White Rock Medical Center

All Charges

Charge

Type

Setting

Price

each additional 100 sq cm wound surface area, or part thereof-location face,scalp,neck,ears,genitalia,hands,feet, and/or multiple digits

Facility

$7,316.92

Service Code	HCPCS 15278
Hospital Charge Code	994056
Hospital Revenue Code	361
Min. Negotiated Rate	$658.52
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$658.52
Rate for Payer: BCBS of TX Blue Advantage	$2,195.08
Rate for Payer: BCBS of TX Blue Essentials	$2,634.09
Rate for Payer: BCBS of TX PPO	$2,926.77
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cigna Medicaid	$5,268.18
Rate for Payer: Molina CHIP/Medicaid	$5,268.18
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	$5,268.18
Rate for Payer: Scott and White EPO/PPO	$3,658.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,268.18
Rate for Payer: Superior Health Plan EPO	$995.10

each additional 100 sq cm wound surface area, or part thereof-location face,scalp,neck,ears,genitalia,hands,feet, and/or multiple digits

Facility

$7,316.92

Service Code	HCPCS 15278
Hospital Charge Code	994056
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,975.51

each additional anatomic site

Facility

$1,245.60

Service Code	HCPCS 0599T
Hospital Charge Code	994051
Hospital Revenue Code	361
Min. Negotiated Rate	$112.10
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$112.10
Rate for Payer: Cash Price	$847.01
Rate for Payer: Cash Price	$847.01
Rate for Payer: Cigna Medicaid	$896.83
Rate for Payer: Molina CHIP/Medicaid	$896.83
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	$896.83
Rate for Payer: Scott and White EPO/PPO	$622.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$896.83
Rate for Payer: Superior Health Plan EPO	$169.40

each additional anatomic site

Facility

$1,245.60

Service Code	HCPCS 0599T
Hospital Charge Code	994051
Hospital Revenue Code	361
Rate for Payer: Cash Price	$847.01

Ear Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107067
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$222.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$92.70
Rate for Payer: BCBS of TX Blue Essentials	$111.24
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$123.60
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cigna Medicaid	$222.48
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$222.48
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$222.48
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.48
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

Ear Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107067
Hospital Revenue Code	306
Rate for Payer: Cash Price	$210.12

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$23,010.90

Service Code	MSDRG 147
Min. Negotiated Rate	$10,597.12
Max. Negotiated Rate	$23,010.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,078.94
Rate for Payer: Amerigroup Medicare	$14,078.94
Rate for Payer: BCBS of TX Medicare	$14,078.94
Rate for Payer: Cigna Commercial	$16,376.92
Rate for Payer: Cigna Medicare	$14,078.94
Rate for Payer: Employer Direct Commercial	$14,078.94
Rate for Payer: Humana Medicare/TRICARE	$14,078.94
Rate for Payer: Molina Dual Medicare/Medicaid	$14,078.94
Rate for Payer: Molina Medicare	$14,078.94
Rate for Payer: Multiplan Auto	$23,010.90
Rate for Payer: Multiplan Commercial	$23,010.90
Rate for Payer: Multiplan Workers Comp	$23,010.90
Rate for Payer: Scott and White EPO/PPO	$10,597.12
Rate for Payer: Scott and White Medicare	$14,078.94
Rate for Payer: Superior Health Plan EPO	$14,078.94
Rate for Payer: Superior Health Plan Medicare	$14,078.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,078.94
Rate for Payer: Universal American Medicare	$14,078.94
Rate for Payer: Wellcare Medicare	$14,078.94
Rate for Payer: Wellmed Medicare	$14,078.94

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC

Facility

$38,269.80

Service Code	MSDRG 146
Min. Negotiated Rate	$16,538.66
Max. Negotiated Rate	$38,269.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,278.56
Rate for Payer: Amerigroup Medicare	$20,278.56
Rate for Payer: BCBS of TX Medicare	$20,278.56
Rate for Payer: Cigna Commercial	$27,272.11
Rate for Payer: Cigna Medicare	$20,278.56
Rate for Payer: Employer Direct Commercial	$20,278.56
Rate for Payer: Humana Medicare/TRICARE	$20,278.56
Rate for Payer: Molina Dual Medicare/Medicaid	$20,278.56
Rate for Payer: Molina Medicare	$20,278.56
Rate for Payer: Multiplan Auto	$38,269.80
Rate for Payer: Multiplan Commercial	$38,269.80
Rate for Payer: Multiplan Workers Comp	$38,269.80
Rate for Payer: Scott and White EPO/PPO	$17,624.25
Rate for Payer: Scott and White Medicare	$20,278.56
Rate for Payer: Superior Health Plan EPO	$20,278.56
Rate for Payer: Superior Health Plan Medicare	$20,278.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,278.56
Rate for Payer: Universal American Medicare	$20,278.56
Rate for Payer: Wellcare Medicare	$20,278.56
Rate for Payer: Wellmed Medicare	$20,278.56

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC

Facility

$15,534.40

Service Code	MSDRG 148
Min. Negotiated Rate	$6,224.68
Max. Negotiated Rate	$15,534.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,602.04
Rate for Payer: Amerigroup Medicare	$10,602.04
Rate for Payer: BCBS of TX Medicare	$10,602.04
Rate for Payer: Cigna Commercial	$10,266.65
Rate for Payer: Cigna Medicare	$10,602.04
Rate for Payer: Employer Direct Commercial	$10,602.04
Rate for Payer: Humana Medicare/TRICARE	$10,602.04
Rate for Payer: Molina Dual Medicare/Medicaid	$10,602.04
Rate for Payer: Molina Medicare	$10,602.04
Rate for Payer: Multiplan Auto	$15,534.40
Rate for Payer: Multiplan Commercial	$15,534.40
Rate for Payer: Multiplan Workers Comp	$15,534.40
Rate for Payer: Scott and White EPO/PPO	$7,154.00
Rate for Payer: Scott and White Medicare	$10,602.04
Rate for Payer: Superior Health Plan EPO	$10,602.04
Rate for Payer: Superior Health Plan Medicare	$10,602.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,602.04
Rate for Payer: Universal American Medicare	$10,602.04
Rate for Payer: Wellcare Medicare	$10,602.04
Rate for Payer: Wellmed Medicare	$10,602.04

EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES

Facility

$3,234.02

Service Code	APR-DRG 1101
Min. Negotiated Rate	$3,049.15
Max. Negotiated Rate	$3,234.02
Rate for Payer: Amerigroup CHIP/Medicaid	$3,049.15
Rate for Payer: Cigna Medicaid	$3,049.15
Rate for Payer: Molina CHIP/Medicaid	$3,049.15
Rate for Payer: Parkland Medicaid	$3,049.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,234.02

EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES

Facility

$5,179.56

Service Code	APR-DRG 1102
Min. Negotiated Rate	$4,883.47
Max. Negotiated Rate	$5,179.56
Rate for Payer: Amerigroup CHIP/Medicaid	$4,883.47
Rate for Payer: Cigna Medicaid	$4,883.47
Rate for Payer: Molina CHIP/Medicaid	$4,883.47
Rate for Payer: Parkland Medicaid	$4,883.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,179.56

EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES

Facility

$10,274.63

Service Code	APR-DRG 1104
Min. Negotiated Rate	$9,687.28
Max. Negotiated Rate	$10,274.63
Rate for Payer: Amerigroup CHIP/Medicaid	$9,687.28
Rate for Payer: Cigna Medicaid	$9,687.28
Rate for Payer: Molina CHIP/Medicaid	$9,687.28
Rate for Payer: Parkland Medicaid	$9,687.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,274.63

EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES

Facility

$5,571.08

Service Code	APR-DRG 1103
Min. Negotiated Rate	$5,252.61
Max. Negotiated Rate	$5,571.08
Rate for Payer: Amerigroup CHIP/Medicaid	$5,252.61
Rate for Payer: Cigna Medicaid	$5,252.61
Rate for Payer: Molina CHIP/Medicaid	$5,252.61
Rate for Payer: Parkland Medicaid	$5,252.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,571.08

EAR, NOSE, MOUTH & THROAT MALIGNANCY W CC

Facility

$23,010.90

Service Code	MSDRG 147
Min. Negotiated Rate	$10,597.12
Max. Negotiated Rate	$23,010.90
Rate for Payer: BCBS of TX Blue Advantage	$10,754.30
Rate for Payer: BCBS of TX Blue Essentials	$12,903.91
Rate for Payer: BCBS of TX PPO	$14,338.23

EAR, NOSE, MOUTH & THROAT MALIGNANCY W MCC

Facility

$38,269.80

Service Code	MSDRG 146
Min. Negotiated Rate	$16,538.66
Max. Negotiated Rate	$38,269.80
Rate for Payer: BCBS of TX Blue Advantage	$16,538.66
Rate for Payer: BCBS of TX Blue Essentials	$19,844.47
Rate for Payer: BCBS of TX PPO	$22,050.26

EAR, NOSE, MOUTH & THROAT MALIGNANCY W/O CC/MCC

Facility

$15,534.40

Service Code	MSDRG 148
Min. Negotiated Rate	$6,224.68
Max. Negotiated Rate	$15,534.40
Rate for Payer: BCBS of TX Blue Advantage	$6,224.68
Rate for Payer: BCBS of TX Blue Essentials	$7,468.89
Rate for Payer: BCBS of TX PPO	$8,299.09

Easyfuse Instrument Packmid/Hindfoot

Facility

$3,427.70

Hospital Charge Code	146397
Hospital Revenue Code	272
Min. Negotiated Rate	$308.49
Max. Negotiated Rate	$2,467.94
Rate for Payer: Amerigroup CHIP/Medicaid	$308.49
Rate for Payer: BCBS of TX Blue Advantage	$1,028.31
Rate for Payer: BCBS of TX Blue Essentials	$1,233.97
Rate for Payer: BCBS of TX PPO	$1,371.08
Rate for Payer: Cash Price	$2,330.84
Rate for Payer: Cigna Medicaid	$2,467.94
Rate for Payer: Molina CHIP/Medicaid	$2,467.94
Rate for Payer: Multiplan Auto	$2,228.01
Rate for Payer: Multiplan Commercial	$2,228.01
Rate for Payer: Multiplan Workers Comp	$2,228.01
Rate for Payer: Parkland Medicaid	$2,467.94
Rate for Payer: Scott and White EPO/PPO	$1,713.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,467.94
Rate for Payer: Superior Health Plan EPO	$466.17

Easyfuse Instrument Packmid/Hindfoot

Facility

$3,427.70

Hospital Charge Code	146397
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,330.84

EASYFUSE INSTRUMENT PACKMID / HINDFOOT

Facility

$2,038.46

Hospital Charge Code	993542
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,386.15

EASYFUSE INSTRUMENT PACKMID / HINDFOOT

Facility

$2,038.46

Hospital Charge Code	993542
Hospital Revenue Code	270
Min. Negotiated Rate	$183.46
Max. Negotiated Rate	$1,467.69
Rate for Payer: Amerigroup CHIP/Medicaid	$183.46
Rate for Payer: BCBS of TX Blue Advantage	$611.54
Rate for Payer: BCBS of TX Blue Essentials	$733.85
Rate for Payer: BCBS of TX PPO	$815.38
Rate for Payer: Cash Price	$1,386.15
Rate for Payer: Cigna Medicaid	$1,467.69
Rate for Payer: Molina CHIP/Medicaid	$1,467.69
Rate for Payer: Multiplan Auto	$1,325.00
Rate for Payer: Multiplan Commercial	$1,325.00
Rate for Payer: Multiplan Workers Comp	$1,325.00
Rate for Payer: Parkland Medicaid	$1,467.69
Rate for Payer: Scott and White EPO/PPO	$1,019.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,467.69
Rate for Payer: Superior Health Plan EPO	$277.23

EASYFUSE STAPLE 20X20 NITINOL 2-LEG

Facility

$15,234.34

Service Code	HCPCS C1776
Hospital Charge Code	992377
Hospital Revenue Code	278
Min. Negotiated Rate	$3,808.59
Max. Negotiated Rate	$7,617.17
Rate for Payer: Cash Price	$10,359.35
Rate for Payer: Cigna Commercial	$3,808.59
Rate for Payer: Multiplan Auto	$7,617.17
Rate for Payer: Multiplan Commercial	$7,617.17
Rate for Payer: Multiplan Workers Comp	$7,617.17
Rate for Payer: Scott and White EPO/PPO	$7,617.17

EASYFUSE STAPLE 20X20 NITINOL 2-LEG

Facility

$15,234.34

Service Code	HCPCS C1776
Hospital Charge Code	992377
Hospital Revenue Code	278
Min. Negotiated Rate	$1,371.09
Max. Negotiated Rate	$10,968.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1,371.09
Rate for Payer: BCBS of TX Blue Advantage	$4,570.30
Rate for Payer: BCBS of TX Blue Essentials	$5,484.36
Rate for Payer: BCBS of TX PPO	$6,093.74
Rate for Payer: Cash Price	$10,359.35
Rate for Payer: Cigna Medicaid	$10,968.72
Rate for Payer: Molina CHIP/Medicaid	$10,968.72
Rate for Payer: Multiplan Auto	$7,617.17
Rate for Payer: Multiplan Commercial	$7,617.17
Rate for Payer: Multiplan Workers Comp	$7,617.17
Rate for Payer: Parkland Medicaid	$10,968.72
Rate for Payer: Scott and White EPO/PPO	$7,617.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,968.72
Rate for Payer: Superior Health Plan EPO	$2,071.87

EATING DISORDERS

Facility

$14,308.66

Service Code	APR-DRG 7593
Min. Negotiated Rate	$13,490.71
Max. Negotiated Rate	$14,308.66
Rate for Payer: Amerigroup CHIP/Medicaid	$13,490.71
Rate for Payer: Cigna Medicaid	$13,490.71
Rate for Payer: Molina CHIP/Medicaid	$13,490.71
Rate for Payer: Parkland Medicaid	$13,490.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,308.66

EATING DISORDERS

Facility

$7,232.98

Service Code	APR-DRG 7592
Min. Negotiated Rate	$6,819.50
Max. Negotiated Rate	$7,232.98
Rate for Payer: Amerigroup CHIP/Medicaid	$6,819.50
Rate for Payer: Cigna Medicaid	$6,819.50
Rate for Payer: Molina CHIP/Medicaid	$6,819.50
Rate for Payer: Parkland Medicaid	$6,819.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,232.98

EATING DISORDERS

Facility

$20,894.01

Service Code	APR-DRG 7594
Min. Negotiated Rate	$19,699.60
Max. Negotiated Rate	$20,894.01
Rate for Payer: Amerigroup CHIP/Medicaid	$19,699.60
Rate for Payer: Cigna Medicaid	$19,699.60
Rate for Payer: Molina CHIP/Medicaid	$19,699.60
Rate for Payer: Parkland Medicaid	$19,699.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,894.01

Know your out-of-pocket cost for care.

All Charges