White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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

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

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	$440.17
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

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

TRACH HL -- DHF

Facility

$33.10

Hospital Charge Code	80349855
Hospital Revenue Code	270
Rate for Payer: Cash Price	$22.51

TRACH SUCT CATH -- DHF

Facility

$542.49

Hospital Charge Code	82073958
Hospital Revenue Code	270
Min. Negotiated Rate	$48.82
Max. Negotiated Rate	$390.59
Rate for Payer: Amerigroup CHIP/Medicaid	$48.82
Rate for Payer: BCBS of TX Blue Advantage	$162.75
Rate for Payer: BCBS of TX Blue Essentials	$195.30
Rate for Payer: BCBS of TX PPO	$217.00
Rate for Payer: Cash Price	$368.89
Rate for Payer: Cigna Medicaid	$390.59
Rate for Payer: Molina CHIP/Medicaid	$390.59
Rate for Payer: Multiplan Auto	$352.62
Rate for Payer: Multiplan Commercial	$352.62
Rate for Payer: Multiplan Workers Comp	$352.62
Rate for Payer: Parkland Medicaid	$390.59
Rate for Payer: Scott and White EPO/PPO	$271.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$390.59
Rate for Payer: Superior Health Plan EPO	$73.78

TRACH SUCT CATH -- DHF

Facility

$542.49

Hospital Charge Code	82073958
Hospital Revenue Code	270
Rate for Payer: Cash Price	$368.89

TRACH TB HOLDER -- DHF

Facility

$18.44

Hospital Charge Code	82073941
Hospital Revenue Code	271
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$13.28
Rate for Payer: Amerigroup CHIP/Medicaid	$1.66
Rate for Payer: BCBS of TX Blue Advantage	$5.53
Rate for Payer: BCBS of TX Blue Essentials	$6.64
Rate for Payer: BCBS of TX PPO	$7.38
Rate for Payer: Cash Price	$12.54
Rate for Payer: Cigna Medicaid	$13.28
Rate for Payer: Molina CHIP/Medicaid	$13.28
Rate for Payer: Multiplan Auto	$11.99
Rate for Payer: Multiplan Commercial	$11.99
Rate for Payer: Multiplan Workers Comp	$11.99
Rate for Payer: Parkland Medicaid	$13.28
Rate for Payer: Scott and White EPO/PPO	$9.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.28
Rate for Payer: Superior Health Plan EPO	$2.51

TRACH TB HOLDER -- DHF

Facility

$18.44

Hospital Charge Code	82073941
Hospital Revenue Code	271
Rate for Payer: Cash Price	$12.54

TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.

Facility

$263,176.60

Service Code	MSDRG 004
Min. Negotiated Rate	$98,205.12
Max. Negotiated Rate	$263,176.60
Rate for Payer: BCBS of TX Blue Advantage	$98,205.12
Rate for Payer: BCBS of TX Blue Essentials	$117,834.72
Rate for Payer: BCBS of TX PPO	$130,932.55

traMADol 50 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77853744
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

traMADol 50 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77853744
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

tranexamic acid 100 mg/mL IV Soln 10 mL

Facility

$87.77

Service Code	HCPCS J3490
Hospital Charge Code	77854252
Hospital Revenue Code	250
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$63.19
Rate for Payer: Amerigroup CHIP/Medicaid	$7.90
Rate for Payer: BCBS of TX Blue Advantage	$26.33
Rate for Payer: BCBS of TX Blue Essentials	$31.60
Rate for Payer: BCBS of TX PPO	$35.11
Rate for Payer: Cash Price	$59.68
Rate for Payer: Cigna Medicaid	$63.19
Rate for Payer: Molina CHIP/Medicaid	$63.19
Rate for Payer: Multiplan Auto	$57.05
Rate for Payer: Multiplan Commercial	$57.05
Rate for Payer: Multiplan Workers Comp	$57.05
Rate for Payer: Parkland Medicaid	$63.19
Rate for Payer: Scott and White EPO/PPO	$43.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.19
Rate for Payer: Superior Health Plan EPO	$11.94

tranexamic acid 100 mg/mL IV Soln 10 mL

Facility

$87.77

Service Code	HCPCS J3490
Hospital Charge Code	77854252
Hospital Revenue Code	250
Rate for Payer: Cash Price	$59.68

Transection or avulsion of; greater occipital nerve

Facility

$8,987.60

Service Code	HCPCS 64744
Hospital Charge Code	9900844
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cash Price	$6,111.57
Rate for Payer: Cash Price	$6,111.57
Rate for Payer: Cash Price	$6,111.57
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$6,471.07
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$6,471.07
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$6,471.07
Rate for Payer: Scott and White EPO/PPO	$3,629.00
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,471.07
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Transection or avulsion of; greater occipital nerve

Facility

$10,000.00

Service Code	CPT 64744
Hospital Charge Code	36064744
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$3,629.00
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Transection or avulsion of; greater occipital nerve

Facility

$8,987.60

Service Code	HCPCS 64744
Hospital Charge Code	9900844
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,111.57

Transection or avulsion of other spinal nerve, extradural

Facility

$8,987.60

Service Code	HCPCS 64772
Hospital Charge Code	9900845
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,111.57

Transection or avulsion of other spinal nerve, extradural

Facility

$10,000.00

Service Code	CPT 64772
Hospital Charge Code	36064772
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$3,629.00
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Transection or avulsion of other spinal nerve, extradural

Facility

$8,987.60

Service Code	HCPCS 64772
Hospital Charge Code	9900845
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cash Price	$6,111.57
Rate for Payer: Cash Price	$6,111.57
Rate for Payer: Cash Price	$6,111.57
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$6,471.07
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$6,471.07
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$6,471.07
Rate for Payer: Scott and White EPO/PPO	$3,629.00
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,471.07
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Transfer of tendon to restore intrinsic function ring and small finger

Facility

$10,000.00

Service Code	CPT 26497
Hospital Charge Code	36026497
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Transfer of tendon to restore intrinsic function ring and small finger

Facility

$16,424.70

Service Code	HCPCS 26497
Hospital Charge Code	9900346
Hospital Revenue Code	360
Rate for Payer: Cash Price	$11,168.80

Transfer of tendon to restore intrinsic function ring and small finger

Facility

$16,424.70

Service Code	HCPCS 26497
Hospital Charge Code	9900346
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$11,825.78
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$11,168.80
Rate for Payer: Cash Price	$11,168.80
Rate for Payer: Cash Price	$11,168.80
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$11,825.78
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$11,825.78
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$11,825.78
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,825.78
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Transfer or transplant of single tendon (with muscle redirection or rerouting); deep (eg, anterior

Facility

$18,794.85

Service Code	HCPCS 27691
Hospital Charge Code	9900438
Hospital Revenue Code	360
Rate for Payer: Cash Price	$12,780.50

Know your out-of-pocket cost for care.

All Charges