White Rock Medical Center

All Charges

Charge

Type

Setting

Price

COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC

Facility

$74,280.25

Service Code	MSDRG 430
Min. Negotiated Rate	$47,027.31
Max. Negotiated Rate	$74,280.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47,027.31
Rate for Payer: Amerigroup Medicare	$47,027.31
Rate for Payer: BCBS of TX Medicare	$47,027.31
Rate for Payer: Cigna Commercial	$74,280.25
Rate for Payer: Cigna Medicare	$47,027.31
Rate for Payer: Employer Direct Commercial	$47,027.31
Rate for Payer: Humana Medicare/TRICARE	$47,027.31
Rate for Payer: Molina Dual Medicare/Medicaid	$47,027.31
Rate for Payer: Molina Medicare	$47,027.31
Rate for Payer: Scott and White Medicare	$47,027.31
Rate for Payer: Superior Health Plan EPO	$47,027.31
Rate for Payer: Superior Health Plan Medicare	$47,027.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$47,027.31
Rate for Payer: Universal American Medicare	$47,027.31
Rate for Payer: Wellcare Medicare	$47,027.31
Rate for Payer: Wellmed Medicare	$47,027.31

COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC

Facility

$115,727.10

Service Code	MSDRG 454
Min. Negotiated Rate	$53,295.38
Max. Negotiated Rate	$115,727.10
Rate for Payer: Multiplan Auto	$115,727.10
Rate for Payer: Multiplan Commercial	$115,727.10
Rate for Payer: Multiplan Workers Comp	$115,727.10
Rate for Payer: Scott and White EPO/PPO	$53,295.38

COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC

Facility

$173,941.20

Service Code	MSDRG 453
Min. Negotiated Rate	$80,104.50
Max. Negotiated Rate	$173,941.20
Rate for Payer: Multiplan Auto	$173,941.20
Rate for Payer: Multiplan Commercial	$173,941.20
Rate for Payer: Multiplan Workers Comp	$173,941.20
Rate for Payer: Scott and White EPO/PPO	$80,104.50

COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC

Facility

$90,972.00

Service Code	MSDRG 455
Min. Negotiated Rate	$41,895.00
Max. Negotiated Rate	$90,972.00
Rate for Payer: Multiplan Auto	$90,972.00
Rate for Payer: Multiplan Commercial	$90,972.00
Rate for Payer: Multiplan Workers Comp	$90,972.00
Rate for Payer: Scott and White EPO/PPO	$41,895.00

COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC

Facility

$115,727.10

Service Code	MSDRG 454
Min. Negotiated Rate	$53,295.38
Max. Negotiated Rate	$115,727.10
Rate for Payer: BCBS of TX Blue Advantage	$54,496.48
Rate for Payer: BCBS of TX Blue Essentials	$65,389.44
Rate for Payer: BCBS of TX PPO	$72,657.75

COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC

Facility

$173,941.20

Service Code	MSDRG 453
Min. Negotiated Rate	$80,104.50
Max. Negotiated Rate	$173,941.20
Rate for Payer: BCBS of TX Blue Advantage	$81,673.34
Rate for Payer: BCBS of TX Blue Essentials	$97,998.51
Rate for Payer: BCBS of TX PPO	$108,891.46

COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC

Facility

$90,972.00

Service Code	MSDRG 455
Min. Negotiated Rate	$41,895.00
Max. Negotiated Rate	$90,972.00
Rate for Payer: BCBS of TX Blue Advantage	$43,000.00
Rate for Payer: BCBS of TX Blue Essentials	$51,595.00
Rate for Payer: BCBS of TX PPO	$57,330.00

COMP EP ABL AFIB

Facility

$34,838.00

Service Code	HCPCS 93656
Hospital Charge Code	4613663
Hospital Revenue Code	480
Min. Negotiated Rate	$1,123.49
Max. Negotiated Rate	$55,502.46
Rate for Payer: Amerigroup CHIP/Medicaid	$3,135.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,256.97
Rate for Payer: Amerigroup Medicare	$26,256.97
Rate for Payer: BCBS of TX Blue Advantage	$34,126.90
Rate for Payer: BCBS of TX Blue Essentials	$40,870.54
Rate for Payer: BCBS of TX Medicare	$26,256.97
Rate for Payer: BCBS of TX PPO	$51,496.88
Rate for Payer: Cash Price	$23,689.84
Rate for Payer: Cash Price	$23,689.84
Rate for Payer: Cash Price	$23,689.84
Rate for Payer: Cigna Commercial	$55,502.46
Rate for Payer: Cigna Medicaid	$25,083.36
Rate for Payer: Cigna Medicare	$26,256.97
Rate for Payer: Employer Direct Commercial	$26,256.97
Rate for Payer: Humana Medicare/TRICARE	$26,256.97
Rate for Payer: Molina CHIP/Medicaid	$25,083.36
Rate for Payer: Molina Dual Medicare/Medicaid	$26,256.97
Rate for Payer: Molina Medicare	$26,256.97
Rate for Payer: Multiplan Auto	$22,644.70
Rate for Payer: Multiplan Commercial	$22,644.70
Rate for Payer: Multiplan Workers Comp	$22,644.70
Rate for Payer: Parkland Medicaid	$25,083.36
Rate for Payer: Scott and White EPO/PPO	$1,123.49
Rate for Payer: Scott and White Medicare	$26,256.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,083.36
Rate for Payer: Superior Health Plan EPO	$26,256.97
Rate for Payer: Superior Health Plan Medicare	$26,256.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,256.97
Rate for Payer: Universal American Medicare	$26,256.97
Rate for Payer: Wellcare Medicare	$26,256.97
Rate for Payer: Wellmed Medicare	$26,256.97

COMP EP ABL AFIB

Facility

$34,838.00

Service Code	HCPCS 93656
Hospital Charge Code	4613663
Hospital Revenue Code	480
Rate for Payer: Cash Price	$23,689.84

COMP EP/ABLAT V-TACH 3D

Facility

$28,038.00

Service Code	HCPCS 93654
Hospital Charge Code	4613654
Hospital Revenue Code	480
Rate for Payer: Cash Price	$19,065.84

COMP EP/ABLAT V-TACH 3D

Facility

$28,038.00

Service Code	HCPCS 93654
Hospital Charge Code	4613654
Hospital Revenue Code	480
Min. Negotiated Rate	$1,193.64
Max. Negotiated Rate	$55,502.46
Rate for Payer: Amerigroup CHIP/Medicaid	$2,523.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,256.97
Rate for Payer: Amerigroup Medicare	$26,256.97
Rate for Payer: BCBS of TX Blue Advantage	$34,126.90
Rate for Payer: BCBS of TX Blue Essentials	$40,870.54
Rate for Payer: BCBS of TX Medicare	$26,256.97
Rate for Payer: BCBS of TX PPO	$51,496.88
Rate for Payer: Cash Price	$19,065.84
Rate for Payer: Cash Price	$19,065.84
Rate for Payer: Cash Price	$19,065.84
Rate for Payer: Cigna Commercial	$55,502.46
Rate for Payer: Cigna Medicaid	$20,187.36
Rate for Payer: Cigna Medicare	$26,256.97
Rate for Payer: Employer Direct Commercial	$26,256.97
Rate for Payer: Humana Medicare/TRICARE	$26,256.97
Rate for Payer: Molina CHIP/Medicaid	$20,187.36
Rate for Payer: Molina Dual Medicare/Medicaid	$26,256.97
Rate for Payer: Molina Medicare	$26,256.97
Rate for Payer: Multiplan Auto	$18,224.70
Rate for Payer: Multiplan Commercial	$18,224.70
Rate for Payer: Multiplan Workers Comp	$18,224.70
Rate for Payer: Parkland Medicaid	$20,187.36
Rate for Payer: Scott and White EPO/PPO	$1,193.64
Rate for Payer: Scott and White Medicare	$26,256.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,187.36
Rate for Payer: Superior Health Plan EPO	$26,256.97
Rate for Payer: Superior Health Plan Medicare	$26,256.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,256.97
Rate for Payer: Universal American Medicare	$26,256.97
Rate for Payer: Wellcare Medicare	$26,256.97
Rate for Payer: Wellmed Medicare	$26,256.97

COMP EP EVAL/LV RECORD

Facility

$6,966.00

Service Code	HCPCS 93622
Hospital Charge Code	4610612
Hospital Revenue Code	480
Rate for Payer: Cash Price	$4,736.88

COMP EP EVAL/LV RECORD

Facility

$6,966.00

Service Code	HCPCS 93622
Hospital Charge Code	4610612
Hospital Revenue Code	480
Min. Negotiated Rate	$626.94
Max. Negotiated Rate	$5,015.52
Rate for Payer: Amerigroup CHIP/Medicaid	$626.94
Rate for Payer: BCBS of TX Blue Advantage	$2,089.80
Rate for Payer: BCBS of TX Blue Essentials	$2,507.76
Rate for Payer: BCBS of TX PPO	$2,786.40
Rate for Payer: Cash Price	$4,736.88
Rate for Payer: Cigna Medicaid	$5,015.52
Rate for Payer: Molina CHIP/Medicaid	$5,015.52
Rate for Payer: Multiplan Auto	$4,527.90
Rate for Payer: Multiplan Commercial	$4,527.90
Rate for Payer: Multiplan Workers Comp	$4,527.90
Rate for Payer: Parkland Medicaid	$5,015.52
Rate for Payer: Scott and White EPO/PPO	$3,483.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,015.52
Rate for Payer: Superior Health Plan EPO	$947.38

COMP EP IND/ABLA SVT

Facility

$23,874.00

Service Code	HCPCS 93653
Hospital Charge Code	4613653
Hospital Revenue Code	480
Min. Negotiated Rate	$990.77
Max. Negotiated Rate	$55,502.46
Rate for Payer: Amerigroup CHIP/Medicaid	$2,148.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,256.97
Rate for Payer: Amerigroup Medicare	$26,256.97
Rate for Payer: BCBS of TX Blue Advantage	$34,126.90
Rate for Payer: BCBS of TX Blue Essentials	$40,870.54
Rate for Payer: BCBS of TX Medicare	$26,256.97
Rate for Payer: BCBS of TX PPO	$51,496.88
Rate for Payer: Cash Price	$16,234.32
Rate for Payer: Cash Price	$16,234.32
Rate for Payer: Cash Price	$16,234.32
Rate for Payer: Cigna Commercial	$55,502.46
Rate for Payer: Cigna Medicaid	$17,189.28
Rate for Payer: Cigna Medicare	$26,256.97
Rate for Payer: Employer Direct Commercial	$26,256.97
Rate for Payer: Humana Medicare/TRICARE	$26,256.97
Rate for Payer: Molina CHIP/Medicaid	$17,189.28
Rate for Payer: Molina Dual Medicare/Medicaid	$26,256.97
Rate for Payer: Molina Medicare	$26,256.97
Rate for Payer: Multiplan Auto	$15,518.10
Rate for Payer: Multiplan Commercial	$15,518.10
Rate for Payer: Multiplan Workers Comp	$15,518.10
Rate for Payer: Parkland Medicaid	$17,189.28
Rate for Payer: Scott and White EPO/PPO	$990.77
Rate for Payer: Scott and White Medicare	$26,256.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,189.28
Rate for Payer: Superior Health Plan EPO	$26,256.97
Rate for Payer: Superior Health Plan Medicare	$26,256.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,256.97
Rate for Payer: Universal American Medicare	$26,256.97
Rate for Payer: Wellcare Medicare	$26,256.97
Rate for Payer: Wellmed Medicare	$26,256.97

COMP EP IND/ABLA SVT

Facility

$23,874.00

Service Code	HCPCS 93653
Hospital Charge Code	4613653
Hospital Revenue Code	480
Rate for Payer: Cash Price	$16,234.32

COMP EP W/O INDUC/ARRYTH

Facility

$7,540.00

Service Code	HCPCS 93619
Hospital Charge Code	4610615
Hospital Revenue Code	480
Rate for Payer: Cash Price	$5,127.20

COMP EP W/O INDUC/ARRYTH

Facility

$7,540.00

Service Code	HCPCS 93619
Hospital Charge Code	4610615
Hospital Revenue Code	480
Min. Negotiated Rate	$678.60
Max. Negotiated Rate	$16,562.21
Rate for Payer: Amerigroup CHIP/Medicaid	$678.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Amerigroup Medicare	$7,835.21
Rate for Payer: BCBS of TX Blue Advantage	$2,262.00
Rate for Payer: BCBS of TX Blue Essentials	$2,714.40
Rate for Payer: BCBS of TX Medicare	$7,835.21
Rate for Payer: BCBS of TX PPO	$3,016.00
Rate for Payer: Cash Price	$5,127.20
Rate for Payer: Cash Price	$5,127.20
Rate for Payer: Cash Price	$5,127.20
Rate for Payer: Cigna Commercial	$16,562.21
Rate for Payer: Cigna Medicaid	$5,428.80
Rate for Payer: Cigna Medicare	$7,835.21
Rate for Payer: Employer Direct Commercial	$7,835.21
Rate for Payer: Humana Medicare/TRICARE	$7,835.21
Rate for Payer: Molina CHIP/Medicaid	$5,428.80
Rate for Payer: Molina Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Molina Medicare	$7,835.21
Rate for Payer: Multiplan Auto	$4,901.00
Rate for Payer: Multiplan Commercial	$4,901.00
Rate for Payer: Multiplan Workers Comp	$4,901.00
Rate for Payer: Parkland Medicaid	$5,428.80
Rate for Payer: Scott and White EPO/PPO	$3,770.00
Rate for Payer: Scott and White Medicare	$7,835.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,428.80
Rate for Payer: Superior Health Plan EPO	$7,835.21
Rate for Payer: Superior Health Plan Medicare	$7,835.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Universal American Medicare	$7,835.21
Rate for Payer: Wellcare Medicare	$7,835.21
Rate for Payer: Wellmed Medicare	$7,835.21

Complement, Total (CH50) SO

Facility

$215.00

Service Code	HCPCS 86162
Hospital Charge Code	1702521
Hospital Revenue Code	302
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$154.80
Rate for Payer: Amerigroup CHIP/Medicaid	$7.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.32
Rate for Payer: Amerigroup Medicare	$20.32
Rate for Payer: BCBS of TX Blue Advantage	$64.50
Rate for Payer: BCBS of TX Blue Essentials	$77.40
Rate for Payer: BCBS of TX Medicare	$20.32
Rate for Payer: BCBS of TX PPO	$86.00
Rate for Payer: Cash Price	$146.20
Rate for Payer: Cash Price	$146.20
Rate for Payer: Cigna Medicaid	$154.80
Rate for Payer: Cigna Medicare	$20.32
Rate for Payer: Employer Direct Commercial	$20.32
Rate for Payer: Humana Medicare/TRICARE	$20.32
Rate for Payer: Molina CHIP/Medicaid	$154.80
Rate for Payer: Molina Dual Medicare/Medicaid	$20.32
Rate for Payer: Molina Medicare	$20.32
Rate for Payer: Multiplan Auto	$139.75
Rate for Payer: Multiplan Commercial	$139.75
Rate for Payer: Multiplan Workers Comp	$139.75
Rate for Payer: Parkland Medicaid	$154.80
Rate for Payer: Scott and White EPO/PPO	$25.40
Rate for Payer: Scott and White Medicare	$20.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$154.80
Rate for Payer: Superior Health Plan EPO	$20.32
Rate for Payer: Superior Health Plan Medicare	$20.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.32
Rate for Payer: Universal American Medicare	$20.32
Rate for Payer: Wellcare Medicare	$20.32
Rate for Payer: Wellmed Medicare	$20.32

Complement, Total (CH50) SO

Facility

$215.00

Service Code	HCPCS 86162
Hospital Charge Code	1702521
Hospital Revenue Code	302
Rate for Payer: Cash Price	$146.20

complete kit

Facility

$98.74

Hospital Charge Code	993573
Hospital Revenue Code	270
Min. Negotiated Rate	$8.89
Max. Negotiated Rate	$71.09
Rate for Payer: Amerigroup CHIP/Medicaid	$8.89
Rate for Payer: BCBS of TX Blue Advantage	$29.62
Rate for Payer: BCBS of TX Blue Essentials	$35.55
Rate for Payer: BCBS of TX PPO	$39.50
Rate for Payer: Cash Price	$67.14
Rate for Payer: Cigna Medicaid	$71.09
Rate for Payer: Molina CHIP/Medicaid	$71.09
Rate for Payer: Multiplan Auto	$64.18
Rate for Payer: Multiplan Commercial	$64.18
Rate for Payer: Multiplan Workers Comp	$64.18
Rate for Payer: Parkland Medicaid	$71.09
Rate for Payer: Scott and White EPO/PPO	$49.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$71.09
Rate for Payer: Superior Health Plan EPO	$13.43

complete kit

Facility

$98.74

Hospital Charge Code	993573
Hospital Revenue Code	270
Rate for Payer: Cash Price	$67.14

COMPLEX AORTIC ARCH PROCEDURES

Facility

$145,786.14

Service Code	MSDRG 209
Min. Negotiated Rate	$87,715.87
Max. Negotiated Rate	$145,786.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$87,715.87
Rate for Payer: Amerigroup Medicare	$87,715.87
Rate for Payer: BCBS of TX Medicare	$87,715.87
Rate for Payer: Cigna Commercial	$145,786.14
Rate for Payer: Cigna Medicare	$87,715.87
Rate for Payer: Employer Direct Commercial	$87,715.87
Rate for Payer: Humana Medicare/TRICARE	$87,715.87
Rate for Payer: Molina Dual Medicare/Medicaid	$87,715.87
Rate for Payer: Molina Medicare	$87,715.87
Rate for Payer: Scott and White Medicare	$87,715.87
Rate for Payer: Superior Health Plan EPO	$87,715.87
Rate for Payer: Superior Health Plan Medicare	$87,715.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$87,715.87
Rate for Payer: Universal American Medicare	$87,715.87
Rate for Payer: Wellcare Medicare	$87,715.87
Rate for Payer: Wellmed Medicare	$87,715.87

COMPLICATED PEPTIC ULCER W CC

Facility

$20,054.50

Service Code	MSDRG 381
Min. Negotiated Rate	$9,235.62
Max. Negotiated Rate	$20,054.50
Rate for Payer: BCBS of TX Blue Advantage	$9,417.00
Rate for Payer: BCBS of TX Blue Essentials	$11,299.31
Rate for Payer: BCBS of TX PPO	$12,555.27

COMPLICATED PEPTIC ULCER WITH CC

Facility

$20,054.50

Service Code	MSDRG 381
Min. Negotiated Rate	$9,235.62
Max. Negotiated Rate	$20,054.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,701.09
Rate for Payer: Amerigroup Medicare	$12,701.09
Rate for Payer: BCBS of TX Medicare	$12,701.09
Rate for Payer: Cigna Commercial	$13,955.48
Rate for Payer: Cigna Medicare	$12,701.09
Rate for Payer: Employer Direct Commercial	$12,701.09
Rate for Payer: Humana Medicare/TRICARE	$12,701.09
Rate for Payer: Molina Dual Medicare/Medicaid	$12,701.09
Rate for Payer: Molina Medicare	$12,701.09
Rate for Payer: Multiplan Auto	$20,054.50
Rate for Payer: Multiplan Commercial	$20,054.50
Rate for Payer: Multiplan Workers Comp	$20,054.50
Rate for Payer: Scott and White EPO/PPO	$9,235.62
Rate for Payer: Scott and White Medicare	$12,701.09
Rate for Payer: Superior Health Plan EPO	$12,701.09
Rate for Payer: Superior Health Plan Medicare	$12,701.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,701.09
Rate for Payer: Universal American Medicare	$12,701.09
Rate for Payer: Wellcare Medicare	$12,701.09
Rate for Payer: Wellmed Medicare	$12,701.09

COMPLICATED PEPTIC ULCER WITH MCC

Facility

$36,177.90

Service Code	MSDRG 380
Min. Negotiated Rate	$16,660.88
Max. Negotiated Rate	$36,177.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,141.09
Rate for Payer: Amerigroup Medicare	$19,141.09
Rate for Payer: BCBS of TX Medicare	$19,141.09
Rate for Payer: Cigna Commercial	$25,273.14
Rate for Payer: Cigna Medicare	$19,141.09
Rate for Payer: Employer Direct Commercial	$19,141.09
Rate for Payer: Humana Medicare/TRICARE	$19,141.09
Rate for Payer: Molina Dual Medicare/Medicaid	$19,141.09
Rate for Payer: Molina Medicare	$19,141.09
Rate for Payer: Multiplan Auto	$36,177.90
Rate for Payer: Multiplan Commercial	$36,177.90
Rate for Payer: Multiplan Workers Comp	$36,177.90
Rate for Payer: Scott and White EPO/PPO	$16,660.88
Rate for Payer: Scott and White Medicare	$19,141.09
Rate for Payer: Superior Health Plan EPO	$19,141.09
Rate for Payer: Superior Health Plan Medicare	$19,141.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,141.09
Rate for Payer: Universal American Medicare	$19,141.09
Rate for Payer: Wellcare Medicare	$19,141.09
Rate for Payer: Wellmed Medicare	$19,141.09

Know your out-of-pocket cost for care.

All Charges