White Rock Medical Center

All Charges

Charge

Type

Setting

Price

12.6 to 20.0 cm

Facility

$1,143.00

Service Code	CPT 12016
Hospital Charge Code	8776543
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,005.84

12.6 to 20.0 cm

Facility

$1,134.67

Service Code	CPT 12005
Hospital Charge Code	8538504
Hospital Revenue Code	450
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$826.08
Rate for Payer: Aetna Commercial	$624.07
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$102.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$998.51
Rate for Payer: Cash Price	$998.51
Rate for Payer: Cash Price	$998.51
Rate for Payer: Cigna Commercial	$826.08
Rate for Payer: Cigna Medicaid	$143.08
Rate for Payer: Cigna Medicare	$364.67
Rate for Payer: Employer Direct Commercial	$364.67
Rate for Payer: Humana Medicare/TRICARE	$364.67
Rate for Payer: Molina CHIP/Medicaid	$143.08
Rate for Payer: Molina Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$737.54
Rate for Payer: Multiplan Commercial	$737.54
Rate for Payer: Multiplan Workers Comp	$737.54
Rate for Payer: Parkland Medicaid	$143.08
Rate for Payer: Scott and White EPO/PPO	$6.52
Rate for Payer: Scott and White Medicare	$364.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$143.08
Rate for Payer: Superior Health Plan EPO	$364.67
Rate for Payer: Superior Health Plan Medicare	$364.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$364.67
Rate for Payer: Universal American Medicare	$364.67
Rate for Payer: Wellcare Medicare	$364.67
Rate for Payer: Wellmed Medicare	$364.67

12.6 to 20.0 cm

Facility

$1,134.67

Service Code	CPT 12005
Hospital Charge Code	8538504
Hospital Revenue Code	450
Rate for Payer: Cash Price	$998.51

12.6 to 20.0 cm

Facility

$1,143.00

Service Code	CPT 12016
Hospital Charge Code	8776543
Hospital Revenue Code	450
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$826.08
Rate for Payer: Aetna Commercial	$628.65
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$102.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,005.84
Rate for Payer: Cash Price	$1,005.84
Rate for Payer: Cash Price	$1,005.84
Rate for Payer: Cigna Commercial	$826.08
Rate for Payer: Cigna Medicaid	$143.08
Rate for Payer: Cigna Medicare	$364.67
Rate for Payer: Employer Direct Commercial	$364.67
Rate for Payer: Humana Medicare/TRICARE	$364.67
Rate for Payer: Molina CHIP/Medicaid	$143.08
Rate for Payer: Molina Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$742.95
Rate for Payer: Multiplan Commercial	$742.95
Rate for Payer: Multiplan Workers Comp	$742.95
Rate for Payer: Parkland Medicaid	$143.08
Rate for Payer: Scott and White EPO/PPO	$6.52
Rate for Payer: Scott and White Medicare	$364.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$143.08
Rate for Payer: Superior Health Plan EPO	$364.67
Rate for Payer: Superior Health Plan Medicare	$364.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$364.67
Rate for Payer: Universal American Medicare	$364.67
Rate for Payer: Wellcare Medicare	$364.67
Rate for Payer: Wellmed Medicare	$364.67

129 - v34 MSDRG

Facility

$20,042.30

Service Code	MSDRG 129
Hospital Charge Code	129
Min. Negotiated Rate	$20,042.30
Max. Negotiated Rate	$20,042.30
Rate for Payer: BCBS of TX Blue Advantage	$20,042.30

129 - v36 MSDRG

Facility

$27,873.85

Service Code	MSDRG 129
Hospital Charge Code	1291
Min. Negotiated Rate	$25,085.49
Max. Negotiated Rate	$27,873.85
Rate for Payer: BCBS of TX Blue Essentials	$25,085.49
Rate for Payer: BCBS of TX PPO	$27,873.85

130 - v34 MSDRG

Facility

$12,554.28

Service Code	MSDRG 130
Hospital Charge Code	130
Min. Negotiated Rate	$12,554.28
Max. Negotiated Rate	$12,554.28
Rate for Payer: BCBS of TX Blue Advantage	$12,554.28

130 - v36 MSDRG

Facility

$17,098.10

Service Code	MSDRG 130
Hospital Charge Code	1301
Min. Negotiated Rate	$15,387.69
Max. Negotiated Rate	$17,098.10
Rate for Payer: BCBS of TX Blue Essentials	$15,387.69
Rate for Payer: BCBS of TX PPO	$17,098.10

131 - v34 MSDRG

Facility

$22,137.26

Service Code	MSDRG 131
Hospital Charge Code	131
Min. Negotiated Rate	$22,137.26
Max. Negotiated Rate	$22,137.26
Rate for Payer: BCBS of TX Blue Advantage	$22,137.26

131 - v36 MSDRG

Facility

$30,137.23

Service Code	MSDRG 131
Hospital Charge Code	1311
Min. Negotiated Rate	$27,122.46
Max. Negotiated Rate	$30,137.23
Rate for Payer: BCBS of TX Blue Essentials	$27,122.46
Rate for Payer: BCBS of TX PPO	$30,137.23

132 - v34 MSDRG

Facility

$12,403.78

Service Code	MSDRG 132
Hospital Charge Code	132
Min. Negotiated Rate	$12,403.78
Max. Negotiated Rate	$12,403.78
Rate for Payer: BCBS of TX Blue Advantage	$12,403.78

132 - v36 MSDRG

Facility

$17,526.93

Service Code	MSDRG 132
Hospital Charge Code	1321
Min. Negotiated Rate	$15,773.62
Max. Negotiated Rate	$17,526.93
Rate for Payer: BCBS of TX Blue Essentials	$15,773.62
Rate for Payer: BCBS of TX PPO	$17,526.93

133 - v34 MSDRG

Facility

$16,466.42

Service Code	MSDRG 133
Hospital Charge Code	133
Min. Negotiated Rate	$16,466.42
Max. Negotiated Rate	$16,466.42
Rate for Payer: BCBS of TX Blue Advantage	$16,466.42

133 - v36 MSDRG

Facility

$24,062.55

Service Code	MSDRG 133
Hospital Charge Code	1331
Min. Negotiated Rate	$21,655.45
Max. Negotiated Rate	$24,062.55
Rate for Payer: BCBS of TX Blue Essentials	$21,655.45
Rate for Payer: BCBS of TX PPO	$24,062.55

134 - v34 MSDRG

Facility

$9,042.90

Service Code	MSDRG 134
Hospital Charge Code	134
Min. Negotiated Rate	$9,042.90
Max. Negotiated Rate	$9,042.90
Rate for Payer: BCBS of TX Blue Advantage	$9,042.90

134 - v36 MSDRG

Facility

$13,744.29

Service Code	MSDRG 134
Hospital Charge Code	1341
Min. Negotiated Rate	$12,369.39
Max. Negotiated Rate	$13,744.29
Rate for Payer: BCBS of TX Blue Essentials	$12,369.39
Rate for Payer: BCBS of TX PPO	$13,744.29

20.1 to 30.0 cm

Facility

$1,189.29

Service Code	CPT 12006
Hospital Charge Code	8538503
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,046.58

20.1 to 30.0 cm

Facility

$1,189.29

Service Code	CPT 12006
Hospital Charge Code	8538503
Hospital Revenue Code	450
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$826.08
Rate for Payer: Aetna Commercial	$654.11
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$107.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,046.58
Rate for Payer: Cash Price	$1,046.58
Rate for Payer: Cash Price	$1,046.58
Rate for Payer: Cigna Commercial	$826.08
Rate for Payer: Cigna Medicaid	$143.08
Rate for Payer: Cigna Medicare	$364.67
Rate for Payer: Employer Direct Commercial	$364.67
Rate for Payer: Humana Medicare/TRICARE	$364.67
Rate for Payer: Molina CHIP/Medicaid	$143.08
Rate for Payer: Molina Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$773.04
Rate for Payer: Multiplan Commercial	$773.04
Rate for Payer: Multiplan Workers Comp	$773.04
Rate for Payer: Parkland Medicaid	$143.08
Rate for Payer: Scott and White EPO/PPO	$6.52
Rate for Payer: Scott and White Medicare	$364.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$143.08
Rate for Payer: Superior Health Plan EPO	$364.67
Rate for Payer: Superior Health Plan Medicare	$364.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$364.67
Rate for Payer: Universal American Medicare	$364.67
Rate for Payer: Wellcare Medicare	$364.67
Rate for Payer: Wellmed Medicare	$364.67

20+ Minutes of Monitoring 99457

Facility

$183.00

Service Code	CPT 99457
Hospital Charge Code	6019908
Hospital Revenue Code	510
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$118.95
Rate for Payer: Aetna Commercial	$100.65
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: BCBS of TX Blue Advantage	$56.45
Rate for Payer: BCBS of TX Blue Essentials	$67.48
Rate for Payer: BCBS of TX PPO	$75.26
Rate for Payer: Cash Price	$161.04
Rate for Payer: Cash Price	$161.04
Rate for Payer: Multiplan Auto	$118.95
Rate for Payer: Multiplan Commercial	$118.95
Rate for Payer: Multiplan Workers Comp	$118.95
Rate for Payer: Scott and White EPO/PPO	$91.50

222 - v34 MSDRG

Facility

$72,313.96

Service Code	MSDRG 222
Hospital Charge Code	222
Min. Negotiated Rate	$72,313.96
Max. Negotiated Rate	$72,313.96
Rate for Payer: BCBS of TX Blue Advantage	$72,313.96

222 - v36 MSDRG

Facility

$93,301.14

Service Code	MSDRG 222
Hospital Charge Code	2221
Min. Negotiated Rate	$83,967.77
Max. Negotiated Rate	$93,301.14
Rate for Payer: BCBS of TX Blue Essentials	$83,967.77
Rate for Payer: BCBS of TX PPO	$93,301.14

223 - v34 MSDRG

Facility

$56,002.34

Service Code	MSDRG 223
Hospital Charge Code	223
Min. Negotiated Rate	$56,002.34
Max. Negotiated Rate	$56,002.34
Rate for Payer: BCBS of TX Blue Advantage	$56,002.34

223 - v36 MSDRG

Facility

$72,880.19

Service Code	MSDRG 223
Hospital Charge Code	2231
Min. Negotiated Rate	$65,589.63
Max. Negotiated Rate	$72,880.19
Rate for Payer: BCBS of TX Blue Essentials	$65,589.63
Rate for Payer: BCBS of TX PPO	$72,880.19

224 - v34 MSDRG

Facility

$65,233.58

Service Code	MSDRG 224
Hospital Charge Code	224
Min. Negotiated Rate	$65,233.58
Max. Negotiated Rate	$65,233.58
Rate for Payer: BCBS of TX Blue Advantage	$65,233.58

224 - v36 MSDRG

Facility

$85,131.61

Service Code	MSDRG 224
Hospital Charge Code	2241
Min. Negotiated Rate	$76,615.48
Max. Negotiated Rate	$85,131.61
Rate for Payer: BCBS of TX Blue Essentials	$76,615.48
Rate for Payer: BCBS of TX PPO	$85,131.61

Know your out-of-pocket cost for care.

All Charges