White Rock Medical Center

All Charges

Charge

Type

Setting

Price

torsemide 20 mg Tab

Facility

$10.70

Service Code	HCPCS J3490
Hospital Charge Code	77852661
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7.28

torsemide 20 mg Tab

Facility

$10.70

Service Code	HCPCS J3490
Hospital Charge Code	77852661
Hospital Revenue Code	250
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$7.70
Rate for Payer: Amerigroup CHIP/Medicaid	$0.96
Rate for Payer: BCBS of TX Blue Advantage	$3.21
Rate for Payer: BCBS of TX Blue Essentials	$3.85
Rate for Payer: BCBS of TX PPO	$4.28
Rate for Payer: Cash Price	$7.28
Rate for Payer: Cigna Medicaid	$7.70
Rate for Payer: Molina CHIP/Medicaid	$7.70
Rate for Payer: Multiplan Auto	$6.96
Rate for Payer: Multiplan Commercial	$6.96
Rate for Payer: Multiplan Workers Comp	$6.96
Rate for Payer: Parkland Medicaid	$7.70
Rate for Payer: Scott and White EPO/PPO	$5.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.70
Rate for Payer: Superior Health Plan EPO	$1.46

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate pr

Facility

$87,590.52

Service Code	HCPCS 22856
Hospital Charge Code	9900209
Hospital Revenue Code	360
Rate for Payer: Cash Price	$59,561.55

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate pr

Facility

$40,184.12

Service Code	CPT 22856
Hospital Charge Code	36022856
Hospital Revenue Code	360
Min. Negotiated Rate	$9,913.52
Max. Negotiated Rate	$40,184.12
Rate for Payer: Amerigroup CHIP/Medicaid	$9,913.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,613.72
Rate for Payer: Amerigroup Medicare	$17,613.72
Rate for Payer: BCBS of TX Blue Advantage	$26,629.95
Rate for Payer: BCBS of TX Blue Essentials	$31,892.16
Rate for Payer: BCBS of TX Medicare	$17,613.72
Rate for Payer: BCBS of TX PPO	$40,184.12
Rate for Payer: Cigna Commercial	$37,232.21
Rate for Payer: Cigna Medicare	$17,613.72
Rate for Payer: Employer Direct Commercial	$17,613.72
Rate for Payer: Humana Medicare/TRICARE	$17,613.72
Rate for Payer: Molina Dual Medicare/Medicaid	$17,613.72
Rate for Payer: Molina Medicare	$17,613.72
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	$31,530.55
Rate for Payer: Scott and White Medicare	$17,613.72
Rate for Payer: Superior Health Plan EPO	$17,613.72
Rate for Payer: Superior Health Plan Medicare	$17,613.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,613.72
Rate for Payer: Universal American Medicare	$17,613.72
Rate for Payer: Wellcare Medicare	$17,613.72
Rate for Payer: Wellmed Medicare	$17,613.72

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate pr

Facility

$87,590.52

Service Code	HCPCS 22856
Hospital Charge Code	9900209
Hospital Revenue Code	360
Min. Negotiated Rate	$9,913.52
Max. Negotiated Rate	$63,065.17
Rate for Payer: Amerigroup CHIP/Medicaid	$9,913.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,613.72
Rate for Payer: Amerigroup Medicare	$17,613.72
Rate for Payer: BCBS of TX Blue Advantage	$26,629.95
Rate for Payer: BCBS of TX Blue Essentials	$31,892.16
Rate for Payer: BCBS of TX Medicare	$17,613.72
Rate for Payer: BCBS of TX PPO	$40,184.12
Rate for Payer: Cash Price	$59,561.55
Rate for Payer: Cash Price	$59,561.55
Rate for Payer: Cash Price	$59,561.55
Rate for Payer: Cigna Commercial	$37,232.21
Rate for Payer: Cigna Medicaid	$63,065.17
Rate for Payer: Cigna Medicare	$17,613.72
Rate for Payer: Employer Direct Commercial	$17,613.72
Rate for Payer: Humana Medicare/TRICARE	$17,613.72
Rate for Payer: Molina CHIP/Medicaid	$63,065.17
Rate for Payer: Molina Dual Medicare/Medicaid	$17,613.72
Rate for Payer: Molina Medicare	$17,613.72
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	$63,065.17
Rate for Payer: Scott and White EPO/PPO	$31,530.55
Rate for Payer: Scott and White Medicare	$17,613.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63,065.17
Rate for Payer: Superior Health Plan EPO	$17,613.72
Rate for Payer: Superior Health Plan Medicare	$17,613.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,613.72
Rate for Payer: Universal American Medicare	$17,613.72
Rate for Payer: Wellcare Medicare	$17,613.72
Rate for Payer: Wellmed Medicare	$17,613.72

Total Iron Binding Capacity

Facility

$317.00

Service Code	HCPCS 83550
Hospital Charge Code	1601038
Hospital Revenue Code	301
Min. Negotiated Rate	$3.41
Max. Negotiated Rate	$228.24
Rate for Payer: Amerigroup CHIP/Medicaid	$3.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.74
Rate for Payer: Amerigroup Medicare	$8.74
Rate for Payer: BCBS of TX Blue Advantage	$95.10
Rate for Payer: BCBS of TX Blue Essentials	$114.12
Rate for Payer: BCBS of TX Medicare	$8.74
Rate for Payer: BCBS of TX PPO	$126.80
Rate for Payer: Cash Price	$215.56
Rate for Payer: Cash Price	$215.56
Rate for Payer: Cigna Medicaid	$228.24
Rate for Payer: Cigna Medicare	$8.74
Rate for Payer: Employer Direct Commercial	$8.74
Rate for Payer: Humana Medicare/TRICARE	$8.74
Rate for Payer: Molina CHIP/Medicaid	$228.24
Rate for Payer: Molina Dual Medicare/Medicaid	$8.74
Rate for Payer: Molina Medicare	$8.74
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$228.24
Rate for Payer: Scott and White EPO/PPO	$10.93
Rate for Payer: Scott and White Medicare	$8.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$228.24
Rate for Payer: Superior Health Plan EPO	$8.74
Rate for Payer: Superior Health Plan Medicare	$8.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.74
Rate for Payer: Universal American Medicare	$8.74
Rate for Payer: Wellcare Medicare	$8.74
Rate for Payer: Wellmed Medicare	$8.74

Total Iron Binding Capacity

Facility

$317.00

Service Code	HCPCS 83550
Hospital Charge Code	1601038
Hospital Revenue Code	301
Rate for Payer: Cash Price	$215.56

Total thyroid lobectomy, unilateral with or without isthmusectomy

Facility

$12,837.39

Service Code	CPT 60220
Hospital Charge Code	36060220
Hospital Revenue Code	360
Min. Negotiated Rate	$1,888.85
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup CHIP/Medicaid	$1,888.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Total thyroid lobectomy, unilateral with or without isthmusectomy

Facility

$30,362.64

Service Code	HCPCS 60220
Hospital Charge Code	9900732
Hospital Revenue Code	360
Min. Negotiated Rate	$1,888.85
Max. Negotiated Rate	$21,861.10
Rate for Payer: Amerigroup CHIP/Medicaid	$1,888.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$20,646.60
Rate for Payer: Cash Price	$20,646.60
Rate for Payer: Cash Price	$20,646.60
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$21,861.10
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$21,861.10
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$21,861.10
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,861.10
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Total thyroid lobectomy, unilateral with or without isthmusectomy

Facility

$30,362.64

Service Code	HCPCS 60220
Hospital Charge Code	9900732
Hospital Revenue Code	360
Rate for Payer: Cash Price	$20,646.60

TOURNIQUET, BLUE, 1'X18', ROLLED & BANDED

Facility

$0.60

Hospital Charge Code	993086
Hospital Revenue Code	270
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.43
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.18
Rate for Payer: BCBS of TX Blue Essentials	$0.22
Rate for Payer: BCBS of TX PPO	$0.24
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna Medicaid	$0.43
Rate for Payer: Molina CHIP/Medicaid	$0.43
Rate for Payer: Multiplan Auto	$0.39
Rate for Payer: Multiplan Commercial	$0.39
Rate for Payer: Multiplan Workers Comp	$0.39
Rate for Payer: Parkland Medicaid	$0.43
Rate for Payer: Scott and White EPO/PPO	$0.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.43
Rate for Payer: Superior Health Plan EPO	$0.08

TOURNIQUET, BLUE, 1'X18', ROLLED & BANDED

Facility

$0.60

Hospital Charge Code	993086
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.41

TOWEL 27X17IN 6 PK CTTN OR BLU STRL

Facility

$12.39

Hospital Charge Code	992830
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8.43

TOWEL 27X17IN 6 PK CTTN OR BLU STRL

Facility

$12.39

Hospital Charge Code	992830
Hospital Revenue Code	272
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$8.92
Rate for Payer: Amerigroup CHIP/Medicaid	$1.12
Rate for Payer: BCBS of TX Blue Advantage	$3.72
Rate for Payer: BCBS of TX Blue Essentials	$4.46
Rate for Payer: BCBS of TX PPO	$4.96
Rate for Payer: Cash Price	$8.43
Rate for Payer: Cigna Medicaid	$8.92
Rate for Payer: Molina CHIP/Medicaid	$8.92
Rate for Payer: Multiplan Auto	$8.05
Rate for Payer: Multiplan Commercial	$8.05
Rate for Payer: Multiplan Workers Comp	$8.05
Rate for Payer: Parkland Medicaid	$8.92
Rate for Payer: Scott and White EPO/PPO	$6.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.92
Rate for Payer: Superior Health Plan EPO	$1.69

TOWELETTE, CASTILE SOAP, 1M/CS

Facility

$1.23

Hospital Charge Code	993227
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.84

TOWELETTE, CASTILE SOAP, 1M/CS

Facility

$1.23

Hospital Charge Code	993227
Hospital Revenue Code	270
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.89
Rate for Payer: Amerigroup CHIP/Medicaid	$0.11
Rate for Payer: BCBS of TX Blue Advantage	$0.37
Rate for Payer: BCBS of TX Blue Essentials	$0.44
Rate for Payer: BCBS of TX PPO	$0.49
Rate for Payer: Cash Price	$0.84
Rate for Payer: Cigna Medicaid	$0.89
Rate for Payer: Molina CHIP/Medicaid	$0.89
Rate for Payer: Multiplan Auto	$0.80
Rate for Payer: Multiplan Commercial	$0.80
Rate for Payer: Multiplan Workers Comp	$0.80
Rate for Payer: Parkland Medicaid	$0.89
Rate for Payer: Scott and White EPO/PPO	$0.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.89
Rate for Payer: Superior Health Plan EPO	$0.17

TOWEL, HAND, MATIC, IPLY, NATRL 6 RL/700

Facility

$26.70

Hospital Charge Code	993345
Hospital Revenue Code	270
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$19.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2.40
Rate for Payer: BCBS of TX Blue Advantage	$8.01
Rate for Payer: BCBS of TX Blue Essentials	$9.61
Rate for Payer: BCBS of TX PPO	$10.68
Rate for Payer: Cash Price	$18.16
Rate for Payer: Cigna Medicaid	$19.22
Rate for Payer: Molina CHIP/Medicaid	$19.22
Rate for Payer: Multiplan Auto	$17.36
Rate for Payer: Multiplan Commercial	$17.36
Rate for Payer: Multiplan Workers Comp	$17.36
Rate for Payer: Parkland Medicaid	$19.22
Rate for Payer: Scott and White EPO/PPO	$13.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.22
Rate for Payer: Superior Health Plan EPO	$3.63

TOWEL, HAND, MATIC, IPLY, NATRL 6 RL/700

Facility

$26.70

Hospital Charge Code	993345
Hospital Revenue Code	270
Rate for Payer: Cash Price	$18.16

TOWEL, OR, DSP, WHITE, DTX, 2/PK, 40PK/CS

Facility

$1.96

Hospital Charge Code	992881
Hospital Revenue Code	272
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$1.41
Rate for Payer: Amerigroup CHIP/Medicaid	$0.18
Rate for Payer: BCBS of TX Blue Advantage	$0.59
Rate for Payer: BCBS of TX Blue Essentials	$0.71
Rate for Payer: BCBS of TX PPO	$0.78
Rate for Payer: Cash Price	$1.33
Rate for Payer: Cigna Medicaid	$1.41
Rate for Payer: Molina CHIP/Medicaid	$1.41
Rate for Payer: Multiplan Auto	$1.27
Rate for Payer: Multiplan Commercial	$1.27
Rate for Payer: Multiplan Workers Comp	$1.27
Rate for Payer: Parkland Medicaid	$1.41
Rate for Payer: Scott and White EPO/PPO	$0.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.41
Rate for Payer: Superior Health Plan EPO	$0.27

TOWEL, OR, DSP, WHITE, DTX, 2/PK, 40PK/CS

Facility

$1.96

Hospital Charge Code	992881
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1.33

TOWEL, STERILE DISPOSABLE DELEX OR TOWEL, BLUE

Facility

$49.58

Hospital Charge Code	993782
Hospital Revenue Code	272
Min. Negotiated Rate	$4.46
Max. Negotiated Rate	$35.70
Rate for Payer: Amerigroup CHIP/Medicaid	$4.46
Rate for Payer: BCBS of TX Blue Advantage	$14.87
Rate for Payer: BCBS of TX Blue Essentials	$17.85
Rate for Payer: BCBS of TX PPO	$19.83
Rate for Payer: Cash Price	$33.71
Rate for Payer: Cigna Medicaid	$35.70
Rate for Payer: Molina CHIP/Medicaid	$35.70
Rate for Payer: Multiplan Auto	$32.23
Rate for Payer: Multiplan Commercial	$32.23
Rate for Payer: Multiplan Workers Comp	$32.23
Rate for Payer: Parkland Medicaid	$35.70
Rate for Payer: Scott and White EPO/PPO	$24.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.70
Rate for Payer: Superior Health Plan EPO	$6.74

TOWEL, STERILE DISPOSABLE DELEX OR TOWEL, BLUE

Facility

$49.58

Hospital Charge Code	993782
Hospital Revenue Code	272
Rate for Payer: Cash Price	$33.71

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$5,964.49

Service Code	APR-DRG 8162
Min. Negotiated Rate	$5,623.53
Max. Negotiated Rate	$5,964.49
Rate for Payer: Amerigroup CHIP/Medicaid	$5,623.53
Rate for Payer: Cigna Medicaid	$5,623.53
Rate for Payer: Molina CHIP/Medicaid	$5,623.53
Rate for Payer: Parkland Medicaid	$5,623.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,964.49

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$6,686.81

Service Code	APR-DRG 8163
Min. Negotiated Rate	$6,304.56
Max. Negotiated Rate	$6,686.81
Rate for Payer: Amerigroup CHIP/Medicaid	$6,304.56
Rate for Payer: Cigna Medicaid	$6,304.56
Rate for Payer: Molina CHIP/Medicaid	$6,304.56
Rate for Payer: Parkland Medicaid	$6,304.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,686.81

TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES

Facility

$7,409.12

Service Code	APR-DRG 8164
Min. Negotiated Rate	$6,985.58
Max. Negotiated Rate	$7,409.12
Rate for Payer: Amerigroup CHIP/Medicaid	$6,985.58
Rate for Payer: Cigna Medicaid	$6,985.58
Rate for Payer: Molina CHIP/Medicaid	$6,985.58
Rate for Payer: Parkland Medicaid	$6,985.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,409.12

Know your out-of-pocket cost for care.

All Charges