White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC

Facility

$44,378.30

Service Code	MSDRG 085
Min. Negotiated Rate	$18,748.00
Max. Negotiated Rate	$44,378.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,410.90
Rate for Payer: Amerigroup Medicare	$21,410.90
Rate for Payer: BCBS of TX Medicare	$21,410.90
Rate for Payer: Cigna Commercial	$29,262.07
Rate for Payer: Cigna Medicare	$21,410.90
Rate for Payer: Employer Direct Commercial	$21,410.90
Rate for Payer: Humana Medicare/TRICARE	$21,410.90
Rate for Payer: Molina Dual Medicare/Medicaid	$21,410.90
Rate for Payer: Molina Medicare	$21,410.90
Rate for Payer: Multiplan Auto	$44,378.30
Rate for Payer: Multiplan Commercial	$44,378.30
Rate for Payer: Multiplan Workers Comp	$44,378.30
Rate for Payer: Scott and White EPO/PPO	$20,437.38
Rate for Payer: Scott and White Medicare	$21,410.90
Rate for Payer: Superior Health Plan EPO	$21,410.90
Rate for Payer: Superior Health Plan Medicare	$21,410.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,410.90
Rate for Payer: Universal American Medicare	$21,410.90
Rate for Payer: Wellcare Medicare	$21,410.90
Rate for Payer: Wellmed Medicare	$21,410.90

TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC

Facility

$43,040.70

Service Code	MSDRG 082
Min. Negotiated Rate	$18,563.96
Max. Negotiated Rate	$43,040.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,511.30
Rate for Payer: Amerigroup Medicare	$21,511.30
Rate for Payer: BCBS of TX Medicare	$21,511.30
Rate for Payer: Cigna Commercial	$29,438.53
Rate for Payer: Cigna Medicare	$21,511.30
Rate for Payer: Employer Direct Commercial	$21,511.30
Rate for Payer: Humana Medicare/TRICARE	$21,511.30
Rate for Payer: Molina Dual Medicare/Medicaid	$21,511.30
Rate for Payer: Molina Medicare	$21,511.30
Rate for Payer: Multiplan Auto	$43,040.70
Rate for Payer: Multiplan Commercial	$43,040.70
Rate for Payer: Multiplan Workers Comp	$43,040.70
Rate for Payer: Scott and White EPO/PPO	$19,821.38
Rate for Payer: Scott and White Medicare	$21,511.30
Rate for Payer: Superior Health Plan EPO	$21,511.30
Rate for Payer: Superior Health Plan Medicare	$21,511.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,511.30
Rate for Payer: Universal American Medicare	$21,511.30
Rate for Payer: Wellcare Medicare	$21,511.30
Rate for Payer: Wellmed Medicare	$21,511.30

TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC

Facility

$16,575.60

Service Code	MSDRG 087
Min. Negotiated Rate	$7,269.58
Max. Negotiated Rate	$16,575.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,463.94
Rate for Payer: Amerigroup Medicare	$11,463.94
Rate for Payer: BCBS of TX Medicare	$11,463.94
Rate for Payer: Cigna Commercial	$11,781.34
Rate for Payer: Cigna Medicare	$11,463.94
Rate for Payer: Employer Direct Commercial	$11,463.94
Rate for Payer: Humana Medicare/TRICARE	$11,463.94
Rate for Payer: Molina Dual Medicare/Medicaid	$11,463.94
Rate for Payer: Molina Medicare	$11,463.94
Rate for Payer: Multiplan Auto	$16,575.60
Rate for Payer: Multiplan Commercial	$16,575.60
Rate for Payer: Multiplan Workers Comp	$16,575.60
Rate for Payer: Scott and White EPO/PPO	$7,633.50
Rate for Payer: Scott and White Medicare	$11,463.94
Rate for Payer: Superior Health Plan EPO	$11,463.94
Rate for Payer: Superior Health Plan Medicare	$11,463.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,463.94
Rate for Payer: Universal American Medicare	$11,463.94
Rate for Payer: Wellcare Medicare	$11,463.94
Rate for Payer: Wellmed Medicare	$11,463.94

TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC

Facility

$17,413.50

Service Code	MSDRG 084
Min. Negotiated Rate	$7,940.38
Max. Negotiated Rate	$17,413.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,765.16
Rate for Payer: Amerigroup Medicare	$11,765.16
Rate for Payer: BCBS of TX Medicare	$11,765.16
Rate for Payer: Cigna Commercial	$12,310.70
Rate for Payer: Cigna Medicare	$11,765.16
Rate for Payer: Employer Direct Commercial	$11,765.16
Rate for Payer: Humana Medicare/TRICARE	$11,765.16
Rate for Payer: Molina Dual Medicare/Medicaid	$11,765.16
Rate for Payer: Molina Medicare	$11,765.16
Rate for Payer: Multiplan Auto	$17,413.50
Rate for Payer: Multiplan Commercial	$17,413.50
Rate for Payer: Multiplan Workers Comp	$17,413.50
Rate for Payer: Scott and White EPO/PPO	$8,019.38
Rate for Payer: Scott and White Medicare	$11,765.16
Rate for Payer: Superior Health Plan EPO	$11,765.16
Rate for Payer: Superior Health Plan Medicare	$11,765.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,765.16
Rate for Payer: Universal American Medicare	$11,765.16
Rate for Payer: Wellcare Medicare	$11,765.16
Rate for Payer: Wellmed Medicare	$11,765.16

TRAUMATIC STUPOR & COMA, COMA <1 HR W CC

Facility

$24,694.30

Service Code	MSDRG 086
Min. Negotiated Rate	$10,690.66
Max. Negotiated Rate	$24,694.30
Rate for Payer: BCBS of TX Blue Advantage	$10,690.66
Rate for Payer: BCBS of TX Blue Essentials	$12,827.55
Rate for Payer: BCBS of TX PPO	$14,253.38

TRAUMATIC STUPOR & COMA, COMA >1 HR W CC

Facility

$25,615.80

Service Code	MSDRG 083
Min. Negotiated Rate	$11,137.00
Max. Negotiated Rate	$25,615.80
Rate for Payer: BCBS of TX Blue Advantage	$11,137.00
Rate for Payer: BCBS of TX Blue Essentials	$13,363.10
Rate for Payer: BCBS of TX PPO	$14,848.47

TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC

Facility

$44,378.30

Service Code	MSDRG 085
Min. Negotiated Rate	$18,748.00
Max. Negotiated Rate	$44,378.30
Rate for Payer: BCBS of TX Blue Advantage	$18,748.00
Rate for Payer: BCBS of TX Blue Essentials	$22,495.42
Rate for Payer: BCBS of TX PPO	$24,995.88

TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC

Facility

$43,040.70

Service Code	MSDRG 082
Min. Negotiated Rate	$18,563.96
Max. Negotiated Rate	$43,040.70
Rate for Payer: BCBS of TX Blue Advantage	$18,563.96
Rate for Payer: BCBS of TX Blue Essentials	$22,274.59
Rate for Payer: BCBS of TX PPO	$24,750.51

TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC

Facility

$16,575.60

Service Code	MSDRG 087
Min. Negotiated Rate	$7,269.58
Max. Negotiated Rate	$16,575.60
Rate for Payer: BCBS of TX Blue Advantage	$7,269.58
Rate for Payer: BCBS of TX Blue Essentials	$8,722.65
Rate for Payer: BCBS of TX PPO	$9,692.21

TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC

Facility

$17,413.50

Service Code	MSDRG 084
Min. Negotiated Rate	$7,940.38
Max. Negotiated Rate	$17,413.50
Rate for Payer: BCBS of TX Blue Advantage	$7,940.38
Rate for Payer: BCBS of TX Blue Essentials	$9,527.53
Rate for Payer: BCBS of TX PPO	$10,586.56

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC

Facility

$28,674.80

Service Code	MSDRG 604
Min. Negotiated Rate	$12,184.48
Max. Negotiated Rate	$28,674.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,549.14
Rate for Payer: Amerigroup Medicare	$15,549.14
Rate for Payer: BCBS of TX Medicare	$15,549.14
Rate for Payer: Cigna Commercial	$18,960.65
Rate for Payer: Cigna Medicare	$15,549.14
Rate for Payer: Employer Direct Commercial	$15,549.14
Rate for Payer: Humana Medicare/TRICARE	$15,549.14
Rate for Payer: Molina Dual Medicare/Medicaid	$15,549.14
Rate for Payer: Molina Medicare	$15,549.14
Rate for Payer: Multiplan Auto	$28,674.80
Rate for Payer: Multiplan Commercial	$28,674.80
Rate for Payer: Multiplan Workers Comp	$28,674.80
Rate for Payer: Scott and White EPO/PPO	$13,205.50
Rate for Payer: Scott and White Medicare	$15,549.14
Rate for Payer: Superior Health Plan EPO	$15,549.14
Rate for Payer: Superior Health Plan Medicare	$15,549.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,549.14
Rate for Payer: Universal American Medicare	$15,549.14
Rate for Payer: Wellcare Medicare	$15,549.14
Rate for Payer: Wellmed Medicare	$15,549.14

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC

Facility

$17,297.60

Service Code	MSDRG 605
Min. Negotiated Rate	$7,400.30
Max. Negotiated Rate	$17,297.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,473.47
Rate for Payer: Amerigroup Medicare	$11,473.47
Rate for Payer: BCBS of TX Medicare	$11,473.47
Rate for Payer: Cigna Commercial	$11,798.08
Rate for Payer: Cigna Medicare	$11,473.47
Rate for Payer: Employer Direct Commercial	$11,473.47
Rate for Payer: Humana Medicare/TRICARE	$11,473.47
Rate for Payer: Molina Dual Medicare/Medicaid	$11,473.47
Rate for Payer: Molina Medicare	$11,473.47
Rate for Payer: Multiplan Auto	$17,297.60
Rate for Payer: Multiplan Commercial	$17,297.60
Rate for Payer: Multiplan Workers Comp	$17,297.60
Rate for Payer: Scott and White EPO/PPO	$7,966.00
Rate for Payer: Scott and White Medicare	$11,473.47
Rate for Payer: Superior Health Plan EPO	$11,473.47
Rate for Payer: Superior Health Plan Medicare	$11,473.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,473.47
Rate for Payer: Universal American Medicare	$11,473.47
Rate for Payer: Wellcare Medicare	$11,473.47
Rate for Payer: Wellmed Medicare	$11,473.47

TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W MCC

Facility

$28,674.80

Service Code	MSDRG 604
Min. Negotiated Rate	$12,184.48
Max. Negotiated Rate	$28,674.80
Rate for Payer: BCBS of TX Blue Advantage	$12,184.48
Rate for Payer: BCBS of TX Blue Essentials	$14,619.96
Rate for Payer: BCBS of TX PPO	$16,245.03

TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC

Facility

$17,297.60

Service Code	MSDRG 605
Min. Negotiated Rate	$7,400.30
Max. Negotiated Rate	$17,297.60
Rate for Payer: BCBS of TX Blue Advantage	$7,400.30
Rate for Payer: BCBS of TX Blue Essentials	$8,879.50
Rate for Payer: BCBS of TX PPO	$9,866.49

TRAY, ANES SPINAL 25G X 3

Facility

$117.81

Hospital Charge Code	80829153
Hospital Revenue Code	272
Min. Negotiated Rate	$10.60
Max. Negotiated Rate	$84.82
Rate for Payer: Amerigroup CHIP/Medicaid	$10.60
Rate for Payer: BCBS of TX Blue Advantage	$35.34
Rate for Payer: BCBS of TX Blue Essentials	$42.41
Rate for Payer: BCBS of TX PPO	$47.12
Rate for Payer: Cash Price	$80.11
Rate for Payer: Cigna Medicaid	$84.82
Rate for Payer: Molina CHIP/Medicaid	$84.82
Rate for Payer: Multiplan Auto	$76.58
Rate for Payer: Multiplan Commercial	$76.58
Rate for Payer: Multiplan Workers Comp	$76.58
Rate for Payer: Parkland Medicaid	$84.82
Rate for Payer: Scott and White EPO/PPO	$58.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.82
Rate for Payer: Superior Health Plan EPO	$16.02

TRAY, ANES SPINAL 25G X 3

Facility

$117.81

Hospital Charge Code	80829153
Hospital Revenue Code	272
Rate for Payer: Cash Price	$80.11

TRAY CATH 6FR PERI INS MINTRDCR PWRLN

Facility

$2,247.07

Service Code	HCPCS A4316
Hospital Charge Code	992660
Hospital Revenue Code	272
Min. Negotiated Rate	$47.84
Max. Negotiated Rate	$1,617.89
Rate for Payer: Amerigroup CHIP/Medicaid	$202.24
Rate for Payer: BCBS of TX Blue Advantage	$47.84
Rate for Payer: BCBS of TX Blue Essentials	$57.40
Rate for Payer: BCBS of TX PPO	$63.67
Rate for Payer: Cash Price	$1,528.01
Rate for Payer: Cash Price	$1,528.01
Rate for Payer: Cigna Medicaid	$1,617.89
Rate for Payer: Molina CHIP/Medicaid	$1,617.89
Rate for Payer: Multiplan Auto	$1,460.60
Rate for Payer: Multiplan Commercial	$1,460.60
Rate for Payer: Multiplan Workers Comp	$1,460.60
Rate for Payer: Parkland Medicaid	$1,617.89
Rate for Payer: Scott and White EPO/PPO	$48.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,617.89
Rate for Payer: Superior Health Plan EPO	$305.60

TRAY CATH 6FR PERI INS MINTRDCR PWRLN

Facility

$2,247.07

Service Code	HCPCS A4316
Hospital Charge Code	992660
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,528.01

TRAY CATH CEN VEN SHERLOCK DBL LUMEN 5FR 3CG

Facility

$569.28

Service Code	HCPCS C1750
Hospital Charge Code	993277
Hospital Revenue Code	270
Rate for Payer: Cash Price	$387.11

TRAY CATH CEN VEN SHERLOCK DBL LUMEN 5FR 3CG

Facility

$569.28

Service Code	HCPCS C1750
Hospital Charge Code	993277
Hospital Revenue Code	270
Min. Negotiated Rate	$51.24
Max. Negotiated Rate	$409.88
Rate for Payer: Amerigroup CHIP/Medicaid	$51.24
Rate for Payer: BCBS of TX Blue Advantage	$170.78
Rate for Payer: BCBS of TX Blue Essentials	$204.94
Rate for Payer: BCBS of TX PPO	$227.71
Rate for Payer: Cash Price	$387.11
Rate for Payer: Cigna Medicaid	$409.88
Rate for Payer: Molina CHIP/Medicaid	$409.88
Rate for Payer: Multiplan Auto	$370.03
Rate for Payer: Multiplan Commercial	$370.03
Rate for Payer: Multiplan Workers Comp	$370.03
Rate for Payer: Parkland Medicaid	$409.88
Rate for Payer: Scott and White EPO/PPO	$284.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$409.88
Rate for Payer: Superior Health Plan EPO	$77.42

TRAY, CATH, CLOSED, URET, W/PVP, VIN

Facility

$22.38

Service Code	HCPCS C1758
Hospital Charge Code	993231
Hospital Revenue Code	270
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$16.11
Rate for Payer: Amerigroup CHIP/Medicaid	$2.01
Rate for Payer: BCBS of TX Blue Advantage	$6.71
Rate for Payer: BCBS of TX Blue Essentials	$8.06
Rate for Payer: BCBS of TX PPO	$8.95
Rate for Payer: Cash Price	$15.22
Rate for Payer: Cigna Medicaid	$16.11
Rate for Payer: Molina CHIP/Medicaid	$16.11
Rate for Payer: Multiplan Auto	$14.55
Rate for Payer: Multiplan Commercial	$14.55
Rate for Payer: Multiplan Workers Comp	$14.55
Rate for Payer: Parkland Medicaid	$16.11
Rate for Payer: Scott and White EPO/PPO	$11.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.11
Rate for Payer: Superior Health Plan EPO	$3.04

TRAY, CATH, CLOSED, URET, W/PVP, VIN

Facility

$22.38

Service Code	HCPCS C1758
Hospital Charge Code	993231
Hospital Revenue Code	270
Rate for Payer: Cash Price	$15.22

TRAY CATHETER TRIPLE LUMEN CURVD 13F X 20CM L

Facility

$912.62

Service Code	HCPCS C1725
Hospital Charge Code	992523
Hospital Revenue Code	270
Min. Negotiated Rate	$82.14
Max. Negotiated Rate	$657.09
Rate for Payer: Amerigroup CHIP/Medicaid	$82.14
Rate for Payer: BCBS of TX Blue Advantage	$273.79
Rate for Payer: BCBS of TX Blue Essentials	$328.54
Rate for Payer: BCBS of TX PPO	$365.05
Rate for Payer: Cash Price	$620.58
Rate for Payer: Cigna Medicaid	$657.09
Rate for Payer: Molina CHIP/Medicaid	$657.09
Rate for Payer: Multiplan Auto	$593.20
Rate for Payer: Multiplan Commercial	$593.20
Rate for Payer: Multiplan Workers Comp	$593.20
Rate for Payer: Parkland Medicaid	$657.09
Rate for Payer: Scott and White EPO/PPO	$456.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$657.09
Rate for Payer: Superior Health Plan EPO	$124.12

TRAY CATHETER TRIPLE LUMEN CURVD 13F X 20CM L

Facility

$912.62

Service Code	HCPCS C1725
Hospital Charge Code	992523
Hospital Revenue Code	270
Rate for Payer: Cash Price	$620.58

TRAY CATH FOLEY SIL 16FR 2000ML ANTIREFLUX VLV

Facility

$126.32

Service Code	HCPCS C1758
Hospital Charge Code	993259
Hospital Revenue Code	270
Min. Negotiated Rate	$11.37
Max. Negotiated Rate	$90.95
Rate for Payer: Amerigroup CHIP/Medicaid	$11.37
Rate for Payer: BCBS of TX Blue Advantage	$37.90
Rate for Payer: BCBS of TX Blue Essentials	$45.48
Rate for Payer: BCBS of TX PPO	$50.53
Rate for Payer: Cash Price	$85.90
Rate for Payer: Cigna Medicaid	$90.95
Rate for Payer: Molina CHIP/Medicaid	$90.95
Rate for Payer: Multiplan Auto	$82.11
Rate for Payer: Multiplan Commercial	$82.11
Rate for Payer: Multiplan Workers Comp	$82.11
Rate for Payer: Parkland Medicaid	$90.95
Rate for Payer: Scott and White EPO/PPO	$63.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.95
Rate for Payer: Superior Health Plan EPO	$17.18

Know your out-of-pocket cost for care.

All Charges