White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SMART Stent 7mm X 40mm

Facility

$3,795.18

Service Code	HCPCS C1876
Hospital Charge Code	991293
Hospital Revenue Code	278
Min. Negotiated Rate	$341.57
Max. Negotiated Rate	$2,732.53
Rate for Payer: Amerigroup CHIP/Medicaid	$341.57
Rate for Payer: BCBS of TX Blue Advantage	$1,138.55
Rate for Payer: BCBS of TX Blue Essentials	$1,366.26
Rate for Payer: BCBS of TX PPO	$1,518.07
Rate for Payer: Cash Price	$2,580.72
Rate for Payer: Cigna Medicaid	$2,732.53
Rate for Payer: Molina CHIP/Medicaid	$2,732.53
Rate for Payer: Multiplan Auto	$1,897.59
Rate for Payer: Multiplan Commercial	$1,897.59
Rate for Payer: Multiplan Workers Comp	$1,897.59
Rate for Payer: Parkland Medicaid	$2,732.53
Rate for Payer: Scott and White EPO/PPO	$1,897.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,732.53
Rate for Payer: Superior Health Plan EPO	$516.14

SMART Stent 7mm X 40mm

Facility

$3,795.18

Service Code	HCPCS C1876
Hospital Charge Code	991293
Hospital Revenue Code	278
Min. Negotiated Rate	$948.79
Max. Negotiated Rate	$1,897.59
Rate for Payer: Cash Price	$2,580.72
Rate for Payer: Cigna Commercial	$948.79
Rate for Payer: Multiplan Auto	$1,897.59
Rate for Payer: Multiplan Commercial	$1,897.59
Rate for Payer: Multiplan Workers Comp	$1,897.59
Rate for Payer: Scott and White EPO/PPO	$1,897.59

SMART Stent 7mm X 80mm

Facility

$3,795.18

Service Code	HCPCS C1876
Hospital Charge Code	991294
Hospital Revenue Code	278
Min. Negotiated Rate	$948.79
Max. Negotiated Rate	$1,897.59
Rate for Payer: Cash Price	$2,580.72
Rate for Payer: Cigna Commercial	$948.79
Rate for Payer: Multiplan Auto	$1,897.59
Rate for Payer: Multiplan Commercial	$1,897.59
Rate for Payer: Multiplan Workers Comp	$1,897.59
Rate for Payer: Scott and White EPO/PPO	$1,897.59

SMART Stent 7mm X 80mm

Facility

$3,795.18

Service Code	HCPCS C1876
Hospital Charge Code	991294
Hospital Revenue Code	278
Min. Negotiated Rate	$341.57
Max. Negotiated Rate	$2,732.53
Rate for Payer: Amerigroup CHIP/Medicaid	$341.57
Rate for Payer: BCBS of TX Blue Advantage	$1,138.55
Rate for Payer: BCBS of TX Blue Essentials	$1,366.26
Rate for Payer: BCBS of TX PPO	$1,518.07
Rate for Payer: Cash Price	$2,580.72
Rate for Payer: Cigna Medicaid	$2,732.53
Rate for Payer: Molina CHIP/Medicaid	$2,732.53
Rate for Payer: Multiplan Auto	$1,897.59
Rate for Payer: Multiplan Commercial	$1,897.59
Rate for Payer: Multiplan Workers Comp	$1,897.59
Rate for Payer: Parkland Medicaid	$2,732.53
Rate for Payer: Scott and White EPO/PPO	$1,897.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,732.53
Rate for Payer: Superior Health Plan EPO	$516.14

SMART Vascular Stent

Facility

$5,373.49

Service Code	HCPCS C1876
Hospital Charge Code	991292
Hospital Revenue Code	278
Min. Negotiated Rate	$1,343.37
Max. Negotiated Rate	$2,686.74
Rate for Payer: Cash Price	$3,653.97
Rate for Payer: Cigna Commercial	$1,343.37
Rate for Payer: Multiplan Auto	$2,686.74
Rate for Payer: Multiplan Commercial	$2,686.74
Rate for Payer: Multiplan Workers Comp	$2,686.74
Rate for Payer: Scott and White EPO/PPO	$2,686.74

SMART Vascular Stent

Facility

$5,373.49

Service Code	HCPCS C1876
Hospital Charge Code	991292
Hospital Revenue Code	278
Min. Negotiated Rate	$483.61
Max. Negotiated Rate	$3,868.91
Rate for Payer: Amerigroup CHIP/Medicaid	$483.61
Rate for Payer: BCBS of TX Blue Advantage	$1,612.05
Rate for Payer: BCBS of TX Blue Essentials	$1,934.46
Rate for Payer: BCBS of TX PPO	$2,149.40
Rate for Payer: Cash Price	$3,653.97
Rate for Payer: Cigna Medicaid	$3,868.91
Rate for Payer: Molina CHIP/Medicaid	$3,868.91
Rate for Payer: Multiplan Auto	$2,686.74
Rate for Payer: Multiplan Commercial	$2,686.74
Rate for Payer: Multiplan Workers Comp	$2,686.74
Rate for Payer: Parkland Medicaid	$3,868.91
Rate for Payer: Scott and White EPO/PPO	$2,686.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,868.91
Rate for Payer: Superior Health Plan EPO	$730.79

SMART VASCULAR STENT SYSTEM SFA 6MM X 120MM X 120CM

Facility

$5,376.51

Service Code	HCPCS C1876
Hospital Charge Code	991289
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.13
Max. Negotiated Rate	$2,688.26
Rate for Payer: Cash Price	$3,656.03
Rate for Payer: Cigna Commercial	$1,344.13
Rate for Payer: Multiplan Auto	$2,688.26
Rate for Payer: Multiplan Commercial	$2,688.26
Rate for Payer: Multiplan Workers Comp	$2,688.26
Rate for Payer: Scott and White EPO/PPO	$2,688.26

SMART VASCULAR STENT SYSTEM SFA 6MM X 120MM X 120CM

Facility

$5,376.51

Service Code	HCPCS C1876
Hospital Charge Code	991289
Hospital Revenue Code	278
Min. Negotiated Rate	$483.89
Max. Negotiated Rate	$3,871.09
Rate for Payer: Amerigroup CHIP/Medicaid	$483.89
Rate for Payer: BCBS of TX Blue Advantage	$1,612.95
Rate for Payer: BCBS of TX Blue Essentials	$1,935.54
Rate for Payer: BCBS of TX PPO	$2,150.60
Rate for Payer: Cash Price	$3,656.03
Rate for Payer: Cigna Medicaid	$3,871.09
Rate for Payer: Molina CHIP/Medicaid	$3,871.09
Rate for Payer: Multiplan Auto	$2,688.26
Rate for Payer: Multiplan Commercial	$2,688.26
Rate for Payer: Multiplan Workers Comp	$2,688.26
Rate for Payer: Parkland Medicaid	$3,871.09
Rate for Payer: Scott and White EPO/PPO	$2,688.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,871.09
Rate for Payer: Superior Health Plan EPO	$731.21

SMSL50201

Facility

$680.22

Service Code	HCPCS C1713
Hospital Charge Code	991240
Hospital Revenue Code	278
Min. Negotiated Rate	$170.06
Max. Negotiated Rate	$340.11
Rate for Payer: Cash Price	$462.55
Rate for Payer: Cigna Commercial	$170.06
Rate for Payer: Multiplan Auto	$340.11
Rate for Payer: Multiplan Commercial	$340.11
Rate for Payer: Multiplan Workers Comp	$340.11
Rate for Payer: Scott and White EPO/PPO	$340.11

SMSL50201

Facility

$680.22

Service Code	HCPCS C1713
Hospital Charge Code	991240
Hospital Revenue Code	278
Min. Negotiated Rate	$61.22
Max. Negotiated Rate	$489.76
Rate for Payer: Amerigroup CHIP/Medicaid	$61.22
Rate for Payer: BCBS of TX Blue Advantage	$204.07
Rate for Payer: BCBS of TX Blue Essentials	$244.88
Rate for Payer: BCBS of TX PPO	$272.09
Rate for Payer: Cash Price	$462.55
Rate for Payer: Cigna Medicaid	$489.76
Rate for Payer: Molina CHIP/Medicaid	$489.76
Rate for Payer: Multiplan Auto	$340.11
Rate for Payer: Multiplan Commercial	$340.11
Rate for Payer: Multiplan Workers Comp	$340.11
Rate for Payer: Parkland Medicaid	$489.76
Rate for Payer: Scott and White EPO/PPO	$340.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$489.76
Rate for Payer: Superior Health Plan EPO	$92.51

SNARE OV/CRS/HEX -- DHF

Facility

$1,126.42

Hospital Charge Code	80826704
Hospital Revenue Code	272
Min. Negotiated Rate	$101.38
Max. Negotiated Rate	$811.02
Rate for Payer: Amerigroup CHIP/Medicaid	$101.38
Rate for Payer: BCBS of TX Blue Advantage	$337.93
Rate for Payer: BCBS of TX Blue Essentials	$405.51
Rate for Payer: BCBS of TX PPO	$450.57
Rate for Payer: Cash Price	$765.97
Rate for Payer: Cigna Medicaid	$811.02
Rate for Payer: Molina CHIP/Medicaid	$811.02
Rate for Payer: Multiplan Auto	$732.17
Rate for Payer: Multiplan Commercial	$732.17
Rate for Payer: Multiplan Workers Comp	$732.17
Rate for Payer: Parkland Medicaid	$811.02
Rate for Payer: Scott and White EPO/PPO	$563.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$811.02
Rate for Payer: Superior Health Plan EPO	$153.19

SNARE OV/CRS/HEX -- DHF

Facility

$1,126.42

Hospital Charge Code	80826704
Hospital Revenue Code	272
Rate for Payer: Cash Price	$765.97

SOAP HAND FOAMING SPECTRUM 1000ML

Facility

$56.26

Hospital Charge Code	993274
Hospital Revenue Code	270
Rate for Payer: Cash Price	$38.26

SOAP HAND FOAMING SPECTRUM 1000ML

Facility

$56.26

Hospital Charge Code	993274
Hospital Revenue Code	270
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$40.51
Rate for Payer: Amerigroup CHIP/Medicaid	$5.06
Rate for Payer: BCBS of TX Blue Advantage	$16.88
Rate for Payer: BCBS of TX Blue Essentials	$20.25
Rate for Payer: BCBS of TX PPO	$22.50
Rate for Payer: Cash Price	$38.26
Rate for Payer: Cigna Medicaid	$40.51
Rate for Payer: Molina CHIP/Medicaid	$40.51
Rate for Payer: Multiplan Auto	$36.57
Rate for Payer: Multiplan Commercial	$36.57
Rate for Payer: Multiplan Workers Comp	$36.57
Rate for Payer: Parkland Medicaid	$40.51
Rate for Payer: Scott and White EPO/PPO	$28.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.51
Rate for Payer: Superior Health Plan EPO	$7.65

sodium bicarbonate 650 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77815310
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

sodium bicarbonate 650 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77815310
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

sodium bicarbonate 8.4% IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77815473
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

sodium bicarbonate 8.4% IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77815473
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

sodium biphosphate-sodium phosphate 7 g-19 g Enema 133 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77815785
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

sodium biphosphate-sodium phosphate 7 g-19 g Enema 133 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77815785
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Sodium Chloride 0.45% IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77339500
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

Sodium Chloride 0.45% IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77339500
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

sodium chloride 0.65% Nasal Spray 45 mL

Facility

$9.35

Service Code	HCPCS J3490
Hospital Charge Code	77816570
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.73
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.81
Rate for Payer: BCBS of TX Blue Essentials	$3.37
Rate for Payer: BCBS of TX PPO	$3.74
Rate for Payer: Cash Price	$6.36
Rate for Payer: Cigna Medicaid	$6.73
Rate for Payer: Molina CHIP/Medicaid	$6.73
Rate for Payer: Multiplan Auto	$6.08
Rate for Payer: Multiplan Commercial	$6.08
Rate for Payer: Multiplan Workers Comp	$6.08
Rate for Payer: Parkland Medicaid	$6.73
Rate for Payer: Scott and White EPO/PPO	$4.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.73
Rate for Payer: Superior Health Plan EPO	$1.27

sodium chloride 0.65% Nasal Spray 45 mL

Facility

$9.35

Service Code	HCPCS J3490
Hospital Charge Code	77816570
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.36

sodium chloride 0.9% Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS A4216
Hospital Charge Code	77817000
Hospital Revenue Code	272
Rate for Payer: Cash Price	$87.16

Know your out-of-pocket cost for care.

All Charges