White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$47,655.80

Service Code	MSDRG 982
Min. Negotiated Rate	$21,094.94
Max. Negotiated Rate	$47,655.80
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	$47,655.80
Rate for Payer: Multiplan Commercial	$47,655.80
Rate for Payer: Multiplan Workers Comp	$47,655.80
Rate for Payer: Scott and White EPO/PPO	$21,946.75
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

$87,027.60

Service Code	MSDRG 981
Min. Negotiated Rate	$37,586.30
Max. Negotiated Rate	$87,027.60
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	$87,027.60
Rate for Payer: Multiplan Commercial	$87,027.60
Rate for Payer: Multiplan Workers Comp	$87,027.60
Rate for Payer: Scott and White EPO/PPO	$40,078.50
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

$31,733.80

Service Code	MSDRG 983
Min. Negotiated Rate	$13,494.26
Max. Negotiated Rate	$31,733.80
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	$31,733.80
Rate for Payer: Multiplan Commercial	$31,733.80
Rate for Payer: Multiplan Workers Comp	$31,733.80
Rate for Payer: Scott and White EPO/PPO	$14,614.25
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

$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

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 W CC

Facility

$47,655.80

Service Code	MSDRG 982
Min. Negotiated Rate	$21,094.94
Max. Negotiated Rate	$47,655.80
Rate for Payer: BCBS of TX Blue Advantage	$21,094.94
Rate for Payer: BCBS of TX Blue Essentials	$25,311.48
Rate for Payer: BCBS of TX PPO	$28,124.95

EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC

Facility

$87,027.60

Service Code	MSDRG 981
Min. Negotiated Rate	$37,586.30
Max. Negotiated Rate	$87,027.60
Rate for Payer: BCBS of TX Blue Advantage	$37,586.30
Rate for Payer: BCBS of TX Blue Essentials	$45,099.19
Rate for Payer: BCBS of TX PPO	$50,112.15

EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC

Facility

$31,733.80

Service Code	MSDRG 983
Min. Negotiated Rate	$13,494.26
Max. Negotiated Rate	$31,733.80
Rate for Payer: BCBS of TX Blue Advantage	$13,494.26
Rate for Payer: BCBS of TX Blue Essentials	$16,191.54
Rate for Payer: BCBS of TX PPO	$17,991.30

EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT

Facility

$17,800.68

Service Code	APR-DRG 8434
Min. Negotiated Rate	$16,783.11
Max. Negotiated Rate	$17,800.68
Rate for Payer: Amerigroup CHIP/Medicaid	$16,783.11
Rate for Payer: Cigna Medicaid	$16,783.11
Rate for Payer: Molina CHIP/Medicaid	$16,783.11
Rate for Payer: Parkland Medicaid	$16,783.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,800.68

EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT

Facility

$2,871.54

Service Code	APR-DRG 8431
Min. Negotiated Rate	$2,707.39
Max. Negotiated Rate	$2,871.54
Rate for Payer: Amerigroup CHIP/Medicaid	$2,707.39
Rate for Payer: Cigna Medicaid	$2,707.39
Rate for Payer: Molina CHIP/Medicaid	$2,707.39
Rate for Payer: Parkland Medicaid	$2,707.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,871.54

EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT

Facility

$6,414.48

Service Code	APR-DRG 8433
Min. Negotiated Rate	$6,047.79
Max. Negotiated Rate	$6,414.48
Rate for Payer: Amerigroup CHIP/Medicaid	$6,047.79
Rate for Payer: Cigna Medicaid	$6,047.79
Rate for Payer: Molina CHIP/Medicaid	$6,047.79
Rate for Payer: Parkland Medicaid	$6,047.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,414.48

EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT

Facility

$5,332.32

Service Code	APR-DRG 8432
Min. Negotiated Rate	$5,027.50
Max. Negotiated Rate	$5,332.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5,027.50
Rate for Payer: Cigna Medicaid	$5,027.50
Rate for Payer: Molina CHIP/Medicaid	$5,027.50
Rate for Payer: Parkland Medicaid	$5,027.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,332.32

EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT

Facility

$41,572.64

Service Code	APR-DRG 8413
Min. Negotiated Rate	$39,196.14
Max. Negotiated Rate	$41,572.64
Rate for Payer: Amerigroup CHIP/Medicaid	$39,196.14
Rate for Payer: Cigna Medicaid	$39,196.14
Rate for Payer: Molina CHIP/Medicaid	$39,196.14
Rate for Payer: Parkland Medicaid	$39,196.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41,572.64

EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT

Facility

$27,015.41

Service Code	APR-DRG 8412
Min. Negotiated Rate	$25,471.07
Max. Negotiated Rate	$27,015.41
Rate for Payer: Amerigroup CHIP/Medicaid	$25,471.07
Rate for Payer: Cigna Medicaid	$25,471.07
Rate for Payer: Molina CHIP/Medicaid	$25,471.07
Rate for Payer: Parkland Medicaid	$25,471.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,015.41

EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT

Facility

$26,805.31

Service Code	APR-DRG 8411
Min. Negotiated Rate	$25,272.99
Max. Negotiated Rate	$26,805.31
Rate for Payer: Amerigroup CHIP/Medicaid	$25,272.99
Rate for Payer: Cigna Medicaid	$25,272.99
Rate for Payer: Molina CHIP/Medicaid	$25,272.99
Rate for Payer: Parkland Medicaid	$25,272.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26,805.31

EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT

Facility

$96,188.85

Service Code	APR-DRG 8414
Min. Negotiated Rate	$90,690.22
Max. Negotiated Rate	$96,188.85
Rate for Payer: Amerigroup CHIP/Medicaid	$90,690.22
Rate for Payer: Cigna Medicaid	$90,690.22
Rate for Payer: Molina CHIP/Medicaid	$90,690.22
Rate for Payer: Parkland Medicaid	$90,690.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96,188.85

External Cephalic Version

Facility

$3,271.00

Service Code	HCPCS 59412
Hospital Charge Code	300491
Hospital Revenue Code	361
Min. Negotiated Rate	$294.39
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$294.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,251.88
Rate for Payer: Amerigroup Medicare	$3,251.88
Rate for Payer: BCBS of TX Blue Advantage	$4,171.83
Rate for Payer: BCBS of TX Blue Essentials	$4,996.20
Rate for Payer: BCBS of TX Medicare	$3,251.88
Rate for Payer: BCBS of TX PPO	$6,295.21
Rate for Payer: Cash Price	$2,224.28
Rate for Payer: Cash Price	$2,224.28
Rate for Payer: Cash Price	$2,224.28
Rate for Payer: Cigna Commercial	$6,873.88
Rate for Payer: Cigna Medicaid	$2,355.12
Rate for Payer: Cigna Medicare	$3,251.88
Rate for Payer: Employer Direct Commercial	$3,251.88
Rate for Payer: Humana Medicare/TRICARE	$3,251.88
Rate for Payer: Molina CHIP/Medicaid	$2,355.12
Rate for Payer: Molina Dual Medicare/Medicaid	$3,251.88
Rate for Payer: Molina Medicare	$3,251.88
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	$2,355.12
Rate for Payer: Scott and White EPO/PPO	$5,289.52
Rate for Payer: Scott and White Medicare	$3,251.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,355.12
Rate for Payer: Superior Health Plan EPO	$3,251.88
Rate for Payer: Superior Health Plan Medicare	$3,251.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,251.88
Rate for Payer: Universal American Medicare	$3,251.88
Rate for Payer: Wellcare Medicare	$3,251.88
Rate for Payer: Wellmed Medicare	$3,251.88

External Cephalic Version

Facility

$3,271.00

Service Code	HCPCS 59412
Hospital Charge Code	300491
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,224.28

EXTERNAL HEART ASSIST SYSTEMS

Facility

$30,387.10

Service Code	APR-DRG 1782
Min. Negotiated Rate	$28,650.02
Max. Negotiated Rate	$30,387.10
Rate for Payer: Amerigroup CHIP/Medicaid	$28,650.02
Rate for Payer: Cigna Medicaid	$28,650.02
Rate for Payer: Molina CHIP/Medicaid	$28,650.02
Rate for Payer: Parkland Medicaid	$28,650.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30,387.10

EXTERNAL HEART ASSIST SYSTEMS

Facility

$27,855.41

Service Code	APR-DRG 1781
Min. Negotiated Rate	$26,263.05
Max. Negotiated Rate	$27,855.41
Rate for Payer: Amerigroup CHIP/Medicaid	$26,263.05
Rate for Payer: Cigna Medicaid	$26,263.05
Rate for Payer: Molina CHIP/Medicaid	$26,263.05
Rate for Payer: Parkland Medicaid	$26,263.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,855.41

EXTERNAL HEART ASSIST SYSTEMS

Facility

$35,405.22

Service Code	APR-DRG 1783
Min. Negotiated Rate	$33,381.28
Max. Negotiated Rate	$35,405.22
Rate for Payer: Amerigroup CHIP/Medicaid	$33,381.28
Rate for Payer: Cigna Medicaid	$33,381.28
Rate for Payer: Molina CHIP/Medicaid	$33,381.28
Rate for Payer: Parkland Medicaid	$33,381.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35,405.22

EXTERNAL HEART ASSIST SYSTEMS

Facility

$55,325.33

Service Code	APR-DRG 1784
Min. Negotiated Rate	$52,162.66
Max. Negotiated Rate	$55,325.33
Rate for Payer: Amerigroup CHIP/Medicaid	$52,162.66
Rate for Payer: Cigna Medicaid	$52,162.66
Rate for Payer: Molina CHIP/Medicaid	$52,162.66
Rate for Payer: Parkland Medicaid	$52,162.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$55,325.33

Extracapsular cataract removal

Facility

$10,000.00

Service Code	CPT 66984
Hospital Charge Code	36066984
Hospital Revenue Code	360
Min. Negotiated Rate	$849.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$849.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Amerigroup Medicare	$2,318.34
Rate for Payer: BCBS of TX Blue Advantage	$3,376.51
Rate for Payer: BCBS of TX Blue Essentials	$4,043.72
Rate for Payer: BCBS of TX Medicare	$2,318.34
Rate for Payer: BCBS of TX PPO	$5,095.09
Rate for Payer: Cigna Commercial	$4,900.56
Rate for Payer: Cigna Medicare	$2,318.34
Rate for Payer: Employer Direct Commercial	$2,318.34
Rate for Payer: Humana Medicare/TRICARE	$2,318.34
Rate for Payer: Molina Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Molina Medicare	$2,318.34
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	$3,942.78
Rate for Payer: Scott and White Medicare	$2,318.34
Rate for Payer: Superior Health Plan EPO	$2,318.34
Rate for Payer: Superior Health Plan Medicare	$2,318.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,318.34
Rate for Payer: Universal American Medicare	$2,318.34
Rate for Payer: Wellcare Medicare	$2,318.34
Rate for Payer: Wellmed Medicare	$2,318.34

Know your out-of-pocket cost for care.

All Charges