White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction,

Facility

$10,000.00

Service Code	CPT 26135
Hospital Charge Code	36026135
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	$5,476.44
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

Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction,

Facility

$13,200.00

Service Code	HCPCS 26135
Hospital Charge Code	9900322
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	$8,976.00
Rate for Payer: Cash Price	$8,976.00
Rate for Payer: Cash Price	$8,976.00
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$9,504.00
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	$9,504.00
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	$9,504.00
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,504.00
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

Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction,

Facility

$13,200.00

Service Code	HCPCS 26135
Hospital Charge Code	9900322
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,976.00

Synovectomy, tendon sheath, foot; flexor

Facility

$7,783.60

Service Code	HCPCS 28086
Hospital Charge Code	9900468
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,292.85

Synovectomy, tendon sheath, foot; flexor

Facility

$10,000.00

Service Code	CPT 28086
Hospital Charge Code	36028086
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	$5,476.44
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

Synovectomy, tendon sheath, foot; flexor

Facility

$7,783.60

Service Code	HCPCS 28086
Hospital Charge Code	9900468
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	$5,292.85
Rate for Payer: Cash Price	$5,292.85
Rate for Payer: Cash Price	$5,292.85
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$5,604.19
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	$5,604.19
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	$5,604.19
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,604.19
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

Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendo

Facility

$8,354.10

Service Code	HCPCS 26145
Hospital Charge Code	9900323
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,680.79

Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendo

Facility

$10,000.00

Service Code	CPT 26145
Hospital Charge Code	36026145
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendo

Facility

$8,354.10

Service Code	HCPCS 26145
Hospital Charge Code	9900323
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cash Price	$5,680.79
Rate for Payer: Cash Price	$5,680.79
Rate for Payer: Cash Price	$5,680.79
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$6,014.95
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina CHIP/Medicaid	$6,014.95
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$6,014.95
Rate for Payer: Scott and White EPO/PPO	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,014.95
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

Synthetic undercast

Facility

$5.50

Hospital Charge Code	993753
Hospital Revenue Code	271
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$3.96
Rate for Payer: Amerigroup CHIP/Medicaid	$0.50
Rate for Payer: BCBS of TX Blue Advantage	$1.65
Rate for Payer: BCBS of TX Blue Essentials	$1.98
Rate for Payer: BCBS of TX PPO	$2.20
Rate for Payer: Cash Price	$3.74
Rate for Payer: Cigna Medicaid	$3.96
Rate for Payer: Molina CHIP/Medicaid	$3.96
Rate for Payer: Multiplan Auto	$3.58
Rate for Payer: Multiplan Commercial	$3.58
Rate for Payer: Multiplan Workers Comp	$3.58
Rate for Payer: Parkland Medicaid	$3.96
Rate for Payer: Scott and White EPO/PPO	$2.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.96
Rate for Payer: Superior Health Plan EPO	$0.75

Synthetic undercast

Facility

$5.50

Hospital Charge Code	993753
Hospital Revenue Code	271
Rate for Payer: Cash Price	$3.74

SYRGE, MALE, LUER-LOK, 3ML, STERILE DISP

Facility

$0.49

Hospital Charge Code	993234
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.33

SYRGE, MALE, LUER-LOK, 3ML, STERILE DISP

Facility

$0.49

Hospital Charge Code	993234
Hospital Revenue Code	270
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.35
Rate for Payer: Amerigroup CHIP/Medicaid	$0.04
Rate for Payer: BCBS of TX Blue Advantage	$0.15
Rate for Payer: BCBS of TX Blue Essentials	$0.18
Rate for Payer: BCBS of TX PPO	$0.20
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna Medicaid	$0.35
Rate for Payer: Molina CHIP/Medicaid	$0.35
Rate for Payer: Multiplan Auto	$0.32
Rate for Payer: Multiplan Commercial	$0.32
Rate for Payer: Multiplan Workers Comp	$0.32
Rate for Payer: Parkland Medicaid	$0.35
Rate for Payer: Scott and White EPO/PPO	$0.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.35
Rate for Payer: Superior Health Plan EPO	$0.07

SYRINGE 10ML LF STRL LL TIP DISP MED

Facility

$2.44

Hospital Charge Code	993035
Hospital Revenue Code	270
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$1.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.22
Rate for Payer: BCBS of TX Blue Advantage	$0.73
Rate for Payer: BCBS of TX Blue Essentials	$0.88
Rate for Payer: BCBS of TX PPO	$0.98
Rate for Payer: Cash Price	$1.66
Rate for Payer: Cigna Medicaid	$1.76
Rate for Payer: Molina CHIP/Medicaid	$1.76
Rate for Payer: Multiplan Auto	$1.59
Rate for Payer: Multiplan Commercial	$1.59
Rate for Payer: Multiplan Workers Comp	$1.59
Rate for Payer: Parkland Medicaid	$1.76
Rate for Payer: Scott and White EPO/PPO	$1.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.76
Rate for Payer: Superior Health Plan EPO	$0.33

SYRINGE 10ML LF STRL LL TIP DISP MED

Facility

$2.44

Hospital Charge Code	993035
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.66

SYRINGE, 30ML, LUER-LOK TIP, DISPOSABLE

Facility

$1.87

Hospital Charge Code	993747
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1.27

SYRINGE, 30ML, LUER-LOK TIP, DISPOSABLE

Facility

$1.87

Hospital Charge Code	993747
Hospital Revenue Code	272
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$1.35
Rate for Payer: Amerigroup CHIP/Medicaid	$0.17
Rate for Payer: BCBS of TX Blue Advantage	$0.56
Rate for Payer: BCBS of TX Blue Essentials	$0.67
Rate for Payer: BCBS of TX PPO	$0.75
Rate for Payer: Cash Price	$1.27
Rate for Payer: Cigna Medicaid	$1.35
Rate for Payer: Molina CHIP/Medicaid	$1.35
Rate for Payer: Multiplan Auto	$1.22
Rate for Payer: Multiplan Commercial	$1.22
Rate for Payer: Multiplan Workers Comp	$1.22
Rate for Payer: Parkland Medicaid	$1.35
Rate for Payer: Scott and White EPO/PPO	$0.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.35
Rate for Payer: Superior Health Plan EPO	$0.25

SYRINGE, 8ML, PLASTIC, LOR-LUBE SLIP

Facility

$11.18

Hospital Charge Code	992764
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.60

SYRINGE, 8ML, PLASTIC, LOR-LUBE SLIP

Facility

$11.18

Hospital Charge Code	992764
Hospital Revenue Code	270
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$8.05
Rate for Payer: Amerigroup CHIP/Medicaid	$1.01
Rate for Payer: BCBS of TX Blue Advantage	$3.35
Rate for Payer: BCBS of TX Blue Essentials	$4.02
Rate for Payer: BCBS of TX PPO	$4.47
Rate for Payer: Cash Price	$7.60
Rate for Payer: Cigna Medicaid	$8.05
Rate for Payer: Molina CHIP/Medicaid	$8.05
Rate for Payer: Multiplan Auto	$7.27
Rate for Payer: Multiplan Commercial	$7.27
Rate for Payer: Multiplan Workers Comp	$7.27
Rate for Payer: Parkland Medicaid	$8.05
Rate for Payer: Scott and White EPO/PPO	$5.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.05
Rate for Payer: Superior Health Plan EPO	$1.52

SYRINGE ALLIANCE II DIL/INFL M00550600

Facility

$132.57

Hospital Charge Code	115780
Hospital Revenue Code	272
Rate for Payer: Cash Price	$90.15

SYRINGE ALLIANCE II DIL/INFL M00550600

Facility

$132.57

Hospital Charge Code	115780
Hospital Revenue Code	272
Min. Negotiated Rate	$11.93
Max. Negotiated Rate	$95.45
Rate for Payer: Amerigroup CHIP/Medicaid	$11.93
Rate for Payer: BCBS of TX Blue Advantage	$39.77
Rate for Payer: BCBS of TX Blue Essentials	$47.73
Rate for Payer: BCBS of TX PPO	$53.03
Rate for Payer: Cash Price	$90.15
Rate for Payer: Cigna Medicaid	$95.45
Rate for Payer: Molina CHIP/Medicaid	$95.45
Rate for Payer: Multiplan Auto	$86.17
Rate for Payer: Multiplan Commercial	$86.17
Rate for Payer: Multiplan Workers Comp	$86.17
Rate for Payer: Parkland Medicaid	$95.45
Rate for Payer: Scott and White EPO/PPO	$66.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$95.45
Rate for Payer: Superior Health Plan EPO	$18.03

SYRINGE, CATH TIP, 50ML, ORD QTY 160

Facility

$4.66

Hospital Charge Code	993073
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.17

SYRINGE, CATH TIP, 50ML, ORD QTY 160

Facility

$4.66

Hospital Charge Code	993073
Hospital Revenue Code	270
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$3.36
Rate for Payer: Amerigroup CHIP/Medicaid	$0.42
Rate for Payer: BCBS of TX Blue Advantage	$1.40
Rate for Payer: BCBS of TX Blue Essentials	$1.68
Rate for Payer: BCBS of TX PPO	$1.86
Rate for Payer: Cash Price	$3.17
Rate for Payer: Cigna Medicaid	$3.36
Rate for Payer: Molina CHIP/Medicaid	$3.36
Rate for Payer: Multiplan Auto	$3.03
Rate for Payer: Multiplan Commercial	$3.03
Rate for Payer: Multiplan Workers Comp	$3.03
Rate for Payer: Parkland Medicaid	$3.36
Rate for Payer: Scott and White EPO/PPO	$2.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.36
Rate for Payer: Superior Health Plan EPO	$0.63

SYRINGE,IRRIGATION,BULB,60ML,STERILE

Facility

$4.19

Hospital Charge Code	993116
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.85

SYRINGE,IRRIGATION,BULB,60ML,STERILE

Facility

$4.19

Hospital Charge Code	993116
Hospital Revenue Code	270
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$3.02
Rate for Payer: Amerigroup CHIP/Medicaid	$0.38
Rate for Payer: BCBS of TX Blue Advantage	$1.26
Rate for Payer: BCBS of TX Blue Essentials	$1.51
Rate for Payer: BCBS of TX PPO	$1.68
Rate for Payer: Cash Price	$2.85
Rate for Payer: Cigna Medicaid	$3.02
Rate for Payer: Molina CHIP/Medicaid	$3.02
Rate for Payer: Multiplan Auto	$2.72
Rate for Payer: Multiplan Commercial	$2.72
Rate for Payer: Multiplan Workers Comp	$2.72
Rate for Payer: Parkland Medicaid	$3.02
Rate for Payer: Scott and White EPO/PPO	$2.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.02
Rate for Payer: Superior Health Plan EPO	$0.57

Know your out-of-pocket cost for care.

All Charges