White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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
Rate for Payer: Cash Price	$308.10

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 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

$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

$5,768.73

Service Code	APR-DRG 6623
Min. Negotiated Rate	$5,438.96
Max. Negotiated Rate	$5,768.73
Rate for Payer: Amerigroup CHIP/Medicaid	$5,438.96
Rate for Payer: Cigna Medicaid	$5,438.96
Rate for Payer: Molina CHIP/Medicaid	$5,438.96
Rate for Payer: Parkland Medicaid	$5,438.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,768.73

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

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

SIDE KICK LOW-PROFILE WALKER BOOT, SIZE M

Facility

$257.33

Hospital Charge Code	993918
Hospital Revenue Code	274
Min. Negotiated Rate	$23.16
Max. Negotiated Rate	$185.28
Rate for Payer: Amerigroup CHIP/Medicaid	$23.16
Rate for Payer: BCBS of TX Blue Advantage	$77.20
Rate for Payer: BCBS of TX Blue Essentials	$92.64
Rate for Payer: BCBS of TX PPO	$102.93
Rate for Payer: Cash Price	$174.98
Rate for Payer: Cigna Medicaid	$185.28
Rate for Payer: Molina CHIP/Medicaid	$185.28
Rate for Payer: Multiplan Auto	$128.66
Rate for Payer: Multiplan Commercial	$128.66
Rate for Payer: Multiplan Workers Comp	$128.66
Rate for Payer: Parkland Medicaid	$185.28
Rate for Payer: Scott and White EPO/PPO	$128.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$185.28
Rate for Payer: Superior Health Plan EPO	$35.00

SIDE KICK LOW-PROFILE WALKER BOOT, SIZE M

Facility

$257.33

Hospital Charge Code	993918
Hospital Revenue Code	274
Min. Negotiated Rate	$64.33
Max. Negotiated Rate	$128.66
Rate for Payer: Cash Price	$174.98
Rate for Payer: Cigna Commercial	$64.33
Rate for Payer: Multiplan Auto	$128.66
Rate for Payer: Multiplan Commercial	$128.66
Rate for Payer: Multiplan Workers Comp	$128.66
Rate for Payer: Scott and White EPO/PPO	$128.66

SIDE KICK LOW-PROFILE WALKER BOOT, SIZE S

Facility

$161.90

Hospital Charge Code	993913
Hospital Revenue Code	274
Min. Negotiated Rate	$14.57
Max. Negotiated Rate	$116.57
Rate for Payer: Amerigroup CHIP/Medicaid	$14.57
Rate for Payer: BCBS of TX Blue Advantage	$48.57
Rate for Payer: BCBS of TX Blue Essentials	$58.28
Rate for Payer: BCBS of TX PPO	$64.76
Rate for Payer: Cash Price	$110.09
Rate for Payer: Cigna Medicaid	$116.57
Rate for Payer: Molina CHIP/Medicaid	$116.57
Rate for Payer: Multiplan Auto	$80.95
Rate for Payer: Multiplan Commercial	$80.95
Rate for Payer: Multiplan Workers Comp	$80.95
Rate for Payer: Parkland Medicaid	$116.57
Rate for Payer: Scott and White EPO/PPO	$80.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$116.57
Rate for Payer: Superior Health Plan EPO	$22.02

SIDE KICK LOW-PROFILE WALKER BOOT, SIZE S

Facility

$161.90

Hospital Charge Code	993913
Hospital Revenue Code	274
Min. Negotiated Rate	$40.48
Max. Negotiated Rate	$80.95
Rate for Payer: Cash Price	$110.09
Rate for Payer: Cigna Commercial	$40.48
Rate for Payer: Multiplan Auto	$80.95
Rate for Payer: Multiplan Commercial	$80.95
Rate for Payer: Multiplan Workers Comp	$80.95
Rate for Payer: Scott and White EPO/PPO	$80.95

Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

Facility

$3,646.84

Service Code	HCPCS 45330
Hospital Charge Code	994069
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,479.85

Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

Facility

$3,646.84

Service Code	HCPCS 45330
Hospital Charge Code	994069
Hospital Revenue Code	360
Min. Negotiated Rate	$130.67
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$130.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$934.20
Rate for Payer: Amerigroup Medicare	$934.20
Rate for Payer: BCBS of TX Blue Advantage	$242.88
Rate for Payer: BCBS of TX Blue Essentials	$290.88
Rate for Payer: BCBS of TX Medicare	$934.20
Rate for Payer: BCBS of TX PPO	$366.51
Rate for Payer: Cash Price	$2,479.85
Rate for Payer: Cash Price	$2,479.85
Rate for Payer: Cash Price	$2,479.85
Rate for Payer: Cigna Commercial	$1,974.73
Rate for Payer: Cigna Medicaid	$2,625.72
Rate for Payer: Cigna Medicare	$934.20
Rate for Payer: Employer Direct Commercial	$934.20
Rate for Payer: Humana Medicare/TRICARE	$934.20
Rate for Payer: Molina CHIP/Medicaid	$2,625.72
Rate for Payer: Molina Dual Medicare/Medicaid	$934.20
Rate for Payer: Molina Medicare	$934.20
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	$2,625.72
Rate for Payer: Scott and White EPO/PPO	$1,728.27
Rate for Payer: Scott and White Medicare	$934.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,625.72
Rate for Payer: Superior Health Plan EPO	$934.20
Rate for Payer: Superior Health Plan Medicare	$934.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$934.20
Rate for Payer: Universal American Medicare	$934.20
Rate for Payer: Wellcare Medicare	$934.20
Rate for Payer: Wellmed Medicare	$934.20

Sigmoid Scope

Facility

$6,156.24

Hospital Charge Code	993683
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4,186.24

Sigmoid Scope

Facility

$6,156.24

Hospital Charge Code	993683
Hospital Revenue Code	270
Min. Negotiated Rate	$554.06
Max. Negotiated Rate	$4,432.49
Rate for Payer: Amerigroup CHIP/Medicaid	$554.06
Rate for Payer: BCBS of TX Blue Advantage	$1,846.87
Rate for Payer: BCBS of TX Blue Essentials	$2,216.25
Rate for Payer: BCBS of TX PPO	$2,462.50
Rate for Payer: Cash Price	$4,186.24
Rate for Payer: Cigna Medicaid	$4,432.49
Rate for Payer: Molina CHIP/Medicaid	$4,432.49
Rate for Payer: Multiplan Auto	$4,001.56
Rate for Payer: Multiplan Commercial	$4,001.56
Rate for Payer: Multiplan Workers Comp	$4,001.56
Rate for Payer: Parkland Medicaid	$4,432.49
Rate for Payer: Scott and White EPO/PPO	$3,078.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,432.49
Rate for Payer: Superior Health Plan EPO	$837.25

SIGNIA RELOAD PURPLE

Facility

$2,495.40

Hospital Charge Code	992345
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,696.87

SIGNIA RELOAD PURPLE

Facility

$2,495.40

Hospital Charge Code	992345
Hospital Revenue Code	272
Min. Negotiated Rate	$224.59
Max. Negotiated Rate	$1,796.69
Rate for Payer: Amerigroup CHIP/Medicaid	$224.59
Rate for Payer: BCBS of TX Blue Advantage	$748.62
Rate for Payer: BCBS of TX Blue Essentials	$898.34
Rate for Payer: BCBS of TX PPO	$998.16
Rate for Payer: Cash Price	$1,696.87
Rate for Payer: Cigna Medicaid	$1,796.69
Rate for Payer: Molina CHIP/Medicaid	$1,796.69
Rate for Payer: Multiplan Auto	$1,622.01
Rate for Payer: Multiplan Commercial	$1,622.01
Rate for Payer: Multiplan Workers Comp	$1,622.01
Rate for Payer: Parkland Medicaid	$1,796.69
Rate for Payer: Scott and White EPO/PPO	$1,247.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,796.69
Rate for Payer: Superior Health Plan EPO	$339.37

SIGNIA SHELL

Facility

$1,153.16

Hospital Charge Code	992692
Hospital Revenue Code	272
Min. Negotiated Rate	$103.78
Max. Negotiated Rate	$830.28
Rate for Payer: Amerigroup CHIP/Medicaid	$103.78
Rate for Payer: BCBS of TX Blue Advantage	$345.95
Rate for Payer: BCBS of TX Blue Essentials	$415.14
Rate for Payer: BCBS of TX PPO	$461.26
Rate for Payer: Cash Price	$784.15
Rate for Payer: Cigna Medicaid	$830.28
Rate for Payer: Molina CHIP/Medicaid	$830.28
Rate for Payer: Multiplan Auto	$749.55
Rate for Payer: Multiplan Commercial	$749.55
Rate for Payer: Multiplan Workers Comp	$749.55
Rate for Payer: Parkland Medicaid	$830.28
Rate for Payer: Scott and White EPO/PPO	$576.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$830.28
Rate for Payer: Superior Health Plan EPO	$156.83

SIGNIA SHELL

Facility

$1,153.16

Hospital Charge Code	992692
Hospital Revenue Code	272
Rate for Payer: Cash Price	$784.15

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$25,114.20

Service Code	MSDRG 555
Min. Negotiated Rate	$11,001.12
Max. Negotiated Rate	$25,114.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,447.58
Rate for Payer: Amerigroup Medicare	$14,447.58
Rate for Payer: BCBS of TX Medicare	$14,447.58
Rate for Payer: Cigna Commercial	$17,024.78
Rate for Payer: Cigna Medicare	$14,447.58
Rate for Payer: Employer Direct Commercial	$14,447.58
Rate for Payer: Humana Medicare/TRICARE	$14,447.58
Rate for Payer: Molina Dual Medicare/Medicaid	$14,447.58
Rate for Payer: Molina Medicare	$14,447.58
Rate for Payer: Multiplan Auto	$25,114.20
Rate for Payer: Multiplan Commercial	$25,114.20
Rate for Payer: Multiplan Workers Comp	$25,114.20
Rate for Payer: Scott and White EPO/PPO	$11,565.75
Rate for Payer: Scott and White Medicare	$14,447.58
Rate for Payer: Superior Health Plan EPO	$14,447.58
Rate for Payer: Superior Health Plan Medicare	$14,447.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,447.58
Rate for Payer: Universal American Medicare	$14,447.58
Rate for Payer: Wellcare Medicare	$14,447.58
Rate for Payer: Wellmed Medicare	$14,447.58

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC

Facility

$15,781.40

Service Code	MSDRG 556
Min. Negotiated Rate	$6,602.22
Max. Negotiated Rate	$15,781.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,847.57
Rate for Payer: Amerigroup Medicare	$10,847.57
Rate for Payer: BCBS of TX Medicare	$10,847.57
Rate for Payer: Cigna Commercial	$10,698.13
Rate for Payer: Cigna Medicare	$10,847.57
Rate for Payer: Employer Direct Commercial	$10,847.57
Rate for Payer: Humana Medicare/TRICARE	$10,847.57
Rate for Payer: Molina Dual Medicare/Medicaid	$10,847.57
Rate for Payer: Molina Medicare	$10,847.57
Rate for Payer: Multiplan Auto	$15,781.40
Rate for Payer: Multiplan Commercial	$15,781.40
Rate for Payer: Multiplan Workers Comp	$15,781.40
Rate for Payer: Scott and White EPO/PPO	$7,267.75
Rate for Payer: Scott and White Medicare	$10,847.57
Rate for Payer: Superior Health Plan EPO	$10,847.57
Rate for Payer: Superior Health Plan Medicare	$10,847.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,847.57
Rate for Payer: Universal American Medicare	$10,847.57
Rate for Payer: Wellcare Medicare	$10,847.57
Rate for Payer: Wellmed Medicare	$10,847.57

Know your out-of-pocket cost for care.

All Charges