White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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 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 DIAGNOSES W CC/MCC

Facility

$20,478.20

Service Code	MSDRG 729
Min. Negotiated Rate	$9,305.20
Max. Negotiated Rate	$20,478.20
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

$20,478.20

Service Code	MSDRG 729
Min. Negotiated Rate	$9,305.20
Max. Negotiated Rate	$20,478.20
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	$20,478.20
Rate for Payer: Multiplan Commercial	$20,478.20
Rate for Payer: Multiplan Workers Comp	$20,478.20
Rate for Payer: Scott and White EPO/PPO	$9,430.75
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

$12,460.20

Service Code	MSDRG 730
Min. Negotiated Rate	$4,888.24
Max. Negotiated Rate	$12,460.20
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	$12,460.20
Rate for Payer: Multiplan Commercial	$12,460.20
Rate for Payer: Multiplan Workers Comp	$12,460.20
Rate for Payer: Scott and White EPO/PPO	$5,738.25
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

$12,460.20

Service Code	MSDRG 730
Min. Negotiated Rate	$4,888.24
Max. Negotiated Rate	$12,460.20
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

$33,635.70

Service Code	MSDRG 717
Min. Negotiated Rate	$15,490.12
Max. Negotiated Rate	$33,635.70
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	$33,635.70
Rate for Payer: Multiplan Commercial	$33,635.70
Rate for Payer: Multiplan Workers Comp	$33,635.70
Rate for Payer: Scott and White EPO/PPO	$15,490.12
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

$24,111.00

Service Code	MSDRG 718
Min. Negotiated Rate	$10,600.36
Max. Negotiated Rate	$24,111.00
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	$24,111.00
Rate for Payer: Multiplan Commercial	$24,111.00
Rate for Payer: Multiplan Workers Comp	$24,111.00
Rate for Payer: Scott and White EPO/PPO	$11,103.75
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

$42,430.80

Service Code	MSDRG 715
Min. Negotiated Rate	$19,005.14
Max. Negotiated Rate	$42,430.80
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	$42,430.80
Rate for Payer: Multiplan Commercial	$42,430.80
Rate for Payer: Multiplan Workers Comp	$42,430.80
Rate for Payer: Scott and White EPO/PPO	$19,540.50
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

$24,971.70

Service Code	MSDRG 716
Min. Negotiated Rate	$11,500.12
Max. Negotiated Rate	$24,971.70
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	$24,971.70
Rate for Payer: Multiplan Commercial	$24,971.70
Rate for Payer: Multiplan Workers Comp	$24,971.70
Rate for Payer: Scott and White EPO/PPO	$11,500.12
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

OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W CC/MCC

Facility

$33,635.70

Service Code	MSDRG 717
Min. Negotiated Rate	$15,490.12
Max. Negotiated Rate	$33,635.70
Rate for Payer: BCBS of TX Blue Advantage	$16,806.98
Rate for Payer: BCBS of TX Blue Essentials	$20,166.42
Rate for Payer: BCBS of TX PPO	$22,408.00

OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W/O CC/MCC

Facility

$24,111.00

Service Code	MSDRG 718
Min. Negotiated Rate	$10,600.36
Max. Negotiated Rate	$24,111.00
Rate for Payer: BCBS of TX Blue Advantage	$10,600.36
Rate for Payer: BCBS of TX Blue Essentials	$12,719.20
Rate for Payer: BCBS of TX PPO	$14,132.99

OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC FOR MALIGNANCY W CC/MCC

Facility

$42,430.80

Service Code	MSDRG 715
Min. Negotiated Rate	$19,005.14
Max. Negotiated Rate	$42,430.80
Rate for Payer: BCBS of TX Blue Advantage	$19,005.14
Rate for Payer: BCBS of TX Blue Essentials	$22,803.96
Rate for Payer: BCBS of TX PPO	$25,338.71

OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC FOR MALIGNANCY W/O CC/MCC

Facility

$24,971.70

Service Code	MSDRG 716
Min. Negotiated Rate	$11,500.12
Max. Negotiated Rate	$24,971.70
Rate for Payer: BCBS of TX Blue Advantage	$12,581.80
Rate for Payer: BCBS of TX Blue Essentials	$15,096.70
Rate for Payer: BCBS of TX PPO	$16,774.76

OTHER MENTAL DISORDER DIAGNOSES

Facility

$24,633.50

Service Code	MSDRG 887
Min. Negotiated Rate	$9,154.70
Max. Negotiated Rate	$24,633.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,608.74
Rate for Payer: Amerigroup Medicare	$12,608.74
Rate for Payer: BCBS of TX Blue Advantage	$9,154.70
Rate for Payer: BCBS of TX Blue Essentials	$10,984.58
Rate for Payer: BCBS of TX Medicare	$12,608.74
Rate for Payer: BCBS of TX PPO	$12,205.56
Rate for Payer: Cigna Commercial	$13,793.19
Rate for Payer: Cigna Medicare	$12,608.74
Rate for Payer: Employer Direct Commercial	$12,608.74
Rate for Payer: Molina Dual Medicare/Medicaid	$12,608.74
Rate for Payer: Molina Medicare	$12,608.74
Rate for Payer: Multiplan Auto	$24,633.50
Rate for Payer: Multiplan Commercial	$24,633.50
Rate for Payer: Multiplan Workers Comp	$24,633.50
Rate for Payer: Scott and White EPO/PPO	$11,344.38
Rate for Payer: Scott and White Medicare	$12,608.74
Rate for Payer: Superior Health Plan EPO	$12,608.74
Rate for Payer: Superior Health Plan Medicare	$12,608.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,608.74
Rate for Payer: Universal American Medicare	$12,608.74
Rate for Payer: Wellcare Medicare	$12,608.74
Rate for Payer: Wellmed Medicare	$12,608.74

OTHER MENTAL HEALTH DISORDERS

Facility

$4,427.07

Service Code	APR-DRG 7602
Min. Negotiated Rate	$4,173.99
Max. Negotiated Rate	$4,427.07
Rate for Payer: Amerigroup CHIP/Medicaid	$4,173.99
Rate for Payer: Cigna Medicaid	$4,173.99
Rate for Payer: Molina CHIP/Medicaid	$4,173.99
Rate for Payer: Parkland Medicaid	$4,173.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,427.07

OTHER MENTAL HEALTH DISORDERS

Facility

$9,350.89

Service Code	APR-DRG 7604
Min. Negotiated Rate	$8,816.35
Max. Negotiated Rate	$9,350.89
Rate for Payer: Amerigroup CHIP/Medicaid	$8,816.35
Rate for Payer: Cigna Medicaid	$8,816.35
Rate for Payer: Molina CHIP/Medicaid	$8,816.35
Rate for Payer: Parkland Medicaid	$8,816.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,350.89

OTHER MENTAL HEALTH DISORDERS

Facility

$6,888.98

Service Code	APR-DRG 7603
Min. Negotiated Rate	$6,495.17
Max. Negotiated Rate	$6,888.98
Rate for Payer: Amerigroup CHIP/Medicaid	$6,495.17
Rate for Payer: Cigna Medicaid	$6,495.17
Rate for Payer: Molina CHIP/Medicaid	$6,495.17
Rate for Payer: Parkland Medicaid	$6,495.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,888.98

OTHER MENTAL HEALTH DISORDERS

Facility

$1,830.50

Service Code	APR-DRG 7601
Min. Negotiated Rate	$1,725.86
Max. Negotiated Rate	$1,830.50
Rate for Payer: Amerigroup CHIP/Medicaid	$1,725.86
Rate for Payer: Cigna Medicaid	$1,725.86
Rate for Payer: Molina CHIP/Medicaid	$1,725.86
Rate for Payer: Parkland Medicaid	$1,725.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,830.50

OTHER MULTIPLE SIGNIFICANT TRAUMA W CC

Facility

$27,825.50

Service Code	MSDRG 964
Min. Negotiated Rate	$12,684.14
Max. Negotiated Rate	$27,825.50
Rate for Payer: BCBS of TX Blue Advantage	$12,684.14
Rate for Payer: BCBS of TX Blue Essentials	$15,219.49
Rate for Payer: BCBS of TX PPO	$16,911.20

OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC

Facility

$27,825.50

Service Code	MSDRG 964
Min. Negotiated Rate	$12,684.14
Max. Negotiated Rate	$27,825.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,992.54
Rate for Payer: Amerigroup Medicare	$15,992.54
Rate for Payer: BCBS of TX Medicare	$15,992.54
Rate for Payer: Cigna Commercial	$19,739.89
Rate for Payer: Cigna Medicare	$15,992.54
Rate for Payer: Employer Direct Commercial	$15,992.54
Rate for Payer: Humana Medicare/TRICARE	$15,992.54
Rate for Payer: Molina Dual Medicare/Medicaid	$15,992.54
Rate for Payer: Molina Medicare	$15,992.54
Rate for Payer: Multiplan Auto	$27,825.50
Rate for Payer: Multiplan Commercial	$27,825.50
Rate for Payer: Multiplan Workers Comp	$27,825.50
Rate for Payer: Scott and White EPO/PPO	$12,814.38
Rate for Payer: Scott and White Medicare	$15,992.54
Rate for Payer: Superior Health Plan EPO	$15,992.54
Rate for Payer: Superior Health Plan Medicare	$15,992.54
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,992.54
Rate for Payer: Universal American Medicare	$15,992.54
Rate for Payer: Wellcare Medicare	$15,992.54
Rate for Payer: Wellmed Medicare	$15,992.54

OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC

Facility

$52,690.80

Service Code	MSDRG 963
Min. Negotiated Rate	$24,037.00
Max. Negotiated Rate	$52,690.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24,796.16
Rate for Payer: Amerigroup Medicare	$24,796.16
Rate for Payer: BCBS of TX Medicare	$24,796.16
Rate for Payer: Cigna Commercial	$35,211.34
Rate for Payer: Cigna Medicare	$24,796.16
Rate for Payer: Employer Direct Commercial	$24,796.16
Rate for Payer: Humana Medicare/TRICARE	$24,796.16
Rate for Payer: Molina Dual Medicare/Medicaid	$24,796.16
Rate for Payer: Molina Medicare	$24,796.16
Rate for Payer: Multiplan Auto	$52,690.80
Rate for Payer: Multiplan Commercial	$52,690.80
Rate for Payer: Multiplan Workers Comp	$52,690.80
Rate for Payer: Scott and White EPO/PPO	$24,265.50
Rate for Payer: Scott and White Medicare	$24,796.16
Rate for Payer: Superior Health Plan EPO	$24,796.16
Rate for Payer: Superior Health Plan Medicare	$24,796.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$24,796.16
Rate for Payer: Universal American Medicare	$24,796.16
Rate for Payer: Wellcare Medicare	$24,796.16
Rate for Payer: Wellmed Medicare	$24,796.16

Know your out-of-pocket cost for care.

All Charges