White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SLEEVE SKIN ARM REGULAR

Facility

$16.34

Hospital Charge Code	8576467
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11.11

SLEEVE SKIN ARM REGULAR

Facility

$16.34

Hospital Charge Code	8576467
Hospital Revenue Code	272
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$11.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1.47
Rate for Payer: BCBS of TX Blue Advantage	$4.90
Rate for Payer: BCBS of TX Blue Essentials	$5.88
Rate for Payer: BCBS of TX PPO	$6.54
Rate for Payer: Cash Price	$11.11
Rate for Payer: Cigna Medicaid	$11.76
Rate for Payer: Molina CHIP/Medicaid	$11.76
Rate for Payer: Multiplan Auto	$10.62
Rate for Payer: Multiplan Commercial	$10.62
Rate for Payer: Multiplan Workers Comp	$10.62
Rate for Payer: Parkland Medicaid	$11.76
Rate for Payer: Scott and White EPO/PPO	$8.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.76
Rate for Payer: Superior Health Plan EPO	$2.22

SLEEVE, SKIN ARM REGULAR

Facility

$10.46

Hospital Charge Code	993437
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7.11

SLEEVE, SKIN ARM REGULAR

Facility

$10.46

Hospital Charge Code	993437
Hospital Revenue Code	272
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$7.53
Rate for Payer: Amerigroup CHIP/Medicaid	$0.94
Rate for Payer: BCBS of TX Blue Advantage	$3.14
Rate for Payer: BCBS of TX Blue Essentials	$3.77
Rate for Payer: BCBS of TX PPO	$4.18
Rate for Payer: Cash Price	$7.11
Rate for Payer: Cigna Medicaid	$7.53
Rate for Payer: Molina CHIP/Medicaid	$7.53
Rate for Payer: Multiplan Auto	$6.80
Rate for Payer: Multiplan Commercial	$6.80
Rate for Payer: Multiplan Workers Comp	$6.80
Rate for Payer: Parkland Medicaid	$7.53
Rate for Payer: Scott and White EPO/PPO	$5.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.53
Rate for Payer: Superior Health Plan EPO	$1.42

SLEEVE, STABILITY, TROCAR, XCEL, 12MMX100MM

Facility

$77.06

Hospital Charge Code	992850
Hospital Revenue Code	272
Min. Negotiated Rate	$6.94
Max. Negotiated Rate	$55.48
Rate for Payer: Amerigroup CHIP/Medicaid	$6.94
Rate for Payer: BCBS of TX Blue Advantage	$23.12
Rate for Payer: BCBS of TX Blue Essentials	$27.74
Rate for Payer: BCBS of TX PPO	$30.82
Rate for Payer: Cash Price	$52.40
Rate for Payer: Cigna Medicaid	$55.48
Rate for Payer: Molina CHIP/Medicaid	$55.48
Rate for Payer: Multiplan Auto	$50.09
Rate for Payer: Multiplan Commercial	$50.09
Rate for Payer: Multiplan Workers Comp	$50.09
Rate for Payer: Parkland Medicaid	$55.48
Rate for Payer: Scott and White EPO/PPO	$38.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$55.48
Rate for Payer: Superior Health Plan EPO	$10.48

SLEEVE, STABILITY, TROCAR, XCEL, 12MMX100MM

Facility

$77.06

Hospital Charge Code	992850
Hospital Revenue Code	272
Rate for Payer: Cash Price	$52.40

SLEEVE TRAC STAR FOM FRARM WRST VLCR

Facility

$499.40

Hospital Charge Code	992609
Hospital Revenue Code	272
Min. Negotiated Rate	$44.95
Max. Negotiated Rate	$359.57
Rate for Payer: Amerigroup CHIP/Medicaid	$44.95
Rate for Payer: BCBS of TX Blue Advantage	$149.82
Rate for Payer: BCBS of TX Blue Essentials	$179.78
Rate for Payer: BCBS of TX PPO	$199.76
Rate for Payer: Cash Price	$339.59
Rate for Payer: Cigna Medicaid	$359.57
Rate for Payer: Molina CHIP/Medicaid	$359.57
Rate for Payer: Multiplan Auto	$324.61
Rate for Payer: Multiplan Commercial	$324.61
Rate for Payer: Multiplan Workers Comp	$324.61
Rate for Payer: Parkland Medicaid	$359.57
Rate for Payer: Scott and White EPO/PPO	$249.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$359.57
Rate for Payer: Superior Health Plan EPO	$67.92

SLEEVE TRAC STAR FOM FRARM WRST VLCR

Facility

$499.40

Hospital Charge Code	992609
Hospital Revenue Code	272
Rate for Payer: Cash Price	$339.59

SLEVE ALLERGAN -- DHF

Facility

$42.83

Hospital Charge Code	81850901
Hospital Revenue Code	270
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$30.84
Rate for Payer: Amerigroup CHIP/Medicaid	$3.85
Rate for Payer: BCBS of TX Blue Advantage	$12.85
Rate for Payer: BCBS of TX Blue Essentials	$15.42
Rate for Payer: BCBS of TX PPO	$17.13
Rate for Payer: Cash Price	$29.12
Rate for Payer: Cigna Medicaid	$30.84
Rate for Payer: Molina CHIP/Medicaid	$30.84
Rate for Payer: Multiplan Auto	$27.84
Rate for Payer: Multiplan Commercial	$27.84
Rate for Payer: Multiplan Workers Comp	$27.84
Rate for Payer: Parkland Medicaid	$30.84
Rate for Payer: Scott and White EPO/PPO	$21.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.84
Rate for Payer: Superior Health Plan EPO	$5.82

SLEVE ALLERGAN -- DHF

Facility

$42.83

Hospital Charge Code	81850901
Hospital Revenue Code	270
Rate for Payer: Cash Price	$29.12

SLING, ARM, DELUXE, XL

Facility

$12.26

Hospital Charge Code	993225
Hospital Revenue Code	270
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$8.83
Rate for Payer: Amerigroup CHIP/Medicaid	$1.10
Rate for Payer: BCBS of TX Blue Advantage	$3.68
Rate for Payer: BCBS of TX Blue Essentials	$4.41
Rate for Payer: BCBS of TX PPO	$4.90
Rate for Payer: Cash Price	$8.34
Rate for Payer: Cigna Medicaid	$8.83
Rate for Payer: Molina CHIP/Medicaid	$8.83
Rate for Payer: Multiplan Auto	$7.97
Rate for Payer: Multiplan Commercial	$7.97
Rate for Payer: Multiplan Workers Comp	$7.97
Rate for Payer: Parkland Medicaid	$8.83
Rate for Payer: Scott and White EPO/PPO	$6.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.83
Rate for Payer: Superior Health Plan EPO	$1.67

SLING, ARM, DELUXE, XL

Facility

$12.26

Hospital Charge Code	993225
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.34

SLING, ARM FASHION NAVY X-LARGE -- DHF

Facility

$96.69

Hospital Charge Code	81144453
Hospital Revenue Code	271
Rate for Payer: Cash Price	$65.75

SLING, ARM FASHION NAVY X-LARGE -- DHF

Facility

$96.69

Hospital Charge Code	81144453
Hospital Revenue Code	271
Min. Negotiated Rate	$8.70
Max. Negotiated Rate	$69.62
Rate for Payer: Amerigroup CHIP/Medicaid	$8.70
Rate for Payer: BCBS of TX Blue Advantage	$29.01
Rate for Payer: BCBS of TX Blue Essentials	$34.81
Rate for Payer: BCBS of TX PPO	$38.68
Rate for Payer: Cash Price	$65.75
Rate for Payer: Cigna Medicaid	$69.62
Rate for Payer: Molina CHIP/Medicaid	$69.62
Rate for Payer: Multiplan Auto	$62.85
Rate for Payer: Multiplan Commercial	$62.85
Rate for Payer: Multiplan Workers Comp	$62.85
Rate for Payer: Parkland Medicaid	$69.62
Rate for Payer: Scott and White EPO/PPO	$48.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.62
Rate for Payer: Superior Health Plan EPO	$13.15

SLING, ARM, UNIVERSAL, W/PADDED STRAP

Facility

$18.80

Hospital Charge Code	993368
Hospital Revenue Code	270
Rate for Payer: Cash Price	$12.78

SLING, ARM, UNIVERSAL, W/PADDED STRAP

Facility

$18.80

Hospital Charge Code	993368
Hospital Revenue Code	270
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$13.54
Rate for Payer: Amerigroup CHIP/Medicaid	$1.69
Rate for Payer: BCBS of TX Blue Advantage	$5.64
Rate for Payer: BCBS of TX Blue Essentials	$6.77
Rate for Payer: BCBS of TX PPO	$7.52
Rate for Payer: Cash Price	$12.78
Rate for Payer: Cigna Medicaid	$13.54
Rate for Payer: Molina CHIP/Medicaid	$13.54
Rate for Payer: Multiplan Auto	$12.22
Rate for Payer: Multiplan Commercial	$12.22
Rate for Payer: Multiplan Workers Comp	$12.22
Rate for Payer: Parkland Medicaid	$13.54
Rate for Payer: Scott and White EPO/PPO	$9.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.54
Rate for Payer: Superior Health Plan EPO	$2.56

SLING, URETHRAL DESARAFOR

Facility

$3,098.55

Service Code	HCPCS C1771
Hospital Charge Code	992637
Hospital Revenue Code	278
Min. Negotiated Rate	$278.87
Max. Negotiated Rate	$2,230.96
Rate for Payer: Amerigroup CHIP/Medicaid	$278.87
Rate for Payer: BCBS of TX Blue Advantage	$929.57
Rate for Payer: BCBS of TX Blue Essentials	$1,115.48
Rate for Payer: BCBS of TX PPO	$1,239.42
Rate for Payer: Cash Price	$2,107.01
Rate for Payer: Cigna Medicaid	$2,230.96
Rate for Payer: Molina CHIP/Medicaid	$2,230.96
Rate for Payer: Multiplan Auto	$1,549.28
Rate for Payer: Multiplan Commercial	$1,549.28
Rate for Payer: Multiplan Workers Comp	$1,549.28
Rate for Payer: Parkland Medicaid	$2,230.96
Rate for Payer: Scott and White EPO/PPO	$1,549.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,230.96
Rate for Payer: Superior Health Plan EPO	$421.40

SLING, URETHRAL DESARAFOR

Facility

$3,098.55

Service Code	HCPCS C1771
Hospital Charge Code	992637
Hospital Revenue Code	278
Min. Negotiated Rate	$774.64
Max. Negotiated Rate	$1,549.28
Rate for Payer: Cash Price	$2,107.01
Rate for Payer: Cigna Commercial	$774.64
Rate for Payer: Multiplan Auto	$1,549.28
Rate for Payer: Multiplan Commercial	$1,549.28
Rate for Payer: Multiplan Workers Comp	$1,549.28
Rate for Payer: Scott and White EPO/PPO	$1,549.28

SLIPPER, DBLE TRD, BARIATRIC, YELLOW

Facility

$4.55

Hospital Charge Code	993198
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.09

SLIPPER, DBLE TRD, BARIATRIC, YELLOW

Facility

$4.55

Hospital Charge Code	993198
Hospital Revenue Code	270
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$3.28
Rate for Payer: Amerigroup CHIP/Medicaid	$0.41
Rate for Payer: BCBS of TX Blue Advantage	$1.36
Rate for Payer: BCBS of TX Blue Essentials	$1.64
Rate for Payer: BCBS of TX PPO	$1.82
Rate for Payer: Cash Price	$3.09
Rate for Payer: Cigna Medicaid	$3.28
Rate for Payer: Molina CHIP/Medicaid	$3.28
Rate for Payer: Multiplan Auto	$2.96
Rate for Payer: Multiplan Commercial	$2.96
Rate for Payer: Multiplan Workers Comp	$2.96
Rate for Payer: Parkland Medicaid	$3.28
Rate for Payer: Scott and White EPO/PPO	$2.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.28
Rate for Payer: Superior Health Plan EPO	$0.62

SLIPPER, FALL PREV, YELLOW, LARGE

Facility

$2.94

Hospital Charge Code	993208
Hospital Revenue Code	270
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$2.12
Rate for Payer: Amerigroup CHIP/Medicaid	$0.26
Rate for Payer: BCBS of TX Blue Advantage	$0.88
Rate for Payer: BCBS of TX Blue Essentials	$1.06
Rate for Payer: BCBS of TX PPO	$1.18
Rate for Payer: Cash Price	$2.00
Rate for Payer: Cigna Medicaid	$2.12
Rate for Payer: Molina CHIP/Medicaid	$2.12
Rate for Payer: Multiplan Auto	$1.91
Rate for Payer: Multiplan Commercial	$1.91
Rate for Payer: Multiplan Workers Comp	$1.91
Rate for Payer: Parkland Medicaid	$2.12
Rate for Payer: Scott and White EPO/PPO	$1.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.12
Rate for Payer: Superior Health Plan EPO	$0.40

SLIPPER, FALL PREV, YELLOW, LARGE

Facility

$2.94

Hospital Charge Code	993208
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.00

SLIPPER, FALL PREV, YELLOW, XL

Facility

$4.10

Hospital Charge Code	993898
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.79

SLIPPER, FALL PREV, YELLOW, XL

Facility

$4.10

Hospital Charge Code	993898
Hospital Revenue Code	270
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$2.95
Rate for Payer: Amerigroup CHIP/Medicaid	$0.37
Rate for Payer: BCBS of TX Blue Advantage	$1.23
Rate for Payer: BCBS of TX Blue Essentials	$1.48
Rate for Payer: BCBS of TX PPO	$1.64
Rate for Payer: Cash Price	$2.79
Rate for Payer: Cigna Medicaid	$2.95
Rate for Payer: Molina CHIP/Medicaid	$2.95
Rate for Payer: Multiplan Auto	$2.67
Rate for Payer: Multiplan Commercial	$2.67
Rate for Payer: Multiplan Workers Comp	$2.67
Rate for Payer: Parkland Medicaid	$2.95
Rate for Payer: Scott and White EPO/PPO	$2.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.95
Rate for Payer: Superior Health Plan EPO	$0.56

SLITTER CATH -- DHF

Facility

$151.58

Hospital Charge Code	40049900
Hospital Revenue Code	272
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$109.14
Rate for Payer: Amerigroup CHIP/Medicaid	$13.64
Rate for Payer: BCBS of TX Blue Advantage	$45.47
Rate for Payer: BCBS of TX Blue Essentials	$54.57
Rate for Payer: BCBS of TX PPO	$60.63
Rate for Payer: Cash Price	$103.07
Rate for Payer: Cigna Medicaid	$109.14
Rate for Payer: Molina CHIP/Medicaid	$109.14
Rate for Payer: Multiplan Auto	$98.53
Rate for Payer: Multiplan Commercial	$98.53
Rate for Payer: Multiplan Workers Comp	$98.53
Rate for Payer: Parkland Medicaid	$109.14
Rate for Payer: Scott and White EPO/PPO	$75.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.14
Rate for Payer: Superior Health Plan EPO	$20.61

Know your out-of-pocket cost for care.

All Charges