White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PENIS PROCEDURES WITHOUT CC/MCC

Facility

$26,622.80

Service Code	MSDRG 710
Min. Negotiated Rate	$12,260.50
Max. Negotiated Rate	$26,622.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,029.52
Rate for Payer: Amerigroup Medicare	$15,029.52
Rate for Payer: BCBS of TX Medicare	$15,029.52
Rate for Payer: Cigna Commercial	$18,047.46
Rate for Payer: Cigna Medicare	$15,029.52
Rate for Payer: Employer Direct Commercial	$15,029.52
Rate for Payer: Humana Medicare/TRICARE	$15,029.52
Rate for Payer: Molina Dual Medicare/Medicaid	$15,029.52
Rate for Payer: Molina Medicare	$15,029.52
Rate for Payer: Multiplan Auto	$26,622.80
Rate for Payer: Multiplan Commercial	$26,622.80
Rate for Payer: Multiplan Workers Comp	$26,622.80
Rate for Payer: Scott and White EPO/PPO	$12,260.50
Rate for Payer: Scott and White Medicare	$15,029.52
Rate for Payer: Superior Health Plan EPO	$15,029.52
Rate for Payer: Superior Health Plan Medicare	$15,029.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,029.52
Rate for Payer: Universal American Medicare	$15,029.52
Rate for Payer: Wellcare Medicare	$15,029.52
Rate for Payer: Wellmed Medicare	$15,029.52

PENIS PROCEDURES W/O CC/MCC

Facility

$26,622.80

Service Code	MSDRG 710
Min. Negotiated Rate	$12,260.50
Max. Negotiated Rate	$26,622.80
Rate for Payer: BCBS of TX Blue Advantage	$14,357.70
Rate for Payer: BCBS of TX Blue Essentials	$17,227.57
Rate for Payer: BCBS of TX PPO	$19,142.49

PENIS, TESTES AND SCROTAL PROCEDURES

Facility

$37,771.33

Service Code	APR-DRG 4834
Min. Negotiated Rate	$35,612.13
Max. Negotiated Rate	$37,771.33
Rate for Payer: Amerigroup CHIP/Medicaid	$35,612.13
Rate for Payer: Cigna Medicaid	$35,612.13
Rate for Payer: Molina CHIP/Medicaid	$35,612.13
Rate for Payer: Parkland Medicaid	$35,612.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37,771.33

PENIS, TESTES AND SCROTAL PROCEDURES

Facility

$4,295.43

Service Code	APR-DRG 4831
Min. Negotiated Rate	$4,049.88
Max. Negotiated Rate	$4,295.43
Rate for Payer: Amerigroup CHIP/Medicaid	$4,049.88
Rate for Payer: Cigna Medicaid	$4,049.88
Rate for Payer: Molina CHIP/Medicaid	$4,049.88
Rate for Payer: Parkland Medicaid	$4,049.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,295.43

PENIS, TESTES AND SCROTAL PROCEDURES

Facility

$6,116.12

Service Code	APR-DRG 4832
Min. Negotiated Rate	$5,766.49
Max. Negotiated Rate	$6,116.12
Rate for Payer: Amerigroup CHIP/Medicaid	$5,766.49
Rate for Payer: Cigna Medicaid	$5,766.49
Rate for Payer: Molina CHIP/Medicaid	$5,766.49
Rate for Payer: Parkland Medicaid	$5,766.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,116.12

PENIS, TESTES AND SCROTAL PROCEDURES

Facility

$7,084.36

Service Code	APR-DRG 4833
Min. Negotiated Rate	$6,679.39
Max. Negotiated Rate	$7,084.36
Rate for Payer: Amerigroup CHIP/Medicaid	$6,679.39
Rate for Payer: Cigna Medicaid	$6,679.39
Rate for Payer: Molina CHIP/Medicaid	$6,679.39
Rate for Payer: Parkland Medicaid	$6,679.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,084.36

PEPTIC ULCER AND GASTRITIS

Facility

$14,878.97

Service Code	APR-DRG 2414
Min. Negotiated Rate	$14,028.42
Max. Negotiated Rate	$14,878.97
Rate for Payer: Amerigroup CHIP/Medicaid	$14,028.42
Rate for Payer: Cigna Medicaid	$14,028.42
Rate for Payer: Molina CHIP/Medicaid	$14,028.42
Rate for Payer: Parkland Medicaid	$14,028.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,878.97

PEPTIC ULCER AND GASTRITIS

Facility

$6,123.66

Service Code	APR-DRG 2413
Min. Negotiated Rate	$5,773.60
Max. Negotiated Rate	$6,123.66
Rate for Payer: Amerigroup CHIP/Medicaid	$5,773.60
Rate for Payer: Cigna Medicaid	$5,773.60
Rate for Payer: Molina CHIP/Medicaid	$5,773.60
Rate for Payer: Parkland Medicaid	$5,773.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,123.66

PEPTIC ULCER AND GASTRITIS

Facility

$3,742.09

Service Code	APR-DRG 2412
Min. Negotiated Rate	$3,528.18
Max. Negotiated Rate	$3,742.09
Rate for Payer: Amerigroup CHIP/Medicaid	$3,528.18
Rate for Payer: Cigna Medicaid	$3,528.18
Rate for Payer: Molina CHIP/Medicaid	$3,528.18
Rate for Payer: Parkland Medicaid	$3,528.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,742.09

PEPTIC ULCER AND GASTRITIS

Facility

$3,197.05

Service Code	APR-DRG 2411
Min. Negotiated Rate	$3,014.29
Max. Negotiated Rate	$3,197.05
Rate for Payer: Amerigroup CHIP/Medicaid	$3,014.29
Rate for Payer: Cigna Medicaid	$3,014.29
Rate for Payer: Molina CHIP/Medicaid	$3,014.29
Rate for Payer: Parkland Medicaid	$3,014.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,197.05

PERC AUG 1 BD LUMB/IMG

Facility

$15,995.00

Service Code	HCPCS 22514
Hospital Charge Code	4619720
Hospital Revenue Code	361
Rate for Payer: Cash Price	$10,876.60

PERC AUG 1 BD LUMB/IMG

Facility

$15,995.00

Service Code	HCPCS 22514
Hospital Charge Code	4619720
Hospital Revenue Code	361
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$10,876.60
Rate for Payer: Cash Price	$10,876.60
Rate for Payer: Cash Price	$10,876.60
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$11,516.40
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$11,516.40
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$11,516.40
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,516.40
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

PERC AUG 1 BD THOR/IMG

Facility

$15,995.00

Service Code	HCPCS 22513
Hospital Charge Code	4619718
Hospital Revenue Code	361
Rate for Payer: Cash Price	$10,876.60

PERC AUG 1 BD THOR/IMG

Facility

$15,995.00

Service Code	HCPCS 22513
Hospital Charge Code	4619718
Hospital Revenue Code	361
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$10,876.60
Rate for Payer: Cash Price	$10,876.60
Rate for Payer: Cash Price	$10,876.60
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$11,516.40
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$11,516.40
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$11,516.40
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,516.40
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

PERC AUG ADD T/L IMG

Facility

$5,864.00

Service Code	HCPCS 22515
Hospital Charge Code	4619719
Hospital Revenue Code	360
Min. Negotiated Rate	$527.76
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$527.76
Rate for Payer: BCBS of TX Blue Advantage	$1,759.20
Rate for Payer: BCBS of TX Blue Essentials	$2,111.04
Rate for Payer: BCBS of TX PPO	$2,345.60
Rate for Payer: Cash Price	$3,987.52
Rate for Payer: Cash Price	$3,987.52
Rate for Payer: Cigna Medicaid	$4,222.08
Rate for Payer: Molina CHIP/Medicaid	$4,222.08
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	$4,222.08
Rate for Payer: Scott and White EPO/PPO	$2,932.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,222.08
Rate for Payer: Superior Health Plan EPO	$797.50

PERC AUG ADD T/L IMG

Facility

$5,864.00

Service Code	HCPCS 22515
Hospital Charge Code	4619719
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,987.52

PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC

Facility

$23,816.03

Service Code	MSDRG 247
Min. Negotiated Rate	$17,863.06
Max. Negotiated Rate	$23,816.03
Rate for Payer: BCBS of TX Blue Advantage	$17,863.06
Rate for Payer: BCBS of TX Blue Essentials	$21,433.59
Rate for Payer: BCBS of TX PPO	$23,816.03

PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC

Facility

$22,818.49

Service Code	MSDRG 249
Min. Negotiated Rate	$17,114.86
Max. Negotiated Rate	$22,818.49
Rate for Payer: BCBS of TX Blue Advantage	$17,114.86
Rate for Payer: BCBS of TX Blue Essentials	$20,535.84
Rate for Payer: BCBS of TX PPO	$22,818.49

PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC

Facility

$41,467.50

Service Code	MSDRG 250
Min. Negotiated Rate	$19,096.88
Max. Negotiated Rate	$41,467.50
Rate for Payer: BCBS of TX Blue Advantage	$22,246.48
Rate for Payer: BCBS of TX Blue Essentials	$26,693.19
Rate for Payer: BCBS of TX PPO	$29,660.25

PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC

Facility

$28,395.50

Service Code	MSDRG 251
Min. Negotiated Rate	$13,076.88
Max. Negotiated Rate	$28,395.50
Rate for Payer: BCBS of TX Blue Advantage	$14,429.08
Rate for Payer: BCBS of TX Blue Essentials	$17,313.22
Rate for Payer: BCBS of TX PPO	$19,237.65

PERC CHOLECYSTOSTOMY

Facility

$7,171.00

Service Code	HCPCS 47490
Hospital Charge Code	4617600
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,876.28

PERC CHOLECYSTOSTOMY

Facility

$7,171.00

Service Code	HCPCS 47490
Hospital Charge Code	4617600
Hospital Revenue Code	360
Min. Negotiated Rate	$645.39
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$645.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Amerigroup Medicare	$3,596.72
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX Medicare	$3,596.72
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cash Price	$4,876.28
Rate for Payer: Cash Price	$4,876.28
Rate for Payer: Cash Price	$4,876.28
Rate for Payer: Cigna Commercial	$7,602.81
Rate for Payer: Cigna Medicaid	$5,163.12
Rate for Payer: Cigna Medicare	$3,596.72
Rate for Payer: Employer Direct Commercial	$3,596.72
Rate for Payer: Humana Medicare/TRICARE	$3,596.72
Rate for Payer: Molina CHIP/Medicaid	$5,163.12
Rate for Payer: Molina Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Molina Medicare	$3,596.72
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	$5,163.12
Rate for Payer: Scott and White EPO/PPO	$6,653.93
Rate for Payer: Scott and White Medicare	$3,596.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,163.12
Rate for Payer: Superior Health Plan EPO	$3,596.72
Rate for Payer: Superior Health Plan Medicare	$3,596.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Universal American Medicare	$3,596.72
Rate for Payer: Wellcare Medicare	$3,596.72
Rate for Payer: Wellmed Medicare	$3,596.72

PERC CORON THROMBECT

Facility

$4,146.00

Service Code	HCPCS 92973
Hospital Charge Code	4612973
Hospital Revenue Code	481
Min. Negotiated Rate	$373.14
Max. Negotiated Rate	$2,985.12
Rate for Payer: Amerigroup CHIP/Medicaid	$373.14
Rate for Payer: BCBS of TX Blue Advantage	$1,243.80
Rate for Payer: BCBS of TX Blue Essentials	$1,492.56
Rate for Payer: BCBS of TX PPO	$1,658.40
Rate for Payer: Cash Price	$2,819.28
Rate for Payer: Cigna Medicaid	$2,985.12
Rate for Payer: Molina CHIP/Medicaid	$2,985.12
Rate for Payer: Multiplan Auto	$2,694.90
Rate for Payer: Multiplan Commercial	$2,694.90
Rate for Payer: Multiplan Workers Comp	$2,694.90
Rate for Payer: Parkland Medicaid	$2,985.12
Rate for Payer: Scott and White EPO/PPO	$2,073.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,985.12
Rate for Payer: Superior Health Plan EPO	$563.86

PERC CORON THROMBECT

Facility

$4,146.00

Service Code	HCPCS 92973
Hospital Charge Code	4612973
Hospital Revenue Code	481
Rate for Payer: Cash Price	$2,819.28

Perc Coro Revasc DES/Chronic 1st

Facility

$34,358.00

Hospital Charge Code	8400469
Hospital Revenue Code	481
Min. Negotiated Rate	$3,092.22
Max. Negotiated Rate	$24,737.76
Rate for Payer: Amerigroup CHIP/Medicaid	$3,092.22
Rate for Payer: BCBS of TX Blue Advantage	$10,307.40
Rate for Payer: BCBS of TX Blue Essentials	$12,368.88
Rate for Payer: BCBS of TX PPO	$13,743.20
Rate for Payer: Cash Price	$23,363.44
Rate for Payer: Cigna Medicaid	$24,737.76
Rate for Payer: Molina CHIP/Medicaid	$24,737.76
Rate for Payer: Multiplan Auto	$22,332.70
Rate for Payer: Multiplan Commercial	$22,332.70
Rate for Payer: Multiplan Workers Comp	$22,332.70
Rate for Payer: Parkland Medicaid	$24,737.76
Rate for Payer: Scott and White EPO/PPO	$17,179.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,737.76
Rate for Payer: Superior Health Plan EPO	$4,672.69

Know your out-of-pocket cost for care.

All Charges