White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TB GASTROSTOMY -- DHF

Facility

$1,241.12

Hospital Charge Code	81775306
Hospital Revenue Code	272
Min. Negotiated Rate	$111.70
Max. Negotiated Rate	$806.73
Rate for Payer: Aetna Commercial	$682.62
Rate for Payer: Amerigroup CHIP/Medicaid	$111.70
Rate for Payer: BCBS of TX Blue Advantage	$372.34
Rate for Payer: BCBS of TX Blue Essentials	$446.80
Rate for Payer: BCBS of TX PPO	$496.45
Rate for Payer: Cash Price	$1,092.19
Rate for Payer: Multiplan Auto	$806.73
Rate for Payer: Multiplan Commercial	$806.73
Rate for Payer: Multiplan Workers Comp	$806.73
Rate for Payer: Scott and White EPO/PPO	$620.56
Rate for Payer: Superior Health Plan EPO	$168.79

TB GASTROSTOMY -- DHF

Facility

$1,241.12

Hospital Charge Code	81775306
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,092.19

TB INTRAMED -- DHF

Facility

$496.20

Hospital Charge Code	54200969
Hospital Revenue Code	270
Rate for Payer: Cash Price	$436.66

TB INTRAMED -- DHF

Facility

$496.20

Hospital Charge Code	54200969
Hospital Revenue Code	270
Min. Negotiated Rate	$44.66
Max. Negotiated Rate	$322.53
Rate for Payer: Aetna Commercial	$272.91
Rate for Payer: Amerigroup CHIP/Medicaid	$44.66
Rate for Payer: BCBS of TX Blue Advantage	$148.86
Rate for Payer: BCBS of TX Blue Essentials	$178.63
Rate for Payer: BCBS of TX PPO	$198.48
Rate for Payer: Cash Price	$436.66
Rate for Payer: Multiplan Auto	$322.53
Rate for Payer: Multiplan Commercial	$322.53
Rate for Payer: Multiplan Workers Comp	$322.53
Rate for Payer: Scott and White EPO/PPO	$248.10
Rate for Payer: Superior Health Plan EPO	$67.48

TB INTUBATION LMA -- DHF

Facility

$85.04

Hospital Charge Code	80347248
Hospital Revenue Code	270
Rate for Payer: Cash Price	$74.84

TB INTUBATION LMA -- DHF

Facility

$85.04

Hospital Charge Code	80347248
Hospital Revenue Code	270
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$55.28
Rate for Payer: Aetna Commercial	$46.77
Rate for Payer: Amerigroup CHIP/Medicaid	$7.65
Rate for Payer: BCBS of TX Blue Advantage	$25.51
Rate for Payer: BCBS of TX Blue Essentials	$30.61
Rate for Payer: BCBS of TX PPO	$34.02
Rate for Payer: Cash Price	$74.84
Rate for Payer: Multiplan Auto	$55.28
Rate for Payer: Multiplan Commercial	$55.28
Rate for Payer: Multiplan Workers Comp	$55.28
Rate for Payer: Scott and White EPO/PPO	$42.52
Rate for Payer: Superior Health Plan EPO	$11.57

TB IRRIGAT 2 -- DHF

Facility

$435.84

Hospital Charge Code	80347271
Hospital Revenue Code	272
Rate for Payer: Cash Price	$383.54

TB IRRIGAT 2 -- DHF

Facility

$435.84

Hospital Charge Code	80347271
Hospital Revenue Code	272
Min. Negotiated Rate	$39.23
Max. Negotiated Rate	$283.30
Rate for Payer: Aetna Commercial	$239.71
Rate for Payer: Amerigroup CHIP/Medicaid	$39.23
Rate for Payer: BCBS of TX Blue Advantage	$130.75
Rate for Payer: BCBS of TX Blue Essentials	$156.90
Rate for Payer: BCBS of TX PPO	$174.34
Rate for Payer: Cash Price	$383.54
Rate for Payer: Multiplan Auto	$283.30
Rate for Payer: Multiplan Commercial	$283.30
Rate for Payer: Multiplan Workers Comp	$283.30
Rate for Payer: Scott and White EPO/PPO	$217.92
Rate for Payer: Superior Health Plan EPO	$59.27

tbo-filgrastim 300 mcg/0.5 mL Subcut Soln 0.5 mL

Facility

$738.70

Service Code	HCPCS J1447
Hospital Charge Code	77836891
Hospital Revenue Code	636
Min. Negotiated Rate	$184.68
Max. Negotiated Rate	$369.35
Rate for Payer: Cash Price	$502.32
Rate for Payer: Cigna Commercial	$184.68
Rate for Payer: Scott and White EPO/PPO	$369.35

tbo-filgrastim 300 mcg/0.5 mL Subcut Soln 0.5 mL

Facility

$738.70

Service Code	HCPCS J1447
Hospital Charge Code	77836891
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$480.16
Rate for Payer: Aetna Medicare	$0.66
Rate for Payer: Amerigroup CHIP/Medicaid	$66.48
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$0.44
Rate for Payer: Amerigroup Medicare	$0.44
Rate for Payer: BCBS of TX Blue Advantage	$1.19
Rate for Payer: BCBS of TX Blue Essentials	$1.43
Rate for Payer: BCBS of TX Medicare	$0.44
Rate for Payer: BCBS of TX PPO	$1.58
Rate for Payer: Cash Price	$502.32
Rate for Payer: Cash Price	$502.32
Rate for Payer: Cigna Medicare	$0.44
Rate for Payer: Employer Direct Commercial	$0.44
Rate for Payer: Humana Medicare/TRICARE	$0.44
Rate for Payer: Molina Dual Medicare/Medicaid	$0.44
Rate for Payer: Molina Medicare	$0.44
Rate for Payer: Multiplan Auto	$480.16
Rate for Payer: Multiplan Commercial	$480.16
Rate for Payer: Multiplan Workers Comp	$480.16
Rate for Payer: Scott and White EPO/PPO	$369.35
Rate for Payer: Scott and White Medicare	$0.44
Rate for Payer: Superior Health Plan EPO	$0.44
Rate for Payer: Superior Health Plan Medicare	$0.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$0.44
Rate for Payer: Universal American Medicare	$0.44
Rate for Payer: Wellcare Medicare	$0.44
Rate for Payer: Wellmed Medicare	$0.44

TB SYRNG FILL -- DHF

Facility

$321.94

Hospital Charge Code	80347958
Hospital Revenue Code	270
Rate for Payer: Cash Price	$283.31

TB SYRNG FILL -- DHF

Facility

$321.94

Hospital Charge Code	80347958
Hospital Revenue Code	270
Min. Negotiated Rate	$28.97
Max. Negotiated Rate	$209.26
Rate for Payer: Aetna Commercial	$177.07
Rate for Payer: Amerigroup CHIP/Medicaid	$28.97
Rate for Payer: BCBS of TX Blue Advantage	$96.58
Rate for Payer: BCBS of TX Blue Essentials	$115.90
Rate for Payer: BCBS of TX PPO	$128.78
Rate for Payer: Cash Price	$283.31
Rate for Payer: Multiplan Auto	$209.26
Rate for Payer: Multiplan Commercial	$209.26
Rate for Payer: Multiplan Workers Comp	$209.26
Rate for Payer: Scott and White EPO/PPO	$160.97
Rate for Payer: Superior Health Plan EPO	$43.78

TB TRACH

Facility

$199.44

Hospital Charge Code	82073107
Hospital Revenue Code	272
Rate for Payer: Cash Price	$175.51

TB TRACH

Facility

$199.44

Hospital Charge Code	82073107
Hospital Revenue Code	272
Min. Negotiated Rate	$17.95
Max. Negotiated Rate	$129.64
Rate for Payer: Aetna Commercial	$109.69
Rate for Payer: Amerigroup CHIP/Medicaid	$17.95
Rate for Payer: BCBS of TX Blue Advantage	$59.83
Rate for Payer: BCBS of TX Blue Essentials	$71.80
Rate for Payer: BCBS of TX PPO	$79.78
Rate for Payer: Cash Price	$175.51
Rate for Payer: Multiplan Auto	$129.64
Rate for Payer: Multiplan Commercial	$129.64
Rate for Payer: Multiplan Workers Comp	$129.64
Rate for Payer: Scott and White EPO/PPO	$99.72
Rate for Payer: Superior Health Plan EPO	$27.12

TB TRACH BIVONA TTS 7MM

Facility

$350.85

Hospital Charge Code	112445
Hospital Revenue Code	272
Rate for Payer: Cash Price	$308.75

TB TRACH BIVONA TTS 7MM

Facility

$350.85

Hospital Charge Code	112445
Hospital Revenue Code	272
Min. Negotiated Rate	$31.58
Max. Negotiated Rate	$228.05
Rate for Payer: Aetna Commercial	$192.97
Rate for Payer: Amerigroup CHIP/Medicaid	$31.58
Rate for Payer: BCBS of TX Blue Advantage	$105.26
Rate for Payer: BCBS of TX Blue Essentials	$126.31
Rate for Payer: BCBS of TX PPO	$140.34
Rate for Payer: Cash Price	$308.75
Rate for Payer: Multiplan Auto	$228.05
Rate for Payer: Multiplan Commercial	$228.05
Rate for Payer: Multiplan Workers Comp	$228.05
Rate for Payer: Scott and White EPO/PPO	$175.42
Rate for Payer: Superior Health Plan EPO	$47.72

TB TRACH CF/FLEX SZ 6 W/INNER CANNULA

Facility

$262.46

Hospital Charge Code	145497
Hospital Revenue Code	272
Rate for Payer: Cash Price	$230.96

TB TRACH CF/FLEX SZ 6 W/INNER CANNULA

Facility

$262.46

Hospital Charge Code	145497
Hospital Revenue Code	272
Min. Negotiated Rate	$23.62
Max. Negotiated Rate	$170.60
Rate for Payer: Aetna Commercial	$144.35
Rate for Payer: Amerigroup CHIP/Medicaid	$23.62
Rate for Payer: BCBS of TX Blue Advantage	$78.74
Rate for Payer: BCBS of TX Blue Essentials	$94.49
Rate for Payer: BCBS of TX PPO	$104.98
Rate for Payer: Cash Price	$230.96
Rate for Payer: Multiplan Auto	$170.60
Rate for Payer: Multiplan Commercial	$170.60
Rate for Payer: Multiplan Workers Comp	$170.60
Rate for Payer: Scott and White EPO/PPO	$131.23
Rate for Payer: Superior Health Plan EPO	$35.69

tb trach fenes uncuffed bl 7mm

Facility

$194.54

Hospital Charge Code	8638505
Hospital Revenue Code	272
Min. Negotiated Rate	$17.51
Max. Negotiated Rate	$126.45
Rate for Payer: Aetna Commercial	$107.00
Rate for Payer: Amerigroup CHIP/Medicaid	$17.51
Rate for Payer: BCBS of TX Blue Advantage	$58.36
Rate for Payer: BCBS of TX Blue Essentials	$70.03
Rate for Payer: BCBS of TX PPO	$77.82
Rate for Payer: Cash Price	$171.20
Rate for Payer: Multiplan Auto	$126.45
Rate for Payer: Multiplan Commercial	$126.45
Rate for Payer: Multiplan Workers Comp	$126.45
Rate for Payer: Scott and White EPO/PPO	$97.27
Rate for Payer: Superior Health Plan EPO	$26.46

tb trach fenes uncuffed bl 7mm

Facility

$194.54

Hospital Charge Code	8638505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$171.20

TB TRACH LOW PRESSURE

Facility

$409.37

Hospital Charge Code	112381
Hospital Revenue Code	272
Rate for Payer: Cash Price	$360.25

TB TRACH LOW PRESSURE

Facility

$409.37

Hospital Charge Code	112381
Hospital Revenue Code	272
Min. Negotiated Rate	$36.84
Max. Negotiated Rate	$266.09
Rate for Payer: Aetna Commercial	$225.15
Rate for Payer: Amerigroup CHIP/Medicaid	$36.84
Rate for Payer: BCBS of TX Blue Advantage	$122.81
Rate for Payer: BCBS of TX Blue Essentials	$147.37
Rate for Payer: BCBS of TX PPO	$163.75
Rate for Payer: Cash Price	$360.25
Rate for Payer: Multiplan Auto	$266.09
Rate for Payer: Multiplan Commercial	$266.09
Rate for Payer: Multiplan Workers Comp	$266.09
Rate for Payer: Scott and White EPO/PPO	$204.68
Rate for Payer: Superior Health Plan EPO	$55.67

TB TRACH PORTEX FLEX CUFF SZ 7

Facility

$121.08

Hospital Charge Code	132344
Hospital Revenue Code	272
Rate for Payer: Cash Price	$106.55

TB TRACH PORTEX FLEX CUFF SZ 7

Facility

$121.08

Hospital Charge Code	132344
Hospital Revenue Code	272
Min. Negotiated Rate	$10.90
Max. Negotiated Rate	$78.70
Rate for Payer: Aetna Commercial	$66.59
Rate for Payer: Amerigroup CHIP/Medicaid	$10.90
Rate for Payer: BCBS of TX Blue Advantage	$36.32
Rate for Payer: BCBS of TX Blue Essentials	$43.59
Rate for Payer: BCBS of TX PPO	$48.43
Rate for Payer: Cash Price	$106.55
Rate for Payer: Multiplan Auto	$78.70
Rate for Payer: Multiplan Commercial	$78.70
Rate for Payer: Multiplan Workers Comp	$78.70
Rate for Payer: Scott and White EPO/PPO	$60.54
Rate for Payer: Superior Health Plan EPO	$16.47

TB TRACH RT -- DHF

Facility

$308.38

Hospital Charge Code	82073131
Hospital Revenue Code	272
Min. Negotiated Rate	$27.75
Max. Negotiated Rate	$200.45
Rate for Payer: Aetna Commercial	$169.61
Rate for Payer: Amerigroup CHIP/Medicaid	$27.75
Rate for Payer: BCBS of TX Blue Advantage	$92.51
Rate for Payer: BCBS of TX Blue Essentials	$111.02
Rate for Payer: BCBS of TX PPO	$123.35
Rate for Payer: Cash Price	$271.37
Rate for Payer: Multiplan Auto	$200.45
Rate for Payer: Multiplan Commercial	$200.45
Rate for Payer: Multiplan Workers Comp	$200.45
Rate for Payer: Scott and White EPO/PPO	$154.19
Rate for Payer: Superior Health Plan EPO	$41.94

Know your out-of-pocket cost for care.

All Charges