White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Exploration of penetrating wound (separate procedure) extremity

Facility

$3,731.82

Service Code	HCPCS 20103
Hospital Charge Code	9900166
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,537.64

Exploration of penetrating wound (separate procedure) extremity

Facility

$3,731.82

Service Code	HCPCS 20103
Hospital Charge Code	9900166
Hospital Revenue Code	360
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$257.60
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	$1,018.72
Rate for Payer: BCBS of TX Blue Essentials	$1,220.02
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$2,537.64
Rate for Payer: Cash Price	$2,537.64
Rate for Payer: Cash Price	$2,537.64
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$2,686.91
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	$2,686.91
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	$2,686.91
Rate for Payer: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,686.91
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

Exploration of penetrating wound (separate procedure) extremity

Facility

$10,000.00

Service Code	CPT 20103
Hospital Charge Code	36020103
Hospital Revenue Code	360
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$257.60
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	$1,018.72
Rate for Payer: BCBS of TX Blue Essentials	$1,220.02
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$1,537.23
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	$2,743.07
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

Exploration, retroperitoneal area with or without biopsy

Facility

$7,221.44

Service Code	HCPCS 49010
Hospital Charge Code	994110
Hospital Revenue Code	360
Min. Negotiated Rate	$649.93
Max. Negotiated Rate	$13,746.84
Rate for Payer: Amerigroup CHIP/Medicaid	$649.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Amerigroup Medicare	$6,503.32
Rate for Payer: BCBS of TX Blue Advantage	$1,618.98
Rate for Payer: BCBS of TX Blue Essentials	$1,938.90
Rate for Payer: BCBS of TX Medicare	$6,503.32
Rate for Payer: BCBS of TX PPO	$2,443.01
Rate for Payer: Cash Price	$4,910.58
Rate for Payer: Cash Price	$4,910.58
Rate for Payer: Cash Price	$4,910.58
Rate for Payer: Cigna Commercial	$13,746.84
Rate for Payer: Cigna Medicaid	$5,199.44
Rate for Payer: Cigna Medicare	$6,503.32
Rate for Payer: Employer Direct Commercial	$6,503.32
Rate for Payer: Humana Medicare/TRICARE	$6,503.32
Rate for Payer: Molina CHIP/Medicaid	$5,199.44
Rate for Payer: Molina Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Molina Medicare	$6,503.32
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	$5,199.44
Rate for Payer: Scott and White EPO/PPO	$3,610.72
Rate for Payer: Scott and White Medicare	$6,503.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,199.44
Rate for Payer: Superior Health Plan EPO	$6,503.32
Rate for Payer: Superior Health Plan Medicare	$6,503.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Universal American Medicare	$6,503.32
Rate for Payer: Wellcare Medicare	$6,503.32
Rate for Payer: Wellmed Medicare	$6,503.32

Exploration, retroperitoneal area with or without biopsy

Facility

$7,221.44

Service Code	HCPCS 49010
Hospital Charge Code	994110
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,910.58

expressbraid graft manipulator

Facility

$267.41

Hospital Charge Code	8720588
Hospital Revenue Code	272
Rate for Payer: Cash Price	$181.84

expressbraid graft manipulator

Facility

$267.41

Hospital Charge Code	8720588
Hospital Revenue Code	272
Min. Negotiated Rate	$24.07
Max. Negotiated Rate	$192.54
Rate for Payer: Amerigroup CHIP/Medicaid	$24.07
Rate for Payer: BCBS of TX Blue Advantage	$80.22
Rate for Payer: BCBS of TX Blue Essentials	$96.27
Rate for Payer: BCBS of TX PPO	$106.96
Rate for Payer: Cash Price	$181.84
Rate for Payer: Cigna Medicaid	$192.54
Rate for Payer: Molina CHIP/Medicaid	$192.54
Rate for Payer: Multiplan Auto	$173.82
Rate for Payer: Multiplan Commercial	$173.82
Rate for Payer: Multiplan Workers Comp	$173.82
Rate for Payer: Parkland Medicaid	$192.54
Rate for Payer: Scott and White EPO/PPO	$133.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.54
Rate for Payer: Superior Health Plan EPO	$36.37

EXPRESSEW NEEDLE

Facility

$1,120.47

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

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

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
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

EXTENSION, IV MRI PUMP SE

Facility

$451.73

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

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 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

$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

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

Facility

$57,627.00

Service Code	MSDRG 933
Min. Negotiated Rate	$24,598.58
Max. Negotiated Rate	$57,627.00
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	$57,627.00
Rate for Payer: Multiplan Commercial	$57,627.00
Rate for Payer: Multiplan Workers Comp	$57,627.00
Rate for Payer: Scott and White EPO/PPO	$26,538.75
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

$360,661.80

Service Code	MSDRG 927
Min. Negotiated Rate	$158,106.70
Max. Negotiated Rate	$360,661.80
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	$360,661.80
Rate for Payer: Multiplan Commercial	$360,661.80
Rate for Payer: Multiplan Workers Comp	$360,661.80
Rate for Payer: Scott and White EPO/PPO	$166,094.25
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

$57,627.00

Service Code	MSDRG 933
Min. Negotiated Rate	$24,598.58
Max. Negotiated Rate	$57,627.00
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

$360,661.80

Service Code	MSDRG 927
Min. Negotiated Rate	$158,106.70
Max. Negotiated Rate	$360,661.80
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

$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

$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

$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 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

Know your out-of-pocket cost for care.

All Charges