White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Aortography, abdominal, by serialography, radiological supervision and interpretation

Facility

$23,831.76

Service Code	HCPCS 75625
Hospital Charge Code	2302644
Hospital Revenue Code	360
Rate for Payer: Cash Price	$16,205.60

AORTOGRAPHY THORACIC

Facility

$4,382.00

Service Code	HCPCS 75605
Hospital Charge Code	2320273
Hospital Revenue Code	320
Rate for Payer: Cash Price	$2,979.76

AORTOGRAPHY THORACIC

Facility

$4,382.00

Service Code	HCPCS 75605
Hospital Charge Code	2320273
Hospital Revenue Code	320
Min. Negotiated Rate	$120.95
Max. Negotiated Rate	$11,815.91
Rate for Payer: Amerigroup CHIP/Medicaid	$120.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Amerigroup Medicare	$5,589.84
Rate for Payer: BCBS of TX Blue Advantage	$7,583.71
Rate for Payer: BCBS of TX Blue Essentials	$9,100.46
Rate for Payer: BCBS of TX Medicare	$5,589.84
Rate for Payer: BCBS of TX PPO	$10,157.58
Rate for Payer: Cash Price	$2,979.76
Rate for Payer: Cash Price	$2,979.76
Rate for Payer: Cash Price	$2,979.76
Rate for Payer: Cigna Commercial	$11,815.91
Rate for Payer: Cigna Medicaid	$3,155.04
Rate for Payer: Cigna Medicare	$5,589.84
Rate for Payer: Employer Direct Commercial	$5,589.84
Rate for Payer: Humana Medicare/TRICARE	$5,589.84
Rate for Payer: Molina CHIP/Medicaid	$3,155.04
Rate for Payer: Molina Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Molina Medicare	$5,589.84
Rate for Payer: Multiplan Auto	$2,848.30
Rate for Payer: Multiplan Commercial	$2,848.30
Rate for Payer: Multiplan Workers Comp	$2,848.30
Rate for Payer: Parkland Medicaid	$3,155.04
Rate for Payer: Scott and White EPO/PPO	$8,384.76
Rate for Payer: Scott and White Medicare	$5,589.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,155.04
Rate for Payer: Superior Health Plan EPO	$5,589.84
Rate for Payer: Superior Health Plan Medicare	$5,589.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,589.84
Rate for Payer: Universal American Medicare	$5,589.84
Rate for Payer: Wellcare Medicare	$5,589.84
Rate for Payer: Wellmed Medicare	$5,589.84

apixaban 2.5 mg Tab

Facility

$34.55

Service Code	HCPCS J3490
Hospital Charge Code	77380440
Hospital Revenue Code	636
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.27
Rate for Payer: Cash Price	$23.49
Rate for Payer: Cigna Commercial	$8.64
Rate for Payer: Scott and White EPO/PPO	$17.27

apixaban 2.5 mg Tab

Facility

$34.55

Service Code	HCPCS J3490
Hospital Charge Code	77380440
Hospital Revenue Code	636
Min. Negotiated Rate	$3.11
Max. Negotiated Rate	$24.88
Rate for Payer: Amerigroup CHIP/Medicaid	$3.11
Rate for Payer: BCBS of TX Blue Advantage	$10.37
Rate for Payer: BCBS of TX Blue Essentials	$12.44
Rate for Payer: BCBS of TX PPO	$13.82
Rate for Payer: Cash Price	$23.49
Rate for Payer: Cigna Medicaid	$24.88
Rate for Payer: Molina CHIP/Medicaid	$24.88
Rate for Payer: Multiplan Auto	$22.46
Rate for Payer: Multiplan Commercial	$22.46
Rate for Payer: Multiplan Workers Comp	$22.46
Rate for Payer: Parkland Medicaid	$24.88
Rate for Payer: Scott and White EPO/PPO	$17.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.88
Rate for Payer: Superior Health Plan EPO	$4.70

apixaban 5 mg Tab

Facility

$34.55

Service Code	HCPCS J3490
Hospital Charge Code	77380489
Hospital Revenue Code	636
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.27
Rate for Payer: Cash Price	$23.49
Rate for Payer: Cigna Commercial	$8.64
Rate for Payer: Scott and White EPO/PPO	$17.27

apixaban 5 mg Tab

Facility

$34.55

Service Code	HCPCS J3490
Hospital Charge Code	77380489
Hospital Revenue Code	636
Min. Negotiated Rate	$3.11
Max. Negotiated Rate	$24.88
Rate for Payer: Amerigroup CHIP/Medicaid	$3.11
Rate for Payer: BCBS of TX Blue Advantage	$10.37
Rate for Payer: BCBS of TX Blue Essentials	$12.44
Rate for Payer: BCBS of TX PPO	$13.82
Rate for Payer: Cash Price	$23.49
Rate for Payer: Cigna Medicaid	$24.88
Rate for Payer: Molina CHIP/Medicaid	$24.88
Rate for Payer: Multiplan Auto	$22.46
Rate for Payer: Multiplan Commercial	$22.46
Rate for Payer: Multiplan Workers Comp	$22.46
Rate for Payer: Parkland Medicaid	$24.88
Rate for Payer: Scott and White EPO/PPO	$17.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.88
Rate for Payer: Superior Health Plan EPO	$4.70

APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC

Facility

$19,957.72

Service Code	MSDRG 339
Min. Negotiated Rate	$14,969.16
Max. Negotiated Rate	$19,957.72
Rate for Payer: BCBS of TX Blue Advantage	$14,969.16
Rate for Payer: BCBS of TX Blue Essentials	$17,961.25
Rate for Payer: BCBS of TX PPO	$19,957.72

APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W MCC

Facility

$32,847.80

Service Code	MSDRG 338
Min. Negotiated Rate	$24,637.28
Max. Negotiated Rate	$32,847.80
Rate for Payer: BCBS of TX Blue Advantage	$24,637.28
Rate for Payer: BCBS of TX Blue Essentials	$29,561.87
Rate for Payer: BCBS of TX PPO	$32,847.80

APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC

Facility

$13,619.31

Service Code	MSDRG 340
Min. Negotiated Rate	$10,215.08
Max. Negotiated Rate	$13,619.31
Rate for Payer: BCBS of TX Blue Advantage	$10,215.08
Rate for Payer: BCBS of TX Blue Essentials	$12,256.91
Rate for Payer: BCBS of TX PPO	$13,619.31

APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS

Facility

$9,166.82

Service Code	APR-DRG 2333
Min. Negotiated Rate	$8,642.80
Max. Negotiated Rate	$9,166.82
Rate for Payer: Amerigroup CHIP/Medicaid	$8,642.80
Rate for Payer: Cigna Medicaid	$8,642.80
Rate for Payer: Molina CHIP/Medicaid	$8,642.80
Rate for Payer: Parkland Medicaid	$8,642.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,166.82

APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS

Facility

$25,870.26

Service Code	APR-DRG 2334
Min. Negotiated Rate	$24,391.39
Max. Negotiated Rate	$25,870.26
Rate for Payer: Amerigroup CHIP/Medicaid	$24,391.39
Rate for Payer: Cigna Medicaid	$24,391.39
Rate for Payer: Molina CHIP/Medicaid	$24,391.39
Rate for Payer: Parkland Medicaid	$24,391.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,870.26

APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS

Facility

$7,133.02

Service Code	APR-DRG 2332
Min. Negotiated Rate	$6,725.26
Max. Negotiated Rate	$7,133.02
Rate for Payer: Amerigroup CHIP/Medicaid	$6,725.26
Rate for Payer: Cigna Medicaid	$6,725.26
Rate for Payer: Molina CHIP/Medicaid	$6,725.26
Rate for Payer: Parkland Medicaid	$6,725.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,133.02

APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS

Facility

$5,156.93

Service Code	APR-DRG 2331
Min. Negotiated Rate	$4,862.13
Max. Negotiated Rate	$5,156.93
Rate for Payer: Amerigroup CHIP/Medicaid	$4,862.13
Rate for Payer: Cigna Medicaid	$4,862.13
Rate for Payer: Molina CHIP/Medicaid	$4,862.13
Rate for Payer: Parkland Medicaid	$4,862.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,156.93

APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS

Facility

$6,040.30

Service Code	APR-DRG 2343
Min. Negotiated Rate	$5,695.01
Max. Negotiated Rate	$6,040.30
Rate for Payer: Amerigroup CHIP/Medicaid	$5,695.01
Rate for Payer: Cigna Medicaid	$5,695.01
Rate for Payer: Molina CHIP/Medicaid	$5,695.01
Rate for Payer: Parkland Medicaid	$5,695.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,040.30

APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS

Facility

$4,854.42

Service Code	APR-DRG 2342
Min. Negotiated Rate	$4,576.92
Max. Negotiated Rate	$4,854.42
Rate for Payer: Amerigroup CHIP/Medicaid	$4,576.92
Rate for Payer: Cigna Medicaid	$4,576.92
Rate for Payer: Molina CHIP/Medicaid	$4,576.92
Rate for Payer: Parkland Medicaid	$4,576.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,854.42

APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS

Facility

$16,128.60

Service Code	APR-DRG 2344
Min. Negotiated Rate	$15,206.61
Max. Negotiated Rate	$16,128.60
Rate for Payer: Amerigroup CHIP/Medicaid	$15,206.61
Rate for Payer: Cigna Medicaid	$15,206.61
Rate for Payer: Molina CHIP/Medicaid	$15,206.61
Rate for Payer: Parkland Medicaid	$15,206.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,128.60

APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS

Facility

$3,693.81

Service Code	APR-DRG 2341
Min. Negotiated Rate	$3,482.66
Max. Negotiated Rate	$3,693.81
Rate for Payer: Amerigroup CHIP/Medicaid	$3,482.66
Rate for Payer: Cigna Medicaid	$3,482.66
Rate for Payer: Molina CHIP/Medicaid	$3,482.66
Rate for Payer: Parkland Medicaid	$3,482.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,693.81

APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC

Facility

$16,267.96

Service Code	MSDRG 342
Min. Negotiated Rate	$12,201.68
Max. Negotiated Rate	$16,267.96
Rate for Payer: BCBS of TX Blue Advantage	$12,201.68
Rate for Payer: BCBS of TX Blue Essentials	$14,640.60
Rate for Payer: BCBS of TX PPO	$16,267.96

APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W MCC

Facility

$26,194.08

Service Code	MSDRG 341
Min. Negotiated Rate	$19,646.70
Max. Negotiated Rate	$26,194.08
Rate for Payer: BCBS of TX Blue Advantage	$19,646.70
Rate for Payer: BCBS of TX Blue Essentials	$23,573.76
Rate for Payer: BCBS of TX PPO	$26,194.08

APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC

Facility

$12,444.05

Service Code	MSDRG 343
Min. Negotiated Rate	$9,333.58
Max. Negotiated Rate	$12,444.05
Rate for Payer: BCBS of TX Blue Advantage	$9,333.58
Rate for Payer: BCBS of TX Blue Essentials	$11,199.21
Rate for Payer: BCBS of TX PPO	$12,444.05

APPENDIX PROCEDURES WITH CC

Facility

$28,758.40

Service Code	MSDRG 398
Min. Negotiated Rate	$13,244.00
Max. Negotiated Rate	$28,758.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,853.30
Rate for Payer: Amerigroup Medicare	$15,853.30
Rate for Payer: BCBS of TX Medicare	$15,853.30
Rate for Payer: Cigna Commercial	$19,495.17
Rate for Payer: Cigna Medicare	$15,853.30
Rate for Payer: Employer Direct Commercial	$15,853.30
Rate for Payer: Humana Medicare/TRICARE	$15,853.30
Rate for Payer: Molina Dual Medicare/Medicaid	$15,853.30
Rate for Payer: Molina Medicare	$15,853.30
Rate for Payer: Multiplan Auto	$28,758.40
Rate for Payer: Multiplan Commercial	$28,758.40
Rate for Payer: Multiplan Workers Comp	$28,758.40
Rate for Payer: Scott and White EPO/PPO	$13,244.00
Rate for Payer: Scott and White Medicare	$15,853.30
Rate for Payer: Superior Health Plan EPO	$15,853.30
Rate for Payer: Superior Health Plan Medicare	$15,853.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,853.30
Rate for Payer: Universal American Medicare	$15,853.30
Rate for Payer: Wellcare Medicare	$15,853.30
Rate for Payer: Wellmed Medicare	$15,853.30

APPENDIX PROCEDURES WITH MCC

Facility

$45,503.10

Service Code	MSDRG 397
Min. Negotiated Rate	$20,955.38
Max. Negotiated Rate	$45,503.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,312.37
Rate for Payer: Amerigroup Medicare	$22,312.37
Rate for Payer: BCBS of TX Medicare	$22,312.37
Rate for Payer: Cigna Commercial	$30,846.31
Rate for Payer: Cigna Medicare	$22,312.37
Rate for Payer: Employer Direct Commercial	$22,312.37
Rate for Payer: Humana Medicare/TRICARE	$22,312.37
Rate for Payer: Molina Dual Medicare/Medicaid	$22,312.37
Rate for Payer: Molina Medicare	$22,312.37
Rate for Payer: Multiplan Auto	$45,503.10
Rate for Payer: Multiplan Commercial	$45,503.10
Rate for Payer: Multiplan Workers Comp	$45,503.10
Rate for Payer: Scott and White EPO/PPO	$20,955.38
Rate for Payer: Scott and White Medicare	$22,312.37
Rate for Payer: Superior Health Plan EPO	$22,312.37
Rate for Payer: Superior Health Plan Medicare	$22,312.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,312.37
Rate for Payer: Universal American Medicare	$22,312.37
Rate for Payer: Wellcare Medicare	$22,312.37
Rate for Payer: Wellmed Medicare	$22,312.37

APPENDIX PROCEDURES WITHOUT CC/MCC

Facility

$21,749.30

Service Code	MSDRG 399
Min. Negotiated Rate	$10,016.12
Max. Negotiated Rate	$21,749.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,149.62
Rate for Payer: Amerigroup Medicare	$13,149.62
Rate for Payer: BCBS of TX Medicare	$13,149.62
Rate for Payer: Cigna Commercial	$14,743.74
Rate for Payer: Cigna Medicare	$13,149.62
Rate for Payer: Employer Direct Commercial	$13,149.62
Rate for Payer: Humana Medicare/TRICARE	$13,149.62
Rate for Payer: Molina Dual Medicare/Medicaid	$13,149.62
Rate for Payer: Molina Medicare	$13,149.62
Rate for Payer: Multiplan Auto	$21,749.30
Rate for Payer: Multiplan Commercial	$21,749.30
Rate for Payer: Multiplan Workers Comp	$21,749.30
Rate for Payer: Scott and White EPO/PPO	$10,016.12
Rate for Payer: Scott and White Medicare	$13,149.62
Rate for Payer: Superior Health Plan EPO	$13,149.62
Rate for Payer: Superior Health Plan Medicare	$13,149.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,149.62
Rate for Payer: Universal American Medicare	$13,149.62
Rate for Payer: Wellcare Medicare	$13,149.62
Rate for Payer: Wellmed Medicare	$13,149.62

Application of a modality to 1 or more areas; infrared

Facility

$41.00

Service Code	HCPCS 97026 GP
Hospital Charge Code	9385000
Hospital Revenue Code	420
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3.69
Rate for Payer: BCBS of TX Blue Advantage	$12.30
Rate for Payer: BCBS of TX Blue Essentials	$14.76
Rate for Payer: BCBS of TX PPO	$16.40
Rate for Payer: Cash Price	$27.88
Rate for Payer: Cash Price	$27.88
Rate for Payer: Cash Price	$27.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$29.52
Rate for Payer: Molina CHIP/Medicaid	$29.52
Rate for Payer: Multiplan Auto	$26.65
Rate for Payer: Multiplan Commercial	$26.65
Rate for Payer: Multiplan Workers Comp	$26.65
Rate for Payer: Parkland Medicaid	$29.52
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.52
Rate for Payer: Superior Health Plan EPO	$5.58

Know your out-of-pocket cost for care.

All Charges