White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHEMOTHERAPY FOR ACUTE LEUKEMIA

Facility

$41,615.26

Service Code	APR-DRG 6954
Min. Negotiated Rate	$39,236.33
Max. Negotiated Rate	$41,615.26
Rate for Payer: Amerigroup CHIP/Medicaid	$39,236.33
Rate for Payer: Cigna Medicaid	$39,236.33
Rate for Payer: Molina CHIP/Medicaid	$39,236.33
Rate for Payer: Parkland Medicaid	$39,236.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41,615.26

CHEMOTHERAPY FOR ACUTE LEUKEMIA

Facility

$4,034.04

Service Code	APR-DRG 6951
Min. Negotiated Rate	$3,803.43
Max. Negotiated Rate	$4,034.04
Rate for Payer: Amerigroup CHIP/Medicaid	$3,803.43
Rate for Payer: Cigna Medicaid	$3,803.43
Rate for Payer: Molina CHIP/Medicaid	$3,803.43
Rate for Payer: Parkland Medicaid	$3,803.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,034.04

CHEMOTHERAPY FOR ACUTE LEUKEMIA

Facility

$14,217.38

Service Code	APR-DRG 6953
Min. Negotiated Rate	$13,404.65
Max. Negotiated Rate	$14,217.38
Rate for Payer: Amerigroup CHIP/Medicaid	$13,404.65
Rate for Payer: Cigna Medicaid	$13,404.65
Rate for Payer: Molina CHIP/Medicaid	$13,404.65
Rate for Payer: Parkland Medicaid	$13,404.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,217.38

Chemotherapy Inf up to 1 Hour Single or Initial Drug 96413

Facility

$555.00

Service Code	HCPCS 96413
Hospital Charge Code	1500271
Hospital Revenue Code	335
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$701.38
Rate for Payer: Amerigroup CHIP/Medicaid	$49.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$331.81
Rate for Payer: Amerigroup Medicare	$331.81
Rate for Payer: BCBS of TX Blue Advantage	$166.50
Rate for Payer: BCBS of TX Blue Essentials	$199.80
Rate for Payer: BCBS of TX Medicare	$331.81
Rate for Payer: BCBS of TX PPO	$222.00
Rate for Payer: Cash Price	$377.40
Rate for Payer: Cash Price	$377.40
Rate for Payer: Cash Price	$377.40
Rate for Payer: Cigna Commercial	$701.38
Rate for Payer: Cigna Medicaid	$399.60
Rate for Payer: Cigna Medicare	$331.81
Rate for Payer: Employer Direct Commercial	$331.81
Rate for Payer: Humana Medicare/TRICARE	$331.81
Rate for Payer: Molina CHIP/Medicaid	$399.60
Rate for Payer: Molina Dual Medicare/Medicaid	$331.81
Rate for Payer: Molina Medicare	$331.81
Rate for Payer: Multiplan Auto	$360.75
Rate for Payer: Multiplan Commercial	$360.75
Rate for Payer: Multiplan Workers Comp	$360.75
Rate for Payer: Parkland Medicaid	$399.60
Rate for Payer: Scott and White EPO/PPO	$497.71
Rate for Payer: Scott and White Medicare	$331.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$399.60
Rate for Payer: Superior Health Plan EPO	$331.81
Rate for Payer: Superior Health Plan Medicare	$331.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$331.81
Rate for Payer: Universal American Medicare	$331.81
Rate for Payer: Wellcare Medicare	$331.81
Rate for Payer: Wellmed Medicare	$331.81

Chemotherapy Inf up to 1 Hour Single or Initial Drug 96413

Facility

$555.00

Service Code	HCPCS 96413
Hospital Charge Code	1500271
Hospital Revenue Code	335
Rate for Payer: Cash Price	$377.40

Chemotherapy Infusion Each Additional Hour 96415

Facility

$124.00

Service Code	HCPCS 96415
Hospital Charge Code	1500289
Hospital Revenue Code	335
Rate for Payer: Cash Price	$84.32

Chemotherapy Infusion Each Additional Hour 96415

Facility

$124.00

Service Code	HCPCS 96415
Hospital Charge Code	1500289
Hospital Revenue Code	335
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$152.89
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$37.20
Rate for Payer: BCBS of TX Blue Essentials	$44.64
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$49.60
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$89.28
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$89.28
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Parkland Medicaid	$89.28
Rate for Payer: Scott and White EPO/PPO	$108.50
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.28
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC

Facility

$91,281.70

Service Code	MSDRG 837
Min. Negotiated Rate	$39,970.92
Max. Negotiated Rate	$91,281.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$39,970.92
Rate for Payer: Amerigroup Medicare	$39,970.92
Rate for Payer: BCBS of TX Medicare	$39,970.92
Rate for Payer: Cigna Commercial	$61,879.38
Rate for Payer: Cigna Medicare	$39,970.92
Rate for Payer: Employer Direct Commercial	$39,970.92
Rate for Payer: Humana Medicare/TRICARE	$39,970.92
Rate for Payer: Molina Dual Medicare/Medicaid	$39,970.92
Rate for Payer: Molina Medicare	$39,970.92
Rate for Payer: Multiplan Auto	$91,281.70
Rate for Payer: Multiplan Commercial	$91,281.70
Rate for Payer: Multiplan Workers Comp	$91,281.70
Rate for Payer: Scott and White EPO/PPO	$42,037.62
Rate for Payer: Scott and White Medicare	$39,970.92
Rate for Payer: Superior Health Plan EPO	$39,970.92
Rate for Payer: Superior Health Plan Medicare	$39,970.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$39,970.92
Rate for Payer: Universal American Medicare	$39,970.92
Rate for Payer: Wellcare Medicare	$39,970.92
Rate for Payer: Wellmed Medicare	$39,970.92

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT

Facility

$39,660.60

Service Code	MSDRG 838
Min. Negotiated Rate	$18,264.75
Max. Negotiated Rate	$39,660.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,058.69
Rate for Payer: Amerigroup Medicare	$20,058.69
Rate for Payer: BCBS of TX Medicare	$20,058.69
Rate for Payer: Cigna Commercial	$26,885.71
Rate for Payer: Cigna Medicare	$20,058.69
Rate for Payer: Employer Direct Commercial	$20,058.69
Rate for Payer: Humana Medicare/TRICARE	$20,058.69
Rate for Payer: Molina Dual Medicare/Medicaid	$20,058.69
Rate for Payer: Molina Medicare	$20,058.69
Rate for Payer: Multiplan Auto	$39,660.60
Rate for Payer: Multiplan Commercial	$39,660.60
Rate for Payer: Multiplan Workers Comp	$39,660.60
Rate for Payer: Scott and White EPO/PPO	$18,264.75
Rate for Payer: Scott and White Medicare	$20,058.69
Rate for Payer: Superior Health Plan EPO	$20,058.69
Rate for Payer: Superior Health Plan Medicare	$20,058.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,058.69
Rate for Payer: Universal American Medicare	$20,058.69
Rate for Payer: Wellcare Medicare	$20,058.69
Rate for Payer: Wellmed Medicare	$20,058.69

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$27,434.10

Service Code	MSDRG 839
Min. Negotiated Rate	$10,800.74
Max. Negotiated Rate	$27,434.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,342.46
Rate for Payer: Amerigroup Medicare	$15,342.46
Rate for Payer: BCBS of TX Medicare	$15,342.46
Rate for Payer: Cigna Commercial	$18,597.43
Rate for Payer: Cigna Medicare	$15,342.46
Rate for Payer: Employer Direct Commercial	$15,342.46
Rate for Payer: Humana Medicare/TRICARE	$15,342.46
Rate for Payer: Molina Dual Medicare/Medicaid	$15,342.46
Rate for Payer: Molina Medicare	$15,342.46
Rate for Payer: Multiplan Auto	$27,434.10
Rate for Payer: Multiplan Commercial	$27,434.10
Rate for Payer: Multiplan Workers Comp	$27,434.10
Rate for Payer: Scott and White EPO/PPO	$12,634.12
Rate for Payer: Scott and White Medicare	$15,342.46
Rate for Payer: Superior Health Plan EPO	$15,342.46
Rate for Payer: Superior Health Plan Medicare	$15,342.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,342.46
Rate for Payer: Universal American Medicare	$15,342.46
Rate for Payer: Wellcare Medicare	$15,342.46
Rate for Payer: Wellmed Medicare	$15,342.46

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC

Facility

$24,855.80

Service Code	MSDRG 847
Min. Negotiated Rate	$11,407.90
Max. Negotiated Rate	$24,855.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,347.92
Rate for Payer: Amerigroup Medicare	$14,347.92
Rate for Payer: BCBS of TX Medicare	$14,347.92
Rate for Payer: Cigna Commercial	$16,849.62
Rate for Payer: Cigna Medicare	$14,347.92
Rate for Payer: Employer Direct Commercial	$14,347.92
Rate for Payer: Humana Medicare/TRICARE	$14,347.92
Rate for Payer: Molina Dual Medicare/Medicaid	$14,347.92
Rate for Payer: Molina Medicare	$14,347.92
Rate for Payer: Multiplan Auto	$24,855.80
Rate for Payer: Multiplan Commercial	$24,855.80
Rate for Payer: Multiplan Workers Comp	$24,855.80
Rate for Payer: Scott and White EPO/PPO	$11,446.75
Rate for Payer: Scott and White Medicare	$14,347.92
Rate for Payer: Superior Health Plan EPO	$14,347.92
Rate for Payer: Superior Health Plan Medicare	$14,347.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,347.92
Rate for Payer: Universal American Medicare	$14,347.92
Rate for Payer: Wellcare Medicare	$14,347.92
Rate for Payer: Wellmed Medicare	$14,347.92

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC

Facility

$49,257.50

Service Code	MSDRG 846
Min. Negotiated Rate	$22,684.38
Max. Negotiated Rate	$49,257.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,760.58
Rate for Payer: Amerigroup Medicare	$23,760.58
Rate for Payer: BCBS of TX Medicare	$23,760.58
Rate for Payer: Cigna Commercial	$33,391.40
Rate for Payer: Cigna Medicare	$23,760.58
Rate for Payer: Employer Direct Commercial	$23,760.58
Rate for Payer: Humana Medicare/TRICARE	$23,760.58
Rate for Payer: Molina Dual Medicare/Medicaid	$23,760.58
Rate for Payer: Molina Medicare	$23,760.58
Rate for Payer: Multiplan Auto	$49,257.50
Rate for Payer: Multiplan Commercial	$49,257.50
Rate for Payer: Multiplan Workers Comp	$49,257.50
Rate for Payer: Scott and White EPO/PPO	$22,684.38
Rate for Payer: Scott and White Medicare	$23,760.58
Rate for Payer: Superior Health Plan EPO	$23,760.58
Rate for Payer: Superior Health Plan Medicare	$23,760.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,760.58
Rate for Payer: Universal American Medicare	$23,760.58
Rate for Payer: Wellcare Medicare	$23,760.58
Rate for Payer: Wellmed Medicare	$23,760.58

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$16,138.60

Service Code	MSDRG 848
Min. Negotiated Rate	$7,432.25
Max. Negotiated Rate	$16,138.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,985.35
Rate for Payer: Amerigroup Medicare	$10,985.35
Rate for Payer: BCBS of TX Medicare	$10,985.35
Rate for Payer: Cigna Commercial	$10,940.27
Rate for Payer: Cigna Medicare	$10,985.35
Rate for Payer: Employer Direct Commercial	$10,985.35
Rate for Payer: Humana Medicare/TRICARE	$10,985.35
Rate for Payer: Molina Dual Medicare/Medicaid	$10,985.35
Rate for Payer: Molina Medicare	$10,985.35
Rate for Payer: Multiplan Auto	$16,138.60
Rate for Payer: Multiplan Commercial	$16,138.60
Rate for Payer: Multiplan Workers Comp	$16,138.60
Rate for Payer: Scott and White EPO/PPO	$7,432.25
Rate for Payer: Scott and White Medicare	$10,985.35
Rate for Payer: Superior Health Plan EPO	$10,985.35
Rate for Payer: Superior Health Plan Medicare	$10,985.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,985.35
Rate for Payer: Universal American Medicare	$10,985.35
Rate for Payer: Wellcare Medicare	$10,985.35
Rate for Payer: Wellmed Medicare	$10,985.35

CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC

Facility

$24,855.80

Service Code	MSDRG 847
Min. Negotiated Rate	$11,407.90
Max. Negotiated Rate	$24,855.80
Rate for Payer: BCBS of TX Blue Advantage	$11,407.90
Rate for Payer: BCBS of TX Blue Essentials	$13,688.15
Rate for Payer: BCBS of TX PPO	$15,209.65

CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W MCC

Facility

$49,257.50

Service Code	MSDRG 846
Min. Negotiated Rate	$22,684.38
Max. Negotiated Rate	$49,257.50
Rate for Payer: BCBS of TX Blue Advantage	$24,233.94
Rate for Payer: BCBS of TX Blue Essentials	$29,077.91
Rate for Payer: BCBS of TX PPO	$32,310.04

CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W/O CC/MCC

Facility

$16,138.60

Service Code	MSDRG 848
Min. Negotiated Rate	$7,432.25
Max. Negotiated Rate	$16,138.60
Rate for Payer: BCBS of TX Blue Advantage	$8,020.36
Rate for Payer: BCBS of TX Blue Essentials	$9,623.50
Rate for Payer: BCBS of TX PPO	$10,693.19

CHEMO W ACUTE LEUKEMIA AS SDX OR W HIGH DOSE CHEMO AGENT W MCC

Facility

$91,281.70

Service Code	MSDRG 837
Min. Negotiated Rate	$39,970.92
Max. Negotiated Rate	$91,281.70
Rate for Payer: BCBS of TX Blue Advantage	$46,217.26
Rate for Payer: BCBS of TX Blue Essentials	$55,455.34
Rate for Payer: BCBS of TX PPO	$61,619.43

CHEMO W ACUTE LEUKEMIA AS SDX W CC OR HIGH DOSE CHEMO AGENT

Facility

$39,660.60

Service Code	MSDRG 838
Min. Negotiated Rate	$18,264.75
Max. Negotiated Rate	$39,660.60
Rate for Payer: BCBS of TX Blue Advantage	$20,232.36
Rate for Payer: BCBS of TX Blue Essentials	$24,276.48
Rate for Payer: BCBS of TX PPO	$26,974.91

CHEMO W ACUTE LEUKEMIA AS SDX W/O CC/MCC

Facility

$27,434.10

Service Code	MSDRG 839
Min. Negotiated Rate	$10,800.74
Max. Negotiated Rate	$27,434.10
Rate for Payer: BCBS of TX Blue Advantage	$10,800.74
Rate for Payer: BCBS of TX Blue Essentials	$12,959.63
Rate for Payer: BCBS of TX PPO	$14,400.15

Chest / breast drape, 30.5 x 30.5

Facility

$36.89

Hospital Charge Code	992787
Hospital Revenue Code	272
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$26.56
Rate for Payer: Amerigroup CHIP/Medicaid	$3.32
Rate for Payer: BCBS of TX Blue Advantage	$11.07
Rate for Payer: BCBS of TX Blue Essentials	$13.28
Rate for Payer: BCBS of TX PPO	$14.76
Rate for Payer: Cash Price	$25.09
Rate for Payer: Cigna Medicaid	$26.56
Rate for Payer: Molina CHIP/Medicaid	$26.56
Rate for Payer: Multiplan Auto	$23.98
Rate for Payer: Multiplan Commercial	$23.98
Rate for Payer: Multiplan Workers Comp	$23.98
Rate for Payer: Parkland Medicaid	$26.56
Rate for Payer: Scott and White EPO/PPO	$18.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.56
Rate for Payer: Superior Health Plan EPO	$5.02

Chest / breast drape, 30.5 x 30.5

Facility

$36.89

Hospital Charge Code	992787
Hospital Revenue Code	272
Rate for Payer: Cash Price	$25.09

chest drainage kit

Facility

$240.71

Hospital Charge Code	993260
Hospital Revenue Code	270
Min. Negotiated Rate	$21.66
Max. Negotiated Rate	$173.31
Rate for Payer: Amerigroup CHIP/Medicaid	$21.66
Rate for Payer: BCBS of TX Blue Advantage	$72.21
Rate for Payer: BCBS of TX Blue Essentials	$86.66
Rate for Payer: BCBS of TX PPO	$96.28
Rate for Payer: Cash Price	$163.68
Rate for Payer: Cigna Medicaid	$173.31
Rate for Payer: Molina CHIP/Medicaid	$173.31
Rate for Payer: Multiplan Auto	$156.46
Rate for Payer: Multiplan Commercial	$156.46
Rate for Payer: Multiplan Workers Comp	$156.46
Rate for Payer: Parkland Medicaid	$173.31
Rate for Payer: Scott and White EPO/PPO	$120.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$173.31
Rate for Payer: Superior Health Plan EPO	$32.74

chest drainage kit

Facility

$240.71

Hospital Charge Code	993260
Hospital Revenue Code	270
Rate for Payer: Cash Price	$163.68

CHEST PAIN

Facility

$2,721.04

Service Code	APR-DRG 2032
Min. Negotiated Rate	$2,565.49
Max. Negotiated Rate	$2,721.04
Rate for Payer: Amerigroup CHIP/Medicaid	$2,565.49
Rate for Payer: Cigna Medicaid	$2,565.49
Rate for Payer: Molina CHIP/Medicaid	$2,565.49
Rate for Payer: Parkland Medicaid	$2,565.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,721.04

CHEST PAIN

Facility

$6,094.24

Service Code	APR-DRG 2034
Min. Negotiated Rate	$5,745.87
Max. Negotiated Rate	$6,094.24
Rate for Payer: Amerigroup CHIP/Medicaid	$5,745.87
Rate for Payer: Cigna Medicaid	$5,745.87
Rate for Payer: Molina CHIP/Medicaid	$5,745.87
Rate for Payer: Parkland Medicaid	$5,745.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,094.24

Know your out-of-pocket cost for care.

All Charges