White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC

Facility

$18,302.70

Service Code	MSDRG 315
Min. Negotiated Rate	$8,220.74
Max. Negotiated Rate	$18,302.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,820.12
Rate for Payer: Amerigroup Medicare	$11,820.12
Rate for Payer: BCBS of TX Medicare	$11,820.12
Rate for Payer: Cigna Commercial	$12,407.30
Rate for Payer: Cigna Medicare	$11,820.12
Rate for Payer: Employer Direct Commercial	$11,820.12
Rate for Payer: Humana Medicare/TRICARE	$11,820.12
Rate for Payer: Molina Dual Medicare/Medicaid	$11,820.12
Rate for Payer: Molina Medicare	$11,820.12
Rate for Payer: Multiplan Auto	$18,302.70
Rate for Payer: Multiplan Commercial	$18,302.70
Rate for Payer: Multiplan Workers Comp	$18,302.70
Rate for Payer: Scott and White EPO/PPO	$8,428.88
Rate for Payer: Scott and White Medicare	$11,820.12
Rate for Payer: Superior Health Plan EPO	$11,820.12
Rate for Payer: Superior Health Plan Medicare	$11,820.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,820.12
Rate for Payer: Universal American Medicare	$11,820.12
Rate for Payer: Wellcare Medicare	$11,820.12
Rate for Payer: Wellmed Medicare	$11,820.12

OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC

Facility

$39,618.80

Service Code	MSDRG 314
Min. Negotiated Rate	$17,398.66
Max. Negotiated Rate	$39,618.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,042.57
Rate for Payer: Amerigroup Medicare	$20,042.57
Rate for Payer: BCBS of TX Medicare	$20,042.57
Rate for Payer: Cigna Commercial	$26,857.38
Rate for Payer: Cigna Medicare	$20,042.57
Rate for Payer: Employer Direct Commercial	$20,042.57
Rate for Payer: Humana Medicare/TRICARE	$20,042.57
Rate for Payer: Molina Dual Medicare/Medicaid	$20,042.57
Rate for Payer: Molina Medicare	$20,042.57
Rate for Payer: Multiplan Auto	$39,618.80
Rate for Payer: Multiplan Commercial	$39,618.80
Rate for Payer: Multiplan Workers Comp	$39,618.80
Rate for Payer: Scott and White EPO/PPO	$18,245.50
Rate for Payer: Scott and White Medicare	$20,042.57
Rate for Payer: Superior Health Plan EPO	$20,042.57
Rate for Payer: Superior Health Plan Medicare	$20,042.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,042.57
Rate for Payer: Universal American Medicare	$20,042.57
Rate for Payer: Wellcare Medicare	$20,042.57
Rate for Payer: Wellmed Medicare	$20,042.57

OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC

Facility

$12,959.90

Service Code	MSDRG 316
Min. Negotiated Rate	$5,968.38
Max. Negotiated Rate	$12,959.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,759.21
Rate for Payer: Amerigroup Medicare	$9,759.21
Rate for Payer: BCBS of TX Medicare	$9,759.21
Rate for Payer: Cigna Commercial	$8,785.45
Rate for Payer: Cigna Medicare	$9,759.21
Rate for Payer: Employer Direct Commercial	$9,759.21
Rate for Payer: Humana Medicare/TRICARE	$9,759.21
Rate for Payer: Molina Dual Medicare/Medicaid	$9,759.21
Rate for Payer: Molina Medicare	$9,759.21
Rate for Payer: Multiplan Auto	$12,959.90
Rate for Payer: Multiplan Commercial	$12,959.90
Rate for Payer: Multiplan Workers Comp	$12,959.90
Rate for Payer: Scott and White EPO/PPO	$5,968.38
Rate for Payer: Scott and White Medicare	$9,759.21
Rate for Payer: Superior Health Plan EPO	$9,759.21
Rate for Payer: Superior Health Plan Medicare	$9,759.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,759.21
Rate for Payer: Universal American Medicare	$9,759.21
Rate for Payer: Wellcare Medicare	$9,759.21
Rate for Payer: Wellmed Medicare	$9,759.21

OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC

Facility

$39,618.80

Service Code	MSDRG 314
Min. Negotiated Rate	$17,398.66
Max. Negotiated Rate	$39,618.80
Rate for Payer: BCBS of TX Blue Advantage	$17,398.66
Rate for Payer: BCBS of TX Blue Essentials	$20,876.37
Rate for Payer: BCBS of TX PPO	$23,196.86

OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC/MCC

Facility

$12,959.90

Service Code	MSDRG 316
Min. Negotiated Rate	$5,968.38
Max. Negotiated Rate	$12,959.90
Rate for Payer: BCBS of TX Blue Advantage	$6,461.18
Rate for Payer: BCBS of TX Blue Essentials	$7,752.66
Rate for Payer: BCBS of TX PPO	$8,614.41

OTHER CIRCULATORY SYSTEM O.R. PROCEDURES

Facility

$63,471.40

Service Code	MSDRG 264
Min. Negotiated Rate	$27,163.96
Max. Negotiated Rate	$63,471.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29,243.42
Rate for Payer: Amerigroup Medicare	$29,243.42
Rate for Payer: BCBS of TX Blue Advantage	$27,163.96
Rate for Payer: BCBS of TX Blue Essentials	$32,593.59
Rate for Payer: BCBS of TX Medicare	$29,243.42
Rate for Payer: BCBS of TX PPO	$36,216.51
Rate for Payer: Cigna Commercial	$43,026.93
Rate for Payer: Cigna Medicare	$29,243.42
Rate for Payer: Employer Direct Commercial	$29,243.42
Rate for Payer: Humana Medicare/TRICARE	$29,243.42
Rate for Payer: Molina Dual Medicare/Medicaid	$29,243.42
Rate for Payer: Molina Medicare	$29,243.42
Rate for Payer: Multiplan Auto	$63,471.40
Rate for Payer: Multiplan Commercial	$63,471.40
Rate for Payer: Multiplan Workers Comp	$63,471.40
Rate for Payer: Scott and White EPO/PPO	$29,230.25
Rate for Payer: Scott and White Medicare	$29,243.42
Rate for Payer: Superior Health Plan EPO	$29,243.42
Rate for Payer: Superior Health Plan Medicare	$29,243.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$29,243.42
Rate for Payer: Universal American Medicare	$29,243.42
Rate for Payer: Wellcare Medicare	$29,243.42
Rate for Payer: Wellmed Medicare	$29,243.42

OTHER CIRCULATORY SYSTEM PROCEDURES

Facility

$19,448.24

Service Code	APR-DRG 1802
Min. Negotiated Rate	$18,336.48
Max. Negotiated Rate	$19,448.24
Rate for Payer: Amerigroup CHIP/Medicaid	$18,336.48
Rate for Payer: Cigna Medicaid	$18,336.48
Rate for Payer: Molina CHIP/Medicaid	$18,336.48
Rate for Payer: Parkland Medicaid	$18,336.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,448.24

OTHER CIRCULATORY SYSTEM PROCEDURES

Facility

$22,688.30

Service Code	APR-DRG 1801
Min. Negotiated Rate	$21,391.32
Max. Negotiated Rate	$22,688.30
Rate for Payer: Amerigroup CHIP/Medicaid	$21,391.32
Rate for Payer: Cigna Medicaid	$21,391.32
Rate for Payer: Molina CHIP/Medicaid	$21,391.32
Rate for Payer: Parkland Medicaid	$21,391.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,688.30

OTHER CIRCULATORY SYSTEM PROCEDURES

Facility

$16,208.19

Service Code	APR-DRG 1803
Min. Negotiated Rate	$15,281.65
Max. Negotiated Rate	$16,208.19
Rate for Payer: Amerigroup CHIP/Medicaid	$15,281.65
Rate for Payer: Cigna Medicaid	$15,281.65
Rate for Payer: Molina CHIP/Medicaid	$15,281.65
Rate for Payer: Parkland Medicaid	$15,281.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,208.19

OTHER CIRCULATORY SYSTEM PROCEDURES

Facility

$25,043.09

Service Code	APR-DRG 1804
Min. Negotiated Rate	$23,611.50
Max. Negotiated Rate	$25,043.09
Rate for Payer: Amerigroup CHIP/Medicaid	$23,611.50
Rate for Payer: Cigna Medicaid	$23,611.50
Rate for Payer: Molina CHIP/Medicaid	$23,611.50
Rate for Payer: Parkland Medicaid	$23,611.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,043.09

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 COMPLICATIONS OF TREATMENT

Facility

$15,286.72

Service Code	APR-DRG 8134
Min. Negotiated Rate	$14,412.85
Max. Negotiated Rate	$15,286.72
Rate for Payer: Amerigroup CHIP/Medicaid	$14,412.85
Rate for Payer: Cigna Medicaid	$14,412.85
Rate for Payer: Molina CHIP/Medicaid	$14,412.85
Rate for Payer: Parkland Medicaid	$14,412.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,286.72

OTHER COMPLICATIONS OF TREATMENT

Facility

$5,802.30

Service Code	APR-DRG 8133
Min. Negotiated Rate	$5,470.61
Max. Negotiated Rate	$5,802.30
Rate for Payer: Amerigroup CHIP/Medicaid	$5,470.61
Rate for Payer: Cigna Medicaid	$5,470.61
Rate for Payer: Molina CHIP/Medicaid	$5,470.61
Rate for Payer: Parkland Medicaid	$5,470.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,802.30

OTHER COMPLICATIONS OF TREATMENT

Facility

$3,628.56

Service Code	APR-DRG 8132
Min. Negotiated Rate	$3,421.13
Max. Negotiated Rate	$3,628.56
Rate for Payer: Amerigroup CHIP/Medicaid	$3,421.13
Rate for Payer: Cigna Medicaid	$3,421.13
Rate for Payer: Molina CHIP/Medicaid	$3,421.13
Rate for Payer: Parkland Medicaid	$3,421.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,628.56

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

$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

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

$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 W CC

Facility

$17,778.30

Service Code	MSDRG 394
Min. Negotiated Rate	$8,093.46
Max. Negotiated Rate	$17,778.30
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

$17,778.30

Service Code	MSDRG 394
Min. Negotiated Rate	$8,093.46
Max. Negotiated Rate	$17,778.30
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	$17,778.30
Rate for Payer: Multiplan Commercial	$17,778.30
Rate for Payer: Multiplan Workers Comp	$17,778.30
Rate for Payer: Scott and White EPO/PPO	$8,187.38
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

$30,386.70

Service Code	MSDRG 393
Min. Negotiated Rate	$13,993.88
Max. Negotiated Rate	$30,386.70
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	$30,386.70
Rate for Payer: Multiplan Commercial	$30,386.70
Rate for Payer: Multiplan Workers Comp	$30,386.70
Rate for Payer: Scott and White EPO/PPO	$13,993.88
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

Know your out-of-pocket cost for care.

All Charges