White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DIGESTIVE MALIGNANCY

Facility

$3,946.53

Service Code	APR-DRG 2401
Min. Negotiated Rate	$3,720.93
Max. Negotiated Rate	$3,946.53
Rate for Payer: Amerigroup CHIP/Medicaid	$3,720.93
Rate for Payer: Cigna Medicaid	$3,720.93
Rate for Payer: Molina CHIP/Medicaid	$3,720.93
Rate for Payer: Parkland Medicaid	$3,720.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,946.53

DIGESTIVE MALIGNANCY

Facility

$6,343.19

Service Code	APR-DRG 2403
Min. Negotiated Rate	$5,980.58
Max. Negotiated Rate	$6,343.19
Rate for Payer: Amerigroup CHIP/Medicaid	$5,980.58
Rate for Payer: Cigna Medicaid	$5,980.58
Rate for Payer: Molina CHIP/Medicaid	$5,980.58
Rate for Payer: Parkland Medicaid	$5,980.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,343.19

DIGESTIVE MALIGNANCY

Facility

$4,521.36

Service Code	APR-DRG 2402
Min. Negotiated Rate	$4,262.90
Max. Negotiated Rate	$4,521.36
Rate for Payer: Amerigroup CHIP/Medicaid	$4,262.90
Rate for Payer: Cigna Medicaid	$4,262.90
Rate for Payer: Molina CHIP/Medicaid	$4,262.90
Rate for Payer: Parkland Medicaid	$4,262.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,521.36

DIGESTIVE MALIGNANCY W CC

Facility

$22,982.40

Service Code	MSDRG 375
Min. Negotiated Rate	$10,377.62
Max. Negotiated Rate	$22,982.40
Rate for Payer: BCBS of TX Blue Advantage	$10,377.62
Rate for Payer: BCBS of TX Blue Essentials	$12,451.94
Rate for Payer: BCBS of TX PPO	$13,836.02

DIGESTIVE MALIGNANCY WITH CC

Facility

$22,982.40

Service Code	MSDRG 375
Min. Negotiated Rate	$10,377.62
Max. Negotiated Rate	$22,982.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,625.27
Rate for Payer: Amerigroup Medicare	$13,625.27
Rate for Payer: BCBS of TX Medicare	$13,625.27
Rate for Payer: Cigna Commercial	$15,579.65
Rate for Payer: Cigna Medicare	$13,625.27
Rate for Payer: Employer Direct Commercial	$13,625.27
Rate for Payer: Humana Medicare/TRICARE	$13,625.27
Rate for Payer: Molina Dual Medicare/Medicaid	$13,625.27
Rate for Payer: Molina Medicare	$13,625.27
Rate for Payer: Multiplan Auto	$22,982.40
Rate for Payer: Multiplan Commercial	$22,982.40
Rate for Payer: Multiplan Workers Comp	$22,982.40
Rate for Payer: Scott and White EPO/PPO	$10,584.00
Rate for Payer: Scott and White Medicare	$13,625.27
Rate for Payer: Superior Health Plan EPO	$13,625.27
Rate for Payer: Superior Health Plan Medicare	$13,625.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,625.27
Rate for Payer: Universal American Medicare	$13,625.27
Rate for Payer: Wellcare Medicare	$13,625.27
Rate for Payer: Wellmed Medicare	$13,625.27

DIGESTIVE MALIGNANCY WITH MCC

Facility

$40,635.30

Service Code	MSDRG 374
Min. Negotiated Rate	$17,759.00
Max. Negotiated Rate	$40,635.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,434.66
Rate for Payer: Amerigroup Medicare	$20,434.66
Rate for Payer: BCBS of TX Medicare	$20,434.66
Rate for Payer: Cigna Commercial	$27,546.46
Rate for Payer: Cigna Medicare	$20,434.66
Rate for Payer: Employer Direct Commercial	$20,434.66
Rate for Payer: Humana Medicare/TRICARE	$20,434.66
Rate for Payer: Molina Dual Medicare/Medicaid	$20,434.66
Rate for Payer: Molina Medicare	$20,434.66
Rate for Payer: Multiplan Auto	$40,635.30
Rate for Payer: Multiplan Commercial	$40,635.30
Rate for Payer: Multiplan Workers Comp	$40,635.30
Rate for Payer: Scott and White EPO/PPO	$18,713.62
Rate for Payer: Scott and White Medicare	$20,434.66
Rate for Payer: Superior Health Plan EPO	$20,434.66
Rate for Payer: Superior Health Plan Medicare	$20,434.66
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,434.66
Rate for Payer: Universal American Medicare	$20,434.66
Rate for Payer: Wellcare Medicare	$20,434.66
Rate for Payer: Wellmed Medicare	$20,434.66

DIGESTIVE MALIGNANCY WITHOUT CC/MCC

Facility

$17,561.70

Service Code	MSDRG 376
Min. Negotiated Rate	$7,875.02
Max. Negotiated Rate	$17,561.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,534.30
Rate for Payer: Amerigroup Medicare	$11,534.30
Rate for Payer: BCBS of TX Medicare	$11,534.30
Rate for Payer: Cigna Commercial	$11,904.98
Rate for Payer: Cigna Medicare	$11,534.30
Rate for Payer: Employer Direct Commercial	$11,534.30
Rate for Payer: Humana Medicare/TRICARE	$11,534.30
Rate for Payer: Molina Dual Medicare/Medicaid	$11,534.30
Rate for Payer: Molina Medicare	$11,534.30
Rate for Payer: Multiplan Auto	$17,561.70
Rate for Payer: Multiplan Commercial	$17,561.70
Rate for Payer: Multiplan Workers Comp	$17,561.70
Rate for Payer: Scott and White EPO/PPO	$8,087.62
Rate for Payer: Scott and White Medicare	$11,534.30
Rate for Payer: Superior Health Plan EPO	$11,534.30
Rate for Payer: Superior Health Plan Medicare	$11,534.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,534.30
Rate for Payer: Universal American Medicare	$11,534.30
Rate for Payer: Wellcare Medicare	$11,534.30
Rate for Payer: Wellmed Medicare	$11,534.30

DIGESTIVE MALIGNANCY W MCC

Facility

$40,635.30

Service Code	MSDRG 374
Min. Negotiated Rate	$17,759.00
Max. Negotiated Rate	$40,635.30
Rate for Payer: BCBS of TX Blue Advantage	$17,759.00
Rate for Payer: BCBS of TX Blue Essentials	$21,308.74
Rate for Payer: BCBS of TX PPO	$23,677.29

DIGESTIVE MALIGNANCY W/O CC/MCC

Facility

$17,561.70

Service Code	MSDRG 376
Min. Negotiated Rate	$7,875.02
Max. Negotiated Rate	$17,561.70
Rate for Payer: BCBS of TX Blue Advantage	$7,875.02
Rate for Payer: BCBS of TX Blue Essentials	$9,449.11
Rate for Payer: BCBS of TX PPO	$10,499.42

digoxin 125 mcg (0.125 mg) Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77513612
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

digoxin 125 mcg (0.125 mg) Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77513612
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

digoxin 250 mcg (0.25 mg) Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77513714
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

digoxin 250 mcg (0.25 mg) Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77513714
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

digoxin 250 mcg/mL (0.25 mg/mL) Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77513767
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

digoxin 250 mcg/mL (0.25 mg/mL) Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77513767
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

Digoxin Level

Facility

$389.00

Service Code	HCPCS 80162
Hospital Charge Code	1602812
Hospital Revenue Code	300
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$280.08
Rate for Payer: Amerigroup CHIP/Medicaid	$5.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.28
Rate for Payer: Amerigroup Medicare	$13.28
Rate for Payer: BCBS of TX Blue Advantage	$116.70
Rate for Payer: BCBS of TX Blue Essentials	$140.04
Rate for Payer: BCBS of TX Medicare	$13.28
Rate for Payer: BCBS of TX PPO	$155.60
Rate for Payer: Cash Price	$264.52
Rate for Payer: Cash Price	$264.52
Rate for Payer: Cigna Medicaid	$280.08
Rate for Payer: Cigna Medicare	$13.28
Rate for Payer: Employer Direct Commercial	$13.28
Rate for Payer: Humana Medicare/TRICARE	$13.28
Rate for Payer: Molina CHIP/Medicaid	$280.08
Rate for Payer: Molina Dual Medicare/Medicaid	$13.28
Rate for Payer: Molina Medicare	$13.28
Rate for Payer: Multiplan Auto	$252.85
Rate for Payer: Multiplan Commercial	$252.85
Rate for Payer: Multiplan Workers Comp	$252.85
Rate for Payer: Parkland Medicaid	$280.08
Rate for Payer: Scott and White EPO/PPO	$16.60
Rate for Payer: Scott and White Medicare	$13.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$280.08
Rate for Payer: Superior Health Plan EPO	$13.28
Rate for Payer: Superior Health Plan Medicare	$13.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.28
Rate for Payer: Universal American Medicare	$13.28
Rate for Payer: Wellcare Medicare	$13.28
Rate for Payer: Wellmed Medicare	$13.28

Digoxin Level

Facility

$389.00

Service Code	HCPCS 80162
Hospital Charge Code	1602812
Hospital Revenue Code	300
Rate for Payer: Cash Price	$264.52

Digoxin, Serum SO

Facility

$104.00

Service Code	HCPCS 80162
Hospital Charge Code	9130978
Hospital Revenue Code	301
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$74.88
Rate for Payer: Amerigroup CHIP/Medicaid	$5.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.28
Rate for Payer: Amerigroup Medicare	$13.28
Rate for Payer: BCBS of TX Blue Advantage	$31.20
Rate for Payer: BCBS of TX Blue Essentials	$37.44
Rate for Payer: BCBS of TX Medicare	$13.28
Rate for Payer: BCBS of TX PPO	$41.60
Rate for Payer: Cash Price	$70.72
Rate for Payer: Cash Price	$70.72
Rate for Payer: Cigna Medicaid	$74.88
Rate for Payer: Cigna Medicare	$13.28
Rate for Payer: Employer Direct Commercial	$13.28
Rate for Payer: Humana Medicare/TRICARE	$13.28
Rate for Payer: Molina CHIP/Medicaid	$74.88
Rate for Payer: Molina Dual Medicare/Medicaid	$13.28
Rate for Payer: Molina Medicare	$13.28
Rate for Payer: Multiplan Auto	$67.60
Rate for Payer: Multiplan Commercial	$67.60
Rate for Payer: Multiplan Workers Comp	$67.60
Rate for Payer: Parkland Medicaid	$74.88
Rate for Payer: Scott and White EPO/PPO	$16.60
Rate for Payer: Scott and White Medicare	$13.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.88
Rate for Payer: Superior Health Plan EPO	$13.28
Rate for Payer: Superior Health Plan Medicare	$13.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.28
Rate for Payer: Universal American Medicare	$13.28
Rate for Payer: Wellcare Medicare	$13.28
Rate for Payer: Wellmed Medicare	$13.28

Digoxin, Serum SO

Facility

$104.00

Service Code	HCPCS 80162
Hospital Charge Code	9130978
Hospital Revenue Code	301
Rate for Payer: Cash Price	$70.72

DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$19,161.96

Service Code	APR-DRG 5174
Min. Negotiated Rate	$18,066.56
Max. Negotiated Rate	$19,161.96
Rate for Payer: Amerigroup CHIP/Medicaid	$18,066.56
Rate for Payer: Cigna Medicaid	$18,066.56
Rate for Payer: Molina CHIP/Medicaid	$18,066.56
Rate for Payer: Parkland Medicaid	$18,066.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,161.96

DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$4,554.93

Service Code	APR-DRG 5172
Min. Negotiated Rate	$4,294.55
Max. Negotiated Rate	$4,554.93
Rate for Payer: Amerigroup CHIP/Medicaid	$4,294.55
Rate for Payer: Cigna Medicaid	$4,294.55
Rate for Payer: Molina CHIP/Medicaid	$4,294.55
Rate for Payer: Parkland Medicaid	$4,294.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,554.93

DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$7,002.51

Service Code	APR-DRG 5173
Min. Negotiated Rate	$6,602.22
Max. Negotiated Rate	$7,002.51
Rate for Payer: Amerigroup CHIP/Medicaid	$6,602.22
Rate for Payer: Cigna Medicaid	$6,602.22
Rate for Payer: Molina CHIP/Medicaid	$6,602.22
Rate for Payer: Parkland Medicaid	$6,602.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,002.51

DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$3,041.27

Service Code	APR-DRG 5171
Min. Negotiated Rate	$2,867.42
Max. Negotiated Rate	$3,041.27
Rate for Payer: Amerigroup CHIP/Medicaid	$2,867.42
Rate for Payer: Cigna Medicaid	$2,867.42
Rate for Payer: Molina CHIP/Medicaid	$2,867.42
Rate for Payer: Parkland Medicaid	$2,867.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,041.27

Dilation of esophagus, over guide wire

Facility

$10,000.00

Service Code	CPT 43453
Hospital Charge Code	36043453
Hospital Revenue Code	360
Min. Negotiated Rate	$564.97
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Amerigroup Medicare	$1,927.65
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX Medicare	$1,927.65
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cigna Commercial	$4,074.70
Rate for Payer: Cigna Medicare	$1,927.65
Rate for Payer: Employer Direct Commercial	$1,927.65
Rate for Payer: Humana Medicare/TRICARE	$1,927.65
Rate for Payer: Molina Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Molina Medicare	$1,927.65
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	$3,566.15
Rate for Payer: Scott and White Medicare	$1,927.65
Rate for Payer: Superior Health Plan EPO	$1,927.65
Rate for Payer: Superior Health Plan Medicare	$1,927.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,927.65
Rate for Payer: Universal American Medicare	$1,927.65
Rate for Payer: Wellcare Medicare	$1,927.65
Rate for Payer: Wellmed Medicare	$1,927.65

Dilation of esophagus, over guide wire

Facility

$4,617.17

Service Code	HCPCS 43453
Hospital Charge Code	9900683
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,139.68

Know your out-of-pocket cost for care.

All Charges