White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Carboxyhemoglobin

Facility

$192.00

Service Code	HCPCS 82375
Hospital Charge Code	4000584
Hospital Revenue Code	301
Rate for Payer: Cash Price	$130.56

Carboxyhemoglobin

Facility

$192.00

Service Code	HCPCS 82375
Hospital Charge Code	4000584
Hospital Revenue Code	301
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$138.24
Rate for Payer: Amerigroup CHIP/Medicaid	$4.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.32
Rate for Payer: Amerigroup Medicare	$12.32
Rate for Payer: BCBS of TX Blue Advantage	$57.60
Rate for Payer: BCBS of TX Blue Essentials	$69.12
Rate for Payer: BCBS of TX Medicare	$12.32
Rate for Payer: BCBS of TX PPO	$76.80
Rate for Payer: Cash Price	$130.56
Rate for Payer: Cash Price	$130.56
Rate for Payer: Cigna Medicaid	$138.24
Rate for Payer: Cigna Medicare	$12.32
Rate for Payer: Employer Direct Commercial	$12.32
Rate for Payer: Humana Medicare/TRICARE	$12.32
Rate for Payer: Molina CHIP/Medicaid	$138.24
Rate for Payer: Molina Dual Medicare/Medicaid	$12.32
Rate for Payer: Molina Medicare	$12.32
Rate for Payer: Multiplan Auto	$124.80
Rate for Payer: Multiplan Commercial	$124.80
Rate for Payer: Multiplan Workers Comp	$124.80
Rate for Payer: Parkland Medicaid	$138.24
Rate for Payer: Scott and White EPO/PPO	$15.40
Rate for Payer: Scott and White Medicare	$12.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$138.24
Rate for Payer: Superior Health Plan EPO	$12.32
Rate for Payer: Superior Health Plan Medicare	$12.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.32
Rate for Payer: Universal American Medicare	$12.32
Rate for Payer: Wellcare Medicare	$12.32
Rate for Payer: Wellmed Medicare	$12.32

CARDIAC ARREST AND SHOCK

Facility

$10,156.95

Service Code	APR-DRG 1964
Min. Negotiated Rate	$9,576.32
Max. Negotiated Rate	$10,156.95
Rate for Payer: Amerigroup CHIP/Medicaid	$9,576.32
Rate for Payer: Cigna Medicaid	$9,576.32
Rate for Payer: Molina CHIP/Medicaid	$9,576.32
Rate for Payer: Parkland Medicaid	$9,576.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,156.95

CARDIAC ARREST AND SHOCK

Facility

$2,469.83

Service Code	APR-DRG 1961
Min. Negotiated Rate	$2,328.65
Max. Negotiated Rate	$2,469.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2,328.65
Rate for Payer: Cigna Medicaid	$2,328.65
Rate for Payer: Molina CHIP/Medicaid	$2,328.65
Rate for Payer: Parkland Medicaid	$2,328.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,469.83

CARDIAC ARREST AND SHOCK

Facility

$3,261.93

Service Code	APR-DRG 1962
Min. Negotiated Rate	$3,075.46
Max. Negotiated Rate	$3,261.93
Rate for Payer: Amerigroup CHIP/Medicaid	$3,075.46
Rate for Payer: Cigna Medicaid	$3,075.46
Rate for Payer: Molina CHIP/Medicaid	$3,075.46
Rate for Payer: Parkland Medicaid	$3,075.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,261.93

CARDIAC ARREST AND SHOCK

Facility

$4,737.87

Service Code	APR-DRG 1963
Min. Negotiated Rate	$4,467.03
Max. Negotiated Rate	$4,737.87
Rate for Payer: Amerigroup CHIP/Medicaid	$4,467.03
Rate for Payer: Cigna Medicaid	$4,467.03
Rate for Payer: Molina CHIP/Medicaid	$4,467.03
Rate for Payer: Parkland Medicaid	$4,467.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,737.87

CARDIAC ARREST, UNEXPLAINED W CC

Facility

$11,846.50

Service Code	MSDRG 297
Min. Negotiated Rate	$5,455.62
Max. Negotiated Rate	$11,846.50
Rate for Payer: BCBS of TX Blue Advantage	$5,610.64
Rate for Payer: BCBS of TX Blue Essentials	$6,732.12
Rate for Payer: BCBS of TX PPO	$7,480.42

CARDIAC ARREST, UNEXPLAINED WITH CC

Facility

$11,846.50

Service Code	MSDRG 297
Min. Negotiated Rate	$5,455.62
Max. Negotiated Rate	$11,846.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,406.68
Rate for Payer: Amerigroup Medicare	$9,406.68
Rate for Payer: BCBS of TX Medicare	$9,406.68
Rate for Payer: Cigna Commercial	$8,030.68
Rate for Payer: Cigna Medicare	$9,406.68
Rate for Payer: Employer Direct Commercial	$9,406.68
Rate for Payer: Humana Medicare/TRICARE	$9,406.68
Rate for Payer: Molina Dual Medicare/Medicaid	$9,406.68
Rate for Payer: Molina Medicare	$9,406.68
Rate for Payer: Multiplan Auto	$11,846.50
Rate for Payer: Multiplan Commercial	$11,846.50
Rate for Payer: Multiplan Workers Comp	$11,846.50
Rate for Payer: Scott and White EPO/PPO	$5,455.62
Rate for Payer: Scott and White Medicare	$9,406.68
Rate for Payer: Superior Health Plan EPO	$9,406.68
Rate for Payer: Superior Health Plan Medicare	$9,406.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,406.68
Rate for Payer: Universal American Medicare	$9,406.68
Rate for Payer: Wellcare Medicare	$9,406.68
Rate for Payer: Wellmed Medicare	$9,406.68

CARDIAC ARREST, UNEXPLAINED WITH MCC

Facility

$29,676.10

Service Code	MSDRG 296
Min. Negotiated Rate	$13,205.30
Max. Negotiated Rate	$29,676.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,207.29
Rate for Payer: Amerigroup Medicare	$16,207.29
Rate for Payer: BCBS of TX Medicare	$16,207.29
Rate for Payer: Cigna Commercial	$20,117.27
Rate for Payer: Cigna Medicare	$16,207.29
Rate for Payer: Employer Direct Commercial	$16,207.29
Rate for Payer: Humana Medicare/TRICARE	$16,207.29
Rate for Payer: Molina Dual Medicare/Medicaid	$16,207.29
Rate for Payer: Molina Medicare	$16,207.29
Rate for Payer: Multiplan Auto	$29,676.10
Rate for Payer: Multiplan Commercial	$29,676.10
Rate for Payer: Multiplan Workers Comp	$29,676.10
Rate for Payer: Scott and White EPO/PPO	$13,666.62
Rate for Payer: Scott and White Medicare	$16,207.29
Rate for Payer: Superior Health Plan EPO	$16,207.29
Rate for Payer: Superior Health Plan Medicare	$16,207.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,207.29
Rate for Payer: Universal American Medicare	$16,207.29
Rate for Payer: Wellcare Medicare	$16,207.29
Rate for Payer: Wellmed Medicare	$16,207.29

CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC

Facility

$8,646.90

Service Code	MSDRG 298
Min. Negotiated Rate	$3,982.12
Max. Negotiated Rate	$8,646.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,095.52
Rate for Payer: Amerigroup Medicare	$8,095.52
Rate for Payer: BCBS of TX Medicare	$8,095.52
Rate for Payer: Cigna Commercial	$5,861.69
Rate for Payer: Cigna Medicare	$8,095.52
Rate for Payer: Employer Direct Commercial	$8,095.52
Rate for Payer: Humana Medicare/TRICARE	$8,095.52
Rate for Payer: Molina Dual Medicare/Medicaid	$8,095.52
Rate for Payer: Molina Medicare	$8,095.52
Rate for Payer: Multiplan Auto	$8,646.90
Rate for Payer: Multiplan Commercial	$8,646.90
Rate for Payer: Multiplan Workers Comp	$8,646.90
Rate for Payer: Scott and White EPO/PPO	$3,982.12
Rate for Payer: Scott and White Medicare	$8,095.52
Rate for Payer: Superior Health Plan EPO	$8,095.52
Rate for Payer: Superior Health Plan Medicare	$8,095.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,095.52
Rate for Payer: Universal American Medicare	$8,095.52
Rate for Payer: Wellcare Medicare	$8,095.52
Rate for Payer: Wellmed Medicare	$8,095.52

CARDIAC ARREST, UNEXPLAINED W MCC OR PERIPHERAL EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility

$29,676.10

Service Code	MSDRG 296
Min. Negotiated Rate	$13,205.30
Max. Negotiated Rate	$29,676.10
Rate for Payer: BCBS of TX Blue Advantage	$13,205.30
Rate for Payer: BCBS of TX Blue Essentials	$15,844.82
Rate for Payer: BCBS of TX PPO	$17,606.04

CARDIAC ARREST, UNEXPLAINED W/O CC/MCC

Facility

$8,646.90

Service Code	MSDRG 298
Min. Negotiated Rate	$3,982.12
Max. Negotiated Rate	$8,646.90
Rate for Payer: BCBS of TX Blue Advantage	$4,149.50
Rate for Payer: BCBS of TX Blue Essentials	$4,978.92
Rate for Payer: BCBS of TX PPO	$5,532.35

CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS

Facility

$4,479.50

Service Code	APR-DRG 2013
Min. Negotiated Rate	$4,223.43
Max. Negotiated Rate	$4,479.50
Rate for Payer: Amerigroup CHIP/Medicaid	$4,223.43
Rate for Payer: Cigna Medicaid	$4,223.43
Rate for Payer: Molina CHIP/Medicaid	$4,223.43
Rate for Payer: Parkland Medicaid	$4,223.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,479.50

CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS

Facility

$2,904.36

Service Code	APR-DRG 2012
Min. Negotiated Rate	$2,738.33
Max. Negotiated Rate	$2,904.36
Rate for Payer: Amerigroup CHIP/Medicaid	$2,738.33
Rate for Payer: Cigna Medicaid	$2,738.33
Rate for Payer: Molina CHIP/Medicaid	$2,738.33
Rate for Payer: Parkland Medicaid	$2,738.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,904.36

CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS

Facility

$7,411.01

Service Code	APR-DRG 2014
Min. Negotiated Rate	$6,987.36
Max. Negotiated Rate	$7,411.01
Rate for Payer: Amerigroup CHIP/Medicaid	$6,987.36
Rate for Payer: Cigna Medicaid	$6,987.36
Rate for Payer: Molina CHIP/Medicaid	$6,987.36
Rate for Payer: Parkland Medicaid	$6,987.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,411.01

CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS

Facility

$2,286.90

Service Code	APR-DRG 2011
Min. Negotiated Rate	$2,156.17
Max. Negotiated Rate	$2,286.90
Rate for Payer: Amerigroup CHIP/Medicaid	$2,156.17
Rate for Payer: Cigna Medicaid	$2,156.17
Rate for Payer: Molina CHIP/Medicaid	$2,156.17
Rate for Payer: Parkland Medicaid	$2,156.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,286.90

CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC

Facility

$13,978.30

Service Code	MSDRG 309
Min. Negotiated Rate	$6,437.38
Max. Negotiated Rate	$13,978.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,152.05
Rate for Payer: Amerigroup Medicare	$10,152.05
Rate for Payer: BCBS of TX Medicare	$10,152.05
Rate for Payer: Cigna Commercial	$9,475.82
Rate for Payer: Cigna Medicare	$10,152.05
Rate for Payer: Employer Direct Commercial	$10,152.05
Rate for Payer: Humana Medicare/TRICARE	$10,152.05
Rate for Payer: Molina Dual Medicare/Medicaid	$10,152.05
Rate for Payer: Molina Medicare	$10,152.05
Rate for Payer: Multiplan Auto	$13,978.30
Rate for Payer: Multiplan Commercial	$13,978.30
Rate for Payer: Multiplan Workers Comp	$13,978.30
Rate for Payer: Scott and White EPO/PPO	$6,437.38
Rate for Payer: Scott and White Medicare	$10,152.05
Rate for Payer: Superior Health Plan EPO	$10,152.05
Rate for Payer: Superior Health Plan Medicare	$10,152.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,152.05
Rate for Payer: Universal American Medicare	$10,152.05
Rate for Payer: Wellcare Medicare	$10,152.05
Rate for Payer: Wellmed Medicare	$10,152.05

CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC

Facility

$22,876.00

Service Code	MSDRG 308
Min. Negotiated Rate	$10,350.96
Max. Negotiated Rate	$22,876.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,584.23
Rate for Payer: Amerigroup Medicare	$13,584.23
Rate for Payer: BCBS of TX Medicare	$13,584.23
Rate for Payer: Cigna Commercial	$15,507.52
Rate for Payer: Cigna Medicare	$13,584.23
Rate for Payer: Employer Direct Commercial	$13,584.23
Rate for Payer: Humana Medicare/TRICARE	$13,584.23
Rate for Payer: Molina Dual Medicare/Medicaid	$13,584.23
Rate for Payer: Molina Medicare	$13,584.23
Rate for Payer: Multiplan Auto	$22,876.00
Rate for Payer: Multiplan Commercial	$22,876.00
Rate for Payer: Multiplan Workers Comp	$22,876.00
Rate for Payer: Scott and White EPO/PPO	$10,535.00
Rate for Payer: Scott and White Medicare	$13,584.23
Rate for Payer: Superior Health Plan EPO	$13,584.23
Rate for Payer: Superior Health Plan Medicare	$13,584.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,584.23
Rate for Payer: Universal American Medicare	$13,584.23
Rate for Payer: Wellcare Medicare	$13,584.23
Rate for Payer: Wellmed Medicare	$13,584.23

CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC

Facility

$10,755.90

Service Code	MSDRG 310
Min. Negotiated Rate	$4,835.78
Max. Negotiated Rate	$10,755.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,909.05
Rate for Payer: Amerigroup Medicare	$8,909.05
Rate for Payer: BCBS of TX Medicare	$8,909.05
Rate for Payer: Cigna Commercial	$7,291.37
Rate for Payer: Cigna Medicare	$8,909.05
Rate for Payer: Employer Direct Commercial	$8,909.05
Rate for Payer: Humana Medicare/TRICARE	$8,909.05
Rate for Payer: Molina Dual Medicare/Medicaid	$8,909.05
Rate for Payer: Molina Medicare	$8,909.05
Rate for Payer: Multiplan Auto	$10,755.90
Rate for Payer: Multiplan Commercial	$10,755.90
Rate for Payer: Multiplan Workers Comp	$10,755.90
Rate for Payer: Scott and White EPO/PPO	$4,953.38
Rate for Payer: Scott and White Medicare	$8,909.05
Rate for Payer: Superior Health Plan EPO	$8,909.05
Rate for Payer: Superior Health Plan Medicare	$8,909.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,909.05
Rate for Payer: Universal American Medicare	$8,909.05
Rate for Payer: Wellcare Medicare	$8,909.05
Rate for Payer: Wellmed Medicare	$8,909.05

CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC

Facility

$13,978.30

Service Code	MSDRG 309
Min. Negotiated Rate	$6,437.38
Max. Negotiated Rate	$13,978.30
Rate for Payer: BCBS of TX Blue Advantage	$6,566.10
Rate for Payer: BCBS of TX Blue Essentials	$7,878.56
Rate for Payer: BCBS of TX PPO	$8,754.29

CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC

Facility

$22,876.00

Service Code	MSDRG 308
Min. Negotiated Rate	$10,350.96
Max. Negotiated Rate	$22,876.00
Rate for Payer: BCBS of TX Blue Advantage	$10,350.96
Rate for Payer: BCBS of TX Blue Essentials	$12,419.95
Rate for Payer: BCBS of TX PPO	$13,800.48

CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC

Facility

$10,755.90

Service Code	MSDRG 310
Min. Negotiated Rate	$4,835.78
Max. Negotiated Rate	$10,755.90
Rate for Payer: BCBS of TX Blue Advantage	$4,835.78
Rate for Payer: BCBS of TX Blue Essentials	$5,802.37
Rate for Payer: BCBS of TX PPO	$6,447.33

CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE

Facility

$6,773.18

Service Code	APR-DRG 1913
Min. Negotiated Rate	$6,385.99
Max. Negotiated Rate	$6,773.18
Rate for Payer: Amerigroup CHIP/Medicaid	$6,385.99
Rate for Payer: Cigna Medicaid	$6,385.99
Rate for Payer: Molina CHIP/Medicaid	$6,385.99
Rate for Payer: Parkland Medicaid	$6,385.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,773.18

CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE

Facility

$4,094.01

Service Code	APR-DRG 1911
Min. Negotiated Rate	$3,859.98
Max. Negotiated Rate	$4,094.01
Rate for Payer: Amerigroup CHIP/Medicaid	$3,859.98
Rate for Payer: Cigna Medicaid	$3,859.98
Rate for Payer: Molina CHIP/Medicaid	$3,859.98
Rate for Payer: Parkland Medicaid	$3,859.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,094.01

CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE

Facility

$8,450.54

Service Code	APR-DRG 1914
Min. Negotiated Rate	$7,967.47
Max. Negotiated Rate	$8,450.54
Rate for Payer: Amerigroup CHIP/Medicaid	$7,967.47
Rate for Payer: Cigna Medicaid	$7,967.47
Rate for Payer: Molina CHIP/Medicaid	$7,967.47
Rate for Payer: Parkland Medicaid	$7,967.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,450.54

Know your out-of-pocket cost for care.

All Charges