White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SHOE POST-OP SPEC1 -- DHF

Facility

$116.00

Hospital Charge Code	81144230
Hospital Revenue Code	271
Min. Negotiated Rate	$10.44
Max. Negotiated Rate	$83.52
Rate for Payer: Amerigroup CHIP/Medicaid	$10.44
Rate for Payer: BCBS of TX Blue Advantage	$34.80
Rate for Payer: BCBS of TX Blue Essentials	$41.76
Rate for Payer: BCBS of TX PPO	$46.40
Rate for Payer: Cash Price	$78.88
Rate for Payer: Cigna Medicaid	$83.52
Rate for Payer: Molina CHIP/Medicaid	$83.52
Rate for Payer: Multiplan Auto	$75.40
Rate for Payer: Multiplan Commercial	$75.40
Rate for Payer: Multiplan Workers Comp	$75.40
Rate for Payer: Parkland Medicaid	$83.52
Rate for Payer: Scott and White EPO/PPO	$58.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83.52
Rate for Payer: Superior Health Plan EPO	$15.78

SHOE POST-OP SPEC1 -- DHF

Facility

$116.00

Hospital Charge Code	81144230
Hospital Revenue Code	271
Rate for Payer: Cash Price	$78.88

SHOULDER AND ELBOW JOINT REPLACEMENT

Facility

$21,082.98

Service Code	APR-DRG 3224
Min. Negotiated Rate	$19,877.77
Max. Negotiated Rate	$21,082.98
Rate for Payer: Amerigroup CHIP/Medicaid	$19,877.77
Rate for Payer: Cigna Medicaid	$19,877.77
Rate for Payer: Molina CHIP/Medicaid	$19,877.77
Rate for Payer: Parkland Medicaid	$19,877.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,082.98

SHOULDER AND ELBOW JOINT REPLACEMENT

Facility

$8,172.55

Service Code	APR-DRG 3221
Min. Negotiated Rate	$7,705.37
Max. Negotiated Rate	$8,172.55
Rate for Payer: Amerigroup CHIP/Medicaid	$7,705.37
Rate for Payer: Cigna Medicaid	$7,705.37
Rate for Payer: Molina CHIP/Medicaid	$7,705.37
Rate for Payer: Parkland Medicaid	$7,705.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,172.55

SHOULDER AND ELBOW JOINT REPLACEMENT

Facility

$13,264.61

Service Code	APR-DRG 3223
Min. Negotiated Rate	$12,506.33
Max. Negotiated Rate	$13,264.61
Rate for Payer: Amerigroup CHIP/Medicaid	$12,506.33
Rate for Payer: Cigna Medicaid	$12,506.33
Rate for Payer: Molina CHIP/Medicaid	$12,506.33
Rate for Payer: Parkland Medicaid	$12,506.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,264.61

SHOULDER AND ELBOW JOINT REPLACEMENT

Facility

$9,856.33

Service Code	APR-DRG 3222
Min. Negotiated Rate	$9,292.89
Max. Negotiated Rate	$9,856.33
Rate for Payer: Amerigroup CHIP/Medicaid	$9,292.89
Rate for Payer: Cigna Medicaid	$9,292.89
Rate for Payer: Molina CHIP/Medicaid	$9,292.89
Rate for Payer: Parkland Medicaid	$9,292.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,856.33

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC

Facility

$39,508.60

Service Code	MSDRG 511
Min. Negotiated Rate	$15,886.78
Max. Negotiated Rate	$39,508.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,000.06
Rate for Payer: Amerigroup Medicare	$20,000.06
Rate for Payer: BCBS of TX Medicare	$20,000.06
Rate for Payer: Cigna Commercial	$26,782.67
Rate for Payer: Cigna Medicare	$20,000.06
Rate for Payer: Employer Direct Commercial	$20,000.06
Rate for Payer: Humana Medicare/TRICARE	$20,000.06
Rate for Payer: Molina Dual Medicare/Medicaid	$20,000.06
Rate for Payer: Molina Medicare	$20,000.06
Rate for Payer: Multiplan Auto	$39,508.60
Rate for Payer: Multiplan Commercial	$39,508.60
Rate for Payer: Multiplan Workers Comp	$39,508.60
Rate for Payer: Scott and White EPO/PPO	$18,194.75
Rate for Payer: Scott and White Medicare	$20,000.06
Rate for Payer: Superior Health Plan EPO	$20,000.06
Rate for Payer: Superior Health Plan Medicare	$20,000.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,000.06
Rate for Payer: Universal American Medicare	$20,000.06
Rate for Payer: Wellcare Medicare	$20,000.06
Rate for Payer: Wellmed Medicare	$20,000.06

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC

Facility

$57,389.50

Service Code	MSDRG 510
Min. Negotiated Rate	$23,498.64
Max. Negotiated Rate	$57,389.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,897.41
Rate for Payer: Amerigroup Medicare	$26,897.41
Rate for Payer: BCBS of TX Medicare	$26,897.41
Rate for Payer: Cigna Commercial	$38,904.04
Rate for Payer: Cigna Medicare	$26,897.41
Rate for Payer: Employer Direct Commercial	$26,897.41
Rate for Payer: Humana Medicare/TRICARE	$26,897.41
Rate for Payer: Molina Dual Medicare/Medicaid	$26,897.41
Rate for Payer: Molina Medicare	$26,897.41
Rate for Payer: Multiplan Auto	$57,389.50
Rate for Payer: Multiplan Commercial	$57,389.50
Rate for Payer: Multiplan Workers Comp	$57,389.50
Rate for Payer: Scott and White EPO/PPO	$26,429.38
Rate for Payer: Scott and White Medicare	$26,897.41
Rate for Payer: Superior Health Plan EPO	$26,897.41
Rate for Payer: Superior Health Plan Medicare	$26,897.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,897.41
Rate for Payer: Universal American Medicare	$26,897.41
Rate for Payer: Wellcare Medicare	$26,897.41
Rate for Payer: Wellmed Medicare	$26,897.41

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$31,452.60

Service Code	MSDRG 512
Min. Negotiated Rate	$13,090.06
Max. Negotiated Rate	$31,452.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,892.55
Rate for Payer: Amerigroup Medicare	$16,892.55
Rate for Payer: BCBS of TX Medicare	$16,892.55
Rate for Payer: Cigna Commercial	$21,321.55
Rate for Payer: Cigna Medicare	$16,892.55
Rate for Payer: Employer Direct Commercial	$16,892.55
Rate for Payer: Humana Medicare/TRICARE	$16,892.55
Rate for Payer: Molina Dual Medicare/Medicaid	$16,892.55
Rate for Payer: Molina Medicare	$16,892.55
Rate for Payer: Multiplan Auto	$31,452.60
Rate for Payer: Multiplan Commercial	$31,452.60
Rate for Payer: Multiplan Workers Comp	$31,452.60
Rate for Payer: Scott and White EPO/PPO	$14,484.75
Rate for Payer: Scott and White Medicare	$16,892.55
Rate for Payer: Superior Health Plan EPO	$16,892.55
Rate for Payer: Superior Health Plan Medicare	$16,892.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,892.55
Rate for Payer: Universal American Medicare	$16,892.55
Rate for Payer: Wellcare Medicare	$16,892.55
Rate for Payer: Wellmed Medicare	$16,892.55

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

Facility

$39,508.60

Service Code	MSDRG 511
Min. Negotiated Rate	$15,886.78
Max. Negotiated Rate	$39,508.60
Rate for Payer: BCBS of TX Blue Advantage	$15,886.78
Rate for Payer: BCBS of TX Blue Essentials	$19,062.29
Rate for Payer: BCBS of TX PPO	$21,181.14

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

Facility

$57,389.50

Service Code	MSDRG 510
Min. Negotiated Rate	$23,498.64
Max. Negotiated Rate	$57,389.50
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

$31,452.60

Service Code	MSDRG 512
Min. Negotiated Rate	$13,090.06
Max. Negotiated Rate	$31,452.60
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

$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

$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

$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

$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

$10,000.00

Service Code	CPT 75809
Hospital Charge Code	36075809
Hospital Revenue Code	360
Min. Negotiated Rate	$105.02
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 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

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	$320.64
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

SHUTTLE RELAY

Facility

$142.78

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

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 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

$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	$6,161.55
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

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

Know your out-of-pocket cost for care.

All Charges