White Rock Medical Center

All Charges

Charge

Type

Setting

Price

NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE

Facility

$1,358.63

Service Code	APR-DRG 5801
Min. Negotiated Rate	$1,280.97
Max. Negotiated Rate	$1,358.63
Rate for Payer: Amerigroup CHIP/Medicaid	$1,280.97
Rate for Payer: Cigna Medicaid	$1,280.97
Rate for Payer: Molina CHIP/Medicaid	$1,280.97
Rate for Payer: Parkland Medicaid	$1,280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,358.63

NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE

Facility

$5,784.19

Service Code	APR-DRG 5804
Min. Negotiated Rate	$5,453.54
Max. Negotiated Rate	$5,784.19
Rate for Payer: Amerigroup CHIP/Medicaid	$5,453.54
Rate for Payer: Cigna Medicaid	$5,453.54
Rate for Payer: Molina CHIP/Medicaid	$5,453.54
Rate for Payer: Parkland Medicaid	$5,453.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,784.19

NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE

Facility

$3,194.41

Service Code	APR-DRG 5803
Min. Negotiated Rate	$3,011.81
Max. Negotiated Rate	$3,194.41
Rate for Payer: Amerigroup CHIP/Medicaid	$3,011.81
Rate for Payer: Cigna Medicaid	$3,011.81
Rate for Payer: Molina CHIP/Medicaid	$3,011.81
Rate for Payer: Parkland Medicaid	$3,011.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,194.41

NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE

Facility

$1,977.60

Service Code	APR-DRG 5802
Min. Negotiated Rate	$1,864.55
Max. Negotiated Rate	$1,977.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1,864.55
Rate for Payer: Cigna Medicaid	$1,864.55
Rate for Payer: Molina CHIP/Medicaid	$1,864.55
Rate for Payer: Parkland Medicaid	$1,864.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,977.60

NEONATE WITH ECMO

Facility

$242,580.05

Service Code	APR-DRG 5833
Min. Negotiated Rate	$228,712.97
Max. Negotiated Rate	$242,580.05
Rate for Payer: Amerigroup CHIP/Medicaid	$228,712.97
Rate for Payer: Cigna Medicaid	$228,712.97
Rate for Payer: Molina CHIP/Medicaid	$228,712.97
Rate for Payer: Parkland Medicaid	$228,712.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$242,580.05

NEONATE WITH ECMO

Facility

$106,430.29

Service Code	APR-DRG 5831
Min. Negotiated Rate	$100,346.20
Max. Negotiated Rate	$106,430.29
Rate for Payer: Amerigroup CHIP/Medicaid	$100,346.20
Rate for Payer: Cigna Medicaid	$100,346.20
Rate for Payer: Molina CHIP/Medicaid	$100,346.20
Rate for Payer: Parkland Medicaid	$100,346.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$106,430.29

NEONATE WITH ECMO

Facility

$286,479.19

Service Code	APR-DRG 5834
Min. Negotiated Rate	$270,102.62
Max. Negotiated Rate	$286,479.19
Rate for Payer: Amerigroup CHIP/Medicaid	$270,102.62
Rate for Payer: Cigna Medicaid	$270,102.62
Rate for Payer: Molina CHIP/Medicaid	$270,102.62
Rate for Payer: Parkland Medicaid	$270,102.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$286,479.19

NEONATE WITH ECMO

Facility

$120,872.10

Service Code	APR-DRG 5832
Min. Negotiated Rate	$113,962.45
Max. Negotiated Rate	$120,872.10
Rate for Payer: Amerigroup CHIP/Medicaid	$113,962.45
Rate for Payer: Cigna Medicaid	$113,962.45
Rate for Payer: Molina CHIP/Medicaid	$113,962.45
Rate for Payer: Parkland Medicaid	$113,962.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120,872.10

NEONATE WITH OTHER SIGNIFICANT PROBLEMS

Facility

$28,406.90

Service Code	MSDRG 794
Min. Negotiated Rate	$11,715.78
Max. Negotiated Rate	$28,406.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,577.00
Rate for Payer: Amerigroup Medicare	$15,577.00
Rate for Payer: BCBS of TX Medicare	$15,577.00
Rate for Payer: Cigna Commercial	$19,009.59
Rate for Payer: Cigna Medicare	$15,577.00
Rate for Payer: Employer Direct Commercial	$15,577.00
Rate for Payer: Humana Medicare/TRICARE	$15,577.00
Rate for Payer: Molina Dual Medicare/Medicaid	$15,577.00
Rate for Payer: Molina Medicare	$15,577.00
Rate for Payer: Multiplan Auto	$28,406.90
Rate for Payer: Multiplan Commercial	$28,406.90
Rate for Payer: Multiplan Workers Comp	$28,406.90
Rate for Payer: Scott and White EPO/PPO	$13,082.12
Rate for Payer: Scott and White Medicare	$15,577.00
Rate for Payer: Superior Health Plan EPO	$15,577.00
Rate for Payer: Superior Health Plan Medicare	$15,577.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,577.00
Rate for Payer: Universal American Medicare	$15,577.00
Rate for Payer: Wellcare Medicare	$15,577.00
Rate for Payer: Wellmed Medicare	$15,577.00

NEONATE W OTHER SIGNIFICANT PROBLEMS

Facility

$28,406.90

Service Code	MSDRG 794
Min. Negotiated Rate	$11,715.78
Max. Negotiated Rate	$28,406.90
Rate for Payer: BCBS of TX Blue Advantage	$11,715.78
Rate for Payer: BCBS of TX Blue Essentials	$14,057.57
Rate for Payer: BCBS of TX PPO	$15,620.13

neostigmine 1 mg/mL IV Soln 10 mL (Bloxiverz)

Facility

$128.00

Service Code	HCPCS J2710
Hospital Charge Code	77723323
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

neostigmine 1 mg/mL IV Soln 10 mL (Bloxiverz)

Facility

$128.00

Service Code	HCPCS J2710
Hospital Charge Code	77723323
Hospital Revenue Code	636
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$1.30
Rate for Payer: BCBS of TX Blue Essentials	$1.57
Rate for Payer: BCBS of TX PPO	$1.74
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

NEPHRITIS AND NEPHROSIS

Facility

$2,890.40

Service Code	APR-DRG 4621
Min. Negotiated Rate	$2,725.17
Max. Negotiated Rate	$2,890.40
Rate for Payer: Amerigroup CHIP/Medicaid	$2,725.17
Rate for Payer: Cigna Medicaid	$2,725.17
Rate for Payer: Molina CHIP/Medicaid	$2,725.17
Rate for Payer: Parkland Medicaid	$2,725.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,890.40

NEPHRITIS AND NEPHROSIS

Facility

$20,912.11

Service Code	APR-DRG 4624
Min. Negotiated Rate	$19,716.67
Max. Negotiated Rate	$20,912.11
Rate for Payer: Amerigroup CHIP/Medicaid	$19,716.67
Rate for Payer: Cigna Medicaid	$19,716.67
Rate for Payer: Molina CHIP/Medicaid	$19,716.67
Rate for Payer: Parkland Medicaid	$19,716.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,912.11

NEPHRITIS AND NEPHROSIS

Facility

$9,431.99

Service Code	APR-DRG 4623
Min. Negotiated Rate	$8,892.81
Max. Negotiated Rate	$9,431.99
Rate for Payer: Amerigroup CHIP/Medicaid	$8,892.81
Rate for Payer: Cigna Medicaid	$8,892.81
Rate for Payer: Molina CHIP/Medicaid	$8,892.81
Rate for Payer: Parkland Medicaid	$8,892.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,431.99

NEPHRITIS AND NEPHROSIS

Facility

$4,150.96

Service Code	APR-DRG 4622
Min. Negotiated Rate	$3,913.68
Max. Negotiated Rate	$4,150.96
Rate for Payer: Amerigroup CHIP/Medicaid	$3,913.68
Rate for Payer: Cigna Medicaid	$3,913.68
Rate for Payer: Molina CHIP/Medicaid	$3,913.68
Rate for Payer: Parkland Medicaid	$3,913.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,150.96

Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve

Facility

$18,635.09

Service Code	CPT 64910
Hospital Charge Code	36064910
Hospital Revenue Code	360
Min. Negotiated Rate	$3,104.96
Max. Negotiated Rate	$18,635.09
Rate for Payer: Amerigroup CHIP/Medicaid	$3,104.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,815.84
Rate for Payer: Amerigroup Medicare	$8,815.84
Rate for Payer: BCBS of TX Blue Advantage	$9,200.05
Rate for Payer: BCBS of TX Blue Essentials	$11,018.02
Rate for Payer: BCBS of TX Medicare	$8,815.84
Rate for Payer: BCBS of TX PPO	$13,882.71
Rate for Payer: Cigna Commercial	$18,635.09
Rate for Payer: Cigna Medicare	$8,815.84
Rate for Payer: Employer Direct Commercial	$8,815.84
Rate for Payer: Humana Medicare/TRICARE	$8,815.84
Rate for Payer: Molina Dual Medicare/Medicaid	$8,815.84
Rate for Payer: Molina Medicare	$8,815.84
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	$11,270.57
Rate for Payer: Scott and White Medicare	$8,815.84
Rate for Payer: Superior Health Plan EPO	$8,815.84
Rate for Payer: Superior Health Plan Medicare	$8,815.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,815.84
Rate for Payer: Universal American Medicare	$8,815.84
Rate for Payer: Wellcare Medicare	$8,815.84
Rate for Payer: Wellmed Medicare	$8,815.84

Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve

Facility

$17,100.87

Service Code	HCPCS 64910
Hospital Charge Code	9900856
Hospital Revenue Code	360
Min. Negotiated Rate	$3,104.96
Max. Negotiated Rate	$18,635.09
Rate for Payer: Amerigroup CHIP/Medicaid	$3,104.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,815.84
Rate for Payer: Amerigroup Medicare	$8,815.84
Rate for Payer: BCBS of TX Blue Advantage	$9,200.05
Rate for Payer: BCBS of TX Blue Essentials	$11,018.02
Rate for Payer: BCBS of TX Medicare	$8,815.84
Rate for Payer: BCBS of TX PPO	$13,882.71
Rate for Payer: Cash Price	$11,628.59
Rate for Payer: Cash Price	$11,628.59
Rate for Payer: Cash Price	$11,628.59
Rate for Payer: Cigna Commercial	$18,635.09
Rate for Payer: Cigna Medicaid	$12,312.63
Rate for Payer: Cigna Medicare	$8,815.84
Rate for Payer: Employer Direct Commercial	$8,815.84
Rate for Payer: Humana Medicare/TRICARE	$8,815.84
Rate for Payer: Molina CHIP/Medicaid	$12,312.63
Rate for Payer: Molina Dual Medicare/Medicaid	$8,815.84
Rate for Payer: Molina Medicare	$8,815.84
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	$12,312.63
Rate for Payer: Scott and White EPO/PPO	$11,270.57
Rate for Payer: Scott and White Medicare	$8,815.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,312.63
Rate for Payer: Superior Health Plan EPO	$8,815.84
Rate for Payer: Superior Health Plan Medicare	$8,815.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,815.84
Rate for Payer: Universal American Medicare	$8,815.84
Rate for Payer: Wellcare Medicare	$8,815.84
Rate for Payer: Wellmed Medicare	$8,815.84

Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve

Facility

$17,100.87

Service Code	HCPCS 64910
Hospital Charge Code	9900856
Hospital Revenue Code	360
Rate for Payer: Cash Price	$11,628.59

NERVOUS SYSTEM MALIGNANCY

Facility

$5,666.13

Service Code	APR-DRG 0413
Min. Negotiated Rate	$5,342.23
Max. Negotiated Rate	$5,666.13
Rate for Payer: Amerigroup CHIP/Medicaid	$5,342.23
Rate for Payer: Cigna Medicaid	$5,342.23
Rate for Payer: Molina CHIP/Medicaid	$5,342.23
Rate for Payer: Parkland Medicaid	$5,342.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,666.13

NERVOUS SYSTEM MALIGNANCY

Facility

$9,725.82

Service Code	APR-DRG 0414
Min. Negotiated Rate	$9,169.84
Max. Negotiated Rate	$9,725.82
Rate for Payer: Amerigroup CHIP/Medicaid	$9,169.84
Rate for Payer: Cigna Medicaid	$9,169.84
Rate for Payer: Molina CHIP/Medicaid	$9,169.84
Rate for Payer: Parkland Medicaid	$9,169.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,725.82

NERVOUS SYSTEM MALIGNANCY

Facility

$4,121.17

Service Code	APR-DRG 0412
Min. Negotiated Rate	$3,885.58
Max. Negotiated Rate	$4,121.17
Rate for Payer: Amerigroup CHIP/Medicaid	$3,885.58
Rate for Payer: Cigna Medicaid	$3,885.58
Rate for Payer: Molina CHIP/Medicaid	$3,885.58
Rate for Payer: Parkland Medicaid	$3,885.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,121.17

NERVOUS SYSTEM MALIGNANCY

Facility

$3,832.99

Service Code	APR-DRG 0411
Min. Negotiated Rate	$3,613.88
Max. Negotiated Rate	$3,832.99
Rate for Payer: Amerigroup CHIP/Medicaid	$3,613.88
Rate for Payer: Cigna Medicaid	$3,613.88
Rate for Payer: Molina CHIP/Medicaid	$3,613.88
Rate for Payer: Parkland Medicaid	$3,613.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,832.99

NERVOUS SYSTEM NEOPLASMS WITH MCC

Facility

$26,353.00

Service Code	MSDRG 054
Min. Negotiated Rate	$11,322.76
Max. Negotiated Rate	$26,353.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,950.77
Rate for Payer: Amerigroup Medicare	$15,950.77
Rate for Payer: BCBS of TX Medicare	$15,950.77
Rate for Payer: Cigna Commercial	$19,666.47
Rate for Payer: Cigna Medicare	$15,950.77
Rate for Payer: Employer Direct Commercial	$15,950.77
Rate for Payer: Humana Medicare/TRICARE	$15,950.77
Rate for Payer: Molina Dual Medicare/Medicaid	$15,950.77
Rate for Payer: Molina Medicare	$15,950.77
Rate for Payer: Multiplan Auto	$26,353.00
Rate for Payer: Multiplan Commercial	$26,353.00
Rate for Payer: Multiplan Workers Comp	$26,353.00
Rate for Payer: Scott and White EPO/PPO	$12,136.25
Rate for Payer: Scott and White Medicare	$15,950.77
Rate for Payer: Superior Health Plan EPO	$15,950.77
Rate for Payer: Superior Health Plan Medicare	$15,950.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,950.77
Rate for Payer: Universal American Medicare	$15,950.77
Rate for Payer: Wellcare Medicare	$15,950.77
Rate for Payer: Wellmed Medicare	$15,950.77

NERVOUS SYSTEM NEOPLASMS WITHOUT MCC

Facility

$19,157.70

Service Code	MSDRG 055
Min. Negotiated Rate	$8,822.62
Max. Negotiated Rate	$19,157.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,232.76
Rate for Payer: Amerigroup Medicare	$12,232.76
Rate for Payer: BCBS of TX Medicare	$12,232.76
Rate for Payer: Cigna Commercial	$13,132.45
Rate for Payer: Cigna Medicare	$12,232.76
Rate for Payer: Employer Direct Commercial	$12,232.76
Rate for Payer: Humana Medicare/TRICARE	$12,232.76
Rate for Payer: Molina Dual Medicare/Medicaid	$12,232.76
Rate for Payer: Molina Medicare	$12,232.76
Rate for Payer: Multiplan Auto	$19,157.70
Rate for Payer: Multiplan Commercial	$19,157.70
Rate for Payer: Multiplan Workers Comp	$19,157.70
Rate for Payer: Scott and White EPO/PPO	$8,822.62
Rate for Payer: Scott and White Medicare	$12,232.76
Rate for Payer: Superior Health Plan EPO	$12,232.76
Rate for Payer: Superior Health Plan Medicare	$12,232.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,232.76
Rate for Payer: Universal American Medicare	$12,232.76
Rate for Payer: Wellcare Medicare	$12,232.76
Rate for Payer: Wellmed Medicare	$12,232.76

Know your out-of-pocket cost for care.

All Charges