White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$10,591.09

Service Code	APR-DRG 9121
Min. Negotiated Rate	$9,985.65
Max. Negotiated Rate	$10,591.09
Rate for Payer: Amerigroup CHIP/Medicaid	$9,985.65
Rate for Payer: Cigna Medicaid	$9,985.65
Rate for Payer: Molina CHIP/Medicaid	$9,985.65
Rate for Payer: Parkland Medicaid	$9,985.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,591.09

MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY

Facility

$6,691.33

Service Code	APR-DRG 3432
Min. Negotiated Rate	$6,308.82
Max. Negotiated Rate	$6,691.33
Rate for Payer: Amerigroup CHIP/Medicaid	$6,308.82
Rate for Payer: Cigna Medicaid	$6,308.82
Rate for Payer: Molina CHIP/Medicaid	$6,308.82
Rate for Payer: Parkland Medicaid	$6,308.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,691.33

MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY

Facility

$19,544.80

Service Code	APR-DRG 3434
Min. Negotiated Rate	$18,427.52
Max. Negotiated Rate	$19,544.80
Rate for Payer: Amerigroup CHIP/Medicaid	$18,427.52
Rate for Payer: Cigna Medicaid	$18,427.52
Rate for Payer: Molina CHIP/Medicaid	$18,427.52
Rate for Payer: Parkland Medicaid	$18,427.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,544.80

MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY

Facility

$5,458.30

Service Code	APR-DRG 3431
Min. Negotiated Rate	$5,146.28
Max. Negotiated Rate	$5,458.30
Rate for Payer: Amerigroup CHIP/Medicaid	$5,146.28
Rate for Payer: Cigna Medicaid	$5,146.28
Rate for Payer: Molina CHIP/Medicaid	$5,146.28
Rate for Payer: Parkland Medicaid	$5,146.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,458.30

MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY

Facility

$7,924.36

Service Code	APR-DRG 3433
Min. Negotiated Rate	$7,471.37
Max. Negotiated Rate	$7,924.36
Rate for Payer: Amerigroup CHIP/Medicaid	$7,471.37
Rate for Payer: Cigna Medicaid	$7,471.37
Rate for Payer: Molina CHIP/Medicaid	$7,471.37
Rate for Payer: Parkland Medicaid	$7,471.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,924.36

MUSTANG 4.0 X 100 135CM

Facility

$4,176.80

Service Code	HCPCS C1726
Hospital Charge Code	993673
Hospital Revenue Code	272
Min. Negotiated Rate	$375.91
Max. Negotiated Rate	$3,007.30
Rate for Payer: Amerigroup CHIP/Medicaid	$375.91
Rate for Payer: BCBS of TX Blue Advantage	$1,253.04
Rate for Payer: BCBS of TX Blue Essentials	$1,503.65
Rate for Payer: BCBS of TX PPO	$1,670.72
Rate for Payer: Cash Price	$2,840.22
Rate for Payer: Cigna Medicaid	$3,007.30
Rate for Payer: Molina CHIP/Medicaid	$3,007.30
Rate for Payer: Multiplan Auto	$2,714.92
Rate for Payer: Multiplan Commercial	$2,714.92
Rate for Payer: Multiplan Workers Comp	$2,714.92
Rate for Payer: Parkland Medicaid	$3,007.30
Rate for Payer: Scott and White EPO/PPO	$2,088.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,007.30
Rate for Payer: Superior Health Plan EPO	$568.04

MUSTANG 4.0 X 100 135CM

Facility

$4,176.80

Service Code	HCPCS C1726
Hospital Charge Code	993673
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,840.22

MUSTANG 5.0 X 100 135CM

Facility

$4,176.80

Service Code	HCPCS C1726
Hospital Charge Code	993675
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,840.22

MUSTANG 5.0 X 100 135CM

Facility

$4,176.80

Service Code	HCPCS C1726
Hospital Charge Code	993675
Hospital Revenue Code	272
Min. Negotiated Rate	$375.91
Max. Negotiated Rate	$3,007.30
Rate for Payer: Amerigroup CHIP/Medicaid	$375.91
Rate for Payer: BCBS of TX Blue Advantage	$1,253.04
Rate for Payer: BCBS of TX Blue Essentials	$1,503.65
Rate for Payer: BCBS of TX PPO	$1,670.72
Rate for Payer: Cash Price	$2,840.22
Rate for Payer: Cigna Medicaid	$3,007.30
Rate for Payer: Molina CHIP/Medicaid	$3,007.30
Rate for Payer: Multiplan Auto	$2,714.92
Rate for Payer: Multiplan Commercial	$2,714.92
Rate for Payer: Multiplan Workers Comp	$2,714.92
Rate for Payer: Parkland Medicaid	$3,007.30
Rate for Payer: Scott and White EPO/PPO	$2,088.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,007.30
Rate for Payer: Superior Health Plan EPO	$568.04

MUSTANG 5.0 X 40 135CM

Facility

$6,265.20

Service Code	HCPCS C1726
Hospital Charge Code	993674
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,260.34

MUSTANG 5.0 X 40 135CM

Facility

$6,265.20

Service Code	HCPCS C1726
Hospital Charge Code	993674
Hospital Revenue Code	272
Min. Negotiated Rate	$563.87
Max. Negotiated Rate	$4,510.94
Rate for Payer: Amerigroup CHIP/Medicaid	$563.87
Rate for Payer: BCBS of TX Blue Advantage	$1,879.56
Rate for Payer: BCBS of TX Blue Essentials	$2,255.47
Rate for Payer: BCBS of TX PPO	$2,506.08
Rate for Payer: Cash Price	$4,260.34
Rate for Payer: Cigna Medicaid	$4,510.94
Rate for Payer: Molina CHIP/Medicaid	$4,510.94
Rate for Payer: Multiplan Auto	$4,072.38
Rate for Payer: Multiplan Commercial	$4,072.38
Rate for Payer: Multiplan Workers Comp	$4,072.38
Rate for Payer: Parkland Medicaid	$4,510.94
Rate for Payer: Scott and White EPO/PPO	$3,132.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,510.94
Rate for Payer: Superior Health Plan EPO	$852.07

MUSTANG 6.0 X 100 135CM

Facility

$4,176.80

Service Code	HCPCS C1726
Hospital Charge Code	993677
Hospital Revenue Code	272
Min. Negotiated Rate	$375.91
Max. Negotiated Rate	$3,007.30
Rate for Payer: Amerigroup CHIP/Medicaid	$375.91
Rate for Payer: BCBS of TX Blue Advantage	$1,253.04
Rate for Payer: BCBS of TX Blue Essentials	$1,503.65
Rate for Payer: BCBS of TX PPO	$1,670.72
Rate for Payer: Cash Price	$2,840.22
Rate for Payer: Cigna Medicaid	$3,007.30
Rate for Payer: Molina CHIP/Medicaid	$3,007.30
Rate for Payer: Multiplan Auto	$2,714.92
Rate for Payer: Multiplan Commercial	$2,714.92
Rate for Payer: Multiplan Workers Comp	$2,714.92
Rate for Payer: Parkland Medicaid	$3,007.30
Rate for Payer: Scott and White EPO/PPO	$2,088.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,007.30
Rate for Payer: Superior Health Plan EPO	$568.04

MUSTANG 6.0 X 100 135CM

Facility

$4,176.80

Service Code	HCPCS C1726
Hospital Charge Code	993677
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,840.22

MUSTANG 6.0 X 40 135CM

Facility

$8,353.60

Service Code	HCPCS C1726
Hospital Charge Code	993676
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,680.45

MUSTANG 6.0 X 40 135CM

Facility

$8,353.60

Service Code	HCPCS C1726
Hospital Charge Code	993676
Hospital Revenue Code	272
Min. Negotiated Rate	$751.82
Max. Negotiated Rate	$6,014.59
Rate for Payer: Amerigroup CHIP/Medicaid	$751.82
Rate for Payer: BCBS of TX Blue Advantage	$2,506.08
Rate for Payer: BCBS of TX Blue Essentials	$3,007.30
Rate for Payer: BCBS of TX PPO	$3,341.44
Rate for Payer: Cash Price	$5,680.45
Rate for Payer: Cigna Medicaid	$6,014.59
Rate for Payer: Molina CHIP/Medicaid	$6,014.59
Rate for Payer: Multiplan Auto	$5,429.84
Rate for Payer: Multiplan Commercial	$5,429.84
Rate for Payer: Multiplan Workers Comp	$5,429.84
Rate for Payer: Parkland Medicaid	$6,014.59
Rate for Payer: Scott and White EPO/PPO	$4,176.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,014.59
Rate for Payer: Superior Health Plan EPO	$1,136.09

MUSTANG 7.0 X 100 135CM

Facility

$4,176.80

Service Code	HCPCS C1726
Hospital Charge Code	993679
Hospital Revenue Code	272
Min. Negotiated Rate	$375.91
Max. Negotiated Rate	$3,007.30
Rate for Payer: Amerigroup CHIP/Medicaid	$375.91
Rate for Payer: BCBS of TX Blue Advantage	$1,253.04
Rate for Payer: BCBS of TX Blue Essentials	$1,503.65
Rate for Payer: BCBS of TX PPO	$1,670.72
Rate for Payer: Cash Price	$2,840.22
Rate for Payer: Cigna Medicaid	$3,007.30
Rate for Payer: Molina CHIP/Medicaid	$3,007.30
Rate for Payer: Multiplan Auto	$2,714.92
Rate for Payer: Multiplan Commercial	$2,714.92
Rate for Payer: Multiplan Workers Comp	$2,714.92
Rate for Payer: Parkland Medicaid	$3,007.30
Rate for Payer: Scott and White EPO/PPO	$2,088.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,007.30
Rate for Payer: Superior Health Plan EPO	$568.04

MUSTANG 7.0 X 100 135CM

Facility

$4,176.80

Service Code	HCPCS C1726
Hospital Charge Code	993679
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,840.22

MUSTANG 7.0 X 40 135CM

Facility

$4,176.80

Hospital Charge Code	992636
Hospital Revenue Code	272
Min. Negotiated Rate	$375.91
Max. Negotiated Rate	$3,007.30
Rate for Payer: Amerigroup CHIP/Medicaid	$375.91
Rate for Payer: BCBS of TX Blue Advantage	$1,253.04
Rate for Payer: BCBS of TX Blue Essentials	$1,503.65
Rate for Payer: BCBS of TX PPO	$1,670.72
Rate for Payer: Cash Price	$2,840.22
Rate for Payer: Cigna Medicaid	$3,007.30
Rate for Payer: Molina CHIP/Medicaid	$3,007.30
Rate for Payer: Multiplan Auto	$2,714.92
Rate for Payer: Multiplan Commercial	$2,714.92
Rate for Payer: Multiplan Workers Comp	$2,714.92
Rate for Payer: Parkland Medicaid	$3,007.30
Rate for Payer: Scott and White EPO/PPO	$2,088.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,007.30
Rate for Payer: Superior Health Plan EPO	$568.04

MUSTANG 7.0 X 40 135CM

Facility

$4,176.80

Hospital Charge Code	992636
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,840.22

Mycoplasma pneumoniae, IgM Ab SO

Facility

$340.00

Service Code	HCPCS 86738
Hospital Charge Code	1701200
Hospital Revenue Code	302
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$244.80
Rate for Payer: Amerigroup CHIP/Medicaid	$5.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.24
Rate for Payer: Amerigroup Medicare	$13.24
Rate for Payer: BCBS of TX Blue Advantage	$102.00
Rate for Payer: BCBS of TX Blue Essentials	$122.40
Rate for Payer: BCBS of TX Medicare	$13.24
Rate for Payer: BCBS of TX PPO	$136.00
Rate for Payer: Cash Price	$231.20
Rate for Payer: Cash Price	$231.20
Rate for Payer: Cigna Medicaid	$244.80
Rate for Payer: Cigna Medicare	$13.24
Rate for Payer: Employer Direct Commercial	$13.24
Rate for Payer: Humana Medicare/TRICARE	$13.24
Rate for Payer: Molina CHIP/Medicaid	$244.80
Rate for Payer: Molina Dual Medicare/Medicaid	$13.24
Rate for Payer: Molina Medicare	$13.24
Rate for Payer: Multiplan Auto	$221.00
Rate for Payer: Multiplan Commercial	$221.00
Rate for Payer: Multiplan Workers Comp	$221.00
Rate for Payer: Parkland Medicaid	$244.80
Rate for Payer: Scott and White EPO/PPO	$16.55
Rate for Payer: Scott and White Medicare	$13.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$244.80
Rate for Payer: Superior Health Plan EPO	$13.24
Rate for Payer: Superior Health Plan Medicare	$13.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.24
Rate for Payer: Universal American Medicare	$13.24
Rate for Payer: Wellcare Medicare	$13.24
Rate for Payer: Wellmed Medicare	$13.24

Mycoplasma pneumoniae, IgM Ab SO

Facility

$340.00

Service Code	HCPCS 86738
Hospital Charge Code	1701200
Hospital Revenue Code	302
Rate for Payer: Cash Price	$231.20

Myelin Basic Protein, CSF SO

Facility

$162.00

Service Code	HCPCS 83873
Hospital Charge Code	1703073
Hospital Revenue Code	301
Min. Negotiated Rate	$6.71
Max. Negotiated Rate	$116.64
Rate for Payer: Amerigroup CHIP/Medicaid	$6.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.20
Rate for Payer: Amerigroup Medicare	$17.20
Rate for Payer: BCBS of TX Blue Advantage	$48.60
Rate for Payer: BCBS of TX Blue Essentials	$58.32
Rate for Payer: BCBS of TX Medicare	$17.20
Rate for Payer: BCBS of TX PPO	$64.80
Rate for Payer: Cash Price	$110.16
Rate for Payer: Cash Price	$110.16
Rate for Payer: Cigna Medicaid	$116.64
Rate for Payer: Cigna Medicare	$17.20
Rate for Payer: Employer Direct Commercial	$17.20
Rate for Payer: Humana Medicare/TRICARE	$17.20
Rate for Payer: Molina CHIP/Medicaid	$116.64
Rate for Payer: Molina Dual Medicare/Medicaid	$17.20
Rate for Payer: Molina Medicare	$17.20
Rate for Payer: Multiplan Auto	$105.30
Rate for Payer: Multiplan Commercial	$105.30
Rate for Payer: Multiplan Workers Comp	$105.30
Rate for Payer: Parkland Medicaid	$116.64
Rate for Payer: Scott and White EPO/PPO	$21.50
Rate for Payer: Scott and White Medicare	$17.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$116.64
Rate for Payer: Superior Health Plan EPO	$17.20
Rate for Payer: Superior Health Plan Medicare	$17.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.20
Rate for Payer: Universal American Medicare	$17.20
Rate for Payer: Wellcare Medicare	$17.20
Rate for Payer: Wellmed Medicare	$17.20

Myelin Basic Protein, CSF SO

Facility

$162.00

Service Code	HCPCS 83873
Hospital Charge Code	1703073
Hospital Revenue Code	301
Rate for Payer: Cash Price	$110.16

Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more r

Facility

$2,192.01

Service Code	HCPCS 62305
Hospital Charge Code	3181103
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,490.57

Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more r

Facility

$2,192.01

Service Code	HCPCS 62305
Hospital Charge Code	3181103
Hospital Revenue Code	360
Min. Negotiated Rate	$197.28
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$197.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$787.49
Rate for Payer: Amerigroup Medicare	$787.49
Rate for Payer: BCBS of TX Blue Advantage	$1,136.97
Rate for Payer: BCBS of TX Blue Essentials	$1,361.64
Rate for Payer: BCBS of TX Medicare	$787.49
Rate for Payer: BCBS of TX PPO	$1,715.67
Rate for Payer: Cash Price	$1,490.57
Rate for Payer: Cash Price	$1,490.57
Rate for Payer: Cash Price	$1,490.57
Rate for Payer: Cigna Commercial	$1,664.61
Rate for Payer: Cigna Medicaid	$1,578.25
Rate for Payer: Cigna Medicare	$787.49
Rate for Payer: Employer Direct Commercial	$787.49
Rate for Payer: Humana Medicare/TRICARE	$787.49
Rate for Payer: Molina CHIP/Medicaid	$1,578.25
Rate for Payer: Molina Dual Medicare/Medicaid	$787.49
Rate for Payer: Molina Medicare	$787.49
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	$1,578.25
Rate for Payer: Scott and White EPO/PPO	$1,354.68
Rate for Payer: Scott and White Medicare	$787.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,578.25
Rate for Payer: Superior Health Plan EPO	$787.49
Rate for Payer: Superior Health Plan Medicare	$787.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$787.49
Rate for Payer: Universal American Medicare	$787.49
Rate for Payer: Wellcare Medicare	$787.49
Rate for Payer: Wellmed Medicare	$787.49

Know your out-of-pocket cost for care.

All Charges