White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SILTEX® Breast Tissue Expander with Suture Tabs

Facility

$8,535.20

Service Code	HCPCS L8699
Hospital Charge Code	993862
Hospital Revenue Code	278
Min. Negotiated Rate	$2,133.80
Max. Negotiated Rate	$4,267.60
Rate for Payer: Cash Price	$5,803.94
Rate for Payer: Cigna Commercial	$2,133.80
Rate for Payer: Multiplan Auto	$4,267.60
Rate for Payer: Multiplan Commercial	$4,267.60
Rate for Payer: Multiplan Workers Comp	$4,267.60
Rate for Payer: Scott and White EPO/PPO	$4,267.60

SILTEX® Breast Tissue Expander with Suture Tabs

Facility

$8,535.20

Service Code	HCPCS L8699
Hospital Charge Code	993862
Hospital Revenue Code	278
Min. Negotiated Rate	$768.17
Max. Negotiated Rate	$6,145.34
Rate for Payer: Amerigroup CHIP/Medicaid	$768.17
Rate for Payer: BCBS of TX Blue Advantage	$2,560.56
Rate for Payer: BCBS of TX Blue Essentials	$3,072.67
Rate for Payer: BCBS of TX PPO	$3,414.08
Rate for Payer: Cash Price	$5,803.94
Rate for Payer: Cigna Medicaid	$6,145.34
Rate for Payer: Molina CHIP/Medicaid	$6,145.34
Rate for Payer: Multiplan Auto	$4,267.60
Rate for Payer: Multiplan Commercial	$4,267.60
Rate for Payer: Multiplan Workers Comp	$4,267.60
Rate for Payer: Parkland Medicaid	$6,145.34
Rate for Payer: Scott and White EPO/PPO	$4,267.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,145.34
Rate for Payer: Superior Health Plan EPO	$1,160.79

silver nitrate Stick

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77812333
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

silver nitrate Stick

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77812333
Hospital Revenue Code	636
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

SILVERSOAKER, ON-Q,5 IN, 270ML X DUAL

Facility

$828.48

Hospital Charge Code	992762
Hospital Revenue Code	272
Min. Negotiated Rate	$74.56
Max. Negotiated Rate	$596.51
Rate for Payer: Amerigroup CHIP/Medicaid	$74.56
Rate for Payer: BCBS of TX Blue Advantage	$248.54
Rate for Payer: BCBS of TX Blue Essentials	$298.25
Rate for Payer: BCBS of TX PPO	$331.39
Rate for Payer: Cash Price	$563.37
Rate for Payer: Cigna Medicaid	$596.51
Rate for Payer: Molina CHIP/Medicaid	$596.51
Rate for Payer: Multiplan Auto	$538.51
Rate for Payer: Multiplan Commercial	$538.51
Rate for Payer: Multiplan Workers Comp	$538.51
Rate for Payer: Parkland Medicaid	$596.51
Rate for Payer: Scott and White EPO/PPO	$414.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$596.51
Rate for Payer: Superior Health Plan EPO	$112.67

SILVERSOAKER, ON-Q,5 IN, 270ML X DUAL

Facility

$828.48

Hospital Charge Code	992762
Hospital Revenue Code	272
Rate for Payer: Cash Price	$563.37

silver sulfADIAZINE 1% Cream 50 g

Facility

$29.00

Service Code	HCPCS J3490
Hospital Charge Code	77812704
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.72

silver sulfADIAZINE 1% Cream 50 g

Facility

$29.00

Service Code	HCPCS J3490
Hospital Charge Code	77812704
Hospital Revenue Code	250
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$20.88
Rate for Payer: Amerigroup CHIP/Medicaid	$2.61
Rate for Payer: BCBS of TX Blue Advantage	$8.70
Rate for Payer: BCBS of TX Blue Essentials	$10.44
Rate for Payer: BCBS of TX PPO	$11.60
Rate for Payer: Cash Price	$19.72
Rate for Payer: Cigna Medicaid	$20.88
Rate for Payer: Molina CHIP/Medicaid	$20.88
Rate for Payer: Multiplan Auto	$18.85
Rate for Payer: Multiplan Commercial	$18.85
Rate for Payer: Multiplan Workers Comp	$18.85
Rate for Payer: Parkland Medicaid	$20.88
Rate for Payer: Scott and White EPO/PPO	$14.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.88
Rate for Payer: Superior Health Plan EPO	$3.94

simethicone 40 mg/0.6 mL Oral Liquid 30 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77813459
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

simethicone 40 mg/0.6 mL Oral Liquid 30 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77813459
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

simethicone 80 mg Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77813565
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

simethicone 80 mg Chew Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77813565
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$15,963.80

Service Code	MSDRG 194
Min. Negotiated Rate	$7,351.75
Max. Negotiated Rate	$15,963.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,666.55
Rate for Payer: Amerigroup Medicare	$10,666.55
Rate for Payer: BCBS of TX Medicare	$10,666.55
Rate for Payer: Cigna Commercial	$10,379.99
Rate for Payer: Cigna Medicare	$10,666.55
Rate for Payer: Employer Direct Commercial	$10,666.55
Rate for Payer: Humana Medicare/TRICARE	$10,666.55
Rate for Payer: Molina Dual Medicare/Medicaid	$10,666.55
Rate for Payer: Molina Medicare	$10,666.55
Rate for Payer: Multiplan Auto	$15,963.80
Rate for Payer: Multiplan Commercial	$15,963.80
Rate for Payer: Multiplan Workers Comp	$15,963.80
Rate for Payer: Scott and White EPO/PPO	$7,351.75
Rate for Payer: Scott and White Medicare	$10,666.55
Rate for Payer: Superior Health Plan EPO	$10,666.55
Rate for Payer: Superior Health Plan Medicare	$10,666.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,666.55
Rate for Payer: Universal American Medicare	$10,666.55
Rate for Payer: Wellcare Medicare	$10,666.55
Rate for Payer: Wellmed Medicare	$10,666.55

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$24,675.30

Service Code	MSDRG 193
Min. Negotiated Rate	$11,323.62
Max. Negotiated Rate	$24,675.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,393.35
Rate for Payer: Amerigroup Medicare	$14,393.35
Rate for Payer: BCBS of TX Medicare	$14,393.35
Rate for Payer: Cigna Commercial	$16,929.47
Rate for Payer: Cigna Medicare	$14,393.35
Rate for Payer: Employer Direct Commercial	$14,393.35
Rate for Payer: Humana Medicare/TRICARE	$14,393.35
Rate for Payer: Molina Dual Medicare/Medicaid	$14,393.35
Rate for Payer: Molina Medicare	$14,393.35
Rate for Payer: Multiplan Auto	$24,675.30
Rate for Payer: Multiplan Commercial	$24,675.30
Rate for Payer: Multiplan Workers Comp	$24,675.30
Rate for Payer: Scott and White EPO/PPO	$11,363.62
Rate for Payer: Scott and White Medicare	$14,393.35
Rate for Payer: Superior Health Plan EPO	$14,393.35
Rate for Payer: Superior Health Plan Medicare	$14,393.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,393.35
Rate for Payer: Universal American Medicare	$14,393.35
Rate for Payer: Wellcare Medicare	$14,393.35
Rate for Payer: Wellmed Medicare	$14,393.35

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$12,194.20

Service Code	MSDRG 195
Min. Negotiated Rate	$5,615.75
Max. Negotiated Rate	$12,194.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,366.37
Rate for Payer: Amerigroup Medicare	$9,366.37
Rate for Payer: BCBS of TX Medicare	$9,366.37
Rate for Payer: Cigna Commercial	$8,095.08
Rate for Payer: Cigna Medicare	$9,366.37
Rate for Payer: Employer Direct Commercial	$9,366.37
Rate for Payer: Humana Medicare/TRICARE	$9,366.37
Rate for Payer: Molina Dual Medicare/Medicaid	$9,366.37
Rate for Payer: Molina Medicare	$9,366.37
Rate for Payer: Multiplan Auto	$12,194.20
Rate for Payer: Multiplan Commercial	$12,194.20
Rate for Payer: Multiplan Workers Comp	$12,194.20
Rate for Payer: Scott and White EPO/PPO	$5,615.75
Rate for Payer: Scott and White Medicare	$9,366.37
Rate for Payer: Superior Health Plan EPO	$9,366.37
Rate for Payer: Superior Health Plan Medicare	$9,366.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,366.37
Rate for Payer: Universal American Medicare	$9,366.37
Rate for Payer: Wellcare Medicare	$9,366.37
Rate for Payer: Wellmed Medicare	$9,366.37

SIMPLE PNEUMONIA & PLEURISY W CC

Facility

$15,963.80

Service Code	MSDRG 194
Min. Negotiated Rate	$7,351.75
Max. Negotiated Rate	$15,963.80
Rate for Payer: BCBS of TX Blue Advantage	$7,741.72
Rate for Payer: BCBS of TX Blue Essentials	$9,289.16
Rate for Payer: BCBS of TX PPO	$10,321.69

SIMPLE PNEUMONIA & PLEURISY W MCC

Facility

$24,675.30

Service Code	MSDRG 193
Min. Negotiated Rate	$11,323.62
Max. Negotiated Rate	$24,675.30
Rate for Payer: BCBS of TX Blue Advantage	$11,323.62
Rate for Payer: BCBS of TX Blue Essentials	$13,587.03
Rate for Payer: BCBS of TX PPO	$15,097.28

SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC

Facility

$12,194.20

Service Code	MSDRG 195
Min. Negotiated Rate	$5,615.75
Max. Negotiated Rate	$12,194.20
Rate for Payer: BCBS of TX Blue Advantage	$5,906.48
Rate for Payer: BCBS of TX Blue Essentials	$7,087.09
Rate for Payer: BCBS of TX PPO	$7,874.85

SIMPLEX P FULL DOSE 1 PACK

Facility

$431.53

Hospital Charge Code	993435
Hospital Revenue Code	272
Rate for Payer: Cash Price	$293.44

SIMPLEX P FULL DOSE 1 PACK

Facility

$431.53

Hospital Charge Code	993435
Hospital Revenue Code	272
Min. Negotiated Rate	$38.84
Max. Negotiated Rate	$310.70
Rate for Payer: Amerigroup CHIP/Medicaid	$38.84
Rate for Payer: BCBS of TX Blue Advantage	$129.46
Rate for Payer: BCBS of TX Blue Essentials	$155.35
Rate for Payer: BCBS of TX PPO	$172.61
Rate for Payer: Cash Price	$293.44
Rate for Payer: Cigna Medicaid	$310.70
Rate for Payer: Molina CHIP/Medicaid	$310.70
Rate for Payer: Multiplan Auto	$280.49
Rate for Payer: Multiplan Commercial	$280.49
Rate for Payer: Multiplan Workers Comp	$280.49
Rate for Payer: Parkland Medicaid	$310.70
Rate for Payer: Scott and White EPO/PPO	$215.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$310.70
Rate for Payer: Superior Health Plan EPO	$58.69

SIMPLEX P WITH TOBRAMYCIN 1 PACK

Facility

$2,152.05

Service Code	HCPCS C1734
Hospital Charge Code	992283
Hospital Revenue Code	278
Min. Negotiated Rate	$193.68
Max. Negotiated Rate	$1,549.48
Rate for Payer: Amerigroup CHIP/Medicaid	$193.68
Rate for Payer: BCBS of TX Blue Advantage	$645.62
Rate for Payer: BCBS of TX Blue Essentials	$774.74
Rate for Payer: BCBS of TX PPO	$860.82
Rate for Payer: Cash Price	$1,463.39
Rate for Payer: Cigna Medicaid	$1,549.48
Rate for Payer: Molina CHIP/Medicaid	$1,549.48
Rate for Payer: Multiplan Auto	$1,076.03
Rate for Payer: Multiplan Commercial	$1,076.03
Rate for Payer: Multiplan Workers Comp	$1,076.03
Rate for Payer: Parkland Medicaid	$1,549.48
Rate for Payer: Scott and White EPO/PPO	$1,076.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,549.48
Rate for Payer: Superior Health Plan EPO	$292.68

SIMPLEX P WITH TOBRAMYCIN 1 PACK

Facility

$2,152.05

Service Code	HCPCS C1734
Hospital Charge Code	992283
Hospital Revenue Code	278
Min. Negotiated Rate	$538.01
Max. Negotiated Rate	$1,076.03
Rate for Payer: Cash Price	$1,463.39
Rate for Payer: Cigna Commercial	$538.01
Rate for Payer: Multiplan Auto	$1,076.03
Rate for Payer: Multiplan Commercial	$1,076.03
Rate for Payer: Multiplan Workers Comp	$1,076.03
Rate for Payer: Scott and White EPO/PPO	$1,076.03

SIMPULSE SOLO SYSTEM W/ ULTREXSPLASH

Facility

$420.86

Hospital Charge Code	992900
Hospital Revenue Code	270
Rate for Payer: Cash Price	$286.18

SIMPULSE SOLO SYSTEM W/ ULTREXSPLASH

Facility

$420.86

Hospital Charge Code	992900
Hospital Revenue Code	270
Min. Negotiated Rate	$37.88
Max. Negotiated Rate	$303.02
Rate for Payer: Amerigroup CHIP/Medicaid	$37.88
Rate for Payer: BCBS of TX Blue Advantage	$126.26
Rate for Payer: BCBS of TX Blue Essentials	$151.51
Rate for Payer: BCBS of TX PPO	$168.34
Rate for Payer: Cash Price	$286.18
Rate for Payer: Cigna Medicaid	$303.02
Rate for Payer: Molina CHIP/Medicaid	$303.02
Rate for Payer: Multiplan Auto	$273.56
Rate for Payer: Multiplan Commercial	$273.56
Rate for Payer: Multiplan Workers Comp	$273.56
Rate for Payer: Parkland Medicaid	$303.02
Rate for Payer: Scott and White EPO/PPO	$210.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$303.02
Rate for Payer: Superior Health Plan EPO	$57.24

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$106,230.90

Service Code	MSDRG 008
Min. Negotiated Rate	$45,141.40
Max. Negotiated Rate	$106,230.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$45,836.34
Rate for Payer: Amerigroup Medicare	$45,836.34
Rate for Payer: BCBS of TX Medicare	$45,836.34
Rate for Payer: Cigna Commercial	$72,187.25
Rate for Payer: Cigna Medicare	$45,836.34
Rate for Payer: Employer Direct Commercial	$45,836.34
Rate for Payer: Molina Dual Medicare/Medicaid	$45,836.34
Rate for Payer: Molina Medicare	$45,836.34
Rate for Payer: Multiplan Auto	$106,230.90
Rate for Payer: Multiplan Commercial	$106,230.90
Rate for Payer: Multiplan Workers Comp	$106,230.90
Rate for Payer: Scott and White EPO/PPO	$48,922.12
Rate for Payer: Scott and White Medicare	$45,836.34
Rate for Payer: Superior Health Plan EPO	$45,836.34
Rate for Payer: Superior Health Plan Medicare	$45,836.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$45,836.34
Rate for Payer: Universal American Medicare	$45,836.34
Rate for Payer: Wellcare Medicare	$45,836.34
Rate for Payer: Wellmed Medicare	$45,836.34

Know your out-of-pocket cost for care.

All Charges