White Rock Medical Center

All Charges

Charge

Type

Setting

Price

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC

Facility

$11,787.60

Service Code	MSDRG 759
Min. Negotiated Rate	$5,428.50
Max. Negotiated Rate	$11,787.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,623.62
Rate for Payer: Amerigroup Medicare	$9,623.62
Rate for Payer: BCBS of TX Medicare	$9,623.62
Rate for Payer: Cigna Commercial	$8,547.17
Rate for Payer: Cigna Medicare	$9,623.62
Rate for Payer: Employer Direct Commercial	$9,623.62
Rate for Payer: Humana Medicare/TRICARE	$9,623.62
Rate for Payer: Molina Dual Medicare/Medicaid	$9,623.62
Rate for Payer: Molina Medicare	$9,623.62
Rate for Payer: Multiplan Auto	$11,787.60
Rate for Payer: Multiplan Commercial	$11,787.60
Rate for Payer: Multiplan Workers Comp	$11,787.60
Rate for Payer: Scott and White EPO/PPO	$5,428.50
Rate for Payer: Scott and White Medicare	$9,623.62
Rate for Payer: Superior Health Plan EPO	$9,623.62
Rate for Payer: Superior Health Plan Medicare	$9,623.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,623.62
Rate for Payer: Universal American Medicare	$9,623.62
Rate for Payer: Wellcare Medicare	$9,623.62
Rate for Payer: Wellmed Medicare	$9,623.62

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W MCC

Facility

$26,071.80

Service Code	MSDRG 757
Min. Negotiated Rate	$12,006.75
Max. Negotiated Rate	$26,071.80
Rate for Payer: BCBS of TX Blue Advantage	$12,391.74
Rate for Payer: BCBS of TX Blue Essentials	$14,868.65
Rate for Payer: BCBS of TX PPO	$16,521.36

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC

Facility

$11,787.60

Service Code	MSDRG 759
Min. Negotiated Rate	$5,428.50
Max. Negotiated Rate	$11,787.60
Rate for Payer: BCBS of TX Blue Advantage	$6,112.02
Rate for Payer: BCBS of TX Blue Essentials	$7,333.71
Rate for Payer: BCBS of TX PPO	$8,148.89

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$6,493.31

Service Code	APR-DRG 1133
Min. Negotiated Rate	$6,122.12
Max. Negotiated Rate	$6,493.31
Rate for Payer: Amerigroup CHIP/Medicaid	$6,122.12
Rate for Payer: Cigna Medicaid	$6,122.12
Rate for Payer: Molina CHIP/Medicaid	$6,122.12
Rate for Payer: Parkland Medicaid	$6,122.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,493.31

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$2,180.53

Service Code	APR-DRG 1132
Min. Negotiated Rate	$2,055.88
Max. Negotiated Rate	$2,180.53
Rate for Payer: Amerigroup CHIP/Medicaid	$2,055.88
Rate for Payer: Cigna Medicaid	$2,055.88
Rate for Payer: Molina CHIP/Medicaid	$2,055.88
Rate for Payer: Parkland Medicaid	$2,055.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,180.53

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$10,499.06

Service Code	APR-DRG 1134
Min. Negotiated Rate	$9,898.88
Max. Negotiated Rate	$10,499.06
Rate for Payer: Amerigroup CHIP/Medicaid	$9,898.88
Rate for Payer: Cigna Medicaid	$9,898.88
Rate for Payer: Molina CHIP/Medicaid	$9,898.88
Rate for Payer: Parkland Medicaid	$9,898.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,499.06

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$1,438.22

Service Code	APR-DRG 1131
Min. Negotiated Rate	$1,356.01
Max. Negotiated Rate	$1,438.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,356.01
Rate for Payer: Cigna Medicaid	$1,356.01
Rate for Payer: Molina CHIP/Medicaid	$1,356.01
Rate for Payer: Parkland Medicaid	$1,356.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,438.22

Infectious agent antigen detection by immunoassay technique qualitative or semiquantitative; Shiga-like toxin

Facility

$182.00

Service Code	HCPCS 87427
Hospital Charge Code	8239741
Hospital Revenue Code	301
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$131.04
Rate for Payer: Amerigroup CHIP/Medicaid	$4.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.98
Rate for Payer: Amerigroup Medicare	$11.98
Rate for Payer: BCBS of TX Blue Advantage	$54.60
Rate for Payer: BCBS of TX Blue Essentials	$65.52
Rate for Payer: BCBS of TX Medicare	$11.98
Rate for Payer: BCBS of TX PPO	$72.80
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cigna Medicaid	$131.04
Rate for Payer: Cigna Medicare	$11.98
Rate for Payer: Employer Direct Commercial	$11.98
Rate for Payer: Humana Medicare/TRICARE	$11.98
Rate for Payer: Molina CHIP/Medicaid	$131.04
Rate for Payer: Molina Dual Medicare/Medicaid	$11.98
Rate for Payer: Molina Medicare	$11.98
Rate for Payer: Multiplan Auto	$118.30
Rate for Payer: Multiplan Commercial	$118.30
Rate for Payer: Multiplan Workers Comp	$118.30
Rate for Payer: Parkland Medicaid	$131.04
Rate for Payer: Scott and White EPO/PPO	$14.97
Rate for Payer: Scott and White Medicare	$11.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.04
Rate for Payer: Superior Health Plan EPO	$11.98
Rate for Payer: Superior Health Plan Medicare	$11.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.98
Rate for Payer: Universal American Medicare	$11.98
Rate for Payer: Wellcare Medicare	$11.98
Rate for Payer: Wellmed Medicare	$11.98

Infectious agent antigen detection by immunoassay technique qualitative or semiquantitative; Shiga-like toxin

Facility

$182.00

Service Code	HCPCS 87427
Hospital Charge Code	8239741
Hospital Revenue Code	301
Rate for Payer: Cash Price	$123.76

INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE

Facility

$7,222.79

Service Code	APR-DRG 7102
Min. Negotiated Rate	$6,809.90
Max. Negotiated Rate	$7,222.79
Rate for Payer: Amerigroup CHIP/Medicaid	$6,809.90
Rate for Payer: Cigna Medicaid	$6,809.90
Rate for Payer: Molina CHIP/Medicaid	$6,809.90
Rate for Payer: Parkland Medicaid	$6,809.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,222.79

INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE

Facility

$5,015.10

Service Code	APR-DRG 7101
Min. Negotiated Rate	$4,728.42
Max. Negotiated Rate	$5,015.10
Rate for Payer: Amerigroup CHIP/Medicaid	$4,728.42
Rate for Payer: Cigna Medicaid	$4,728.42
Rate for Payer: Molina CHIP/Medicaid	$4,728.42
Rate for Payer: Parkland Medicaid	$4,728.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,015.10

INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE

Facility

$30,335.43

Service Code	APR-DRG 7104
Min. Negotiated Rate	$28,601.30
Max. Negotiated Rate	$30,335.43
Rate for Payer: Amerigroup CHIP/Medicaid	$28,601.30
Rate for Payer: Cigna Medicaid	$28,601.30
Rate for Payer: Molina CHIP/Medicaid	$28,601.30
Rate for Payer: Parkland Medicaid	$28,601.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30,335.43

INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE

Facility

$12,519.66

Service Code	APR-DRG 7103
Min. Negotiated Rate	$11,803.97
Max. Negotiated Rate	$12,519.66
Rate for Payer: Amerigroup CHIP/Medicaid	$11,803.97
Rate for Payer: Cigna Medicaid	$11,803.97
Rate for Payer: Molina CHIP/Medicaid	$11,803.97
Rate for Payer: Parkland Medicaid	$11,803.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,519.66

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC

Facility

$39,056.40

Service Code	MSDRG 854
Min. Negotiated Rate	$17,986.50
Max. Negotiated Rate	$39,056.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,404.21
Rate for Payer: Amerigroup Medicare	$19,404.21
Rate for Payer: BCBS of TX Medicare	$19,404.21
Rate for Payer: Cigna Commercial	$25,735.53
Rate for Payer: Cigna Medicare	$19,404.21
Rate for Payer: Employer Direct Commercial	$19,404.21
Rate for Payer: Humana Medicare/TRICARE	$19,404.21
Rate for Payer: Molina Dual Medicare/Medicaid	$19,404.21
Rate for Payer: Molina Medicare	$19,404.21
Rate for Payer: Multiplan Auto	$39,056.40
Rate for Payer: Multiplan Commercial	$39,056.40
Rate for Payer: Multiplan Workers Comp	$39,056.40
Rate for Payer: Scott and White EPO/PPO	$17,986.50
Rate for Payer: Scott and White Medicare	$19,404.21
Rate for Payer: Superior Health Plan EPO	$19,404.21
Rate for Payer: Superior Health Plan Medicare	$19,404.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,404.21
Rate for Payer: Universal American Medicare	$19,404.21
Rate for Payer: Wellcare Medicare	$19,404.21
Rate for Payer: Wellmed Medicare	$19,404.21

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC

Facility

$93,119.00

Service Code	MSDRG 853
Min. Negotiated Rate	$40,955.20
Max. Negotiated Rate	$93,119.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$40,955.20
Rate for Payer: Amerigroup Medicare	$40,955.20
Rate for Payer: BCBS of TX Medicare	$40,955.20
Rate for Payer: Cigna Commercial	$63,609.17
Rate for Payer: Cigna Medicare	$40,955.20
Rate for Payer: Employer Direct Commercial	$40,955.20
Rate for Payer: Humana Medicare/TRICARE	$40,955.20
Rate for Payer: Molina Dual Medicare/Medicaid	$40,955.20
Rate for Payer: Molina Medicare	$40,955.20
Rate for Payer: Multiplan Auto	$93,119.00
Rate for Payer: Multiplan Commercial	$93,119.00
Rate for Payer: Multiplan Workers Comp	$93,119.00
Rate for Payer: Scott and White EPO/PPO	$42,883.75
Rate for Payer: Scott and White Medicare	$40,955.20
Rate for Payer: Superior Health Plan EPO	$40,955.20
Rate for Payer: Superior Health Plan Medicare	$40,955.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$40,955.20
Rate for Payer: Universal American Medicare	$40,955.20
Rate for Payer: Wellcare Medicare	$40,955.20
Rate for Payer: Wellmed Medicare	$40,955.20

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$29,026.30

Service Code	MSDRG 855
Min. Negotiated Rate	$13,367.38
Max. Negotiated Rate	$29,026.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,733.10
Rate for Payer: Amerigroup Medicare	$15,733.10
Rate for Payer: BCBS of TX Medicare	$15,733.10
Rate for Payer: Cigna Commercial	$19,283.94
Rate for Payer: Cigna Medicare	$15,733.10
Rate for Payer: Employer Direct Commercial	$15,733.10
Rate for Payer: Humana Medicare/TRICARE	$15,733.10
Rate for Payer: Molina Dual Medicare/Medicaid	$15,733.10
Rate for Payer: Molina Medicare	$15,733.10
Rate for Payer: Multiplan Auto	$29,026.30
Rate for Payer: Multiplan Commercial	$29,026.30
Rate for Payer: Multiplan Workers Comp	$29,026.30
Rate for Payer: Scott and White EPO/PPO	$13,367.38
Rate for Payer: Scott and White Medicare	$15,733.10
Rate for Payer: Superior Health Plan EPO	$15,733.10
Rate for Payer: Superior Health Plan Medicare	$15,733.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,733.10
Rate for Payer: Universal American Medicare	$15,733.10
Rate for Payer: Wellcare Medicare	$15,733.10
Rate for Payer: Wellmed Medicare	$15,733.10

INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC

Facility

$39,056.40

Service Code	MSDRG 854
Min. Negotiated Rate	$17,986.50
Max. Negotiated Rate	$39,056.40
Rate for Payer: BCBS of TX Blue Advantage	$18,944.08
Rate for Payer: BCBS of TX Blue Essentials	$22,730.69
Rate for Payer: BCBS of TX PPO	$25,257.30

INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC

Facility

$93,119.00

Service Code	MSDRG 853
Min. Negotiated Rate	$40,955.20
Max. Negotiated Rate	$93,119.00
Rate for Payer: BCBS of TX Blue Advantage	$43,491.06
Rate for Payer: BCBS of TX Blue Essentials	$52,184.21
Rate for Payer: BCBS of TX PPO	$57,984.71

INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W/O CC/MCC

Facility

$29,026.30

Service Code	MSDRG 855
Min. Negotiated Rate	$13,367.38
Max. Negotiated Rate	$29,026.30
Rate for Payer: BCBS of TX Blue Advantage	$13,416.00
Rate for Payer: BCBS of TX Blue Essentials	$16,097.64
Rate for Payer: BCBS of TX PPO	$17,886.96

Inf for Therapy, Prophylaxis, Dx Initial up to 1 Hour 96365

Facility

$300.00

Service Code	HCPCS 96365
Hospital Charge Code	1500412
Hospital Revenue Code	260
Rate for Payer: Cash Price	$204.00

Inf for Therapy, Prophylaxis, Dx Initial up to 1 Hour 96365

Facility

$300.00

Service Code	HCPCS 96365
Hospital Charge Code	1500412
Hospital Revenue Code	260
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$451.67
Rate for Payer: Amerigroup CHIP/Medicaid	$27.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$90.00
Rate for Payer: BCBS of TX Blue Essentials	$108.00
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$120.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$216.00
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$216.00
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$195.00
Rate for Payer: Multiplan Commercial	$195.00
Rate for Payer: Multiplan Workers Comp	$195.00
Rate for Payer: Parkland Medicaid	$216.00
Rate for Payer: Scott and White EPO/PPO	$77.31
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.00
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

Inf for Therapy, Prophylaxis, Dx Initial up to 1 Hour 96368

Facility

$149.00

Service Code	HCPCS 96368
Hospital Charge Code	1500362
Hospital Revenue Code	260
Rate for Payer: Cash Price	$101.32

Inf for Therapy, Prophylaxis, Dx Initial up to 1 Hour 96368

Facility

$149.00

Service Code	HCPCS 96368
Hospital Charge Code	1500362
Hospital Revenue Code	260
Min. Negotiated Rate	$13.41
Max. Negotiated Rate	$107.28
Rate for Payer: Amerigroup CHIP/Medicaid	$13.41
Rate for Payer: BCBS of TX Blue Advantage	$44.70
Rate for Payer: BCBS of TX Blue Essentials	$53.64
Rate for Payer: BCBS of TX PPO	$59.60
Rate for Payer: Cash Price	$101.32
Rate for Payer: Cash Price	$101.32
Rate for Payer: Cigna Medicaid	$107.28
Rate for Payer: Molina CHIP/Medicaid	$107.28
Rate for Payer: Multiplan Auto	$96.85
Rate for Payer: Multiplan Commercial	$96.85
Rate for Payer: Multiplan Workers Comp	$96.85
Rate for Payer: Parkland Medicaid	$107.28
Rate for Payer: Scott and White EPO/PPO	$24.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$107.28
Rate for Payer: Superior Health Plan EPO	$20.26

Inf for Therapy Prophylaxis or Dx Each Addl Hour 96366

Facility

$153.00

Service Code	HCPCS 96366
Hospital Charge Code	5202395
Hospital Revenue Code	260
Rate for Payer: Cash Price	$104.04

Inf for Therapy Prophylaxis or Dx Each Addl Hour 96366

Facility

$153.00

Service Code	HCPCS 96366
Hospital Charge Code	5202395
Hospital Revenue Code	260
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$110.16
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47.04
Rate for Payer: Amerigroup Medicare	$47.04
Rate for Payer: BCBS of TX Blue Advantage	$45.90
Rate for Payer: BCBS of TX Blue Essentials	$55.08
Rate for Payer: BCBS of TX Medicare	$47.04
Rate for Payer: BCBS of TX PPO	$61.20
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cigna Commercial	$99.43
Rate for Payer: Cigna Medicaid	$110.16
Rate for Payer: Cigna Medicare	$47.04
Rate for Payer: Employer Direct Commercial	$47.04
Rate for Payer: Humana Medicare/TRICARE	$47.04
Rate for Payer: Molina CHIP/Medicaid	$110.16
Rate for Payer: Molina Dual Medicare/Medicaid	$47.04
Rate for Payer: Molina Medicare	$47.04
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Parkland Medicaid	$110.16
Rate for Payer: Scott and White EPO/PPO	$25.11
Rate for Payer: Scott and White Medicare	$47.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.16
Rate for Payer: Superior Health Plan EPO	$47.04
Rate for Payer: Superior Health Plan Medicare	$47.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$47.04
Rate for Payer: Universal American Medicare	$47.04
Rate for Payer: Wellcare Medicare	$47.04
Rate for Payer: Wellmed Medicare	$47.04

Know your out-of-pocket cost for care.

All Charges