White Rock Medical Center

All Charges

Charge

Type

Setting

Price

*Multilayer Compression Wrap -> Below the Knee Left

Facility

$993.50

Service Code	HCPCS 29581
Hospital Charge Code	7150830
Hospital Revenue Code	361
Min. Negotiated Rate	$51.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$51.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$112.86
Rate for Payer: BCBS of TX Blue Essentials	$135.16
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$170.30
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
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	$715.32
Rate for Payer: Scott and White EPO/PPO	$266.58
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

*Multilayer Compression Wrap -> Below the Knee Left

Facility

$993.50

Service Code	HCPCS 29581
Hospital Charge Code	7150830
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

*Multilayer Compression Wrap -> Below the Knee Right

Facility

$993.50

Service Code	HCPCS 29581
Hospital Charge Code	7150829
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

*Multilayer Compression Wrap -> Below the Knee Right

Facility

$993.50

Service Code	HCPCS 29581
Hospital Charge Code	7150829
Hospital Revenue Code	361
Min. Negotiated Rate	$51.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$51.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$112.86
Rate for Payer: BCBS of TX Blue Essentials	$135.16
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$170.30
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
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	$715.32
Rate for Payer: Scott and White EPO/PPO	$266.58
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC

Facility

$92,975.57

Service Code	MSDRG 427
Min. Negotiated Rate	$57,665.38
Max. Negotiated Rate	$92,975.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$57,665.38
Rate for Payer: Amerigroup Medicare	$57,665.38
Rate for Payer: BCBS of TX Medicare	$57,665.38
Rate for Payer: Cigna Commercial	$92,975.57
Rate for Payer: Cigna Medicare	$57,665.38
Rate for Payer: Employer Direct Commercial	$57,665.38
Rate for Payer: Humana Medicare/TRICARE	$57,665.38
Rate for Payer: Molina Dual Medicare/Medicaid	$57,665.38
Rate for Payer: Molina Medicare	$57,665.38
Rate for Payer: Scott and White Medicare	$57,665.38
Rate for Payer: Superior Health Plan EPO	$57,665.38
Rate for Payer: Superior Health Plan Medicare	$57,665.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$57,665.38
Rate for Payer: Universal American Medicare	$57,665.38
Rate for Payer: Wellcare Medicare	$57,665.38
Rate for Payer: Wellmed Medicare	$57,665.38

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$141,953.06

Service Code	MSDRG 426
Min. Negotiated Rate	$85,534.74
Max. Negotiated Rate	$141,953.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$85,534.74
Rate for Payer: Amerigroup Medicare	$85,534.74
Rate for Payer: BCBS of TX Medicare	$85,534.74
Rate for Payer: Cigna Commercial	$141,953.06
Rate for Payer: Cigna Medicare	$85,534.74
Rate for Payer: Employer Direct Commercial	$85,534.74
Rate for Payer: Humana Medicare/TRICARE	$85,534.74
Rate for Payer: Molina Dual Medicare/Medicaid	$85,534.74
Rate for Payer: Molina Medicare	$85,534.74
Rate for Payer: Scott and White Medicare	$85,534.74
Rate for Payer: Superior Health Plan EPO	$85,534.74
Rate for Payer: Superior Health Plan Medicare	$85,534.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$85,534.74
Rate for Payer: Universal American Medicare	$85,534.74
Rate for Payer: Wellcare Medicare	$85,534.74
Rate for Payer: Wellmed Medicare	$85,534.74

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC

Facility

$72,411.36

Service Code	MSDRG 428
Min. Negotiated Rate	$45,963.87
Max. Negotiated Rate	$72,411.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$45,963.87
Rate for Payer: Amerigroup Medicare	$45,963.87
Rate for Payer: BCBS of TX Medicare	$45,963.87
Rate for Payer: Cigna Commercial	$72,411.36
Rate for Payer: Cigna Medicare	$45,963.87
Rate for Payer: Employer Direct Commercial	$45,963.87
Rate for Payer: Humana Medicare/TRICARE	$45,963.87
Rate for Payer: Molina Dual Medicare/Medicaid	$45,963.87
Rate for Payer: Molina Medicare	$45,963.87
Rate for Payer: Scott and White Medicare	$45,963.87
Rate for Payer: Superior Health Plan EPO	$45,963.87
Rate for Payer: Superior Health Plan Medicare	$45,963.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$45,963.87
Rate for Payer: Universal American Medicare	$45,963.87
Rate for Payer: Wellcare Medicare	$45,963.87
Rate for Payer: Wellmed Medicare	$45,963.87

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$86,059.01

Service Code	MSDRG 447
Min. Negotiated Rate	$53,729.70
Max. Negotiated Rate	$86,059.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$53,729.70
Rate for Payer: Amerigroup Medicare	$53,729.70
Rate for Payer: BCBS of TX Medicare	$53,729.70
Rate for Payer: Cigna Commercial	$86,059.01
Rate for Payer: Cigna Medicare	$53,729.70
Rate for Payer: Employer Direct Commercial	$53,729.70
Rate for Payer: Humana Medicare/TRICARE	$53,729.70
Rate for Payer: Molina Dual Medicare/Medicaid	$53,729.70
Rate for Payer: Molina Medicare	$53,729.70
Rate for Payer: Scott and White Medicare	$53,729.70
Rate for Payer: Superior Health Plan EPO	$53,729.70
Rate for Payer: Superior Health Plan Medicare	$53,729.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$53,729.70
Rate for Payer: Universal American Medicare	$53,729.70
Rate for Payer: Wellcare Medicare	$53,729.70
Rate for Payer: Wellmed Medicare	$53,729.70

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$54,621.50

Service Code	MSDRG 448
Min. Negotiated Rate	$35,841.02
Max. Negotiated Rate	$54,621.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35,841.02
Rate for Payer: Amerigroup Medicare	$35,841.02
Rate for Payer: BCBS of TX Medicare	$35,841.02
Rate for Payer: Cigna Commercial	$54,621.50
Rate for Payer: Cigna Medicare	$35,841.02
Rate for Payer: Employer Direct Commercial	$35,841.02
Rate for Payer: Humana Medicare/TRICARE	$35,841.02
Rate for Payer: Molina Dual Medicare/Medicaid	$35,841.02
Rate for Payer: Molina Medicare	$35,841.02
Rate for Payer: Scott and White Medicare	$35,841.02
Rate for Payer: Superior Health Plan EPO	$35,841.02
Rate for Payer: Superior Health Plan Medicare	$35,841.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$35,841.02
Rate for Payer: Universal American Medicare	$35,841.02
Rate for Payer: Wellcare Medicare	$35,841.02
Rate for Payer: Wellmed Medicare	$35,841.02

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC

Facility

$21,726.50

Service Code	MSDRG 059
Min. Negotiated Rate	$9,453.98
Max. Negotiated Rate	$21,726.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,854.67
Rate for Payer: Amerigroup Medicare	$13,854.67
Rate for Payer: BCBS of TX Medicare	$13,854.67
Rate for Payer: Cigna Commercial	$15,982.79
Rate for Payer: Cigna Medicare	$13,854.67
Rate for Payer: Employer Direct Commercial	$13,854.67
Rate for Payer: Humana Medicare/TRICARE	$13,854.67
Rate for Payer: Molina Dual Medicare/Medicaid	$13,854.67
Rate for Payer: Molina Medicare	$13,854.67
Rate for Payer: Multiplan Auto	$21,726.50
Rate for Payer: Multiplan Commercial	$21,726.50
Rate for Payer: Multiplan Workers Comp	$21,726.50
Rate for Payer: Scott and White EPO/PPO	$10,005.62
Rate for Payer: Scott and White Medicare	$13,854.67
Rate for Payer: Superior Health Plan EPO	$13,854.67
Rate for Payer: Superior Health Plan Medicare	$13,854.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,854.67
Rate for Payer: Universal American Medicare	$13,854.67
Rate for Payer: Wellcare Medicare	$13,854.67
Rate for Payer: Wellmed Medicare	$13,854.67

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC

Facility

$32,780.70

Service Code	MSDRG 058
Min. Negotiated Rate	$15,096.38
Max. Negotiated Rate	$32,780.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,289.05
Rate for Payer: Amerigroup Medicare	$17,289.05
Rate for Payer: BCBS of TX Medicare	$17,289.05
Rate for Payer: Cigna Commercial	$22,018.36
Rate for Payer: Cigna Medicare	$17,289.05
Rate for Payer: Employer Direct Commercial	$17,289.05
Rate for Payer: Humana Medicare/TRICARE	$17,289.05
Rate for Payer: Molina Dual Medicare/Medicaid	$17,289.05
Rate for Payer: Molina Medicare	$17,289.05
Rate for Payer: Multiplan Auto	$32,780.70
Rate for Payer: Multiplan Commercial	$32,780.70
Rate for Payer: Multiplan Workers Comp	$32,780.70
Rate for Payer: Scott and White EPO/PPO	$15,096.38
Rate for Payer: Scott and White Medicare	$17,289.05
Rate for Payer: Superior Health Plan EPO	$17,289.05
Rate for Payer: Superior Health Plan Medicare	$17,289.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,289.05
Rate for Payer: Universal American Medicare	$17,289.05
Rate for Payer: Wellcare Medicare	$17,289.05
Rate for Payer: Wellmed Medicare	$17,289.05

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC

Facility

$17,219.70

Service Code	MSDRG 060
Min. Negotiated Rate	$7,161.22
Max. Negotiated Rate	$17,219.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,501.32
Rate for Payer: Amerigroup Medicare	$11,501.32
Rate for Payer: BCBS of TX Medicare	$11,501.32
Rate for Payer: Cigna Commercial	$11,847.02
Rate for Payer: Cigna Medicare	$11,501.32
Rate for Payer: Employer Direct Commercial	$11,501.32
Rate for Payer: Humana Medicare/TRICARE	$11,501.32
Rate for Payer: Molina Dual Medicare/Medicaid	$11,501.32
Rate for Payer: Molina Medicare	$11,501.32
Rate for Payer: Multiplan Auto	$17,219.70
Rate for Payer: Multiplan Commercial	$17,219.70
Rate for Payer: Multiplan Workers Comp	$17,219.70
Rate for Payer: Scott and White EPO/PPO	$7,930.12
Rate for Payer: Scott and White Medicare	$11,501.32
Rate for Payer: Superior Health Plan EPO	$11,501.32
Rate for Payer: Superior Health Plan Medicare	$11,501.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,501.32
Rate for Payer: Universal American Medicare	$11,501.32
Rate for Payer: Wellcare Medicare	$11,501.32
Rate for Payer: Wellmed Medicare	$11,501.32

MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W CC

Facility

$21,726.50

Service Code	MSDRG 059
Min. Negotiated Rate	$9,453.98
Max. Negotiated Rate	$21,726.50
Rate for Payer: BCBS of TX Blue Advantage	$9,453.98
Rate for Payer: BCBS of TX Blue Essentials	$11,343.68
Rate for Payer: BCBS of TX PPO	$12,604.57

MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W MCC

Facility

$32,780.70

Service Code	MSDRG 058
Min. Negotiated Rate	$15,096.38
Max. Negotiated Rate	$32,780.70
Rate for Payer: BCBS of TX Blue Advantage	$15,132.56
Rate for Payer: BCBS of TX Blue Essentials	$18,157.31
Rate for Payer: BCBS of TX PPO	$20,175.57

MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W/O CC/MCC

Facility

$17,219.70

Service Code	MSDRG 060
Min. Negotiated Rate	$7,161.22
Max. Negotiated Rate	$17,219.70
Rate for Payer: BCBS of TX Blue Advantage	$7,161.22
Rate for Payer: BCBS of TX Blue Essentials	$8,592.63
Rate for Payer: BCBS of TX PPO	$9,547.74

MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES

Facility

$22,209.27

Service Code	APR-DRG 0433
Min. Negotiated Rate	$20,939.67
Max. Negotiated Rate	$22,209.27
Rate for Payer: Amerigroup CHIP/Medicaid	$20,939.67
Rate for Payer: Cigna Medicaid	$20,939.67
Rate for Payer: Molina CHIP/Medicaid	$20,939.67
Rate for Payer: Parkland Medicaid	$20,939.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,209.27

MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES

Facility

$53,365.45

Service Code	APR-DRG 0434
Min. Negotiated Rate	$50,314.82
Max. Negotiated Rate	$53,365.45
Rate for Payer: Amerigroup CHIP/Medicaid	$50,314.82
Rate for Payer: Cigna Medicaid	$50,314.82
Rate for Payer: Molina CHIP/Medicaid	$50,314.82
Rate for Payer: Parkland Medicaid	$50,314.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53,365.45

MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES

Facility

$6,963.29

Service Code	APR-DRG 0432
Min. Negotiated Rate	$6,565.23
Max. Negotiated Rate	$6,963.29
Rate for Payer: Amerigroup CHIP/Medicaid	$6,565.23
Rate for Payer: Cigna Medicaid	$6,565.23
Rate for Payer: Molina CHIP/Medicaid	$6,565.23
Rate for Payer: Parkland Medicaid	$6,565.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,963.29

MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES

Facility

$4,681.67

Service Code	APR-DRG 0431
Min. Negotiated Rate	$4,414.04
Max. Negotiated Rate	$4,681.67
Rate for Payer: Amerigroup CHIP/Medicaid	$4,414.04
Rate for Payer: Cigna Medicaid	$4,414.04
Rate for Payer: Molina CHIP/Medicaid	$4,414.04
Rate for Payer: Parkland Medicaid	$4,414.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,681.67

MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE

Facility

$19,053.70

Service Code	APR-DRG 9304
Min. Negotiated Rate	$17,964.50
Max. Negotiated Rate	$19,053.70
Rate for Payer: Amerigroup CHIP/Medicaid	$17,964.50
Rate for Payer: Cigna Medicaid	$17,964.50
Rate for Payer: Molina CHIP/Medicaid	$17,964.50
Rate for Payer: Parkland Medicaid	$17,964.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,053.70

MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE

Facility

$6,177.98

Service Code	APR-DRG 9302
Min. Negotiated Rate	$5,824.81
Max. Negotiated Rate	$6,177.98
Rate for Payer: Amerigroup CHIP/Medicaid	$5,824.81
Rate for Payer: Cigna Medicaid	$5,824.81
Rate for Payer: Molina CHIP/Medicaid	$5,824.81
Rate for Payer: Parkland Medicaid	$5,824.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,177.98

MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE

Facility

$4,411.23

Service Code	APR-DRG 9301
Min. Negotiated Rate	$4,159.06
Max. Negotiated Rate	$4,411.23
Rate for Payer: Amerigroup CHIP/Medicaid	$4,159.06
Rate for Payer: Cigna Medicaid	$4,159.06
Rate for Payer: Molina CHIP/Medicaid	$4,159.06
Rate for Payer: Parkland Medicaid	$4,159.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,411.23

MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE

Facility

$7,944.35

Service Code	APR-DRG 9303
Min. Negotiated Rate	$7,490.22
Max. Negotiated Rate	$7,944.35
Rate for Payer: Amerigroup CHIP/Medicaid	$7,490.22
Rate for Payer: Cigna Medicaid	$7,490.22
Rate for Payer: Molina CHIP/Medicaid	$7,490.22
Rate for Payer: Parkland Medicaid	$7,490.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,944.35

Multiple Vitamins IV Soln 10 mL

Facility

$630.99

Service Code	HCPCS J3490
Hospital Charge Code	77715887
Hospital Revenue Code	250
Min. Negotiated Rate	$56.79
Max. Negotiated Rate	$454.31
Rate for Payer: Amerigroup CHIP/Medicaid	$56.79
Rate for Payer: BCBS of TX Blue Advantage	$189.30
Rate for Payer: BCBS of TX Blue Essentials	$227.16
Rate for Payer: BCBS of TX PPO	$252.40
Rate for Payer: Cash Price	$429.07
Rate for Payer: Cigna Medicaid	$454.31
Rate for Payer: Molina CHIP/Medicaid	$454.31
Rate for Payer: Multiplan Auto	$410.14
Rate for Payer: Multiplan Commercial	$410.14
Rate for Payer: Multiplan Workers Comp	$410.14
Rate for Payer: Parkland Medicaid	$454.31
Rate for Payer: Scott and White EPO/PPO	$315.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$454.31
Rate for Payer: Superior Health Plan EPO	$85.81

Multiple Vitamins IV Soln 10 mL

Facility

$630.99

Service Code	HCPCS J3490
Hospital Charge Code	77715887
Hospital Revenue Code	250
Rate for Payer: Cash Price	$429.07

Know your out-of-pocket cost for care.

All Charges