White Rock Medical Center

All Charges

Charge

Type

Setting

Price

INTERSTITIAL LUNG DISEASE W MCC

Facility

$35,856.80

Service Code	MSDRG 196
Min. Negotiated Rate	$14,087.66
Max. Negotiated Rate	$35,856.80
Rate for Payer: BCBS of TX Blue Advantage	$14,087.66
Rate for Payer: BCBS of TX Blue Essentials	$16,903.55
Rate for Payer: BCBS of TX PPO	$18,782.45

INTERSTITIAL LUNG DISEASE W/O CC/MCC

Facility

$13,607.80

Service Code	MSDRG 198
Min. Negotiated Rate	$6,266.75
Max. Negotiated Rate	$13,607.80
Rate for Payer: BCBS of TX Blue Advantage	$6,523.10
Rate for Payer: BCBS of TX Blue Essentials	$7,826.96
Rate for Payer: BCBS of TX PPO	$8,696.96

INTESTINAL OBSTRUCTION

Facility

$2,934.15

Service Code	APR-DRG 2472
Min. Negotiated Rate	$2,766.42
Max. Negotiated Rate	$2,934.15
Rate for Payer: Amerigroup CHIP/Medicaid	$2,766.42
Rate for Payer: Cigna Medicaid	$2,766.42
Rate for Payer: Molina CHIP/Medicaid	$2,766.42
Rate for Payer: Parkland Medicaid	$2,766.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,934.15

INTESTINAL OBSTRUCTION

Facility

$10,215.03

Service Code	APR-DRG 2474
Min. Negotiated Rate	$9,631.09
Max. Negotiated Rate	$10,215.03
Rate for Payer: Amerigroup CHIP/Medicaid	$9,631.09
Rate for Payer: Cigna Medicaid	$9,631.09
Rate for Payer: Molina CHIP/Medicaid	$9,631.09
Rate for Payer: Parkland Medicaid	$9,631.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,215.03

INTESTINAL OBSTRUCTION

Facility

$4,758.62

Service Code	APR-DRG 2473
Min. Negotiated Rate	$4,486.59
Max. Negotiated Rate	$4,758.62
Rate for Payer: Amerigroup CHIP/Medicaid	$4,486.59
Rate for Payer: Cigna Medicaid	$4,486.59
Rate for Payer: Molina CHIP/Medicaid	$4,486.59
Rate for Payer: Parkland Medicaid	$4,486.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,758.62

INTESTINAL OBSTRUCTION

Facility

$2,092.27

Service Code	APR-DRG 2471
Min. Negotiated Rate	$1,972.66
Max. Negotiated Rate	$2,092.27
Rate for Payer: Amerigroup CHIP/Medicaid	$1,972.66
Rate for Payer: Cigna Medicaid	$1,972.66
Rate for Payer: Molina CHIP/Medicaid	$1,972.66
Rate for Payer: Parkland Medicaid	$1,972.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,092.27

Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for intestinal obstruction

Facility

$44,600.00

Service Code	HCPCS 44615
Hospital Charge Code	9900924
Hospital Revenue Code	360
Min. Negotiated Rate	$1,874.17
Max. Negotiated Rate	$32,112.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4,014.00
Rate for Payer: BCBS of TX Blue Advantage	$1,874.17
Rate for Payer: BCBS of TX Blue Essentials	$2,244.52
Rate for Payer: BCBS of TX PPO	$2,828.10
Rate for Payer: Cash Price	$30,328.00
Rate for Payer: Cash Price	$30,328.00
Rate for Payer: Cash Price	$30,328.00
Rate for Payer: Cigna Medicaid	$32,112.00
Rate for Payer: Molina CHIP/Medicaid	$32,112.00
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	$32,112.00
Rate for Payer: Scott and White EPO/PPO	$22,300.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32,112.00
Rate for Payer: Superior Health Plan EPO	$6,065.60

Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for intestinal obstruction

Facility

$44,600.00

Service Code	HCPCS 44615
Hospital Charge Code	9900924
Hospital Revenue Code	360
Rate for Payer: Cash Price	$30,328.00

INTRACARD ECHO

Facility

$5,734.00

Service Code	HCPCS 93662
Hospital Charge Code	4613662
Hospital Revenue Code	480
Rate for Payer: Cash Price	$3,899.12

INTRACARD ECHO

Facility

$5,734.00

Service Code	HCPCS 93662
Hospital Charge Code	4613662
Hospital Revenue Code	480
Min. Negotiated Rate	$516.06
Max. Negotiated Rate	$4,128.48
Rate for Payer: Amerigroup CHIP/Medicaid	$516.06
Rate for Payer: BCBS of TX Blue Advantage	$1,720.20
Rate for Payer: BCBS of TX Blue Essentials	$2,064.24
Rate for Payer: BCBS of TX PPO	$2,293.60
Rate for Payer: Cash Price	$3,899.12
Rate for Payer: Cigna Medicaid	$4,128.48
Rate for Payer: Molina CHIP/Medicaid	$4,128.48
Rate for Payer: Multiplan Auto	$3,727.10
Rate for Payer: Multiplan Commercial	$3,727.10
Rate for Payer: Multiplan Workers Comp	$3,727.10
Rate for Payer: Parkland Medicaid	$4,128.48
Rate for Payer: Scott and White EPO/PPO	$2,867.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,128.48
Rate for Payer: Superior Health Plan EPO	$779.82

INTRA CORONARY ULTRASOUND

Facility

$7,415.00

Service Code	HCPCS 92978
Hospital Charge Code	2302214
Hospital Revenue Code	480
Min. Negotiated Rate	$667.35
Max. Negotiated Rate	$5,338.80
Rate for Payer: Amerigroup CHIP/Medicaid	$667.35
Rate for Payer: BCBS of TX Blue Advantage	$2,224.50
Rate for Payer: BCBS of TX Blue Essentials	$2,669.40
Rate for Payer: BCBS of TX PPO	$2,966.00
Rate for Payer: Cash Price	$5,042.20
Rate for Payer: Cigna Medicaid	$5,338.80
Rate for Payer: Molina CHIP/Medicaid	$5,338.80
Rate for Payer: Multiplan Auto	$4,819.75
Rate for Payer: Multiplan Commercial	$4,819.75
Rate for Payer: Multiplan Workers Comp	$4,819.75
Rate for Payer: Parkland Medicaid	$5,338.80
Rate for Payer: Scott and White EPO/PPO	$3,707.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,338.80
Rate for Payer: Superior Health Plan EPO	$1,008.44

INTRA CORONARY ULTRASOUND

Facility

$7,415.00

Service Code	HCPCS 92978
Hospital Charge Code	2302214
Hospital Revenue Code	480
Rate for Payer: Cash Price	$5,042.20

INTRACRANIAL HEMORRHAGE

Facility

$12,829.33

Service Code	APR-DRG 0444
Min. Negotiated Rate	$12,095.94
Max. Negotiated Rate	$12,829.33
Rate for Payer: Amerigroup CHIP/Medicaid	$12,095.94
Rate for Payer: Cigna Medicaid	$12,095.94
Rate for Payer: Molina CHIP/Medicaid	$12,095.94
Rate for Payer: Parkland Medicaid	$12,095.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,829.33

INTRACRANIAL HEMORRHAGE

Facility

$6,650.97

Service Code	APR-DRG 0442
Min. Negotiated Rate	$6,270.77
Max. Negotiated Rate	$6,650.97
Rate for Payer: Amerigroup CHIP/Medicaid	$6,270.77
Rate for Payer: Cigna Medicaid	$6,270.77
Rate for Payer: Molina CHIP/Medicaid	$6,270.77
Rate for Payer: Parkland Medicaid	$6,270.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,650.97

INTRACRANIAL HEMORRHAGE

Facility

$4,124.94

Service Code	APR-DRG 0441
Min. Negotiated Rate	$3,889.14
Max. Negotiated Rate	$4,124.94
Rate for Payer: Amerigroup CHIP/Medicaid	$3,889.14
Rate for Payer: Cigna Medicaid	$3,889.14
Rate for Payer: Molina CHIP/Medicaid	$3,889.14
Rate for Payer: Parkland Medicaid	$3,889.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,124.94

INTRACRANIAL HEMORRHAGE

Facility

$8,169.54

Service Code	APR-DRG 0443
Min. Negotiated Rate	$7,702.53
Max. Negotiated Rate	$8,169.54
Rate for Payer: Amerigroup CHIP/Medicaid	$7,702.53
Rate for Payer: Cigna Medicaid	$7,702.53
Rate for Payer: Molina CHIP/Medicaid	$7,702.53
Rate for Payer: Parkland Medicaid	$7,702.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,169.54

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS

Facility

$19,195.70

Service Code	MSDRG 065
Min. Negotiated Rate	$8,840.12
Max. Negotiated Rate	$19,195.70
Rate for Payer: BCBS of TX Blue Advantage	$8,870.90
Rate for Payer: BCBS of TX Blue Essentials	$10,644.05
Rate for Payer: BCBS of TX PPO	$11,827.18

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS

Facility

$19,195.70

Service Code	MSDRG 065
Min. Negotiated Rate	$8,840.12
Max. Negotiated Rate	$19,195.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,164.60
Rate for Payer: Amerigroup Medicare	$12,164.60
Rate for Payer: BCBS of TX Medicare	$12,164.60
Rate for Payer: Cigna Commercial	$13,012.66
Rate for Payer: Cigna Medicare	$12,164.60
Rate for Payer: Employer Direct Commercial	$12,164.60
Rate for Payer: Humana Medicare/TRICARE	$12,164.60
Rate for Payer: Molina Dual Medicare/Medicaid	$12,164.60
Rate for Payer: Molina Medicare	$12,164.60
Rate for Payer: Multiplan Auto	$19,195.70
Rate for Payer: Multiplan Commercial	$19,195.70
Rate for Payer: Multiplan Workers Comp	$19,195.70
Rate for Payer: Scott and White EPO/PPO	$8,840.12
Rate for Payer: Scott and White Medicare	$12,164.60
Rate for Payer: Superior Health Plan EPO	$12,164.60
Rate for Payer: Superior Health Plan Medicare	$12,164.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,164.60
Rate for Payer: Universal American Medicare	$12,164.60
Rate for Payer: Wellcare Medicare	$12,164.60
Rate for Payer: Wellmed Medicare	$12,164.60

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC

Facility

$38,209.00

Service Code	MSDRG 064
Min. Negotiated Rate	$16,075.12
Max. Negotiated Rate	$38,209.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,498.74
Rate for Payer: Amerigroup Medicare	$19,498.74
Rate for Payer: BCBS of TX Medicare	$19,498.74
Rate for Payer: Cigna Commercial	$25,901.68
Rate for Payer: Cigna Medicare	$19,498.74
Rate for Payer: Employer Direct Commercial	$19,498.74
Rate for Payer: Humana Medicare/TRICARE	$19,498.74
Rate for Payer: Molina Dual Medicare/Medicaid	$19,498.74
Rate for Payer: Molina Medicare	$19,498.74
Rate for Payer: Multiplan Auto	$38,209.00
Rate for Payer: Multiplan Commercial	$38,209.00
Rate for Payer: Multiplan Workers Comp	$38,209.00
Rate for Payer: Scott and White EPO/PPO	$17,596.25
Rate for Payer: Scott and White Medicare	$19,498.74
Rate for Payer: Superior Health Plan EPO	$19,498.74
Rate for Payer: Superior Health Plan Medicare	$19,498.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,498.74
Rate for Payer: Universal American Medicare	$19,498.74
Rate for Payer: Wellcare Medicare	$19,498.74
Rate for Payer: Wellmed Medicare	$19,498.74

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC

Facility

$13,003.60

Service Code	MSDRG 066
Min. Negotiated Rate	$5,988.50
Max. Negotiated Rate	$13,003.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,776.07
Rate for Payer: Amerigroup Medicare	$9,776.07
Rate for Payer: BCBS of TX Medicare	$9,776.07
Rate for Payer: Cigna Commercial	$8,815.07
Rate for Payer: Cigna Medicare	$9,776.07
Rate for Payer: Employer Direct Commercial	$9,776.07
Rate for Payer: Humana Medicare/TRICARE	$9,776.07
Rate for Payer: Molina Dual Medicare/Medicaid	$9,776.07
Rate for Payer: Molina Medicare	$9,776.07
Rate for Payer: Multiplan Auto	$13,003.60
Rate for Payer: Multiplan Commercial	$13,003.60
Rate for Payer: Multiplan Workers Comp	$13,003.60
Rate for Payer: Scott and White EPO/PPO	$5,988.50
Rate for Payer: Scott and White Medicare	$9,776.07
Rate for Payer: Superior Health Plan EPO	$9,776.07
Rate for Payer: Superior Health Plan Medicare	$9,776.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,776.07
Rate for Payer: Universal American Medicare	$9,776.07
Rate for Payer: Wellcare Medicare	$9,776.07
Rate for Payer: Wellmed Medicare	$9,776.07

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC

Facility

$38,209.00

Service Code	MSDRG 064
Min. Negotiated Rate	$16,075.12
Max. Negotiated Rate	$38,209.00
Rate for Payer: BCBS of TX Blue Advantage	$16,075.12
Rate for Payer: BCBS of TX Blue Essentials	$19,288.27
Rate for Payer: BCBS of TX PPO	$21,432.25

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC

Facility

$13,003.60

Service Code	MSDRG 066
Min. Negotiated Rate	$5,988.50
Max. Negotiated Rate	$13,003.60
Rate for Payer: BCBS of TX Blue Advantage	$6,250.48
Rate for Payer: BCBS of TX Blue Essentials	$7,499.85
Rate for Payer: BCBS of TX PPO	$8,333.49

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC

Facility

$100,582.20

Service Code	MSDRG 021
Min. Negotiated Rate	$43,558.49
Max. Negotiated Rate	$100,582.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43,558.49
Rate for Payer: Amerigroup Medicare	$43,558.49
Rate for Payer: BCBS of TX Medicare	$43,558.49
Rate for Payer: Cigna Commercial	$68,184.14
Rate for Payer: Cigna Medicare	$43,558.49
Rate for Payer: Employer Direct Commercial	$43,558.49
Rate for Payer: Humana Medicare/TRICARE	$43,558.49
Rate for Payer: Molina Dual Medicare/Medicaid	$43,558.49
Rate for Payer: Molina Medicare	$43,558.49
Rate for Payer: Multiplan Auto	$100,582.20
Rate for Payer: Multiplan Commercial	$100,582.20
Rate for Payer: Multiplan Workers Comp	$100,582.20
Rate for Payer: Scott and White EPO/PPO	$46,320.75
Rate for Payer: Scott and White Medicare	$43,558.49
Rate for Payer: Superior Health Plan EPO	$43,558.49
Rate for Payer: Superior Health Plan Medicare	$43,558.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$43,558.49
Rate for Payer: Universal American Medicare	$43,558.49
Rate for Payer: Wellcare Medicare	$43,558.49
Rate for Payer: Wellmed Medicare	$43,558.49

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC

Facility

$149,507.20

Service Code	MSDRG 020
Min. Negotiated Rate	$62,430.71
Max. Negotiated Rate	$149,507.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62,430.71
Rate for Payer: Amerigroup Medicare	$62,430.71
Rate for Payer: BCBS of TX Medicare	$62,430.71
Rate for Payer: Cigna Commercial	$101,350.14
Rate for Payer: Cigna Medicare	$62,430.71
Rate for Payer: Employer Direct Commercial	$62,430.71
Rate for Payer: Humana Medicare/TRICARE	$62,430.71
Rate for Payer: Molina Dual Medicare/Medicaid	$62,430.71
Rate for Payer: Molina Medicare	$62,430.71
Rate for Payer: Multiplan Auto	$149,507.20
Rate for Payer: Multiplan Commercial	$149,507.20
Rate for Payer: Multiplan Workers Comp	$149,507.20
Rate for Payer: Scott and White EPO/PPO	$68,852.00
Rate for Payer: Scott and White Medicare	$62,430.71
Rate for Payer: Superior Health Plan EPO	$62,430.71
Rate for Payer: Superior Health Plan Medicare	$62,430.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$62,430.71
Rate for Payer: Universal American Medicare	$62,430.71
Rate for Payer: Wellcare Medicare	$62,430.71
Rate for Payer: Wellmed Medicare	$62,430.71

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC

Facility

$59,135.89

Service Code	MSDRG 022
Min. Negotiated Rate	$26,907.12
Max. Negotiated Rate	$59,135.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,047.33
Rate for Payer: Amerigroup Medicare	$28,047.33
Rate for Payer: BCBS of TX Medicare	$28,047.33
Rate for Payer: Cigna Commercial	$39,607.29
Rate for Payer: Cigna Medicare	$28,047.33
Rate for Payer: Employer Direct Commercial	$28,047.33
Rate for Payer: Humana Medicare/TRICARE	$28,047.33
Rate for Payer: Molina Dual Medicare/Medicaid	$28,047.33
Rate for Payer: Molina Medicare	$28,047.33
Rate for Payer: Multiplan Auto	$58,426.90
Rate for Payer: Multiplan Commercial	$58,426.90
Rate for Payer: Multiplan Workers Comp	$58,426.90
Rate for Payer: Scott and White EPO/PPO	$26,907.12
Rate for Payer: Scott and White Medicare	$28,047.33
Rate for Payer: Superior Health Plan EPO	$28,047.33
Rate for Payer: Superior Health Plan Medicare	$28,047.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,047.33
Rate for Payer: Universal American Medicare	$28,047.33
Rate for Payer: Wellcare Medicare	$28,047.33
Rate for Payer: Wellmed Medicare	$28,047.33

Know your out-of-pocket cost for care.

All Charges