White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD

Facility

$12,012.72

Service Code	APR-DRG 1324
Min. Negotiated Rate	$11,326.01
Max. Negotiated Rate	$12,012.72
Rate for Payer: Amerigroup CHIP/Medicaid	$11,326.01
Rate for Payer: Cigna Medicaid	$11,326.01
Rate for Payer: Molina CHIP/Medicaid	$11,326.01
Rate for Payer: Parkland Medicaid	$11,326.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,012.72

BRACE BACK LSO L0631

Facility

$4,652.27

Hospital Charge Code	137832
Hospital Revenue Code	274
Min. Negotiated Rate	$1,163.07
Max. Negotiated Rate	$2,326.14
Rate for Payer: Cash Price	$3,163.54
Rate for Payer: Cigna Commercial	$1,163.07
Rate for Payer: Multiplan Auto	$2,326.14
Rate for Payer: Multiplan Commercial	$2,326.14
Rate for Payer: Multiplan Workers Comp	$2,326.14
Rate for Payer: Scott and White EPO/PPO	$2,326.14

BRACE BACK LSO L0631

Facility

$4,652.27

Hospital Charge Code	137832
Hospital Revenue Code	274
Min. Negotiated Rate	$418.70
Max. Negotiated Rate	$3,349.63
Rate for Payer: Amerigroup CHIP/Medicaid	$418.70
Rate for Payer: BCBS of TX Blue Advantage	$1,395.68
Rate for Payer: BCBS of TX Blue Essentials	$1,674.82
Rate for Payer: BCBS of TX PPO	$1,860.91
Rate for Payer: Cash Price	$3,163.54
Rate for Payer: Cigna Medicaid	$3,349.63
Rate for Payer: Molina CHIP/Medicaid	$3,349.63
Rate for Payer: Multiplan Auto	$2,326.14
Rate for Payer: Multiplan Commercial	$2,326.14
Rate for Payer: Multiplan Workers Comp	$2,326.14
Rate for Payer: Parkland Medicaid	$3,349.63
Rate for Payer: Scott and White EPO/PPO	$2,326.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,349.63
Rate for Payer: Superior Health Plan EPO	$632.71

brace hip abduction custom

Facility

$3,887.15

Hospital Charge Code	8672528
Hospital Revenue Code	274
Min. Negotiated Rate	$971.79
Max. Negotiated Rate	$1,943.58
Rate for Payer: Cash Price	$2,643.26
Rate for Payer: Cigna Commercial	$971.79
Rate for Payer: Multiplan Auto	$1,943.58
Rate for Payer: Multiplan Commercial	$1,943.58
Rate for Payer: Multiplan Workers Comp	$1,943.58
Rate for Payer: Scott and White EPO/PPO	$1,943.58

brace hip abduction custom

Facility

$3,887.15

Hospital Charge Code	8672528
Hospital Revenue Code	274
Min. Negotiated Rate	$349.84
Max. Negotiated Rate	$2,798.75
Rate for Payer: Amerigroup CHIP/Medicaid	$349.84
Rate for Payer: BCBS of TX Blue Advantage	$1,166.14
Rate for Payer: BCBS of TX Blue Essentials	$1,399.37
Rate for Payer: BCBS of TX PPO	$1,554.86
Rate for Payer: Cash Price	$2,643.26
Rate for Payer: Cigna Medicaid	$2,798.75
Rate for Payer: Molina CHIP/Medicaid	$2,798.75
Rate for Payer: Multiplan Auto	$1,943.58
Rate for Payer: Multiplan Commercial	$1,943.58
Rate for Payer: Multiplan Workers Comp	$1,943.58
Rate for Payer: Parkland Medicaid	$2,798.75
Rate for Payer: Scott and White EPO/PPO	$1,943.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,798.75
Rate for Payer: Superior Health Plan EPO	$528.65

BRACES, CURAD UNIVERSAL THUMB BRACE

Facility

$68.49

Hospital Charge Code	993777
Hospital Revenue Code	274
Min. Negotiated Rate	$6.16
Max. Negotiated Rate	$49.31
Rate for Payer: Amerigroup CHIP/Medicaid	$6.16
Rate for Payer: BCBS of TX Blue Advantage	$20.55
Rate for Payer: BCBS of TX Blue Essentials	$24.66
Rate for Payer: BCBS of TX PPO	$27.40
Rate for Payer: Cash Price	$46.57
Rate for Payer: Cigna Medicaid	$49.31
Rate for Payer: Molina CHIP/Medicaid	$49.31
Rate for Payer: Multiplan Auto	$34.24
Rate for Payer: Multiplan Commercial	$34.24
Rate for Payer: Multiplan Workers Comp	$34.24
Rate for Payer: Parkland Medicaid	$49.31
Rate for Payer: Scott and White EPO/PPO	$34.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.31
Rate for Payer: Superior Health Plan EPO	$9.31

BRACES, CURAD UNIVERSAL THUMB BRACE

Facility

$68.49

Hospital Charge Code	993777
Hospital Revenue Code	274
Min. Negotiated Rate	$17.12
Max. Negotiated Rate	$34.24
Rate for Payer: Cash Price	$46.57
Rate for Payer: Cigna Commercial	$17.12
Rate for Payer: Multiplan Auto	$34.24
Rate for Payer: Multiplan Commercial	$34.24
Rate for Payer: Multiplan Workers Comp	$34.24
Rate for Payer: Scott and White EPO/PPO	$34.24

BRACE TLSO L0464

Facility

$6,736.04

Hospital Charge Code	8528473
Hospital Revenue Code	272
Min. Negotiated Rate	$606.24
Max. Negotiated Rate	$4,849.95
Rate for Payer: Amerigroup CHIP/Medicaid	$606.24
Rate for Payer: BCBS of TX Blue Advantage	$2,020.81
Rate for Payer: BCBS of TX Blue Essentials	$2,424.97
Rate for Payer: BCBS of TX PPO	$2,694.42
Rate for Payer: Cash Price	$4,580.51
Rate for Payer: Cigna Medicaid	$4,849.95
Rate for Payer: Molina CHIP/Medicaid	$4,849.95
Rate for Payer: Multiplan Auto	$4,378.43
Rate for Payer: Multiplan Commercial	$4,378.43
Rate for Payer: Multiplan Workers Comp	$4,378.43
Rate for Payer: Parkland Medicaid	$4,849.95
Rate for Payer: Scott and White EPO/PPO	$3,368.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,849.95
Rate for Payer: Superior Health Plan EPO	$916.10

BRACE TLSO L0464

Facility

$6,736.04

Hospital Charge Code	8528473
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,580.51

BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA

Facility

$5,097.71

Service Code	APR-DRG 0562
Min. Negotiated Rate	$4,806.30
Max. Negotiated Rate	$5,097.71
Rate for Payer: Amerigroup CHIP/Medicaid	$4,806.30
Rate for Payer: Cigna Medicaid	$4,806.30
Rate for Payer: Molina CHIP/Medicaid	$4,806.30
Rate for Payer: Parkland Medicaid	$4,806.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,097.71

BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA

Facility

$7,787.44

Service Code	APR-DRG 0563
Min. Negotiated Rate	$7,342.28
Max. Negotiated Rate	$7,787.44
Rate for Payer: Amerigroup CHIP/Medicaid	$7,342.28
Rate for Payer: Cigna Medicaid	$7,342.28
Rate for Payer: Molina CHIP/Medicaid	$7,342.28
Rate for Payer: Parkland Medicaid	$7,342.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,787.44

BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA

Facility

$3,614.98

Service Code	APR-DRG 0561
Min. Negotiated Rate	$3,408.33
Max. Negotiated Rate	$3,614.98
Rate for Payer: Amerigroup CHIP/Medicaid	$3,408.33
Rate for Payer: Cigna Medicaid	$3,408.33
Rate for Payer: Molina CHIP/Medicaid	$3,408.33
Rate for Payer: Parkland Medicaid	$3,408.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,614.98

BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA

Facility

$14,949.13

Service Code	APR-DRG 0564
Min. Negotiated Rate	$14,094.56
Max. Negotiated Rate	$14,949.13
Rate for Payer: Amerigroup CHIP/Medicaid	$14,094.56
Rate for Payer: Cigna Medicaid	$14,094.56
Rate for Payer: Molina CHIP/Medicaid	$14,094.56
Rate for Payer: Parkland Medicaid	$14,094.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,949.13

BRCE ANKLE -- DHF

Facility

$206.86

Hospital Charge Code	81140451
Hospital Revenue Code	270
Min. Negotiated Rate	$18.62
Max. Negotiated Rate	$148.94
Rate for Payer: Amerigroup CHIP/Medicaid	$18.62
Rate for Payer: BCBS of TX Blue Advantage	$62.06
Rate for Payer: BCBS of TX Blue Essentials	$74.47
Rate for Payer: BCBS of TX PPO	$82.74
Rate for Payer: Cash Price	$140.66
Rate for Payer: Cigna Medicaid	$148.94
Rate for Payer: Molina CHIP/Medicaid	$148.94
Rate for Payer: Multiplan Auto	$134.46
Rate for Payer: Multiplan Commercial	$134.46
Rate for Payer: Multiplan Workers Comp	$134.46
Rate for Payer: Parkland Medicaid	$148.94
Rate for Payer: Scott and White EPO/PPO	$103.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$148.94
Rate for Payer: Superior Health Plan EPO	$28.13

BRCE ANKLE -- DHF

Facility

$206.86

Hospital Charge Code	81140451
Hospital Revenue Code	270
Rate for Payer: Cash Price	$140.66

BRCE ORTHOPEDIC -- DHF

Facility

$3,483.88

Hospital Charge Code	81141053
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2,369.04

BRCE ORTHOPEDIC -- DHF

Facility

$3,483.88

Hospital Charge Code	81141053
Hospital Revenue Code	270
Min. Negotiated Rate	$313.55
Max. Negotiated Rate	$2,508.39
Rate for Payer: Amerigroup CHIP/Medicaid	$313.55
Rate for Payer: BCBS of TX Blue Advantage	$1,045.16
Rate for Payer: BCBS of TX Blue Essentials	$1,254.20
Rate for Payer: BCBS of TX PPO	$1,393.55
Rate for Payer: Cash Price	$2,369.04
Rate for Payer: Cigna Medicaid	$2,508.39
Rate for Payer: Molina CHIP/Medicaid	$2,508.39
Rate for Payer: Multiplan Auto	$2,264.52
Rate for Payer: Multiplan Commercial	$2,264.52
Rate for Payer: Multiplan Workers Comp	$2,264.52
Rate for Payer: Parkland Medicaid	$2,508.39
Rate for Payer: Scott and White EPO/PPO	$1,741.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,508.39
Rate for Payer: Superior Health Plan EPO	$473.81

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC

Facility

$40,580.20

Service Code	MSDRG 584
Min. Negotiated Rate	$16,094.04
Max. Negotiated Rate	$40,580.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,449.33
Rate for Payer: Amerigroup Medicare	$20,449.33
Rate for Payer: BCBS of TX Medicare	$20,449.33
Rate for Payer: Cigna Commercial	$27,572.22
Rate for Payer: Cigna Medicare	$20,449.33
Rate for Payer: Employer Direct Commercial	$20,449.33
Rate for Payer: Humana Medicare/TRICARE	$20,449.33
Rate for Payer: Molina Dual Medicare/Medicaid	$20,449.33
Rate for Payer: Molina Medicare	$20,449.33
Rate for Payer: Multiplan Auto	$40,580.20
Rate for Payer: Multiplan Commercial	$40,580.20
Rate for Payer: Multiplan Workers Comp	$40,580.20
Rate for Payer: Scott and White EPO/PPO	$18,688.25
Rate for Payer: Scott and White Medicare	$20,449.33
Rate for Payer: Superior Health Plan EPO	$20,449.33
Rate for Payer: Superior Health Plan Medicare	$20,449.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,449.33
Rate for Payer: Universal American Medicare	$20,449.33
Rate for Payer: Wellcare Medicare	$20,449.33
Rate for Payer: Wellmed Medicare	$20,449.33

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC

Facility

$34,980.90

Service Code	MSDRG 585
Min. Negotiated Rate	$13,465.02
Max. Negotiated Rate	$34,980.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,898.50
Rate for Payer: Amerigroup Medicare	$18,898.50
Rate for Payer: BCBS of TX Medicare	$18,898.50
Rate for Payer: Cigna Commercial	$24,846.81
Rate for Payer: Cigna Medicare	$18,898.50
Rate for Payer: Employer Direct Commercial	$18,898.50
Rate for Payer: Humana Medicare/TRICARE	$18,898.50
Rate for Payer: Molina Dual Medicare/Medicaid	$18,898.50
Rate for Payer: Molina Medicare	$18,898.50
Rate for Payer: Multiplan Auto	$34,980.90
Rate for Payer: Multiplan Commercial	$34,980.90
Rate for Payer: Multiplan Workers Comp	$34,980.90
Rate for Payer: Scott and White EPO/PPO	$16,109.62
Rate for Payer: Scott and White Medicare	$18,898.50
Rate for Payer: Superior Health Plan EPO	$18,898.50
Rate for Payer: Superior Health Plan Medicare	$18,898.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,898.50
Rate for Payer: Universal American Medicare	$18,898.50
Rate for Payer: Wellcare Medicare	$18,898.50
Rate for Payer: Wellmed Medicare	$18,898.50

BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W CC/MCC

Facility

$40,580.20

Service Code	MSDRG 584
Min. Negotiated Rate	$16,094.04
Max. Negotiated Rate	$40,580.20
Rate for Payer: BCBS of TX Blue Advantage	$16,094.04
Rate for Payer: BCBS of TX Blue Essentials	$19,310.98
Rate for Payer: BCBS of TX PPO	$21,457.47

BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC

Facility

$34,980.90

Service Code	MSDRG 585
Min. Negotiated Rate	$13,465.02
Max. Negotiated Rate	$34,980.90
Rate for Payer: BCBS of TX Blue Advantage	$13,465.02
Rate for Payer: BCBS of TX Blue Essentials	$16,156.46
Rate for Payer: BCBS of TX PPO	$17,952.32

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$12,743.71

Service Code	APR-DRG 3633
Min. Negotiated Rate	$12,015.21
Max. Negotiated Rate	$12,743.71
Rate for Payer: Amerigroup CHIP/Medicaid	$12,015.21
Rate for Payer: Cigna Medicaid	$12,015.21
Rate for Payer: Molina CHIP/Medicaid	$12,015.21
Rate for Payer: Parkland Medicaid	$12,015.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,743.71

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$4,487.42

Service Code	APR-DRG 3631
Min. Negotiated Rate	$4,230.89
Max. Negotiated Rate	$4,487.42
Rate for Payer: Amerigroup CHIP/Medicaid	$4,230.89
Rate for Payer: Cigna Medicaid	$4,230.89
Rate for Payer: Molina CHIP/Medicaid	$4,230.89
Rate for Payer: Parkland Medicaid	$4,230.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,487.42

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$8,774.17

Service Code	APR-DRG 3632
Min. Negotiated Rate	$8,272.60
Max. Negotiated Rate	$8,774.17
Rate for Payer: Amerigroup CHIP/Medicaid	$8,272.60
Rate for Payer: Cigna Medicaid	$8,272.60
Rate for Payer: Molina CHIP/Medicaid	$8,272.60
Rate for Payer: Parkland Medicaid	$8,272.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,774.17

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$17,232.26

Service Code	APR-DRG 3634
Min. Negotiated Rate	$16,247.18
Max. Negotiated Rate	$17,232.26
Rate for Payer: Amerigroup CHIP/Medicaid	$16,247.18
Rate for Payer: Cigna Medicaid	$16,247.18
Rate for Payer: Molina CHIP/Medicaid	$16,247.18
Rate for Payer: Parkland Medicaid	$16,247.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,232.26

Know your out-of-pocket cost for care.

All Charges