White Rock Medical Center

All Charges

Charge

Type

Setting

Price

NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION

Facility

$2,718.02

Service Code	APR-DRG 6391
Min. Negotiated Rate	$2,562.65
Max. Negotiated Rate	$2,718.02
Rate for Payer: Amerigroup CHIP/Medicaid	$2,562.65
Rate for Payer: Cigna Medicaid	$2,562.65
Rate for Payer: Molina CHIP/Medicaid	$2,562.65
Rate for Payer: Parkland Medicaid	$2,562.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,718.02

NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION

Facility

$9,350.52

Service Code	APR-DRG 6393
Min. Negotiated Rate	$8,815.99
Max. Negotiated Rate	$9,350.52
Rate for Payer: Amerigroup CHIP/Medicaid	$8,815.99
Rate for Payer: Cigna Medicaid	$8,815.99
Rate for Payer: Molina CHIP/Medicaid	$8,815.99
Rate for Payer: Parkland Medicaid	$8,815.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,350.52

NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION

Facility

$5,593.34

Service Code	APR-DRG 6392
Min. Negotiated Rate	$5,273.59
Max. Negotiated Rate	$5,593.34
Rate for Payer: Amerigroup CHIP/Medicaid	$5,273.59
Rate for Payer: Cigna Medicaid	$5,273.59
Rate for Payer: Molina CHIP/Medicaid	$5,273.59
Rate for Payer: Parkland Medicaid	$5,273.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,593.34

NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION

Facility

$17,731.65

Service Code	APR-DRG 6394
Min. Negotiated Rate	$16,718.03
Max. Negotiated Rate	$17,731.65
Rate for Payer: Amerigroup CHIP/Medicaid	$16,718.03
Rate for Payer: Cigna Medicaid	$16,718.03
Rate for Payer: Molina CHIP/Medicaid	$16,718.03
Rate for Payer: Parkland Medicaid	$16,718.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,731.65

NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION

Facility

$25,737.87

Service Code	APR-DRG 6344
Min. Negotiated Rate	$24,266.56
Max. Negotiated Rate	$25,737.87
Rate for Payer: Amerigroup CHIP/Medicaid	$24,266.56
Rate for Payer: Cigna Medicaid	$24,266.56
Rate for Payer: Molina CHIP/Medicaid	$24,266.56
Rate for Payer: Parkland Medicaid	$24,266.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,737.87

NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION

Facility

$6,262.09

Service Code	APR-DRG 6342
Min. Negotiated Rate	$5,904.12
Max. Negotiated Rate	$6,262.09
Rate for Payer: Amerigroup CHIP/Medicaid	$5,904.12
Rate for Payer: Cigna Medicaid	$5,904.12
Rate for Payer: Molina CHIP/Medicaid	$5,904.12
Rate for Payer: Parkland Medicaid	$5,904.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,262.09

NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION

Facility

$8,716.08

Service Code	APR-DRG 6343
Min. Negotiated Rate	$8,217.83
Max. Negotiated Rate	$8,716.08
Rate for Payer: Amerigroup CHIP/Medicaid	$8,217.83
Rate for Payer: Cigna Medicaid	$8,217.83
Rate for Payer: Molina CHIP/Medicaid	$8,217.83
Rate for Payer: Parkland Medicaid	$8,217.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,716.08

NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION

Facility

$3,647.79

Service Code	APR-DRG 6341
Min. Negotiated Rate	$3,439.27
Max. Negotiated Rate	$3,647.79
Rate for Payer: Amerigroup CHIP/Medicaid	$3,439.27
Rate for Payer: Cigna Medicaid	$3,439.27
Rate for Payer: Molina CHIP/Medicaid	$3,439.27
Rate for Payer: Parkland Medicaid	$3,439.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,647.79

NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE

Facility

$91,888.90

Service Code	APR-DRG 5914
Min. Negotiated Rate	$86,636.07
Max. Negotiated Rate	$91,888.90
Rate for Payer: Amerigroup CHIP/Medicaid	$86,636.07
Rate for Payer: Cigna Medicaid	$86,636.07
Rate for Payer: Molina CHIP/Medicaid	$86,636.07
Rate for Payer: Parkland Medicaid	$86,636.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91,888.90

NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE

Facility

$49,959.44

Service Code	APR-DRG 5912
Min. Negotiated Rate	$47,103.51
Max. Negotiated Rate	$49,959.44
Rate for Payer: Amerigroup CHIP/Medicaid	$47,103.51
Rate for Payer: Cigna Medicaid	$47,103.51
Rate for Payer: Molina CHIP/Medicaid	$47,103.51
Rate for Payer: Parkland Medicaid	$47,103.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49,959.44

NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE

Facility

$60,508.66

Service Code	APR-DRG 5913
Min. Negotiated Rate	$57,049.68
Max. Negotiated Rate	$60,508.66
Rate for Payer: Amerigroup CHIP/Medicaid	$57,049.68
Rate for Payer: Cigna Medicaid	$57,049.68
Rate for Payer: Molina CHIP/Medicaid	$57,049.68
Rate for Payer: Parkland Medicaid	$57,049.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$60,508.66

NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE

Facility

$36,021.17

Service Code	APR-DRG 5911
Min. Negotiated Rate	$33,962.02
Max. Negotiated Rate	$36,021.17
Rate for Payer: Amerigroup CHIP/Medicaid	$33,962.02
Rate for Payer: Cigna Medicaid	$33,962.02
Rate for Payer: Molina CHIP/Medicaid	$33,962.02
Rate for Payer: Parkland Medicaid	$33,962.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36,021.17

NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION

Facility

$12,808.58

Service Code	APR-DRG 5894
Min. Negotiated Rate	$12,076.38
Max. Negotiated Rate	$12,808.58
Rate for Payer: Amerigroup CHIP/Medicaid	$12,076.38
Rate for Payer: Cigna Medicaid	$12,076.38
Rate for Payer: Molina CHIP/Medicaid	$12,076.38
Rate for Payer: Parkland Medicaid	$12,076.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,808.58

NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION

Facility

$74,157.62

Service Code	APR-DRG 5892
Min. Negotiated Rate	$69,918.40
Max. Negotiated Rate	$74,157.62
Rate for Payer: Amerigroup CHIP/Medicaid	$69,918.40
Rate for Payer: Cigna Medicaid	$69,918.40
Rate for Payer: Molina CHIP/Medicaid	$69,918.40
Rate for Payer: Parkland Medicaid	$69,918.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74,157.62

NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION

Facility

$76,513.92

Service Code	APR-DRG 5891
Min. Negotiated Rate	$72,140.00
Max. Negotiated Rate	$76,513.92
Rate for Payer: Amerigroup CHIP/Medicaid	$72,140.00
Rate for Payer: Cigna Medicaid	$72,140.00
Rate for Payer: Molina CHIP/Medicaid	$72,140.00
Rate for Payer: Parkland Medicaid	$72,140.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76,513.92

NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION

Facility

$69,558.18

Service Code	APR-DRG 5893
Min. Negotiated Rate	$65,581.89
Max. Negotiated Rate	$69,558.18
Rate for Payer: Amerigroup CHIP/Medicaid	$65,581.89
Rate for Payer: Cigna Medicaid	$65,581.89
Rate for Payer: Molina CHIP/Medicaid	$65,581.89
Rate for Payer: Parkland Medicaid	$65,581.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69,558.18

NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE

Facility

$76,284.97

Service Code	APR-DRG 5934
Min. Negotiated Rate	$71,924.14
Max. Negotiated Rate	$76,284.97
Rate for Payer: Amerigroup CHIP/Medicaid	$71,924.14
Rate for Payer: Cigna Medicaid	$71,924.14
Rate for Payer: Molina CHIP/Medicaid	$71,924.14
Rate for Payer: Parkland Medicaid	$71,924.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76,284.97

NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE

Facility

$11,177.24

Service Code	APR-DRG 5931
Min. Negotiated Rate	$10,538.29
Max. Negotiated Rate	$11,177.24
Rate for Payer: Amerigroup CHIP/Medicaid	$10,538.29
Rate for Payer: Cigna Medicaid	$10,538.29
Rate for Payer: Molina CHIP/Medicaid	$10,538.29
Rate for Payer: Parkland Medicaid	$10,538.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,177.24

NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE

Facility

$54,484.20

Service Code	APR-DRG 5933
Min. Negotiated Rate	$51,369.61
Max. Negotiated Rate	$54,484.20
Rate for Payer: Amerigroup CHIP/Medicaid	$51,369.61
Rate for Payer: Cigna Medicaid	$51,369.61
Rate for Payer: Molina CHIP/Medicaid	$51,369.61
Rate for Payer: Parkland Medicaid	$51,369.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$54,484.20

NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE

Facility

$42,806.05

Service Code	APR-DRG 5932
Min. Negotiated Rate	$40,359.04
Max. Negotiated Rate	$42,806.05
Rate for Payer: Amerigroup CHIP/Medicaid	$40,359.04
Rate for Payer: Cigna Medicaid	$40,359.04
Rate for Payer: Molina CHIP/Medicaid	$40,359.04
Rate for Payer: Parkland Medicaid	$40,359.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42,806.05

NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY

Facility

$34,690.20

Service Code	MSDRG 789
Min. Negotiated Rate	$14,307.82
Max. Negotiated Rate	$34,690.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,968.45
Rate for Payer: Amerigroup Medicare	$17,968.45
Rate for Payer: BCBS of TX Blue Advantage	$14,307.82
Rate for Payer: BCBS of TX Blue Essentials	$17,167.72
Rate for Payer: BCBS of TX Medicare	$17,968.45
Rate for Payer: BCBS of TX PPO	$19,075.98
Rate for Payer: Cigna Commercial	$23,212.34
Rate for Payer: Cigna Medicare	$17,968.45
Rate for Payer: Employer Direct Commercial	$17,968.45
Rate for Payer: Humana Medicare/TRICARE	$17,968.45
Rate for Payer: Molina Dual Medicare/Medicaid	$17,968.45
Rate for Payer: Molina Medicare	$17,968.45
Rate for Payer: Multiplan Auto	$34,690.20
Rate for Payer: Multiplan Commercial	$34,690.20
Rate for Payer: Multiplan Workers Comp	$34,690.20
Rate for Payer: Scott and White EPO/PPO	$15,975.75
Rate for Payer: Scott and White Medicare	$17,968.45
Rate for Payer: Superior Health Plan EPO	$17,968.45
Rate for Payer: Superior Health Plan Medicare	$17,968.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,968.45
Rate for Payer: Universal American Medicare	$17,968.45
Rate for Payer: Wellcare Medicare	$17,968.45
Rate for Payer: Wellmed Medicare	$17,968.45

NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE

Facility

$617.84

Service Code	APR-DRG 5811
Min. Negotiated Rate	$582.52
Max. Negotiated Rate	$617.84
Rate for Payer: Amerigroup CHIP/Medicaid	$582.52
Rate for Payer: Cigna Medicaid	$582.52
Rate for Payer: Molina CHIP/Medicaid	$582.52
Rate for Payer: Parkland Medicaid	$582.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$617.84

NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE

Facility

$1,458.97

Service Code	APR-DRG 5813
Min. Negotiated Rate	$1,375.57
Max. Negotiated Rate	$1,458.97
Rate for Payer: Amerigroup CHIP/Medicaid	$1,375.57
Rate for Payer: Cigna Medicaid	$1,375.57
Rate for Payer: Molina CHIP/Medicaid	$1,375.57
Rate for Payer: Parkland Medicaid	$1,375.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,458.97

NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE

Facility

$2,824.01

Service Code	APR-DRG 5814
Min. Negotiated Rate	$2,662.58
Max. Negotiated Rate	$2,824.01
Rate for Payer: Amerigroup CHIP/Medicaid	$2,662.58
Rate for Payer: Cigna Medicaid	$2,662.58
Rate for Payer: Molina CHIP/Medicaid	$2,662.58
Rate for Payer: Parkland Medicaid	$2,662.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,824.01

NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE

Facility

$997.29

Service Code	APR-DRG 5812
Min. Negotiated Rate	$940.28
Max. Negotiated Rate	$997.29
Rate for Payer: Amerigroup CHIP/Medicaid	$940.28
Rate for Payer: Cigna Medicaid	$940.28
Rate for Payer: Molina CHIP/Medicaid	$940.28
Rate for Payer: Parkland Medicaid	$940.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$997.29

Know your out-of-pocket cost for care.

All Charges