White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Thyroid Stimulating Hormone

Facility

$502.00

Service Code	HCPCS 84443
Hospital Charge Code	1602275
Hospital Revenue Code	301
Rate for Payer: Cash Price	$341.36

Thyroxine

Facility

$256.00

Service Code	HCPCS 84436
Hospital Charge Code	4104436
Hospital Revenue Code	301
Rate for Payer: Cash Price	$174.08

Thyroxine

Facility

$256.00

Service Code	HCPCS 84436
Hospital Charge Code	4104436
Hospital Revenue Code	301
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$184.32
Rate for Payer: Amerigroup CHIP/Medicaid	$2.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.87
Rate for Payer: Amerigroup Medicare	$6.87
Rate for Payer: BCBS of TX Blue Advantage	$76.80
Rate for Payer: BCBS of TX Blue Essentials	$92.16
Rate for Payer: BCBS of TX Medicare	$6.87
Rate for Payer: BCBS of TX PPO	$102.40
Rate for Payer: Cash Price	$174.08
Rate for Payer: Cash Price	$174.08
Rate for Payer: Cigna Medicaid	$184.32
Rate for Payer: Cigna Medicare	$6.87
Rate for Payer: Employer Direct Commercial	$6.87
Rate for Payer: Humana Medicare/TRICARE	$6.87
Rate for Payer: Molina CHIP/Medicaid	$184.32
Rate for Payer: Molina Dual Medicare/Medicaid	$6.87
Rate for Payer: Molina Medicare	$6.87
Rate for Payer: Multiplan Auto	$166.40
Rate for Payer: Multiplan Commercial	$166.40
Rate for Payer: Multiplan Workers Comp	$166.40
Rate for Payer: Parkland Medicaid	$184.32
Rate for Payer: Scott and White EPO/PPO	$8.59
Rate for Payer: Scott and White Medicare	$6.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$184.32
Rate for Payer: Superior Health Plan EPO	$6.87
Rate for Payer: Superior Health Plan Medicare	$6.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.87
Rate for Payer: Universal American Medicare	$6.87
Rate for Payer: Wellcare Medicare	$6.87
Rate for Payer: Wellmed Medicare	$6.87

Thyroxine (T4) SO

Facility

$49.49

Service Code	HCPCS 84436
Hospital Charge Code	1602283
Hospital Revenue Code	301
Rate for Payer: Cash Price	$33.65

Thyroxine (T4) SO

Facility

$49.49

Service Code	HCPCS 84436
Hospital Charge Code	1602283
Hospital Revenue Code	301
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$35.63
Rate for Payer: Amerigroup CHIP/Medicaid	$2.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.87
Rate for Payer: Amerigroup Medicare	$6.87
Rate for Payer: BCBS of TX Blue Advantage	$14.85
Rate for Payer: BCBS of TX Blue Essentials	$17.82
Rate for Payer: BCBS of TX Medicare	$6.87
Rate for Payer: BCBS of TX PPO	$19.80
Rate for Payer: Cash Price	$33.65
Rate for Payer: Cash Price	$33.65
Rate for Payer: Cigna Medicaid	$35.63
Rate for Payer: Cigna Medicare	$6.87
Rate for Payer: Employer Direct Commercial	$6.87
Rate for Payer: Humana Medicare/TRICARE	$6.87
Rate for Payer: Molina CHIP/Medicaid	$35.63
Rate for Payer: Molina Dual Medicare/Medicaid	$6.87
Rate for Payer: Molina Medicare	$6.87
Rate for Payer: Multiplan Auto	$32.17
Rate for Payer: Multiplan Commercial	$32.17
Rate for Payer: Multiplan Workers Comp	$32.17
Rate for Payer: Parkland Medicaid	$35.63
Rate for Payer: Scott and White EPO/PPO	$8.59
Rate for Payer: Scott and White Medicare	$6.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.63
Rate for Payer: Superior Health Plan EPO	$6.87
Rate for Payer: Superior Health Plan Medicare	$6.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.87
Rate for Payer: Universal American Medicare	$6.87
Rate for Payer: Wellcare Medicare	$6.87
Rate for Payer: Wellmed Medicare	$6.87

Tiagabine (Gabitril) SO

Facility

$224.00

Service Code	HCPCS 80199
Hospital Charge Code	8486568
Hospital Revenue Code	301
Min. Negotiated Rate	$10.57
Max. Negotiated Rate	$161.28
Rate for Payer: Amerigroup CHIP/Medicaid	$10.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.11
Rate for Payer: Amerigroup Medicare	$27.11
Rate for Payer: BCBS of TX Blue Advantage	$67.20
Rate for Payer: BCBS of TX Blue Essentials	$80.64
Rate for Payer: BCBS of TX Medicare	$27.11
Rate for Payer: BCBS of TX PPO	$89.60
Rate for Payer: Cash Price	$152.32
Rate for Payer: Cash Price	$152.32
Rate for Payer: Cigna Medicaid	$161.28
Rate for Payer: Cigna Medicare	$27.11
Rate for Payer: Employer Direct Commercial	$27.11
Rate for Payer: Humana Medicare/TRICARE	$27.11
Rate for Payer: Molina CHIP/Medicaid	$161.28
Rate for Payer: Molina Dual Medicare/Medicaid	$27.11
Rate for Payer: Molina Medicare	$27.11
Rate for Payer: Multiplan Auto	$145.60
Rate for Payer: Multiplan Commercial	$145.60
Rate for Payer: Multiplan Workers Comp	$145.60
Rate for Payer: Parkland Medicaid	$161.28
Rate for Payer: Scott and White EPO/PPO	$33.89
Rate for Payer: Scott and White Medicare	$27.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$161.28
Rate for Payer: Superior Health Plan EPO	$27.11
Rate for Payer: Superior Health Plan Medicare	$27.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.11
Rate for Payer: Universal American Medicare	$27.11
Rate for Payer: Wellcare Medicare	$27.11
Rate for Payer: Wellmed Medicare	$27.11

Tiagabine (Gabitril) SO

Facility

$224.00

Service Code	HCPCS 80199
Hospital Charge Code	8486568
Hospital Revenue Code	301
Rate for Payer: Cash Price	$152.32

Tibial bearing insert

Facility

$6,626.51

Service Code	HCPCS C1734
Hospital Charge Code	992215
Hospital Revenue Code	278
Min. Negotiated Rate	$596.39
Max. Negotiated Rate	$4,771.09
Rate for Payer: Amerigroup CHIP/Medicaid	$596.39
Rate for Payer: BCBS of TX Blue Advantage	$1,987.95
Rate for Payer: BCBS of TX Blue Essentials	$2,385.54
Rate for Payer: BCBS of TX PPO	$2,650.60
Rate for Payer: Cash Price	$4,506.03
Rate for Payer: Cigna Medicaid	$4,771.09
Rate for Payer: Molina CHIP/Medicaid	$4,771.09
Rate for Payer: Multiplan Auto	$3,313.26
Rate for Payer: Multiplan Commercial	$3,313.26
Rate for Payer: Multiplan Workers Comp	$3,313.26
Rate for Payer: Parkland Medicaid	$4,771.09
Rate for Payer: Scott and White EPO/PPO	$3,313.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,771.09
Rate for Payer: Superior Health Plan EPO	$901.21

Tibial bearing insert

Facility

$6,626.51

Service Code	HCPCS C1734
Hospital Charge Code	992215
Hospital Revenue Code	278
Min. Negotiated Rate	$1,656.63
Max. Negotiated Rate	$3,313.26
Rate for Payer: Cash Price	$4,506.03
Rate for Payer: Cigna Commercial	$1,656.63
Rate for Payer: Multiplan Auto	$3,313.26
Rate for Payer: Multiplan Commercial	$3,313.26
Rate for Payer: Multiplan Workers Comp	$3,313.26
Rate for Payer: Scott and White EPO/PPO	$3,313.26

Tibial component

Facility

$9,638.55

Service Code	HCPCS C1734
Hospital Charge Code	992214
Hospital Revenue Code	278
Min. Negotiated Rate	$867.47
Max. Negotiated Rate	$6,939.76
Rate for Payer: Amerigroup CHIP/Medicaid	$867.47
Rate for Payer: BCBS of TX Blue Advantage	$2,891.57
Rate for Payer: BCBS of TX Blue Essentials	$3,469.88
Rate for Payer: BCBS of TX PPO	$3,855.42
Rate for Payer: Cash Price	$6,554.21
Rate for Payer: Cigna Medicaid	$6,939.76
Rate for Payer: Molina CHIP/Medicaid	$6,939.76
Rate for Payer: Multiplan Auto	$4,819.27
Rate for Payer: Multiplan Commercial	$4,819.27
Rate for Payer: Multiplan Workers Comp	$4,819.27
Rate for Payer: Parkland Medicaid	$6,939.76
Rate for Payer: Scott and White EPO/PPO	$4,819.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,939.76
Rate for Payer: Superior Health Plan EPO	$1,310.84

Tibial component

Facility

$9,638.55

Service Code	HCPCS C1734
Hospital Charge Code	992214
Hospital Revenue Code	278
Min. Negotiated Rate	$2,409.64
Max. Negotiated Rate	$4,819.27
Rate for Payer: Cash Price	$6,554.21
Rate for Payer: Cigna Commercial	$2,409.64
Rate for Payer: Multiplan Auto	$4,819.27
Rate for Payer: Multiplan Commercial	$4,819.27
Rate for Payer: Multiplan Workers Comp	$4,819.27
Rate for Payer: Scott and White EPO/PPO	$4,819.27

TIBIAL NAIL

Facility

$23,494.00

Service Code	HCPCS C1776
Hospital Charge Code	8502477
Hospital Revenue Code	278
Min. Negotiated Rate	$5,873.50
Max. Negotiated Rate	$11,747.00
Rate for Payer: Cash Price	$15,975.92
Rate for Payer: Cigna Commercial	$5,873.50
Rate for Payer: Multiplan Auto	$11,747.00
Rate for Payer: Multiplan Commercial	$11,747.00
Rate for Payer: Multiplan Workers Comp	$11,747.00
Rate for Payer: Scott and White EPO/PPO	$11,747.00

TIBIAL NAIL

Facility

$23,494.00

Service Code	HCPCS C1776
Hospital Charge Code	8502477
Hospital Revenue Code	278
Min. Negotiated Rate	$2,114.46
Max. Negotiated Rate	$16,915.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2,114.46
Rate for Payer: BCBS of TX Blue Advantage	$7,048.20
Rate for Payer: BCBS of TX Blue Essentials	$8,457.84
Rate for Payer: BCBS of TX PPO	$9,397.60
Rate for Payer: Cash Price	$15,975.92
Rate for Payer: Cigna Medicaid	$16,915.68
Rate for Payer: Molina CHIP/Medicaid	$16,915.68
Rate for Payer: Multiplan Auto	$11,747.00
Rate for Payer: Multiplan Commercial	$11,747.00
Rate for Payer: Multiplan Workers Comp	$11,747.00
Rate for Payer: Parkland Medicaid	$16,915.68
Rate for Payer: Scott and White EPO/PPO	$11,747.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,915.68
Rate for Payer: Superior Health Plan EPO	$3,195.18

ticagrelor 90 mg Tab

Facility

$23.34

Service Code	HCPCS J3490
Hospital Charge Code	7450946
Hospital Revenue Code	250
Rate for Payer: Cash Price	$15.87

ticagrelor 90 mg Tab

Facility

$23.34

Service Code	HCPCS J3490
Hospital Charge Code	7450946
Hospital Revenue Code	250
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$16.80
Rate for Payer: Amerigroup CHIP/Medicaid	$2.10
Rate for Payer: BCBS of TX Blue Advantage	$7.00
Rate for Payer: BCBS of TX Blue Essentials	$8.40
Rate for Payer: BCBS of TX PPO	$9.34
Rate for Payer: Cash Price	$15.87
Rate for Payer: Cigna Medicaid	$16.80
Rate for Payer: Molina CHIP/Medicaid	$16.80
Rate for Payer: Multiplan Auto	$15.17
Rate for Payer: Multiplan Commercial	$15.17
Rate for Payer: Multiplan Workers Comp	$15.17
Rate for Payer: Parkland Medicaid	$16.80
Rate for Payer: Scott and White EPO/PPO	$11.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.80
Rate for Payer: Superior Health Plan EPO	$3.17

ticagrelor 90 mg tablet

Facility

$15.87

Service Code	HCPCS J3490
Hospital Charge Code	77846602
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.79

ticagrelor 90 mg tablet

Facility

$15.87

Service Code	HCPCS J3490
Hospital Charge Code	77846602
Hospital Revenue Code	250
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$11.43
Rate for Payer: Amerigroup CHIP/Medicaid	$1.43
Rate for Payer: BCBS of TX Blue Advantage	$4.76
Rate for Payer: BCBS of TX Blue Essentials	$5.71
Rate for Payer: BCBS of TX PPO	$6.35
Rate for Payer: Cash Price	$10.79
Rate for Payer: Cigna Medicaid	$11.43
Rate for Payer: Molina CHIP/Medicaid	$11.43
Rate for Payer: Multiplan Auto	$10.32
Rate for Payer: Multiplan Commercial	$10.32
Rate for Payer: Multiplan Workers Comp	$10.32
Rate for Payer: Parkland Medicaid	$11.43
Rate for Payer: Scott and White EPO/PPO	$7.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.43
Rate for Payer: Superior Health Plan EPO	$2.16

TIGHTROPE II RT W/ DEPLOYING SUTURE

Facility

$4,784.00

Service Code	HCPCS C1713
Hospital Charge Code	146504
Hospital Revenue Code	278
Min. Negotiated Rate	$430.56
Max. Negotiated Rate	$3,444.48
Rate for Payer: Amerigroup CHIP/Medicaid	$430.56
Rate for Payer: BCBS of TX Blue Advantage	$1,435.20
Rate for Payer: BCBS of TX Blue Essentials	$1,722.24
Rate for Payer: BCBS of TX PPO	$1,913.60
Rate for Payer: Cash Price	$3,253.12
Rate for Payer: Cigna Medicaid	$3,444.48
Rate for Payer: Molina CHIP/Medicaid	$3,444.48
Rate for Payer: Multiplan Auto	$2,392.00
Rate for Payer: Multiplan Commercial	$2,392.00
Rate for Payer: Multiplan Workers Comp	$2,392.00
Rate for Payer: Parkland Medicaid	$3,444.48
Rate for Payer: Scott and White EPO/PPO	$2,392.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,444.48
Rate for Payer: Superior Health Plan EPO	$650.62

TIGHTROPE II RT W/ DEPLOYING SUTURE

Facility

$4,784.00

Service Code	HCPCS C1713
Hospital Charge Code	146504
Hospital Revenue Code	278
Min. Negotiated Rate	$1,196.00
Max. Negotiated Rate	$2,392.00
Rate for Payer: Cash Price	$3,253.12
Rate for Payer: Cigna Commercial	$1,196.00
Rate for Payer: Multiplan Auto	$2,392.00
Rate for Payer: Multiplan Commercial	$2,392.00
Rate for Payer: Multiplan Workers Comp	$2,392.00
Rate for Payer: Scott and White EPO/PPO	$2,392.00

TI LAG SCREW 10.5 X 80 MM

Facility

$5,048.19

Service Code	HCPCS C1713
Hospital Charge Code	993143
Hospital Revenue Code	278
Min. Negotiated Rate	$1,262.05
Max. Negotiated Rate	$2,524.09
Rate for Payer: Cash Price	$3,432.77
Rate for Payer: Cigna Commercial	$1,262.05
Rate for Payer: Multiplan Auto	$2,524.09
Rate for Payer: Multiplan Commercial	$2,524.09
Rate for Payer: Multiplan Workers Comp	$2,524.09
Rate for Payer: Scott and White EPO/PPO	$2,524.09

TI LAG SCREW 10.5 X 80 MM

Facility

$5,048.19

Service Code	HCPCS C1713
Hospital Charge Code	993143
Hospital Revenue Code	278
Min. Negotiated Rate	$454.34
Max. Negotiated Rate	$3,634.70
Rate for Payer: Amerigroup CHIP/Medicaid	$454.34
Rate for Payer: BCBS of TX Blue Advantage	$1,514.46
Rate for Payer: BCBS of TX Blue Essentials	$1,817.35
Rate for Payer: BCBS of TX PPO	$2,019.28
Rate for Payer: Cash Price	$3,432.77
Rate for Payer: Cigna Medicaid	$3,634.70
Rate for Payer: Molina CHIP/Medicaid	$3,634.70
Rate for Payer: Multiplan Auto	$2,524.09
Rate for Payer: Multiplan Commercial	$2,524.09
Rate for Payer: Multiplan Workers Comp	$2,524.09
Rate for Payer: Parkland Medicaid	$3,634.70
Rate for Payer: Scott and White EPO/PPO	$2,524.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,634.70
Rate for Payer: Superior Health Plan EPO	$686.55

timolol 0.5% Ophth Soln 5 mL

Facility

$39.95

Service Code	HCPCS J3490
Hospital Charge Code	77847369
Hospital Revenue Code	250
Rate for Payer: Cash Price	$27.17

timolol 0.5% Ophth Soln 5 mL

Facility

$39.95

Service Code	HCPCS J3490
Hospital Charge Code	77847369
Hospital Revenue Code	250
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$28.76
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$11.98
Rate for Payer: BCBS of TX Blue Essentials	$14.38
Rate for Payer: BCBS of TX PPO	$15.98
Rate for Payer: Cash Price	$27.17
Rate for Payer: Cigna Medicaid	$28.76
Rate for Payer: Molina CHIP/Medicaid	$28.76
Rate for Payer: Multiplan Auto	$25.97
Rate for Payer: Multiplan Commercial	$25.97
Rate for Payer: Multiplan Workers Comp	$25.97
Rate for Payer: Parkland Medicaid	$28.76
Rate for Payer: Scott and White EPO/PPO	$19.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.76
Rate for Payer: Superior Health Plan EPO	$5.43

TIP, CATHETER FLEX 45CM FOR SEALANT FIBRIN 5ML -- DHF

Facility

$284.38

Hospital Charge Code	80385024
Hospital Revenue Code	272
Rate for Payer: Cash Price	$193.38

TIP, CATHETER FLEX 45CM FOR SEALANT FIBRIN 5ML -- DHF

Facility

$284.38

Hospital Charge Code	80385024
Hospital Revenue Code	272
Min. Negotiated Rate	$25.59
Max. Negotiated Rate	$204.75
Rate for Payer: Amerigroup CHIP/Medicaid	$25.59
Rate for Payer: BCBS of TX Blue Advantage	$85.31
Rate for Payer: BCBS of TX Blue Essentials	$102.38
Rate for Payer: BCBS of TX PPO	$113.75
Rate for Payer: Cash Price	$193.38
Rate for Payer: Cigna Medicaid	$204.75
Rate for Payer: Molina CHIP/Medicaid	$204.75
Rate for Payer: Multiplan Auto	$184.85
Rate for Payer: Multiplan Commercial	$184.85
Rate for Payer: Multiplan Workers Comp	$184.85
Rate for Payer: Parkland Medicaid	$204.75
Rate for Payer: Scott and White EPO/PPO	$142.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$204.75
Rate for Payer: Superior Health Plan EPO	$38.68

Know your out-of-pocket cost for care.

All Charges