White Rock Medical Center

All Charges

Charge

Type

Setting

Price

NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$43,491.90

Service Code	MSDRG 987
Min. Negotiated Rate	$28,613.06
Max. Negotiated Rate	$43,491.90
Rate for Payer: Aetna Commercial	$37,987.88
Rate for Payer: Aetna Medicare	$40,426.67
Rate for Payer: BCBS of TX Blue Advantage	$28,613.06
Rate for Payer: BCBS of TX Blue Essentials	$34,389.10
Rate for Payer: BCBS of TX PPO	$38,211.59
Rate for Payer: Cigna Commercial	$43,491.90

NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$15,845.79

Service Code	MSDRG 989
Min. Negotiated Rate	$9,085.04
Max. Negotiated Rate	$15,845.79
Rate for Payer: Aetna Commercial	$12,153.38
Rate for Payer: Aetna Medicare	$15,845.79
Rate for Payer: BCBS of TX Blue Advantage	$9,085.04
Rate for Payer: BCBS of TX Blue Essentials	$10,738.98
Rate for Payer: BCBS of TX PPO	$11,932.67
Rate for Payer: Cigna Commercial	$13,914.26

NON-MALIGNANT BREAST DISORDERS WITH CC/MCC

Facility

$15,259.20

Service Code	MSDRG 600
Min. Negotiated Rate	$8,679.98
Max. Negotiated Rate	$15,259.20
Rate for Payer: Aetna Commercial	$11,536.88
Rate for Payer: Aetna Medicare	$15,259.20
Rate for Payer: BCBS of TX Blue Advantage	$8,679.98
Rate for Payer: BCBS of TX Blue Essentials	$9,864.96
Rate for Payer: BCBS of TX PPO	$10,961.50
Rate for Payer: Cigna Commercial	$13,208.44

NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC

Facility

$11,063.22

Service Code	MSDRG 601
Min. Negotiated Rate	$5,685.46
Max. Negotiated Rate	$11,063.22
Rate for Payer: Aetna Commercial	$7,004.25
Rate for Payer: Aetna Medicare	$11,063.22
Rate for Payer: BCBS of TX Blue Advantage	$5,685.46
Rate for Payer: BCBS of TX Blue Essentials	$6,389.52
Rate for Payer: BCBS of TX PPO	$7,099.75
Rate for Payer: Cigna Commercial	$8,019.09

Non-Selective Debridement

Facility

$358.00

Service Code	CPT 97602
Hospital Charge Code	7150055
Hospital Revenue Code	761
Min. Negotiated Rate	$27.68
Max. Negotiated Rate	$414.75
Rate for Payer: Aetna Commercial	$196.90
Rate for Payer: Aetna Medicare	$274.63
Rate for Payer: Amerigroup CHIP/Medicaid	$32.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$27.68
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	$27.68
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$232.70
Rate for Payer: Multiplan Commercial	$232.70
Rate for Payer: Multiplan Workers Comp	$232.70
Rate for Payer: Parkland Medicaid	$27.68
Rate for Payer: Scott and White EPO/PPO	$179.00
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.68
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

NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC

Facility

$15,647.76

Service Code	MSDRG 071
Min. Negotiated Rate	$8,436.60
Max. Negotiated Rate	$15,647.76
Rate for Payer: Aetna Commercial	$11,945.25
Rate for Payer: Aetna Medicare	$15,647.76
Rate for Payer: BCBS of TX Blue Advantage	$8,436.60
Rate for Payer: BCBS of TX Blue Essentials	$10,172.47
Rate for Payer: BCBS of TX PPO	$11,303.18
Rate for Payer: Cigna Commercial	$13,675.98

NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC

Facility

$23,437.12

Service Code	MSDRG 070
Min. Negotiated Rate	$14,004.24
Max. Negotiated Rate	$23,437.12
Rate for Payer: Aetna Commercial	$20,131.88
Rate for Payer: Aetna Medicare	$23,437.12
Rate for Payer: BCBS of TX Blue Advantage	$14,004.24
Rate for Payer: BCBS of TX Blue Essentials	$16,977.85
Rate for Payer: BCBS of TX PPO	$18,865.01
Rate for Payer: Cigna Commercial	$23,048.76

NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC

Facility

$12,663.47

Service Code	MSDRG 072
Min. Negotiated Rate	$6,324.44
Max. Negotiated Rate	$12,663.47
Rate for Payer: Aetna Commercial	$8,808.75
Rate for Payer: Aetna Medicare	$12,663.47
Rate for Payer: BCBS of TX Blue Advantage	$6,324.44
Rate for Payer: BCBS of TX Blue Essentials	$7,656.70
Rate for Payer: BCBS of TX PPO	$8,507.77
Rate for Payer: Cigna Commercial	$10,085.04

NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC

Facility

$19,448.79

Service Code	MSDRG 067
Min. Negotiated Rate	$11,501.64
Max. Negotiated Rate	$19,448.79
Rate for Payer: Aetna Commercial	$15,940.12
Rate for Payer: Aetna Medicare	$19,448.79
Rate for Payer: BCBS of TX Blue Advantage	$11,501.64
Rate for Payer: BCBS of TX Blue Essentials	$15,492.95
Rate for Payer: BCBS of TX PPO	$17,215.05
Rate for Payer: Cigna Commercial	$18,249.67

NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC

Facility

$13,605.43

Service Code	MSDRG 068
Min. Negotiated Rate	$7,445.88
Max. Negotiated Rate	$13,605.43
Rate for Payer: Aetna Commercial	$9,798.75
Rate for Payer: Aetna Medicare	$13,605.43
Rate for Payer: BCBS of TX Blue Advantage	$7,445.88
Rate for Payer: BCBS of TX Blue Essentials	$9,273.69
Rate for Payer: BCBS of TX PPO	$10,304.49
Rate for Payer: Cigna Commercial	$11,218.48

NONTRAUMATIC STUPOR AND COMA WITH MCC

Facility

$28,448.06

Service Code	MSDRG 080
Min. Negotiated Rate	$10,806.76
Max. Negotiated Rate	$28,448.06
Rate for Payer: Aetna Commercial	$24,847.88
Rate for Payer: Aetna Medicare	$27,924.30
Rate for Payer: BCBS of TX Blue Advantage	$10,806.76
Rate for Payer: BCBS of TX Blue Essentials	$19,387.34
Rate for Payer: BCBS of TX PPO	$21,542.32
Rate for Payer: Cigna Commercial	$28,448.06

NONTRAUMATIC STUPOR AND COMA WITHOUT MCC

Facility

$14,017.53

Service Code	MSDRG 081
Min. Negotiated Rate	$6,583.30
Max. Negotiated Rate	$14,017.53
Rate for Payer: Aetna Commercial	$10,231.88
Rate for Payer: Aetna Medicare	$14,017.53
Rate for Payer: BCBS of TX Blue Advantage	$6,583.30
Rate for Payer: BCBS of TX Blue Essentials	$8,818.62
Rate for Payer: BCBS of TX PPO	$9,798.84
Rate for Payer: Cigna Commercial	$11,714.36

norepinephrine 8 mg-NaCl 0.9% 250 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	78415626
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

norepinephrine 8 mg-NaCl 0.9% 250 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	78415626
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

NORMAL NEWBORN

Facility

$6,441.18

Service Code	MSDRG 795
Min. Negotiated Rate	$1,523.06
Max. Negotiated Rate	$6,441.18
Rate for Payer: Aetna Commercial	$2,269.12
Rate for Payer: Aetna Medicare	$6,441.18
Rate for Payer: BCBS of TX Blue Advantage	$1,523.06
Rate for Payer: BCBS of TX Blue Essentials	$1,902.82
Rate for Payer: BCBS of TX PPO	$2,114.33
Rate for Payer: Cigna Commercial	$2,597.90

nortriptyline 25 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77730046
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

nortriptyline 25 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77730046
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

Npwt Dme <= 50 Sq cm

Facility

$304.00

Service Code	CPT 97605
Hospital Charge Code	7150618
Hospital Revenue Code	761
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$414.75
Rate for Payer: Aetna Commercial	$167.20
Rate for Payer: Aetna Medicare	$274.63
Rate for Payer: Amerigroup CHIP/Medicaid	$27.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cigna Commercial	$414.75
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 Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$197.60
Rate for Payer: Multiplan Commercial	$197.60
Rate for Payer: Multiplan Workers Comp	$197.60
Rate for Payer: Scott and White EPO/PPO	$29.71
Rate for Payer: Scott and White Medicare	$183.09
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

Npwt Dme >50 Sq cm

Facility

$400.00

Service Code	CPT 97606
Hospital Charge Code	7150626
Hospital Revenue Code	761
Min. Negotiated Rate	$32.61
Max. Negotiated Rate	$826.08
Rate for Payer: Aetna Commercial	$220.00
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$36.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cigna Commercial	$826.08
Rate for Payer: Cigna Medicare	$364.67
Rate for Payer: Employer Direct Commercial	$364.67
Rate for Payer: Humana Medicare/TRICARE	$364.67
Rate for Payer: Molina Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$260.00
Rate for Payer: Multiplan Commercial	$260.00
Rate for Payer: Multiplan Workers Comp	$260.00
Rate for Payer: Scott and White EPO/PPO	$32.61
Rate for Payer: Scott and White Medicare	$364.67
Rate for Payer: Superior Health Plan EPO	$364.67
Rate for Payer: Superior Health Plan Medicare	$364.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$364.67
Rate for Payer: Universal American Medicare	$364.67
Rate for Payer: Wellcare Medicare	$364.67
Rate for Payer: Wellmed Medicare	$364.67

Npwt Nondme <= 50 Sq cm

Facility

$688.00

Service Code	CPT 97607
Hospital Charge Code	7150921
Hospital Revenue Code	761
Min. Negotiated Rate	$25.71
Max. Negotiated Rate	$826.08
Rate for Payer: Aetna Commercial	$378.40
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$61.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$605.44
Rate for Payer: Cash Price	$605.44
Rate for Payer: Cash Price	$605.44
Rate for Payer: Cigna Commercial	$826.08
Rate for Payer: Cigna Medicare	$364.67
Rate for Payer: Employer Direct Commercial	$364.67
Rate for Payer: Humana Medicare/TRICARE	$364.67
Rate for Payer: Molina Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$447.20
Rate for Payer: Multiplan Commercial	$447.20
Rate for Payer: Multiplan Workers Comp	$447.20
Rate for Payer: Scott and White EPO/PPO	$25.71
Rate for Payer: Scott and White Medicare	$364.67
Rate for Payer: Superior Health Plan EPO	$364.67
Rate for Payer: Superior Health Plan Medicare	$364.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$364.67
Rate for Payer: Universal American Medicare	$364.67
Rate for Payer: Wellcare Medicare	$364.67
Rate for Payer: Wellmed Medicare	$364.67

NT-proBNP SO

Facility

$499.00

Service Code	CPT 83880
Hospital Charge Code	8486564
Hospital Revenue Code	301
Min. Negotiated Rate	$15.31
Max. Negotiated Rate	$324.35
Rate for Payer: Aetna Commercial	$41.23
Rate for Payer: Aetna Medicare	$58.89
Rate for Payer: Amerigroup CHIP/Medicaid	$15.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$39.26
Rate for Payer: Amerigroup Medicare	$39.26
Rate for Payer: BCBS of TX Blue Advantage	$64.78
Rate for Payer: BCBS of TX Blue Essentials	$77.73
Rate for Payer: BCBS of TX Medicare	$39.26
Rate for Payer: BCBS of TX PPO	$86.76
Rate for Payer: Cash Price	$439.12
Rate for Payer: Cash Price	$439.12
Rate for Payer: Cigna Medicaid	$39.26
Rate for Payer: Cigna Medicare	$39.26
Rate for Payer: Employer Direct Commercial	$39.26
Rate for Payer: Humana Medicare/TRICARE	$39.26
Rate for Payer: Molina CHIP/Medicaid	$39.26
Rate for Payer: Molina Dual Medicare/Medicaid	$39.26
Rate for Payer: Molina Medicare	$39.26
Rate for Payer: Multiplan Auto	$324.35
Rate for Payer: Multiplan Commercial	$324.35
Rate for Payer: Multiplan Workers Comp	$324.35
Rate for Payer: Parkland Medicaid	$39.26
Rate for Payer: Scott and White EPO/PPO	$49.08
Rate for Payer: Scott and White Medicare	$39.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.26
Rate for Payer: Superior Health Plan EPO	$39.26
Rate for Payer: Superior Health Plan Medicare	$39.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$39.26
Rate for Payer: Universal American Medicare	$39.26
Rate for Payer: Wellcare Medicare	$39.26
Rate for Payer: Wellmed Medicare	$39.26

NT-proBNP SO

Facility

$499.00

Service Code	CPT 83880
Hospital Charge Code	8486564
Hospital Revenue Code	301
Rate for Payer: Cash Price	$439.12

NTRAPX C FFR W/3D FUNCJL MAP

Facility

$11,321.53

Service Code	CPT 0523T
Hospital Charge Code	8850574
Hospital Revenue Code	481
Min. Negotiated Rate	$1,018.94
Max. Negotiated Rate	$7,358.99
Rate for Payer: Aetna Commercial	$6,226.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1,018.94
Rate for Payer: Cash Price	$9,962.95
Rate for Payer: Multiplan Auto	$7,358.99
Rate for Payer: Multiplan Commercial	$7,358.99
Rate for Payer: Multiplan Workers Comp	$7,358.99
Rate for Payer: Scott and White EPO/PPO	$5,660.77
Rate for Payer: Superior Health Plan EPO	$1,539.73

NTRAPX C FFR W/3D FUNCJL MAP

Facility

$11,321.53

Service Code	CPT 0523T
Hospital Charge Code	8850574
Hospital Revenue Code	481
Rate for Payer: Cash Price	$9,962.95

Nursemaid Elbow Child w/ Manipulation

Facility

$777.00

Service Code	CPT 24640
Hospital Charge Code	8398504
Hospital Revenue Code	450
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$505.05
Rate for Payer: Aetna Commercial	$427.35
Rate for Payer: Aetna Medicare	$323.50
Rate for Payer: Amerigroup CHIP/Medicaid	$69.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$215.67
Rate for Payer: Amerigroup Medicare	$215.67
Rate for Payer: BCBS of TX Blue Advantage	$93.42
Rate for Payer: BCBS of TX Blue Essentials	$111.88
Rate for Payer: BCBS of TX Medicare	$215.67
Rate for Payer: BCBS of TX PPO	$140.97
Rate for Payer: Cash Price	$683.76
Rate for Payer: Cash Price	$683.76
Rate for Payer: Cash Price	$683.76
Rate for Payer: Cigna Commercial	$488.55
Rate for Payer: Cigna Medicaid	$49.00
Rate for Payer: Cigna Medicare	$215.67
Rate for Payer: Employer Direct Commercial	$215.67
Rate for Payer: Humana Medicare/TRICARE	$215.67
Rate for Payer: Molina CHIP/Medicaid	$49.00
Rate for Payer: Molina Dual Medicare/Medicaid	$215.67
Rate for Payer: Molina Medicare	$215.67
Rate for Payer: Multiplan Auto	$505.05
Rate for Payer: Multiplan Commercial	$505.05
Rate for Payer: Multiplan Workers Comp	$505.05
Rate for Payer: Parkland Medicaid	$49.00
Rate for Payer: Scott and White EPO/PPO	$99.47
Rate for Payer: Scott and White Medicare	$215.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.00
Rate for Payer: Superior Health Plan EPO	$215.67
Rate for Payer: Superior Health Plan Medicare	$215.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$215.67
Rate for Payer: Universal American Medicare	$215.67
Rate for Payer: Wellcare Medicare	$215.67
Rate for Payer: Wellmed Medicare	$215.67

Know your out-of-pocket cost for care.

All Charges