White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Transferrin

Facility

$308.00

Service Code	CPT 84466
Hospital Charge Code	1600998
Hospital Revenue Code	301
Min. Negotiated Rate	$4.98
Max. Negotiated Rate	$200.20
Rate for Payer: Aetna Commercial	$13.40
Rate for Payer: Aetna Medicare	$19.14
Rate for Payer: Amerigroup CHIP/Medicaid	$4.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.76
Rate for Payer: Amerigroup Medicare	$12.76
Rate for Payer: BCBS of TX Blue Advantage	$21.05
Rate for Payer: BCBS of TX Blue Essentials	$25.26
Rate for Payer: BCBS of TX Medicare	$12.76
Rate for Payer: BCBS of TX PPO	$28.20
Rate for Payer: Cash Price	$271.04
Rate for Payer: Cash Price	$271.04
Rate for Payer: Cigna Medicaid	$12.76
Rate for Payer: Cigna Medicare	$12.76
Rate for Payer: Employer Direct Commercial	$12.76
Rate for Payer: Humana Medicare/TRICARE	$12.76
Rate for Payer: Molina CHIP/Medicaid	$12.76
Rate for Payer: Molina Dual Medicare/Medicaid	$12.76
Rate for Payer: Molina Medicare	$12.76
Rate for Payer: Multiplan Auto	$200.20
Rate for Payer: Multiplan Commercial	$200.20
Rate for Payer: Multiplan Workers Comp	$200.20
Rate for Payer: Parkland Medicaid	$12.76
Rate for Payer: Scott and White EPO/PPO	$15.95
Rate for Payer: Scott and White Medicare	$12.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.76
Rate for Payer: Superior Health Plan EPO	$12.76
Rate for Payer: Superior Health Plan Medicare	$12.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.76
Rate for Payer: Universal American Medicare	$12.76
Rate for Payer: Wellcare Medicare	$12.76
Rate for Payer: Wellmed Medicare	$12.76

Transferrin SO

Facility

$308.00

Service Code	CPT 84466
Hospital Charge Code	1600998
Hospital Revenue Code	301
Rate for Payer: Cash Price	$271.04

Transferrin SO

Facility

$308.00

Service Code	CPT 84466
Hospital Charge Code	1600998
Hospital Revenue Code	301
Min. Negotiated Rate	$4.98
Max. Negotiated Rate	$200.20
Rate for Payer: Aetna Commercial	$13.40
Rate for Payer: Aetna Medicare	$19.14
Rate for Payer: Amerigroup CHIP/Medicaid	$4.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.76
Rate for Payer: Amerigroup Medicare	$12.76
Rate for Payer: BCBS of TX Blue Advantage	$21.05
Rate for Payer: BCBS of TX Blue Essentials	$25.26
Rate for Payer: BCBS of TX Medicare	$12.76
Rate for Payer: BCBS of TX PPO	$28.20
Rate for Payer: Cash Price	$271.04
Rate for Payer: Cash Price	$271.04
Rate for Payer: Cigna Medicaid	$12.76
Rate for Payer: Cigna Medicare	$12.76
Rate for Payer: Employer Direct Commercial	$12.76
Rate for Payer: Humana Medicare/TRICARE	$12.76
Rate for Payer: Molina CHIP/Medicaid	$12.76
Rate for Payer: Molina Dual Medicare/Medicaid	$12.76
Rate for Payer: Molina Medicare	$12.76
Rate for Payer: Multiplan Auto	$200.20
Rate for Payer: Multiplan Commercial	$200.20
Rate for Payer: Multiplan Workers Comp	$200.20
Rate for Payer: Parkland Medicaid	$12.76
Rate for Payer: Scott and White EPO/PPO	$15.95
Rate for Payer: Scott and White Medicare	$12.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.76
Rate for Payer: Superior Health Plan EPO	$12.76
Rate for Payer: Superior Health Plan Medicare	$12.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.76
Rate for Payer: Universal American Medicare	$12.76
Rate for Payer: Wellcare Medicare	$12.76
Rate for Payer: Wellmed Medicare	$12.76

TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC

Facility

$12,831.52

Service Code	MSDRG 069
Min. Negotiated Rate	$6,340.78
Max. Negotiated Rate	$12,831.52
Rate for Payer: Aetna Commercial	$8,985.38
Rate for Payer: Aetna Medicare	$12,831.52
Rate for Payer: BCBS of TX Blue Advantage	$6,340.78
Rate for Payer: BCBS of TX Blue Essentials	$7,899.19
Rate for Payer: BCBS of TX PPO	$8,777.22
Rate for Payer: Cigna Commercial	$10,287.26

TRANSLUMBAR RENAL CYST

Facility

$1,145.00

Service Code	CPT 74470
Hospital Charge Code	4614470
Hospital Revenue Code	320
Min. Negotiated Rate	$81.35
Max. Negotiated Rate	$1,142.91
Rate for Payer: Aetna Commercial	$549.17
Rate for Payer: Aetna Medicare	$756.79
Rate for Payer: Amerigroup CHIP/Medicaid	$81.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$504.53
Rate for Payer: Amerigroup Medicare	$504.53
Rate for Payer: BCBS of TX Blue Advantage	$794.61
Rate for Payer: BCBS of TX Blue Essentials	$953.53
Rate for Payer: BCBS of TX Medicare	$504.53
Rate for Payer: BCBS of TX PPO	$1,064.29
Rate for Payer: Cash Price	$1,007.60
Rate for Payer: Cash Price	$1,007.60
Rate for Payer: Cash Price	$1,007.60
Rate for Payer: Cigna Commercial	$1,142.91
Rate for Payer: Cigna Medicaid	$81.35
Rate for Payer: Cigna Medicare	$504.53
Rate for Payer: Employer Direct Commercial	$504.53
Rate for Payer: Humana Medicare/TRICARE	$504.53
Rate for Payer: Molina CHIP/Medicaid	$81.35
Rate for Payer: Molina Dual Medicare/Medicaid	$504.53
Rate for Payer: Molina Medicare	$504.53
Rate for Payer: Multiplan Auto	$744.25
Rate for Payer: Multiplan Commercial	$744.25
Rate for Payer: Multiplan Workers Comp	$744.25
Rate for Payer: Parkland Medicaid	$81.35
Rate for Payer: Scott and White EPO/PPO	$572.50
Rate for Payer: Scott and White Medicare	$504.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.35
Rate for Payer: Superior Health Plan EPO	$504.53
Rate for Payer: Superior Health Plan Medicare	$504.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$504.53
Rate for Payer: Universal American Medicare	$504.53
Rate for Payer: Wellcare Medicare	$504.53
Rate for Payer: Wellmed Medicare	$504.53

TRANSLUMBAR RENAL CYST

Facility

$1,145.00

Service Code	CPT 74470
Hospital Charge Code	4614470
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,007.60

Transluminal dilation of aqueous outflow canal (eg, canaloplasty); without retention of device or st

Facility

$10,000.00

Service Code	CPT 66174
Hospital Charge Code	36066174
Hospital Revenue Code	360
Min. Negotiated Rate	$3,718.40
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$5,577.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,718.40
Rate for Payer: Amerigroup Medicare	$3,718.40
Rate for Payer: BCBS of TX Blue Advantage	$6,376.61
Rate for Payer: BCBS of TX Blue Essentials	$7,636.66
Rate for Payer: BCBS of TX Medicare	$3,718.40
Rate for Payer: BCBS of TX PPO	$9,622.19
Rate for Payer: Cigna Commercial	$8,423.25
Rate for Payer: Cigna Medicare	$3,718.40
Rate for Payer: Employer Direct Commercial	$3,718.40
Rate for Payer: Humana Medicare/TRICARE	$3,718.40
Rate for Payer: Molina Dual Medicare/Medicaid	$3,718.40
Rate for Payer: Molina Medicare	$3,718.40
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	$6,879.04
Rate for Payer: Scott and White Medicare	$3,718.40
Rate for Payer: Superior Health Plan EPO	$3,718.40
Rate for Payer: Superior Health Plan Medicare	$3,718.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,718.40
Rate for Payer: Universal American Medicare	$3,718.40
Rate for Payer: Wellcare Medicare	$3,718.40
Rate for Payer: Wellmed Medicare	$3,718.40

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniate

Facility

$15,074.51

Service Code	CPT 63056
Hospital Charge Code	36063056
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Amerigroup Medicare	$6,542.72
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$6,542.72
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$14,821.16
Rate for Payer: Cigna Medicaid	$2,398.52
Rate for Payer: Cigna Medicare	$6,542.72
Rate for Payer: Employer Direct Commercial	$6,542.72
Rate for Payer: Humana Medicare/TRICARE	$6,542.72
Rate for Payer: Molina CHIP/Medicaid	$2,398.52
Rate for Payer: Molina Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Molina Medicare	$6,542.72
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	$2,398.52
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$6,542.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,398.52
Rate for Payer: Superior Health Plan EPO	$6,542.72
Rate for Payer: Superior Health Plan Medicare	$6,542.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Universal American Medicare	$6,542.72
Rate for Payer: Wellcare Medicare	$6,542.72
Rate for Payer: Wellmed Medicare	$6,542.72

TRANSURETHRAL PROCEDURES WITH CC

Facility

$20,708.67

Service Code	MSDRG 669
Min. Negotiated Rate	$11,233.32
Max. Negotiated Rate	$20,708.67
Rate for Payer: Aetna Commercial	$17,264.25
Rate for Payer: Aetna Medicare	$20,708.67
Rate for Payer: BCBS of TX Blue Advantage	$11,233.32
Rate for Payer: BCBS of TX Blue Essentials	$16,329.82
Rate for Payer: BCBS of TX PPO	$18,144.94
Rate for Payer: Cigna Commercial	$19,765.65

TRANSURETHRAL PROCEDURES WITH MCC

Facility

$36,295.84

Service Code	MSDRG 668
Min. Negotiated Rate	$21,099.24
Max. Negotiated Rate	$36,295.84
Rate for Payer: Aetna Commercial	$31,702.50
Rate for Payer: Aetna Medicare	$34,446.30
Rate for Payer: BCBS of TX Blue Advantage	$21,099.24
Rate for Payer: BCBS of TX Blue Essentials	$29,043.86
Rate for Payer: BCBS of TX PPO	$32,272.20
Rate for Payer: Cigna Commercial	$36,295.84

TRANSURETHRAL PROCEDURES WITHOUT CC/MCC

Facility

$14,585.95

Service Code	MSDRG 670
Min. Negotiated Rate	$8,300.72
Max. Negotiated Rate	$14,585.95
Rate for Payer: Aetna Commercial	$10,829.25
Rate for Payer: Aetna Medicare	$14,585.95
Rate for Payer: BCBS of TX Blue Advantage	$8,300.72
Rate for Payer: BCBS of TX Blue Essentials	$9,942.36
Rate for Payer: BCBS of TX PPO	$11,047.49
Rate for Payer: Cigna Commercial	$12,398.29

TRANSURETHRAL PROSTATECTOMY WITH CC/MCC

Facility

$19,810.60

Service Code	MSDRG 713
Min. Negotiated Rate	$13,715.28
Max. Negotiated Rate	$19,810.60
Rate for Payer: Aetna Commercial	$16,320.38
Rate for Payer: Aetna Medicare	$19,810.60
Rate for Payer: BCBS of TX Blue Advantage	$13,715.28
Rate for Payer: BCBS of TX Blue Essentials	$15,100.82
Rate for Payer: BCBS of TX PPO	$16,779.34
Rate for Payer: Cigna Commercial	$18,685.02

TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC

Facility

$14,542.05

Service Code	MSDRG 714
Min. Negotiated Rate	$7,232.60
Max. Negotiated Rate	$14,542.05
Rate for Payer: Aetna Commercial	$10,783.12
Rate for Payer: Aetna Medicare	$14,542.05
Rate for Payer: BCBS of TX Blue Advantage	$7,232.60
Rate for Payer: BCBS of TX Blue Essentials	$9,395.45
Rate for Payer: BCBS of TX PPO	$10,439.79
Rate for Payer: Cigna Commercial	$12,345.48

Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by i

Facility

$10,000.00

Service Code	CPT 64488
Hospital Charge Code	36064488
Hospital Revenue Code	360
Min. Negotiated Rate	$51.26
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$51.26
Rate for Payer: Cigna Medicaid	$51.26
Rate for Payer: Molina CHIP/Medicaid	$51.26
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	$51.26
Rate for Payer: Scott and White EPO/PPO	$83.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.26

Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral by

Facility

$10,000.00

Service Code	CPT 64486
Hospital Charge Code	36064486
Hospital Revenue Code	360
Min. Negotiated Rate	$41.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$41.42
Rate for Payer: Cigna Medicaid	$41.42
Rate for Payer: Molina CHIP/Medicaid	$41.42
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	$41.42
Rate for Payer: Scott and White EPO/PPO	$66.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41.42

transwarmer infant transport mattress

Facility

$105.01

Hospital Charge Code	8630564
Hospital Revenue Code	272
Rate for Payer: Cash Price	$92.41

transwarmer infant transport mattress

Facility

$105.01

Hospital Charge Code	8630564
Hospital Revenue Code	272
Min. Negotiated Rate	$9.45
Max. Negotiated Rate	$68.26
Rate for Payer: Aetna Commercial	$57.76
Rate for Payer: Amerigroup CHIP/Medicaid	$9.45
Rate for Payer: BCBS of TX Blue Advantage	$31.50
Rate for Payer: BCBS of TX Blue Essentials	$37.80
Rate for Payer: BCBS of TX PPO	$42.00
Rate for Payer: Cash Price	$92.41
Rate for Payer: Multiplan Auto	$68.26
Rate for Payer: Multiplan Commercial	$68.26
Rate for Payer: Multiplan Workers Comp	$68.26
Rate for Payer: Scott and White EPO/PPO	$52.51
Rate for Payer: Superior Health Plan EPO	$14.28

TRAP, TISSUE COLLECTION BERKELEY SAFETOUCH -- DHF

Facility

$45.04

Hospital Charge Code	80316458
Hospital Revenue Code	272
Rate for Payer: Cash Price	$39.64

TRAP, TISSUE COLLECTION BERKELEY SAFETOUCH -- DHF

Facility

$45.04

Hospital Charge Code	80316458
Hospital Revenue Code	272
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$29.28
Rate for Payer: Aetna Commercial	$24.77
Rate for Payer: Amerigroup CHIP/Medicaid	$4.05
Rate for Payer: BCBS of TX Blue Advantage	$13.51
Rate for Payer: BCBS of TX Blue Essentials	$16.21
Rate for Payer: BCBS of TX PPO	$18.02
Rate for Payer: Cash Price	$39.64
Rate for Payer: Multiplan Auto	$29.28
Rate for Payer: Multiplan Commercial	$29.28
Rate for Payer: Multiplan Workers Comp	$29.28
Rate for Payer: Scott and White EPO/PPO	$22.52
Rate for Payer: Superior Health Plan EPO	$6.13

Trauma 1 (full)

Facility

$7,088.00

Service Code	HCPCS G0390
Hospital Charge Code	4204071
Hospital Revenue Code	681
Rate for Payer: Cash Price	$6,237.44

Trauma 1 (full)

Facility

$7,088.00

Service Code	HCPCS G0390
Hospital Charge Code	4204071
Hospital Revenue Code	681
Min. Negotiated Rate	$637.92
Max. Negotiated Rate	$4,607.20
Rate for Payer: Aetna Commercial	$3,898.40
Rate for Payer: Aetna Medicare	$1,878.16
Rate for Payer: Amerigroup CHIP/Medicaid	$637.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,252.11
Rate for Payer: Amerigroup Medicare	$1,252.11
Rate for Payer: BCBS of TX Blue Advantage	$1,550.60
Rate for Payer: BCBS of TX Blue Essentials	$1,853.59
Rate for Payer: BCBS of TX Medicare	$1,252.11
Rate for Payer: BCBS of TX PPO	$2,067.47
Rate for Payer: Cash Price	$6,237.44
Rate for Payer: Cash Price	$6,237.44
Rate for Payer: Cash Price	$6,237.44
Rate for Payer: Cigna Commercial	$2,836.40
Rate for Payer: Cigna Medicare	$1,252.11
Rate for Payer: Employer Direct Commercial	$1,252.11
Rate for Payer: Humana Medicare/TRICARE	$1,252.11
Rate for Payer: Molina Dual Medicare/Medicaid	$1,252.11
Rate for Payer: Molina Medicare	$1,252.11
Rate for Payer: Multiplan Auto	$4,607.20
Rate for Payer: Multiplan Commercial	$4,607.20
Rate for Payer: Multiplan Workers Comp	$4,607.20
Rate for Payer: Scott and White EPO/PPO	$3,544.00
Rate for Payer: Scott and White Medicare	$1,252.11
Rate for Payer: Superior Health Plan EPO	$1,252.11
Rate for Payer: Superior Health Plan Medicare	$1,252.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,252.11
Rate for Payer: Universal American Medicare	$1,252.11
Rate for Payer: Wellcare Medicare	$1,252.11
Rate for Payer: Wellmed Medicare	$1,252.11

Trauma Response - Level II Trauma

Facility

$5,316.00

Service Code	HCPCS G0390
Hospital Charge Code	4204072
Hospital Revenue Code	682
Min. Negotiated Rate	$478.44
Max. Negotiated Rate	$3,455.40
Rate for Payer: Aetna Commercial	$2,923.80
Rate for Payer: Aetna Medicare	$1,878.16
Rate for Payer: Amerigroup CHIP/Medicaid	$478.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,252.11
Rate for Payer: Amerigroup Medicare	$1,252.11
Rate for Payer: BCBS of TX Blue Advantage	$1,550.60
Rate for Payer: BCBS of TX Blue Essentials	$1,853.59
Rate for Payer: BCBS of TX Medicare	$1,252.11
Rate for Payer: BCBS of TX PPO	$2,067.47
Rate for Payer: Cash Price	$4,678.08
Rate for Payer: Cash Price	$4,678.08
Rate for Payer: Cash Price	$4,678.08
Rate for Payer: Cigna Commercial	$2,836.40
Rate for Payer: Cigna Medicare	$1,252.11
Rate for Payer: Employer Direct Commercial	$1,252.11
Rate for Payer: Humana Medicare/TRICARE	$1,252.11
Rate for Payer: Molina Dual Medicare/Medicaid	$1,252.11
Rate for Payer: Molina Medicare	$1,252.11
Rate for Payer: Multiplan Auto	$3,455.40
Rate for Payer: Multiplan Commercial	$3,455.40
Rate for Payer: Multiplan Workers Comp	$3,455.40
Rate for Payer: Scott and White EPO/PPO	$2,658.00
Rate for Payer: Scott and White Medicare	$1,252.11
Rate for Payer: Superior Health Plan EPO	$1,252.11
Rate for Payer: Superior Health Plan Medicare	$1,252.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,252.11
Rate for Payer: Universal American Medicare	$1,252.11
Rate for Payer: Wellcare Medicare	$1,252.11
Rate for Payer: Wellmed Medicare	$1,252.11

Trauma Response - Level II Trauma

Facility

$5,316.00

Service Code	HCPCS G0390
Hospital Charge Code	4204072
Hospital Revenue Code	682
Rate for Payer: Cash Price	$4,678.08

TRAUMATIC INJURY WITH MCC

Facility

$20,279.43

Service Code	MSDRG 913
Min. Negotiated Rate	$10,759.46
Max. Negotiated Rate	$20,279.43
Rate for Payer: Aetna Commercial	$16,813.12
Rate for Payer: Aetna Medicare	$20,279.43
Rate for Payer: BCBS of TX Blue Advantage	$10,759.46
Rate for Payer: BCBS of TX Blue Essentials	$15,188.54
Rate for Payer: BCBS of TX PPO	$16,876.81
Rate for Payer: Cigna Commercial	$19,249.16

TRAUMATIC INJURY WITHOUT MCC

Facility

$13,998.28

Service Code	MSDRG 914
Min. Negotiated Rate	$6,565.24
Max. Negotiated Rate	$13,998.28
Rate for Payer: Aetna Commercial	$10,211.62
Rate for Payer: Aetna Medicare	$13,998.28
Rate for Payer: BCBS of TX Blue Advantage	$6,565.24
Rate for Payer: BCBS of TX Blue Essentials	$8,645.26
Rate for Payer: BCBS of TX PPO	$9,606.21
Rate for Payer: Cigna Commercial	$11,691.18

Know your out-of-pocket cost for care.

All Charges