White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SYRINGELUER-LOCK,5,MLBD

Facility

$4.13

Hospital Charge Code	993113
Hospital Revenue Code	270
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$2.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.37
Rate for Payer: BCBS of TX Blue Advantage	$1.24
Rate for Payer: BCBS of TX Blue Essentials	$1.49
Rate for Payer: BCBS of TX PPO	$1.65
Rate for Payer: Cash Price	$2.81
Rate for Payer: Cigna Medicaid	$2.97
Rate for Payer: Molina CHIP/Medicaid	$2.97
Rate for Payer: Multiplan Auto	$2.68
Rate for Payer: Multiplan Commercial	$2.68
Rate for Payer: Multiplan Workers Comp	$2.68
Rate for Payer: Parkland Medicaid	$2.97
Rate for Payer: Scott and White EPO/PPO	$2.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.97
Rate for Payer: Superior Health Plan EPO	$0.56

SYRINGELUER-LOCK,5,MLBD

Facility

$4.13

Hospital Charge Code	993113
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.81

SYRINGE MEDRAD -- DHF

Facility

$39.41

Hospital Charge Code	80345465
Hospital Revenue Code	272
Rate for Payer: Cash Price	$26.80

SYRINGE MEDRAD -- DHF

Facility

$39.41

Hospital Charge Code	80345465
Hospital Revenue Code	272
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$28.38
Rate for Payer: Amerigroup CHIP/Medicaid	$3.55
Rate for Payer: BCBS of TX Blue Advantage	$11.82
Rate for Payer: BCBS of TX Blue Essentials	$14.19
Rate for Payer: BCBS of TX PPO	$15.76
Rate for Payer: Cash Price	$26.80
Rate for Payer: Cigna Medicaid	$28.38
Rate for Payer: Molina CHIP/Medicaid	$28.38
Rate for Payer: Multiplan Auto	$25.62
Rate for Payer: Multiplan Commercial	$25.62
Rate for Payer: Multiplan Workers Comp	$25.62
Rate for Payer: Parkland Medicaid	$28.38
Rate for Payer: Scott and White EPO/PPO	$19.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.38
Rate for Payer: Superior Health Plan EPO	$5.36

SYRINGE, SAFETY GLIDE, 1ML, 25G X 5/8'

Facility

$4.04

Hospital Charge Code	993072
Hospital Revenue Code	270
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$2.91
Rate for Payer: Amerigroup CHIP/Medicaid	$0.36
Rate for Payer: BCBS of TX Blue Advantage	$1.21
Rate for Payer: BCBS of TX Blue Essentials	$1.45
Rate for Payer: BCBS of TX PPO	$1.62
Rate for Payer: Cash Price	$2.75
Rate for Payer: Cigna Medicaid	$2.91
Rate for Payer: Molina CHIP/Medicaid	$2.91
Rate for Payer: Multiplan Auto	$2.63
Rate for Payer: Multiplan Commercial	$2.63
Rate for Payer: Multiplan Workers Comp	$2.63
Rate for Payer: Parkland Medicaid	$2.91
Rate for Payer: Scott and White EPO/PPO	$2.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.91
Rate for Payer: Superior Health Plan EPO	$0.55

SYRINGE, SAFETY GLIDE, 1ML, 25G X 5/8'

Facility

$4.04

Hospital Charge Code	993072
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.75

SYRINGE SINGLE STELLANT W/SPIKE

Facility

$46.77

Hospital Charge Code	993338
Hospital Revenue Code	270
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$33.67
Rate for Payer: Amerigroup CHIP/Medicaid	$4.21
Rate for Payer: BCBS of TX Blue Advantage	$14.03
Rate for Payer: BCBS of TX Blue Essentials	$16.84
Rate for Payer: BCBS of TX PPO	$18.71
Rate for Payer: Cash Price	$31.80
Rate for Payer: Cigna Medicaid	$33.67
Rate for Payer: Molina CHIP/Medicaid	$33.67
Rate for Payer: Multiplan Auto	$30.40
Rate for Payer: Multiplan Commercial	$30.40
Rate for Payer: Multiplan Workers Comp	$30.40
Rate for Payer: Parkland Medicaid	$33.67
Rate for Payer: Scott and White EPO/PPO	$23.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.67
Rate for Payer: Superior Health Plan EPO	$6.36

SYRINGE SINGLE STELLANT W/SPIKE

Facility

$46.77

Hospital Charge Code	993338
Hospital Revenue Code	270
Rate for Payer: Cash Price	$31.80

SYRINGE, W/ 150 ML FAST TURN TUBE

Facility

$27.60

Hospital Charge Code	993774
Hospital Revenue Code	272
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$19.87
Rate for Payer: Amerigroup CHIP/Medicaid	$2.48
Rate for Payer: BCBS of TX Blue Advantage	$8.28
Rate for Payer: BCBS of TX Blue Essentials	$9.94
Rate for Payer: BCBS of TX PPO	$11.04
Rate for Payer: Cash Price	$18.77
Rate for Payer: Cigna Medicaid	$19.87
Rate for Payer: Molina CHIP/Medicaid	$19.87
Rate for Payer: Multiplan Auto	$17.94
Rate for Payer: Multiplan Commercial	$17.94
Rate for Payer: Multiplan Workers Comp	$17.94
Rate for Payer: Parkland Medicaid	$19.87
Rate for Payer: Scott and White EPO/PPO	$13.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.87
Rate for Payer: Superior Health Plan EPO	$3.75

SYRINGE, W/ 150 ML FAST TURN TUBE

Facility

$27.60

Hospital Charge Code	993774
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18.77

SYS CALIB SLV GASTRECTMY -- DHF

Facility

$886.66

Hospital Charge Code	80849417
Hospital Revenue Code	272
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$638.40
Rate for Payer: Amerigroup CHIP/Medicaid	$79.80
Rate for Payer: BCBS of TX Blue Advantage	$266.00
Rate for Payer: BCBS of TX Blue Essentials	$319.20
Rate for Payer: BCBS of TX PPO	$354.66
Rate for Payer: Cash Price	$602.93
Rate for Payer: Cigna Medicaid	$638.40
Rate for Payer: Molina CHIP/Medicaid	$638.40
Rate for Payer: Multiplan Auto	$576.33
Rate for Payer: Multiplan Commercial	$576.33
Rate for Payer: Multiplan Workers Comp	$576.33
Rate for Payer: Parkland Medicaid	$638.40
Rate for Payer: Scott and White EPO/PPO	$443.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$638.40
Rate for Payer: Superior Health Plan EPO	$120.59

SYS CALIB SLV GASTRECTMY -- DHF

Facility

$886.66

Hospital Charge Code	80849417
Hospital Revenue Code	272
Rate for Payer: Cash Price	$602.93

SYS CEMT MIX & DEL WO -- DHF

Facility

$4,443.50

Hospital Charge Code	81786956
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,021.58

SYS CEMT MIX & DEL WO -- DHF

Facility

$4,443.50

Hospital Charge Code	81786956
Hospital Revenue Code	272
Min. Negotiated Rate	$399.92
Max. Negotiated Rate	$3,199.32
Rate for Payer: Amerigroup CHIP/Medicaid	$399.92
Rate for Payer: BCBS of TX Blue Advantage	$1,333.05
Rate for Payer: BCBS of TX Blue Essentials	$1,599.66
Rate for Payer: BCBS of TX PPO	$1,777.40
Rate for Payer: Cash Price	$3,021.58
Rate for Payer: Cigna Medicaid	$3,199.32
Rate for Payer: Molina CHIP/Medicaid	$3,199.32
Rate for Payer: Multiplan Auto	$2,888.28
Rate for Payer: Multiplan Commercial	$2,888.28
Rate for Payer: Multiplan Workers Comp	$2,888.28
Rate for Payer: Parkland Medicaid	$3,199.32
Rate for Payer: Scott and White EPO/PPO	$2,221.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,199.32
Rate for Payer: Superior Health Plan EPO	$604.32

SYS GASTRIC POSITIONING -- DHF

Facility

$1,248.50

Hospital Charge Code	81877912
Hospital Revenue Code	272
Rate for Payer: Cash Price	$848.98

SYS GASTRIC POSITIONING -- DHF

Facility

$1,248.50

Hospital Charge Code	81877912
Hospital Revenue Code	272
Min. Negotiated Rate	$112.36
Max. Negotiated Rate	$898.92
Rate for Payer: Amerigroup CHIP/Medicaid	$112.36
Rate for Payer: BCBS of TX Blue Advantage	$374.55
Rate for Payer: BCBS of TX Blue Essentials	$449.46
Rate for Payer: BCBS of TX PPO	$499.40
Rate for Payer: Cash Price	$848.98
Rate for Payer: Cigna Medicaid	$898.92
Rate for Payer: Molina CHIP/Medicaid	$898.92
Rate for Payer: Multiplan Auto	$811.52
Rate for Payer: Multiplan Commercial	$811.52
Rate for Payer: Multiplan Workers Comp	$811.52
Rate for Payer: Parkland Medicaid	$898.92
Rate for Payer: Scott and White EPO/PPO	$624.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$898.92
Rate for Payer: Superior Health Plan EPO	$169.80

SYS GRAFT PREP SPEEDTRAP -- DHF

Facility

$454.00

Hospital Charge Code	81949307
Hospital Revenue Code	272
Rate for Payer: Cash Price	$308.72

SYS GRAFT PREP SPEEDTRAP -- DHF

Facility

$454.00

Hospital Charge Code	81949307
Hospital Revenue Code	272
Min. Negotiated Rate	$40.86
Max. Negotiated Rate	$326.88
Rate for Payer: Amerigroup CHIP/Medicaid	$40.86
Rate for Payer: BCBS of TX Blue Advantage	$136.20
Rate for Payer: BCBS of TX Blue Essentials	$163.44
Rate for Payer: BCBS of TX PPO	$181.60
Rate for Payer: Cash Price	$308.72
Rate for Payer: Cigna Medicaid	$326.88
Rate for Payer: Molina CHIP/Medicaid	$326.88
Rate for Payer: Multiplan Auto	$295.10
Rate for Payer: Multiplan Commercial	$295.10
Rate for Payer: Multiplan Workers Comp	$295.10
Rate for Payer: Parkland Medicaid	$326.88
Rate for Payer: Scott and White EPO/PPO	$227.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$326.88
Rate for Payer: Superior Health Plan EPO	$61.74

SYS LARYNGOSCOPE -- DHF

Facility

$54.79

Hospital Charge Code	80899073
Hospital Revenue Code	272
Rate for Payer: Cash Price	$37.26

SYS LARYNGOSCOPE -- DHF

Facility

$54.79

Hospital Charge Code	80899073
Hospital Revenue Code	272
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$39.45
Rate for Payer: Amerigroup CHIP/Medicaid	$4.93
Rate for Payer: BCBS of TX Blue Advantage	$16.44
Rate for Payer: BCBS of TX Blue Essentials	$19.72
Rate for Payer: BCBS of TX PPO	$21.92
Rate for Payer: Cash Price	$37.26
Rate for Payer: Cigna Medicaid	$39.45
Rate for Payer: Molina CHIP/Medicaid	$39.45
Rate for Payer: Multiplan Auto	$35.61
Rate for Payer: Multiplan Commercial	$35.61
Rate for Payer: Multiplan Workers Comp	$35.61
Rate for Payer: Parkland Medicaid	$39.45
Rate for Payer: Scott and White EPO/PPO	$27.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.45
Rate for Payer: Superior Health Plan EPO	$7.45

SYS LARYNGOSCOPE TRULITE

Facility

$60.97

Hospital Charge Code	8556474
Hospital Revenue Code	272
Min. Negotiated Rate	$5.49
Max. Negotiated Rate	$43.90
Rate for Payer: Amerigroup CHIP/Medicaid	$5.49
Rate for Payer: BCBS of TX Blue Advantage	$18.29
Rate for Payer: BCBS of TX Blue Essentials	$21.95
Rate for Payer: BCBS of TX PPO	$24.39
Rate for Payer: Cash Price	$41.46
Rate for Payer: Cigna Medicaid	$43.90
Rate for Payer: Molina CHIP/Medicaid	$43.90
Rate for Payer: Multiplan Auto	$39.63
Rate for Payer: Multiplan Commercial	$39.63
Rate for Payer: Multiplan Workers Comp	$39.63
Rate for Payer: Parkland Medicaid	$43.90
Rate for Payer: Scott and White EPO/PPO	$30.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.90
Rate for Payer: Superior Health Plan EPO	$8.29

SYS LARYNGOSCOPE TRULITE

Facility

$60.97

Hospital Charge Code	8556474
Hospital Revenue Code	272
Rate for Payer: Cash Price	$41.46

SYS MAXILLARY SINUS BLN -- DHF

Facility

$16,116.00

Service Code	HCPCS C1726
Hospital Charge Code	81774648
Hospital Revenue Code	278
Min. Negotiated Rate	$4,029.00
Max. Negotiated Rate	$8,058.00
Rate for Payer: Cash Price	$10,958.88
Rate for Payer: Cigna Commercial	$4,029.00
Rate for Payer: Multiplan Auto	$8,058.00
Rate for Payer: Multiplan Commercial	$8,058.00
Rate for Payer: Multiplan Workers Comp	$8,058.00
Rate for Payer: Scott and White EPO/PPO	$8,058.00

SYS MAXILLARY SINUS BLN -- DHF

Facility

$16,116.00

Service Code	HCPCS C1726
Hospital Charge Code	81774648
Hospital Revenue Code	278
Min. Negotiated Rate	$1,450.44
Max. Negotiated Rate	$11,603.52
Rate for Payer: Amerigroup CHIP/Medicaid	$1,450.44
Rate for Payer: BCBS of TX Blue Advantage	$4,834.80
Rate for Payer: BCBS of TX Blue Essentials	$5,801.76
Rate for Payer: BCBS of TX PPO	$6,446.40
Rate for Payer: Cash Price	$10,958.88
Rate for Payer: Cigna Medicaid	$11,603.52
Rate for Payer: Molina CHIP/Medicaid	$11,603.52
Rate for Payer: Multiplan Auto	$8,058.00
Rate for Payer: Multiplan Commercial	$8,058.00
Rate for Payer: Multiplan Workers Comp	$8,058.00
Rate for Payer: Parkland Medicaid	$11,603.52
Rate for Payer: Scott and White EPO/PPO	$8,058.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,603.52
Rate for Payer: Superior Health Plan EPO	$2,191.78

SYS ORBT ARTHRCM 1.50 SOLID 145CM

Facility

$16,775.30

Hospital Charge Code	8582477
Hospital Revenue Code	272
Min. Negotiated Rate	$1,509.78
Max. Negotiated Rate	$12,078.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,509.78
Rate for Payer: BCBS of TX Blue Advantage	$5,032.59
Rate for Payer: BCBS of TX Blue Essentials	$6,039.11
Rate for Payer: BCBS of TX PPO	$6,710.12
Rate for Payer: Cash Price	$11,407.20
Rate for Payer: Cigna Medicaid	$12,078.22
Rate for Payer: Molina CHIP/Medicaid	$12,078.22
Rate for Payer: Multiplan Auto	$10,903.94
Rate for Payer: Multiplan Commercial	$10,903.94
Rate for Payer: Multiplan Workers Comp	$10,903.94
Rate for Payer: Parkland Medicaid	$12,078.22
Rate for Payer: Scott and White EPO/PPO	$8,387.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,078.22
Rate for Payer: Superior Health Plan EPO	$2,281.44

Know your out-of-pocket cost for care.

All Charges