White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DIABETES

Facility

$4,226.03

Service Code	APR-DRG 4203
Min. Negotiated Rate	$3,984.44
Max. Negotiated Rate	$4,226.03
Rate for Payer: Amerigroup CHIP/Medicaid	$3,984.44
Rate for Payer: Cigna Medicaid	$3,984.44
Rate for Payer: Molina CHIP/Medicaid	$3,984.44
Rate for Payer: Parkland Medicaid	$3,984.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,226.03

DIABETES

Facility

$2,725.19

Service Code	APR-DRG 4202
Min. Negotiated Rate	$2,569.41
Max. Negotiated Rate	$2,725.19
Rate for Payer: Amerigroup CHIP/Medicaid	$2,569.41
Rate for Payer: Cigna Medicaid	$2,569.41
Rate for Payer: Molina CHIP/Medicaid	$2,569.41
Rate for Payer: Parkland Medicaid	$2,569.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,725.19

DIABETES

Facility

$2,156.39

Service Code	APR-DRG 4201
Min. Negotiated Rate	$2,033.12
Max. Negotiated Rate	$2,156.39
Rate for Payer: Amerigroup CHIP/Medicaid	$2,033.12
Rate for Payer: Cigna Medicaid	$2,033.12
Rate for Payer: Molina CHIP/Medicaid	$2,033.12
Rate for Payer: Parkland Medicaid	$2,033.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,156.39

Diabetes Self Mgmnt Group per 30 Min

Facility

$109.00

Hospital Charge Code	8590002
Hospital Revenue Code	510
Rate for Payer: Cash Price	$74.12

Diabetes Self Mgmnt Group per 30 Min

Facility

$109.00

Hospital Charge Code	8590002
Hospital Revenue Code	510
Min. Negotiated Rate	$9.81
Max. Negotiated Rate	$78.48
Rate for Payer: Amerigroup CHIP/Medicaid	$9.81
Rate for Payer: BCBS of TX Blue Advantage	$32.70
Rate for Payer: BCBS of TX Blue Essentials	$39.24
Rate for Payer: BCBS of TX PPO	$43.60
Rate for Payer: Cash Price	$74.12
Rate for Payer: Cigna Medicaid	$78.48
Rate for Payer: Molina CHIP/Medicaid	$78.48
Rate for Payer: Multiplan Auto	$70.85
Rate for Payer: Multiplan Commercial	$70.85
Rate for Payer: Multiplan Workers Comp	$70.85
Rate for Payer: Parkland Medicaid	$78.48
Rate for Payer: Scott and White EPO/PPO	$54.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$78.48

Diabetes Self Mgmnt Individual 30 Min

Facility

$194.00

Hospital Charge Code	8590001
Hospital Revenue Code	510
Min. Negotiated Rate	$17.46
Max. Negotiated Rate	$139.68
Rate for Payer: Amerigroup CHIP/Medicaid	$17.46
Rate for Payer: BCBS of TX Blue Advantage	$58.20
Rate for Payer: BCBS of TX Blue Essentials	$69.84
Rate for Payer: BCBS of TX PPO	$77.60
Rate for Payer: Cash Price	$131.92
Rate for Payer: Cigna Medicaid	$139.68
Rate for Payer: Molina CHIP/Medicaid	$139.68
Rate for Payer: Multiplan Auto	$126.10
Rate for Payer: Multiplan Commercial	$126.10
Rate for Payer: Multiplan Workers Comp	$126.10
Rate for Payer: Parkland Medicaid	$139.68
Rate for Payer: Scott and White EPO/PPO	$97.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$139.68

Diabetes Self Mgmnt Individual 30 Min

Facility

$194.00

Hospital Charge Code	8590001
Hospital Revenue Code	510
Rate for Payer: Cash Price	$131.92

DIABETES W CC

Facility

$17,027.80

Service Code	MSDRG 638
Min. Negotiated Rate	$7,500.92
Max. Negotiated Rate	$17,027.80
Rate for Payer: BCBS of TX Blue Advantage	$7,500.92
Rate for Payer: BCBS of TX Blue Essentials	$9,000.23
Rate for Payer: BCBS of TX PPO	$10,000.65

DIABETES WITH CC

Facility

$17,027.80

Service Code	MSDRG 638
Min. Negotiated Rate	$7,500.92
Max. Negotiated Rate	$17,027.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,328.35
Rate for Payer: Amerigroup Medicare	$11,328.35
Rate for Payer: BCBS of TX Medicare	$11,328.35
Rate for Payer: Cigna Commercial	$11,543.06
Rate for Payer: Cigna Medicare	$11,328.35
Rate for Payer: Employer Direct Commercial	$11,328.35
Rate for Payer: Humana Medicare/TRICARE	$11,328.35
Rate for Payer: Molina Dual Medicare/Medicaid	$11,328.35
Rate for Payer: Molina Medicare	$11,328.35
Rate for Payer: Multiplan Auto	$17,027.80
Rate for Payer: Multiplan Commercial	$17,027.80
Rate for Payer: Multiplan Workers Comp	$17,027.80
Rate for Payer: Scott and White EPO/PPO	$7,841.75
Rate for Payer: Scott and White Medicare	$11,328.35
Rate for Payer: Superior Health Plan EPO	$11,328.35
Rate for Payer: Superior Health Plan Medicare	$11,328.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,328.35
Rate for Payer: Universal American Medicare	$11,328.35
Rate for Payer: Wellcare Medicare	$11,328.35
Rate for Payer: Wellmed Medicare	$11,328.35

DIABETES WITH MCC

Facility

$27,297.30

Service Code	MSDRG 637
Min. Negotiated Rate	$11,879.18
Max. Negotiated Rate	$27,297.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,289.69
Rate for Payer: Amerigroup Medicare	$15,289.69
Rate for Payer: BCBS of TX Medicare	$15,289.69
Rate for Payer: Cigna Commercial	$18,504.70
Rate for Payer: Cigna Medicare	$15,289.69
Rate for Payer: Employer Direct Commercial	$15,289.69
Rate for Payer: Humana Medicare/TRICARE	$15,289.69
Rate for Payer: Molina Dual Medicare/Medicaid	$15,289.69
Rate for Payer: Molina Medicare	$15,289.69
Rate for Payer: Multiplan Auto	$27,297.30
Rate for Payer: Multiplan Commercial	$27,297.30
Rate for Payer: Multiplan Workers Comp	$27,297.30
Rate for Payer: Scott and White EPO/PPO	$12,571.12
Rate for Payer: Scott and White Medicare	$15,289.69
Rate for Payer: Superior Health Plan EPO	$15,289.69
Rate for Payer: Superior Health Plan Medicare	$15,289.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,289.69
Rate for Payer: Universal American Medicare	$15,289.69
Rate for Payer: Wellcare Medicare	$15,289.69
Rate for Payer: Wellmed Medicare	$15,289.69

DIABETES WITHOUT CC/MCC

Facility

$11,802.80

Service Code	MSDRG 639
Min. Negotiated Rate	$5,434.34
Max. Negotiated Rate	$11,802.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,312.86
Rate for Payer: Amerigroup Medicare	$9,312.86
Rate for Payer: BCBS of TX Medicare	$9,312.86
Rate for Payer: Cigna Commercial	$8,001.06
Rate for Payer: Cigna Medicare	$9,312.86
Rate for Payer: Employer Direct Commercial	$9,312.86
Rate for Payer: Humana Medicare/TRICARE	$9,312.86
Rate for Payer: Molina Dual Medicare/Medicaid	$9,312.86
Rate for Payer: Molina Medicare	$9,312.86
Rate for Payer: Multiplan Auto	$11,802.80
Rate for Payer: Multiplan Commercial	$11,802.80
Rate for Payer: Multiplan Workers Comp	$11,802.80
Rate for Payer: Scott and White EPO/PPO	$5,435.50
Rate for Payer: Scott and White Medicare	$9,312.86
Rate for Payer: Superior Health Plan EPO	$9,312.86
Rate for Payer: Superior Health Plan Medicare	$9,312.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,312.86
Rate for Payer: Universal American Medicare	$9,312.86
Rate for Payer: Wellcare Medicare	$9,312.86
Rate for Payer: Wellmed Medicare	$9,312.86

DIABETES W MCC

Facility

$27,297.30

Service Code	MSDRG 637
Min. Negotiated Rate	$11,879.18
Max. Negotiated Rate	$27,297.30
Rate for Payer: BCBS of TX Blue Advantage	$11,879.18
Rate for Payer: BCBS of TX Blue Essentials	$14,253.63
Rate for Payer: BCBS of TX PPO	$15,837.99

DIABETES W/O CC/MCC

Facility

$11,802.80

Service Code	MSDRG 639
Min. Negotiated Rate	$5,434.34
Max. Negotiated Rate	$11,802.80
Rate for Payer: BCBS of TX Blue Advantage	$5,434.34
Rate for Payer: BCBS of TX Blue Essentials	$6,520.58
Rate for Payer: BCBS of TX PPO	$7,245.37

Diagnostic bone marrow aspiration(s)

Facility

$6,331.50

Service Code	HCPCS 38220
Hospital Charge Code	9900635
Hospital Revenue Code	360
Min. Negotiated Rate	$92.74
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$92.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$204.31
Rate for Payer: BCBS of TX Blue Essentials	$244.68
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$308.30
Rate for Payer: Cash Price	$4,305.42
Rate for Payer: Cash Price	$4,305.42
Rate for Payer: Cash Price	$4,305.42
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,558.68
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$4,558.68
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$4,558.68
Rate for Payer: Scott and White EPO/PPO	$3,069.37
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,558.68
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

Diagnostic bone marrow aspiration(s)

Facility

$6,331.50

Service Code	HCPCS 38220
Hospital Charge Code	9900635
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,305.42

Diagnostic bone marrow aspiration(s)

Facility

$10,000.00

Service Code	CPT 38220
Hospital Charge Code	36038220
Hospital Revenue Code	360
Min. Negotiated Rate	$92.74
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$92.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$204.31
Rate for Payer: BCBS of TX Blue Essentials	$244.68
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$308.30
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$3,069.37
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

DIALYSIS CIRCUIT EMBOLJ

Facility

$10,870.00

Service Code	HCPCS 36909
Hospital Charge Code	2351108
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,391.60

DIALYSIS CIRCUIT EMBOLJ

Facility

$10,870.00

Service Code	HCPCS 36909
Hospital Charge Code	2351108
Hospital Revenue Code	360
Min. Negotiated Rate	$978.30
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$978.30
Rate for Payer: BCBS of TX Blue Advantage	$3,261.00
Rate for Payer: BCBS of TX Blue Essentials	$3,913.20
Rate for Payer: BCBS of TX PPO	$4,348.00
Rate for Payer: Cash Price	$7,391.60
Rate for Payer: Cash Price	$7,391.60
Rate for Payer: Cigna Medicaid	$7,826.40
Rate for Payer: Molina CHIP/Medicaid	$7,826.40
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	$7,826.40
Rate for Payer: Scott and White EPO/PPO	$5,435.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,826.40
Rate for Payer: Superior Health Plan EPO	$1,478.32

Dialysis Treatment Charge -> IP Hemodialysis Treatment Complete

Facility

$4,750.00

Hospital Charge Code	800011
Hospital Revenue Code	801
Rate for Payer: Cash Price	$3,230.00

Dialysis Treatment Charge -> IP Hemodialysis Treatment Complete

Facility

$4,750.00

Hospital Charge Code	800011
Hospital Revenue Code	801
Min. Negotiated Rate	$427.50
Max. Negotiated Rate	$3,420.00
Rate for Payer: Amerigroup CHIP/Medicaid	$427.50
Rate for Payer: BCBS of TX Blue Advantage	$1,425.00
Rate for Payer: BCBS of TX Blue Essentials	$1,710.00
Rate for Payer: BCBS of TX PPO	$1,900.00
Rate for Payer: Cash Price	$3,230.00
Rate for Payer: Cigna Medicaid	$3,420.00
Rate for Payer: Molina CHIP/Medicaid	$3,420.00
Rate for Payer: Multiplan Auto	$3,087.50
Rate for Payer: Multiplan Commercial	$3,087.50
Rate for Payer: Multiplan Workers Comp	$3,087.50
Rate for Payer: Parkland Medicaid	$3,420.00
Rate for Payer: Scott and White EPO/PPO	$2,375.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,420.00
Rate for Payer: Superior Health Plan EPO	$646.00

Dialysis Treatment Charge -> OP Hemodialysis Treatment Complete

Facility

$2,811.00

Service Code	HCPCS 90935
Hospital Charge Code	800029
Hospital Revenue Code	829
Min. Negotiated Rate	$252.99
Max. Negotiated Rate	$2,023.92
Rate for Payer: Amerigroup CHIP/Medicaid	$252.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$689.44
Rate for Payer: Amerigroup Medicare	$689.44
Rate for Payer: BCBS of TX Blue Advantage	$843.30
Rate for Payer: BCBS of TX Blue Essentials	$1,011.96
Rate for Payer: BCBS of TX Medicare	$689.44
Rate for Payer: BCBS of TX PPO	$1,124.40
Rate for Payer: Cash Price	$1,911.48
Rate for Payer: Cash Price	$1,911.48
Rate for Payer: Cash Price	$1,911.48
Rate for Payer: Cigna Commercial	$1,457.36
Rate for Payer: Cigna Medicaid	$2,023.92
Rate for Payer: Cigna Medicare	$689.44
Rate for Payer: Employer Direct Commercial	$689.44
Rate for Payer: Humana Medicare/TRICARE	$689.44
Rate for Payer: Molina CHIP/Medicaid	$2,023.92
Rate for Payer: Molina Dual Medicare/Medicaid	$689.44
Rate for Payer: Molina Medicare	$689.44
Rate for Payer: Multiplan Auto	$1,827.15
Rate for Payer: Multiplan Commercial	$1,827.15
Rate for Payer: Multiplan Workers Comp	$1,827.15
Rate for Payer: Parkland Medicaid	$2,023.92
Rate for Payer: Scott and White EPO/PPO	$1,405.50
Rate for Payer: Scott and White Medicare	$689.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,023.92
Rate for Payer: Superior Health Plan EPO	$689.44
Rate for Payer: Superior Health Plan Medicare	$689.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$689.44
Rate for Payer: Universal American Medicare	$689.44
Rate for Payer: Wellcare Medicare	$689.44
Rate for Payer: Wellmed Medicare	$689.44

Dialysis Treatment Charge -> OP Hemodialysis Treatment Complete

Facility

$2,811.00

Service Code	HCPCS 90935
Hospital Charge Code	800029
Hospital Revenue Code	829
Rate for Payer: Cash Price	$1,911.48

Dialysis Treatment Charge -> Peritoneal Dialysis Treatment Complete

Facility

$5,866.00

Service Code	HCPCS 90945
Hospital Charge Code	810001
Hospital Revenue Code	804
Rate for Payer: Cash Price	$3,988.88

Dialysis Treatment Charge -> Peritoneal Dialysis Treatment Complete

Facility

$5,866.00

Service Code	HCPCS 90945
Hospital Charge Code	810001
Hospital Revenue Code	804
Min. Negotiated Rate	$419.16
Max. Negotiated Rate	$4,223.52
Rate for Payer: Amerigroup CHIP/Medicaid	$527.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$419.16
Rate for Payer: Amerigroup Medicare	$419.16
Rate for Payer: BCBS of TX Blue Advantage	$1,759.80
Rate for Payer: BCBS of TX Blue Essentials	$2,111.76
Rate for Payer: BCBS of TX Medicare	$419.16
Rate for Payer: BCBS of TX PPO	$2,346.40
Rate for Payer: Cash Price	$3,988.88
Rate for Payer: Cash Price	$3,988.88
Rate for Payer: Cash Price	$3,988.88
Rate for Payer: Cigna Commercial	$886.05
Rate for Payer: Cigna Medicaid	$4,223.52
Rate for Payer: Cigna Medicare	$419.16
Rate for Payer: Employer Direct Commercial	$419.16
Rate for Payer: Humana Medicare/TRICARE	$419.16
Rate for Payer: Molina CHIP/Medicaid	$4,223.52
Rate for Payer: Molina Dual Medicare/Medicaid	$419.16
Rate for Payer: Molina Medicare	$419.16
Rate for Payer: Multiplan Auto	$3,812.90
Rate for Payer: Multiplan Commercial	$3,812.90
Rate for Payer: Multiplan Workers Comp	$3,812.90
Rate for Payer: Parkland Medicaid	$4,223.52
Rate for Payer: Scott and White EPO/PPO	$2,933.00
Rate for Payer: Scott and White Medicare	$419.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,223.52
Rate for Payer: Superior Health Plan EPO	$419.16
Rate for Payer: Superior Health Plan Medicare	$419.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$419.16
Rate for Payer: Universal American Medicare	$419.16
Rate for Payer: Wellcare Medicare	$419.16
Rate for Payer: Wellmed Medicare	$419.16

Dialysis Treatment Charge -> TPE Complete

Facility

$3,926.00

Service Code	HCPCS 36514
Hospital Charge Code	810005
Hospital Revenue Code	940
Min. Negotiated Rate	$353.34
Max. Negotiated Rate	$3,335.52
Rate for Payer: Amerigroup CHIP/Medicaid	$353.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,564.52
Rate for Payer: Amerigroup Medicare	$1,564.52
Rate for Payer: BCBS of TX Blue Advantage	$2,210.45
Rate for Payer: BCBS of TX Blue Essentials	$2,647.24
Rate for Payer: BCBS of TX Medicare	$1,564.52
Rate for Payer: BCBS of TX PPO	$3,335.52
Rate for Payer: Cash Price	$2,669.68
Rate for Payer: Cash Price	$2,669.68
Rate for Payer: Cash Price	$2,669.68
Rate for Payer: Cigna Commercial	$3,307.12
Rate for Payer: Cigna Medicaid	$2,826.72
Rate for Payer: Cigna Medicare	$1,564.52
Rate for Payer: Employer Direct Commercial	$1,564.52
Rate for Payer: Humana Medicare/TRICARE	$1,564.52
Rate for Payer: Molina CHIP/Medicaid	$2,826.72
Rate for Payer: Molina Dual Medicare/Medicaid	$1,564.52
Rate for Payer: Molina Medicare	$1,564.52
Rate for Payer: Multiplan Auto	$2,551.90
Rate for Payer: Multiplan Commercial	$2,551.90
Rate for Payer: Multiplan Workers Comp	$2,551.90
Rate for Payer: Parkland Medicaid	$2,826.72
Rate for Payer: Scott and White EPO/PPO	$1,963.00
Rate for Payer: Scott and White Medicare	$1,564.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,826.72
Rate for Payer: Superior Health Plan EPO	$1,564.52
Rate for Payer: Superior Health Plan Medicare	$1,564.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,564.52
Rate for Payer: Universal American Medicare	$1,564.52
Rate for Payer: Wellcare Medicare	$1,564.52
Rate for Payer: Wellmed Medicare	$1,564.52

Know your out-of-pocket cost for care.

All Charges