White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PT Ultrasound Units

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	4252024
Hospital Revenue Code	420
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.90
Rate for Payer: BCBS of TX Blue Advantage	$33.00
Rate for Payer: BCBS of TX Blue Essentials	$39.60
Rate for Payer: BCBS of TX PPO	$44.00
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$79.20
Rate for Payer: Molina CHIP/Medicaid	$79.20
Rate for Payer: Multiplan Auto	$71.50
Rate for Payer: Multiplan Commercial	$71.50
Rate for Payer: Multiplan Workers Comp	$71.50
Rate for Payer: Parkland Medicaid	$79.20
Rate for Payer: Scott and White EPO/PPO	$17.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$14.96

PT Ultrasound Units

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	4252024
Hospital Revenue Code	420
Rate for Payer: Cash Price	$74.80

PT Unattended E-Stim Assistant Units

Facility

$160.00

Hospital Charge Code	4252047
Hospital Revenue Code	420
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.40
Rate for Payer: BCBS of TX Blue Advantage	$48.00
Rate for Payer: BCBS of TX Blue Essentials	$57.60
Rate for Payer: BCBS of TX PPO	$64.00
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$115.20
Rate for Payer: Molina CHIP/Medicaid	$115.20
Rate for Payer: Multiplan Auto	$104.00
Rate for Payer: Multiplan Commercial	$104.00
Rate for Payer: Multiplan Workers Comp	$104.00
Rate for Payer: Parkland Medicaid	$115.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.20
Rate for Payer: Superior Health Plan EPO	$21.76

PT Unattended E-Stim Assistant Units

Facility

$160.00

Hospital Charge Code	4252047
Hospital Revenue Code	420
Rate for Payer: Cash Price	$108.80

PT Unattended E-Stim Units

Facility

$160.00

Hospital Charge Code	4252020
Hospital Revenue Code	420
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.40
Rate for Payer: BCBS of TX Blue Advantage	$48.00
Rate for Payer: BCBS of TX Blue Essentials	$57.60
Rate for Payer: BCBS of TX PPO	$64.00
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$115.20
Rate for Payer: Molina CHIP/Medicaid	$115.20
Rate for Payer: Multiplan Auto	$104.00
Rate for Payer: Multiplan Commercial	$104.00
Rate for Payer: Multiplan Workers Comp	$104.00
Rate for Payer: Parkland Medicaid	$115.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.20
Rate for Payer: Superior Health Plan EPO	$21.76

PT Unattended E-Stim Units

Facility

$160.00

Hospital Charge Code	4252020
Hospital Revenue Code	420
Rate for Payer: Cash Price	$108.80

PT Work Hardening-Each Addl Hour Assistant Units

Facility

$175.00

Service Code	HCPCS 97546
Hospital Charge Code	5715508
Hospital Revenue Code	420
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$52.50
Rate for Payer: BCBS of TX Blue Essentials	$63.00
Rate for Payer: BCBS of TX PPO	$70.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$126.00
Rate for Payer: Molina CHIP/Medicaid	$126.00
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Parkland Medicaid	$126.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.00
Rate for Payer: Superior Health Plan EPO	$23.80

PT Work Hardening-Each Addl Hour Assistant Units

Facility

$175.00

Service Code	HCPCS 97546
Hospital Charge Code	5715508
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.00

PULMONARY EDEMA AND RESPIRATORY FAILURE

Facility

$22,933.00

Service Code	MSDRG 189
Min. Negotiated Rate	$10,561.25
Max. Negotiated Rate	$22,933.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,814.37
Rate for Payer: Amerigroup Medicare	$13,814.37
Rate for Payer: BCBS of TX Medicare	$13,814.37
Rate for Payer: Cigna Commercial	$15,911.95
Rate for Payer: Cigna Medicare	$13,814.37
Rate for Payer: Employer Direct Commercial	$13,814.37
Rate for Payer: Humana Medicare/TRICARE	$13,814.37
Rate for Payer: Molina Dual Medicare/Medicaid	$13,814.37
Rate for Payer: Molina Medicare	$13,814.37
Rate for Payer: Multiplan Auto	$22,933.00
Rate for Payer: Multiplan Commercial	$22,933.00
Rate for Payer: Multiplan Workers Comp	$22,933.00
Rate for Payer: Scott and White EPO/PPO	$10,561.25
Rate for Payer: Scott and White Medicare	$13,814.37
Rate for Payer: Superior Health Plan EPO	$13,814.37
Rate for Payer: Superior Health Plan Medicare	$13,814.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,814.37
Rate for Payer: Universal American Medicare	$13,814.37
Rate for Payer: Wellcare Medicare	$13,814.37
Rate for Payer: Wellmed Medicare	$13,814.37

PULMONARY EDEMA & RESPIRATORY FAILURE

Facility

$22,933.00

Service Code	MSDRG 189
Min. Negotiated Rate	$10,561.25
Max. Negotiated Rate	$22,933.00
Rate for Payer: BCBS of TX Blue Advantage	$10,623.58
Rate for Payer: BCBS of TX Blue Essentials	$12,747.06
Rate for Payer: BCBS of TX PPO	$14,163.95

PULMONARY EMBOLISM

Facility

$11,373.38

Service Code	APR-DRG 1344
Min. Negotiated Rate	$10,723.22
Max. Negotiated Rate	$11,373.38
Rate for Payer: Amerigroup CHIP/Medicaid	$10,723.22
Rate for Payer: Cigna Medicaid	$10,723.22
Rate for Payer: Molina CHIP/Medicaid	$10,723.22
Rate for Payer: Parkland Medicaid	$10,723.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,373.38

PULMONARY EMBOLISM

Facility

$3,332.84

Service Code	APR-DRG 1341
Min. Negotiated Rate	$3,142.32
Max. Negotiated Rate	$3,332.84
Rate for Payer: Amerigroup CHIP/Medicaid	$3,142.32
Rate for Payer: Cigna Medicaid	$3,142.32
Rate for Payer: Molina CHIP/Medicaid	$3,142.32
Rate for Payer: Parkland Medicaid	$3,142.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,332.84

PULMONARY EMBOLISM

Facility

$5,750.25

Service Code	APR-DRG 1343
Min. Negotiated Rate	$5,421.53
Max. Negotiated Rate	$5,750.25
Rate for Payer: Amerigroup CHIP/Medicaid	$5,421.53
Rate for Payer: Cigna Medicaid	$5,421.53
Rate for Payer: Molina CHIP/Medicaid	$5,421.53
Rate for Payer: Parkland Medicaid	$5,421.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,750.25

PULMONARY EMBOLISM

Facility

$3,848.46

Service Code	APR-DRG 1342
Min. Negotiated Rate	$3,628.46
Max. Negotiated Rate	$3,848.46
Rate for Payer: Amerigroup CHIP/Medicaid	$3,628.46
Rate for Payer: Cigna Medicaid	$3,628.46
Rate for Payer: Molina CHIP/Medicaid	$3,628.46
Rate for Payer: Parkland Medicaid	$3,628.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,848.46

PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE

Facility

$26,539.20

Service Code	MSDRG 175
Min. Negotiated Rate	$12,222.00
Max. Negotiated Rate	$26,539.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,827.22
Rate for Payer: Amerigroup Medicare	$14,827.22
Rate for Payer: BCBS of TX Medicare	$14,827.22
Rate for Payer: Cigna Commercial	$17,691.97
Rate for Payer: Cigna Medicare	$14,827.22
Rate for Payer: Employer Direct Commercial	$14,827.22
Rate for Payer: Humana Medicare/TRICARE	$14,827.22
Rate for Payer: Molina Dual Medicare/Medicaid	$14,827.22
Rate for Payer: Molina Medicare	$14,827.22
Rate for Payer: Multiplan Auto	$26,539.20
Rate for Payer: Multiplan Commercial	$26,539.20
Rate for Payer: Multiplan Workers Comp	$26,539.20
Rate for Payer: Scott and White EPO/PPO	$12,222.00
Rate for Payer: Scott and White Medicare	$14,827.22
Rate for Payer: Superior Health Plan EPO	$14,827.22
Rate for Payer: Superior Health Plan Medicare	$14,827.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,827.22
Rate for Payer: Universal American Medicare	$14,827.22
Rate for Payer: Wellcare Medicare	$14,827.22
Rate for Payer: Wellmed Medicare	$14,827.22

PULMONARY EMBOLISM WITHOUT MCC

Facility

$15,534.40

Service Code	MSDRG 176
Min. Negotiated Rate	$7,154.00
Max. Negotiated Rate	$15,534.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,659.96
Rate for Payer: Amerigroup Medicare	$10,659.96
Rate for Payer: BCBS of TX Medicare	$10,659.96
Rate for Payer: Cigna Commercial	$10,368.40
Rate for Payer: Cigna Medicare	$10,659.96
Rate for Payer: Employer Direct Commercial	$10,659.96
Rate for Payer: Humana Medicare/TRICARE	$10,659.96
Rate for Payer: Molina Dual Medicare/Medicaid	$10,659.96
Rate for Payer: Molina Medicare	$10,659.96
Rate for Payer: Multiplan Auto	$15,534.40
Rate for Payer: Multiplan Commercial	$15,534.40
Rate for Payer: Multiplan Workers Comp	$15,534.40
Rate for Payer: Scott and White EPO/PPO	$7,154.00
Rate for Payer: Scott and White Medicare	$10,659.96
Rate for Payer: Superior Health Plan EPO	$10,659.96
Rate for Payer: Superior Health Plan Medicare	$10,659.96
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,659.96
Rate for Payer: Universal American Medicare	$10,659.96
Rate for Payer: Wellcare Medicare	$10,659.96
Rate for Payer: Wellmed Medicare	$10,659.96

PULMONARY EMBOLISM W MCC

Facility

$26,539.20

Service Code	MSDRG 175
Min. Negotiated Rate	$12,222.00
Max. Negotiated Rate	$26,539.20
Rate for Payer: BCBS of TX Blue Advantage	$12,598.14
Rate for Payer: BCBS of TX Blue Essentials	$15,116.30
Rate for Payer: BCBS of TX PPO	$16,796.54

PULMONARY EMBOLISM W/O MCC

Facility

$15,534.40

Service Code	MSDRG 176
Min. Negotiated Rate	$7,154.00
Max. Negotiated Rate	$15,534.40
Rate for Payer: BCBS of TX Blue Advantage	$7,731.40
Rate for Payer: BCBS of TX Blue Essentials	$9,276.78
Rate for Payer: BCBS of TX PPO	$10,307.93

Pulmonary Oxygen Per Hour Units

Facility

$29.68

Hospital Charge Code	16046034600
Hospital Revenue Code	270
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$21.37
Rate for Payer: Amerigroup CHIP/Medicaid	$2.67
Rate for Payer: BCBS of TX Blue Advantage	$8.90
Rate for Payer: BCBS of TX Blue Essentials	$10.68
Rate for Payer: BCBS of TX PPO	$11.87
Rate for Payer: Cash Price	$20.18
Rate for Payer: Cigna Medicaid	$21.37
Rate for Payer: Molina CHIP/Medicaid	$21.37
Rate for Payer: Multiplan Auto	$19.29
Rate for Payer: Multiplan Commercial	$19.29
Rate for Payer: Multiplan Workers Comp	$19.29
Rate for Payer: Parkland Medicaid	$21.37
Rate for Payer: Scott and White EPO/PPO	$14.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.37
Rate for Payer: Superior Health Plan EPO	$4.04

Pulmonary Oxygen Per Hour Units

Facility

$29.68

Hospital Charge Code	16046034600
Hospital Revenue Code	270
Rate for Payer: Cash Price	$20.18

Pulmonary Rehab - 1 Hour Sess Units BCE

Facility

$54.00

Hospital Charge Code	6030237
Hospital Revenue Code	410
Rate for Payer: Cash Price	$36.72

Pulmonary Rehab - 1 Hour Sess Units BCE

Facility

$54.00

Hospital Charge Code	6030237
Hospital Revenue Code	410
Min. Negotiated Rate	$4.86
Max. Negotiated Rate	$180.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4.86
Rate for Payer: BCBS of TX Blue Advantage	$16.20
Rate for Payer: BCBS of TX Blue Essentials	$19.44
Rate for Payer: BCBS of TX PPO	$21.60
Rate for Payer: Cash Price	$36.72
Rate for Payer: Cash Price	$36.72
Rate for Payer: Cigna Medicaid	$38.88
Rate for Payer: Molina CHIP/Medicaid	$38.88
Rate for Payer: Multiplan Auto	$35.10
Rate for Payer: Multiplan Commercial	$35.10
Rate for Payer: Multiplan Workers Comp	$35.10
Rate for Payer: Parkland Medicaid	$38.88
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.88
Rate for Payer: Superior Health Plan EPO	$7.34

Pulmonary Rehab with Conti Oximetry Monitoring BCE

Facility

$56.85

Service Code	HCPCS 94626
Hospital Charge Code	8844559
Hospital Revenue Code	948
Rate for Payer: Cash Price	$38.66

Pulmonary Rehab with Conti Oximetry Monitoring BCE

Facility

$56.85

Service Code	HCPCS 94626
Hospital Charge Code	8844559
Hospital Revenue Code	948
Min. Negotiated Rate	$5.12
Max. Negotiated Rate	$125.27
Rate for Payer: Amerigroup CHIP/Medicaid	$5.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$17.05
Rate for Payer: BCBS of TX Blue Essentials	$20.47
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$22.74
Rate for Payer: Cash Price	$38.66
Rate for Payer: Cash Price	$38.66
Rate for Payer: Cash Price	$38.66
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$40.93
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	$40.93
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
Rate for Payer: Multiplan Auto	$36.95
Rate for Payer: Multiplan Commercial	$36.95
Rate for Payer: Multiplan Workers Comp	$36.95
Rate for Payer: Parkland Medicaid	$40.93
Rate for Payer: Scott and White EPO/PPO	$33.21
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.93
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

Pulmonary Rehab w/o Cont Oximetry Monitoring BCE

Facility

$56.25

Service Code	HCPCS 94625
Hospital Charge Code	8846559
Hospital Revenue Code	948
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$125.27
Rate for Payer: Amerigroup CHIP/Medicaid	$5.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$16.88
Rate for Payer: BCBS of TX Blue Essentials	$20.25
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$22.50
Rate for Payer: Cash Price	$38.25
Rate for Payer: Cash Price	$38.25
Rate for Payer: Cash Price	$38.25
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$40.50
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	$40.50
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
Rate for Payer: Multiplan Auto	$36.56
Rate for Payer: Multiplan Commercial	$36.56
Rate for Payer: Multiplan Workers Comp	$36.56
Rate for Payer: Parkland Medicaid	$40.50
Rate for Payer: Scott and White EPO/PPO	$22.51
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.50
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

Know your out-of-pocket cost for care.

All Charges