White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TB FD JEJUNAL -- DHF

Facility

$1,043.07

Hospital Charge Code	80346703
Hospital Revenue Code	272
Min. Negotiated Rate	$93.88
Max. Negotiated Rate	$751.01
Rate for Payer: Amerigroup CHIP/Medicaid	$93.88
Rate for Payer: BCBS of TX Blue Advantage	$312.92
Rate for Payer: BCBS of TX Blue Essentials	$375.51
Rate for Payer: BCBS of TX PPO	$417.23
Rate for Payer: Cash Price	$709.29
Rate for Payer: Cigna Medicaid	$751.01
Rate for Payer: Molina CHIP/Medicaid	$751.01
Rate for Payer: Multiplan Auto	$678.00
Rate for Payer: Multiplan Commercial	$678.00
Rate for Payer: Multiplan Workers Comp	$678.00
Rate for Payer: Parkland Medicaid	$751.01
Rate for Payer: Scott and White EPO/PPO	$521.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$751.01
Rate for Payer: Superior Health Plan EPO	$141.86

TB FD JEJUNAL -- DHF

Facility

$1,043.07

Hospital Charge Code	80346703
Hospital Revenue Code	272
Rate for Payer: Cash Price	$709.29

TB FEED -- DHF

Facility

$331.23

Hospital Charge Code	80346802
Hospital Revenue Code	270
Rate for Payer: Cash Price	$225.24

TB FEED -- DHF

Facility

$331.23

Hospital Charge Code	80346802
Hospital Revenue Code	270
Min. Negotiated Rate	$29.81
Max. Negotiated Rate	$238.49
Rate for Payer: Amerigroup CHIP/Medicaid	$29.81
Rate for Payer: BCBS of TX Blue Advantage	$99.37
Rate for Payer: BCBS of TX Blue Essentials	$119.24
Rate for Payer: BCBS of TX PPO	$132.49
Rate for Payer: Cash Price	$225.24
Rate for Payer: Cigna Medicaid	$238.49
Rate for Payer: Molina CHIP/Medicaid	$238.49
Rate for Payer: Multiplan Auto	$215.30
Rate for Payer: Multiplan Commercial	$215.30
Rate for Payer: Multiplan Workers Comp	$215.30
Rate for Payer: Parkland Medicaid	$238.49
Rate for Payer: Scott and White EPO/PPO	$165.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$238.49
Rate for Payer: Superior Health Plan EPO	$45.05

TB FEED INFANT -- DHF

Facility

$134.88

Hospital Charge Code	80346885
Hospital Revenue Code	272
Rate for Payer: Cash Price	$91.72

TB FEED INFANT -- DHF

Facility

$134.88

Hospital Charge Code	80346885
Hospital Revenue Code	272
Min. Negotiated Rate	$12.14
Max. Negotiated Rate	$97.11
Rate for Payer: Amerigroup CHIP/Medicaid	$12.14
Rate for Payer: BCBS of TX Blue Advantage	$40.46
Rate for Payer: BCBS of TX Blue Essentials	$48.56
Rate for Payer: BCBS of TX PPO	$53.95
Rate for Payer: Cash Price	$91.72
Rate for Payer: Cigna Medicaid	$97.11
Rate for Payer: Molina CHIP/Medicaid	$97.11
Rate for Payer: Multiplan Auto	$87.67
Rate for Payer: Multiplan Commercial	$87.67
Rate for Payer: Multiplan Workers Comp	$87.67
Rate for Payer: Parkland Medicaid	$97.11
Rate for Payer: Scott and White EPO/PPO	$67.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.11
Rate for Payer: Superior Health Plan EPO	$18.34

TB GASTROSTOMY -- DHF

Facility

$1,241.12

Hospital Charge Code	81775306
Hospital Revenue Code	272
Rate for Payer: Cash Price	$843.96

TB GASTROSTOMY -- DHF

Facility

$1,241.12

Hospital Charge Code	81775306
Hospital Revenue Code	272
Min. Negotiated Rate	$111.70
Max. Negotiated Rate	$893.61
Rate for Payer: Amerigroup CHIP/Medicaid	$111.70
Rate for Payer: BCBS of TX Blue Advantage	$372.34
Rate for Payer: BCBS of TX Blue Essentials	$446.80
Rate for Payer: BCBS of TX PPO	$496.45
Rate for Payer: Cash Price	$843.96
Rate for Payer: Cigna Medicaid	$893.61
Rate for Payer: Molina CHIP/Medicaid	$893.61
Rate for Payer: Multiplan Auto	$806.73
Rate for Payer: Multiplan Commercial	$806.73
Rate for Payer: Multiplan Workers Comp	$806.73
Rate for Payer: Parkland Medicaid	$893.61
Rate for Payer: Scott and White EPO/PPO	$620.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$893.61
Rate for Payer: Superior Health Plan EPO	$168.79

TBG, HIGH PRESS, 72, M/F, FIX, LL, CLEAR

Facility

$24.18

Hospital Charge Code	993721
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.44

TBG, HIGH PRESS, 72, M/F, FIX, LL, CLEAR

Facility

$24.18

Hospital Charge Code	993721
Hospital Revenue Code	270
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$17.41
Rate for Payer: Amerigroup CHIP/Medicaid	$2.18
Rate for Payer: BCBS of TX Blue Advantage	$7.25
Rate for Payer: BCBS of TX Blue Essentials	$8.70
Rate for Payer: BCBS of TX PPO	$9.67
Rate for Payer: Cash Price	$16.44
Rate for Payer: Cigna Medicaid	$17.41
Rate for Payer: Molina CHIP/Medicaid	$17.41
Rate for Payer: Multiplan Auto	$15.72
Rate for Payer: Multiplan Commercial	$15.72
Rate for Payer: Multiplan Workers Comp	$15.72
Rate for Payer: Parkland Medicaid	$17.41
Rate for Payer: Scott and White EPO/PPO	$12.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.41
Rate for Payer: Superior Health Plan EPO	$3.29

TB INTRAMED -- DHF

Facility

$496.20

Hospital Charge Code	54200969
Hospital Revenue Code	270
Min. Negotiated Rate	$44.66
Max. Negotiated Rate	$357.26
Rate for Payer: Amerigroup CHIP/Medicaid	$44.66
Rate for Payer: BCBS of TX Blue Advantage	$148.86
Rate for Payer: BCBS of TX Blue Essentials	$178.63
Rate for Payer: BCBS of TX PPO	$198.48
Rate for Payer: Cash Price	$337.42
Rate for Payer: Cigna Medicaid	$357.26
Rate for Payer: Molina CHIP/Medicaid	$357.26
Rate for Payer: Multiplan Auto	$322.53
Rate for Payer: Multiplan Commercial	$322.53
Rate for Payer: Multiplan Workers Comp	$322.53
Rate for Payer: Parkland Medicaid	$357.26
Rate for Payer: Scott and White EPO/PPO	$248.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$357.26
Rate for Payer: Superior Health Plan EPO	$67.48

TB INTRAMED -- DHF

Facility

$496.20

Hospital Charge Code	54200969
Hospital Revenue Code	270
Rate for Payer: Cash Price	$337.42

TB INTUBATION LMA -- DHF

Facility

$85.04

Hospital Charge Code	80347248
Hospital Revenue Code	270
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$61.23
Rate for Payer: Amerigroup CHIP/Medicaid	$7.65
Rate for Payer: BCBS of TX Blue Advantage	$25.51
Rate for Payer: BCBS of TX Blue Essentials	$30.61
Rate for Payer: BCBS of TX PPO	$34.02
Rate for Payer: Cash Price	$57.83
Rate for Payer: Cigna Medicaid	$61.23
Rate for Payer: Molina CHIP/Medicaid	$61.23
Rate for Payer: Multiplan Auto	$55.28
Rate for Payer: Multiplan Commercial	$55.28
Rate for Payer: Multiplan Workers Comp	$55.28
Rate for Payer: Parkland Medicaid	$61.23
Rate for Payer: Scott and White EPO/PPO	$42.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$61.23
Rate for Payer: Superior Health Plan EPO	$11.57

TB INTUBATION LMA -- DHF

Facility

$85.04

Hospital Charge Code	80347248
Hospital Revenue Code	270
Rate for Payer: Cash Price	$57.83

TB IRRIGAT 2 -- DHF

Facility

$435.84

Hospital Charge Code	80347271
Hospital Revenue Code	272
Min. Negotiated Rate	$39.23
Max. Negotiated Rate	$313.80
Rate for Payer: Amerigroup CHIP/Medicaid	$39.23
Rate for Payer: BCBS of TX Blue Advantage	$130.75
Rate for Payer: BCBS of TX Blue Essentials	$156.90
Rate for Payer: BCBS of TX PPO	$174.34
Rate for Payer: Cash Price	$296.37
Rate for Payer: Cigna Medicaid	$313.80
Rate for Payer: Molina CHIP/Medicaid	$313.80
Rate for Payer: Multiplan Auto	$283.30
Rate for Payer: Multiplan Commercial	$283.30
Rate for Payer: Multiplan Workers Comp	$283.30
Rate for Payer: Parkland Medicaid	$313.80
Rate for Payer: Scott and White EPO/PPO	$217.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$313.80
Rate for Payer: Superior Health Plan EPO	$59.27

TB IRRIGAT 2 -- DHF

Facility

$435.84

Hospital Charge Code	80347271
Hospital Revenue Code	272
Rate for Payer: Cash Price	$296.37

tbo-filgrastim 300 mcg/0.5 mL Subcut Soln 0.5 mL

Facility

$512.71

Service Code	HCPCS J1447
Hospital Charge Code	77836891
Hospital Revenue Code	636
Min. Negotiated Rate	$128.18
Max. Negotiated Rate	$256.36
Rate for Payer: Cash Price	$348.64
Rate for Payer: Cigna Commercial	$128.18
Rate for Payer: Scott and White EPO/PPO	$256.36

tbo-filgrastim 300 mcg/0.5 mL Subcut Soln 0.5 mL

Facility

$512.71

Service Code	HCPCS J1447
Hospital Charge Code	77836891
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$369.15
Rate for Payer: Amerigroup CHIP/Medicaid	$46.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$0.24
Rate for Payer: Amerigroup Medicare	$0.24
Rate for Payer: BCBS of TX Blue Advantage	$1.19
Rate for Payer: BCBS of TX Blue Essentials	$1.43
Rate for Payer: BCBS of TX Medicare	$0.24
Rate for Payer: BCBS of TX PPO	$1.58
Rate for Payer: Cash Price	$348.64
Rate for Payer: Cash Price	$348.64
Rate for Payer: Cigna Medicaid	$369.15
Rate for Payer: Cigna Medicare	$0.24
Rate for Payer: Employer Direct Commercial	$0.24
Rate for Payer: Humana Medicare/TRICARE	$0.24
Rate for Payer: Molina CHIP/Medicaid	$369.15
Rate for Payer: Molina Dual Medicare/Medicaid	$0.24
Rate for Payer: Molina Medicare	$0.24
Rate for Payer: Multiplan Auto	$333.26
Rate for Payer: Multiplan Commercial	$333.26
Rate for Payer: Multiplan Workers Comp	$333.26
Rate for Payer: Parkland Medicaid	$369.15
Rate for Payer: Scott and White EPO/PPO	$256.36
Rate for Payer: Scott and White Medicare	$0.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$369.15
Rate for Payer: Superior Health Plan EPO	$0.24
Rate for Payer: Superior Health Plan Medicare	$0.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$0.24
Rate for Payer: Universal American Medicare	$0.24
Rate for Payer: Wellcare Medicare	$0.24
Rate for Payer: Wellmed Medicare	$0.24

TB SYRNG FILL -- DHF

Facility

$321.94

Hospital Charge Code	80347958
Hospital Revenue Code	270
Min. Negotiated Rate	$28.97
Max. Negotiated Rate	$231.80
Rate for Payer: Amerigroup CHIP/Medicaid	$28.97
Rate for Payer: BCBS of TX Blue Advantage	$96.58
Rate for Payer: BCBS of TX Blue Essentials	$115.90
Rate for Payer: BCBS of TX PPO	$128.78
Rate for Payer: Cash Price	$218.92
Rate for Payer: Cigna Medicaid	$231.80
Rate for Payer: Molina CHIP/Medicaid	$231.80
Rate for Payer: Multiplan Auto	$209.26
Rate for Payer: Multiplan Commercial	$209.26
Rate for Payer: Multiplan Workers Comp	$209.26
Rate for Payer: Parkland Medicaid	$231.80
Rate for Payer: Scott and White EPO/PPO	$160.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$231.80
Rate for Payer: Superior Health Plan EPO	$43.78

TB SYRNG FILL -- DHF

Facility

$321.94

Hospital Charge Code	80347958
Hospital Revenue Code	270
Rate for Payer: Cash Price	$218.92

TB TRACH CF/FLEX SZ 6 W/INNER CANNULA

Facility

$262.46

Hospital Charge Code	145497
Hospital Revenue Code	272
Rate for Payer: Cash Price	$178.47

TB TRACH CF/FLEX SZ 6 W/INNER CANNULA

Facility

$262.46

Hospital Charge Code	145497
Hospital Revenue Code	272
Min. Negotiated Rate	$23.62
Max. Negotiated Rate	$188.97
Rate for Payer: Amerigroup CHIP/Medicaid	$23.62
Rate for Payer: BCBS of TX Blue Advantage	$78.74
Rate for Payer: BCBS of TX Blue Essentials	$94.49
Rate for Payer: BCBS of TX PPO	$104.98
Rate for Payer: Cash Price	$178.47
Rate for Payer: Cigna Medicaid	$188.97
Rate for Payer: Molina CHIP/Medicaid	$188.97
Rate for Payer: Multiplan Auto	$170.60
Rate for Payer: Multiplan Commercial	$170.60
Rate for Payer: Multiplan Workers Comp	$170.60
Rate for Payer: Parkland Medicaid	$188.97
Rate for Payer: Scott and White EPO/PPO	$131.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$188.97
Rate for Payer: Superior Health Plan EPO	$35.69

tb trach fenes uncuffed bl 7mm

Facility

$194.54

Hospital Charge Code	8638505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.29

tb trach fenes uncuffed bl 7mm

Facility

$194.54

Hospital Charge Code	8638505
Hospital Revenue Code	272
Min. Negotiated Rate	$17.51
Max. Negotiated Rate	$140.07
Rate for Payer: Amerigroup CHIP/Medicaid	$17.51
Rate for Payer: BCBS of TX Blue Advantage	$58.36
Rate for Payer: BCBS of TX Blue Essentials	$70.03
Rate for Payer: BCBS of TX PPO	$77.82
Rate for Payer: Cash Price	$132.29
Rate for Payer: Cigna Medicaid	$140.07
Rate for Payer: Molina CHIP/Medicaid	$140.07
Rate for Payer: Multiplan Auto	$126.45
Rate for Payer: Multiplan Commercial	$126.45
Rate for Payer: Multiplan Workers Comp	$126.45
Rate for Payer: Parkland Medicaid	$140.07
Rate for Payer: Scott and White EPO/PPO	$97.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.07
Rate for Payer: Superior Health Plan EPO	$26.46

TB TRACH FLEX SHILEY 5.5

Facility

$499.40

Hospital Charge Code	145688
Hospital Revenue Code	272
Rate for Payer: Cash Price	$339.59

Know your out-of-pocket cost for care.

All Charges