White Rock Medical Center

All Charges

Charge

Type

Setting

Price

EXPRESSEW NEEDLE

Facility

$1,120.47

Hospital Charge Code	992663
Hospital Revenue Code	272
Min. Negotiated Rate	$100.84
Max. Negotiated Rate	$806.74
Rate for Payer: Amerigroup CHIP/Medicaid	$100.84
Rate for Payer: BCBS of TX Blue Advantage	$336.14
Rate for Payer: BCBS of TX Blue Essentials	$403.37
Rate for Payer: BCBS of TX PPO	$448.19
Rate for Payer: Cash Price	$761.92
Rate for Payer: Cigna Medicaid	$806.74
Rate for Payer: Molina CHIP/Medicaid	$806.74
Rate for Payer: Multiplan Auto	$728.31
Rate for Payer: Multiplan Commercial	$728.31
Rate for Payer: Multiplan Workers Comp	$728.31
Rate for Payer: Parkland Medicaid	$806.74
Rate for Payer: Scott and White EPO/PPO	$560.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$806.74
Rate for Payer: Superior Health Plan EPO	$152.38

EXPRESSEW NEEDLE

Facility

$1,120.47

Hospital Charge Code	992663
Hospital Revenue Code	272
Rate for Payer: Cash Price	$761.92

Extend-Spect.Beta-Lacta.Detct. SO

Facility

$114.00

Service Code	HCPCS 87185
Hospital Charge Code	1630041
Hospital Revenue Code	306
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$82.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.75
Rate for Payer: Amerigroup Medicare	$4.75
Rate for Payer: BCBS of TX Blue Advantage	$34.20
Rate for Payer: BCBS of TX Blue Essentials	$41.04
Rate for Payer: BCBS of TX Medicare	$4.75
Rate for Payer: BCBS of TX PPO	$45.60
Rate for Payer: Cash Price	$77.52
Rate for Payer: Cash Price	$77.52
Rate for Payer: Cigna Medicaid	$82.08
Rate for Payer: Cigna Medicare	$4.75
Rate for Payer: Employer Direct Commercial	$4.75
Rate for Payer: Humana Medicare/TRICARE	$4.75
Rate for Payer: Molina CHIP/Medicaid	$82.08
Rate for Payer: Molina Dual Medicare/Medicaid	$4.75
Rate for Payer: Molina Medicare	$4.75
Rate for Payer: Multiplan Auto	$74.10
Rate for Payer: Multiplan Commercial	$74.10
Rate for Payer: Multiplan Workers Comp	$74.10
Rate for Payer: Parkland Medicaid	$82.08
Rate for Payer: Scott and White EPO/PPO	$5.94
Rate for Payer: Scott and White Medicare	$4.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$82.08
Rate for Payer: Superior Health Plan EPO	$4.75
Rate for Payer: Superior Health Plan Medicare	$4.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.75
Rate for Payer: Universal American Medicare	$4.75
Rate for Payer: Wellcare Medicare	$4.75
Rate for Payer: Wellmed Medicare	$4.75

Extend-Spect.Beta-Lacta.Detct. SO

Facility

$114.00

Service Code	HCPCS 87185
Hospital Charge Code	1630041
Hospital Revenue Code	306
Rate for Payer: Cash Price	$77.52

EXTENSION, IV MRI PUMP SE

Facility

$451.73

Hospital Charge Code	992736
Hospital Revenue Code	270
Rate for Payer: Cash Price	$307.18

EXTENSION, IV MRI PUMP SE

Facility

$451.73

Hospital Charge Code	992736
Hospital Revenue Code	270
Min. Negotiated Rate	$40.66
Max. Negotiated Rate	$325.25
Rate for Payer: Amerigroup CHIP/Medicaid	$40.66
Rate for Payer: BCBS of TX Blue Advantage	$135.52
Rate for Payer: BCBS of TX Blue Essentials	$162.62
Rate for Payer: BCBS of TX PPO	$180.69
Rate for Payer: Cash Price	$307.18
Rate for Payer: Cigna Medicaid	$325.25
Rate for Payer: Molina CHIP/Medicaid	$325.25
Rate for Payer: Multiplan Auto	$293.62
Rate for Payer: Multiplan Commercial	$293.62
Rate for Payer: Multiplan Workers Comp	$293.62
Rate for Payer: Parkland Medicaid	$325.25
Rate for Payer: Scott and White EPO/PPO	$225.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$325.25
Rate for Payer: Superior Health Plan EPO	$61.44

EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$14,564.02

Service Code	APR-DRG 9113
Min. Negotiated Rate	$13,731.47
Max. Negotiated Rate	$14,564.02
Rate for Payer: Amerigroup CHIP/Medicaid	$13,731.47
Rate for Payer: Cigna Medicaid	$13,731.47
Rate for Payer: Molina CHIP/Medicaid	$13,731.47
Rate for Payer: Parkland Medicaid	$13,731.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,564.02

EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$7,818.00

Service Code	APR-DRG 9112
Min. Negotiated Rate	$7,371.08
Max. Negotiated Rate	$7,818.00
Rate for Payer: Amerigroup CHIP/Medicaid	$7,371.08
Rate for Payer: Cigna Medicaid	$7,371.08
Rate for Payer: Molina CHIP/Medicaid	$7,371.08
Rate for Payer: Parkland Medicaid	$7,371.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,818.00

EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$38,899.50

Service Code	APR-DRG 9114
Min. Negotiated Rate	$36,675.81
Max. Negotiated Rate	$38,899.50
Rate for Payer: Amerigroup CHIP/Medicaid	$36,675.81
Rate for Payer: Cigna Medicaid	$36,675.81
Rate for Payer: Molina CHIP/Medicaid	$36,675.81
Rate for Payer: Parkland Medicaid	$36,675.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38,899.50

EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$6,998.74

Service Code	APR-DRG 9111
Min. Negotiated Rate	$6,598.66
Max. Negotiated Rate	$6,998.74
Rate for Payer: Amerigroup CHIP/Medicaid	$6,598.66
Rate for Payer: Cigna Medicaid	$6,598.66
Rate for Payer: Molina CHIP/Medicaid	$6,598.66
Rate for Payer: Parkland Medicaid	$6,598.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,998.74

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT

Facility

$72,517.30

Service Code	MSDRG 933
Min. Negotiated Rate	$24,598.58
Max. Negotiated Rate	$72,517.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$33,300.78
Rate for Payer: Amerigroup Medicare	$33,300.78
Rate for Payer: BCBS of TX Medicare	$33,300.78
Rate for Payer: Cigna Commercial	$49,159.10
Rate for Payer: Cigna Medicare	$33,300.78
Rate for Payer: Employer Direct Commercial	$33,300.78
Rate for Payer: Humana Medicare/TRICARE	$33,300.78
Rate for Payer: Molina Dual Medicare/Medicaid	$33,300.78
Rate for Payer: Molina Medicare	$33,300.78
Rate for Payer: Multiplan Auto	$72,517.30
Rate for Payer: Multiplan Commercial	$72,517.30
Rate for Payer: Multiplan Workers Comp	$72,517.30
Rate for Payer: Scott and White EPO/PPO	$33,396.12
Rate for Payer: Scott and White Medicare	$33,300.78
Rate for Payer: Superior Health Plan EPO	$33,300.78
Rate for Payer: Superior Health Plan Medicare	$33,300.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$33,300.78
Rate for Payer: Universal American Medicare	$33,300.78
Rate for Payer: Wellcare Medicare	$33,300.78
Rate for Payer: Wellmed Medicare	$33,300.78

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT

Facility

$350,173.80

Service Code	MSDRG 927
Min. Negotiated Rate	$158,106.70
Max. Negotiated Rate	$350,173.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$161,238.45
Rate for Payer: Amerigroup Medicare	$161,238.45
Rate for Payer: BCBS of TX Medicare	$161,238.45
Rate for Payer: Cigna Commercial	$237,380.98
Rate for Payer: Cigna Medicare	$161,238.45
Rate for Payer: Employer Direct Commercial	$161,238.45
Rate for Payer: Humana Medicare/TRICARE	$161,238.45
Rate for Payer: Molina Dual Medicare/Medicaid	$161,238.45
Rate for Payer: Molina Medicare	$161,238.45
Rate for Payer: Multiplan Auto	$350,173.80
Rate for Payer: Multiplan Commercial	$350,173.80
Rate for Payer: Multiplan Workers Comp	$350,173.80
Rate for Payer: Scott and White EPO/PPO	$161,264.25
Rate for Payer: Scott and White Medicare	$161,238.45
Rate for Payer: Superior Health Plan EPO	$161,238.45
Rate for Payer: Superior Health Plan Medicare	$161,238.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$161,238.45
Rate for Payer: Universal American Medicare	$161,238.45
Rate for Payer: Wellcare Medicare	$161,238.45
Rate for Payer: Wellmed Medicare	$161,238.45

EXTENSIVE BURNS OR FULL THICKNESS BURNS W MV >96 HRS W/O SKIN GRAFT

Facility

$72,517.30

Service Code	MSDRG 933
Min. Negotiated Rate	$24,598.58
Max. Negotiated Rate	$72,517.30
Rate for Payer: BCBS of TX Blue Advantage	$24,598.58
Rate for Payer: BCBS of TX Blue Essentials	$29,515.44
Rate for Payer: BCBS of TX PPO	$32,796.20

EXTENSIVE BURNS OR FULL THICKNESS BURNS W MV >96 HRS W SKIN GRAFT

Facility

$350,173.80

Service Code	MSDRG 927
Min. Negotiated Rate	$158,106.70
Max. Negotiated Rate	$350,173.80
Rate for Payer: BCBS of TX Blue Advantage	$158,106.70
Rate for Payer: BCBS of TX Blue Essentials	$189,709.66
Rate for Payer: BCBS of TX PPO	$210,796.68

EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$10,574.49

Service Code	APR-DRG 7922
Min. Negotiated Rate	$9,970.00
Max. Negotiated Rate	$10,574.49
Rate for Payer: Amerigroup CHIP/Medicaid	$9,970.00
Rate for Payer: Cigna Medicaid	$9,970.00
Rate for Payer: Molina CHIP/Medicaid	$9,970.00
Rate for Payer: Parkland Medicaid	$9,970.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,574.49

EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$41,797.07

Service Code	APR-DRG 7924
Min. Negotiated Rate	$39,407.74
Max. Negotiated Rate	$41,797.07
Rate for Payer: Amerigroup CHIP/Medicaid	$39,407.74
Rate for Payer: Cigna Medicaid	$39,407.74
Rate for Payer: Molina CHIP/Medicaid	$39,407.74
Rate for Payer: Parkland Medicaid	$39,407.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41,797.07

EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$21,794.36

Service Code	APR-DRG 7923
Min. Negotiated Rate	$20,548.48
Max. Negotiated Rate	$21,794.36
Rate for Payer: Amerigroup CHIP/Medicaid	$20,548.48
Rate for Payer: Cigna Medicaid	$20,548.48
Rate for Payer: Molina CHIP/Medicaid	$20,548.48
Rate for Payer: Parkland Medicaid	$20,548.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,794.36

EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$6,583.83

Service Code	APR-DRG 7921
Min. Negotiated Rate	$6,207.47
Max. Negotiated Rate	$6,583.83
Rate for Payer: Amerigroup CHIP/Medicaid	$6,207.47
Rate for Payer: Cigna Medicaid	$6,207.47
Rate for Payer: Molina CHIP/Medicaid	$6,207.47
Rate for Payer: Parkland Medicaid	$6,207.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,583.83

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC

Facility

$46,711.50

Service Code	MSDRG 982
Min. Negotiated Rate	$21,094.94
Max. Negotiated Rate	$46,711.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,778.50
Rate for Payer: Amerigroup Medicare	$22,778.50
Rate for Payer: BCBS of TX Medicare	$22,778.50
Rate for Payer: Cigna Commercial	$31,665.48
Rate for Payer: Cigna Medicare	$22,778.50
Rate for Payer: Employer Direct Commercial	$22,778.50
Rate for Payer: Humana Medicare/TRICARE	$22,778.50
Rate for Payer: Molina Dual Medicare/Medicaid	$22,778.50
Rate for Payer: Molina Medicare	$22,778.50
Rate for Payer: Multiplan Auto	$46,711.50
Rate for Payer: Multiplan Commercial	$46,711.50
Rate for Payer: Multiplan Workers Comp	$46,711.50
Rate for Payer: Scott and White EPO/PPO	$21,511.88
Rate for Payer: Scott and White Medicare	$22,778.50
Rate for Payer: Superior Health Plan EPO	$22,778.50
Rate for Payer: Superior Health Plan Medicare	$22,778.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,778.50
Rate for Payer: Universal American Medicare	$22,778.50
Rate for Payer: Wellcare Medicare	$22,778.50
Rate for Payer: Wellmed Medicare	$22,778.50

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$89,144.20

Service Code	MSDRG 981
Min. Negotiated Rate	$37,586.30
Max. Negotiated Rate	$89,144.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$39,146.40
Rate for Payer: Amerigroup Medicare	$39,146.40
Rate for Payer: BCBS of TX Medicare	$39,146.40
Rate for Payer: Cigna Commercial	$60,430.38
Rate for Payer: Cigna Medicare	$39,146.40
Rate for Payer: Employer Direct Commercial	$39,146.40
Rate for Payer: Humana Medicare/TRICARE	$39,146.40
Rate for Payer: Molina Dual Medicare/Medicaid	$39,146.40
Rate for Payer: Molina Medicare	$39,146.40
Rate for Payer: Multiplan Auto	$89,144.20
Rate for Payer: Multiplan Commercial	$89,144.20
Rate for Payer: Multiplan Workers Comp	$89,144.20
Rate for Payer: Scott and White EPO/PPO	$41,053.25
Rate for Payer: Scott and White Medicare	$39,146.40
Rate for Payer: Superior Health Plan EPO	$39,146.40
Rate for Payer: Superior Health Plan Medicare	$39,146.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$39,146.40
Rate for Payer: Universal American Medicare	$39,146.40
Rate for Payer: Wellcare Medicare	$39,146.40
Rate for Payer: Wellmed Medicare	$39,146.40

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$32,566.00

Service Code	MSDRG 983
Min. Negotiated Rate	$13,494.26
Max. Negotiated Rate	$32,566.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,322.03
Rate for Payer: Amerigroup Medicare	$17,322.03
Rate for Payer: BCBS of TX Medicare	$17,322.03
Rate for Payer: Cigna Commercial	$22,076.32
Rate for Payer: Cigna Medicare	$17,322.03
Rate for Payer: Employer Direct Commercial	$17,322.03
Rate for Payer: Humana Medicare/TRICARE	$17,322.03
Rate for Payer: Molina Dual Medicare/Medicaid	$17,322.03
Rate for Payer: Molina Medicare	$17,322.03
Rate for Payer: Multiplan Auto	$32,566.00
Rate for Payer: Multiplan Commercial	$32,566.00
Rate for Payer: Multiplan Workers Comp	$32,566.00
Rate for Payer: Scott and White EPO/PPO	$14,997.50
Rate for Payer: Scott and White Medicare	$17,322.03
Rate for Payer: Superior Health Plan EPO	$17,322.03
Rate for Payer: Superior Health Plan Medicare	$17,322.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,322.03
Rate for Payer: Universal American Medicare	$17,322.03
Rate for Payer: Wellcare Medicare	$17,322.03
Rate for Payer: Wellmed Medicare	$17,322.03

EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$9,767.69

Service Code	APR-DRG 9502
Min. Negotiated Rate	$9,209.32
Max. Negotiated Rate	$9,767.69
Rate for Payer: Amerigroup CHIP/Medicaid	$9,209.32
Rate for Payer: Cigna Medicaid	$9,209.32
Rate for Payer: Molina CHIP/Medicaid	$9,209.32
Rate for Payer: Parkland Medicaid	$9,209.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,767.69

EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$6,494.44

Service Code	APR-DRG 9501
Min. Negotiated Rate	$6,123.19
Max. Negotiated Rate	$6,494.44
Rate for Payer: Amerigroup CHIP/Medicaid	$6,123.19
Rate for Payer: Cigna Medicaid	$6,123.19
Rate for Payer: Molina CHIP/Medicaid	$6,123.19
Rate for Payer: Parkland Medicaid	$6,123.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,494.44

EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$44,551.68

Service Code	APR-DRG 9504
Min. Negotiated Rate	$42,004.88
Max. Negotiated Rate	$44,551.68
Rate for Payer: Amerigroup CHIP/Medicaid	$42,004.88
Rate for Payer: Cigna Medicaid	$42,004.88
Rate for Payer: Molina CHIP/Medicaid	$42,004.88
Rate for Payer: Parkland Medicaid	$42,004.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44,551.68

EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$15,792.53

Service Code	APR-DRG 9503
Min. Negotiated Rate	$14,889.75
Max. Negotiated Rate	$15,792.53
Rate for Payer: Amerigroup CHIP/Medicaid	$14,889.75
Rate for Payer: Cigna Medicaid	$14,889.75
Rate for Payer: Molina CHIP/Medicaid	$14,889.75
Rate for Payer: Parkland Medicaid	$14,889.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,792.53

Know your out-of-pocket cost for care.

All Charges