White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TENSIX DBM CRUSH MIX 2.5 CC PREHYDATED PUTTY W/CHIPS

Facility

$8,714.70

Service Code	HCPCS C9359
Hospital Charge Code	993152
Hospital Revenue Code	278
Min. Negotiated Rate	$2,178.68
Max. Negotiated Rate	$4,357.35
Rate for Payer: Cash Price	$5,926.00
Rate for Payer: Cigna Commercial	$2,178.68
Rate for Payer: Multiplan Auto	$4,357.35
Rate for Payer: Multiplan Commercial	$4,357.35
Rate for Payer: Multiplan Workers Comp	$4,357.35
Rate for Payer: Scott and White EPO/PPO	$4,357.35

TENSIX DBM CRUSH MIX 2.5 CC PREHYDATED PUTTY W/CHIPS

Facility

$8,714.70

Service Code	HCPCS C9359
Hospital Charge Code	992411
Hospital Revenue Code	278
Min. Negotiated Rate	$2,178.68
Max. Negotiated Rate	$4,357.35
Rate for Payer: Cash Price	$5,926.00
Rate for Payer: Cigna Commercial	$2,178.68
Rate for Payer: Multiplan Auto	$4,357.35
Rate for Payer: Multiplan Commercial	$4,357.35
Rate for Payer: Multiplan Workers Comp	$4,357.35
Rate for Payer: Scott and White EPO/PPO	$4,357.35

TENSIX DBM CRUSH MIX 2.5 CC PREHYDATED PUTTY W/CHIPS

Facility

$8,714.70

Service Code	HCPCS C9359
Hospital Charge Code	992411
Hospital Revenue Code	278
Min. Negotiated Rate	$784.32
Max. Negotiated Rate	$6,274.58
Rate for Payer: Amerigroup CHIP/Medicaid	$784.32
Rate for Payer: BCBS of TX Blue Advantage	$2,614.41
Rate for Payer: BCBS of TX Blue Essentials	$3,137.29
Rate for Payer: BCBS of TX PPO	$3,485.88
Rate for Payer: Cash Price	$5,926.00
Rate for Payer: Cigna Medicaid	$6,274.58
Rate for Payer: Molina CHIP/Medicaid	$6,274.58
Rate for Payer: Multiplan Auto	$4,357.35
Rate for Payer: Multiplan Commercial	$4,357.35
Rate for Payer: Multiplan Workers Comp	$4,357.35
Rate for Payer: Parkland Medicaid	$6,274.58
Rate for Payer: Scott and White EPO/PPO	$4,357.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,274.58
Rate for Payer: Superior Health Plan EPO	$1,185.20

TENSIX DBM CRUSH MIX 2.5 CC PREHYDATED PUTTY W/CHIPS

Facility

$8,714.70

Service Code	HCPCS C9359
Hospital Charge Code	993152
Hospital Revenue Code	278
Min. Negotiated Rate	$784.32
Max. Negotiated Rate	$6,274.58
Rate for Payer: Amerigroup CHIP/Medicaid	$784.32
Rate for Payer: BCBS of TX Blue Advantage	$2,614.41
Rate for Payer: BCBS of TX Blue Essentials	$3,137.29
Rate for Payer: BCBS of TX PPO	$3,485.88
Rate for Payer: Cash Price	$5,926.00
Rate for Payer: Cigna Medicaid	$6,274.58
Rate for Payer: Molina CHIP/Medicaid	$6,274.58
Rate for Payer: Multiplan Auto	$4,357.35
Rate for Payer: Multiplan Commercial	$4,357.35
Rate for Payer: Multiplan Workers Comp	$4,357.35
Rate for Payer: Parkland Medicaid	$6,274.58
Rate for Payer: Scott and White EPO/PPO	$4,357.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,274.58
Rate for Payer: Superior Health Plan EPO	$1,185.20

Tensix dbm putty 10 cc prehydrated putty

Facility

$16,276.20

Service Code	HCPCS C9359
Hospital Charge Code	992204
Hospital Revenue Code	278
Min. Negotiated Rate	$4,069.05
Max. Negotiated Rate	$8,138.10
Rate for Payer: Cash Price	$11,067.82
Rate for Payer: Cigna Commercial	$4,069.05
Rate for Payer: Multiplan Auto	$8,138.10
Rate for Payer: Multiplan Commercial	$8,138.10
Rate for Payer: Multiplan Workers Comp	$8,138.10
Rate for Payer: Scott and White EPO/PPO	$8,138.10

Tensix dbm putty 10 cc prehydrated putty

Facility

$16,276.20

Service Code	HCPCS C9359
Hospital Charge Code	992204
Hospital Revenue Code	278
Min. Negotiated Rate	$1,464.86
Max. Negotiated Rate	$11,718.86
Rate for Payer: Amerigroup CHIP/Medicaid	$1,464.86
Rate for Payer: BCBS of TX Blue Advantage	$4,882.86
Rate for Payer: BCBS of TX Blue Essentials	$5,859.43
Rate for Payer: BCBS of TX PPO	$6,510.48
Rate for Payer: Cash Price	$11,067.82
Rate for Payer: Cigna Medicaid	$11,718.86
Rate for Payer: Molina CHIP/Medicaid	$11,718.86
Rate for Payer: Multiplan Auto	$8,138.10
Rate for Payer: Multiplan Commercial	$8,138.10
Rate for Payer: Multiplan Workers Comp	$8,138.10
Rate for Payer: Parkland Medicaid	$11,718.86
Rate for Payer: Scott and White EPO/PPO	$8,138.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,718.86
Rate for Payer: Superior Health Plan EPO	$2,213.56

terazosin 5 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77838679
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

terazosin 5 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77838679
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

terbutaline 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3105
Hospital Charge Code	9301
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$4.00
Rate for Payer: BCBS of TX Blue Essentials	$4.80
Rate for Payer: BCBS of TX PPO	$5.33
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

terbutaline 1 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J3105
Hospital Charge Code	9301
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

TEST, AST-GN95 CARD

Facility

$8.58

Hospital Charge Code	993549
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.83

TEST, AST-GN95 CARD

Facility

$8.58

Hospital Charge Code	993549
Hospital Revenue Code	270
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$6.18
Rate for Payer: Amerigroup CHIP/Medicaid	$0.77
Rate for Payer: BCBS of TX Blue Advantage	$2.57
Rate for Payer: BCBS of TX Blue Essentials	$3.09
Rate for Payer: BCBS of TX PPO	$3.43
Rate for Payer: Cash Price	$5.83
Rate for Payer: Cigna Medicaid	$6.18
Rate for Payer: Molina CHIP/Medicaid	$6.18
Rate for Payer: Multiplan Auto	$5.58
Rate for Payer: Multiplan Commercial	$5.58
Rate for Payer: Multiplan Workers Comp	$5.58
Rate for Payer: Parkland Medicaid	$6.18
Rate for Payer: Scott and White EPO/PPO	$4.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.18
Rate for Payer: Superior Health Plan EPO	$1.17

TEST, BNP, TRIAGE, CLIA WAIVED, 25EA/BX

Facility

$211.82

Hospital Charge Code	993075
Hospital Revenue Code	270
Min. Negotiated Rate	$19.06
Max. Negotiated Rate	$152.51
Rate for Payer: Amerigroup CHIP/Medicaid	$19.06
Rate for Payer: BCBS of TX Blue Advantage	$63.55
Rate for Payer: BCBS of TX Blue Essentials	$76.26
Rate for Payer: BCBS of TX PPO	$84.73
Rate for Payer: Cash Price	$144.04
Rate for Payer: Cigna Medicaid	$152.51
Rate for Payer: Molina CHIP/Medicaid	$152.51
Rate for Payer: Multiplan Auto	$137.68
Rate for Payer: Multiplan Commercial	$137.68
Rate for Payer: Multiplan Workers Comp	$137.68
Rate for Payer: Parkland Medicaid	$152.51
Rate for Payer: Scott and White EPO/PPO	$105.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$152.51
Rate for Payer: Superior Health Plan EPO	$28.81

TEST, BNP, TRIAGE, CLIA WAIVED, 25EA/BX

Facility

$211.82

Hospital Charge Code	993075
Hospital Revenue Code	270
Rate for Payer: Cash Price	$144.04

Test Cards for ISED Analyzers, 1000 Tests

Facility

$8,265.71

Hospital Charge Code	993335
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5,620.68

Test Cards for ISED Analyzers, 1000 Tests

Facility

$8,265.71

Hospital Charge Code	993335
Hospital Revenue Code	270
Min. Negotiated Rate	$743.91
Max. Negotiated Rate	$5,951.31
Rate for Payer: Amerigroup CHIP/Medicaid	$743.91
Rate for Payer: BCBS of TX Blue Advantage	$2,479.71
Rate for Payer: BCBS of TX Blue Essentials	$2,975.66
Rate for Payer: BCBS of TX PPO	$3,306.28
Rate for Payer: Cash Price	$5,620.68
Rate for Payer: Cigna Medicaid	$5,951.31
Rate for Payer: Molina CHIP/Medicaid	$5,951.31
Rate for Payer: Multiplan Auto	$5,372.71
Rate for Payer: Multiplan Commercial	$5,372.71
Rate for Payer: Multiplan Workers Comp	$5,372.71
Rate for Payer: Parkland Medicaid	$5,951.31
Rate for Payer: Scott and White EPO/PPO	$4,132.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,951.31
Rate for Payer: Superior Health Plan EPO	$1,124.14

TESTES PROCEDURES W CC/MCC

Facility

$39,592.20

Service Code	MSDRG 711
Min. Negotiated Rate	$17,918.10
Max. Negotiated Rate	$39,592.20
Rate for Payer: BCBS of TX Blue Advantage	$17,918.10
Rate for Payer: BCBS of TX Blue Essentials	$21,499.64
Rate for Payer: BCBS of TX PPO	$23,889.41

TESTES PROCEDURES WITH CC/MCC

Facility

$39,592.20

Service Code	MSDRG 711
Min. Negotiated Rate	$17,918.10
Max. Negotiated Rate	$39,592.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,032.31
Rate for Payer: Amerigroup Medicare	$20,032.31
Rate for Payer: BCBS of TX Medicare	$20,032.31
Rate for Payer: Cigna Commercial	$26,839.34
Rate for Payer: Cigna Medicare	$20,032.31
Rate for Payer: Employer Direct Commercial	$20,032.31
Rate for Payer: Humana Medicare/TRICARE	$20,032.31
Rate for Payer: Molina Dual Medicare/Medicaid	$20,032.31
Rate for Payer: Molina Medicare	$20,032.31
Rate for Payer: Multiplan Auto	$39,592.20
Rate for Payer: Multiplan Commercial	$39,592.20
Rate for Payer: Multiplan Workers Comp	$39,592.20
Rate for Payer: Scott and White EPO/PPO	$18,233.25
Rate for Payer: Scott and White Medicare	$20,032.31
Rate for Payer: Superior Health Plan EPO	$20,032.31
Rate for Payer: Superior Health Plan Medicare	$20,032.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,032.31
Rate for Payer: Universal American Medicare	$20,032.31
Rate for Payer: Wellcare Medicare	$20,032.31
Rate for Payer: Wellmed Medicare	$20,032.31

TESTES PROCEDURES WITHOUT CC/MCC

Facility

$20,894.30

Service Code	MSDRG 712
Min. Negotiated Rate	$9,260.48
Max. Negotiated Rate	$20,894.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,819.80
Rate for Payer: Amerigroup Medicare	$12,819.80
Rate for Payer: BCBS of TX Medicare	$12,819.80
Rate for Payer: Cigna Commercial	$14,164.14
Rate for Payer: Cigna Medicare	$12,819.80
Rate for Payer: Employer Direct Commercial	$12,819.80
Rate for Payer: Humana Medicare/TRICARE	$12,819.80
Rate for Payer: Molina Dual Medicare/Medicaid	$12,819.80
Rate for Payer: Molina Medicare	$12,819.80
Rate for Payer: Multiplan Auto	$20,894.30
Rate for Payer: Multiplan Commercial	$20,894.30
Rate for Payer: Multiplan Workers Comp	$20,894.30
Rate for Payer: Scott and White EPO/PPO	$9,622.38
Rate for Payer: Scott and White Medicare	$12,819.80
Rate for Payer: Superior Health Plan EPO	$12,819.80
Rate for Payer: Superior Health Plan Medicare	$12,819.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,819.80
Rate for Payer: Universal American Medicare	$12,819.80
Rate for Payer: Wellcare Medicare	$12,819.80
Rate for Payer: Wellmed Medicare	$12,819.80

TESTES PROCEDURES W/O CC/MCC

Facility

$20,894.30

Service Code	MSDRG 712
Min. Negotiated Rate	$9,260.48
Max. Negotiated Rate	$20,894.30
Rate for Payer: BCBS of TX Blue Advantage	$9,260.48
Rate for Payer: BCBS of TX Blue Essentials	$11,111.50
Rate for Payer: BCBS of TX PPO	$12,346.59

TEST GEM K BG/HCT/CO-OX 150

Facility

$6,379.93

Hospital Charge Code	993823
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4,338.35

TEST GEM K BG/HCT/CO-OX 150

Facility

$6,379.93

Hospital Charge Code	993823
Hospital Revenue Code	270
Min. Negotiated Rate	$574.19
Max. Negotiated Rate	$4,593.55
Rate for Payer: Amerigroup CHIP/Medicaid	$574.19
Rate for Payer: BCBS of TX Blue Advantage	$1,913.98
Rate for Payer: BCBS of TX Blue Essentials	$2,296.77
Rate for Payer: BCBS of TX PPO	$2,551.97
Rate for Payer: Cash Price	$4,338.35
Rate for Payer: Cigna Medicaid	$4,593.55
Rate for Payer: Molina CHIP/Medicaid	$4,593.55
Rate for Payer: Multiplan Auto	$4,146.95
Rate for Payer: Multiplan Commercial	$4,146.95
Rate for Payer: Multiplan Workers Comp	$4,146.95
Rate for Payer: Parkland Medicaid	$4,593.55
Rate for Payer: Scott and White EPO/PPO	$3,189.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,593.55
Rate for Payer: Superior Health Plan EPO	$867.67

TEST, GIARDIA/CRYPTOSPORIDIUM QUIK

Facility

$79.78

Hospital Charge Code	993341
Hospital Revenue Code	270
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$57.44
Rate for Payer: Amerigroup CHIP/Medicaid	$7.18
Rate for Payer: BCBS of TX Blue Advantage	$23.93
Rate for Payer: BCBS of TX Blue Essentials	$28.72
Rate for Payer: BCBS of TX PPO	$31.91
Rate for Payer: Cash Price	$54.25
Rate for Payer: Cigna Medicaid	$57.44
Rate for Payer: Molina CHIP/Medicaid	$57.44
Rate for Payer: Multiplan Auto	$51.86
Rate for Payer: Multiplan Commercial	$51.86
Rate for Payer: Multiplan Workers Comp	$51.86
Rate for Payer: Parkland Medicaid	$57.44
Rate for Payer: Scott and White EPO/PPO	$39.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$57.44
Rate for Payer: Superior Health Plan EPO	$10.85

TEST, GIARDIA/CRYPTOSPORIDIUM QUIK

Facility

$79.78

Hospital Charge Code	993341
Hospital Revenue Code	270
Rate for Payer: Cash Price	$54.25

TEST, HCG, CASSETTES, FOR USE W/ BAH178

Facility

$7.90

Hospital Charge Code	993868
Hospital Revenue Code	279
Rate for Payer: Cash Price	$5.37

Know your out-of-pocket cost for care.

All Charges