White Rock Medical Center

All Charges

Charge

Type

Setting

Price

342 - v34 MSDRG

Facility

$11,614.30

Service Code	MSDRG 342
Hospital Charge Code	342
Min. Negotiated Rate	$11,614.30
Max. Negotiated Rate	$11,614.30
Rate for Payer: BCBS of TX Blue Advantage	$11,614.30

342 - v36 MSDRG

Facility

$16,267.96

Service Code	MSDRG 342
Hospital Charge Code	3421
Min. Negotiated Rate	$14,640.60
Max. Negotiated Rate	$16,267.96
Rate for Payer: BCBS of TX Blue Essentials	$14,640.60
Rate for Payer: BCBS of TX PPO	$16,267.96

343 - v34 MSDRG

Facility

$8,770.28

Service Code	MSDRG 343
Hospital Charge Code	343
Min. Negotiated Rate	$8,770.28
Max. Negotiated Rate	$8,770.28
Rate for Payer: BCBS of TX Blue Advantage	$8,770.28

343 - v36 MSDRG

Facility

$12,444.05

Service Code	MSDRG 343
Hospital Charge Code	3431
Min. Negotiated Rate	$11,199.21
Max. Negotiated Rate	$12,444.05
Rate for Payer: BCBS of TX Blue Essentials	$11,199.21
Rate for Payer: BCBS of TX PPO	$12,444.05

3RD ORDER SELEC ABDOMEN/PELVIS

Facility

$4,484.00

Service Code	CPT 36247
Hospital Charge Code	2300176
Hospital Revenue Code	361
Min. Negotiated Rate	$403.56
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,466.20
Rate for Payer: Amerigroup CHIP/Medicaid	$403.56
Rate for Payer: Cash Price	$3,945.92
Rate for Payer: Cash Price	$3,945.92
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	$2,242.00
Rate for Payer: Superior Health Plan EPO	$609.82

3RD ORDER SELEC ABDOMEN/PELVIS

Facility

$4,484.00

Service Code	CPT 36247
Hospital Charge Code	2300176
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,945.92

5-HIAA,Quant.,24 Hr Urine SO

Facility

$80.00

Service Code	CPT 83497
Hospital Charge Code	1702067
Hospital Revenue Code	301
Min. Negotiated Rate	$5.03
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$13.54
Rate for Payer: Aetna Medicare	$19.35
Rate for Payer: Amerigroup CHIP/Medicaid	$5.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.90
Rate for Payer: Amerigroup Medicare	$12.90
Rate for Payer: BCBS of TX Blue Advantage	$21.28
Rate for Payer: BCBS of TX Blue Essentials	$25.54
Rate for Payer: BCBS of TX Medicare	$12.90
Rate for Payer: BCBS of TX PPO	$28.51
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cigna Medicaid	$12.90
Rate for Payer: Cigna Medicare	$12.90
Rate for Payer: Employer Direct Commercial	$12.90
Rate for Payer: Humana Medicare/TRICARE	$12.90
Rate for Payer: Molina CHIP/Medicaid	$12.90
Rate for Payer: Molina Dual Medicare/Medicaid	$12.90
Rate for Payer: Molina Medicare	$12.90
Rate for Payer: Multiplan Auto	$52.00
Rate for Payer: Multiplan Commercial	$52.00
Rate for Payer: Multiplan Workers Comp	$52.00
Rate for Payer: Parkland Medicaid	$12.90
Rate for Payer: Scott and White EPO/PPO	$16.12
Rate for Payer: Scott and White Medicare	$12.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.90
Rate for Payer: Superior Health Plan EPO	$12.90
Rate for Payer: Superior Health Plan Medicare	$12.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.90
Rate for Payer: Universal American Medicare	$12.90
Rate for Payer: Wellcare Medicare	$12.90
Rate for Payer: Wellmed Medicare	$12.90

5-HIAA,Quant.,24 Hr Urine SO

Facility

$80.00

Service Code	CPT 83497
Hospital Charge Code	1702067
Hospital Revenue Code	301
Rate for Payer: Cash Price	$70.40

685 - v34 MSDRG

Facility

$8,968.94

Service Code	MSDRG 685
Hospital Charge Code	685
Min. Negotiated Rate	$8,968.94
Max. Negotiated Rate	$8,968.94
Rate for Payer: BCBS of TX Blue Advantage	$8,968.94

691 - v34 MSDRG

Facility

$13,819.34

Service Code	MSDRG 691
Hospital Charge Code	691
Min. Negotiated Rate	$13,819.34
Max. Negotiated Rate	$13,819.34
Rate for Payer: BCBS of TX Blue Advantage	$13,819.34

691 - v36 MSDRG

Facility

$18,623.08

Service Code	MSDRG 691
Hospital Charge Code	6911
Min. Negotiated Rate	$16,760.12
Max. Negotiated Rate	$18,623.08
Rate for Payer: BCBS of TX Blue Essentials	$16,760.12
Rate for Payer: BCBS of TX PPO	$18,623.08

692 - v34 MSDRG

Facility

$10,899.64

Service Code	MSDRG 692
Hospital Charge Code	692
Min. Negotiated Rate	$10,899.64
Max. Negotiated Rate	$10,899.64
Rate for Payer: BCBS of TX Blue Advantage	$10,899.64

692 - v36 MSDRG

Facility

$12,963.46

Service Code	MSDRG 692
Hospital Charge Code	6921
Min. Negotiated Rate	$11,666.66
Max. Negotiated Rate	$12,963.46
Rate for Payer: BCBS of TX Blue Essentials	$11,666.66
Rate for Payer: BCBS of TX PPO	$12,963.46

733692 9+Oxycodone+Crt-Scr SO

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1640102
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$206.05
Rate for Payer: Aetna Commercial	$65.24
Rate for Payer: Aetna Medicare	$93.21
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$102.53
Rate for Payer: BCBS of TX Blue Essentials	$123.04
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$137.33
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cigna Medicaid	$62.14
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$62.14
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$62.14
Rate for Payer: Scott and White EPO/PPO	$77.68
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.14
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

74248 UPPER GI SM INT F-THRU STD

Facility

$981.00

Service Code	CPT 74248 FY
Hospital Charge Code	3100002
Hospital Revenue Code	320
Min. Negotiated Rate	$59.54
Max. Negotiated Rate	$637.65
Rate for Payer: Aetna Commercial	$59.54
Rate for Payer: Amerigroup CHIP/Medicaid	$83.86
Rate for Payer: BCBS of TX Blue Advantage	$79.08
Rate for Payer: BCBS of TX Blue Essentials	$94.90
Rate for Payer: BCBS of TX PPO	$105.93
Rate for Payer: Cash Price	$863.28
Rate for Payer: Cash Price	$863.28
Rate for Payer: Cigna Medicaid	$83.86
Rate for Payer: Molina CHIP/Medicaid	$83.86
Rate for Payer: Multiplan Auto	$637.65
Rate for Payer: Multiplan Commercial	$637.65
Rate for Payer: Multiplan Workers Comp	$637.65
Rate for Payer: Parkland Medicaid	$83.86
Rate for Payer: Scott and White EPO/PPO	$490.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83.86
Rate for Payer: Superior Health Plan EPO	$133.42

765 - v34 MSDRG

Facility

$9,767.88

Service Code	MSDRG 765
Hospital Charge Code	765
Min. Negotiated Rate	$9,767.88
Max. Negotiated Rate	$9,767.88
Rate for Payer: BCBS of TX Blue Advantage	$9,767.88

766 - v34 MSDRG

Facility

$6,966.00

Service Code	MSDRG 766
Hospital Charge Code	766
Min. Negotiated Rate	$6,966.00
Max. Negotiated Rate	$6,966.00
Rate for Payer: BCBS of TX Blue Advantage	$6,966.00

767 - v34 MSDRG

Facility

$7,658.30

Service Code	MSDRG 767
Hospital Charge Code	767
Min. Negotiated Rate	$7,658.30
Max. Negotiated Rate	$7,658.30
Rate for Payer: BCBS of TX Blue Advantage	$7,658.30

7.6 to 12.5 cm

Facility

$998.50

Service Code	CPT 12015
Hospital Charge Code	8776544
Hospital Revenue Code	450
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$649.02
Rate for Payer: Aetna Commercial	$549.18
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$89.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$878.68
Rate for Payer: Cash Price	$878.68
Rate for Payer: Cash Price	$878.68
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$74.34
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina CHIP/Medicaid	$74.34
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$649.02
Rate for Payer: Multiplan Commercial	$649.02
Rate for Payer: Multiplan Workers Comp	$649.02
Rate for Payer: Parkland Medicaid	$74.34
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.34
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

7.6 to 12.5 cm

Facility

$998.50

Service Code	CPT 12015
Hospital Charge Code	8776544
Hospital Revenue Code	450
Rate for Payer: Cash Price	$878.68

774 - v34 MSDRG

Facility

$6,847.32

Service Code	MSDRG 774
Hospital Charge Code	774
Min. Negotiated Rate	$6,847.32
Max. Negotiated Rate	$6,847.32
Rate for Payer: BCBS of TX Blue Advantage	$6,847.32

775 - v34 MSDRG

Facility

$5,240.84

Service Code	MSDRG 775
Hospital Charge Code	775
Min. Negotiated Rate	$5,240.84
Max. Negotiated Rate	$5,240.84
Rate for Payer: BCBS of TX Blue Advantage	$5,240.84

777 - v34 MSDRG

Facility

$8,511.42

Service Code	MSDRG 777
Hospital Charge Code	777
Min. Negotiated Rate	$8,511.42
Max. Negotiated Rate	$8,511.42
Rate for Payer: BCBS of TX Blue Advantage	$8,511.42

778 - v34 MSDRG

Facility

$5,228.80

Service Code	MSDRG 778
Hospital Charge Code	778
Min. Negotiated Rate	$5,228.80
Max. Negotiated Rate	$5,228.80
Rate for Payer: BCBS of TX Blue Advantage	$5,228.80

780 - v34 MSDRG

Facility

$5,245.14

Service Code	MSDRG 780
Hospital Charge Code	780
Min. Negotiated Rate	$5,245.14
Max. Negotiated Rate	$5,245.14
Rate for Payer: BCBS of TX Blue Advantage	$5,245.14

Know your out-of-pocket cost for care.

All Charges