White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER O.R. PROCEDURES FOR INJURIES WITH MCC

Facility

$48,341.80

Service Code	MSDRG 907
Min. Negotiated Rate	$33,265.66
Max. Negotiated Rate	$48,341.80
Rate for Payer: Aetna Commercial	$41,844.38
Rate for Payer: Aetna Medicare	$44,096.04
Rate for Payer: BCBS of TX Blue Advantage	$33,265.66
Rate for Payer: BCBS of TX Blue Essentials	$43,505.94
Rate for Payer: BCBS of TX PPO	$48,341.80
Rate for Payer: Cigna Commercial	$47,907.16

OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC

Facility

$18,800.12

Service Code	MSDRG 909
Min. Negotiated Rate	$11,274.60
Max. Negotiated Rate	$18,800.12
Rate for Payer: Aetna Commercial	$15,258.38
Rate for Payer: Aetna Medicare	$18,800.12
Rate for Payer: BCBS of TX Blue Advantage	$11,274.60
Rate for Payer: BCBS of TX Blue Essentials	$13,676.80
Rate for Payer: BCBS of TX PPO	$15,197.04
Rate for Payer: Cigna Commercial	$17,469.14

OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC

Facility

$52,097.02

Service Code	MSDRG 958
Min. Negotiated Rate	$33,188.26
Max. Negotiated Rate	$52,097.02
Rate for Payer: Aetna Commercial	$45,504.00
Rate for Payer: Aetna Medicare	$47,578.08
Rate for Payer: BCBS of TX Blue Advantage	$33,188.26
Rate for Payer: BCBS of TX Blue Essentials	$43,131.36
Rate for Payer: BCBS of TX PPO	$47,925.59
Rate for Payer: Cigna Commercial	$52,097.02

OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC

Facility

$93,154.60

Service Code	MSDRG 957
Min. Negotiated Rate	$59,268.62
Max. Negotiated Rate	$93,154.60
Rate for Payer: Aetna Commercial	$81,365.62
Rate for Payer: Aetna Medicare	$81,699.51
Rate for Payer: BCBS of TX Blue Advantage	$59,268.62
Rate for Payer: BCBS of TX Blue Essentials	$78,408.92
Rate for Payer: BCBS of TX PPO	$87,124.40
Rate for Payer: Cigna Commercial	$93,154.60

OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC

Facility

$32,617.31

Service Code	MSDRG 959
Min. Negotiated Rate	$21,736.50
Max. Negotiated Rate	$32,617.31
Rate for Payer: Aetna Commercial	$28,489.50
Rate for Payer: Aetna Medicare	$31,389.21
Rate for Payer: BCBS of TX Blue Advantage	$21,736.50
Rate for Payer: BCBS of TX Blue Essentials	$25,288.77
Rate for Payer: BCBS of TX PPO	$28,099.73
Rate for Payer: Cigna Commercial	$32,617.31

OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC

Facility

$24,172.51

Service Code	MSDRG 803
Min. Negotiated Rate	$15,281.34
Max. Negotiated Rate	$24,172.51
Rate for Payer: Aetna Commercial	$20,904.75
Rate for Payer: Aetna Medicare	$24,172.51
Rate for Payer: BCBS of TX Blue Advantage	$15,281.34
Rate for Payer: BCBS of TX Blue Essentials	$17,770.35
Rate for Payer: BCBS of TX PPO	$19,745.60
Rate for Payer: Cigna Commercial	$23,933.62

OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC

Facility

$43,667.06

Service Code	MSDRG 802
Min. Negotiated Rate	$27,200.94
Max. Negotiated Rate	$43,667.06
Rate for Payer: Aetna Commercial	$38,140.88
Rate for Payer: Aetna Medicare	$41,005.79
Rate for Payer: BCBS of TX Blue Advantage	$27,200.94
Rate for Payer: BCBS of TX Blue Essentials	$34,539.76
Rate for Payer: BCBS of TX PPO	$38,379.00
Rate for Payer: Cigna Commercial	$43,667.06

OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC

Facility

$17,238.42

Service Code	MSDRG 804
Min. Negotiated Rate	$10,630.46
Max. Negotiated Rate	$17,238.42
Rate for Payer: Aetna Commercial	$13,617.00
Rate for Payer: Aetna Medicare	$17,238.42
Rate for Payer: BCBS of TX Blue Advantage	$10,630.46
Rate for Payer: BCBS of TX Blue Essentials	$12,697.53
Rate for Payer: BCBS of TX PPO	$14,108.91
Rate for Payer: Cigna Commercial	$15,589.95

OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC

Facility

$23,659.78

Service Code	MSDRG 205
Min. Negotiated Rate	$12,599.00
Max. Negotiated Rate	$23,659.78
Rate for Payer: Aetna Commercial	$20,365.88
Rate for Payer: Aetna Medicare	$23,659.78
Rate for Payer: BCBS of TX Blue Advantage	$12,599.00
Rate for Payer: BCBS of TX Blue Essentials	$15,663.21
Rate for Payer: BCBS of TX PPO	$17,404.24
Rate for Payer: Cigna Commercial	$23,316.66

OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC

Facility

$14,060.35

Service Code	MSDRG 206
Min. Negotiated Rate	$7,155.20
Max. Negotiated Rate	$14,060.35
Rate for Payer: Aetna Commercial	$10,276.88
Rate for Payer: Aetna Medicare	$14,060.35
Rate for Payer: BCBS of TX Blue Advantage	$7,155.20
Rate for Payer: BCBS of TX Blue Essentials	$8,910.46
Rate for Payer: BCBS of TX PPO	$9,900.89
Rate for Payer: Cigna Commercial	$11,765.88

OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC

Facility

$23,761.46

Service Code	MSDRG 167
Min. Negotiated Rate	$16,813.00
Max. Negotiated Rate	$23,761.46
Rate for Payer: Aetna Commercial	$20,472.75
Rate for Payer: Aetna Medicare	$23,761.46
Rate for Payer: BCBS of TX Blue Advantage	$16,813.00
Rate for Payer: BCBS of TX Blue Essentials	$19,581.33
Rate for Payer: BCBS of TX PPO	$21,757.88
Rate for Payer: Cigna Commercial	$23,439.02

OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC

Facility

$52,264.46

Service Code	MSDRG 166
Min. Negotiated Rate	$30,583.32
Max. Negotiated Rate	$52,264.46
Rate for Payer: Aetna Commercial	$45,650.25
Rate for Payer: Aetna Medicare	$47,717.22
Rate for Payer: BCBS of TX Blue Advantage	$30,583.32
Rate for Payer: BCBS of TX Blue Essentials	$36,095.86
Rate for Payer: BCBS of TX PPO	$40,108.07
Rate for Payer: Cigna Commercial	$52,264.46

OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC

Facility

$18,793.69

Service Code	MSDRG 168
Min. Negotiated Rate	$11,488.74
Max. Negotiated Rate	$18,793.69
Rate for Payer: Aetna Commercial	$15,251.62
Rate for Payer: Aetna Medicare	$18,793.69
Rate for Payer: BCBS of TX Blue Advantage	$11,488.74
Rate for Payer: BCBS of TX Blue Essentials	$13,843.97
Rate for Payer: BCBS of TX PPO	$15,382.79
Rate for Payer: Cigna Commercial	$17,461.42

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC

Facility

$22,977.93

Service Code	MSDRG 580
Min. Negotiated Rate	$14,175.38
Max. Negotiated Rate	$22,977.93
Rate for Payer: Aetna Commercial	$19,649.25
Rate for Payer: Aetna Medicare	$22,977.93
Rate for Payer: BCBS of TX Blue Advantage	$14,175.38
Rate for Payer: BCBS of TX Blue Essentials	$16,405.15
Rate for Payer: BCBS of TX PPO	$18,228.65
Rate for Payer: Cigna Commercial	$22,496.21

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC

Facility

$43,047.54

Service Code	MSDRG 579
Min. Negotiated Rate	$23,390.28
Max. Negotiated Rate	$43,047.54
Rate for Payer: Aetna Commercial	$37,599.75
Rate for Payer: Aetna Medicare	$40,057.38
Rate for Payer: BCBS of TX Blue Advantage	$23,390.28
Rate for Payer: BCBS of TX Blue Essentials	$28,870.50
Rate for Payer: BCBS of TX PPO	$32,079.57
Rate for Payer: Cigna Commercial	$43,047.54

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC

Facility

$18,697.38

Service Code	MSDRG 581
Min. Negotiated Rate	$10,892.76
Max. Negotiated Rate	$18,697.38
Rate for Payer: Aetna Commercial	$15,150.38
Rate for Payer: Aetna Medicare	$18,697.38
Rate for Payer: BCBS of TX Blue Advantage	$10,892.76
Rate for Payer: BCBS of TX Blue Essentials	$12,758.41
Rate for Payer: BCBS of TX PPO	$14,176.56
Rate for Payer: Cigna Commercial	$17,345.50

OTHER VASCULAR PROCEDURES WITH CC

Facility

$32,858.17

Service Code	MSDRG 253
Min. Negotiated Rate	$22,739.26
Max. Negotiated Rate	$32,858.17
Rate for Payer: Aetna Commercial	$28,699.88
Rate for Payer: Aetna Medicare	$31,589.37
Rate for Payer: BCBS of TX Blue Advantage	$22,739.26
Rate for Payer: BCBS of TX Blue Essentials	$26,770.58
Rate for Payer: BCBS of TX PPO	$29,746.24
Rate for Payer: Cigna Commercial	$32,858.17

OTHER VASCULAR PROCEDURES WITH MCC

Facility

$43,196.94

Service Code	MSDRG 252
Min. Negotiated Rate	$28,488.36
Max. Negotiated Rate	$43,196.94
Rate for Payer: Aetna Commercial	$37,730.25
Rate for Payer: Aetna Medicare	$40,181.54
Rate for Payer: BCBS of TX Blue Advantage	$28,488.36
Rate for Payer: BCBS of TX Blue Essentials	$33,637.88
Rate for Payer: BCBS of TX PPO	$37,376.87
Rate for Payer: Cigna Commercial	$43,196.94

OTHER VASCULAR PROCEDURES WITHOUT CC/MCC

Facility

$22,854.84

Service Code	MSDRG 254
Min. Negotiated Rate	$15,277.04
Max. Negotiated Rate	$22,854.84
Rate for Payer: Aetna Commercial	$19,519.88
Rate for Payer: Aetna Medicare	$22,854.84
Rate for Payer: BCBS of TX Blue Advantage	$15,277.04
Rate for Payer: BCBS of TX Blue Essentials	$18,677.39
Rate for Payer: BCBS of TX PPO	$20,753.46
Rate for Payer: Cigna Commercial	$22,348.09

OT Iontophoresis Assistant Units

Facility

$111.00

Service Code	CPT 97033 CO,GO
Hospital Charge Code	5810015
Hospital Revenue Code	430
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$36.99
Rate for Payer: BCBS of TX Blue Essentials	$44.22
Rate for Payer: BCBS of TX PPO	$49.32
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$15.10

OT Iontophoresis Assistant Units BCE

Facility

$111.00

Service Code	CPT 97033 CO,GO
Hospital Charge Code	5810015
Hospital Revenue Code	430
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$36.99
Rate for Payer: BCBS of TX Blue Essentials	$44.22
Rate for Payer: BCBS of TX PPO	$49.32
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$15.10

OT Iontophoresis Assistant Units BCE

Facility

$111.00

Service Code	CPT 97033 CO,GO
Hospital Charge Code	5810015
Hospital Revenue Code	430
Rate for Payer: Cash Price	$97.68

OT Iontophoresis Units

Facility

$111.00

Service Code	CPT 97033 GO
Hospital Charge Code	5815272
Hospital Revenue Code	430
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$36.99
Rate for Payer: BCBS of TX Blue Essentials	$44.22
Rate for Payer: BCBS of TX PPO	$49.32
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$15.10

OT Iontophoresis Units BCE

Facility

$111.00

Service Code	CPT 97033 GO
Hospital Charge Code	5815272
Hospital Revenue Code	430
Rate for Payer: Cash Price	$97.68

OT Iontophoresis Units BCE

Facility

$111.00

Service Code	CPT 97033 GO
Hospital Charge Code	5815272
Hospital Revenue Code	430
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$36.99
Rate for Payer: BCBS of TX Blue Essentials	$44.22
Rate for Payer: BCBS of TX PPO	$49.32
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$15.10

Know your out-of-pocket cost for care.

All Charges