White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OT Attended E-Stim Assistant Units

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	4300008
Hospital Revenue Code	430
Rate for Payer: Cash Price	$94.52

OT Attended E-Stim Assistant Units

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	4300008
Hospital Revenue Code	430
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$41.70
Rate for Payer: BCBS of TX Blue Essentials	$50.04
Rate for Payer: BCBS of TX PPO	$55.60
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$100.08
Rate for Payer: Molina CHIP/Medicaid	$100.08
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Parkland Medicaid	$100.08
Rate for Payer: Scott and White EPO/PPO	$17.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100.08
Rate for Payer: Superior Health Plan EPO	$18.90

OT Attended E-Stim Units

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	4300042
Hospital Revenue Code	430
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$41.70
Rate for Payer: BCBS of TX Blue Essentials	$50.04
Rate for Payer: BCBS of TX PPO	$55.60
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$100.08
Rate for Payer: Molina CHIP/Medicaid	$100.08
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Parkland Medicaid	$100.08
Rate for Payer: Scott and White EPO/PPO	$17.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100.08
Rate for Payer: Superior Health Plan EPO	$18.90

OT Attended E-Stim Units

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	4300042
Hospital Revenue Code	430
Rate for Payer: Cash Price	$94.52

OT Evaluation Units, High Complexity

Facility

$384.00

Service Code	HCPCS 97167
Hospital Charge Code	4305102
Hospital Revenue Code	434
Min. Negotiated Rate	$52.22
Max. Negotiated Rate	$276.48
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$115.20
Rate for Payer: BCBS of TX Blue Essentials	$138.24
Rate for Payer: BCBS of TX PPO	$153.60
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$276.48
Rate for Payer: Molina CHIP/Medicaid	$276.48
Rate for Payer: Multiplan Auto	$249.60
Rate for Payer: Multiplan Commercial	$249.60
Rate for Payer: Multiplan Workers Comp	$249.60
Rate for Payer: Parkland Medicaid	$276.48
Rate for Payer: Scott and White EPO/PPO	$125.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$276.48
Rate for Payer: Superior Health Plan EPO	$52.22

OT Evaluation Units, High Complexity

Facility

$384.00

Service Code	HCPCS 97167
Hospital Charge Code	4305102
Hospital Revenue Code	434
Rate for Payer: Cash Price	$261.12

OT Evaluation Units, Low Complexity

Facility

$191.00

Service Code	HCPCS 97165
Hospital Charge Code	4305100
Hospital Revenue Code	434
Min. Negotiated Rate	$25.98
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$57.30
Rate for Payer: BCBS of TX Blue Essentials	$68.76
Rate for Payer: BCBS of TX PPO	$76.40
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$137.52
Rate for Payer: Molina CHIP/Medicaid	$137.52
Rate for Payer: Multiplan Auto	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Parkland Medicaid	$137.52
Rate for Payer: Scott and White EPO/PPO	$125.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$25.98

OT Evaluation Units, Low Complexity

Facility

$191.00

Service Code	HCPCS 97165
Hospital Charge Code	4305100
Hospital Revenue Code	434
Rate for Payer: Cash Price	$129.88

OT Evaluation Units, Moderate Complexity

Facility

$288.00

Service Code	HCPCS 97166
Hospital Charge Code	4305101
Hospital Revenue Code	434
Rate for Payer: Cash Price	$195.84

OT Evaluation Units, Moderate Complexity

Facility

$288.00

Service Code	HCPCS 97166
Hospital Charge Code	4305101
Hospital Revenue Code	434
Min. Negotiated Rate	$39.17
Max. Negotiated Rate	$207.36
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$86.40
Rate for Payer: BCBS of TX Blue Essentials	$103.68
Rate for Payer: BCBS of TX PPO	$115.20
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$207.36
Rate for Payer: Molina CHIP/Medicaid	$207.36
Rate for Payer: Multiplan Auto	$187.20
Rate for Payer: Multiplan Commercial	$187.20
Rate for Payer: Multiplan Workers Comp	$187.20
Rate for Payer: Parkland Medicaid	$207.36
Rate for Payer: Scott and White EPO/PPO	$125.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$207.36
Rate for Payer: Superior Health Plan EPO	$39.17

OTHER AFTERCARE AND CONVALESCENCE

Facility

$5,465.47

Service Code	APR-DRG 8621
Min. Negotiated Rate	$5,153.04
Max. Negotiated Rate	$5,465.47
Rate for Payer: Amerigroup CHIP/Medicaid	$5,153.04
Rate for Payer: Cigna Medicaid	$5,153.04
Rate for Payer: Molina CHIP/Medicaid	$5,153.04
Rate for Payer: Parkland Medicaid	$5,153.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,465.47

OTHER AFTERCARE AND CONVALESCENCE

Facility

$11,036.17

Service Code	APR-DRG 8623
Min. Negotiated Rate	$10,405.29
Max. Negotiated Rate	$11,036.17
Rate for Payer: Amerigroup CHIP/Medicaid	$10,405.29
Rate for Payer: Cigna Medicaid	$10,405.29
Rate for Payer: Molina CHIP/Medicaid	$10,405.29
Rate for Payer: Parkland Medicaid	$10,405.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,036.17

OTHER AFTERCARE AND CONVALESCENCE

Facility

$16,420.92

Service Code	APR-DRG 8624
Min. Negotiated Rate	$15,482.22
Max. Negotiated Rate	$16,420.92
Rate for Payer: Amerigroup CHIP/Medicaid	$15,482.22
Rate for Payer: Cigna Medicaid	$15,482.22
Rate for Payer: Molina CHIP/Medicaid	$15,482.22
Rate for Payer: Parkland Medicaid	$15,482.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,420.92

OTHER AFTERCARE AND CONVALESCENCE

Facility

$7,384.23

Service Code	APR-DRG 8622
Min. Negotiated Rate	$6,962.11
Max. Negotiated Rate	$7,384.23
Rate for Payer: Amerigroup CHIP/Medicaid	$6,962.11
Rate for Payer: Cigna Medicaid	$6,962.11
Rate for Payer: Molina CHIP/Medicaid	$6,962.11
Rate for Payer: Parkland Medicaid	$6,962.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,384.23

OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE

Facility

$2,602.60

Service Code	APR-DRG 2531
Min. Negotiated Rate	$2,453.83
Max. Negotiated Rate	$2,602.60
Rate for Payer: Amerigroup CHIP/Medicaid	$2,453.83
Rate for Payer: Cigna Medicaid	$2,453.83
Rate for Payer: Molina CHIP/Medicaid	$2,453.83
Rate for Payer: Parkland Medicaid	$2,453.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,602.60

OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE

Facility

$8,206.88

Service Code	APR-DRG 2534
Min. Negotiated Rate	$7,737.73
Max. Negotiated Rate	$8,206.88
Rate for Payer: Amerigroup CHIP/Medicaid	$7,737.73
Rate for Payer: Cigna Medicaid	$7,737.73
Rate for Payer: Molina CHIP/Medicaid	$7,737.73
Rate for Payer: Parkland Medicaid	$7,737.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,206.88

OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE

Facility

$3,534.26

Service Code	APR-DRG 2532
Min. Negotiated Rate	$3,332.22
Max. Negotiated Rate	$3,534.26
Rate for Payer: Amerigroup CHIP/Medicaid	$3,332.22
Rate for Payer: Cigna Medicaid	$3,332.22
Rate for Payer: Molina CHIP/Medicaid	$3,332.22
Rate for Payer: Parkland Medicaid	$3,332.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,534.26

OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE

Facility

$4,843.86

Service Code	APR-DRG 2533
Min. Negotiated Rate	$4,566.96
Max. Negotiated Rate	$4,843.86
Rate for Payer: Amerigroup CHIP/Medicaid	$4,566.96
Rate for Payer: Cigna Medicaid	$4,566.96
Rate for Payer: Molina CHIP/Medicaid	$4,566.96
Rate for Payer: Parkland Medicaid	$4,566.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,843.86

OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS

Facility

$2,272.56

Service Code	APR-DRG 6631
Min. Negotiated Rate	$2,142.65
Max. Negotiated Rate	$2,272.56
Rate for Payer: Amerigroup CHIP/Medicaid	$2,142.65
Rate for Payer: Cigna Medicaid	$2,142.65
Rate for Payer: Molina CHIP/Medicaid	$2,142.65
Rate for Payer: Parkland Medicaid	$2,142.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,272.56

OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS

Facility

$8,791.14

Service Code	APR-DRG 6634
Min. Negotiated Rate	$8,288.60
Max. Negotiated Rate	$8,791.14
Rate for Payer: Amerigroup CHIP/Medicaid	$8,288.60
Rate for Payer: Cigna Medicaid	$8,288.60
Rate for Payer: Molina CHIP/Medicaid	$8,288.60
Rate for Payer: Parkland Medicaid	$8,288.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,791.14

OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS

Facility

$3,159.34

Service Code	APR-DRG 6632
Min. Negotiated Rate	$2,978.73
Max. Negotiated Rate	$3,159.34
Rate for Payer: Amerigroup CHIP/Medicaid	$2,978.73
Rate for Payer: Cigna Medicaid	$2,978.73
Rate for Payer: Molina CHIP/Medicaid	$2,978.73
Rate for Payer: Parkland Medicaid	$2,978.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,159.34

OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS

Facility

$5,186.73

Service Code	APR-DRG 6633
Min. Negotiated Rate	$4,890.23
Max. Negotiated Rate	$5,186.73
Rate for Payer: Amerigroup CHIP/Medicaid	$4,890.23
Rate for Payer: Cigna Medicaid	$4,890.23
Rate for Payer: Molina CHIP/Medicaid	$4,890.23
Rate for Payer: Parkland Medicaid	$4,890.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,186.73

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC

Facility

$30,211.90

Service Code	MSDRG 818
Min. Negotiated Rate	$11,683.10
Max. Negotiated Rate	$30,211.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,255.88
Rate for Payer: Amerigroup Medicare	$13,255.88
Rate for Payer: BCBS of TX Medicare	$13,255.88
Rate for Payer: Cigna Commercial	$13,578.10
Rate for Payer: Cigna Medicare	$13,255.88
Rate for Payer: Employer Direct Commercial	$13,255.88
Rate for Payer: Humana Medicare/TRICARE	$13,255.88
Rate for Payer: Molina Dual Medicare/Medicaid	$13,255.88
Rate for Payer: Molina Medicare	$13,255.88
Rate for Payer: Multiplan Auto	$30,211.90
Rate for Payer: Multiplan Commercial	$30,211.90
Rate for Payer: Multiplan Workers Comp	$30,211.90
Rate for Payer: Scott and White EPO/PPO	$13,913.38
Rate for Payer: Scott and White Medicare	$13,255.88
Rate for Payer: Superior Health Plan EPO	$13,255.88
Rate for Payer: Superior Health Plan Medicare	$13,255.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,255.88
Rate for Payer: Universal American Medicare	$13,255.88
Rate for Payer: Wellcare Medicare	$13,255.88
Rate for Payer: Wellmed Medicare	$13,255.88

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC

Facility

$59,466.20

Service Code	MSDRG 817
Min. Negotiated Rate	$21,481.98
Max. Negotiated Rate	$59,466.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,481.98
Rate for Payer: Amerigroup Medicare	$21,481.98
Rate for Payer: BCBS of TX Medicare	$21,481.98
Rate for Payer: Cigna Commercial	$21,741.44
Rate for Payer: Cigna Medicare	$21,481.98
Rate for Payer: Employer Direct Commercial	$21,481.98
Rate for Payer: Humana Medicare/TRICARE	$21,481.98
Rate for Payer: Molina Dual Medicare/Medicaid	$21,481.98
Rate for Payer: Molina Medicare	$21,481.98
Rate for Payer: Multiplan Auto	$59,466.20
Rate for Payer: Multiplan Commercial	$59,466.20
Rate for Payer: Multiplan Workers Comp	$59,466.20
Rate for Payer: Scott and White EPO/PPO	$27,385.75
Rate for Payer: Scott and White Medicare	$21,481.98
Rate for Payer: Superior Health Plan EPO	$21,481.98
Rate for Payer: Superior Health Plan Medicare	$21,481.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,481.98
Rate for Payer: Universal American Medicare	$21,481.98
Rate for Payer: Wellcare Medicare	$21,481.98
Rate for Payer: Wellmed Medicare	$21,481.98

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$16,881.50

Service Code	MSDRG 819
Min. Negotiated Rate	$7,215.40
Max. Negotiated Rate	$16,881.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,062.31
Rate for Payer: Amerigroup Medicare	$11,062.31
Rate for Payer: BCBS of TX Medicare	$11,062.31
Rate for Payer: Cigna Commercial	$11,075.51
Rate for Payer: Cigna Medicare	$11,062.31
Rate for Payer: Employer Direct Commercial	$11,062.31
Rate for Payer: Humana Medicare/TRICARE	$11,062.31
Rate for Payer: Molina Dual Medicare/Medicaid	$11,062.31
Rate for Payer: Molina Medicare	$11,062.31
Rate for Payer: Multiplan Auto	$16,881.50
Rate for Payer: Multiplan Commercial	$16,881.50
Rate for Payer: Multiplan Workers Comp	$16,881.50
Rate for Payer: Scott and White EPO/PPO	$7,774.38
Rate for Payer: Scott and White Medicare	$11,062.31
Rate for Payer: Superior Health Plan EPO	$11,062.31
Rate for Payer: Superior Health Plan Medicare	$11,062.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,062.31
Rate for Payer: Universal American Medicare	$11,062.31
Rate for Payer: Wellcare Medicare	$11,062.31
Rate for Payer: Wellmed Medicare	$11,062.31

Know your out-of-pocket cost for care.

All Charges