White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TRY TRIP/LUMEN -- DHF

Facility

$838.67

Service Code	HCPCS C1751
Hospital Charge Code	80843709
Hospital Revenue Code	278
Min. Negotiated Rate	$209.67
Max. Negotiated Rate	$419.34
Rate for Payer: Aetna Commercial	$251.60
Rate for Payer: Cash Price	$738.03
Rate for Payer: Cigna Commercial	$209.67
Rate for Payer: Multiplan Auto	$419.34
Rate for Payer: Multiplan Commercial	$419.34
Rate for Payer: Multiplan Workers Comp	$419.34
Rate for Payer: Scott and White EPO/PPO	$419.34

TRY UMBL ART CTH -- DHF

Facility

$292.41

Hospital Charge Code	80843956
Hospital Revenue Code	272
Min. Negotiated Rate	$26.32
Max. Negotiated Rate	$190.07
Rate for Payer: Aetna Commercial	$160.83
Rate for Payer: Amerigroup CHIP/Medicaid	$26.32
Rate for Payer: BCBS of TX Blue Advantage	$87.72
Rate for Payer: BCBS of TX Blue Essentials	$105.27
Rate for Payer: BCBS of TX PPO	$116.96
Rate for Payer: Cash Price	$257.32
Rate for Payer: Multiplan Auto	$190.07
Rate for Payer: Multiplan Commercial	$190.07
Rate for Payer: Multiplan Workers Comp	$190.07
Rate for Payer: Scott and White EPO/PPO	$146.20
Rate for Payer: Superior Health Plan EPO	$39.77

TRY UMBL ART CTH -- DHF

Facility

$292.41

Hospital Charge Code	80843956
Hospital Revenue Code	272
Rate for Payer: Cash Price	$257.32

tTG IgA/G SO

Facility

$215.00

Service Code	CPT 83516
Hospital Charge Code	1706019
Hospital Revenue Code	301
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$139.75
Rate for Payer: Aetna Commercial	$12.11
Rate for Payer: Aetna Medicare	$17.30
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.53
Rate for Payer: Amerigroup Medicare	$11.53
Rate for Payer: BCBS of TX Blue Advantage	$19.02
Rate for Payer: BCBS of TX Blue Essentials	$22.83
Rate for Payer: BCBS of TX Medicare	$11.53
Rate for Payer: BCBS of TX PPO	$25.48
Rate for Payer: Cash Price	$189.20
Rate for Payer: Cash Price	$189.20
Rate for Payer: Cigna Medicaid	$11.53
Rate for Payer: Cigna Medicare	$11.53
Rate for Payer: Employer Direct Commercial	$11.53
Rate for Payer: Humana Medicare/TRICARE	$11.53
Rate for Payer: Molina CHIP/Medicaid	$11.53
Rate for Payer: Molina Dual Medicare/Medicaid	$11.53
Rate for Payer: Molina Medicare	$11.53
Rate for Payer: Multiplan Auto	$139.75
Rate for Payer: Multiplan Commercial	$139.75
Rate for Payer: Multiplan Workers Comp	$139.75
Rate for Payer: Parkland Medicaid	$11.53
Rate for Payer: Scott and White EPO/PPO	$14.41
Rate for Payer: Scott and White Medicare	$11.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.53
Rate for Payer: Superior Health Plan EPO	$11.53
Rate for Payer: Superior Health Plan Medicare	$11.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.53
Rate for Payer: Universal American Medicare	$11.53
Rate for Payer: Wellcare Medicare	$11.53
Rate for Payer: Wellmed Medicare	$11.53

tTG IgA/G SO

Facility

$215.00

Service Code	CPT 83516
Hospital Charge Code	1706019
Hospital Revenue Code	301
Rate for Payer: Cash Price	$189.20

t-Transglutaminase (tTG) IgA SO

Facility

$372.00

Service Code	CPT 86364
Hospital Charge Code	1706019
Hospital Revenue Code	301
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$241.80
Rate for Payer: Aetna Commercial	$12.11
Rate for Payer: Aetna Medicare	$17.30
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.53
Rate for Payer: Amerigroup Medicare	$11.53
Rate for Payer: BCBS of TX Blue Advantage	$19.02
Rate for Payer: BCBS of TX Blue Essentials	$22.83
Rate for Payer: BCBS of TX Medicare	$11.53
Rate for Payer: BCBS of TX PPO	$25.48
Rate for Payer: Cash Price	$327.36
Rate for Payer: Cash Price	$327.36
Rate for Payer: Cigna Medicaid	$11.53
Rate for Payer: Cigna Medicare	$11.53
Rate for Payer: Employer Direct Commercial	$11.53
Rate for Payer: Humana Medicare/TRICARE	$11.53
Rate for Payer: Molina CHIP/Medicaid	$11.53
Rate for Payer: Molina Dual Medicare/Medicaid	$11.53
Rate for Payer: Molina Medicare	$11.53
Rate for Payer: Multiplan Auto	$241.80
Rate for Payer: Multiplan Commercial	$241.80
Rate for Payer: Multiplan Workers Comp	$241.80
Rate for Payer: Parkland Medicaid	$11.53
Rate for Payer: Scott and White EPO/PPO	$14.41
Rate for Payer: Scott and White Medicare	$11.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.53
Rate for Payer: Superior Health Plan EPO	$11.53
Rate for Payer: Superior Health Plan Medicare	$11.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.53
Rate for Payer: Universal American Medicare	$11.53
Rate for Payer: Wellcare Medicare	$11.53
Rate for Payer: Wellmed Medicare	$11.53

t-Transglutaminase (tTG) IgG SO

Facility

$372.00

Service Code	CPT 86364
Hospital Charge Code	1706019
Hospital Revenue Code	301
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$241.80
Rate for Payer: Aetna Commercial	$12.11
Rate for Payer: Aetna Medicare	$17.30
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.53
Rate for Payer: Amerigroup Medicare	$11.53
Rate for Payer: BCBS of TX Blue Advantage	$19.02
Rate for Payer: BCBS of TX Blue Essentials	$22.83
Rate for Payer: BCBS of TX Medicare	$11.53
Rate for Payer: BCBS of TX PPO	$25.48
Rate for Payer: Cash Price	$327.36
Rate for Payer: Cash Price	$327.36
Rate for Payer: Cigna Medicaid	$11.53
Rate for Payer: Cigna Medicare	$11.53
Rate for Payer: Employer Direct Commercial	$11.53
Rate for Payer: Humana Medicare/TRICARE	$11.53
Rate for Payer: Molina CHIP/Medicaid	$11.53
Rate for Payer: Molina Dual Medicare/Medicaid	$11.53
Rate for Payer: Molina Medicare	$11.53
Rate for Payer: Multiplan Auto	$241.80
Rate for Payer: Multiplan Commercial	$241.80
Rate for Payer: Multiplan Workers Comp	$241.80
Rate for Payer: Parkland Medicaid	$11.53
Rate for Payer: Scott and White EPO/PPO	$14.41
Rate for Payer: Scott and White Medicare	$11.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.53
Rate for Payer: Superior Health Plan EPO	$11.53
Rate for Payer: Superior Health Plan Medicare	$11.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.53
Rate for Payer: Universal American Medicare	$11.53
Rate for Payer: Wellcare Medicare	$11.53
Rate for Payer: Wellmed Medicare	$11.53

t-Transglutaminase (tTG) IgG SO

Facility

$372.00

Service Code	CPT 86364
Hospital Charge Code	1706019
Hospital Revenue Code	301
Rate for Payer: Cash Price	$327.36

TUBE, CALIBRATION SINGLE FOR LAP-BAND -- DHF

Facility

$631.63

Hospital Charge Code	81775165
Hospital Revenue Code	272
Min. Negotiated Rate	$56.85
Max. Negotiated Rate	$410.56
Rate for Payer: Aetna Commercial	$347.40
Rate for Payer: Amerigroup CHIP/Medicaid	$56.85
Rate for Payer: BCBS of TX Blue Advantage	$189.49
Rate for Payer: BCBS of TX Blue Essentials	$227.39
Rate for Payer: BCBS of TX PPO	$252.65
Rate for Payer: Cash Price	$555.83
Rate for Payer: Multiplan Auto	$410.56
Rate for Payer: Multiplan Commercial	$410.56
Rate for Payer: Multiplan Workers Comp	$410.56
Rate for Payer: Scott and White EPO/PPO	$315.82
Rate for Payer: Superior Health Plan EPO	$85.90

TUBE, CALIBRATION SINGLE FOR LAP-BAND -- DHF

Facility

$631.63

Hospital Charge Code	81775165
Hospital Revenue Code	272
Rate for Payer: Cash Price	$555.83

TUBE, CONNECTING 9/32 I.D, 240'''' LGTH -- DHF

Facility

$87.80

Hospital Charge Code	81855850
Hospital Revenue Code	272
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$57.07
Rate for Payer: Aetna Commercial	$48.29
Rate for Payer: Amerigroup CHIP/Medicaid	$7.90
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.61
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$77.26
Rate for Payer: Multiplan Auto	$57.07
Rate for Payer: Multiplan Commercial	$57.07
Rate for Payer: Multiplan Workers Comp	$57.07
Rate for Payer: Scott and White EPO/PPO	$43.90
Rate for Payer: Superior Health Plan EPO	$11.94

TUBE, CONNECTING 9/32 I.D, 240'''' LGTH -- DHF

Facility

$87.80

Hospital Charge Code	81855850
Hospital Revenue Code	272
Rate for Payer: Cash Price	$77.26

TUBE INJECTOR TRANSFER -- DHF

Facility

$321.67

Hospital Charge Code	81799017
Hospital Revenue Code	272
Rate for Payer: Cash Price	$283.07

TUBE INJECTOR TRANSFER -- DHF

Facility

$321.67

Hospital Charge Code	81799017
Hospital Revenue Code	272
Min. Negotiated Rate	$28.95
Max. Negotiated Rate	$209.09
Rate for Payer: Aetna Commercial	$176.92
Rate for Payer: Amerigroup CHIP/Medicaid	$28.95
Rate for Payer: BCBS of TX Blue Advantage	$96.50
Rate for Payer: BCBS of TX Blue Essentials	$115.80
Rate for Payer: BCBS of TX PPO	$128.67
Rate for Payer: Cash Price	$283.07
Rate for Payer: Multiplan Auto	$209.09
Rate for Payer: Multiplan Commercial	$209.09
Rate for Payer: Multiplan Workers Comp	$209.09
Rate for Payer: Scott and White EPO/PPO	$160.84
Rate for Payer: Superior Health Plan EPO	$43.75

TUBE SET HI-FLOW PNEUMOCLEAR W/SMK EVAC

Facility

$144.41

Hospital Charge Code	8556476
Hospital Revenue Code	272
Rate for Payer: Cash Price	$127.08

TUBE SET HI-FLOW PNEUMOCLEAR W/SMK EVAC

Facility

$144.41

Hospital Charge Code	8556476
Hospital Revenue Code	272
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$93.87
Rate for Payer: Aetna Commercial	$79.43
Rate for Payer: Amerigroup CHIP/Medicaid	$13.00
Rate for Payer: BCBS of TX Blue Advantage	$43.32
Rate for Payer: BCBS of TX Blue Essentials	$51.99
Rate for Payer: BCBS of TX PPO	$57.76
Rate for Payer: Cash Price	$127.08
Rate for Payer: Multiplan Auto	$93.87
Rate for Payer: Multiplan Commercial	$93.87
Rate for Payer: Multiplan Workers Comp	$93.87
Rate for Payer: Scott and White EPO/PPO	$72.20
Rate for Payer: Superior Health Plan EPO	$19.64

TUBE SET HIGH FLOW PNEUMOCLEAR

Facility

$43.31

Hospital Charge Code	8556475
Hospital Revenue Code	272
Min. Negotiated Rate	$3.90
Max. Negotiated Rate	$28.15
Rate for Payer: Aetna Commercial	$23.82
Rate for Payer: Amerigroup CHIP/Medicaid	$3.90
Rate for Payer: BCBS of TX Blue Advantage	$12.99
Rate for Payer: BCBS of TX Blue Essentials	$15.59
Rate for Payer: BCBS of TX PPO	$17.32
Rate for Payer: Cash Price	$38.11
Rate for Payer: Multiplan Auto	$28.15
Rate for Payer: Multiplan Commercial	$28.15
Rate for Payer: Multiplan Workers Comp	$28.15
Rate for Payer: Scott and White EPO/PPO	$21.66
Rate for Payer: Superior Health Plan EPO	$5.89

TUBE SET HIGH FLOW PNEUMOCLEAR

Facility

$43.31

Hospital Charge Code	8556475
Hospital Revenue Code	272
Rate for Payer: Cash Price	$38.11

TUBING, ARTHROSCOPY CASSETTE INFLOW -- DHF

Facility

$276.94

Hospital Charge Code	81860082
Hospital Revenue Code	272
Rate for Payer: Cash Price	$243.71

TUBING, ARTHROSCOPY CASSETTE INFLOW -- DHF

Facility

$276.94

Hospital Charge Code	81860082
Hospital Revenue Code	272
Min. Negotiated Rate	$24.92
Max. Negotiated Rate	$180.01
Rate for Payer: Aetna Commercial	$152.32
Rate for Payer: Amerigroup CHIP/Medicaid	$24.92
Rate for Payer: BCBS of TX Blue Advantage	$83.08
Rate for Payer: BCBS of TX Blue Essentials	$99.70
Rate for Payer: BCBS of TX PPO	$110.78
Rate for Payer: Cash Price	$243.71
Rate for Payer: Multiplan Auto	$180.01
Rate for Payer: Multiplan Commercial	$180.01
Rate for Payer: Multiplan Workers Comp	$180.01
Rate for Payer: Scott and White EPO/PPO	$138.47
Rate for Payer: Superior Health Plan EPO	$37.66

TUBING, GAS LINE HIGH PRESS SIDE-KICK MANIPULATOR -- DHF

Facility

$246.25

Hospital Charge Code	80347206
Hospital Revenue Code	270
Min. Negotiated Rate	$22.16
Max. Negotiated Rate	$160.06
Rate for Payer: Aetna Commercial	$135.44
Rate for Payer: Amerigroup CHIP/Medicaid	$22.16
Rate for Payer: BCBS of TX Blue Advantage	$73.88
Rate for Payer: BCBS of TX Blue Essentials	$88.65
Rate for Payer: BCBS of TX PPO	$98.50
Rate for Payer: Cash Price	$216.70
Rate for Payer: Multiplan Auto	$160.06
Rate for Payer: Multiplan Commercial	$160.06
Rate for Payer: Multiplan Workers Comp	$160.06
Rate for Payer: Scott and White EPO/PPO	$123.12
Rate for Payer: Superior Health Plan EPO	$33.49

TUBING, GAS LINE HIGH PRESS SIDE-KICK MANIPULATOR -- DHF

Facility

$246.25

Hospital Charge Code	80347206
Hospital Revenue Code	270
Rate for Payer: Cash Price	$216.70

TUBING, INSUFFLATOR FOR 20 LITER UNIT -- DHF

Facility

$46.80

Hospital Charge Code	81777054
Hospital Revenue Code	270
Rate for Payer: Cash Price	$41.18

TUBING, INSUFFLATOR FOR 20 LITER UNIT -- DHF

Facility

$46.80

Hospital Charge Code	81777054
Hospital Revenue Code	270
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$30.42
Rate for Payer: Aetna Commercial	$25.74
Rate for Payer: Amerigroup CHIP/Medicaid	$4.21
Rate for Payer: BCBS of TX Blue Advantage	$14.04
Rate for Payer: BCBS of TX Blue Essentials	$16.85
Rate for Payer: BCBS of TX PPO	$18.72
Rate for Payer: Cash Price	$41.18
Rate for Payer: Multiplan Auto	$30.42
Rate for Payer: Multiplan Commercial	$30.42
Rate for Payer: Multiplan Workers Comp	$30.42
Rate for Payer: Scott and White EPO/PPO	$23.40
Rate for Payer: Superior Health Plan EPO	$6.36

TUBING, INSUFLOW LAPAROSCOPIC FILTER HEATER 8'4'''' -- DHF

Facility

$1,930.01

Hospital Charge Code	80324957
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,698.41

Know your out-of-pocket cost for care.

All Charges