White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Suction assisted lipectomy upper extremity

Facility

$12,243.00

Service Code	HCPCS 15878
Hospital Charge Code	9900149
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,325.24

Suction assisted lipectomy upper extremity

Facility

$12,243.00

Service Code	HCPCS 15878
Hospital Charge Code	9900149
Hospital Revenue Code	360
Min. Negotiated Rate	$1,101.87
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,101.87
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	$8,325.24
Rate for Payer: Cash Price	$8,325.24
Rate for Payer: Cash Price	$8,325.24
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$8,814.96
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	$8,814.96
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	$8,814.96
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	$8,814.96
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

Suction assisted lipectomy upper extremity

Facility

$10,000.00

Service Code	CPT 15878
Hospital Charge Code	36015878
Hospital Revenue Code	360
Min. Negotiated Rate	$2,072.68
Max. Negotiated Rate	$10,000.00
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: Cigna Commercial	$4,381.27
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 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: Scott and White EPO/PPO	$3,834.46
Rate for Payer: Scott and White Medicare	$2,072.68
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

sugammadex 100mg/2ml

Facility

$280.90

Service Code	HCPCS J3490
Hospital Charge Code	78353651
Hospital Revenue Code	250
Min. Negotiated Rate	$25.28
Max. Negotiated Rate	$202.25
Rate for Payer: Amerigroup CHIP/Medicaid	$25.28
Rate for Payer: BCBS of TX Blue Advantage	$84.27
Rate for Payer: BCBS of TX Blue Essentials	$101.12
Rate for Payer: BCBS of TX PPO	$112.36
Rate for Payer: Cash Price	$191.01
Rate for Payer: Cigna Medicaid	$202.25
Rate for Payer: Molina CHIP/Medicaid	$202.25
Rate for Payer: Multiplan Auto	$182.59
Rate for Payer: Multiplan Commercial	$182.59
Rate for Payer: Multiplan Workers Comp	$182.59
Rate for Payer: Parkland Medicaid	$202.25
Rate for Payer: Scott and White EPO/PPO	$140.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$202.25
Rate for Payer: Superior Health Plan EPO	$38.20

sugammadex 100mg/2ml

Facility

$280.90

Service Code	HCPCS J3490
Hospital Charge Code	78353651
Hospital Revenue Code	250
Rate for Payer: Cash Price	$191.01

sulfamethoxazole-trimethoprim 400 mg-80 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77833565
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

sulfamethoxazole-trimethoprim 400 mg-80 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77833565
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

sulfamethoxazole-trimethoprim 800 mg-160 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77833777
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

sulfamethoxazole-trimethoprim 800 mg-160 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77833777
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Soln

Facility

$128.00

Service Code	HCPCS j3490
Hospital Charge Code	77833614
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Soln

Facility

$128.00

Service Code	HCPCS j3490
Hospital Charge Code	77833614
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

Sulfonylurea Screen, QT SO

Facility

$281.00

Service Code	HCPCS 80377
Hospital Charge Code	1700005
Hospital Revenue Code	300
Rate for Payer: Cash Price	$191.08

Sulfonylurea Screen, QT SO

Facility

$281.00

Service Code	HCPCS 80377
Hospital Charge Code	1700005
Hospital Revenue Code	300
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$202.32
Rate for Payer: Amerigroup CHIP/Medicaid	$3.03
Rate for Payer: BCBS of TX Blue Advantage	$84.30
Rate for Payer: BCBS of TX Blue Essentials	$101.16
Rate for Payer: BCBS of TX PPO	$112.40
Rate for Payer: Cash Price	$191.08
Rate for Payer: Cash Price	$191.08
Rate for Payer: Cigna Medicaid	$202.32
Rate for Payer: Molina CHIP/Medicaid	$202.32
Rate for Payer: Multiplan Auto	$182.65
Rate for Payer: Multiplan Commercial	$182.65
Rate for Payer: Multiplan Workers Comp	$182.65
Rate for Payer: Parkland Medicaid	$202.32
Rate for Payer: Scott and White EPO/PPO	$140.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$202.32
Rate for Payer: Superior Health Plan EPO	$38.22

SUMAtriptan 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77834401
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

SUMAtriptan 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77834401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

SUMAtriptan 6 mg/0.5 mL Subcut Soln 0.5 mL

Facility

$128.00

Service Code	HCPCS J3030
Hospital Charge Code	77834607
Hospital Revenue Code	636
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$35.08
Rate for Payer: BCBS of TX Blue Essentials	$42.09
Rate for Payer: BCBS of TX PPO	$46.69
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

SUMAtriptan 6 mg/0.5 mL Subcut Soln 0.5 mL

Facility

$128.00

Service Code	HCPCS J3030
Hospital Charge Code	77834607
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

SUPERBAG SPECIMEN RETRIEVAL 7MMX140ML PNI0140

Facility

$165.66

Hospital Charge Code	8538535
Hospital Revenue Code	272
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$119.28
Rate for Payer: Amerigroup CHIP/Medicaid	$14.91
Rate for Payer: BCBS of TX Blue Advantage	$49.70
Rate for Payer: BCBS of TX Blue Essentials	$59.64
Rate for Payer: BCBS of TX PPO	$66.26
Rate for Payer: Cash Price	$112.65
Rate for Payer: Cigna Medicaid	$119.28
Rate for Payer: Molina CHIP/Medicaid	$119.28
Rate for Payer: Multiplan Auto	$107.68
Rate for Payer: Multiplan Commercial	$107.68
Rate for Payer: Multiplan Workers Comp	$107.68
Rate for Payer: Parkland Medicaid	$119.28
Rate for Payer: Scott and White EPO/PPO	$82.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$119.28
Rate for Payer: Superior Health Plan EPO	$22.53

SUPERBAG SPECIMEN RETRIEVAL 7MMX140ML PNI0140

Facility

$165.66

Hospital Charge Code	8538535
Hospital Revenue Code	272
Rate for Payer: Cash Price	$112.65

SUPERIOR VENACAVAGRAM

Facility

$2,529.00

Service Code	HCPCS 75827
Hospital Charge Code	4615828
Hospital Revenue Code	323
Rate for Payer: Cash Price	$1,719.72

SUPERIOR VENACAVAGRAM

Facility

$2,529.00

Service Code	HCPCS 75827
Hospital Charge Code	4615828
Hospital Revenue Code	323
Min. Negotiated Rate	$118.95
Max. Negotiated Rate	$3,342.63
Rate for Payer: Amerigroup CHIP/Medicaid	$118.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Amerigroup Medicare	$1,581.33
Rate for Payer: BCBS of TX Blue Advantage	$1,040.34
Rate for Payer: BCBS of TX Blue Essentials	$1,248.41
Rate for Payer: BCBS of TX Medicare	$1,581.33
Rate for Payer: BCBS of TX PPO	$1,393.43
Rate for Payer: Cash Price	$1,719.72
Rate for Payer: Cash Price	$1,719.72
Rate for Payer: Cash Price	$1,719.72
Rate for Payer: Cigna Commercial	$3,342.63
Rate for Payer: Cigna Medicaid	$1,820.88
Rate for Payer: Cigna Medicare	$1,581.33
Rate for Payer: Employer Direct Commercial	$1,581.33
Rate for Payer: Humana Medicare/TRICARE	$1,581.33
Rate for Payer: Molina CHIP/Medicaid	$1,820.88
Rate for Payer: Molina Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Molina Medicare	$1,581.33
Rate for Payer: Multiplan Auto	$1,643.85
Rate for Payer: Multiplan Commercial	$1,643.85
Rate for Payer: Multiplan Workers Comp	$1,643.85
Rate for Payer: Parkland Medicaid	$1,820.88
Rate for Payer: Scott and White EPO/PPO	$2,371.99
Rate for Payer: Scott and White Medicare	$1,581.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,820.88
Rate for Payer: Superior Health Plan EPO	$1,581.33
Rate for Payer: Superior Health Plan Medicare	$1,581.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Universal American Medicare	$1,581.33
Rate for Payer: Wellcare Medicare	$1,581.33
Rate for Payer: Wellmed Medicare	$1,581.33

Super Sani-Cloth Germicidal Wipes Large Canister 160/Cn

Facility

$109.64

Hospital Charge Code	992710
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.56

Super Sani-Cloth Germicidal Wipes Large Canister 160/Cn

Facility

$109.64

Hospital Charge Code	992710
Hospital Revenue Code	270
Min. Negotiated Rate	$9.87
Max. Negotiated Rate	$78.94
Rate for Payer: Amerigroup CHIP/Medicaid	$9.87
Rate for Payer: BCBS of TX Blue Advantage	$32.89
Rate for Payer: BCBS of TX Blue Essentials	$39.47
Rate for Payer: BCBS of TX PPO	$43.86
Rate for Payer: Cash Price	$74.56
Rate for Payer: Cigna Medicaid	$78.94
Rate for Payer: Molina CHIP/Medicaid	$78.94
Rate for Payer: Multiplan Auto	$71.27
Rate for Payer: Multiplan Commercial	$71.27
Rate for Payer: Multiplan Workers Comp	$71.27
Rate for Payer: Parkland Medicaid	$78.94
Rate for Payer: Scott and White EPO/PPO	$54.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$78.94
Rate for Payer: Superior Health Plan EPO	$14.91

Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s)

Facility

$21,622.80

Service Code	HCPCS 36253
Hospital Charge Code	991237
Hospital Revenue Code	480
Rate for Payer: Cash Price	$14,703.50

Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s)

Facility

$21,622.80

Service Code	HCPCS 36253
Hospital Charge Code	991237
Hospital Revenue Code	480
Min. Negotiated Rate	$1,946.05
Max. Negotiated Rate	$15,568.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1,946.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Amerigroup Medicare	$5,589.84
Rate for Payer: BCBS of TX Blue Advantage	$7,675.64
Rate for Payer: BCBS of TX Blue Essentials	$9,192.38
Rate for Payer: BCBS of TX Medicare	$5,589.84
Rate for Payer: BCBS of TX PPO	$11,582.40
Rate for Payer: Cash Price	$14,703.50
Rate for Payer: Cash Price	$14,703.50
Rate for Payer: Cash Price	$14,703.50
Rate for Payer: Cigna Commercial	$11,815.91
Rate for Payer: Cigna Medicaid	$15,568.42
Rate for Payer: Cigna Medicare	$5,589.84
Rate for Payer: Employer Direct Commercial	$5,589.84
Rate for Payer: Humana Medicare/TRICARE	$5,589.84
Rate for Payer: Molina CHIP/Medicaid	$15,568.42
Rate for Payer: Molina Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Molina Medicare	$5,589.84
Rate for Payer: Multiplan Auto	$14,054.82
Rate for Payer: Multiplan Commercial	$14,054.82
Rate for Payer: Multiplan Workers Comp	$14,054.82
Rate for Payer: Parkland Medicaid	$15,568.42
Rate for Payer: Scott and White EPO/PPO	$10,811.40
Rate for Payer: Scott and White Medicare	$5,589.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,568.42
Rate for Payer: Superior Health Plan EPO	$5,589.84
Rate for Payer: Superior Health Plan Medicare	$5,589.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Universal American Medicare	$5,589.84
Rate for Payer: Wellcare Medicare	$5,589.84
Rate for Payer: Wellmed Medicare	$5,589.84

Know your out-of-pocket cost for care.

All Charges