White Rock Medical Center

All Charges

Charge

Type

Setting

Price

HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC

Facility

$40,236.30

Service Code	MSDRG 522
Min. Negotiated Rate	$18,529.88
Max. Negotiated Rate	$40,236.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,280.76
Rate for Payer: Amerigroup Medicare	$20,280.76
Rate for Payer: BCBS of TX Medicare	$20,280.76
Rate for Payer: Cigna Commercial	$27,275.98
Rate for Payer: Cigna Medicare	$20,280.76
Rate for Payer: Employer Direct Commercial	$20,280.76
Rate for Payer: Humana Medicare/TRICARE	$20,280.76
Rate for Payer: Molina Dual Medicare/Medicaid	$20,280.76
Rate for Payer: Molina Medicare	$20,280.76
Rate for Payer: Multiplan Auto	$40,236.30
Rate for Payer: Multiplan Commercial	$40,236.30
Rate for Payer: Multiplan Workers Comp	$40,236.30
Rate for Payer: Scott and White EPO/PPO	$18,529.88
Rate for Payer: Scott and White Medicare	$20,280.76
Rate for Payer: Superior Health Plan EPO	$20,280.76
Rate for Payer: Superior Health Plan Medicare	$20,280.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,280.76
Rate for Payer: Universal American Medicare	$20,280.76
Rate for Payer: Wellcare Medicare	$20,280.76
Rate for Payer: Wellmed Medicare	$20,280.76

HIS BUNDLE RECORDING

Facility

$6,825.00

Service Code	HCPCS 93600
Hospital Charge Code	4613600
Hospital Revenue Code	480
Rate for Payer: Cash Price	$4,641.00

HIS BUNDLE RECORDING

Facility

$6,825.00

Service Code	HCPCS 93600
Hospital Charge Code	4613600
Hospital Revenue Code	480
Min. Negotiated Rate	$614.25
Max. Negotiated Rate	$16,562.21
Rate for Payer: Amerigroup CHIP/Medicaid	$614.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Amerigroup Medicare	$7,835.21
Rate for Payer: BCBS of TX Blue Advantage	$9,829.14
Rate for Payer: BCBS of TX Blue Essentials	$11,771.42
Rate for Payer: BCBS of TX Medicare	$7,835.21
Rate for Payer: BCBS of TX PPO	$14,831.99
Rate for Payer: Cash Price	$4,641.00
Rate for Payer: Cash Price	$4,641.00
Rate for Payer: Cash Price	$4,641.00
Rate for Payer: Cigna Commercial	$16,562.21
Rate for Payer: Cigna Medicaid	$4,914.00
Rate for Payer: Cigna Medicare	$7,835.21
Rate for Payer: Employer Direct Commercial	$7,835.21
Rate for Payer: Humana Medicare/TRICARE	$7,835.21
Rate for Payer: Molina CHIP/Medicaid	$4,914.00
Rate for Payer: Molina Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Molina Medicare	$7,835.21
Rate for Payer: Multiplan Auto	$4,436.25
Rate for Payer: Multiplan Commercial	$4,436.25
Rate for Payer: Multiplan Workers Comp	$4,436.25
Rate for Payer: Parkland Medicaid	$4,914.00
Rate for Payer: Scott and White EPO/PPO	$3,412.50
Rate for Payer: Scott and White Medicare	$7,835.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,914.00
Rate for Payer: Superior Health Plan EPO	$7,835.21
Rate for Payer: Superior Health Plan Medicare	$7,835.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Universal American Medicare	$7,835.21
Rate for Payer: Wellcare Medicare	$7,835.21
Rate for Payer: Wellmed Medicare	$7,835.21

HIV 1/2 Abs

Facility

$234.00

Service Code	HCPCS 86703
Hospital Charge Code	1602879
Hospital Revenue Code	302
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$168.48
Rate for Payer: Amerigroup CHIP/Medicaid	$5.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.71
Rate for Payer: Amerigroup Medicare	$13.71
Rate for Payer: BCBS of TX Blue Advantage	$70.20
Rate for Payer: BCBS of TX Blue Essentials	$84.24
Rate for Payer: BCBS of TX Medicare	$13.71
Rate for Payer: BCBS of TX PPO	$93.60
Rate for Payer: Cash Price	$159.12
Rate for Payer: Cash Price	$159.12
Rate for Payer: Cigna Medicaid	$168.48
Rate for Payer: Cigna Medicare	$13.71
Rate for Payer: Employer Direct Commercial	$13.71
Rate for Payer: Humana Medicare/TRICARE	$13.71
Rate for Payer: Molina CHIP/Medicaid	$168.48
Rate for Payer: Molina Dual Medicare/Medicaid	$13.71
Rate for Payer: Molina Medicare	$13.71
Rate for Payer: Multiplan Auto	$152.10
Rate for Payer: Multiplan Commercial	$152.10
Rate for Payer: Multiplan Workers Comp	$152.10
Rate for Payer: Parkland Medicaid	$168.48
Rate for Payer: Scott and White EPO/PPO	$17.14
Rate for Payer: Scott and White Medicare	$13.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$168.48
Rate for Payer: Superior Health Plan EPO	$13.71
Rate for Payer: Superior Health Plan Medicare	$13.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.71
Rate for Payer: Universal American Medicare	$13.71
Rate for Payer: Wellcare Medicare	$13.71
Rate for Payer: Wellmed Medicare	$13.71

HIV 1/2 Abs

Facility

$234.00

Service Code	HCPCS 86703
Hospital Charge Code	1602879
Hospital Revenue Code	302
Rate for Payer: Cash Price	$159.12

HIV-1/HIV-2 Qualitative RNA SO

Facility

$414.00

Service Code	HCPCS 87535
Hospital Charge Code	8738617
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$298.08
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$124.20
Rate for Payer: BCBS of TX Blue Essentials	$149.04
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$165.60
Rate for Payer: Cash Price	$281.52
Rate for Payer: Cash Price	$281.52
Rate for Payer: Cigna Medicaid	$298.08
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$298.08
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$269.10
Rate for Payer: Multiplan Commercial	$269.10
Rate for Payer: Multiplan Workers Comp	$269.10
Rate for Payer: Parkland Medicaid	$298.08
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$298.08
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

HIV-1/HIV-2 Qualitative RNA SO

Facility

$414.00

Service Code	HCPCS 87535
Hospital Charge Code	8738617
Hospital Revenue Code	306
Rate for Payer: Cash Price	$281.52

HIV-1/O/2, 4th Generation SO

Facility

$190.00

Service Code	HCPCS 87389 QW
Hospital Charge Code	1640071
Hospital Revenue Code	302
Rate for Payer: Cash Price	$129.20

HIV-1/O/2, 4th Generation SO

Facility

$190.00

Service Code	HCPCS 87389 QW
Hospital Charge Code	1640071
Hospital Revenue Code	302
Min. Negotiated Rate	$9.39
Max. Negotiated Rate	$136.80
Rate for Payer: Amerigroup CHIP/Medicaid	$9.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24.08
Rate for Payer: Amerigroup Medicare	$24.08
Rate for Payer: BCBS of TX Blue Advantage	$57.00
Rate for Payer: BCBS of TX Blue Essentials	$68.40
Rate for Payer: BCBS of TX Medicare	$24.08
Rate for Payer: BCBS of TX PPO	$76.00
Rate for Payer: Cash Price	$129.20
Rate for Payer: Cash Price	$129.20
Rate for Payer: Cigna Medicaid	$136.80
Rate for Payer: Cigna Medicare	$24.08
Rate for Payer: Employer Direct Commercial	$24.08
Rate for Payer: Humana Medicare/TRICARE	$24.08
Rate for Payer: Molina CHIP/Medicaid	$136.80
Rate for Payer: Molina Dual Medicare/Medicaid	$24.08
Rate for Payer: Molina Medicare	$24.08
Rate for Payer: Multiplan Auto	$123.50
Rate for Payer: Multiplan Commercial	$123.50
Rate for Payer: Multiplan Workers Comp	$123.50
Rate for Payer: Parkland Medicaid	$136.80
Rate for Payer: Scott and White EPO/PPO	$30.10
Rate for Payer: Scott and White Medicare	$24.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$136.80
Rate for Payer: Superior Health Plan EPO	$24.08
Rate for Payer: Superior Health Plan Medicare	$24.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$24.08
Rate for Payer: Universal American Medicare	$24.08
Rate for Payer: Wellcare Medicare	$24.08
Rate for Payer: Wellmed Medicare	$24.08

HIV W EXTENSIVE O.R. PROCEDURE W MCC

Facility

$116,304.70

Service Code	MSDRG 969
Min. Negotiated Rate	$48,148.82
Max. Negotiated Rate	$116,304.70
Rate for Payer: BCBS of TX Blue Advantage	$48,148.82
Rate for Payer: BCBS of TX Blue Essentials	$57,772.99
Rate for Payer: BCBS of TX PPO	$64,194.69

HIV W EXTENSIVE O.R. PROCEDURE W/O MCC

Facility

$50,110.60

Service Code	MSDRG 970
Min. Negotiated Rate	$23,077.25
Max. Negotiated Rate	$50,110.60
Rate for Payer: BCBS of TX Blue Advantage	$23,974.22
Rate for Payer: BCBS of TX Blue Essentials	$28,766.28
Rate for Payer: BCBS of TX PPO	$31,963.77

HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC

Facility

$116,304.70

Service Code	MSDRG 969
Min. Negotiated Rate	$48,148.82
Max. Negotiated Rate	$116,304.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$49,623.25
Rate for Payer: Amerigroup Medicare	$49,623.25
Rate for Payer: BCBS of TX Medicare	$49,623.25
Rate for Payer: Cigna Commercial	$78,842.34
Rate for Payer: Cigna Medicare	$49,623.25
Rate for Payer: Employer Direct Commercial	$49,623.25
Rate for Payer: Humana Medicare/TRICARE	$49,623.25
Rate for Payer: Molina Dual Medicare/Medicaid	$49,623.25
Rate for Payer: Molina Medicare	$49,623.25
Rate for Payer: Multiplan Auto	$116,304.70
Rate for Payer: Multiplan Commercial	$116,304.70
Rate for Payer: Multiplan Workers Comp	$116,304.70
Rate for Payer: Scott and White EPO/PPO	$53,561.38
Rate for Payer: Scott and White Medicare	$49,623.25
Rate for Payer: Superior Health Plan EPO	$49,623.25
Rate for Payer: Superior Health Plan Medicare	$49,623.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$49,623.25
Rate for Payer: Universal American Medicare	$49,623.25
Rate for Payer: Wellcare Medicare	$49,623.25
Rate for Payer: Wellmed Medicare	$49,623.25

HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC

Facility

$50,110.60

Service Code	MSDRG 970
Min. Negotiated Rate	$23,077.25
Max. Negotiated Rate	$50,110.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24,089.66
Rate for Payer: Amerigroup Medicare	$24,089.66
Rate for Payer: BCBS of TX Medicare	$24,089.66
Rate for Payer: Cigna Commercial	$33,969.71
Rate for Payer: Cigna Medicare	$24,089.66
Rate for Payer: Employer Direct Commercial	$24,089.66
Rate for Payer: Humana Medicare/TRICARE	$24,089.66
Rate for Payer: Molina Dual Medicare/Medicaid	$24,089.66
Rate for Payer: Molina Medicare	$24,089.66
Rate for Payer: Multiplan Auto	$50,110.60
Rate for Payer: Multiplan Commercial	$50,110.60
Rate for Payer: Multiplan Workers Comp	$50,110.60
Rate for Payer: Scott and White EPO/PPO	$23,077.25
Rate for Payer: Scott and White Medicare	$24,089.66
Rate for Payer: Superior Health Plan EPO	$24,089.66
Rate for Payer: Superior Health Plan Medicare	$24,089.66
Rate for Payer: Universal American Dual Medicare/Medicaid	$24,089.66
Rate for Payer: Universal American Medicare	$24,089.66
Rate for Payer: Wellcare Medicare	$24,089.66
Rate for Payer: Wellmed Medicare	$24,089.66

HIV WITH MAJOR HIV RELATED CONDITION

Facility

$3,155.94

Service Code	APR-DRG 8921
Min. Negotiated Rate	$2,975.53
Max. Negotiated Rate	$3,155.94
Rate for Payer: Amerigroup CHIP/Medicaid	$2,975.53
Rate for Payer: Cigna Medicaid	$2,975.53
Rate for Payer: Molina CHIP/Medicaid	$2,975.53
Rate for Payer: Parkland Medicaid	$2,975.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,155.94

HIV WITH MAJOR HIV RELATED CONDITION

Facility

$9,287.15

Service Code	APR-DRG 8924
Min. Negotiated Rate	$8,756.25
Max. Negotiated Rate	$9,287.15
Rate for Payer: Amerigroup CHIP/Medicaid	$8,756.25
Rate for Payer: Cigna Medicaid	$8,756.25
Rate for Payer: Molina CHIP/Medicaid	$8,756.25
Rate for Payer: Parkland Medicaid	$8,756.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,287.15

HIV WITH MAJOR HIV RELATED CONDITION

Facility

$6,130.83

Service Code	APR-DRG 8923
Min. Negotiated Rate	$5,780.36
Max. Negotiated Rate	$6,130.83
Rate for Payer: Amerigroup CHIP/Medicaid	$5,780.36
Rate for Payer: Cigna Medicaid	$5,780.36
Rate for Payer: Molina CHIP/Medicaid	$5,780.36
Rate for Payer: Parkland Medicaid	$5,780.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,130.83

HIV WITH MAJOR HIV RELATED CONDITION

Facility

$3,941.63

Service Code	APR-DRG 8922
Min. Negotiated Rate	$3,716.30
Max. Negotiated Rate	$3,941.63
Rate for Payer: Amerigroup CHIP/Medicaid	$3,716.30
Rate for Payer: Cigna Medicaid	$3,716.30
Rate for Payer: Molina CHIP/Medicaid	$3,716.30
Rate for Payer: Parkland Medicaid	$3,716.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,941.63

HIV WITH MAJOR RELATED CONDITION WITH CC

Facility

$24,605.00

Service Code	MSDRG 975
Min. Negotiated Rate	$11,093.14
Max. Negotiated Rate	$24,605.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,251.16
Rate for Payer: Amerigroup Medicare	$14,251.16
Rate for Payer: BCBS of TX Medicare	$14,251.16
Rate for Payer: Cigna Commercial	$16,679.60
Rate for Payer: Cigna Medicare	$14,251.16
Rate for Payer: Employer Direct Commercial	$14,251.16
Rate for Payer: Humana Medicare/TRICARE	$14,251.16
Rate for Payer: Molina Dual Medicare/Medicaid	$14,251.16
Rate for Payer: Molina Medicare	$14,251.16
Rate for Payer: Multiplan Auto	$24,605.00
Rate for Payer: Multiplan Commercial	$24,605.00
Rate for Payer: Multiplan Workers Comp	$24,605.00
Rate for Payer: Scott and White EPO/PPO	$11,331.25
Rate for Payer: Scott and White Medicare	$14,251.16
Rate for Payer: Superior Health Plan EPO	$14,251.16
Rate for Payer: Superior Health Plan Medicare	$14,251.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,251.16
Rate for Payer: Universal American Medicare	$14,251.16
Rate for Payer: Wellcare Medicare	$14,251.16
Rate for Payer: Wellmed Medicare	$14,251.16

HIV WITH MAJOR RELATED CONDITION WITH MCC

Facility

$54,834.00

Service Code	MSDRG 974
Min. Negotiated Rate	$23,417.80
Max. Negotiated Rate	$54,834.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25,911.64
Rate for Payer: Amerigroup Medicare	$25,911.64
Rate for Payer: BCBS of TX Medicare	$25,911.64
Rate for Payer: Cigna Commercial	$37,171.68
Rate for Payer: Cigna Medicare	$25,911.64
Rate for Payer: Employer Direct Commercial	$25,911.64
Rate for Payer: Humana Medicare/TRICARE	$25,911.64
Rate for Payer: Molina Dual Medicare/Medicaid	$25,911.64
Rate for Payer: Molina Medicare	$25,911.64
Rate for Payer: Multiplan Auto	$54,834.00
Rate for Payer: Multiplan Commercial	$54,834.00
Rate for Payer: Multiplan Workers Comp	$54,834.00
Rate for Payer: Scott and White EPO/PPO	$25,252.50
Rate for Payer: Scott and White Medicare	$25,911.64
Rate for Payer: Superior Health Plan EPO	$25,911.64
Rate for Payer: Superior Health Plan Medicare	$25,911.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$25,911.64
Rate for Payer: Universal American Medicare	$25,911.64
Rate for Payer: Wellcare Medicare	$25,911.64
Rate for Payer: Wellmed Medicare	$25,911.64

HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC

Facility

$16,995.50

Service Code	MSDRG 976
Min. Negotiated Rate	$7,826.88
Max. Negotiated Rate	$16,995.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,375.99
Rate for Payer: Amerigroup Medicare	$11,375.99
Rate for Payer: BCBS of TX Medicare	$11,375.99
Rate for Payer: Cigna Commercial	$11,521.16
Rate for Payer: Cigna Medicare	$11,375.99
Rate for Payer: Employer Direct Commercial	$11,375.99
Rate for Payer: Humana Medicare/TRICARE	$11,375.99
Rate for Payer: Molina Dual Medicare/Medicaid	$11,375.99
Rate for Payer: Molina Medicare	$11,375.99
Rate for Payer: Multiplan Auto	$16,995.50
Rate for Payer: Multiplan Commercial	$16,995.50
Rate for Payer: Multiplan Workers Comp	$16,995.50
Rate for Payer: Scott and White EPO/PPO	$7,826.88
Rate for Payer: Scott and White Medicare	$11,375.99
Rate for Payer: Superior Health Plan EPO	$11,375.99
Rate for Payer: Superior Health Plan Medicare	$11,375.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,375.99
Rate for Payer: Universal American Medicare	$11,375.99
Rate for Payer: Wellcare Medicare	$11,375.99
Rate for Payer: Wellmed Medicare	$11,375.99

HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$17,478.56

Service Code	APR-DRG 8904
Min. Negotiated Rate	$16,479.40
Max. Negotiated Rate	$17,478.56
Rate for Payer: Amerigroup CHIP/Medicaid	$16,479.40
Rate for Payer: Cigna Medicaid	$16,479.40
Rate for Payer: Molina CHIP/Medicaid	$16,479.40
Rate for Payer: Parkland Medicaid	$16,479.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,478.56

HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$4,722.78

Service Code	APR-DRG 8902
Min. Negotiated Rate	$4,452.81
Max. Negotiated Rate	$4,722.78
Rate for Payer: Amerigroup CHIP/Medicaid	$4,452.81
Rate for Payer: Cigna Medicaid	$4,452.81
Rate for Payer: Molina CHIP/Medicaid	$4,452.81
Rate for Payer: Parkland Medicaid	$4,452.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,722.78

HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$4,364.45

Service Code	APR-DRG 8901
Min. Negotiated Rate	$4,114.96
Max. Negotiated Rate	$4,364.45
Rate for Payer: Amerigroup CHIP/Medicaid	$4,114.96
Rate for Payer: Cigna Medicaid	$4,114.96
Rate for Payer: Molina CHIP/Medicaid	$4,114.96
Rate for Payer: Parkland Medicaid	$4,114.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,364.45

HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$8,280.05

Service Code	APR-DRG 8903
Min. Negotiated Rate	$7,806.72
Max. Negotiated Rate	$8,280.05
Rate for Payer: Amerigroup CHIP/Medicaid	$7,806.72
Rate for Payer: Cigna Medicaid	$7,806.72
Rate for Payer: Molina CHIP/Medicaid	$7,806.72
Rate for Payer: Parkland Medicaid	$7,806.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,280.05

HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS

Facility

$3,929.56

Service Code	APR-DRG 8932
Min. Negotiated Rate	$3,704.92
Max. Negotiated Rate	$3,929.56
Rate for Payer: Amerigroup CHIP/Medicaid	$3,704.92
Rate for Payer: Cigna Medicaid	$3,704.92
Rate for Payer: Molina CHIP/Medicaid	$3,704.92
Rate for Payer: Parkland Medicaid	$3,704.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,929.56

Know your out-of-pocket cost for care.

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