White Rock Medical Center

All Charges

Charge

Type

Setting

Price

T3 Uptake

Facility

$199.00

Service Code	HCPCS 84479
Hospital Charge Code	1602267
Hospital Revenue Code	301
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$143.28
Rate for Payer: Amerigroup CHIP/Medicaid	$2.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.47
Rate for Payer: Amerigroup Medicare	$6.47
Rate for Payer: BCBS of TX Blue Advantage	$59.70
Rate for Payer: BCBS of TX Blue Essentials	$71.64
Rate for Payer: BCBS of TX Medicare	$6.47
Rate for Payer: BCBS of TX PPO	$79.60
Rate for Payer: Cash Price	$135.32
Rate for Payer: Cash Price	$135.32
Rate for Payer: Cigna Medicaid	$143.28
Rate for Payer: Cigna Medicare	$6.47
Rate for Payer: Employer Direct Commercial	$6.47
Rate for Payer: Humana Medicare/TRICARE	$6.47
Rate for Payer: Molina CHIP/Medicaid	$143.28
Rate for Payer: Molina Dual Medicare/Medicaid	$6.47
Rate for Payer: Molina Medicare	$6.47
Rate for Payer: Multiplan Auto	$129.35
Rate for Payer: Multiplan Commercial	$129.35
Rate for Payer: Multiplan Workers Comp	$129.35
Rate for Payer: Parkland Medicaid	$143.28
Rate for Payer: Scott and White EPO/PPO	$8.09
Rate for Payer: Scott and White Medicare	$6.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$143.28
Rate for Payer: Superior Health Plan EPO	$6.47
Rate for Payer: Superior Health Plan Medicare	$6.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.47
Rate for Payer: Universal American Medicare	$6.47
Rate for Payer: Wellcare Medicare	$6.47
Rate for Payer: Wellmed Medicare	$6.47

T3 Uptake

Facility

$199.00

Service Code	HCPCS 84479
Hospital Charge Code	4104250
Hospital Revenue Code	301
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$143.28
Rate for Payer: Amerigroup CHIP/Medicaid	$2.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.47
Rate for Payer: Amerigroup Medicare	$6.47
Rate for Payer: BCBS of TX Blue Advantage	$59.70
Rate for Payer: BCBS of TX Blue Essentials	$71.64
Rate for Payer: BCBS of TX Medicare	$6.47
Rate for Payer: BCBS of TX PPO	$79.60
Rate for Payer: Cash Price	$135.32
Rate for Payer: Cash Price	$135.32
Rate for Payer: Cigna Medicaid	$143.28
Rate for Payer: Cigna Medicare	$6.47
Rate for Payer: Employer Direct Commercial	$6.47
Rate for Payer: Humana Medicare/TRICARE	$6.47
Rate for Payer: Molina CHIP/Medicaid	$143.28
Rate for Payer: Molina Dual Medicare/Medicaid	$6.47
Rate for Payer: Molina Medicare	$6.47
Rate for Payer: Multiplan Auto	$129.35
Rate for Payer: Multiplan Commercial	$129.35
Rate for Payer: Multiplan Workers Comp	$129.35
Rate for Payer: Parkland Medicaid	$143.28
Rate for Payer: Scott and White EPO/PPO	$8.09
Rate for Payer: Scott and White Medicare	$6.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$143.28
Rate for Payer: Superior Health Plan EPO	$6.47
Rate for Payer: Superior Health Plan Medicare	$6.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.47
Rate for Payer: Universal American Medicare	$6.47
Rate for Payer: Wellcare Medicare	$6.47
Rate for Payer: Wellmed Medicare	$6.47

T3 Uptake

Facility

$199.00

Service Code	HCPCS 84479
Hospital Charge Code	4104250
Hospital Revenue Code	301
Rate for Payer: Cash Price	$135.32

Tacrolimus (FK506), Blood SO

Facility

$681.00

Service Code	HCPCS 80197
Hospital Charge Code	1708973
Hospital Revenue Code	300
Rate for Payer: Cash Price	$463.08

Tacrolimus (FK506), Blood SO

Facility

$681.00

Service Code	HCPCS 80197
Hospital Charge Code	1708973
Hospital Revenue Code	300
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$490.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.73
Rate for Payer: Amerigroup Medicare	$13.73
Rate for Payer: BCBS of TX Blue Advantage	$204.30
Rate for Payer: BCBS of TX Blue Essentials	$245.16
Rate for Payer: BCBS of TX Medicare	$13.73
Rate for Payer: BCBS of TX PPO	$272.40
Rate for Payer: Cash Price	$463.08
Rate for Payer: Cash Price	$463.08
Rate for Payer: Cigna Medicaid	$490.32
Rate for Payer: Cigna Medicare	$13.73
Rate for Payer: Employer Direct Commercial	$13.73
Rate for Payer: Humana Medicare/TRICARE	$13.73
Rate for Payer: Molina CHIP/Medicaid	$490.32
Rate for Payer: Molina Dual Medicare/Medicaid	$13.73
Rate for Payer: Molina Medicare	$13.73
Rate for Payer: Multiplan Auto	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
Rate for Payer: Parkland Medicaid	$490.32
Rate for Payer: Scott and White EPO/PPO	$17.16
Rate for Payer: Scott and White Medicare	$13.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$490.32
Rate for Payer: Superior Health Plan EPO	$13.73
Rate for Payer: Superior Health Plan Medicare	$13.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.73
Rate for Payer: Universal American Medicare	$13.73
Rate for Payer: Wellcare Medicare	$13.73
Rate for Payer: Wellmed Medicare	$13.73

TAG, WRITE-ON VENDOR, BLUE

Facility

$1.23

Hospital Charge Code	992949
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.84

TAG, WRITE-ON VENDOR, BLUE

Facility

$1.23

Hospital Charge Code	992949
Hospital Revenue Code	270
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.89
Rate for Payer: Amerigroup CHIP/Medicaid	$0.11
Rate for Payer: BCBS of TX Blue Advantage	$0.37
Rate for Payer: BCBS of TX Blue Essentials	$0.44
Rate for Payer: BCBS of TX PPO	$0.49
Rate for Payer: Cash Price	$0.84
Rate for Payer: Cigna Medicaid	$0.89
Rate for Payer: Molina CHIP/Medicaid	$0.89
Rate for Payer: Multiplan Auto	$0.80
Rate for Payer: Multiplan Commercial	$0.80
Rate for Payer: Multiplan Workers Comp	$0.80
Rate for Payer: Parkland Medicaid	$0.89
Rate for Payer: Scott and White EPO/PPO	$0.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.89
Rate for Payer: Superior Health Plan EPO	$0.17

Talectomy (astragalectomy)

Facility

$27,265.32

Service Code	HCPCS 28130
Hospital Charge Code	992001
Hospital Revenue Code	360
Rate for Payer: Cash Price	$18,540.42

Talectomy (astragalectomy)

Facility

$27,265.32

Service Code	HCPCS 28130
Hospital Charge Code	992001
Hospital Revenue Code	360
Min. Negotiated Rate	$3,192.14
Max. Negotiated Rate	$19,631.03
Rate for Payer: Amerigroup CHIP/Medicaid	$3,192.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
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	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$18,540.42
Rate for Payer: Cash Price	$18,540.42
Rate for Payer: Cash Price	$18,540.42
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$19,631.03
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$19,631.03
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$19,631.03
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,631.03
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

tamsulosin 0.4 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78407675
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

tamsulosin 0.4 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78407675
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

TANGNTL BX SKIN EA SEP/ADDL

Facility

$399.00

Service Code	HCPCS 11103
Hospital Charge Code	7150053
Hospital Revenue Code	361
Rate for Payer: Cash Price	$271.32

TANGNTL BX SKIN EA SEP/ADDL

Facility

$399.00

Service Code	HCPCS 11103
Hospital Charge Code	7150053
Hospital Revenue Code	361
Min. Negotiated Rate	$35.91
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$35.91
Rate for Payer: BCBS of TX Blue Advantage	$119.70
Rate for Payer: BCBS of TX Blue Essentials	$143.64
Rate for Payer: BCBS of TX PPO	$159.60
Rate for Payer: Cash Price	$271.32
Rate for Payer: Cash Price	$271.32
Rate for Payer: Cigna Medicaid	$287.28
Rate for Payer: Molina CHIP/Medicaid	$287.28
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	$287.28
Rate for Payer: Scott and White EPO/PPO	$199.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$287.28
Rate for Payer: Superior Health Plan EPO	$54.26

TANGNTL BX SKIN SINGLE LES

Facility

$715.00

Service Code	HCPCS 11102
Hospital Charge Code	7150050
Hospital Revenue Code	361
Rate for Payer: Cash Price	$486.20

TANGNTL BX SKIN SINGLE LES

Facility

$715.00

Service Code	HCPCS 11102
Hospital Charge Code	7150050
Hospital Revenue Code	361
Min. Negotiated Rate	$64.23
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$64.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$126.57
Rate for Payer: BCBS of TX Blue Essentials	$151.58
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$190.99
Rate for Payer: Cash Price	$486.20
Rate for Payer: Cash Price	$486.20
Rate for Payer: Cash Price	$486.20
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$514.80
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$514.80
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$514.80
Rate for Payer: Scott and White EPO/PPO	$338.72
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$514.80
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

TAPE, ATTEST, LEADFREE, STEAM, IND

Facility

$22.53

Hospital Charge Code	992979
Hospital Revenue Code	272
Rate for Payer: Cash Price	$15.32

TAPE, ATTEST, LEADFREE, STEAM, IND

Facility

$22.53

Hospital Charge Code	992979
Hospital Revenue Code	272
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$16.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2.03
Rate for Payer: BCBS of TX Blue Advantage	$6.76
Rate for Payer: BCBS of TX Blue Essentials	$8.11
Rate for Payer: BCBS of TX PPO	$9.01
Rate for Payer: Cash Price	$15.32
Rate for Payer: Cigna Medicaid	$16.22
Rate for Payer: Molina CHIP/Medicaid	$16.22
Rate for Payer: Multiplan Auto	$14.64
Rate for Payer: Multiplan Commercial	$14.64
Rate for Payer: Multiplan Workers Comp	$14.64
Rate for Payer: Parkland Medicaid	$16.22
Rate for Payer: Scott and White EPO/PPO	$11.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.22
Rate for Payer: Superior Health Plan EPO	$3.06

TAPE, CLOTH SOFT SURGICAL 4' X 10 YARDS -- DHF

Facility

$36.69

Hospital Charge Code	80349004
Hospital Revenue Code	270
Rate for Payer: Cash Price	$24.95

TAPE, CLOTH SOFT SURGICAL 4' X 10 YARDS -- DHF

Facility

$36.69

Hospital Charge Code	80349004
Hospital Revenue Code	270
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$26.42
Rate for Payer: Amerigroup CHIP/Medicaid	$3.30
Rate for Payer: BCBS of TX Blue Advantage	$11.01
Rate for Payer: BCBS of TX Blue Essentials	$13.21
Rate for Payer: BCBS of TX PPO	$14.68
Rate for Payer: Cash Price	$24.95
Rate for Payer: Cigna Medicaid	$26.42
Rate for Payer: Molina CHIP/Medicaid	$26.42
Rate for Payer: Multiplan Auto	$23.85
Rate for Payer: Multiplan Commercial	$23.85
Rate for Payer: Multiplan Workers Comp	$23.85
Rate for Payer: Parkland Medicaid	$26.42
Rate for Payer: Scott and White EPO/PPO	$18.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.42
Rate for Payer: Superior Health Plan EPO	$4.99

TAPE, COTTON UMBILICAL 1/8' X 30 -- DHF

Facility

$96.69

Hospital Charge Code	81950008
Hospital Revenue Code	272
Min. Negotiated Rate	$8.70
Max. Negotiated Rate	$69.62
Rate for Payer: Amerigroup CHIP/Medicaid	$8.70
Rate for Payer: BCBS of TX Blue Advantage	$29.01
Rate for Payer: BCBS of TX Blue Essentials	$34.81
Rate for Payer: BCBS of TX PPO	$38.68
Rate for Payer: Cash Price	$65.75
Rate for Payer: Cigna Medicaid	$69.62
Rate for Payer: Molina CHIP/Medicaid	$69.62
Rate for Payer: Multiplan Auto	$62.85
Rate for Payer: Multiplan Commercial	$62.85
Rate for Payer: Multiplan Workers Comp	$62.85
Rate for Payer: Parkland Medicaid	$69.62
Rate for Payer: Scott and White EPO/PPO	$48.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.62
Rate for Payer: Superior Health Plan EPO	$13.15

TAPE, COTTON UMBILICAL 1/8' X 30 -- DHF

Facility

$96.69

Hospital Charge Code	81950008
Hospital Revenue Code	272
Rate for Payer: Cash Price	$65.75

TAPE INDCTR STR SLSR 60YD RL CHM

Facility

$9.19

Hospital Charge Code	992588
Hospital Revenue Code	272
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$6.62
Rate for Payer: Amerigroup CHIP/Medicaid	$0.83
Rate for Payer: BCBS of TX Blue Advantage	$2.76
Rate for Payer: BCBS of TX Blue Essentials	$3.31
Rate for Payer: BCBS of TX PPO	$3.68
Rate for Payer: Cash Price	$6.25
Rate for Payer: Cigna Medicaid	$6.62
Rate for Payer: Molina CHIP/Medicaid	$6.62
Rate for Payer: Multiplan Auto	$5.97
Rate for Payer: Multiplan Commercial	$5.97
Rate for Payer: Multiplan Workers Comp	$5.97
Rate for Payer: Parkland Medicaid	$6.62
Rate for Payer: Scott and White EPO/PPO	$4.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.62
Rate for Payer: Superior Health Plan EPO	$1.25

TAPE INDCTR STR SLSR 60YD RL CHM

Facility

$9.19

Hospital Charge Code	992588
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6.25

TAPE, PAPER, SURGICAL, MICROPORE 2'X10YD

Facility

$3.54

Hospital Charge Code	993226
Hospital Revenue Code	270
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$2.55
Rate for Payer: Amerigroup CHIP/Medicaid	$0.32
Rate for Payer: BCBS of TX Blue Advantage	$1.06
Rate for Payer: BCBS of TX Blue Essentials	$1.27
Rate for Payer: BCBS of TX PPO	$1.42
Rate for Payer: Cash Price	$2.41
Rate for Payer: Cigna Medicaid	$2.55
Rate for Payer: Molina CHIP/Medicaid	$2.55
Rate for Payer: Multiplan Auto	$2.30
Rate for Payer: Multiplan Commercial	$2.30
Rate for Payer: Multiplan Workers Comp	$2.30
Rate for Payer: Parkland Medicaid	$2.55
Rate for Payer: Scott and White EPO/PPO	$1.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.55
Rate for Payer: Superior Health Plan EPO	$0.48

TAPE, PAPER, SURGICAL, MICROPORE 2'X10YD

Facility

$3.54

Hospital Charge Code	993226
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.41

Know your out-of-pocket cost for care.

All Charges