White Rock Medical Center

All Charges

Charge

Type

Setting

Price

.Tissue Grinding SO

Facility

$46.01

Service Code	HCPCS 87176
Hospital Charge Code	9058994
Hospital Revenue Code	306
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$33.13
Rate for Payer: Amerigroup CHIP/Medicaid	$2.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.88
Rate for Payer: Amerigroup Medicare	$5.88
Rate for Payer: BCBS of TX Blue Advantage	$13.80
Rate for Payer: BCBS of TX Blue Essentials	$16.56
Rate for Payer: BCBS of TX Medicare	$5.88
Rate for Payer: BCBS of TX PPO	$18.40
Rate for Payer: Cash Price	$31.29
Rate for Payer: Cash Price	$31.29
Rate for Payer: Cigna Medicaid	$33.13
Rate for Payer: Cigna Medicare	$5.88
Rate for Payer: Employer Direct Commercial	$5.88
Rate for Payer: Humana Medicare/TRICARE	$5.88
Rate for Payer: Molina CHIP/Medicaid	$33.13
Rate for Payer: Molina Dual Medicare/Medicaid	$5.88
Rate for Payer: Molina Medicare	$5.88
Rate for Payer: Multiplan Auto	$29.91
Rate for Payer: Multiplan Commercial	$29.91
Rate for Payer: Multiplan Workers Comp	$29.91
Rate for Payer: Parkland Medicaid	$33.13
Rate for Payer: Scott and White EPO/PPO	$7.35
Rate for Payer: Scott and White Medicare	$5.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.13
Rate for Payer: Superior Health Plan EPO	$5.88
Rate for Payer: Superior Health Plan Medicare	$5.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.88
Rate for Payer: Universal American Medicare	$5.88
Rate for Payer: Wellcare Medicare	$5.88
Rate for Payer: Wellmed Medicare	$5.88

TISSUE KLNX 5X8IN

Facility

$1.26

Hospital Charge Code	993794
Hospital Revenue Code	270
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.91
Rate for Payer: Amerigroup CHIP/Medicaid	$0.11
Rate for Payer: BCBS of TX Blue Advantage	$0.38
Rate for Payer: BCBS of TX Blue Essentials	$0.45
Rate for Payer: BCBS of TX PPO	$0.50
Rate for Payer: Cash Price	$0.86
Rate for Payer: Cigna Medicaid	$0.91
Rate for Payer: Molina CHIP/Medicaid	$0.91
Rate for Payer: Multiplan Auto	$0.82
Rate for Payer: Multiplan Commercial	$0.82
Rate for Payer: Multiplan Workers Comp	$0.82
Rate for Payer: Parkland Medicaid	$0.91
Rate for Payer: Scott and White EPO/PPO	$0.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.91
Rate for Payer: Superior Health Plan EPO	$0.17

TISSUE KLNX 5X8IN

Facility

$1.26

Hospital Charge Code	993794
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.86

TISSUE TOILET SMALL CORE

Facility

$2.20

Hospital Charge Code	993583
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.50

TISSUE TOILET SMALL CORE

Facility

$2.20

Hospital Charge Code	993583
Hospital Revenue Code	270
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$1.58
Rate for Payer: Amerigroup CHIP/Medicaid	$0.20
Rate for Payer: BCBS of TX Blue Advantage	$0.66
Rate for Payer: BCBS of TX Blue Essentials	$0.79
Rate for Payer: BCBS of TX PPO	$0.88
Rate for Payer: Cash Price	$1.50
Rate for Payer: Cigna Medicaid	$1.58
Rate for Payer: Molina CHIP/Medicaid	$1.58
Rate for Payer: Multiplan Auto	$1.43
Rate for Payer: Multiplan Commercial	$1.43
Rate for Payer: Multiplan Workers Comp	$1.43
Rate for Payer: Parkland Medicaid	$1.58
Rate for Payer: Scott and White EPO/PPO	$1.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.58
Rate for Payer: Superior Health Plan EPO	$0.30

tiZANidine 2 mg Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77848621
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

tiZANidine 2 mg Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77848621
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

tiZANidine 4 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77848723
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

tiZANidine 4 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77848723
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

T-Lymphocyte Helper/Suppressor SO

Facility

$764.00

Service Code	HCPCS 86360
Hospital Charge Code	1708981
Hospital Revenue Code	302
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$550.08
Rate for Payer: Amerigroup CHIP/Medicaid	$18.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$46.98
Rate for Payer: Amerigroup Medicare	$46.98
Rate for Payer: BCBS of TX Blue Advantage	$229.20
Rate for Payer: BCBS of TX Blue Essentials	$275.04
Rate for Payer: BCBS of TX Medicare	$46.98
Rate for Payer: BCBS of TX PPO	$305.60
Rate for Payer: Cash Price	$519.52
Rate for Payer: Cash Price	$519.52
Rate for Payer: Cigna Medicaid	$550.08
Rate for Payer: Cigna Medicare	$46.98
Rate for Payer: Employer Direct Commercial	$46.98
Rate for Payer: Humana Medicare/TRICARE	$46.98
Rate for Payer: Molina CHIP/Medicaid	$550.08
Rate for Payer: Molina Dual Medicare/Medicaid	$46.98
Rate for Payer: Molina Medicare	$46.98
Rate for Payer: Multiplan Auto	$496.60
Rate for Payer: Multiplan Commercial	$496.60
Rate for Payer: Multiplan Workers Comp	$496.60
Rate for Payer: Parkland Medicaid	$550.08
Rate for Payer: Scott and White EPO/PPO	$58.73
Rate for Payer: Scott and White Medicare	$46.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$550.08
Rate for Payer: Superior Health Plan EPO	$46.98
Rate for Payer: Superior Health Plan Medicare	$46.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$46.98
Rate for Payer: Universal American Medicare	$46.98
Rate for Payer: Wellcare Medicare	$46.98
Rate for Payer: Wellmed Medicare	$46.98

T-Lymphocyte Helper/Suppressor SO

Facility

$764.00

Service Code	HCPCS 86360
Hospital Charge Code	1708981
Hospital Revenue Code	302
Rate for Payer: Cash Price	$519.52

TOBACCO COUNSEL >10MIN SYMTOMATIC

Facility

$97.00

Service Code	HCPCS 99407
Hospital Charge Code	6010376
Hospital Revenue Code	942
Rate for Payer: Cash Price	$65.96

TOBACCO COUNSEL >10MIN SYMTOMATIC

Facility

$97.00

Service Code	HCPCS 99407
Hospital Charge Code	6010376
Hospital Revenue Code	942
Min. Negotiated Rate	$8.73
Max. Negotiated Rate	$79.55
Rate for Payer: Amerigroup CHIP/Medicaid	$8.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37.64
Rate for Payer: Amerigroup Medicare	$37.64
Rate for Payer: BCBS of TX Blue Advantage	$29.10
Rate for Payer: BCBS of TX Blue Essentials	$34.92
Rate for Payer: BCBS of TX Medicare	$37.64
Rate for Payer: BCBS of TX PPO	$38.80
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cash Price	$65.96
Rate for Payer: Cigna Commercial	$79.55
Rate for Payer: Cigna Medicaid	$69.84
Rate for Payer: Cigna Medicare	$37.64
Rate for Payer: Employer Direct Commercial	$37.64
Rate for Payer: Humana Medicare/TRICARE	$37.64
Rate for Payer: Molina CHIP/Medicaid	$69.84
Rate for Payer: Molina Dual Medicare/Medicaid	$37.64
Rate for Payer: Molina Medicare	$37.64
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$69.84
Rate for Payer: Scott and White EPO/PPO	$30.38
Rate for Payer: Scott and White Medicare	$37.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.84
Rate for Payer: Superior Health Plan EPO	$37.64
Rate for Payer: Superior Health Plan Medicare	$37.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$37.64
Rate for Payer: Universal American Medicare	$37.64
Rate for Payer: Wellcare Medicare	$37.64
Rate for Payer: Wellmed Medicare	$37.64

tobramycin 0.3% Ophth Soln 5 mL

Facility

$40.18

Service Code	HCPCS J3490
Hospital Charge Code	77848880
Hospital Revenue Code	250
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$28.93
Rate for Payer: Amerigroup CHIP/Medicaid	$3.62
Rate for Payer: BCBS of TX Blue Advantage	$12.05
Rate for Payer: BCBS of TX Blue Essentials	$14.46
Rate for Payer: BCBS of TX PPO	$16.07
Rate for Payer: Cash Price	$27.32
Rate for Payer: Cigna Medicaid	$28.93
Rate for Payer: Molina CHIP/Medicaid	$28.93
Rate for Payer: Multiplan Auto	$26.12
Rate for Payer: Multiplan Commercial	$26.12
Rate for Payer: Multiplan Workers Comp	$26.12
Rate for Payer: Parkland Medicaid	$28.93
Rate for Payer: Scott and White EPO/PPO	$20.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.93
Rate for Payer: Superior Health Plan EPO	$5.46

tobramycin 0.3% Ophth Soln 5 mL

Facility

$40.18

Service Code	HCPCS J3490
Hospital Charge Code	77848880
Hospital Revenue Code	250
Rate for Payer: Cash Price	$27.32

tobramycin 40 mg/mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS J3260
Hospital Charge Code	78411432
Hospital Revenue Code	636
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.65
Rate for Payer: BCBS of TX Blue Essentials	$0.78
Rate for Payer: BCBS of TX PPO	$0.87
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

tobramycin 40 mg/mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS J3260
Hospital Charge Code	78411432
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

Tobramycin Level Trough

Facility

$396.00

Service Code	HCPCS 80200
Hospital Charge Code	1601475
Hospital Revenue Code	300
Rate for Payer: Cash Price	$269.28

Tobramycin Level Trough

Facility

$396.00

Service Code	HCPCS 80200
Hospital Charge Code	1601475
Hospital Revenue Code	300
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$285.12
Rate for Payer: Amerigroup CHIP/Medicaid	$6.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.13
Rate for Payer: Amerigroup Medicare	$16.13
Rate for Payer: BCBS of TX Blue Advantage	$118.80
Rate for Payer: BCBS of TX Blue Essentials	$142.56
Rate for Payer: BCBS of TX Medicare	$16.13
Rate for Payer: BCBS of TX PPO	$158.40
Rate for Payer: Cash Price	$269.28
Rate for Payer: Cash Price	$269.28
Rate for Payer: Cigna Medicaid	$285.12
Rate for Payer: Cigna Medicare	$16.13
Rate for Payer: Employer Direct Commercial	$16.13
Rate for Payer: Humana Medicare/TRICARE	$16.13
Rate for Payer: Molina CHIP/Medicaid	$285.12
Rate for Payer: Molina Dual Medicare/Medicaid	$16.13
Rate for Payer: Molina Medicare	$16.13
Rate for Payer: Multiplan Auto	$257.40
Rate for Payer: Multiplan Commercial	$257.40
Rate for Payer: Multiplan Workers Comp	$257.40
Rate for Payer: Parkland Medicaid	$285.12
Rate for Payer: Scott and White EPO/PPO	$20.16
Rate for Payer: Scott and White Medicare	$16.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$285.12
Rate for Payer: Superior Health Plan EPO	$16.13
Rate for Payer: Superior Health Plan Medicare	$16.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.13
Rate for Payer: Universal American Medicare	$16.13
Rate for Payer: Wellcare Medicare	$16.13
Rate for Payer: Wellmed Medicare	$16.13

TOMCAT SHAVER

Facility

$779.02

Hospital Charge Code	993592
Hospital Revenue Code	272
Min. Negotiated Rate	$70.11
Max. Negotiated Rate	$560.89
Rate for Payer: Amerigroup CHIP/Medicaid	$70.11
Rate for Payer: BCBS of TX Blue Advantage	$233.71
Rate for Payer: BCBS of TX Blue Essentials	$280.45
Rate for Payer: BCBS of TX PPO	$311.61
Rate for Payer: Cash Price	$529.73
Rate for Payer: Cigna Medicaid	$560.89
Rate for Payer: Molina CHIP/Medicaid	$560.89
Rate for Payer: Multiplan Auto	$506.36
Rate for Payer: Multiplan Commercial	$506.36
Rate for Payer: Multiplan Workers Comp	$506.36
Rate for Payer: Parkland Medicaid	$560.89
Rate for Payer: Scott and White EPO/PPO	$389.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$560.89
Rate for Payer: Superior Health Plan EPO	$105.95

TOMCAT SHAVER

Facility

$779.02

Hospital Charge Code	993592
Hospital Revenue Code	272
Rate for Payer: Cash Price	$529.73

Tomcat shaver blade f - series -5

Facility

$351.49

Hospital Charge Code	993584
Hospital Revenue Code	272
Rate for Payer: Cash Price	$239.01

Tomcat shaver blade f - series -5

Facility

$351.49

Hospital Charge Code	993584
Hospital Revenue Code	272
Min. Negotiated Rate	$31.63
Max. Negotiated Rate	$253.07
Rate for Payer: Amerigroup CHIP/Medicaid	$31.63
Rate for Payer: BCBS of TX Blue Advantage	$105.45
Rate for Payer: BCBS of TX Blue Essentials	$126.54
Rate for Payer: BCBS of TX PPO	$140.60
Rate for Payer: Cash Price	$239.01
Rate for Payer: Cigna Medicaid	$253.07
Rate for Payer: Molina CHIP/Medicaid	$253.07
Rate for Payer: Multiplan Auto	$228.47
Rate for Payer: Multiplan Commercial	$228.47
Rate for Payer: Multiplan Workers Comp	$228.47
Rate for Payer: Parkland Medicaid	$253.07
Rate for Payer: Scott and White EPO/PPO	$175.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$253.07
Rate for Payer: Superior Health Plan EPO	$47.80

TONSIL AND ADENOID PROCEDURES

Facility

$6,406.18

Service Code	APR-DRG 0973
Min. Negotiated Rate	$6,039.97
Max. Negotiated Rate	$6,406.18
Rate for Payer: Amerigroup CHIP/Medicaid	$6,039.97
Rate for Payer: Cigna Medicaid	$6,039.97
Rate for Payer: Molina CHIP/Medicaid	$6,039.97
Rate for Payer: Parkland Medicaid	$6,039.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,406.18

TONSIL AND ADENOID PROCEDURES

Facility

$14,786.19

Service Code	APR-DRG 0974
Min. Negotiated Rate	$13,940.93
Max. Negotiated Rate	$14,786.19
Rate for Payer: Amerigroup CHIP/Medicaid	$13,940.93
Rate for Payer: Cigna Medicaid	$13,940.93
Rate for Payer: Molina CHIP/Medicaid	$13,940.93
Rate for Payer: Parkland Medicaid	$13,940.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,786.19

Know your out-of-pocket cost for care.

All Charges