White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$12.99

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 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
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	$68.60
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

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

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	$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

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 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 FIBRILLAR 2X4

Facility

$485.00

Hospital Charge Code	8568494
Hospital Revenue Code	272
Min. Negotiated Rate	$43.65
Max. Negotiated Rate	$349.20
Rate for Payer: Amerigroup CHIP/Medicaid	$43.65
Rate for Payer: BCBS of TX Blue Advantage	$145.50
Rate for Payer: BCBS of TX Blue Essentials	$174.60
Rate for Payer: BCBS of TX PPO	$194.00
Rate for Payer: Cash Price	$329.80
Rate for Payer: Cigna Medicaid	$349.20
Rate for Payer: Molina CHIP/Medicaid	$349.20
Rate for Payer: Multiplan Auto	$315.25
Rate for Payer: Multiplan Commercial	$315.25
Rate for Payer: Multiplan Workers Comp	$315.25
Rate for Payer: Parkland Medicaid	$349.20
Rate for Payer: Scott and White EPO/PPO	$242.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$349.20
Rate for Payer: Superior Health Plan EPO	$65.96

SURGICAL FIBRILLAR 2X4

Facility

$485.00

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

SURGICAL HOOD TS2 00992040112

Facility

$124.85

Hospital Charge Code	144892
Hospital Revenue Code	270
Min. Negotiated Rate	$11.24
Max. Negotiated Rate	$89.89
Rate for Payer: Amerigroup CHIP/Medicaid	$11.24
Rate for Payer: BCBS of TX Blue Advantage	$37.45
Rate for Payer: BCBS of TX Blue Essentials	$44.95
Rate for Payer: BCBS of TX PPO	$49.94
Rate for Payer: Cash Price	$84.90
Rate for Payer: Cigna Medicaid	$89.89
Rate for Payer: Molina CHIP/Medicaid	$89.89
Rate for Payer: Multiplan Auto	$81.15
Rate for Payer: Multiplan Commercial	$81.15
Rate for Payer: Multiplan Workers Comp	$81.15
Rate for Payer: Parkland Medicaid	$89.89
Rate for Payer: Scott and White EPO/PPO	$62.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.89
Rate for Payer: Superior Health Plan EPO	$16.98

SURGICAL HOOD TS2 00992040112

Facility

$124.85

Hospital Charge Code	144892
Hospital Revenue Code	270
Rate for Payer: Cash Price	$84.90

Surgical irrigation tubesingle pack

Facility

$440.38

Hospital Charge Code	993410
Hospital Revenue Code	272
Min. Negotiated Rate	$39.63
Max. Negotiated Rate	$317.07
Rate for Payer: Amerigroup CHIP/Medicaid	$39.63
Rate for Payer: BCBS of TX Blue Advantage	$132.11
Rate for Payer: BCBS of TX Blue Essentials	$158.54
Rate for Payer: BCBS of TX PPO	$176.15
Rate for Payer: Cash Price	$299.46
Rate for Payer: Cigna Medicaid	$317.07
Rate for Payer: Molina CHIP/Medicaid	$317.07
Rate for Payer: Multiplan Auto	$286.25
Rate for Payer: Multiplan Commercial	$286.25
Rate for Payer: Multiplan Workers Comp	$286.25
Rate for Payer: Parkland Medicaid	$317.07
Rate for Payer: Scott and White EPO/PPO	$220.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$317.07
Rate for Payer: Superior Health Plan EPO	$59.89

Surgical irrigation tubesingle pack

Facility

$440.38

Hospital Charge Code	993410
Hospital Revenue Code	272
Rate for Payer: Cash Price	$299.46

Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar, trunk, arms, legs; First 100 sq. cm. (adults) or 1% of body area of infants & children

Facility

$7,316.92

Service Code	HCPCS 15002
Hospital Charge Code	994053
Hospital Revenue Code	361
Min. Negotiated Rate	$742.44
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$784.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
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	$742.44
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$5,268.18
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina CHIP/Medicaid	$5,268.18
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
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	$5,268.18
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,268.18
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar, trunk, arms, legs; First 100 sq. cm. (adults) or 1% of body area of infants & children

Facility

$7,316.92

Service Code	HCPCS 15002
Hospital Charge Code	994053
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,975.51

Know your out-of-pocket cost for care.

All Charges