White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC

Facility

$17,288.10

Service Code	MSDRG 965
Min. Negotiated Rate	$7,961.62
Max. Negotiated Rate	$17,288.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,653.03
Rate for Payer: Amerigroup Medicare	$11,653.03
Rate for Payer: BCBS of TX Medicare	$11,653.03
Rate for Payer: Cigna Commercial	$12,113.64
Rate for Payer: Cigna Medicare	$11,653.03
Rate for Payer: Employer Direct Commercial	$11,653.03
Rate for Payer: Humana Medicare/TRICARE	$11,653.03
Rate for Payer: Molina Dual Medicare/Medicaid	$11,653.03
Rate for Payer: Molina Medicare	$11,653.03
Rate for Payer: Multiplan Auto	$17,288.10
Rate for Payer: Multiplan Commercial	$17,288.10
Rate for Payer: Multiplan Workers Comp	$17,288.10
Rate for Payer: Scott and White EPO/PPO	$7,961.62
Rate for Payer: Scott and White Medicare	$11,653.03
Rate for Payer: Superior Health Plan EPO	$11,653.03
Rate for Payer: Superior Health Plan Medicare	$11,653.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,653.03
Rate for Payer: Universal American Medicare	$11,653.03
Rate for Payer: Wellcare Medicare	$11,653.03
Rate for Payer: Wellmed Medicare	$11,653.03

OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC

Facility

$52,690.80

Service Code	MSDRG 963
Min. Negotiated Rate	$24,037.00
Max. Negotiated Rate	$52,690.80
Rate for Payer: BCBS of TX Blue Advantage	$24,037.00
Rate for Payer: BCBS of TX Blue Essentials	$28,841.60
Rate for Payer: BCBS of TX PPO	$32,047.47

OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC

Facility

$17,288.10

Service Code	MSDRG 965
Min. Negotiated Rate	$7,961.62
Max. Negotiated Rate	$17,288.10
Rate for Payer: BCBS of TX Blue Advantage	$8,378.98
Rate for Payer: BCBS of TX Blue Essentials	$10,053.80
Rate for Payer: BCBS of TX PPO	$11,171.32

OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC

Facility

$18,760.60

Service Code	MSDRG 565
Min. Negotiated Rate	$8,391.88
Max. Negotiated Rate	$18,760.60
Rate for Payer: BCBS of TX Blue Advantage	$8,391.88
Rate for Payer: BCBS of TX Blue Essentials	$10,069.28
Rate for Payer: BCBS of TX PPO	$11,188.52

OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W MCC

Facility

$29,512.70

Service Code	MSDRG 564
Min. Negotiated Rate	$13,520.92
Max. Negotiated Rate	$29,512.70
Rate for Payer: BCBS of TX Blue Advantage	$13,520.92
Rate for Payer: BCBS of TX Blue Essentials	$16,223.53
Rate for Payer: BCBS of TX PPO	$18,026.85

OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W/O CC/MCC

Facility

$14,111.30

Service Code	MSDRG 566
Min. Negotiated Rate	$6,498.62
Max. Negotiated Rate	$14,111.30
Rate for Payer: BCBS of TX Blue Advantage	$6,555.78
Rate for Payer: BCBS of TX Blue Essentials	$7,866.17
Rate for Payer: BCBS of TX PPO	$8,740.53

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES

Facility

$6,264.35

Service Code	APR-DRG 3513
Min. Negotiated Rate	$5,906.25
Max. Negotiated Rate	$6,264.35
Rate for Payer: Amerigroup CHIP/Medicaid	$5,906.25
Rate for Payer: Cigna Medicaid	$5,906.25
Rate for Payer: Molina CHIP/Medicaid	$5,906.25
Rate for Payer: Parkland Medicaid	$5,906.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,264.35

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES

Facility

$3,493.52

Service Code	APR-DRG 3512
Min. Negotiated Rate	$3,293.82
Max. Negotiated Rate	$3,493.52
Rate for Payer: Amerigroup CHIP/Medicaid	$3,293.82
Rate for Payer: Cigna Medicaid	$3,293.82
Rate for Payer: Molina CHIP/Medicaid	$3,293.82
Rate for Payer: Parkland Medicaid	$3,293.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,493.52

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES

Facility

$18,177.49

Service Code	APR-DRG 3514
Min. Negotiated Rate	$17,138.38
Max. Negotiated Rate	$18,177.49
Rate for Payer: Amerigroup CHIP/Medicaid	$17,138.38
Rate for Payer: Cigna Medicaid	$17,138.38
Rate for Payer: Molina CHIP/Medicaid	$17,138.38
Rate for Payer: Parkland Medicaid	$17,138.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,177.49

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES

Facility

$3,019.02

Service Code	APR-DRG 3511
Min. Negotiated Rate	$2,846.44
Max. Negotiated Rate	$3,019.02
Rate for Payer: Amerigroup CHIP/Medicaid	$2,846.44
Rate for Payer: Cigna Medicaid	$2,846.44
Rate for Payer: Molina CHIP/Medicaid	$2,846.44
Rate for Payer: Parkland Medicaid	$2,846.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,019.02

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC

Facility

$18,760.60

Service Code	MSDRG 565
Min. Negotiated Rate	$8,391.88
Max. Negotiated Rate	$18,760.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,901.48
Rate for Payer: Amerigroup Medicare	$11,901.48
Rate for Payer: BCBS of TX Medicare	$11,901.48
Rate for Payer: Cigna Commercial	$12,550.27
Rate for Payer: Cigna Medicare	$11,901.48
Rate for Payer: Employer Direct Commercial	$11,901.48
Rate for Payer: Humana Medicare/TRICARE	$11,901.48
Rate for Payer: Molina Dual Medicare/Medicaid	$11,901.48
Rate for Payer: Molina Medicare	$11,901.48
Rate for Payer: Multiplan Auto	$18,760.60
Rate for Payer: Multiplan Commercial	$18,760.60
Rate for Payer: Multiplan Workers Comp	$18,760.60
Rate for Payer: Scott and White EPO/PPO	$8,639.75
Rate for Payer: Scott and White Medicare	$11,901.48
Rate for Payer: Superior Health Plan EPO	$11,901.48
Rate for Payer: Superior Health Plan Medicare	$11,901.48
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,901.48
Rate for Payer: Universal American Medicare	$11,901.48
Rate for Payer: Wellcare Medicare	$11,901.48
Rate for Payer: Wellmed Medicare	$11,901.48

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC

Facility

$29,512.70

Service Code	MSDRG 564
Min. Negotiated Rate	$13,520.92
Max. Negotiated Rate	$29,512.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,073.17
Rate for Payer: Amerigroup Medicare	$16,073.17
Rate for Payer: BCBS of TX Medicare	$16,073.17
Rate for Payer: Cigna Commercial	$19,881.57
Rate for Payer: Cigna Medicare	$16,073.17
Rate for Payer: Employer Direct Commercial	$16,073.17
Rate for Payer: Humana Medicare/TRICARE	$16,073.17
Rate for Payer: Molina Dual Medicare/Medicaid	$16,073.17
Rate for Payer: Molina Medicare	$16,073.17
Rate for Payer: Multiplan Auto	$29,512.70
Rate for Payer: Multiplan Commercial	$29,512.70
Rate for Payer: Multiplan Workers Comp	$29,512.70
Rate for Payer: Scott and White EPO/PPO	$13,591.38
Rate for Payer: Scott and White Medicare	$16,073.17
Rate for Payer: Superior Health Plan EPO	$16,073.17
Rate for Payer: Superior Health Plan Medicare	$16,073.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,073.17
Rate for Payer: Universal American Medicare	$16,073.17
Rate for Payer: Wellcare Medicare	$16,073.17
Rate for Payer: Wellmed Medicare	$16,073.17

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC

Facility

$14,111.30

Service Code	MSDRG 566
Min. Negotiated Rate	$6,498.62
Max. Negotiated Rate	$14,111.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,251.72
Rate for Payer: Amerigroup Medicare	$10,251.72
Rate for Payer: BCBS of TX Medicare	$10,251.72
Rate for Payer: Cigna Commercial	$9,650.98
Rate for Payer: Cigna Medicare	$10,251.72
Rate for Payer: Employer Direct Commercial	$10,251.72
Rate for Payer: Humana Medicare/TRICARE	$10,251.72
Rate for Payer: Molina Dual Medicare/Medicaid	$10,251.72
Rate for Payer: Molina Medicare	$10,251.72
Rate for Payer: Multiplan Auto	$14,111.30
Rate for Payer: Multiplan Commercial	$14,111.30
Rate for Payer: Multiplan Workers Comp	$14,111.30
Rate for Payer: Scott and White EPO/PPO	$6,498.62
Rate for Payer: Scott and White Medicare	$10,251.72
Rate for Payer: Superior Health Plan EPO	$10,251.72
Rate for Payer: Superior Health Plan Medicare	$10,251.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,251.72
Rate for Payer: Universal American Medicare	$10,251.72
Rate for Payer: Wellcare Medicare	$10,251.72
Rate for Payer: Wellmed Medicare	$10,251.72

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC

Facility

$38,642.20

Service Code	MSDRG 516
Min. Negotiated Rate	$16,214.44
Max. Negotiated Rate	$38,642.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,990.53
Rate for Payer: Amerigroup Medicare	$19,990.53
Rate for Payer: BCBS of TX Medicare	$19,990.53
Rate for Payer: Cigna Commercial	$26,765.93
Rate for Payer: Cigna Medicare	$19,990.53
Rate for Payer: Employer Direct Commercial	$19,990.53
Rate for Payer: Humana Medicare/TRICARE	$19,990.53
Rate for Payer: Molina Dual Medicare/Medicaid	$19,990.53
Rate for Payer: Molina Medicare	$19,990.53
Rate for Payer: Multiplan Auto	$38,642.20
Rate for Payer: Multiplan Commercial	$38,642.20
Rate for Payer: Multiplan Workers Comp	$38,642.20
Rate for Payer: Scott and White EPO/PPO	$17,795.75
Rate for Payer: Scott and White Medicare	$19,990.53
Rate for Payer: Superior Health Plan EPO	$19,990.53
Rate for Payer: Superior Health Plan Medicare	$19,990.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,990.53
Rate for Payer: Universal American Medicare	$19,990.53
Rate for Payer: Wellcare Medicare	$19,990.53
Rate for Payer: Wellmed Medicare	$19,990.53

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC

Facility

$59,238.20

Service Code	MSDRG 515
Min. Negotiated Rate	$26,505.20
Max. Negotiated Rate	$59,238.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,116.94
Rate for Payer: Amerigroup Medicare	$28,116.94
Rate for Payer: BCBS of TX Medicare	$28,116.94
Rate for Payer: Cigna Commercial	$41,047.27
Rate for Payer: Cigna Medicare	$28,116.94
Rate for Payer: Employer Direct Commercial	$28,116.94
Rate for Payer: Humana Medicare/TRICARE	$28,116.94
Rate for Payer: Molina Dual Medicare/Medicaid	$28,116.94
Rate for Payer: Molina Medicare	$28,116.94
Rate for Payer: Multiplan Auto	$59,238.20
Rate for Payer: Multiplan Commercial	$59,238.20
Rate for Payer: Multiplan Workers Comp	$59,238.20
Rate for Payer: Scott and White EPO/PPO	$27,280.75
Rate for Payer: Scott and White Medicare	$28,116.94
Rate for Payer: Superior Health Plan EPO	$28,116.94
Rate for Payer: Superior Health Plan Medicare	$28,116.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,116.94
Rate for Payer: Universal American Medicare	$28,116.94
Rate for Payer: Wellcare Medicare	$28,116.94
Rate for Payer: Wellmed Medicare	$28,116.94

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC

Facility

$28,688.10

Service Code	MSDRG 517
Min. Negotiated Rate	$11,875.74
Max. Negotiated Rate	$28,688.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,022.59
Rate for Payer: Amerigroup Medicare	$16,022.59
Rate for Payer: BCBS of TX Medicare	$16,022.59
Rate for Payer: Cigna Commercial	$19,792.70
Rate for Payer: Cigna Medicare	$16,022.59
Rate for Payer: Employer Direct Commercial	$16,022.59
Rate for Payer: Humana Medicare/TRICARE	$16,022.59
Rate for Payer: Molina Dual Medicare/Medicaid	$16,022.59
Rate for Payer: Molina Medicare	$16,022.59
Rate for Payer: Multiplan Auto	$28,688.10
Rate for Payer: Multiplan Commercial	$28,688.10
Rate for Payer: Multiplan Workers Comp	$28,688.10
Rate for Payer: Scott and White EPO/PPO	$13,211.62
Rate for Payer: Scott and White Medicare	$16,022.59
Rate for Payer: Superior Health Plan EPO	$16,022.59
Rate for Payer: Superior Health Plan Medicare	$16,022.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,022.59
Rate for Payer: Universal American Medicare	$16,022.59
Rate for Payer: Wellcare Medicare	$16,022.59
Rate for Payer: Wellmed Medicare	$16,022.59

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES

Facility

$7,089.27

Service Code	APR-DRG 3202
Min. Negotiated Rate	$6,684.01
Max. Negotiated Rate	$7,089.27
Rate for Payer: Amerigroup CHIP/Medicaid	$6,684.01
Rate for Payer: Cigna Medicaid	$6,684.01
Rate for Payer: Molina CHIP/Medicaid	$6,684.01
Rate for Payer: Parkland Medicaid	$6,684.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,089.27

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES

Facility

$19,529.71

Service Code	APR-DRG 3204
Min. Negotiated Rate	$18,413.30
Max. Negotiated Rate	$19,529.71
Rate for Payer: Amerigroup CHIP/Medicaid	$18,413.30
Rate for Payer: Cigna Medicaid	$18,413.30
Rate for Payer: Molina CHIP/Medicaid	$18,413.30
Rate for Payer: Parkland Medicaid	$18,413.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,529.71

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES

Facility

$5,866.04

Service Code	APR-DRG 3201
Min. Negotiated Rate	$5,530.71
Max. Negotiated Rate	$5,866.04
Rate for Payer: Amerigroup CHIP/Medicaid	$5,530.71
Rate for Payer: Cigna Medicaid	$5,530.71
Rate for Payer: Molina CHIP/Medicaid	$5,530.71
Rate for Payer: Parkland Medicaid	$5,530.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,866.04

OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES

Facility

$11,285.87

Service Code	APR-DRG 3203
Min. Negotiated Rate	$10,640.72
Max. Negotiated Rate	$11,285.87
Rate for Payer: Amerigroup CHIP/Medicaid	$10,640.72
Rate for Payer: Cigna Medicaid	$10,640.72
Rate for Payer: Molina CHIP/Medicaid	$10,640.72
Rate for Payer: Parkland Medicaid	$10,640.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,285.87

OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC

Facility

$38,642.20

Service Code	MSDRG 516
Min. Negotiated Rate	$16,214.44
Max. Negotiated Rate	$38,642.20
Rate for Payer: BCBS of TX Blue Advantage	$16,214.44
Rate for Payer: BCBS of TX Blue Essentials	$19,455.44
Rate for Payer: BCBS of TX PPO	$21,618.00

OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC

Facility

$59,238.20

Service Code	MSDRG 515
Min. Negotiated Rate	$26,505.20
Max. Negotiated Rate	$59,238.20
Rate for Payer: BCBS of TX Blue Advantage	$26,505.20
Rate for Payer: BCBS of TX Blue Essentials	$31,803.16
Rate for Payer: BCBS of TX PPO	$35,338.21

OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC

Facility

$28,688.10

Service Code	MSDRG 517
Min. Negotiated Rate	$11,875.74
Max. Negotiated Rate	$28,688.10
Rate for Payer: BCBS of TX Blue Advantage	$11,875.74
Rate for Payer: BCBS of TX Blue Essentials	$14,249.51
Rate for Payer: BCBS of TX PPO	$15,833.40

OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC

Facility

$21,671.40

Service Code	MSDRG 844
Min. Negotiated Rate	$9,980.25
Max. Negotiated Rate	$21,671.40
Rate for Payer: BCBS of TX Blue Advantage	$10,137.68
Rate for Payer: BCBS of TX Blue Essentials	$12,164.04
Rate for Payer: BCBS of TX PPO	$13,516.12

OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W MCC

Facility

$36,810.60

Service Code	MSDRG 843
Min. Negotiated Rate	$15,875.60
Max. Negotiated Rate	$36,810.60
Rate for Payer: BCBS of TX Blue Advantage	$15,875.60
Rate for Payer: BCBS of TX Blue Essentials	$19,048.87
Rate for Payer: BCBS of TX PPO	$21,166.24

Know your out-of-pocket cost for care.

All Charges