White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC

Facility

$19,229.90

Service Code	MSDRG 699
Min. Negotiated Rate	$8,839.94
Max. Negotiated Rate	$19,229.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,199.04
Rate for Payer: Amerigroup Medicare	$12,199.04
Rate for Payer: BCBS of TX Medicare	$12,199.04
Rate for Payer: Cigna Commercial	$13,073.20
Rate for Payer: Cigna Medicare	$12,199.04
Rate for Payer: Employer Direct Commercial	$12,199.04
Rate for Payer: Humana Medicare/TRICARE	$12,199.04
Rate for Payer: Molina Dual Medicare/Medicaid	$12,199.04
Rate for Payer: Molina Medicare	$12,199.04
Rate for Payer: Multiplan Auto	$19,229.90
Rate for Payer: Multiplan Commercial	$19,229.90
Rate for Payer: Multiplan Workers Comp	$19,229.90
Rate for Payer: Scott and White EPO/PPO	$8,855.88
Rate for Payer: Scott and White Medicare	$12,199.04
Rate for Payer: Superior Health Plan EPO	$12,199.04
Rate for Payer: Superior Health Plan Medicare	$12,199.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,199.04
Rate for Payer: Universal American Medicare	$12,199.04
Rate for Payer: Wellcare Medicare	$12,199.04
Rate for Payer: Wellmed Medicare	$12,199.04

OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC

Facility

$30,447.50

Service Code	MSDRG 698
Min. Negotiated Rate	$13,889.86
Max. Negotiated Rate	$30,447.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,885.22
Rate for Payer: Amerigroup Medicare	$16,885.22
Rate for Payer: BCBS of TX Medicare	$16,885.22
Rate for Payer: Cigna Commercial	$21,308.67
Rate for Payer: Cigna Medicare	$16,885.22
Rate for Payer: Employer Direct Commercial	$16,885.22
Rate for Payer: Humana Medicare/TRICARE	$16,885.22
Rate for Payer: Molina Dual Medicare/Medicaid	$16,885.22
Rate for Payer: Molina Medicare	$16,885.22
Rate for Payer: Multiplan Auto	$30,447.50
Rate for Payer: Multiplan Commercial	$30,447.50
Rate for Payer: Multiplan Workers Comp	$30,447.50
Rate for Payer: Scott and White EPO/PPO	$14,021.88
Rate for Payer: Scott and White Medicare	$16,885.22
Rate for Payer: Superior Health Plan EPO	$16,885.22
Rate for Payer: Superior Health Plan Medicare	$16,885.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,885.22
Rate for Payer: Universal American Medicare	$16,885.22
Rate for Payer: Wellcare Medicare	$16,885.22
Rate for Payer: Wellmed Medicare	$16,885.22

OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC

Facility

$14,075.20

Service Code	MSDRG 700
Min. Negotiated Rate	$6,482.00
Max. Negotiated Rate	$14,075.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,816.37
Rate for Payer: Amerigroup Medicare	$9,816.37
Rate for Payer: BCBS of TX Medicare	$9,816.37
Rate for Payer: Cigna Commercial	$8,885.91
Rate for Payer: Cigna Medicare	$9,816.37
Rate for Payer: Employer Direct Commercial	$9,816.37
Rate for Payer: Humana Medicare/TRICARE	$9,816.37
Rate for Payer: Molina Dual Medicare/Medicaid	$9,816.37
Rate for Payer: Molina Medicare	$9,816.37
Rate for Payer: Multiplan Auto	$14,075.20
Rate for Payer: Multiplan Commercial	$14,075.20
Rate for Payer: Multiplan Workers Comp	$14,075.20
Rate for Payer: Scott and White EPO/PPO	$6,482.00
Rate for Payer: Scott and White Medicare	$9,816.37
Rate for Payer: Superior Health Plan EPO	$9,816.37
Rate for Payer: Superior Health Plan Medicare	$9,816.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,816.37
Rate for Payer: Universal American Medicare	$9,816.37
Rate for Payer: Wellcare Medicare	$9,816.37
Rate for Payer: Wellmed Medicare	$9,816.37

OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC

Facility

$45,039.50

Service Code	MSDRG 674
Min. Negotiated Rate	$19,884.06
Max. Negotiated Rate	$45,039.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,899.74
Rate for Payer: Amerigroup Medicare	$21,899.74
Rate for Payer: BCBS of TX Medicare	$21,899.74
Rate for Payer: Cigna Commercial	$30,121.17
Rate for Payer: Cigna Medicare	$21,899.74
Rate for Payer: Employer Direct Commercial	$21,899.74
Rate for Payer: Humana Medicare/TRICARE	$21,899.74
Rate for Payer: Molina Dual Medicare/Medicaid	$21,899.74
Rate for Payer: Molina Medicare	$21,899.74
Rate for Payer: Multiplan Auto	$45,039.50
Rate for Payer: Multiplan Commercial	$45,039.50
Rate for Payer: Multiplan Workers Comp	$45,039.50
Rate for Payer: Scott and White EPO/PPO	$20,741.88
Rate for Payer: Scott and White Medicare	$21,899.74
Rate for Payer: Superior Health Plan EPO	$21,899.74
Rate for Payer: Superior Health Plan Medicare	$21,899.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,899.74
Rate for Payer: Universal American Medicare	$21,899.74
Rate for Payer: Wellcare Medicare	$21,899.74
Rate for Payer: Wellmed Medicare	$21,899.74

OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC

Facility

$66,386.00

Service Code	MSDRG 673
Min. Negotiated Rate	$30,572.50
Max. Negotiated Rate	$66,386.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35,553.72
Rate for Payer: Amerigroup Medicare	$35,553.72
Rate for Payer: BCBS of TX Medicare	$35,553.72
Rate for Payer: Cigna Commercial	$54,116.61
Rate for Payer: Cigna Medicare	$35,553.72
Rate for Payer: Employer Direct Commercial	$35,553.72
Rate for Payer: Humana Medicare/TRICARE	$35,553.72
Rate for Payer: Molina Dual Medicare/Medicaid	$35,553.72
Rate for Payer: Molina Medicare	$35,553.72
Rate for Payer: Multiplan Auto	$66,386.00
Rate for Payer: Multiplan Commercial	$66,386.00
Rate for Payer: Multiplan Workers Comp	$66,386.00
Rate for Payer: Scott and White EPO/PPO	$30,572.50
Rate for Payer: Scott and White Medicare	$35,553.72
Rate for Payer: Superior Health Plan EPO	$35,553.72
Rate for Payer: Superior Health Plan Medicare	$35,553.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$35,553.72
Rate for Payer: Universal American Medicare	$35,553.72
Rate for Payer: Wellcare Medicare	$35,553.72
Rate for Payer: Wellmed Medicare	$35,553.72

OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC

Facility

$32,041.60

Service Code	MSDRG 675
Min. Negotiated Rate	$13,977.58
Max. Negotiated Rate	$32,041.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,789.94
Rate for Payer: Amerigroup Medicare	$16,789.94
Rate for Payer: BCBS of TX Medicare	$16,789.94
Rate for Payer: Cigna Commercial	$21,141.23
Rate for Payer: Cigna Medicare	$16,789.94
Rate for Payer: Employer Direct Commercial	$16,789.94
Rate for Payer: Humana Medicare/TRICARE	$16,789.94
Rate for Payer: Molina Dual Medicare/Medicaid	$16,789.94
Rate for Payer: Molina Medicare	$16,789.94
Rate for Payer: Multiplan Auto	$32,041.60
Rate for Payer: Multiplan Commercial	$32,041.60
Rate for Payer: Multiplan Workers Comp	$32,041.60
Rate for Payer: Scott and White EPO/PPO	$14,756.00
Rate for Payer: Scott and White Medicare	$16,789.94
Rate for Payer: Superior Health Plan EPO	$16,789.94
Rate for Payer: Superior Health Plan Medicare	$16,789.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,789.94
Rate for Payer: Universal American Medicare	$16,789.94
Rate for Payer: Wellcare Medicare	$16,789.94
Rate for Payer: Wellmed Medicare	$16,789.94

OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES

Facility

$4,094.39

Service Code	APR-DRG 4471
Min. Negotiated Rate	$3,860.33
Max. Negotiated Rate	$4,094.39
Rate for Payer: Amerigroup CHIP/Medicaid	$3,860.33
Rate for Payer: Cigna Medicaid	$3,860.33
Rate for Payer: Molina CHIP/Medicaid	$3,860.33
Rate for Payer: Parkland Medicaid	$3,860.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,094.39

OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES

Facility

$46,774.45

Service Code	APR-DRG 4474
Min. Negotiated Rate	$44,100.59
Max. Negotiated Rate	$46,774.45
Rate for Payer: Amerigroup CHIP/Medicaid	$44,100.59
Rate for Payer: Cigna Medicaid	$44,100.59
Rate for Payer: Molina CHIP/Medicaid	$44,100.59
Rate for Payer: Parkland Medicaid	$44,100.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,774.45

OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES

Facility

$6,463.89

Service Code	APR-DRG 4472
Min. Negotiated Rate	$6,094.38
Max. Negotiated Rate	$6,463.89
Rate for Payer: Amerigroup CHIP/Medicaid	$6,094.38
Rate for Payer: Cigna Medicaid	$6,094.38
Rate for Payer: Molina CHIP/Medicaid	$6,094.38
Rate for Payer: Parkland Medicaid	$6,094.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,463.89

OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES

Facility

$10,441.35

Service Code	APR-DRG 4473
Min. Negotiated Rate	$9,844.47
Max. Negotiated Rate	$10,441.35
Rate for Payer: Amerigroup CHIP/Medicaid	$9,844.47
Rate for Payer: Cigna Medicaid	$9,844.47
Rate for Payer: Molina CHIP/Medicaid	$9,844.47
Rate for Payer: Parkland Medicaid	$9,844.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,441.35

OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC

Facility

$19,229.90

Service Code	MSDRG 699
Min. Negotiated Rate	$8,839.94
Max. Negotiated Rate	$19,229.90
Rate for Payer: BCBS of TX Blue Advantage	$8,839.94
Rate for Payer: BCBS of TX Blue Essentials	$10,606.90
Rate for Payer: BCBS of TX PPO	$11,785.90

OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC

Facility

$30,447.50

Service Code	MSDRG 698
Min. Negotiated Rate	$13,889.86
Max. Negotiated Rate	$30,447.50
Rate for Payer: BCBS of TX Blue Advantage	$13,889.86
Rate for Payer: BCBS of TX Blue Essentials	$16,666.22
Rate for Payer: BCBS of TX PPO	$18,518.74

OTHER KIDNEY & URINARY TRACT DIAGNOSES W/O CC/MCC

Facility

$14,075.20

Service Code	MSDRG 700
Min. Negotiated Rate	$6,482.00
Max. Negotiated Rate	$14,075.20
Rate for Payer: BCBS of TX Blue Advantage	$6,533.42
Rate for Payer: BCBS of TX Blue Essentials	$7,839.34
Rate for Payer: BCBS of TX PPO	$8,710.72

OTHER KIDNEY & URINARY TRACT PROCEDURES W CC

Facility

$45,039.50

Service Code	MSDRG 674
Min. Negotiated Rate	$19,884.06
Max. Negotiated Rate	$45,039.50
Rate for Payer: BCBS of TX Blue Advantage	$19,884.06
Rate for Payer: BCBS of TX Blue Essentials	$23,858.56
Rate for Payer: BCBS of TX PPO	$26,510.54

OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC

Facility

$66,386.00

Service Code	MSDRG 673
Min. Negotiated Rate	$30,572.50
Max. Negotiated Rate	$66,386.00
Rate for Payer: BCBS of TX Blue Advantage	$30,764.78
Rate for Payer: BCBS of TX Blue Essentials	$36,914.16
Rate for Payer: BCBS of TX PPO	$41,017.32

OTHER KIDNEY & URINARY TRACT PROCEDURES W/O CC/MCC

Facility

$32,041.60

Service Code	MSDRG 675
Min. Negotiated Rate	$13,977.58
Max. Negotiated Rate	$32,041.60
Rate for Payer: BCBS of TX Blue Advantage	$13,977.58
Rate for Payer: BCBS of TX Blue Essentials	$16,771.47
Rate for Payer: BCBS of TX PPO	$18,635.69

OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC

Facility

$66,192.20

Service Code	MSDRG 271
Min. Negotiated Rate	$30,046.68
Max. Negotiated Rate	$66,192.20
Rate for Payer: BCBS of TX Blue Advantage	$30,046.68
Rate for Payer: BCBS of TX Blue Essentials	$36,052.52
Rate for Payer: BCBS of TX PPO	$40,059.91

OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC

Facility

$66,192.20

Service Code	MSDRG 271
Min. Negotiated Rate	$30,046.68
Max. Negotiated Rate	$66,192.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,824.29
Rate for Payer: Amerigroup Medicare	$30,824.29
Rate for Payer: BCBS of TX Medicare	$30,824.29
Rate for Payer: Cigna Commercial	$45,805.14
Rate for Payer: Cigna Medicare	$30,824.29
Rate for Payer: Employer Direct Commercial	$30,824.29
Rate for Payer: Humana Medicare/TRICARE	$30,824.29
Rate for Payer: Molina Dual Medicare/Medicaid	$30,824.29
Rate for Payer: Molina Medicare	$30,824.29
Rate for Payer: Multiplan Auto	$66,192.20
Rate for Payer: Multiplan Commercial	$66,192.20
Rate for Payer: Multiplan Workers Comp	$66,192.20
Rate for Payer: Scott and White EPO/PPO	$30,483.25
Rate for Payer: Scott and White Medicare	$30,824.29
Rate for Payer: Superior Health Plan EPO	$30,824.29
Rate for Payer: Superior Health Plan Medicare	$30,824.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,824.29
Rate for Payer: Universal American Medicare	$30,824.29
Rate for Payer: Wellcare Medicare	$30,824.29
Rate for Payer: Wellmed Medicare	$30,824.29

OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC

Facility

$97,139.40

Service Code	MSDRG 270
Min. Negotiated Rate	$43,430.21
Max. Negotiated Rate	$97,139.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43,430.21
Rate for Payer: Amerigroup Medicare	$43,430.21
Rate for Payer: BCBS of TX Medicare	$43,430.21
Rate for Payer: Cigna Commercial	$67,958.74
Rate for Payer: Cigna Medicare	$43,430.21
Rate for Payer: Employer Direct Commercial	$43,430.21
Rate for Payer: Humana Medicare/TRICARE	$43,430.21
Rate for Payer: Molina Dual Medicare/Medicaid	$43,430.21
Rate for Payer: Molina Medicare	$43,430.21
Rate for Payer: Multiplan Auto	$97,139.40
Rate for Payer: Multiplan Commercial	$97,139.40
Rate for Payer: Multiplan Workers Comp	$97,139.40
Rate for Payer: Scott and White EPO/PPO	$44,735.25
Rate for Payer: Scott and White Medicare	$43,430.21
Rate for Payer: Superior Health Plan EPO	$43,430.21
Rate for Payer: Superior Health Plan Medicare	$43,430.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$43,430.21
Rate for Payer: Universal American Medicare	$43,430.21
Rate for Payer: Wellcare Medicare	$43,430.21
Rate for Payer: Wellmed Medicare	$43,430.21

OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC

Facility

$49,331.60

Service Code	MSDRG 272
Min. Negotiated Rate	$22,515.66
Max. Negotiated Rate	$49,331.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,471.08
Rate for Payer: Amerigroup Medicare	$23,471.08
Rate for Payer: BCBS of TX Medicare	$23,471.08
Rate for Payer: Cigna Commercial	$32,882.64
Rate for Payer: Cigna Medicare	$23,471.08
Rate for Payer: Employer Direct Commercial	$23,471.08
Rate for Payer: Humana Medicare/TRICARE	$23,471.08
Rate for Payer: Molina Dual Medicare/Medicaid	$23,471.08
Rate for Payer: Molina Medicare	$23,471.08
Rate for Payer: Multiplan Auto	$49,331.60
Rate for Payer: Multiplan Commercial	$49,331.60
Rate for Payer: Multiplan Workers Comp	$49,331.60
Rate for Payer: Scott and White EPO/PPO	$22,718.50
Rate for Payer: Scott and White Medicare	$23,471.08
Rate for Payer: Superior Health Plan EPO	$23,471.08
Rate for Payer: Superior Health Plan Medicare	$23,471.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,471.08
Rate for Payer: Universal American Medicare	$23,471.08
Rate for Payer: Wellcare Medicare	$23,471.08
Rate for Payer: Wellmed Medicare	$23,471.08

OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC

Facility

$97,139.40

Service Code	MSDRG 270
Min. Negotiated Rate	$43,430.21
Max. Negotiated Rate	$97,139.40
Rate for Payer: BCBS of TX Blue Advantage	$43,530.62
Rate for Payer: BCBS of TX Blue Essentials	$52,231.68
Rate for Payer: BCBS of TX PPO	$58,037.45

OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC

Facility

$49,331.60

Service Code	MSDRG 272
Min. Negotiated Rate	$22,515.66
Max. Negotiated Rate	$49,331.60
Rate for Payer: BCBS of TX Blue Advantage	$22,515.66
Rate for Payer: BCBS of TX Blue Essentials	$27,016.17
Rate for Payer: BCBS of TX PPO	$30,019.13

OTHER MAJOR HEAD AND NECK PROCEDURES

Facility

$24,369.05

Service Code	APR-DRG 0913
Min. Negotiated Rate	$22,975.99
Max. Negotiated Rate	$24,369.05
Rate for Payer: Amerigroup CHIP/Medicaid	$22,975.99
Rate for Payer: Cigna Medicaid	$22,975.99
Rate for Payer: Molina CHIP/Medicaid	$22,975.99
Rate for Payer: Parkland Medicaid	$22,975.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,369.05

OTHER MAJOR HEAD AND NECK PROCEDURES

Facility

$5,118.08

Service Code	APR-DRG 0911
Min. Negotiated Rate	$4,825.50
Max. Negotiated Rate	$5,118.08
Rate for Payer: Amerigroup CHIP/Medicaid	$4,825.50
Rate for Payer: Cigna Medicaid	$4,825.50
Rate for Payer: Molina CHIP/Medicaid	$4,825.50
Rate for Payer: Parkland Medicaid	$4,825.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,118.08

OTHER MAJOR HEAD AND NECK PROCEDURES

Facility

$33,964.36

Service Code	APR-DRG 0914
Min. Negotiated Rate	$32,022.79
Max. Negotiated Rate	$33,964.36
Rate for Payer: Amerigroup CHIP/Medicaid	$32,022.79
Rate for Payer: Cigna Medicaid	$32,022.79
Rate for Payer: Molina CHIP/Medicaid	$32,022.79
Rate for Payer: Parkland Medicaid	$32,022.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33,964.36

Know your out-of-pocket cost for care.

All Charges