White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Streptococcus Pneumoniae Antigen Urine

Facility

$117.00

Service Code	HCPCS 87899
Hospital Charge Code	4107893
Hospital Revenue Code	306
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$84.24
Rate for Payer: Amerigroup CHIP/Medicaid	$6.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.07
Rate for Payer: Amerigroup Medicare	$16.07
Rate for Payer: BCBS of TX Blue Advantage	$35.10
Rate for Payer: BCBS of TX Blue Essentials	$42.12
Rate for Payer: BCBS of TX Medicare	$16.07
Rate for Payer: BCBS of TX PPO	$46.80
Rate for Payer: Cash Price	$79.56
Rate for Payer: Cash Price	$79.56
Rate for Payer: Cigna Medicaid	$84.24
Rate for Payer: Cigna Medicare	$16.07
Rate for Payer: Employer Direct Commercial	$16.07
Rate for Payer: Humana Medicare/TRICARE	$16.07
Rate for Payer: Molina CHIP/Medicaid	$84.24
Rate for Payer: Molina Dual Medicare/Medicaid	$16.07
Rate for Payer: Molina Medicare	$16.07
Rate for Payer: Multiplan Auto	$76.05
Rate for Payer: Multiplan Commercial	$76.05
Rate for Payer: Multiplan Workers Comp	$76.05
Rate for Payer: Parkland Medicaid	$84.24
Rate for Payer: Scott and White EPO/PPO	$20.09
Rate for Payer: Scott and White Medicare	$16.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.24
Rate for Payer: Superior Health Plan EPO	$16.07
Rate for Payer: Superior Health Plan Medicare	$16.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.07
Rate for Payer: Universal American Medicare	$16.07
Rate for Payer: Wellcare Medicare	$16.07
Rate for Payer: Wellmed Medicare	$16.07

STRIP BOVINE PERICARDIUM DRY VERITAS 60 THIN

Facility

$887.41

Hospital Charge Code	992370
Hospital Revenue Code	272
Min. Negotiated Rate	$79.87
Max. Negotiated Rate	$638.94
Rate for Payer: Amerigroup CHIP/Medicaid	$79.87
Rate for Payer: BCBS of TX Blue Advantage	$266.22
Rate for Payer: BCBS of TX Blue Essentials	$319.47
Rate for Payer: BCBS of TX PPO	$354.96
Rate for Payer: Cash Price	$603.44
Rate for Payer: Cigna Medicaid	$638.94
Rate for Payer: Molina CHIP/Medicaid	$638.94
Rate for Payer: Multiplan Auto	$576.82
Rate for Payer: Multiplan Commercial	$576.82
Rate for Payer: Multiplan Workers Comp	$576.82
Rate for Payer: Parkland Medicaid	$638.94
Rate for Payer: Scott and White EPO/PPO	$443.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$638.94
Rate for Payer: Superior Health Plan EPO	$120.69

STRIP BOVINE PERICARDIUM DRY VERITAS 60 THIN

Facility

$887.41

Hospital Charge Code	992370
Hospital Revenue Code	272
Rate for Payer: Cash Price	$603.44

STRUT, EXTERNAL FIXATOR QUICK ADJUST MEDIUM

Facility

$4,409.11

Hospital Charge Code	138507
Hospital Revenue Code	272
Min. Negotiated Rate	$396.82
Max. Negotiated Rate	$3,174.56
Rate for Payer: Amerigroup CHIP/Medicaid	$396.82
Rate for Payer: BCBS of TX Blue Advantage	$1,322.73
Rate for Payer: BCBS of TX Blue Essentials	$1,587.28
Rate for Payer: BCBS of TX PPO	$1,763.64
Rate for Payer: Cash Price	$2,998.19
Rate for Payer: Cigna Medicaid	$3,174.56
Rate for Payer: Molina CHIP/Medicaid	$3,174.56
Rate for Payer: Multiplan Auto	$2,865.92
Rate for Payer: Multiplan Commercial	$2,865.92
Rate for Payer: Multiplan Workers Comp	$2,865.92
Rate for Payer: Parkland Medicaid	$3,174.56
Rate for Payer: Scott and White EPO/PPO	$2,204.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,174.56
Rate for Payer: Superior Health Plan EPO	$599.64

STRUT, EXTERNAL FIXATOR QUICK ADJUST MEDIUM

Facility

$4,409.11

Hospital Charge Code	138507
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,998.19

StrykeFlow2 Pump and Handpiece Assembly with 10 ft. Tubing

Facility

$154.95

Hospital Charge Code	993636
Hospital Revenue Code	270
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$111.56
Rate for Payer: Amerigroup CHIP/Medicaid	$13.95
Rate for Payer: BCBS of TX Blue Advantage	$46.48
Rate for Payer: BCBS of TX Blue Essentials	$55.78
Rate for Payer: BCBS of TX PPO	$61.98
Rate for Payer: Cash Price	$105.37
Rate for Payer: Cigna Medicaid	$111.56
Rate for Payer: Molina CHIP/Medicaid	$111.56
Rate for Payer: Multiplan Auto	$100.72
Rate for Payer: Multiplan Commercial	$100.72
Rate for Payer: Multiplan Workers Comp	$100.72
Rate for Payer: Parkland Medicaid	$111.56
Rate for Payer: Scott and White EPO/PPO	$77.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111.56
Rate for Payer: Superior Health Plan EPO	$21.07

StrykeFlow2 Pump and Handpiece Assembly with 10 ft. Tubing

Facility

$154.95

Hospital Charge Code	993636
Hospital Revenue Code	270
Rate for Payer: Cash Price	$105.37

STRYKEFLOW II W/ DISPOSABLE TIP

Facility

$358.04

Hospital Charge Code	992759
Hospital Revenue Code	272
Min. Negotiated Rate	$32.22
Max. Negotiated Rate	$257.79
Rate for Payer: Amerigroup CHIP/Medicaid	$32.22
Rate for Payer: BCBS of TX Blue Advantage	$107.41
Rate for Payer: BCBS of TX Blue Essentials	$128.89
Rate for Payer: BCBS of TX PPO	$143.22
Rate for Payer: Cash Price	$243.47
Rate for Payer: Cigna Medicaid	$257.79
Rate for Payer: Molina CHIP/Medicaid	$257.79
Rate for Payer: Multiplan Auto	$232.73
Rate for Payer: Multiplan Commercial	$232.73
Rate for Payer: Multiplan Workers Comp	$232.73
Rate for Payer: Parkland Medicaid	$257.79
Rate for Payer: Scott and White EPO/PPO	$179.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$257.79
Rate for Payer: Superior Health Plan EPO	$48.69

STRYKEFLOW II W/ DISPOSABLE TIP

Facility

$358.04

Hospital Charge Code	992759
Hospital Revenue Code	272
Rate for Payer: Cash Price	$243.47

STRYKER HOOD

Facility

$127.12

Hospital Charge Code	992694
Hospital Revenue Code	272
Rate for Payer: Cash Price	$86.44

STRYKER HOOD

Facility

$127.12

Hospital Charge Code	992694
Hospital Revenue Code	272
Min. Negotiated Rate	$11.44
Max. Negotiated Rate	$91.53
Rate for Payer: Amerigroup CHIP/Medicaid	$11.44
Rate for Payer: BCBS of TX Blue Advantage	$38.14
Rate for Payer: BCBS of TX Blue Essentials	$45.76
Rate for Payer: BCBS of TX PPO	$50.85
Rate for Payer: Cash Price	$86.44
Rate for Payer: Cigna Medicaid	$91.53
Rate for Payer: Molina CHIP/Medicaid	$91.53
Rate for Payer: Multiplan Auto	$82.63
Rate for Payer: Multiplan Commercial	$82.63
Rate for Payer: Multiplan Workers Comp	$82.63
Rate for Payer: Parkland Medicaid	$91.53
Rate for Payer: Scott and White EPO/PPO	$63.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.53
Rate for Payer: Superior Health Plan EPO	$17.29

Stryker Hook Serfas Energy Probe, 3.5 mm Size OD

Facility

$239.71

Hospital Charge Code	993687
Hospital Revenue Code	270
Rate for Payer: Cash Price	$163.00

Stryker Hook Serfas Energy Probe, 3.5 mm Size OD

Facility

$239.71

Hospital Charge Code	993687
Hospital Revenue Code	270
Min. Negotiated Rate	$21.57
Max. Negotiated Rate	$172.59
Rate for Payer: Amerigroup CHIP/Medicaid	$21.57
Rate for Payer: BCBS of TX Blue Advantage	$71.91
Rate for Payer: BCBS of TX Blue Essentials	$86.30
Rate for Payer: BCBS of TX PPO	$95.88
Rate for Payer: Cash Price	$163.00
Rate for Payer: Cigna Medicaid	$172.59
Rate for Payer: Molina CHIP/Medicaid	$172.59
Rate for Payer: Multiplan Auto	$155.81
Rate for Payer: Multiplan Commercial	$155.81
Rate for Payer: Multiplan Workers Comp	$155.81
Rate for Payer: Parkland Medicaid	$172.59
Rate for Payer: Scott and White EPO/PPO	$119.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$172.59
Rate for Payer: Superior Health Plan EPO	$32.60

STRYKER PRECISION THIN (5.5X0.38X11.5MM)SAW BLADE

Facility

$528.80

Hospital Charge Code	993158
Hospital Revenue Code	270
Min. Negotiated Rate	$47.59
Max. Negotiated Rate	$380.74
Rate for Payer: Amerigroup CHIP/Medicaid	$47.59
Rate for Payer: BCBS of TX Blue Advantage	$158.64
Rate for Payer: BCBS of TX Blue Essentials	$190.37
Rate for Payer: BCBS of TX PPO	$211.52
Rate for Payer: Cash Price	$359.58
Rate for Payer: Cigna Medicaid	$380.74
Rate for Payer: Molina CHIP/Medicaid	$380.74
Rate for Payer: Multiplan Auto	$343.72
Rate for Payer: Multiplan Commercial	$343.72
Rate for Payer: Multiplan Workers Comp	$343.72
Rate for Payer: Parkland Medicaid	$380.74
Rate for Payer: Scott and White EPO/PPO	$264.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$380.74
Rate for Payer: Superior Health Plan EPO	$71.92

STRYKER PRECISION THIN (5.5X0.38X11.5MM)SAW BLADE

Facility

$528.80

Hospital Charge Code	993158
Hospital Revenue Code	270
Rate for Payer: Cash Price	$359.58

ST TSR IMP -- DHF

Facility

$170.92

Hospital Charge Code	80827785
Hospital Revenue Code	270
Rate for Payer: Cash Price	$116.23

ST TSR IMP -- DHF

Facility

$170.92

Hospital Charge Code	80827785
Hospital Revenue Code	270
Min. Negotiated Rate	$15.38
Max. Negotiated Rate	$123.06
Rate for Payer: Amerigroup CHIP/Medicaid	$15.38
Rate for Payer: BCBS of TX Blue Advantage	$51.28
Rate for Payer: BCBS of TX Blue Essentials	$61.53
Rate for Payer: BCBS of TX PPO	$68.37
Rate for Payer: Cash Price	$116.23
Rate for Payer: Cigna Medicaid	$123.06
Rate for Payer: Molina CHIP/Medicaid	$123.06
Rate for Payer: Multiplan Auto	$111.10
Rate for Payer: Multiplan Commercial	$111.10
Rate for Payer: Multiplan Workers Comp	$111.10
Rate for Payer: Parkland Medicaid	$123.06
Rate for Payer: Scott and White EPO/PPO	$85.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$123.06
Rate for Payer: Superior Health Plan EPO	$23.25

ST TUBING REFIL -- DHF

Facility

$82.27

Hospital Charge Code	81853103
Hospital Revenue Code	270
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$59.23
Rate for Payer: Amerigroup CHIP/Medicaid	$7.40
Rate for Payer: BCBS of TX Blue Advantage	$24.68
Rate for Payer: BCBS of TX Blue Essentials	$29.62
Rate for Payer: BCBS of TX PPO	$32.91
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cigna Medicaid	$59.23
Rate for Payer: Molina CHIP/Medicaid	$59.23
Rate for Payer: Multiplan Auto	$53.48
Rate for Payer: Multiplan Commercial	$53.48
Rate for Payer: Multiplan Workers Comp	$53.48
Rate for Payer: Parkland Medicaid	$59.23
Rate for Payer: Scott and White EPO/PPO	$41.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.23
Rate for Payer: Superior Health Plan EPO	$11.19

ST TUBING REFIL -- DHF

Facility

$82.27

Hospital Charge Code	81853103
Hospital Revenue Code	270
Rate for Payer: Cash Price	$55.94

STYLET INTBT GLD RT RGD GLIDESCOPE

Facility

$174.79

Hospital Charge Code	115522
Hospital Revenue Code	272
Rate for Payer: Cash Price	$118.86

STYLET INTBT GLD RT RGD GLIDESCOPE

Facility

$174.79

Hospital Charge Code	115522
Hospital Revenue Code	272
Min. Negotiated Rate	$15.73
Max. Negotiated Rate	$125.85
Rate for Payer: Amerigroup CHIP/Medicaid	$15.73
Rate for Payer: BCBS of TX Blue Advantage	$52.44
Rate for Payer: BCBS of TX Blue Essentials	$62.92
Rate for Payer: BCBS of TX PPO	$69.92
Rate for Payer: Cash Price	$118.86
Rate for Payer: Cigna Medicaid	$125.85
Rate for Payer: Molina CHIP/Medicaid	$125.85
Rate for Payer: Multiplan Auto	$113.61
Rate for Payer: Multiplan Commercial	$113.61
Rate for Payer: Multiplan Workers Comp	$113.61
Rate for Payer: Parkland Medicaid	$125.85
Rate for Payer: Scott and White EPO/PPO	$87.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.85
Rate for Payer: Superior Health Plan EPO	$23.77

STYLET,INTUBATING, 14 FR

Facility

$8.43

Hospital Charge Code	992911
Hospital Revenue Code	272
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$6.07
Rate for Payer: Amerigroup CHIP/Medicaid	$0.76
Rate for Payer: BCBS of TX Blue Advantage	$2.53
Rate for Payer: BCBS of TX Blue Essentials	$3.03
Rate for Payer: BCBS of TX PPO	$3.37
Rate for Payer: Cash Price	$5.73
Rate for Payer: Cigna Medicaid	$6.07
Rate for Payer: Molina CHIP/Medicaid	$6.07
Rate for Payer: Multiplan Auto	$5.48
Rate for Payer: Multiplan Commercial	$5.48
Rate for Payer: Multiplan Workers Comp	$5.48
Rate for Payer: Parkland Medicaid	$6.07
Rate for Payer: Scott and White EPO/PPO	$4.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.07
Rate for Payer: Superior Health Plan EPO	$1.15

STYLET,INTUBATING, 14 FR

Facility

$8.43

Hospital Charge Code	992911
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.73

STYLET PERITONEAL CATHETER

Facility

$227.00

Hospital Charge Code	8484502
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$163.44
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$154.36
Rate for Payer: Cigna Medicaid	$163.44
Rate for Payer: Molina CHIP/Medicaid	$163.44
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Parkland Medicaid	$163.44
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.44
Rate for Payer: Superior Health Plan EPO	$30.87

STYLET PERITONEAL CATHETER

Facility

$227.00

Hospital Charge Code	8484502
Hospital Revenue Code	272
Rate for Payer: Cash Price	$154.36

Know your out-of-pocket cost for care.

All Charges