAROTOMY TRANSVERSE -- DHF

Facility

$445.91

Hospital Charge Code	81623050
Hospital Revenue Code	272
Min. Negotiated Rate	$40.13
Max. Negotiated Rate	$321.06
Rate for Payer: Amerigroup CHIP/Medicaid	$40.13
Rate for Payer: BCBS of TX Blue Advantage	$133.77
Rate for Payer: BCBS of TX Blue Essentials	$160.53
Rate for Payer: BCBS of TX PPO	$178.36
Rate for Payer: Cash Price	$303.22
Rate for Payer: Cigna Medicaid	$321.06
Rate for Payer: Molina CHIP/Medicaid	$321.06
Rate for Payer: Multiplan Auto	$289.84
Rate for Payer: Multiplan Commercial	$289.84
Rate for Payer: Multiplan Workers Comp	$289.84
Rate for Payer: Parkland Medicaid	$321.06
Rate for Payer: Scott and White EPO/PPO	$222.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$321.06
Rate for Payer: Superior Health Plan EPO	$60.64

SHEET, LAPAROTOMY TRANSVERSE -- DHF

Facility

$445.91

Hospital Charge Code	81623050
Hospital Revenue Code	272
Rate for Payer: Cash Price	$303.22

SHEET REPOSITION COMFORT GLIDE REPROCESSED 40X80

Facility

$263.54

Hospital Charge Code	993043
Hospital Revenue Code	270
Rate for Payer: Cash Price	$179.21

SHEET REPOSITION COMFORT GLIDE REPROCESSED 40X80

Facility

$263.54

Hospital Charge Code	993043
Hospital Revenue Code	270
Min. Negotiated Rate	$23.72
Max. Negotiated Rate	$189.75
Rate for Payer: Amerigroup CHIP/Medicaid	$23.72
Rate for Payer: BCBS of TX Blue Advantage	$79.06
Rate for Payer: BCBS of TX Blue Essentials	$94.87
Rate for Payer: BCBS of TX PPO	$105.42
Rate for Payer: Cash Price	$179.21
Rate for Payer: Cigna Medicaid	$189.75
Rate for Payer: Molina CHIP/Medicaid	$189.75
Rate for Payer: Multiplan Auto	$171.30
Rate for Payer: Multiplan Commercial	$171.30
Rate for Payer: Multiplan Workers Comp	$171.30
Rate for Payer: Parkland Medicaid	$189.75
Rate for Payer: Scott and White EPO/PPO	$131.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$189.75
Rate for Payer: Superior Health Plan EPO	$35.84

SHEET, THYROID W/ARMBOARD COVERS -- DHF

Facility

$372.24

Hospital Charge Code	81624652
Hospital Revenue Code	272
Rate for Payer: Cash Price	$253.12

SHEET, THYROID W/ARMBOARD COVERS -- DHF

Facility

$372.24

Hospital Charge Code	81624652
Hospital Revenue Code	272
Min. Negotiated Rate	$33.50
Max. Negotiated Rate	$268.01
Rate for Payer: Amerigroup CHIP/Medicaid	$33.50
Rate for Payer: BCBS of TX Blue Advantage	$111.67
Rate for Payer: BCBS of TX Blue Essentials	$134.01
Rate for Payer: BCBS of TX PPO	$148.90
Rate for Payer: Cash Price	$253.12
Rate for Payer: Cigna Medicaid	$268.01
Rate for Payer: Molina CHIP/Medicaid	$268.01
Rate for Payer: Multiplan Auto	$241.96
Rate for Payer: Multiplan Commercial	$241.96
Rate for Payer: Multiplan Workers Comp	$241.96
Rate for Payer: Parkland Medicaid	$268.01
Rate for Payer: Scott and White EPO/PPO	$186.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$268.01
Rate for Payer: Superior Health Plan EPO	$50.62

SHEET, T, THYROID, ST, 12/CS

Facility

$24.36

Hospital Charge Code	992852
Hospital Revenue Code	272
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$17.54
Rate for Payer: Amerigroup CHIP/Medicaid	$2.19
Rate for Payer: BCBS of TX Blue Advantage	$7.31
Rate for Payer: BCBS of TX Blue Essentials	$8.77
Rate for Payer: BCBS of TX PPO	$9.74
Rate for Payer: Cash Price	$16.56
Rate for Payer: Cigna Medicaid	$17.54
Rate for Payer: Molina CHIP/Medicaid	$17.54
Rate for Payer: Multiplan Auto	$15.83
Rate for Payer: Multiplan Commercial	$15.83
Rate for Payer: Multiplan Workers Comp	$15.83
Rate for Payer: Parkland Medicaid	$17.54
Rate for Payer: Scott and White EPO/PPO	$12.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.54
Rate for Payer: Superior Health Plan EPO	$3.31

SHEET, T, THYROID, ST, 12/CS

Facility

$24.36

Hospital Charge Code	992852
Hospital Revenue Code	272
Rate for Payer: Cash Price	$16.56

SHELL, DISPOSABLE ENDOSCOPIC SIGNIA STAPLER -- DHF

Facility

$2,407.34

Hospital Charge Code	80899024
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,636.99

SHELL, DISPOSABLE ENDOSCOPIC SIGNIA STAPLER -- DHF

Facility

$2,407.34

Hospital Charge Code	80899024
Hospital Revenue Code	272
Min. Negotiated Rate	$216.66
Max. Negotiated Rate	$1,733.28
Rate for Payer: Amerigroup CHIP/Medicaid	$216.66
Rate for Payer: BCBS of TX Blue Advantage	$722.20
Rate for Payer: BCBS of TX Blue Essentials	$866.64
Rate for Payer: BCBS of TX PPO	$962.94
Rate for Payer: Cash Price	$1,636.99
Rate for Payer: Cigna Medicaid	$1,733.28
Rate for Payer: Molina CHIP/Medicaid	$1,733.28
Rate for Payer: Multiplan Auto	$1,564.77
Rate for Payer: Multiplan Commercial	$1,564.77
Rate for Payer: Multiplan Workers Comp	$1,564.77
Rate for Payer: Parkland Medicaid	$1,733.28
Rate for Payer: Scott and White EPO/PPO	$1,203.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,733.28
Rate for Payer: Superior Health Plan EPO	$327.40

SHELL, POWER, CONTROL, SIGNIA

Facility

$494.00

Hospital Charge Code	992780
Hospital Revenue Code	272
Rate for Payer: Cash Price	$335.92

SHELL, POWER, CONTROL, SIGNIA

Facility

$494.00

Hospital Charge Code	992780
Hospital Revenue Code	272
Min. Negotiated Rate	$44.46
Max. Negotiated Rate	$355.68
Rate for Payer: Amerigroup CHIP/Medicaid	$44.46
Rate for Payer: BCBS of TX Blue Advantage	$148.20
Rate for Payer: BCBS of TX Blue Essentials	$177.84
Rate for Payer: BCBS of TX PPO	$197.60
Rate for Payer: Cash Price	$335.92
Rate for Payer: Cigna Medicaid	$355.68
Rate for Payer: Molina CHIP/Medicaid	$355.68
Rate for Payer: Multiplan Auto	$321.10
Rate for Payer: Multiplan Commercial	$321.10
Rate for Payer: Multiplan Workers Comp	$321.10
Rate for Payer: Parkland Medicaid	$355.68
Rate for Payer: Scott and White EPO/PPO	$247.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$355.68
Rate for Payer: Superior Health Plan EPO	$67.18

SHFT REAMER MODULAR -- DHF

Facility

$1,574.76

Hospital Charge Code	80826829
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,070.84

SHFT REAMER MODULAR -- DHF

Facility

$1,574.76

Hospital Charge Code	80826829
Hospital Revenue Code	272
Min. Negotiated Rate	$141.73
Max. Negotiated Rate	$1,133.83
Rate for Payer: Amerigroup CHIP/Medicaid	$141.73
Rate for Payer: BCBS of TX Blue Advantage	$472.43
Rate for Payer: BCBS of TX Blue Essentials	$566.91
Rate for Payer: BCBS of TX PPO	$629.90
Rate for Payer: Cash Price	$1,070.84
Rate for Payer: Cigna Medicaid	$1,133.83
Rate for Payer: Molina CHIP/Medicaid	$1,133.83
Rate for Payer: Multiplan Auto	$1,023.59
Rate for Payer: Multiplan Commercial	$1,023.59
Rate for Payer: Multiplan Workers Comp	$1,023.59
Rate for Payer: Parkland Medicaid	$1,133.83
Rate for Payer: Scott and White EPO/PPO	$787.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,133.83
Rate for Payer: Superior Health Plan EPO	$214.17

SHIELD NPL 20MM SM

Facility

$18.48

Hospital Charge Code	111289
Hospital Revenue Code	270
Rate for Payer: Cash Price	$12.57

SHIELD NPL 20MM SM

Facility

$18.48

Hospital Charge Code	111289
Hospital Revenue Code	270
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$13.31
Rate for Payer: Amerigroup CHIP/Medicaid	$1.66
Rate for Payer: BCBS of TX Blue Advantage	$5.54
Rate for Payer: BCBS of TX Blue Essentials	$6.65
Rate for Payer: BCBS of TX PPO	$7.39
Rate for Payer: Cash Price	$12.57
Rate for Payer: Cigna Medicaid	$13.31
Rate for Payer: Molina CHIP/Medicaid	$13.31
Rate for Payer: Multiplan Auto	$12.01
Rate for Payer: Multiplan Commercial	$12.01
Rate for Payer: Multiplan Workers Comp	$12.01
Rate for Payer: Parkland Medicaid	$13.31
Rate for Payer: Scott and White EPO/PPO	$9.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.31
Rate for Payer: Superior Health Plan EPO	$2.51

Shiga Toxin I

Facility

$117.00

Service Code	HCPCS 87899
Hospital Charge Code	4107908
Hospital Revenue Code	306
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$84.24
Rate for Payer: Amerigroup CHIP/Medicaid	$6.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.07
Rate for Payer: Amerigroup Medicare	$16.07
Rate for Payer: BCBS of TX Blue Advantage	$35.10
Rate for Payer: BCBS of TX Blue Essentials	$42.12
Rate for Payer: BCBS of TX Medicare	$16.07
Rate for Payer: BCBS of TX PPO	$46.80
Rate for Payer: Cash Price	$79.56
Rate for Payer: Cash Price	$79.56
Rate for Payer: Cigna Medicaid	$84.24
Rate for Payer: Cigna Medicare	$16.07
Rate for Payer: Employer Direct Commercial	$16.07
Rate for Payer: Humana Medicare/TRICARE	$16.07
Rate for Payer: Molina CHIP/Medicaid	$84.24
Rate for Payer: Molina Dual Medicare/Medicaid	$16.07
Rate for Payer: Molina Medicare	$16.07
Rate for Payer: Multiplan Auto	$76.05
Rate for Payer: Multiplan Commercial	$76.05
Rate for Payer: Multiplan Workers Comp	$76.05
Rate for Payer: Parkland Medicaid	$84.24
Rate for Payer: Scott and White EPO/PPO	$20.09
Rate for Payer: Scott and White Medicare	$16.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.24
Rate for Payer: Superior Health Plan EPO	$16.07
Rate for Payer: Superior Health Plan Medicare	$16.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.07
Rate for Payer: Universal American Medicare	$16.07
Rate for Payer: Wellcare Medicare	$16.07
Rate for Payer: Wellmed Medicare	$16.07

Shiga Toxin I

Facility

$117.00

Service Code	HCPCS 87899
Hospital Charge Code	4107908
Hospital Revenue Code	306
Rate for Payer: Cash Price	$79.56

Shiga Toxin II

Facility

$117.00

Service Code	HCPCS 87899
Hospital Charge Code	4107909
Hospital Revenue Code	306
Rate for Payer: Cash Price	$79.56

Know your out-of-pocket cost for care.

All Charges