White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)

Facility

$3,172.95

Service Code	HCPCS 62272
Hospital Charge Code	9900742
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,157.61

Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)

Facility

$3,172.95

Service Code	HCPCS 62272
Hospital Charge Code	9900742
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$2,157.61
Rate for Payer: Cash Price	$2,157.61
Rate for Payer: Cash Price	$2,157.61
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$2,284.52
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$2,284.52
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$2,284.52
Rate for Payer: Scott and White EPO/PPO	$1,311.84
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,284.52
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

SPINAL PUNCTURE THERAPTC

Facility

$1,519.00

Service Code	HCPCS 62272
Hospital Charge Code	4612272
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,032.92

SPINAL PUNCTURE THERAPTC

Facility

$1,519.00

Service Code	HCPCS 62272
Hospital Charge Code	4612272
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$1,032.92
Rate for Payer: Cash Price	$1,032.92
Rate for Payer: Cash Price	$1,032.92
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$1,093.68
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$1,093.68
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$1,093.68
Rate for Payer: Scott and White EPO/PPO	$1,311.84
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,093.68
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

SPIROMETER, INCNTIV, VOLDYNE, 4000ML

Facility

$18.81

Service Code	HCPCS A9284
Hospital Charge Code	993976
Hospital Revenue Code	279
Rate for Payer: Cash Price	$12.79

SPIROMETER, INCNTIV, VOLDYNE, 4000ML

Facility

$18.81

Service Code	HCPCS A9284
Hospital Charge Code	993976
Hospital Revenue Code	279
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	$12.79
Rate for Payer: Cigna Medicaid	$13.54
Rate for Payer: Molina CHIP/Medicaid	$13.54
Rate for Payer: Multiplan Auto	$12.23
Rate for Payer: Multiplan Commercial	$12.23
Rate for Payer: Multiplan Workers Comp	$12.23
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

spironolactone 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77826262
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

spironolactone 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77826262
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

SPLENECTOMY

Facility

$20,845.35

Service Code	APR-DRG 6504
Min. Negotiated Rate	$19,653.73
Max. Negotiated Rate	$20,845.35
Rate for Payer: Amerigroup CHIP/Medicaid	$19,653.73
Rate for Payer: Cigna Medicaid	$19,653.73
Rate for Payer: Molina CHIP/Medicaid	$19,653.73
Rate for Payer: Parkland Medicaid	$19,653.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,845.35

SPLENECTOMY

Facility

$8,884.69

Service Code	APR-DRG 6502
Min. Negotiated Rate	$8,376.79
Max. Negotiated Rate	$8,884.69
Rate for Payer: Amerigroup CHIP/Medicaid	$8,376.79
Rate for Payer: Cigna Medicaid	$8,376.79
Rate for Payer: Molina CHIP/Medicaid	$8,376.79
Rate for Payer: Parkland Medicaid	$8,376.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,884.69

SPLENECTOMY

Facility

$13,593.14

Service Code	APR-DRG 6503
Min. Negotiated Rate	$12,816.09
Max. Negotiated Rate	$13,593.14
Rate for Payer: Amerigroup CHIP/Medicaid	$12,816.09
Rate for Payer: Cigna Medicaid	$12,816.09
Rate for Payer: Molina CHIP/Medicaid	$12,816.09
Rate for Payer: Parkland Medicaid	$12,816.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,593.14

SPLENECTOMY

Facility

$6,224.00

Service Code	APR-DRG 6501
Min. Negotiated Rate	$5,868.20
Max. Negotiated Rate	$6,224.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,868.20
Rate for Payer: Cigna Medicaid	$5,868.20
Rate for Payer: Molina CHIP/Medicaid	$5,868.20
Rate for Payer: Parkland Medicaid	$5,868.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,224.00

SPLENECTOMY W CC

Facility

$53,378.60

Service Code	MSDRG 800
Min. Negotiated Rate	$22,590.48
Max. Negotiated Rate	$53,378.60
Rate for Payer: BCBS of TX Blue Advantage	$22,590.48
Rate for Payer: BCBS of TX Blue Essentials	$27,105.95
Rate for Payer: BCBS of TX PPO	$30,118.89

SPLENECTOMY W MCC

Facility

$86,049.10

Service Code	MSDRG 799
Min. Negotiated Rate	$37,952.50
Max. Negotiated Rate	$86,049.10
Rate for Payer: BCBS of TX Blue Advantage	$40,433.76
Rate for Payer: BCBS of TX Blue Essentials	$48,515.81
Rate for Payer: BCBS of TX PPO	$53,908.55

SPLENECTOMY W/O CC/MCC

Facility

$36,269.10

Service Code	MSDRG 801
Min. Negotiated Rate	$13,384.18
Max. Negotiated Rate	$36,269.10
Rate for Payer: BCBS of TX Blue Advantage	$13,384.18
Rate for Payer: BCBS of TX Blue Essentials	$16,059.46
Rate for Payer: BCBS of TX PPO	$17,844.54

SPLENIC PROCEDURES WITH CC

Facility

$53,378.60

Service Code	MSDRG 800
Min. Negotiated Rate	$22,590.48
Max. Negotiated Rate	$53,378.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25,350.23
Rate for Payer: Amerigroup Medicare	$25,350.23
Rate for Payer: BCBS of TX Medicare	$25,350.23
Rate for Payer: Cigna Commercial	$36,185.07
Rate for Payer: Cigna Medicare	$25,350.23
Rate for Payer: Employer Direct Commercial	$25,350.23
Rate for Payer: Humana Medicare/TRICARE	$25,350.23
Rate for Payer: Molina Dual Medicare/Medicaid	$25,350.23
Rate for Payer: Molina Medicare	$25,350.23
Rate for Payer: Multiplan Auto	$53,378.60
Rate for Payer: Multiplan Commercial	$53,378.60
Rate for Payer: Multiplan Workers Comp	$53,378.60
Rate for Payer: Scott and White EPO/PPO	$24,582.25
Rate for Payer: Scott and White Medicare	$25,350.23
Rate for Payer: Superior Health Plan EPO	$25,350.23
Rate for Payer: Superior Health Plan Medicare	$25,350.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$25,350.23
Rate for Payer: Universal American Medicare	$25,350.23
Rate for Payer: Wellcare Medicare	$25,350.23
Rate for Payer: Wellmed Medicare	$25,350.23

SPLENIC PROCEDURES WITH MCC

Facility

$86,049.10

Service Code	MSDRG 799
Min. Negotiated Rate	$37,952.50
Max. Negotiated Rate	$86,049.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37,952.50
Rate for Payer: Amerigroup Medicare	$37,952.50
Rate for Payer: BCBS of TX Medicare	$37,952.50
Rate for Payer: Cigna Commercial	$58,332.23
Rate for Payer: Cigna Medicare	$37,952.50
Rate for Payer: Employer Direct Commercial	$37,952.50
Rate for Payer: Humana Medicare/TRICARE	$37,952.50
Rate for Payer: Molina Dual Medicare/Medicaid	$37,952.50
Rate for Payer: Molina Medicare	$37,952.50
Rate for Payer: Multiplan Auto	$86,049.10
Rate for Payer: Multiplan Commercial	$86,049.10
Rate for Payer: Multiplan Workers Comp	$86,049.10
Rate for Payer: Scott and White EPO/PPO	$39,627.88
Rate for Payer: Scott and White Medicare	$37,952.50
Rate for Payer: Superior Health Plan EPO	$37,952.50
Rate for Payer: Superior Health Plan Medicare	$37,952.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$37,952.50
Rate for Payer: Universal American Medicare	$37,952.50
Rate for Payer: Wellcare Medicare	$37,952.50
Rate for Payer: Wellmed Medicare	$37,952.50

SPLENIC PROCEDURES WITHOUT CC/MCC

Facility

$36,269.10

Service Code	MSDRG 801
Min. Negotiated Rate	$13,384.18
Max. Negotiated Rate	$36,269.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,750.46
Rate for Payer: Amerigroup Medicare	$18,750.46
Rate for Payer: BCBS of TX Medicare	$18,750.46
Rate for Payer: Cigna Commercial	$24,586.63
Rate for Payer: Cigna Medicare	$18,750.46
Rate for Payer: Employer Direct Commercial	$18,750.46
Rate for Payer: Humana Medicare/TRICARE	$18,750.46
Rate for Payer: Molina Dual Medicare/Medicaid	$18,750.46
Rate for Payer: Molina Medicare	$18,750.46
Rate for Payer: Multiplan Auto	$36,269.10
Rate for Payer: Multiplan Commercial	$36,269.10
Rate for Payer: Multiplan Workers Comp	$36,269.10
Rate for Payer: Scott and White EPO/PPO	$16,702.88
Rate for Payer: Scott and White Medicare	$18,750.46
Rate for Payer: Superior Health Plan EPO	$18,750.46
Rate for Payer: Superior Health Plan Medicare	$18,750.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,750.46
Rate for Payer: Universal American Medicare	$18,750.46
Rate for Payer: Wellcare Medicare	$18,750.46
Rate for Payer: Wellmed Medicare	$18,750.46

SPLINT, 12 3-PANEL KNEE

Facility

$53.98

Hospital Charge Code	993366
Hospital Revenue Code	270
Min. Negotiated Rate	$4.86
Max. Negotiated Rate	$38.87
Rate for Payer: Amerigroup CHIP/Medicaid	$4.86
Rate for Payer: BCBS of TX Blue Advantage	$16.19
Rate for Payer: BCBS of TX Blue Essentials	$19.43
Rate for Payer: BCBS of TX PPO	$21.59
Rate for Payer: Cash Price	$36.71
Rate for Payer: Cigna Medicaid	$38.87
Rate for Payer: Molina CHIP/Medicaid	$38.87
Rate for Payer: Multiplan Auto	$35.09
Rate for Payer: Multiplan Commercial	$35.09
Rate for Payer: Multiplan Workers Comp	$35.09
Rate for Payer: Parkland Medicaid	$38.87
Rate for Payer: Scott and White EPO/PPO	$26.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.87
Rate for Payer: Superior Health Plan EPO	$7.34

SPLINT, 12 3-PANEL KNEE

Facility

$53.98

Hospital Charge Code	993366
Hospital Revenue Code	270
Rate for Payer: Cash Price	$36.71

SPLINT, KNEE, BASIC, 20', UNIVERSAL

Facility

$63.15

Hospital Charge Code	993917
Hospital Revenue Code	274
Min. Negotiated Rate	$5.68
Max. Negotiated Rate	$45.47
Rate for Payer: Amerigroup CHIP/Medicaid	$5.68
Rate for Payer: BCBS of TX Blue Advantage	$18.95
Rate for Payer: BCBS of TX Blue Essentials	$22.73
Rate for Payer: BCBS of TX PPO	$25.26
Rate for Payer: Cash Price	$42.94
Rate for Payer: Cigna Medicaid	$45.47
Rate for Payer: Molina CHIP/Medicaid	$45.47
Rate for Payer: Multiplan Auto	$31.57
Rate for Payer: Multiplan Commercial	$31.57
Rate for Payer: Multiplan Workers Comp	$31.57
Rate for Payer: Parkland Medicaid	$45.47
Rate for Payer: Scott and White EPO/PPO	$31.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$45.47
Rate for Payer: Superior Health Plan EPO	$8.59

SPLINT, KNEE, BASIC, 20', UNIVERSAL

Facility

$63.15

Hospital Charge Code	993917
Hospital Revenue Code	274
Min. Negotiated Rate	$15.79
Max. Negotiated Rate	$31.57
Rate for Payer: Cash Price	$42.94
Rate for Payer: Cigna Commercial	$15.79
Rate for Payer: Multiplan Auto	$31.57
Rate for Payer: Multiplan Commercial	$31.57
Rate for Payer: Multiplan Workers Comp	$31.57
Rate for Payer: Scott and White EPO/PPO	$31.57

SPLINT, PLASTERS, 5' X 30'

Facility

$1.78

Hospital Charge Code	993981
Hospital Revenue Code	271
Rate for Payer: Cash Price	$1.21

SPLINT, PLASTERS, 5' X 30'

Facility

$1.78

Hospital Charge Code	993981
Hospital Revenue Code	271
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$1.28
Rate for Payer: Amerigroup CHIP/Medicaid	$0.16
Rate for Payer: BCBS of TX Blue Advantage	$0.53
Rate for Payer: BCBS of TX Blue Essentials	$0.64
Rate for Payer: BCBS of TX PPO	$0.71
Rate for Payer: Cash Price	$1.21
Rate for Payer: Cigna Medicaid	$1.28
Rate for Payer: Molina CHIP/Medicaid	$1.28
Rate for Payer: Multiplan Auto	$1.16
Rate for Payer: Multiplan Commercial	$1.16
Rate for Payer: Multiplan Workers Comp	$1.16
Rate for Payer: Parkland Medicaid	$1.28
Rate for Payer: Scott and White EPO/PPO	$0.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.28
Rate for Payer: Superior Health Plan EPO	$0.24

SPLIT GRAFT FACE, NECK, FEET

Facility

$10,000.00

Service Code	CPT 15120
Hospital Charge Code	36015120
Hospital Revenue Code	360
Min. Negotiated Rate	$1,457.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,457.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,559.87
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
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: Scott and White EPO/PPO	$6,585.76
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

Know your out-of-pocket cost for care.

All Charges