White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Thyrotropin Receptor Ab, Serum SO

Facility

$222.00

Service Code	CPT 83520
Hospital Charge Code	1706332
Hospital Revenue Code	301
Min. Negotiated Rate	$6.74
Max. Negotiated Rate	$144.30
Rate for Payer: Aetna Commercial	$18.13
Rate for Payer: Aetna Medicare	$25.90
Rate for Payer: Amerigroup CHIP/Medicaid	$6.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.27
Rate for Payer: Amerigroup Medicare	$17.27
Rate for Payer: BCBS of TX Blue Advantage	$28.50
Rate for Payer: BCBS of TX Blue Essentials	$34.19
Rate for Payer: BCBS of TX Medicare	$17.27
Rate for Payer: BCBS of TX PPO	$38.17
Rate for Payer: Cash Price	$195.36
Rate for Payer: Cash Price	$195.36
Rate for Payer: Cigna Medicaid	$17.27
Rate for Payer: Cigna Medicare	$17.27
Rate for Payer: Employer Direct Commercial	$17.27
Rate for Payer: Humana Medicare/TRICARE	$17.27
Rate for Payer: Molina CHIP/Medicaid	$17.27
Rate for Payer: Molina Dual Medicare/Medicaid	$17.27
Rate for Payer: Molina Medicare	$17.27
Rate for Payer: Multiplan Auto	$144.30
Rate for Payer: Multiplan Commercial	$144.30
Rate for Payer: Multiplan Workers Comp	$144.30
Rate for Payer: Parkland Medicaid	$17.27
Rate for Payer: Scott and White EPO/PPO	$21.59
Rate for Payer: Scott and White Medicare	$17.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.27
Rate for Payer: Superior Health Plan EPO	$17.27
Rate for Payer: Superior Health Plan Medicare	$17.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.27
Rate for Payer: Universal American Medicare	$17.27
Rate for Payer: Wellcare Medicare	$17.27
Rate for Payer: Wellmed Medicare	$17.27

Thyroxine

Facility

$256.00

Service Code	CPT 84436
Hospital Charge Code	4104436
Hospital Revenue Code	301
Rate for Payer: Cash Price	$225.28

Thyroxine

Facility

$256.00

Service Code	CPT 84436
Hospital Charge Code	4104436
Hospital Revenue Code	301
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$166.40
Rate for Payer: Aetna Commercial	$7.21
Rate for Payer: Aetna Medicare	$10.30
Rate for Payer: Amerigroup CHIP/Medicaid	$2.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.87
Rate for Payer: Amerigroup Medicare	$6.87
Rate for Payer: BCBS of TX Blue Advantage	$11.34
Rate for Payer: BCBS of TX Blue Essentials	$13.60
Rate for Payer: BCBS of TX Medicare	$6.87
Rate for Payer: BCBS of TX PPO	$15.18
Rate for Payer: Cash Price	$225.28
Rate for Payer: Cash Price	$225.28
Rate for Payer: Cigna Medicaid	$6.87
Rate for Payer: Cigna Medicare	$6.87
Rate for Payer: Employer Direct Commercial	$6.87
Rate for Payer: Humana Medicare/TRICARE	$6.87
Rate for Payer: Molina CHIP/Medicaid	$6.87
Rate for Payer: Molina Dual Medicare/Medicaid	$6.87
Rate for Payer: Molina Medicare	$6.87
Rate for Payer: Multiplan Auto	$166.40
Rate for Payer: Multiplan Commercial	$166.40
Rate for Payer: Multiplan Workers Comp	$166.40
Rate for Payer: Parkland Medicaid	$6.87
Rate for Payer: Scott and White EPO/PPO	$8.59
Rate for Payer: Scott and White Medicare	$6.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.87
Rate for Payer: Superior Health Plan EPO	$6.87
Rate for Payer: Superior Health Plan Medicare	$6.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.87
Rate for Payer: Universal American Medicare	$6.87
Rate for Payer: Wellcare Medicare	$6.87
Rate for Payer: Wellmed Medicare	$6.87

Tiagabine (Gabitril) SO

Facility

$224.00

Service Code	CPT 80199
Hospital Charge Code	8486568
Hospital Revenue Code	301
Rate for Payer: Cash Price	$197.12

Tiagabine (Gabitril) SO

Facility

$224.00

Service Code	CPT 80199
Hospital Charge Code	8486568
Hospital Revenue Code	301
Min. Negotiated Rate	$10.57
Max. Negotiated Rate	$145.60
Rate for Payer: Aetna Commercial	$28.47
Rate for Payer: Aetna Medicare	$40.66
Rate for Payer: Amerigroup CHIP/Medicaid	$10.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.11
Rate for Payer: Amerigroup Medicare	$27.11
Rate for Payer: BCBS of TX Blue Advantage	$44.73
Rate for Payer: BCBS of TX Blue Essentials	$53.68
Rate for Payer: BCBS of TX Medicare	$27.11
Rate for Payer: BCBS of TX PPO	$59.91
Rate for Payer: Cash Price	$197.12
Rate for Payer: Cash Price	$197.12
Rate for Payer: Cigna Medicaid	$27.11
Rate for Payer: Cigna Medicare	$27.11
Rate for Payer: Employer Direct Commercial	$27.11
Rate for Payer: Humana Medicare/TRICARE	$27.11
Rate for Payer: Molina CHIP/Medicaid	$27.11
Rate for Payer: Molina Dual Medicare/Medicaid	$27.11
Rate for Payer: Molina Medicare	$27.11
Rate for Payer: Multiplan Auto	$145.60
Rate for Payer: Multiplan Commercial	$145.60
Rate for Payer: Multiplan Workers Comp	$145.60
Rate for Payer: Parkland Medicaid	$27.11
Rate for Payer: Scott and White EPO/PPO	$33.89
Rate for Payer: Scott and White Medicare	$27.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.11
Rate for Payer: Superior Health Plan EPO	$27.11
Rate for Payer: Superior Health Plan Medicare	$27.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.11
Rate for Payer: Universal American Medicare	$27.11
Rate for Payer: Wellcare Medicare	$27.11
Rate for Payer: Wellmed Medicare	$27.11

TIBIAL NAIL

Facility

$23,493.97

Service Code	HCPCS C1713
Hospital Charge Code	8502477
Hospital Revenue Code	278
Min. Negotiated Rate	$5,873.49
Max. Negotiated Rate	$11,746.98
Rate for Payer: Aetna Commercial	$7,048.19
Rate for Payer: Cash Price	$20,674.69
Rate for Payer: Cigna Commercial	$5,873.49
Rate for Payer: Multiplan Auto	$11,746.98
Rate for Payer: Multiplan Commercial	$11,746.98
Rate for Payer: Multiplan Workers Comp	$11,746.98
Rate for Payer: Scott and White EPO/PPO	$11,746.98

TIBIAL NAIL

Facility

$23,493.97

Service Code	HCPCS C1713
Hospital Charge Code	8502477
Hospital Revenue Code	278
Min. Negotiated Rate	$2,114.46
Max. Negotiated Rate	$11,746.98
Rate for Payer: Aetna Commercial	$7,048.19
Rate for Payer: Amerigroup CHIP/Medicaid	$2,114.46
Rate for Payer: BCBS of TX Blue Advantage	$7,048.19
Rate for Payer: BCBS of TX Blue Essentials	$8,457.83
Rate for Payer: BCBS of TX PPO	$9,397.59
Rate for Payer: Cash Price	$20,674.69
Rate for Payer: Multiplan Auto	$11,746.98
Rate for Payer: Multiplan Commercial	$11,746.98
Rate for Payer: Multiplan Workers Comp	$11,746.98
Rate for Payer: Scott and White EPO/PPO	$11,746.98
Rate for Payer: Superior Health Plan EPO	$3,195.18

ticagrelor 90 mg tablet

Facility

$15.87

Service Code	HCPCS J3490
Hospital Charge Code	77846602
Hospital Revenue Code	250
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$10.32
Rate for Payer: Amerigroup CHIP/Medicaid	$1.43
Rate for Payer: BCBS of TX Blue Advantage	$4.76
Rate for Payer: BCBS of TX Blue Essentials	$5.71
Rate for Payer: BCBS of TX PPO	$6.35
Rate for Payer: Cash Price	$10.79
Rate for Payer: Multiplan Auto	$10.32
Rate for Payer: Multiplan Commercial	$10.32
Rate for Payer: Multiplan Workers Comp	$10.32
Rate for Payer: Scott and White EPO/PPO	$7.94
Rate for Payer: Superior Health Plan EPO	$2.16

ticagrelor 90 mg tablet

Facility

$15.87

Service Code	HCPCS J3490
Hospital Charge Code	77846602
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.79

TILT TABLE TEST - CATH LAB

Facility

$1,399.00

Service Code	CPT 93660
Hospital Charge Code	2301141
Hospital Revenue Code	480
Min. Negotiated Rate	$8.77
Max. Negotiated Rate	$1,110.40
Rate for Payer: Aetna Commercial	$769.45
Rate for Payer: Aetna Medicare	$735.27
Rate for Payer: Amerigroup CHIP/Medicaid	$125.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$490.18
Rate for Payer: Amerigroup Medicare	$490.18
Rate for Payer: BCBS of TX Blue Advantage	$115.38
Rate for Payer: BCBS of TX Blue Essentials	$137.92
Rate for Payer: BCBS of TX Medicare	$490.18
Rate for Payer: BCBS of TX PPO	$153.84
Rate for Payer: Cash Price	$1,231.12
Rate for Payer: Cash Price	$1,231.12
Rate for Payer: Cash Price	$1,231.12
Rate for Payer: Cigna Commercial	$1,110.40
Rate for Payer: Cigna Medicaid	$127.77
Rate for Payer: Cigna Medicare	$490.18
Rate for Payer: Employer Direct Commercial	$490.18
Rate for Payer: Humana Medicare/TRICARE	$490.18
Rate for Payer: Molina CHIP/Medicaid	$127.77
Rate for Payer: Molina Dual Medicare/Medicaid	$490.18
Rate for Payer: Molina Medicare	$490.18
Rate for Payer: Multiplan Auto	$909.35
Rate for Payer: Multiplan Commercial	$909.35
Rate for Payer: Multiplan Workers Comp	$909.35
Rate for Payer: Parkland Medicaid	$127.77
Rate for Payer: Scott and White EPO/PPO	$8.77
Rate for Payer: Scott and White Medicare	$490.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$127.77
Rate for Payer: Superior Health Plan EPO	$490.18
Rate for Payer: Superior Health Plan Medicare	$490.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$490.18
Rate for Payer: Universal American Medicare	$490.18
Rate for Payer: Wellcare Medicare	$490.18
Rate for Payer: Wellmed Medicare	$490.18

TILT TABLE TEST - CATH LAB

Facility

$1,399.00

Service Code	CPT 93660
Hospital Charge Code	2301141
Hospital Revenue Code	480
Rate for Payer: Cash Price	$1,231.12

TIP, CATHETER FLEX 45CM FOR SEALANT FIBRIN 5ML -- DHF

Facility

$284.38

Hospital Charge Code	80385024
Hospital Revenue Code	272
Min. Negotiated Rate	$25.59
Max. Negotiated Rate	$184.85
Rate for Payer: Aetna Commercial	$156.41
Rate for Payer: Amerigroup CHIP/Medicaid	$25.59
Rate for Payer: BCBS of TX Blue Advantage	$85.31
Rate for Payer: BCBS of TX Blue Essentials	$102.38
Rate for Payer: BCBS of TX PPO	$113.75
Rate for Payer: Cash Price	$250.25
Rate for Payer: Multiplan Auto	$184.85
Rate for Payer: Multiplan Commercial	$184.85
Rate for Payer: Multiplan Workers Comp	$184.85
Rate for Payer: Scott and White EPO/PPO	$142.19
Rate for Payer: Superior Health Plan EPO	$38.68

TIP, CATHETER FLEX 45CM FOR SEALANT FIBRIN 5ML -- DHF

Facility

$284.38

Hospital Charge Code	80385024
Hospital Revenue Code	272
Rate for Payer: Cash Price	$250.25

TIP FLEX VISTASEAL 45CM

Facility

$710.96

Hospital Charge Code	8494510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$625.64

TIP FLEX VISTASEAL 45CM

Facility

$710.96

Hospital Charge Code	8494510
Hospital Revenue Code	272
Min. Negotiated Rate	$63.99
Max. Negotiated Rate	$462.12
Rate for Payer: Aetna Commercial	$391.03
Rate for Payer: Amerigroup CHIP/Medicaid	$63.99
Rate for Payer: BCBS of TX Blue Advantage	$213.29
Rate for Payer: BCBS of TX Blue Essentials	$255.95
Rate for Payer: BCBS of TX PPO	$284.38
Rate for Payer: Cash Price	$625.64
Rate for Payer: Multiplan Auto	$462.12
Rate for Payer: Multiplan Commercial	$462.12
Rate for Payer: Multiplan Workers Comp	$462.12
Rate for Payer: Scott and White EPO/PPO	$355.48
Rate for Payer: Superior Health Plan EPO	$96.69

TIP, GRASPER ALIS LAPSCP. DISP. -- DHF

Facility

$597.62

Hospital Charge Code	81775736
Hospital Revenue Code	270
Min. Negotiated Rate	$53.79
Max. Negotiated Rate	$388.45
Rate for Payer: Aetna Commercial	$328.69
Rate for Payer: Amerigroup CHIP/Medicaid	$53.79
Rate for Payer: BCBS of TX Blue Advantage	$179.29
Rate for Payer: BCBS of TX Blue Essentials	$215.14
Rate for Payer: BCBS of TX PPO	$239.05
Rate for Payer: Cash Price	$525.91
Rate for Payer: Multiplan Auto	$388.45
Rate for Payer: Multiplan Commercial	$388.45
Rate for Payer: Multiplan Workers Comp	$388.45
Rate for Payer: Scott and White EPO/PPO	$298.81
Rate for Payer: Superior Health Plan EPO	$81.28

TIP, GRASPER BABCOCK 10MM DISP. -- DHF

Facility

$597.62

Hospital Charge Code	81775736
Hospital Revenue Code	270
Min. Negotiated Rate	$53.79
Max. Negotiated Rate	$388.45
Rate for Payer: Aetna Commercial	$328.69
Rate for Payer: Amerigroup CHIP/Medicaid	$53.79
Rate for Payer: BCBS of TX Blue Advantage	$179.29
Rate for Payer: BCBS of TX Blue Essentials	$215.14
Rate for Payer: BCBS of TX PPO	$239.05
Rate for Payer: Cash Price	$525.91
Rate for Payer: Multiplan Auto	$388.45
Rate for Payer: Multiplan Commercial	$388.45
Rate for Payer: Multiplan Workers Comp	$388.45
Rate for Payer: Scott and White EPO/PPO	$298.81
Rate for Payer: Superior Health Plan EPO	$81.28

TIP, GRASPER LAPCLINCH - DISPOSABLE -- DHF

Facility

$597.62

Hospital Charge Code	81775736
Hospital Revenue Code	270
Min. Negotiated Rate	$53.79
Max. Negotiated Rate	$388.45
Rate for Payer: Aetna Commercial	$328.69
Rate for Payer: Amerigroup CHIP/Medicaid	$53.79
Rate for Payer: BCBS of TX Blue Advantage	$179.29
Rate for Payer: BCBS of TX Blue Essentials	$215.14
Rate for Payer: BCBS of TX PPO	$239.05
Rate for Payer: Cash Price	$525.91
Rate for Payer: Multiplan Auto	$388.45
Rate for Payer: Multiplan Commercial	$388.45
Rate for Payer: Multiplan Workers Comp	$388.45
Rate for Payer: Scott and White EPO/PPO	$298.81
Rate for Payer: Superior Health Plan EPO	$81.28

TIP, GRASPER MARYLAND DISSECTOR SERRATED 18.8MM -- DHF

Facility

$597.62

Hospital Charge Code	81775736
Hospital Revenue Code	270
Min. Negotiated Rate	$53.79
Max. Negotiated Rate	$388.45
Rate for Payer: Aetna Commercial	$328.69
Rate for Payer: Amerigroup CHIP/Medicaid	$53.79
Rate for Payer: BCBS of TX Blue Advantage	$179.29
Rate for Payer: BCBS of TX Blue Essentials	$215.14
Rate for Payer: BCBS of TX PPO	$239.05
Rate for Payer: Cash Price	$525.91
Rate for Payer: Multiplan Auto	$388.45
Rate for Payer: Multiplan Commercial	$388.45
Rate for Payer: Multiplan Workers Comp	$388.45
Rate for Payer: Scott and White EPO/PPO	$298.81
Rate for Payer: Superior Health Plan EPO	$81.28

TIP, LONG FENESTRATED - DISPOSABLE -- DHF

Facility

$597.62

Hospital Charge Code	81775736
Hospital Revenue Code	270
Min. Negotiated Rate	$53.79
Max. Negotiated Rate	$388.45
Rate for Payer: Aetna Commercial	$328.69
Rate for Payer: Amerigroup CHIP/Medicaid	$53.79
Rate for Payer: BCBS of TX Blue Advantage	$179.29
Rate for Payer: BCBS of TX Blue Essentials	$215.14
Rate for Payer: BCBS of TX PPO	$239.05
Rate for Payer: Cash Price	$525.91
Rate for Payer: Multiplan Auto	$388.45
Rate for Payer: Multiplan Commercial	$388.45
Rate for Payer: Multiplan Workers Comp	$388.45
Rate for Payer: Scott and White EPO/PPO	$298.81
Rate for Payer: Superior Health Plan EPO	$81.28

TIP RIGID VISTASEAL 35CM

Facility

$710.96

Hospital Charge Code	8494507
Hospital Revenue Code	272
Rate for Payer: Cash Price	$625.64

TIP RIGID VISTASEAL 35CM

Facility

$710.96

Hospital Charge Code	8494507
Hospital Revenue Code	272
Min. Negotiated Rate	$63.99
Max. Negotiated Rate	$462.12
Rate for Payer: Aetna Commercial	$391.03
Rate for Payer: Amerigroup CHIP/Medicaid	$63.99
Rate for Payer: BCBS of TX Blue Advantage	$213.29
Rate for Payer: BCBS of TX Blue Essentials	$255.95
Rate for Payer: BCBS of TX PPO	$284.38
Rate for Payer: Cash Price	$625.64
Rate for Payer: Multiplan Auto	$462.12
Rate for Payer: Multiplan Commercial	$462.12
Rate for Payer: Multiplan Workers Comp	$462.12
Rate for Payer: Scott and White EPO/PPO	$355.48
Rate for Payer: Superior Health Plan EPO	$96.69

TIP, SCISSOR 5MM BABCOCK - DISPOSABLE -- DHF

Facility

$597.62

Hospital Charge Code	81775736
Hospital Revenue Code	270
Min. Negotiated Rate	$53.79
Max. Negotiated Rate	$388.45
Rate for Payer: Aetna Commercial	$328.69
Rate for Payer: Amerigroup CHIP/Medicaid	$53.79
Rate for Payer: BCBS of TX Blue Advantage	$179.29
Rate for Payer: BCBS of TX Blue Essentials	$215.14
Rate for Payer: BCBS of TX PPO	$239.05
Rate for Payer: Cash Price	$525.91
Rate for Payer: Multiplan Auto	$388.45
Rate for Payer: Multiplan Commercial	$388.45
Rate for Payer: Multiplan Workers Comp	$388.45
Rate for Payer: Scott and White EPO/PPO	$298.81
Rate for Payer: Superior Health Plan EPO	$81.28

TIP, SCISSOR ENDOCUT CURVED DISPOSABLE -- DHF

Facility

$597.62

Hospital Charge Code	81775736
Hospital Revenue Code	270
Min. Negotiated Rate	$53.79
Max. Negotiated Rate	$388.45
Rate for Payer: Aetna Commercial	$328.69
Rate for Payer: Amerigroup CHIP/Medicaid	$53.79
Rate for Payer: BCBS of TX Blue Advantage	$179.29
Rate for Payer: BCBS of TX Blue Essentials	$215.14
Rate for Payer: BCBS of TX PPO	$239.05
Rate for Payer: Cash Price	$525.91
Rate for Payer: Multiplan Auto	$388.45
Rate for Payer: Multiplan Commercial	$388.45
Rate for Payer: Multiplan Workers Comp	$388.45
Rate for Payer: Scott and White EPO/PPO	$298.81
Rate for Payer: Superior Health Plan EPO	$81.28

TIP, SCISSOR ENDOCUT MINI DISPOSABLE -- DHF

Facility

$597.62

Hospital Charge Code	81775736
Hospital Revenue Code	270
Min. Negotiated Rate	$53.79
Max. Negotiated Rate	$388.45
Rate for Payer: Aetna Commercial	$328.69
Rate for Payer: Amerigroup CHIP/Medicaid	$53.79
Rate for Payer: BCBS of TX Blue Advantage	$179.29
Rate for Payer: BCBS of TX Blue Essentials	$215.14
Rate for Payer: BCBS of TX PPO	$239.05
Rate for Payer: Cash Price	$525.91
Rate for Payer: Multiplan Auto	$388.45
Rate for Payer: Multiplan Commercial	$388.45
Rate for Payer: Multiplan Workers Comp	$388.45
Rate for Payer: Scott and White EPO/PPO	$298.81
Rate for Payer: Superior Health Plan EPO	$81.28

Know your out-of-pocket cost for care.

All Charges