White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER COMPLICATIONS OF TREATMENT

Facility

$2,916.43

Service Code	APR-DRG 8131
Min. Negotiated Rate	$2,749.71
Max. Negotiated Rate	$2,916.43
Rate for Payer: Amerigroup CHIP/Medicaid	$2,749.71
Rate for Payer: Cigna Medicaid	$2,749.71
Rate for Payer: Molina CHIP/Medicaid	$2,749.71
Rate for Payer: Parkland Medicaid	$2,749.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,916.43

OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES

Facility

$7,112.65

Service Code	APR-DRG 2292
Min. Negotiated Rate	$6,706.06
Max. Negotiated Rate	$7,112.65
Rate for Payer: Amerigroup CHIP/Medicaid	$6,706.06
Rate for Payer: Cigna Medicaid	$6,706.06
Rate for Payer: Molina CHIP/Medicaid	$6,706.06
Rate for Payer: Parkland Medicaid	$6,706.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,112.65

OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES

Facility

$19,837.88

Service Code	APR-DRG 2294
Min. Negotiated Rate	$18,703.85
Max. Negotiated Rate	$19,837.88
Rate for Payer: Amerigroup CHIP/Medicaid	$18,703.85
Rate for Payer: Cigna Medicaid	$18,703.85
Rate for Payer: Molina CHIP/Medicaid	$18,703.85
Rate for Payer: Parkland Medicaid	$18,703.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,837.88

OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES

Facility

$14,474.25

Service Code	APR-DRG 2293
Min. Negotiated Rate	$13,646.83
Max. Negotiated Rate	$14,474.25
Rate for Payer: Amerigroup CHIP/Medicaid	$13,646.83
Rate for Payer: Cigna Medicaid	$13,646.83
Rate for Payer: Molina CHIP/Medicaid	$13,646.83
Rate for Payer: Parkland Medicaid	$13,646.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,474.25

OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES

Facility

$5,127.51

Service Code	APR-DRG 2291
Min. Negotiated Rate	$4,834.39
Max. Negotiated Rate	$5,127.51
Rate for Payer: Amerigroup CHIP/Medicaid	$4,834.39
Rate for Payer: Cigna Medicaid	$4,834.39
Rate for Payer: Molina CHIP/Medicaid	$4,834.39
Rate for Payer: Parkland Medicaid	$4,834.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,127.51

OTHER DIGESTIVE SYSTEM DIAGNOSES

Facility

$14,517.25

Service Code	APR-DRG 2544
Min. Negotiated Rate	$13,687.37
Max. Negotiated Rate	$14,517.25
Rate for Payer: Amerigroup CHIP/Medicaid	$13,687.37
Rate for Payer: Cigna Medicaid	$13,687.37
Rate for Payer: Molina CHIP/Medicaid	$13,687.37
Rate for Payer: Parkland Medicaid	$13,687.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,517.25

OTHER DIGESTIVE SYSTEM DIAGNOSES

Facility

$4,034.79

Service Code	APR-DRG 2542
Min. Negotiated Rate	$3,804.14
Max. Negotiated Rate	$4,034.79
Rate for Payer: Amerigroup CHIP/Medicaid	$3,804.14
Rate for Payer: Cigna Medicaid	$3,804.14
Rate for Payer: Molina CHIP/Medicaid	$3,804.14
Rate for Payer: Parkland Medicaid	$3,804.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,034.79

OTHER DIGESTIVE SYSTEM DIAGNOSES

Facility

$6,568.37

Service Code	APR-DRG 2543
Min. Negotiated Rate	$6,192.89
Max. Negotiated Rate	$6,568.37
Rate for Payer: Amerigroup CHIP/Medicaid	$6,192.89
Rate for Payer: Cigna Medicaid	$6,192.89
Rate for Payer: Molina CHIP/Medicaid	$6,192.89
Rate for Payer: Parkland Medicaid	$6,192.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,568.37

OTHER DIGESTIVE SYSTEM DIAGNOSES

Facility

$2,431.36

Service Code	APR-DRG 2541
Min. Negotiated Rate	$2,292.37
Max. Negotiated Rate	$2,431.36
Rate for Payer: Amerigroup CHIP/Medicaid	$2,292.37
Rate for Payer: Cigna Medicaid	$2,292.37
Rate for Payer: Molina CHIP/Medicaid	$2,292.37
Rate for Payer: Parkland Medicaid	$2,292.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,431.36

OTHER DIGESTIVE SYSTEM DIAGNOSES W CC

Facility

$17,917.00

Service Code	MSDRG 394
Min. Negotiated Rate	$8,093.46
Max. Negotiated Rate	$17,917.00
Rate for Payer: BCBS of TX Blue Advantage	$8,093.46
Rate for Payer: BCBS of TX Blue Essentials	$9,711.21
Rate for Payer: BCBS of TX PPO	$10,790.65

OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC

Facility

$17,917.00

Service Code	MSDRG 394
Min. Negotiated Rate	$8,093.46
Max. Negotiated Rate	$17,917.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,617.85
Rate for Payer: Amerigroup Medicare	$11,617.85
Rate for Payer: BCBS of TX Medicare	$11,617.85
Rate for Payer: Cigna Commercial	$12,051.82
Rate for Payer: Cigna Medicare	$11,617.85
Rate for Payer: Employer Direct Commercial	$11,617.85
Rate for Payer: Humana Medicare/TRICARE	$11,617.85
Rate for Payer: Molina Dual Medicare/Medicaid	$11,617.85
Rate for Payer: Molina Medicare	$11,617.85
Rate for Payer: Multiplan Auto	$17,917.00
Rate for Payer: Multiplan Commercial	$17,917.00
Rate for Payer: Multiplan Workers Comp	$17,917.00
Rate for Payer: Scott and White EPO/PPO	$8,251.25
Rate for Payer: Scott and White Medicare	$11,617.85
Rate for Payer: Superior Health Plan EPO	$11,617.85
Rate for Payer: Superior Health Plan Medicare	$11,617.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,617.85
Rate for Payer: Universal American Medicare	$11,617.85
Rate for Payer: Wellcare Medicare	$11,617.85
Rate for Payer: Wellmed Medicare	$11,617.85

OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC

Facility

$30,614.70

Service Code	MSDRG 393
Min. Negotiated Rate	$14,040.36
Max. Negotiated Rate	$30,614.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,481.39
Rate for Payer: Amerigroup Medicare	$16,481.39
Rate for Payer: BCBS of TX Medicare	$16,481.39
Rate for Payer: Cigna Commercial	$20,598.98
Rate for Payer: Cigna Medicare	$16,481.39
Rate for Payer: Employer Direct Commercial	$16,481.39
Rate for Payer: Humana Medicare/TRICARE	$16,481.39
Rate for Payer: Molina Dual Medicare/Medicaid	$16,481.39
Rate for Payer: Molina Medicare	$16,481.39
Rate for Payer: Multiplan Auto	$30,614.70
Rate for Payer: Multiplan Commercial	$30,614.70
Rate for Payer: Multiplan Workers Comp	$30,614.70
Rate for Payer: Scott and White EPO/PPO	$14,098.88
Rate for Payer: Scott and White Medicare	$16,481.39
Rate for Payer: Superior Health Plan EPO	$16,481.39
Rate for Payer: Superior Health Plan Medicare	$16,481.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,481.39
Rate for Payer: Universal American Medicare	$16,481.39
Rate for Payer: Wellcare Medicare	$16,481.39
Rate for Payer: Wellmed Medicare	$16,481.39

OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC

Facility

$12,253.10

Service Code	MSDRG 395
Min. Negotiated Rate	$5,642.88
Max. Negotiated Rate	$12,253.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,516.61
Rate for Payer: Amerigroup Medicare	$9,516.61
Rate for Payer: BCBS of TX Medicare	$9,516.61
Rate for Payer: Cigna Commercial	$8,359.12
Rate for Payer: Cigna Medicare	$9,516.61
Rate for Payer: Employer Direct Commercial	$9,516.61
Rate for Payer: Humana Medicare/TRICARE	$9,516.61
Rate for Payer: Molina Dual Medicare/Medicaid	$9,516.61
Rate for Payer: Molina Medicare	$9,516.61
Rate for Payer: Multiplan Auto	$12,253.10
Rate for Payer: Multiplan Commercial	$12,253.10
Rate for Payer: Multiplan Workers Comp	$12,253.10
Rate for Payer: Scott and White EPO/PPO	$5,642.88
Rate for Payer: Scott and White Medicare	$9,516.61
Rate for Payer: Superior Health Plan EPO	$9,516.61
Rate for Payer: Superior Health Plan Medicare	$9,516.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,516.61
Rate for Payer: Universal American Medicare	$9,516.61
Rate for Payer: Wellcare Medicare	$9,516.61
Rate for Payer: Wellmed Medicare	$9,516.61

OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC

Facility

$30,614.70

Service Code	MSDRG 393
Min. Negotiated Rate	$14,040.36
Max. Negotiated Rate	$30,614.70
Rate for Payer: BCBS of TX Blue Advantage	$14,040.36
Rate for Payer: BCBS of TX Blue Essentials	$16,846.80
Rate for Payer: BCBS of TX PPO	$18,719.39

OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC

Facility

$12,253.10

Service Code	MSDRG 395
Min. Negotiated Rate	$5,642.88
Max. Negotiated Rate	$12,253.10
Rate for Payer: BCBS of TX Blue Advantage	$5,817.90
Rate for Payer: BCBS of TX Blue Essentials	$6,980.80
Rate for Payer: BCBS of TX PPO	$7,756.75

OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC

Facility

$42,677.80

Service Code	MSDRG 357
Min. Negotiated Rate	$18,375.62
Max. Negotiated Rate	$42,677.80
Rate for Payer: BCBS of TX Blue Advantage	$18,375.62
Rate for Payer: BCBS of TX Blue Essentials	$22,048.61
Rate for Payer: BCBS of TX PPO	$24,499.40

OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC

Facility

$42,677.80

Service Code	MSDRG 357
Min. Negotiated Rate	$18,375.62
Max. Negotiated Rate	$42,677.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,803.73
Rate for Payer: Amerigroup Medicare	$21,803.73
Rate for Payer: BCBS of TX Medicare	$21,803.73
Rate for Payer: Cigna Commercial	$29,952.44
Rate for Payer: Cigna Medicare	$21,803.73
Rate for Payer: Employer Direct Commercial	$21,803.73
Rate for Payer: Humana Medicare/TRICARE	$21,803.73
Rate for Payer: Molina Dual Medicare/Medicaid	$21,803.73
Rate for Payer: Molina Medicare	$21,803.73
Rate for Payer: Multiplan Auto	$42,677.80
Rate for Payer: Multiplan Commercial	$42,677.80
Rate for Payer: Multiplan Workers Comp	$42,677.80
Rate for Payer: Scott and White EPO/PPO	$19,654.25
Rate for Payer: Scott and White Medicare	$21,803.73
Rate for Payer: Superior Health Plan EPO	$21,803.73
Rate for Payer: Superior Health Plan Medicare	$21,803.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,803.73
Rate for Payer: Universal American Medicare	$21,803.73
Rate for Payer: Wellcare Medicare	$21,803.73
Rate for Payer: Wellmed Medicare	$21,803.73

OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC

Facility

$80,227.50

Service Code	MSDRG 356
Min. Negotiated Rate	$34,191.02
Max. Negotiated Rate	$80,227.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$36,955.02
Rate for Payer: Amerigroup Medicare	$36,955.02
Rate for Payer: BCBS of TX Medicare	$36,955.02
Rate for Payer: Cigna Commercial	$56,579.26
Rate for Payer: Cigna Medicare	$36,955.02
Rate for Payer: Employer Direct Commercial	$36,955.02
Rate for Payer: Humana Medicare/TRICARE	$36,955.02
Rate for Payer: Molina Dual Medicare/Medicaid	$36,955.02
Rate for Payer: Molina Medicare	$36,955.02
Rate for Payer: Multiplan Auto	$80,227.50
Rate for Payer: Multiplan Commercial	$80,227.50
Rate for Payer: Multiplan Workers Comp	$80,227.50
Rate for Payer: Scott and White EPO/PPO	$36,946.88
Rate for Payer: Scott and White Medicare	$36,955.02
Rate for Payer: Superior Health Plan EPO	$36,955.02
Rate for Payer: Superior Health Plan Medicare	$36,955.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$36,955.02
Rate for Payer: Universal American Medicare	$36,955.02
Rate for Payer: Wellcare Medicare	$36,955.02
Rate for Payer: Wellmed Medicare	$36,955.02

OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC

Facility

$26,356.80

Service Code	MSDRG 358
Min. Negotiated Rate	$11,595.38
Max. Negotiated Rate	$26,356.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,005.34
Rate for Payer: Amerigroup Medicare	$15,005.34
Rate for Payer: BCBS of TX Medicare	$15,005.34
Rate for Payer: Cigna Commercial	$18,004.95
Rate for Payer: Cigna Medicare	$15,005.34
Rate for Payer: Employer Direct Commercial	$15,005.34
Rate for Payer: Humana Medicare/TRICARE	$15,005.34
Rate for Payer: Molina Dual Medicare/Medicaid	$15,005.34
Rate for Payer: Molina Medicare	$15,005.34
Rate for Payer: Multiplan Auto	$26,356.80
Rate for Payer: Multiplan Commercial	$26,356.80
Rate for Payer: Multiplan Workers Comp	$26,356.80
Rate for Payer: Scott and White EPO/PPO	$12,138.00
Rate for Payer: Scott and White Medicare	$15,005.34
Rate for Payer: Superior Health Plan EPO	$15,005.34
Rate for Payer: Superior Health Plan Medicare	$15,005.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,005.34
Rate for Payer: Universal American Medicare	$15,005.34
Rate for Payer: Wellcare Medicare	$15,005.34
Rate for Payer: Wellmed Medicare	$15,005.34

OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC

Facility

$80,227.50

Service Code	MSDRG 356
Min. Negotiated Rate	$34,191.02
Max. Negotiated Rate	$80,227.50
Rate for Payer: BCBS of TX Blue Advantage	$34,191.02
Rate for Payer: BCBS of TX Blue Essentials	$41,025.25
Rate for Payer: BCBS of TX PPO	$45,585.38

OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC/MCC

Facility

$26,356.80

Service Code	MSDRG 358
Min. Negotiated Rate	$11,595.38
Max. Negotiated Rate	$26,356.80
Rate for Payer: BCBS of TX Blue Advantage	$11,595.38
Rate for Payer: BCBS of TX Blue Essentials	$13,913.11
Rate for Payer: BCBS of TX PPO	$15,459.61

OTHER DISORDERS OF NERVOUS SYSTEM

Facility

$9,032.54

Service Code	APR-DRG 0583
Min. Negotiated Rate	$8,516.20
Max. Negotiated Rate	$9,032.54
Rate for Payer: Amerigroup CHIP/Medicaid	$8,516.20
Rate for Payer: Cigna Medicaid	$8,516.20
Rate for Payer: Molina CHIP/Medicaid	$8,516.20
Rate for Payer: Parkland Medicaid	$8,516.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,032.54

OTHER DISORDERS OF NERVOUS SYSTEM

Facility

$3,983.12

Service Code	APR-DRG 0581
Min. Negotiated Rate	$3,755.42
Max. Negotiated Rate	$3,983.12
Rate for Payer: Amerigroup CHIP/Medicaid	$3,755.42
Rate for Payer: Cigna Medicaid	$3,755.42
Rate for Payer: Molina CHIP/Medicaid	$3,755.42
Rate for Payer: Parkland Medicaid	$3,755.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,983.12

OTHER DISORDERS OF NERVOUS SYSTEM

Facility

$18,253.31

Service Code	APR-DRG 0584
Min. Negotiated Rate	$17,209.86
Max. Negotiated Rate	$18,253.31
Rate for Payer: Amerigroup CHIP/Medicaid	$17,209.86
Rate for Payer: Cigna Medicaid	$17,209.86
Rate for Payer: Molina CHIP/Medicaid	$17,209.86
Rate for Payer: Parkland Medicaid	$17,209.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,253.31

OTHER DISORDERS OF NERVOUS SYSTEM

Facility

$5,637.09

Service Code	APR-DRG 0582
Min. Negotiated Rate	$5,314.85
Max. Negotiated Rate	$5,637.09
Rate for Payer: Amerigroup CHIP/Medicaid	$5,314.85
Rate for Payer: Cigna Medicaid	$5,314.85
Rate for Payer: Molina CHIP/Medicaid	$5,314.85
Rate for Payer: Parkland Medicaid	$5,314.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,637.09

Know your out-of-pocket cost for care.

All Charges