White Rock Medical Center

All Charges

Charge

Type

Setting

Price

STENT URETERAL 6FR 26CM WITH GUIDEWIRE PERCUFLEX

Facility

$597.33

Hospital Charge Code	119753
Hospital Revenue Code	272
Min. Negotiated Rate	$53.76
Max. Negotiated Rate	$430.08
Rate for Payer: Amerigroup CHIP/Medicaid	$53.76
Rate for Payer: BCBS of TX Blue Advantage	$179.20
Rate for Payer: BCBS of TX Blue Essentials	$215.04
Rate for Payer: BCBS of TX PPO	$238.93
Rate for Payer: Cash Price	$406.18
Rate for Payer: Cigna Medicaid	$430.08
Rate for Payer: Molina CHIP/Medicaid	$430.08
Rate for Payer: Multiplan Auto	$388.26
Rate for Payer: Multiplan Commercial	$388.26
Rate for Payer: Multiplan Workers Comp	$388.26
Rate for Payer: Parkland Medicaid	$430.08
Rate for Payer: Scott and White EPO/PPO	$298.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$430.08
Rate for Payer: Superior Health Plan EPO	$81.24

STENT URETERAL LUBRIFLEX 6X26

Facility

$672.19

Hospital Charge Code	145716
Hospital Revenue Code	272
Min. Negotiated Rate	$60.50
Max. Negotiated Rate	$483.98
Rate for Payer: Amerigroup CHIP/Medicaid	$60.50
Rate for Payer: BCBS of TX Blue Advantage	$201.66
Rate for Payer: BCBS of TX Blue Essentials	$241.99
Rate for Payer: BCBS of TX PPO	$268.88
Rate for Payer: Cash Price	$457.09
Rate for Payer: Cigna Medicaid	$483.98
Rate for Payer: Molina CHIP/Medicaid	$483.98
Rate for Payer: Multiplan Auto	$436.92
Rate for Payer: Multiplan Commercial	$436.92
Rate for Payer: Multiplan Workers Comp	$436.92
Rate for Payer: Parkland Medicaid	$483.98
Rate for Payer: Scott and White EPO/PPO	$336.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$483.98
Rate for Payer: Superior Health Plan EPO	$91.42

STENT URETERAL LUBRIFLEX 6X26

Facility

$672.19

Hospital Charge Code	145716
Hospital Revenue Code	272
Rate for Payer: Cash Price	$457.09

Stereotactic computer-assisted (navigational) procedure; cranial, extradural

Facility

$2,736.00

Service Code	HCPCS 61782
Hospital Charge Code	9900738
Hospital Revenue Code	360
Min. Negotiated Rate	$246.24
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$246.24
Rate for Payer: BCBS of TX Blue Advantage	$820.80
Rate for Payer: BCBS of TX Blue Essentials	$984.96
Rate for Payer: BCBS of TX PPO	$1,094.40
Rate for Payer: Cash Price	$1,860.48
Rate for Payer: Cash Price	$1,860.48
Rate for Payer: Cigna Medicaid	$1,969.92
Rate for Payer: Molina CHIP/Medicaid	$1,969.92
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	$1,969.92
Rate for Payer: Scott and White EPO/PPO	$1,368.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,969.92
Rate for Payer: Superior Health Plan EPO	$372.10

Stereotactic computer-assisted (navigational) procedure; cranial, extradural

Facility

$10,000.00

Service Code	CPT 61782
Hospital Charge Code	36061782
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$10,000.00
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

Stereotactic computer-assisted (navigational) procedure; cranial, extradural

Facility

$2,736.00

Service Code	HCPCS 61782
Hospital Charge Code	9900738
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,860.48

Steri-drape large drape, 17' x 23'

Facility

$4.90

Hospital Charge Code	992792
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.33

Steri-drape large drape, 17' x 23'

Facility

$4.90

Hospital Charge Code	992792
Hospital Revenue Code	272
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$3.53
Rate for Payer: Amerigroup CHIP/Medicaid	$0.44
Rate for Payer: BCBS of TX Blue Advantage	$1.47
Rate for Payer: BCBS of TX Blue Essentials	$1.76
Rate for Payer: BCBS of TX PPO	$1.96
Rate for Payer: Cash Price	$3.33
Rate for Payer: Cigna Medicaid	$3.53
Rate for Payer: Molina CHIP/Medicaid	$3.53
Rate for Payer: Multiplan Auto	$3.19
Rate for Payer: Multiplan Commercial	$3.19
Rate for Payer: Multiplan Workers Comp	$3.19
Rate for Payer: Parkland Medicaid	$3.53
Rate for Payer: Scott and White EPO/PPO	$2.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.53
Rate for Payer: Superior Health Plan EPO	$0.67

STERILE 11MM CANNULATED ENTRY DRILL

Facility

$3,159.84

Hospital Charge Code	993895
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,148.69

STERILE 11MM CANNULATED ENTRY DRILL

Facility

$3,159.84

Hospital Charge Code	993895
Hospital Revenue Code	272
Min. Negotiated Rate	$284.39
Max. Negotiated Rate	$2,275.08
Rate for Payer: Amerigroup CHIP/Medicaid	$284.39
Rate for Payer: BCBS of TX Blue Advantage	$947.95
Rate for Payer: BCBS of TX Blue Essentials	$1,137.54
Rate for Payer: BCBS of TX PPO	$1,263.94
Rate for Payer: Cash Price	$2,148.69
Rate for Payer: Cigna Medicaid	$2,275.08
Rate for Payer: Molina CHIP/Medicaid	$2,275.08
Rate for Payer: Multiplan Auto	$2,053.90
Rate for Payer: Multiplan Commercial	$2,053.90
Rate for Payer: Multiplan Workers Comp	$2,053.90
Rate for Payer: Parkland Medicaid	$2,275.08
Rate for Payer: Scott and White EPO/PPO	$1,579.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,275.08
Rate for Payer: Superior Health Plan EPO	$429.74

Sterile bouble Stocklinette

Facility

$16.29

Hospital Charge Code	992833
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11.08

Sterile bouble Stocklinette

Facility

$16.29

Hospital Charge Code	992833
Hospital Revenue Code	272
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$11.73
Rate for Payer: Amerigroup CHIP/Medicaid	$1.47
Rate for Payer: BCBS of TX Blue Advantage	$4.89
Rate for Payer: BCBS of TX Blue Essentials	$5.86
Rate for Payer: BCBS of TX PPO	$6.52
Rate for Payer: Cash Price	$11.08
Rate for Payer: Cigna Medicaid	$11.73
Rate for Payer: Molina CHIP/Medicaid	$11.73
Rate for Payer: Multiplan Auto	$10.59
Rate for Payer: Multiplan Commercial	$10.59
Rate for Payer: Multiplan Workers Comp	$10.59
Rate for Payer: Parkland Medicaid	$11.73
Rate for Payer: Scott and White EPO/PPO	$8.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.73
Rate for Payer: Superior Health Plan EPO	$2.22

Sterile disposable deluxe OR towel, blue, 4/pk

Facility

$8.32

Hospital Charge Code	992793
Hospital Revenue Code	272
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$5.99
Rate for Payer: Amerigroup CHIP/Medicaid	$0.75
Rate for Payer: BCBS of TX Blue Advantage	$2.50
Rate for Payer: BCBS of TX Blue Essentials	$3.00
Rate for Payer: BCBS of TX PPO	$3.33
Rate for Payer: Cash Price	$5.66
Rate for Payer: Cigna Medicaid	$5.99
Rate for Payer: Molina CHIP/Medicaid	$5.99
Rate for Payer: Multiplan Auto	$5.41
Rate for Payer: Multiplan Commercial	$5.41
Rate for Payer: Multiplan Workers Comp	$5.41
Rate for Payer: Parkland Medicaid	$5.99
Rate for Payer: Scott and White EPO/PPO	$4.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.99
Rate for Payer: Superior Health Plan EPO	$1.13

Sterile disposable deluxe OR towel, blue, 4/pk

Facility

$8.32

Hospital Charge Code	992793
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.66

Sterile Nonreinforced sirus surgical gowns with setin sleeves and towel size 2xL

Facility

$10.80

Hospital Charge Code	992794
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7.34

Sterile Nonreinforced sirus surgical gowns with setin sleeves and towel size 2xL

Facility

$10.80

Hospital Charge Code	992794
Hospital Revenue Code	272
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$7.78
Rate for Payer: Amerigroup CHIP/Medicaid	$0.97
Rate for Payer: BCBS of TX Blue Advantage	$3.24
Rate for Payer: BCBS of TX Blue Essentials	$3.89
Rate for Payer: BCBS of TX PPO	$4.32
Rate for Payer: Cash Price	$7.34
Rate for Payer: Cigna Medicaid	$7.78
Rate for Payer: Molina CHIP/Medicaid	$7.78
Rate for Payer: Multiplan Auto	$7.02
Rate for Payer: Multiplan Commercial	$7.02
Rate for Payer: Multiplan Workers Comp	$7.02
Rate for Payer: Parkland Medicaid	$7.78
Rate for Payer: Scott and White EPO/PPO	$5.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.78
Rate for Payer: Superior Health Plan EPO	$1.47

Sterile nonreinforced sirus surgical gowns with setin sleeves and towel,size XL

Facility

$8.84

Hospital Charge Code	992795
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6.01

Sterile nonreinforced sirus surgical gowns with setin sleeves and towel,size XL

Facility

$8.84

Hospital Charge Code	992795
Hospital Revenue Code	272
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$6.36
Rate for Payer: Amerigroup CHIP/Medicaid	$0.80
Rate for Payer: BCBS of TX Blue Advantage	$2.65
Rate for Payer: BCBS of TX Blue Essentials	$3.18
Rate for Payer: BCBS of TX PPO	$3.54
Rate for Payer: Cash Price	$6.01
Rate for Payer: Cigna Medicaid	$6.36
Rate for Payer: Molina CHIP/Medicaid	$6.36
Rate for Payer: Multiplan Auto	$5.75
Rate for Payer: Multiplan Commercial	$5.75
Rate for Payer: Multiplan Workers Comp	$5.75
Rate for Payer: Parkland Medicaid	$6.36
Rate for Payer: Scott and White EPO/PPO	$4.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.36
Rate for Payer: Superior Health Plan EPO	$1.20

Sterile Precice Fast Distractor Max Packaged

Facility

$5,257.32

Hospital Charge Code	993901
Hospital Revenue Code	272
Min. Negotiated Rate	$473.16
Max. Negotiated Rate	$3,785.27
Rate for Payer: Amerigroup CHIP/Medicaid	$473.16
Rate for Payer: BCBS of TX Blue Advantage	$1,577.20
Rate for Payer: BCBS of TX Blue Essentials	$1,892.64
Rate for Payer: BCBS of TX PPO	$2,102.93
Rate for Payer: Cash Price	$3,574.98
Rate for Payer: Cigna Medicaid	$3,785.27
Rate for Payer: Molina CHIP/Medicaid	$3,785.27
Rate for Payer: Multiplan Auto	$3,417.26
Rate for Payer: Multiplan Commercial	$3,417.26
Rate for Payer: Multiplan Workers Comp	$3,417.26
Rate for Payer: Parkland Medicaid	$3,785.27
Rate for Payer: Scott and White EPO/PPO	$2,628.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,785.27
Rate for Payer: Superior Health Plan EPO	$715.00

Sterile Precice Fast Distractor Max Packaged

Facility

$5,257.32

Hospital Charge Code	993901
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,574.98

Sterile Utility Skin Marker with Ruler

Facility

$3.65

Hospital Charge Code	992879
Hospital Revenue Code	272
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$2.63
Rate for Payer: Amerigroup CHIP/Medicaid	$0.33
Rate for Payer: BCBS of TX Blue Advantage	$1.09
Rate for Payer: BCBS of TX Blue Essentials	$1.31
Rate for Payer: BCBS of TX PPO	$1.46
Rate for Payer: Cash Price	$2.48
Rate for Payer: Cigna Medicaid	$2.63
Rate for Payer: Molina CHIP/Medicaid	$2.63
Rate for Payer: Multiplan Auto	$2.37
Rate for Payer: Multiplan Commercial	$2.37
Rate for Payer: Multiplan Workers Comp	$2.37
Rate for Payer: Parkland Medicaid	$2.63
Rate for Payer: Scott and White EPO/PPO	$1.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.63
Rate for Payer: Superior Health Plan EPO	$0.50

Sterile Utility Skin Marker with Ruler

Facility

$3.65

Hospital Charge Code	992879
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2.48

sterile water Inj Soln 1000 mL

Facility

$128.17

Service Code	HCPCS A4217
Hospital Charge Code	77827275
Hospital Revenue Code	258
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$5.28
Rate for Payer: BCBS of TX Blue Essentials	$6.33
Rate for Payer: BCBS of TX PPO	$7.03
Rate for Payer: Cash Price	$87.16
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

sterile water Inj Soln 1000 mL

Facility

$128.17

Service Code	HCPCS A4217
Hospital Charge Code	77827275
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

sterile water Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS A4216
Hospital Charge Code	77827157
Hospital Revenue Code	270
Rate for Payer: Cash Price	$87.16

Know your out-of-pocket cost for care.

All Charges