White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PERC SACRL AUGMENT UNIL

Facility

$14,016.00

Service Code	HCPCS 0200T
Hospital Charge Code	5052899
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,530.88

PERC TRNSHEP PORT W/EVL

Facility

$4,336.00

Service Code	HCPCS 75885
Hospital Charge Code	4615885
Hospital Revenue Code	323
Rate for Payer: Cash Price	$2,948.48

PERC TRNSHEP PORT W/EVL

Facility

$4,336.00

Service Code	HCPCS 75885
Hospital Charge Code	4615885
Hospital Revenue Code	323
Min. Negotiated Rate	$136.66
Max. Negotiated Rate	$6,704.76
Rate for Payer: Amerigroup CHIP/Medicaid	$136.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Amerigroup Medicare	$3,171.87
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX Medicare	$3,171.87
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$2,948.48
Rate for Payer: Cash Price	$2,948.48
Rate for Payer: Cash Price	$2,948.48
Rate for Payer: Cigna Commercial	$6,704.76
Rate for Payer: Cigna Medicaid	$3,121.92
Rate for Payer: Cigna Medicare	$3,171.87
Rate for Payer: Employer Direct Commercial	$3,171.87
Rate for Payer: Humana Medicare/TRICARE	$3,171.87
Rate for Payer: Molina CHIP/Medicaid	$3,121.92
Rate for Payer: Molina Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Molina Medicare	$3,171.87
Rate for Payer: Multiplan Auto	$2,818.40
Rate for Payer: Multiplan Commercial	$2,818.40
Rate for Payer: Multiplan Workers Comp	$2,818.40
Rate for Payer: Parkland Medicaid	$3,121.92
Rate for Payer: Scott and White EPO/PPO	$168.18
Rate for Payer: Scott and White Medicare	$3,171.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,121.92
Rate for Payer: Superior Health Plan EPO	$3,171.87
Rate for Payer: Superior Health Plan Medicare	$3,171.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,171.87
Rate for Payer: Universal American Medicare	$3,171.87
Rate for Payer: Wellcare Medicare	$3,171.87
Rate for Payer: Wellmed Medicare	$3,171.87

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC

Facility

$76,247.00

Service Code	MSDRG 273
Min. Negotiated Rate	$31,411.50
Max. Negotiated Rate	$76,247.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$34,995.98
Rate for Payer: Amerigroup Medicare	$34,995.98
Rate for Payer: BCBS of TX Medicare	$34,995.98
Rate for Payer: Cigna Commercial	$53,136.44
Rate for Payer: Cigna Medicare	$34,995.98
Rate for Payer: Employer Direct Commercial	$34,995.98
Rate for Payer: Humana Medicare/TRICARE	$34,995.98
Rate for Payer: Molina Dual Medicare/Medicaid	$34,995.98
Rate for Payer: Molina Medicare	$34,995.98
Rate for Payer: Multiplan Auto	$76,247.00
Rate for Payer: Multiplan Commercial	$76,247.00
Rate for Payer: Multiplan Workers Comp	$76,247.00
Rate for Payer: Scott and White EPO/PPO	$35,113.75
Rate for Payer: Scott and White Medicare	$34,995.98
Rate for Payer: Superior Health Plan EPO	$34,995.98
Rate for Payer: Superior Health Plan Medicare	$34,995.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$34,995.98
Rate for Payer: Universal American Medicare	$34,995.98
Rate for Payer: Wellcare Medicare	$34,995.98
Rate for Payer: Wellmed Medicare	$34,995.98

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC

Facility

$63,830.50

Service Code	MSDRG 274
Min. Negotiated Rate	$25,613.38
Max. Negotiated Rate	$63,830.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,885.04
Rate for Payer: Amerigroup Medicare	$28,885.04
Rate for Payer: BCBS of TX Medicare	$28,885.04
Rate for Payer: Cigna Commercial	$42,397.10
Rate for Payer: Cigna Medicare	$28,885.04
Rate for Payer: Employer Direct Commercial	$28,885.04
Rate for Payer: Humana Medicare/TRICARE	$28,885.04
Rate for Payer: Molina Dual Medicare/Medicaid	$28,885.04
Rate for Payer: Molina Medicare	$28,885.04
Rate for Payer: Multiplan Auto	$63,830.50
Rate for Payer: Multiplan Commercial	$63,830.50
Rate for Payer: Multiplan Workers Comp	$63,830.50
Rate for Payer: Scott and White EPO/PPO	$29,395.62
Rate for Payer: Scott and White Medicare	$28,885.04
Rate for Payer: Superior Health Plan EPO	$28,885.04
Rate for Payer: Superior Health Plan Medicare	$28,885.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,885.04
Rate for Payer: Universal American Medicare	$28,885.04
Rate for Payer: Wellcare Medicare	$28,885.04
Rate for Payer: Wellmed Medicare	$28,885.04

PERCUTANEOUS CARDIAC INTERVENTION WITH AMI

Facility

$18,460.01

Service Code	APR-DRG 1744
Min. Negotiated Rate	$17,404.74
Max. Negotiated Rate	$18,460.01
Rate for Payer: Amerigroup CHIP/Medicaid	$17,404.74
Rate for Payer: Cigna Medicaid	$17,404.74
Rate for Payer: Molina CHIP/Medicaid	$17,404.74
Rate for Payer: Parkland Medicaid	$17,404.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,460.01

PERCUTANEOUS CARDIAC INTERVENTION WITH AMI

Facility

$11,292.66

Service Code	APR-DRG 1743
Min. Negotiated Rate	$10,647.12
Max. Negotiated Rate	$11,292.66
Rate for Payer: Amerigroup CHIP/Medicaid	$10,647.12
Rate for Payer: Cigna Medicaid	$10,647.12
Rate for Payer: Molina CHIP/Medicaid	$10,647.12
Rate for Payer: Parkland Medicaid	$10,647.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,292.66

PERCUTANEOUS CARDIAC INTERVENTION WITH AMI

Facility

$9,719.03

Service Code	APR-DRG 1742
Min. Negotiated Rate	$9,163.44
Max. Negotiated Rate	$9,719.03
Rate for Payer: Amerigroup CHIP/Medicaid	$9,163.44
Rate for Payer: Cigna Medicaid	$9,163.44
Rate for Payer: Molina CHIP/Medicaid	$9,163.44
Rate for Payer: Parkland Medicaid	$9,163.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,719.03

PERCUTANEOUS CARDIAC INTERVENTION WITH AMI

Facility

$8,318.15

Service Code	APR-DRG 1741
Min. Negotiated Rate	$7,842.64
Max. Negotiated Rate	$8,318.15
Rate for Payer: Amerigroup CHIP/Medicaid	$7,842.64
Rate for Payer: Cigna Medicaid	$7,842.64
Rate for Payer: Molina CHIP/Medicaid	$7,842.64
Rate for Payer: Parkland Medicaid	$7,842.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,318.15

PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI

Facility

$9,271.68

Service Code	APR-DRG 1751
Min. Negotiated Rate	$8,741.67
Max. Negotiated Rate	$9,271.68
Rate for Payer: Amerigroup CHIP/Medicaid	$8,741.67
Rate for Payer: Cigna Medicaid	$8,741.67
Rate for Payer: Molina CHIP/Medicaid	$8,741.67
Rate for Payer: Parkland Medicaid	$8,741.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,271.68

PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI

Facility

$14,819.38

Service Code	APR-DRG 1753
Min. Negotiated Rate	$13,972.23
Max. Negotiated Rate	$14,819.38
Rate for Payer: Amerigroup CHIP/Medicaid	$13,972.23
Rate for Payer: Cigna Medicaid	$13,972.23
Rate for Payer: Molina CHIP/Medicaid	$13,972.23
Rate for Payer: Parkland Medicaid	$13,972.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,819.38

PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI

Facility

$10,936.97

Service Code	APR-DRG 1752
Min. Negotiated Rate	$10,311.76
Max. Negotiated Rate	$10,936.97
Rate for Payer: Amerigroup CHIP/Medicaid	$10,311.76
Rate for Payer: Cigna Medicaid	$10,311.76
Rate for Payer: Molina CHIP/Medicaid	$10,311.76
Rate for Payer: Parkland Medicaid	$10,311.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,936.97

PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI

Facility

$24,330.20

Service Code	APR-DRG 1754
Min. Negotiated Rate	$22,939.36
Max. Negotiated Rate	$24,330.20
Rate for Payer: Amerigroup CHIP/Medicaid	$22,939.36
Rate for Payer: Cigna Medicaid	$22,939.36
Rate for Payer: Molina CHIP/Medicaid	$22,939.36
Rate for Payer: Parkland Medicaid	$22,939.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,330.20

PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS

Facility

$56,912.60

Service Code	MSDRG 246
Min. Negotiated Rate	$26,209.75
Max. Negotiated Rate	$56,912.60
Rate for Payer: BCBS of TX Blue Advantage	$27,853.68
Rate for Payer: BCBS of TX Blue Essentials	$33,421.18
Rate for Payer: BCBS of TX PPO	$37,136.08

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS

Facility

$56,912.60

Service Code	MSDRG 246
Min. Negotiated Rate	$26,209.75
Max. Negotiated Rate	$56,912.60
Rate for Payer: Multiplan Auto	$56,912.60
Rate for Payer: Multiplan Commercial	$56,912.60
Rate for Payer: Multiplan Workers Comp	$56,912.60
Rate for Payer: Scott and White EPO/PPO	$26,209.75

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC

Facility

$36,280.50

Service Code	MSDRG 247
Min. Negotiated Rate	$16,708.12
Max. Negotiated Rate	$36,280.50
Rate for Payer: Multiplan Auto	$36,280.50
Rate for Payer: Multiplan Commercial	$36,280.50
Rate for Payer: Multiplan Workers Comp	$36,280.50
Rate for Payer: Scott and White EPO/PPO	$16,708.12

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES

Facility

$35,043.90

Service Code	MSDRG 321
Min. Negotiated Rate	$24,700.90
Max. Negotiated Rate	$35,043.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24,700.90
Rate for Payer: Amerigroup Medicare	$24,700.90
Rate for Payer: BCBS of TX Medicare	$24,700.90
Rate for Payer: Cigna Commercial	$35,043.90
Rate for Payer: Cigna Medicare	$24,700.90
Rate for Payer: Employer Direct Commercial	$24,700.90
Rate for Payer: Humana Medicare/TRICARE	$24,700.90
Rate for Payer: Molina Dual Medicare/Medicaid	$24,700.90
Rate for Payer: Molina Medicare	$24,700.90
Rate for Payer: Scott and White Medicare	$24,700.90
Rate for Payer: Superior Health Plan EPO	$24,700.90
Rate for Payer: Superior Health Plan Medicare	$24,700.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$24,700.90
Rate for Payer: Universal American Medicare	$24,700.90
Rate for Payer: Wellcare Medicare	$24,700.90
Rate for Payer: Wellmed Medicare	$24,700.90

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$22,707.44

Service Code	MSDRG 322
Min. Negotiated Rate	$17,681.16
Max. Negotiated Rate	$22,707.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,681.16
Rate for Payer: Amerigroup Medicare	$17,681.16
Rate for Payer: BCBS of TX Medicare	$17,681.16
Rate for Payer: Cigna Commercial	$22,707.44
Rate for Payer: Cigna Medicare	$17,681.16
Rate for Payer: Employer Direct Commercial	$17,681.16
Rate for Payer: Humana Medicare/TRICARE	$17,681.16
Rate for Payer: Molina Dual Medicare/Medicaid	$17,681.16
Rate for Payer: Molina Medicare	$17,681.16
Rate for Payer: Scott and White Medicare	$17,681.16
Rate for Payer: Superior Health Plan EPO	$17,681.16
Rate for Payer: Superior Health Plan Medicare	$17,681.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,681.16
Rate for Payer: Universal American Medicare	$17,681.16
Rate for Payer: Wellcare Medicare	$17,681.16
Rate for Payer: Wellmed Medicare	$17,681.16

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS

Facility

$57,186.20

Service Code	MSDRG 248
Min. Negotiated Rate	$26,335.75
Max. Negotiated Rate	$57,186.20
Rate for Payer: Multiplan Auto	$57,186.20
Rate for Payer: Multiplan Commercial	$57,186.20
Rate for Payer: Multiplan Workers Comp	$57,186.20
Rate for Payer: Scott and White EPO/PPO	$26,335.75

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC

Facility

$34,517.30

Service Code	MSDRG 249
Min. Negotiated Rate	$15,896.12
Max. Negotiated Rate	$34,517.30
Rate for Payer: Multiplan Auto	$34,517.30
Rate for Payer: Multiplan Commercial	$34,517.30
Rate for Payer: Multiplan Workers Comp	$34,517.30
Rate for Payer: Scott and White EPO/PPO	$15,896.12

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC

Facility

$45,974.30

Service Code	MSDRG 250
Min. Negotiated Rate	$20,755.67
Max. Negotiated Rate	$45,974.30
Rate for Payer: Multiplan Auto	$45,974.30
Rate for Payer: Multiplan Commercial	$45,974.30
Rate for Payer: Multiplan Workers Comp	$45,974.30
Rate for Payer: Scott and White EPO/PPO	$21,172.38

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITHOUT MCC

Facility

$30,880.70

Service Code	MSDRG 251
Min. Negotiated Rate	$14,221.38
Max. Negotiated Rate	$30,880.70
Rate for Payer: Multiplan Auto	$30,880.70
Rate for Payer: Multiplan Commercial	$30,880.70
Rate for Payer: Multiplan Workers Comp	$30,880.70
Rate for Payer: Scott and White EPO/PPO	$14,221.38

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC

Facility

$45,974.30

Service Code	MSDRG 250
Min. Negotiated Rate	$20,755.67
Max. Negotiated Rate	$45,974.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,755.67
Rate for Payer: Amerigroup Medicare	$20,755.67
Rate for Payer: BCBS of TX Medicare	$20,755.67
Rate for Payer: Cigna Commercial	$28,110.60
Rate for Payer: Cigna Medicare	$20,755.67
Rate for Payer: Employer Direct Commercial	$20,755.67
Rate for Payer: Humana Medicare/TRICARE	$20,755.67
Rate for Payer: Molina Dual Medicare/Medicaid	$20,755.67
Rate for Payer: Molina Medicare	$20,755.67
Rate for Payer: Scott and White Medicare	$20,755.67
Rate for Payer: Superior Health Plan EPO	$20,755.67
Rate for Payer: Superior Health Plan Medicare	$20,755.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,755.67
Rate for Payer: Universal American Medicare	$20,755.67
Rate for Payer: Wellcare Medicare	$20,755.67
Rate for Payer: Wellmed Medicare	$20,755.67

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC

Facility

$30,880.70

Service Code	MSDRG 251
Min. Negotiated Rate	$14,221.38
Max. Negotiated Rate	$30,880.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,713.31
Rate for Payer: Amerigroup Medicare	$15,713.31
Rate for Payer: BCBS of TX Medicare	$15,713.31
Rate for Payer: Cigna Commercial	$19,249.16
Rate for Payer: Cigna Medicare	$15,713.31
Rate for Payer: Employer Direct Commercial	$15,713.31
Rate for Payer: Humana Medicare/TRICARE	$15,713.31
Rate for Payer: Molina Dual Medicare/Medicaid	$15,713.31
Rate for Payer: Molina Medicare	$15,713.31
Rate for Payer: Scott and White Medicare	$15,713.31
Rate for Payer: Superior Health Plan EPO	$15,713.31
Rate for Payer: Superior Health Plan Medicare	$15,713.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,713.31
Rate for Payer: Universal American Medicare	$15,713.31
Rate for Payer: Wellcare Medicare	$15,713.31
Rate for Payer: Wellmed Medicare	$15,713.31

PERCUTANEOUS CARDIOVASCULAR PROCEDURES W NON-DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS

Facility

$57,186.20

Service Code	MSDRG 248
Min. Negotiated Rate	$26,335.75
Max. Negotiated Rate	$57,186.20
Rate for Payer: BCBS of TX Blue Advantage	$27,284.36
Rate for Payer: BCBS of TX Blue Essentials	$32,738.06
Rate for Payer: BCBS of TX PPO	$36,377.03

Know your out-of-pocket cost for care.

All Charges