White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$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

$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

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC

Facility

$19,342.00

Service Code	MSDRG 372
Min. Negotiated Rate	$8,907.50
Max. Negotiated Rate	$19,342.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,243.02
Rate for Payer: Amerigroup Medicare	$12,243.02
Rate for Payer: BCBS of TX Medicare	$12,243.02
Rate for Payer: Cigna Commercial	$13,150.48
Rate for Payer: Cigna Medicare	$12,243.02
Rate for Payer: Employer Direct Commercial	$12,243.02
Rate for Payer: Humana Medicare/TRICARE	$12,243.02
Rate for Payer: Molina Dual Medicare/Medicaid	$12,243.02
Rate for Payer: Molina Medicare	$12,243.02
Rate for Payer: Multiplan Auto	$19,342.00
Rate for Payer: Multiplan Commercial	$19,342.00
Rate for Payer: Multiplan Workers Comp	$19,342.00
Rate for Payer: Scott and White EPO/PPO	$8,907.50
Rate for Payer: Scott and White Medicare	$12,243.02
Rate for Payer: Superior Health Plan EPO	$12,243.02
Rate for Payer: Superior Health Plan Medicare	$12,243.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,243.02
Rate for Payer: Universal American Medicare	$12,243.02
Rate for Payer: Wellcare Medicare	$12,243.02
Rate for Payer: Wellmed Medicare	$12,243.02

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC

Facility

$32,144.20

Service Code	MSDRG 371
Min. Negotiated Rate	$14,803.25
Max. Negotiated Rate	$32,144.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,755.17
Rate for Payer: Amerigroup Medicare	$17,755.17
Rate for Payer: BCBS of TX Medicare	$17,755.17
Rate for Payer: Cigna Commercial	$22,837.53
Rate for Payer: Cigna Medicare	$17,755.17
Rate for Payer: Employer Direct Commercial	$17,755.17
Rate for Payer: Humana Medicare/TRICARE	$17,755.17
Rate for Payer: Molina Dual Medicare/Medicaid	$17,755.17
Rate for Payer: Molina Medicare	$17,755.17
Rate for Payer: Multiplan Auto	$32,144.20
Rate for Payer: Multiplan Commercial	$32,144.20
Rate for Payer: Multiplan Workers Comp	$32,144.20
Rate for Payer: Scott and White EPO/PPO	$14,803.25
Rate for Payer: Scott and White Medicare	$17,755.17
Rate for Payer: Superior Health Plan EPO	$17,755.17
Rate for Payer: Superior Health Plan Medicare	$17,755.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,755.17
Rate for Payer: Universal American Medicare	$17,755.17
Rate for Payer: Wellcare Medicare	$17,755.17
Rate for Payer: Wellmed Medicare	$17,755.17

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC

Facility

$13,794.00

Service Code	MSDRG 373
Min. Negotiated Rate	$6,352.50
Max. Negotiated Rate	$13,794.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,091.22
Rate for Payer: Amerigroup Medicare	$10,091.22
Rate for Payer: BCBS of TX Medicare	$10,091.22
Rate for Payer: Cigna Commercial	$9,368.91
Rate for Payer: Cigna Medicare	$10,091.22
Rate for Payer: Employer Direct Commercial	$10,091.22
Rate for Payer: Humana Medicare/TRICARE	$10,091.22
Rate for Payer: Molina Dual Medicare/Medicaid	$10,091.22
Rate for Payer: Molina Medicare	$10,091.22
Rate for Payer: Multiplan Auto	$13,794.00
Rate for Payer: Multiplan Commercial	$13,794.00
Rate for Payer: Multiplan Workers Comp	$13,794.00
Rate for Payer: Scott and White EPO/PPO	$6,352.50
Rate for Payer: Scott and White Medicare	$10,091.22
Rate for Payer: Superior Health Plan EPO	$10,091.22
Rate for Payer: Superior Health Plan Medicare	$10,091.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,091.22
Rate for Payer: Universal American Medicare	$10,091.22
Rate for Payer: Wellcare Medicare	$10,091.22
Rate for Payer: Wellmed Medicare	$10,091.22

MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC

Facility

$19,342.00

Service Code	MSDRG 372
Min. Negotiated Rate	$8,907.50
Max. Negotiated Rate	$19,342.00
Rate for Payer: BCBS of TX Blue Advantage	$8,930.24
Rate for Payer: BCBS of TX Blue Essentials	$10,715.25
Rate for Payer: BCBS of TX PPO	$11,906.29

MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC

Facility

$32,144.20

Service Code	MSDRG 371
Min. Negotiated Rate	$14,803.25
Max. Negotiated Rate	$32,144.20
Rate for Payer: BCBS of TX Blue Advantage	$14,953.68
Rate for Payer: BCBS of TX Blue Essentials	$17,942.68
Rate for Payer: BCBS of TX PPO	$19,937.08

MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W/O CC/MCC

Facility

$13,794.00

Service Code	MSDRG 373
Min. Negotiated Rate	$6,352.50
Max. Negotiated Rate	$13,794.00
Rate for Payer: BCBS of TX Blue Advantage	$6,515.36
Rate for Payer: BCBS of TX Blue Essentials	$7,817.67
Rate for Payer: BCBS of TX PPO	$8,686.64

MAJOR HEAD AND NECK PROCEDURES WITH CC

Facility

$42,419.40

Service Code	MSDRG 141
Min. Negotiated Rate	$19,535.25
Max. Negotiated Rate	$42,419.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,745.41
Rate for Payer: Amerigroup Medicare	$20,745.41
Rate for Payer: BCBS of TX Medicare	$20,745.41
Rate for Payer: Cigna Commercial	$28,092.57
Rate for Payer: Cigna Medicare	$20,745.41
Rate for Payer: Employer Direct Commercial	$20,745.41
Rate for Payer: Humana Medicare/TRICARE	$20,745.41
Rate for Payer: Molina Dual Medicare/Medicaid	$20,745.41
Rate for Payer: Molina Medicare	$20,745.41
Rate for Payer: Multiplan Auto	$42,419.40
Rate for Payer: Multiplan Commercial	$42,419.40
Rate for Payer: Multiplan Workers Comp	$42,419.40
Rate for Payer: Scott and White EPO/PPO	$19,535.25
Rate for Payer: Scott and White Medicare	$20,745.41
Rate for Payer: Superior Health Plan EPO	$20,745.41
Rate for Payer: Superior Health Plan Medicare	$20,745.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,745.41
Rate for Payer: Universal American Medicare	$20,745.41
Rate for Payer: Wellcare Medicare	$20,745.41
Rate for Payer: Wellmed Medicare	$20,745.41

MAJOR HEAD AND NECK PROCEDURES WITH MCC

Facility

$78,969.70

Service Code	MSDRG 140
Min. Negotiated Rate	$36,020.58
Max. Negotiated Rate	$78,969.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$36,020.58
Rate for Payer: Amerigroup Medicare	$36,020.58
Rate for Payer: BCBS of TX Medicare	$36,020.58
Rate for Payer: Cigna Commercial	$54,937.06
Rate for Payer: Cigna Medicare	$36,020.58
Rate for Payer: Employer Direct Commercial	$36,020.58
Rate for Payer: Humana Medicare/TRICARE	$36,020.58
Rate for Payer: Molina Dual Medicare/Medicaid	$36,020.58
Rate for Payer: Molina Medicare	$36,020.58
Rate for Payer: Multiplan Auto	$78,969.70
Rate for Payer: Multiplan Commercial	$78,969.70
Rate for Payer: Multiplan Workers Comp	$78,969.70
Rate for Payer: Scott and White EPO/PPO	$36,367.62
Rate for Payer: Scott and White Medicare	$36,020.58
Rate for Payer: Superior Health Plan EPO	$36,020.58
Rate for Payer: Superior Health Plan Medicare	$36,020.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$36,020.58
Rate for Payer: Universal American Medicare	$36,020.58
Rate for Payer: Wellcare Medicare	$36,020.58
Rate for Payer: Wellmed Medicare	$36,020.58

MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC

Facility

$32,332.30

Service Code	MSDRG 142
Min. Negotiated Rate	$14,889.88
Max. Negotiated Rate	$32,332.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,460.14
Rate for Payer: Amerigroup Medicare	$16,460.14
Rate for Payer: BCBS of TX Medicare	$16,460.14
Rate for Payer: Cigna Commercial	$20,561.63
Rate for Payer: Cigna Medicare	$16,460.14
Rate for Payer: Employer Direct Commercial	$16,460.14
Rate for Payer: Humana Medicare/TRICARE	$16,460.14
Rate for Payer: Molina Dual Medicare/Medicaid	$16,460.14
Rate for Payer: Molina Medicare	$16,460.14
Rate for Payer: Multiplan Auto	$32,332.30
Rate for Payer: Multiplan Commercial	$32,332.30
Rate for Payer: Multiplan Workers Comp	$32,332.30
Rate for Payer: Scott and White EPO/PPO	$14,889.88
Rate for Payer: Scott and White Medicare	$16,460.14
Rate for Payer: Superior Health Plan EPO	$16,460.14
Rate for Payer: Superior Health Plan Medicare	$16,460.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,460.14
Rate for Payer: Universal American Medicare	$16,460.14
Rate for Payer: Wellcare Medicare	$16,460.14
Rate for Payer: Wellmed Medicare	$16,460.14

MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE

Facility

$27,873.85

Service Code	MSDRG 129
Min. Negotiated Rate	$20,906.60
Max. Negotiated Rate	$27,873.85
Rate for Payer: BCBS of TX Blue Advantage	$20,906.60
Rate for Payer: BCBS of TX Blue Essentials	$25,085.49
Rate for Payer: BCBS of TX PPO	$27,873.85

MAJOR HEAD & NECK PROCEDURES W/O CC/MCC

Facility

$17,098.10

Service Code	MSDRG 130
Min. Negotiated Rate	$12,824.32
Max. Negotiated Rate	$17,098.10
Rate for Payer: BCBS of TX Blue Advantage	$12,824.32
Rate for Payer: BCBS of TX Blue Essentials	$15,387.69
Rate for Payer: BCBS of TX PPO	$17,098.10

MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC

Facility

$23,098.30

Service Code	MSDRG 809
Min. Negotiated Rate	$10,358.70
Max. Negotiated Rate	$23,098.30
Rate for Payer: BCBS of TX Blue Advantage	$10,358.70
Rate for Payer: BCBS of TX Blue Essentials	$12,429.24
Rate for Payer: BCBS of TX PPO	$13,810.80

MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC

Facility

$40,679.00

Service Code	MSDRG 808
Min. Negotiated Rate	$18,483.12
Max. Negotiated Rate	$40,679.00
Rate for Payer: BCBS of TX Blue Advantage	$18,483.12
Rate for Payer: BCBS of TX Blue Essentials	$22,177.59
Rate for Payer: BCBS of TX PPO	$24,642.73

MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W/O CC/MCC

Facility

$17,837.20

Service Code	MSDRG 810
Min. Negotiated Rate	$7,929.20
Max. Negotiated Rate	$17,837.20
Rate for Payer: BCBS of TX Blue Advantage	$7,929.20
Rate for Payer: BCBS of TX Blue Essentials	$9,514.12
Rate for Payer: BCBS of TX PPO	$10,571.65

MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC

Facility

$23,098.30

Service Code	MSDRG 809
Min. Negotiated Rate	$10,358.70
Max. Negotiated Rate	$23,098.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,037.90
Rate for Payer: Amerigroup Medicare	$14,037.90
Rate for Payer: BCBS of TX Medicare	$14,037.90
Rate for Payer: Cigna Commercial	$16,304.79
Rate for Payer: Cigna Medicare	$14,037.90
Rate for Payer: Employer Direct Commercial	$14,037.90
Rate for Payer: Humana Medicare/TRICARE	$14,037.90
Rate for Payer: Molina Dual Medicare/Medicaid	$14,037.90
Rate for Payer: Molina Medicare	$14,037.90
Rate for Payer: Multiplan Auto	$23,098.30
Rate for Payer: Multiplan Commercial	$23,098.30
Rate for Payer: Multiplan Workers Comp	$23,098.30
Rate for Payer: Scott and White EPO/PPO	$10,637.38
Rate for Payer: Scott and White Medicare	$14,037.90
Rate for Payer: Superior Health Plan EPO	$14,037.90
Rate for Payer: Superior Health Plan Medicare	$14,037.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,037.90
Rate for Payer: Universal American Medicare	$14,037.90
Rate for Payer: Wellcare Medicare	$14,037.90
Rate for Payer: Wellmed Medicare	$14,037.90

MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC

Facility

$40,679.00

Service Code	MSDRG 808
Min. Negotiated Rate	$18,483.12
Max. Negotiated Rate	$40,679.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,941.83
Rate for Payer: Amerigroup Medicare	$20,941.83
Rate for Payer: BCBS of TX Medicare	$20,941.83
Rate for Payer: Cigna Commercial	$28,437.75
Rate for Payer: Cigna Medicare	$20,941.83
Rate for Payer: Employer Direct Commercial	$20,941.83
Rate for Payer: Humana Medicare/TRICARE	$20,941.83
Rate for Payer: Molina Dual Medicare/Medicaid	$20,941.83
Rate for Payer: Molina Medicare	$20,941.83
Rate for Payer: Multiplan Auto	$40,679.00
Rate for Payer: Multiplan Commercial	$40,679.00
Rate for Payer: Multiplan Workers Comp	$40,679.00
Rate for Payer: Scott and White EPO/PPO	$18,733.75
Rate for Payer: Scott and White Medicare	$20,941.83
Rate for Payer: Superior Health Plan EPO	$20,941.83
Rate for Payer: Superior Health Plan Medicare	$20,941.83
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,941.83
Rate for Payer: Universal American Medicare	$20,941.83
Rate for Payer: Wellcare Medicare	$20,941.83
Rate for Payer: Wellmed Medicare	$20,941.83

MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC

Facility

$17,837.20

Service Code	MSDRG 810
Min. Negotiated Rate	$7,929.20
Max. Negotiated Rate	$17,837.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,430.65
Rate for Payer: Amerigroup Medicare	$12,430.65
Rate for Payer: BCBS of TX Medicare	$12,430.65
Rate for Payer: Cigna Commercial	$13,480.21
Rate for Payer: Cigna Medicare	$12,430.65
Rate for Payer: Employer Direct Commercial	$12,430.65
Rate for Payer: Humana Medicare/TRICARE	$12,430.65
Rate for Payer: Molina Dual Medicare/Medicaid	$12,430.65
Rate for Payer: Molina Medicare	$12,430.65
Rate for Payer: Multiplan Auto	$17,837.20
Rate for Payer: Multiplan Commercial	$17,837.20
Rate for Payer: Multiplan Workers Comp	$17,837.20
Rate for Payer: Scott and White EPO/PPO	$8,214.50
Rate for Payer: Scott and White Medicare	$12,430.65
Rate for Payer: Superior Health Plan EPO	$12,430.65
Rate for Payer: Superior Health Plan Medicare	$12,430.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,430.65
Rate for Payer: Universal American Medicare	$12,430.65
Rate for Payer: Wellcare Medicare	$12,430.65
Rate for Payer: Wellmed Medicare	$12,430.65

MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION

Facility

$4,895.91

Service Code	APR-DRG 6601
Min. Negotiated Rate	$4,616.04
Max. Negotiated Rate	$4,895.91
Rate for Payer: Amerigroup CHIP/Medicaid	$4,616.04
Rate for Payer: Cigna Medicaid	$4,616.04
Rate for Payer: Molina CHIP/Medicaid	$4,616.04
Rate for Payer: Parkland Medicaid	$4,616.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,895.91

MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION

Facility

$4,930.24

Service Code	APR-DRG 6602
Min. Negotiated Rate	$4,648.40
Max. Negotiated Rate	$4,930.24
Rate for Payer: Amerigroup CHIP/Medicaid	$4,648.40
Rate for Payer: Cigna Medicaid	$4,648.40
Rate for Payer: Molina CHIP/Medicaid	$4,648.40
Rate for Payer: Parkland Medicaid	$4,648.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,930.24

MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION

Facility

$32,857.69

Service Code	APR-DRG 6604
Min. Negotiated Rate	$30,979.38
Max. Negotiated Rate	$32,857.69
Rate for Payer: Amerigroup CHIP/Medicaid	$30,979.38
Rate for Payer: Cigna Medicaid	$30,979.38
Rate for Payer: Molina CHIP/Medicaid	$30,979.38
Rate for Payer: Parkland Medicaid	$30,979.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32,857.69

MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION

Facility

$7,992.63

Service Code	APR-DRG 6603
Min. Negotiated Rate	$7,535.74
Max. Negotiated Rate	$7,992.63
Rate for Payer: Amerigroup CHIP/Medicaid	$7,535.74
Rate for Payer: Cigna Medicaid	$7,535.74
Rate for Payer: Molina CHIP/Medicaid	$7,535.74
Rate for Payer: Parkland Medicaid	$7,535.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,992.63

Know your out-of-pocket cost for care.

All Charges