White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$39,483.90

Service Code	MSDRG 516
Min. Negotiated Rate	$16,214.44
Max. Negotiated Rate	$39,483.90
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	$39,483.90
Rate for Payer: Multiplan Commercial	$39,483.90
Rate for Payer: Multiplan Workers Comp	$39,483.90
Rate for Payer: Scott and White EPO/PPO	$18,183.38
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

$60,551.10

Service Code	MSDRG 515
Min. Negotiated Rate	$26,505.20
Max. Negotiated Rate	$60,551.10
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	$60,551.10
Rate for Payer: Multiplan Commercial	$60,551.10
Rate for Payer: Multiplan Workers Comp	$60,551.10
Rate for Payer: Scott and White EPO/PPO	$27,885.38
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

$29,197.30

Service Code	MSDRG 517
Min. Negotiated Rate	$11,875.74
Max. Negotiated Rate	$29,197.30
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	$29,197.30
Rate for Payer: Multiplan Commercial	$29,197.30
Rate for Payer: Multiplan Workers Comp	$29,197.30
Rate for Payer: Scott and White EPO/PPO	$13,446.12
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

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

Facility

$39,483.90

Service Code	MSDRG 516
Min. Negotiated Rate	$16,214.44
Max. Negotiated Rate	$39,483.90
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

$60,551.10

Service Code	MSDRG 515
Min. Negotiated Rate	$26,505.20
Max. Negotiated Rate	$60,551.10
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

$29,197.30

Service Code	MSDRG 517
Min. Negotiated Rate	$11,875.74
Max. Negotiated Rate	$29,197.30
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

$23,130.60

Service Code	MSDRG 844
Min. Negotiated Rate	$10,137.68
Max. Negotiated Rate	$23,130.60
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

$37,901.20

Service Code	MSDRG 843
Min. Negotiated Rate	$15,875.60
Max. Negotiated Rate	$37,901.20
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

OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC/MCC

Facility

$16,180.40

Service Code	MSDRG 845
Min. Negotiated Rate	$7,449.32
Max. Negotiated Rate	$16,180.40
Rate for Payer: BCBS of TX Blue Advantage	$7,449.32
Rate for Payer: BCBS of TX Blue Essentials	$8,938.32
Rate for Payer: BCBS of TX PPO	$9,931.85

OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC

Facility

$23,130.60

Service Code	MSDRG 844
Min. Negotiated Rate	$10,137.68
Max. Negotiated Rate	$23,130.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,682.43
Rate for Payer: Amerigroup Medicare	$13,682.43
Rate for Payer: BCBS of TX Medicare	$13,682.43
Rate for Payer: Cigna Commercial	$15,680.11
Rate for Payer: Cigna Medicare	$13,682.43
Rate for Payer: Employer Direct Commercial	$13,682.43
Rate for Payer: Humana Medicare/TRICARE	$13,682.43
Rate for Payer: Molina Dual Medicare/Medicaid	$13,682.43
Rate for Payer: Molina Medicare	$13,682.43
Rate for Payer: Multiplan Auto	$23,130.60
Rate for Payer: Multiplan Commercial	$23,130.60
Rate for Payer: Multiplan Workers Comp	$23,130.60
Rate for Payer: Scott and White EPO/PPO	$10,652.25
Rate for Payer: Scott and White Medicare	$13,682.43
Rate for Payer: Superior Health Plan EPO	$13,682.43
Rate for Payer: Superior Health Plan Medicare	$13,682.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,682.43
Rate for Payer: Universal American Medicare	$13,682.43
Rate for Payer: Wellcare Medicare	$13,682.43
Rate for Payer: Wellmed Medicare	$13,682.43

OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC

Facility

$37,901.20

Service Code	MSDRG 843
Min. Negotiated Rate	$15,875.60
Max. Negotiated Rate	$37,901.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,380.02
Rate for Payer: Amerigroup Medicare	$19,380.02
Rate for Payer: BCBS of TX Medicare	$19,380.02
Rate for Payer: Cigna Commercial	$25,693.02
Rate for Payer: Cigna Medicare	$19,380.02
Rate for Payer: Employer Direct Commercial	$19,380.02
Rate for Payer: Humana Medicare/TRICARE	$19,380.02
Rate for Payer: Molina Dual Medicare/Medicaid	$19,380.02
Rate for Payer: Molina Medicare	$19,380.02
Rate for Payer: Multiplan Auto	$37,901.20
Rate for Payer: Multiplan Commercial	$37,901.20
Rate for Payer: Multiplan Workers Comp	$37,901.20
Rate for Payer: Scott and White EPO/PPO	$17,454.50
Rate for Payer: Scott and White Medicare	$19,380.02
Rate for Payer: Superior Health Plan EPO	$19,380.02
Rate for Payer: Superior Health Plan Medicare	$19,380.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,380.02
Rate for Payer: Universal American Medicare	$19,380.02
Rate for Payer: Wellcare Medicare	$19,380.02
Rate for Payer: Wellmed Medicare	$19,380.02

OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC

Facility

$16,180.40

Service Code	MSDRG 845
Min. Negotiated Rate	$7,449.32
Max. Negotiated Rate	$16,180.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,001.49
Rate for Payer: Amerigroup Medicare	$11,001.49
Rate for Payer: BCBS of TX Medicare	$11,001.49
Rate for Payer: Cigna Commercial	$10,968.61
Rate for Payer: Cigna Medicare	$11,001.49
Rate for Payer: Employer Direct Commercial	$11,001.49
Rate for Payer: Humana Medicare/TRICARE	$11,001.49
Rate for Payer: Molina Dual Medicare/Medicaid	$11,001.49
Rate for Payer: Molina Medicare	$11,001.49
Rate for Payer: Multiplan Auto	$16,180.40
Rate for Payer: Multiplan Commercial	$16,180.40
Rate for Payer: Multiplan Workers Comp	$16,180.40
Rate for Payer: Scott and White EPO/PPO	$7,451.50
Rate for Payer: Scott and White Medicare	$11,001.49
Rate for Payer: Superior Health Plan EPO	$11,001.49
Rate for Payer: Superior Health Plan Medicare	$11,001.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,001.49
Rate for Payer: Universal American Medicare	$11,001.49
Rate for Payer: Wellcare Medicare	$11,001.49
Rate for Payer: Wellmed Medicare	$11,001.49

OTHER NERVOUS SYSTEM AND RELATED PROCEDURES

Facility

$6,593.26

Service Code	APR-DRG 0261
Min. Negotiated Rate	$6,216.36
Max. Negotiated Rate	$6,593.26
Rate for Payer: Amerigroup CHIP/Medicaid	$6,216.36
Rate for Payer: Cigna Medicaid	$6,216.36
Rate for Payer: Molina CHIP/Medicaid	$6,216.36
Rate for Payer: Parkland Medicaid	$6,216.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,593.26

OTHER NERVOUS SYSTEM AND RELATED PROCEDURES

Facility

$10,666.90

Service Code	APR-DRG 0262
Min. Negotiated Rate	$10,057.13
Max. Negotiated Rate	$10,666.90
Rate for Payer: Amerigroup CHIP/Medicaid	$10,057.13
Rate for Payer: Cigna Medicaid	$10,057.13
Rate for Payer: Molina CHIP/Medicaid	$10,057.13
Rate for Payer: Parkland Medicaid	$10,057.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,666.90

OTHER NERVOUS SYSTEM AND RELATED PROCEDURES

Facility

$16,156.89

Service Code	APR-DRG 0263
Min. Negotiated Rate	$15,233.28
Max. Negotiated Rate	$16,156.89
Rate for Payer: Amerigroup CHIP/Medicaid	$15,233.28
Rate for Payer: Cigna Medicaid	$15,233.28
Rate for Payer: Molina CHIP/Medicaid	$15,233.28
Rate for Payer: Parkland Medicaid	$15,233.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,156.89

OTHER NERVOUS SYSTEM AND RELATED PROCEDURES

Facility

$42,991.63

Service Code	APR-DRG 0264
Min. Negotiated Rate	$40,534.01
Max. Negotiated Rate	$42,991.63
Rate for Payer: Amerigroup CHIP/Medicaid	$40,534.01
Rate for Payer: Cigna Medicaid	$40,534.01
Rate for Payer: Molina CHIP/Medicaid	$40,534.01
Rate for Payer: Parkland Medicaid	$40,534.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42,991.63

OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS

Facility

$2,179.78

Service Code	APR-DRG 4252
Min. Negotiated Rate	$2,055.17
Max. Negotiated Rate	$2,179.78
Rate for Payer: Amerigroup CHIP/Medicaid	$2,055.17
Rate for Payer: Cigna Medicaid	$2,055.17
Rate for Payer: Molina CHIP/Medicaid	$2,055.17
Rate for Payer: Parkland Medicaid	$2,055.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,179.78

OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS

Facility

$3,668.54

Service Code	APR-DRG 4253
Min. Negotiated Rate	$3,458.83
Max. Negotiated Rate	$3,668.54
Rate for Payer: Amerigroup CHIP/Medicaid	$3,458.83
Rate for Payer: Cigna Medicaid	$3,458.83
Rate for Payer: Molina CHIP/Medicaid	$3,458.83
Rate for Payer: Parkland Medicaid	$3,458.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,668.54

OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS

Facility

$2,151.11

Service Code	APR-DRG 4251
Min. Negotiated Rate	$2,028.14
Max. Negotiated Rate	$2,151.11
Rate for Payer: Amerigroup CHIP/Medicaid	$2,028.14
Rate for Payer: Cigna Medicaid	$2,028.14
Rate for Payer: Molina CHIP/Medicaid	$2,028.14
Rate for Payer: Parkland Medicaid	$2,028.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,151.11

OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS

Facility

$8,401.13

Service Code	APR-DRG 4254
Min. Negotiated Rate	$7,920.88
Max. Negotiated Rate	$8,401.13
Rate for Payer: Amerigroup CHIP/Medicaid	$7,920.88
Rate for Payer: Cigna Medicaid	$7,920.88
Rate for Payer: Molina CHIP/Medicaid	$7,920.88
Rate for Payer: Parkland Medicaid	$7,920.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,401.13

OTHER OPEN CRANIOTOMY

Facility

$20,900.42

Service Code	APR-DRG 0273
Min. Negotiated Rate	$19,705.65
Max. Negotiated Rate	$20,900.42
Rate for Payer: Amerigroup CHIP/Medicaid	$19,705.65
Rate for Payer: Cigna Medicaid	$19,705.65
Rate for Payer: Molina CHIP/Medicaid	$19,705.65
Rate for Payer: Parkland Medicaid	$19,705.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,900.42

Know your out-of-pocket cost for care.

All Charges