White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CERVICAL SPINAL FUSION WITHOUT CC/MCC

Facility

$46,384.70

Service Code	MSDRG 473
Min. Negotiated Rate	$20,406.94
Max. Negotiated Rate	$46,384.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,652.44
Rate for Payer: Amerigroup Medicare	$22,652.44
Rate for Payer: BCBS of TX Medicare	$22,652.44
Rate for Payer: Cigna Commercial	$31,443.94
Rate for Payer: Cigna Medicare	$22,652.44
Rate for Payer: Employer Direct Commercial	$22,652.44
Rate for Payer: Humana Medicare/TRICARE	$22,652.44
Rate for Payer: Molina Dual Medicare/Medicaid	$22,652.44
Rate for Payer: Molina Medicare	$22,652.44
Rate for Payer: Multiplan Auto	$46,384.70
Rate for Payer: Multiplan Commercial	$46,384.70
Rate for Payer: Multiplan Workers Comp	$46,384.70
Rate for Payer: Scott and White EPO/PPO	$21,361.38
Rate for Payer: Scott and White Medicare	$22,652.44
Rate for Payer: Superior Health Plan EPO	$22,652.44
Rate for Payer: Superior Health Plan Medicare	$22,652.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,652.44
Rate for Payer: Universal American Medicare	$22,652.44
Rate for Payer: Wellcare Medicare	$22,652.44
Rate for Payer: Wellmed Medicare	$22,652.44

CERVICAL SPINAL FUSION W MCC

Facility

$91,745.30

Service Code	MSDRG 471
Min. Negotiated Rate	$40,149.76
Max. Negotiated Rate	$91,745.30
Rate for Payer: BCBS of TX Blue Advantage	$43,092.02
Rate for Payer: BCBS of TX Blue Essentials	$51,705.41
Rate for Payer: BCBS of TX PPO	$57,452.69

CERVICAL SPINAL FUSION W/O CC/MCC

Facility

$46,384.70

Service Code	MSDRG 473
Min. Negotiated Rate	$20,406.94
Max. Negotiated Rate	$46,384.70
Rate for Payer: BCBS of TX Blue Advantage	$20,406.94
Rate for Payer: BCBS of TX Blue Essentials	$24,485.96
Rate for Payer: BCBS of TX PPO	$27,207.67

CESAREAN SECTION WITHOUT STERILIZATION

Facility

$7,303.51

Service Code	APR-DRG 5404
Min. Negotiated Rate	$6,886.01
Max. Negotiated Rate	$7,303.51
Rate for Payer: Amerigroup CHIP/Medicaid	$6,886.01
Rate for Payer: Cigna Medicaid	$6,886.01
Rate for Payer: Molina CHIP/Medicaid	$6,886.01
Rate for Payer: Parkland Medicaid	$6,886.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,303.51

CESAREAN SECTION WITHOUT STERILIZATION

Facility

$2,198.63

Service Code	APR-DRG 5401
Min. Negotiated Rate	$2,072.95
Max. Negotiated Rate	$2,198.63
Rate for Payer: Amerigroup CHIP/Medicaid	$2,072.95
Rate for Payer: Cigna Medicaid	$2,072.95
Rate for Payer: Molina CHIP/Medicaid	$2,072.95
Rate for Payer: Parkland Medicaid	$2,072.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,198.63

CESAREAN SECTION WITHOUT STERILIZATION

Facility

$3,723.99

Service Code	APR-DRG 5403
Min. Negotiated Rate	$3,511.11
Max. Negotiated Rate	$3,723.99
Rate for Payer: Amerigroup CHIP/Medicaid	$3,511.11
Rate for Payer: Cigna Medicaid	$3,511.11
Rate for Payer: Molina CHIP/Medicaid	$3,511.11
Rate for Payer: Parkland Medicaid	$3,511.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,723.99

CESAREAN SECTION WITHOUT STERILIZATION

Facility

$2,725.57

Service Code	APR-DRG 5402
Min. Negotiated Rate	$2,569.76
Max. Negotiated Rate	$2,725.57
Rate for Payer: Amerigroup CHIP/Medicaid	$2,569.76
Rate for Payer: Cigna Medicaid	$2,569.76
Rate for Payer: Molina CHIP/Medicaid	$2,569.76
Rate for Payer: Parkland Medicaid	$2,569.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,725.57

CESAREAN SECTION WITHOUT STERILIZATION WITH CC

Facility

$21,219.20

Service Code	MSDRG 787
Min. Negotiated Rate	$6,879.00
Max. Negotiated Rate	$21,219.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,945.14
Rate for Payer: Amerigroup Medicare	$12,945.14
Rate for Payer: BCBS of TX Medicare	$12,945.14
Rate for Payer: Cigna Commercial	$6,879.00
Rate for Payer: Cigna Medicare	$12,945.14
Rate for Payer: Employer Direct Commercial	$12,945.14
Rate for Payer: Humana Medicare/TRICARE	$12,945.14
Rate for Payer: Molina Dual Medicare/Medicaid	$12,945.14
Rate for Payer: Molina Medicare	$12,945.14
Rate for Payer: Multiplan Auto	$21,219.20
Rate for Payer: Multiplan Commercial	$21,219.20
Rate for Payer: Multiplan Workers Comp	$21,219.20
Rate for Payer: Scott and White EPO/PPO	$9,772.00
Rate for Payer: Scott and White Medicare	$12,945.14
Rate for Payer: Superior Health Plan EPO	$12,945.14
Rate for Payer: Superior Health Plan Medicare	$12,945.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,945.14
Rate for Payer: Universal American Medicare	$12,945.14
Rate for Payer: Wellcare Medicare	$12,945.14
Rate for Payer: Wellmed Medicare	$12,945.14

CESAREAN SECTION WITHOUT STERILIZATION WITH MCC

Facility

$31,340.50

Service Code	MSDRG 786
Min. Negotiated Rate	$6,879.00
Max. Negotiated Rate	$31,340.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,849.32
Rate for Payer: Amerigroup Medicare	$16,849.32
Rate for Payer: BCBS of TX Medicare	$16,849.32
Rate for Payer: Cigna Commercial	$6,879.00
Rate for Payer: Cigna Medicare	$16,849.32
Rate for Payer: Employer Direct Commercial	$16,849.32
Rate for Payer: Humana Medicare/TRICARE	$16,849.32
Rate for Payer: Molina Dual Medicare/Medicaid	$16,849.32
Rate for Payer: Molina Medicare	$16,849.32
Rate for Payer: Multiplan Auto	$31,340.50
Rate for Payer: Multiplan Commercial	$31,340.50
Rate for Payer: Multiplan Workers Comp	$31,340.50
Rate for Payer: Scott and White EPO/PPO	$14,433.12
Rate for Payer: Scott and White Medicare	$16,849.32
Rate for Payer: Superior Health Plan EPO	$16,849.32
Rate for Payer: Superior Health Plan Medicare	$16,849.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,849.32
Rate for Payer: Universal American Medicare	$16,849.32
Rate for Payer: Wellcare Medicare	$16,849.32
Rate for Payer: Wellmed Medicare	$16,849.32

CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC

Facility

$18,217.20

Service Code	MSDRG 788
Min. Negotiated Rate	$6,879.00
Max. Negotiated Rate	$18,217.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,787.15
Rate for Payer: Amerigroup Medicare	$11,787.15
Rate for Payer: BCBS of TX Medicare	$11,787.15
Rate for Payer: Cigna Commercial	$6,879.00
Rate for Payer: Cigna Medicare	$11,787.15
Rate for Payer: Employer Direct Commercial	$11,787.15
Rate for Payer: Humana Medicare/TRICARE	$11,787.15
Rate for Payer: Molina Dual Medicare/Medicaid	$11,787.15
Rate for Payer: Molina Medicare	$11,787.15
Rate for Payer: Multiplan Auto	$18,217.20
Rate for Payer: Multiplan Commercial	$18,217.20
Rate for Payer: Multiplan Workers Comp	$18,217.20
Rate for Payer: Scott and White EPO/PPO	$8,389.50
Rate for Payer: Scott and White Medicare	$11,787.15
Rate for Payer: Superior Health Plan EPO	$11,787.15
Rate for Payer: Superior Health Plan Medicare	$11,787.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,787.15
Rate for Payer: Universal American Medicare	$11,787.15
Rate for Payer: Wellcare Medicare	$11,787.15
Rate for Payer: Wellmed Medicare	$11,787.15

CESAREAN SECTION WITH STERILIZATION

Facility

$10,981.48

Service Code	APR-DRG 5394
Min. Negotiated Rate	$10,353.72
Max. Negotiated Rate	$10,981.48
Rate for Payer: Amerigroup CHIP/Medicaid	$10,353.72
Rate for Payer: Cigna Medicaid	$10,353.72
Rate for Payer: Molina CHIP/Medicaid	$10,353.72
Rate for Payer: Parkland Medicaid	$10,353.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,981.48

CESAREAN SECTION WITH STERILIZATION

Facility

$2,778.00

Service Code	APR-DRG 5392
Min. Negotiated Rate	$2,619.19
Max. Negotiated Rate	$2,778.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2,619.19
Rate for Payer: Cigna Medicaid	$2,619.19
Rate for Payer: Molina CHIP/Medicaid	$2,619.19
Rate for Payer: Parkland Medicaid	$2,619.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,778.00

CESAREAN SECTION WITH STERILIZATION

Facility

$4,383.69

Service Code	APR-DRG 5393
Min. Negotiated Rate	$4,133.10
Max. Negotiated Rate	$4,383.69
Rate for Payer: Amerigroup CHIP/Medicaid	$4,133.10
Rate for Payer: Cigna Medicaid	$4,133.10
Rate for Payer: Molina CHIP/Medicaid	$4,133.10
Rate for Payer: Parkland Medicaid	$4,133.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,383.69

CESAREAN SECTION WITH STERILIZATION

Facility

$2,303.87

Service Code	APR-DRG 5391
Min. Negotiated Rate	$2,172.17
Max. Negotiated Rate	$2,303.87
Rate for Payer: Amerigroup CHIP/Medicaid	$2,172.17
Rate for Payer: Cigna Medicaid	$2,172.17
Rate for Payer: Molina CHIP/Medicaid	$2,172.17
Rate for Payer: Parkland Medicaid	$2,172.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,303.87

CESAREAN SECTION WITH STERILIZATION WITH CC

Facility

$20,141.90

Service Code	MSDRG 784
Min. Negotiated Rate	$6,879.00
Max. Negotiated Rate	$20,141.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,529.59
Rate for Payer: Amerigroup Medicare	$12,529.59
Rate for Payer: BCBS of TX Medicare	$12,529.59
Rate for Payer: Cigna Commercial	$6,879.00
Rate for Payer: Cigna Medicare	$12,529.59
Rate for Payer: Employer Direct Commercial	$12,529.59
Rate for Payer: Humana Medicare/TRICARE	$12,529.59
Rate for Payer: Molina Dual Medicare/Medicaid	$12,529.59
Rate for Payer: Molina Medicare	$12,529.59
Rate for Payer: Multiplan Auto	$20,141.90
Rate for Payer: Multiplan Commercial	$20,141.90
Rate for Payer: Multiplan Workers Comp	$20,141.90
Rate for Payer: Scott and White EPO/PPO	$9,275.88
Rate for Payer: Scott and White Medicare	$12,529.59
Rate for Payer: Superior Health Plan EPO	$12,529.59
Rate for Payer: Superior Health Plan Medicare	$12,529.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,529.59
Rate for Payer: Universal American Medicare	$12,529.59
Rate for Payer: Wellcare Medicare	$12,529.59
Rate for Payer: Wellmed Medicare	$12,529.59

CESAREAN SECTION WITH STERILIZATION WITH MCC

Facility

$46,646.90

Service Code	MSDRG 783
Min. Negotiated Rate	$6,879.00
Max. Negotiated Rate	$46,646.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,753.57
Rate for Payer: Amerigroup Medicare	$22,753.57
Rate for Payer: BCBS of TX Medicare	$22,753.57
Rate for Payer: Cigna Commercial	$6,879.00
Rate for Payer: Cigna Medicare	$22,753.57
Rate for Payer: Employer Direct Commercial	$22,753.57
Rate for Payer: Humana Medicare/TRICARE	$22,753.57
Rate for Payer: Molina Dual Medicare/Medicaid	$22,753.57
Rate for Payer: Molina Medicare	$22,753.57
Rate for Payer: Multiplan Auto	$46,646.90
Rate for Payer: Multiplan Commercial	$46,646.90
Rate for Payer: Multiplan Workers Comp	$46,646.90
Rate for Payer: Scott and White EPO/PPO	$21,482.12
Rate for Payer: Scott and White Medicare	$22,753.57
Rate for Payer: Superior Health Plan EPO	$22,753.57
Rate for Payer: Superior Health Plan Medicare	$22,753.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,753.57
Rate for Payer: Universal American Medicare	$22,753.57
Rate for Payer: Wellcare Medicare	$22,753.57
Rate for Payer: Wellmed Medicare	$22,753.57

CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC

Facility

$18,198.20

Service Code	MSDRG 785
Min. Negotiated Rate	$6,879.00
Max. Negotiated Rate	$18,198.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,779.83
Rate for Payer: Amerigroup Medicare	$11,779.83
Rate for Payer: BCBS of TX Medicare	$11,779.83
Rate for Payer: Cigna Commercial	$6,879.00
Rate for Payer: Cigna Medicare	$11,779.83
Rate for Payer: Employer Direct Commercial	$11,779.83
Rate for Payer: Humana Medicare/TRICARE	$11,779.83
Rate for Payer: Molina Dual Medicare/Medicaid	$11,779.83
Rate for Payer: Molina Medicare	$11,779.83
Rate for Payer: Multiplan Auto	$18,198.20
Rate for Payer: Multiplan Commercial	$18,198.20
Rate for Payer: Multiplan Workers Comp	$18,198.20
Rate for Payer: Scott and White EPO/PPO	$8,380.75
Rate for Payer: Scott and White Medicare	$11,779.83
Rate for Payer: Superior Health Plan EPO	$11,779.83
Rate for Payer: Superior Health Plan Medicare	$11,779.83
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,779.83
Rate for Payer: Universal American Medicare	$11,779.83
Rate for Payer: Wellcare Medicare	$11,779.83
Rate for Payer: Wellmed Medicare	$11,779.83

CESAREAN SECTION W/O STERILIZATION W CC

Facility

$21,219.20

Service Code	MSDRG 787
Min. Negotiated Rate	$6,879.00
Max. Negotiated Rate	$21,219.20
Rate for Payer: BCBS of TX Blue Advantage	$9,297.46
Rate for Payer: BCBS of TX Blue Essentials	$11,155.87
Rate for Payer: BCBS of TX PPO	$12,395.89

CESAREAN SECTION W/O STERILIZATION W MCC

Facility

$31,340.50

Service Code	MSDRG 786
Min. Negotiated Rate	$6,879.00
Max. Negotiated Rate	$31,340.50
Rate for Payer: BCBS of TX Blue Advantage	$13,371.28
Rate for Payer: BCBS of TX Blue Essentials	$16,043.98
Rate for Payer: BCBS of TX PPO	$17,827.34

CESAREAN SECTION W/O STERILIZATION W/O CC/MCC

Facility

$18,217.20

Service Code	MSDRG 788
Min. Negotiated Rate	$6,879.00
Max. Negotiated Rate	$18,217.20
Rate for Payer: BCBS of TX Blue Advantage	$7,746.02
Rate for Payer: BCBS of TX Blue Essentials	$9,294.32
Rate for Payer: BCBS of TX PPO	$10,327.43

CESAREAN SECTION W STERILIZATION W CC

Facility

$20,141.90

Service Code	MSDRG 784
Min. Negotiated Rate	$6,879.00
Max. Negotiated Rate	$20,141.90
Rate for Payer: BCBS of TX Blue Advantage	$9,478.06
Rate for Payer: BCBS of TX Blue Essentials	$11,372.57
Rate for Payer: BCBS of TX PPO	$12,636.68

CESAREAN SECTION W STERILIZATION W MCC

Facility

$46,646.90

Service Code	MSDRG 783
Min. Negotiated Rate	$6,879.00
Max. Negotiated Rate	$46,646.90
Rate for Payer: BCBS of TX Blue Advantage	$15,011.30
Rate for Payer: BCBS of TX Blue Essentials	$18,011.81
Rate for Payer: BCBS of TX PPO	$20,013.90

CESAREAN SECTION W STERILIZATION W/O CC/MCC

Facility

$18,198.20

Service Code	MSDRG 785
Min. Negotiated Rate	$6,879.00
Max. Negotiated Rate	$18,198.20
Rate for Payer: BCBS of TX Blue Advantage	$7,271.30
Rate for Payer: BCBS of TX Blue Essentials	$8,724.71
Rate for Payer: BCBS of TX PPO	$9,694.50

cetirizine 10 mg Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77452444
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

cetirizine 10 mg Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77452444
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Know your out-of-pocket cost for care.

All Charges