White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$620.58

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 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

TRAY CATH FOLEY SIL 16FR 2000ML ANTIREFLUX VLV

Facility

$126.32

Service Code	HCPCS C1758
Hospital Charge Code	993259
Hospital Revenue Code	270
Rate for Payer: Cash Price	$85.90

tray debridement

Facility

$17.71

Hospital Charge Code	8676541
Hospital Revenue Code	272
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$12.75
Rate for Payer: Amerigroup CHIP/Medicaid	$1.59
Rate for Payer: BCBS of TX Blue Advantage	$5.31
Rate for Payer: BCBS of TX Blue Essentials	$6.38
Rate for Payer: BCBS of TX PPO	$7.08
Rate for Payer: Cash Price	$12.04
Rate for Payer: Cigna Medicaid	$12.75
Rate for Payer: Molina CHIP/Medicaid	$12.75
Rate for Payer: Multiplan Auto	$11.51
Rate for Payer: Multiplan Commercial	$11.51
Rate for Payer: Multiplan Workers Comp	$11.51
Rate for Payer: Parkland Medicaid	$12.75
Rate for Payer: Scott and White EPO/PPO	$8.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.75
Rate for Payer: Superior Health Plan EPO	$2.41

tray debridement

Facility

$17.71

Hospital Charge Code	8676541
Hospital Revenue Code	272
Rate for Payer: Cash Price	$12.04

TRAY, FOLEY, 100% SIL, 16FR 10ML

Facility

$31.58

Hospital Charge Code	993880
Hospital Revenue Code	272
Rate for Payer: Cash Price	$21.47

TRAY, FOLEY, 100% SIL, 16FR 10ML

Facility

$31.58

Hospital Charge Code	993880
Hospital Revenue Code	272
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$22.74
Rate for Payer: Amerigroup CHIP/Medicaid	$2.84
Rate for Payer: BCBS of TX Blue Advantage	$9.47
Rate for Payer: BCBS of TX Blue Essentials	$11.37
Rate for Payer: BCBS of TX PPO	$12.63
Rate for Payer: Cash Price	$21.47
Rate for Payer: Cigna Medicaid	$22.74
Rate for Payer: Molina CHIP/Medicaid	$22.74
Rate for Payer: Multiplan Auto	$20.53
Rate for Payer: Multiplan Commercial	$20.53
Rate for Payer: Multiplan Workers Comp	$20.53
Rate for Payer: Parkland Medicaid	$22.74
Rate for Payer: Scott and White EPO/PPO	$15.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.74
Rate for Payer: Superior Health Plan EPO	$4.29

TRAY, FOLEY ALL SIL CATH 16F 350ML URINMTR LTX FRE -- DHF

Facility

$94.97

Hospital Charge Code	80831308
Hospital Revenue Code	272
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$68.38
Rate for Payer: Amerigroup CHIP/Medicaid	$8.55
Rate for Payer: BCBS of TX Blue Advantage	$28.49
Rate for Payer: BCBS of TX Blue Essentials	$34.19
Rate for Payer: BCBS of TX PPO	$37.99
Rate for Payer: Cash Price	$64.58
Rate for Payer: Cigna Medicaid	$68.38
Rate for Payer: Molina CHIP/Medicaid	$68.38
Rate for Payer: Multiplan Auto	$61.73
Rate for Payer: Multiplan Commercial	$61.73
Rate for Payer: Multiplan Workers Comp	$61.73
Rate for Payer: Parkland Medicaid	$68.38
Rate for Payer: Scott and White EPO/PPO	$47.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$68.38
Rate for Payer: Superior Health Plan EPO	$12.92

TRAY, FOLEY ALL SIL CATH 16F 350ML URINMTR LTX FRE -- DHF

Facility

$94.97

Hospital Charge Code	80831308
Hospital Revenue Code	272
Rate for Payer: Cash Price	$64.58

TRAY, IRRIGATION, PISTON SYRINGE, 60ML, STRL

Facility

$4.79

Hospital Charge Code	993761
Hospital Revenue Code	272
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$3.45
Rate for Payer: Amerigroup CHIP/Medicaid	$0.43
Rate for Payer: BCBS of TX Blue Advantage	$1.44
Rate for Payer: BCBS of TX Blue Essentials	$1.72
Rate for Payer: BCBS of TX PPO	$1.92
Rate for Payer: Cash Price	$3.26
Rate for Payer: Cigna Medicaid	$3.45
Rate for Payer: Molina CHIP/Medicaid	$3.45
Rate for Payer: Multiplan Auto	$3.11
Rate for Payer: Multiplan Commercial	$3.11
Rate for Payer: Multiplan Workers Comp	$3.11
Rate for Payer: Parkland Medicaid	$3.45
Rate for Payer: Scott and White EPO/PPO	$2.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.45
Rate for Payer: Superior Health Plan EPO	$0.65

TRAY, IRRIGATION, PISTON SYRINGE, 60ML, STRL

Facility

$4.79

Hospital Charge Code	993761
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.26

TRAY, SKIN, SCRUB, WET, PREMIUM

Facility

$34.46

Hospital Charge Code	992975
Hospital Revenue Code	270
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$24.81
Rate for Payer: Amerigroup CHIP/Medicaid	$3.10
Rate for Payer: BCBS of TX Blue Advantage	$10.34
Rate for Payer: BCBS of TX Blue Essentials	$12.41
Rate for Payer: BCBS of TX PPO	$13.78
Rate for Payer: Cash Price	$23.43
Rate for Payer: Cigna Medicaid	$24.81
Rate for Payer: Molina CHIP/Medicaid	$24.81
Rate for Payer: Multiplan Auto	$22.40
Rate for Payer: Multiplan Commercial	$22.40
Rate for Payer: Multiplan Workers Comp	$22.40
Rate for Payer: Parkland Medicaid	$24.81
Rate for Payer: Scott and White EPO/PPO	$17.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.81
Rate for Payer: Superior Health Plan EPO	$4.69

TRAY, SKIN, SCRUB, WET, PREMIUM

Facility

$34.46

Hospital Charge Code	992975
Hospital Revenue Code	270
Rate for Payer: Cash Price	$23.43

TRAY THORCNTS 18GAX16CM SAFE-T-CENTESIS

Facility

$251.06

Hospital Charge Code	103837
Hospital Revenue Code	272
Min. Negotiated Rate	$22.60
Max. Negotiated Rate	$180.76
Rate for Payer: Amerigroup CHIP/Medicaid	$22.60
Rate for Payer: BCBS of TX Blue Advantage	$75.32
Rate for Payer: BCBS of TX Blue Essentials	$90.38
Rate for Payer: BCBS of TX PPO	$100.42
Rate for Payer: Cash Price	$170.72
Rate for Payer: Cigna Medicaid	$180.76
Rate for Payer: Molina CHIP/Medicaid	$180.76
Rate for Payer: Multiplan Auto	$163.19
Rate for Payer: Multiplan Commercial	$163.19
Rate for Payer: Multiplan Workers Comp	$163.19
Rate for Payer: Parkland Medicaid	$180.76
Rate for Payer: Scott and White EPO/PPO	$125.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.76
Rate for Payer: Superior Health Plan EPO	$34.14

TRAY THORCNTS 18GAX16CM SAFE-T-CENTESIS

Facility

$251.06

Hospital Charge Code	103837
Hospital Revenue Code	272
Rate for Payer: Cash Price	$170.72

TRAY, TRACHEOSTOMY CARE 8

Facility

$749.28

Hospital Charge Code	133826
Hospital Revenue Code	272
Min. Negotiated Rate	$67.44
Max. Negotiated Rate	$539.48
Rate for Payer: Amerigroup CHIP/Medicaid	$67.44
Rate for Payer: BCBS of TX Blue Advantage	$224.78
Rate for Payer: BCBS of TX Blue Essentials	$269.74
Rate for Payer: BCBS of TX PPO	$299.71
Rate for Payer: Cash Price	$509.51
Rate for Payer: Cigna Medicaid	$539.48
Rate for Payer: Molina CHIP/Medicaid	$539.48
Rate for Payer: Multiplan Auto	$487.03
Rate for Payer: Multiplan Commercial	$487.03
Rate for Payer: Multiplan Workers Comp	$487.03
Rate for Payer: Parkland Medicaid	$539.48
Rate for Payer: Scott and White EPO/PPO	$374.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$539.48
Rate for Payer: Superior Health Plan EPO	$101.90

TRAY, TRACHEOSTOMY CARE 8

Facility

$749.28

Hospital Charge Code	133826
Hospital Revenue Code	272
Rate for Payer: Cash Price	$509.51

tray uretheral catheter

Facility

$19.52

Hospital Charge Code	8634514
Hospital Revenue Code	272
Rate for Payer: Cash Price	$13.27

tray uretheral catheter

Facility

$19.52

Hospital Charge Code	8634514
Hospital Revenue Code	272
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$14.05
Rate for Payer: Amerigroup CHIP/Medicaid	$1.76
Rate for Payer: BCBS of TX Blue Advantage	$5.86
Rate for Payer: BCBS of TX Blue Essentials	$7.03
Rate for Payer: BCBS of TX PPO	$7.81
Rate for Payer: Cash Price	$13.27
Rate for Payer: Cigna Medicaid	$14.05
Rate for Payer: Molina CHIP/Medicaid	$14.05
Rate for Payer: Multiplan Auto	$12.69
Rate for Payer: Multiplan Commercial	$12.69
Rate for Payer: Multiplan Workers Comp	$12.69
Rate for Payer: Parkland Medicaid	$14.05
Rate for Payer: Scott and White EPO/PPO	$9.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.05
Rate for Payer: Superior Health Plan EPO	$2.65

traZODone 50 mg Tab

Facility

$9.35

Service Code	HCPCS J3490
Hospital Charge Code	77854831
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.36

traZODone 50 mg Tab

Facility

$9.35

Service Code	HCPCS J3490
Hospital Charge Code	77854831
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.73
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.81
Rate for Payer: BCBS of TX Blue Essentials	$3.37
Rate for Payer: BCBS of TX PPO	$3.74
Rate for Payer: Cash Price	$6.36
Rate for Payer: Cigna Medicaid	$6.73
Rate for Payer: Molina CHIP/Medicaid	$6.73
Rate for Payer: Multiplan Auto	$6.08
Rate for Payer: Multiplan Commercial	$6.08
Rate for Payer: Multiplan Workers Comp	$6.08
Rate for Payer: Parkland Medicaid	$6.73
Rate for Payer: Scott and White EPO/PPO	$4.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.73
Rate for Payer: Superior Health Plan EPO	$1.27

Treat Clavical Dislocation

Facility

$72,580.00

Service Code	HCPCS 23550
Hospital Charge Code	9900229
Hospital Revenue Code	360
Min. Negotiated Rate	$3,155.24
Max. Negotiated Rate	$52,257.60
Rate for Payer: Amerigroup CHIP/Medicaid	$3,155.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$49,354.40
Rate for Payer: Cash Price	$49,354.40
Rate for Payer: Cash Price	$49,354.40
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$52,257.60
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$52,257.60
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$52,257.60
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52,257.60
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Know your out-of-pocket cost for care.

All Charges