White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$12,590.00

Service Code	HCPCS 36254
Hospital Charge Code	991238
Hospital Revenue Code	480
Rate for Payer: Cash Price	$8,561.20

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

Facility

$12,590.00

Service Code	HCPCS 36254
Hospital Charge Code	991238
Hospital Revenue Code	480
Min. Negotiated Rate	$1,133.10
Max. Negotiated Rate	$9,064.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1,133.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$8,561.20
Rate for Payer: Cash Price	$8,561.20
Rate for Payer: Cash Price	$8,561.20
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$9,064.80
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$9,064.80
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
Rate for Payer: Multiplan Auto	$8,183.50
Rate for Payer: Multiplan Commercial	$8,183.50
Rate for Payer: Multiplan Workers Comp	$8,183.50
Rate for Payer: Parkland Medicaid	$9,064.80
Rate for Payer: Scott and White EPO/PPO	$6,295.00
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,064.80
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

SUPER SHUTTLE

Facility

$342.54

Hospital Charge Code	992643
Hospital Revenue Code	272
Min. Negotiated Rate	$30.83
Max. Negotiated Rate	$246.63
Rate for Payer: Amerigroup CHIP/Medicaid	$30.83
Rate for Payer: BCBS of TX Blue Advantage	$102.76
Rate for Payer: BCBS of TX Blue Essentials	$123.31
Rate for Payer: BCBS of TX PPO	$137.02
Rate for Payer: Cash Price	$232.93
Rate for Payer: Cigna Medicaid	$246.63
Rate for Payer: Molina CHIP/Medicaid	$246.63
Rate for Payer: Multiplan Auto	$222.65
Rate for Payer: Multiplan Commercial	$222.65
Rate for Payer: Multiplan Workers Comp	$222.65
Rate for Payer: Parkland Medicaid	$246.63
Rate for Payer: Scott and White EPO/PPO	$171.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$246.63
Rate for Payer: Superior Health Plan EPO	$46.59

SUPER SHUTTLE

Facility

$342.54

Hospital Charge Code	992643
Hospital Revenue Code	272
Rate for Payer: Cash Price	$232.93

SUPPORT, ABDOMINAL ELASTIC 12' W 26-50 UNIVERSAL -- DHF

Facility

$53.51

Hospital Charge Code	80240104
Hospital Revenue Code	270
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$38.53
Rate for Payer: Amerigroup CHIP/Medicaid	$4.82
Rate for Payer: BCBS of TX Blue Advantage	$16.05
Rate for Payer: BCBS of TX Blue Essentials	$19.26
Rate for Payer: BCBS of TX PPO	$21.40
Rate for Payer: Cash Price	$36.39
Rate for Payer: Cigna Medicaid	$38.53
Rate for Payer: Molina CHIP/Medicaid	$38.53
Rate for Payer: Multiplan Auto	$34.78
Rate for Payer: Multiplan Commercial	$34.78
Rate for Payer: Multiplan Workers Comp	$34.78
Rate for Payer: Parkland Medicaid	$38.53
Rate for Payer: Scott and White EPO/PPO	$26.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.53
Rate for Payer: Superior Health Plan EPO	$7.28

SUPPORT, ABDOMINAL ELASTIC 12' W 26-50 UNIVERSAL -- DHF

Facility

$53.51

Hospital Charge Code	80240104
Hospital Revenue Code	270
Rate for Payer: Cash Price	$36.39

support breast

Facility

$174.52

Hospital Charge Code	80931702
Hospital Revenue Code	274
Min. Negotiated Rate	$15.71
Max. Negotiated Rate	$125.65
Rate for Payer: Amerigroup CHIP/Medicaid	$15.71
Rate for Payer: BCBS of TX Blue Advantage	$52.36
Rate for Payer: BCBS of TX Blue Essentials	$62.83
Rate for Payer: BCBS of TX PPO	$69.81
Rate for Payer: Cash Price	$118.67
Rate for Payer: Cigna Medicaid	$125.65
Rate for Payer: Molina CHIP/Medicaid	$125.65
Rate for Payer: Multiplan Auto	$87.26
Rate for Payer: Multiplan Commercial	$87.26
Rate for Payer: Multiplan Workers Comp	$87.26
Rate for Payer: Parkland Medicaid	$125.65
Rate for Payer: Scott and White EPO/PPO	$87.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.65
Rate for Payer: Superior Health Plan EPO	$23.73

support breast

Facility

$174.52

Hospital Charge Code	80931702
Hospital Revenue Code	274
Min. Negotiated Rate	$43.63
Max. Negotiated Rate	$87.26
Rate for Payer: Cash Price	$118.67
Rate for Payer: Cigna Commercial	$43.63
Rate for Payer: Multiplan Auto	$87.26
Rate for Payer: Multiplan Commercial	$87.26
Rate for Payer: Multiplan Workers Comp	$87.26
Rate for Payer: Scott and White EPO/PPO	$87.26

SUPPORT HEAD SLOTTED POSITIONER ADULT

Facility

$19.10

Hospital Charge Code	993044
Hospital Revenue Code	270
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$13.75
Rate for Payer: Amerigroup CHIP/Medicaid	$1.72
Rate for Payer: BCBS of TX Blue Advantage	$5.73
Rate for Payer: BCBS of TX Blue Essentials	$6.88
Rate for Payer: BCBS of TX PPO	$7.64
Rate for Payer: Cash Price	$12.99
Rate for Payer: Cigna Medicaid	$13.75
Rate for Payer: Molina CHIP/Medicaid	$13.75
Rate for Payer: Multiplan Auto	$12.41
Rate for Payer: Multiplan Commercial	$12.41
Rate for Payer: Multiplan Workers Comp	$12.41
Rate for Payer: Parkland Medicaid	$13.75
Rate for Payer: Scott and White EPO/PPO	$9.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.75
Rate for Payer: Superior Health Plan EPO	$2.60

SUPPORT HEAD SLOTTED POSITIONER ADULT

Facility

$19.10

Hospital Charge Code	993044
Hospital Revenue Code	270
Rate for Payer: Cash Price	$12.99

support scrotal

Facility

$43.77

Hospital Charge Code	80341456
Hospital Revenue Code	270
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$31.51
Rate for Payer: Amerigroup CHIP/Medicaid	$3.94
Rate for Payer: BCBS of TX Blue Advantage	$13.13
Rate for Payer: BCBS of TX Blue Essentials	$15.76
Rate for Payer: BCBS of TX PPO	$17.51
Rate for Payer: Cash Price	$29.76
Rate for Payer: Cigna Medicaid	$31.51
Rate for Payer: Molina CHIP/Medicaid	$31.51
Rate for Payer: Multiplan Auto	$28.45
Rate for Payer: Multiplan Commercial	$28.45
Rate for Payer: Multiplan Workers Comp	$28.45
Rate for Payer: Parkland Medicaid	$31.51
Rate for Payer: Scott and White EPO/PPO	$21.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.51
Rate for Payer: Superior Health Plan EPO	$5.95

support scrotal

Facility

$43.77

Hospital Charge Code	80341456
Hospital Revenue Code	270
Rate for Payer: Cash Price	$29.76

SUPPORT, WRIST/FOREARM UNIV, LEFT

Facility

$188.67

Hospital Charge Code	993094
Hospital Revenue Code	270
Min. Negotiated Rate	$16.98
Max. Negotiated Rate	$135.84
Rate for Payer: Amerigroup CHIP/Medicaid	$16.98
Rate for Payer: BCBS of TX Blue Advantage	$56.60
Rate for Payer: BCBS of TX Blue Essentials	$67.92
Rate for Payer: BCBS of TX PPO	$75.47
Rate for Payer: Cash Price	$128.30
Rate for Payer: Cigna Medicaid	$135.84
Rate for Payer: Molina CHIP/Medicaid	$135.84
Rate for Payer: Multiplan Auto	$122.64
Rate for Payer: Multiplan Commercial	$122.64
Rate for Payer: Multiplan Workers Comp	$122.64
Rate for Payer: Parkland Medicaid	$135.84
Rate for Payer: Scott and White EPO/PPO	$94.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.84
Rate for Payer: Superior Health Plan EPO	$25.66

SUPPORT, WRIST/FOREARM UNIV, LEFT

Facility

$188.67

Hospital Charge Code	993094
Hospital Revenue Code	270
Rate for Payer: Cash Price	$128.30

Surfactant Administration Units

Facility

$176.00

Service Code	HCPCS 94610
Hospital Charge Code	5504610
Hospital Revenue Code	460
Rate for Payer: Cash Price	$119.68

Surfactant Administration Units

Facility

$176.00

Service Code	HCPCS 94610
Hospital Charge Code	5504610
Hospital Revenue Code	460
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$464.99
Rate for Payer: Amerigroup CHIP/Medicaid	$15.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$219.97
Rate for Payer: Amerigroup Medicare	$219.97
Rate for Payer: BCBS of TX Blue Advantage	$52.80
Rate for Payer: BCBS of TX Blue Essentials	$63.36
Rate for Payer: BCBS of TX Medicare	$219.97
Rate for Payer: BCBS of TX PPO	$70.40
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cigna Commercial	$464.99
Rate for Payer: Cigna Medicaid	$126.72
Rate for Payer: Cigna Medicare	$219.97
Rate for Payer: Employer Direct Commercial	$219.97
Rate for Payer: Humana Medicare/TRICARE	$219.97
Rate for Payer: Molina CHIP/Medicaid	$126.72
Rate for Payer: Molina Dual Medicare/Medicaid	$219.97
Rate for Payer: Molina Medicare	$219.97
Rate for Payer: Multiplan Auto	$114.40
Rate for Payer: Multiplan Commercial	$114.40
Rate for Payer: Multiplan Workers Comp	$114.40
Rate for Payer: Parkland Medicaid	$126.72
Rate for Payer: Scott and White EPO/PPO	$88.00
Rate for Payer: Scott and White Medicare	$219.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.72
Rate for Payer: Superior Health Plan EPO	$219.97
Rate for Payer: Superior Health Plan Medicare	$219.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$219.97
Rate for Payer: Universal American Medicare	$219.97
Rate for Payer: Wellcare Medicare	$219.97
Rate for Payer: Wellmed Medicare	$219.97

SURFIX SS SCREW+CAP DIA 3.5 L16MM STER

Facility

$2,771.08

Service Code	HCPCS C1713
Hospital Charge Code	992403
Hospital Revenue Code	278
Min. Negotiated Rate	$249.40
Max. Negotiated Rate	$1,995.18
Rate for Payer: Amerigroup CHIP/Medicaid	$249.40
Rate for Payer: BCBS of TX Blue Advantage	$831.32
Rate for Payer: BCBS of TX Blue Essentials	$997.59
Rate for Payer: BCBS of TX PPO	$1,108.43
Rate for Payer: Cash Price	$1,884.33
Rate for Payer: Cigna Medicaid	$1,995.18
Rate for Payer: Molina CHIP/Medicaid	$1,995.18
Rate for Payer: Multiplan Auto	$1,385.54
Rate for Payer: Multiplan Commercial	$1,385.54
Rate for Payer: Multiplan Workers Comp	$1,385.54
Rate for Payer: Parkland Medicaid	$1,995.18
Rate for Payer: Scott and White EPO/PPO	$1,385.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,995.18
Rate for Payer: Superior Health Plan EPO	$376.87

SURFIX SS SCREW+CAP DIA 3.5 L16MM STER

Facility

$2,771.08

Service Code	HCPCS C1713
Hospital Charge Code	992403
Hospital Revenue Code	278
Min. Negotiated Rate	$692.77
Max. Negotiated Rate	$1,385.54
Rate for Payer: Cash Price	$1,884.33
Rate for Payer: Cigna Commercial	$692.77
Rate for Payer: Multiplan Auto	$1,385.54
Rate for Payer: Multiplan Commercial	$1,385.54
Rate for Payer: Multiplan Workers Comp	$1,385.54
Rate for Payer: Scott and White EPO/PPO	$1,385.54

SURFIX SS SCREW+CAP DIA 3.5 L20MM STER

Facility

$2,771.08

Service Code	HCPCS C1713
Hospital Charge Code	992404
Hospital Revenue Code	278
Min. Negotiated Rate	$692.77
Max. Negotiated Rate	$1,385.54
Rate for Payer: Cash Price	$1,884.33
Rate for Payer: Cigna Commercial	$692.77
Rate for Payer: Multiplan Auto	$1,385.54
Rate for Payer: Multiplan Commercial	$1,385.54
Rate for Payer: Multiplan Workers Comp	$1,385.54
Rate for Payer: Scott and White EPO/PPO	$1,385.54

SURFIX SS SCREW+CAP DIA 3.5 L20MM STER

Facility

$2,771.08

Service Code	HCPCS C1713
Hospital Charge Code	992404
Hospital Revenue Code	278
Min. Negotiated Rate	$249.40
Max. Negotiated Rate	$1,995.18
Rate for Payer: Amerigroup CHIP/Medicaid	$249.40
Rate for Payer: BCBS of TX Blue Advantage	$831.32
Rate for Payer: BCBS of TX Blue Essentials	$997.59
Rate for Payer: BCBS of TX PPO	$1,108.43
Rate for Payer: Cash Price	$1,884.33
Rate for Payer: Cigna Medicaid	$1,995.18
Rate for Payer: Molina CHIP/Medicaid	$1,995.18
Rate for Payer: Multiplan Auto	$1,385.54
Rate for Payer: Multiplan Commercial	$1,385.54
Rate for Payer: Multiplan Workers Comp	$1,385.54
Rate for Payer: Parkland Medicaid	$1,995.18
Rate for Payer: Scott and White EPO/PPO	$1,385.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,995.18
Rate for Payer: Superior Health Plan EPO	$376.87

SURFIX SS SCREW+CAP DIA 3.5 L22MM STER

Facility

$2,771.08

Service Code	HCPCS C1713
Hospital Charge Code	992405
Hospital Revenue Code	278
Min. Negotiated Rate	$692.77
Max. Negotiated Rate	$1,385.54
Rate for Payer: Cash Price	$1,884.33
Rate for Payer: Cigna Commercial	$692.77
Rate for Payer: Multiplan Auto	$1,385.54
Rate for Payer: Multiplan Commercial	$1,385.54
Rate for Payer: Multiplan Workers Comp	$1,385.54
Rate for Payer: Scott and White EPO/PPO	$1,385.54

SURFIX SS SCREW+CAP DIA 3.5 L22MM STER

Facility

$2,771.08

Service Code	HCPCS C1713
Hospital Charge Code	992405
Hospital Revenue Code	278
Min. Negotiated Rate	$249.40
Max. Negotiated Rate	$1,995.18
Rate for Payer: Amerigroup CHIP/Medicaid	$249.40
Rate for Payer: BCBS of TX Blue Advantage	$831.32
Rate for Payer: BCBS of TX Blue Essentials	$997.59
Rate for Payer: BCBS of TX PPO	$1,108.43
Rate for Payer: Cash Price	$1,884.33
Rate for Payer: Cigna Medicaid	$1,995.18
Rate for Payer: Molina CHIP/Medicaid	$1,995.18
Rate for Payer: Multiplan Auto	$1,385.54
Rate for Payer: Multiplan Commercial	$1,385.54
Rate for Payer: Multiplan Workers Comp	$1,385.54
Rate for Payer: Parkland Medicaid	$1,995.18
Rate for Payer: Scott and White EPO/PPO	$1,385.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,995.18
Rate for Payer: Superior Health Plan EPO	$376.87

Surgical boot/shoe, each

Facility

$150.00

Service Code	HCPCS L3260
Hospital Charge Code	990949
Hospital Revenue Code	272
Rate for Payer: Cash Price	$102.00

Surgical boot/shoe, each

Facility

$150.00

Service Code	HCPCS L3260
Hospital Charge Code	990949
Hospital Revenue Code	272
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$108.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.50
Rate for Payer: BCBS of TX Blue Advantage	$45.00
Rate for Payer: BCBS of TX Blue Essentials	$54.00
Rate for Payer: BCBS of TX PPO	$60.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cigna Medicaid	$108.00
Rate for Payer: Molina CHIP/Medicaid	$108.00
Rate for Payer: Multiplan Auto	$97.50
Rate for Payer: Multiplan Commercial	$97.50
Rate for Payer: Multiplan Workers Comp	$97.50
Rate for Payer: Parkland Medicaid	$108.00
Rate for Payer: Scott and White EPO/PPO	$75.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.00
Rate for Payer: Superior Health Plan EPO	$20.40

SURGICAL FIBRILLAR 2X4

Facility

$485.00

Hospital Charge Code	8568494
Hospital Revenue Code	272
Rate for Payer: Cash Price	$329.80

Know your out-of-pocket cost for care.

All Charges