White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MAJOR CHEST TRAUMA W/O CC/MCC

Facility

$14,943.50

Service Code	MSDRG 185
Min. Negotiated Rate	$6,297.78
Max. Negotiated Rate	$14,943.50
Rate for Payer: BCBS of TX Blue Advantage	$6,297.78
Rate for Payer: BCBS of TX Blue Essentials	$7,556.60
Rate for Payer: BCBS of TX PPO	$8,396.55

MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$10,887.18

Service Code	APR-DRG 0892
Min. Negotiated Rate	$10,264.82
Max. Negotiated Rate	$10,887.18
Rate for Payer: Amerigroup CHIP/Medicaid	$10,264.82
Rate for Payer: Cigna Medicaid	$10,264.82
Rate for Payer: Molina CHIP/Medicaid	$10,264.82
Rate for Payer: Parkland Medicaid	$10,264.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,887.18

MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$10,083.02

Service Code	APR-DRG 0891
Min. Negotiated Rate	$9,506.62
Max. Negotiated Rate	$10,083.02
Rate for Payer: Amerigroup CHIP/Medicaid	$9,506.62
Rate for Payer: Cigna Medicaid	$9,506.62
Rate for Payer: Molina CHIP/Medicaid	$9,506.62
Rate for Payer: Parkland Medicaid	$9,506.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,083.02

MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$19,885.78

Service Code	APR-DRG 0893
Min. Negotiated Rate	$18,749.01
Max. Negotiated Rate	$19,885.78
Rate for Payer: Amerigroup CHIP/Medicaid	$18,749.01
Rate for Payer: Cigna Medicaid	$18,749.01
Rate for Payer: Molina CHIP/Medicaid	$18,749.01
Rate for Payer: Parkland Medicaid	$18,749.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,885.78

MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$37,366.23

Service Code	APR-DRG 0894
Min. Negotiated Rate	$35,230.19
Max. Negotiated Rate	$37,366.23
Rate for Payer: Amerigroup CHIP/Medicaid	$35,230.19
Rate for Payer: Cigna Medicaid	$35,230.19
Rate for Payer: Molina CHIP/Medicaid	$35,230.19
Rate for Payer: Parkland Medicaid	$35,230.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37,366.23

MAJOR CUSTOM PACK

Facility

$212.84

Hospital Charge Code	992880
Hospital Revenue Code	272
Min. Negotiated Rate	$19.16
Max. Negotiated Rate	$153.24
Rate for Payer: Amerigroup CHIP/Medicaid	$19.16
Rate for Payer: BCBS of TX Blue Advantage	$63.85
Rate for Payer: BCBS of TX Blue Essentials	$76.62
Rate for Payer: BCBS of TX PPO	$85.14
Rate for Payer: Cash Price	$144.73
Rate for Payer: Cigna Medicaid	$153.24
Rate for Payer: Molina CHIP/Medicaid	$153.24
Rate for Payer: Multiplan Auto	$138.35
Rate for Payer: Multiplan Commercial	$138.35
Rate for Payer: Multiplan Workers Comp	$138.35
Rate for Payer: Parkland Medicaid	$153.24
Rate for Payer: Scott and White EPO/PPO	$106.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$153.24
Rate for Payer: Superior Health Plan EPO	$28.95

MAJOR CUSTOM PACK

Facility

$212.84

Hospital Charge Code	992880
Hospital Revenue Code	272
Rate for Payer: Cash Price	$144.73

MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES

Facility

$1,805.60

Service Code	APR-DRG 7512
Min. Negotiated Rate	$1,702.39
Max. Negotiated Rate	$1,805.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1,702.39
Rate for Payer: Cigna Medicaid	$1,702.39
Rate for Payer: Molina CHIP/Medicaid	$1,702.39
Rate for Payer: Parkland Medicaid	$1,702.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,805.60

MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES

Facility

$2,844.76

Service Code	APR-DRG 7513
Min. Negotiated Rate	$2,682.14
Max. Negotiated Rate	$2,844.76
Rate for Payer: Amerigroup CHIP/Medicaid	$2,682.14
Rate for Payer: Cigna Medicaid	$2,682.14
Rate for Payer: Molina CHIP/Medicaid	$2,682.14
Rate for Payer: Parkland Medicaid	$2,682.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,844.76

MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES

Facility

$3,883.92

Service Code	APR-DRG 7514
Min. Negotiated Rate	$3,661.89
Max. Negotiated Rate	$3,883.92
Rate for Payer: Amerigroup CHIP/Medicaid	$3,661.89
Rate for Payer: Cigna Medicaid	$3,661.89
Rate for Payer: Molina CHIP/Medicaid	$3,661.89
Rate for Payer: Parkland Medicaid	$3,661.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,883.92

MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES

Facility

$1,498.57

Service Code	APR-DRG 7511
Min. Negotiated Rate	$1,412.91
Max. Negotiated Rate	$1,498.57
Rate for Payer: Amerigroup CHIP/Medicaid	$1,412.91
Rate for Payer: Cigna Medicaid	$1,412.91
Rate for Payer: Molina CHIP/Medicaid	$1,412.91
Rate for Payer: Parkland Medicaid	$1,412.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,498.57

MAJOR ESOPHAGEAL DISORDERS

Facility

$13,031.13

Service Code	APR-DRG 2424
Min. Negotiated Rate	$12,286.20
Max. Negotiated Rate	$13,031.13
Rate for Payer: Amerigroup CHIP/Medicaid	$12,286.20
Rate for Payer: Cigna Medicaid	$12,286.20
Rate for Payer: Molina CHIP/Medicaid	$12,286.20
Rate for Payer: Parkland Medicaid	$12,286.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,031.13

MAJOR ESOPHAGEAL DISORDERS

Facility

$3,521.44

Service Code	APR-DRG 2422
Min. Negotiated Rate	$3,320.13
Max. Negotiated Rate	$3,521.44
Rate for Payer: Amerigroup CHIP/Medicaid	$3,320.13
Rate for Payer: Cigna Medicaid	$3,320.13
Rate for Payer: Molina CHIP/Medicaid	$3,320.13
Rate for Payer: Parkland Medicaid	$3,320.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,521.44

MAJOR ESOPHAGEAL DISORDERS

Facility

$5,643.50

Service Code	APR-DRG 2423
Min. Negotiated Rate	$5,320.89
Max. Negotiated Rate	$5,643.50
Rate for Payer: Amerigroup CHIP/Medicaid	$5,320.89
Rate for Payer: Cigna Medicaid	$5,320.89
Rate for Payer: Molina CHIP/Medicaid	$5,320.89
Rate for Payer: Parkland Medicaid	$5,320.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,643.50

MAJOR ESOPHAGEAL DISORDERS

Facility

$3,270.98

Service Code	APR-DRG 2421
Min. Negotiated Rate	$3,084.00
Max. Negotiated Rate	$3,270.98
Rate for Payer: Amerigroup CHIP/Medicaid	$3,084.00
Rate for Payer: Cigna Medicaid	$3,084.00
Rate for Payer: Molina CHIP/Medicaid	$3,084.00
Rate for Payer: Parkland Medicaid	$3,084.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,270.98

MAJOR ESOPHAGEAL DISORDERS W CC

Facility

$19,003.80

Service Code	MSDRG 369
Min. Negotiated Rate	$8,751.75
Max. Negotiated Rate	$19,003.80
Rate for Payer: BCBS of TX Blue Advantage	$9,535.68
Rate for Payer: BCBS of TX Blue Essentials	$11,441.71
Rate for Payer: BCBS of TX PPO	$12,713.50

MAJOR ESOPHAGEAL DISORDERS WITH CC

Facility

$19,003.80

Service Code	MSDRG 369
Min. Negotiated Rate	$8,751.75
Max. Negotiated Rate	$19,003.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,090.56
Rate for Payer: Amerigroup Medicare	$12,090.56
Rate for Payer: BCBS of TX Medicare	$12,090.56
Rate for Payer: Cigna Commercial	$12,882.58
Rate for Payer: Cigna Medicare	$12,090.56
Rate for Payer: Employer Direct Commercial	$12,090.56
Rate for Payer: Humana Medicare/TRICARE	$12,090.56
Rate for Payer: Molina Dual Medicare/Medicaid	$12,090.56
Rate for Payer: Molina Medicare	$12,090.56
Rate for Payer: Multiplan Auto	$19,003.80
Rate for Payer: Multiplan Commercial	$19,003.80
Rate for Payer: Multiplan Workers Comp	$19,003.80
Rate for Payer: Scott and White EPO/PPO	$8,751.75
Rate for Payer: Scott and White Medicare	$12,090.56
Rate for Payer: Superior Health Plan EPO	$12,090.56
Rate for Payer: Superior Health Plan Medicare	$12,090.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,090.56
Rate for Payer: Universal American Medicare	$12,090.56
Rate for Payer: Wellcare Medicare	$12,090.56
Rate for Payer: Wellmed Medicare	$12,090.56

MAJOR ESOPHAGEAL DISORDERS WITH MCC

Facility

$30,246.10

Service Code	MSDRG 368
Min. Negotiated Rate	$13,929.12
Max. Negotiated Rate	$30,246.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,427.16
Rate for Payer: Amerigroup Medicare	$16,427.16
Rate for Payer: BCBS of TX Medicare	$16,427.16
Rate for Payer: Cigna Commercial	$20,503.67
Rate for Payer: Cigna Medicare	$16,427.16
Rate for Payer: Employer Direct Commercial	$16,427.16
Rate for Payer: Humana Medicare/TRICARE	$16,427.16
Rate for Payer: Molina Dual Medicare/Medicaid	$16,427.16
Rate for Payer: Molina Medicare	$16,427.16
Rate for Payer: Multiplan Auto	$30,246.10
Rate for Payer: Multiplan Commercial	$30,246.10
Rate for Payer: Multiplan Workers Comp	$30,246.10
Rate for Payer: Scott and White EPO/PPO	$13,929.12
Rate for Payer: Scott and White Medicare	$16,427.16
Rate for Payer: Superior Health Plan EPO	$16,427.16
Rate for Payer: Superior Health Plan Medicare	$16,427.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,427.16
Rate for Payer: Universal American Medicare	$16,427.16
Rate for Payer: Wellcare Medicare	$16,427.16
Rate for Payer: Wellmed Medicare	$16,427.16

MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC

Facility

$13,315.20

Service Code	MSDRG 370
Min. Negotiated Rate	$6,132.00
Max. Negotiated Rate	$13,315.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,896.26
Rate for Payer: Amerigroup Medicare	$9,896.26
Rate for Payer: BCBS of TX Medicare	$9,896.26
Rate for Payer: Cigna Commercial	$9,026.30
Rate for Payer: Cigna Medicare	$9,896.26
Rate for Payer: Employer Direct Commercial	$9,896.26
Rate for Payer: Humana Medicare/TRICARE	$9,896.26
Rate for Payer: Molina Dual Medicare/Medicaid	$9,896.26
Rate for Payer: Molina Medicare	$9,896.26
Rate for Payer: Multiplan Auto	$13,315.20
Rate for Payer: Multiplan Commercial	$13,315.20
Rate for Payer: Multiplan Workers Comp	$13,315.20
Rate for Payer: Scott and White EPO/PPO	$6,132.00
Rate for Payer: Scott and White Medicare	$9,896.26
Rate for Payer: Superior Health Plan EPO	$9,896.26
Rate for Payer: Superior Health Plan Medicare	$9,896.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,896.26
Rate for Payer: Universal American Medicare	$9,896.26
Rate for Payer: Wellcare Medicare	$9,896.26
Rate for Payer: Wellmed Medicare	$9,896.26

MAJOR ESOPHAGEAL DISORDERS W MCC

Facility

$30,246.10

Service Code	MSDRG 368
Min. Negotiated Rate	$13,929.12
Max. Negotiated Rate	$30,246.10
Rate for Payer: BCBS of TX Blue Advantage	$16,718.40
Rate for Payer: BCBS of TX Blue Essentials	$20,060.14
Rate for Payer: BCBS of TX PPO	$22,289.90

MAJOR ESOPHAGEAL DISORDERS W/O CC/MCC

Facility

$13,315.20

Service Code	MSDRG 370
Min. Negotiated Rate	$6,132.00
Max. Negotiated Rate	$13,315.20
Rate for Payer: BCBS of TX Blue Advantage	$6,392.38
Rate for Payer: BCBS of TX Blue Essentials	$7,670.11
Rate for Payer: BCBS of TX PPO	$8,522.68

MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS

Facility

$3,655.34

Service Code	APR-DRG 2482
Min. Negotiated Rate	$3,446.38
Max. Negotiated Rate	$3,655.34
Rate for Payer: Amerigroup CHIP/Medicaid	$3,446.38
Rate for Payer: Cigna Medicaid	$3,446.38
Rate for Payer: Molina CHIP/Medicaid	$3,446.38
Rate for Payer: Parkland Medicaid	$3,446.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,655.34

MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS

Facility

$17,277.90

Service Code	APR-DRG 2484
Min. Negotiated Rate	$16,290.21
Max. Negotiated Rate	$17,277.90
Rate for Payer: Amerigroup CHIP/Medicaid	$16,290.21
Rate for Payer: Cigna Medicaid	$16,290.21
Rate for Payer: Molina CHIP/Medicaid	$16,290.21
Rate for Payer: Parkland Medicaid	$16,290.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,277.90

MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS

Facility

$5,175.03

Service Code	APR-DRG 2483
Min. Negotiated Rate	$4,879.20
Max. Negotiated Rate	$5,175.03
Rate for Payer: Amerigroup CHIP/Medicaid	$4,879.20
Rate for Payer: Cigna Medicaid	$4,879.20
Rate for Payer: Molina CHIP/Medicaid	$4,879.20
Rate for Payer: Parkland Medicaid	$4,879.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,175.03

MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS

Facility

$1,679.62

Service Code	APR-DRG 2481
Min. Negotiated Rate	$1,583.61
Max. Negotiated Rate	$1,679.62
Rate for Payer: Amerigroup CHIP/Medicaid	$1,583.61
Rate for Payer: Cigna Medicaid	$1,583.61
Rate for Payer: Molina CHIP/Medicaid	$1,583.61
Rate for Payer: Parkland Medicaid	$1,583.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,679.62

Know your out-of-pocket cost for care.

All Charges