White Rock Medical Center

All Charges

Charge

Type

Setting

Price

NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W MCC

Facility

$73,875.80

Service Code	MSDRG 097
Min. Negotiated Rate	$30,434.54
Max. Negotiated Rate	$73,875.80
Rate for Payer: BCBS of TX Blue Advantage	$30,434.54
Rate for Payer: BCBS of TX Blue Essentials	$36,517.91
Rate for Payer: BCBS of TX PPO	$40,577.03

NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W/O CC/MCC

Facility

$26,571.50

Service Code	MSDRG 099
Min. Negotiated Rate	$10,946.94
Max. Negotiated Rate	$26,571.50
Rate for Payer: BCBS of TX Blue Advantage	$10,946.94
Rate for Payer: BCBS of TX Blue Essentials	$13,135.06
Rate for Payer: BCBS of TX PPO	$14,595.07

Noncontact real-time fluorescence wound imaging first anatomic site

Facility

$1,245.60

Service Code	HCPCS 0598T
Hospital Charge Code	994050
Hospital Revenue Code	361
Min. Negotiated Rate	$112.10
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$112.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$417.62
Rate for Payer: BCBS of TX Blue Essentials	$501.14
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$559.35
Rate for Payer: Cash Price	$847.01
Rate for Payer: Cash Price	$847.01
Rate for Payer: Cash Price	$847.01
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$896.83
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$896.83
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
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	$896.83
Rate for Payer: Scott and White EPO/PPO	$622.80
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$896.83
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

Noncontact real-time fluorescence wound imaging first anatomic site

Facility

$1,245.60

Service Code	HCPCS 0598T
Hospital Charge Code	994050
Hospital Revenue Code	361
Rate for Payer: Cash Price	$847.01

NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT

Facility

$18,487.54

Service Code	APR-DRG 3234
Min. Negotiated Rate	$17,430.70
Max. Negotiated Rate	$18,487.54
Rate for Payer: Amerigroup CHIP/Medicaid	$17,430.70
Rate for Payer: Cigna Medicaid	$17,430.70
Rate for Payer: Molina CHIP/Medicaid	$17,430.70
Rate for Payer: Parkland Medicaid	$17,430.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,487.54

NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT

Facility

$9,414.26

Service Code	APR-DRG 3232
Min. Negotiated Rate	$8,876.09
Max. Negotiated Rate	$9,414.26
Rate for Payer: Amerigroup CHIP/Medicaid	$8,876.09
Rate for Payer: Cigna Medicaid	$8,876.09
Rate for Payer: Molina CHIP/Medicaid	$8,876.09
Rate for Payer: Parkland Medicaid	$8,876.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,414.26

NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT

Facility

$7,587.16

Service Code	APR-DRG 3231
Min. Negotiated Rate	$7,153.44
Max. Negotiated Rate	$7,587.16
Rate for Payer: Amerigroup CHIP/Medicaid	$7,153.44
Rate for Payer: Cigna Medicaid	$7,153.44
Rate for Payer: Molina CHIP/Medicaid	$7,153.44
Rate for Payer: Parkland Medicaid	$7,153.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,587.16

NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT

Facility

$11,956.51

Service Code	APR-DRG 3233
Min. Negotiated Rate	$11,273.02
Max. Negotiated Rate	$11,956.51
Rate for Payer: Amerigroup CHIP/Medicaid	$11,273.02
Rate for Payer: Cigna Medicaid	$11,273.02
Rate for Payer: Molina CHIP/Medicaid	$11,273.02
Rate for Payer: Parkland Medicaid	$11,273.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,956.51

NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT

Facility

$10,727.63

Service Code	APR-DRG 3251
Min. Negotiated Rate	$10,114.39
Max. Negotiated Rate	$10,727.63
Rate for Payer: Amerigroup CHIP/Medicaid	$10,114.39
Rate for Payer: Cigna Medicaid	$10,114.39
Rate for Payer: Molina CHIP/Medicaid	$10,114.39
Rate for Payer: Parkland Medicaid	$10,114.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,727.63

NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT

Facility

$23,351.39

Service Code	APR-DRG 3254
Min. Negotiated Rate	$22,016.51
Max. Negotiated Rate	$23,351.39
Rate for Payer: Amerigroup CHIP/Medicaid	$22,016.51
Rate for Payer: Cigna Medicaid	$22,016.51
Rate for Payer: Molina CHIP/Medicaid	$22,016.51
Rate for Payer: Parkland Medicaid	$22,016.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,351.39

NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT

Facility

$13,616.90

Service Code	APR-DRG 3253
Min. Negotiated Rate	$12,838.49
Max. Negotiated Rate	$13,616.90
Rate for Payer: Amerigroup CHIP/Medicaid	$12,838.49
Rate for Payer: Cigna Medicaid	$12,838.49
Rate for Payer: Molina CHIP/Medicaid	$12,838.49
Rate for Payer: Parkland Medicaid	$12,838.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,616.90

NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT

Facility

$11,707.57

Service Code	APR-DRG 3252
Min. Negotiated Rate	$11,038.31
Max. Negotiated Rate	$11,707.57
Rate for Payer: Amerigroup CHIP/Medicaid	$11,038.31
Rate for Payer: Cigna Medicaid	$11,038.31
Rate for Payer: Molina CHIP/Medicaid	$11,038.31
Rate for Payer: Parkland Medicaid	$11,038.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,707.57

NON-EXTENSIVE BURNS

Facility

$38,457.90

Service Code	MSDRG 935
Min. Negotiated Rate	$15,666.62
Max. Negotiated Rate	$38,457.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,857.87
Rate for Payer: Amerigroup Medicare	$19,857.87
Rate for Payer: BCBS of TX Blue Advantage	$15,666.62
Rate for Payer: BCBS of TX Blue Essentials	$18,798.12
Rate for Payer: BCBS of TX Medicare	$19,857.87
Rate for Payer: BCBS of TX PPO	$20,887.61
Rate for Payer: Cigna Commercial	$26,532.80
Rate for Payer: Cigna Medicare	$19,857.87
Rate for Payer: Employer Direct Commercial	$19,857.87
Rate for Payer: Humana Medicare/TRICARE	$19,857.87
Rate for Payer: Molina Dual Medicare/Medicaid	$19,857.87
Rate for Payer: Molina Medicare	$19,857.87
Rate for Payer: Multiplan Auto	$38,457.90
Rate for Payer: Multiplan Commercial	$38,457.90
Rate for Payer: Multiplan Workers Comp	$38,457.90
Rate for Payer: Scott and White EPO/PPO	$17,710.88
Rate for Payer: Scott and White Medicare	$19,857.87
Rate for Payer: Superior Health Plan EPO	$19,857.87
Rate for Payer: Superior Health Plan Medicare	$19,857.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,857.87
Rate for Payer: Universal American Medicare	$19,857.87
Rate for Payer: Wellcare Medicare	$19,857.87
Rate for Payer: Wellmed Medicare	$19,857.87

NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$5,181.45

Service Code	APR-DRG 7942
Min. Negotiated Rate	$4,885.25
Max. Negotiated Rate	$5,181.45
Rate for Payer: Amerigroup CHIP/Medicaid	$4,885.25
Rate for Payer: Cigna Medicaid	$4,885.25
Rate for Payer: Molina CHIP/Medicaid	$4,885.25
Rate for Payer: Parkland Medicaid	$4,885.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,181.45

NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$2,842.12

Service Code	APR-DRG 7941
Min. Negotiated Rate	$2,679.65
Max. Negotiated Rate	$2,842.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2,679.65
Rate for Payer: Cigna Medicaid	$2,679.65
Rate for Payer: Molina CHIP/Medicaid	$2,679.65
Rate for Payer: Parkland Medicaid	$2,679.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,842.12

NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$14,180.42

Service Code	APR-DRG 7944
Min. Negotiated Rate	$13,369.80
Max. Negotiated Rate	$14,180.42
Rate for Payer: Amerigroup CHIP/Medicaid	$13,369.80
Rate for Payer: Cigna Medicaid	$13,369.80
Rate for Payer: Molina CHIP/Medicaid	$13,369.80
Rate for Payer: Parkland Medicaid	$13,369.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,180.42

NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$7,226.56

Service Code	APR-DRG 7943
Min. Negotiated Rate	$6,813.46
Max. Negotiated Rate	$7,226.56
Rate for Payer: Amerigroup CHIP/Medicaid	$6,813.46
Rate for Payer: Cigna Medicaid	$6,813.46
Rate for Payer: Molina CHIP/Medicaid	$6,813.46
Rate for Payer: Parkland Medicaid	$6,813.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,226.56

NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC

Facility

$32,231.60

Service Code	MSDRG 988
Min. Negotiated Rate	$14,560.66
Max. Negotiated Rate	$32,231.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,806.06
Rate for Payer: Amerigroup Medicare	$16,806.06
Rate for Payer: BCBS of TX Medicare	$16,806.06
Rate for Payer: Cigna Commercial	$21,169.57
Rate for Payer: Cigna Medicare	$16,806.06
Rate for Payer: Employer Direct Commercial	$16,806.06
Rate for Payer: Humana Medicare/TRICARE	$16,806.06
Rate for Payer: Molina Dual Medicare/Medicaid	$16,806.06
Rate for Payer: Molina Medicare	$16,806.06
Rate for Payer: Multiplan Auto	$32,231.60
Rate for Payer: Multiplan Commercial	$32,231.60
Rate for Payer: Multiplan Workers Comp	$32,231.60
Rate for Payer: Scott and White EPO/PPO	$14,843.50
Rate for Payer: Scott and White Medicare	$16,806.06
Rate for Payer: Superior Health Plan EPO	$16,806.06
Rate for Payer: Superior Health Plan Medicare	$16,806.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,806.06
Rate for Payer: Universal American Medicare	$16,806.06
Rate for Payer: Wellcare Medicare	$16,806.06
Rate for Payer: Wellmed Medicare	$16,806.06

NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$63,049.60

Service Code	MSDRG 987
Min. Negotiated Rate	$28,660.36
Max. Negotiated Rate	$63,049.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29,886.92
Rate for Payer: Amerigroup Medicare	$29,886.92
Rate for Payer: BCBS of TX Medicare	$29,886.92
Rate for Payer: Cigna Commercial	$44,157.79
Rate for Payer: Cigna Medicare	$29,886.92
Rate for Payer: Employer Direct Commercial	$29,886.92
Rate for Payer: Humana Medicare/TRICARE	$29,886.92
Rate for Payer: Molina Dual Medicare/Medicaid	$29,886.92
Rate for Payer: Molina Medicare	$29,886.92
Rate for Payer: Multiplan Auto	$63,049.60
Rate for Payer: Multiplan Commercial	$63,049.60
Rate for Payer: Multiplan Workers Comp	$63,049.60
Rate for Payer: Scott and White EPO/PPO	$29,036.00
Rate for Payer: Scott and White Medicare	$29,886.92
Rate for Payer: Superior Health Plan EPO	$29,886.92
Rate for Payer: Superior Health Plan Medicare	$29,886.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$29,886.92
Rate for Payer: Universal American Medicare	$29,886.92
Rate for Payer: Wellcare Medicare	$29,886.92
Rate for Payer: Wellmed Medicare	$29,886.92

NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$20,945.60

Service Code	MSDRG 989
Min. Negotiated Rate	$8,950.02
Max. Negotiated Rate	$20,945.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,549.05
Rate for Payer: Amerigroup Medicare	$13,549.05
Rate for Payer: BCBS of TX Medicare	$13,549.05
Rate for Payer: Cigna Commercial	$15,445.70
Rate for Payer: Cigna Medicare	$13,549.05
Rate for Payer: Employer Direct Commercial	$13,549.05
Rate for Payer: Humana Medicare/TRICARE	$13,549.05
Rate for Payer: Molina Dual Medicare/Medicaid	$13,549.05
Rate for Payer: Molina Medicare	$13,549.05
Rate for Payer: Multiplan Auto	$20,945.60
Rate for Payer: Multiplan Commercial	$20,945.60
Rate for Payer: Multiplan Workers Comp	$20,945.60
Rate for Payer: Scott and White EPO/PPO	$9,646.00
Rate for Payer: Scott and White Medicare	$13,549.05
Rate for Payer: Superior Health Plan EPO	$13,549.05
Rate for Payer: Superior Health Plan Medicare	$13,549.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,549.05
Rate for Payer: Universal American Medicare	$13,549.05
Rate for Payer: Wellcare Medicare	$13,549.05
Rate for Payer: Wellmed Medicare	$13,549.05

NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$4,835.19

Service Code	APR-DRG 9521
Min. Negotiated Rate	$4,558.78
Max. Negotiated Rate	$4,835.19
Rate for Payer: Amerigroup CHIP/Medicaid	$4,558.78
Rate for Payer: Cigna Medicaid	$4,558.78
Rate for Payer: Molina CHIP/Medicaid	$4,558.78
Rate for Payer: Parkland Medicaid	$4,558.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,835.19

NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$6,490.29

Service Code	APR-DRG 9522
Min. Negotiated Rate	$6,119.27
Max. Negotiated Rate	$6,490.29
Rate for Payer: Amerigroup CHIP/Medicaid	$6,119.27
Rate for Payer: Cigna Medicaid	$6,119.27
Rate for Payer: Molina CHIP/Medicaid	$6,119.27
Rate for Payer: Parkland Medicaid	$6,119.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,490.29

NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$18,928.48

Service Code	APR-DRG 9523
Min. Negotiated Rate	$17,846.43
Max. Negotiated Rate	$18,928.48
Rate for Payer: Amerigroup CHIP/Medicaid	$17,846.43
Rate for Payer: Cigna Medicaid	$17,846.43
Rate for Payer: Molina CHIP/Medicaid	$17,846.43
Rate for Payer: Parkland Medicaid	$17,846.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,928.48

NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$39,258.21

Service Code	APR-DRG 9524
Min. Negotiated Rate	$37,014.01
Max. Negotiated Rate	$39,258.21
Rate for Payer: Amerigroup CHIP/Medicaid	$37,014.01
Rate for Payer: Cigna Medicaid	$37,014.01
Rate for Payer: Molina CHIP/Medicaid	$37,014.01
Rate for Payer: Parkland Medicaid	$37,014.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39,258.21

NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC

Facility

$32,231.60

Service Code	MSDRG 988
Min. Negotiated Rate	$14,560.66
Max. Negotiated Rate	$32,231.60
Rate for Payer: BCBS of TX Blue Advantage	$14,560.66
Rate for Payer: BCBS of TX Blue Essentials	$17,471.10
Rate for Payer: BCBS of TX PPO	$19,413.08

Know your out-of-pocket cost for care.

All Charges