White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SWABSTICK, PVP-1,3/PK

Facility

$0.27

Hospital Charge Code	992919
Hospital Revenue Code	270
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.19
Rate for Payer: Amerigroup CHIP/Medicaid	$0.02
Rate for Payer: BCBS of TX Blue Advantage	$0.08
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.11
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna Medicaid	$0.19
Rate for Payer: Molina CHIP/Medicaid	$0.19
Rate for Payer: Multiplan Auto	$0.18
Rate for Payer: Multiplan Commercial	$0.18
Rate for Payer: Multiplan Workers Comp	$0.18
Rate for Payer: Parkland Medicaid	$0.19
Rate for Payer: Scott and White EPO/PPO	$0.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.19
Rate for Payer: Superior Health Plan EPO	$0.04

SWABSTICK, PVP-1,3/PK

Facility

$0.27

Hospital Charge Code	992919
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.18

SWAB TINCTURE BENZOIN STERILE

Facility

$9.41

Hospital Charge Code	993597
Hospital Revenue Code	270
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$6.78
Rate for Payer: Amerigroup CHIP/Medicaid	$0.85
Rate for Payer: BCBS of TX Blue Advantage	$2.82
Rate for Payer: BCBS of TX Blue Essentials	$3.39
Rate for Payer: BCBS of TX PPO	$3.76
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna Medicaid	$6.78
Rate for Payer: Molina CHIP/Medicaid	$6.78
Rate for Payer: Multiplan Auto	$6.12
Rate for Payer: Multiplan Commercial	$6.12
Rate for Payer: Multiplan Workers Comp	$6.12
Rate for Payer: Parkland Medicaid	$6.78
Rate for Payer: Scott and White EPO/PPO	$4.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.78
Rate for Payer: Superior Health Plan EPO	$1.28

SWAB TINCTURE BENZOIN STERILE

Facility

$9.41

Hospital Charge Code	993597
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.40

SWEEN CRM -- DHF

Facility

$110.27

Hospital Charge Code	80343551
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.98

SWEEN CRM -- DHF

Facility

$110.27

Hospital Charge Code	80343551
Hospital Revenue Code	270
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$79.39
Rate for Payer: Amerigroup CHIP/Medicaid	$9.92
Rate for Payer: BCBS of TX Blue Advantage	$33.08
Rate for Payer: BCBS of TX Blue Essentials	$39.70
Rate for Payer: BCBS of TX PPO	$44.11
Rate for Payer: Cash Price	$74.98
Rate for Payer: Cigna Medicaid	$79.39
Rate for Payer: Molina CHIP/Medicaid	$79.39
Rate for Payer: Multiplan Auto	$71.68
Rate for Payer: Multiplan Commercial	$71.68
Rate for Payer: Multiplan Workers Comp	$71.68
Rate for Payer: Parkland Medicaid	$79.39
Rate for Payer: Scott and White EPO/PPO	$55.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.39
Rate for Payer: Superior Health Plan EPO	$15.00

SWITCHING STICK

Facility

$774.43

Hospital Charge Code	8414480
Hospital Revenue Code	272
Rate for Payer: Cash Price	$526.61

SWITCHING STICK

Facility

$774.43

Hospital Charge Code	8414480
Hospital Revenue Code	272
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$557.59
Rate for Payer: Amerigroup CHIP/Medicaid	$69.70
Rate for Payer: BCBS of TX Blue Advantage	$232.33
Rate for Payer: BCBS of TX Blue Essentials	$278.79
Rate for Payer: BCBS of TX PPO	$309.77
Rate for Payer: Cash Price	$526.61
Rate for Payer: Cigna Medicaid	$557.59
Rate for Payer: Molina CHIP/Medicaid	$557.59
Rate for Payer: Multiplan Auto	$503.38
Rate for Payer: Multiplan Commercial	$503.38
Rate for Payer: Multiplan Workers Comp	$503.38
Rate for Payer: Parkland Medicaid	$557.59
Rate for Payer: Scott and White EPO/PPO	$387.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$557.59
Rate for Payer: Superior Health Plan EPO	$105.32

SYDESMOSIS PLATE ORTHOLOC 3DI PLATING SYSTEM

Facility

$3,783.13

Service Code	HCPCS C1713
Hospital Charge Code	992271
Hospital Revenue Code	278
Min. Negotiated Rate	$945.78
Max. Negotiated Rate	$1,891.57
Rate for Payer: Cash Price	$2,572.53
Rate for Payer: Cigna Commercial	$945.78
Rate for Payer: Multiplan Auto	$1,891.57
Rate for Payer: Multiplan Commercial	$1,891.57
Rate for Payer: Multiplan Workers Comp	$1,891.57
Rate for Payer: Scott and White EPO/PPO	$1,891.57

SYDESMOSIS PLATE ORTHOLOC 3DI PLATING SYSTEM

Facility

$3,783.13

Service Code	HCPCS C1713
Hospital Charge Code	992271
Hospital Revenue Code	278
Min. Negotiated Rate	$340.48
Max. Negotiated Rate	$2,723.85
Rate for Payer: Amerigroup CHIP/Medicaid	$340.48
Rate for Payer: BCBS of TX Blue Advantage	$1,134.94
Rate for Payer: BCBS of TX Blue Essentials	$1,361.93
Rate for Payer: BCBS of TX PPO	$1,513.25
Rate for Payer: Cash Price	$2,572.53
Rate for Payer: Cigna Medicaid	$2,723.85
Rate for Payer: Molina CHIP/Medicaid	$2,723.85
Rate for Payer: Multiplan Auto	$1,891.57
Rate for Payer: Multiplan Commercial	$1,891.57
Rate for Payer: Multiplan Workers Comp	$1,891.57
Rate for Payer: Parkland Medicaid	$2,723.85
Rate for Payer: Scott and White EPO/PPO	$1,891.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,723.85
Rate for Payer: Superior Health Plan EPO	$514.51

Sympathectomy; digital arteries, each digit

Facility

$9,198.15

Service Code	HCPCS 64820
Hospital Charge Code	9900848
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cash Price	$6,254.74
Rate for Payer: Cash Price	$6,254.74
Rate for Payer: Cash Price	$6,254.74
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$6,622.67
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$6,622.67
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$6,622.67
Rate for Payer: Scott and White EPO/PPO	$3,629.00
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,622.67
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Sympathectomy; digital arteries, each digit

Facility

$10,000.00

Service Code	CPT 64820
Hospital Charge Code	36064820
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$3,629.00
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Sympathectomy; digital arteries, each digit

Facility

$9,198.15

Service Code	HCPCS 64820
Hospital Charge Code	9900848
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,254.74

Sympathectomy; ulnar artery

Facility

$12,336.12

Service Code	HCPCS 64822
Hospital Charge Code	9900849
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,388.56

Sympathectomy; ulnar artery

Facility

$10,000.00

Service Code	CPT 64822
Hospital Charge Code	36064822
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Sympathectomy; ulnar artery

Facility

$12,336.12

Service Code	HCPCS 64822
Hospital Charge Code	9900849
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$8,882.01
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$8,882.01
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$8,882.01
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,882.01
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

SYMPHION FLUID MANAGMENT KIT FG-0202

Facility

$1,811.46

Hospital Charge Code	145145
Hospital Revenue Code	272
Min. Negotiated Rate	$163.03
Max. Negotiated Rate	$1,304.25
Rate for Payer: Amerigroup CHIP/Medicaid	$163.03
Rate for Payer: BCBS of TX Blue Advantage	$543.44
Rate for Payer: BCBS of TX Blue Essentials	$652.13
Rate for Payer: BCBS of TX PPO	$724.58
Rate for Payer: Cash Price	$1,231.79
Rate for Payer: Cigna Medicaid	$1,304.25
Rate for Payer: Molina CHIP/Medicaid	$1,304.25
Rate for Payer: Multiplan Auto	$1,177.45
Rate for Payer: Multiplan Commercial	$1,177.45
Rate for Payer: Multiplan Workers Comp	$1,177.45
Rate for Payer: Parkland Medicaid	$1,304.25
Rate for Payer: Scott and White EPO/PPO	$905.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,304.25
Rate for Payer: Superior Health Plan EPO	$246.36

SYMPHION FLUID MANAGMENT KIT FG-0202

Facility

$1,811.46

Hospital Charge Code	145145
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,231.79

SYMPHION RESECTING DEVICE FG-0201

Facility

$4,535.46

Hospital Charge Code	145144
Hospital Revenue Code	272
Min. Negotiated Rate	$408.19
Max. Negotiated Rate	$3,265.53
Rate for Payer: Amerigroup CHIP/Medicaid	$408.19
Rate for Payer: BCBS of TX Blue Advantage	$1,360.64
Rate for Payer: BCBS of TX Blue Essentials	$1,632.77
Rate for Payer: BCBS of TX PPO	$1,814.18
Rate for Payer: Cash Price	$3,084.11
Rate for Payer: Cigna Medicaid	$3,265.53
Rate for Payer: Molina CHIP/Medicaid	$3,265.53
Rate for Payer: Multiplan Auto	$2,948.05
Rate for Payer: Multiplan Commercial	$2,948.05
Rate for Payer: Multiplan Workers Comp	$2,948.05
Rate for Payer: Parkland Medicaid	$3,265.53
Rate for Payer: Scott and White EPO/PPO	$2,267.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,265.53
Rate for Payer: Superior Health Plan EPO	$616.82

SYMPHION RESECTING DEVICE FG-0201

Facility

$4,535.46

Hospital Charge Code	145144
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,084.11

SYNCOPE AND COLLAPSE

Facility

$16,560.40

Service Code	MSDRG 312
Min. Negotiated Rate	$6,892.90
Max. Negotiated Rate	$16,560.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,148.05
Rate for Payer: Amerigroup Medicare	$11,148.05
Rate for Payer: BCBS of TX Medicare	$11,148.05
Rate for Payer: Cigna Commercial	$11,226.21
Rate for Payer: Cigna Medicare	$11,148.05
Rate for Payer: Employer Direct Commercial	$11,148.05
Rate for Payer: Humana Medicare/TRICARE	$11,148.05
Rate for Payer: Molina Dual Medicare/Medicaid	$11,148.05
Rate for Payer: Molina Medicare	$11,148.05
Rate for Payer: Multiplan Auto	$16,560.40
Rate for Payer: Multiplan Commercial	$16,560.40
Rate for Payer: Multiplan Workers Comp	$16,560.40
Rate for Payer: Scott and White EPO/PPO	$7,626.50
Rate for Payer: Scott and White Medicare	$11,148.05
Rate for Payer: Superior Health Plan EPO	$11,148.05
Rate for Payer: Superior Health Plan Medicare	$11,148.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,148.05
Rate for Payer: Universal American Medicare	$11,148.05
Rate for Payer: Wellcare Medicare	$11,148.05
Rate for Payer: Wellmed Medicare	$11,148.05

SYNCOPE AND COLLAPSE

Facility

$2,430.23

Service Code	APR-DRG 2041
Min. Negotiated Rate	$2,291.30
Max. Negotiated Rate	$2,430.23
Rate for Payer: Amerigroup CHIP/Medicaid	$2,291.30
Rate for Payer: Cigna Medicaid	$2,291.30
Rate for Payer: Molina CHIP/Medicaid	$2,291.30
Rate for Payer: Parkland Medicaid	$2,291.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,430.23

SYNCOPE AND COLLAPSE

Facility

$3,536.15

Service Code	APR-DRG 2043
Min. Negotiated Rate	$3,334.00
Max. Negotiated Rate	$3,536.15
Rate for Payer: Amerigroup CHIP/Medicaid	$3,334.00
Rate for Payer: Cigna Medicaid	$3,334.00
Rate for Payer: Molina CHIP/Medicaid	$3,334.00
Rate for Payer: Parkland Medicaid	$3,334.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,536.15

SYNCOPE AND COLLAPSE

Facility

$3,215.91

Service Code	APR-DRG 2042
Min. Negotiated Rate	$3,032.08
Max. Negotiated Rate	$3,215.91
Rate for Payer: Amerigroup CHIP/Medicaid	$3,032.08
Rate for Payer: Cigna Medicaid	$3,032.08
Rate for Payer: Molina CHIP/Medicaid	$3,032.08
Rate for Payer: Parkland Medicaid	$3,032.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,215.91

SYNCOPE AND COLLAPSE

Facility

$11,780.74

Service Code	APR-DRG 2044
Min. Negotiated Rate	$11,107.30
Max. Negotiated Rate	$11,780.74
Rate for Payer: Amerigroup CHIP/Medicaid	$11,107.30
Rate for Payer: Cigna Medicaid	$11,107.30
Rate for Payer: Molina CHIP/Medicaid	$11,107.30
Rate for Payer: Parkland Medicaid	$11,107.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,780.74

Know your out-of-pocket cost for care.

All Charges