White Rock Medical Center

All Charges

Charge

Type

Setting

Price

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC

Facility

$30,001.00

Service Code	MSDRG 658
Min. Negotiated Rate	$13,471.04
Max. Negotiated Rate	$30,001.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,133.26
Rate for Payer: Amerigroup Medicare	$16,133.26
Rate for Payer: BCBS of TX Medicare	$16,133.26
Rate for Payer: Cigna Commercial	$19,987.18
Rate for Payer: Cigna Medicare	$16,133.26
Rate for Payer: Employer Direct Commercial	$16,133.26
Rate for Payer: Humana Medicare/TRICARE	$16,133.26
Rate for Payer: Molina Dual Medicare/Medicaid	$16,133.26
Rate for Payer: Molina Medicare	$16,133.26
Rate for Payer: Multiplan Auto	$30,001.00
Rate for Payer: Multiplan Commercial	$30,001.00
Rate for Payer: Multiplan Workers Comp	$30,001.00
Rate for Payer: Scott and White EPO/PPO	$13,816.25
Rate for Payer: Scott and White Medicare	$16,133.26
Rate for Payer: Superior Health Plan EPO	$16,133.26
Rate for Payer: Superior Health Plan Medicare	$16,133.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,133.26
Rate for Payer: Universal American Medicare	$16,133.26
Rate for Payer: Wellcare Medicare	$16,133.26
Rate for Payer: Wellmed Medicare	$16,133.26

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC

Facility

$26,812.80

Service Code	MSDRG 660
Min. Negotiated Rate	$12,348.00
Max. Negotiated Rate	$26,812.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,446.85
Rate for Payer: Amerigroup Medicare	$14,446.85
Rate for Payer: BCBS of TX Medicare	$14,446.85
Rate for Payer: Cigna Commercial	$17,023.50
Rate for Payer: Cigna Medicare	$14,446.85
Rate for Payer: Employer Direct Commercial	$14,446.85
Rate for Payer: Humana Medicare/TRICARE	$14,446.85
Rate for Payer: Molina Dual Medicare/Medicaid	$14,446.85
Rate for Payer: Molina Medicare	$14,446.85
Rate for Payer: Multiplan Auto	$26,812.80
Rate for Payer: Multiplan Commercial	$26,812.80
Rate for Payer: Multiplan Workers Comp	$26,812.80
Rate for Payer: Scott and White EPO/PPO	$12,348.00
Rate for Payer: Scott and White Medicare	$14,446.85
Rate for Payer: Superior Health Plan EPO	$14,446.85
Rate for Payer: Superior Health Plan Medicare	$14,446.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,446.85
Rate for Payer: Universal American Medicare	$14,446.85
Rate for Payer: Wellcare Medicare	$14,446.85
Rate for Payer: Wellmed Medicare	$14,446.85

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC

Facility

$48,961.10

Service Code	MSDRG 659
Min. Negotiated Rate	$22,547.88
Max. Negotiated Rate	$48,961.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,382.40
Rate for Payer: Amerigroup Medicare	$23,382.40
Rate for Payer: BCBS of TX Medicare	$23,382.40
Rate for Payer: Cigna Commercial	$32,726.79
Rate for Payer: Cigna Medicare	$23,382.40
Rate for Payer: Employer Direct Commercial	$23,382.40
Rate for Payer: Humana Medicare/TRICARE	$23,382.40
Rate for Payer: Molina Dual Medicare/Medicaid	$23,382.40
Rate for Payer: Molina Medicare	$23,382.40
Rate for Payer: Multiplan Auto	$48,961.10
Rate for Payer: Multiplan Commercial	$48,961.10
Rate for Payer: Multiplan Workers Comp	$48,961.10
Rate for Payer: Scott and White EPO/PPO	$22,547.88
Rate for Payer: Scott and White Medicare	$23,382.40
Rate for Payer: Superior Health Plan EPO	$23,382.40
Rate for Payer: Superior Health Plan Medicare	$23,382.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,382.40
Rate for Payer: Universal American Medicare	$23,382.40
Rate for Payer: Wellcare Medicare	$23,382.40
Rate for Payer: Wellmed Medicare	$23,382.40

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC

Facility

$20,480.10

Service Code	MSDRG 661
Min. Negotiated Rate	$9,226.08
Max. Negotiated Rate	$20,480.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,348.55
Rate for Payer: Amerigroup Medicare	$12,348.55
Rate for Payer: BCBS of TX Medicare	$12,348.55
Rate for Payer: Cigna Commercial	$13,335.95
Rate for Payer: Cigna Medicare	$12,348.55
Rate for Payer: Employer Direct Commercial	$12,348.55
Rate for Payer: Humana Medicare/TRICARE	$12,348.55
Rate for Payer: Molina Dual Medicare/Medicaid	$12,348.55
Rate for Payer: Molina Medicare	$12,348.55
Rate for Payer: Multiplan Auto	$20,480.10
Rate for Payer: Multiplan Commercial	$20,480.10
Rate for Payer: Multiplan Workers Comp	$20,480.10
Rate for Payer: Scott and White EPO/PPO	$9,431.62
Rate for Payer: Scott and White Medicare	$12,348.55
Rate for Payer: Superior Health Plan EPO	$12,348.55
Rate for Payer: Superior Health Plan Medicare	$12,348.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,348.55
Rate for Payer: Universal American Medicare	$12,348.55
Rate for Payer: Wellcare Medicare	$12,348.55
Rate for Payer: Wellmed Medicare	$12,348.55

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$4,256.96

Service Code	APR-DRG 4633
Min. Negotiated Rate	$4,013.61
Max. Negotiated Rate	$4,256.96
Rate for Payer: Amerigroup CHIP/Medicaid	$4,013.61
Rate for Payer: Cigna Medicaid	$4,013.61
Rate for Payer: Molina CHIP/Medicaid	$4,013.61
Rate for Payer: Parkland Medicaid	$4,013.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,256.96

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$2,773.47

Service Code	APR-DRG 4632
Min. Negotiated Rate	$2,614.93
Max. Negotiated Rate	$2,773.47
Rate for Payer: Amerigroup CHIP/Medicaid	$2,614.93
Rate for Payer: Cigna Medicaid	$2,614.93
Rate for Payer: Molina CHIP/Medicaid	$2,614.93
Rate for Payer: Parkland Medicaid	$2,614.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,773.47

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$1,957.99

Service Code	APR-DRG 4631
Min. Negotiated Rate	$1,846.06
Max. Negotiated Rate	$1,957.99
Rate for Payer: Amerigroup CHIP/Medicaid	$1,846.06
Rate for Payer: Cigna Medicaid	$1,846.06
Rate for Payer: Molina CHIP/Medicaid	$1,846.06
Rate for Payer: Parkland Medicaid	$1,846.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,957.99

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$8,092.59

Service Code	APR-DRG 4634
Min. Negotiated Rate	$7,629.98
Max. Negotiated Rate	$8,092.59
Rate for Payer: Amerigroup CHIP/Medicaid	$7,629.98
Rate for Payer: Cigna Medicaid	$7,629.98
Rate for Payer: Molina CHIP/Medicaid	$7,629.98
Rate for Payer: Parkland Medicaid	$7,629.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,092.59

KIDNEY AND URINARY TRACT INFECTIONS WITH MCC

Facility

$21,794.90

Service Code	MSDRG 689
Min. Negotiated Rate	$9,559.76
Max. Negotiated Rate	$21,794.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,263.96
Rate for Payer: Amerigroup Medicare	$13,263.96
Rate for Payer: BCBS of TX Medicare	$13,263.96
Rate for Payer: Cigna Commercial	$14,944.66
Rate for Payer: Cigna Medicare	$13,263.96
Rate for Payer: Employer Direct Commercial	$13,263.96
Rate for Payer: Humana Medicare/TRICARE	$13,263.96
Rate for Payer: Molina Dual Medicare/Medicaid	$13,263.96
Rate for Payer: Molina Medicare	$13,263.96
Rate for Payer: Multiplan Auto	$21,794.90
Rate for Payer: Multiplan Commercial	$21,794.90
Rate for Payer: Multiplan Workers Comp	$21,794.90
Rate for Payer: Scott and White EPO/PPO	$10,037.12
Rate for Payer: Scott and White Medicare	$13,263.96
Rate for Payer: Superior Health Plan EPO	$13,263.96
Rate for Payer: Superior Health Plan Medicare	$13,263.96
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,263.96
Rate for Payer: Universal American Medicare	$13,263.96
Rate for Payer: Wellcare Medicare	$13,263.96
Rate for Payer: Wellmed Medicare	$13,263.96

KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC

Facility

$15,116.40

Service Code	MSDRG 690
Min. Negotiated Rate	$6,829.26
Max. Negotiated Rate	$15,116.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,692.94
Rate for Payer: Amerigroup Medicare	$10,692.94
Rate for Payer: BCBS of TX Medicare	$10,692.94
Rate for Payer: Cigna Commercial	$10,426.36
Rate for Payer: Cigna Medicare	$10,692.94
Rate for Payer: Employer Direct Commercial	$10,692.94
Rate for Payer: Humana Medicare/TRICARE	$10,692.94
Rate for Payer: Molina Dual Medicare/Medicaid	$10,692.94
Rate for Payer: Molina Medicare	$10,692.94
Rate for Payer: Multiplan Auto	$15,116.40
Rate for Payer: Multiplan Commercial	$15,116.40
Rate for Payer: Multiplan Workers Comp	$15,116.40
Rate for Payer: Scott and White EPO/PPO	$6,961.50
Rate for Payer: Scott and White Medicare	$10,692.94
Rate for Payer: Superior Health Plan EPO	$10,692.94
Rate for Payer: Superior Health Plan Medicare	$10,692.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,692.94
Rate for Payer: Universal American Medicare	$10,692.94
Rate for Payer: Wellcare Medicare	$10,692.94
Rate for Payer: Wellmed Medicare	$10,692.94

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

$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 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 NEOPLASMS WITH CC

Facility

$19,756.20

Service Code	MSDRG 687
Min. Negotiated Rate	$9,061.82
Max. Negotiated Rate	$19,756.20
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	$19,756.20
Rate for Payer: Multiplan Commercial	$19,756.20
Rate for Payer: Multiplan Workers Comp	$19,756.20
Rate for Payer: Scott and White EPO/PPO	$9,098.25
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

$32,258.20

Service Code	MSDRG 686
Min. Negotiated Rate	$14,771.36
Max. Negotiated Rate	$32,258.20
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	$32,258.20
Rate for Payer: Multiplan Commercial	$32,258.20
Rate for Payer: Multiplan Workers Comp	$32,258.20
Rate for Payer: Scott and White EPO/PPO	$14,855.75
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

$16,461.60

Service Code	MSDRG 688
Min. Negotiated Rate	$6,801.74
Max. Negotiated Rate	$16,461.60
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	$16,461.60
Rate for Payer: Multiplan Commercial	$16,461.60
Rate for Payer: Multiplan Workers Comp	$16,461.60
Rate for Payer: Scott and White EPO/PPO	$7,581.00
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

$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

$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

$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 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 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 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

$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

$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

Know your out-of-pocket cost for care.

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