White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DECELLULARIZED DERMIS 6X10 MESHED

Facility

$518.00

Service Code	HCPCS Q4152
Hospital Charge Code	146030
Hospital Revenue Code	278
Min. Negotiated Rate	$129.50
Max. Negotiated Rate	$259.00
Rate for Payer: Cash Price	$352.24
Rate for Payer: Cigna Commercial	$129.50
Rate for Payer: Multiplan Auto	$259.00
Rate for Payer: Multiplan Commercial	$259.00
Rate for Payer: Multiplan Workers Comp	$259.00
Rate for Payer: Scott and White EPO/PPO	$259.00

DECELLULARIZED DERMIS 6X10 MESHED

Facility

$518.00

Service Code	HCPCS Q4152
Hospital Charge Code	146030
Hospital Revenue Code	278
Min. Negotiated Rate	$46.62
Max. Negotiated Rate	$372.96
Rate for Payer: Amerigroup CHIP/Medicaid	$46.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$155.40
Rate for Payer: BCBS of TX Blue Essentials	$186.48
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$207.20
Rate for Payer: Cash Price	$352.24
Rate for Payer: Cash Price	$352.24
Rate for Payer: Cash Price	$352.24
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$372.96
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$372.96
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$259.00
Rate for Payer: Multiplan Commercial	$259.00
Rate for Payer: Multiplan Workers Comp	$259.00
Rate for Payer: Parkland Medicaid	$372.96
Rate for Payer: Scott and White EPO/PPO	$259.00
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$372.96
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment

Facility

$12,978.44

Service Code	HCPCS 27602
Hospital Charge Code	994118
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$8,825.34
Rate for Payer: Cash Price	$8,825.34
Rate for Payer: Cash Price	$8,825.34
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$9,344.48
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$9,344.48
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$9,344.48
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,344.48
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment

Facility

$12,978.44

Service Code	HCPCS 27602
Hospital Charge Code	994118
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,825.34

Decompression fasciotomy, leg; anterior and/or lateral compartments only

Facility

$10,000.00

Service Code	CPT 27600
Hospital Charge Code	36027600
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Decompression fasciotomy, leg; anterior and/or lateral compartments only

Facility

$11,569.12

Service Code	HCPCS 27600
Hospital Charge Code	9900416
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,867.00

Decompression fasciotomy, leg; anterior and/or lateral compartments only

Facility

$11,569.12

Service Code	HCPCS 27600
Hospital Charge Code	9900416
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$7,867.00
Rate for Payer: Cash Price	$7,867.00
Rate for Payer: Cash Price	$7,867.00
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$8,329.77
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$8,329.77
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$8,329.77
Rate for Payer: Scott and White EPO/PPO	$6,080.78
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,329.77
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Decompression of tibia nerve

Facility

$10,526.34

Service Code	HCPCS 28035
Hospital Charge Code	9900461
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,157.91

Decompression of tibia nerve

Facility

$10,000.00

Service Code	CPT 28035
Hospital Charge Code	36028035
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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: Scott and White EPO/PPO	$3,629.00
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Decompression of tibia nerve

Facility

$10,526.34

Service Code	HCPCS 28035
Hospital Charge Code	9900461
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$7,578.96
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$7,578.96
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
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	$7,578.96
Rate for Payer: Scott and White EPO/PPO	$3,629.00
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,578.96
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

DECTECTOR CO2 PEDI

Facility

$29.56

Hospital Charge Code	131479
Hospital Revenue Code	270
Rate for Payer: Cash Price	$20.10

DECTECTOR CO2 PEDI

Facility

$29.56

Hospital Charge Code	131479
Hospital Revenue Code	270
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$21.28
Rate for Payer: Amerigroup CHIP/Medicaid	$2.66
Rate for Payer: BCBS of TX Blue Advantage	$8.87
Rate for Payer: BCBS of TX Blue Essentials	$10.64
Rate for Payer: BCBS of TX PPO	$11.82
Rate for Payer: Cash Price	$20.10
Rate for Payer: Cigna Medicaid	$21.28
Rate for Payer: Molina CHIP/Medicaid	$21.28
Rate for Payer: Multiplan Auto	$19.21
Rate for Payer: Multiplan Commercial	$19.21
Rate for Payer: Multiplan Workers Comp	$19.21
Rate for Payer: Parkland Medicaid	$21.28
Rate for Payer: Scott and White EPO/PPO	$14.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.28
Rate for Payer: Superior Health Plan EPO	$4.02

DEEP VEIN THROMBOPHLEBITIS W CC/MCC

Facility

$13,309.73

Service Code	MSDRG 294
Min. Negotiated Rate	$9,982.88
Max. Negotiated Rate	$13,309.73
Rate for Payer: BCBS of TX Blue Advantage	$9,982.88
Rate for Payer: BCBS of TX Blue Essentials	$11,978.30
Rate for Payer: BCBS of TX PPO	$13,309.73

DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC

Facility

$6,321.21

Service Code	MSDRG 295
Min. Negotiated Rate	$4,741.18
Max. Negotiated Rate	$6,321.21
Rate for Payer: BCBS of TX Blue Advantage	$4,741.18
Rate for Payer: BCBS of TX Blue Essentials	$5,688.86
Rate for Payer: BCBS of TX PPO	$6,321.21

DEFIBRILLATOR IMPLANTS

Facility

$13,190.68

Service Code	APR-DRG 1791
Min. Negotiated Rate	$12,436.63
Max. Negotiated Rate	$13,190.68
Rate for Payer: Amerigroup CHIP/Medicaid	$12,436.63
Rate for Payer: Cigna Medicaid	$12,436.63
Rate for Payer: Molina CHIP/Medicaid	$12,436.63
Rate for Payer: Parkland Medicaid	$12,436.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,190.68

DEFIBRILLATOR IMPLANTS

Facility

$27,184.39

Service Code	APR-DRG 1794
Min. Negotiated Rate	$25,630.39
Max. Negotiated Rate	$27,184.39
Rate for Payer: Amerigroup CHIP/Medicaid	$25,630.39
Rate for Payer: Cigna Medicaid	$25,630.39
Rate for Payer: Molina CHIP/Medicaid	$25,630.39
Rate for Payer: Parkland Medicaid	$25,630.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,184.39

DEFIBRILLATOR IMPLANTS

Facility

$20,844.60

Service Code	APR-DRG 1793
Min. Negotiated Rate	$19,653.01
Max. Negotiated Rate	$20,844.60
Rate for Payer: Amerigroup CHIP/Medicaid	$19,653.01
Rate for Payer: Cigna Medicaid	$19,653.01
Rate for Payer: Molina CHIP/Medicaid	$19,653.01
Rate for Payer: Parkland Medicaid	$19,653.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,844.60

DEFIBRILLATOR IMPLANTS

Facility

$17,656.97

Service Code	APR-DRG 1792
Min. Negotiated Rate	$16,647.61
Max. Negotiated Rate	$17,656.97
Rate for Payer: Amerigroup CHIP/Medicaid	$16,647.61
Rate for Payer: Cigna Medicaid	$16,647.61
Rate for Payer: Molina CHIP/Medicaid	$16,647.61
Rate for Payer: Parkland Medicaid	$16,647.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,656.97

DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS

Facility

$19,026.92

Service Code	APR-DRG 0424
Min. Negotiated Rate	$17,939.25
Max. Negotiated Rate	$19,026.92
Rate for Payer: Amerigroup CHIP/Medicaid	$17,939.25
Rate for Payer: Cigna Medicaid	$17,939.25
Rate for Payer: Molina CHIP/Medicaid	$17,939.25
Rate for Payer: Parkland Medicaid	$17,939.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,026.92

DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS

Facility

$7,679.95

Service Code	APR-DRG 0423
Min. Negotiated Rate	$7,240.92
Max. Negotiated Rate	$7,679.95
Rate for Payer: Amerigroup CHIP/Medicaid	$7,240.92
Rate for Payer: Cigna Medicaid	$7,240.92
Rate for Payer: Molina CHIP/Medicaid	$7,240.92
Rate for Payer: Parkland Medicaid	$7,240.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,679.95

DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS

Facility

$3,531.24

Service Code	APR-DRG 0421
Min. Negotiated Rate	$3,329.38
Max. Negotiated Rate	$3,531.24
Rate for Payer: Amerigroup CHIP/Medicaid	$3,329.38
Rate for Payer: Cigna Medicaid	$3,329.38
Rate for Payer: Molina CHIP/Medicaid	$3,329.38
Rate for Payer: Parkland Medicaid	$3,329.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,531.24

DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS

Facility

$4,886.86

Service Code	APR-DRG 0422
Min. Negotiated Rate	$4,607.50
Max. Negotiated Rate	$4,886.86
Rate for Payer: Amerigroup CHIP/Medicaid	$4,607.50
Rate for Payer: Cigna Medicaid	$4,607.50
Rate for Payer: Molina CHIP/Medicaid	$4,607.50
Rate for Payer: Parkland Medicaid	$4,607.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,886.86

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC

Facility

$44,138.90

Service Code	MSDRG 056
Min. Negotiated Rate	$18,270.70
Max. Negotiated Rate	$44,138.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,786.14
Rate for Payer: Amerigroup Medicare	$21,786.14
Rate for Payer: BCBS of TX Medicare	$21,786.14
Rate for Payer: Cigna Commercial	$29,921.53
Rate for Payer: Cigna Medicare	$21,786.14
Rate for Payer: Employer Direct Commercial	$21,786.14
Rate for Payer: Humana Medicare/TRICARE	$21,786.14
Rate for Payer: Molina Dual Medicare/Medicaid	$21,786.14
Rate for Payer: Molina Medicare	$21,786.14
Rate for Payer: Multiplan Auto	$44,138.90
Rate for Payer: Multiplan Commercial	$44,138.90
Rate for Payer: Multiplan Workers Comp	$44,138.90
Rate for Payer: Scott and White EPO/PPO	$20,327.12
Rate for Payer: Scott and White Medicare	$21,786.14
Rate for Payer: Superior Health Plan EPO	$21,786.14
Rate for Payer: Superior Health Plan Medicare	$21,786.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,786.14
Rate for Payer: Universal American Medicare	$21,786.14
Rate for Payer: Wellcare Medicare	$21,786.14
Rate for Payer: Wellmed Medicare	$21,786.14

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC

Facility

$24,616.40

Service Code	MSDRG 057
Min. Negotiated Rate	$10,396.54
Max. Negotiated Rate	$24,616.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,255.58
Rate for Payer: Amerigroup Medicare	$14,255.58
Rate for Payer: BCBS of TX Medicare	$14,255.58
Rate for Payer: Cigna Commercial	$16,687.33
Rate for Payer: Cigna Medicare	$14,255.58
Rate for Payer: Employer Direct Commercial	$14,255.58
Rate for Payer: Humana Medicare/TRICARE	$14,255.58
Rate for Payer: Molina Dual Medicare/Medicaid	$14,255.58
Rate for Payer: Molina Medicare	$14,255.58
Rate for Payer: Multiplan Auto	$24,616.40
Rate for Payer: Multiplan Commercial	$24,616.40
Rate for Payer: Multiplan Workers Comp	$24,616.40
Rate for Payer: Scott and White EPO/PPO	$11,336.50
Rate for Payer: Scott and White Medicare	$14,255.58
Rate for Payer: Superior Health Plan EPO	$14,255.58
Rate for Payer: Superior Health Plan Medicare	$14,255.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,255.58
Rate for Payer: Universal American Medicare	$14,255.58
Rate for Payer: Wellcare Medicare	$14,255.58
Rate for Payer: Wellmed Medicare	$14,255.58

DEGENERATIVE NERVOUS SYSTEM DISORDERS W MCC

Facility

$44,138.90

Service Code	MSDRG 056
Min. Negotiated Rate	$18,270.70
Max. Negotiated Rate	$44,138.90
Rate for Payer: BCBS of TX Blue Advantage	$18,270.70
Rate for Payer: BCBS of TX Blue Essentials	$21,922.72
Rate for Payer: BCBS of TX PPO	$24,359.52

Know your out-of-pocket cost for care.

All Charges