White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$12,104.03
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 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 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	$12,104.03
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 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

$36,280.50

Service Code	MSDRG 247
Min. Negotiated Rate	$16,708.12
Max. Negotiated Rate	$36,280.50
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

$34,517.30

Service Code	MSDRG 249
Min. Negotiated Rate	$15,896.12
Max. Negotiated Rate	$34,517.30
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

$45,974.30

Service Code	MSDRG 250
Min. Negotiated Rate	$20,755.67
Max. Negotiated Rate	$45,974.30
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

$30,880.70

Service Code	MSDRG 251
Min. Negotiated Rate	$14,221.38
Max. Negotiated Rate	$30,880.70
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
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	$5,853.44
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 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 COR DRUG-ELUT STNT

Facility

$27,809.00

Hospital Charge Code	2350060
Hospital Revenue Code	481
Min. Negotiated Rate	$2,502.81
Max. Negotiated Rate	$20,022.48
Rate for Payer: Amerigroup CHIP/Medicaid	$2,502.81
Rate for Payer: BCBS of TX Blue Advantage	$8,342.70
Rate for Payer: BCBS of TX Blue Essentials	$10,011.24
Rate for Payer: BCBS of TX PPO	$11,123.60
Rate for Payer: Cash Price	$18,910.12
Rate for Payer: Cigna Medicaid	$20,022.48
Rate for Payer: Molina CHIP/Medicaid	$20,022.48
Rate for Payer: Multiplan Auto	$18,075.85
Rate for Payer: Multiplan Commercial	$18,075.85
Rate for Payer: Multiplan Workers Comp	$18,075.85
Rate for Payer: Parkland Medicaid	$20,022.48
Rate for Payer: Scott and White EPO/PPO	$13,904.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,022.48
Rate for Payer: Superior Health Plan EPO	$3,782.02

PERC COR DRUG-ELUT STNT

Facility

$27,809.00

Hospital Charge Code	2350060
Hospital Revenue Code	481
Rate for Payer: Cash Price	$18,910.12

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 CORON THROMBECT

Facility

$4,146.00

Service Code	HCPCS 92973
Hospital Charge Code	4612973
Hospital Revenue Code	481
Min. Negotiated Rate	$208.86
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: 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	$208.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,985.12
Rate for Payer: Superior Health Plan EPO	$563.86

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

Perc Coro Revasc DES/Chronic 1st

Facility

$34,358.00

Hospital Charge Code	8400469
Hospital Revenue Code	481
Rate for Payer: Cash Price	$23,363.44

PERC DRUG-ELUT STNT ADDL

Facility

$11,036.00

Hospital Charge Code	2350061
Hospital Revenue Code	481
Min. Negotiated Rate	$993.24
Max. Negotiated Rate	$7,945.92
Rate for Payer: Amerigroup CHIP/Medicaid	$993.24
Rate for Payer: BCBS of TX Blue Advantage	$3,310.80
Rate for Payer: BCBS of TX Blue Essentials	$3,972.96
Rate for Payer: BCBS of TX PPO	$4,414.40
Rate for Payer: Cash Price	$7,504.48
Rate for Payer: Cigna Medicaid	$7,945.92
Rate for Payer: Molina CHIP/Medicaid	$7,945.92
Rate for Payer: Multiplan Auto	$7,173.40
Rate for Payer: Multiplan Commercial	$7,173.40
Rate for Payer: Multiplan Workers Comp	$7,173.40
Rate for Payer: Parkland Medicaid	$7,945.92
Rate for Payer: Scott and White EPO/PPO	$5,518.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,945.92
Rate for Payer: Superior Health Plan EPO	$1,500.90

PERC DRUG-ELUT STNT ADDL

Facility

$11,036.00

Hospital Charge Code	2350061
Hospital Revenue Code	481
Rate for Payer: Cash Price	$7,504.48

PERC RF ABLATE RENL TUMR

Facility

$12,650.00

Service Code	HCPCS 50592
Hospital Charge Code	3800008
Hospital Revenue Code	360
Min. Negotiated Rate	$1,888.85
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup CHIP/Medicaid	$1,888.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$8,602.00
Rate for Payer: Cash Price	$8,602.00
Rate for Payer: Cash Price	$8,602.00
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$9,108.00
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$9,108.00
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$9,108.00
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,108.00
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

PERC RF ABLATE RENL TUMR

Facility

$12,650.00

Service Code	HCPCS 50592
Hospital Charge Code	3800008
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,602.00

PERC RF ABLATE RENL TUMR

Facility

$12,650.00

Service Code	HCPCS 50592
Hospital Charge Code	3802410
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,602.00

PERC RF ABLATE RENL TUMR

Facility

$12,650.00

Service Code	HCPCS 50592
Hospital Charge Code	3802410
Hospital Revenue Code	360
Min. Negotiated Rate	$1,888.85
Max. Negotiated Rate	$12,837.39
Rate for Payer: Amerigroup CHIP/Medicaid	$1,888.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$8,602.00
Rate for Payer: Cash Price	$8,602.00
Rate for Payer: Cash Price	$8,602.00
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$9,108.00
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$9,108.00
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
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	$9,108.00
Rate for Payer: Scott and White EPO/PPO	$9,762.30
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,108.00
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

PERC SACRL AUGMENT UNIL

Facility

$14,016.00

Service Code	HCPCS 0200T
Hospital Charge Code	5052899
Hospital Revenue Code	360
Min. Negotiated Rate	$1,261.44
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,261.44
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	$9,530.88
Rate for Payer: Cash Price	$9,530.88
Rate for Payer: Cash Price	$9,530.88
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$10,091.52
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	$10,091.52
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	$10,091.52
Rate for Payer: Scott and White EPO/PPO	$7,008.00
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,091.52
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

Know your out-of-pocket cost for care.

All Charges