White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MAJOR PROCEDURE - BREAST

Facility

$9,777.99

Service Code	HCPCS 19328
Hospital Charge Code	9900158
Hospital Revenue Code	360
Min. Negotiated Rate	$963.66
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$963.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Amerigroup Medicare	$3,933.28
Rate for Payer: BCBS of TX Blue Advantage	$5,059.35
Rate for Payer: BCBS of TX Blue Essentials	$6,059.10
Rate for Payer: BCBS of TX Medicare	$3,933.28
Rate for Payer: BCBS of TX PPO	$7,634.47
Rate for Payer: Cash Price	$6,649.03
Rate for Payer: Cash Price	$6,649.03
Rate for Payer: Cash Price	$6,649.03
Rate for Payer: Cigna Commercial	$8,314.23
Rate for Payer: Cigna Medicaid	$7,040.15
Rate for Payer: Cigna Medicare	$3,933.28
Rate for Payer: Employer Direct Commercial	$3,933.28
Rate for Payer: Humana Medicare/TRICARE	$3,933.28
Rate for Payer: Molina CHIP/Medicaid	$7,040.15
Rate for Payer: Molina Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Molina Medicare	$3,933.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$7,040.15
Rate for Payer: Scott and White EPO/PPO	$7,276.57
Rate for Payer: Scott and White Medicare	$3,933.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,040.15
Rate for Payer: Superior Health Plan EPO	$3,933.28
Rate for Payer: Superior Health Plan Medicare	$3,933.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Universal American Medicare	$3,933.28
Rate for Payer: Wellcare Medicare	$3,933.28
Rate for Payer: Wellmed Medicare	$3,933.28

MAJOR PROCEDURE - BREAST

Facility

$10,000.00

Service Code	CPT 19328
Hospital Charge Code	36019328
Hospital Revenue Code	360
Min. Negotiated Rate	$963.66
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$963.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Amerigroup Medicare	$3,933.28
Rate for Payer: BCBS of TX Blue Advantage	$5,059.35
Rate for Payer: BCBS of TX Blue Essentials	$6,059.10
Rate for Payer: BCBS of TX Medicare	$3,933.28
Rate for Payer: BCBS of TX PPO	$7,634.47
Rate for Payer: Cigna Commercial	$8,314.23
Rate for Payer: Cigna Medicare	$3,933.28
Rate for Payer: Employer Direct Commercial	$3,933.28
Rate for Payer: Humana Medicare/TRICARE	$3,933.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Molina Medicare	$3,933.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$7,276.57
Rate for Payer: Scott and White Medicare	$3,933.28
Rate for Payer: Superior Health Plan EPO	$3,933.28
Rate for Payer: Superior Health Plan Medicare	$3,933.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,933.28
Rate for Payer: Universal American Medicare	$3,933.28
Rate for Payer: Wellcare Medicare	$3,933.28
Rate for Payer: Wellmed Medicare	$3,933.28

MAJOR PROCEDURE, ORTHOPEDIC - OTHER

Facility

$30,822.00

Service Code	HCPCS 22852
Hospital Charge Code	9900208
Hospital Revenue Code	360
Min. Negotiated Rate	$1,216.34
Max. Negotiated Rate	$22,191.84
Rate for Payer: Amerigroup CHIP/Medicaid	$2,773.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$1,216.34
Rate for Payer: BCBS of TX Blue Essentials	$1,456.70
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$1,835.44
Rate for Payer: Cash Price	$20,958.96
Rate for Payer: Cash Price	$20,958.96
Rate for Payer: Cash Price	$20,958.96
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$22,191.84
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$22,191.84
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$22,191.84
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,191.84
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

MAJOR PROCEDURE, ORTHOPEDIC - OTHER

Facility

$30,822.00

Service Code	HCPCS 22852
Hospital Charge Code	9900208
Hospital Revenue Code	360
Rate for Payer: Cash Price	$20,958.96

MAJOR PROCEDURE, ORTHOPEDIC - OTHER

Facility

$15,408.22

Service Code	CPT 22852
Hospital Charge Code	36022852
Hospital Revenue Code	360
Min. Negotiated Rate	$1,216.34
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$1,216.34
Rate for Payer: BCBS of TX Blue Essentials	$1,456.70
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$1,835.44
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

MAJOR RESPIRATORY AND CHEST PROCEDURES

Facility

$12,856.11

Service Code	APR-DRG 1203
Min. Negotiated Rate	$12,121.19
Max. Negotiated Rate	$12,856.11
Rate for Payer: Amerigroup CHIP/Medicaid	$12,121.19
Rate for Payer: Cigna Medicaid	$12,121.19
Rate for Payer: Molina CHIP/Medicaid	$12,121.19
Rate for Payer: Parkland Medicaid	$12,121.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,856.11

MAJOR RESPIRATORY AND CHEST PROCEDURES

Facility

$9,117.41

Service Code	APR-DRG 1202
Min. Negotiated Rate	$8,596.22
Max. Negotiated Rate	$9,117.41
Rate for Payer: Amerigroup CHIP/Medicaid	$8,596.22
Rate for Payer: Cigna Medicaid	$8,596.22
Rate for Payer: Molina CHIP/Medicaid	$8,596.22
Rate for Payer: Parkland Medicaid	$8,596.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,117.41

MAJOR RESPIRATORY AND CHEST PROCEDURES

Facility

$37,915.42

Service Code	APR-DRG 1204
Min. Negotiated Rate	$35,747.98
Max. Negotiated Rate	$37,915.42
Rate for Payer: Amerigroup CHIP/Medicaid	$35,747.98
Rate for Payer: Cigna Medicaid	$35,747.98
Rate for Payer: Molina CHIP/Medicaid	$35,747.98
Rate for Payer: Parkland Medicaid	$35,747.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37,915.42

MAJOR RESPIRATORY AND CHEST PROCEDURES

Facility

$8,912.60

Service Code	APR-DRG 1201
Min. Negotiated Rate	$8,403.11
Max. Negotiated Rate	$8,912.60
Rate for Payer: Amerigroup CHIP/Medicaid	$8,403.11
Rate for Payer: Cigna Medicaid	$8,403.11
Rate for Payer: Molina CHIP/Medicaid	$8,403.11
Rate for Payer: Parkland Medicaid	$8,403.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,912.60

MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS

Facility

$11,736.24

Service Code	APR-DRG 1374
Min. Negotiated Rate	$11,065.33
Max. Negotiated Rate	$11,736.24
Rate for Payer: Amerigroup CHIP/Medicaid	$11,065.33
Rate for Payer: Cigna Medicaid	$11,065.33
Rate for Payer: Molina CHIP/Medicaid	$11,065.33
Rate for Payer: Parkland Medicaid	$11,065.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,736.24

MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS

Facility

$6,352.99

Service Code	APR-DRG 1373
Min. Negotiated Rate	$5,989.83
Max. Negotiated Rate	$6,352.99
Rate for Payer: Amerigroup CHIP/Medicaid	$5,989.83
Rate for Payer: Cigna Medicaid	$5,989.83
Rate for Payer: Molina CHIP/Medicaid	$5,989.83
Rate for Payer: Parkland Medicaid	$5,989.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,352.99

MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS

Facility

$4,351.25

Service Code	APR-DRG 1372
Min. Negotiated Rate	$4,102.51
Max. Negotiated Rate	$4,351.25
Rate for Payer: Amerigroup CHIP/Medicaid	$4,102.51
Rate for Payer: Cigna Medicaid	$4,102.51
Rate for Payer: Molina CHIP/Medicaid	$4,102.51
Rate for Payer: Parkland Medicaid	$4,102.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,351.25

MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS

Facility

$3,034.86

Service Code	APR-DRG 1371
Min. Negotiated Rate	$2,861.37
Max. Negotiated Rate	$3,034.86
Rate for Payer: Amerigroup CHIP/Medicaid	$2,861.37
Rate for Payer: Cigna Medicaid	$2,861.37
Rate for Payer: Molina CHIP/Medicaid	$2,861.37
Rate for Payer: Parkland Medicaid	$2,861.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,034.86

MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC

Facility

$34,321.60

Service Code	MSDRG 507
Min. Negotiated Rate	$15,806.00
Max. Negotiated Rate	$34,321.60
Rate for Payer: BCBS of TX Blue Advantage	$16,705.50
Rate for Payer: BCBS of TX Blue Essentials	$20,044.66
Rate for Payer: BCBS of TX PPO	$22,272.71

MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC

Facility

$34,321.60

Service Code	MSDRG 507
Min. Negotiated Rate	$15,806.00
Max. Negotiated Rate	$34,321.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,999.23
Rate for Payer: Amerigroup Medicare	$17,999.23
Rate for Payer: BCBS of TX Medicare	$17,999.23
Rate for Payer: Cigna Commercial	$23,266.43
Rate for Payer: Cigna Medicare	$17,999.23
Rate for Payer: Employer Direct Commercial	$17,999.23
Rate for Payer: Humana Medicare/TRICARE	$17,999.23
Rate for Payer: Molina Dual Medicare/Medicaid	$17,999.23
Rate for Payer: Molina Medicare	$17,999.23
Rate for Payer: Multiplan Auto	$34,321.60
Rate for Payer: Multiplan Commercial	$34,321.60
Rate for Payer: Multiplan Workers Comp	$34,321.60
Rate for Payer: Scott and White EPO/PPO	$15,806.00
Rate for Payer: Scott and White Medicare	$17,999.23
Rate for Payer: Superior Health Plan EPO	$17,999.23
Rate for Payer: Superior Health Plan Medicare	$17,999.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,999.23
Rate for Payer: Universal American Medicare	$17,999.23
Rate for Payer: Wellcare Medicare	$17,999.23
Rate for Payer: Wellmed Medicare	$17,999.23

MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC

Facility

$28,773.60

Service Code	MSDRG 508
Min. Negotiated Rate	$12,447.64
Max. Negotiated Rate	$28,773.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,859.16
Rate for Payer: Amerigroup Medicare	$15,859.16
Rate for Payer: BCBS of TX Medicare	$15,859.16
Rate for Payer: Cigna Commercial	$19,505.47
Rate for Payer: Cigna Medicare	$15,859.16
Rate for Payer: Employer Direct Commercial	$15,859.16
Rate for Payer: Humana Medicare/TRICARE	$15,859.16
Rate for Payer: Molina Dual Medicare/Medicaid	$15,859.16
Rate for Payer: Molina Medicare	$15,859.16
Rate for Payer: Multiplan Auto	$28,773.60
Rate for Payer: Multiplan Commercial	$28,773.60
Rate for Payer: Multiplan Workers Comp	$28,773.60
Rate for Payer: Scott and White EPO/PPO	$13,251.00
Rate for Payer: Scott and White Medicare	$15,859.16
Rate for Payer: Superior Health Plan EPO	$15,859.16
Rate for Payer: Superior Health Plan Medicare	$15,859.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,859.16
Rate for Payer: Universal American Medicare	$15,859.16
Rate for Payer: Wellcare Medicare	$15,859.16
Rate for Payer: Wellmed Medicare	$15,859.16

MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC

Facility

$28,773.60

Service Code	MSDRG 508
Min. Negotiated Rate	$12,447.64
Max. Negotiated Rate	$28,773.60
Rate for Payer: BCBS of TX Blue Advantage	$12,447.64
Rate for Payer: BCBS of TX Blue Essentials	$14,935.72
Rate for Payer: BCBS of TX PPO	$16,595.89

MAJOR SKIN DISORDERS

Facility

$5,344.01

Service Code	APR-DRG 3813
Min. Negotiated Rate	$5,038.52
Max. Negotiated Rate	$5,344.01
Rate for Payer: Amerigroup CHIP/Medicaid	$5,038.52
Rate for Payer: Cigna Medicaid	$5,038.52
Rate for Payer: Molina CHIP/Medicaid	$5,038.52
Rate for Payer: Parkland Medicaid	$5,038.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,344.01

MAJOR SKIN DISORDERS

Facility

$1,641.53

Service Code	APR-DRG 3811
Min. Negotiated Rate	$1,547.69
Max. Negotiated Rate	$1,641.53
Rate for Payer: Amerigroup CHIP/Medicaid	$1,547.69
Rate for Payer: Cigna Medicaid	$1,547.69
Rate for Payer: Molina CHIP/Medicaid	$1,547.69
Rate for Payer: Parkland Medicaid	$1,547.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,641.53

MAJOR SKIN DISORDERS

Facility

$2,991.86

Service Code	APR-DRG 3812
Min. Negotiated Rate	$2,820.83
Max. Negotiated Rate	$2,991.86
Rate for Payer: Amerigroup CHIP/Medicaid	$2,820.83
Rate for Payer: Cigna Medicaid	$2,820.83
Rate for Payer: Molina CHIP/Medicaid	$2,820.83
Rate for Payer: Parkland Medicaid	$2,820.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,991.86

MAJOR SKIN DISORDERS

Facility

$20,139.25

Service Code	APR-DRG 3814
Min. Negotiated Rate	$18,987.99
Max. Negotiated Rate	$20,139.25
Rate for Payer: Amerigroup CHIP/Medicaid	$18,987.99
Rate for Payer: Cigna Medicaid	$18,987.99
Rate for Payer: Molina CHIP/Medicaid	$18,987.99
Rate for Payer: Parkland Medicaid	$18,987.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,139.25

MAJOR SKIN DISORDERS WITH MCC

Facility

$40,293.30

Service Code	MSDRG 595
Min. Negotiated Rate	$17,087.34
Max. Negotiated Rate	$40,293.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,302.75
Rate for Payer: Amerigroup Medicare	$20,302.75
Rate for Payer: BCBS of TX Medicare	$20,302.75
Rate for Payer: Cigna Commercial	$27,314.62
Rate for Payer: Cigna Medicare	$20,302.75
Rate for Payer: Employer Direct Commercial	$20,302.75
Rate for Payer: Humana Medicare/TRICARE	$20,302.75
Rate for Payer: Molina Dual Medicare/Medicaid	$20,302.75
Rate for Payer: Molina Medicare	$20,302.75
Rate for Payer: Multiplan Auto	$40,293.30
Rate for Payer: Multiplan Commercial	$40,293.30
Rate for Payer: Multiplan Workers Comp	$40,293.30
Rate for Payer: Scott and White EPO/PPO	$18,556.12
Rate for Payer: Scott and White Medicare	$20,302.75
Rate for Payer: Superior Health Plan EPO	$20,302.75
Rate for Payer: Superior Health Plan Medicare	$20,302.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,302.75
Rate for Payer: Universal American Medicare	$20,302.75
Rate for Payer: Wellcare Medicare	$20,302.75
Rate for Payer: Wellmed Medicare	$20,302.75

MAJOR SKIN DISORDERS WITHOUT MCC

Facility

$20,567.50

Service Code	MSDRG 596
Min. Negotiated Rate	$8,698.90
Max. Negotiated Rate	$20,567.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,693.76
Rate for Payer: Amerigroup Medicare	$12,693.76
Rate for Payer: BCBS of TX Medicare	$12,693.76
Rate for Payer: Cigna Commercial	$13,942.60
Rate for Payer: Cigna Medicare	$12,693.76
Rate for Payer: Employer Direct Commercial	$12,693.76
Rate for Payer: Humana Medicare/TRICARE	$12,693.76
Rate for Payer: Molina Dual Medicare/Medicaid	$12,693.76
Rate for Payer: Molina Medicare	$12,693.76
Rate for Payer: Multiplan Auto	$20,567.50
Rate for Payer: Multiplan Commercial	$20,567.50
Rate for Payer: Multiplan Workers Comp	$20,567.50
Rate for Payer: Scott and White EPO/PPO	$9,471.88
Rate for Payer: Scott and White Medicare	$12,693.76
Rate for Payer: Superior Health Plan EPO	$12,693.76
Rate for Payer: Superior Health Plan Medicare	$12,693.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,693.76
Rate for Payer: Universal American Medicare	$12,693.76
Rate for Payer: Wellcare Medicare	$12,693.76
Rate for Payer: Wellmed Medicare	$12,693.76

MAJOR SKIN DISORDERS W MCC

Facility

$40,293.30

Service Code	MSDRG 595
Min. Negotiated Rate	$17,087.34
Max. Negotiated Rate	$40,293.30
Rate for Payer: BCBS of TX Blue Advantage	$17,087.34
Rate for Payer: BCBS of TX Blue Essentials	$20,502.82
Rate for Payer: BCBS of TX PPO	$22,781.80

MAJOR SKIN DISORDERS W/O MCC

Facility

$20,567.50

Service Code	MSDRG 596
Min. Negotiated Rate	$8,698.90
Max. Negotiated Rate	$20,567.50
Rate for Payer: BCBS of TX Blue Advantage	$8,698.90
Rate for Payer: BCBS of TX Blue Essentials	$10,437.67
Rate for Payer: BCBS of TX PPO	$11,597.86

Know your out-of-pocket cost for care.

All Charges