White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CORO CATH ANGIO+RT HT CATH

Facility

$23,666.00

Service Code	HCPCS 93456
Hospital Charge Code	2320525
Hospital Revenue Code	481
Min. Negotiated Rate	$1,365.97
Max. Negotiated Rate	$17,039.52
Rate for Payer: Amerigroup CHIP/Medicaid	$2,129.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,256.70
Rate for Payer: Amerigroup Medicare	$3,256.70
Rate for Payer: BCBS of TX Blue Advantage	$4,759.42
Rate for Payer: BCBS of TX Blue Essentials	$5,699.90
Rate for Payer: BCBS of TX Medicare	$3,256.70
Rate for Payer: BCBS of TX PPO	$7,181.87
Rate for Payer: Cash Price	$16,092.88
Rate for Payer: Cash Price	$16,092.88
Rate for Payer: Cash Price	$16,092.88
Rate for Payer: Cigna Commercial	$6,884.08
Rate for Payer: Cigna Medicaid	$17,039.52
Rate for Payer: Cigna Medicare	$3,256.70
Rate for Payer: Employer Direct Commercial	$3,256.70
Rate for Payer: Humana Medicare/TRICARE	$3,256.70
Rate for Payer: Molina CHIP/Medicaid	$17,039.52
Rate for Payer: Molina Dual Medicare/Medicaid	$3,256.70
Rate for Payer: Molina Medicare	$3,256.70
Rate for Payer: Multiplan Auto	$15,382.90
Rate for Payer: Multiplan Commercial	$15,382.90
Rate for Payer: Multiplan Workers Comp	$15,382.90
Rate for Payer: Parkland Medicaid	$17,039.52
Rate for Payer: Scott and White EPO/PPO	$1,365.97
Rate for Payer: Scott and White Medicare	$3,256.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,039.52
Rate for Payer: Superior Health Plan EPO	$3,256.70
Rate for Payer: Superior Health Plan Medicare	$3,256.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,256.70
Rate for Payer: Universal American Medicare	$3,256.70
Rate for Payer: Wellcare Medicare	$3,256.70
Rate for Payer: Wellmed Medicare	$3,256.70

CORO GRAFT REVAS D-ELU STENT 1 ART

Facility

$15,984.00

Hospital Charge Code	2350064
Hospital Revenue Code	481
Rate for Payer: Cash Price	$10,869.12

CORO GRAFT REVAS D-ELU STENT 1 ART

Facility

$15,984.00

Hospital Charge Code	2350064
Hospital Revenue Code	481
Min. Negotiated Rate	$1,438.56
Max. Negotiated Rate	$11,508.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,438.56
Rate for Payer: BCBS of TX Blue Advantage	$4,795.20
Rate for Payer: BCBS of TX Blue Essentials	$5,754.24
Rate for Payer: BCBS of TX PPO	$6,393.60
Rate for Payer: Cash Price	$10,869.12
Rate for Payer: Cigna Medicaid	$11,508.48
Rate for Payer: Molina CHIP/Medicaid	$11,508.48
Rate for Payer: Multiplan Auto	$10,389.60
Rate for Payer: Multiplan Commercial	$10,389.60
Rate for Payer: Multiplan Workers Comp	$10,389.60
Rate for Payer: Parkland Medicaid	$11,508.48
Rate for Payer: Scott and White EPO/PPO	$7,992.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,508.48
Rate for Payer: Superior Health Plan EPO	$2,173.82

CORONARY BYPASS W CARDIAC CATH W MCC

Facility

$147,153.10

Service Code	MSDRG 233
Min. Negotiated Rate	$60,791.96
Max. Negotiated Rate	$147,153.10
Rate for Payer: BCBS of TX Blue Advantage	$65,684.22
Rate for Payer: BCBS of TX Blue Essentials	$78,813.43
Rate for Payer: BCBS of TX PPO	$87,573.87

CORONARY BYPASS W CARDIAC CATH W/O MCC

Facility

$98,539.70

Service Code	MSDRG 234
Min. Negotiated Rate	$44,265.92
Max. Negotiated Rate	$98,539.70
Rate for Payer: BCBS of TX Blue Advantage	$44,265.92
Rate for Payer: BCBS of TX Blue Essentials	$53,113.96
Rate for Payer: BCBS of TX PPO	$59,017.80

CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$36,751.79

Service Code	APR-DRG 1654
Min. Negotiated Rate	$34,650.87
Max. Negotiated Rate	$36,751.79
Rate for Payer: Amerigroup CHIP/Medicaid	$34,650.87
Rate for Payer: Cigna Medicaid	$34,650.87
Rate for Payer: Molina CHIP/Medicaid	$34,650.87
Rate for Payer: Parkland Medicaid	$34,650.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36,751.79

CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$19,928.78

Service Code	APR-DRG 1652
Min. Negotiated Rate	$18,789.55
Max. Negotiated Rate	$19,928.78
Rate for Payer: Amerigroup CHIP/Medicaid	$18,789.55
Rate for Payer: Cigna Medicaid	$18,789.55
Rate for Payer: Molina CHIP/Medicaid	$18,789.55
Rate for Payer: Parkland Medicaid	$18,789.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,928.78

CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$24,163.48

Service Code	APR-DRG 1653
Min. Negotiated Rate	$22,782.18
Max. Negotiated Rate	$24,163.48
Rate for Payer: Amerigroup CHIP/Medicaid	$22,782.18
Rate for Payer: Cigna Medicaid	$22,782.18
Rate for Payer: Molina CHIP/Medicaid	$22,782.18
Rate for Payer: Parkland Medicaid	$22,782.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,163.48

CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$17,029.33

Service Code	APR-DRG 1651
Min. Negotiated Rate	$16,055.85
Max. Negotiated Rate	$17,029.33
Rate for Payer: Amerigroup CHIP/Medicaid	$16,055.85
Rate for Payer: Cigna Medicaid	$16,055.85
Rate for Payer: Molina CHIP/Medicaid	$16,055.85
Rate for Payer: Parkland Medicaid	$16,055.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,029.33

CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC

Facility

$147,153.10

Service Code	MSDRG 233
Min. Negotiated Rate	$60,791.96
Max. Negotiated Rate	$147,153.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$60,791.96
Rate for Payer: Amerigroup Medicare	$60,791.96
Rate for Payer: BCBS of TX Medicare	$60,791.96
Rate for Payer: Cigna Commercial	$98,470.18
Rate for Payer: Cigna Medicare	$60,791.96
Rate for Payer: Employer Direct Commercial	$60,791.96
Rate for Payer: Humana Medicare/TRICARE	$60,791.96
Rate for Payer: Molina Dual Medicare/Medicaid	$60,791.96
Rate for Payer: Molina Medicare	$60,791.96
Rate for Payer: Multiplan Auto	$147,153.10
Rate for Payer: Multiplan Commercial	$147,153.10
Rate for Payer: Multiplan Workers Comp	$147,153.10
Rate for Payer: Scott and White EPO/PPO	$67,767.88
Rate for Payer: Scott and White Medicare	$60,791.96
Rate for Payer: Superior Health Plan EPO	$60,791.96
Rate for Payer: Superior Health Plan Medicare	$60,791.96
Rate for Payer: Universal American Dual Medicare/Medicaid	$60,791.96
Rate for Payer: Universal American Medicare	$60,791.96
Rate for Payer: Wellcare Medicare	$60,791.96
Rate for Payer: Wellmed Medicare	$60,791.96

CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC

Facility

$98,539.70

Service Code	MSDRG 234
Min. Negotiated Rate	$44,265.92
Max. Negotiated Rate	$98,539.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$44,796.35
Rate for Payer: Amerigroup Medicare	$44,796.35
Rate for Payer: BCBS of TX Medicare	$44,796.35
Rate for Payer: Cigna Commercial	$70,359.58
Rate for Payer: Cigna Medicare	$44,796.35
Rate for Payer: Employer Direct Commercial	$44,796.35
Rate for Payer: Humana Medicare/TRICARE	$44,796.35
Rate for Payer: Molina Dual Medicare/Medicaid	$44,796.35
Rate for Payer: Molina Medicare	$44,796.35
Rate for Payer: Multiplan Auto	$98,539.70
Rate for Payer: Multiplan Commercial	$98,539.70
Rate for Payer: Multiplan Workers Comp	$98,539.70
Rate for Payer: Scott and White EPO/PPO	$45,380.12
Rate for Payer: Scott and White Medicare	$44,796.35
Rate for Payer: Superior Health Plan EPO	$44,796.35
Rate for Payer: Superior Health Plan Medicare	$44,796.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$44,796.35
Rate for Payer: Universal American Medicare	$44,796.35
Rate for Payer: Wellcare Medicare	$44,796.35
Rate for Payer: Wellmed Medicare	$44,796.35

CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$28,402.33

Service Code	APR-DRG 1664
Min. Negotiated Rate	$26,778.71
Max. Negotiated Rate	$28,402.33
Rate for Payer: Amerigroup CHIP/Medicaid	$26,778.71
Rate for Payer: Cigna Medicaid	$26,778.71
Rate for Payer: Molina CHIP/Medicaid	$26,778.71
Rate for Payer: Parkland Medicaid	$26,778.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28,402.33

CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$14,292.07

Service Code	APR-DRG 1661
Min. Negotiated Rate	$13,475.06
Max. Negotiated Rate	$14,292.07
Rate for Payer: Amerigroup CHIP/Medicaid	$13,475.06
Rate for Payer: Cigna Medicaid	$13,475.06
Rate for Payer: Molina CHIP/Medicaid	$13,475.06
Rate for Payer: Parkland Medicaid	$13,475.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,292.07

CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$20,195.83

Service Code	APR-DRG 1663
Min. Negotiated Rate	$19,041.34
Max. Negotiated Rate	$20,195.83
Rate for Payer: Amerigroup CHIP/Medicaid	$19,041.34
Rate for Payer: Cigna Medicaid	$19,041.34
Rate for Payer: Molina CHIP/Medicaid	$19,041.34
Rate for Payer: Parkland Medicaid	$19,041.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,195.83

CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$15,781.59

Service Code	APR-DRG 1662
Min. Negotiated Rate	$14,879.43
Max. Negotiated Rate	$15,781.59
Rate for Payer: Amerigroup CHIP/Medicaid	$14,879.43
Rate for Payer: Cigna Medicaid	$14,879.43
Rate for Payer: Molina CHIP/Medicaid	$14,879.43
Rate for Payer: Parkland Medicaid	$14,879.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,781.59

CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC

Facility

$113,810.00

Service Code	MSDRG 235
Min. Negotiated Rate	$47,771.21
Max. Negotiated Rate	$113,810.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47,771.21
Rate for Payer: Amerigroup Medicare	$47,771.21
Rate for Payer: BCBS of TX Medicare	$47,771.21
Rate for Payer: Cigna Commercial	$75,587.57
Rate for Payer: Cigna Medicare	$47,771.21
Rate for Payer: Employer Direct Commercial	$47,771.21
Rate for Payer: Humana Medicare/TRICARE	$47,771.21
Rate for Payer: Molina Dual Medicare/Medicaid	$47,771.21
Rate for Payer: Molina Medicare	$47,771.21
Rate for Payer: Multiplan Auto	$113,810.00
Rate for Payer: Multiplan Commercial	$113,810.00
Rate for Payer: Multiplan Workers Comp	$113,810.00
Rate for Payer: Scott and White EPO/PPO	$52,412.50
Rate for Payer: Scott and White Medicare	$47,771.21
Rate for Payer: Superior Health Plan EPO	$47,771.21
Rate for Payer: Superior Health Plan Medicare	$47,771.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$47,771.21
Rate for Payer: Universal American Medicare	$47,771.21
Rate for Payer: Wellcare Medicare	$47,771.21
Rate for Payer: Wellmed Medicare	$47,771.21

CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC

Facility

$77,489.60

Service Code	MSDRG 236
Min. Negotiated Rate	$33,766.18
Max. Negotiated Rate	$77,489.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35,459.91
Rate for Payer: Amerigroup Medicare	$35,459.91
Rate for Payer: BCBS of TX Medicare	$35,459.91
Rate for Payer: Cigna Commercial	$53,951.74
Rate for Payer: Cigna Medicare	$35,459.91
Rate for Payer: Employer Direct Commercial	$35,459.91
Rate for Payer: Humana Medicare/TRICARE	$35,459.91
Rate for Payer: Molina Dual Medicare/Medicaid	$35,459.91
Rate for Payer: Molina Medicare	$35,459.91
Rate for Payer: Multiplan Auto	$77,489.60
Rate for Payer: Multiplan Commercial	$77,489.60
Rate for Payer: Multiplan Workers Comp	$77,489.60
Rate for Payer: Scott and White EPO/PPO	$35,686.00
Rate for Payer: Scott and White Medicare	$35,459.91
Rate for Payer: Superior Health Plan EPO	$35,459.91
Rate for Payer: Superior Health Plan Medicare	$35,459.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$35,459.91
Rate for Payer: Universal American Medicare	$35,459.91
Rate for Payer: Wellcare Medicare	$35,459.91
Rate for Payer: Wellmed Medicare	$35,459.91

CORONARY BYPASS WITH PTCA WITH MCC

Facility

$159,470.80

Service Code	MSDRG 231
Min. Negotiated Rate	$66,543.04
Max. Negotiated Rate	$159,470.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$66,543.04
Rate for Payer: Amerigroup Medicare	$66,543.04
Rate for Payer: BCBS of TX Medicare	$66,543.04
Rate for Payer: Cigna Commercial	$108,577.11
Rate for Payer: Cigna Medicare	$66,543.04
Rate for Payer: Employer Direct Commercial	$66,543.04
Rate for Payer: Humana Medicare/TRICARE	$66,543.04
Rate for Payer: Molina Dual Medicare/Medicaid	$66,543.04
Rate for Payer: Molina Medicare	$66,543.04
Rate for Payer: Multiplan Auto	$159,470.80
Rate for Payer: Multiplan Commercial	$159,470.80
Rate for Payer: Multiplan Workers Comp	$159,470.80
Rate for Payer: Scott and White EPO/PPO	$73,440.50
Rate for Payer: Scott and White Medicare	$66,543.04
Rate for Payer: Superior Health Plan EPO	$66,543.04
Rate for Payer: Superior Health Plan Medicare	$66,543.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$66,543.04
Rate for Payer: Universal American Medicare	$66,543.04
Rate for Payer: Wellcare Medicare	$66,543.04
Rate for Payer: Wellmed Medicare	$66,543.04

CORONARY BYPASS WITH PTCA WITHOUT MCC

Facility

$111,298.20

Service Code	MSDRG 232
Min. Negotiated Rate	$49,193.02
Max. Negotiated Rate	$111,298.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$49,193.02
Rate for Payer: Amerigroup Medicare	$49,193.02
Rate for Payer: BCBS of TX Medicare	$49,193.02
Rate for Payer: Cigna Commercial	$78,086.29
Rate for Payer: Cigna Medicare	$49,193.02
Rate for Payer: Employer Direct Commercial	$49,193.02
Rate for Payer: Humana Medicare/TRICARE	$49,193.02
Rate for Payer: Molina Dual Medicare/Medicaid	$49,193.02
Rate for Payer: Molina Medicare	$49,193.02
Rate for Payer: Multiplan Auto	$111,298.20
Rate for Payer: Multiplan Commercial	$111,298.20
Rate for Payer: Multiplan Workers Comp	$111,298.20
Rate for Payer: Scott and White EPO/PPO	$51,255.75
Rate for Payer: Scott and White Medicare	$49,193.02
Rate for Payer: Superior Health Plan EPO	$49,193.02
Rate for Payer: Superior Health Plan Medicare	$49,193.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$49,193.02
Rate for Payer: Universal American Medicare	$49,193.02
Rate for Payer: Wellcare Medicare	$49,193.02
Rate for Payer: Wellmed Medicare	$49,193.02

CORONARY BYPASS W/O CARDIAC CATH W MCC

Facility

$113,810.00

Service Code	MSDRG 235
Min. Negotiated Rate	$47,771.21
Max. Negotiated Rate	$113,810.00
Rate for Payer: BCBS of TX Blue Advantage	$49,965.14
Rate for Payer: BCBS of TX Blue Essentials	$59,952.36
Rate for Payer: BCBS of TX PPO	$66,616.31

CORONARY BYPASS W/O CARDIAC CATH W/O MCC

Facility

$77,489.60

Service Code	MSDRG 236
Min. Negotiated Rate	$33,766.18
Max. Negotiated Rate	$77,489.60
Rate for Payer: BCBS of TX Blue Advantage	$33,766.18
Rate for Payer: BCBS of TX Blue Essentials	$40,515.49
Rate for Payer: BCBS of TX PPO	$45,018.96

CORONARY BYPASS W PTCA W MCC

Facility

$159,470.80

Service Code	MSDRG 231
Min. Negotiated Rate	$66,543.04
Max. Negotiated Rate	$159,470.80
Rate for Payer: BCBS of TX Blue Advantage	$72,230.54
Rate for Payer: BCBS of TX Blue Essentials	$86,668.25
Rate for Payer: BCBS of TX PPO	$96,301.79

CORONARY BYPASS W PTCA W/O MCC

Facility

$111,298.20

Service Code	MSDRG 232
Min. Negotiated Rate	$49,193.02
Max. Negotiated Rate	$111,298.20
Rate for Payer: BCBS of TX Blue Advantage	$52,979.44
Rate for Payer: BCBS of TX Blue Essentials	$63,569.17
Rate for Payer: BCBS of TX PPO	$70,635.15

CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC

Facility

$55,736.91

Service Code	MSDRG 323
Min. Negotiated Rate	$36,475.71
Max. Negotiated Rate	$55,736.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$36,475.71
Rate for Payer: Amerigroup Medicare	$36,475.71
Rate for Payer: BCBS of TX Medicare	$36,475.71
Rate for Payer: Cigna Commercial	$55,736.91
Rate for Payer: Cigna Medicare	$36,475.71
Rate for Payer: Employer Direct Commercial	$36,475.71
Rate for Payer: Humana Medicare/TRICARE	$36,475.71
Rate for Payer: Molina Dual Medicare/Medicaid	$36,475.71
Rate for Payer: Molina Medicare	$36,475.71
Rate for Payer: Scott and White Medicare	$36,475.71
Rate for Payer: Superior Health Plan EPO	$36,475.71
Rate for Payer: Superior Health Plan Medicare	$36,475.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$36,475.71
Rate for Payer: Universal American Medicare	$36,475.71
Rate for Payer: Wellcare Medicare	$36,475.71
Rate for Payer: Wellmed Medicare	$36,475.71

CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$40,584.88

Service Code	MSDRG 324
Min. Negotiated Rate	$27,853.85
Max. Negotiated Rate	$40,584.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27,853.85
Rate for Payer: Amerigroup Medicare	$27,853.85
Rate for Payer: BCBS of TX Medicare	$27,853.85
Rate for Payer: Cigna Commercial	$40,584.88
Rate for Payer: Cigna Medicare	$27,853.85
Rate for Payer: Employer Direct Commercial	$27,853.85
Rate for Payer: Humana Medicare/TRICARE	$27,853.85
Rate for Payer: Molina Dual Medicare/Medicaid	$27,853.85
Rate for Payer: Molina Medicare	$27,853.85
Rate for Payer: Scott and White Medicare	$27,853.85
Rate for Payer: Superior Health Plan EPO	$27,853.85
Rate for Payer: Superior Health Plan Medicare	$27,853.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$27,853.85
Rate for Payer: Universal American Medicare	$27,853.85
Rate for Payer: Wellcare Medicare	$27,853.85
Rate for Payer: Wellmed Medicare	$27,853.85

Know your out-of-pocket cost for care.

All Charges