White Rock Medical Center

All Charges

Charge

Type

Setting

Price

tetrahydrozoline 0.05% Ophth Soln 15 mL

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	777777
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

tetrahydrozoline 0.05% Ophth Soln 15 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77777777
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

TgAb+Thyroglobulin,IMA or RIA SO

Facility

$115.86

Service Code	HCPCS 86800
Hospital Charge Code	1700343
Hospital Revenue Code	302
Rate for Payer: Cash Price	$78.78

TgAb+Thyroglobulin,IMA or RIA SO

Facility

$115.86

Service Code	HCPCS 86800
Hospital Charge Code	1700343
Hospital Revenue Code	302
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$83.42
Rate for Payer: Amerigroup CHIP/Medicaid	$6.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.91
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: BCBS of TX Blue Advantage	$34.76
Rate for Payer: BCBS of TX Blue Essentials	$41.71
Rate for Payer: BCBS of TX Medicare	$15.91
Rate for Payer: BCBS of TX PPO	$46.34
Rate for Payer: Cash Price	$78.78
Rate for Payer: Cash Price	$78.78
Rate for Payer: Cigna Medicaid	$83.42
Rate for Payer: Cigna Medicare	$15.91
Rate for Payer: Employer Direct Commercial	$15.91
Rate for Payer: Humana Medicare/TRICARE	$15.91
Rate for Payer: Molina CHIP/Medicaid	$83.42
Rate for Payer: Molina Dual Medicare/Medicaid	$15.91
Rate for Payer: Molina Medicare	$15.91
Rate for Payer: Multiplan Auto	$75.31
Rate for Payer: Multiplan Commercial	$75.31
Rate for Payer: Multiplan Workers Comp	$75.31
Rate for Payer: Parkland Medicaid	$83.42
Rate for Payer: Scott and White EPO/PPO	$19.89
Rate for Payer: Scott and White Medicare	$15.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83.42
Rate for Payer: Superior Health Plan EPO	$15.91
Rate for Payer: Superior Health Plan Medicare	$15.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.91
Rate for Payer: Universal American Medicare	$15.91
Rate for Payer: Wellcare Medicare	$15.91
Rate for Payer: Wellmed Medicare	$15.91

TGR001

Facility

$1,948.66

Hospital Charge Code	991227
Hospital Revenue Code	272
Min. Negotiated Rate	$175.38
Max. Negotiated Rate	$1,403.04
Rate for Payer: Amerigroup CHIP/Medicaid	$175.38
Rate for Payer: BCBS of TX Blue Advantage	$584.60
Rate for Payer: BCBS of TX Blue Essentials	$701.52
Rate for Payer: BCBS of TX PPO	$779.46
Rate for Payer: Cash Price	$1,325.09
Rate for Payer: Cigna Medicaid	$1,403.04
Rate for Payer: Molina CHIP/Medicaid	$1,403.04
Rate for Payer: Multiplan Auto	$1,266.63
Rate for Payer: Multiplan Commercial	$1,266.63
Rate for Payer: Multiplan Workers Comp	$1,266.63
Rate for Payer: Parkland Medicaid	$1,403.04
Rate for Payer: Scott and White EPO/PPO	$974.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,403.04
Rate for Payer: Superior Health Plan EPO	$265.02

TGR001

Facility

$1,948.66

Hospital Charge Code	991227
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,325.09

Theophylline, Serum SO

Facility

$437.00

Service Code	HCPCS 80198
Hospital Charge Code	1602986
Hospital Revenue Code	300
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$314.64
Rate for Payer: Amerigroup CHIP/Medicaid	$5.51
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.14
Rate for Payer: Amerigroup Medicare	$14.14
Rate for Payer: BCBS of TX Blue Advantage	$131.10
Rate for Payer: BCBS of TX Blue Essentials	$157.32
Rate for Payer: BCBS of TX Medicare	$14.14
Rate for Payer: BCBS of TX PPO	$174.80
Rate for Payer: Cash Price	$297.16
Rate for Payer: Cash Price	$297.16
Rate for Payer: Cigna Medicaid	$314.64
Rate for Payer: Cigna Medicare	$14.14
Rate for Payer: Employer Direct Commercial	$14.14
Rate for Payer: Humana Medicare/TRICARE	$14.14
Rate for Payer: Molina CHIP/Medicaid	$314.64
Rate for Payer: Molina Dual Medicare/Medicaid	$14.14
Rate for Payer: Molina Medicare	$14.14
Rate for Payer: Multiplan Auto	$284.05
Rate for Payer: Multiplan Commercial	$284.05
Rate for Payer: Multiplan Workers Comp	$284.05
Rate for Payer: Parkland Medicaid	$314.64
Rate for Payer: Scott and White EPO/PPO	$17.68
Rate for Payer: Scott and White Medicare	$14.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$314.64
Rate for Payer: Superior Health Plan EPO	$14.14
Rate for Payer: Superior Health Plan Medicare	$14.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.14
Rate for Payer: Universal American Medicare	$14.14
Rate for Payer: Wellcare Medicare	$14.14
Rate for Payer: Wellmed Medicare	$14.14

Theophylline, Serum SO

Facility

$437.00

Service Code	HCPCS 80198
Hospital Charge Code	1602986
Hospital Revenue Code	300
Rate for Payer: Cash Price	$297.16

The Ramp

Facility

$3,763.66

Hospital Charge Code	992633
Hospital Revenue Code	270
Min. Negotiated Rate	$338.73
Max. Negotiated Rate	$2,709.84
Rate for Payer: Amerigroup CHIP/Medicaid	$338.73
Rate for Payer: BCBS of TX Blue Advantage	$1,129.10
Rate for Payer: BCBS of TX Blue Essentials	$1,354.92
Rate for Payer: BCBS of TX PPO	$1,505.46
Rate for Payer: Cash Price	$2,559.29
Rate for Payer: Cigna Medicaid	$2,709.84
Rate for Payer: Molina CHIP/Medicaid	$2,709.84
Rate for Payer: Multiplan Auto	$2,446.38
Rate for Payer: Multiplan Commercial	$2,446.38
Rate for Payer: Multiplan Workers Comp	$2,446.38
Rate for Payer: Parkland Medicaid	$2,709.84
Rate for Payer: Scott and White EPO/PPO	$1,881.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,709.84
Rate for Payer: Superior Health Plan EPO	$511.86

The Ramp

Facility

$3,763.66

Hospital Charge Code	992633
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2,559.29

Therapeutic Multiple Vitamins with Minerals Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77843867
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Therapeutic Multiple Vitamins with Minerals Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77843867
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

Therapeutic Phlebotomy 99195

Facility

$265.00

Service Code	HCPCS 99195
Hospital Charge Code	7002603
Hospital Revenue Code	940
Min. Negotiated Rate	$23.85
Max. Negotiated Rate	$282.53
Rate for Payer: Amerigroup CHIP/Medicaid	$23.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$182.08
Rate for Payer: BCBS of TX Blue Essentials	$218.06
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$274.76
Rate for Payer: Cash Price	$180.20
Rate for Payer: Cash Price	$180.20
Rate for Payer: Cash Price	$180.20
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$190.80
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$190.80
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$172.25
Rate for Payer: Multiplan Commercial	$172.25
Rate for Payer: Multiplan Workers Comp	$172.25
Rate for Payer: Parkland Medicaid	$190.80
Rate for Payer: Scott and White EPO/PPO	$132.50
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$190.80
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

Therapeutic Phlebotomy 99195

Facility

$265.00

Service Code	HCPCS 99195
Hospital Charge Code	3609195
Hospital Revenue Code	940
Rate for Payer: Cash Price	$180.20

Therapeutic Phlebotomy 99195

Facility

$265.00

Service Code	HCPCS 99195
Hospital Charge Code	7002603
Hospital Revenue Code	940
Rate for Payer: Cash Price	$180.20

Therapeutic Phlebotomy 99195

Facility

$265.00

Service Code	HCPCS 99195
Hospital Charge Code	3609195
Hospital Revenue Code	940
Min. Negotiated Rate	$23.85
Max. Negotiated Rate	$282.53
Rate for Payer: Amerigroup CHIP/Medicaid	$23.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$182.08
Rate for Payer: BCBS of TX Blue Essentials	$218.06
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$274.76
Rate for Payer: Cash Price	$180.20
Rate for Payer: Cash Price	$180.20
Rate for Payer: Cash Price	$180.20
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$190.80
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$190.80
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$172.25
Rate for Payer: Multiplan Commercial	$172.25
Rate for Payer: Multiplan Workers Comp	$172.25
Rate for Payer: Parkland Medicaid	$190.80
Rate for Payer: Scott and White EPO/PPO	$132.50
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$190.80
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

Facility

$10,000.00

Service Code	CPT 96372
Hospital Charge Code	36096372
Hospital Revenue Code	360
Min. Negotiated Rate	$72.33
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
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: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

Facility

$280.00

Service Code	HCPCS 96372
Hospital Charge Code	9900912
Hospital Revenue Code	260
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$201.60
Rate for Payer: Amerigroup CHIP/Medicaid	$25.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$84.00
Rate for Payer: BCBS of TX Blue Essentials	$100.80
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$112.00
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$201.60
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$201.60
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
Rate for Payer: Multiplan Auto	$182.00
Rate for Payer: Multiplan Commercial	$182.00
Rate for Payer: Multiplan Workers Comp	$182.00
Rate for Payer: Parkland Medicaid	$201.60
Rate for Payer: Scott and White EPO/PPO	$140.00
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$201.60
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

Facility

$280.00

Service Code	HCPCS 96372
Hospital Charge Code	9900912
Hospital Revenue Code	260
Rate for Payer: Cash Price	$190.40

Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

Facility

$330.00

Service Code	HCPCS 96375
Hospital Charge Code	8932543
Hospital Revenue Code	260
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$237.60
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47.04
Rate for Payer: Amerigroup Medicare	$47.04
Rate for Payer: BCBS of TX Blue Advantage	$99.00
Rate for Payer: BCBS of TX Blue Essentials	$118.80
Rate for Payer: BCBS of TX Medicare	$47.04
Rate for Payer: BCBS of TX PPO	$132.00
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cigna Commercial	$99.43
Rate for Payer: Cigna Medicaid	$237.60
Rate for Payer: Cigna Medicare	$47.04
Rate for Payer: Employer Direct Commercial	$47.04
Rate for Payer: Humana Medicare/TRICARE	$47.04
Rate for Payer: Molina CHIP/Medicaid	$237.60
Rate for Payer: Molina Dual Medicare/Medicaid	$47.04
Rate for Payer: Molina Medicare	$47.04
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Parkland Medicaid	$237.60
Rate for Payer: Scott and White EPO/PPO	$165.00
Rate for Payer: Scott and White Medicare	$47.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$237.60
Rate for Payer: Superior Health Plan EPO	$47.04
Rate for Payer: Superior Health Plan Medicare	$47.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$47.04
Rate for Payer: Universal American Medicare	$47.04
Rate for Payer: Wellcare Medicare	$47.04
Rate for Payer: Wellmed Medicare	$47.04

Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

Facility

$330.00

Service Code	HCPCS 96375
Hospital Charge Code	8932543
Hospital Revenue Code	260
Rate for Payer: Cash Price	$224.40

Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

Facility

$330.00

Service Code	HCPCS 96375
Hospital Charge Code	7003650
Hospital Revenue Code	260
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$237.60
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47.04
Rate for Payer: Amerigroup Medicare	$47.04
Rate for Payer: BCBS of TX Blue Advantage	$99.00
Rate for Payer: BCBS of TX Blue Essentials	$118.80
Rate for Payer: BCBS of TX Medicare	$47.04
Rate for Payer: BCBS of TX PPO	$132.00
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cigna Commercial	$99.43
Rate for Payer: Cigna Medicaid	$237.60
Rate for Payer: Cigna Medicare	$47.04
Rate for Payer: Employer Direct Commercial	$47.04
Rate for Payer: Humana Medicare/TRICARE	$47.04
Rate for Payer: Molina CHIP/Medicaid	$237.60
Rate for Payer: Molina Dual Medicare/Medicaid	$47.04
Rate for Payer: Molina Medicare	$47.04
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Parkland Medicaid	$237.60
Rate for Payer: Scott and White EPO/PPO	$165.00
Rate for Payer: Scott and White Medicare	$47.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$237.60
Rate for Payer: Superior Health Plan EPO	$47.04
Rate for Payer: Superior Health Plan Medicare	$47.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$47.04
Rate for Payer: Universal American Medicare	$47.04
Rate for Payer: Wellcare Medicare	$47.04
Rate for Payer: Wellmed Medicare	$47.04

Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

Facility

$330.00

Service Code	HCPCS 96375
Hospital Charge Code	7003650
Hospital Revenue Code	260
Rate for Payer: Cash Price	$224.40

Therapy, Prophylactic, Diagnostic Injection SQ or IM 96372

Facility

$280.00

Service Code	HCPCS 96372
Hospital Charge Code	1500370
Hospital Revenue Code	260
Rate for Payer: Cash Price	$190.40

Therapy, Prophylactic, Diagnostic Injection SQ or IM 96372

Facility

$280.00

Service Code	HCPCS 96372
Hospital Charge Code	1500370
Hospital Revenue Code	260
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$201.60
Rate for Payer: Amerigroup CHIP/Medicaid	$25.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$84.00
Rate for Payer: BCBS of TX Blue Essentials	$100.80
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$112.00
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$201.60
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$201.60
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
Rate for Payer: Multiplan Auto	$182.00
Rate for Payer: Multiplan Commercial	$182.00
Rate for Payer: Multiplan Workers Comp	$182.00
Rate for Payer: Parkland Medicaid	$201.60
Rate for Payer: Scott and White EPO/PPO	$140.00
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$201.60
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

Know your out-of-pocket cost for care.

All Charges