White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$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 WITH O.R. PROCEDURES WITH CC

Facility

$37,963.90

Service Code	MSDRG 854
Min. Negotiated Rate	$17,483.38
Max. Negotiated Rate	$37,963.90
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	$37,963.90
Rate for Payer: Multiplan Commercial	$37,963.90
Rate for Payer: Multiplan Workers Comp	$37,963.90
Rate for Payer: Scott and White EPO/PPO	$17,483.38
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

$93,833.40

Service Code	MSDRG 853
Min. Negotiated Rate	$40,955.20
Max. Negotiated Rate	$93,833.40
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	$93,833.40
Rate for Payer: Multiplan Commercial	$93,833.40
Rate for Payer: Multiplan Workers Comp	$93,833.40
Rate for Payer: Scott and White EPO/PPO	$43,212.75
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

$28,446.80

Service Code	MSDRG 855
Min. Negotiated Rate	$13,100.50
Max. Negotiated Rate	$28,446.80
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	$28,446.80
Rate for Payer: Multiplan Commercial	$28,446.80
Rate for Payer: Multiplan Workers Comp	$28,446.80
Rate for Payer: Scott and White EPO/PPO	$13,100.50
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

$37,963.90

Service Code	MSDRG 854
Min. Negotiated Rate	$17,483.38
Max. Negotiated Rate	$37,963.90
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

$93,833.40

Service Code	MSDRG 853
Min. Negotiated Rate	$40,955.20
Max. Negotiated Rate	$93,833.40
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

$28,446.80

Service Code	MSDRG 855
Min. Negotiated Rate	$13,100.50
Max. Negotiated Rate	$28,446.80
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	$150.00
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
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: 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	$74.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$107.28
Rate for Payer: Superior Health Plan EPO	$20.26

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 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	$76.50
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

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	1500347
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	1500347
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	$76.50
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

Inf for Tx Prophylaxis Dx Addl Seq Infusion New Drug 96367

Facility

$175.00

Service Code	HCPCS 96367
Hospital Charge Code	7003627
Hospital Revenue Code	260
Rate for Payer: Cash Price	$119.00

Inf for Tx Prophylaxis Dx Addl Seq Infusion New Drug 96367

Facility

$175.00

Service Code	HCPCS 96367
Hospital Charge Code	7003627
Hospital Revenue Code	260
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$152.89
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$72.33
Rate for Payer: Amerigroup Medicare	$72.33
Rate for Payer: BCBS of TX Blue Advantage	$52.50
Rate for Payer: BCBS of TX Blue Essentials	$63.00
Rate for Payer: BCBS of TX Medicare	$72.33
Rate for Payer: BCBS of TX PPO	$70.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cigna Commercial	$152.89
Rate for Payer: Cigna Medicaid	$126.00
Rate for Payer: Cigna Medicare	$72.33
Rate for Payer: Employer Direct Commercial	$72.33
Rate for Payer: Humana Medicare/TRICARE	$72.33
Rate for Payer: Molina CHIP/Medicaid	$126.00
Rate for Payer: Molina Dual Medicare/Medicaid	$72.33
Rate for Payer: Molina Medicare	$72.33
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Parkland Medicaid	$126.00
Rate for Payer: Scott and White EPO/PPO	$87.50
Rate for Payer: Scott and White Medicare	$72.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.00
Rate for Payer: Superior Health Plan EPO	$72.33
Rate for Payer: Superior Health Plan Medicare	$72.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$72.33
Rate for Payer: Universal American Medicare	$72.33
Rate for Payer: Wellcare Medicare	$72.33
Rate for Payer: Wellmed Medicare	$72.33

INFINITY AIM MENISCAL REPAIR DEVICE 25 DEGREE CURVED

Facility

$1,702.50

Hospital Charge Code	992647
Hospital Revenue Code	272
Min. Negotiated Rate	$153.22
Max. Negotiated Rate	$1,225.80
Rate for Payer: Amerigroup CHIP/Medicaid	$153.22
Rate for Payer: BCBS of TX Blue Advantage	$510.75
Rate for Payer: BCBS of TX Blue Essentials	$612.90
Rate for Payer: BCBS of TX PPO	$681.00
Rate for Payer: Cash Price	$1,157.70
Rate for Payer: Cigna Medicaid	$1,225.80
Rate for Payer: Molina CHIP/Medicaid	$1,225.80
Rate for Payer: Multiplan Auto	$1,106.62
Rate for Payer: Multiplan Commercial	$1,106.62
Rate for Payer: Multiplan Workers Comp	$1,106.62
Rate for Payer: Parkland Medicaid	$1,225.80
Rate for Payer: Scott and White EPO/PPO	$851.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,225.80
Rate for Payer: Superior Health Plan EPO	$231.54

INFINITY AIM MENISCAL REPAIR DEVICE 25 DEGREE CURVED

Facility

$1,702.50

Hospital Charge Code	992647
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,157.70

INFINITY AIM SUTURE CUTTER AND SKID

Facility

$544.80

Hospital Charge Code	992648
Hospital Revenue Code	272
Rate for Payer: Cash Price	$370.46

INFINITY AIM SUTURE CUTTER AND SKID

Facility

$544.80

Hospital Charge Code	992648
Hospital Revenue Code	272
Min. Negotiated Rate	$49.03
Max. Negotiated Rate	$392.26
Rate for Payer: Amerigroup CHIP/Medicaid	$49.03
Rate for Payer: BCBS of TX Blue Advantage	$163.44
Rate for Payer: BCBS of TX Blue Essentials	$196.13
Rate for Payer: BCBS of TX PPO	$217.92
Rate for Payer: Cash Price	$370.46
Rate for Payer: Cigna Medicaid	$392.26
Rate for Payer: Molina CHIP/Medicaid	$392.26
Rate for Payer: Multiplan Auto	$354.12
Rate for Payer: Multiplan Commercial	$354.12
Rate for Payer: Multiplan Workers Comp	$354.12
Rate for Payer: Parkland Medicaid	$392.26
Rate for Payer: Scott and White EPO/PPO	$272.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$392.26
Rate for Payer: Superior Health Plan EPO	$74.09

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$28,175.10

Service Code	MSDRG 727
Min. Negotiated Rate	$12,366.80
Max. Negotiated Rate	$28,175.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,628.29
Rate for Payer: Amerigroup Medicare	$15,628.29
Rate for Payer: BCBS of TX Medicare	$15,628.29
Rate for Payer: Cigna Commercial	$19,099.75
Rate for Payer: Cigna Medicare	$15,628.29
Rate for Payer: Employer Direct Commercial	$15,628.29
Rate for Payer: Humana Medicare/TRICARE	$15,628.29
Rate for Payer: Molina Dual Medicare/Medicaid	$15,628.29
Rate for Payer: Molina Medicare	$15,628.29
Rate for Payer: Multiplan Auto	$28,175.10
Rate for Payer: Multiplan Commercial	$28,175.10
Rate for Payer: Multiplan Workers Comp	$28,175.10
Rate for Payer: Scott and White EPO/PPO	$12,975.38
Rate for Payer: Scott and White Medicare	$15,628.29
Rate for Payer: Superior Health Plan EPO	$15,628.29
Rate for Payer: Superior Health Plan Medicare	$15,628.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,628.29
Rate for Payer: Universal American Medicare	$15,628.29
Rate for Payer: Wellcare Medicare	$15,628.29
Rate for Payer: Wellmed Medicare	$15,628.29

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC

Facility

$15,412.80

Service Code	MSDRG 728
Min. Negotiated Rate	$6,806.04
Max. Negotiated Rate	$15,412.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,705.38
Rate for Payer: Amerigroup Medicare	$10,705.38
Rate for Payer: BCBS of TX Medicare	$10,705.38
Rate for Payer: Cigna Commercial	$10,448.26
Rate for Payer: Cigna Medicare	$10,705.38
Rate for Payer: Employer Direct Commercial	$10,705.38
Rate for Payer: Humana Medicare/TRICARE	$10,705.38
Rate for Payer: Molina Dual Medicare/Medicaid	$10,705.38
Rate for Payer: Molina Medicare	$10,705.38
Rate for Payer: Multiplan Auto	$15,412.80
Rate for Payer: Multiplan Commercial	$15,412.80
Rate for Payer: Multiplan Workers Comp	$15,412.80
Rate for Payer: Scott and White EPO/PPO	$7,098.00
Rate for Payer: Scott and White Medicare	$10,705.38
Rate for Payer: Superior Health Plan EPO	$10,705.38
Rate for Payer: Superior Health Plan Medicare	$10,705.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,705.38
Rate for Payer: Universal American Medicare	$10,705.38
Rate for Payer: Wellcare Medicare	$10,705.38
Rate for Payer: Wellmed Medicare	$10,705.38

Know your out-of-pocket cost for care.

All Charges