White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC

Facility

$18,380.53

Service Code	MSDRG 086
Min. Negotiated Rate	$9,816.04
Max. Negotiated Rate	$18,380.53
Rate for Payer: Aetna Commercial	$14,817.38
Rate for Payer: Aetna Medicare	$18,380.53
Rate for Payer: BCBS of TX Blue Advantage	$9,816.04
Rate for Payer: BCBS of TX Blue Essentials	$12,827.55
Rate for Payer: BCBS of TX PPO	$14,253.38
Rate for Payer: Cigna Commercial	$16,964.25

TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC

Facility

$18,801.22

Service Code	MSDRG 083
Min. Negotiated Rate	$11,022.62
Max. Negotiated Rate	$18,801.22
Rate for Payer: Aetna Commercial	$15,259.50
Rate for Payer: Aetna Medicare	$18,801.22
Rate for Payer: BCBS of TX Blue Advantage	$11,022.62
Rate for Payer: BCBS of TX Blue Essentials	$13,363.10
Rate for Payer: BCBS of TX PPO	$14,848.47
Rate for Payer: Cigna Commercial	$17,470.43

TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC

Facility

$29,273.66

Service Code	MSDRG 085
Min. Negotiated Rate	$17,228.38
Max. Negotiated Rate	$29,273.66
Rate for Payer: Aetna Commercial	$25,569.00
Rate for Payer: Aetna Medicare	$28,610.43
Rate for Payer: BCBS of TX Blue Advantage	$17,228.38
Rate for Payer: BCBS of TX Blue Essentials	$22,495.42
Rate for Payer: BCBS of TX PPO	$24,995.88
Rate for Payer: Cigna Commercial	$29,273.66

TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC

Facility

$29,344.50

Service Code	MSDRG 082
Min. Negotiated Rate	$17,267.94
Max. Negotiated Rate	$29,344.50
Rate for Payer: Aetna Commercial	$25,630.88
Rate for Payer: Aetna Medicare	$28,669.31
Rate for Payer: BCBS of TX Blue Advantage	$17,267.94
Rate for Payer: BCBS of TX Blue Essentials	$22,274.59
Rate for Payer: BCBS of TX PPO	$24,750.51
Rate for Payer: Cigna Commercial	$29,344.50

TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC

Facility

$13,768.14

Service Code	MSDRG 087
Min. Negotiated Rate	$6,940.20
Max. Negotiated Rate	$13,768.14
Rate for Payer: Aetna Commercial	$9,969.75
Rate for Payer: Aetna Medicare	$13,768.14
Rate for Payer: BCBS of TX Blue Advantage	$6,940.20
Rate for Payer: BCBS of TX Blue Essentials	$8,722.65
Rate for Payer: BCBS of TX PPO	$9,692.21
Rate for Payer: Cigna Commercial	$11,414.26

TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC

Facility

$14,126.73

Service Code	MSDRG 084
Min. Negotiated Rate	$7,965.32
Max. Negotiated Rate	$14,126.73
Rate for Payer: Aetna Commercial	$10,346.62
Rate for Payer: Aetna Medicare	$14,126.73
Rate for Payer: BCBS of TX Blue Advantage	$7,965.32
Rate for Payer: BCBS of TX Blue Essentials	$9,527.53
Rate for Payer: BCBS of TX PPO	$10,586.56
Rate for Payer: Cigna Commercial	$11,845.74

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC

Facility

$20,404.67

Service Code	MSDRG 604
Min. Negotiated Rate	$11,594.52
Max. Negotiated Rate	$20,404.67
Rate for Payer: Aetna Commercial	$16,944.75
Rate for Payer: Aetna Medicare	$20,404.67
Rate for Payer: BCBS of TX Blue Advantage	$11,594.52
Rate for Payer: BCBS of TX Blue Essentials	$14,619.96
Rate for Payer: BCBS of TX PPO	$16,245.03
Rate for Payer: Cigna Commercial	$19,399.86

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC

Facility

$14,010.05

Service Code	MSDRG 605
Min. Negotiated Rate	$7,011.58
Max. Negotiated Rate	$14,010.05
Rate for Payer: Aetna Commercial	$10,224.00
Rate for Payer: Aetna Medicare	$14,010.05
Rate for Payer: BCBS of TX Blue Advantage	$7,011.58
Rate for Payer: BCBS of TX Blue Essentials	$8,879.50
Rate for Payer: BCBS of TX PPO	$9,866.49
Rate for Payer: Cigna Commercial	$11,705.34

TRAY CATHETER THORCNTS- SAF-T

Facility

$251.06

Hospital Charge Code	103837
Hospital Revenue Code	272
Min. Negotiated Rate	$22.60
Max. Negotiated Rate	$163.19
Rate for Payer: Aetna Commercial	$138.08
Rate for Payer: Amerigroup CHIP/Medicaid	$22.60
Rate for Payer: BCBS of TX Blue Advantage	$75.32
Rate for Payer: BCBS of TX Blue Essentials	$90.38
Rate for Payer: BCBS of TX PPO	$100.42
Rate for Payer: Cash Price	$220.93
Rate for Payer: Multiplan Auto	$163.19
Rate for Payer: Multiplan Commercial	$163.19
Rate for Payer: Multiplan Workers Comp	$163.19
Rate for Payer: Scott and White EPO/PPO	$125.53
Rate for Payer: Superior Health Plan EPO	$34.14

TRAY CATHETER THORCNTS- SAF-T

Facility

$251.06

Hospital Charge Code	103837
Hospital Revenue Code	272
Rate for Payer: Cash Price	$220.93

tray debridement

Facility

$17.71

Hospital Charge Code	8676541
Hospital Revenue Code	272
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$11.51
Rate for Payer: Aetna Commercial	$9.74
Rate for Payer: Amerigroup CHIP/Medicaid	$1.59
Rate for Payer: BCBS of TX Blue Advantage	$5.31
Rate for Payer: BCBS of TX Blue Essentials	$6.38
Rate for Payer: BCBS of TX PPO	$7.08
Rate for Payer: Cash Price	$15.58
Rate for Payer: Multiplan Auto	$11.51
Rate for Payer: Multiplan Commercial	$11.51
Rate for Payer: Multiplan Workers Comp	$11.51
Rate for Payer: Scott and White EPO/PPO	$8.86
Rate for Payer: Superior Health Plan EPO	$2.41

tray debridement

Facility

$17.71

Hospital Charge Code	8676541
Hospital Revenue Code	272
Rate for Payer: Cash Price	$15.58

TRAY, FOLEY ALL SIL CATH 16F 350ML URINMTR LTX FRE -- DHF

Facility

$94.97

Hospital Charge Code	80831308
Hospital Revenue Code	272
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$61.73
Rate for Payer: Aetna Commercial	$52.23
Rate for Payer: Amerigroup CHIP/Medicaid	$8.55
Rate for Payer: BCBS of TX Blue Advantage	$28.49
Rate for Payer: BCBS of TX Blue Essentials	$34.19
Rate for Payer: BCBS of TX PPO	$37.99
Rate for Payer: Cash Price	$83.57
Rate for Payer: Multiplan Auto	$61.73
Rate for Payer: Multiplan Commercial	$61.73
Rate for Payer: Multiplan Workers Comp	$61.73
Rate for Payer: Scott and White EPO/PPO	$47.48
Rate for Payer: Superior Health Plan EPO	$12.92

TRAY, FOLEY ALL SIL CATH 16F 350ML URINMTR LTX FRE -- DHF

Facility

$94.97

Hospital Charge Code	80831308
Hospital Revenue Code	272
Rate for Payer: Cash Price	$83.57

TRAY, TRACHEOSTOMY CARE 8

Facility

$749.28

Hospital Charge Code	133826
Hospital Revenue Code	272
Min. Negotiated Rate	$67.44
Max. Negotiated Rate	$487.03
Rate for Payer: Aetna Commercial	$412.10
Rate for Payer: Amerigroup CHIP/Medicaid	$67.44
Rate for Payer: BCBS of TX Blue Advantage	$224.78
Rate for Payer: BCBS of TX Blue Essentials	$269.74
Rate for Payer: BCBS of TX PPO	$299.71
Rate for Payer: Cash Price	$659.37
Rate for Payer: Multiplan Auto	$487.03
Rate for Payer: Multiplan Commercial	$487.03
Rate for Payer: Multiplan Workers Comp	$487.03
Rate for Payer: Scott and White EPO/PPO	$374.64
Rate for Payer: Superior Health Plan EPO	$101.90

TRAY, TRACHEOSTOMY CARE 8

Facility

$749.28

Hospital Charge Code	133826
Hospital Revenue Code	272
Rate for Payer: Cash Price	$659.37

tray uretheral catheter

Facility

$19.52

Hospital Charge Code	8634514
Hospital Revenue Code	272
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$12.69
Rate for Payer: Aetna Commercial	$10.74
Rate for Payer: Amerigroup CHIP/Medicaid	$1.76
Rate for Payer: BCBS of TX Blue Advantage	$5.86
Rate for Payer: BCBS of TX Blue Essentials	$7.03
Rate for Payer: BCBS of TX PPO	$7.81
Rate for Payer: Cash Price	$17.18
Rate for Payer: Multiplan Auto	$12.69
Rate for Payer: Multiplan Commercial	$12.69
Rate for Payer: Multiplan Workers Comp	$12.69
Rate for Payer: Scott and White EPO/PPO	$9.76
Rate for Payer: Superior Health Plan EPO	$2.65

tray uretheral catheter

Facility

$19.52

Hospital Charge Code	8634514
Hospital Revenue Code	272
Rate for Payer: Cash Price	$17.18

traZODone 50 mg Tab

Facility

$9.35

Service Code	HCPCS J3490
Hospital Charge Code	77854831
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.36

traZODone 50 mg Tab

Facility

$9.35

Service Code	HCPCS J3490
Hospital Charge Code	77854831
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.08
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.81
Rate for Payer: BCBS of TX Blue Essentials	$3.37
Rate for Payer: BCBS of TX PPO	$3.74
Rate for Payer: Cash Price	$6.36
Rate for Payer: Multiplan Auto	$6.08
Rate for Payer: Multiplan Commercial	$6.08
Rate for Payer: Multiplan Workers Comp	$6.08
Rate for Payer: Scott and White EPO/PPO	$4.67
Rate for Payer: Superior Health Plan EPO	$1.27

Treat Clavical Dislocation

Facility

$15,074.51

Service Code	CPT 23550
Hospital Charge Code	36023550
Hospital Revenue Code	360
Min. Negotiated Rate	$3,155.24
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	$3,155.24
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	$3,155.24
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	$3,155.24
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	$3,155.24
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	$3,155.24
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

Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each

Facility

$10,000.00

Service Code	CPT 28450
Hospital Charge Code	36028450
Hospital Revenue Code	360
Min. Negotiated Rate	$85.32
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$323.50
Rate for Payer: Amerigroup CHIP/Medicaid	$85.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$215.67
Rate for Payer: Amerigroup Medicare	$215.67
Rate for Payer: BCBS of TX Blue Advantage	$181.96
Rate for Payer: BCBS of TX Blue Essentials	$217.92
Rate for Payer: BCBS of TX Medicare	$215.67
Rate for Payer: BCBS of TX PPO	$274.58
Rate for Payer: Cigna Commercial	$488.55
Rate for Payer: Cigna Medicaid	$85.32
Rate for Payer: Cigna Medicare	$215.67
Rate for Payer: Employer Direct Commercial	$215.67
Rate for Payer: Humana Medicare/TRICARE	$215.67
Rate for Payer: Molina CHIP/Medicaid	$85.32
Rate for Payer: Molina Dual Medicare/Medicaid	$215.67
Rate for Payer: Molina Medicare	$215.67
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	$85.32
Rate for Payer: Scott and White EPO/PPO	$398.99
Rate for Payer: Scott and White Medicare	$215.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$85.32
Rate for Payer: Superior Health Plan EPO	$215.67
Rate for Payer: Superior Health Plan Medicare	$215.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$215.67
Rate for Payer: Universal American Medicare	$215.67
Rate for Payer: Wellcare Medicare	$215.67
Rate for Payer: Wellmed Medicare	$215.67

Treponema pallidum Antibodies SO

Facility

$243.00

Service Code	CPT 86780
Hospital Charge Code	1606045
Hospital Revenue Code	302
Rate for Payer: Cash Price	$213.84

Treponema pallidum Antibodies SO

Facility

$243.00

Service Code	CPT 86780
Hospital Charge Code	1606045
Hospital Revenue Code	302
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$157.95
Rate for Payer: Aetna Commercial	$13.89
Rate for Payer: Aetna Medicare	$19.86
Rate for Payer: Amerigroup CHIP/Medicaid	$5.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.24
Rate for Payer: Amerigroup Medicare	$13.24
Rate for Payer: BCBS of TX Blue Advantage	$21.85
Rate for Payer: BCBS of TX Blue Essentials	$26.22
Rate for Payer: BCBS of TX Medicare	$13.24
Rate for Payer: BCBS of TX PPO	$29.26
Rate for Payer: Cash Price	$213.84
Rate for Payer: Cash Price	$213.84
Rate for Payer: Cigna Medicaid	$13.24
Rate for Payer: Cigna Medicare	$13.24
Rate for Payer: Employer Direct Commercial	$13.24
Rate for Payer: Humana Medicare/TRICARE	$13.24
Rate for Payer: Molina CHIP/Medicaid	$13.24
Rate for Payer: Molina Dual Medicare/Medicaid	$13.24
Rate for Payer: Molina Medicare	$13.24
Rate for Payer: Multiplan Auto	$157.95
Rate for Payer: Multiplan Commercial	$157.95
Rate for Payer: Multiplan Workers Comp	$157.95
Rate for Payer: Parkland Medicaid	$13.24
Rate for Payer: Scott and White EPO/PPO	$16.55
Rate for Payer: Scott and White Medicare	$13.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.24
Rate for Payer: Superior Health Plan EPO	$13.24
Rate for Payer: Superior Health Plan Medicare	$13.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.24
Rate for Payer: Universal American Medicare	$13.24
Rate for Payer: Wellcare Medicare	$13.24
Rate for Payer: Wellmed Medicare	$13.24

Triage Patient Type:Established Patient

Facility

$211.00

Service Code	CPT 99213
Hospital Charge Code	3101201
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$137.15
Rate for Payer: Aetna Commercial	$116.05
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$90.31
Rate for Payer: BCBS of TX Blue Essentials	$107.95
Rate for Payer: BCBS of TX PPO	$120.41
Rate for Payer: Cash Price	$185.68
Rate for Payer: Cash Price	$185.68
Rate for Payer: Cigna Medicaid	$31.23
Rate for Payer: Molina CHIP/Medicaid	$31.23
Rate for Payer: Multiplan Auto	$137.15
Rate for Payer: Multiplan Commercial	$137.15
Rate for Payer: Multiplan Workers Comp	$137.15
Rate for Payer: Parkland Medicaid	$31.23
Rate for Payer: Scott and White EPO/PPO	$80.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.23

Know your out-of-pocket cost for care.

All Charges