White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$29,807.20

Service Code	MSDRG 836
Min. Negotiated Rate	$10,428.36
Max. Negotiated Rate	$29,807.20
Rate for Payer: Multiplan Auto	$29,807.20
Rate for Payer: Multiplan Commercial	$29,807.20
Rate for Payer: Multiplan Workers Comp	$29,807.20
Rate for Payer: Scott and White EPO/PPO	$13,727.00

ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC

Facility

$39,844.90

Service Code	MSDRG 835
Min. Negotiated Rate	$18,349.62
Max. Negotiated Rate	$39,844.90
Rate for Payer: BCBS of TX Blue Advantage	$18,369.60
Rate for Payer: BCBS of TX Blue Essentials	$22,041.38
Rate for Payer: BCBS of TX PPO	$24,491.38

ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC

Facility

$105,070.00

Service Code	MSDRG 834
Min. Negotiated Rate	$44,995.69
Max. Negotiated Rate	$105,070.00
Rate for Payer: BCBS of TX Blue Advantage	$47,367.08
Rate for Payer: BCBS of TX Blue Essentials	$56,834.99
Rate for Payer: BCBS of TX PPO	$63,152.43

ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W/O CC/MCC

Facility

$29,807.20

Service Code	MSDRG 836
Min. Negotiated Rate	$10,428.36
Max. Negotiated Rate	$29,807.20
Rate for Payer: BCBS of TX Blue Advantage	$10,428.36
Rate for Payer: BCBS of TX Blue Essentials	$12,512.82
Rate for Payer: BCBS of TX PPO	$13,903.67

ACUTE MAJOR EYE INFECTIONS W CC/MCC

Facility

$23,280.70

Service Code	MSDRG 121
Min. Negotiated Rate	$9,109.98
Max. Negotiated Rate	$23,280.70
Rate for Payer: BCBS of TX Blue Advantage	$9,109.98
Rate for Payer: BCBS of TX Blue Essentials	$10,930.92
Rate for Payer: BCBS of TX PPO	$12,145.93

ACUTE MAJOR EYE INFECTIONS WITH CC/MCC

Facility

$23,280.70

Service Code	MSDRG 121
Min. Negotiated Rate	$9,109.98
Max. Negotiated Rate	$23,280.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,285.93
Rate for Payer: Amerigroup Medicare	$13,285.93
Rate for Payer: BCBS of TX Medicare	$13,285.93
Rate for Payer: Cigna Commercial	$14,983.30
Rate for Payer: Cigna Medicare	$13,285.93
Rate for Payer: Employer Direct Commercial	$13,285.93
Rate for Payer: Humana Medicare/TRICARE	$13,285.93
Rate for Payer: Molina Dual Medicare/Medicaid	$13,285.93
Rate for Payer: Molina Medicare	$13,285.93
Rate for Payer: Multiplan Auto	$23,280.70
Rate for Payer: Multiplan Commercial	$23,280.70
Rate for Payer: Multiplan Workers Comp	$23,280.70
Rate for Payer: Scott and White EPO/PPO	$10,721.38
Rate for Payer: Scott and White Medicare	$13,285.93
Rate for Payer: Superior Health Plan EPO	$13,285.93
Rate for Payer: Superior Health Plan Medicare	$13,285.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,285.93
Rate for Payer: Universal American Medicare	$13,285.93
Rate for Payer: Wellcare Medicare	$13,285.93
Rate for Payer: Wellmed Medicare	$13,285.93

ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC

Facility

$13,125.20

Service Code	MSDRG 122
Min. Negotiated Rate	$6,044.50
Max. Negotiated Rate	$13,125.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,519.23
Rate for Payer: Amerigroup Medicare	$10,519.23
Rate for Payer: BCBS of TX Medicare	$10,519.23
Rate for Payer: Cigna Commercial	$10,121.10
Rate for Payer: Cigna Medicare	$10,519.23
Rate for Payer: Employer Direct Commercial	$10,519.23
Rate for Payer: Humana Medicare/TRICARE	$10,519.23
Rate for Payer: Molina Dual Medicare/Medicaid	$10,519.23
Rate for Payer: Molina Medicare	$10,519.23
Rate for Payer: Multiplan Auto	$13,125.20
Rate for Payer: Multiplan Commercial	$13,125.20
Rate for Payer: Multiplan Workers Comp	$13,125.20
Rate for Payer: Scott and White EPO/PPO	$6,044.50
Rate for Payer: Scott and White Medicare	$10,519.23
Rate for Payer: Superior Health Plan EPO	$10,519.23
Rate for Payer: Superior Health Plan Medicare	$10,519.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,519.23
Rate for Payer: Universal American Medicare	$10,519.23
Rate for Payer: Wellcare Medicare	$10,519.23
Rate for Payer: Wellmed Medicare	$10,519.23

ACUTE MAJOR EYE INFECTIONS W/O CC/MCC

Facility

$13,125.20

Service Code	MSDRG 122
Min. Negotiated Rate	$6,044.50
Max. Negotiated Rate	$13,125.20
Rate for Payer: BCBS of TX Blue Advantage	$6,069.88
Rate for Payer: BCBS of TX Blue Essentials	$7,283.15
Rate for Payer: BCBS of TX PPO	$8,092.70

ACUTE MYOCARDIAL INFARCTION

Facility

$5,323.27

Service Code	APR-DRG 1903
Min. Negotiated Rate	$5,018.96
Max. Negotiated Rate	$5,323.27
Rate for Payer: Amerigroup CHIP/Medicaid	$5,018.96
Rate for Payer: Cigna Medicaid	$5,018.96
Rate for Payer: Molina CHIP/Medicaid	$5,018.96
Rate for Payer: Parkland Medicaid	$5,018.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,323.27

ACUTE MYOCARDIAL INFARCTION

Facility

$9,393.51

Service Code	APR-DRG 1904
Min. Negotiated Rate	$8,856.53
Max. Negotiated Rate	$9,393.51
Rate for Payer: Amerigroup CHIP/Medicaid	$8,856.53
Rate for Payer: Cigna Medicaid	$8,856.53
Rate for Payer: Molina CHIP/Medicaid	$8,856.53
Rate for Payer: Parkland Medicaid	$8,856.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,393.51

ACUTE MYOCARDIAL INFARCTION

Facility

$4,013.29

Service Code	APR-DRG 1902
Min. Negotiated Rate	$3,783.87
Max. Negotiated Rate	$4,013.29
Rate for Payer: Amerigroup CHIP/Medicaid	$3,783.87
Rate for Payer: Cigna Medicaid	$3,783.87
Rate for Payer: Molina CHIP/Medicaid	$3,783.87
Rate for Payer: Parkland Medicaid	$3,783.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,013.29

ACUTE MYOCARDIAL INFARCTION

Facility

$3,731.53

Service Code	APR-DRG 1901
Min. Negotiated Rate	$3,518.22
Max. Negotiated Rate	$3,731.53
Rate for Payer: Amerigroup CHIP/Medicaid	$3,518.22
Rate for Payer: Cigna Medicaid	$3,518.22
Rate for Payer: Molina CHIP/Medicaid	$3,518.22
Rate for Payer: Parkland Medicaid	$3,518.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,731.53

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC

Facility

$17,453.40

Service Code	MSDRG 281
Min. Negotiated Rate	$8,037.75
Max. Negotiated Rate	$17,453.40
Rate for Payer: BCBS of TX Blue Advantage	$8,424.56
Rate for Payer: BCBS of TX Blue Essentials	$10,108.49
Rate for Payer: BCBS of TX PPO	$11,232.09

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC

Facility

$17,453.40

Service Code	MSDRG 281
Min. Negotiated Rate	$8,037.75
Max. Negotiated Rate	$17,453.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,496.18
Rate for Payer: Amerigroup Medicare	$11,496.18
Rate for Payer: BCBS of TX Medicare	$11,496.18
Rate for Payer: Cigna Commercial	$11,838.01
Rate for Payer: Cigna Medicare	$11,496.18
Rate for Payer: Employer Direct Commercial	$11,496.18
Rate for Payer: Humana Medicare/TRICARE	$11,496.18
Rate for Payer: Molina Dual Medicare/Medicaid	$11,496.18
Rate for Payer: Molina Medicare	$11,496.18
Rate for Payer: Multiplan Auto	$17,453.40
Rate for Payer: Multiplan Commercial	$17,453.40
Rate for Payer: Multiplan Workers Comp	$17,453.40
Rate for Payer: Scott and White EPO/PPO	$8,037.75
Rate for Payer: Scott and White Medicare	$11,496.18
Rate for Payer: Superior Health Plan EPO	$11,496.18
Rate for Payer: Superior Health Plan Medicare	$11,496.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,496.18
Rate for Payer: Universal American Medicare	$11,496.18
Rate for Payer: Wellcare Medicare	$11,496.18
Rate for Payer: Wellmed Medicare	$11,496.18

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC

Facility

$30,521.60

Service Code	MSDRG 280
Min. Negotiated Rate	$14,056.00
Max. Negotiated Rate	$30,521.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,516.57
Rate for Payer: Amerigroup Medicare	$16,516.57
Rate for Payer: BCBS of TX Medicare	$16,516.57
Rate for Payer: Cigna Commercial	$20,660.81
Rate for Payer: Cigna Medicare	$16,516.57
Rate for Payer: Employer Direct Commercial	$16,516.57
Rate for Payer: Humana Medicare/TRICARE	$16,516.57
Rate for Payer: Molina Dual Medicare/Medicaid	$16,516.57
Rate for Payer: Molina Medicare	$16,516.57
Rate for Payer: Multiplan Auto	$30,521.60
Rate for Payer: Multiplan Commercial	$30,521.60
Rate for Payer: Multiplan Workers Comp	$30,521.60
Rate for Payer: Scott and White EPO/PPO	$14,056.00
Rate for Payer: Scott and White Medicare	$16,516.57
Rate for Payer: Superior Health Plan EPO	$16,516.57
Rate for Payer: Superior Health Plan Medicare	$16,516.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,516.57
Rate for Payer: Universal American Medicare	$16,516.57
Rate for Payer: Wellcare Medicare	$16,516.57
Rate for Payer: Wellmed Medicare	$16,516.57

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC

Facility

$13,617.30

Service Code	MSDRG 282
Min. Negotiated Rate	$6,271.12
Max. Negotiated Rate	$13,617.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,059.70
Rate for Payer: Amerigroup Medicare	$10,059.70
Rate for Payer: BCBS of TX Medicare	$10,059.70
Rate for Payer: Cigna Commercial	$9,313.53
Rate for Payer: Cigna Medicare	$10,059.70
Rate for Payer: Employer Direct Commercial	$10,059.70
Rate for Payer: Humana Medicare/TRICARE	$10,059.70
Rate for Payer: Molina Dual Medicare/Medicaid	$10,059.70
Rate for Payer: Molina Medicare	$10,059.70
Rate for Payer: Multiplan Auto	$13,617.30
Rate for Payer: Multiplan Commercial	$13,617.30
Rate for Payer: Multiplan Workers Comp	$13,617.30
Rate for Payer: Scott and White EPO/PPO	$6,271.12
Rate for Payer: Scott and White Medicare	$10,059.70
Rate for Payer: Superior Health Plan EPO	$10,059.70
Rate for Payer: Superior Health Plan Medicare	$10,059.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,059.70
Rate for Payer: Universal American Medicare	$10,059.70
Rate for Payer: Wellcare Medicare	$10,059.70
Rate for Payer: Wellmed Medicare	$10,059.70

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC

Facility

$30,521.60

Service Code	MSDRG 280
Min. Negotiated Rate	$14,056.00
Max. Negotiated Rate	$30,521.60
Rate for Payer: BCBS of TX Blue Advantage	$14,251.06
Rate for Payer: BCBS of TX Blue Essentials	$17,099.61
Rate for Payer: BCBS of TX PPO	$19,000.31

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC

Facility

$13,617.30

Service Code	MSDRG 282
Min. Negotiated Rate	$6,271.12
Max. Negotiated Rate	$13,617.30
Rate for Payer: BCBS of TX Blue Advantage	$6,441.40
Rate for Payer: BCBS of TX Blue Essentials	$7,728.93
Rate for Payer: BCBS of TX PPO	$8,588.03

ACUTE MYOCARDIAL INFARCTION, EXPIRED W CC

Facility

$13,972.60

Service Code	MSDRG 284
Min. Negotiated Rate	$6,434.75
Max. Negotiated Rate	$13,972.60
Rate for Payer: BCBS of TX Blue Advantage	$6,592.76
Rate for Payer: BCBS of TX Blue Essentials	$7,910.55
Rate for Payer: BCBS of TX PPO	$8,789.84

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC

Facility

$13,972.60

Service Code	MSDRG 284
Min. Negotiated Rate	$6,434.75
Max. Negotiated Rate	$13,972.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,833.23
Rate for Payer: Amerigroup Medicare	$9,833.23
Rate for Payer: BCBS of TX Medicare	$9,833.23
Rate for Payer: Cigna Commercial	$8,915.54
Rate for Payer: Cigna Medicare	$9,833.23
Rate for Payer: Employer Direct Commercial	$9,833.23
Rate for Payer: Humana Medicare/TRICARE	$9,833.23
Rate for Payer: Molina Dual Medicare/Medicaid	$9,833.23
Rate for Payer: Molina Medicare	$9,833.23
Rate for Payer: Multiplan Auto	$13,972.60
Rate for Payer: Multiplan Commercial	$13,972.60
Rate for Payer: Multiplan Workers Comp	$13,972.60
Rate for Payer: Scott and White EPO/PPO	$6,434.75
Rate for Payer: Scott and White Medicare	$9,833.23
Rate for Payer: Superior Health Plan EPO	$9,833.23
Rate for Payer: Superior Health Plan Medicare	$9,833.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,833.23
Rate for Payer: Universal American Medicare	$9,833.23
Rate for Payer: Wellcare Medicare	$9,833.23
Rate for Payer: Wellmed Medicare	$9,833.23

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC

Facility

$36,453.40

Service Code	MSDRG 283
Min. Negotiated Rate	$15,520.42
Max. Negotiated Rate	$36,453.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,277.42
Rate for Payer: Amerigroup Medicare	$19,277.42
Rate for Payer: BCBS of TX Medicare	$19,277.42
Rate for Payer: Cigna Commercial	$25,512.70
Rate for Payer: Cigna Medicare	$19,277.42
Rate for Payer: Employer Direct Commercial	$19,277.42
Rate for Payer: Humana Medicare/TRICARE	$19,277.42
Rate for Payer: Molina Dual Medicare/Medicaid	$19,277.42
Rate for Payer: Molina Medicare	$19,277.42
Rate for Payer: Multiplan Auto	$36,453.40
Rate for Payer: Multiplan Commercial	$36,453.40
Rate for Payer: Multiplan Workers Comp	$36,453.40
Rate for Payer: Scott and White EPO/PPO	$16,787.75
Rate for Payer: Scott and White Medicare	$19,277.42
Rate for Payer: Superior Health Plan EPO	$19,277.42
Rate for Payer: Superior Health Plan Medicare	$19,277.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,277.42
Rate for Payer: Universal American Medicare	$19,277.42
Rate for Payer: Wellcare Medicare	$19,277.42
Rate for Payer: Wellmed Medicare	$19,277.42

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

Facility

$10,294.20

Service Code	MSDRG 285
Min. Negotiated Rate	$4,740.75
Max. Negotiated Rate	$10,294.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,149.42
Rate for Payer: Amerigroup Medicare	$9,149.42
Rate for Payer: BCBS of TX Medicare	$9,149.42
Rate for Payer: Cigna Commercial	$7,713.83
Rate for Payer: Cigna Medicare	$9,149.42
Rate for Payer: Employer Direct Commercial	$9,149.42
Rate for Payer: Humana Medicare/TRICARE	$9,149.42
Rate for Payer: Molina Dual Medicare/Medicaid	$9,149.42
Rate for Payer: Molina Medicare	$9,149.42
Rate for Payer: Multiplan Auto	$10,294.20
Rate for Payer: Multiplan Commercial	$10,294.20
Rate for Payer: Multiplan Workers Comp	$10,294.20
Rate for Payer: Scott and White EPO/PPO	$4,740.75
Rate for Payer: Scott and White Medicare	$9,149.42
Rate for Payer: Superior Health Plan EPO	$9,149.42
Rate for Payer: Superior Health Plan Medicare	$9,149.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,149.42
Rate for Payer: Universal American Medicare	$9,149.42
Rate for Payer: Wellcare Medicare	$9,149.42
Rate for Payer: Wellmed Medicare	$9,149.42

ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC

Facility

$36,453.40

Service Code	MSDRG 283
Min. Negotiated Rate	$15,520.42
Max. Negotiated Rate	$36,453.40
Rate for Payer: BCBS of TX Blue Advantage	$15,520.42
Rate for Payer: BCBS of TX Blue Essentials	$18,622.70
Rate for Payer: BCBS of TX PPO	$20,692.69

ACUTE MYOCARDIAL INFARCTION, EXPIRED W/O CC/MCC

Facility

$10,294.20

Service Code	MSDRG 285
Min. Negotiated Rate	$4,740.75
Max. Negotiated Rate	$10,294.20
Rate for Payer: BCBS of TX Blue Advantage	$5,129.04
Rate for Payer: BCBS of TX Blue Essentials	$6,154.25
Rate for Payer: BCBS of TX PPO	$6,838.32

ACUTE & SUBACUTE ENDOCARDITIS W CC

Facility

$30,534.90

Service Code	MSDRG 289
Min. Negotiated Rate	$14,062.12
Max. Negotiated Rate	$30,534.90
Rate for Payer: BCBS of TX Blue Advantage	$14,705.14
Rate for Payer: BCBS of TX Blue Essentials	$17,644.46
Rate for Payer: BCBS of TX PPO	$19,605.71

Know your out-of-pocket cost for care.

All Charges