White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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
Rate for Payer: Cash Price	$35.18

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

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

traceable refrigerator and freezer digital thermometer

Facility

$584.16

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

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

Facility

$74,280.50

Service Code	MSDRG 012
Min. Negotiated Rate	$32,797.82
Max. Negotiated Rate	$74,280.50
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	$74,280.50
Rate for Payer: Multiplan Commercial	$74,280.50
Rate for Payer: Multiplan Workers Comp	$74,280.50
Rate for Payer: Scott and White EPO/PPO	$34,208.12
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

$98,138.80

Service Code	MSDRG 011
Min. Negotiated Rate	$42,246.64
Max. Negotiated Rate	$98,138.80
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	$98,138.80
Rate for Payer: Multiplan Commercial	$98,138.80
Rate for Payer: Multiplan Workers Comp	$98,138.80
Rate for Payer: Scott and White EPO/PPO	$45,195.50
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

$53,737.70

Service Code	MSDRG 013
Min. Negotiated Rate	$20,007.90
Max. Negotiated Rate	$53,737.70
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	$53,737.70
Rate for Payer: Multiplan Commercial	$53,737.70
Rate for Payer: Multiplan Workers Comp	$53,737.70
Rate for Payer: Scott and White EPO/PPO	$24,747.62
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

$74,280.50

Service Code	MSDRG 012
Min. Negotiated Rate	$32,797.82
Max. Negotiated Rate	$74,280.50
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

$98,138.80

Service Code	MSDRG 011
Min. Negotiated Rate	$42,246.64
Max. Negotiated Rate	$98,138.80
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

$53,737.70

Service Code	MSDRG 013
Min. Negotiated Rate	$20,007.90
Max. Negotiated Rate	$53,737.70
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

$260,902.30

Service Code	MSDRG 004
Min. Negotiated Rate	$98,205.12
Max. Negotiated Rate	$260,902.30
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	$260,902.30
Rate for Payer: Multiplan Commercial	$260,902.30
Rate for Payer: Multiplan Workers Comp	$260,902.30
Rate for Payer: Scott and White EPO/PPO	$120,152.38
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

$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

$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

$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 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 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

TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE

Facility

$40,874.09

Service Code	APR-DRG 0052
Min. Negotiated Rate	$38,537.52
Max. Negotiated Rate	$40,874.09
Rate for Payer: Amerigroup CHIP/Medicaid	$38,537.52
Rate for Payer: Cigna Medicaid	$38,537.52
Rate for Payer: Molina CHIP/Medicaid	$38,537.52
Rate for Payer: Parkland Medicaid	$38,537.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40,874.09

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

$44,758.00

Service Code	APR-DRG 0053
Min. Negotiated Rate	$42,199.41
Max. Negotiated Rate	$44,758.00
Rate for Payer: Amerigroup CHIP/Medicaid	$42,199.41
Rate for Payer: Cigna Medicaid	$42,199.41
Rate for Payer: Molina CHIP/Medicaid	$42,199.41
Rate for Payer: Parkland Medicaid	$42,199.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44,758.00

Tracheotomy tube change prior to establishment of fistula tract BCE

Facility

$1,813.00

Service Code	HCPCS 31502
Hospital Charge Code	8912662
Hospital Revenue Code	361
Min. Negotiated Rate	$87.58
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$87.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$237.93
Rate for Payer: Amerigroup Medicare	$237.93
Rate for Payer: BCBS of TX Blue Advantage	$340.08
Rate for Payer: BCBS of TX Blue Essentials	$407.28
Rate for Payer: BCBS of TX Medicare	$237.93
Rate for Payer: BCBS of TX PPO	$513.17
Rate for Payer: Cash Price	$1,232.84
Rate for Payer: Cash Price	$1,232.84
Rate for Payer: Cash Price	$1,232.84
Rate for Payer: Cigna Commercial	$502.95
Rate for Payer: Cigna Medicaid	$1,305.36
Rate for Payer: Cigna Medicare	$237.93
Rate for Payer: Employer Direct Commercial	$237.93
Rate for Payer: Humana Medicare/TRICARE	$237.93
Rate for Payer: Molina CHIP/Medicaid	$1,305.36
Rate for Payer: Molina Dual Medicare/Medicaid	$237.93
Rate for Payer: Molina Medicare	$237.93
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	$1,305.36
Rate for Payer: Scott and White EPO/PPO	$413.27
Rate for Payer: Scott and White Medicare	$237.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,305.36
Rate for Payer: Superior Health Plan EPO	$237.93
Rate for Payer: Superior Health Plan Medicare	$237.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$237.93
Rate for Payer: Universal American Medicare	$237.93
Rate for Payer: Wellcare Medicare	$237.93
Rate for Payer: Wellmed Medicare	$237.93

Tracheotomy tube change prior to establishment of fistula tract BCE

Facility

$1,813.00

Service Code	HCPCS 31502
Hospital Charge Code	8912662
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,232.84

TRACH HL -- DHF

Facility

$33.10

Hospital Charge Code	80349855
Hospital Revenue Code	270
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$23.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2.98
Rate for Payer: BCBS of TX Blue Advantage	$9.93
Rate for Payer: BCBS of TX Blue Essentials	$11.92
Rate for Payer: BCBS of TX PPO	$13.24
Rate for Payer: Cash Price	$22.51
Rate for Payer: Cigna Medicaid	$23.83
Rate for Payer: Molina CHIP/Medicaid	$23.83
Rate for Payer: Multiplan Auto	$21.52
Rate for Payer: Multiplan Commercial	$21.52
Rate for Payer: Multiplan Workers Comp	$21.52
Rate for Payer: Parkland Medicaid	$23.83
Rate for Payer: Scott and White EPO/PPO	$16.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.83
Rate for Payer: Superior Health Plan EPO	$4.50

Know your out-of-pocket cost for care.

All Charges