White Rock Medical Center

All Charges

Charge

Type

Setting

Price

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC

Facility

$25,798.64

Service Code	MSDRG 064
Min. Negotiated Rate	$15,065.48
Max. Negotiated Rate	$25,798.64
Rate for Payer: Aetna Commercial	$22,533.75
Rate for Payer: Aetna Medicare	$25,722.48
Rate for Payer: BCBS of TX Blue Advantage	$15,065.48
Rate for Payer: BCBS of TX Blue Essentials	$19,288.27
Rate for Payer: BCBS of TX PPO	$21,432.25
Rate for Payer: Cigna Commercial	$25,798.64

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC

Facility

$11,641.25

Service Code	MSDRG 066
Min. Negotiated Rate	$6,419.04
Max. Negotiated Rate	$11,641.25
Rate for Payer: Aetna Commercial	$7,734.38
Rate for Payer: Aetna Medicare	$11,641.25
Rate for Payer: BCBS of TX Blue Advantage	$6,419.04
Rate for Payer: BCBS of TX Blue Essentials	$7,499.85
Rate for Payer: BCBS of TX PPO	$8,333.49
Rate for Payer: Cigna Commercial	$8,855.00

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC

Facility

$90,645.61

Service Code	MSDRG 021
Min. Negotiated Rate	$62,702.60
Max. Negotiated Rate	$90,645.61
Rate for Payer: Aetna Commercial	$69,090.75
Rate for Payer: Aetna Medicare	$70,020.27
Rate for Payer: BCBS of TX Blue Advantage	$62,702.60
Rate for Payer: BCBS of TX Blue Essentials	$81,577.89
Rate for Payer: BCBS of TX PPO	$90,645.61
Rate for Payer: Cigna Commercial	$79,101.23

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC

Facility

$119,536.49

Service Code	MSDRG 020
Min. Negotiated Rate	$83,465.58
Max. Negotiated Rate	$119,536.49
Rate for Payer: Aetna Commercial	$95,089.50
Rate for Payer: Aetna Medicare	$94,757.43
Rate for Payer: BCBS of TX Blue Advantage	$83,465.58
Rate for Payer: BCBS of TX Blue Essentials	$107,578.67
Rate for Payer: BCBS of TX PPO	$119,536.49
Rate for Payer: Cigna Commercial	$108,866.91

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC

Facility

$59,135.89

Service Code	MSDRG 022
Min. Negotiated Rate	$39,112.88
Max. Negotiated Rate	$59,135.89
Rate for Payer: Aetna Commercial	$39,112.88
Rate for Payer: Aetna Medicare	$46,271.11
Rate for Payer: BCBS of TX Blue Advantage	$39,641.70
Rate for Payer: BCBS of TX Blue Essentials	$53,220.24
Rate for Payer: BCBS of TX PPO	$59,135.89
Rate for Payer: Cigna Commercial	$44,779.90

INTRAOCULAR PROCEDURES WITH CC/MCC

Facility

$23,879.24

Service Code	MSDRG 116
Min. Negotiated Rate	$13,559.62
Max. Negotiated Rate	$23,879.24
Rate for Payer: Aetna Commercial	$20,596.50
Rate for Payer: Aetna Medicare	$23,879.24
Rate for Payer: BCBS of TX Blue Advantage	$13,559.62
Rate for Payer: BCBS of TX Blue Essentials	$17,624.85
Rate for Payer: BCBS of TX PPO	$19,583.93
Rate for Payer: Cigna Commercial	$23,580.70

INTRAOCULAR PROCEDURES WITHOUT CC/MCC

Facility

$17,109.94

Service Code	MSDRG 117
Min. Negotiated Rate	$7,328.06
Max. Negotiated Rate	$17,109.94
Rate for Payer: Aetna Commercial	$13,482.00
Rate for Payer: Aetna Medicare	$17,109.94
Rate for Payer: BCBS of TX Blue Advantage	$7,328.06
Rate for Payer: BCBS of TX Blue Essentials	$10,344.80
Rate for Payer: BCBS of TX PPO	$11,494.67
Rate for Payer: Cigna Commercial	$15,435.39

INTRAVASCULAR STENT 1ST ARTERY

Facility

$24,854.00

Service Code	CPT 37236
Hospital Charge Code	2350071
Hospital Revenue Code	481
Rate for Payer: Cash Price	$21,871.52

INTRAVASCULAR STENT 1ST ARTERY

Facility

$24,854.00

Service Code	CPT 37236
Hospital Charge Code	2350071
Hospital Revenue Code	481
Min. Negotiated Rate	$520.49
Max. Negotiated Rate	$24,969.37
Rate for Payer: Aetna Commercial	$8,755.00
Rate for Payer: Aetna Medicare	$15,091.60
Rate for Payer: Amerigroup CHIP/Medicaid	$2,236.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Amerigroup Medicare	$10,061.07
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$10,061.07
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$21,871.52
Rate for Payer: Cash Price	$21,871.52
Rate for Payer: Cash Price	$21,871.52
Rate for Payer: Cigna Commercial	$22,791.24
Rate for Payer: Cigna Medicaid	$5,004.56
Rate for Payer: Cigna Medicare	$10,061.07
Rate for Payer: Employer Direct Commercial	$10,061.07
Rate for Payer: Humana Medicare/TRICARE	$10,061.07
Rate for Payer: Molina CHIP/Medicaid	$5,004.56
Rate for Payer: Molina Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Molina Medicare	$10,061.07
Rate for Payer: Multiplan Auto	$16,155.10
Rate for Payer: Multiplan Commercial	$16,155.10
Rate for Payer: Multiplan Workers Comp	$16,155.10
Rate for Payer: Parkland Medicaid	$5,004.56
Rate for Payer: Scott and White EPO/PPO	$520.49
Rate for Payer: Scott and White Medicare	$10,061.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,004.56
Rate for Payer: Superior Health Plan EPO	$10,061.07
Rate for Payer: Superior Health Plan Medicare	$10,061.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Universal American Medicare	$10,061.07
Rate for Payer: Wellcare Medicare	$10,061.07
Rate for Payer: Wellmed Medicare	$10,061.07

Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

Facility

$10,000.00

Service Code	CPT 96361
Hospital Charge Code	36096361
Hospital Revenue Code	360
Min. Negotiated Rate	$15.21
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$23.82
Rate for Payer: BCBS of TX Blue Essentials	$28.48
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$31.76
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
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	$15.21
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

Intravenous infusion, hydration; initial, 31 minutes to 1 hour

Facility

$10,000.00

Service Code	CPT 96360
Hospital Charge Code	36096360
Hospital Revenue Code	360
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$67.09
Rate for Payer: BCBS of TX Blue Essentials	$80.20
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$89.46
Rate for Payer: Cigna Commercial	$444.05
Rate for Payer: Cigna Medicare	$196.02
Rate for Payer: Employer Direct Commercial	$196.02
Rate for Payer: Humana Medicare/TRICARE	$196.02
Rate for Payer: Molina Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
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	$39.95
Rate for Payer: Scott and White Medicare	$196.02
Rate for Payer: Superior Health Plan EPO	$196.02
Rate for Payer: Superior Health Plan Medicare	$196.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$196.02
Rate for Payer: Universal American Medicare	$196.02
Rate for Payer: Wellcare Medicare	$196.02
Rate for Payer: Wellmed Medicare	$196.02

INTRCRD EP 3DMAP

Facility

$8,562.00

Service Code	CPT 93613
Hospital Charge Code	4613613
Hospital Revenue Code	480
Min. Negotiated Rate	$345.59
Max. Negotiated Rate	$5,565.30
Rate for Payer: Aetna Commercial	$4,709.10
Rate for Payer: Amerigroup CHIP/Medicaid	$770.58
Rate for Payer: BCBS of TX Blue Advantage	$541.17
Rate for Payer: BCBS of TX Blue Essentials	$646.92
Rate for Payer: BCBS of TX PPO	$721.57
Rate for Payer: Cash Price	$7,534.56
Rate for Payer: Cash Price	$7,534.56
Rate for Payer: Multiplan Auto	$5,565.30
Rate for Payer: Multiplan Commercial	$5,565.30
Rate for Payer: Multiplan Workers Comp	$5,565.30
Rate for Payer: Scott and White EPO/PPO	$345.59
Rate for Payer: Superior Health Plan EPO	$1,164.43

INTRCRD EP 3DMAP

Facility

$8,562.00

Service Code	CPT 93613
Hospital Charge Code	4613613
Hospital Revenue Code	480
Rate for Payer: Cash Price	$7,534.56

INTRO CATH -- DHF

Facility

$267.72

Hospital Charge Code	81826307
Hospital Revenue Code	272
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$174.02
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Amerigroup CHIP/Medicaid	$24.09
Rate for Payer: BCBS of TX Blue Advantage	$80.32
Rate for Payer: BCBS of TX Blue Essentials	$96.38
Rate for Payer: BCBS of TX PPO	$107.09
Rate for Payer: Cash Price	$235.59
Rate for Payer: Multiplan Auto	$174.02
Rate for Payer: Multiplan Commercial	$174.02
Rate for Payer: Multiplan Workers Comp	$174.02
Rate for Payer: Scott and White EPO/PPO	$133.86
Rate for Payer: Superior Health Plan EPO	$36.41

INTRO CATH -- DHF

Facility

$267.72

Hospital Charge Code	81826307
Hospital Revenue Code	272
Rate for Payer: Cash Price	$235.59

INTRO, CATHETER AORTA

Facility

$2,583.00

Service Code	CPT 36200
Hospital Charge Code	2301778
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,273.04

INTRO, CATHETER AORTA

Facility

$2,583.00

Service Code	CPT 36200
Hospital Charge Code	2301778
Hospital Revenue Code	360
Min. Negotiated Rate	$232.47
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,420.65
Rate for Payer: Amerigroup CHIP/Medicaid	$232.47
Rate for Payer: Cash Price	$2,273.04
Rate for Payer: Cash Price	$2,273.04
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	$1,291.50
Rate for Payer: Superior Health Plan EPO	$351.29

INTRO CATH/NDL DIAL-CIRC +S&I

Facility

$3,242.00

Service Code	CPT 36901
Hospital Charge Code	2351100
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,852.96

INTRO CATH/NDL DIAL-CIRC +S&I

Facility

$3,242.00

Service Code	CPT 36901
Hospital Charge Code	2351100
Hospital Revenue Code	360
Min. Negotiated Rate	$446.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,197.02
Rate for Payer: Amerigroup CHIP/Medicaid	$446.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,464.68
Rate for Payer: Amerigroup Medicare	$1,464.68
Rate for Payer: BCBS of TX Blue Advantage	$957.68
Rate for Payer: BCBS of TX Blue Essentials	$1,146.92
Rate for Payer: BCBS of TX Medicare	$1,464.68
Rate for Payer: BCBS of TX PPO	$1,445.12
Rate for Payer: Cash Price	$2,852.96
Rate for Payer: Cash Price	$2,852.96
Rate for Payer: Cigna Commercial	$3,317.93
Rate for Payer: Cigna Medicaid	$446.27
Rate for Payer: Cigna Medicare	$1,464.68
Rate for Payer: Employer Direct Commercial	$1,464.68
Rate for Payer: Humana Medicare/TRICARE	$1,464.68
Rate for Payer: Molina CHIP/Medicaid	$446.27
Rate for Payer: Molina Dual Medicare/Medicaid	$1,464.68
Rate for Payer: Molina Medicare	$1,464.68
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: Parkland Medicaid	$446.27
Rate for Payer: Scott and White EPO/PPO	$2,709.66
Rate for Payer: Scott and White Medicare	$1,464.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$446.27
Rate for Payer: Superior Health Plan EPO	$1,464.68
Rate for Payer: Superior Health Plan Medicare	$1,464.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,464.68
Rate for Payer: Universal American Medicare	$1,464.68
Rate for Payer: Wellcare Medicare	$1,464.68
Rate for Payer: Wellmed Medicare	$1,464.68

INTRO CATHVAS -- DHF

Facility

$772.26

Hospital Charge Code	81826455
Hospital Revenue Code	272
Rate for Payer: Cash Price	$679.59

INTRO CATHVAS -- DHF

Facility

$772.26

Hospital Charge Code	81826455
Hospital Revenue Code	272
Min. Negotiated Rate	$69.50
Max. Negotiated Rate	$501.97
Rate for Payer: Aetna Commercial	$424.74
Rate for Payer: Amerigroup CHIP/Medicaid	$69.50
Rate for Payer: BCBS of TX Blue Advantage	$231.68
Rate for Payer: BCBS of TX Blue Essentials	$278.01
Rate for Payer: BCBS of TX PPO	$308.90
Rate for Payer: Cash Price	$679.59
Rate for Payer: Multiplan Auto	$501.97
Rate for Payer: Multiplan Commercial	$501.97
Rate for Payer: Multiplan Workers Comp	$501.97
Rate for Payer: Scott and White EPO/PPO	$386.13
Rate for Payer: Superior Health Plan EPO	$105.03

INTRODUCER ACC VALVE

Facility

$227.00

Service Code	HCPCS C1894
Hospital Charge Code	8414456
Hospital Revenue Code	272
Rate for Payer: Cash Price	$199.76

INTRODUCER ACC VALVE

Facility

$227.00

Service Code	HCPCS C1894
Hospital Charge Code	8414456
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$147.55
Rate for Payer: Aetna Commercial	$124.85
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$199.76
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan EPO	$30.87

INTRODUCER MERIT PRELUDE

Facility

$227.00

Hospital Charge Code	8478524
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$147.55
Rate for Payer: Aetna Commercial	$124.85
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$199.76
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan EPO	$30.87

INTRODUCER MERIT PRELUDE

Facility

$227.00

Hospital Charge Code	8478524
Hospital Revenue Code	272
Rate for Payer: Cash Price	$199.76

Know your out-of-pocket cost for care.

All Charges