White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER KIDNEY & URINARY TRACT PROCEDURES W CC

Facility

$44,433.40

Service Code	MSDRG 674
Min. Negotiated Rate	$19,884.06
Max. Negotiated Rate	$44,433.40
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

$79,830.40

Service Code	MSDRG 673
Min. Negotiated Rate	$30,764.78
Max. Negotiated Rate	$79,830.40
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

$31,186.60

Service Code	MSDRG 675
Min. Negotiated Rate	$13,977.58
Max. Negotiated Rate	$31,186.60
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

$67,569.70

Service Code	MSDRG 271
Min. Negotiated Rate	$30,046.68
Max. Negotiated Rate	$67,569.70
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

$67,569.70

Service Code	MSDRG 271
Min. Negotiated Rate	$30,046.68
Max. Negotiated Rate	$67,569.70
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	$67,569.70
Rate for Payer: Multiplan Commercial	$67,569.70
Rate for Payer: Multiplan Workers Comp	$67,569.70
Rate for Payer: Scott and White EPO/PPO	$31,117.62
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

$100,249.70

Service Code	MSDRG 270
Min. Negotiated Rate	$43,430.21
Max. Negotiated Rate	$100,249.70
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	$100,249.70
Rate for Payer: Multiplan Commercial	$100,249.70
Rate for Payer: Multiplan Workers Comp	$100,249.70
Rate for Payer: Scott and White EPO/PPO	$46,167.62
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

$48,507.00

Service Code	MSDRG 272
Min. Negotiated Rate	$22,338.75
Max. Negotiated Rate	$48,507.00
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	$48,507.00
Rate for Payer: Multiplan Commercial	$48,507.00
Rate for Payer: Multiplan Workers Comp	$48,507.00
Rate for Payer: Scott and White EPO/PPO	$22,338.75
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

$100,249.70

Service Code	MSDRG 270
Min. Negotiated Rate	$43,430.21
Max. Negotiated Rate	$100,249.70
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

$48,507.00

Service Code	MSDRG 272
Min. Negotiated Rate	$22,338.75
Max. Negotiated Rate	$48,507.00
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

$11,031.65

Service Code	APR-DRG 0912
Min. Negotiated Rate	$10,401.02
Max. Negotiated Rate	$11,031.65
Rate for Payer: Amerigroup CHIP/Medicaid	$10,401.02
Rate for Payer: Cigna Medicaid	$10,401.02
Rate for Payer: Molina CHIP/Medicaid	$10,401.02
Rate for Payer: Parkland Medicaid	$10,401.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,031.65

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

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

$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 MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES

Facility

$7,504.18

Service Code	APR-DRG 4842
Min. Negotiated Rate	$7,075.20
Max. Negotiated Rate	$7,504.18
Rate for Payer: Amerigroup CHIP/Medicaid	$7,075.20
Rate for Payer: Cigna Medicaid	$7,075.20
Rate for Payer: Molina CHIP/Medicaid	$7,075.20
Rate for Payer: Parkland Medicaid	$7,075.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,504.18

OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES

Facility

$8,980.87

Service Code	APR-DRG 4843
Min. Negotiated Rate	$8,467.48
Max. Negotiated Rate	$8,980.87
Rate for Payer: Amerigroup CHIP/Medicaid	$8,467.48
Rate for Payer: Cigna Medicaid	$8,467.48
Rate for Payer: Molina CHIP/Medicaid	$8,467.48
Rate for Payer: Parkland Medicaid	$8,467.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,980.87

OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES

Facility

$23,932.26

Service Code	APR-DRG 4844
Min. Negotiated Rate	$22,564.18
Max. Negotiated Rate	$23,932.26
Rate for Payer: Amerigroup CHIP/Medicaid	$22,564.18
Rate for Payer: Cigna Medicaid	$22,564.18
Rate for Payer: Molina CHIP/Medicaid	$22,564.18
Rate for Payer: Parkland Medicaid	$22,564.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,932.26

OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES

Facility

$6,741.88

Service Code	APR-DRG 4841
Min. Negotiated Rate	$6,356.48
Max. Negotiated Rate	$6,741.88
Rate for Payer: Amerigroup CHIP/Medicaid	$6,356.48
Rate for Payer: Cigna Medicaid	$6,356.48
Rate for Payer: Molina CHIP/Medicaid	$6,356.48
Rate for Payer: Parkland Medicaid	$6,356.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,741.88

OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W CC/MCC

Facility

$20,115.30

Service Code	MSDRG 729
Min. Negotiated Rate	$9,263.62
Max. Negotiated Rate	$20,115.30
Rate for Payer: BCBS of TX Blue Advantage	$9,305.20
Rate for Payer: BCBS of TX Blue Essentials	$11,165.16
Rate for Payer: BCBS of TX PPO	$12,406.21

OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC

Facility

$20,115.30

Service Code	MSDRG 729
Min. Negotiated Rate	$9,263.62
Max. Negotiated Rate	$20,115.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,519.31
Rate for Payer: Amerigroup Medicare	$12,519.31
Rate for Payer: BCBS of TX Medicare	$12,519.31
Rate for Payer: Cigna Commercial	$13,636.06
Rate for Payer: Cigna Medicare	$12,519.31
Rate for Payer: Employer Direct Commercial	$12,519.31
Rate for Payer: Humana Medicare/TRICARE	$12,519.31
Rate for Payer: Molina Dual Medicare/Medicaid	$12,519.31
Rate for Payer: Molina Medicare	$12,519.31
Rate for Payer: Multiplan Auto	$20,115.30
Rate for Payer: Multiplan Commercial	$20,115.30
Rate for Payer: Multiplan Workers Comp	$20,115.30
Rate for Payer: Scott and White EPO/PPO	$9,263.62
Rate for Payer: Scott and White Medicare	$12,519.31
Rate for Payer: Superior Health Plan EPO	$12,519.31
Rate for Payer: Superior Health Plan Medicare	$12,519.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,519.31
Rate for Payer: Universal American Medicare	$12,519.31
Rate for Payer: Wellcare Medicare	$12,519.31
Rate for Payer: Wellmed Medicare	$12,519.31

OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC

Facility

$12,768.00

Service Code	MSDRG 730
Min. Negotiated Rate	$4,888.24
Max. Negotiated Rate	$12,768.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,685.19
Rate for Payer: Amerigroup Medicare	$9,685.19
Rate for Payer: BCBS of TX Medicare	$9,685.19
Rate for Payer: Cigna Commercial	$8,655.36
Rate for Payer: Cigna Medicare	$9,685.19
Rate for Payer: Employer Direct Commercial	$9,685.19
Rate for Payer: Humana Medicare/TRICARE	$9,685.19
Rate for Payer: Molina Dual Medicare/Medicaid	$9,685.19
Rate for Payer: Molina Medicare	$9,685.19
Rate for Payer: Multiplan Auto	$12,768.00
Rate for Payer: Multiplan Commercial	$12,768.00
Rate for Payer: Multiplan Workers Comp	$12,768.00
Rate for Payer: Scott and White EPO/PPO	$5,880.00
Rate for Payer: Scott and White Medicare	$9,685.19
Rate for Payer: Superior Health Plan EPO	$9,685.19
Rate for Payer: Superior Health Plan Medicare	$9,685.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,685.19
Rate for Payer: Universal American Medicare	$9,685.19
Rate for Payer: Wellcare Medicare	$9,685.19
Rate for Payer: Wellmed Medicare	$9,685.19

OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W/O CC/MCC

Facility

$12,768.00

Service Code	MSDRG 730
Min. Negotiated Rate	$4,888.24
Max. Negotiated Rate	$12,768.00
Rate for Payer: BCBS of TX Blue Advantage	$4,888.24
Rate for Payer: BCBS of TX Blue Essentials	$5,865.32
Rate for Payer: BCBS of TX PPO	$6,517.27

OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC

Facility

$35,919.50

Service Code	MSDRG 717
Min. Negotiated Rate	$16,541.88
Max. Negotiated Rate	$35,919.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,615.61
Rate for Payer: Amerigroup Medicare	$18,615.61
Rate for Payer: BCBS of TX Medicare	$18,615.61
Rate for Payer: Cigna Commercial	$24,349.64
Rate for Payer: Cigna Medicare	$18,615.61
Rate for Payer: Employer Direct Commercial	$18,615.61
Rate for Payer: Humana Medicare/TRICARE	$18,615.61
Rate for Payer: Molina Dual Medicare/Medicaid	$18,615.61
Rate for Payer: Molina Medicare	$18,615.61
Rate for Payer: Multiplan Auto	$35,919.50
Rate for Payer: Multiplan Commercial	$35,919.50
Rate for Payer: Multiplan Workers Comp	$35,919.50
Rate for Payer: Scott and White EPO/PPO	$16,541.88
Rate for Payer: Scott and White Medicare	$18,615.61
Rate for Payer: Superior Health Plan EPO	$18,615.61
Rate for Payer: Superior Health Plan Medicare	$18,615.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,615.61
Rate for Payer: Universal American Medicare	$18,615.61
Rate for Payer: Wellcare Medicare	$18,615.61
Rate for Payer: Wellmed Medicare	$18,615.61

OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC

Facility

$25,518.90

Service Code	MSDRG 718
Min. Negotiated Rate	$10,600.36
Max. Negotiated Rate	$25,518.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,603.69
Rate for Payer: Amerigroup Medicare	$14,603.69
Rate for Payer: BCBS of TX Medicare	$14,603.69
Rate for Payer: Cigna Commercial	$17,299.13
Rate for Payer: Cigna Medicare	$14,603.69
Rate for Payer: Employer Direct Commercial	$14,603.69
Rate for Payer: Humana Medicare/TRICARE	$14,603.69
Rate for Payer: Molina Dual Medicare/Medicaid	$14,603.69
Rate for Payer: Molina Medicare	$14,603.69
Rate for Payer: Multiplan Auto	$25,518.90
Rate for Payer: Multiplan Commercial	$25,518.90
Rate for Payer: Multiplan Workers Comp	$25,518.90
Rate for Payer: Scott and White EPO/PPO	$11,752.12
Rate for Payer: Scott and White Medicare	$14,603.69
Rate for Payer: Superior Health Plan EPO	$14,603.69
Rate for Payer: Superior Health Plan Medicare	$14,603.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,603.69
Rate for Payer: Universal American Medicare	$14,603.69
Rate for Payer: Wellcare Medicare	$14,603.69
Rate for Payer: Wellmed Medicare	$14,603.69

OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC

Facility

$42,508.70

Service Code	MSDRG 715
Min. Negotiated Rate	$19,005.14
Max. Negotiated Rate	$42,508.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,157.30
Rate for Payer: Amerigroup Medicare	$21,157.30
Rate for Payer: BCBS of TX Medicare	$21,157.30
Rate for Payer: Cigna Commercial	$28,816.42
Rate for Payer: Cigna Medicare	$21,157.30
Rate for Payer: Employer Direct Commercial	$21,157.30
Rate for Payer: Humana Medicare/TRICARE	$21,157.30
Rate for Payer: Molina Dual Medicare/Medicaid	$21,157.30
Rate for Payer: Molina Medicare	$21,157.30
Rate for Payer: Multiplan Auto	$42,508.70
Rate for Payer: Multiplan Commercial	$42,508.70
Rate for Payer: Multiplan Workers Comp	$42,508.70
Rate for Payer: Scott and White EPO/PPO	$19,576.38
Rate for Payer: Scott and White Medicare	$21,157.30
Rate for Payer: Superior Health Plan EPO	$21,157.30
Rate for Payer: Superior Health Plan Medicare	$21,157.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,157.30
Rate for Payer: Universal American Medicare	$21,157.30
Rate for Payer: Wellcare Medicare	$21,157.30
Rate for Payer: Wellmed Medicare	$21,157.30

OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC

Facility

$27,949.00

Service Code	MSDRG 716
Min. Negotiated Rate	$12,581.80
Max. Negotiated Rate	$27,949.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,541.08
Rate for Payer: Amerigroup Medicare	$15,541.08
Rate for Payer: BCBS of TX Medicare	$15,541.08
Rate for Payer: Cigna Commercial	$18,946.48
Rate for Payer: Cigna Medicare	$15,541.08
Rate for Payer: Employer Direct Commercial	$15,541.08
Rate for Payer: Humana Medicare/TRICARE	$15,541.08
Rate for Payer: Molina Dual Medicare/Medicaid	$15,541.08
Rate for Payer: Molina Medicare	$15,541.08
Rate for Payer: Multiplan Auto	$27,949.00
Rate for Payer: Multiplan Commercial	$27,949.00
Rate for Payer: Multiplan Workers Comp	$27,949.00
Rate for Payer: Scott and White EPO/PPO	$12,871.25
Rate for Payer: Scott and White Medicare	$15,541.08
Rate for Payer: Superior Health Plan EPO	$15,541.08
Rate for Payer: Superior Health Plan Medicare	$15,541.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,541.08
Rate for Payer: Universal American Medicare	$15,541.08
Rate for Payer: Wellcare Medicare	$15,541.08
Rate for Payer: Wellmed Medicare	$15,541.08

Know your out-of-pocket cost for care.

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