White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER DISORDERS OF NERVOUS SYSTEM W CC

Facility

$18,891.70

Service Code	MSDRG 092
Min. Negotiated Rate	$8,112.38
Max. Negotiated Rate	$18,891.70
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

$18,891.70

Service Code	MSDRG 092
Min. Negotiated Rate	$8,112.38
Max. Negotiated Rate	$18,891.70
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	$18,891.70
Rate for Payer: Multiplan Commercial	$18,891.70
Rate for Payer: Multiplan Workers Comp	$18,891.70
Rate for Payer: Scott and White EPO/PPO	$8,700.12
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

$32,820.60

Service Code	MSDRG 091
Min. Negotiated Rate	$13,863.20
Max. Negotiated Rate	$32,820.60
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	$32,820.60
Rate for Payer: Multiplan Commercial	$32,820.60
Rate for Payer: Multiplan Workers Comp	$32,820.60
Rate for Payer: Scott and White EPO/PPO	$15,114.75
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

$14,531.20

Service Code	MSDRG 093
Min. Negotiated Rate	$6,345.08
Max. Negotiated Rate	$14,531.20
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	$14,531.20
Rate for Payer: Multiplan Commercial	$14,531.20
Rate for Payer: Multiplan Workers Comp	$14,531.20
Rate for Payer: Scott and White EPO/PPO	$6,692.00
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

$32,820.60

Service Code	MSDRG 091
Min. Negotiated Rate	$13,863.20
Max. Negotiated Rate	$32,820.60
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

$14,531.20

Service Code	MSDRG 093
Min. Negotiated Rate	$6,345.08
Max. Negotiated Rate	$14,531.20
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

Facility

$26,613.30

Service Code	MSDRG 124
Min. Negotiated Rate	$11,449.18
Max. Negotiated Rate	$26,613.30
Rate for Payer: Multiplan Auto	$26,613.30
Rate for Payer: Multiplan Commercial	$26,613.30
Rate for Payer: Multiplan Workers Comp	$26,613.30
Rate for Payer: Scott and White EPO/PPO	$12,256.12

OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT

Facility

$26,613.30

Service Code	MSDRG 124
Min. Negotiated Rate	$11,449.18
Max. Negotiated Rate	$26,613.30
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: 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

$16,379.90

Service Code	MSDRG 125
Min. Negotiated Rate	$6,967.72
Max. Negotiated Rate	$16,379.90
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	$16,379.90
Rate for Payer: Multiplan Commercial	$16,379.90
Rate for Payer: Multiplan Workers Comp	$16,379.90
Rate for Payer: Scott and White EPO/PPO	$7,543.38
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

$26,613.30

Service Code	MSDRG 124
Min. Negotiated Rate	$11,449.18
Max. Negotiated Rate	$26,613.30
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

$16,379.90

Service Code	MSDRG 125
Min. Negotiated Rate	$6,967.72
Max. Negotiated Rate	$16,379.90
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

$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

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

$4,498.36

Service Code	APR-DRG 2833
Min. Negotiated Rate	$4,241.21
Max. Negotiated Rate	$4,498.36
Rate for Payer: Amerigroup CHIP/Medicaid	$4,241.21
Rate for Payer: Cigna Medicaid	$4,241.21
Rate for Payer: Molina CHIP/Medicaid	$4,241.21
Rate for Payer: Parkland Medicaid	$4,241.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,498.36

OTHER DISORDERS OF THE LIVER

Facility

$2,363.47

Service Code	APR-DRG 2831
Min. Negotiated Rate	$2,228.36
Max. Negotiated Rate	$2,363.47
Rate for Payer: Amerigroup CHIP/Medicaid	$2,228.36
Rate for Payer: Cigna Medicaid	$2,228.36
Rate for Payer: Molina CHIP/Medicaid	$2,228.36
Rate for Payer: Parkland Medicaid	$2,228.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,363.47

OTHER DRUG ABUSE AND DEPENDENCE

Facility

$4,350.12

Service Code	APR-DRG 7763
Min. Negotiated Rate	$4,101.45
Max. Negotiated Rate	$4,350.12
Rate for Payer: Amerigroup CHIP/Medicaid	$4,101.45
Rate for Payer: Cigna Medicaid	$4,101.45
Rate for Payer: Molina CHIP/Medicaid	$4,101.45
Rate for Payer: Parkland Medicaid	$4,101.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,350.12

OTHER DRUG ABUSE AND DEPENDENCE

Facility

$2,300.10

Service Code	APR-DRG 7762
Min. Negotiated Rate	$2,168.61
Max. Negotiated Rate	$2,300.10
Rate for Payer: Amerigroup CHIP/Medicaid	$2,168.61
Rate for Payer: Cigna Medicaid	$2,168.61
Rate for Payer: Molina CHIP/Medicaid	$2,168.61
Rate for Payer: Parkland Medicaid	$2,168.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,300.10

OTHER DRUG ABUSE AND DEPENDENCE

Facility

$1,512.91

Service Code	APR-DRG 7761
Min. Negotiated Rate	$1,426.42
Max. Negotiated Rate	$1,512.91
Rate for Payer: Amerigroup CHIP/Medicaid	$1,426.42
Rate for Payer: Cigna Medicaid	$1,426.42
Rate for Payer: Molina CHIP/Medicaid	$1,426.42
Rate for Payer: Parkland Medicaid	$1,426.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,512.91

OTHER DRUG ABUSE AND DEPENDENCE

Facility

$8,449.03

Service Code	APR-DRG 7764
Min. Negotiated Rate	$7,966.04
Max. Negotiated Rate	$8,449.03
Rate for Payer: Amerigroup CHIP/Medicaid	$7,966.04
Rate for Payer: Cigna Medicaid	$7,966.04
Rate for Payer: Molina CHIP/Medicaid	$7,966.04
Rate for Payer: Parkland Medicaid	$7,966.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,449.03

OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC

Facility

$17,466.70

Service Code	MSDRG 155
Min. Negotiated Rate	$7,596.38
Max. Negotiated Rate	$17,466.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,477.13
Rate for Payer: Amerigroup Medicare	$11,477.13
Rate for Payer: BCBS of TX Medicare	$11,477.13
Rate for Payer: Cigna Commercial	$11,804.52
Rate for Payer: Cigna Medicare	$11,477.13
Rate for Payer: Employer Direct Commercial	$11,477.13
Rate for Payer: Humana Medicare/TRICARE	$11,477.13
Rate for Payer: Molina Dual Medicare/Medicaid	$11,477.13
Rate for Payer: Molina Medicare	$11,477.13
Rate for Payer: Multiplan Auto	$17,466.70
Rate for Payer: Multiplan Commercial	$17,466.70
Rate for Payer: Multiplan Workers Comp	$17,466.70
Rate for Payer: Scott and White EPO/PPO	$8,043.88
Rate for Payer: Scott and White Medicare	$11,477.13
Rate for Payer: Superior Health Plan EPO	$11,477.13
Rate for Payer: Superior Health Plan Medicare	$11,477.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,477.13
Rate for Payer: Universal American Medicare	$11,477.13
Rate for Payer: Wellcare Medicare	$11,477.13
Rate for Payer: Wellmed Medicare	$11,477.13

OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC

Facility

$28,555.10

Service Code	MSDRG 154
Min. Negotiated Rate	$12,439.90
Max. Negotiated Rate	$28,555.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,219.01
Rate for Payer: Amerigroup Medicare	$16,219.01
Rate for Payer: BCBS of TX Medicare	$16,219.01
Rate for Payer: Cigna Commercial	$20,137.88
Rate for Payer: Cigna Medicare	$16,219.01
Rate for Payer: Employer Direct Commercial	$16,219.01
Rate for Payer: Humana Medicare/TRICARE	$16,219.01
Rate for Payer: Molina Dual Medicare/Medicaid	$16,219.01
Rate for Payer: Molina Medicare	$16,219.01
Rate for Payer: Multiplan Auto	$28,555.10
Rate for Payer: Multiplan Commercial	$28,555.10
Rate for Payer: Multiplan Workers Comp	$28,555.10
Rate for Payer: Scott and White EPO/PPO	$13,150.38
Rate for Payer: Scott and White Medicare	$16,219.01
Rate for Payer: Superior Health Plan EPO	$16,219.01
Rate for Payer: Superior Health Plan Medicare	$16,219.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,219.01
Rate for Payer: Universal American Medicare	$16,219.01
Rate for Payer: Wellcare Medicare	$16,219.01
Rate for Payer: Wellmed Medicare	$16,219.01

OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC

Facility

$12,952.30

Service Code	MSDRG 156
Min. Negotiated Rate	$5,675.14
Max. Negotiated Rate	$12,952.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,825.18
Rate for Payer: Amerigroup Medicare	$9,825.18
Rate for Payer: BCBS of TX Medicare	$9,825.18
Rate for Payer: Cigna Commercial	$8,901.37
Rate for Payer: Cigna Medicare	$9,825.18
Rate for Payer: Employer Direct Commercial	$9,825.18
Rate for Payer: Humana Medicare/TRICARE	$9,825.18
Rate for Payer: Molina Dual Medicare/Medicaid	$9,825.18
Rate for Payer: Molina Medicare	$9,825.18
Rate for Payer: Multiplan Auto	$12,952.30
Rate for Payer: Multiplan Commercial	$12,952.30
Rate for Payer: Multiplan Workers Comp	$12,952.30
Rate for Payer: Scott and White EPO/PPO	$5,964.88
Rate for Payer: Scott and White Medicare	$9,825.18
Rate for Payer: Superior Health Plan EPO	$9,825.18
Rate for Payer: Superior Health Plan Medicare	$9,825.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,825.18
Rate for Payer: Universal American Medicare	$9,825.18
Rate for Payer: Wellcare Medicare	$9,825.18
Rate for Payer: Wellmed Medicare	$9,825.18

OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC

Facility

$34,376.70

Service Code	MSDRG 144
Min. Negotiated Rate	$15,831.38
Max. Negotiated Rate	$34,376.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,460.55
Rate for Payer: Amerigroup Medicare	$17,460.55
Rate for Payer: BCBS of TX Medicare	$17,460.55
Rate for Payer: Cigna Commercial	$22,319.75
Rate for Payer: Cigna Medicare	$17,460.55
Rate for Payer: Employer Direct Commercial	$17,460.55
Rate for Payer: Humana Medicare/TRICARE	$17,460.55
Rate for Payer: Molina Dual Medicare/Medicaid	$17,460.55
Rate for Payer: Molina Medicare	$17,460.55
Rate for Payer: Multiplan Auto	$34,376.70
Rate for Payer: Multiplan Commercial	$34,376.70
Rate for Payer: Multiplan Workers Comp	$34,376.70
Rate for Payer: Scott and White EPO/PPO	$15,831.38
Rate for Payer: Scott and White Medicare	$17,460.55
Rate for Payer: Superior Health Plan EPO	$17,460.55
Rate for Payer: Superior Health Plan Medicare	$17,460.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,460.55
Rate for Payer: Universal American Medicare	$17,460.55
Rate for Payer: Wellcare Medicare	$17,460.55
Rate for Payer: Wellmed Medicare	$17,460.55

OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC

Facility

$60,279.40

Service Code	MSDRG 143
Min. Negotiated Rate	$27,760.25
Max. Negotiated Rate	$60,279.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$32,219.02
Rate for Payer: Amerigroup Medicare	$32,219.02
Rate for Payer: BCBS of TX Medicare	$32,219.02
Rate for Payer: Cigna Commercial	$48,256.21
Rate for Payer: Cigna Medicare	$32,219.02
Rate for Payer: Employer Direct Commercial	$32,219.02
Rate for Payer: Humana Medicare/TRICARE	$32,219.02
Rate for Payer: Molina Dual Medicare/Medicaid	$32,219.02
Rate for Payer: Molina Medicare	$32,219.02
Rate for Payer: Multiplan Auto	$60,279.40
Rate for Payer: Multiplan Commercial	$60,279.40
Rate for Payer: Multiplan Workers Comp	$60,279.40
Rate for Payer: Scott and White EPO/PPO	$27,760.25
Rate for Payer: Scott and White Medicare	$32,219.02
Rate for Payer: Superior Health Plan EPO	$32,219.02
Rate for Payer: Superior Health Plan Medicare	$32,219.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$32,219.02
Rate for Payer: Universal American Medicare	$32,219.02
Rate for Payer: Wellcare Medicare	$32,219.02
Rate for Payer: Wellmed Medicare	$32,219.02

OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC

Facility

$22,948.20

Service Code	MSDRG 145
Min. Negotiated Rate	$10,568.25
Max. Negotiated Rate	$22,948.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,571.78
Rate for Payer: Amerigroup Medicare	$13,571.78
Rate for Payer: BCBS of TX Medicare	$13,571.78
Rate for Payer: Cigna Commercial	$15,485.62
Rate for Payer: Cigna Medicare	$13,571.78
Rate for Payer: Employer Direct Commercial	$13,571.78
Rate for Payer: Humana Medicare/TRICARE	$13,571.78
Rate for Payer: Molina Dual Medicare/Medicaid	$13,571.78
Rate for Payer: Molina Medicare	$13,571.78
Rate for Payer: Multiplan Auto	$22,948.20
Rate for Payer: Multiplan Commercial	$22,948.20
Rate for Payer: Multiplan Workers Comp	$22,948.20
Rate for Payer: Scott and White EPO/PPO	$10,568.25
Rate for Payer: Scott and White Medicare	$13,571.78
Rate for Payer: Superior Health Plan EPO	$13,571.78
Rate for Payer: Superior Health Plan Medicare	$13,571.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,571.78
Rate for Payer: Universal American Medicare	$13,571.78
Rate for Payer: Wellcare Medicare	$13,571.78
Rate for Payer: Wellmed Medicare	$13,571.78

Know your out-of-pocket cost for care.

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