White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIDNEY AND URINARY TRACT MALIGNANCY

Facility

$4,195.85

Service Code	APR-DRG 4611
Min. Negotiated Rate	$3,955.99
Max. Negotiated Rate	$4,195.85
Rate for Payer: Amerigroup CHIP/Medicaid	$3,955.99
Rate for Payer: Cigna Medicaid	$3,955.99
Rate for Payer: Molina CHIP/Medicaid	$3,955.99
Rate for Payer: Parkland Medicaid	$3,955.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,195.85

KIDNEY AND URINARY TRACT MALIGNANCY

Facility

$4,719.01

Service Code	APR-DRG 4612
Min. Negotiated Rate	$4,449.25
Max. Negotiated Rate	$4,719.01
Rate for Payer: Amerigroup CHIP/Medicaid	$4,449.25
Rate for Payer: Cigna Medicaid	$4,449.25
Rate for Payer: Molina CHIP/Medicaid	$4,449.25
Rate for Payer: Parkland Medicaid	$4,449.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,719.01

KIDNEY AND URINARY TRACT MALIGNANCY

Facility

$9,095.54

Service Code	APR-DRG 4613
Min. Negotiated Rate	$8,575.59
Max. Negotiated Rate	$9,095.54
Rate for Payer: Amerigroup CHIP/Medicaid	$8,575.59
Rate for Payer: Cigna Medicaid	$8,575.59
Rate for Payer: Molina CHIP/Medicaid	$8,575.59
Rate for Payer: Parkland Medicaid	$8,575.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,095.54

KIDNEY AND URINARY TRACT MALIGNANCY

Facility

$19,582.52

Service Code	APR-DRG 4614
Min. Negotiated Rate	$18,463.09
Max. Negotiated Rate	$19,582.52
Rate for Payer: Amerigroup CHIP/Medicaid	$18,463.09
Rate for Payer: Cigna Medicaid	$18,463.09
Rate for Payer: Molina CHIP/Medicaid	$18,463.09
Rate for Payer: Parkland Medicaid	$18,463.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,582.52

KIDNEY AND URINARY TRACT NEOPLASMS WITH CC

Facility

$19,908.20

Service Code	MSDRG 687
Min. Negotiated Rate	$9,061.82
Max. Negotiated Rate	$19,908.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,439.43
Rate for Payer: Amerigroup Medicare	$12,439.43
Rate for Payer: BCBS of TX Medicare	$12,439.43
Rate for Payer: Cigna Commercial	$13,495.66
Rate for Payer: Cigna Medicare	$12,439.43
Rate for Payer: Employer Direct Commercial	$12,439.43
Rate for Payer: Humana Medicare/TRICARE	$12,439.43
Rate for Payer: Molina Dual Medicare/Medicaid	$12,439.43
Rate for Payer: Molina Medicare	$12,439.43
Rate for Payer: Multiplan Auto	$19,908.20
Rate for Payer: Multiplan Commercial	$19,908.20
Rate for Payer: Multiplan Workers Comp	$19,908.20
Rate for Payer: Scott and White EPO/PPO	$9,168.25
Rate for Payer: Scott and White Medicare	$12,439.43
Rate for Payer: Superior Health Plan EPO	$12,439.43
Rate for Payer: Superior Health Plan Medicare	$12,439.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,439.43
Rate for Payer: Universal American Medicare	$12,439.43
Rate for Payer: Wellcare Medicare	$12,439.43
Rate for Payer: Wellmed Medicare	$12,439.43

KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC

Facility

$34,270.30

Service Code	MSDRG 686
Min. Negotiated Rate	$14,771.36
Max. Negotiated Rate	$34,270.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,979.44
Rate for Payer: Amerigroup Medicare	$17,979.44
Rate for Payer: BCBS of TX Medicare	$17,979.44
Rate for Payer: Cigna Commercial	$23,231.66
Rate for Payer: Cigna Medicare	$17,979.44
Rate for Payer: Employer Direct Commercial	$17,979.44
Rate for Payer: Humana Medicare/TRICARE	$17,979.44
Rate for Payer: Molina Dual Medicare/Medicaid	$17,979.44
Rate for Payer: Molina Medicare	$17,979.44
Rate for Payer: Multiplan Auto	$34,270.30
Rate for Payer: Multiplan Commercial	$34,270.30
Rate for Payer: Multiplan Workers Comp	$34,270.30
Rate for Payer: Scott and White EPO/PPO	$15,782.38
Rate for Payer: Scott and White Medicare	$17,979.44
Rate for Payer: Superior Health Plan EPO	$17,979.44
Rate for Payer: Superior Health Plan Medicare	$17,979.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,979.44
Rate for Payer: Universal American Medicare	$17,979.44
Rate for Payer: Wellcare Medicare	$17,979.44
Rate for Payer: Wellmed Medicare	$17,979.44

KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC

Facility

$15,015.70

Service Code	MSDRG 688
Min. Negotiated Rate	$6,801.74
Max. Negotiated Rate	$15,015.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,552.21
Rate for Payer: Amerigroup Medicare	$10,552.21
Rate for Payer: BCBS of TX Medicare	$10,552.21
Rate for Payer: Cigna Commercial	$10,179.06
Rate for Payer: Cigna Medicare	$10,552.21
Rate for Payer: Employer Direct Commercial	$10,552.21
Rate for Payer: Humana Medicare/TRICARE	$10,552.21
Rate for Payer: Molina Dual Medicare/Medicaid	$10,552.21
Rate for Payer: Molina Medicare	$10,552.21
Rate for Payer: Multiplan Auto	$15,015.70
Rate for Payer: Multiplan Commercial	$15,015.70
Rate for Payer: Multiplan Workers Comp	$15,015.70
Rate for Payer: Scott and White EPO/PPO	$6,915.12
Rate for Payer: Scott and White Medicare	$10,552.21
Rate for Payer: Superior Health Plan EPO	$10,552.21
Rate for Payer: Superior Health Plan Medicare	$10,552.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,552.21
Rate for Payer: Universal American Medicare	$10,552.21
Rate for Payer: Wellcare Medicare	$10,552.21
Rate for Payer: Wellmed Medicare	$10,552.21

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility

$8,304.19

Service Code	APR-DRG 4422
Min. Negotiated Rate	$7,829.48
Max. Negotiated Rate	$8,304.19
Rate for Payer: Amerigroup CHIP/Medicaid	$7,829.48
Rate for Payer: Cigna Medicaid	$7,829.48
Rate for Payer: Molina CHIP/Medicaid	$7,829.48
Rate for Payer: Parkland Medicaid	$7,829.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,304.19

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility

$7,043.25

Service Code	APR-DRG 4421
Min. Negotiated Rate	$6,640.62
Max. Negotiated Rate	$7,043.25
Rate for Payer: Amerigroup CHIP/Medicaid	$6,640.62
Rate for Payer: Cigna Medicaid	$6,640.62
Rate for Payer: Molina CHIP/Medicaid	$6,640.62
Rate for Payer: Parkland Medicaid	$6,640.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,043.25

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility

$13,282.71

Service Code	APR-DRG 4423
Min. Negotiated Rate	$12,523.40
Max. Negotiated Rate	$13,282.71
Rate for Payer: Amerigroup CHIP/Medicaid	$12,523.40
Rate for Payer: Cigna Medicaid	$12,523.40
Rate for Payer: Molina CHIP/Medicaid	$12,523.40
Rate for Payer: Parkland Medicaid	$12,523.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,282.71

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility

$39,500.74

Service Code	APR-DRG 4424
Min. Negotiated Rate	$37,242.68
Max. Negotiated Rate	$39,500.74
Rate for Payer: Amerigroup CHIP/Medicaid	$37,242.68
Rate for Payer: Cigna Medicaid	$37,242.68
Rate for Payer: Molina CHIP/Medicaid	$37,242.68
Rate for Payer: Parkland Medicaid	$37,242.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39,500.74

KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY

Facility

$5,010.96

Service Code	APR-DRG 4431
Min. Negotiated Rate	$4,724.50
Max. Negotiated Rate	$5,010.96
Rate for Payer: Amerigroup CHIP/Medicaid	$4,724.50
Rate for Payer: Cigna Medicaid	$4,724.50
Rate for Payer: Molina CHIP/Medicaid	$4,724.50
Rate for Payer: Parkland Medicaid	$4,724.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,010.96

KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY

Facility

$10,908.31

Service Code	APR-DRG 4433
Min. Negotiated Rate	$10,284.73
Max. Negotiated Rate	$10,908.31
Rate for Payer: Amerigroup CHIP/Medicaid	$10,284.73
Rate for Payer: Cigna Medicaid	$10,284.73
Rate for Payer: Molina CHIP/Medicaid	$10,284.73
Rate for Payer: Parkland Medicaid	$10,284.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,908.31

KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY

Facility

$25,055.53

Service Code	APR-DRG 4434
Min. Negotiated Rate	$23,623.23
Max. Negotiated Rate	$25,055.53
Rate for Payer: Amerigroup CHIP/Medicaid	$23,623.23
Rate for Payer: Cigna Medicaid	$23,623.23
Rate for Payer: Molina CHIP/Medicaid	$23,623.23
Rate for Payer: Parkland Medicaid	$23,623.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,055.53

KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY

Facility

$6,941.79

Service Code	APR-DRG 4432
Min. Negotiated Rate	$6,544.96
Max. Negotiated Rate	$6,941.79
Rate for Payer: Amerigroup CHIP/Medicaid	$6,544.96
Rate for Payer: Cigna Medicaid	$6,544.96
Rate for Payer: Molina CHIP/Medicaid	$6,544.96
Rate for Payer: Parkland Medicaid	$6,544.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,941.79

KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC

Facility

$21,732.20

Service Code	MSDRG 695
Min. Negotiated Rate	$9,878.82
Max. Negotiated Rate	$21,732.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,143.03
Rate for Payer: Amerigroup Medicare	$13,143.03
Rate for Payer: BCBS of TX Medicare	$13,143.03
Rate for Payer: Cigna Commercial	$14,732.14
Rate for Payer: Cigna Medicare	$13,143.03
Rate for Payer: Employer Direct Commercial	$13,143.03
Rate for Payer: Humana Medicare/TRICARE	$13,143.03
Rate for Payer: Molina Dual Medicare/Medicaid	$13,143.03
Rate for Payer: Molina Medicare	$13,143.03
Rate for Payer: Multiplan Auto	$21,732.20
Rate for Payer: Multiplan Commercial	$21,732.20
Rate for Payer: Multiplan Workers Comp	$21,732.20
Rate for Payer: Scott and White EPO/PPO	$10,008.25
Rate for Payer: Scott and White Medicare	$13,143.03
Rate for Payer: Superior Health Plan EPO	$13,143.03
Rate for Payer: Superior Health Plan Medicare	$13,143.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,143.03
Rate for Payer: Universal American Medicare	$13,143.03
Rate for Payer: Wellcare Medicare	$13,143.03
Rate for Payer: Wellmed Medicare	$13,143.03

KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$13,091.00

Service Code	MSDRG 696
Min. Negotiated Rate	$5,921.96
Max. Negotiated Rate	$13,091.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,809.78
Rate for Payer: Amerigroup Medicare	$9,809.78
Rate for Payer: BCBS of TX Medicare	$9,809.78
Rate for Payer: Cigna Commercial	$8,874.32
Rate for Payer: Cigna Medicare	$9,809.78
Rate for Payer: Employer Direct Commercial	$9,809.78
Rate for Payer: Humana Medicare/TRICARE	$9,809.78
Rate for Payer: Molina Dual Medicare/Medicaid	$9,809.78
Rate for Payer: Molina Medicare	$9,809.78
Rate for Payer: Multiplan Auto	$13,091.00
Rate for Payer: Multiplan Commercial	$13,091.00
Rate for Payer: Multiplan Workers Comp	$13,091.00
Rate for Payer: Scott and White EPO/PPO	$6,028.75
Rate for Payer: Scott and White Medicare	$9,809.78
Rate for Payer: Superior Health Plan EPO	$9,809.78
Rate for Payer: Superior Health Plan Medicare	$9,809.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,809.78
Rate for Payer: Universal American Medicare	$9,809.78
Rate for Payer: Wellcare Medicare	$9,809.78
Rate for Payer: Wellmed Medicare	$9,809.78

KIDNEY TRANSPLANT

Facility

$38,202.46

Service Code	APR-DRG 4403
Min. Negotiated Rate	$36,018.61
Max. Negotiated Rate	$38,202.46
Rate for Payer: Amerigroup CHIP/Medicaid	$36,018.61
Rate for Payer: Cigna Medicaid	$36,018.61
Rate for Payer: Molina CHIP/Medicaid	$36,018.61
Rate for Payer: Parkland Medicaid	$36,018.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38,202.46

KIDNEY TRANSPLANT

Facility

$61,360.50

Service Code	MSDRG 652
Min. Negotiated Rate	$28,258.12
Max. Negotiated Rate	$61,360.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,429.17
Rate for Payer: Amerigroup Medicare	$28,429.17
Rate for Payer: BCBS of TX Blue Advantage	$28,505.56
Rate for Payer: BCBS of TX Blue Essentials	$34,203.36
Rate for Payer: BCBS of TX Medicare	$28,429.17
Rate for Payer: BCBS of TX PPO	$38,005.20
Rate for Payer: Cigna Commercial	$41,595.96
Rate for Payer: Cigna Medicare	$28,429.17
Rate for Payer: Employer Direct Commercial	$28,429.17
Rate for Payer: Molina Dual Medicare/Medicaid	$28,429.17
Rate for Payer: Molina Medicare	$28,429.17
Rate for Payer: Multiplan Auto	$61,360.50
Rate for Payer: Multiplan Commercial	$61,360.50
Rate for Payer: Multiplan Workers Comp	$61,360.50
Rate for Payer: Scott and White EPO/PPO	$28,258.12
Rate for Payer: Scott and White Medicare	$28,429.17
Rate for Payer: Superior Health Plan EPO	$28,429.17
Rate for Payer: Superior Health Plan Medicare	$28,429.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,429.17
Rate for Payer: Universal American Medicare	$28,429.17
Rate for Payer: Wellcare Medicare	$28,429.17
Rate for Payer: Wellmed Medicare	$28,429.17

KIDNEY TRANSPLANT

Facility

$62,417.61

Service Code	APR-DRG 4404
Min. Negotiated Rate	$58,849.51
Max. Negotiated Rate	$62,417.61
Rate for Payer: Amerigroup CHIP/Medicaid	$58,849.51
Rate for Payer: Cigna Medicaid	$58,849.51
Rate for Payer: Molina CHIP/Medicaid	$58,849.51
Rate for Payer: Parkland Medicaid	$58,849.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62,417.61

KIDNEY TRANSPLANT

Facility

$23,032.67

Service Code	APR-DRG 4401
Min. Negotiated Rate	$21,716.01
Max. Negotiated Rate	$23,032.67
Rate for Payer: Amerigroup CHIP/Medicaid	$21,716.01
Rate for Payer: Cigna Medicaid	$21,716.01
Rate for Payer: Molina CHIP/Medicaid	$21,716.01
Rate for Payer: Parkland Medicaid	$21,716.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,032.67

KIDNEY TRANSPLANT

Facility

$24,571.22

Service Code	APR-DRG 4402
Min. Negotiated Rate	$23,166.61
Max. Negotiated Rate	$24,571.22
Rate for Payer: Amerigroup CHIP/Medicaid	$23,166.61
Rate for Payer: Cigna Medicaid	$23,166.61
Rate for Payer: Molina CHIP/Medicaid	$23,166.61
Rate for Payer: Parkland Medicaid	$23,166.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,571.22

KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC

Facility

$89,326.60

Service Code	MSDRG 650
Min. Negotiated Rate	$39,216.76
Max. Negotiated Rate	$89,326.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$39,216.76
Rate for Payer: Amerigroup Medicare	$39,216.76
Rate for Payer: BCBS of TX Medicare	$39,216.76
Rate for Payer: Cigna Commercial	$60,554.03
Rate for Payer: Cigna Medicare	$39,216.76
Rate for Payer: Employer Direct Commercial	$39,216.76
Rate for Payer: Humana Medicare/TRICARE	$39,216.76
Rate for Payer: Molina Dual Medicare/Medicaid	$39,216.76
Rate for Payer: Molina Medicare	$39,216.76
Rate for Payer: Multiplan Auto	$89,326.60
Rate for Payer: Multiplan Commercial	$89,326.60
Rate for Payer: Multiplan Workers Comp	$89,326.60
Rate for Payer: Scott and White EPO/PPO	$41,137.25
Rate for Payer: Scott and White Medicare	$39,216.76
Rate for Payer: Superior Health Plan EPO	$39,216.76
Rate for Payer: Superior Health Plan Medicare	$39,216.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$39,216.76
Rate for Payer: Universal American Medicare	$39,216.76
Rate for Payer: Wellcare Medicare	$39,216.76
Rate for Payer: Wellmed Medicare	$39,216.76

KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC

Facility

$70,410.20

Service Code	MSDRG 651
Min. Negotiated Rate	$31,919.99
Max. Negotiated Rate	$70,410.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$31,919.99
Rate for Payer: Amerigroup Medicare	$31,919.99
Rate for Payer: BCBS of TX Medicare	$31,919.99
Rate for Payer: Cigna Commercial	$47,730.70
Rate for Payer: Cigna Medicare	$31,919.99
Rate for Payer: Employer Direct Commercial	$31,919.99
Rate for Payer: Humana Medicare/TRICARE	$31,919.99
Rate for Payer: Molina Dual Medicare/Medicaid	$31,919.99
Rate for Payer: Molina Medicare	$31,919.99
Rate for Payer: Multiplan Auto	$70,410.20
Rate for Payer: Multiplan Commercial	$70,410.20
Rate for Payer: Multiplan Workers Comp	$70,410.20
Rate for Payer: Scott and White EPO/PPO	$32,425.75
Rate for Payer: Scott and White Medicare	$31,919.99
Rate for Payer: Superior Health Plan EPO	$31,919.99
Rate for Payer: Superior Health Plan Medicare	$31,919.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$31,919.99
Rate for Payer: Universal American Medicare	$31,919.99
Rate for Payer: Wellcare Medicare	$31,919.99
Rate for Payer: Wellmed Medicare	$31,919.99

KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC

Facility

$34,770.00

Service Code	MSDRG 657
Min. Negotiated Rate	$16,012.50
Max. Negotiated Rate	$34,770.00
Rate for Payer: BCBS of TX Blue Advantage	$16,747.64
Rate for Payer: BCBS of TX Blue Essentials	$20,095.22
Rate for Payer: BCBS of TX PPO	$22,328.89

Know your out-of-pocket cost for care.

All Charges