White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DENTAL AND ORAL DISEASES WITHOUT CC/MCC

Facility

$14,248.10

Service Code	MSDRG 159
Min. Negotiated Rate	$5,834.24
Max. Negotiated Rate	$14,248.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,952.70
Rate for Payer: Amerigroup Medicare	$9,952.70
Rate for Payer: BCBS of TX Medicare	$9,952.70
Rate for Payer: Cigna Commercial	$9,125.48
Rate for Payer: Cigna Medicare	$9,952.70
Rate for Payer: Employer Direct Commercial	$9,952.70
Rate for Payer: Humana Medicare/TRICARE	$9,952.70
Rate for Payer: Molina Dual Medicare/Medicaid	$9,952.70
Rate for Payer: Molina Medicare	$9,952.70
Rate for Payer: Multiplan Auto	$14,248.10
Rate for Payer: Multiplan Commercial	$14,248.10
Rate for Payer: Multiplan Workers Comp	$14,248.10
Rate for Payer: Scott and White EPO/PPO	$6,561.62
Rate for Payer: Scott and White Medicare	$9,952.70
Rate for Payer: Superior Health Plan EPO	$9,952.70
Rate for Payer: Superior Health Plan Medicare	$9,952.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,952.70
Rate for Payer: Universal American Medicare	$9,952.70
Rate for Payer: Wellcare Medicare	$9,952.70
Rate for Payer: Wellmed Medicare	$9,952.70

DENTAL DISEASES AND DISORDERS

Facility

$4,026.12

Service Code	APR-DRG 1143
Min. Negotiated Rate	$3,795.96
Max. Negotiated Rate	$4,026.12
Rate for Payer: Amerigroup CHIP/Medicaid	$3,795.96
Rate for Payer: Cigna Medicaid	$3,795.96
Rate for Payer: Molina CHIP/Medicaid	$3,795.96
Rate for Payer: Parkland Medicaid	$3,795.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,026.12

DENTAL DISEASES AND DISORDERS

Facility

$13,257.06

Service Code	APR-DRG 1144
Min. Negotiated Rate	$12,499.22
Max. Negotiated Rate	$13,257.06
Rate for Payer: Amerigroup CHIP/Medicaid	$12,499.22
Rate for Payer: Cigna Medicaid	$12,499.22
Rate for Payer: Molina CHIP/Medicaid	$12,499.22
Rate for Payer: Parkland Medicaid	$12,499.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,257.06

DENTAL DISEASES AND DISORDERS

Facility

$2,751.97

Service Code	APR-DRG 1142
Min. Negotiated Rate	$2,594.65
Max. Negotiated Rate	$2,751.97
Rate for Payer: Amerigroup CHIP/Medicaid	$2,594.65
Rate for Payer: Cigna Medicaid	$2,594.65
Rate for Payer: Molina CHIP/Medicaid	$2,594.65
Rate for Payer: Parkland Medicaid	$2,594.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,751.97

DENTAL DISEASES AND DISORDERS

Facility

$2,244.27

Service Code	APR-DRG 1141
Min. Negotiated Rate	$2,115.98
Max. Negotiated Rate	$2,244.27
Rate for Payer: Amerigroup CHIP/Medicaid	$2,115.98
Rate for Payer: Cigna Medicaid	$2,115.98
Rate for Payer: Molina CHIP/Medicaid	$2,115.98
Rate for Payer: Parkland Medicaid	$2,115.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,244.27

DENTAL & ORAL DISEASES W CC

Facility

$17,652.90

Service Code	MSDRG 158
Min. Negotiated Rate	$7,656.58
Max. Negotiated Rate	$17,652.90
Rate for Payer: BCBS of TX Blue Advantage	$7,656.58
Rate for Payer: BCBS of TX Blue Essentials	$9,187.01
Rate for Payer: BCBS of TX PPO	$10,208.18

DENTAL & ORAL DISEASES W MCC

Facility

$31,764.20

Service Code	MSDRG 157
Min. Negotiated Rate	$14,387.80
Max. Negotiated Rate	$31,764.20
Rate for Payer: BCBS of TX Blue Advantage	$14,387.80
Rate for Payer: BCBS of TX Blue Essentials	$17,263.69
Rate for Payer: BCBS of TX PPO	$19,182.62

DENTAL & ORAL DISEASES W/O CC/MCC

Facility

$14,248.10

Service Code	MSDRG 159
Min. Negotiated Rate	$5,834.24
Max. Negotiated Rate	$14,248.10
Rate for Payer: BCBS of TX Blue Advantage	$5,834.24
Rate for Payer: BCBS of TX Blue Essentials	$7,000.41
Rate for Payer: BCBS of TX PPO	$7,778.53

DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER

Facility

$1,779.95

Service Code	APR-DRG 7542
Min. Negotiated Rate	$1,678.20
Max. Negotiated Rate	$1,779.95
Rate for Payer: Amerigroup CHIP/Medicaid	$1,678.20
Rate for Payer: Cigna Medicaid	$1,678.20
Rate for Payer: Molina CHIP/Medicaid	$1,678.20
Rate for Payer: Parkland Medicaid	$1,678.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,779.95

DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER

Facility

$3,198.94

Service Code	APR-DRG 7543
Min. Negotiated Rate	$3,016.07
Max. Negotiated Rate	$3,198.94
Rate for Payer: Amerigroup CHIP/Medicaid	$3,016.07
Rate for Payer: Cigna Medicaid	$3,016.07
Rate for Payer: Molina CHIP/Medicaid	$3,016.07
Rate for Payer: Parkland Medicaid	$3,016.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,198.94

DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER

Facility

$1,265.09

Service Code	APR-DRG 7541
Min. Negotiated Rate	$1,192.77
Max. Negotiated Rate	$1,265.09
Rate for Payer: Amerigroup CHIP/Medicaid	$1,192.77
Rate for Payer: Cigna Medicaid	$1,192.77
Rate for Payer: Molina CHIP/Medicaid	$1,192.77
Rate for Payer: Parkland Medicaid	$1,192.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,265.09

DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER

Facility

$9,235.10

Service Code	APR-DRG 7544
Min. Negotiated Rate	$8,707.17
Max. Negotiated Rate	$9,235.10
Rate for Payer: Amerigroup CHIP/Medicaid	$8,707.17
Rate for Payer: Cigna Medicaid	$8,707.17
Rate for Payer: Molina CHIP/Medicaid	$8,707.17
Rate for Payer: Parkland Medicaid	$8,707.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,235.10

DEPRESSIVE NEUROSES

Facility

$16,254.50

Service Code	MSDRG 881
Min. Negotiated Rate	$6,523.10
Max. Negotiated Rate	$16,254.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,655.97
Rate for Payer: Amerigroup Medicare	$11,655.97
Rate for Payer: BCBS of TX Blue Advantage	$6,523.10
Rate for Payer: BCBS of TX Blue Essentials	$7,826.96
Rate for Payer: BCBS of TX Medicare	$11,655.97
Rate for Payer: BCBS of TX PPO	$8,696.96
Rate for Payer: Cigna Commercial	$12,118.79
Rate for Payer: Cigna Medicare	$11,655.97
Rate for Payer: Employer Direct Commercial	$11,655.97
Rate for Payer: Molina Dual Medicare/Medicaid	$11,655.97
Rate for Payer: Molina Medicare	$11,655.97
Rate for Payer: Multiplan Auto	$16,254.50
Rate for Payer: Multiplan Commercial	$16,254.50
Rate for Payer: Multiplan Workers Comp	$16,254.50
Rate for Payer: Scott and White EPO/PPO	$7,485.62
Rate for Payer: Scott and White Medicare	$11,655.97
Rate for Payer: Superior Health Plan EPO	$11,655.97
Rate for Payer: Superior Health Plan Medicare	$11,655.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,655.97
Rate for Payer: Universal American Medicare	$11,655.97
Rate for Payer: Wellcare Medicare	$11,655.97
Rate for Payer: Wellmed Medicare	$11,655.97

DERMACARRIER -- DHF

Facility

$546.91

Hospital Charge Code	81740102
Hospital Revenue Code	272
Min. Negotiated Rate	$49.22
Max. Negotiated Rate	$393.78
Rate for Payer: Amerigroup CHIP/Medicaid	$49.22
Rate for Payer: BCBS of TX Blue Advantage	$164.07
Rate for Payer: BCBS of TX Blue Essentials	$196.89
Rate for Payer: BCBS of TX PPO	$218.76
Rate for Payer: Cash Price	$371.90
Rate for Payer: Cigna Medicaid	$393.78
Rate for Payer: Molina CHIP/Medicaid	$393.78
Rate for Payer: Multiplan Auto	$355.49
Rate for Payer: Multiplan Commercial	$355.49
Rate for Payer: Multiplan Workers Comp	$355.49
Rate for Payer: Parkland Medicaid	$393.78
Rate for Payer: Scott and White EPO/PPO	$273.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$393.78
Rate for Payer: Superior Health Plan EPO	$74.38

DERMACARRIER -- DHF

Facility

$546.91

Hospital Charge Code	81740102
Hospital Revenue Code	272
Rate for Payer: Cash Price	$371.90

DERMAGRAFT PER SQ CM

Facility

$280.00

Service Code	HCPCS Q4106
Hospital Charge Code	82461260
Hospital Revenue Code	278
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cigna Commercial	$70.00
Rate for Payer: Multiplan Auto	$140.00
Rate for Payer: Multiplan Commercial	$140.00
Rate for Payer: Multiplan Workers Comp	$140.00
Rate for Payer: Scott and White EPO/PPO	$140.00

DERMAGRAFT PER SQ CM

Facility

$280.00

Service Code	HCPCS Q4106
Hospital Charge Code	82461260
Hospital Revenue Code	278
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$201.60
Rate for Payer: Amerigroup CHIP/Medicaid	$25.20
Rate for Payer: BCBS of TX Blue Advantage	$84.00
Rate for Payer: BCBS of TX Blue Essentials	$100.80
Rate for Payer: BCBS of TX PPO	$112.00
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cigna Medicaid	$201.60
Rate for Payer: Molina CHIP/Medicaid	$201.60
Rate for Payer: Multiplan Auto	$140.00
Rate for Payer: Multiplan Commercial	$140.00
Rate for Payer: Multiplan Workers Comp	$140.00
Rate for Payer: Parkland Medicaid	$201.60
Rate for Payer: Scott and White EPO/PPO	$140.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$201.60
Rate for Payer: Superior Health Plan EPO	$38.08

Dermal substitute, native, non-denatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters

Facility

$2,500.00

Service Code	HCPCS C9360
Hospital Charge Code	990940
Hospital Revenue Code	278
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Amerigroup CHIP/Medicaid	$225.00
Rate for Payer: BCBS of TX Blue Advantage	$750.00
Rate for Payer: BCBS of TX Blue Essentials	$900.00
Rate for Payer: BCBS of TX PPO	$1,000.00
Rate for Payer: Cash Price	$1,700.00
Rate for Payer: Cigna Medicaid	$1,800.00
Rate for Payer: Molina CHIP/Medicaid	$1,800.00
Rate for Payer: Multiplan Auto	$1,250.00
Rate for Payer: Multiplan Commercial	$1,250.00
Rate for Payer: Multiplan Workers Comp	$1,250.00
Rate for Payer: Parkland Medicaid	$1,800.00
Rate for Payer: Scott and White EPO/PPO	$1,250.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,800.00
Rate for Payer: Superior Health Plan EPO	$340.00

Dermal substitute, native, non-denatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters

Facility

$2,500.00

Service Code	HCPCS C9360
Hospital Charge Code	990940
Hospital Revenue Code	278
Min. Negotiated Rate	$625.00
Max. Negotiated Rate	$1,250.00
Rate for Payer: Cash Price	$1,700.00
Rate for Payer: Cigna Commercial	$625.00
Rate for Payer: Multiplan Auto	$1,250.00
Rate for Payer: Multiplan Commercial	$1,250.00
Rate for Payer: Multiplan Workers Comp	$1,250.00
Rate for Payer: Scott and White EPO/PPO	$1,250.00

DERMAPURE ALLOGRAFT 4X6

Facility

$17,778.00

Service Code	HCPCS C1762
Hospital Charge Code	146366
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.02
Max. Negotiated Rate	$12,800.16
Rate for Payer: Amerigroup CHIP/Medicaid	$1,600.02
Rate for Payer: BCBS of TX Blue Advantage	$5,333.40
Rate for Payer: BCBS of TX Blue Essentials	$6,400.08
Rate for Payer: BCBS of TX PPO	$7,111.20
Rate for Payer: Cash Price	$12,089.04
Rate for Payer: Cigna Medicaid	$12,800.16
Rate for Payer: Molina CHIP/Medicaid	$12,800.16
Rate for Payer: Multiplan Auto	$8,889.00
Rate for Payer: Multiplan Commercial	$8,889.00
Rate for Payer: Multiplan Workers Comp	$8,889.00
Rate for Payer: Parkland Medicaid	$12,800.16
Rate for Payer: Scott and White EPO/PPO	$8,889.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,800.16
Rate for Payer: Superior Health Plan EPO	$2,417.81

DERMAPURE ALLOGRAFT 4X6

Facility

$17,778.00

Service Code	HCPCS C1762
Hospital Charge Code	146366
Hospital Revenue Code	278
Min. Negotiated Rate	$4,444.50
Max. Negotiated Rate	$8,889.00
Rate for Payer: Cash Price	$12,089.04
Rate for Payer: Cigna Commercial	$4,444.50
Rate for Payer: Multiplan Auto	$8,889.00
Rate for Payer: Multiplan Commercial	$8,889.00
Rate for Payer: Multiplan Workers Comp	$8,889.00
Rate for Payer: Scott and White EPO/PPO	$8,889.00

desflurane Inh Liquid 240 mL

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	77495057
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

desflurane Inh Liquid 240 mL

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	77495057
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

desmopressin 4 mcg/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2597
Hospital Charge Code	78431185
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

desmopressin 4 mcg/mL Inj Soln 1 mL

Facility

$128.00

Service Code	HCPCS J2597
Hospital Charge Code	78431185
Hospital Revenue Code	636
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$3.13
Rate for Payer: BCBS of TX Blue Essentials	$3.76
Rate for Payer: BCBS of TX PPO	$4.17
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

Know your out-of-pocket cost for care.

All Charges