White Rock Medical Center

All Charges

Charge

Type

Setting

Price

96373- Intra-Arterial Injection

Facility

$360.00

Service Code	CPT 96373
Hospital Charge Code	6100783
Hospital Revenue Code	260
Rate for Payer: Cash Price	$316.80

96374- IV Injection, single/initial

Facility

$360.00

Service Code	CPT 96374
Hospital Charge Code	5202437
Hospital Revenue Code	260
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$444.05
Rate for Payer: Aetna Commercial	$198.00
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup CHIP/Medicaid	$32.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$68.97
Rate for Payer: BCBS of TX Blue Essentials	$82.45
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$91.96
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$444.05
Rate for Payer: Cigna Medicare	$196.02
Rate for Payer: Employer Direct Commercial	$196.02
Rate for Payer: Humana Medicare/TRICARE	$196.02
Rate for Payer: Molina Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
Rate for Payer: Multiplan Auto	$234.00
Rate for Payer: Multiplan Commercial	$234.00
Rate for Payer: Multiplan Workers Comp	$234.00
Rate for Payer: Scott and White EPO/PPO	$3.51
Rate for Payer: Scott and White Medicare	$196.02
Rate for Payer: Superior Health Plan EPO	$196.02
Rate for Payer: Superior Health Plan Medicare	$196.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$196.02
Rate for Payer: Universal American Medicare	$196.02
Rate for Payer: Wellcare Medicare	$196.02
Rate for Payer: Wellmed Medicare	$196.02

96374- IV Injection, single/initial

Facility

$360.00

Service Code	CPT 96374
Hospital Charge Code	5202437
Hospital Revenue Code	260
Rate for Payer: Cash Price	$316.80

96375- IV Injection, add new drug

Facility

$330.00

Service Code	CPT 96375
Hospital Charge Code	5202445
Hospital Revenue Code	260
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$214.50
Rate for Payer: Aetna Commercial	$181.50
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$29.48
Rate for Payer: BCBS of TX Blue Essentials	$35.24
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$39.30
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Scott and White EPO/PPO	$0.78
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

96375- IV Injection, add new drug

Facility

$330.00

Service Code	CPT 96375
Hospital Charge Code	5202445
Hospital Revenue Code	260
Rate for Payer: Cash Price	$290.40

96376- IV Injection, add same drug

Facility

$330.00

Service Code	CPT 96376
Hospital Charge Code	5202452
Hospital Revenue Code	260
Rate for Payer: Cash Price	$290.40

96376- IV Injection, add same drug

Facility

$330.00

Service Code	CPT 96376
Hospital Charge Code	5202452
Hospital Revenue Code	260
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$214.50
Rate for Payer: Aetna Commercial	$181.50
Rate for Payer: Amerigroup CHIP/Medicaid	$29.70
Rate for Payer: BCBS of TX Blue Advantage	$41.39
Rate for Payer: BCBS of TX Blue Essentials	$49.48
Rate for Payer: BCBS of TX PPO	$55.19
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Multiplan Auto	$214.50
Rate for Payer: Multiplan Commercial	$214.50
Rate for Payer: Multiplan Workers Comp	$214.50
Rate for Payer: Scott and White EPO/PPO	$165.00
Rate for Payer: Superior Health Plan EPO	$44.88

984 - v34 MSDRG

Facility

$29,333.74

Service Code	MSDRG 984
Hospital Charge Code	984
Min. Negotiated Rate	$29,333.74
Max. Negotiated Rate	$29,333.74
Rate for Payer: BCBS of TX Blue Advantage	$29,333.74

985 - v34 MSDRG

Facility

$15,542.78

Service Code	MSDRG 985
Hospital Charge Code	985
Min. Negotiated Rate	$15,542.78
Max. Negotiated Rate	$15,542.78
Rate for Payer: BCBS of TX Blue Advantage	$15,542.78

986 - v34 MSDRG

Facility

$9,570.08

Service Code	MSDRG 986
Hospital Charge Code	986
Min. Negotiated Rate	$9,570.08
Max. Negotiated Rate	$9,570.08
Rate for Payer: BCBS of TX Blue Advantage	$9,570.08

99281 - Level 1

Facility

$375.00

Service Code	CPT 99281
Hospital Charge Code	5201777
Hospital Revenue Code	450
Rate for Payer: Cash Price	$330.00

99281 - Level 1

Facility

$375.00

Service Code	CPT 99281
Hospital Charge Code	5201777
Hospital Revenue Code	450
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$750.00
Rate for Payer: Aetna Commercial	$750.00
Rate for Payer: Aetna Medicare	$121.78
Rate for Payer: Amerigroup CHIP/Medicaid	$280.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$81.19
Rate for Payer: Amerigroup Medicare	$81.19
Rate for Payer: BCBS of TX Blue Advantage	$121.14
Rate for Payer: BCBS of TX Blue Essentials	$144.81
Rate for Payer: BCBS of TX Medicare	$81.19
Rate for Payer: BCBS of TX PPO	$161.52
Rate for Payer: Cash Price	$330.00
Rate for Payer: Cash Price	$330.00
Rate for Payer: Cash Price	$330.00
Rate for Payer: Cigna Commercial	$323.31
Rate for Payer: Cigna Medicare	$81.19
Rate for Payer: Employer Direct Commercial	$81.19
Rate for Payer: Humana Medicare/TRICARE	$81.19
Rate for Payer: Molina Dual Medicare/Medicaid	$81.19
Rate for Payer: Molina Medicare	$81.19
Rate for Payer: Multiplan Auto	$243.75
Rate for Payer: Multiplan Commercial	$243.75
Rate for Payer: Multiplan Workers Comp	$243.75
Rate for Payer: Scott and White EPO/PPO	$1.45
Rate for Payer: Scott and White Medicare	$81.19
Rate for Payer: Superior Health Plan EPO	$81.19
Rate for Payer: Superior Health Plan Medicare	$81.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$81.19
Rate for Payer: Universal American Medicare	$81.19
Rate for Payer: Wellcare Medicare	$81.19
Rate for Payer: Wellmed Medicare	$81.19

99282 - Level 2

Facility

$762.00

Service Code	CPT 99282
Hospital Charge Code	5201785
Hospital Revenue Code	450
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$1,500.00
Rate for Payer: Aetna Commercial	$1,500.00
Rate for Payer: Aetna Medicare	$224.36
Rate for Payer: Amerigroup CHIP/Medicaid	$280.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$149.57
Rate for Payer: Amerigroup Medicare	$149.57
Rate for Payer: BCBS of TX Blue Advantage	$222.65
Rate for Payer: BCBS of TX Blue Essentials	$266.16
Rate for Payer: BCBS of TX Medicare	$149.57
Rate for Payer: BCBS of TX PPO	$296.87
Rate for Payer: Cash Price	$670.56
Rate for Payer: Cash Price	$670.56
Rate for Payer: Cash Price	$670.56
Rate for Payer: Cigna Commercial	$595.62
Rate for Payer: Cigna Medicare	$149.57
Rate for Payer: Employer Direct Commercial	$149.57
Rate for Payer: Humana Medicare/TRICARE	$149.57
Rate for Payer: Molina Dual Medicare/Medicaid	$149.57
Rate for Payer: Molina Medicare	$149.57
Rate for Payer: Multiplan Auto	$495.30
Rate for Payer: Multiplan Commercial	$495.30
Rate for Payer: Multiplan Workers Comp	$495.30
Rate for Payer: Scott and White EPO/PPO	$2.67
Rate for Payer: Scott and White Medicare	$149.57
Rate for Payer: Superior Health Plan EPO	$149.57
Rate for Payer: Superior Health Plan Medicare	$149.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$149.57
Rate for Payer: Universal American Medicare	$149.57
Rate for Payer: Wellcare Medicare	$149.57
Rate for Payer: Wellmed Medicare	$149.57

99282 - Level 2

Facility

$762.00

Service Code	CPT 99282
Hospital Charge Code	5201785
Hospital Revenue Code	450
Rate for Payer: Cash Price	$670.56

99283 - Level 3

Facility

$1,554.00

Service Code	CPT 99283
Hospital Charge Code	5201793
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,367.52

99283 - Level 3

Facility

$1,554.00

Service Code	CPT 99283
Hospital Charge Code	5201793
Hospital Revenue Code	450
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$2,050.00
Rate for Payer: Aetna Commercial	$2,050.00
Rate for Payer: Aetna Medicare	$391.41
Rate for Payer: Amerigroup CHIP/Medicaid	$280.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$260.94
Rate for Payer: Amerigroup Medicare	$260.94
Rate for Payer: BCBS of TX Blue Advantage	$388.61
Rate for Payer: BCBS of TX Blue Essentials	$464.55
Rate for Payer: BCBS of TX Medicare	$260.94
Rate for Payer: BCBS of TX PPO	$518.15
Rate for Payer: Cash Price	$1,367.52
Rate for Payer: Cash Price	$1,367.52
Rate for Payer: Cash Price	$1,367.52
Rate for Payer: Cigna Commercial	$1,039.11
Rate for Payer: Cigna Medicare	$260.94
Rate for Payer: Employer Direct Commercial	$260.94
Rate for Payer: Humana Medicare/TRICARE	$260.94
Rate for Payer: Molina Dual Medicare/Medicaid	$260.94
Rate for Payer: Molina Medicare	$260.94
Rate for Payer: Multiplan Auto	$1,010.10
Rate for Payer: Multiplan Commercial	$1,010.10
Rate for Payer: Multiplan Workers Comp	$1,010.10
Rate for Payer: Scott and White EPO/PPO	$4.67
Rate for Payer: Scott and White Medicare	$260.94
Rate for Payer: Superior Health Plan EPO	$260.94
Rate for Payer: Superior Health Plan Medicare	$260.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$260.94
Rate for Payer: Universal American Medicare	$260.94
Rate for Payer: Wellcare Medicare	$260.94
Rate for Payer: Wellmed Medicare	$260.94

99284 - Level 4

Facility

$2,117.00

Service Code	CPT 99284
Hospital Charge Code	5201801
Hospital Revenue Code	450
Min. Negotiated Rate	$7.24
Max. Negotiated Rate	$2,350.00
Rate for Payer: Aetna Commercial	$2,350.00
Rate for Payer: Aetna Medicare	$607.59
Rate for Payer: Amerigroup CHIP/Medicaid	$280.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$405.06
Rate for Payer: Amerigroup Medicare	$405.06
Rate for Payer: BCBS of TX Blue Advantage	$612.11
Rate for Payer: BCBS of TX Blue Essentials	$731.72
Rate for Payer: BCBS of TX Medicare	$405.06
Rate for Payer: BCBS of TX PPO	$816.15
Rate for Payer: Cash Price	$1,862.96
Rate for Payer: Cash Price	$1,862.96
Rate for Payer: Cash Price	$1,862.96
Rate for Payer: Cigna Commercial	$1,613.02
Rate for Payer: Cigna Medicare	$405.06
Rate for Payer: Employer Direct Commercial	$405.06
Rate for Payer: Humana Medicare/TRICARE	$405.06
Rate for Payer: Molina Dual Medicare/Medicaid	$405.06
Rate for Payer: Molina Medicare	$405.06
Rate for Payer: Multiplan Auto	$1,376.05
Rate for Payer: Multiplan Commercial	$1,376.05
Rate for Payer: Multiplan Workers Comp	$1,376.05
Rate for Payer: Scott and White EPO/PPO	$7.24
Rate for Payer: Scott and White Medicare	$405.06
Rate for Payer: Superior Health Plan EPO	$405.06
Rate for Payer: Superior Health Plan Medicare	$405.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$405.06
Rate for Payer: Universal American Medicare	$405.06
Rate for Payer: Wellcare Medicare	$405.06
Rate for Payer: Wellmed Medicare	$405.06

99284 - Level 4

Facility

$2,117.00

Service Code	CPT 99284
Hospital Charge Code	5201801
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,862.96

99285 - Level 5

Facility

$3,040.00

Service Code	CPT 99285
Hospital Charge Code	5201819
Hospital Revenue Code	450
Min. Negotiated Rate	$10.51
Max. Negotiated Rate	$3,123.61
Rate for Payer: Aetna Commercial	$2,500.00
Rate for Payer: Aetna Medicare	$881.13
Rate for Payer: Amerigroup CHIP/Medicaid	$280.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$587.42
Rate for Payer: Amerigroup Medicare	$587.42
Rate for Payer: BCBS of TX Blue Advantage	$877.85
Rate for Payer: BCBS of TX Blue Essentials	$1,049.38
Rate for Payer: BCBS of TX Medicare	$587.42
Rate for Payer: BCBS of TX PPO	$1,170.46
Rate for Payer: Cash Price	$2,675.20
Rate for Payer: Cash Price	$2,675.20
Rate for Payer: Cash Price	$2,675.20
Rate for Payer: Cigna Commercial	$3,123.61
Rate for Payer: Cigna Medicare	$587.42
Rate for Payer: Employer Direct Commercial	$587.42
Rate for Payer: Humana Medicare/TRICARE	$587.42
Rate for Payer: Molina Dual Medicare/Medicaid	$587.42
Rate for Payer: Molina Medicare	$587.42
Rate for Payer: Multiplan Auto	$1,976.00
Rate for Payer: Multiplan Commercial	$1,976.00
Rate for Payer: Multiplan Workers Comp	$1,976.00
Rate for Payer: Scott and White EPO/PPO	$10.51
Rate for Payer: Scott and White Medicare	$587.42
Rate for Payer: Superior Health Plan EPO	$587.42
Rate for Payer: Superior Health Plan Medicare	$587.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$587.42
Rate for Payer: Universal American Medicare	$587.42
Rate for Payer: Wellcare Medicare	$587.42
Rate for Payer: Wellmed Medicare	$587.42

99285 - Level 5

Facility

$3,040.00

Service Code	CPT 99285
Hospital Charge Code	5201819
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,675.20

ABD AORTA W/BI LWR EXT

Facility

$4,977.00

Service Code	CPT 75630
Hospital Charge Code	4615631
Hospital Revenue Code	323
Min. Negotiated Rate	$52.13
Max. Negotiated Rate	$6,603.56
Rate for Payer: Aetna Commercial	$74.94
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$156.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Amerigroup Medicare	$2,915.10
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	$2,915.10
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$4,379.76
Rate for Payer: Cash Price	$4,379.76
Rate for Payer: Cash Price	$4,379.76
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$156.71
Rate for Payer: Cigna Medicare	$2,915.10
Rate for Payer: Employer Direct Commercial	$2,915.10
Rate for Payer: Humana Medicare/TRICARE	$2,915.10
Rate for Payer: Molina CHIP/Medicaid	$156.71
Rate for Payer: Molina Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Molina Medicare	$2,915.10
Rate for Payer: Multiplan Auto	$3,235.05
Rate for Payer: Multiplan Commercial	$3,235.05
Rate for Payer: Multiplan Workers Comp	$3,235.05
Rate for Payer: Parkland Medicaid	$156.71
Rate for Payer: Scott and White EPO/PPO	$52.13
Rate for Payer: Scott and White Medicare	$2,915.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$156.71
Rate for Payer: Superior Health Plan EPO	$2,915.10
Rate for Payer: Superior Health Plan Medicare	$2,915.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Universal American Medicare	$2,915.10
Rate for Payer: Wellcare Medicare	$2,915.10
Rate for Payer: Wellmed Medicare	$2,915.10

ABD AORTA W/BI LWR EXT

Facility

$4,977.00

Service Code	CPT 75630
Hospital Charge Code	4615631
Hospital Revenue Code	323
Rate for Payer: Cash Price	$4,379.76

ABD PARACENTESIS W/IMAGE

Facility

$1,947.00

Service Code	CPT 49083
Hospital Charge Code	4619083
Hospital Revenue Code	361
Min. Negotiated Rate	$18.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$1,243.53
Rate for Payer: Amerigroup CHIP/Medicaid	$334.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$829.02
Rate for Payer: Amerigroup Medicare	$829.02
Rate for Payer: BCBS of TX Blue Advantage	$1,312.49
Rate for Payer: BCBS of TX Blue Essentials	$1,571.84
Rate for Payer: BCBS of TX Medicare	$829.02
Rate for Payer: BCBS of TX PPO	$1,980.52
Rate for Payer: Cash Price	$1,713.36
Rate for Payer: Cash Price	$1,713.36
Rate for Payer: Cigna Commercial	$1,877.98
Rate for Payer: Cigna Medicaid	$334.95
Rate for Payer: Cigna Medicare	$829.02
Rate for Payer: Employer Direct Commercial	$829.02
Rate for Payer: Humana Medicare/TRICARE	$829.02
Rate for Payer: Molina CHIP/Medicaid	$334.95
Rate for Payer: Molina Dual Medicare/Medicaid	$829.02
Rate for Payer: Molina Medicare	$829.02
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	$334.95
Rate for Payer: Scott and White EPO/PPO	$18.29
Rate for Payer: Scott and White Medicare	$829.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$334.95
Rate for Payer: Superior Health Plan EPO	$829.02
Rate for Payer: Superior Health Plan Medicare	$829.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$829.02
Rate for Payer: Universal American Medicare	$829.02
Rate for Payer: Wellcare Medicare	$829.02
Rate for Payer: Wellmed Medicare	$829.02

ABD PARACENTESIS W/IMAGE

Facility

$1,947.00

Service Code	CPT 49083
Hospital Charge Code	4619083
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,713.36

ABLATION-AV NODE

Facility

$7,540.00

Service Code	CPT 93650
Hospital Charge Code	4610650
Hospital Revenue Code	480
Rate for Payer: Cash Price	$6,635.20

Know your out-of-pocket cost for care.

All Charges