White Rock Medical Center

All Charges

Charge

Type

Setting

Price

HYPERTENSION

Facility

$2,781.77

Service Code	APR-DRG 1991
Min. Negotiated Rate	$2,622.75
Max. Negotiated Rate	$2,781.77
Rate for Payer: Amerigroup CHIP/Medicaid	$2,622.75
Rate for Payer: Cigna Medicaid	$2,622.75
Rate for Payer: Molina CHIP/Medicaid	$2,622.75
Rate for Payer: Parkland Medicaid	$2,622.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,781.77

HYPERTENSION

Facility

$3,021.28

Service Code	APR-DRG 1992
Min. Negotiated Rate	$2,848.57
Max. Negotiated Rate	$3,021.28
Rate for Payer: Amerigroup CHIP/Medicaid	$2,848.57
Rate for Payer: Cigna Medicaid	$2,848.57
Rate for Payer: Molina CHIP/Medicaid	$2,848.57
Rate for Payer: Parkland Medicaid	$2,848.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,021.28

HYPERTENSION

Facility

$8,104.66

Service Code	APR-DRG 1994
Min. Negotiated Rate	$7,641.36
Max. Negotiated Rate	$8,104.66
Rate for Payer: Amerigroup CHIP/Medicaid	$7,641.36
Rate for Payer: Cigna Medicaid	$7,641.36
Rate for Payer: Molina CHIP/Medicaid	$7,641.36
Rate for Payer: Parkland Medicaid	$7,641.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,104.66

HYPERTENSION WITH MCC

Facility

$20,873.40

Service Code	MSDRG 304
Min. Negotiated Rate	$9,297.46
Max. Negotiated Rate	$20,873.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,481.63
Rate for Payer: Amerigroup Medicare	$13,481.63
Rate for Payer: BCBS of TX Medicare	$13,481.63
Rate for Payer: Cigna Commercial	$15,327.20
Rate for Payer: Cigna Medicare	$13,481.63
Rate for Payer: Employer Direct Commercial	$13,481.63
Rate for Payer: Humana Medicare/TRICARE	$13,481.63
Rate for Payer: Molina Dual Medicare/Medicaid	$13,481.63
Rate for Payer: Molina Medicare	$13,481.63
Rate for Payer: Multiplan Auto	$20,873.40
Rate for Payer: Multiplan Commercial	$20,873.40
Rate for Payer: Multiplan Workers Comp	$20,873.40
Rate for Payer: Scott and White EPO/PPO	$9,612.75
Rate for Payer: Scott and White Medicare	$13,481.63
Rate for Payer: Superior Health Plan EPO	$13,481.63
Rate for Payer: Superior Health Plan Medicare	$13,481.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,481.63
Rate for Payer: Universal American Medicare	$13,481.63
Rate for Payer: Wellcare Medicare	$13,481.63
Rate for Payer: Wellmed Medicare	$13,481.63

HYPERTENSION WITHOUT MCC

Facility

$14,166.40

Service Code	MSDRG 305
Min. Negotiated Rate	$6,191.14
Max. Negotiated Rate	$14,166.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,294.23
Rate for Payer: Amerigroup Medicare	$10,294.23
Rate for Payer: BCBS of TX Medicare	$10,294.23
Rate for Payer: Cigna Commercial	$9,725.69
Rate for Payer: Cigna Medicare	$10,294.23
Rate for Payer: Employer Direct Commercial	$10,294.23
Rate for Payer: Humana Medicare/TRICARE	$10,294.23
Rate for Payer: Molina Dual Medicare/Medicaid	$10,294.23
Rate for Payer: Molina Medicare	$10,294.23
Rate for Payer: Multiplan Auto	$14,166.40
Rate for Payer: Multiplan Commercial	$14,166.40
Rate for Payer: Multiplan Workers Comp	$14,166.40
Rate for Payer: Scott and White EPO/PPO	$6,524.00
Rate for Payer: Scott and White Medicare	$10,294.23
Rate for Payer: Superior Health Plan EPO	$10,294.23
Rate for Payer: Superior Health Plan Medicare	$10,294.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,294.23
Rate for Payer: Universal American Medicare	$10,294.23
Rate for Payer: Wellcare Medicare	$10,294.23
Rate for Payer: Wellmed Medicare	$10,294.23

HYPERTENSION W MCC

Facility

$20,873.40

Service Code	MSDRG 304
Min. Negotiated Rate	$9,297.46
Max. Negotiated Rate	$20,873.40
Rate for Payer: BCBS of TX Blue Advantage	$9,297.46
Rate for Payer: BCBS of TX Blue Essentials	$11,155.87
Rate for Payer: BCBS of TX PPO	$12,395.89

HYPERTENSION W/O MCC

Facility

$14,166.40

Service Code	MSDRG 305
Min. Negotiated Rate	$6,191.14
Max. Negotiated Rate	$14,166.40
Rate for Payer: BCBS of TX Blue Advantage	$6,191.14
Rate for Payer: BCBS of TX Blue Essentials	$7,428.65
Rate for Payer: BCBS of TX PPO	$8,254.37

HYPERTENSIVE ENCEPHALOPATHY W CC

Facility

$18,863.20

Service Code	MSDRG 078
Min. Negotiated Rate	$8,342.86
Max. Negotiated Rate	$18,863.20
Rate for Payer: BCBS of TX Blue Advantage	$8,342.86
Rate for Payer: BCBS of TX Blue Essentials	$10,010.46
Rate for Payer: BCBS of TX PPO	$11,123.17

HYPERTENSIVE ENCEPHALOPATHY WITH CC

Facility

$18,863.20

Service Code	MSDRG 078
Min. Negotiated Rate	$8,342.86
Max. Negotiated Rate	$18,863.20
Rate for Payer: Multiplan Auto	$18,863.20
Rate for Payer: Multiplan Commercial	$18,863.20
Rate for Payer: Multiplan Workers Comp	$18,863.20
Rate for Payer: Scott and White EPO/PPO	$8,687.00

HYPERTENSIVE ENCEPHALOPATHY WITH MCC

Facility

$29,719.80

Service Code	MSDRG 077
Min. Negotiated Rate	$13,347.20
Max. Negotiated Rate	$29,719.80
Rate for Payer: Multiplan Auto	$29,719.80
Rate for Payer: Multiplan Commercial	$29,719.80
Rate for Payer: Multiplan Workers Comp	$29,719.80
Rate for Payer: Scott and White EPO/PPO	$13,686.75

HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC

Facility

$13,944.10

Service Code	MSDRG 079
Min. Negotiated Rate	$6,419.90
Max. Negotiated Rate	$13,944.10
Rate for Payer: Multiplan Auto	$13,944.10
Rate for Payer: Multiplan Commercial	$13,944.10
Rate for Payer: Multiplan Workers Comp	$13,944.10
Rate for Payer: Scott and White EPO/PPO	$6,421.62

HYPERTENSIVE ENCEPHALOPATHY W MCC

Facility

$29,719.80

Service Code	MSDRG 077
Min. Negotiated Rate	$13,347.20
Max. Negotiated Rate	$29,719.80
Rate for Payer: BCBS of TX Blue Advantage	$13,347.20
Rate for Payer: BCBS of TX Blue Essentials	$16,015.09
Rate for Payer: BCBS of TX PPO	$17,795.23

HYPERTENSIVE ENCEPHALOPATHY W/O CC/MCC

Facility

$13,944.10

Service Code	MSDRG 079
Min. Negotiated Rate	$6,419.90
Max. Negotiated Rate	$13,944.10
Rate for Payer: BCBS of TX Blue Advantage	$6,419.90
Rate for Payer: BCBS of TX Blue Essentials	$7,703.13
Rate for Payer: BCBS of TX PPO	$8,559.37

HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS

Facility

$9,017.08

Service Code	APR-DRG 4224
Min. Negotiated Rate	$8,501.62
Max. Negotiated Rate	$9,017.08
Rate for Payer: Amerigroup CHIP/Medicaid	$8,501.62
Rate for Payer: Cigna Medicaid	$8,501.62
Rate for Payer: Molina CHIP/Medicaid	$8,501.62
Rate for Payer: Parkland Medicaid	$8,501.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,017.08

HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS

Facility

$1,208.51

Service Code	APR-DRG 4221
Min. Negotiated Rate	$1,139.43
Max. Negotiated Rate	$1,208.51
Rate for Payer: Amerigroup CHIP/Medicaid	$1,139.43
Rate for Payer: Cigna Medicaid	$1,139.43
Rate for Payer: Molina CHIP/Medicaid	$1,139.43
Rate for Payer: Parkland Medicaid	$1,139.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,208.51

HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS

Facility

$2,031.92

Service Code	APR-DRG 4222
Min. Negotiated Rate	$1,915.76
Max. Negotiated Rate	$2,031.92
Rate for Payer: Amerigroup CHIP/Medicaid	$1,915.76
Rate for Payer: Cigna Medicaid	$1,915.76
Rate for Payer: Molina CHIP/Medicaid	$1,915.76
Rate for Payer: Parkland Medicaid	$1,915.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,031.92

HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS

Facility

$3,623.65

Service Code	APR-DRG 4223
Min. Negotiated Rate	$3,416.51
Max. Negotiated Rate	$3,623.65
Rate for Payer: Amerigroup CHIP/Medicaid	$3,416.51
Rate for Payer: Cigna Medicaid	$3,416.51
Rate for Payer: Molina CHIP/Medicaid	$3,416.51
Rate for Payer: Parkland Medicaid	$3,416.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,623.65

IABP INSERTION PERCUTANEOUS

Facility

$7,398.00

Service Code	HCPCS 33967
Hospital Charge Code	2302784
Hospital Revenue Code	481
Min. Negotiated Rate	$306.90
Max. Negotiated Rate	$5,326.56
Rate for Payer: Amerigroup CHIP/Medicaid	$665.82
Rate for Payer: BCBS of TX Blue Advantage	$455.01
Rate for Payer: BCBS of TX Blue Essentials	$544.92
Rate for Payer: BCBS of TX PPO	$686.60
Rate for Payer: Cash Price	$5,030.64
Rate for Payer: Cash Price	$5,030.64
Rate for Payer: Cigna Medicaid	$5,326.56
Rate for Payer: Molina CHIP/Medicaid	$5,326.56
Rate for Payer: Multiplan Auto	$4,808.70
Rate for Payer: Multiplan Commercial	$4,808.70
Rate for Payer: Multiplan Workers Comp	$4,808.70
Rate for Payer: Parkland Medicaid	$5,326.56
Rate for Payer: Scott and White EPO/PPO	$306.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,326.56
Rate for Payer: Superior Health Plan EPO	$1,006.13

IABP INSERTION PERCUTANEOUS

Facility

$7,398.00

Service Code	HCPCS 33967
Hospital Charge Code	2302784
Hospital Revenue Code	481
Rate for Payer: Cash Price	$5,030.64

IB200020

Facility

$746.99

Service Code	HCPCS C1713
Hospital Charge Code	991089
Hospital Revenue Code	278
Min. Negotiated Rate	$186.75
Max. Negotiated Rate	$373.50
Rate for Payer: Cash Price	$507.95
Rate for Payer: Cigna Commercial	$186.75
Rate for Payer: Multiplan Auto	$373.50
Rate for Payer: Multiplan Commercial	$373.50
Rate for Payer: Multiplan Workers Comp	$373.50
Rate for Payer: Scott and White EPO/PPO	$373.50

IB200020

Facility

$746.99

Service Code	HCPCS C1713
Hospital Charge Code	991089
Hospital Revenue Code	278
Min. Negotiated Rate	$67.23
Max. Negotiated Rate	$537.83
Rate for Payer: Amerigroup CHIP/Medicaid	$67.23
Rate for Payer: BCBS of TX Blue Advantage	$224.10
Rate for Payer: BCBS of TX Blue Essentials	$268.92
Rate for Payer: BCBS of TX PPO	$298.80
Rate for Payer: Cash Price	$507.95
Rate for Payer: Cigna Medicaid	$537.83
Rate for Payer: Molina CHIP/Medicaid	$537.83
Rate for Payer: Multiplan Auto	$373.50
Rate for Payer: Multiplan Commercial	$373.50
Rate for Payer: Multiplan Workers Comp	$373.50
Rate for Payer: Parkland Medicaid	$537.83
Rate for Payer: Scott and White EPO/PPO	$373.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$537.83
Rate for Payer: Superior Health Plan EPO	$101.59

IB200051

Facility

$1,710.84

Service Code	HCPCS C1713
Hospital Charge Code	991090
Hospital Revenue Code	278
Min. Negotiated Rate	$427.71
Max. Negotiated Rate	$855.42
Rate for Payer: Cash Price	$1,163.37
Rate for Payer: Cigna Commercial	$427.71
Rate for Payer: Multiplan Auto	$855.42
Rate for Payer: Multiplan Commercial	$855.42
Rate for Payer: Multiplan Workers Comp	$855.42
Rate for Payer: Scott and White EPO/PPO	$855.42

IB200051

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Charge Code	991050
Hospital Revenue Code	278
Min. Negotiated Rate	$415.75
Max. Negotiated Rate	$831.50
Rate for Payer: Cash Price	$1,130.84
Rate for Payer: Cigna Commercial	$415.75
Rate for Payer: Multiplan Auto	$831.50
Rate for Payer: Multiplan Commercial	$831.50
Rate for Payer: Multiplan Workers Comp	$831.50
Rate for Payer: Scott and White EPO/PPO	$831.50

IB200051

Facility

$1,710.84

Service Code	HCPCS C1713
Hospital Charge Code	991090
Hospital Revenue Code	278
Min. Negotiated Rate	$153.98
Max. Negotiated Rate	$1,231.80
Rate for Payer: Amerigroup CHIP/Medicaid	$153.98
Rate for Payer: BCBS of TX Blue Advantage	$513.25
Rate for Payer: BCBS of TX Blue Essentials	$615.90
Rate for Payer: BCBS of TX PPO	$684.34
Rate for Payer: Cash Price	$1,163.37
Rate for Payer: Cigna Medicaid	$1,231.80
Rate for Payer: Molina CHIP/Medicaid	$1,231.80
Rate for Payer: Multiplan Auto	$855.42
Rate for Payer: Multiplan Commercial	$855.42
Rate for Payer: Multiplan Workers Comp	$855.42
Rate for Payer: Parkland Medicaid	$1,231.80
Rate for Payer: Scott and White EPO/PPO	$855.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,231.80
Rate for Payer: Superior Health Plan EPO	$232.67

IB200051

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Charge Code	991050
Hospital Revenue Code	278
Min. Negotiated Rate	$149.67
Max. Negotiated Rate	$1,197.36
Rate for Payer: Amerigroup CHIP/Medicaid	$149.67
Rate for Payer: BCBS of TX Blue Advantage	$498.90
Rate for Payer: BCBS of TX Blue Essentials	$598.68
Rate for Payer: BCBS of TX PPO	$665.20
Rate for Payer: Cash Price	$1,130.84
Rate for Payer: Cigna Medicaid	$1,197.36
Rate for Payer: Molina CHIP/Medicaid	$1,197.36
Rate for Payer: Multiplan Auto	$831.50
Rate for Payer: Multiplan Commercial	$831.50
Rate for Payer: Multiplan Workers Comp	$831.50
Rate for Payer: Parkland Medicaid	$1,197.36
Rate for Payer: Scott and White EPO/PPO	$831.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,197.36
Rate for Payer: Superior Health Plan EPO	$226.17

Know your out-of-pocket cost for care.

All Charges