White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC

Facility

$12,331.00

Service Code	MSDRG 395
Min. Negotiated Rate	$5,678.75
Max. Negotiated Rate	$12,331.00
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	$12,331.00
Rate for Payer: Multiplan Commercial	$12,331.00
Rate for Payer: Multiplan Workers Comp	$12,331.00
Rate for Payer: Scott and White EPO/PPO	$5,678.75
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

$30,386.70

Service Code	MSDRG 393
Min. Negotiated Rate	$13,993.88
Max. Negotiated Rate	$30,386.70
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

$12,331.00

Service Code	MSDRG 395
Min. Negotiated Rate	$5,678.75
Max. Negotiated Rate	$12,331.00
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

$44,184.50

Service Code	MSDRG 357
Min. Negotiated Rate	$18,375.62
Max. Negotiated Rate	$44,184.50
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

$44,184.50

Service Code	MSDRG 357
Min. Negotiated Rate	$18,375.62
Max. Negotiated Rate	$44,184.50
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	$44,184.50
Rate for Payer: Multiplan Commercial	$44,184.50
Rate for Payer: Multiplan Workers Comp	$44,184.50
Rate for Payer: Scott and White EPO/PPO	$20,348.12
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

$83,463.20

Service Code	MSDRG 356
Min. Negotiated Rate	$34,191.02
Max. Negotiated Rate	$83,463.20
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	$83,463.20
Rate for Payer: Multiplan Commercial	$83,463.20
Rate for Payer: Multiplan Workers Comp	$83,463.20
Rate for Payer: Scott and White EPO/PPO	$38,437.00
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

$26,560.10

Service Code	MSDRG 358
Min. Negotiated Rate	$11,595.38
Max. Negotiated Rate	$26,560.10
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	$26,560.10
Rate for Payer: Multiplan Commercial	$26,560.10
Rate for Payer: Multiplan Workers Comp	$26,560.10
Rate for Payer: Scott and White EPO/PPO	$12,231.62
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

$83,463.20

Service Code	MSDRG 356
Min. Negotiated Rate	$34,191.02
Max. Negotiated Rate	$83,463.20
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

$26,560.10

Service Code	MSDRG 358
Min. Negotiated Rate	$11,595.38
Max. Negotiated Rate	$26,560.10
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

$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

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

$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

$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 W CC

Facility

$19,437.00

Service Code	MSDRG 092
Min. Negotiated Rate	$8,112.38
Max. Negotiated Rate	$19,437.00
Rate for Payer: BCBS of TX Blue Advantage	$8,112.38
Rate for Payer: BCBS of TX Blue Essentials	$9,733.91
Rate for Payer: BCBS of TX PPO	$10,815.88

OTHER DISORDERS OF NERVOUS SYSTEM WITH CC

Facility

$19,437.00

Service Code	MSDRG 092
Min. Negotiated Rate	$8,112.38
Max. Negotiated Rate	$19,437.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,257.67
Rate for Payer: Amerigroup Medicare	$12,257.67
Rate for Payer: BCBS of TX Medicare	$12,257.67
Rate for Payer: Cigna Commercial	$13,176.24
Rate for Payer: Cigna Medicare	$12,257.67
Rate for Payer: Employer Direct Commercial	$12,257.67
Rate for Payer: Humana Medicare/TRICARE	$12,257.67
Rate for Payer: Molina Dual Medicare/Medicaid	$12,257.67
Rate for Payer: Molina Medicare	$12,257.67
Rate for Payer: Multiplan Auto	$19,437.00
Rate for Payer: Multiplan Commercial	$19,437.00
Rate for Payer: Multiplan Workers Comp	$19,437.00
Rate for Payer: Scott and White EPO/PPO	$8,951.25
Rate for Payer: Scott and White Medicare	$12,257.67
Rate for Payer: Superior Health Plan EPO	$12,257.67
Rate for Payer: Superior Health Plan Medicare	$12,257.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,257.67
Rate for Payer: Universal American Medicare	$12,257.67
Rate for Payer: Wellcare Medicare	$12,257.67
Rate for Payer: Wellmed Medicare	$12,257.67

OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC

Facility

$33,367.80

Service Code	MSDRG 091
Min. Negotiated Rate	$13,863.20
Max. Negotiated Rate	$33,367.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,631.30
Rate for Payer: Amerigroup Medicare	$17,631.30
Rate for Payer: BCBS of TX Medicare	$17,631.30
Rate for Payer: Cigna Commercial	$22,619.86
Rate for Payer: Cigna Medicare	$17,631.30
Rate for Payer: Employer Direct Commercial	$17,631.30
Rate for Payer: Humana Medicare/TRICARE	$17,631.30
Rate for Payer: Molina Dual Medicare/Medicaid	$17,631.30
Rate for Payer: Molina Medicare	$17,631.30
Rate for Payer: Multiplan Auto	$33,367.80
Rate for Payer: Multiplan Commercial	$33,367.80
Rate for Payer: Multiplan Workers Comp	$33,367.80
Rate for Payer: Scott and White EPO/PPO	$15,366.75
Rate for Payer: Scott and White Medicare	$17,631.30
Rate for Payer: Superior Health Plan EPO	$17,631.30
Rate for Payer: Superior Health Plan Medicare	$17,631.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,631.30
Rate for Payer: Universal American Medicare	$17,631.30
Rate for Payer: Wellcare Medicare	$17,631.30
Rate for Payer: Wellmed Medicare	$17,631.30

OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC

Facility

$15,129.70

Service Code	MSDRG 093
Min. Negotiated Rate	$6,345.08
Max. Negotiated Rate	$15,129.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,596.18
Rate for Payer: Amerigroup Medicare	$10,596.18
Rate for Payer: BCBS of TX Medicare	$10,596.18
Rate for Payer: Cigna Commercial	$10,256.34
Rate for Payer: Cigna Medicare	$10,596.18
Rate for Payer: Employer Direct Commercial	$10,596.18
Rate for Payer: Humana Medicare/TRICARE	$10,596.18
Rate for Payer: Molina Dual Medicare/Medicaid	$10,596.18
Rate for Payer: Molina Medicare	$10,596.18
Rate for Payer: Multiplan Auto	$15,129.70
Rate for Payer: Multiplan Commercial	$15,129.70
Rate for Payer: Multiplan Workers Comp	$15,129.70
Rate for Payer: Scott and White EPO/PPO	$6,967.62
Rate for Payer: Scott and White Medicare	$10,596.18
Rate for Payer: Superior Health Plan EPO	$10,596.18
Rate for Payer: Superior Health Plan Medicare	$10,596.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,596.18
Rate for Payer: Universal American Medicare	$10,596.18
Rate for Payer: Wellcare Medicare	$10,596.18
Rate for Payer: Wellmed Medicare	$10,596.18

OTHER DISORDERS OF NERVOUS SYSTEM W MCC

Facility

$33,367.80

Service Code	MSDRG 091
Min. Negotiated Rate	$13,863.20
Max. Negotiated Rate	$33,367.80
Rate for Payer: BCBS of TX Blue Advantage	$13,863.20
Rate for Payer: BCBS of TX Blue Essentials	$16,634.23
Rate for Payer: BCBS of TX PPO	$18,483.19

OTHER DISORDERS OF NERVOUS SYSTEM W/O CC/MCC

Facility

$15,129.70

Service Code	MSDRG 093
Min. Negotiated Rate	$6,345.08
Max. Negotiated Rate	$15,129.70
Rate for Payer: BCBS of TX Blue Advantage	$6,345.08
Rate for Payer: BCBS of TX Blue Essentials	$7,613.36
Rate for Payer: BCBS of TX PPO	$8,459.61

OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT

Facility

$25,138.90

Service Code	MSDRG 124
Min. Negotiated Rate	$11,449.18
Max. Negotiated Rate	$25,138.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,457.11
Rate for Payer: Amerigroup Medicare	$14,457.11
Rate for Payer: BCBS of TX Medicare	$14,457.11
Rate for Payer: Cigna Commercial	$17,041.53
Rate for Payer: Cigna Medicare	$14,457.11
Rate for Payer: Employer Direct Commercial	$14,457.11
Rate for Payer: Humana Medicare/TRICARE	$14,457.11
Rate for Payer: Molina Dual Medicare/Medicaid	$14,457.11
Rate for Payer: Molina Medicare	$14,457.11
Rate for Payer: Multiplan Auto	$25,138.90
Rate for Payer: Multiplan Commercial	$25,138.90
Rate for Payer: Multiplan Workers Comp	$25,138.90
Rate for Payer: Scott and White EPO/PPO	$11,577.12
Rate for Payer: Scott and White Medicare	$14,457.11
Rate for Payer: Superior Health Plan EPO	$14,457.11
Rate for Payer: Superior Health Plan Medicare	$14,457.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,457.11
Rate for Payer: Universal American Medicare	$14,457.11
Rate for Payer: Wellcare Medicare	$14,457.11
Rate for Payer: Wellmed Medicare	$14,457.11

OTHER DISORDERS OF THE EYE WITHOUT MCC

Facility

$14,588.20

Service Code	MSDRG 125
Min. Negotiated Rate	$6,718.25
Max. Negotiated Rate	$14,588.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,387.31
Rate for Payer: Amerigroup Medicare	$10,387.31
Rate for Payer: BCBS of TX Medicare	$10,387.31
Rate for Payer: Cigna Commercial	$9,889.26
Rate for Payer: Cigna Medicare	$10,387.31
Rate for Payer: Employer Direct Commercial	$10,387.31
Rate for Payer: Humana Medicare/TRICARE	$10,387.31
Rate for Payer: Molina Dual Medicare/Medicaid	$10,387.31
Rate for Payer: Molina Medicare	$10,387.31
Rate for Payer: Multiplan Auto	$14,588.20
Rate for Payer: Multiplan Commercial	$14,588.20
Rate for Payer: Multiplan Workers Comp	$14,588.20
Rate for Payer: Scott and White EPO/PPO	$6,718.25
Rate for Payer: Scott and White Medicare	$10,387.31
Rate for Payer: Superior Health Plan EPO	$10,387.31
Rate for Payer: Superior Health Plan Medicare	$10,387.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,387.31
Rate for Payer: Universal American Medicare	$10,387.31
Rate for Payer: Wellcare Medicare	$10,387.31
Rate for Payer: Wellmed Medicare	$10,387.31

OTHER DISORDERS OF THE EYE W MCC

Facility

$25,138.90

Service Code	MSDRG 124
Min. Negotiated Rate	$11,449.18
Max. Negotiated Rate	$25,138.90
Rate for Payer: BCBS of TX Blue Advantage	$11,449.18
Rate for Payer: BCBS of TX Blue Essentials	$13,737.68
Rate for Payer: BCBS of TX PPO	$15,264.69

OTHER DISORDERS OF THE EYE W/O MCC

Facility

$14,588.20

Service Code	MSDRG 125
Min. Negotiated Rate	$6,718.25
Max. Negotiated Rate	$14,588.20
Rate for Payer: BCBS of TX Blue Advantage	$6,967.72
Rate for Payer: BCBS of TX Blue Essentials	$8,360.45
Rate for Payer: BCBS of TX PPO	$9,289.75

OTHER DISORDERS OF THE LIVER

Facility

$3,360.00

Service Code	APR-DRG 2832
Min. Negotiated Rate	$3,167.93
Max. Negotiated Rate	$3,360.00
Rate for Payer: Amerigroup CHIP/Medicaid	$3,167.93
Rate for Payer: Cigna Medicaid	$3,167.93
Rate for Payer: Molina CHIP/Medicaid	$3,167.93
Rate for Payer: Parkland Medicaid	$3,167.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,360.00

OTHER DISORDERS OF THE LIVER

Facility

$18,437.38

Service Code	APR-DRG 2834
Min. Negotiated Rate	$17,383.40
Max. Negotiated Rate	$18,437.38
Rate for Payer: Amerigroup CHIP/Medicaid	$17,383.40
Rate for Payer: Cigna Medicaid	$17,383.40
Rate for Payer: Molina CHIP/Medicaid	$17,383.40
Rate for Payer: Parkland Medicaid	$17,383.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,437.38

Know your out-of-pocket cost for care.

All Charges