White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W MCC

Facility

$71,979.60

Service Code	MSDRG 040
Min. Negotiated Rate	$33,058.91
Max. Negotiated Rate	$71,979.60
Rate for Payer: BCBS of TX Blue Advantage	$33,782.52
Rate for Payer: BCBS of TX Blue Essentials	$40,535.10
Rate for Payer: BCBS of TX PPO	$45,040.74

PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC

Facility

$35,144.30

Service Code	MSDRG 042
Min. Negotiated Rate	$16,094.90
Max. Negotiated Rate	$35,144.30
Rate for Payer: BCBS of TX Blue Advantage	$16,094.90
Rate for Payer: BCBS of TX Blue Essentials	$19,312.01
Rate for Payer: BCBS of TX PPO	$21,458.62

PERIPHERAL AND OTHER VASCULAR DISORDERS

Facility

$3,979.34

Service Code	APR-DRG 1972
Min. Negotiated Rate	$3,751.86
Max. Negotiated Rate	$3,979.34
Rate for Payer: Amerigroup CHIP/Medicaid	$3,751.86
Rate for Payer: Cigna Medicaid	$3,751.86
Rate for Payer: Molina CHIP/Medicaid	$3,751.86
Rate for Payer: Parkland Medicaid	$3,751.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,979.34

PERIPHERAL AND OTHER VASCULAR DISORDERS

Facility

$11,474.09

Service Code	APR-DRG 1974
Min. Negotiated Rate	$10,818.17
Max. Negotiated Rate	$11,474.09
Rate for Payer: Amerigroup CHIP/Medicaid	$10,818.17
Rate for Payer: Cigna Medicaid	$10,818.17
Rate for Payer: Molina CHIP/Medicaid	$10,818.17
Rate for Payer: Parkland Medicaid	$10,818.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,474.09

PERIPHERAL AND OTHER VASCULAR DISORDERS

Facility

$5,264.43

Service Code	APR-DRG 1973
Min. Negotiated Rate	$4,963.49
Max. Negotiated Rate	$5,264.43
Rate for Payer: Amerigroup CHIP/Medicaid	$4,963.49
Rate for Payer: Cigna Medicaid	$4,963.49
Rate for Payer: Molina CHIP/Medicaid	$4,963.49
Rate for Payer: Parkland Medicaid	$4,963.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,264.43

PERIPHERAL AND OTHER VASCULAR DISORDERS

Facility

$2,805.91

Service Code	APR-DRG 1971
Min. Negotiated Rate	$2,645.51
Max. Negotiated Rate	$2,805.91
Rate for Payer: Amerigroup CHIP/Medicaid	$2,645.51
Rate for Payer: Cigna Medicaid	$2,645.51
Rate for Payer: Molina CHIP/Medicaid	$2,645.51
Rate for Payer: Parkland Medicaid	$2,645.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,805.91

PERIPHERAL ARTERIAL DISEASE REHAB Units

Facility

$164.00

Service Code	HCPCS 93668
Hospital Charge Code	1100050
Hospital Revenue Code	480
Rate for Payer: Cash Price	$111.52

PERIPHERAL ARTERIAL DISEASE REHAB Units

Facility

$164.00

Service Code	HCPCS 93668
Hospital Charge Code	1100050
Hospital Revenue Code	480
Min. Negotiated Rate	$14.76
Max. Negotiated Rate	$125.27
Rate for Payer: Amerigroup CHIP/Medicaid	$14.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$49.20
Rate for Payer: BCBS of TX Blue Essentials	$59.04
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$65.60
Rate for Payer: Cash Price	$111.52
Rate for Payer: Cash Price	$111.52
Rate for Payer: Cash Price	$111.52
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$118.08
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$118.08
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
Rate for Payer: Multiplan Auto	$106.60
Rate for Payer: Multiplan Commercial	$106.60
Rate for Payer: Multiplan Workers Comp	$106.60
Rate for Payer: Parkland Medicaid	$118.08
Rate for Payer: Scott and White EPO/PPO	$18.09
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.08
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS

Facility

$18,517.34

Service Code	APR-DRG 0484
Min. Negotiated Rate	$17,458.80
Max. Negotiated Rate	$18,517.34
Rate for Payer: Amerigroup CHIP/Medicaid	$17,458.80
Rate for Payer: Cigna Medicaid	$17,458.80
Rate for Payer: Molina CHIP/Medicaid	$17,458.80
Rate for Payer: Parkland Medicaid	$17,458.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,517.34

PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS

Facility

$3,110.68

Service Code	APR-DRG 0482
Min. Negotiated Rate	$2,932.86
Max. Negotiated Rate	$3,110.68
Rate for Payer: Amerigroup CHIP/Medicaid	$2,932.86
Rate for Payer: Cigna Medicaid	$2,932.86
Rate for Payer: Molina CHIP/Medicaid	$2,932.86
Rate for Payer: Parkland Medicaid	$2,932.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,110.68

PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS

Facility

$2,991.11

Service Code	APR-DRG 0481
Min. Negotiated Rate	$2,820.12
Max. Negotiated Rate	$2,991.11
Rate for Payer: Amerigroup CHIP/Medicaid	$2,820.12
Rate for Payer: Cigna Medicaid	$2,820.12
Rate for Payer: Molina CHIP/Medicaid	$2,820.12
Rate for Payer: Parkland Medicaid	$2,820.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,991.11

PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS

Facility

$4,344.09

Service Code	APR-DRG 0483
Min. Negotiated Rate	$4,095.76
Max. Negotiated Rate	$4,344.09
Rate for Payer: Amerigroup CHIP/Medicaid	$4,095.76
Rate for Payer: Cigna Medicaid	$4,095.76
Rate for Payer: Molina CHIP/Medicaid	$4,095.76
Rate for Payer: Parkland Medicaid	$4,095.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,344.09

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR

Facility

$44,423.90

Service Code	MSDRG 041
Min. Negotiated Rate	$20,282.24
Max. Negotiated Rate	$44,423.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,874.41
Rate for Payer: Amerigroup Medicare	$20,874.41
Rate for Payer: BCBS of TX Medicare	$20,874.41
Rate for Payer: Cigna Commercial	$28,319.26
Rate for Payer: Cigna Medicare	$20,874.41
Rate for Payer: Employer Direct Commercial	$20,874.41
Rate for Payer: Humana Medicare/TRICARE	$20,874.41
Rate for Payer: Molina Dual Medicare/Medicaid	$20,874.41
Rate for Payer: Molina Medicare	$20,874.41
Rate for Payer: Multiplan Auto	$44,423.90
Rate for Payer: Multiplan Commercial	$44,423.90
Rate for Payer: Multiplan Workers Comp	$44,423.90
Rate for Payer: Scott and White EPO/PPO	$20,458.38
Rate for Payer: Scott and White Medicare	$20,874.41
Rate for Payer: Superior Health Plan EPO	$20,874.41
Rate for Payer: Superior Health Plan Medicare	$20,874.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,874.41
Rate for Payer: Universal American Medicare	$20,874.41
Rate for Payer: Wellcare Medicare	$20,874.41
Rate for Payer: Wellmed Medicare	$20,874.41

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC

Facility

$71,979.60

Service Code	MSDRG 040
Min. Negotiated Rate	$33,058.91
Max. Negotiated Rate	$71,979.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$33,058.91
Rate for Payer: Amerigroup Medicare	$33,058.91
Rate for Payer: BCBS of TX Medicare	$33,058.91
Rate for Payer: Cigna Commercial	$49,732.26
Rate for Payer: Cigna Medicare	$33,058.91
Rate for Payer: Employer Direct Commercial	$33,058.91
Rate for Payer: Humana Medicare/TRICARE	$33,058.91
Rate for Payer: Molina Dual Medicare/Medicaid	$33,058.91
Rate for Payer: Molina Medicare	$33,058.91
Rate for Payer: Multiplan Auto	$71,979.60
Rate for Payer: Multiplan Commercial	$71,979.60
Rate for Payer: Multiplan Workers Comp	$71,979.60
Rate for Payer: Scott and White EPO/PPO	$33,148.50
Rate for Payer: Scott and White Medicare	$33,058.91
Rate for Payer: Superior Health Plan EPO	$33,058.91
Rate for Payer: Superior Health Plan Medicare	$33,058.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$33,058.91
Rate for Payer: Universal American Medicare	$33,058.91
Rate for Payer: Wellcare Medicare	$33,058.91
Rate for Payer: Wellmed Medicare	$33,058.91

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC

Facility

$35,144.30

Service Code	MSDRG 042
Min. Negotiated Rate	$16,094.90
Max. Negotiated Rate	$35,144.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,422.45
Rate for Payer: Amerigroup Medicare	$17,422.45
Rate for Payer: BCBS of TX Medicare	$17,422.45
Rate for Payer: Cigna Commercial	$22,252.78
Rate for Payer: Cigna Medicare	$17,422.45
Rate for Payer: Employer Direct Commercial	$17,422.45
Rate for Payer: Humana Medicare/TRICARE	$17,422.45
Rate for Payer: Molina Dual Medicare/Medicaid	$17,422.45
Rate for Payer: Molina Medicare	$17,422.45
Rate for Payer: Multiplan Auto	$35,144.30
Rate for Payer: Multiplan Commercial	$35,144.30
Rate for Payer: Multiplan Workers Comp	$35,144.30
Rate for Payer: Scott and White EPO/PPO	$16,184.88
Rate for Payer: Scott and White Medicare	$17,422.45
Rate for Payer: Superior Health Plan EPO	$17,422.45
Rate for Payer: Superior Health Plan Medicare	$17,422.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,422.45
Rate for Payer: Universal American Medicare	$17,422.45
Rate for Payer: Wellcare Medicare	$17,422.45
Rate for Payer: Wellmed Medicare	$17,422.45

Peripherally Inserted Central Catheter Insertion

Facility

$4,307.00

Service Code	HCPCS 36569
Hospital Charge Code	2170090
Hospital Revenue Code	361
Min. Negotiated Rate	$446.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$446.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Amerigroup Medicare	$1,581.33
Rate for Payer: BCBS of TX Blue Advantage	$2,723.99
Rate for Payer: BCBS of TX Blue Essentials	$3,262.26
Rate for Payer: BCBS of TX Medicare	$1,581.33
Rate for Payer: BCBS of TX PPO	$4,110.45
Rate for Payer: Cash Price	$2,928.76
Rate for Payer: Cash Price	$2,928.76
Rate for Payer: Cash Price	$2,928.76
Rate for Payer: Cigna Commercial	$3,342.63
Rate for Payer: Cigna Medicaid	$3,101.04
Rate for Payer: Cigna Medicare	$1,581.33
Rate for Payer: Employer Direct Commercial	$1,581.33
Rate for Payer: Humana Medicare/TRICARE	$1,581.33
Rate for Payer: Molina CHIP/Medicaid	$3,101.04
Rate for Payer: Molina Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Molina Medicare	$1,581.33
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	$3,101.04
Rate for Payer: Scott and White EPO/PPO	$2,709.66
Rate for Payer: Scott and White Medicare	$1,581.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,101.04
Rate for Payer: Superior Health Plan EPO	$1,581.33
Rate for Payer: Superior Health Plan Medicare	$1,581.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Universal American Medicare	$1,581.33
Rate for Payer: Wellcare Medicare	$1,581.33
Rate for Payer: Wellmed Medicare	$1,581.33

Peripherally Inserted Central Catheter Insertion

Facility

$4,307.00

Service Code	HCPCS 36569
Hospital Charge Code	2170090
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,928.76

Peripheral Nerve Block Needle Stimuplex® A 22 Gauge 2 Inch I

Facility

$27.47

Hospital Charge Code	993414
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18.68

Peripheral Nerve Block Needle Stimuplex® A 22 Gauge 2 Inch I

Facility

$27.47

Hospital Charge Code	993414
Hospital Revenue Code	272
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$19.78
Rate for Payer: Amerigroup CHIP/Medicaid	$2.47
Rate for Payer: BCBS of TX Blue Advantage	$8.24
Rate for Payer: BCBS of TX Blue Essentials	$9.89
Rate for Payer: BCBS of TX PPO	$10.99
Rate for Payer: Cash Price	$18.68
Rate for Payer: Cigna Medicaid	$19.78
Rate for Payer: Molina CHIP/Medicaid	$19.78
Rate for Payer: Multiplan Auto	$17.86
Rate for Payer: Multiplan Commercial	$17.86
Rate for Payer: Multiplan Workers Comp	$17.86
Rate for Payer: Parkland Medicaid	$19.78
Rate for Payer: Scott and White EPO/PPO	$13.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.78
Rate for Payer: Superior Health Plan EPO	$3.74

PERIPHERAL VASCULAR DISORDERS W CC

Facility

$19,590.90

Service Code	MSDRG 300
Min. Negotiated Rate	$8,803.82
Max. Negotiated Rate	$19,590.90
Rate for Payer: BCBS of TX Blue Advantage	$8,803.82
Rate for Payer: BCBS of TX Blue Essentials	$10,563.56
Rate for Payer: BCBS of TX PPO	$11,737.74

PERIPHERAL VASCULAR DISORDERS WITH CC

Facility

$19,590.90

Service Code	MSDRG 300
Min. Negotiated Rate	$8,803.82
Max. Negotiated Rate	$19,590.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,583.81
Rate for Payer: Amerigroup Medicare	$12,583.81
Rate for Payer: BCBS of TX Medicare	$12,583.81
Rate for Payer: Cigna Commercial	$13,749.40
Rate for Payer: Cigna Medicare	$12,583.81
Rate for Payer: Employer Direct Commercial	$12,583.81
Rate for Payer: Humana Medicare/TRICARE	$12,583.81
Rate for Payer: Molina Dual Medicare/Medicaid	$12,583.81
Rate for Payer: Molina Medicare	$12,583.81
Rate for Payer: Multiplan Auto	$19,590.90
Rate for Payer: Multiplan Commercial	$19,590.90
Rate for Payer: Multiplan Workers Comp	$19,590.90
Rate for Payer: Scott and White EPO/PPO	$9,022.12
Rate for Payer: Scott and White Medicare	$12,583.81
Rate for Payer: Superior Health Plan EPO	$12,583.81
Rate for Payer: Superior Health Plan Medicare	$12,583.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,583.81
Rate for Payer: Universal American Medicare	$12,583.81
Rate for Payer: Wellcare Medicare	$12,583.81
Rate for Payer: Wellmed Medicare	$12,583.81

PERIPHERAL VASCULAR DISORDERS WITH MCC

Facility

$29,222.00

Service Code	MSDRG 299
Min. Negotiated Rate	$12,473.44
Max. Negotiated Rate	$29,222.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,726.17
Rate for Payer: Amerigroup Medicare	$16,726.17
Rate for Payer: BCBS of TX Medicare	$16,726.17
Rate for Payer: Cigna Commercial	$21,029.18
Rate for Payer: Cigna Medicare	$16,726.17
Rate for Payer: Employer Direct Commercial	$16,726.17
Rate for Payer: Humana Medicare/TRICARE	$16,726.17
Rate for Payer: Molina Dual Medicare/Medicaid	$16,726.17
Rate for Payer: Molina Medicare	$16,726.17
Rate for Payer: Multiplan Auto	$29,222.00
Rate for Payer: Multiplan Commercial	$29,222.00
Rate for Payer: Multiplan Workers Comp	$29,222.00
Rate for Payer: Scott and White EPO/PPO	$13,457.50
Rate for Payer: Scott and White Medicare	$16,726.17
Rate for Payer: Superior Health Plan EPO	$16,726.17
Rate for Payer: Superior Health Plan Medicare	$16,726.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,726.17
Rate for Payer: Universal American Medicare	$16,726.17
Rate for Payer: Wellcare Medicare	$16,726.17
Rate for Payer: Wellmed Medicare	$16,726.17

PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC

Facility

$13,607.80

Service Code	MSDRG 301
Min. Negotiated Rate	$6,245.32
Max. Negotiated Rate	$13,607.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,034.78
Rate for Payer: Amerigroup Medicare	$10,034.78
Rate for Payer: BCBS of TX Medicare	$10,034.78
Rate for Payer: Cigna Commercial	$9,269.74
Rate for Payer: Cigna Medicare	$10,034.78
Rate for Payer: Employer Direct Commercial	$10,034.78
Rate for Payer: Humana Medicare/TRICARE	$10,034.78
Rate for Payer: Molina Dual Medicare/Medicaid	$10,034.78
Rate for Payer: Molina Medicare	$10,034.78
Rate for Payer: Multiplan Auto	$13,607.80
Rate for Payer: Multiplan Commercial	$13,607.80
Rate for Payer: Multiplan Workers Comp	$13,607.80
Rate for Payer: Scott and White EPO/PPO	$6,266.75
Rate for Payer: Scott and White Medicare	$10,034.78
Rate for Payer: Superior Health Plan EPO	$10,034.78
Rate for Payer: Superior Health Plan Medicare	$10,034.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,034.78
Rate for Payer: Universal American Medicare	$10,034.78
Rate for Payer: Wellcare Medicare	$10,034.78
Rate for Payer: Wellmed Medicare	$10,034.78

PERIPHERAL VASCULAR DISORDERS W MCC

Facility

$29,222.00

Service Code	MSDRG 299
Min. Negotiated Rate	$12,473.44
Max. Negotiated Rate	$29,222.00
Rate for Payer: BCBS of TX Blue Advantage	$12,473.44
Rate for Payer: BCBS of TX Blue Essentials	$14,966.68
Rate for Payer: BCBS of TX PPO	$16,630.29

PERIPHERAL VASCULAR DISORDERS W/O CC/MCC

Facility

$13,607.80

Service Code	MSDRG 301
Min. Negotiated Rate	$6,245.32
Max. Negotiated Rate	$13,607.80
Rate for Payer: BCBS of TX Blue Advantage	$6,245.32
Rate for Payer: BCBS of TX Blue Essentials	$7,493.66
Rate for Payer: BCBS of TX PPO	$8,326.61

Know your out-of-pocket cost for care.

All Charges