White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each

Facility

$10,000.00

Service Code	CPT 28450
Hospital Charge Code	36028450
Hospital Revenue Code	360
Min. Negotiated Rate	$85.32
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$85.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$181.96
Rate for Payer: BCBS of TX Blue Essentials	$217.92
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$274.58
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
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	$398.99
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each

Facility

$842.00

Service Code	HCPCS 28450
Hospital Charge Code	9900518
Hospital Revenue Code	360
Rate for Payer: Cash Price	$572.56

Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage

Facility

$50,159.28

Service Code	HCPCS 27759
Hospital Charge Code	991154
Hospital Revenue Code	360
Min. Negotiated Rate	$6,632.92
Max. Negotiated Rate	$36,114.68
Rate for Payer: Amerigroup CHIP/Medicaid	$6,632.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Amerigroup Medicare	$12,897.19
Rate for Payer: BCBS of TX Blue Advantage	$19,874.19
Rate for Payer: BCBS of TX Blue Essentials	$23,801.42
Rate for Payer: BCBS of TX Medicare	$12,897.19
Rate for Payer: BCBS of TX PPO	$29,989.79
Rate for Payer: Cash Price	$34,108.31
Rate for Payer: Cash Price	$34,108.31
Rate for Payer: Cash Price	$34,108.31
Rate for Payer: Cigna Commercial	$27,262.32
Rate for Payer: Cigna Medicaid	$36,114.68
Rate for Payer: Cigna Medicare	$12,897.19
Rate for Payer: Employer Direct Commercial	$12,897.19
Rate for Payer: Humana Medicare/TRICARE	$12,897.19
Rate for Payer: Molina CHIP/Medicaid	$36,114.68
Rate for Payer: Molina Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Molina Medicare	$12,897.19
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	$36,114.68
Rate for Payer: Scott and White EPO/PPO	$22,267.47
Rate for Payer: Scott and White Medicare	$12,897.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36,114.68
Rate for Payer: Superior Health Plan EPO	$12,897.19
Rate for Payer: Superior Health Plan Medicare	$12,897.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Universal American Medicare	$12,897.19
Rate for Payer: Wellcare Medicare	$12,897.19
Rate for Payer: Wellmed Medicare	$12,897.19

Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage

Facility

$50,159.28

Service Code	HCPCS 27759
Hospital Charge Code	991154
Hospital Revenue Code	360
Rate for Payer: Cash Price	$34,108.31

Treponema pallidum Antibodies SO

Facility

$243.00

Service Code	HCPCS 86780
Hospital Charge Code	1606045
Hospital Revenue Code	302
Rate for Payer: Cash Price	$165.24

Treponema pallidum Antibodies SO

Facility

$243.00

Service Code	HCPCS 86780
Hospital Charge Code	1606045
Hospital Revenue Code	302
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$174.96
Rate for Payer: Amerigroup CHIP/Medicaid	$5.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.24
Rate for Payer: Amerigroup Medicare	$13.24
Rate for Payer: BCBS of TX Blue Advantage	$72.90
Rate for Payer: BCBS of TX Blue Essentials	$87.48
Rate for Payer: BCBS of TX Medicare	$13.24
Rate for Payer: BCBS of TX PPO	$97.20
Rate for Payer: Cash Price	$165.24
Rate for Payer: Cash Price	$165.24
Rate for Payer: Cigna Medicaid	$174.96
Rate for Payer: Cigna Medicare	$13.24
Rate for Payer: Employer Direct Commercial	$13.24
Rate for Payer: Humana Medicare/TRICARE	$13.24
Rate for Payer: Molina CHIP/Medicaid	$174.96
Rate for Payer: Molina Dual Medicare/Medicaid	$13.24
Rate for Payer: Molina Medicare	$13.24
Rate for Payer: Multiplan Auto	$157.95
Rate for Payer: Multiplan Commercial	$157.95
Rate for Payer: Multiplan Workers Comp	$157.95
Rate for Payer: Parkland Medicaid	$174.96
Rate for Payer: Scott and White EPO/PPO	$16.55
Rate for Payer: Scott and White Medicare	$13.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$174.96
Rate for Payer: Superior Health Plan EPO	$13.24
Rate for Payer: Superior Health Plan Medicare	$13.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.24
Rate for Payer: Universal American Medicare	$13.24
Rate for Payer: Wellcare Medicare	$13.24
Rate for Payer: Wellmed Medicare	$13.24

TRIAGE BNP: B-TYPE NATRIURETIC PEPTIDE TEST KIT

Facility

$530.24

Hospital Charge Code	993716
Hospital Revenue Code	270
Min. Negotiated Rate	$47.72
Max. Negotiated Rate	$381.77
Rate for Payer: Amerigroup CHIP/Medicaid	$47.72
Rate for Payer: BCBS of TX Blue Advantage	$159.07
Rate for Payer: BCBS of TX Blue Essentials	$190.89
Rate for Payer: BCBS of TX PPO	$212.10
Rate for Payer: Cash Price	$360.56
Rate for Payer: Cigna Medicaid	$381.77
Rate for Payer: Molina CHIP/Medicaid	$381.77
Rate for Payer: Multiplan Auto	$344.66
Rate for Payer: Multiplan Commercial	$344.66
Rate for Payer: Multiplan Workers Comp	$344.66
Rate for Payer: Parkland Medicaid	$381.77
Rate for Payer: Scott and White EPO/PPO	$265.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$381.77
Rate for Payer: Superior Health Plan EPO	$72.11

TRIAGE BNP: B-TYPE NATRIURETIC PEPTIDE TEST KIT

Facility

$530.24

Hospital Charge Code	993716
Hospital Revenue Code	270
Rate for Payer: Cash Price	$360.56

Triage BNP: B-Type Natriuretic Peptide Test Kit 25 / Bx

Facility

$167.23

Hospital Charge Code	993860
Hospital Revenue Code	272
Min. Negotiated Rate	$15.05
Max. Negotiated Rate	$120.41
Rate for Payer: Amerigroup CHIP/Medicaid	$15.05
Rate for Payer: BCBS of TX Blue Advantage	$50.17
Rate for Payer: BCBS of TX Blue Essentials	$60.20
Rate for Payer: BCBS of TX PPO	$66.89
Rate for Payer: Cash Price	$113.72
Rate for Payer: Cigna Medicaid	$120.41
Rate for Payer: Molina CHIP/Medicaid	$120.41
Rate for Payer: Multiplan Auto	$108.70
Rate for Payer: Multiplan Commercial	$108.70
Rate for Payer: Multiplan Workers Comp	$108.70
Rate for Payer: Parkland Medicaid	$120.41
Rate for Payer: Scott and White EPO/PPO	$83.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.41
Rate for Payer: Superior Health Plan EPO	$22.74

Triage BNP: B-Type Natriuretic Peptide Test Kit 25 / Bx

Facility

$167.23

Hospital Charge Code	993860
Hospital Revenue Code	272
Rate for Payer: Cash Price	$113.72

Triage Patient Type -> Established Patient

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	3101201
Hospital Revenue Code	510
Rate for Payer: Cash Price	$143.48

Triage Patient Type -> Established Patient

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	3101201
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$151.92
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$63.30
Rate for Payer: BCBS of TX Blue Essentials	$75.96
Rate for Payer: BCBS of TX PPO	$84.40
Rate for Payer: Cash Price	$143.48
Rate for Payer: Cash Price	$143.48
Rate for Payer: Cigna Medicaid	$151.92
Rate for Payer: Molina CHIP/Medicaid	$151.92
Rate for Payer: Multiplan Auto	$137.15
Rate for Payer: Multiplan Commercial	$137.15
Rate for Payer: Multiplan Workers Comp	$137.15
Rate for Payer: Parkland Medicaid	$151.92
Rate for Payer: Scott and White EPO/PPO	$80.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.92

Triage Patient Type -> New Patient

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	3101200
Hospital Revenue Code	510
Rate for Payer: Cash Price	$279.48

Triage Patient Type -> New Patient

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	3101200
Hospital Revenue Code	510
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$295.92
Rate for Payer: Amerigroup CHIP/Medicaid	$36.99
Rate for Payer: BCBS of TX Blue Advantage	$123.30
Rate for Payer: BCBS of TX Blue Essentials	$147.96
Rate for Payer: BCBS of TX PPO	$164.40
Rate for Payer: Cash Price	$279.48
Rate for Payer: Cash Price	$279.48
Rate for Payer: Cigna Medicaid	$295.92
Rate for Payer: Molina CHIP/Medicaid	$295.92
Rate for Payer: Multiplan Auto	$267.15
Rate for Payer: Multiplan Commercial	$267.15
Rate for Payer: Multiplan Workers Comp	$267.15
Rate for Payer: Parkland Medicaid	$295.92
Rate for Payer: Scott and White EPO/PPO	$99.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$295.92

triamcinolone 0.025% Cream 15 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77856538
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

triamcinolone 0.025% Cream 15 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77856538
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

triamcinolone 0.1% Cream 15 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77857166
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

triamcinolone 0.1% Cream 15 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77857166
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

triamcinolone 10 mg/mL Inj Susp 5 mL

Facility

$128.17

Service Code	HCPCS J3301
Hospital Charge Code	77858154
Hospital Revenue Code	636
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.84
Rate for Payer: BCBS of TX Blue Essentials	$2.21
Rate for Payer: BCBS of TX PPO	$2.45
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

triamcinolone 10 mg/mL Inj Susp 5 mL

Facility

$128.17

Service Code	HCPCS J3301
Hospital Charge Code	77858154
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

triamcinolone acetonide 40 mg/mL Kit

Facility

$128.17

Service Code	HCPCS J3301
Hospital Charge Code	78333838
Hospital Revenue Code	636
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.84
Rate for Payer: BCBS of TX Blue Essentials	$2.21
Rate for Payer: BCBS of TX PPO	$2.45
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

triamcinolone acetonide 40 mg/mL Kit

Facility

$128.17

Service Code	HCPCS J3301
Hospital Charge Code	78333838
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

Trichomonas PCR

Facility

$223.00

Service Code	HCPCS 87661
Hospital Charge Code	7257661
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$160.56
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$66.90
Rate for Payer: BCBS of TX Blue Essentials	$80.28
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$89.20
Rate for Payer: Cash Price	$151.64
Rate for Payer: Cash Price	$151.64
Rate for Payer: Cigna Medicaid	$160.56
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$160.56
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$144.95
Rate for Payer: Multiplan Commercial	$144.95
Rate for Payer: Multiplan Workers Comp	$144.95
Rate for Payer: Parkland Medicaid	$160.56
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$160.56
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

Trichomonas PCR

Facility

$223.00

Service Code	HCPCS 87661
Hospital Charge Code	7257661
Hospital Revenue Code	306
Rate for Payer: Cash Price	$151.64

TRIDENT 0 DEGREE INSERT 36MM

Facility

$6,024.10

Service Code	HCPCS C1776
Hospital Charge Code	992152
Hospital Revenue Code	278
Min. Negotiated Rate	$542.17
Max. Negotiated Rate	$4,337.35
Rate for Payer: Amerigroup CHIP/Medicaid	$542.17
Rate for Payer: BCBS of TX Blue Advantage	$1,807.23
Rate for Payer: BCBS of TX Blue Essentials	$2,168.68
Rate for Payer: BCBS of TX PPO	$2,409.64
Rate for Payer: Cash Price	$4,096.39
Rate for Payer: Cigna Medicaid	$4,337.35
Rate for Payer: Molina CHIP/Medicaid	$4,337.35
Rate for Payer: Multiplan Auto	$3,012.05
Rate for Payer: Multiplan Commercial	$3,012.05
Rate for Payer: Multiplan Workers Comp	$3,012.05
Rate for Payer: Parkland Medicaid	$4,337.35
Rate for Payer: Scott and White EPO/PPO	$3,012.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,337.35
Rate for Payer: Superior Health Plan EPO	$819.28

Know your out-of-pocket cost for care.

All Charges