White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 ver

Facility

$78,288.48

Service Code	HCPCS 64628
Hospital Charge Code	9900825
Hospital Revenue Code	360
Rate for Payer: Cash Price	$53,236.17

thiamine 100 mg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3411
Hospital Charge Code	77844018
Hospital Revenue Code	636
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$4.45
Rate for Payer: BCBS of TX Blue Essentials	$5.34
Rate for Payer: BCBS of TX PPO	$5.93
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

thiamine 100 mg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3411
Hospital Charge Code	77844018
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

thiamine 100 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78436046
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

thiamine 100 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78436046
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Thioglycollate With indicator Fluid, Filtered, 10 mL, 16 x 125 mm Tube

Facility

$14.44

Hospital Charge Code	993362
Hospital Revenue Code	270
Rate for Payer: Cash Price	$9.82

Thioglycollate With indicator Fluid, Filtered, 10 mL, 16 x 125 mm Tube

Facility

$14.44

Hospital Charge Code	993362
Hospital Revenue Code	270
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$10.40
Rate for Payer: Amerigroup CHIP/Medicaid	$1.30
Rate for Payer: BCBS of TX Blue Advantage	$4.33
Rate for Payer: BCBS of TX Blue Essentials	$5.20
Rate for Payer: BCBS of TX PPO	$5.78
Rate for Payer: Cash Price	$9.82
Rate for Payer: Cigna Medicaid	$10.40
Rate for Payer: Molina CHIP/Medicaid	$10.40
Rate for Payer: Multiplan Auto	$9.39
Rate for Payer: Multiplan Commercial	$9.39
Rate for Payer: Multiplan Workers Comp	$9.39
Rate for Payer: Parkland Medicaid	$10.40
Rate for Payer: Scott and White EPO/PPO	$7.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.40
Rate for Payer: Superior Health Plan EPO	$1.96

THN00057

Facility

$21,049.40

Service Code	HCPCS C1713
Hospital Charge Code	991216
Hospital Revenue Code	278
Min. Negotiated Rate	$5,262.35
Max. Negotiated Rate	$10,524.70
Rate for Payer: Cash Price	$14,313.59
Rate for Payer: Cigna Commercial	$5,262.35
Rate for Payer: Multiplan Auto	$10,524.70
Rate for Payer: Multiplan Commercial	$10,524.70
Rate for Payer: Multiplan Workers Comp	$10,524.70
Rate for Payer: Scott and White EPO/PPO	$10,524.70

THN00057

Facility

$21,049.40

Service Code	HCPCS C1713
Hospital Charge Code	991216
Hospital Revenue Code	278
Min. Negotiated Rate	$1,894.45
Max. Negotiated Rate	$15,155.57
Rate for Payer: Amerigroup CHIP/Medicaid	$1,894.45
Rate for Payer: BCBS of TX Blue Advantage	$6,314.82
Rate for Payer: BCBS of TX Blue Essentials	$7,577.78
Rate for Payer: BCBS of TX PPO	$8,419.76
Rate for Payer: Cash Price	$14,313.59
Rate for Payer: Cigna Medicaid	$15,155.57
Rate for Payer: Molina CHIP/Medicaid	$15,155.57
Rate for Payer: Multiplan Auto	$10,524.70
Rate for Payer: Multiplan Commercial	$10,524.70
Rate for Payer: Multiplan Workers Comp	$10,524.70
Rate for Payer: Parkland Medicaid	$15,155.57
Rate for Payer: Scott and White EPO/PPO	$10,524.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,155.57
Rate for Payer: Superior Health Plan EPO	$2,862.72

THN00057OF1024044S

Facility

$10,271.08

Service Code	HCPCS C1734
Hospital Charge Code	991207
Hospital Revenue Code	278
Min. Negotiated Rate	$2,567.77
Max. Negotiated Rate	$5,135.54
Rate for Payer: Cash Price	$6,984.33
Rate for Payer: Cigna Commercial	$2,567.77
Rate for Payer: Multiplan Auto	$5,135.54
Rate for Payer: Multiplan Commercial	$5,135.54
Rate for Payer: Multiplan Workers Comp	$5,135.54
Rate for Payer: Scott and White EPO/PPO	$5,135.54

THN00057OF1024044S

Facility

$10,271.08

Service Code	HCPCS C1734
Hospital Charge Code	991207
Hospital Revenue Code	278
Min. Negotiated Rate	$924.40
Max. Negotiated Rate	$7,395.18
Rate for Payer: Amerigroup CHIP/Medicaid	$924.40
Rate for Payer: BCBS of TX Blue Advantage	$3,081.32
Rate for Payer: BCBS of TX Blue Essentials	$3,697.59
Rate for Payer: BCBS of TX PPO	$4,108.43
Rate for Payer: Cash Price	$6,984.33
Rate for Payer: Cigna Medicaid	$7,395.18
Rate for Payer: Molina CHIP/Medicaid	$7,395.18
Rate for Payer: Multiplan Auto	$5,135.54
Rate for Payer: Multiplan Commercial	$5,135.54
Rate for Payer: Multiplan Workers Comp	$5,135.54
Rate for Payer: Parkland Medicaid	$7,395.18
Rate for Payer: Scott and White EPO/PPO	$5,135.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,395.18
Rate for Payer: Superior Health Plan EPO	$1,396.87

Threaded rod 120 mm

Facility

$481.24

Hospital Charge Code	993384
Hospital Revenue Code	272
Rate for Payer: Cash Price	$327.24

Threaded rod 120 mm

Facility

$481.24

Hospital Charge Code	993384
Hospital Revenue Code	272
Min. Negotiated Rate	$43.31
Max. Negotiated Rate	$346.49
Rate for Payer: Amerigroup CHIP/Medicaid	$43.31
Rate for Payer: BCBS of TX Blue Advantage	$144.37
Rate for Payer: BCBS of TX Blue Essentials	$173.25
Rate for Payer: BCBS of TX PPO	$192.50
Rate for Payer: Cash Price	$327.24
Rate for Payer: Cigna Medicaid	$346.49
Rate for Payer: Molina CHIP/Medicaid	$346.49
Rate for Payer: Multiplan Auto	$312.81
Rate for Payer: Multiplan Commercial	$312.81
Rate for Payer: Multiplan Workers Comp	$312.81
Rate for Payer: Parkland Medicaid	$346.49
Rate for Payer: Scott and White EPO/PPO	$240.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$346.49
Rate for Payer: Superior Health Plan EPO	$65.45

Threaded rod 200 mm

Facility

$553.88

Hospital Charge Code	993385
Hospital Revenue Code	272
Rate for Payer: Cash Price	$376.64

Threaded rod 200 mm

Facility

$553.88

Hospital Charge Code	993385
Hospital Revenue Code	272
Min. Negotiated Rate	$49.85
Max. Negotiated Rate	$398.79
Rate for Payer: Amerigroup CHIP/Medicaid	$49.85
Rate for Payer: BCBS of TX Blue Advantage	$166.16
Rate for Payer: BCBS of TX Blue Essentials	$199.40
Rate for Payer: BCBS of TX PPO	$221.55
Rate for Payer: Cash Price	$376.64
Rate for Payer: Cigna Medicaid	$398.79
Rate for Payer: Molina CHIP/Medicaid	$398.79
Rate for Payer: Multiplan Auto	$360.02
Rate for Payer: Multiplan Commercial	$360.02
Rate for Payer: Multiplan Workers Comp	$360.02
Rate for Payer: Parkland Medicaid	$398.79
Rate for Payer: Scott and White EPO/PPO	$276.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$398.79
Rate for Payer: Superior Health Plan EPO	$75.33

THREADED ROD - LENGTH: 100 mm

Facility

$584.34

Service Code	HCPCS C1734
Hospital Charge Code	992239
Hospital Revenue Code	278
Min. Negotiated Rate	$146.09
Max. Negotiated Rate	$292.17
Rate for Payer: Cash Price	$397.35
Rate for Payer: Cigna Commercial	$146.09
Rate for Payer: Multiplan Auto	$292.17
Rate for Payer: Multiplan Commercial	$292.17
Rate for Payer: Multiplan Workers Comp	$292.17
Rate for Payer: Scott and White EPO/PPO	$292.17

THREADED ROD - LENGTH: 100 mm

Facility

$584.34

Service Code	HCPCS C1734
Hospital Charge Code	992239
Hospital Revenue Code	278
Min. Negotiated Rate	$52.59
Max. Negotiated Rate	$420.72
Rate for Payer: Amerigroup CHIP/Medicaid	$52.59
Rate for Payer: BCBS of TX Blue Advantage	$175.30
Rate for Payer: BCBS of TX Blue Essentials	$210.36
Rate for Payer: BCBS of TX PPO	$233.74
Rate for Payer: Cash Price	$397.35
Rate for Payer: Cigna Medicaid	$420.72
Rate for Payer: Molina CHIP/Medicaid	$420.72
Rate for Payer: Multiplan Auto	$292.17
Rate for Payer: Multiplan Commercial	$292.17
Rate for Payer: Multiplan Workers Comp	$292.17
Rate for Payer: Parkland Medicaid	$420.72
Rate for Payer: Scott and White EPO/PPO	$292.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$420.72
Rate for Payer: Superior Health Plan EPO	$79.47

THREADED ROD - LENGTH: 200 mm

Facility

$584.34

Service Code	HCPCS C1734
Hospital Charge Code	992240
Hospital Revenue Code	278
Min. Negotiated Rate	$146.09
Max. Negotiated Rate	$292.17
Rate for Payer: Cash Price	$397.35
Rate for Payer: Cigna Commercial	$146.09
Rate for Payer: Multiplan Auto	$292.17
Rate for Payer: Multiplan Commercial	$292.17
Rate for Payer: Multiplan Workers Comp	$292.17
Rate for Payer: Scott and White EPO/PPO	$292.17

THREADED ROD - LENGTH: 200 mm

Facility

$584.34

Service Code	HCPCS C1734
Hospital Charge Code	992240
Hospital Revenue Code	278
Min. Negotiated Rate	$52.59
Max. Negotiated Rate	$420.72
Rate for Payer: Amerigroup CHIP/Medicaid	$52.59
Rate for Payer: BCBS of TX Blue Advantage	$175.30
Rate for Payer: BCBS of TX Blue Essentials	$210.36
Rate for Payer: BCBS of TX PPO	$233.74
Rate for Payer: Cash Price	$397.35
Rate for Payer: Cigna Medicaid	$420.72
Rate for Payer: Molina CHIP/Medicaid	$420.72
Rate for Payer: Multiplan Auto	$292.17
Rate for Payer: Multiplan Commercial	$292.17
Rate for Payer: Multiplan Workers Comp	$292.17
Rate for Payer: Parkland Medicaid	$420.72
Rate for Payer: Scott and White EPO/PPO	$292.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$420.72
Rate for Payer: Superior Health Plan EPO	$79.47

thrombin bovine 5000 intl units Topical Powder-Recon

Facility

$150.00

Service Code	HCPCS J3490
Hospital Charge Code	77845021
Hospital Revenue Code	250
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$108.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.50
Rate for Payer: BCBS of TX Blue Advantage	$45.00
Rate for Payer: BCBS of TX Blue Essentials	$54.00
Rate for Payer: BCBS of TX PPO	$60.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cigna Medicaid	$108.00
Rate for Payer: Molina CHIP/Medicaid	$108.00
Rate for Payer: Multiplan Auto	$97.50
Rate for Payer: Multiplan Commercial	$97.50
Rate for Payer: Multiplan Workers Comp	$97.50
Rate for Payer: Parkland Medicaid	$108.00
Rate for Payer: Scott and White EPO/PPO	$75.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.00
Rate for Payer: Superior Health Plan EPO	$20.40

thrombin bovine 5000 intl units Topical Powder-Recon

Facility

$150.00

Service Code	HCPCS J3490
Hospital Charge Code	77845021
Hospital Revenue Code	250
Rate for Payer: Cash Price	$102.00

Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision

Facility

$65,875.00

Service Code	HCPCS 35301
Hospital Charge Code	990972
Hospital Revenue Code	480
Min. Negotiated Rate	$1,339.28
Max. Negotiated Rate	$47,430.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,928.75
Rate for Payer: BCBS of TX Blue Advantage	$1,973.47
Rate for Payer: BCBS of TX Blue Essentials	$2,363.44
Rate for Payer: BCBS of TX PPO	$2,977.93
Rate for Payer: Cash Price	$44,795.00
Rate for Payer: Cash Price	$44,795.00
Rate for Payer: Cigna Medicaid	$47,430.00
Rate for Payer: Molina CHIP/Medicaid	$47,430.00
Rate for Payer: Multiplan Auto	$42,818.75
Rate for Payer: Multiplan Commercial	$42,818.75
Rate for Payer: Multiplan Workers Comp	$42,818.75
Rate for Payer: Parkland Medicaid	$47,430.00
Rate for Payer: Scott and White EPO/PPO	$1,339.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47,430.00
Rate for Payer: Superior Health Plan EPO	$8,959.00

Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision

Facility

$65,875.00

Service Code	HCPCS 35301
Hospital Charge Code	990972
Hospital Revenue Code	480
Rate for Payer: Cash Price	$44,795.00

Thromboendarterectomy, including patch graft, if performed; common femoral

Facility

$64,200.00

Service Code	HCPCS 35371
Hospital Charge Code	991029
Hospital Revenue Code	481
Rate for Payer: Cash Price	$43,656.00

Thromboendarterectomy, including patch graft, if performed; common femoral

Facility

$64,200.00

Service Code	HCPCS 35371
Hospital Charge Code	991029
Hospital Revenue Code	481
Min. Negotiated Rate	$966.19
Max. Negotiated Rate	$46,224.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,778.00
Rate for Payer: BCBS of TX Blue Advantage	$1,426.40
Rate for Payer: BCBS of TX Blue Essentials	$1,708.26
Rate for Payer: BCBS of TX PPO	$2,152.41
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cigna Medicaid	$46,224.00
Rate for Payer: Molina CHIP/Medicaid	$46,224.00
Rate for Payer: Multiplan Auto	$41,730.00
Rate for Payer: Multiplan Commercial	$41,730.00
Rate for Payer: Multiplan Workers Comp	$41,730.00
Rate for Payer: Parkland Medicaid	$46,224.00
Rate for Payer: Scott and White EPO/PPO	$966.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,224.00
Rate for Payer: Superior Health Plan EPO	$8,731.20

Know your out-of-pocket cost for care.

All Charges