White Rock Medical Center

All Charges

Charge

Type

Setting

Price

INPATIENT APRDRG 9121: MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$2.81

Service Code	APR-DRG 9121
Hospital Charge Code	APRDRG 9121
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$2.81
Rate for Payer: Amerigroup CHIP/Medicaid	$2.81
Rate for Payer: Cigna Medicaid	$2.81
Rate for Payer: Molina CHIP/Medicaid	$2.81
Rate for Payer: Parkland Medicaid	$2.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.81

INPATIENT APRDRG 9122: MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$2.93

Service Code	APR-DRG 9122
Hospital Charge Code	APRDRG 9122
Min. Negotiated Rate	$2.93
Max. Negotiated Rate	$2.93
Rate for Payer: Amerigroup CHIP/Medicaid	$2.93
Rate for Payer: Cigna Medicaid	$2.93
Rate for Payer: Molina CHIP/Medicaid	$2.93
Rate for Payer: Parkland Medicaid	$2.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.93

INPATIENT APRDRG 9123: MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$4.46

Service Code	APR-DRG 9123
Hospital Charge Code	APRDRG 9123
Min. Negotiated Rate	$4.46
Max. Negotiated Rate	$4.46
Rate for Payer: Amerigroup CHIP/Medicaid	$4.46
Rate for Payer: Cigna Medicaid	$4.46
Rate for Payer: Molina CHIP/Medicaid	$4.46
Rate for Payer: Parkland Medicaid	$4.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.46

INPATIENT APRDRG 9124: MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$9.89

Service Code	APR-DRG 9124
Hospital Charge Code	APRDRG 9124
Min. Negotiated Rate	$9.89
Max. Negotiated Rate	$9.89
Rate for Payer: Amerigroup CHIP/Medicaid	$9.89
Rate for Payer: Cigna Medicaid	$9.89
Rate for Payer: Molina CHIP/Medicaid	$9.89
Rate for Payer: Parkland Medicaid	$9.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.89

INPATIENT APRDRG 9301: MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE

Facility

$1.17

Service Code	APR-DRG 9301
Hospital Charge Code	APRDRG 9301
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.17
Rate for Payer: Amerigroup CHIP/Medicaid	$1.17
Rate for Payer: Cigna Medicaid	$1.17
Rate for Payer: Molina CHIP/Medicaid	$1.17
Rate for Payer: Parkland Medicaid	$1.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.17

INPATIENT APRDRG 9302: MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE

Facility

$1.64

Service Code	APR-DRG 9302
Hospital Charge Code	APRDRG 9302
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$1.64
Rate for Payer: Amerigroup CHIP/Medicaid	$1.64
Rate for Payer: Cigna Medicaid	$1.64
Rate for Payer: Molina CHIP/Medicaid	$1.64
Rate for Payer: Parkland Medicaid	$1.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.64

INPATIENT APRDRG 9303: MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE

Facility

$2.11

Service Code	APR-DRG 9303
Hospital Charge Code	APRDRG 9303
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$2.11
Rate for Payer: Amerigroup CHIP/Medicaid	$2.11
Rate for Payer: Cigna Medicaid	$2.11
Rate for Payer: Molina CHIP/Medicaid	$2.11
Rate for Payer: Parkland Medicaid	$2.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.11

INPATIENT APRDRG 9304: MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE

Facility

$5.05

Service Code	APR-DRG 9304
Hospital Charge Code	APRDRG 9304
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$5.05
Rate for Payer: Amerigroup CHIP/Medicaid	$5.05
Rate for Payer: Cigna Medicaid	$5.05
Rate for Payer: Molina CHIP/Medicaid	$5.05
Rate for Payer: Parkland Medicaid	$5.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.05

INPATIENT APRDRG 9501: EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$1.72

Service Code	APR-DRG 9501
Hospital Charge Code	APRDRG 9501
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$1.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1.72
Rate for Payer: Cigna Medicaid	$1.72
Rate for Payer: Molina CHIP/Medicaid	$1.72
Rate for Payer: Parkland Medicaid	$1.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.72

INPATIENT APRDRG 9502: EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$2.59

Service Code	APR-DRG 9502
Hospital Charge Code	APRDRG 9502
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$2.59
Rate for Payer: Amerigroup CHIP/Medicaid	$2.59
Rate for Payer: Cigna Medicaid	$2.59
Rate for Payer: Molina CHIP/Medicaid	$2.59
Rate for Payer: Parkland Medicaid	$2.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.59

INPATIENT APRDRG 9503: EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$4.19

Service Code	APR-DRG 9503
Hospital Charge Code	APRDRG 9503
Min. Negotiated Rate	$4.19
Max. Negotiated Rate	$4.19
Rate for Payer: Amerigroup CHIP/Medicaid	$4.19
Rate for Payer: Cigna Medicaid	$4.19
Rate for Payer: Molina CHIP/Medicaid	$4.19
Rate for Payer: Parkland Medicaid	$4.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.19

INPATIENT APRDRG 9504: EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$11.81

Service Code	APR-DRG 9504
Hospital Charge Code	APRDRG 9504
Min. Negotiated Rate	$11.81
Max. Negotiated Rate	$11.81
Rate for Payer: Amerigroup CHIP/Medicaid	$11.81
Rate for Payer: Cigna Medicaid	$11.81
Rate for Payer: Molina CHIP/Medicaid	$11.81
Rate for Payer: Parkland Medicaid	$11.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.81

INPATIENT APRDRG 9511: MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$1.15

Service Code	APR-DRG 9511
Hospital Charge Code	APRDRG 9511
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$1.15
Rate for Payer: Amerigroup CHIP/Medicaid	$1.15
Rate for Payer: Cigna Medicaid	$1.15
Rate for Payer: Molina CHIP/Medicaid	$1.15
Rate for Payer: Parkland Medicaid	$1.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.15

INPATIENT APRDRG 9512: MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$1.73

Service Code	APR-DRG 9512
Hospital Charge Code	APRDRG 9512
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$1.73
Rate for Payer: Amerigroup CHIP/Medicaid	$1.73
Rate for Payer: Cigna Medicaid	$1.73
Rate for Payer: Molina CHIP/Medicaid	$1.73
Rate for Payer: Parkland Medicaid	$1.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.73

INPATIENT APRDRG 9513: MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$3.44

Service Code	APR-DRG 9513
Hospital Charge Code	APRDRG 9513
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$3.44
Rate for Payer: Amerigroup CHIP/Medicaid	$3.44
Rate for Payer: Cigna Medicaid	$3.44
Rate for Payer: Molina CHIP/Medicaid	$3.44
Rate for Payer: Parkland Medicaid	$3.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.44

INPATIENT APRDRG 9514: MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$8.24

Service Code	APR-DRG 9514
Hospital Charge Code	APRDRG 9514
Min. Negotiated Rate	$8.24
Max. Negotiated Rate	$8.24
Rate for Payer: Amerigroup CHIP/Medicaid	$8.24
Rate for Payer: Cigna Medicaid	$8.24
Rate for Payer: Molina CHIP/Medicaid	$8.24
Rate for Payer: Parkland Medicaid	$8.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.24

INPATIENT APRDRG 9521: NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$1.28

Service Code	APR-DRG 9521
Hospital Charge Code	APRDRG 9521
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.28
Rate for Payer: Amerigroup CHIP/Medicaid	$1.28
Rate for Payer: Cigna Medicaid	$1.28
Rate for Payer: Molina CHIP/Medicaid	$1.28
Rate for Payer: Parkland Medicaid	$1.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.28

INPATIENT APRDRG 9522: NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$1.72

Service Code	APR-DRG 9522
Hospital Charge Code	APRDRG 9522
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$1.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1.72
Rate for Payer: Cigna Medicaid	$1.72
Rate for Payer: Molina CHIP/Medicaid	$1.72
Rate for Payer: Parkland Medicaid	$1.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.72

INPATIENT APRDRG 9523: NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$5.02

Service Code	APR-DRG 9523
Hospital Charge Code	APRDRG 9523
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$5.02
Rate for Payer: Amerigroup CHIP/Medicaid	$5.02
Rate for Payer: Cigna Medicaid	$5.02
Rate for Payer: Molina CHIP/Medicaid	$5.02
Rate for Payer: Parkland Medicaid	$5.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.02

INPATIENT APRDRG 9524: NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$10.41

Service Code	APR-DRG 9524
Hospital Charge Code	APRDRG 9524
Min. Negotiated Rate	$10.41
Max. Negotiated Rate	$10.41
Rate for Payer: Amerigroup CHIP/Medicaid	$10.41
Rate for Payer: Cigna Medicaid	$10.41
Rate for Payer: Molina CHIP/Medicaid	$10.41
Rate for Payer: Parkland Medicaid	$10.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.41

INPATIENT-ONLY SERVICE, VERIFY!! Open Fusion, Sacroiliac Joint

Facility

$10,000.00

Service Code	CPT 27280
Hospital Charge Code	36027280
Hospital Revenue Code	360
Min. Negotiated Rate	$2,360.46
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$8,755.00
Rate for Payer: BCBS of TX Blue Advantage	$2,360.46
Rate for Payer: BCBS of TX Blue Essentials	$2,826.90
Rate for Payer: BCBS of TX PPO	$3,561.89
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

INS CATH REN ART 1ST UNI

Facility

$8,679.00

Service Code	CPT 36251
Hospital Charge Code	4616251
Hospital Revenue Code	361
Rate for Payer: Cash Price	$7,637.52

INS CATH REN ART 1ST UNI

Facility

$8,679.00

Service Code	CPT 36251
Hospital Charge Code	4616251
Hospital Revenue Code	361
Min. Negotiated Rate	$64.30
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$781.11
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Amerigroup Medicare	$2,915.10
Rate for Payer: BCBS of TX Blue Advantage	$4,628.04
Rate for Payer: BCBS of TX Blue Essentials	$5,542.56
Rate for Payer: BCBS of TX Medicare	$2,915.10
Rate for Payer: BCBS of TX PPO	$6,983.63
Rate for Payer: Cash Price	$7,637.52
Rate for Payer: Cash Price	$7,637.52
Rate for Payer: Cash Price	$7,637.52
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicare	$2,915.10
Rate for Payer: Employer Direct Commercial	$2,915.10
Rate for Payer: Humana Medicare/TRICARE	$2,915.10
Rate for Payer: Molina Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Molina Medicare	$2,915.10
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	$64.30
Rate for Payer: Scott and White Medicare	$2,915.10
Rate for Payer: Superior Health Plan EPO	$2,915.10
Rate for Payer: Superior Health Plan Medicare	$2,915.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Universal American Medicare	$2,915.10
Rate for Payer: Wellcare Medicare	$2,915.10
Rate for Payer: Wellmed Medicare	$2,915.10

INSER/REPLAC DIFIBRILATOR SUB CUT

Facility

$38,514.00

Service Code	CPT 33270
Hospital Charge Code	2351000
Hospital Revenue Code	481
Rate for Payer: Cash Price	$33,892.32

INSER/REPLAC DIFIBRILATOR SUB CUT

Facility

$38,514.00

Service Code	CPT 33270
Hospital Charge Code	2351000
Hospital Revenue Code	481
Min. Negotiated Rate	$538.09
Max. Negotiated Rate	$81,352.25
Rate for Payer: Aetna Commercial	$21,182.70
Rate for Payer: Aetna Medicare	$45,131.62
Rate for Payer: Amerigroup CHIP/Medicaid	$3,466.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,087.75
Rate for Payer: Amerigroup Medicare	$30,087.75
Rate for Payer: BCBS of TX Blue Advantage	$53,912.01
Rate for Payer: BCBS of TX Blue Essentials	$64,565.28
Rate for Payer: BCBS of TX Medicare	$30,087.75
Rate for Payer: BCBS of TX PPO	$81,352.25
Rate for Payer: Cash Price	$33,892.32
Rate for Payer: Cash Price	$33,892.32
Rate for Payer: Cash Price	$33,892.32
Rate for Payer: Cigna Commercial	$68,157.46
Rate for Payer: Cigna Medicaid	$21,943.90
Rate for Payer: Cigna Medicare	$30,087.75
Rate for Payer: Employer Direct Commercial	$30,087.75
Rate for Payer: Humana Medicare/TRICARE	$30,087.75
Rate for Payer: Molina CHIP/Medicaid	$21,943.90
Rate for Payer: Molina Dual Medicare/Medicaid	$30,087.75
Rate for Payer: Molina Medicare	$30,087.75
Rate for Payer: Multiplan Auto	$25,034.10
Rate for Payer: Multiplan Commercial	$25,034.10
Rate for Payer: Multiplan Workers Comp	$25,034.10
Rate for Payer: Parkland Medicaid	$21,943.90
Rate for Payer: Scott and White EPO/PPO	$538.09
Rate for Payer: Scott and White Medicare	$30,087.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,943.90
Rate for Payer: Superior Health Plan EPO	$30,087.75
Rate for Payer: Superior Health Plan Medicare	$30,087.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,087.75
Rate for Payer: Universal American Medicare	$30,087.75
Rate for Payer: Wellcare Medicare	$30,087.75
Rate for Payer: Wellmed Medicare	$30,087.75

Know your out-of-pocket cost for care.

All Charges