White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES

Facility

$14,399.57

Service Code	APR-DRG 3474
Min. Negotiated Rate	$13,576.42
Max. Negotiated Rate	$14,399.57
Rate for Payer: Amerigroup CHIP/Medicaid	$13,576.42
Rate for Payer: Cigna Medicaid	$13,576.42
Rate for Payer: Molina CHIP/Medicaid	$13,576.42
Rate for Payer: Parkland Medicaid	$13,576.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,399.57

OTHER BLADDER PROCEDURES

Facility

$4,221.50

Service Code	APR-DRG 4451
Min. Negotiated Rate	$3,980.18
Max. Negotiated Rate	$4,221.50
Rate for Payer: Amerigroup CHIP/Medicaid	$3,980.18
Rate for Payer: Cigna Medicaid	$3,980.18
Rate for Payer: Molina CHIP/Medicaid	$3,980.18
Rate for Payer: Parkland Medicaid	$3,980.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,221.50

OTHER BLADDER PROCEDURES

Facility

$6,500.10

Service Code	APR-DRG 4452
Min. Negotiated Rate	$6,128.52
Max. Negotiated Rate	$6,500.10
Rate for Payer: Amerigroup CHIP/Medicaid	$6,128.52
Rate for Payer: Cigna Medicaid	$6,128.52
Rate for Payer: Molina CHIP/Medicaid	$6,128.52
Rate for Payer: Parkland Medicaid	$6,128.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,500.10

OTHER BLADDER PROCEDURES

Facility

$20,365.19

Service Code	APR-DRG 4454
Min. Negotiated Rate	$19,201.01
Max. Negotiated Rate	$20,365.19
Rate for Payer: Amerigroup CHIP/Medicaid	$19,201.01
Rate for Payer: Cigna Medicaid	$19,201.01
Rate for Payer: Molina CHIP/Medicaid	$19,201.01
Rate for Payer: Parkland Medicaid	$19,201.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,365.19

OTHER BLADDER PROCEDURES

Facility

$9,960.43

Service Code	APR-DRG 4453
Min. Negotiated Rate	$9,391.04
Max. Negotiated Rate	$9,960.43
Rate for Payer: Amerigroup CHIP/Medicaid	$9,391.04
Rate for Payer: Cigna Medicaid	$9,391.04
Rate for Payer: Molina CHIP/Medicaid	$9,391.04
Rate for Payer: Parkland Medicaid	$9,391.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,960.43

OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES

Facility

$18,416.63

Service Code	APR-DRG 1672
Min. Negotiated Rate	$17,363.84
Max. Negotiated Rate	$18,416.63
Rate for Payer: Amerigroup CHIP/Medicaid	$17,363.84
Rate for Payer: Cigna Medicaid	$17,363.84
Rate for Payer: Molina CHIP/Medicaid	$17,363.84
Rate for Payer: Parkland Medicaid	$17,363.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,416.63

OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES

Facility

$15,130.56

Service Code	APR-DRG 1671
Min. Negotiated Rate	$14,265.62
Max. Negotiated Rate	$15,130.56
Rate for Payer: Amerigroup CHIP/Medicaid	$14,265.62
Rate for Payer: Cigna Medicaid	$14,265.62
Rate for Payer: Molina CHIP/Medicaid	$14,265.62
Rate for Payer: Parkland Medicaid	$14,265.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,130.56

OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES

Facility

$23,535.08

Service Code	APR-DRG 1673
Min. Negotiated Rate	$22,189.70
Max. Negotiated Rate	$23,535.08
Rate for Payer: Amerigroup CHIP/Medicaid	$22,189.70
Rate for Payer: Cigna Medicaid	$22,189.70
Rate for Payer: Molina CHIP/Medicaid	$22,189.70
Rate for Payer: Parkland Medicaid	$22,189.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,535.08

OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES

Facility

$54,180.94

Service Code	APR-DRG 1674
Min. Negotiated Rate	$51,083.68
Max. Negotiated Rate	$54,180.94
Rate for Payer: Amerigroup CHIP/Medicaid	$51,083.68
Rate for Payer: Cigna Medicaid	$51,083.68
Rate for Payer: Molina CHIP/Medicaid	$51,083.68
Rate for Payer: Parkland Medicaid	$51,083.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$54,180.94

OTHER CARDIOTHORACIC PROCEDURES WITH MCC

Facility

$94,000.60

Service Code	MSDRG 228
Min. Negotiated Rate	$41,019.71
Max. Negotiated Rate	$94,000.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$41,019.71
Rate for Payer: Amerigroup Medicare	$41,019.71
Rate for Payer: BCBS of TX Medicare	$41,019.71
Rate for Payer: Cigna Commercial	$63,722.51
Rate for Payer: Cigna Medicare	$41,019.71
Rate for Payer: Employer Direct Commercial	$41,019.71
Rate for Payer: Humana Medicare/TRICARE	$41,019.71
Rate for Payer: Molina Dual Medicare/Medicaid	$41,019.71
Rate for Payer: Molina Medicare	$41,019.71
Rate for Payer: Multiplan Auto	$94,000.60
Rate for Payer: Multiplan Commercial	$94,000.60
Rate for Payer: Multiplan Workers Comp	$94,000.60
Rate for Payer: Scott and White EPO/PPO	$43,289.75
Rate for Payer: Scott and White Medicare	$41,019.71
Rate for Payer: Superior Health Plan EPO	$41,019.71
Rate for Payer: Superior Health Plan Medicare	$41,019.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$41,019.71
Rate for Payer: Universal American Medicare	$41,019.71
Rate for Payer: Wellcare Medicare	$41,019.71
Rate for Payer: Wellmed Medicare	$41,019.71

OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC

Facility

$59,840.50

Service Code	MSDRG 229
Min. Negotiated Rate	$27,558.12
Max. Negotiated Rate	$59,840.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27,842.86
Rate for Payer: Amerigroup Medicare	$27,842.86
Rate for Payer: BCBS of TX Medicare	$27,842.86
Rate for Payer: Cigna Commercial	$40,565.56
Rate for Payer: Cigna Medicare	$27,842.86
Rate for Payer: Employer Direct Commercial	$27,842.86
Rate for Payer: Humana Medicare/TRICARE	$27,842.86
Rate for Payer: Molina Dual Medicare/Medicaid	$27,842.86
Rate for Payer: Molina Medicare	$27,842.86
Rate for Payer: Multiplan Auto	$59,840.50
Rate for Payer: Multiplan Commercial	$59,840.50
Rate for Payer: Multiplan Workers Comp	$59,840.50
Rate for Payer: Scott and White EPO/PPO	$27,558.12
Rate for Payer: Scott and White Medicare	$27,842.86
Rate for Payer: Superior Health Plan EPO	$27,842.86
Rate for Payer: Superior Health Plan Medicare	$27,842.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$27,842.86
Rate for Payer: Universal American Medicare	$27,842.86
Rate for Payer: Wellcare Medicare	$27,842.86
Rate for Payer: Wellmed Medicare	$27,842.86

OTHER CARDIOTHORACIC PROCEDURES W MCC

Facility

$94,000.60

Service Code	MSDRG 228
Min. Negotiated Rate	$41,019.71
Max. Negotiated Rate	$94,000.60
Rate for Payer: BCBS of TX Blue Advantage	$56,555.32
Rate for Payer: BCBS of TX Blue Essentials	$67,859.81
Rate for Payer: BCBS of TX PPO	$75,402.71

OTHER CARDIOTHORACIC PROCEDURES W/O MCC

Facility

$59,840.50

Service Code	MSDRG 229
Min. Negotiated Rate	$27,558.12
Max. Negotiated Rate	$59,840.50
Rate for Payer: BCBS of TX Blue Advantage	$39,976.24
Rate for Payer: BCBS of TX Blue Essentials	$47,966.84
Rate for Payer: BCBS of TX PPO	$53,298.55

OTHER CEREBROVASCULAR DISORDERS WITH CC

Facility

$19,494.00

Service Code	MSDRG 071
Min. Negotiated Rate	$8,477.88
Max. Negotiated Rate	$19,494.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,279.66
Rate for Payer: Amerigroup Medicare	$12,279.66
Rate for Payer: BCBS of TX Medicare	$12,279.66
Rate for Payer: Cigna Commercial	$13,214.88
Rate for Payer: Cigna Medicare	$12,279.66
Rate for Payer: Employer Direct Commercial	$12,279.66
Rate for Payer: Humana Medicare/TRICARE	$12,279.66
Rate for Payer: Molina Dual Medicare/Medicaid	$12,279.66
Rate for Payer: Molina Medicare	$12,279.66
Rate for Payer: Multiplan Auto	$19,494.00
Rate for Payer: Multiplan Commercial	$19,494.00
Rate for Payer: Multiplan Workers Comp	$19,494.00
Rate for Payer: Scott and White EPO/PPO	$8,977.50
Rate for Payer: Scott and White Medicare	$12,279.66
Rate for Payer: Superior Health Plan EPO	$12,279.66
Rate for Payer: Superior Health Plan Medicare	$12,279.66
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,279.66
Rate for Payer: Universal American Medicare	$12,279.66
Rate for Payer: Wellcare Medicare	$12,279.66
Rate for Payer: Wellmed Medicare	$12,279.66

OTHER CEREBROVASCULAR DISORDERS WITH MCC

Facility

$31,631.20

Service Code	MSDRG 070
Min. Negotiated Rate	$14,149.58
Max. Negotiated Rate	$31,631.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,961.45
Rate for Payer: Amerigroup Medicare	$16,961.45
Rate for Payer: BCBS of TX Medicare	$16,961.45
Rate for Payer: Cigna Commercial	$21,442.62
Rate for Payer: Cigna Medicare	$16,961.45
Rate for Payer: Employer Direct Commercial	$16,961.45
Rate for Payer: Humana Medicare/TRICARE	$16,961.45
Rate for Payer: Molina Dual Medicare/Medicaid	$16,961.45
Rate for Payer: Molina Medicare	$16,961.45
Rate for Payer: Multiplan Auto	$31,631.20
Rate for Payer: Multiplan Commercial	$31,631.20
Rate for Payer: Multiplan Workers Comp	$31,631.20
Rate for Payer: Scott and White EPO/PPO	$14,567.00
Rate for Payer: Scott and White Medicare	$16,961.45
Rate for Payer: Superior Health Plan EPO	$16,961.45
Rate for Payer: Superior Health Plan Medicare	$16,961.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,961.45
Rate for Payer: Universal American Medicare	$16,961.45
Rate for Payer: Wellcare Medicare	$16,961.45
Rate for Payer: Wellmed Medicare	$16,961.45

OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC

Facility

$14,367.80

Service Code	MSDRG 072
Min. Negotiated Rate	$6,381.20
Max. Negotiated Rate	$14,367.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,302.29
Rate for Payer: Amerigroup Medicare	$10,302.29
Rate for Payer: BCBS of TX Medicare	$10,302.29
Rate for Payer: Cigna Commercial	$9,739.86
Rate for Payer: Cigna Medicare	$10,302.29
Rate for Payer: Employer Direct Commercial	$10,302.29
Rate for Payer: Humana Medicare/TRICARE	$10,302.29
Rate for Payer: Molina Dual Medicare/Medicaid	$10,302.29
Rate for Payer: Molina Medicare	$10,302.29
Rate for Payer: Multiplan Auto	$14,367.80
Rate for Payer: Multiplan Commercial	$14,367.80
Rate for Payer: Multiplan Workers Comp	$14,367.80
Rate for Payer: Scott and White EPO/PPO	$6,616.75
Rate for Payer: Scott and White Medicare	$10,302.29
Rate for Payer: Superior Health Plan EPO	$10,302.29
Rate for Payer: Superior Health Plan Medicare	$10,302.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,302.29
Rate for Payer: Universal American Medicare	$10,302.29
Rate for Payer: Wellcare Medicare	$10,302.29
Rate for Payer: Wellmed Medicare	$10,302.29

OTHER CHEMOTHERAPY

Facility

$16,019.22

Service Code	APR-DRG 6964
Min. Negotiated Rate	$15,103.48
Max. Negotiated Rate	$16,019.22
Rate for Payer: Amerigroup CHIP/Medicaid	$15,103.48
Rate for Payer: Cigna Medicaid	$15,103.48
Rate for Payer: Molina CHIP/Medicaid	$15,103.48
Rate for Payer: Parkland Medicaid	$15,103.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,019.22

OTHER CHEMOTHERAPY

Facility

$9,034.05

Service Code	APR-DRG 6963
Min. Negotiated Rate	$8,517.62
Max. Negotiated Rate	$9,034.05
Rate for Payer: Amerigroup CHIP/Medicaid	$8,517.62
Rate for Payer: Cigna Medicaid	$8,517.62
Rate for Payer: Molina CHIP/Medicaid	$8,517.62
Rate for Payer: Parkland Medicaid	$8,517.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,034.05

OTHER CHEMOTHERAPY

Facility

$5,307.43

Service Code	APR-DRG 6962
Min. Negotiated Rate	$5,004.03
Max. Negotiated Rate	$5,307.43
Rate for Payer: Amerigroup CHIP/Medicaid	$5,004.03
Rate for Payer: Cigna Medicaid	$5,004.03
Rate for Payer: Molina CHIP/Medicaid	$5,004.03
Rate for Payer: Parkland Medicaid	$5,004.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,307.43

OTHER CHEMOTHERAPY

Facility

$3,735.30

Service Code	APR-DRG 6961
Min. Negotiated Rate	$3,521.77
Max. Negotiated Rate	$3,735.30
Rate for Payer: Amerigroup CHIP/Medicaid	$3,521.77
Rate for Payer: Cigna Medicaid	$3,521.77
Rate for Payer: Molina CHIP/Medicaid	$3,521.77
Rate for Payer: Parkland Medicaid	$3,521.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,735.30

OTHER CIRCULATORY SYSTEM DIAGNOSES

Facility

$3,005.06

Service Code	APR-DRG 2071
Min. Negotiated Rate	$2,833.28
Max. Negotiated Rate	$3,005.06
Rate for Payer: Amerigroup CHIP/Medicaid	$2,833.28
Rate for Payer: Cigna Medicaid	$2,833.28
Rate for Payer: Molina CHIP/Medicaid	$2,833.28
Rate for Payer: Parkland Medicaid	$2,833.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,005.06

OTHER CIRCULATORY SYSTEM DIAGNOSES

Facility

$3,919.37

Service Code	APR-DRG 2072
Min. Negotiated Rate	$3,695.32
Max. Negotiated Rate	$3,919.37
Rate for Payer: Amerigroup CHIP/Medicaid	$3,695.32
Rate for Payer: Cigna Medicaid	$3,695.32
Rate for Payer: Molina CHIP/Medicaid	$3,695.32
Rate for Payer: Parkland Medicaid	$3,695.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,919.37

OTHER CIRCULATORY SYSTEM DIAGNOSES

Facility

$5,596.35

Service Code	APR-DRG 2073
Min. Negotiated Rate	$5,276.44
Max. Negotiated Rate	$5,596.35
Rate for Payer: Amerigroup CHIP/Medicaid	$5,276.44
Rate for Payer: Cigna Medicaid	$5,276.44
Rate for Payer: Molina CHIP/Medicaid	$5,276.44
Rate for Payer: Parkland Medicaid	$5,276.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,596.35

OTHER CIRCULATORY SYSTEM DIAGNOSES

Facility

$20,593.39

Service Code	APR-DRG 2074
Min. Negotiated Rate	$19,416.17
Max. Negotiated Rate	$20,593.39
Rate for Payer: Amerigroup CHIP/Medicaid	$19,416.17
Rate for Payer: Cigna Medicaid	$19,416.17
Rate for Payer: Molina CHIP/Medicaid	$19,416.17
Rate for Payer: Parkland Medicaid	$19,416.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,593.39

OTHER CIRCULATORY SYSTEM DIAGNOSES W CC

Facility

$18,302.70

Service Code	MSDRG 315
Min. Negotiated Rate	$8,220.74
Max. Negotiated Rate	$18,302.70
Rate for Payer: BCBS of TX Blue Advantage	$8,220.74
Rate for Payer: BCBS of TX Blue Essentials	$9,863.93
Rate for Payer: BCBS of TX PPO	$10,960.35

Know your out-of-pocket cost for care.

All Charges