White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of for

Facility

$13,986.64

Service Code	HCPCS 69660
Hospital Charge Code	9900893
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cash Price	$9,510.92
Rate for Payer: Cash Price	$9,510.92
Rate for Payer: Cash Price	$9,510.92
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicaid	$10,070.38
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina CHIP/Medicaid	$10,070.38
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$10,070.38
Rate for Payer: Scott and White EPO/PPO	$11,001.60
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,070.38
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of for

Facility

$12,570.48

Service Code	CPT 69660
Hospital Charge Code	36069660
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$11,001.60
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Staph Latex

Facility

$144.00

Service Code	HCPCS 87147
Hospital Charge Code	4107148
Hospital Revenue Code	306
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$103.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$43.20
Rate for Payer: BCBS of TX Blue Essentials	$51.84
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$57.60
Rate for Payer: Cash Price	$97.92
Rate for Payer: Cash Price	$97.92
Rate for Payer: Cigna Medicaid	$103.68
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$103.68
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$93.60
Rate for Payer: Multiplan Commercial	$93.60
Rate for Payer: Multiplan Workers Comp	$93.60
Rate for Payer: Parkland Medicaid	$103.68
Rate for Payer: Scott and White EPO/PPO	$6.47
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$103.68
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

Staph Latex

Facility

$144.00

Service Code	HCPCS 87147
Hospital Charge Code	4107148
Hospital Revenue Code	306
Rate for Payer: Cash Price	$97.92

stapler

Facility

$363.20

Hospital Charge Code	992680
Hospital Revenue Code	272
Min. Negotiated Rate	$32.69
Max. Negotiated Rate	$261.50
Rate for Payer: Amerigroup CHIP/Medicaid	$32.69
Rate for Payer: BCBS of TX Blue Advantage	$108.96
Rate for Payer: BCBS of TX Blue Essentials	$130.75
Rate for Payer: BCBS of TX PPO	$145.28
Rate for Payer: Cash Price	$246.98
Rate for Payer: Cigna Medicaid	$261.50
Rate for Payer: Molina CHIP/Medicaid	$261.50
Rate for Payer: Multiplan Auto	$236.08
Rate for Payer: Multiplan Commercial	$236.08
Rate for Payer: Multiplan Workers Comp	$236.08
Rate for Payer: Parkland Medicaid	$261.50
Rate for Payer: Scott and White EPO/PPO	$181.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$261.50
Rate for Payer: Superior Health Plan EPO	$49.40

stapler

Facility

$363.20

Hospital Charge Code	992680
Hospital Revenue Code	272
Rate for Payer: Cash Price	$246.98

stapler contour curved cs40b blue

Facility

$1,435.50

Hospital Charge Code	8666510
Hospital Revenue Code	272
Min. Negotiated Rate	$129.19
Max. Negotiated Rate	$1,033.56
Rate for Payer: Amerigroup CHIP/Medicaid	$129.19
Rate for Payer: BCBS of TX Blue Advantage	$430.65
Rate for Payer: BCBS of TX Blue Essentials	$516.78
Rate for Payer: BCBS of TX PPO	$574.20
Rate for Payer: Cash Price	$976.14
Rate for Payer: Cigna Medicaid	$1,033.56
Rate for Payer: Molina CHIP/Medicaid	$1,033.56
Rate for Payer: Multiplan Auto	$933.08
Rate for Payer: Multiplan Commercial	$933.08
Rate for Payer: Multiplan Workers Comp	$933.08
Rate for Payer: Parkland Medicaid	$1,033.56
Rate for Payer: Scott and White EPO/PPO	$717.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,033.56
Rate for Payer: Superior Health Plan EPO	$195.23

stapler contour curved cs40b blue

Facility

$1,435.50

Hospital Charge Code	8666510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$976.14

STAPLER, DST SERIES EEA XL, 21MM, AQUA

Facility

$9,608.80

Hospital Charge Code	992336
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6,533.98

STAPLER, DST SERIES EEA XL, 21MM, AQUA

Facility

$9,608.80

Hospital Charge Code	992336
Hospital Revenue Code	272
Min. Negotiated Rate	$864.79
Max. Negotiated Rate	$6,918.34
Rate for Payer: Amerigroup CHIP/Medicaid	$864.79
Rate for Payer: BCBS of TX Blue Advantage	$2,882.64
Rate for Payer: BCBS of TX Blue Essentials	$3,459.17
Rate for Payer: BCBS of TX PPO	$3,843.52
Rate for Payer: Cash Price	$6,533.98
Rate for Payer: Cigna Medicaid	$6,918.34
Rate for Payer: Molina CHIP/Medicaid	$6,918.34
Rate for Payer: Multiplan Auto	$6,245.72
Rate for Payer: Multiplan Commercial	$6,245.72
Rate for Payer: Multiplan Workers Comp	$6,245.72
Rate for Payer: Parkland Medicaid	$6,918.34
Rate for Payer: Scott and White EPO/PPO	$4,804.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,918.34
Rate for Payer: Superior Health Plan EPO	$1,306.80

STAPLER, ECHELON FLEX, POWERED, ENDO

Facility

$1,482.64

Hospital Charge Code	992781
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,008.20

STAPLER, ECHELON FLEX, POWERED, ENDO

Facility

$1,482.64

Hospital Charge Code	992781
Hospital Revenue Code	272
Min. Negotiated Rate	$133.44
Max. Negotiated Rate	$1,067.50
Rate for Payer: Amerigroup CHIP/Medicaid	$133.44
Rate for Payer: BCBS of TX Blue Advantage	$444.79
Rate for Payer: BCBS of TX Blue Essentials	$533.75
Rate for Payer: BCBS of TX PPO	$593.06
Rate for Payer: Cash Price	$1,008.20
Rate for Payer: Cigna Medicaid	$1,067.50
Rate for Payer: Molina CHIP/Medicaid	$1,067.50
Rate for Payer: Multiplan Auto	$963.72
Rate for Payer: Multiplan Commercial	$963.72
Rate for Payer: Multiplan Workers Comp	$963.72
Rate for Payer: Parkland Medicaid	$1,067.50
Rate for Payer: Scott and White EPO/PPO	$741.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,067.50
Rate for Payer: Superior Health Plan EPO	$201.64

STAPLER, ECHELON, REINFORCEMENT, 60MM

Facility

$1,316.73

Hospital Charge Code	992310
Hospital Revenue Code	272
Min. Negotiated Rate	$118.51
Max. Negotiated Rate	$948.05
Rate for Payer: Amerigroup CHIP/Medicaid	$118.51
Rate for Payer: BCBS of TX Blue Advantage	$395.02
Rate for Payer: BCBS of TX Blue Essentials	$474.02
Rate for Payer: BCBS of TX PPO	$526.69
Rate for Payer: Cash Price	$895.38
Rate for Payer: Cigna Medicaid	$948.05
Rate for Payer: Molina CHIP/Medicaid	$948.05
Rate for Payer: Multiplan Auto	$855.87
Rate for Payer: Multiplan Commercial	$855.87
Rate for Payer: Multiplan Workers Comp	$855.87
Rate for Payer: Parkland Medicaid	$948.05
Rate for Payer: Scott and White EPO/PPO	$658.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$948.05
Rate for Payer: Superior Health Plan EPO	$179.08

STAPLER, ECHELON, REINFORCEMENT, 60MM

Facility

$1,316.73

Hospital Charge Code	992310
Hospital Revenue Code	272
Rate for Payer: Cash Price	$895.38

STAPLER, EEA XL, 21MM, SINGLE-USE

Facility

$9,137.87

Hospital Charge Code	992337
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6,213.75

STAPLER, EEA XL, 21MM, SINGLE-USE

Facility

$9,137.87

Hospital Charge Code	992337
Hospital Revenue Code	272
Min. Negotiated Rate	$822.41
Max. Negotiated Rate	$6,579.27
Rate for Payer: Amerigroup CHIP/Medicaid	$822.41
Rate for Payer: BCBS of TX Blue Advantage	$2,741.36
Rate for Payer: BCBS of TX Blue Essentials	$3,289.63
Rate for Payer: BCBS of TX PPO	$3,655.15
Rate for Payer: Cash Price	$6,213.75
Rate for Payer: Cigna Medicaid	$6,579.27
Rate for Payer: Molina CHIP/Medicaid	$6,579.27
Rate for Payer: Multiplan Auto	$5,939.62
Rate for Payer: Multiplan Commercial	$5,939.62
Rate for Payer: Multiplan Workers Comp	$5,939.62
Rate for Payer: Parkland Medicaid	$6,579.27
Rate for Payer: Scott and White EPO/PPO	$4,568.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,579.27
Rate for Payer: Superior Health Plan EPO	$1,242.75

STAPLER, INTERNAL CURVE EEA-21MM XL SNGL WHT 4.8MM -- DHF

Facility

$6,510.82

Hospital Charge Code	81930935
Hospital Revenue Code	272
Min. Negotiated Rate	$585.97
Max. Negotiated Rate	$4,687.79
Rate for Payer: Amerigroup CHIP/Medicaid	$585.97
Rate for Payer: BCBS of TX Blue Advantage	$1,953.25
Rate for Payer: BCBS of TX Blue Essentials	$2,343.90
Rate for Payer: BCBS of TX PPO	$2,604.33
Rate for Payer: Cash Price	$4,427.36
Rate for Payer: Cigna Medicaid	$4,687.79
Rate for Payer: Molina CHIP/Medicaid	$4,687.79
Rate for Payer: Multiplan Auto	$4,232.03
Rate for Payer: Multiplan Commercial	$4,232.03
Rate for Payer: Multiplan Workers Comp	$4,232.03
Rate for Payer: Parkland Medicaid	$4,687.79
Rate for Payer: Scott and White EPO/PPO	$3,255.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,687.79
Rate for Payer: Superior Health Plan EPO	$885.47

STAPLER, INTERNAL CURVE EEA-21MM XL SNGL WHT 4.8MM -- DHF

Facility

$6,510.82

Hospital Charge Code	81930935
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,427.36

STAPLER, INTERNAL CURVE ORVIL EEA-21MM XL TIT 35CM -- DHF

Facility

$1,383.59

Hospital Charge Code	81911158
Hospital Revenue Code	272
Min. Negotiated Rate	$124.52
Max. Negotiated Rate	$996.18
Rate for Payer: Amerigroup CHIP/Medicaid	$124.52
Rate for Payer: BCBS of TX Blue Advantage	$415.08
Rate for Payer: BCBS of TX Blue Essentials	$498.09
Rate for Payer: BCBS of TX PPO	$553.44
Rate for Payer: Cash Price	$940.84
Rate for Payer: Cigna Medicaid	$996.18
Rate for Payer: Molina CHIP/Medicaid	$996.18
Rate for Payer: Multiplan Auto	$899.33
Rate for Payer: Multiplan Commercial	$899.33
Rate for Payer: Multiplan Workers Comp	$899.33
Rate for Payer: Parkland Medicaid	$996.18
Rate for Payer: Scott and White EPO/PPO	$691.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$996.18
Rate for Payer: Superior Health Plan EPO	$188.17

STAPLER, INTERNAL CURVE ORVIL EEA-21MM XL TIT 35CM -- DHF

Facility

$1,383.59

Hospital Charge Code	81911158
Hospital Revenue Code	272
Rate for Payer: Cash Price	$940.84

STAPLER, INTERNAL ENDOSCOPIC CRVD INTRALUMINL 21MM -- DHF

Facility

$957.89

Hospital Charge Code	81911554
Hospital Revenue Code	272
Min. Negotiated Rate	$86.21
Max. Negotiated Rate	$689.68
Rate for Payer: Amerigroup CHIP/Medicaid	$86.21
Rate for Payer: BCBS of TX Blue Advantage	$287.37
Rate for Payer: BCBS of TX Blue Essentials	$344.84
Rate for Payer: BCBS of TX PPO	$383.16
Rate for Payer: Cash Price	$651.37
Rate for Payer: Cigna Medicaid	$689.68
Rate for Payer: Molina CHIP/Medicaid	$689.68
Rate for Payer: Multiplan Auto	$622.63
Rate for Payer: Multiplan Commercial	$622.63
Rate for Payer: Multiplan Workers Comp	$622.63
Rate for Payer: Parkland Medicaid	$689.68
Rate for Payer: Scott and White EPO/PPO	$478.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$689.68
Rate for Payer: Superior Health Plan EPO	$130.27

STAPLER, INTERNAL ENDOSCOPIC CRVD INTRALUMINL 21MM -- DHF

Facility

$957.89

Hospital Charge Code	81911554
Hospital Revenue Code	272
Rate for Payer: Cash Price	$651.37

STAPLER INTERNAL ENDOSCOPIC CRVD INTRALUMINL 25MM

Facility

$978.82

Hospital Charge Code	8538528
Hospital Revenue Code	272
Min. Negotiated Rate	$88.09
Max. Negotiated Rate	$704.75
Rate for Payer: Amerigroup CHIP/Medicaid	$88.09
Rate for Payer: BCBS of TX Blue Advantage	$293.65
Rate for Payer: BCBS of TX Blue Essentials	$352.38
Rate for Payer: BCBS of TX PPO	$391.53
Rate for Payer: Cash Price	$665.60
Rate for Payer: Cigna Medicaid	$704.75
Rate for Payer: Molina CHIP/Medicaid	$704.75
Rate for Payer: Multiplan Auto	$636.23
Rate for Payer: Multiplan Commercial	$636.23
Rate for Payer: Multiplan Workers Comp	$636.23
Rate for Payer: Parkland Medicaid	$704.75
Rate for Payer: Scott and White EPO/PPO	$489.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$704.75
Rate for Payer: Superior Health Plan EPO	$133.12

STAPLER INTERNAL ENDOSCOPIC CRVD INTRALUMINL 25MM

Facility

$978.82

Hospital Charge Code	8538528
Hospital Revenue Code	272
Rate for Payer: Cash Price	$665.60

STAPLER INTERNAL ENDOSCOPIC CRVD INTRALUMINL 29MM

Facility

$978.82

Hospital Charge Code	8538534
Hospital Revenue Code	272
Min. Negotiated Rate	$88.09
Max. Negotiated Rate	$704.75
Rate for Payer: Amerigroup CHIP/Medicaid	$88.09
Rate for Payer: BCBS of TX Blue Advantage	$293.65
Rate for Payer: BCBS of TX Blue Essentials	$352.38
Rate for Payer: BCBS of TX PPO	$391.53
Rate for Payer: Cash Price	$665.60
Rate for Payer: Cigna Medicaid	$704.75
Rate for Payer: Molina CHIP/Medicaid	$704.75
Rate for Payer: Multiplan Auto	$636.23
Rate for Payer: Multiplan Commercial	$636.23
Rate for Payer: Multiplan Workers Comp	$636.23
Rate for Payer: Parkland Medicaid	$704.75
Rate for Payer: Scott and White EPO/PPO	$489.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$704.75
Rate for Payer: Superior Health Plan EPO	$133.12

Know your out-of-pocket cost for care.

All Charges