White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$3,679.48

Service Code	APR-DRG 8161
Min. Negotiated Rate	$3,469.14
Max. Negotiated Rate	$3,679.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3,469.14
Rate for Payer: Cigna Medicaid	$3,469.14
Rate for Payer: Molina CHIP/Medicaid	$3,469.14
Rate for Payer: Parkland Medicaid	$3,469.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,679.48

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

$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

$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

Toxoplasma gondii Ab, IgG, Qn SO

Facility

$116.99

Service Code	HCPCS 86777
Hospital Charge Code	1702679
Hospital Revenue Code	302
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$84.23
Rate for Payer: Amerigroup CHIP/Medicaid	$5.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.39
Rate for Payer: Amerigroup Medicare	$14.39
Rate for Payer: BCBS of TX Blue Advantage	$35.10
Rate for Payer: BCBS of TX Blue Essentials	$42.12
Rate for Payer: BCBS of TX Medicare	$14.39
Rate for Payer: BCBS of TX PPO	$46.80
Rate for Payer: Cash Price	$79.55
Rate for Payer: Cash Price	$79.55
Rate for Payer: Cigna Medicaid	$84.23
Rate for Payer: Cigna Medicare	$14.39
Rate for Payer: Employer Direct Commercial	$14.39
Rate for Payer: Humana Medicare/TRICARE	$14.39
Rate for Payer: Molina CHIP/Medicaid	$84.23
Rate for Payer: Molina Dual Medicare/Medicaid	$14.39
Rate for Payer: Molina Medicare	$14.39
Rate for Payer: Multiplan Auto	$76.04
Rate for Payer: Multiplan Commercial	$76.04
Rate for Payer: Multiplan Workers Comp	$76.04
Rate for Payer: Parkland Medicaid	$84.23
Rate for Payer: Scott and White EPO/PPO	$17.99
Rate for Payer: Scott and White Medicare	$14.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.23
Rate for Payer: Superior Health Plan EPO	$14.39
Rate for Payer: Superior Health Plan Medicare	$14.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.39
Rate for Payer: Universal American Medicare	$14.39
Rate for Payer: Wellcare Medicare	$14.39
Rate for Payer: Wellmed Medicare	$14.39

Toxoplasma gondii Ab, IgG, Qn SO

Facility

$116.99

Service Code	HCPCS 86777
Hospital Charge Code	1702679
Hospital Revenue Code	302
Rate for Payer: Cash Price	$79.55

T-PORT ADPT -- DHF

Facility

$51.74

Hospital Charge Code	80345606
Hospital Revenue Code	270
Min. Negotiated Rate	$4.66
Max. Negotiated Rate	$37.25
Rate for Payer: Amerigroup CHIP/Medicaid	$4.66
Rate for Payer: BCBS of TX Blue Advantage	$15.52
Rate for Payer: BCBS of TX Blue Essentials	$18.63
Rate for Payer: BCBS of TX PPO	$20.70
Rate for Payer: Cash Price	$35.18
Rate for Payer: Cigna Medicaid	$37.25
Rate for Payer: Molina CHIP/Medicaid	$37.25
Rate for Payer: Multiplan Auto	$33.63
Rate for Payer: Multiplan Commercial	$33.63
Rate for Payer: Multiplan Workers Comp	$33.63
Rate for Payer: Parkland Medicaid	$37.25
Rate for Payer: Scott and White EPO/PPO	$25.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.25
Rate for Payer: Superior Health Plan EPO	$7.04

T-PORT ADPT -- DHF

Facility

$51.74

Hospital Charge Code	80345606
Hospital Revenue Code	270
Rate for Payer: Cash Price	$35.18

traceable refrigerator and freezer digital thermometer

Facility

$584.16

Hospital Charge Code	993298
Hospital Revenue Code	270
Rate for Payer: Cash Price	$397.23

traceable refrigerator and freezer digital thermometer

Facility

$584.16

Hospital Charge Code	993298
Hospital Revenue Code	270
Min. Negotiated Rate	$52.57
Max. Negotiated Rate	$420.60
Rate for Payer: Amerigroup CHIP/Medicaid	$52.57
Rate for Payer: BCBS of TX Blue Advantage	$175.25
Rate for Payer: BCBS of TX Blue Essentials	$210.30
Rate for Payer: BCBS of TX PPO	$233.66
Rate for Payer: Cash Price	$397.23
Rate for Payer: Cigna Medicaid	$420.60
Rate for Payer: Molina CHIP/Medicaid	$420.60
Rate for Payer: Multiplan Auto	$379.70
Rate for Payer: Multiplan Commercial	$379.70
Rate for Payer: Multiplan Workers Comp	$379.70
Rate for Payer: Parkland Medicaid	$420.60
Rate for Payer: Scott and White EPO/PPO	$292.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$420.60
Rate for Payer: Superior Health Plan EPO	$79.45

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC

Facility

$80,104.00

Service Code	MSDRG 012
Min. Negotiated Rate	$32,797.82
Max. Negotiated Rate	$80,104.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35,659.24
Rate for Payer: Amerigroup Medicare	$35,659.24
Rate for Payer: BCBS of TX Medicare	$35,659.24
Rate for Payer: Cigna Commercial	$54,302.08
Rate for Payer: Cigna Medicare	$35,659.24
Rate for Payer: Employer Direct Commercial	$35,659.24
Rate for Payer: Humana Medicare/TRICARE	$35,659.24
Rate for Payer: Molina Dual Medicare/Medicaid	$35,659.24
Rate for Payer: Molina Medicare	$35,659.24
Rate for Payer: Multiplan Auto	$80,104.00
Rate for Payer: Multiplan Commercial	$80,104.00
Rate for Payer: Multiplan Workers Comp	$80,104.00
Rate for Payer: Scott and White EPO/PPO	$36,890.00
Rate for Payer: Scott and White Medicare	$35,659.24
Rate for Payer: Superior Health Plan EPO	$35,659.24
Rate for Payer: Superior Health Plan Medicare	$35,659.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$35,659.24
Rate for Payer: Universal American Medicare	$35,659.24
Rate for Payer: Wellcare Medicare	$35,659.24
Rate for Payer: Wellmed Medicare	$35,659.24

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC

Facility

$103,627.90

Service Code	MSDRG 011
Min. Negotiated Rate	$42,246.64
Max. Negotiated Rate	$103,627.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$44,733.32
Rate for Payer: Amerigroup Medicare	$44,733.32
Rate for Payer: BCBS of TX Medicare	$44,733.32
Rate for Payer: Cigna Commercial	$70,248.81
Rate for Payer: Cigna Medicare	$44,733.32
Rate for Payer: Employer Direct Commercial	$44,733.32
Rate for Payer: Humana Medicare/TRICARE	$44,733.32
Rate for Payer: Molina Dual Medicare/Medicaid	$44,733.32
Rate for Payer: Molina Medicare	$44,733.32
Rate for Payer: Multiplan Auto	$103,627.90
Rate for Payer: Multiplan Commercial	$103,627.90
Rate for Payer: Multiplan Workers Comp	$103,627.90
Rate for Payer: Scott and White EPO/PPO	$47,723.38
Rate for Payer: Scott and White Medicare	$44,733.32
Rate for Payer: Superior Health Plan EPO	$44,733.32
Rate for Payer: Superior Health Plan Medicare	$44,733.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$44,733.32
Rate for Payer: Universal American Medicare	$44,733.32
Rate for Payer: Wellcare Medicare	$44,733.32
Rate for Payer: Wellmed Medicare	$44,733.32

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC

Facility

$54,754.20

Service Code	MSDRG 013
Min. Negotiated Rate	$20,007.90
Max. Negotiated Rate	$54,754.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25,880.86
Rate for Payer: Amerigroup Medicare	$25,880.86
Rate for Payer: BCBS of TX Medicare	$25,880.86
Rate for Payer: Cigna Commercial	$37,117.58
Rate for Payer: Cigna Medicare	$25,880.86
Rate for Payer: Employer Direct Commercial	$25,880.86
Rate for Payer: Humana Medicare/TRICARE	$25,880.86
Rate for Payer: Molina Dual Medicare/Medicaid	$25,880.86
Rate for Payer: Molina Medicare	$25,880.86
Rate for Payer: Multiplan Auto	$54,754.20
Rate for Payer: Multiplan Commercial	$54,754.20
Rate for Payer: Multiplan Workers Comp	$54,754.20
Rate for Payer: Scott and White EPO/PPO	$25,215.75
Rate for Payer: Scott and White Medicare	$25,880.86
Rate for Payer: Superior Health Plan EPO	$25,880.86
Rate for Payer: Superior Health Plan Medicare	$25,880.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$25,880.86
Rate for Payer: Universal American Medicare	$25,880.86
Rate for Payer: Wellcare Medicare	$25,880.86
Rate for Payer: Wellmed Medicare	$25,880.86

TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES OR LARYNGECTOMY W CC

Facility

$80,104.00

Service Code	MSDRG 012
Min. Negotiated Rate	$32,797.82
Max. Negotiated Rate	$80,104.00
Rate for Payer: BCBS of TX Blue Advantage	$32,797.82
Rate for Payer: BCBS of TX Blue Essentials	$39,353.57
Rate for Payer: BCBS of TX PPO	$43,727.88

TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES OR LARYNGECTOMY W MCC

Facility

$103,627.90

Service Code	MSDRG 011
Min. Negotiated Rate	$42,246.64
Max. Negotiated Rate	$103,627.90
Rate for Payer: BCBS of TX Blue Advantage	$42,246.64
Rate for Payer: BCBS of TX Blue Essentials	$50,691.06
Rate for Payer: BCBS of TX PPO	$56,325.58

TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES OR LARYNGECTOMY W/O CC/MCC

Facility

$54,754.20

Service Code	MSDRG 013
Min. Negotiated Rate	$20,007.90
Max. Negotiated Rate	$54,754.20
Rate for Payer: BCBS of TX Blue Advantage	$20,007.90
Rate for Payer: BCBS of TX Blue Essentials	$24,007.15
Rate for Payer: BCBS of TX PPO	$26,675.65

TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES

Facility

$263,176.60

Service Code	MSDRG 004
Min. Negotiated Rate	$98,205.12
Max. Negotiated Rate	$263,176.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$106,277.34
Rate for Payer: Amerigroup Medicare	$106,277.34
Rate for Payer: BCBS of TX Medicare	$106,277.34
Rate for Payer: Cigna Commercial	$178,406.03
Rate for Payer: Cigna Medicare	$106,277.34
Rate for Payer: Employer Direct Commercial	$106,277.34
Rate for Payer: Humana Medicare/TRICARE	$106,277.34
Rate for Payer: Molina Dual Medicare/Medicaid	$106,277.34
Rate for Payer: Molina Medicare	$106,277.34
Rate for Payer: Multiplan Auto	$263,176.60
Rate for Payer: Multiplan Commercial	$263,176.60
Rate for Payer: Multiplan Workers Comp	$263,176.60
Rate for Payer: Scott and White EPO/PPO	$121,199.75
Rate for Payer: Scott and White Medicare	$106,277.34
Rate for Payer: Superior Health Plan EPO	$106,277.34
Rate for Payer: Superior Health Plan Medicare	$106,277.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$106,277.34
Rate for Payer: Universal American Medicare	$106,277.34
Rate for Payer: Wellcare Medicare	$106,277.34
Rate for Payer: Wellmed Medicare	$106,277.34

TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE

Facility

$40,610.05

Service Code	APR-DRG 0042
Min. Negotiated Rate	$38,288.58
Max. Negotiated Rate	$40,610.05
Rate for Payer: Amerigroup CHIP/Medicaid	$38,288.58
Rate for Payer: Cigna Medicaid	$38,288.58
Rate for Payer: Molina CHIP/Medicaid	$38,288.58
Rate for Payer: Parkland Medicaid	$38,288.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40,610.05

TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE

Facility

$62,111.34

Service Code	APR-DRG 0043
Min. Negotiated Rate	$58,560.74
Max. Negotiated Rate	$62,111.34
Rate for Payer: Amerigroup CHIP/Medicaid	$58,560.74
Rate for Payer: Cigna Medicaid	$58,560.74
Rate for Payer: Molina CHIP/Medicaid	$58,560.74
Rate for Payer: Parkland Medicaid	$58,560.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62,111.34

TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE

Facility

$33,325.03

Service Code	APR-DRG 0041
Min. Negotiated Rate	$31,420.00
Max. Negotiated Rate	$33,325.03
Rate for Payer: Amerigroup CHIP/Medicaid	$31,420.00
Rate for Payer: Cigna Medicaid	$31,420.00
Rate for Payer: Molina CHIP/Medicaid	$31,420.00
Rate for Payer: Parkland Medicaid	$31,420.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33,325.03

TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE

Facility

$96,604.14

Service Code	APR-DRG 0044
Min. Negotiated Rate	$91,081.76
Max. Negotiated Rate	$96,604.14
Rate for Payer: Amerigroup CHIP/Medicaid	$91,081.76
Rate for Payer: Cigna Medicaid	$91,081.76
Rate for Payer: Molina CHIP/Medicaid	$91,081.76
Rate for Payer: Parkland Medicaid	$91,081.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96,604.14

TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE

Facility

$62,132.46

Service Code	APR-DRG 0054
Min. Negotiated Rate	$58,580.66
Max. Negotiated Rate	$62,132.46
Rate for Payer: Amerigroup CHIP/Medicaid	$58,580.66
Rate for Payer: Cigna Medicaid	$58,580.66
Rate for Payer: Molina CHIP/Medicaid	$58,580.66
Rate for Payer: Parkland Medicaid	$58,580.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62,132.46

TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE

Facility

$33,389.15

Service Code	APR-DRG 0051
Min. Negotiated Rate	$31,480.46
Max. Negotiated Rate	$33,389.15
Rate for Payer: Amerigroup CHIP/Medicaid	$31,480.46
Rate for Payer: Cigna Medicaid	$31,480.46
Rate for Payer: Molina CHIP/Medicaid	$31,480.46
Rate for Payer: Parkland Medicaid	$31,480.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33,389.15

Know your out-of-pocket cost for care.

All Charges