White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TONSIL AND ADENOID PROCEDURES

Facility

$3,396.59

Service Code	APR-DRG 0971
Min. Negotiated Rate	$3,202.42
Max. Negotiated Rate	$3,396.59
Rate for Payer: Amerigroup CHIP/Medicaid	$3,202.42
Rate for Payer: Cigna Medicaid	$3,202.42
Rate for Payer: Molina CHIP/Medicaid	$3,202.42
Rate for Payer: Parkland Medicaid	$3,202.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,396.59

TONSIL AND ADENOID PROCEDURES

Facility

$4,792.56

Service Code	APR-DRG 0972
Min. Negotiated Rate	$4,518.60
Max. Negotiated Rate	$4,792.56
Rate for Payer: Amerigroup CHIP/Medicaid	$4,518.60
Rate for Payer: Cigna Medicaid	$4,518.60
Rate for Payer: Molina CHIP/Medicaid	$4,518.60
Rate for Payer: Parkland Medicaid	$4,518.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,792.56

Tonsillectomy and adenoidectomy age 12 or over

Facility

$21,891.12

Service Code	HCPCS 42821
Hospital Charge Code	9900661
Hospital Revenue Code	360
Min. Negotiated Rate	$886.62
Max. Negotiated Rate	$15,761.61
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Amerigroup Medicare	$3,330.57
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cash Price	$14,885.96
Rate for Payer: Cash Price	$14,885.96
Rate for Payer: Cash Price	$14,885.96
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicaid	$15,761.61
Rate for Payer: Cigna Medicare	$3,330.57
Rate for Payer: Employer Direct Commercial	$3,330.57
Rate for Payer: Humana Medicare/TRICARE	$3,330.57
Rate for Payer: Molina CHIP/Medicaid	$15,761.61
Rate for Payer: Molina Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Molina Medicare	$3,330.57
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: Parkland Medicaid	$15,761.61
Rate for Payer: Scott and White EPO/PPO	$5,447.31
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,761.61
Rate for Payer: Superior Health Plan EPO	$3,330.57
Rate for Payer: Superior Health Plan Medicare	$3,330.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Universal American Medicare	$3,330.57
Rate for Payer: Wellcare Medicare	$3,330.57
Rate for Payer: Wellmed Medicare	$3,330.57

Tonsillectomy and adenoidectomy age 12 or over

Facility

$21,891.12

Service Code	HCPCS 42821
Hospital Charge Code	9900661
Hospital Revenue Code	360
Rate for Payer: Cash Price	$14,885.96

Tonsillectomy and adenoidectomy age 12 or over

Facility

$10,000.00

Service Code	CPT 42821
Hospital Charge Code	36042821
Hospital Revenue Code	360
Min. Negotiated Rate	$886.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Amerigroup Medicare	$3,330.57
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicare	$3,330.57
Rate for Payer: Employer Direct Commercial	$3,330.57
Rate for Payer: Humana Medicare/TRICARE	$3,330.57
Rate for Payer: Molina Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Molina Medicare	$3,330.57
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 EPO/PPO	$5,447.31
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan EPO	$3,330.57
Rate for Payer: Superior Health Plan Medicare	$3,330.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Universal American Medicare	$3,330.57
Rate for Payer: Wellcare Medicare	$3,330.57
Rate for Payer: Wellmed Medicare	$3,330.57

Tonsillectomy and adenoidectomy younger than age 12

Facility

$40,688.40

Service Code	HCPCS 42820
Hospital Charge Code	9900660
Hospital Revenue Code	360
Rate for Payer: Cash Price	$27,668.11

Tonsillectomy and adenoidectomy younger than age 12

Facility

$40,688.40

Service Code	HCPCS 42820
Hospital Charge Code	9900660
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$29,295.65
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cash Price	$27,668.11
Rate for Payer: Cash Price	$27,668.11
Rate for Payer: Cash Price	$27,668.11
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicaid	$29,295.65
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina CHIP/Medicaid	$29,295.65
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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: Parkland Medicaid	$29,295.65
Rate for Payer: Scott and White EPO/PPO	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,295.65
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Tonsillectomy and adenoidectomy younger than age 12

Facility

$12,570.48

Service Code	CPT 42820
Hospital Charge Code	36042820
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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 EPO/PPO	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Tonsillectomy, primary or secondary age 12 or over

Facility

$21,891.12

Service Code	HCPCS 42826
Hospital Charge Code	9900662
Hospital Revenue Code	360
Min. Negotiated Rate	$886.62
Max. Negotiated Rate	$15,761.61
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Amerigroup Medicare	$3,330.57
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cash Price	$14,885.96
Rate for Payer: Cash Price	$14,885.96
Rate for Payer: Cash Price	$14,885.96
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicaid	$15,761.61
Rate for Payer: Cigna Medicare	$3,330.57
Rate for Payer: Employer Direct Commercial	$3,330.57
Rate for Payer: Humana Medicare/TRICARE	$3,330.57
Rate for Payer: Molina CHIP/Medicaid	$15,761.61
Rate for Payer: Molina Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Molina Medicare	$3,330.57
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: Parkland Medicaid	$15,761.61
Rate for Payer: Scott and White EPO/PPO	$5,447.31
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,761.61
Rate for Payer: Superior Health Plan EPO	$3,330.57
Rate for Payer: Superior Health Plan Medicare	$3,330.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Universal American Medicare	$3,330.57
Rate for Payer: Wellcare Medicare	$3,330.57
Rate for Payer: Wellmed Medicare	$3,330.57

Tonsillectomy, primary or secondary age 12 or over

Facility

$21,891.12

Service Code	HCPCS 42826
Hospital Charge Code	9900662
Hospital Revenue Code	360
Rate for Payer: Cash Price	$14,885.96

Tonsillectomy, primary or secondary age 12 or over

Facility

$10,000.00

Service Code	CPT 42826
Hospital Charge Code	36042826
Hospital Revenue Code	360
Min. Negotiated Rate	$886.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Amerigroup Medicare	$3,330.57
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicare	$3,330.57
Rate for Payer: Employer Direct Commercial	$3,330.57
Rate for Payer: Humana Medicare/TRICARE	$3,330.57
Rate for Payer: Molina Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Molina Medicare	$3,330.57
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 EPO/PPO	$5,447.31
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan EPO	$3,330.57
Rate for Payer: Superior Health Plan Medicare	$3,330.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Universal American Medicare	$3,330.57
Rate for Payer: Wellcare Medicare	$3,330.57
Rate for Payer: Wellmed Medicare	$3,330.57

TOOL CARD WRNCH TRQ

Facility

$202.71

Hospital Charge Code	114623
Hospital Revenue Code	272
Min. Negotiated Rate	$18.24
Max. Negotiated Rate	$145.95
Rate for Payer: Amerigroup CHIP/Medicaid	$18.24
Rate for Payer: BCBS of TX Blue Advantage	$60.81
Rate for Payer: BCBS of TX Blue Essentials	$72.98
Rate for Payer: BCBS of TX PPO	$81.08
Rate for Payer: Cash Price	$137.84
Rate for Payer: Cigna Medicaid	$145.95
Rate for Payer: Molina CHIP/Medicaid	$145.95
Rate for Payer: Multiplan Auto	$131.76
Rate for Payer: Multiplan Commercial	$131.76
Rate for Payer: Multiplan Workers Comp	$131.76
Rate for Payer: Parkland Medicaid	$145.95
Rate for Payer: Scott and White EPO/PPO	$101.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.95
Rate for Payer: Superior Health Plan EPO	$27.57

TOOL CARD WRNCH TRQ

Facility

$202.71

Hospital Charge Code	114623
Hospital Revenue Code	272
Rate for Payer: Cash Price	$137.84

TOOL PCMKR 2 KIT WRNCH RCHT LD

Facility

$163.44

Hospital Charge Code	114630
Hospital Revenue Code	272
Min. Negotiated Rate	$14.71
Max. Negotiated Rate	$117.68
Rate for Payer: Amerigroup CHIP/Medicaid	$14.71
Rate for Payer: BCBS of TX Blue Advantage	$49.03
Rate for Payer: BCBS of TX Blue Essentials	$58.84
Rate for Payer: BCBS of TX PPO	$65.38
Rate for Payer: Cash Price	$111.14
Rate for Payer: Cigna Medicaid	$117.68
Rate for Payer: Molina CHIP/Medicaid	$117.68
Rate for Payer: Multiplan Auto	$106.24
Rate for Payer: Multiplan Commercial	$106.24
Rate for Payer: Multiplan Workers Comp	$106.24
Rate for Payer: Parkland Medicaid	$117.68
Rate for Payer: Scott and White EPO/PPO	$81.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$117.68
Rate for Payer: Superior Health Plan EPO	$22.23

TOOL PCMKR 2 KIT WRNCH RCHT LD

Facility

$163.44

Hospital Charge Code	114630
Hospital Revenue Code	272
Rate for Payer: Cash Price	$111.14

TOOTHPASTE, .6 OZ

Facility

$0.39

Hospital Charge Code	993264
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.27

TOOTHPASTE, .6 OZ

Facility

$0.39

Hospital Charge Code	993264
Hospital Revenue Code	270
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.28
Rate for Payer: Amerigroup CHIP/Medicaid	$0.04
Rate for Payer: BCBS of TX Blue Advantage	$0.12
Rate for Payer: BCBS of TX Blue Essentials	$0.14
Rate for Payer: BCBS of TX PPO	$0.16
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna Medicaid	$0.28
Rate for Payer: Molina CHIP/Medicaid	$0.28
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	$0.28
Rate for Payer: Scott and White EPO/PPO	$0.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.28
Rate for Payer: Superior Health Plan EPO	$0.05

topiramate 100 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78437264
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

topiramate 100 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78437264
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

topiramate 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77852013
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

topiramate 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77852013
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

Topiramate (Topamax), Serum SO

Facility

$336.00

Service Code	HCPCS 80201
Hospital Charge Code	1739465
Hospital Revenue Code	300
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$241.92
Rate for Payer: Amerigroup CHIP/Medicaid	$4.65
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.92
Rate for Payer: Amerigroup Medicare	$11.92
Rate for Payer: BCBS of TX Blue Advantage	$100.80
Rate for Payer: BCBS of TX Blue Essentials	$120.96
Rate for Payer: BCBS of TX Medicare	$11.92
Rate for Payer: BCBS of TX PPO	$134.40
Rate for Payer: Cash Price	$228.48
Rate for Payer: Cash Price	$228.48
Rate for Payer: Cigna Medicaid	$241.92
Rate for Payer: Cigna Medicare	$11.92
Rate for Payer: Employer Direct Commercial	$11.92
Rate for Payer: Humana Medicare/TRICARE	$11.92
Rate for Payer: Molina CHIP/Medicaid	$241.92
Rate for Payer: Molina Dual Medicare/Medicaid	$11.92
Rate for Payer: Molina Medicare	$11.92
Rate for Payer: Multiplan Auto	$218.40
Rate for Payer: Multiplan Commercial	$218.40
Rate for Payer: Multiplan Workers Comp	$218.40
Rate for Payer: Parkland Medicaid	$241.92
Rate for Payer: Scott and White EPO/PPO	$14.90
Rate for Payer: Scott and White Medicare	$11.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$241.92
Rate for Payer: Superior Health Plan EPO	$11.92
Rate for Payer: Superior Health Plan Medicare	$11.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.92
Rate for Payer: Universal American Medicare	$11.92
Rate for Payer: Wellcare Medicare	$11.92
Rate for Payer: Wellmed Medicare	$11.92

Topiramate (Topamax), Serum SO

Facility

$336.00

Service Code	HCPCS 80201
Hospital Charge Code	1739465
Hospital Revenue Code	300
Rate for Payer: Cash Price	$228.48

TORQUE DVCE -- DHF

Facility

$1,221.26

Hospital Charge Code	80348907
Hospital Revenue Code	270
Rate for Payer: Cash Price	$830.46

TORQUE DVCE -- DHF

Facility

$1,221.26

Hospital Charge Code	80348907
Hospital Revenue Code	270
Min. Negotiated Rate	$109.91
Max. Negotiated Rate	$879.31
Rate for Payer: Amerigroup CHIP/Medicaid	$109.91
Rate for Payer: BCBS of TX Blue Advantage	$366.38
Rate for Payer: BCBS of TX Blue Essentials	$439.65
Rate for Payer: BCBS of TX PPO	$488.50
Rate for Payer: Cash Price	$830.46
Rate for Payer: Cigna Medicaid	$879.31
Rate for Payer: Molina CHIP/Medicaid	$879.31
Rate for Payer: Multiplan Auto	$793.82
Rate for Payer: Multiplan Commercial	$793.82
Rate for Payer: Multiplan Workers Comp	$793.82
Rate for Payer: Parkland Medicaid	$879.31
Rate for Payer: Scott and White EPO/PPO	$610.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$879.31
Rate for Payer: Superior Health Plan EPO	$166.09

Know your out-of-pocket cost for care.

All Charges