White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$63,049.60

Service Code	MSDRG 987
Min. Negotiated Rate	$28,660.36
Max. Negotiated Rate	$63,049.60
Rate for Payer: BCBS of TX Blue Advantage	$28,660.36
Rate for Payer: BCBS of TX Blue Essentials	$34,389.10
Rate for Payer: BCBS of TX PPO	$38,211.59

NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W/O 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: BCBS of TX Blue Advantage	$8,950.02
Rate for Payer: BCBS of TX Blue Essentials	$10,738.98
Rate for Payer: BCBS of TX PPO	$11,932.67

NON-HYPOVOLEMIC SODIUM DISORDERS

Facility

$2,994.50

Service Code	APR-DRG 4262
Min. Negotiated Rate	$2,823.32
Max. Negotiated Rate	$2,994.50
Rate for Payer: Amerigroup CHIP/Medicaid	$2,823.32
Rate for Payer: Cigna Medicaid	$2,823.32
Rate for Payer: Molina CHIP/Medicaid	$2,823.32
Rate for Payer: Parkland Medicaid	$2,823.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,994.50

NON-HYPOVOLEMIC SODIUM DISORDERS

Facility

$11,084.45

Service Code	APR-DRG 4264
Min. Negotiated Rate	$10,450.81
Max. Negotiated Rate	$11,084.45
Rate for Payer: Amerigroup CHIP/Medicaid	$10,450.81
Rate for Payer: Cigna Medicaid	$10,450.81
Rate for Payer: Molina CHIP/Medicaid	$10,450.81
Rate for Payer: Parkland Medicaid	$10,450.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,084.45

NON-HYPOVOLEMIC SODIUM DISORDERS

Facility

$4,591.14

Service Code	APR-DRG 4263
Min. Negotiated Rate	$4,328.69
Max. Negotiated Rate	$4,591.14
Rate for Payer: Amerigroup CHIP/Medicaid	$4,328.69
Rate for Payer: Cigna Medicaid	$4,328.69
Rate for Payer: Molina CHIP/Medicaid	$4,328.69
Rate for Payer: Parkland Medicaid	$4,328.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,591.14

NON-HYPOVOLEMIC SODIUM DISORDERS

Facility

$2,444.56

Service Code	APR-DRG 4261
Min. Negotiated Rate	$2,304.82
Max. Negotiated Rate	$2,444.56
Rate for Payer: Amerigroup CHIP/Medicaid	$2,304.82
Rate for Payer: Cigna Medicaid	$2,304.82
Rate for Payer: Molina CHIP/Medicaid	$2,304.82
Rate for Payer: Parkland Medicaid	$2,304.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,444.56

NON-MALIGNANT BREAST DISORDERS W CC/MCC

Facility

$19,780.90

Service Code	MSDRG 600
Min. Negotiated Rate	$8,221.60
Max. Negotiated Rate	$19,780.90
Rate for Payer: BCBS of TX Blue Advantage	$8,221.60
Rate for Payer: BCBS of TX Blue Essentials	$9,864.96
Rate for Payer: BCBS of TX PPO	$10,961.50

NON-MALIGNANT BREAST DISORDERS WITH CC/MCC

Facility

$19,780.90

Service Code	MSDRG 600
Min. Negotiated Rate	$8,221.60
Max. Negotiated Rate	$19,780.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,393.99
Rate for Payer: Amerigroup Medicare	$12,393.99
Rate for Payer: BCBS of TX Medicare	$12,393.99
Rate for Payer: Cigna Commercial	$13,415.81
Rate for Payer: Cigna Medicare	$12,393.99
Rate for Payer: Employer Direct Commercial	$12,393.99
Rate for Payer: Humana Medicare/TRICARE	$12,393.99
Rate for Payer: Molina Dual Medicare/Medicaid	$12,393.99
Rate for Payer: Molina Medicare	$12,393.99
Rate for Payer: Multiplan Auto	$19,780.90
Rate for Payer: Multiplan Commercial	$19,780.90
Rate for Payer: Multiplan Workers Comp	$19,780.90
Rate for Payer: Scott and White EPO/PPO	$9,109.62
Rate for Payer: Scott and White Medicare	$12,393.99
Rate for Payer: Superior Health Plan EPO	$12,393.99
Rate for Payer: Superior Health Plan Medicare	$12,393.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,393.99
Rate for Payer: Universal American Medicare	$12,393.99
Rate for Payer: Wellcare Medicare	$12,393.99
Rate for Payer: Wellmed Medicare	$12,393.99

NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC

Facility

$13,374.10

Service Code	MSDRG 601
Min. Negotiated Rate	$5,325.12
Max. Negotiated Rate	$13,374.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,194.13
Rate for Payer: Amerigroup Medicare	$9,194.13
Rate for Payer: BCBS of TX Medicare	$9,194.13
Rate for Payer: Cigna Commercial	$7,792.40
Rate for Payer: Cigna Medicare	$9,194.13
Rate for Payer: Employer Direct Commercial	$9,194.13
Rate for Payer: Humana Medicare/TRICARE	$9,194.13
Rate for Payer: Molina Dual Medicare/Medicaid	$9,194.13
Rate for Payer: Molina Medicare	$9,194.13
Rate for Payer: Multiplan Auto	$13,374.10
Rate for Payer: Multiplan Commercial	$13,374.10
Rate for Payer: Multiplan Workers Comp	$13,374.10
Rate for Payer: Scott and White EPO/PPO	$6,159.12
Rate for Payer: Scott and White Medicare	$9,194.13
Rate for Payer: Superior Health Plan EPO	$9,194.13
Rate for Payer: Superior Health Plan Medicare	$9,194.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,194.13
Rate for Payer: Universal American Medicare	$9,194.13
Rate for Payer: Wellcare Medicare	$9,194.13
Rate for Payer: Wellmed Medicare	$9,194.13

NON-MALIGNANT BREAST DISORDERS W/O CC/MCC

Facility

$13,374.10

Service Code	MSDRG 601
Min. Negotiated Rate	$5,325.12
Max. Negotiated Rate	$13,374.10
Rate for Payer: BCBS of TX Blue Advantage	$5,325.12
Rate for Payer: BCBS of TX Blue Essentials	$6,389.52
Rate for Payer: BCBS of TX PPO	$7,099.75

*Non-Selective Debridement

Facility

$358.00

Service Code	HCPCS 97602
Hospital Charge Code	7150055
Hospital Revenue Code	361
Min. Negotiated Rate	$32.22
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$32.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$107.40
Rate for Payer: BCBS of TX Blue Essentials	$128.88
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$143.20
Rate for Payer: Cash Price	$243.44
Rate for Payer: Cash Price	$243.44
Rate for Payer: Cash Price	$243.44
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$257.76
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$257.76
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
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	$257.76
Rate for Payer: Scott and White EPO/PPO	$179.00
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$257.76
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

*Non-Selective Debridement

Facility

$358.00

Service Code	HCPCS 97602
Hospital Charge Code	7150055
Hospital Revenue Code	361
Rate for Payer: Cash Price	$243.44

NONSPECIFIC CEREBROVASCULAR DISORDERS W CC

Facility

$20,311.00

Service Code	MSDRG 071
Min. Negotiated Rate	$8,477.88
Max. Negotiated Rate	$20,311.00
Rate for Payer: BCBS of TX Blue Advantage	$8,477.88
Rate for Payer: BCBS of TX Blue Essentials	$10,172.47
Rate for Payer: BCBS of TX PPO	$11,303.18

NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC

Facility

$20,311.00

Service Code	MSDRG 071
Min. Negotiated Rate	$8,477.88
Max. Negotiated Rate	$20,311.00
Rate for Payer: Multiplan Auto	$20,311.00
Rate for Payer: Multiplan Commercial	$20,311.00
Rate for Payer: Multiplan Workers Comp	$20,311.00
Rate for Payer: Scott and White EPO/PPO	$9,353.75

NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC

Facility

$32,759.80

Service Code	MSDRG 070
Min. Negotiated Rate	$14,149.58
Max. Negotiated Rate	$32,759.80
Rate for Payer: Multiplan Auto	$32,759.80
Rate for Payer: Multiplan Commercial	$32,759.80
Rate for Payer: Multiplan Workers Comp	$32,759.80
Rate for Payer: Scott and White EPO/PPO	$15,086.75

NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC

Facility

$14,668.00

Service Code	MSDRG 072
Min. Negotiated Rate	$6,381.20
Max. Negotiated Rate	$14,668.00
Rate for Payer: Multiplan Auto	$14,668.00
Rate for Payer: Multiplan Commercial	$14,668.00
Rate for Payer: Multiplan Workers Comp	$14,668.00
Rate for Payer: Scott and White EPO/PPO	$6,755.00

NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC

Facility

$32,759.80

Service Code	MSDRG 070
Min. Negotiated Rate	$14,149.58
Max. Negotiated Rate	$32,759.80
Rate for Payer: BCBS of TX Blue Advantage	$14,149.58
Rate for Payer: BCBS of TX Blue Essentials	$16,977.85
Rate for Payer: BCBS of TX PPO	$18,865.01

NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC/MCC

Facility

$14,668.00

Service Code	MSDRG 072
Min. Negotiated Rate	$6,381.20
Max. Negotiated Rate	$14,668.00
Rate for Payer: BCBS of TX Blue Advantage	$6,381.20
Rate for Payer: BCBS of TX Blue Essentials	$7,656.70
Rate for Payer: BCBS of TX PPO	$8,507.77

NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION

Facility

$6,785.25

Service Code	APR-DRG 0463
Min. Negotiated Rate	$6,397.37
Max. Negotiated Rate	$6,785.25
Rate for Payer: Amerigroup CHIP/Medicaid	$6,397.37
Rate for Payer: Cigna Medicaid	$6,397.37
Rate for Payer: Molina CHIP/Medicaid	$6,397.37
Rate for Payer: Parkland Medicaid	$6,397.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,785.25

NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION

Facility

$4,262.99

Service Code	APR-DRG 0462
Min. Negotiated Rate	$4,019.30
Max. Negotiated Rate	$4,262.99
Rate for Payer: Amerigroup CHIP/Medicaid	$4,019.30
Rate for Payer: Cigna Medicaid	$4,019.30
Rate for Payer: Molina CHIP/Medicaid	$4,019.30
Rate for Payer: Parkland Medicaid	$4,019.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,262.99

NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION

Facility

$9,018.59

Service Code	APR-DRG 0464
Min. Negotiated Rate	$8,503.04
Max. Negotiated Rate	$9,018.59
Rate for Payer: Amerigroup CHIP/Medicaid	$8,503.04
Rate for Payer: Cigna Medicaid	$8,503.04
Rate for Payer: Molina CHIP/Medicaid	$8,503.04
Rate for Payer: Parkland Medicaid	$8,503.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,018.59

NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION

Facility

$4,228.29

Service Code	APR-DRG 0461
Min. Negotiated Rate	$3,986.58
Max. Negotiated Rate	$4,228.29
Rate for Payer: Amerigroup CHIP/Medicaid	$3,986.58
Rate for Payer: Cigna Medicaid	$3,986.58
Rate for Payer: Molina CHIP/Medicaid	$3,986.58
Rate for Payer: Parkland Medicaid	$3,986.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,228.29

NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC

Facility

$26,867.90

Service Code	MSDRG 067
Min. Negotiated Rate	$12,373.38
Max. Negotiated Rate	$26,867.90
Rate for Payer: Multiplan Auto	$26,867.90
Rate for Payer: Multiplan Commercial	$26,867.90
Rate for Payer: Multiplan Workers Comp	$26,867.90
Rate for Payer: Scott and White EPO/PPO	$12,373.38

NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC

Facility

$17,170.30

Service Code	MSDRG 068
Min. Negotiated Rate	$7,728.82
Max. Negotiated Rate	$17,170.30
Rate for Payer: Multiplan Auto	$17,170.30
Rate for Payer: Multiplan Commercial	$17,170.30
Rate for Payer: Multiplan Workers Comp	$17,170.30
Rate for Payer: Scott and White EPO/PPO	$7,907.38

NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W MCC

Facility

$26,867.90

Service Code	MSDRG 067
Min. Negotiated Rate	$12,373.38
Max. Negotiated Rate	$26,867.90
Rate for Payer: BCBS of TX Blue Advantage	$12,912.04
Rate for Payer: BCBS of TX Blue Essentials	$15,492.95
Rate for Payer: BCBS of TX PPO	$17,215.05

Know your out-of-pocket cost for care.

All Charges