White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS

Facility

$135,557.40

Service Code	MSDRG 019
Min. Negotiated Rate	$57,049.76
Max. Negotiated Rate	$135,557.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$57,049.76
Rate for Payer: Amerigroup Medicare	$57,049.76
Rate for Payer: BCBS of TX Medicare	$57,049.76
Rate for Payer: Cigna Commercial	$85,358.34
Rate for Payer: Cigna Medicare	$57,049.76
Rate for Payer: Employer Direct Commercial	$57,049.76
Rate for Payer: Humana Medicare/TRICARE	$57,049.76
Rate for Payer: Molina Dual Medicare/Medicaid	$57,049.76
Rate for Payer: Molina Medicare	$57,049.76
Rate for Payer: Multiplan Auto	$135,557.40
Rate for Payer: Multiplan Commercial	$135,557.40
Rate for Payer: Multiplan Workers Comp	$135,557.40
Rate for Payer: Scott and White EPO/PPO	$62,427.75
Rate for Payer: Scott and White Medicare	$57,049.76
Rate for Payer: Superior Health Plan EPO	$57,049.76
Rate for Payer: Superior Health Plan Medicare	$57,049.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$57,049.76
Rate for Payer: Universal American Medicare	$57,049.76
Rate for Payer: Wellcare Medicare	$57,049.76
Rate for Payer: Wellmed Medicare	$57,049.76

SIMULTANEOUS PANCREAS/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: BCBS of TX Blue Advantage	$45,141.40
Rate for Payer: BCBS of TX Blue Essentials	$54,164.43
Rate for Payer: BCBS of TX PPO	$60,185.03

SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$51,784.04

Service Code	MSDRG 402
Min. Negotiated Rate	$34,226.43
Max. Negotiated Rate	$51,784.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$34,226.43
Rate for Payer: Amerigroup Medicare	$34,226.43
Rate for Payer: BCBS of TX Medicare	$34,226.43
Rate for Payer: Cigna Commercial	$51,784.04
Rate for Payer: Cigna Medicare	$34,226.43
Rate for Payer: Employer Direct Commercial	$34,226.43
Rate for Payer: Humana Medicare/TRICARE	$34,226.43
Rate for Payer: Molina Dual Medicare/Medicaid	$34,226.43
Rate for Payer: Molina Medicare	$34,226.43
Rate for Payer: Scott and White Medicare	$34,226.43
Rate for Payer: Superior Health Plan EPO	$34,226.43
Rate for Payer: Superior Health Plan Medicare	$34,226.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$34,226.43
Rate for Payer: Universal American Medicare	$34,226.43
Rate for Payer: Wellcare Medicare	$34,226.43
Rate for Payer: Wellmed Medicare	$34,226.43

SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$68,645.25

Service Code	MSDRG 450
Min. Negotiated Rate	$43,820.85
Max. Negotiated Rate	$68,645.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43,820.85
Rate for Payer: Amerigroup Medicare	$43,820.85
Rate for Payer: BCBS of TX Medicare	$43,820.85
Rate for Payer: Cigna Commercial	$68,645.25
Rate for Payer: Cigna Medicare	$43,820.85
Rate for Payer: Employer Direct Commercial	$43,820.85
Rate for Payer: Humana Medicare/TRICARE	$43,820.85
Rate for Payer: Molina Dual Medicare/Medicaid	$43,820.85
Rate for Payer: Molina Medicare	$43,820.85
Rate for Payer: Scott and White Medicare	$43,820.85
Rate for Payer: Superior Health Plan EPO	$43,820.85
Rate for Payer: Superior Health Plan Medicare	$43,820.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$43,820.85
Rate for Payer: Universal American Medicare	$43,820.85
Rate for Payer: Wellcare Medicare	$43,820.85
Rate for Payer: Wellmed Medicare	$43,820.85

SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$41,607.55

Service Code	MSDRG 451
Min. Negotiated Rate	$28,435.77
Max. Negotiated Rate	$41,607.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,435.77
Rate for Payer: Amerigroup Medicare	$28,435.77
Rate for Payer: BCBS of TX Medicare	$28,435.77
Rate for Payer: Cigna Commercial	$41,607.55
Rate for Payer: Cigna Medicare	$28,435.77
Rate for Payer: Employer Direct Commercial	$28,435.77
Rate for Payer: Humana Medicare/TRICARE	$28,435.77
Rate for Payer: Molina Dual Medicare/Medicaid	$28,435.77
Rate for Payer: Molina Medicare	$28,435.77
Rate for Payer: Scott and White Medicare	$28,435.77
Rate for Payer: Superior Health Plan EPO	$28,435.77
Rate for Payer: Superior Health Plan Medicare	$28,435.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,435.77
Rate for Payer: Universal American Medicare	$28,435.77
Rate for Payer: Wellcare Medicare	$28,435.77
Rate for Payer: Wellmed Medicare	$28,435.77

Single-tread patient slippers, blue, one size fits most

Facility

$3.67

Hospital Charge Code	993319
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.50

Single-tread patient slippers, blue, one size fits most

Facility

$3.67

Hospital Charge Code	993319
Hospital Revenue Code	270
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$2.64
Rate for Payer: Amerigroup CHIP/Medicaid	$0.33
Rate for Payer: BCBS of TX Blue Advantage	$1.10
Rate for Payer: BCBS of TX Blue Essentials	$1.32
Rate for Payer: BCBS of TX PPO	$1.47
Rate for Payer: Cash Price	$2.50
Rate for Payer: Cigna Medicaid	$2.64
Rate for Payer: Molina CHIP/Medicaid	$2.64
Rate for Payer: Multiplan Auto	$2.39
Rate for Payer: Multiplan Commercial	$2.39
Rate for Payer: Multiplan Workers Comp	$2.39
Rate for Payer: Parkland Medicaid	$2.64
Rate for Payer: Scott and White EPO/PPO	$1.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.64
Rate for Payer: Superior Health Plan EPO	$0.50

SINGLE TROCAR WIRE 1.0X150MM CHARLOTTE F&A SYSTEM

Facility

$234.94

Hospital Charge Code	992292
Hospital Revenue Code	272
Min. Negotiated Rate	$21.14
Max. Negotiated Rate	$169.16
Rate for Payer: Amerigroup CHIP/Medicaid	$21.14
Rate for Payer: BCBS of TX Blue Advantage	$70.48
Rate for Payer: BCBS of TX Blue Essentials	$84.58
Rate for Payer: BCBS of TX PPO	$93.98
Rate for Payer: Cash Price	$159.76
Rate for Payer: Cigna Medicaid	$169.16
Rate for Payer: Molina CHIP/Medicaid	$169.16
Rate for Payer: Multiplan Auto	$152.71
Rate for Payer: Multiplan Commercial	$152.71
Rate for Payer: Multiplan Workers Comp	$152.71
Rate for Payer: Parkland Medicaid	$169.16
Rate for Payer: Scott and White EPO/PPO	$117.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$169.16
Rate for Payer: Superior Health Plan EPO	$31.95

SINGLE TROCAR WIRE 1.0X150MM CHARLOTTE F&A SYSTEM

Facility

$234.94

Hospital Charge Code	992292
Hospital Revenue Code	272
Rate for Payer: Cash Price	$159.76

SINGLE TROCAR WIRE 1.6X150MM CHARLOTTE F&A SYSTEM

Facility

$172.52

Hospital Charge Code	993164
Hospital Revenue Code	272
Rate for Payer: Cash Price	$117.31

SINGLE TROCAR WIRE 1.6X150MM CHARLOTTE F&A SYSTEM

Facility

$172.52

Hospital Charge Code	993164
Hospital Revenue Code	272
Min. Negotiated Rate	$15.53
Max. Negotiated Rate	$124.21
Rate for Payer: Amerigroup CHIP/Medicaid	$15.53
Rate for Payer: BCBS of TX Blue Advantage	$51.76
Rate for Payer: BCBS of TX Blue Essentials	$62.11
Rate for Payer: BCBS of TX PPO	$69.01
Rate for Payer: Cash Price	$117.31
Rate for Payer: Cigna Medicaid	$124.21
Rate for Payer: Molina CHIP/Medicaid	$124.21
Rate for Payer: Multiplan Auto	$112.14
Rate for Payer: Multiplan Commercial	$112.14
Rate for Payer: Multiplan Workers Comp	$112.14
Rate for Payer: Parkland Medicaid	$124.21
Rate for Payer: Scott and White EPO/PPO	$86.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$124.21
Rate for Payer: Superior Health Plan EPO	$23.46

Single-Use, Skin-Friendly Arthroscopic Knee Positioner

Facility

$126.74

Hospital Charge Code	993170
Hospital Revenue Code	270
Rate for Payer: Cash Price	$86.18

Single-Use, Skin-Friendly Arthroscopic Knee Positioner

Facility

$126.74

Hospital Charge Code	993170
Hospital Revenue Code	270
Min. Negotiated Rate	$11.41
Max. Negotiated Rate	$91.25
Rate for Payer: Amerigroup CHIP/Medicaid	$11.41
Rate for Payer: BCBS of TX Blue Advantage	$38.02
Rate for Payer: BCBS of TX Blue Essentials	$45.63
Rate for Payer: BCBS of TX PPO	$50.70
Rate for Payer: Cash Price	$86.18
Rate for Payer: Cigna Medicaid	$91.25
Rate for Payer: Molina CHIP/Medicaid	$91.25
Rate for Payer: Multiplan Auto	$82.38
Rate for Payer: Multiplan Commercial	$82.38
Rate for Payer: Multiplan Workers Comp	$82.38
Rate for Payer: Parkland Medicaid	$91.25
Rate for Payer: Scott and White EPO/PPO	$63.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.25
Rate for Payer: Superior Health Plan EPO	$17.24

SINUS AND MASTOID PROCEDURES WITH CC/MCC

Facility

$46,563.30

Service Code	MSDRG 135
Min. Negotiated Rate	$19,764.52
Max. Negotiated Rate	$46,563.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,664.06
Rate for Payer: Amerigroup Medicare	$20,664.06
Rate for Payer: BCBS of TX Medicare	$20,664.06
Rate for Payer: Cigna Commercial	$27,243.78
Rate for Payer: Cigna Medicare	$20,664.06
Rate for Payer: Employer Direct Commercial	$20,664.06
Rate for Payer: Humana Medicare/TRICARE	$20,664.06
Rate for Payer: Molina Dual Medicare/Medicaid	$20,664.06
Rate for Payer: Molina Medicare	$20,664.06
Rate for Payer: Multiplan Auto	$46,563.30
Rate for Payer: Multiplan Commercial	$46,563.30
Rate for Payer: Multiplan Workers Comp	$46,563.30
Rate for Payer: Scott and White EPO/PPO	$21,443.62
Rate for Payer: Scott and White Medicare	$20,664.06
Rate for Payer: Superior Health Plan EPO	$20,664.06
Rate for Payer: Superior Health Plan Medicare	$20,664.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,664.06
Rate for Payer: Universal American Medicare	$20,664.06
Rate for Payer: Wellcare Medicare	$20,664.06
Rate for Payer: Wellmed Medicare	$20,664.06

SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC

Facility

$22,045.70

Service Code	MSDRG 136
Min. Negotiated Rate	$10,152.62
Max. Negotiated Rate	$22,045.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,201.24
Rate for Payer: Amerigroup Medicare	$12,201.24
Rate for Payer: BCBS of TX Medicare	$12,201.24
Rate for Payer: Cigna Commercial	$13,077.06
Rate for Payer: Cigna Medicare	$12,201.24
Rate for Payer: Employer Direct Commercial	$12,201.24
Rate for Payer: Humana Medicare/TRICARE	$12,201.24
Rate for Payer: Molina Dual Medicare/Medicaid	$12,201.24
Rate for Payer: Molina Medicare	$12,201.24
Rate for Payer: Multiplan Auto	$22,045.70
Rate for Payer: Multiplan Commercial	$22,045.70
Rate for Payer: Multiplan Workers Comp	$22,045.70
Rate for Payer: Scott and White EPO/PPO	$10,152.62
Rate for Payer: Scott and White Medicare	$12,201.24
Rate for Payer: Superior Health Plan EPO	$12,201.24
Rate for Payer: Superior Health Plan Medicare	$12,201.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,201.24
Rate for Payer: Universal American Medicare	$12,201.24
Rate for Payer: Wellcare Medicare	$12,201.24
Rate for Payer: Wellmed Medicare	$12,201.24

SINUS & MASTOID PROCEDURES W CC/MCC

Facility

$46,563.30

Service Code	MSDRG 135
Min. Negotiated Rate	$19,764.52
Max. Negotiated Rate	$46,563.30
Rate for Payer: BCBS of TX Blue Advantage	$19,764.52
Rate for Payer: BCBS of TX Blue Essentials	$23,715.13
Rate for Payer: BCBS of TX PPO	$26,351.16

SINUS & MASTOID PROCEDURES W/O CC/MCC

Facility

$22,045.70

Service Code	MSDRG 136
Min. Negotiated Rate	$10,152.62
Max. Negotiated Rate	$22,045.70
Rate for Payer: BCBS of TX Blue Advantage	$10,427.50
Rate for Payer: BCBS of TX Blue Essentials	$12,511.79
Rate for Payer: BCBS of TX PPO	$13,902.52

Sirolimus (Rapamune), Blood SO

Facility

$192.35

Service Code	HCPCS 80195
Hospital Charge Code	9048977
Hospital Revenue Code	301
Rate for Payer: Cash Price	$130.80

Sirolimus (Rapamune), Blood SO

Facility

$192.35

Service Code	HCPCS 80195
Hospital Charge Code	4150253
Hospital Revenue Code	301
Rate for Payer: Cash Price	$130.80

Sirolimus (Rapamune), Blood SO

Facility

$192.35

Service Code	HCPCS 80195
Hospital Charge Code	9048977
Hospital Revenue Code	301
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$138.49
Rate for Payer: Amerigroup CHIP/Medicaid	$5.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.73
Rate for Payer: Amerigroup Medicare	$13.73
Rate for Payer: BCBS of TX Blue Advantage	$57.70
Rate for Payer: BCBS of TX Blue Essentials	$69.25
Rate for Payer: BCBS of TX Medicare	$13.73
Rate for Payer: BCBS of TX PPO	$76.94
Rate for Payer: Cash Price	$130.80
Rate for Payer: Cash Price	$130.80
Rate for Payer: Cigna Medicaid	$138.49
Rate for Payer: Cigna Medicare	$13.73
Rate for Payer: Employer Direct Commercial	$13.73
Rate for Payer: Humana Medicare/TRICARE	$13.73
Rate for Payer: Molina CHIP/Medicaid	$138.49
Rate for Payer: Molina Dual Medicare/Medicaid	$13.73
Rate for Payer: Molina Medicare	$13.73
Rate for Payer: Multiplan Auto	$125.03
Rate for Payer: Multiplan Commercial	$125.03
Rate for Payer: Multiplan Workers Comp	$125.03
Rate for Payer: Parkland Medicaid	$138.49
Rate for Payer: Scott and White EPO/PPO	$17.16
Rate for Payer: Scott and White Medicare	$13.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$138.49
Rate for Payer: Superior Health Plan EPO	$13.73
Rate for Payer: Superior Health Plan Medicare	$13.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.73
Rate for Payer: Universal American Medicare	$13.73
Rate for Payer: Wellcare Medicare	$13.73
Rate for Payer: Wellmed Medicare	$13.73

Sirolimus (Rapamune), Blood SO

Facility

$192.35

Service Code	HCPCS 80195
Hospital Charge Code	4150253
Hospital Revenue Code	301
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$138.49
Rate for Payer: Amerigroup CHIP/Medicaid	$5.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.73
Rate for Payer: Amerigroup Medicare	$13.73
Rate for Payer: BCBS of TX Blue Advantage	$57.70
Rate for Payer: BCBS of TX Blue Essentials	$69.25
Rate for Payer: BCBS of TX Medicare	$13.73
Rate for Payer: BCBS of TX PPO	$76.94
Rate for Payer: Cash Price	$130.80
Rate for Payer: Cash Price	$130.80
Rate for Payer: Cigna Medicaid	$138.49
Rate for Payer: Cigna Medicare	$13.73
Rate for Payer: Employer Direct Commercial	$13.73
Rate for Payer: Humana Medicare/TRICARE	$13.73
Rate for Payer: Molina CHIP/Medicaid	$138.49
Rate for Payer: Molina Dual Medicare/Medicaid	$13.73
Rate for Payer: Molina Medicare	$13.73
Rate for Payer: Multiplan Auto	$125.03
Rate for Payer: Multiplan Commercial	$125.03
Rate for Payer: Multiplan Workers Comp	$125.03
Rate for Payer: Parkland Medicaid	$138.49
Rate for Payer: Scott and White EPO/PPO	$17.16
Rate for Payer: Scott and White Medicare	$13.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$138.49
Rate for Payer: Superior Health Plan EPO	$13.73
Rate for Payer: Superior Health Plan Medicare	$13.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.73
Rate for Payer: Universal American Medicare	$13.73
Rate for Payer: Wellcare Medicare	$13.73
Rate for Payer: Wellmed Medicare	$13.73

Site-Rite Ultrasound Needle Guide Kit, 21g, 48' x 6' Probe Cover, No Taper, 1 cm/1.5 cm/2 cm Depths

Facility

$2,079.32

Hospital Charge Code	993082
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,413.94

Site-Rite Ultrasound Needle Guide Kit, 21g, 48' x 6' Probe Cover, No Taper, 1 cm/1.5 cm/2 cm Depths

Facility

$2,079.32

Hospital Charge Code	993082
Hospital Revenue Code	270
Min. Negotiated Rate	$187.14
Max. Negotiated Rate	$1,497.11
Rate for Payer: Amerigroup CHIP/Medicaid	$187.14
Rate for Payer: BCBS of TX Blue Advantage	$623.80
Rate for Payer: BCBS of TX Blue Essentials	$748.56
Rate for Payer: BCBS of TX PPO	$831.73
Rate for Payer: Cash Price	$1,413.94
Rate for Payer: Cigna Medicaid	$1,497.11
Rate for Payer: Molina CHIP/Medicaid	$1,497.11
Rate for Payer: Multiplan Auto	$1,351.56
Rate for Payer: Multiplan Commercial	$1,351.56
Rate for Payer: Multiplan Workers Comp	$1,351.56
Rate for Payer: Parkland Medicaid	$1,497.11
Rate for Payer: Scott and White EPO/PPO	$1,039.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,497.11
Rate for Payer: Superior Health Plan EPO	$282.79

Site-Rite Ultrasound Needle Guide Kit, 21G, 96' x 6' Probe Cover, 6'-3 Taper, 1 cm/1.5 cm/2 cm Depths

Facility

$122.16

Hospital Charge Code	993071
Hospital Revenue Code	270
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$87.96
Rate for Payer: Amerigroup CHIP/Medicaid	$10.99
Rate for Payer: BCBS of TX Blue Advantage	$36.65
Rate for Payer: BCBS of TX Blue Essentials	$43.98
Rate for Payer: BCBS of TX PPO	$48.86
Rate for Payer: Cash Price	$83.07
Rate for Payer: Cigna Medicaid	$87.96
Rate for Payer: Molina CHIP/Medicaid	$87.96
Rate for Payer: Multiplan Auto	$79.40
Rate for Payer: Multiplan Commercial	$79.40
Rate for Payer: Multiplan Workers Comp	$79.40
Rate for Payer: Parkland Medicaid	$87.96
Rate for Payer: Scott and White EPO/PPO	$61.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$87.96
Rate for Payer: Superior Health Plan EPO	$16.61

Site-Rite Ultrasound Needle Guide Kit, 21G, 96' x 6' Probe Cover, 6'-3 Taper, 1 cm/1.5 cm/2 cm Depths

Facility

$122.16

Hospital Charge Code	993071
Hospital Revenue Code	270
Rate for Payer: Cash Price	$83.07

Know your out-of-pocket cost for care.

All Charges