White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SEF33010

Facility

$259.03

Hospital Charge Code	991001
Hospital Revenue Code	272
Min. Negotiated Rate	$23.31
Max. Negotiated Rate	$186.50
Rate for Payer: Amerigroup CHIP/Medicaid	$23.31
Rate for Payer: BCBS of TX Blue Advantage	$77.71
Rate for Payer: BCBS of TX Blue Essentials	$93.25
Rate for Payer: BCBS of TX PPO	$103.61
Rate for Payer: Cash Price	$176.14
Rate for Payer: Cigna Medicaid	$186.50
Rate for Payer: Molina CHIP/Medicaid	$186.50
Rate for Payer: Multiplan Auto	$168.37
Rate for Payer: Multiplan Commercial	$168.37
Rate for Payer: Multiplan Workers Comp	$168.37
Rate for Payer: Parkland Medicaid	$186.50
Rate for Payer: Scott and White EPO/PPO	$129.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$186.50
Rate for Payer: Superior Health Plan EPO	$35.23

SEF33400

Facility

$2,975.90

Hospital Charge Code	991007
Hospital Revenue Code	272
Min. Negotiated Rate	$267.83
Max. Negotiated Rate	$2,142.65
Rate for Payer: Amerigroup CHIP/Medicaid	$267.83
Rate for Payer: BCBS of TX Blue Advantage	$892.77
Rate for Payer: BCBS of TX Blue Essentials	$1,071.32
Rate for Payer: BCBS of TX PPO	$1,190.36
Rate for Payer: Cash Price	$2,023.61
Rate for Payer: Cigna Medicaid	$2,142.65
Rate for Payer: Molina CHIP/Medicaid	$2,142.65
Rate for Payer: Multiplan Auto	$1,934.34
Rate for Payer: Multiplan Commercial	$1,934.34
Rate for Payer: Multiplan Workers Comp	$1,934.34
Rate for Payer: Parkland Medicaid	$2,142.65
Rate for Payer: Scott and White EPO/PPO	$1,487.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,142.65
Rate for Payer: Superior Health Plan EPO	$404.72

SEF33400

Facility

$2,975.90

Hospital Charge Code	991007
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,023.61

SEF40080

Facility

$861.00

Service Code	HCPCS C1776
Hospital Charge Code	990998
Hospital Revenue Code	278
Min. Negotiated Rate	$77.49
Max. Negotiated Rate	$619.92
Rate for Payer: Amerigroup CHIP/Medicaid	$77.49
Rate for Payer: BCBS of TX Blue Advantage	$258.30
Rate for Payer: BCBS of TX Blue Essentials	$309.96
Rate for Payer: BCBS of TX PPO	$344.40
Rate for Payer: Cash Price	$585.48
Rate for Payer: Cigna Medicaid	$619.92
Rate for Payer: Molina CHIP/Medicaid	$619.92
Rate for Payer: Multiplan Auto	$430.50
Rate for Payer: Multiplan Commercial	$430.50
Rate for Payer: Multiplan Workers Comp	$430.50
Rate for Payer: Parkland Medicaid	$619.92
Rate for Payer: Scott and White EPO/PPO	$430.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$619.92
Rate for Payer: Superior Health Plan EPO	$117.10

SEF40080

Facility

$861.00

Service Code	HCPCS C1776
Hospital Charge Code	990998
Hospital Revenue Code	278
Min. Negotiated Rate	$215.25
Max. Negotiated Rate	$430.50
Rate for Payer: Cash Price	$585.48
Rate for Payer: Cigna Commercial	$215.25
Rate for Payer: Multiplan Auto	$430.50
Rate for Payer: Multiplan Commercial	$430.50
Rate for Payer: Multiplan Workers Comp	$430.50
Rate for Payer: Scott and White EPO/PPO	$430.50

SEF58016

Facility

$10,343.00

Service Code	HCPCS C1713
Hospital Charge Code	991006
Hospital Revenue Code	278
Min. Negotiated Rate	$2,585.75
Max. Negotiated Rate	$5,171.50
Rate for Payer: Cash Price	$7,033.24
Rate for Payer: Cigna Commercial	$2,585.75
Rate for Payer: Multiplan Auto	$5,171.50
Rate for Payer: Multiplan Commercial	$5,171.50
Rate for Payer: Multiplan Workers Comp	$5,171.50
Rate for Payer: Scott and White EPO/PPO	$5,171.50

SEF58016

Facility

$10,343.00

Service Code	HCPCS C1713
Hospital Charge Code	991006
Hospital Revenue Code	278
Min. Negotiated Rate	$930.87
Max. Negotiated Rate	$7,446.96
Rate for Payer: Amerigroup CHIP/Medicaid	$930.87
Rate for Payer: BCBS of TX Blue Advantage	$3,102.90
Rate for Payer: BCBS of TX Blue Essentials	$3,723.48
Rate for Payer: BCBS of TX PPO	$4,137.20
Rate for Payer: Cash Price	$7,033.24
Rate for Payer: Cigna Medicaid	$7,446.96
Rate for Payer: Molina CHIP/Medicaid	$7,446.96
Rate for Payer: Multiplan Auto	$5,171.50
Rate for Payer: Multiplan Commercial	$5,171.50
Rate for Payer: Multiplan Workers Comp	$5,171.50
Rate for Payer: Parkland Medicaid	$7,446.96
Rate for Payer: Scott and White EPO/PPO	$5,171.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,446.96
Rate for Payer: Superior Health Plan EPO	$1,406.65

SEF8016

Facility

$10,343.00

Service Code	HCPCS C1713
Hospital Charge Code	990992
Hospital Revenue Code	278
Min. Negotiated Rate	$930.87
Max. Negotiated Rate	$7,446.96
Rate for Payer: Amerigroup CHIP/Medicaid	$930.87
Rate for Payer: BCBS of TX Blue Advantage	$3,102.90
Rate for Payer: BCBS of TX Blue Essentials	$3,723.48
Rate for Payer: BCBS of TX PPO	$4,137.20
Rate for Payer: Cash Price	$7,033.24
Rate for Payer: Cigna Medicaid	$7,446.96
Rate for Payer: Molina CHIP/Medicaid	$7,446.96
Rate for Payer: Multiplan Auto	$5,171.50
Rate for Payer: Multiplan Commercial	$5,171.50
Rate for Payer: Multiplan Workers Comp	$5,171.50
Rate for Payer: Parkland Medicaid	$7,446.96
Rate for Payer: Scott and White EPO/PPO	$5,171.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,446.96
Rate for Payer: Superior Health Plan EPO	$1,406.65

SEF8016

Facility

$10,343.00

Service Code	HCPCS C1713
Hospital Charge Code	990992
Hospital Revenue Code	278
Min. Negotiated Rate	$2,585.75
Max. Negotiated Rate	$5,171.50
Rate for Payer: Cash Price	$7,033.24
Rate for Payer: Cigna Commercial	$2,585.75
Rate for Payer: Multiplan Auto	$5,171.50
Rate for Payer: Multiplan Commercial	$5,171.50
Rate for Payer: Multiplan Workers Comp	$5,171.50
Rate for Payer: Scott and White EPO/PPO	$5,171.50

SEIZURE

Facility

$4,615.28

Service Code	APR-DRG 0533
Min. Negotiated Rate	$4,351.45
Max. Negotiated Rate	$4,615.28
Rate for Payer: Amerigroup CHIP/Medicaid	$4,351.45
Rate for Payer: Cigna Medicaid	$4,351.45
Rate for Payer: Molina CHIP/Medicaid	$4,351.45
Rate for Payer: Parkland Medicaid	$4,351.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,615.28

SEIZURE

Facility

$10,748.38

Service Code	APR-DRG 0534
Min. Negotiated Rate	$10,133.95
Max. Negotiated Rate	$10,748.38
Rate for Payer: Amerigroup CHIP/Medicaid	$10,133.95
Rate for Payer: Cigna Medicaid	$10,133.95
Rate for Payer: Molina CHIP/Medicaid	$10,133.95
Rate for Payer: Parkland Medicaid	$10,133.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,748.38

SEIZURE

Facility

$3,188.76

Service Code	APR-DRG 0532
Min. Negotiated Rate	$3,006.47
Max. Negotiated Rate	$3,188.76
Rate for Payer: Amerigroup CHIP/Medicaid	$3,006.47
Rate for Payer: Cigna Medicaid	$3,006.47
Rate for Payer: Molina CHIP/Medicaid	$3,006.47
Rate for Payer: Parkland Medicaid	$3,006.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,188.76

SEIZURE

Facility

$2,371.39

Service Code	APR-DRG 0531
Min. Negotiated Rate	$2,235.83
Max. Negotiated Rate	$2,371.39
Rate for Payer: Amerigroup CHIP/Medicaid	$2,235.83
Rate for Payer: Cigna Medicaid	$2,235.83
Rate for Payer: Molina CHIP/Medicaid	$2,235.83
Rate for Payer: Parkland Medicaid	$2,235.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,371.39

SEIZURES WITH MCC

Facility

$36,499.00

Service Code	MSDRG 100
Min. Negotiated Rate	$15,586.64
Max. Negotiated Rate	$36,499.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,954.95
Rate for Payer: Amerigroup Medicare	$18,954.95
Rate for Payer: BCBS of TX Medicare	$18,954.95
Rate for Payer: Cigna Commercial	$24,945.98
Rate for Payer: Cigna Medicare	$18,954.95
Rate for Payer: Employer Direct Commercial	$18,954.95
Rate for Payer: Humana Medicare/TRICARE	$18,954.95
Rate for Payer: Molina Dual Medicare/Medicaid	$18,954.95
Rate for Payer: Molina Medicare	$18,954.95
Rate for Payer: Multiplan Auto	$36,499.00
Rate for Payer: Multiplan Commercial	$36,499.00
Rate for Payer: Multiplan Workers Comp	$36,499.00
Rate for Payer: Scott and White EPO/PPO	$16,808.75
Rate for Payer: Scott and White Medicare	$18,954.95
Rate for Payer: Superior Health Plan EPO	$18,954.95
Rate for Payer: Superior Health Plan Medicare	$18,954.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,954.95
Rate for Payer: Universal American Medicare	$18,954.95
Rate for Payer: Wellcare Medicare	$18,954.95
Rate for Payer: Wellmed Medicare	$18,954.95

SEIZURES WITHOUT MCC

Facility

$17,128.50

Service Code	MSDRG 101
Min. Negotiated Rate	$7,475.98
Max. Negotiated Rate	$17,128.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,375.26
Rate for Payer: Amerigroup Medicare	$11,375.26
Rate for Payer: BCBS of TX Medicare	$11,375.26
Rate for Payer: Cigna Commercial	$11,625.49
Rate for Payer: Cigna Medicare	$11,375.26
Rate for Payer: Employer Direct Commercial	$11,375.26
Rate for Payer: Humana Medicare/TRICARE	$11,375.26
Rate for Payer: Molina Dual Medicare/Medicaid	$11,375.26
Rate for Payer: Molina Medicare	$11,375.26
Rate for Payer: Multiplan Auto	$17,128.50
Rate for Payer: Multiplan Commercial	$17,128.50
Rate for Payer: Multiplan Workers Comp	$17,128.50
Rate for Payer: Scott and White EPO/PPO	$7,888.12
Rate for Payer: Scott and White Medicare	$11,375.26
Rate for Payer: Superior Health Plan EPO	$11,375.26
Rate for Payer: Superior Health Plan Medicare	$11,375.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,375.26
Rate for Payer: Universal American Medicare	$11,375.26
Rate for Payer: Wellcare Medicare	$11,375.26
Rate for Payer: Wellmed Medicare	$11,375.26

SEIZURES W MCC

Facility

$36,499.00

Service Code	MSDRG 100
Min. Negotiated Rate	$15,586.64
Max. Negotiated Rate	$36,499.00
Rate for Payer: BCBS of TX Blue Advantage	$15,586.64
Rate for Payer: BCBS of TX Blue Essentials	$18,702.16
Rate for Payer: BCBS of TX PPO	$20,780.98

SEIZURES W/O MCC

Facility

$17,128.50

Service Code	MSDRG 101
Min. Negotiated Rate	$7,475.98
Max. Negotiated Rate	$17,128.50
Rate for Payer: BCBS of TX Blue Advantage	$7,475.98
Rate for Payer: BCBS of TX Blue Essentials	$8,970.31
Rate for Payer: BCBS of TX PPO	$9,967.39

Select-A-Vent Adult Mask Kit, Universal Tubing Connector

Facility

$8.54

Hospital Charge Code	993374
Hospital Revenue Code	270
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$6.15
Rate for Payer: Amerigroup CHIP/Medicaid	$0.77
Rate for Payer: BCBS of TX Blue Advantage	$2.56
Rate for Payer: BCBS of TX Blue Essentials	$3.07
Rate for Payer: BCBS of TX PPO	$3.42
Rate for Payer: Cash Price	$5.81
Rate for Payer: Cigna Medicaid	$6.15
Rate for Payer: Molina CHIP/Medicaid	$6.15
Rate for Payer: Multiplan Auto	$5.55
Rate for Payer: Multiplan Commercial	$5.55
Rate for Payer: Multiplan Workers Comp	$5.55
Rate for Payer: Parkland Medicaid	$6.15
Rate for Payer: Scott and White EPO/PPO	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.15
Rate for Payer: Superior Health Plan EPO	$1.16

Select-A-Vent Adult Mask Kit, Universal Tubing Connector

Facility

$8.54

Hospital Charge Code	993374
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.81

SELECT CATH PLCMNT, 1ST ORD, ART AB

Facility

$3,394.00

Service Code	HCPCS 36245
Hospital Charge Code	2301802
Hospital Revenue Code	361
Min. Negotiated Rate	$305.46
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$305.46
Rate for Payer: BCBS of TX Blue Advantage	$1,018.20
Rate for Payer: BCBS of TX Blue Essentials	$1,221.84
Rate for Payer: BCBS of TX PPO	$1,357.60
Rate for Payer: Cash Price	$2,307.92
Rate for Payer: Cash Price	$2,307.92
Rate for Payer: Cigna Medicaid	$2,443.68
Rate for Payer: Molina CHIP/Medicaid	$2,443.68
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	$2,443.68
Rate for Payer: Scott and White EPO/PPO	$1,697.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,443.68
Rate for Payer: Superior Health Plan EPO	$461.58

SELECT CATH PLCMNT, 1ST ORD, ART AB

Facility

$3,394.00

Service Code	HCPCS 36245
Hospital Charge Code	2301802
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,307.92

SELECT CATH PLCMNT, 2ND ORD, ART AB

Facility

$3,747.00

Service Code	HCPCS 36246
Hospital Charge Code	2301810
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,547.96

SELECT CATH PLCMNT, 2ND ORD, ART AB

Facility

$3,747.00

Service Code	HCPCS 36246
Hospital Charge Code	2301810
Hospital Revenue Code	361
Min. Negotiated Rate	$337.23
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$337.23
Rate for Payer: BCBS of TX Blue Advantage	$1,124.10
Rate for Payer: BCBS of TX Blue Essentials	$1,348.92
Rate for Payer: BCBS of TX PPO	$1,498.80
Rate for Payer: Cash Price	$2,547.96
Rate for Payer: Cash Price	$2,547.96
Rate for Payer: Cigna Medicaid	$2,697.84
Rate for Payer: Molina CHIP/Medicaid	$2,697.84
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	$2,697.84
Rate for Payer: Scott and White EPO/PPO	$1,873.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,697.84
Rate for Payer: Superior Health Plan EPO	$509.59

SELECT CATH PLCMNT, 2ND ORD, ART TH

Facility

$3,236.00

Service Code	HCPCS 36216
Hospital Charge Code	2301794
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,200.48

SELECT CATH PLCMNT, 2ND ORD, ART TH

Facility

$3,236.00

Service Code	HCPCS 36216
Hospital Charge Code	2301794
Hospital Revenue Code	361
Min. Negotiated Rate	$291.24
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$291.24
Rate for Payer: BCBS of TX Blue Advantage	$970.80
Rate for Payer: BCBS of TX Blue Essentials	$1,164.96
Rate for Payer: BCBS of TX PPO	$1,294.40
Rate for Payer: Cash Price	$2,200.48
Rate for Payer: Cash Price	$2,200.48
Rate for Payer: Cigna Medicaid	$2,329.92
Rate for Payer: Molina CHIP/Medicaid	$2,329.92
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	$2,329.92
Rate for Payer: Scott and White EPO/PPO	$1,618.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,329.92
Rate for Payer: Superior Health Plan EPO	$440.10

Know your out-of-pocket cost for care.

All Charges