White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W MCC

Facility

$54,873.90

Service Code	MSDRG 510
Min. Negotiated Rate	$23,498.64
Max. Negotiated Rate	$54,873.90
Rate for Payer: BCBS of TX Blue Advantage	$23,498.64
Rate for Payer: BCBS of TX Blue Essentials	$28,195.64
Rate for Payer: BCBS of TX PPO	$31,329.70

SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W/O CC/MCC

Facility

$30,523.50

Service Code	MSDRG 512
Min. Negotiated Rate	$13,090.06
Max. Negotiated Rate	$30,523.50
Rate for Payer: BCBS of TX Blue Advantage	$13,090.06
Rate for Payer: BCBS of TX Blue Essentials	$15,706.55
Rate for Payer: BCBS of TX PPO	$17,452.40

SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT

Facility

$38,199.82

Service Code	APR-DRG 3154
Min. Negotiated Rate	$36,016.12
Max. Negotiated Rate	$38,199.82
Rate for Payer: Amerigroup CHIP/Medicaid	$36,016.12
Rate for Payer: Cigna Medicaid	$36,016.12
Rate for Payer: Molina CHIP/Medicaid	$36,016.12
Rate for Payer: Parkland Medicaid	$36,016.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38,199.82

SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT

Facility

$11,386.96

Service Code	APR-DRG 3153
Min. Negotiated Rate	$10,736.02
Max. Negotiated Rate	$11,386.96
Rate for Payer: Amerigroup CHIP/Medicaid	$10,736.02
Rate for Payer: Cigna Medicaid	$10,736.02
Rate for Payer: Molina CHIP/Medicaid	$10,736.02
Rate for Payer: Parkland Medicaid	$10,736.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,386.96

SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT

Facility

$7,258.25

Service Code	APR-DRG 3152
Min. Negotiated Rate	$6,843.33
Max. Negotiated Rate	$7,258.25
Rate for Payer: Amerigroup CHIP/Medicaid	$6,843.33
Rate for Payer: Cigna Medicaid	$6,843.33
Rate for Payer: Molina CHIP/Medicaid	$6,843.33
Rate for Payer: Parkland Medicaid	$6,843.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,258.25

SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT

Facility

$4,130.60

Service Code	APR-DRG 3151
Min. Negotiated Rate	$3,894.47
Max. Negotiated Rate	$4,130.60
Rate for Payer: Amerigroup CHIP/Medicaid	$3,894.47
Rate for Payer: Cigna Medicaid	$3,894.47
Rate for Payer: Molina CHIP/Medicaid	$3,894.47
Rate for Payer: Parkland Medicaid	$3,894.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,130.60

Shuntogram for investigation of previously placed indwelling nonvascular shunt (eg, LeVeen shunt, ve

Facility

$641.28

Service Code	HCPCS 75809
Hospital Charge Code	9900901
Hospital Revenue Code	360
Rate for Payer: Cash Price	$436.07

Shuntogram for investigation of previously placed indwelling nonvascular shunt (eg, LeVeen shunt, ve

Facility

$641.28

Service Code	HCPCS 75809
Hospital Charge Code	9900901
Hospital Revenue Code	360
Min. Negotiated Rate	$57.72
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$57.72
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$436.07
Rate for Payer: Cash Price	$436.07
Rate for Payer: Cash Price	$436.07
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$461.72
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$461.72
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
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	$461.72
Rate for Payer: Scott and White EPO/PPO	$100.85
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$461.72
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

Shuntogram for investigation of previously placed indwelling nonvascular shunt (eg, LeVeen shunt, ve

Facility

$10,000.00

Service Code	CPT 75809
Hospital Charge Code	36075809
Hospital Revenue Code	360
Min. Negotiated Rate	$100.85
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
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	$100.85
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

SHUTTLE RELAY

Facility

$142.78

Hospital Charge Code	992644
Hospital Revenue Code	272
Min. Negotiated Rate	$12.85
Max. Negotiated Rate	$102.80
Rate for Payer: Amerigroup CHIP/Medicaid	$12.85
Rate for Payer: BCBS of TX Blue Advantage	$42.83
Rate for Payer: BCBS of TX Blue Essentials	$51.40
Rate for Payer: BCBS of TX PPO	$57.11
Rate for Payer: Cash Price	$97.09
Rate for Payer: Cigna Medicaid	$102.80
Rate for Payer: Molina CHIP/Medicaid	$102.80
Rate for Payer: Multiplan Auto	$92.81
Rate for Payer: Multiplan Commercial	$92.81
Rate for Payer: Multiplan Workers Comp	$92.81
Rate for Payer: Parkland Medicaid	$102.80
Rate for Payer: Scott and White EPO/PPO	$71.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.80
Rate for Payer: Superior Health Plan EPO	$19.42

SHUTTLE RELAY

Facility

$142.78

Hospital Charge Code	992644
Hospital Revenue Code	272
Rate for Payer: Cash Price	$97.09

SHUTTLE SUT 45 D LT IDL

Facility

$1,813.25

Hospital Charge Code	992127
Hospital Revenue Code	272
Min. Negotiated Rate	$163.19
Max. Negotiated Rate	$1,305.54
Rate for Payer: Amerigroup CHIP/Medicaid	$163.19
Rate for Payer: BCBS of TX Blue Advantage	$543.98
Rate for Payer: BCBS of TX Blue Essentials	$652.77
Rate for Payer: BCBS of TX PPO	$725.30
Rate for Payer: Cash Price	$1,233.01
Rate for Payer: Cigna Medicaid	$1,305.54
Rate for Payer: Molina CHIP/Medicaid	$1,305.54
Rate for Payer: Multiplan Auto	$1,178.61
Rate for Payer: Multiplan Commercial	$1,178.61
Rate for Payer: Multiplan Workers Comp	$1,178.61
Rate for Payer: Parkland Medicaid	$1,305.54
Rate for Payer: Scott and White EPO/PPO	$906.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,305.54
Rate for Payer: Superior Health Plan EPO	$246.60

SHUTTLE SUT 45 D LT IDL

Facility

$1,813.25

Hospital Charge Code	992127
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,233.01

Sialolithotomy; submandibular (submaxillary), complicated, intraoral

Facility

$10,000.00

Service Code	CPT 42335
Hospital Charge Code	36042335
Hospital Revenue Code	360
Min. Negotiated Rate	$252.76
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$252.76
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	$462.87
Rate for Payer: BCBS of TX Blue Essentials	$554.34
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$698.47
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	$5,447.31
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

Sialolithotomy; submandibular (submaxillary), complicated, intraoral

Facility

$14,225.15

Service Code	HCPCS 42335
Hospital Charge Code	9900652
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,673.10

Sialolithotomy; submandibular (submaxillary), complicated, intraoral

Facility

$14,225.15

Service Code	HCPCS 42335
Hospital Charge Code	9900652
Hospital Revenue Code	360
Min. Negotiated Rate	$252.76
Max. Negotiated Rate	$10,242.11
Rate for Payer: Amerigroup CHIP/Medicaid	$252.76
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	$462.87
Rate for Payer: BCBS of TX Blue Essentials	$554.34
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$698.47
Rate for Payer: Cash Price	$9,673.10
Rate for Payer: Cash Price	$9,673.10
Rate for Payer: Cash Price	$9,673.10
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicaid	$10,242.11
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	$10,242.11
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	$10,242.11
Rate for Payer: Scott and White EPO/PPO	$5,447.31
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,242.11
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

SI BRITE TIP 6F 11CM STR

Facility

$49.94

Service Code	HCPCS C1766
Hospital Charge Code	992487
Hospital Revenue Code	272
Rate for Payer: Cash Price	$33.96

SI BRITE TIP 6F 11CM STR

Facility

$49.94

Service Code	HCPCS C1766
Hospital Charge Code	992487
Hospital Revenue Code	272
Min. Negotiated Rate	$4.49
Max. Negotiated Rate	$35.96
Rate for Payer: Amerigroup CHIP/Medicaid	$4.49
Rate for Payer: BCBS of TX Blue Advantage	$14.98
Rate for Payer: BCBS of TX Blue Essentials	$17.98
Rate for Payer: BCBS of TX PPO	$19.98
Rate for Payer: Cash Price	$33.96
Rate for Payer: Cigna Medicaid	$35.96
Rate for Payer: Molina CHIP/Medicaid	$35.96
Rate for Payer: Multiplan Auto	$32.46
Rate for Payer: Multiplan Commercial	$32.46
Rate for Payer: Multiplan Workers Comp	$32.46
Rate for Payer: Parkland Medicaid	$35.96
Rate for Payer: Scott and White EPO/PPO	$24.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.96
Rate for Payer: Superior Health Plan EPO	$6.79

SI BRITE TIP 8F 11CM STR

Facility

$453.09

Service Code	HCPCS C1766
Hospital Charge Code	992488
Hospital Revenue Code	272
Min. Negotiated Rate	$40.78
Max. Negotiated Rate	$326.22
Rate for Payer: Amerigroup CHIP/Medicaid	$40.78
Rate for Payer: BCBS of TX Blue Advantage	$135.93
Rate for Payer: BCBS of TX Blue Essentials	$163.11
Rate for Payer: BCBS of TX PPO	$181.24
Rate for Payer: Cash Price	$308.10
Rate for Payer: Cigna Medicaid	$326.22
Rate for Payer: Molina CHIP/Medicaid	$326.22
Rate for Payer: Multiplan Auto	$294.51
Rate for Payer: Multiplan Commercial	$294.51
Rate for Payer: Multiplan Workers Comp	$294.51
Rate for Payer: Parkland Medicaid	$326.22
Rate for Payer: Scott and White EPO/PPO	$226.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$326.22
Rate for Payer: Superior Health Plan EPO	$61.62

SI BRITE TIP 8F 11CM STR

Facility

$453.09

Service Code	HCPCS C1766
Hospital Charge Code	992488
Hospital Revenue Code	272
Rate for Payer: Cash Price	$308.10

SI BRITE TIP F5 11CM

Facility

$453.09

Service Code	HCPCS C1766
Hospital Charge Code	992486
Hospital Revenue Code	272
Min. Negotiated Rate	$40.78
Max. Negotiated Rate	$326.22
Rate for Payer: Amerigroup CHIP/Medicaid	$40.78
Rate for Payer: BCBS of TX Blue Advantage	$135.93
Rate for Payer: BCBS of TX Blue Essentials	$163.11
Rate for Payer: BCBS of TX PPO	$181.24
Rate for Payer: Cash Price	$308.10
Rate for Payer: Cigna Medicaid	$326.22
Rate for Payer: Molina CHIP/Medicaid	$326.22
Rate for Payer: Multiplan Auto	$294.51
Rate for Payer: Multiplan Commercial	$294.51
Rate for Payer: Multiplan Workers Comp	$294.51
Rate for Payer: Parkland Medicaid	$326.22
Rate for Payer: Scott and White EPO/PPO	$226.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$326.22
Rate for Payer: Superior Health Plan EPO	$61.62

SI BRITE TIP F5 11CM

Facility

$453.09

Service Code	HCPCS C1766
Hospital Charge Code	992486
Hospital Revenue Code	272
Rate for Payer: Cash Price	$308.10

SICKLE CELL ANEMIA CRISIS

Facility

$3,600.65

Service Code	APR-DRG 6622
Min. Negotiated Rate	$3,394.82
Max. Negotiated Rate	$3,600.65
Rate for Payer: Amerigroup CHIP/Medicaid	$3,394.82
Rate for Payer: Cigna Medicaid	$3,394.82
Rate for Payer: Molina CHIP/Medicaid	$3,394.82
Rate for Payer: Parkland Medicaid	$3,394.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,600.65

SICKLE CELL ANEMIA CRISIS

Facility

$2,559.23

Service Code	APR-DRG 6621
Min. Negotiated Rate	$2,412.93
Max. Negotiated Rate	$2,559.23
Rate for Payer: Amerigroup CHIP/Medicaid	$2,412.93
Rate for Payer: Cigna Medicaid	$2,412.93
Rate for Payer: Molina CHIP/Medicaid	$2,412.93
Rate for Payer: Parkland Medicaid	$2,412.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,559.23

SICKLE CELL ANEMIA CRISIS

Facility

$15,041.17

Service Code	APR-DRG 6624
Min. Negotiated Rate	$14,181.34
Max. Negotiated Rate	$15,041.17
Rate for Payer: Amerigroup CHIP/Medicaid	$14,181.34
Rate for Payer: Cigna Medicaid	$14,181.34
Rate for Payer: Molina CHIP/Medicaid	$14,181.34
Rate for Payer: Parkland Medicaid	$14,181.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,041.17

Know your out-of-pocket cost for care.

All Charges