White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES

Facility

$24,557.64

Service Code	APR-DRG 8154
Min. Negotiated Rate	$23,153.81
Max. Negotiated Rate	$24,557.64
Rate for Payer: Amerigroup CHIP/Medicaid	$23,153.81
Rate for Payer: Cigna Medicaid	$23,153.81
Rate for Payer: Molina CHIP/Medicaid	$23,153.81
Rate for Payer: Parkland Medicaid	$23,153.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,557.64

OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES

Facility

$3,211.01

Service Code	APR-DRG 8152
Min. Negotiated Rate	$3,027.45
Max. Negotiated Rate	$3,211.01
Rate for Payer: Amerigroup CHIP/Medicaid	$3,027.45
Rate for Payer: Cigna Medicaid	$3,027.45
Rate for Payer: Molina CHIP/Medicaid	$3,027.45
Rate for Payer: Parkland Medicaid	$3,027.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,211.01

OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES

Facility

$7,484.94

Service Code	APR-DRG 8153
Min. Negotiated Rate	$7,057.06
Max. Negotiated Rate	$7,484.94
Rate for Payer: Amerigroup CHIP/Medicaid	$7,057.06
Rate for Payer: Cigna Medicaid	$7,057.06
Rate for Payer: Molina CHIP/Medicaid	$7,057.06
Rate for Payer: Parkland Medicaid	$7,057.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,484.94

OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES

Facility

$2,108.11

Service Code	APR-DRG 8151
Min. Negotiated Rate	$1,987.60
Max. Negotiated Rate	$2,108.11
Rate for Payer: Amerigroup CHIP/Medicaid	$1,987.60
Rate for Payer: Cigna Medicaid	$1,987.60
Rate for Payer: Molina CHIP/Medicaid	$1,987.60
Rate for Payer: Parkland Medicaid	$1,987.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,108.11

OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC

Facility

$33,238.60

Service Code	MSDRG 922
Min. Negotiated Rate	$13,402.24
Max. Negotiated Rate	$33,238.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,581.47
Rate for Payer: Amerigroup Medicare	$17,581.47
Rate for Payer: BCBS of TX Medicare	$17,581.47
Rate for Payer: Cigna Commercial	$22,532.27
Rate for Payer: Cigna Medicare	$17,581.47
Rate for Payer: Employer Direct Commercial	$17,581.47
Rate for Payer: Humana Medicare/TRICARE	$17,581.47
Rate for Payer: Molina Dual Medicare/Medicaid	$17,581.47
Rate for Payer: Molina Medicare	$17,581.47
Rate for Payer: Multiplan Auto	$33,238.60
Rate for Payer: Multiplan Commercial	$33,238.60
Rate for Payer: Multiplan Workers Comp	$33,238.60
Rate for Payer: Scott and White EPO/PPO	$15,307.25
Rate for Payer: Scott and White Medicare	$17,581.47
Rate for Payer: Superior Health Plan EPO	$17,581.47
Rate for Payer: Superior Health Plan Medicare	$17,581.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,581.47
Rate for Payer: Universal American Medicare	$17,581.47
Rate for Payer: Wellcare Medicare	$17,581.47
Rate for Payer: Wellmed Medicare	$17,581.47

OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC

Facility

$19,336.30

Service Code	MSDRG 923
Min. Negotiated Rate	$7,480.28
Max. Negotiated Rate	$19,336.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,218.84
Rate for Payer: Amerigroup Medicare	$12,218.84
Rate for Payer: BCBS of TX Medicare	$12,218.84
Rate for Payer: Cigna Commercial	$13,107.98
Rate for Payer: Cigna Medicare	$12,218.84
Rate for Payer: Employer Direct Commercial	$12,218.84
Rate for Payer: Humana Medicare/TRICARE	$12,218.84
Rate for Payer: Molina Dual Medicare/Medicaid	$12,218.84
Rate for Payer: Molina Medicare	$12,218.84
Rate for Payer: Multiplan Auto	$19,336.30
Rate for Payer: Multiplan Commercial	$19,336.30
Rate for Payer: Multiplan Workers Comp	$19,336.30
Rate for Payer: Scott and White EPO/PPO	$8,904.88
Rate for Payer: Scott and White Medicare	$12,218.84
Rate for Payer: Superior Health Plan EPO	$12,218.84
Rate for Payer: Superior Health Plan Medicare	$12,218.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,218.84
Rate for Payer: Universal American Medicare	$12,218.84
Rate for Payer: Wellcare Medicare	$12,218.84
Rate for Payer: Wellmed Medicare	$12,218.84

OTHER INJURY, POISONING & TOXIC EFFECT DIAG W MCC

Facility

$33,238.60

Service Code	MSDRG 922
Min. Negotiated Rate	$13,402.24
Max. Negotiated Rate	$33,238.60
Rate for Payer: BCBS of TX Blue Advantage	$13,402.24
Rate for Payer: BCBS of TX Blue Essentials	$16,081.13
Rate for Payer: BCBS of TX PPO	$17,868.61

OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O MCC

Facility

$19,336.30

Service Code	MSDRG 923
Min. Negotiated Rate	$7,480.28
Max. Negotiated Rate	$19,336.30
Rate for Payer: BCBS of TX Blue Advantage	$7,480.28
Rate for Payer: BCBS of TX Blue Essentials	$8,975.47
Rate for Payer: BCBS of TX PPO	$9,973.13

OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS

Facility

$5,861.52

Service Code	APR-DRG 4683
Min. Negotiated Rate	$5,526.44
Max. Negotiated Rate	$5,861.52
Rate for Payer: Amerigroup CHIP/Medicaid	$5,526.44
Rate for Payer: Cigna Medicaid	$5,526.44
Rate for Payer: Molina CHIP/Medicaid	$5,526.44
Rate for Payer: Parkland Medicaid	$5,526.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,861.52

OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS

Facility

$2,875.31

Service Code	APR-DRG 4681
Min. Negotiated Rate	$2,710.94
Max. Negotiated Rate	$2,875.31
Rate for Payer: Amerigroup CHIP/Medicaid	$2,710.94
Rate for Payer: Cigna Medicaid	$2,710.94
Rate for Payer: Molina CHIP/Medicaid	$2,710.94
Rate for Payer: Parkland Medicaid	$2,710.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,875.31

OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS

Facility

$3,220.44

Service Code	APR-DRG 4682
Min. Negotiated Rate	$3,036.34
Max. Negotiated Rate	$3,220.44
Rate for Payer: Amerigroup CHIP/Medicaid	$3,036.34
Rate for Payer: Cigna Medicaid	$3,036.34
Rate for Payer: Molina CHIP/Medicaid	$3,036.34
Rate for Payer: Parkland Medicaid	$3,036.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,220.44

OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS

Facility

$24,848.08

Service Code	APR-DRG 4684
Min. Negotiated Rate	$23,427.64
Max. Negotiated Rate	$24,848.08
Rate for Payer: Amerigroup CHIP/Medicaid	$23,427.64
Rate for Payer: Cigna Medicaid	$23,427.64
Rate for Payer: Molina CHIP/Medicaid	$23,427.64
Rate for Payer: Parkland Medicaid	$23,427.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,848.08

OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC

Facility

$19,285.00

Service Code	MSDRG 699
Min. Negotiated Rate	$8,839.94
Max. Negotiated Rate	$19,285.00
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	$19,285.00
Rate for Payer: Multiplan Commercial	$19,285.00
Rate for Payer: Multiplan Workers Comp	$19,285.00
Rate for Payer: Scott and White EPO/PPO	$8,881.25
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

$31,433.60

Service Code	MSDRG 698
Min. Negotiated Rate	$13,889.86
Max. Negotiated Rate	$31,433.60
Rate for Payer: Multiplan Workers Comp	$31,433.60
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	$31,433.60
Rate for Payer: Multiplan Commercial	$31,433.60
Rate for Payer: Scott and White EPO/PPO	$14,476.00
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

$13,108.10

Service Code	MSDRG 700
Min. Negotiated Rate	$6,036.62
Max. Negotiated Rate	$13,108.10
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	$13,108.10
Rate for Payer: Multiplan Commercial	$13,108.10
Rate for Payer: Multiplan Workers Comp	$13,108.10
Rate for Payer: Scott and White EPO/PPO	$6,036.62
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

$44,433.40

Service Code	MSDRG 674
Min. Negotiated Rate	$19,884.06
Max. Negotiated Rate	$44,433.40
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	$44,433.40
Rate for Payer: Multiplan Commercial	$44,433.40
Rate for Payer: Multiplan Workers Comp	$44,433.40
Rate for Payer: Scott and White EPO/PPO	$20,462.75
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

$79,830.40

Service Code	MSDRG 673
Min. Negotiated Rate	$30,764.78
Max. Negotiated Rate	$79,830.40
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	$79,830.40
Rate for Payer: Multiplan Commercial	$79,830.40
Rate for Payer: Multiplan Workers Comp	$79,830.40
Rate for Payer: Scott and White EPO/PPO	$36,764.00
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

$31,186.60

Service Code	MSDRG 675
Min. Negotiated Rate	$13,977.58
Max. Negotiated Rate	$31,186.60
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	$31,186.60
Rate for Payer: Multiplan Commercial	$31,186.60
Rate for Payer: Multiplan Workers Comp	$31,186.60
Rate for Payer: Scott and White EPO/PPO	$14,362.25
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

$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 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 DIAGNOSES W CC

Facility

$19,285.00

Service Code	MSDRG 699
Min. Negotiated Rate	$8,839.94
Max. Negotiated Rate	$19,285.00
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

$31,433.60

Service Code	MSDRG 698
Min. Negotiated Rate	$13,889.86
Max. Negotiated Rate	$31,433.60
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

$13,108.10

Service Code	MSDRG 700
Min. Negotiated Rate	$6,036.62
Max. Negotiated Rate	$13,108.10
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

Know your out-of-pocket cost for care.

All Charges