White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$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 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 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

HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS

Facility

$10,307.07

Service Code	APR-DRG 8934
Min. Negotiated Rate	$9,717.86
Max. Negotiated Rate	$10,307.07
Rate for Payer: Amerigroup CHIP/Medicaid	$9,717.86
Rate for Payer: Cigna Medicaid	$9,717.86
Rate for Payer: Molina CHIP/Medicaid	$9,717.86
Rate for Payer: Parkland Medicaid	$9,717.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,307.07

HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS

Facility

$2,737.64

Service Code	APR-DRG 8931
Min. Negotiated Rate	$2,581.14
Max. Negotiated Rate	$2,737.64
Rate for Payer: Amerigroup CHIP/Medicaid	$2,581.14
Rate for Payer: Cigna Medicaid	$2,581.14
Rate for Payer: Molina CHIP/Medicaid	$2,581.14
Rate for Payer: Parkland Medicaid	$2,581.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,737.64

HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS

Facility

$5,480.93

Service Code	APR-DRG 8933
Min. Negotiated Rate	$5,167.62
Max. Negotiated Rate	$5,480.93
Rate for Payer: Amerigroup CHIP/Medicaid	$5,167.62
Rate for Payer: Cigna Medicaid	$5,167.62
Rate for Payer: Molina CHIP/Medicaid	$5,167.62
Rate for Payer: Parkland Medicaid	$5,167.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,480.93

HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS

Facility

$7,593.95

Service Code	APR-DRG 8944
Min. Negotiated Rate	$7,159.84
Max. Negotiated Rate	$7,593.95
Rate for Payer: Amerigroup CHIP/Medicaid	$7,159.84
Rate for Payer: Cigna Medicaid	$7,159.84
Rate for Payer: Molina CHIP/Medicaid	$7,159.84
Rate for Payer: Parkland Medicaid	$7,159.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,593.95

HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS

Facility

$3,958.98

Service Code	APR-DRG 8942
Min. Negotiated Rate	$3,732.66
Max. Negotiated Rate	$3,958.98
Rate for Payer: Amerigroup CHIP/Medicaid	$3,732.66
Rate for Payer: Cigna Medicaid	$3,732.66
Rate for Payer: Molina CHIP/Medicaid	$3,732.66
Rate for Payer: Parkland Medicaid	$3,732.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,958.98

HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS

Facility

$5,776.27

Service Code	APR-DRG 8943
Min. Negotiated Rate	$5,446.07
Max. Negotiated Rate	$5,776.27
Rate for Payer: Amerigroup CHIP/Medicaid	$5,446.07
Rate for Payer: Cigna Medicaid	$5,446.07
Rate for Payer: Molina CHIP/Medicaid	$5,446.07
Rate for Payer: Parkland Medicaid	$5,446.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,776.27

HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS

Facility

$3,398.10

Service Code	APR-DRG 8941
Min. Negotiated Rate	$3,203.84
Max. Negotiated Rate	$3,398.10
Rate for Payer: Amerigroup CHIP/Medicaid	$3,203.84
Rate for Payer: Cigna Medicaid	$3,203.84
Rate for Payer: Molina CHIP/Medicaid	$3,203.84
Rate for Payer: Parkland Medicaid	$3,203.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,398.10

HIV WITH OR WITHOUT OTHER RELATED CONDITION

Facility

$24,698.10

Service Code	MSDRG 977
Min. Negotiated Rate	$10,061.14
Max. Negotiated Rate	$24,698.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,270.95
Rate for Payer: Amerigroup Medicare	$14,270.95
Rate for Payer: BCBS of TX Medicare	$14,270.95
Rate for Payer: Cigna Commercial	$16,326.69
Rate for Payer: Cigna Medicare	$14,270.95
Rate for Payer: Employer Direct Commercial	$14,270.95
Rate for Payer: Humana Medicare/TRICARE	$14,270.95
Rate for Payer: Molina Dual Medicare/Medicaid	$14,270.95
Rate for Payer: Molina Medicare	$14,270.95
Rate for Payer: Multiplan Auto	$24,698.10
Rate for Payer: Multiplan Commercial	$24,698.10
Rate for Payer: Multiplan Workers Comp	$24,698.10
Rate for Payer: Scott and White EPO/PPO	$11,374.12
Rate for Payer: Scott and White Medicare	$14,270.95
Rate for Payer: Superior Health Plan EPO	$14,270.95
Rate for Payer: Superior Health Plan Medicare	$14,270.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,270.95
Rate for Payer: Universal American Medicare	$14,270.95
Rate for Payer: Wellcare Medicare	$14,270.95
Rate for Payer: Wellmed Medicare	$14,270.95

HIV W MAJOR RELATED CONDITION W CC

Facility

$26,138.30

Service Code	MSDRG 975
Min. Negotiated Rate	$11,093.14
Max. Negotiated Rate	$26,138.30
Rate for Payer: BCBS of TX Blue Advantage	$11,093.14
Rate for Payer: BCBS of TX Blue Essentials	$13,310.48
Rate for Payer: BCBS of TX PPO	$14,789.99

HIV W MAJOR RELATED CONDITION W MCC

Facility

$54,587.00

Service Code	MSDRG 974
Min. Negotiated Rate	$23,417.80
Max. Negotiated Rate	$54,587.00
Rate for Payer: BCBS of TX Blue Advantage	$23,417.80
Rate for Payer: BCBS of TX Blue Essentials	$28,098.64
Rate for Payer: BCBS of TX PPO	$31,221.92

HIV W MAJOR RELATED CONDITION W/O CC/MCC

Facility

$17,533.20

Service Code	MSDRG 976
Min. Negotiated Rate	$8,071.96
Max. Negotiated Rate	$17,533.20
Rate for Payer: BCBS of TX Blue Advantage	$8,071.96
Rate for Payer: BCBS of TX Blue Essentials	$9,685.41
Rate for Payer: BCBS of TX PPO	$10,761.99

HIV W OR W/O OTHER RELATED CONDITION

Facility

$24,698.10

Service Code	MSDRG 977
Min. Negotiated Rate	$10,061.14
Max. Negotiated Rate	$24,698.10
Rate for Payer: BCBS of TX Blue Advantage	$10,061.14
Rate for Payer: BCBS of TX Blue Essentials	$12,072.20
Rate for Payer: BCBS of TX PPO	$13,414.07

HLA B 27 Disease Association SO

Facility

$503.00

Service Code	HCPCS 81374
Hospital Charge Code	1740985
Hospital Revenue Code	310
Min. Negotiated Rate	$28.99
Max. Negotiated Rate	$362.16
Rate for Payer: Amerigroup CHIP/Medicaid	$28.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$74.33
Rate for Payer: Amerigroup Medicare	$74.33
Rate for Payer: BCBS of TX Blue Advantage	$150.90
Rate for Payer: BCBS of TX Blue Essentials	$181.08
Rate for Payer: BCBS of TX Medicare	$74.33
Rate for Payer: BCBS of TX PPO	$201.20
Rate for Payer: Cash Price	$342.04
Rate for Payer: Cash Price	$342.04
Rate for Payer: Cigna Medicaid	$362.16
Rate for Payer: Cigna Medicare	$74.33
Rate for Payer: Employer Direct Commercial	$74.33
Rate for Payer: Humana Medicare/TRICARE	$74.33
Rate for Payer: Molina CHIP/Medicaid	$362.16
Rate for Payer: Molina Dual Medicare/Medicaid	$74.33
Rate for Payer: Molina Medicare	$74.33
Rate for Payer: Multiplan Auto	$326.95
Rate for Payer: Multiplan Commercial	$326.95
Rate for Payer: Multiplan Workers Comp	$326.95
Rate for Payer: Parkland Medicaid	$362.16
Rate for Payer: Scott and White EPO/PPO	$92.91
Rate for Payer: Scott and White Medicare	$74.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$362.16
Rate for Payer: Superior Health Plan EPO	$74.33
Rate for Payer: Superior Health Plan Medicare	$74.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$74.33
Rate for Payer: Universal American Medicare	$74.33
Rate for Payer: Wellcare Medicare	$74.33
Rate for Payer: Wellmed Medicare	$74.33

HLA B 27 Disease Association SO

Facility

$503.00

Service Code	HCPCS 81374
Hospital Charge Code	1740985
Hospital Revenue Code	310
Rate for Payer: Cash Price	$342.04

HLA B5701 Test SO

Facility

$608.00

Service Code	HCPCS 81381
Hospital Charge Code	1740971
Hospital Revenue Code	310
Rate for Payer: Cash Price	$413.44

HLA B5701 Test SO

Facility

$608.00

Service Code	HCPCS 81381
Hospital Charge Code	1740971
Hospital Revenue Code	310
Min. Negotiated Rate	$66.26
Max. Negotiated Rate	$437.76
Rate for Payer: Amerigroup CHIP/Medicaid	$66.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$169.90
Rate for Payer: Amerigroup Medicare	$169.90
Rate for Payer: BCBS of TX Blue Advantage	$182.40
Rate for Payer: BCBS of TX Blue Essentials	$218.88
Rate for Payer: BCBS of TX Medicare	$169.90
Rate for Payer: BCBS of TX PPO	$243.20
Rate for Payer: Cash Price	$413.44
Rate for Payer: Cash Price	$413.44
Rate for Payer: Cigna Medicaid	$437.76
Rate for Payer: Cigna Medicare	$169.90
Rate for Payer: Employer Direct Commercial	$169.90
Rate for Payer: Humana Medicare/TRICARE	$169.90
Rate for Payer: Molina CHIP/Medicaid	$437.76
Rate for Payer: Molina Dual Medicare/Medicaid	$169.90
Rate for Payer: Molina Medicare	$169.90
Rate for Payer: Multiplan Auto	$395.20
Rate for Payer: Multiplan Commercial	$395.20
Rate for Payer: Multiplan Workers Comp	$395.20
Rate for Payer: Parkland Medicaid	$437.76
Rate for Payer: Scott and White EPO/PPO	$212.38
Rate for Payer: Scott and White Medicare	$169.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$437.76
Rate for Payer: Superior Health Plan EPO	$169.90
Rate for Payer: Superior Health Plan Medicare	$169.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$169.90
Rate for Payer: Universal American Medicare	$169.90
Rate for Payer: Wellcare Medicare	$169.90
Rate for Payer: Wellmed Medicare	$169.90

HL ENDO T -- DHF

Facility

$437.09

Hospital Charge Code	82047507
Hospital Revenue Code	270
Rate for Payer: Cash Price	$297.22

HL ENDO T -- DHF

Facility

$437.09

Hospital Charge Code	82047507
Hospital Revenue Code	270
Min. Negotiated Rate	$39.34
Max. Negotiated Rate	$314.70
Rate for Payer: Amerigroup CHIP/Medicaid	$39.34
Rate for Payer: BCBS of TX Blue Advantage	$131.13
Rate for Payer: BCBS of TX Blue Essentials	$157.35
Rate for Payer: BCBS of TX PPO	$174.84
Rate for Payer: Cash Price	$297.22
Rate for Payer: Cigna Medicaid	$314.70
Rate for Payer: Molina CHIP/Medicaid	$314.70
Rate for Payer: Multiplan Auto	$284.11
Rate for Payer: Multiplan Commercial	$284.11
Rate for Payer: Multiplan Workers Comp	$284.11
Rate for Payer: Parkland Medicaid	$314.70
Rate for Payer: Scott and White EPO/PPO	$218.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$314.70
Rate for Payer: Superior Health Plan EPO	$59.44

HL HAND ADLT -- DHF

Facility

$422.97

Hospital Charge Code	81143109
Hospital Revenue Code	270
Min. Negotiated Rate	$38.07
Max. Negotiated Rate	$304.54
Rate for Payer: Amerigroup CHIP/Medicaid	$38.07
Rate for Payer: BCBS of TX Blue Advantage	$126.89
Rate for Payer: BCBS of TX Blue Essentials	$152.27
Rate for Payer: BCBS of TX PPO	$169.19
Rate for Payer: Cash Price	$287.62
Rate for Payer: Cigna Medicaid	$304.54
Rate for Payer: Molina CHIP/Medicaid	$304.54
Rate for Payer: Multiplan Auto	$274.93
Rate for Payer: Multiplan Commercial	$274.93
Rate for Payer: Multiplan Workers Comp	$274.93
Rate for Payer: Parkland Medicaid	$304.54
Rate for Payer: Scott and White EPO/PPO	$211.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$304.54
Rate for Payer: Superior Health Plan EPO	$57.52

HL HAND ADLT -- DHF

Facility

$422.97

Hospital Charge Code	81143109
Hospital Revenue Code	270
Rate for Payer: Cash Price	$287.62

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