White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TCATH RETRV IVASC FB

Facility

$12,765.00

Service Code	HCPCS 37197
Hospital Charge Code	4617197
Hospital Revenue Code	361
Rate for Payer: Cash Price	$8,680.20

TCATH RETRV IVASC FB

Facility

$12,765.00

Service Code	HCPCS 37197
Hospital Charge Code	4617197
Hospital Revenue Code	361
Min. Negotiated Rate	$1,118.22
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,118.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$8,680.20
Rate for Payer: Cash Price	$8,680.20
Rate for Payer: Cash Price	$8,680.20
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$9,190.80
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$9,190.80
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$9,190.80
Rate for Payer: Scott and White EPO/PPO	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,190.80
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

TCATH TX A/V NONCOR SUBS

Facility

$7,372.00

Service Code	HCPCS 37213
Hospital Charge Code	4617213
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,012.96

TCATH TX A/V NONCOR SUBS

Facility

$7,372.00

Service Code	HCPCS 37213
Hospital Charge Code	4617213
Hospital Revenue Code	360
Min. Negotiated Rate	$663.48
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$663.48
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$2,723.99
Rate for Payer: BCBS of TX Blue Essentials	$3,262.26
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$4,110.45
Rate for Payer: Cash Price	$5,012.96
Rate for Payer: Cash Price	$5,012.96
Rate for Payer: Cash Price	$5,012.96
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$5,307.84
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$5,307.84
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$5,307.84
Rate for Payer: Scott and White EPO/PPO	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,307.84
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

TCATH TX CESSATION

Facility

$4,915.00

Service Code	HCPCS 37214
Hospital Charge Code	4617214
Hospital Revenue Code	360
Min. Negotiated Rate	$442.35
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$442.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$2,723.99
Rate for Payer: BCBS of TX Blue Essentials	$3,262.26
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$4,110.45
Rate for Payer: Cash Price	$3,342.20
Rate for Payer: Cash Price	$3,342.20
Rate for Payer: Cash Price	$3,342.20
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$3,538.80
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$3,538.80
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
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	$3,538.80
Rate for Payer: Scott and White EPO/PPO	$5,392.94
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,538.80
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

TCATH TX CESSATION

Facility

$4,915.00

Service Code	HCPCS 37214
Hospital Charge Code	4617214
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,342.20

TCAT IMPL WRLS P-ART PRS SNR L-T HEMODYN MNTR

Facility

$72,924.00

Service Code	HCPCS 33289
Hospital Charge Code	8398465
Hospital Revenue Code	481
Rate for Payer: Cash Price	$49,588.32

TCAT IMPL WRLS P-ART PRS SNR L-T HEMODYN MNTR

Facility

$72,924.00

Service Code	HCPCS 33289
Hospital Charge Code	8398465
Hospital Revenue Code	481
Min. Negotiated Rate	$397.31
Max. Negotiated Rate	$71,874.26
Rate for Payer: Amerigroup CHIP/Medicaid	$6,563.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,814.06
Rate for Payer: Amerigroup Medicare	$28,814.06
Rate for Payer: BCBS of TX Blue Advantage	$47,630.96
Rate for Payer: BCBS of TX Blue Essentials	$57,043.06
Rate for Payer: BCBS of TX Medicare	$28,814.06
Rate for Payer: BCBS of TX PPO	$71,874.26
Rate for Payer: Cash Price	$49,588.32
Rate for Payer: Cash Price	$49,588.32
Rate for Payer: Cash Price	$49,588.32
Rate for Payer: Cigna Commercial	$60,907.71
Rate for Payer: Cigna Medicaid	$52,505.28
Rate for Payer: Cigna Medicare	$28,814.06
Rate for Payer: Employer Direct Commercial	$28,814.06
Rate for Payer: Humana Medicare/TRICARE	$28,814.06
Rate for Payer: Molina CHIP/Medicaid	$52,505.28
Rate for Payer: Molina Dual Medicare/Medicaid	$28,814.06
Rate for Payer: Molina Medicare	$28,814.06
Rate for Payer: Multiplan Auto	$47,400.60
Rate for Payer: Multiplan Commercial	$47,400.60
Rate for Payer: Multiplan Workers Comp	$47,400.60
Rate for Payer: Parkland Medicaid	$52,505.28
Rate for Payer: Scott and White EPO/PPO	$397.31
Rate for Payer: Scott and White Medicare	$28,814.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52,505.28
Rate for Payer: Superior Health Plan EPO	$28,814.06
Rate for Payer: Superior Health Plan Medicare	$28,814.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,814.06
Rate for Payer: Universal American Medicare	$28,814.06
Rate for Payer: Wellcare Medicare	$28,814.06
Rate for Payer: Wellmed Medicare	$28,814.06

temazepam 15 mg Cap

Facility

$7.65

Service Code	HCPCS j3490
Hospital Charge Code	77837509
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

temazepam 15 mg Cap

Facility

$7.65

Service Code	HCPCS j3490
Hospital Charge Code	77837509
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

TEMPLATE PATELLA PLATE KIT

Facility

$1,398.32

Hospital Charge Code	146666
Hospital Revenue Code	272
Rate for Payer: Cash Price	$950.86

TEMPLATE PATELLA PLATE KIT

Facility

$1,398.32

Hospital Charge Code	146666
Hospital Revenue Code	272
Min. Negotiated Rate	$125.85
Max. Negotiated Rate	$1,006.79
Rate for Payer: Amerigroup CHIP/Medicaid	$125.85
Rate for Payer: BCBS of TX Blue Advantage	$419.50
Rate for Payer: BCBS of TX Blue Essentials	$503.40
Rate for Payer: BCBS of TX PPO	$559.33
Rate for Payer: Cash Price	$950.86
Rate for Payer: Cigna Medicaid	$1,006.79
Rate for Payer: Molina CHIP/Medicaid	$1,006.79
Rate for Payer: Multiplan Auto	$908.91
Rate for Payer: Multiplan Commercial	$908.91
Rate for Payer: Multiplan Workers Comp	$908.91
Rate for Payer: Parkland Medicaid	$1,006.79
Rate for Payer: Scott and White EPO/PPO	$699.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,006.79
Rate for Payer: Superior Health Plan EPO	$190.17

TEMPLATE, SUTURABLE DURAG DURS-1391

Facility

$2,848.19

Hospital Charge Code	992356
Hospital Revenue Code	272
Min. Negotiated Rate	$256.34
Max. Negotiated Rate	$2,050.70
Rate for Payer: Amerigroup CHIP/Medicaid	$256.34
Rate for Payer: BCBS of TX Blue Advantage	$854.46
Rate for Payer: BCBS of TX Blue Essentials	$1,025.35
Rate for Payer: BCBS of TX PPO	$1,139.28
Rate for Payer: Cash Price	$1,936.77
Rate for Payer: Cigna Medicaid	$2,050.70
Rate for Payer: Molina CHIP/Medicaid	$2,050.70
Rate for Payer: Multiplan Auto	$1,851.32
Rate for Payer: Multiplan Commercial	$1,851.32
Rate for Payer: Multiplan Workers Comp	$1,851.32
Rate for Payer: Parkland Medicaid	$2,050.70
Rate for Payer: Scott and White EPO/PPO	$1,424.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,050.70
Rate for Payer: Superior Health Plan EPO	$387.35

TEMPLATE, SUTURABLE DURAG DURS-1391

Facility

$2,848.19

Hospital Charge Code	992356
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,936.77

TEMP PACEMAKER INSERTION

Facility

$8,843.00

Service Code	HCPCS 33210
Hospital Charge Code	2300424
Hospital Revenue Code	481
Rate for Payer: Cash Price	$6,013.24

TEMP PACEMAKER INSERTION

Facility

$8,843.00

Service Code	HCPCS 33210
Hospital Charge Code	2300424
Hospital Revenue Code	481
Min. Negotiated Rate	$191.69
Max. Negotiated Rate	$19,257.46
Rate for Payer: Amerigroup CHIP/Medicaid	$795.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,313.10
Rate for Payer: Amerigroup Medicare	$8,313.10
Rate for Payer: BCBS of TX Blue Advantage	$12,761.89
Rate for Payer: BCBS of TX Blue Essentials	$15,283.70
Rate for Payer: BCBS of TX Medicare	$8,313.10
Rate for Payer: BCBS of TX PPO	$19,257.46
Rate for Payer: Cash Price	$6,013.24
Rate for Payer: Cash Price	$6,013.24
Rate for Payer: Cash Price	$6,013.24
Rate for Payer: Cigna Commercial	$17,572.38
Rate for Payer: Cigna Medicaid	$6,366.96
Rate for Payer: Cigna Medicare	$8,313.10
Rate for Payer: Employer Direct Commercial	$8,313.10
Rate for Payer: Humana Medicare/TRICARE	$8,313.10
Rate for Payer: Molina CHIP/Medicaid	$6,366.96
Rate for Payer: Molina Dual Medicare/Medicaid	$8,313.10
Rate for Payer: Molina Medicare	$8,313.10
Rate for Payer: Multiplan Auto	$5,747.95
Rate for Payer: Multiplan Commercial	$5,747.95
Rate for Payer: Multiplan Workers Comp	$5,747.95
Rate for Payer: Parkland Medicaid	$6,366.96
Rate for Payer: Scott and White EPO/PPO	$191.69
Rate for Payer: Scott and White Medicare	$8,313.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,366.96
Rate for Payer: Superior Health Plan EPO	$8,313.10
Rate for Payer: Superior Health Plan Medicare	$8,313.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,313.10
Rate for Payer: Universal American Medicare	$8,313.10
Rate for Payer: Wellcare Medicare	$8,313.10
Rate for Payer: Wellmed Medicare	$8,313.10

TEMP PROBE SKIN

Facility

$52.66

Hospital Charge Code	81860603
Hospital Revenue Code	270
Min. Negotiated Rate	$4.74
Max. Negotiated Rate	$37.92
Rate for Payer: Amerigroup CHIP/Medicaid	$4.74
Rate for Payer: BCBS of TX Blue Advantage	$15.80
Rate for Payer: BCBS of TX Blue Essentials	$18.96
Rate for Payer: BCBS of TX PPO	$21.06
Rate for Payer: Cash Price	$35.81
Rate for Payer: Cigna Medicaid	$37.92
Rate for Payer: Molina CHIP/Medicaid	$37.92
Rate for Payer: Multiplan Auto	$34.23
Rate for Payer: Multiplan Commercial	$34.23
Rate for Payer: Multiplan Workers Comp	$34.23
Rate for Payer: Parkland Medicaid	$37.92
Rate for Payer: Scott and White EPO/PPO	$26.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.92
Rate for Payer: Superior Health Plan EPO	$7.16

TEMP PROBE SKIN

Facility

$52.66

Hospital Charge Code	81860603
Hospital Revenue Code	270
Rate for Payer: Cash Price	$35.81

TENDONITIS, MYOSITIS AND BURSITIS WITH MCC

Facility

$27,206.10

Service Code	MSDRG 557
Min. Negotiated Rate	$12,318.64
Max. Negotiated Rate	$27,206.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,657.61
Rate for Payer: Amerigroup Medicare	$15,657.61
Rate for Payer: BCBS of TX Medicare	$15,657.61
Rate for Payer: Cigna Commercial	$19,151.27
Rate for Payer: Cigna Medicare	$15,657.61
Rate for Payer: Employer Direct Commercial	$15,657.61
Rate for Payer: Humana Medicare/TRICARE	$15,657.61
Rate for Payer: Molina Dual Medicare/Medicaid	$15,657.61
Rate for Payer: Molina Medicare	$15,657.61
Rate for Payer: Multiplan Auto	$27,206.10
Rate for Payer: Multiplan Commercial	$27,206.10
Rate for Payer: Multiplan Workers Comp	$27,206.10
Rate for Payer: Scott and White EPO/PPO	$12,529.12
Rate for Payer: Scott and White Medicare	$15,657.61
Rate for Payer: Superior Health Plan EPO	$15,657.61
Rate for Payer: Superior Health Plan Medicare	$15,657.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,657.61
Rate for Payer: Universal American Medicare	$15,657.61
Rate for Payer: Wellcare Medicare	$15,657.61
Rate for Payer: Wellmed Medicare	$15,657.61

TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC

Facility

$16,511.00

Service Code	MSDRG 558
Min. Negotiated Rate	$7,426.10
Max. Negotiated Rate	$16,511.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,306.37
Rate for Payer: Amerigroup Medicare	$11,306.37
Rate for Payer: BCBS of TX Medicare	$11,306.37
Rate for Payer: Cigna Commercial	$11,504.42
Rate for Payer: Cigna Medicare	$11,306.37
Rate for Payer: Employer Direct Commercial	$11,306.37
Rate for Payer: Humana Medicare/TRICARE	$11,306.37
Rate for Payer: Molina Dual Medicare/Medicaid	$11,306.37
Rate for Payer: Molina Medicare	$11,306.37
Rate for Payer: Multiplan Auto	$16,511.00
Rate for Payer: Multiplan Commercial	$16,511.00
Rate for Payer: Multiplan Workers Comp	$16,511.00
Rate for Payer: Scott and White EPO/PPO	$7,603.75
Rate for Payer: Scott and White Medicare	$11,306.37
Rate for Payer: Superior Health Plan EPO	$11,306.37
Rate for Payer: Superior Health Plan Medicare	$11,306.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,306.37
Rate for Payer: Universal American Medicare	$11,306.37
Rate for Payer: Wellcare Medicare	$11,306.37
Rate for Payer: Wellmed Medicare	$11,306.37

TENDONITIS, MYOSITIS & BURSITIS W MCC

Facility

$27,206.10

Service Code	MSDRG 557
Min. Negotiated Rate	$12,318.64
Max. Negotiated Rate	$27,206.10
Rate for Payer: BCBS of TX Blue Advantage	$12,318.64
Rate for Payer: BCBS of TX Blue Essentials	$14,780.94
Rate for Payer: BCBS of TX PPO	$16,423.90

TENDONITIS, MYOSITIS & BURSITIS W/O MCC

Facility

$16,511.00

Service Code	MSDRG 558
Min. Negotiated Rate	$7,426.10
Max. Negotiated Rate	$16,511.00
Rate for Payer: BCBS of TX Blue Advantage	$7,426.10
Rate for Payer: BCBS of TX Blue Essentials	$8,910.46
Rate for Payer: BCBS of TX PPO	$9,900.89

TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES

Facility

$5,843.79

Service Code	APR-DRG 3171
Min. Negotiated Rate	$5,509.73
Max. Negotiated Rate	$5,843.79
Rate for Payer: Amerigroup CHIP/Medicaid	$5,509.73
Rate for Payer: Cigna Medicaid	$5,509.73
Rate for Payer: Molina CHIP/Medicaid	$5,509.73
Rate for Payer: Parkland Medicaid	$5,509.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,843.79

TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES

Facility

$10,043.79

Service Code	APR-DRG 3173
Min. Negotiated Rate	$9,469.64
Max. Negotiated Rate	$10,043.79
Rate for Payer: Amerigroup CHIP/Medicaid	$9,469.64
Rate for Payer: Cigna Medicaid	$9,469.64
Rate for Payer: Molina CHIP/Medicaid	$9,469.64
Rate for Payer: Parkland Medicaid	$9,469.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,043.79

TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES

Facility

$6,820.71

Service Code	APR-DRG 3172
Min. Negotiated Rate	$6,430.80
Max. Negotiated Rate	$6,820.71
Rate for Payer: Amerigroup CHIP/Medicaid	$6,430.80
Rate for Payer: Cigna Medicaid	$6,430.80
Rate for Payer: Molina CHIP/Medicaid	$6,430.80
Rate for Payer: Parkland Medicaid	$6,430.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,820.71

Know your out-of-pocket cost for care.

All Charges