White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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 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 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

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

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	$1,546.34
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

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

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

Sigmoid Scope

Facility

$6,156.24

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

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

$25,292.80

Service Code	MSDRG 555
Min. Negotiated Rate	$11,001.12
Max. Negotiated Rate	$25,292.80
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	$25,292.80
Rate for Payer: Multiplan Commercial	$25,292.80
Rate for Payer: Multiplan Workers Comp	$25,292.80
Rate for Payer: Scott and White EPO/PPO	$11,648.00
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

$15,352.00

Service Code	MSDRG 556
Min. Negotiated Rate	$6,602.22
Max. Negotiated Rate	$15,352.00
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	$15,352.00
Rate for Payer: Multiplan Commercial	$15,352.00
Rate for Payer: Multiplan Workers Comp	$15,352.00
Rate for Payer: Scott and White EPO/PPO	$7,070.00
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

SIGNS AND SYMPTOMS WITH MCC

Facility

$23,096.40

Service Code	MSDRG 947
Min. Negotiated Rate	$10,368.16
Max. Negotiated Rate	$23,096.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,063.55
Rate for Payer: Amerigroup Medicare	$14,063.55
Rate for Payer: BCBS of TX Medicare	$14,063.55
Rate for Payer: Cigna Commercial	$16,349.87
Rate for Payer: Cigna Medicare	$14,063.55
Rate for Payer: Employer Direct Commercial	$14,063.55
Rate for Payer: Humana Medicare/TRICARE	$14,063.55
Rate for Payer: Molina Dual Medicare/Medicaid	$14,063.55
Rate for Payer: Molina Medicare	$14,063.55
Rate for Payer: Multiplan Auto	$23,096.40
Rate for Payer: Multiplan Commercial	$23,096.40
Rate for Payer: Multiplan Workers Comp	$23,096.40
Rate for Payer: Scott and White EPO/PPO	$10,636.50
Rate for Payer: Scott and White Medicare	$14,063.55
Rate for Payer: Superior Health Plan EPO	$14,063.55
Rate for Payer: Superior Health Plan Medicare	$14,063.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,063.55
Rate for Payer: Universal American Medicare	$14,063.55
Rate for Payer: Wellcare Medicare	$14,063.55
Rate for Payer: Wellmed Medicare	$14,063.55

SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$14,774.40

Service Code	MSDRG 948
Min. Negotiated Rate	$6,709.72
Max. Negotiated Rate	$14,774.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,626.98
Rate for Payer: Amerigroup Medicare	$10,626.98
Rate for Payer: BCBS of TX Medicare	$10,626.98
Rate for Payer: Cigna Commercial	$10,310.44
Rate for Payer: Cigna Medicare	$10,626.98
Rate for Payer: Employer Direct Commercial	$10,626.98
Rate for Payer: Humana Medicare/TRICARE	$10,626.98
Rate for Payer: Molina Dual Medicare/Medicaid	$10,626.98
Rate for Payer: Molina Medicare	$10,626.98
Rate for Payer: Multiplan Auto	$14,774.40
Rate for Payer: Multiplan Commercial	$14,774.40
Rate for Payer: Multiplan Workers Comp	$14,774.40
Rate for Payer: Scott and White EPO/PPO	$6,804.00
Rate for Payer: Scott and White Medicare	$10,626.98
Rate for Payer: Superior Health Plan EPO	$10,626.98
Rate for Payer: Superior Health Plan Medicare	$10,626.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,626.98
Rate for Payer: Universal American Medicare	$10,626.98
Rate for Payer: Wellcare Medicare	$10,626.98
Rate for Payer: Wellmed Medicare	$10,626.98

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$3,090.69

Service Code	APR-DRG 8612
Min. Negotiated Rate	$2,914.01
Max. Negotiated Rate	$3,090.69
Rate for Payer: Amerigroup CHIP/Medicaid	$2,914.01
Rate for Payer: Cigna Medicaid	$2,914.01
Rate for Payer: Molina CHIP/Medicaid	$2,914.01
Rate for Payer: Parkland Medicaid	$2,914.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,090.69

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$5,871.32

Service Code	APR-DRG 8613
Min. Negotiated Rate	$5,535.69
Max. Negotiated Rate	$5,871.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5,535.69
Rate for Payer: Cigna Medicaid	$5,535.69
Rate for Payer: Molina CHIP/Medicaid	$5,535.69
Rate for Payer: Parkland Medicaid	$5,535.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,871.32

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$11,963.30

Service Code	APR-DRG 8614
Min. Negotiated Rate	$11,279.42
Max. Negotiated Rate	$11,963.30
Rate for Payer: Amerigroup CHIP/Medicaid	$11,279.42
Rate for Payer: Cigna Medicaid	$11,279.42
Rate for Payer: Molina CHIP/Medicaid	$11,279.42
Rate for Payer: Parkland Medicaid	$11,279.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,963.30

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$1,918.38

Service Code	APR-DRG 8611
Min. Negotiated Rate	$1,808.72
Max. Negotiated Rate	$1,918.38
Rate for Payer: Amerigroup CHIP/Medicaid	$1,808.72
Rate for Payer: Cigna Medicaid	$1,808.72
Rate for Payer: Molina CHIP/Medicaid	$1,808.72
Rate for Payer: Parkland Medicaid	$1,808.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,918.38

SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W MCC

Facility

$25,292.80

Service Code	MSDRG 555
Min. Negotiated Rate	$11,001.12
Max. Negotiated Rate	$25,292.80
Rate for Payer: BCBS of TX Blue Advantage	$11,001.12
Rate for Payer: BCBS of TX Blue Essentials	$13,200.06
Rate for Payer: BCBS of TX PPO	$14,667.31

SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC

Facility

$15,352.00

Service Code	MSDRG 556
Min. Negotiated Rate	$6,602.22
Max. Negotiated Rate	$15,352.00
Rate for Payer: BCBS of TX Blue Advantage	$6,602.22
Rate for Payer: BCBS of TX Blue Essentials	$7,921.90
Rate for Payer: BCBS of TX PPO	$8,802.45

SIGNS & SYMPTOMS W MCC

Facility

$23,096.40

Service Code	MSDRG 947
Min. Negotiated Rate	$10,368.16
Max. Negotiated Rate	$23,096.40
Rate for Payer: BCBS of TX Blue Advantage	$10,368.16
Rate for Payer: BCBS of TX Blue Essentials	$12,440.59
Rate for Payer: BCBS of TX PPO	$13,823.41

SIGNS & SYMPTOMS W/O MCC

Facility

$14,774.40

Service Code	MSDRG 948
Min. Negotiated Rate	$6,709.72
Max. Negotiated Rate	$14,774.40
Rate for Payer: BCBS of TX Blue Advantage	$6,709.72
Rate for Payer: BCBS of TX Blue Essentials	$8,050.88
Rate for Payer: BCBS of TX PPO	$8,945.77

Know your out-of-pocket cost for care.

All Charges