White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$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

$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 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

$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

$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 EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC

Facility

$17,413.50

Service Code	MSDRG 155
Min. Negotiated Rate	$7,596.38
Max. Negotiated Rate	$17,413.50
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	$17,413.50
Rate for Payer: Multiplan Commercial	$17,413.50
Rate for Payer: Multiplan Workers Comp	$17,413.50
Rate for Payer: Scott and White EPO/PPO	$8,019.38
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

$29,706.50

Service Code	MSDRG 154
Min. Negotiated Rate	$12,439.90
Max. Negotiated Rate	$29,706.50
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	$29,706.50
Rate for Payer: Multiplan Commercial	$29,706.50
Rate for Payer: Multiplan Workers Comp	$29,706.50
Rate for Payer: Scott and White EPO/PPO	$13,680.62
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

$13,130.90

Service Code	MSDRG 156
Min. Negotiated Rate	$5,675.14
Max. Negotiated Rate	$13,130.90
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	$13,130.90
Rate for Payer: Multiplan Commercial	$13,130.90
Rate for Payer: Multiplan Workers Comp	$13,130.90
Rate for Payer: Scott and White EPO/PPO	$6,047.12
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

$32,925.10

Service Code	MSDRG 144
Min. Negotiated Rate	$15,162.88
Max. Negotiated Rate	$32,925.10
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	$32,925.10
Rate for Payer: Multiplan Commercial	$32,925.10
Rate for Payer: Multiplan Workers Comp	$32,925.10
Rate for Payer: Scott and White EPO/PPO	$15,162.88
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

$71,185.40

Service Code	MSDRG 143
Min. Negotiated Rate	$32,219.02
Max. Negotiated Rate	$71,185.40
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	$71,185.40
Rate for Payer: Multiplan Commercial	$71,185.40
Rate for Payer: Multiplan Workers Comp	$71,185.40
Rate for Payer: Scott and White EPO/PPO	$32,782.75
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

$22,843.70

Service Code	MSDRG 145
Min. Negotiated Rate	$10,520.12
Max. Negotiated Rate	$22,843.70
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	$22,843.70
Rate for Payer: Multiplan Commercial	$22,843.70
Rate for Payer: Multiplan Workers Comp	$22,843.70
Rate for Payer: Scott and White EPO/PPO	$10,520.12
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

OTHER EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility

$5,353.07

Service Code	APR-DRG 0981
Min. Negotiated Rate	$5,047.06
Max. Negotiated Rate	$5,353.07
Rate for Payer: Amerigroup CHIP/Medicaid	$5,047.06
Rate for Payer: Cigna Medicaid	$5,047.06
Rate for Payer: Molina CHIP/Medicaid	$5,047.06
Rate for Payer: Parkland Medicaid	$5,047.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,353.07

OTHER EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility

$13,060.55

Service Code	APR-DRG 0983
Min. Negotiated Rate	$12,313.94
Max. Negotiated Rate	$13,060.55
Rate for Payer: Amerigroup CHIP/Medicaid	$12,313.94
Rate for Payer: Cigna Medicaid	$12,313.94
Rate for Payer: Molina CHIP/Medicaid	$12,313.94
Rate for Payer: Parkland Medicaid	$12,313.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,060.55

OTHER EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility

$24,281.54

Service Code	APR-DRG 0984
Min. Negotiated Rate	$22,893.49
Max. Negotiated Rate	$24,281.54
Rate for Payer: Amerigroup CHIP/Medicaid	$22,893.49
Rate for Payer: Cigna Medicaid	$22,893.49
Rate for Payer: Molina CHIP/Medicaid	$22,893.49
Rate for Payer: Parkland Medicaid	$22,893.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,281.54

OTHER EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility

$7,555.10

Service Code	APR-DRG 0982
Min. Negotiated Rate	$7,123.21
Max. Negotiated Rate	$7,555.10
Rate for Payer: Amerigroup CHIP/Medicaid	$7,123.21
Rate for Payer: Cigna Medicaid	$7,123.21
Rate for Payer: Molina CHIP/Medicaid	$7,123.21
Rate for Payer: Parkland Medicaid	$7,123.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,555.10

OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES

Facility

$7,739.92

Service Code	APR-DRG 1153
Min. Negotiated Rate	$7,297.47
Max. Negotiated Rate	$7,739.92
Rate for Payer: Amerigroup CHIP/Medicaid	$7,297.47
Rate for Payer: Cigna Medicaid	$7,297.47
Rate for Payer: Molina CHIP/Medicaid	$7,297.47
Rate for Payer: Parkland Medicaid	$7,297.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,739.92

OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES

Facility

$14,228.32

Service Code	APR-DRG 1154
Min. Negotiated Rate	$13,414.96
Max. Negotiated Rate	$14,228.32
Rate for Payer: Amerigroup CHIP/Medicaid	$13,414.96
Rate for Payer: Cigna Medicaid	$13,414.96
Rate for Payer: Molina CHIP/Medicaid	$13,414.96
Rate for Payer: Parkland Medicaid	$13,414.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,228.32

OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES

Facility

$3,969.91

Service Code	APR-DRG 1152
Min. Negotiated Rate	$3,742.97
Max. Negotiated Rate	$3,969.91
Rate for Payer: Amerigroup CHIP/Medicaid	$3,742.97
Rate for Payer: Cigna Medicaid	$3,742.97
Rate for Payer: Molina CHIP/Medicaid	$3,742.97
Rate for Payer: Parkland Medicaid	$3,742.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,969.91

OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES

Facility

$2,221.27

Service Code	APR-DRG 1151
Min. Negotiated Rate	$2,094.29
Max. Negotiated Rate	$2,221.27
Rate for Payer: Amerigroup CHIP/Medicaid	$2,094.29
Rate for Payer: Cigna Medicaid	$2,094.29
Rate for Payer: Molina CHIP/Medicaid	$2,094.29
Rate for Payer: Parkland Medicaid	$2,094.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,221.27

OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W CC

Facility

$17,413.50

Service Code	MSDRG 155
Min. Negotiated Rate	$7,596.38
Max. Negotiated Rate	$17,413.50
Rate for Payer: BCBS of TX Blue Advantage	$7,596.38
Rate for Payer: BCBS of TX Blue Essentials	$9,114.77
Rate for Payer: BCBS of TX PPO	$10,127.92

OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W MCC

Facility

$29,706.50

Service Code	MSDRG 154
Min. Negotiated Rate	$12,439.90
Max. Negotiated Rate	$29,706.50
Rate for Payer: BCBS of TX Blue Advantage	$12,439.90
Rate for Payer: BCBS of TX Blue Essentials	$14,926.43
Rate for Payer: BCBS of TX PPO	$16,585.57

OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W/O CC/MCC

Facility

$13,130.90

Service Code	MSDRG 156
Min. Negotiated Rate	$5,675.14
Max. Negotiated Rate	$13,130.90
Rate for Payer: BCBS of TX Blue Advantage	$5,675.14
Rate for Payer: BCBS of TX Blue Essentials	$6,809.51
Rate for Payer: BCBS of TX PPO	$7,566.41

OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W CC/MCC

Facility

$24,062.55

Service Code	MSDRG 133
Min. Negotiated Rate	$18,047.96
Max. Negotiated Rate	$24,062.55
Rate for Payer: BCBS of TX Blue Advantage	$18,047.96
Rate for Payer: BCBS of TX Blue Essentials	$21,655.45
Rate for Payer: BCBS of TX PPO	$24,062.55

OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC

Facility

$13,744.29

Service Code	MSDRG 134
Min. Negotiated Rate	$10,308.82
Max. Negotiated Rate	$13,744.29
Rate for Payer: BCBS of TX Blue Advantage	$10,308.82
Rate for Payer: BCBS of TX Blue Essentials	$12,369.39
Rate for Payer: BCBS of TX PPO	$13,744.29

Know your out-of-pocket cost for care.

All Charges