White Rock Medical Center

All Charges

Charge

Type

Setting

Price

STOMACH, ESOPHAGEAL & DUODENAL PROC W CC

Facility

$46,439.80

Service Code	MSDRG 327
Min. Negotiated Rate	$21,364.98
Max. Negotiated Rate	$46,439.80
Rate for Payer: BCBS of TX Blue Advantage	$21,364.98
Rate for Payer: BCBS of TX Blue Essentials	$25,635.49
Rate for Payer: BCBS of TX PPO	$28,484.98

STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC

Facility

$94,760.60

Service Code	MSDRG 326
Min. Negotiated Rate	$41,312.86
Max. Negotiated Rate	$94,760.60
Rate for Payer: BCBS of TX Blue Advantage	$45,200.74
Rate for Payer: BCBS of TX Blue Essentials	$54,235.63
Rate for Payer: BCBS of TX PPO	$60,264.15

STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC

Facility

$30,443.70

Service Code	MSDRG 328
Min. Negotiated Rate	$13,262.06
Max. Negotiated Rate	$30,443.70
Rate for Payer: BCBS of TX Blue Advantage	$13,262.06
Rate for Payer: BCBS of TX Blue Essentials	$15,912.93
Rate for Payer: BCBS of TX PPO	$17,681.72

Stone Analysis SO

Facility

$157.80

Service Code	HCPCS 82365
Hospital Charge Code	8993058
Hospital Revenue Code	301
Rate for Payer: Cash Price	$107.30

Stone Analysis SO

Facility

$157.80

Service Code	HCPCS 82365
Hospital Charge Code	8993058
Hospital Revenue Code	301
Min. Negotiated Rate	$5.03
Max. Negotiated Rate	$113.62
Rate for Payer: Amerigroup CHIP/Medicaid	$5.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.90
Rate for Payer: Amerigroup Medicare	$12.90
Rate for Payer: BCBS of TX Blue Advantage	$47.34
Rate for Payer: BCBS of TX Blue Essentials	$56.81
Rate for Payer: BCBS of TX Medicare	$12.90
Rate for Payer: BCBS of TX PPO	$63.12
Rate for Payer: Cash Price	$107.30
Rate for Payer: Cash Price	$107.30
Rate for Payer: Cigna Medicaid	$113.62
Rate for Payer: Cigna Medicare	$12.90
Rate for Payer: Employer Direct Commercial	$12.90
Rate for Payer: Humana Medicare/TRICARE	$12.90
Rate for Payer: Molina CHIP/Medicaid	$113.62
Rate for Payer: Molina Dual Medicare/Medicaid	$12.90
Rate for Payer: Molina Medicare	$12.90
Rate for Payer: Multiplan Auto	$102.57
Rate for Payer: Multiplan Commercial	$102.57
Rate for Payer: Multiplan Workers Comp	$102.57
Rate for Payer: Parkland Medicaid	$113.62
Rate for Payer: Scott and White EPO/PPO	$16.12
Rate for Payer: Scott and White Medicare	$12.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$113.62
Rate for Payer: Superior Health Plan EPO	$12.90
Rate for Payer: Superior Health Plan Medicare	$12.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.90
Rate for Payer: Universal American Medicare	$12.90
Rate for Payer: Wellcare Medicare	$12.90
Rate for Payer: Wellmed Medicare	$12.90

Stool Culture

Facility

$375.00

Service Code	HCPCS 87045
Hospital Charge Code	4107055
Hospital Revenue Code	306
Rate for Payer: Cash Price	$255.00

Stool Culture

Facility

$375.00

Service Code	HCPCS 87045
Hospital Charge Code	4107055
Hospital Revenue Code	306
Min. Negotiated Rate	$3.68
Max. Negotiated Rate	$270.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.44
Rate for Payer: Amerigroup Medicare	$9.44
Rate for Payer: BCBS of TX Blue Advantage	$112.50
Rate for Payer: BCBS of TX Blue Essentials	$135.00
Rate for Payer: BCBS of TX Medicare	$9.44
Rate for Payer: BCBS of TX PPO	$150.00
Rate for Payer: Cash Price	$255.00
Rate for Payer: Cash Price	$255.00
Rate for Payer: Cigna Medicaid	$270.00
Rate for Payer: Cigna Medicare	$9.44
Rate for Payer: Employer Direct Commercial	$9.44
Rate for Payer: Humana Medicare/TRICARE	$9.44
Rate for Payer: Molina CHIP/Medicaid	$270.00
Rate for Payer: Molina Dual Medicare/Medicaid	$9.44
Rate for Payer: Molina Medicare	$9.44
Rate for Payer: Multiplan Auto	$243.75
Rate for Payer: Multiplan Commercial	$243.75
Rate for Payer: Multiplan Workers Comp	$243.75
Rate for Payer: Parkland Medicaid	$270.00
Rate for Payer: Scott and White EPO/PPO	$11.80
Rate for Payer: Scott and White Medicare	$9.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$270.00
Rate for Payer: Superior Health Plan EPO	$9.44
Rate for Payer: Superior Health Plan Medicare	$9.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.44
Rate for Payer: Universal American Medicare	$9.44
Rate for Payer: Wellcare Medicare	$9.44
Rate for Payer: Wellmed Medicare	$9.44

STOPCOCK, 3-WAY STD BORE W/ROTATING MALE LUER LOCK -- DHF

Facility

$65.75

Hospital Charge Code	54200860
Hospital Revenue Code	270
Min. Negotiated Rate	$5.92
Max. Negotiated Rate	$47.34
Rate for Payer: Amerigroup CHIP/Medicaid	$5.92
Rate for Payer: BCBS of TX Blue Advantage	$19.73
Rate for Payer: BCBS of TX Blue Essentials	$23.67
Rate for Payer: BCBS of TX PPO	$26.30
Rate for Payer: Cash Price	$44.71
Rate for Payer: Cigna Medicaid	$47.34
Rate for Payer: Molina CHIP/Medicaid	$47.34
Rate for Payer: Multiplan Auto	$42.74
Rate for Payer: Multiplan Commercial	$42.74
Rate for Payer: Multiplan Workers Comp	$42.74
Rate for Payer: Parkland Medicaid	$47.34
Rate for Payer: Scott and White EPO/PPO	$32.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47.34
Rate for Payer: Superior Health Plan EPO	$8.94

STOPCOCK, 3-WAY STD BORE W/ROTATING MALE LUER LOCK -- DHF

Facility

$65.75

Hospital Charge Code	54200860
Hospital Revenue Code	270
Rate for Payer: Cash Price	$44.71

STOPCOCK 3W DBL -- DHF

Facility

$101.80

Hospital Charge Code	54201264
Hospital Revenue Code	270
Min. Negotiated Rate	$9.16
Max. Negotiated Rate	$73.30
Rate for Payer: Amerigroup CHIP/Medicaid	$9.16
Rate for Payer: BCBS of TX Blue Advantage	$30.54
Rate for Payer: BCBS of TX Blue Essentials	$36.65
Rate for Payer: BCBS of TX PPO	$40.72
Rate for Payer: Cash Price	$69.22
Rate for Payer: Cigna Medicaid	$73.30
Rate for Payer: Molina CHIP/Medicaid	$73.30
Rate for Payer: Multiplan Auto	$66.17
Rate for Payer: Multiplan Commercial	$66.17
Rate for Payer: Multiplan Workers Comp	$66.17
Rate for Payer: Parkland Medicaid	$73.30
Rate for Payer: Scott and White EPO/PPO	$50.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$73.30
Rate for Payer: Superior Health Plan EPO	$13.84

STOPCOCK 3W DBL -- DHF

Facility

$101.80

Hospital Charge Code	54201264
Hospital Revenue Code	270
Rate for Payer: Cash Price	$69.22

STOPCOCK W MLL -- DHF

Facility

$108.14

Hospital Charge Code	54202502
Hospital Revenue Code	272
Min. Negotiated Rate	$9.73
Max. Negotiated Rate	$77.86
Rate for Payer: Amerigroup CHIP/Medicaid	$9.73
Rate for Payer: BCBS of TX Blue Advantage	$32.44
Rate for Payer: BCBS of TX Blue Essentials	$38.93
Rate for Payer: BCBS of TX PPO	$43.26
Rate for Payer: Cash Price	$73.54
Rate for Payer: Cigna Medicaid	$77.86
Rate for Payer: Molina CHIP/Medicaid	$77.86
Rate for Payer: Multiplan Auto	$70.29
Rate for Payer: Multiplan Commercial	$70.29
Rate for Payer: Multiplan Workers Comp	$70.29
Rate for Payer: Parkland Medicaid	$77.86
Rate for Payer: Scott and White EPO/PPO	$54.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$77.86
Rate for Payer: Superior Health Plan EPO	$14.71

STOPCOCK W MLL -- DHF

Facility

$108.14

Hospital Charge Code	54202502
Hospital Revenue Code	272
Rate for Payer: Cash Price	$73.54

STPLR SKN SUBCUTICULA -- DHF

Facility

$242.55

Hospital Charge Code	81940017
Hospital Revenue Code	272
Rate for Payer: Cash Price	$164.93

STPLR SKN SUBCUTICULA -- DHF

Facility

$242.55

Hospital Charge Code	81940017
Hospital Revenue Code	272
Min. Negotiated Rate	$21.83
Max. Negotiated Rate	$174.64
Rate for Payer: Amerigroup CHIP/Medicaid	$21.83
Rate for Payer: BCBS of TX Blue Advantage	$72.77
Rate for Payer: BCBS of TX Blue Essentials	$87.32
Rate for Payer: BCBS of TX PPO	$97.02
Rate for Payer: Cash Price	$164.93
Rate for Payer: Cigna Medicaid	$174.64
Rate for Payer: Molina CHIP/Medicaid	$174.64
Rate for Payer: Multiplan Auto	$157.66
Rate for Payer: Multiplan Commercial	$157.66
Rate for Payer: Multiplan Workers Comp	$157.66
Rate for Payer: Parkland Medicaid	$174.64
Rate for Payer: Scott and White EPO/PPO	$121.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$174.64
Rate for Payer: Superior Health Plan EPO	$32.99

ST PRIMARY CNTFLW -- DHF

Facility

$118.74

Hospital Charge Code	54200209
Hospital Revenue Code	270
Min. Negotiated Rate	$10.69
Max. Negotiated Rate	$85.49
Rate for Payer: Amerigroup CHIP/Medicaid	$10.69
Rate for Payer: BCBS of TX Blue Advantage	$35.62
Rate for Payer: BCBS of TX Blue Essentials	$42.75
Rate for Payer: BCBS of TX PPO	$47.50
Rate for Payer: Cash Price	$80.74
Rate for Payer: Cigna Medicaid	$85.49
Rate for Payer: Molina CHIP/Medicaid	$85.49
Rate for Payer: Multiplan Auto	$77.18
Rate for Payer: Multiplan Commercial	$77.18
Rate for Payer: Multiplan Workers Comp	$77.18
Rate for Payer: Parkland Medicaid	$85.49
Rate for Payer: Scott and White EPO/PPO	$59.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$85.49
Rate for Payer: Superior Health Plan EPO	$16.15

ST PRIMARY CNTFLW -- DHF

Facility

$118.74

Hospital Charge Code	54200209
Hospital Revenue Code	270
Rate for Payer: Cash Price	$80.74

STRAP, ABSORBABLE, FIXATION, DEVICE, 5MM

Facility

$2,236.09

Hospital Charge Code	992872
Hospital Revenue Code	272
Min. Negotiated Rate	$201.25
Max. Negotiated Rate	$1,609.98
Rate for Payer: Amerigroup CHIP/Medicaid	$201.25
Rate for Payer: BCBS of TX Blue Advantage	$670.83
Rate for Payer: BCBS of TX Blue Essentials	$804.99
Rate for Payer: BCBS of TX PPO	$894.44
Rate for Payer: Cash Price	$1,520.54
Rate for Payer: Cigna Medicaid	$1,609.98
Rate for Payer: Molina CHIP/Medicaid	$1,609.98
Rate for Payer: Multiplan Auto	$1,453.46
Rate for Payer: Multiplan Commercial	$1,453.46
Rate for Payer: Multiplan Workers Comp	$1,453.46
Rate for Payer: Parkland Medicaid	$1,609.98
Rate for Payer: Scott and White EPO/PPO	$1,118.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,609.98
Rate for Payer: Superior Health Plan EPO	$304.11

STRAP, ABSORBABLE, FIXATION, DEVICE, 5MM

Facility

$2,236.09

Hospital Charge Code	992872
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,520.54

STRAP KNEE/BODY POSITIONING 4W X 33L

Facility

$11.76

Hospital Charge Code	992832
Hospital Revenue Code	270
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$8.47
Rate for Payer: Amerigroup CHIP/Medicaid	$1.06
Rate for Payer: BCBS of TX Blue Advantage	$3.53
Rate for Payer: BCBS of TX Blue Essentials	$4.23
Rate for Payer: BCBS of TX PPO	$4.70
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cigna Medicaid	$8.47
Rate for Payer: Molina CHIP/Medicaid	$8.47
Rate for Payer: Multiplan Auto	$7.64
Rate for Payer: Multiplan Commercial	$7.64
Rate for Payer: Multiplan Workers Comp	$7.64
Rate for Payer: Parkland Medicaid	$8.47
Rate for Payer: Scott and White EPO/PPO	$5.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.47
Rate for Payer: Superior Health Plan EPO	$1.60

STRAP KNEE/BODY POSITIONING 4W X 33L

Facility

$11.76

Hospital Charge Code	992832
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.00

Strapping; ankle and/or foot

Facility

$631.16

Service Code	HCPCS 29540
Hospital Charge Code	994133
Hospital Revenue Code	361
Rate for Payer: Cash Price	$429.19

Strapping; ankle and/or foot

Facility

$631.16

Service Code	HCPCS 29540
Hospital Charge Code	994133
Hospital Revenue Code	361
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$10.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$23.50
Rate for Payer: BCBS of TX Blue Essentials	$28.14
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$35.46
Rate for Payer: Cash Price	$429.19
Rate for Payer: Cash Price	$429.19
Rate for Payer: Cash Price	$429.19
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$454.44
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$454.44
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
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	$454.44
Rate for Payer: Scott and White EPO/PPO	$301.99
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$454.44
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

STRAPPING UNA BOOT LT

Facility

$993.50

Service Code	HCPCS 29580
Hospital Charge Code	7150832
Hospital Revenue Code	361
Min. Negotiated Rate	$33.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$33.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$70.51
Rate for Payer: BCBS of TX Blue Essentials	$84.44
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$106.39
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
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	$715.32
Rate for Payer: Scott and White EPO/PPO	$301.99
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

STRAPPING UNA BOOT LT

Facility

$993.50

Service Code	HCPCS 29580
Hospital Charge Code	7150832
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

Know your out-of-pocket cost for care.

All Charges