White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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
Rate for Payer: Cash Price	$299.46

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 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

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	$1,373.51
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 site by excision of open wounds, burn eschar, or scar each additional 100 sq cm

Facility

$7,316.92

Service Code	HCPCS 15003
Hospital Charge Code	994165
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,975.51

Surgical preparation site by excision of open wounds, burn eschar, or scar each additional 100 sq cm

Facility

$7,316.92

Service Code	HCPCS 15003
Hospital Charge Code	994165
Hospital Revenue Code	361
Min. Negotiated Rate	$658.52
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$658.52
Rate for Payer: BCBS of TX Blue Advantage	$2,195.08
Rate for Payer: BCBS of TX Blue Essentials	$2,634.09
Rate for Payer: BCBS of TX PPO	$2,926.77
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cigna Medicaid	$5,268.18
Rate for Payer: Molina CHIP/Medicaid	$5,268.18
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	$3,658.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,268.18
Rate for Payer: Superior Health Plan EPO	$995.10

SURGICAL SNOW 2X4

Facility

$398.24

Hospital Charge Code	8568493
Hospital Revenue Code	272
Min. Negotiated Rate	$35.84
Max. Negotiated Rate	$286.73
Rate for Payer: Amerigroup CHIP/Medicaid	$35.84
Rate for Payer: BCBS of TX Blue Advantage	$119.47
Rate for Payer: BCBS of TX Blue Essentials	$143.37
Rate for Payer: BCBS of TX PPO	$159.30
Rate for Payer: Cash Price	$270.80
Rate for Payer: Cigna Medicaid	$286.73
Rate for Payer: Molina CHIP/Medicaid	$286.73
Rate for Payer: Multiplan Auto	$258.86
Rate for Payer: Multiplan Commercial	$258.86
Rate for Payer: Multiplan Workers Comp	$258.86
Rate for Payer: Parkland Medicaid	$286.73
Rate for Payer: Scott and White EPO/PPO	$199.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$286.73
Rate for Payer: Superior Health Plan EPO	$54.16

SURGICAL SNOW 2X4

Facility

$398.24

Hospital Charge Code	8568493
Hospital Revenue Code	272
Rate for Payer: Cash Price	$270.80

Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous

Facility

$7,485.12

Service Code	HCPCS 46270
Hospital Charge Code	9900703
Hospital Revenue Code	360
Min. Negotiated Rate	$939.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$939.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,788.31
Rate for Payer: Amerigroup Medicare	$2,788.31
Rate for Payer: BCBS of TX Blue Advantage	$3,914.78
Rate for Payer: BCBS of TX Blue Essentials	$4,688.36
Rate for Payer: BCBS of TX Medicare	$2,788.31
Rate for Payer: BCBS of TX PPO	$5,907.33
Rate for Payer: Cash Price	$5,089.88
Rate for Payer: Cash Price	$5,089.88
Rate for Payer: Cash Price	$5,089.88
Rate for Payer: Cigna Commercial	$5,893.97
Rate for Payer: Cigna Medicaid	$5,389.29
Rate for Payer: Cigna Medicare	$2,788.31
Rate for Payer: Employer Direct Commercial	$2,788.31
Rate for Payer: Humana Medicare/TRICARE	$2,788.31
Rate for Payer: Molina CHIP/Medicaid	$5,389.29
Rate for Payer: Molina Dual Medicare/Medicaid	$2,788.31
Rate for Payer: Molina Medicare	$2,788.31
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	$5,389.29
Rate for Payer: Scott and White EPO/PPO	$5,158.37
Rate for Payer: Scott and White Medicare	$2,788.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,389.29
Rate for Payer: Superior Health Plan EPO	$2,788.31
Rate for Payer: Superior Health Plan Medicare	$2,788.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,788.31
Rate for Payer: Universal American Medicare	$2,788.31
Rate for Payer: Wellcare Medicare	$2,788.31
Rate for Payer: Wellmed Medicare	$2,788.31

Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous

Facility

$10,000.00

Service Code	CPT 46270
Hospital Charge Code	36046270
Hospital Revenue Code	360
Min. Negotiated Rate	$939.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$939.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,788.31
Rate for Payer: Amerigroup Medicare	$2,788.31
Rate for Payer: BCBS of TX Blue Advantage	$3,914.78
Rate for Payer: BCBS of TX Blue Essentials	$4,688.36
Rate for Payer: BCBS of TX Medicare	$2,788.31
Rate for Payer: BCBS of TX PPO	$5,907.33
Rate for Payer: Cigna Commercial	$5,893.97
Rate for Payer: Cigna Medicare	$2,788.31
Rate for Payer: Employer Direct Commercial	$2,788.31
Rate for Payer: Humana Medicare/TRICARE	$2,788.31
Rate for Payer: Molina Dual Medicare/Medicaid	$2,788.31
Rate for Payer: Molina Medicare	$2,788.31
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	$5,158.37
Rate for Payer: Scott and White Medicare	$2,788.31
Rate for Payer: Superior Health Plan EPO	$2,788.31
Rate for Payer: Superior Health Plan Medicare	$2,788.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,788.31
Rate for Payer: Universal American Medicare	$2,788.31
Rate for Payer: Wellcare Medicare	$2,788.31
Rate for Payer: Wellmed Medicare	$2,788.31

Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous

Facility

$7,485.12

Service Code	HCPCS 46270
Hospital Charge Code	9900703
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,089.88

surgicel hemostat 4 X 8 pad

Facility

$47.88

Service Code	HCPCS A9270
Hospital Charge Code	78921545
Hospital Revenue Code	272
Rate for Payer: Cash Price	$32.56

surgicel hemostat 4 X 8 pad

Facility

$47.88

Service Code	HCPCS A9270
Hospital Charge Code	78921545
Hospital Revenue Code	272
Min. Negotiated Rate	$4.31
Max. Negotiated Rate	$34.47
Rate for Payer: Amerigroup CHIP/Medicaid	$4.31
Rate for Payer: BCBS of TX Blue Advantage	$14.36
Rate for Payer: BCBS of TX Blue Essentials	$17.24
Rate for Payer: BCBS of TX PPO	$19.15
Rate for Payer: Cash Price	$32.56
Rate for Payer: Cigna Medicaid	$34.47
Rate for Payer: Molina CHIP/Medicaid	$34.47
Rate for Payer: Multiplan Auto	$31.12
Rate for Payer: Multiplan Commercial	$31.12
Rate for Payer: Multiplan Workers Comp	$31.12
Rate for Payer: Parkland Medicaid	$34.47
Rate for Payer: Scott and White EPO/PPO	$23.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.47
Rate for Payer: Superior Health Plan EPO	$6.51

SURISCREEN RED BLOOD-CELL. 8% REAGENT 3 X 10ML

Facility

$272.81

Hospital Charge Code	993715
Hospital Revenue Code	270
Min. Negotiated Rate	$24.55
Max. Negotiated Rate	$196.42
Rate for Payer: Amerigroup CHIP/Medicaid	$24.55
Rate for Payer: BCBS of TX Blue Advantage	$81.84
Rate for Payer: BCBS of TX Blue Essentials	$98.21
Rate for Payer: BCBS of TX PPO	$109.12
Rate for Payer: Cash Price	$185.51
Rate for Payer: Cigna Medicaid	$196.42
Rate for Payer: Molina CHIP/Medicaid	$196.42
Rate for Payer: Multiplan Auto	$177.33
Rate for Payer: Multiplan Commercial	$177.33
Rate for Payer: Multiplan Workers Comp	$177.33
Rate for Payer: Parkland Medicaid	$196.42
Rate for Payer: Scott and White EPO/PPO	$136.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$196.42
Rate for Payer: Superior Health Plan EPO	$37.10

SURISCREEN RED BLOOD-CELL. 8% REAGENT 3 X 10ML

Facility

$272.81

Hospital Charge Code	993715
Hospital Revenue Code	270
Rate for Payer: Cash Price	$185.51

SUT CATG I -- DHF

Facility

$245.68

Hospital Charge Code	81940819
Hospital Revenue Code	272
Rate for Payer: Cash Price	$167.06

SUT CATG I -- DHF

Facility

$245.68

Hospital Charge Code	81940819
Hospital Revenue Code	272
Min. Negotiated Rate	$22.11
Max. Negotiated Rate	$176.89
Rate for Payer: Amerigroup CHIP/Medicaid	$22.11
Rate for Payer: BCBS of TX Blue Advantage	$73.70
Rate for Payer: BCBS of TX Blue Essentials	$88.44
Rate for Payer: BCBS of TX PPO	$98.27
Rate for Payer: Cash Price	$167.06
Rate for Payer: Cigna Medicaid	$176.89
Rate for Payer: Molina CHIP/Medicaid	$176.89
Rate for Payer: Multiplan Auto	$159.69
Rate for Payer: Multiplan Commercial	$159.69
Rate for Payer: Multiplan Workers Comp	$159.69
Rate for Payer: Parkland Medicaid	$176.89
Rate for Payer: Scott and White EPO/PPO	$122.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$176.89
Rate for Payer: Superior Health Plan EPO	$33.41

SUT CLIP HEMO -- DHF

Facility

$544.80

Hospital Charge Code	81941106
Hospital Revenue Code	272
Min. Negotiated Rate	$49.03
Max. Negotiated Rate	$392.26
Rate for Payer: Amerigroup CHIP/Medicaid	$49.03
Rate for Payer: BCBS of TX Blue Advantage	$163.44
Rate for Payer: BCBS of TX Blue Essentials	$196.13
Rate for Payer: BCBS of TX PPO	$217.92
Rate for Payer: Cash Price	$370.46
Rate for Payer: Cigna Medicaid	$392.26
Rate for Payer: Molina CHIP/Medicaid	$392.26
Rate for Payer: Multiplan Auto	$354.12
Rate for Payer: Multiplan Commercial	$354.12
Rate for Payer: Multiplan Workers Comp	$354.12
Rate for Payer: Parkland Medicaid	$392.26
Rate for Payer: Scott and White EPO/PPO	$272.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$392.26
Rate for Payer: Superior Health Plan EPO	$74.09

SUT CLIP HEMO -- DHF

Facility

$544.80

Hospital Charge Code	81941106
Hospital Revenue Code	272
Rate for Payer: Cash Price	$370.46

SUT CLOS SLK -- DHF

Facility

$239.05

Hospital Charge Code	81941650
Hospital Revenue Code	272
Min. Negotiated Rate	$21.51
Max. Negotiated Rate	$172.12
Rate for Payer: Amerigroup CHIP/Medicaid	$21.51
Rate for Payer: BCBS of TX Blue Advantage	$71.72
Rate for Payer: BCBS of TX Blue Essentials	$86.06
Rate for Payer: BCBS of TX PPO	$95.62
Rate for Payer: Cash Price	$162.55
Rate for Payer: Cigna Medicaid	$172.12
Rate for Payer: Molina CHIP/Medicaid	$172.12
Rate for Payer: Multiplan Auto	$155.38
Rate for Payer: Multiplan Commercial	$155.38
Rate for Payer: Multiplan Workers Comp	$155.38
Rate for Payer: Parkland Medicaid	$172.12
Rate for Payer: Scott and White EPO/PPO	$119.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$172.12
Rate for Payer: Superior Health Plan EPO	$32.51

SUT CLOS SLK -- DHF

Facility

$239.05

Hospital Charge Code	81941650
Hospital Revenue Code	272
Rate for Payer: Cash Price	$162.55

SUT FIBERTAPE -- DHF

Facility

$490.32

Hospital Charge Code	81943334
Hospital Revenue Code	272
Rate for Payer: Cash Price	$333.42

Know your out-of-pocket cost for care.

All Charges