White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Liver Fibrosis Risk Profile SO-Hepatic Function Panel

Facility

$842.23

Service Code	HCPCS 80076
Hospital Charge Code	8993057
Hospital Revenue Code	301
Rate for Payer: Cash Price	$572.72

LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT

Facility

$33,080.61

Service Code	APR-DRG 0012
Min. Negotiated Rate	$31,189.55
Max. Negotiated Rate	$33,080.61
Rate for Payer: Amerigroup CHIP/Medicaid	$31,189.55
Rate for Payer: Cigna Medicaid	$31,189.55
Rate for Payer: Molina CHIP/Medicaid	$31,189.55
Rate for Payer: Parkland Medicaid	$31,189.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33,080.61

LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT

Facility

$83,591.87

Service Code	APR-DRG 0014
Min. Negotiated Rate	$78,813.34
Max. Negotiated Rate	$83,591.87
Rate for Payer: Amerigroup CHIP/Medicaid	$78,813.34
Rate for Payer: Cigna Medicaid	$78,813.34
Rate for Payer: Molina CHIP/Medicaid	$78,813.34
Rate for Payer: Parkland Medicaid	$78,813.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83,591.87

LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT

Facility

$31,838.52

Service Code	APR-DRG 0011
Min. Negotiated Rate	$30,018.48
Max. Negotiated Rate	$31,838.52
Rate for Payer: Amerigroup CHIP/Medicaid	$30,018.48
Rate for Payer: Cigna Medicaid	$30,018.48
Rate for Payer: Molina CHIP/Medicaid	$30,018.48
Rate for Payer: Parkland Medicaid	$30,018.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31,838.52

LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT

Facility

$43,068.57

Service Code	APR-DRG 0013
Min. Negotiated Rate	$40,606.56
Max. Negotiated Rate	$43,068.57
Rate for Payer: Amerigroup CHIP/Medicaid	$40,606.56
Rate for Payer: Cigna Medicaid	$40,606.56
Rate for Payer: Molina CHIP/Medicaid	$40,606.56
Rate for Payer: Parkland Medicaid	$40,606.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43,068.57

LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT

Facility

$216,733.00

Service Code	MSDRG 005
Min. Negotiated Rate	$80,326.01
Max. Negotiated Rate	$216,733.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$80,326.01
Rate for Payer: Amerigroup Medicare	$80,326.01
Rate for Payer: BCBS of TX Medicare	$80,326.01
Rate for Payer: Cigna Commercial	$132,799.24
Rate for Payer: Cigna Medicare	$80,326.01
Rate for Payer: Employer Direct Commercial	$80,326.01
Rate for Payer: Molina Dual Medicare/Medicaid	$80,326.01
Rate for Payer: Molina Medicare	$80,326.01
Rate for Payer: Multiplan Auto	$216,733.00
Rate for Payer: Multiplan Commercial	$216,733.00
Rate for Payer: Multiplan Workers Comp	$216,733.00
Rate for Payer: Scott and White EPO/PPO	$99,811.25
Rate for Payer: Scott and White Medicare	$80,326.01
Rate for Payer: Superior Health Plan EPO	$80,326.01
Rate for Payer: Superior Health Plan Medicare	$80,326.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$80,326.01
Rate for Payer: Universal American Medicare	$80,326.01
Rate for Payer: Wellcare Medicare	$80,326.01
Rate for Payer: Wellmed Medicare	$80,326.01

LIVER TRANSPLANT WITHOUT MCC

Facility

$91,376.70

Service Code	MSDRG 006
Min. Negotiated Rate	$38,744.79
Max. Negotiated Rate	$91,376.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$38,744.79
Rate for Payer: Amerigroup Medicare	$38,744.79
Rate for Payer: BCBS of TX Medicare	$38,744.79
Rate for Payer: Cigna Commercial	$59,724.56
Rate for Payer: Cigna Medicare	$38,744.79
Rate for Payer: Employer Direct Commercial	$38,744.79
Rate for Payer: Molina Dual Medicare/Medicaid	$38,744.79
Rate for Payer: Molina Medicare	$38,744.79
Rate for Payer: Multiplan Auto	$91,376.70
Rate for Payer: Multiplan Commercial	$91,376.70
Rate for Payer: Multiplan Workers Comp	$91,376.70
Rate for Payer: Scott and White EPO/PPO	$42,081.38
Rate for Payer: Scott and White Medicare	$38,744.79
Rate for Payer: Superior Health Plan EPO	$38,744.79
Rate for Payer: Superior Health Plan Medicare	$38,744.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$38,744.79
Rate for Payer: Universal American Medicare	$38,744.79
Rate for Payer: Wellcare Medicare	$38,744.79
Rate for Payer: Wellmed Medicare	$38,744.79

LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT

Facility

$216,733.00

Service Code	MSDRG 005
Min. Negotiated Rate	$80,326.01
Max. Negotiated Rate	$216,733.00
Rate for Payer: BCBS of TX Blue Advantage	$88,188.70
Rate for Payer: BCBS of TX Blue Essentials	$105,816.19
Rate for Payer: BCBS of TX PPO	$117,578.10

LIVER TRANSPLANT W/O MCC

Facility

$91,376.70

Service Code	MSDRG 006
Min. Negotiated Rate	$38,744.79
Max. Negotiated Rate	$91,376.70
Rate for Payer: BCBS of TX Blue Advantage	$41,843.30
Rate for Payer: BCBS of TX Blue Essentials	$50,207.09
Rate for Payer: BCBS of TX PPO	$55,787.82

LNCS ADULT PROBE

Facility

$26.15

Hospital Charge Code	993189
Hospital Revenue Code	270
Rate for Payer: Cash Price	$17.78

LNCS ADULT PROBE

Facility

$26.15

Hospital Charge Code	993189
Hospital Revenue Code	270
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$18.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2.35
Rate for Payer: BCBS of TX Blue Advantage	$7.84
Rate for Payer: BCBS of TX Blue Essentials	$9.41
Rate for Payer: BCBS of TX PPO	$10.46
Rate for Payer: Cash Price	$17.78
Rate for Payer: Cigna Medicaid	$18.83
Rate for Payer: Molina CHIP/Medicaid	$18.83
Rate for Payer: Multiplan Auto	$17.00
Rate for Payer: Multiplan Commercial	$17.00
Rate for Payer: Multiplan Workers Comp	$17.00
Rate for Payer: Parkland Medicaid	$18.83
Rate for Payer: Scott and White EPO/PPO	$13.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.83
Rate for Payer: Superior Health Plan EPO	$3.56

LOADING UNIT, GIA ROTICULATOR 60MM RELOAD 2.5 WHT -- DHF

Facility

$2,982.78

Hospital Charge Code	81366619
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,028.29

LOADING UNIT, GIA ROTICULATOR 60MM RELOAD 2.5 WHT -- DHF

Facility

$2,982.78

Hospital Charge Code	81366619
Hospital Revenue Code	272
Min. Negotiated Rate	$268.45
Max. Negotiated Rate	$2,147.60
Rate for Payer: Amerigroup CHIP/Medicaid	$268.45
Rate for Payer: BCBS of TX Blue Advantage	$894.83
Rate for Payer: BCBS of TX Blue Essentials	$1,073.80
Rate for Payer: BCBS of TX PPO	$1,193.11
Rate for Payer: Cash Price	$2,028.29
Rate for Payer: Cigna Medicaid	$2,147.60
Rate for Payer: Molina CHIP/Medicaid	$2,147.60
Rate for Payer: Multiplan Auto	$1,938.81
Rate for Payer: Multiplan Commercial	$1,938.81
Rate for Payer: Multiplan Workers Comp	$1,938.81
Rate for Payer: Parkland Medicaid	$2,147.60
Rate for Payer: Scott and White EPO/PPO	$1,491.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,147.60
Rate for Payer: Superior Health Plan EPO	$405.66

LOADING UNIT, LINEAR CUTTER 75MM STAPLES TITANIUM -- DHF

Facility

$2,293.43

Hospital Charge Code	81910150
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,559.53

LOADING UNIT, LINEAR CUTTER 75MM STAPLES TITANIUM -- DHF

Facility

$2,293.43

Hospital Charge Code	81910150
Hospital Revenue Code	272
Min. Negotiated Rate	$206.41
Max. Negotiated Rate	$1,651.27
Rate for Payer: Amerigroup CHIP/Medicaid	$206.41
Rate for Payer: BCBS of TX Blue Advantage	$688.03
Rate for Payer: BCBS of TX Blue Essentials	$825.63
Rate for Payer: BCBS of TX PPO	$917.37
Rate for Payer: Cash Price	$1,559.53
Rate for Payer: Cigna Medicaid	$1,651.27
Rate for Payer: Molina CHIP/Medicaid	$1,651.27
Rate for Payer: Multiplan Auto	$1,490.73
Rate for Payer: Multiplan Commercial	$1,490.73
Rate for Payer: Multiplan Workers Comp	$1,490.73
Rate for Payer: Parkland Medicaid	$1,651.27
Rate for Payer: Scott and White EPO/PPO	$1,146.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,651.27
Rate for Payer: Superior Health Plan EPO	$311.91

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC

Facility

$39,894.30

Service Code	MSDRG 496
Min. Negotiated Rate	$16,863.74
Max. Negotiated Rate	$39,894.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,980.91
Rate for Payer: Amerigroup Medicare	$17,980.91
Rate for Payer: BCBS of TX Medicare	$17,980.91
Rate for Payer: Cigna Commercial	$23,234.23
Rate for Payer: Cigna Medicare	$17,980.91
Rate for Payer: Employer Direct Commercial	$17,980.91
Rate for Payer: Humana Medicare/TRICARE	$17,980.91
Rate for Payer: Molina Dual Medicare/Medicaid	$17,980.91
Rate for Payer: Molina Medicare	$17,980.91
Rate for Payer: Multiplan Auto	$39,894.30
Rate for Payer: Multiplan Commercial	$39,894.30
Rate for Payer: Multiplan Workers Comp	$39,894.30
Rate for Payer: Scott and White EPO/PPO	$18,372.38
Rate for Payer: Scott and White Medicare	$17,980.91
Rate for Payer: Superior Health Plan EPO	$17,980.91
Rate for Payer: Superior Health Plan Medicare	$17,980.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,980.91
Rate for Payer: Universal American Medicare	$17,980.91
Rate for Payer: Wellcare Medicare	$17,980.91
Rate for Payer: Wellmed Medicare	$17,980.91

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC

Facility

$70,573.60

Service Code	MSDRG 495
Min. Negotiated Rate	$29,775.78
Max. Negotiated Rate	$70,573.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$31,332.93
Rate for Payer: Amerigroup Medicare	$31,332.93
Rate for Payer: BCBS of TX Medicare	$31,332.93
Rate for Payer: Cigna Commercial	$46,699.02
Rate for Payer: Cigna Medicare	$31,332.93
Rate for Payer: Employer Direct Commercial	$31,332.93
Rate for Payer: Humana Medicare/TRICARE	$31,332.93
Rate for Payer: Molina Dual Medicare/Medicaid	$31,332.93
Rate for Payer: Molina Medicare	$31,332.93
Rate for Payer: Multiplan Auto	$70,573.60
Rate for Payer: Multiplan Commercial	$70,573.60
Rate for Payer: Multiplan Workers Comp	$70,573.60
Rate for Payer: Scott and White EPO/PPO	$32,501.00
Rate for Payer: Scott and White Medicare	$31,332.93
Rate for Payer: Superior Health Plan EPO	$31,332.93
Rate for Payer: Superior Health Plan Medicare	$31,332.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$31,332.93
Rate for Payer: Universal American Medicare	$31,332.93
Rate for Payer: Wellcare Medicare	$31,332.93
Rate for Payer: Wellmed Medicare	$31,332.93

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC

Facility

$28,912.30

Service Code	MSDRG 497
Min. Negotiated Rate	$12,341.00
Max. Negotiated Rate	$28,912.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,615.74
Rate for Payer: Amerigroup Medicare	$13,615.74
Rate for Payer: BCBS of TX Medicare	$13,615.74
Rate for Payer: Cigna Commercial	$14,833.90
Rate for Payer: Cigna Medicare	$13,615.74
Rate for Payer: Employer Direct Commercial	$13,615.74
Rate for Payer: Humana Medicare/TRICARE	$13,615.74
Rate for Payer: Molina Dual Medicare/Medicaid	$13,615.74
Rate for Payer: Molina Medicare	$13,615.74
Rate for Payer: Multiplan Auto	$28,912.30
Rate for Payer: Multiplan Commercial	$28,912.30
Rate for Payer: Multiplan Workers Comp	$28,912.30
Rate for Payer: Scott and White EPO/PPO	$13,314.88
Rate for Payer: Scott and White Medicare	$13,615.74
Rate for Payer: Superior Health Plan EPO	$13,615.74
Rate for Payer: Superior Health Plan Medicare	$13,615.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,615.74
Rate for Payer: Universal American Medicare	$13,615.74
Rate for Payer: Wellcare Medicare	$13,615.74
Rate for Payer: Wellmed Medicare	$13,615.74

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC

Facility

$48,698.90

Service Code	MSDRG 498
Min. Negotiated Rate	$19,590.80
Max. Negotiated Rate	$48,698.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,870.29
Rate for Payer: Amerigroup Medicare	$26,870.29
Rate for Payer: BCBS of TX Medicare	$26,870.29
Rate for Payer: Cigna Commercial	$38,856.38
Rate for Payer: Cigna Medicare	$26,870.29
Rate for Payer: Employer Direct Commercial	$26,870.29
Rate for Payer: Humana Medicare/TRICARE	$26,870.29
Rate for Payer: Molina Dual Medicare/Medicaid	$26,870.29
Rate for Payer: Molina Medicare	$26,870.29
Rate for Payer: Multiplan Auto	$48,698.90
Rate for Payer: Multiplan Commercial	$48,698.90
Rate for Payer: Multiplan Workers Comp	$48,698.90
Rate for Payer: Scott and White EPO/PPO	$22,427.12
Rate for Payer: Scott and White Medicare	$26,870.29
Rate for Payer: Superior Health Plan EPO	$26,870.29
Rate for Payer: Superior Health Plan Medicare	$26,870.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,870.29
Rate for Payer: Universal American Medicare	$26,870.29
Rate for Payer: Wellcare Medicare	$26,870.29
Rate for Payer: Wellmed Medicare	$26,870.29

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC

Facility

$25,950.62

Service Code	MSDRG 499
Min. Negotiated Rate	$9,625.12
Max. Negotiated Rate	$25,950.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,526.60
Rate for Payer: Amerigroup Medicare	$19,526.60
Rate for Payer: BCBS of TX Medicare	$19,526.60
Rate for Payer: Cigna Commercial	$25,950.62
Rate for Payer: Cigna Medicare	$19,526.60
Rate for Payer: Employer Direct Commercial	$19,526.60
Rate for Payer: Humana Medicare/TRICARE	$19,526.60
Rate for Payer: Molina Dual Medicare/Medicaid	$19,526.60
Rate for Payer: Molina Medicare	$19,526.60
Rate for Payer: Multiplan Auto	$25,055.30
Rate for Payer: Multiplan Commercial	$25,055.30
Rate for Payer: Multiplan Workers Comp	$25,055.30
Rate for Payer: Scott and White EPO/PPO	$11,538.62
Rate for Payer: Scott and White Medicare	$19,526.60
Rate for Payer: Superior Health Plan EPO	$19,526.60
Rate for Payer: Superior Health Plan Medicare	$19,526.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,526.60
Rate for Payer: Universal American Medicare	$19,526.60
Rate for Payer: Wellcare Medicare	$19,526.60
Rate for Payer: Wellmed Medicare	$19,526.60

LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W CC

Facility

$39,894.30

Service Code	MSDRG 496
Min. Negotiated Rate	$16,863.74
Max. Negotiated Rate	$39,894.30
Rate for Payer: BCBS of TX Blue Advantage	$16,863.74
Rate for Payer: BCBS of TX Blue Essentials	$20,234.53
Rate for Payer: BCBS of TX PPO	$22,483.68

LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W MCC

Facility

$70,573.60

Service Code	MSDRG 495
Min. Negotiated Rate	$29,775.78
Max. Negotiated Rate	$70,573.60
Rate for Payer: BCBS of TX Blue Advantage	$29,775.78
Rate for Payer: BCBS of TX Blue Essentials	$35,727.47
Rate for Payer: BCBS of TX PPO	$39,698.73

LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W/O CC/MCC

Facility

$28,912.30

Service Code	MSDRG 497
Min. Negotiated Rate	$12,341.00
Max. Negotiated Rate	$28,912.30
Rate for Payer: BCBS of TX Blue Advantage	$12,341.00
Rate for Payer: BCBS of TX Blue Essentials	$14,807.76
Rate for Payer: BCBS of TX PPO	$16,453.71

LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W CC/MCC

Facility

$48,698.90

Service Code	MSDRG 498
Min. Negotiated Rate	$19,590.80
Max. Negotiated Rate	$48,698.90
Rate for Payer: BCBS of TX Blue Advantage	$19,590.80
Rate for Payer: BCBS of TX Blue Essentials	$23,506.68
Rate for Payer: BCBS of TX PPO	$26,119.55

LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W/O CC/MCC

Facility

$25,950.62

Service Code	MSDRG 499
Min. Negotiated Rate	$9,625.12
Max. Negotiated Rate	$25,950.62
Rate for Payer: BCBS of TX Blue Advantage	$9,625.12
Rate for Payer: BCBS of TX Blue Essentials	$11,549.02
Rate for Payer: BCBS of TX PPO	$12,832.75

Know your out-of-pocket cost for care.

All Charges