White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TEST, HCG, CASSETTES, FOR USE W/ BAH178

Facility

$7.90

Hospital Charge Code	993868
Hospital Revenue Code	279
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$5.69
Rate for Payer: Amerigroup CHIP/Medicaid	$0.71
Rate for Payer: BCBS of TX Blue Advantage	$2.37
Rate for Payer: BCBS of TX Blue Essentials	$2.84
Rate for Payer: BCBS of TX PPO	$3.16
Rate for Payer: Cash Price	$5.37
Rate for Payer: Cigna Medicaid	$5.69
Rate for Payer: Molina CHIP/Medicaid	$5.69
Rate for Payer: Multiplan Auto	$5.13
Rate for Payer: Multiplan Commercial	$5.13
Rate for Payer: Multiplan Workers Comp	$5.13
Rate for Payer: Parkland Medicaid	$5.69
Rate for Payer: Scott and White EPO/PPO	$3.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.69
Rate for Payer: Superior Health Plan EPO	$1.07

TEST, LEGIONELLA, URINE, 22 TESTS

Facility

$223.88

Hospital Charge Code	993336
Hospital Revenue Code	270
Rate for Payer: Cash Price	$152.24

TEST, LEGIONELLA, URINE, 22 TESTS

Facility

$223.88

Hospital Charge Code	993336
Hospital Revenue Code	270
Min. Negotiated Rate	$20.15
Max. Negotiated Rate	$161.19
Rate for Payer: Amerigroup CHIP/Medicaid	$20.15
Rate for Payer: BCBS of TX Blue Advantage	$67.16
Rate for Payer: BCBS of TX Blue Essentials	$80.60
Rate for Payer: BCBS of TX PPO	$89.55
Rate for Payer: Cash Price	$152.24
Rate for Payer: Cigna Medicaid	$161.19
Rate for Payer: Molina CHIP/Medicaid	$161.19
Rate for Payer: Multiplan Auto	$145.52
Rate for Payer: Multiplan Commercial	$145.52
Rate for Payer: Multiplan Workers Comp	$145.52
Rate for Payer: Parkland Medicaid	$161.19
Rate for Payer: Scott and White EPO/PPO	$111.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$161.19
Rate for Payer: Superior Health Plan EPO	$30.45

TEST, LEUKO EZ VUE, 25/KT

Facility

$102.58

Hospital Charge Code	993371
Hospital Revenue Code	270
Rate for Payer: Cash Price	$69.75

TEST, LEUKO EZ VUE, 25/KT

Facility

$102.58

Hospital Charge Code	993371
Hospital Revenue Code	270
Min. Negotiated Rate	$9.23
Max. Negotiated Rate	$73.86
Rate for Payer: Amerigroup CHIP/Medicaid	$9.23
Rate for Payer: BCBS of TX Blue Advantage	$30.77
Rate for Payer: BCBS of TX Blue Essentials	$36.93
Rate for Payer: BCBS of TX PPO	$41.03
Rate for Payer: Cash Price	$69.75
Rate for Payer: Cigna Medicaid	$73.86
Rate for Payer: Molina CHIP/Medicaid	$73.86
Rate for Payer: Multiplan Auto	$66.68
Rate for Payer: Multiplan Commercial	$66.68
Rate for Payer: Multiplan Workers Comp	$66.68
Rate for Payer: Parkland Medicaid	$73.86
Rate for Payer: Scott and White EPO/PPO	$51.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$73.86
Rate for Payer: Superior Health Plan EPO	$13.95

Testosterone,Free and Total SO

Facility

$419.00

Service Code	HCPCS 84402
Hospital Charge Code	1706175
Hospital Revenue Code	301
Rate for Payer: Cash Price	$284.92

Testosterone,Free and Total SO

Facility

$419.00

Service Code	HCPCS 84402
Hospital Charge Code	1706175
Hospital Revenue Code	301
Min. Negotiated Rate	$9.93
Max. Negotiated Rate	$301.68
Rate for Payer: Amerigroup CHIP/Medicaid	$9.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25.47
Rate for Payer: Amerigroup Medicare	$25.47
Rate for Payer: BCBS of TX Blue Advantage	$125.70
Rate for Payer: BCBS of TX Blue Essentials	$150.84
Rate for Payer: BCBS of TX Medicare	$25.47
Rate for Payer: BCBS of TX PPO	$167.60
Rate for Payer: Cash Price	$284.92
Rate for Payer: Cash Price	$284.92
Rate for Payer: Cigna Medicaid	$301.68
Rate for Payer: Cigna Medicare	$25.47
Rate for Payer: Employer Direct Commercial	$25.47
Rate for Payer: Humana Medicare/TRICARE	$25.47
Rate for Payer: Molina CHIP/Medicaid	$301.68
Rate for Payer: Molina Dual Medicare/Medicaid	$25.47
Rate for Payer: Molina Medicare	$25.47
Rate for Payer: Multiplan Auto	$272.35
Rate for Payer: Multiplan Commercial	$272.35
Rate for Payer: Multiplan Workers Comp	$272.35
Rate for Payer: Parkland Medicaid	$301.68
Rate for Payer: Scott and White EPO/PPO	$31.84
Rate for Payer: Scott and White Medicare	$25.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$301.68
Rate for Payer: Superior Health Plan EPO	$25.47
Rate for Payer: Superior Health Plan Medicare	$25.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$25.47
Rate for Payer: Universal American Medicare	$25.47
Rate for Payer: Wellcare Medicare	$25.47
Rate for Payer: Wellmed Medicare	$25.47

Testosterone Level Total (Male)

Facility

$374.00

Service Code	HCPCS 84403
Hospital Charge Code	1701556
Hospital Revenue Code	301
Rate for Payer: Cash Price	$254.32

Testosterone Level Total (Male)

Facility

$374.00

Service Code	HCPCS 84403
Hospital Charge Code	1701556
Hospital Revenue Code	301
Min. Negotiated Rate	$10.07
Max. Negotiated Rate	$269.28
Rate for Payer: Amerigroup CHIP/Medicaid	$10.07
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25.81
Rate for Payer: Amerigroup Medicare	$25.81
Rate for Payer: BCBS of TX Blue Advantage	$112.20
Rate for Payer: BCBS of TX Blue Essentials	$134.64
Rate for Payer: BCBS of TX Medicare	$25.81
Rate for Payer: BCBS of TX PPO	$149.60
Rate for Payer: Cash Price	$254.32
Rate for Payer: Cash Price	$254.32
Rate for Payer: Cigna Medicaid	$269.28
Rate for Payer: Cigna Medicare	$25.81
Rate for Payer: Employer Direct Commercial	$25.81
Rate for Payer: Humana Medicare/TRICARE	$25.81
Rate for Payer: Molina CHIP/Medicaid	$269.28
Rate for Payer: Molina Dual Medicare/Medicaid	$25.81
Rate for Payer: Molina Medicare	$25.81
Rate for Payer: Multiplan Auto	$243.10
Rate for Payer: Multiplan Commercial	$243.10
Rate for Payer: Multiplan Workers Comp	$243.10
Rate for Payer: Parkland Medicaid	$269.28
Rate for Payer: Scott and White EPO/PPO	$32.26
Rate for Payer: Scott and White Medicare	$25.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$269.28
Rate for Payer: Superior Health Plan EPO	$25.81
Rate for Payer: Superior Health Plan Medicare	$25.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$25.81
Rate for Payer: Universal American Medicare	$25.81
Rate for Payer: Wellcare Medicare	$25.81
Rate for Payer: Wellmed Medicare	$25.81

TEST, SOFIA, INFLUENZA, A+B FIA

Facility

$79.69

Hospital Charge Code	993327
Hospital Revenue Code	270
Min. Negotiated Rate	$7.17
Max. Negotiated Rate	$57.38
Rate for Payer: Amerigroup CHIP/Medicaid	$7.17
Rate for Payer: BCBS of TX Blue Advantage	$23.91
Rate for Payer: BCBS of TX Blue Essentials	$28.69
Rate for Payer: BCBS of TX PPO	$31.88
Rate for Payer: Cash Price	$54.19
Rate for Payer: Cigna Medicaid	$57.38
Rate for Payer: Molina CHIP/Medicaid	$57.38
Rate for Payer: Multiplan Auto	$51.80
Rate for Payer: Multiplan Commercial	$51.80
Rate for Payer: Multiplan Workers Comp	$51.80
Rate for Payer: Parkland Medicaid	$57.38
Rate for Payer: Scott and White EPO/PPO	$39.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$57.38
Rate for Payer: Superior Health Plan EPO	$10.84

TEST, SOFIA, INFLUENZA, A+B FIA

Facility

$79.69

Hospital Charge Code	993327
Hospital Revenue Code	270
Rate for Payer: Cash Price	$54.19

TEST, SOFIA, STREP A+ FIA, WAIVED

Facility

$27.01

Hospital Charge Code	993328
Hospital Revenue Code	270
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$19.45
Rate for Payer: Amerigroup CHIP/Medicaid	$2.43
Rate for Payer: BCBS of TX Blue Advantage	$8.10
Rate for Payer: BCBS of TX Blue Essentials	$9.72
Rate for Payer: BCBS of TX PPO	$10.80
Rate for Payer: Cash Price	$18.37
Rate for Payer: Cigna Medicaid	$19.45
Rate for Payer: Molina CHIP/Medicaid	$19.45
Rate for Payer: Multiplan Auto	$17.56
Rate for Payer: Multiplan Commercial	$17.56
Rate for Payer: Multiplan Workers Comp	$17.56
Rate for Payer: Parkland Medicaid	$19.45
Rate for Payer: Scott and White EPO/PPO	$13.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.45
Rate for Payer: Superior Health Plan EPO	$3.67

TEST, SOFIA, STREP A+ FIA, WAIVED

Facility

$27.01

Hospital Charge Code	993328
Hospital Revenue Code	270
Rate for Payer: Cash Price	$18.37

TEST, SPFIA RSV FIA

Facility

$244.41

Hospital Charge Code	993694
Hospital Revenue Code	270
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$175.98
Rate for Payer: Amerigroup CHIP/Medicaid	$22.00
Rate for Payer: BCBS of TX Blue Advantage	$73.32
Rate for Payer: BCBS of TX Blue Essentials	$87.99
Rate for Payer: BCBS of TX PPO	$97.76
Rate for Payer: Cash Price	$166.20
Rate for Payer: Cigna Medicaid	$175.98
Rate for Payer: Molina CHIP/Medicaid	$175.98
Rate for Payer: Multiplan Auto	$158.87
Rate for Payer: Multiplan Commercial	$158.87
Rate for Payer: Multiplan Workers Comp	$158.87
Rate for Payer: Parkland Medicaid	$175.98
Rate for Payer: Scott and White EPO/PPO	$122.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$175.98
Rate for Payer: Superior Health Plan EPO	$33.24

TEST, SPFIA RSV FIA

Facility

$244.41

Hospital Charge Code	993694
Hospital Revenue Code	270
Rate for Payer: Cash Price	$166.20

TEST TUBE,12X75MM,PS,250/BAG

Facility

$0.38

Hospital Charge Code	993111
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.26

TEST TUBE,12X75MM,PS,250/BAG

Facility

$0.38

Hospital Charge Code	993111
Hospital Revenue Code	270
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.27
Rate for Payer: Amerigroup CHIP/Medicaid	$0.03
Rate for Payer: BCBS of TX Blue Advantage	$0.11
Rate for Payer: BCBS of TX Blue Essentials	$0.14
Rate for Payer: BCBS of TX PPO	$0.15
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna Medicaid	$0.27
Rate for Payer: Molina CHIP/Medicaid	$0.27
Rate for Payer: Multiplan Auto	$0.25
Rate for Payer: Multiplan Commercial	$0.25
Rate for Payer: Multiplan Workers Comp	$0.25
Rate for Payer: Parkland Medicaid	$0.27
Rate for Payer: Scott and White EPO/PPO	$0.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.27
Rate for Payer: Superior Health Plan EPO	$0.05

tetanus/diphth/pertussis (Adacel Tdap) IM Susp 0.5 mL

Facility

$142.70

Service Code	HCPCS 90715
Hospital Charge Code	77841150
Hospital Revenue Code	636
Min. Negotiated Rate	$35.67
Max. Negotiated Rate	$71.35
Rate for Payer: Cash Price	$97.04
Rate for Payer: Cigna Commercial	$35.67
Rate for Payer: Scott and White EPO/PPO	$71.35

tetanus/diphth/pertussis (Adacel Tdap) IM Susp 0.5 mL

Facility

$142.70

Service Code	HCPCS 90715
Hospital Charge Code	77841150
Hospital Revenue Code	636
Min. Negotiated Rate	$12.84
Max. Negotiated Rate	$102.74
Rate for Payer: Amerigroup CHIP/Medicaid	$12.84
Rate for Payer: BCBS of TX Blue Advantage	$57.30
Rate for Payer: BCBS of TX Blue Essentials	$68.76
Rate for Payer: BCBS of TX PPO	$76.27
Rate for Payer: Cash Price	$97.04
Rate for Payer: Cash Price	$97.04
Rate for Payer: Cigna Medicaid	$102.74
Rate for Payer: Molina CHIP/Medicaid	$102.74
Rate for Payer: Multiplan Auto	$92.75
Rate for Payer: Multiplan Commercial	$92.75
Rate for Payer: Multiplan Workers Comp	$92.75
Rate for Payer: Parkland Medicaid	$102.74
Rate for Payer: Scott and White EPO/PPO	$71.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.74
Rate for Payer: Superior Health Plan EPO	$19.41

tetanus-diptheria toxoid 0.5 ml injection

Facility

$128.00

Service Code	HCPCS 90714
Hospital Charge Code	77841260
Hospital Revenue Code	636
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$26.88
Rate for Payer: BCBS of TX Blue Essentials	$32.26
Rate for Payer: BCBS of TX PPO	$35.78
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

tetanus-diptheria toxoid 0.5 ml injection

Facility

$128.00

Service Code	HCPCS 90714
Hospital Charge Code	77841260
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

tetracaine 0.5% Ophth Soln 5 mL

Facility

$61.56

Service Code	HCPCS J3490
Hospital Charge Code	77841680
Hospital Revenue Code	636
Min. Negotiated Rate	$15.39
Max. Negotiated Rate	$30.78
Rate for Payer: Cash Price	$41.86
Rate for Payer: Cigna Commercial	$15.39
Rate for Payer: Scott and White EPO/PPO	$30.78

tetracaine 0.5% Ophth Soln 5 mL

Facility

$61.56

Service Code	HCPCS J3490
Hospital Charge Code	77841680
Hospital Revenue Code	636
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$44.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5.54
Rate for Payer: BCBS of TX Blue Advantage	$18.47
Rate for Payer: BCBS of TX Blue Essentials	$22.16
Rate for Payer: BCBS of TX PPO	$24.62
Rate for Payer: Cash Price	$41.86
Rate for Payer: Cigna Medicaid	$44.32
Rate for Payer: Molina CHIP/Medicaid	$44.32
Rate for Payer: Multiplan Auto	$40.01
Rate for Payer: Multiplan Commercial	$40.01
Rate for Payer: Multiplan Workers Comp	$40.01
Rate for Payer: Parkland Medicaid	$44.32
Rate for Payer: Scott and White EPO/PPO	$30.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44.32
Rate for Payer: Superior Health Plan EPO	$8.37

tetrahydrozoline 0.05% Ophth Soln 15 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77777777
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

tetrahydrozoline 0.05% Ophth Soln 15 mL

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	777777
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

Know your out-of-pocket cost for care.

All Charges