White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SPLIT GRAFT FACE, NECK, FEET

Facility

$12,523.00

Service Code	HCPCS 15120
Hospital Charge Code	9900123
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: Cash Price	$8,515.64
Rate for Payer: Cash Price	$8,515.64
Rate for Payer: Cash Price	$8,515.64
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicaid	$9,016.56
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 CHIP/Medicaid	$9,016.56
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: Parkland Medicaid	$9,016.56
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 CHIP/Medicaid	$9,016.56
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

SPLIT GRAFT FACE, NECK, FEET

Facility

$12,523.00

Service Code	HCPCS 15120
Hospital Charge Code	9900123
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,515.64

Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm

Facility

$7,316.92

Service Code	HCPCS 15101
Hospital Charge Code	994166
Hospital Revenue Code	361
Min. Negotiated Rate	$658.52
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$658.52
Rate for Payer: BCBS of TX Blue Advantage	$2,195.08
Rate for Payer: BCBS of TX Blue Essentials	$2,634.09
Rate for Payer: BCBS of TX PPO	$2,926.77
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cigna Medicaid	$5,268.18
Rate for Payer: Molina CHIP/Medicaid	$5,268.18
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	$5,268.18
Rate for Payer: Scott and White EPO/PPO	$3,658.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,268.18
Rate for Payer: Superior Health Plan EPO	$995.10

Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm

Facility

$7,316.92

Service Code	HCPCS 15101
Hospital Charge Code	994166
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,975.51

Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)

Facility

$7,316.92

Service Code	HCPCS 15100
Hospital Charge Code	991328
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,975.51

Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)

Facility

$7,316.92

Service Code	HCPCS 15100
Hospital Charge Code	991328
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$5,268.18
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$5,268.18
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$5,268.18
Rate for Payer: Scott and White EPO/PPO	$3,834.46
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,268.18
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

SPLNT IMOBL SHLD -- DHF

Facility

$284.49

Hospital Charge Code	81145757
Hospital Revenue Code	270
Min. Negotiated Rate	$25.60
Max. Negotiated Rate	$204.83
Rate for Payer: Amerigroup CHIP/Medicaid	$25.60
Rate for Payer: BCBS of TX Blue Advantage	$85.35
Rate for Payer: BCBS of TX Blue Essentials	$102.42
Rate for Payer: BCBS of TX PPO	$113.80
Rate for Payer: Cash Price	$193.45
Rate for Payer: Cigna Medicaid	$204.83
Rate for Payer: Molina CHIP/Medicaid	$204.83
Rate for Payer: Multiplan Auto	$184.92
Rate for Payer: Multiplan Commercial	$184.92
Rate for Payer: Multiplan Workers Comp	$184.92
Rate for Payer: Parkland Medicaid	$204.83
Rate for Payer: Scott and White EPO/PPO	$142.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$204.83
Rate for Payer: Superior Health Plan EPO	$38.69

SPLNT IMOBL SHLD -- DHF

Facility

$284.49

Hospital Charge Code	81145757
Hospital Revenue Code	270
Rate for Payer: Cash Price	$193.45

SPLNT KNEE UNN -- DHF

Facility

$284.49

Hospital Charge Code	81145906
Hospital Revenue Code	270
Rate for Payer: Cash Price	$193.45

SPLNT KNEE UNN -- DHF

Facility

$284.49

Hospital Charge Code	81145906
Hospital Revenue Code	270
Min. Negotiated Rate	$25.60
Max. Negotiated Rate	$204.83
Rate for Payer: Amerigroup CHIP/Medicaid	$25.60
Rate for Payer: BCBS of TX Blue Advantage	$85.35
Rate for Payer: BCBS of TX Blue Essentials	$102.42
Rate for Payer: BCBS of TX PPO	$113.80
Rate for Payer: Cash Price	$193.45
Rate for Payer: Cigna Medicaid	$204.83
Rate for Payer: Molina CHIP/Medicaid	$204.83
Rate for Payer: Multiplan Auto	$184.92
Rate for Payer: Multiplan Commercial	$184.92
Rate for Payer: Multiplan Workers Comp	$184.92
Rate for Payer: Parkland Medicaid	$204.83
Rate for Payer: Scott and White EPO/PPO	$142.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$204.83
Rate for Payer: Superior Health Plan EPO	$38.69

SPLNT LEG LONG A -- DHF

Facility

$388.14

Hospital Charge Code	81036055
Hospital Revenue Code	270
Min. Negotiated Rate	$34.93
Max. Negotiated Rate	$279.46
Rate for Payer: Amerigroup CHIP/Medicaid	$34.93
Rate for Payer: BCBS of TX Blue Advantage	$116.44
Rate for Payer: BCBS of TX Blue Essentials	$139.73
Rate for Payer: BCBS of TX PPO	$155.26
Rate for Payer: Cash Price	$263.94
Rate for Payer: Cigna Medicaid	$279.46
Rate for Payer: Molina CHIP/Medicaid	$279.46
Rate for Payer: Multiplan Auto	$252.29
Rate for Payer: Multiplan Commercial	$252.29
Rate for Payer: Multiplan Workers Comp	$252.29
Rate for Payer: Parkland Medicaid	$279.46
Rate for Payer: Scott and White EPO/PPO	$194.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$279.46
Rate for Payer: Superior Health Plan EPO	$52.79

SPLNT LEG LONG A -- DHF

Facility

$388.14

Hospital Charge Code	81036055
Hospital Revenue Code	270
Rate for Payer: Cash Price	$263.94

SPLNT NASAL -- DHF

Facility

$248.60

Hospital Charge Code	80341159
Hospital Revenue Code	270
Min. Negotiated Rate	$22.37
Max. Negotiated Rate	$178.99
Rate for Payer: Amerigroup CHIP/Medicaid	$22.37
Rate for Payer: BCBS of TX Blue Advantage	$74.58
Rate for Payer: BCBS of TX Blue Essentials	$89.50
Rate for Payer: BCBS of TX PPO	$99.44
Rate for Payer: Cash Price	$169.05
Rate for Payer: Cigna Medicaid	$178.99
Rate for Payer: Molina CHIP/Medicaid	$178.99
Rate for Payer: Multiplan Auto	$161.59
Rate for Payer: Multiplan Commercial	$161.59
Rate for Payer: Multiplan Workers Comp	$161.59
Rate for Payer: Parkland Medicaid	$178.99
Rate for Payer: Scott and White EPO/PPO	$124.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$178.99
Rate for Payer: Superior Health Plan EPO	$33.81

SPLNT NASAL -- DHF

Facility

$248.60

Hospital Charge Code	80341159
Hospital Revenue Code	270
Rate for Payer: Cash Price	$169.05

S. PNEUMONIAE, ATCC 49619, KWIK-S,2/PK

Facility

$201.94

Hospital Charge Code	993240
Hospital Revenue Code	270
Min. Negotiated Rate	$18.17
Max. Negotiated Rate	$145.40
Rate for Payer: Amerigroup CHIP/Medicaid	$18.17
Rate for Payer: BCBS of TX Blue Advantage	$60.58
Rate for Payer: BCBS of TX Blue Essentials	$72.70
Rate for Payer: BCBS of TX PPO	$80.78
Rate for Payer: Cash Price	$137.32
Rate for Payer: Cigna Medicaid	$145.40
Rate for Payer: Molina CHIP/Medicaid	$145.40
Rate for Payer: Multiplan Auto	$131.26
Rate for Payer: Multiplan Commercial	$131.26
Rate for Payer: Multiplan Workers Comp	$131.26
Rate for Payer: Parkland Medicaid	$145.40
Rate for Payer: Scott and White EPO/PPO	$100.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.40
Rate for Payer: Superior Health Plan EPO	$27.46

S. PNEUMONIAE, ATCC 49619, KWIK-S,2/PK

Facility

$201.94

Hospital Charge Code	993240
Hospital Revenue Code	270
Rate for Payer: Cash Price	$137.32

sponge abs 6x2 gel

Facility

$16.98

Hospital Charge Code	8660510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11.55

sponge abs 6x2 gel

Facility

$16.98

Hospital Charge Code	8660510
Hospital Revenue Code	272
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$12.23
Rate for Payer: Amerigroup CHIP/Medicaid	$1.53
Rate for Payer: BCBS of TX Blue Advantage	$5.09
Rate for Payer: BCBS of TX Blue Essentials	$6.11
Rate for Payer: BCBS of TX PPO	$6.79
Rate for Payer: Cash Price	$11.55
Rate for Payer: Cigna Medicaid	$12.23
Rate for Payer: Molina CHIP/Medicaid	$12.23
Rate for Payer: Multiplan Auto	$11.04
Rate for Payer: Multiplan Commercial	$11.04
Rate for Payer: Multiplan Workers Comp	$11.04
Rate for Payer: Parkland Medicaid	$12.23
Rate for Payer: Scott and White EPO/PPO	$8.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.23
Rate for Payer: Superior Health Plan EPO	$2.31

SPONGE, LAB, 18'X18', DLX, XR, ST, 5/PK, 40/PK

Facility

$1.47

Hospital Charge Code	993014
Hospital Revenue Code	270
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$1.06
Rate for Payer: Amerigroup CHIP/Medicaid	$0.13
Rate for Payer: BCBS of TX Blue Advantage	$0.44
Rate for Payer: BCBS of TX Blue Essentials	$0.53
Rate for Payer: BCBS of TX PPO	$0.59
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cigna Medicaid	$1.06
Rate for Payer: Molina CHIP/Medicaid	$1.06
Rate for Payer: Multiplan Auto	$0.96
Rate for Payer: Multiplan Commercial	$0.96
Rate for Payer: Multiplan Workers Comp	$0.96
Rate for Payer: Parkland Medicaid	$1.06
Rate for Payer: Scott and White EPO/PPO	$0.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.06
Rate for Payer: Superior Health Plan EPO	$0.20

SPONGE, LAB, 18'X18', DLX, XR, ST, 5/PK, 40/PK

Facility

$1.47

Hospital Charge Code	993014
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.00

SPONGE LAP 4X4IN 16 PLY RADPQ CTTN STRL

Facility

$0.44

Hospital Charge Code	992814
Hospital Revenue Code	270
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.32
Rate for Payer: Amerigroup CHIP/Medicaid	$0.04
Rate for Payer: BCBS of TX Blue Advantage	$0.13
Rate for Payer: BCBS of TX Blue Essentials	$0.16
Rate for Payer: BCBS of TX PPO	$0.18
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna Medicaid	$0.32
Rate for Payer: Molina CHIP/Medicaid	$0.32
Rate for Payer: Multiplan Auto	$0.29
Rate for Payer: Multiplan Commercial	$0.29
Rate for Payer: Multiplan Workers Comp	$0.29
Rate for Payer: Parkland Medicaid	$0.32
Rate for Payer: Scott and White EPO/PPO	$0.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.32
Rate for Payer: Superior Health Plan EPO	$0.06

SPONGE LAP 4X4IN 16 PLY RADPQ CTTN STRL

Facility

$0.44

Hospital Charge Code	992814
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.30

SPONGE WVN CTTN DRSG HRD TRY 4X4IN 12 PLY

Facility

$0.41

Hospital Charge Code	992877
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.28

SPONGE WVN CTTN DRSG HRD TRY 4X4IN 12 PLY

Facility

$0.41

Hospital Charge Code	992877
Hospital Revenue Code	272
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.30
Rate for Payer: Amerigroup CHIP/Medicaid	$0.04
Rate for Payer: BCBS of TX Blue Advantage	$0.12
Rate for Payer: BCBS of TX Blue Essentials	$0.15
Rate for Payer: BCBS of TX PPO	$0.16
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cigna Medicaid	$0.30
Rate for Payer: Molina CHIP/Medicaid	$0.30
Rate for Payer: Multiplan Auto	$0.27
Rate for Payer: Multiplan Commercial	$0.27
Rate for Payer: Multiplan Workers Comp	$0.27
Rate for Payer: Parkland Medicaid	$0.30
Rate for Payer: Scott and White EPO/PPO	$0.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.30
Rate for Payer: Superior Health Plan EPO	$0.06

SPPRT WRIST -- DHF

Facility

$360.44

Hospital Charge Code	80341506
Hospital Revenue Code	270
Rate for Payer: Cash Price	$245.10

Know your out-of-pocket cost for care.

All Charges