White Rock Medical Center

All Charges

Charge

Type

Setting

Price

FRACTURES OF HIP & PELVIS W MCC

Facility

$24,358.00

Service Code	MSDRG 535
Min. Negotiated Rate	$10,791.28
Max. Negotiated Rate	$24,358.00
Rate for Payer: BCBS of TX Blue Advantage	$10,791.28
Rate for Payer: BCBS of TX Blue Essentials	$12,948.28
Rate for Payer: BCBS of TX PPO	$14,387.54

FRACTURES OF HIP & PELVIS W/O MCC

Facility

$15,344.40

Service Code	MSDRG 536
Min. Negotiated Rate	$6,510.20
Max. Negotiated Rate	$15,344.40
Rate for Payer: BCBS of TX Blue Advantage	$6,510.20
Rate for Payer: BCBS of TX Blue Essentials	$7,811.48
Rate for Payer: BCBS of TX PPO	$8,679.76

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC

Facility

$27,071.20

Service Code	MSDRG 562
Min. Negotiated Rate	$12,109.66
Max. Negotiated Rate	$27,071.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,202.49
Rate for Payer: Amerigroup Medicare	$15,202.49
Rate for Payer: BCBS of TX Medicare	$15,202.49
Rate for Payer: Cigna Commercial	$18,351.42
Rate for Payer: Cigna Medicare	$15,202.49
Rate for Payer: Employer Direct Commercial	$15,202.49
Rate for Payer: Humana Medicare/TRICARE	$15,202.49
Rate for Payer: Molina Dual Medicare/Medicaid	$15,202.49
Rate for Payer: Molina Medicare	$15,202.49
Rate for Payer: Multiplan Auto	$27,071.20
Rate for Payer: Multiplan Commercial	$27,071.20
Rate for Payer: Multiplan Workers Comp	$27,071.20
Rate for Payer: Scott and White EPO/PPO	$12,467.00
Rate for Payer: Scott and White Medicare	$15,202.49
Rate for Payer: Superior Health Plan EPO	$15,202.49
Rate for Payer: Superior Health Plan Medicare	$15,202.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,202.49
Rate for Payer: Universal American Medicare	$15,202.49
Rate for Payer: Wellcare Medicare	$15,202.49
Rate for Payer: Wellmed Medicare	$15,202.49

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC

Facility

$17,014.50

Service Code	MSDRG 563
Min. Negotiated Rate	$7,207.66
Max. Negotiated Rate	$17,014.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,323.22
Rate for Payer: Amerigroup Medicare	$11,323.22
Rate for Payer: BCBS of TX Medicare	$11,323.22
Rate for Payer: Cigna Commercial	$11,534.04
Rate for Payer: Cigna Medicare	$11,323.22
Rate for Payer: Employer Direct Commercial	$11,323.22
Rate for Payer: Humana Medicare/TRICARE	$11,323.22
Rate for Payer: Molina Dual Medicare/Medicaid	$11,323.22
Rate for Payer: Molina Medicare	$11,323.22
Rate for Payer: Multiplan Auto	$17,014.50
Rate for Payer: Multiplan Commercial	$17,014.50
Rate for Payer: Multiplan Workers Comp	$17,014.50
Rate for Payer: Scott and White EPO/PPO	$7,835.62
Rate for Payer: Scott and White Medicare	$11,323.22
Rate for Payer: Superior Health Plan EPO	$11,323.22
Rate for Payer: Superior Health Plan Medicare	$11,323.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,323.22
Rate for Payer: Universal American Medicare	$11,323.22
Rate for Payer: Wellcare Medicare	$11,323.22
Rate for Payer: Wellmed Medicare	$11,323.22

frcp bx needle 160cm

Facility

$133.48

Hospital Charge Code	8638506
Hospital Revenue Code	272
Rate for Payer: Cash Price	$90.77

frcp bx needle 160cm

Facility

$133.48

Hospital Charge Code	8638506
Hospital Revenue Code	272
Min. Negotiated Rate	$12.01
Max. Negotiated Rate	$96.11
Rate for Payer: Amerigroup CHIP/Medicaid	$12.01
Rate for Payer: BCBS of TX Blue Advantage	$40.04
Rate for Payer: BCBS of TX Blue Essentials	$48.05
Rate for Payer: BCBS of TX PPO	$53.39
Rate for Payer: Cash Price	$90.77
Rate for Payer: Cigna Medicaid	$96.11
Rate for Payer: Molina CHIP/Medicaid	$96.11
Rate for Payer: Multiplan Auto	$86.76
Rate for Payer: Multiplan Commercial	$86.76
Rate for Payer: Multiplan Workers Comp	$86.76
Rate for Payer: Parkland Medicaid	$96.11
Rate for Payer: Scott and White EPO/PPO	$66.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96.11
Rate for Payer: Superior Health Plan EPO	$18.15

FRCP DISP 1 -- DHF

Facility

$152.07

Hospital Charge Code	80811516
Hospital Revenue Code	272
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$109.49
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: BCBS of TX Blue Advantage	$45.62
Rate for Payer: BCBS of TX Blue Essentials	$54.75
Rate for Payer: BCBS of TX PPO	$60.83
Rate for Payer: Cash Price	$103.41
Rate for Payer: Cigna Medicaid	$109.49
Rate for Payer: Molina CHIP/Medicaid	$109.49
Rate for Payer: Multiplan Auto	$98.85
Rate for Payer: Multiplan Commercial	$98.85
Rate for Payer: Multiplan Workers Comp	$98.85
Rate for Payer: Parkland Medicaid	$109.49
Rate for Payer: Scott and White EPO/PPO	$76.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.49
Rate for Payer: Superior Health Plan EPO	$20.68

FRCP DISP 1 -- DHF

Facility

$152.07

Hospital Charge Code	80811516
Hospital Revenue Code	272
Rate for Payer: Cash Price	$103.41

FRCP DISP 3 -- DHF

Facility

$61.29

Hospital Charge Code	80811532
Hospital Revenue Code	272
Min. Negotiated Rate	$5.52
Max. Negotiated Rate	$44.13
Rate for Payer: Amerigroup CHIP/Medicaid	$5.52
Rate for Payer: BCBS of TX Blue Advantage	$18.39
Rate for Payer: BCBS of TX Blue Essentials	$22.06
Rate for Payer: BCBS of TX PPO	$24.52
Rate for Payer: Cash Price	$41.68
Rate for Payer: Cigna Medicaid	$44.13
Rate for Payer: Molina CHIP/Medicaid	$44.13
Rate for Payer: Multiplan Auto	$39.84
Rate for Payer: Multiplan Commercial	$39.84
Rate for Payer: Multiplan Workers Comp	$39.84
Rate for Payer: Parkland Medicaid	$44.13
Rate for Payer: Scott and White EPO/PPO	$30.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44.13
Rate for Payer: Superior Health Plan EPO	$8.34

FRCP DISP 3 -- DHF

Facility

$61.29

Hospital Charge Code	80811532
Hospital Revenue Code	272
Rate for Payer: Cash Price	$41.68

FRCP GRSPNG -- DHF

Facility

$2,203.45

Hospital Charge Code	80811607
Hospital Revenue Code	272
Min. Negotiated Rate	$198.31
Max. Negotiated Rate	$1,586.48
Rate for Payer: Amerigroup CHIP/Medicaid	$198.31
Rate for Payer: BCBS of TX Blue Advantage	$661.03
Rate for Payer: BCBS of TX Blue Essentials	$793.24
Rate for Payer: BCBS of TX PPO	$881.38
Rate for Payer: Cash Price	$1,498.35
Rate for Payer: Cigna Medicaid	$1,586.48
Rate for Payer: Molina CHIP/Medicaid	$1,586.48
Rate for Payer: Multiplan Auto	$1,432.24
Rate for Payer: Multiplan Commercial	$1,432.24
Rate for Payer: Multiplan Workers Comp	$1,432.24
Rate for Payer: Parkland Medicaid	$1,586.48
Rate for Payer: Scott and White EPO/PPO	$1,101.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,586.48
Rate for Payer: Superior Health Plan EPO	$299.67

FRCP GRSPNG -- DHF

Facility

$2,203.45

Hospital Charge Code	80811607
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,498.35

Free K+L Lt Chains,Qn,U SO

Facility

$168.00

Service Code	HCPCS 83521
Hospital Charge Code	8604525
Hospital Revenue Code	301
Min. Negotiated Rate	$6.74
Max. Negotiated Rate	$120.96
Rate for Payer: Amerigroup CHIP/Medicaid	$6.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.27
Rate for Payer: Amerigroup Medicare	$17.27
Rate for Payer: BCBS of TX Blue Advantage	$50.40
Rate for Payer: BCBS of TX Blue Essentials	$60.48
Rate for Payer: BCBS of TX Medicare	$17.27
Rate for Payer: BCBS of TX PPO	$67.20
Rate for Payer: Cash Price	$114.24
Rate for Payer: Cash Price	$114.24
Rate for Payer: Cigna Medicaid	$120.96
Rate for Payer: Cigna Medicare	$17.27
Rate for Payer: Employer Direct Commercial	$17.27
Rate for Payer: Humana Medicare/TRICARE	$17.27
Rate for Payer: Molina CHIP/Medicaid	$120.96
Rate for Payer: Molina Dual Medicare/Medicaid	$17.27
Rate for Payer: Molina Medicare	$17.27
Rate for Payer: Multiplan Auto	$109.20
Rate for Payer: Multiplan Commercial	$109.20
Rate for Payer: Multiplan Workers Comp	$109.20
Rate for Payer: Parkland Medicaid	$120.96
Rate for Payer: Scott and White EPO/PPO	$21.59
Rate for Payer: Scott and White Medicare	$17.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.96
Rate for Payer: Superior Health Plan EPO	$17.27
Rate for Payer: Superior Health Plan Medicare	$17.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.27
Rate for Payer: Universal American Medicare	$17.27
Rate for Payer: Wellcare Medicare	$17.27
Rate for Payer: Wellmed Medicare	$17.27

Free K+L Lt Chains,Qn,U SO

Facility

$168.00

Service Code	HCPCS 83521
Hospital Charge Code	8604525
Hospital Revenue Code	301
Rate for Payer: Cash Price	$114.24

Free T4 Level

Facility

$316.00

Service Code	HCPCS 84439
Hospital Charge Code	1602317
Hospital Revenue Code	301
Min. Negotiated Rate	$3.52
Max. Negotiated Rate	$227.52
Rate for Payer: Amerigroup CHIP/Medicaid	$3.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.02
Rate for Payer: Amerigroup Medicare	$9.02
Rate for Payer: BCBS of TX Blue Advantage	$94.80
Rate for Payer: BCBS of TX Blue Essentials	$113.76
Rate for Payer: BCBS of TX Medicare	$9.02
Rate for Payer: BCBS of TX PPO	$126.40
Rate for Payer: Cash Price	$214.88
Rate for Payer: Cash Price	$214.88
Rate for Payer: Cigna Medicaid	$227.52
Rate for Payer: Cigna Medicare	$9.02
Rate for Payer: Employer Direct Commercial	$9.02
Rate for Payer: Humana Medicare/TRICARE	$9.02
Rate for Payer: Molina CHIP/Medicaid	$227.52
Rate for Payer: Molina Dual Medicare/Medicaid	$9.02
Rate for Payer: Molina Medicare	$9.02
Rate for Payer: Multiplan Auto	$205.40
Rate for Payer: Multiplan Commercial	$205.40
Rate for Payer: Multiplan Workers Comp	$205.40
Rate for Payer: Parkland Medicaid	$227.52
Rate for Payer: Scott and White EPO/PPO	$11.28
Rate for Payer: Scott and White Medicare	$9.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$227.52
Rate for Payer: Superior Health Plan EPO	$9.02
Rate for Payer: Superior Health Plan Medicare	$9.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.02
Rate for Payer: Universal American Medicare	$9.02
Rate for Payer: Wellcare Medicare	$9.02
Rate for Payer: Wellmed Medicare	$9.02

Free T4 Level

Facility

$316.00

Service Code	HCPCS 84439
Hospital Charge Code	1602317
Hospital Revenue Code	301
Rate for Payer: Cash Price	$214.88

Fructosamine SO

Facility

$76.00

Service Code	HCPCS 82985 QW
Hospital Charge Code	1706522
Hospital Revenue Code	301
Rate for Payer: Cash Price	$51.68

Fructosamine SO

Facility

$76.00

Service Code	HCPCS 82985 QW
Hospital Charge Code	1706522
Hospital Revenue Code	301
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$54.72
Rate for Payer: Amerigroup CHIP/Medicaid	$6.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.76
Rate for Payer: Amerigroup Medicare	$16.76
Rate for Payer: BCBS of TX Blue Advantage	$22.80
Rate for Payer: BCBS of TX Blue Essentials	$27.36
Rate for Payer: BCBS of TX Medicare	$16.76
Rate for Payer: BCBS of TX PPO	$30.40
Rate for Payer: Cash Price	$51.68
Rate for Payer: Cash Price	$51.68
Rate for Payer: Cigna Medicaid	$54.72
Rate for Payer: Cigna Medicare	$16.76
Rate for Payer: Employer Direct Commercial	$16.76
Rate for Payer: Humana Medicare/TRICARE	$16.76
Rate for Payer: Molina CHIP/Medicaid	$54.72
Rate for Payer: Molina Dual Medicare/Medicaid	$16.76
Rate for Payer: Molina Medicare	$16.76
Rate for Payer: Multiplan Auto	$49.40
Rate for Payer: Multiplan Commercial	$49.40
Rate for Payer: Multiplan Workers Comp	$49.40
Rate for Payer: Parkland Medicaid	$54.72
Rate for Payer: Scott and White EPO/PPO	$20.95
Rate for Payer: Scott and White Medicare	$16.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$54.72
Rate for Payer: Superior Health Plan EPO	$16.76
Rate for Payer: Superior Health Plan Medicare	$16.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.76
Rate for Payer: Universal American Medicare	$16.76
Rate for Payer: Wellcare Medicare	$16.76
Rate for Payer: Wellmed Medicare	$16.76

FSH, Serum SO

Facility

$421.00

Service Code	HCPCS 83001 QW
Hospital Charge Code	1601871
Hospital Revenue Code	301
Min. Negotiated Rate	$7.25
Max. Negotiated Rate	$303.12
Rate for Payer: Amerigroup CHIP/Medicaid	$7.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.58
Rate for Payer: Amerigroup Medicare	$18.58
Rate for Payer: BCBS of TX Blue Advantage	$126.30
Rate for Payer: BCBS of TX Blue Essentials	$151.56
Rate for Payer: BCBS of TX Medicare	$18.58
Rate for Payer: BCBS of TX PPO	$168.40
Rate for Payer: Cash Price	$286.28
Rate for Payer: Cash Price	$286.28
Rate for Payer: Cigna Medicaid	$303.12
Rate for Payer: Cigna Medicare	$18.58
Rate for Payer: Employer Direct Commercial	$18.58
Rate for Payer: Humana Medicare/TRICARE	$18.58
Rate for Payer: Molina CHIP/Medicaid	$303.12
Rate for Payer: Molina Dual Medicare/Medicaid	$18.58
Rate for Payer: Molina Medicare	$18.58
Rate for Payer: Multiplan Auto	$273.65
Rate for Payer: Multiplan Commercial	$273.65
Rate for Payer: Multiplan Workers Comp	$273.65
Rate for Payer: Parkland Medicaid	$303.12
Rate for Payer: Scott and White EPO/PPO	$23.23
Rate for Payer: Scott and White Medicare	$18.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$303.12
Rate for Payer: Superior Health Plan EPO	$18.58
Rate for Payer: Superior Health Plan Medicare	$18.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.58
Rate for Payer: Universal American Medicare	$18.58
Rate for Payer: Wellcare Medicare	$18.58
Rate for Payer: Wellmed Medicare	$18.58

FSH, Serum SO

Facility

$421.00

Service Code	HCPCS 83001 QW
Hospital Charge Code	1601871
Hospital Revenue Code	301
Rate for Payer: Cash Price	$286.28

FULL RING DIA 155 mm - ALUMINIUM

Facility

$9,143.56

Service Code	HCPCS C1713
Hospital Charge Code	993427
Hospital Revenue Code	278
Min. Negotiated Rate	$822.92
Max. Negotiated Rate	$6,583.36
Rate for Payer: Amerigroup CHIP/Medicaid	$822.92
Rate for Payer: BCBS of TX Blue Advantage	$2,743.07
Rate for Payer: BCBS of TX Blue Essentials	$3,291.68
Rate for Payer: BCBS of TX PPO	$3,657.42
Rate for Payer: Cash Price	$6,217.62
Rate for Payer: Cigna Medicaid	$6,583.36
Rate for Payer: Molina CHIP/Medicaid	$6,583.36
Rate for Payer: Multiplan Auto	$4,571.78
Rate for Payer: Multiplan Commercial	$4,571.78
Rate for Payer: Multiplan Workers Comp	$4,571.78
Rate for Payer: Parkland Medicaid	$6,583.36
Rate for Payer: Scott and White EPO/PPO	$4,571.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,583.36
Rate for Payer: Superior Health Plan EPO	$1,243.52

FULL RING DIA 155 mm - ALUMINIUM

Facility

$9,143.56

Service Code	HCPCS C1713
Hospital Charge Code	993427
Hospital Revenue Code	278
Min. Negotiated Rate	$2,285.89
Max. Negotiated Rate	$4,571.78
Rate for Payer: Cash Price	$6,217.62
Rate for Payer: Cigna Commercial	$2,285.89
Rate for Payer: Multiplan Auto	$4,571.78
Rate for Payer: Multiplan Commercial	$4,571.78
Rate for Payer: Multiplan Workers Comp	$4,571.78
Rate for Payer: Scott and White EPO/PPO	$4,571.78

FULL TERM NEONATE WITH MAJOR PROBLEMS

Facility

$79,222.40

Service Code	MSDRG 793
Min. Negotiated Rate	$33,100.54
Max. Negotiated Rate	$79,222.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35,319.19
Rate for Payer: Amerigroup Medicare	$35,319.19
Rate for Payer: BCBS of TX Medicare	$35,319.19
Rate for Payer: Cigna Commercial	$53,704.45
Rate for Payer: Cigna Medicare	$35,319.19
Rate for Payer: Employer Direct Commercial	$35,319.19
Rate for Payer: Humana Medicare/TRICARE	$35,319.19
Rate for Payer: Molina Dual Medicare/Medicaid	$35,319.19
Rate for Payer: Molina Medicare	$35,319.19
Rate for Payer: Multiplan Auto	$79,222.40
Rate for Payer: Multiplan Commercial	$79,222.40
Rate for Payer: Multiplan Workers Comp	$79,222.40
Rate for Payer: Scott and White EPO/PPO	$36,484.00
Rate for Payer: Scott and White Medicare	$35,319.19
Rate for Payer: Superior Health Plan EPO	$35,319.19
Rate for Payer: Superior Health Plan Medicare	$35,319.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$35,319.19
Rate for Payer: Universal American Medicare	$35,319.19
Rate for Payer: Wellcare Medicare	$35,319.19
Rate for Payer: Wellmed Medicare	$35,319.19

FULL TERM NEONATE W MAJOR PROBLEMS

Facility

$79,222.40

Service Code	MSDRG 793
Min. Negotiated Rate	$33,100.54
Max. Negotiated Rate	$79,222.40
Rate for Payer: BCBS of TX Blue Advantage	$33,100.54
Rate for Payer: BCBS of TX Blue Essentials	$39,716.80
Rate for Payer: BCBS of TX PPO	$44,131.49

FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY

Facility

$42,001.40

Service Code	MSDRG 934
Min. Negotiated Rate	$15,768.10
Max. Negotiated Rate	$42,001.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,961.62
Rate for Payer: Amerigroup Medicare	$20,961.62
Rate for Payer: BCBS of TX Medicare	$20,961.62
Rate for Payer: Cigna Commercial	$28,472.53
Rate for Payer: Cigna Medicare	$20,961.62
Rate for Payer: Employer Direct Commercial	$20,961.62
Rate for Payer: Humana Medicare/TRICARE	$20,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$20,961.62
Rate for Payer: Molina Medicare	$20,961.62
Rate for Payer: Multiplan Auto	$42,001.40
Rate for Payer: Multiplan Commercial	$42,001.40
Rate for Payer: Multiplan Workers Comp	$42,001.40
Rate for Payer: Scott and White EPO/PPO	$19,342.75
Rate for Payer: Scott and White Medicare	$20,961.62
Rate for Payer: Superior Health Plan EPO	$20,961.62
Rate for Payer: Superior Health Plan Medicare	$20,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,961.62
Rate for Payer: Universal American Medicare	$20,961.62
Rate for Payer: Wellcare Medicare	$20,961.62
Rate for Payer: Wellmed Medicare	$20,961.62

Know your out-of-pocket cost for care.

All Charges