White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$16,064.50

Service Code	MSDRG 845
Min. Negotiated Rate	$7,398.12
Max. Negotiated Rate	$16,064.50
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

$21,671.40

Service Code	MSDRG 844
Min. Negotiated Rate	$9,980.25
Max. Negotiated Rate	$21,671.40
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	$21,671.40
Rate for Payer: Multiplan Commercial	$21,671.40
Rate for Payer: Multiplan Workers Comp	$21,671.40
Rate for Payer: Scott and White EPO/PPO	$9,980.25
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

$36,810.60

Service Code	MSDRG 843
Min. Negotiated Rate	$15,875.60
Max. Negotiated Rate	$36,810.60
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	$36,810.60
Rate for Payer: Multiplan Commercial	$36,810.60
Rate for Payer: Multiplan Workers Comp	$36,810.60
Rate for Payer: Scott and White EPO/PPO	$16,952.25
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

$16,064.50

Service Code	MSDRG 845
Min. Negotiated Rate	$7,398.12
Max. Negotiated Rate	$16,064.50
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	$16,064.50
Rate for Payer: Multiplan Commercial	$16,064.50
Rate for Payer: Multiplan Workers Comp	$16,064.50
Rate for Payer: Scott and White EPO/PPO	$7,398.12
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

$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

$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

$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

$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 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 OPEN CRANIOTOMY

Facility

$23,047.76

Service Code	APR-DRG 0274
Min. Negotiated Rate	$21,730.23
Max. Negotiated Rate	$23,047.76
Rate for Payer: Amerigroup CHIP/Medicaid	$21,730.23
Rate for Payer: Cigna Medicaid	$21,730.23
Rate for Payer: Molina CHIP/Medicaid	$21,730.23
Rate for Payer: Parkland Medicaid	$21,730.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,047.76

OTHER OPEN CRANIOTOMY

Facility

$8,982.00

Service Code	APR-DRG 0271
Min. Negotiated Rate	$8,468.55
Max. Negotiated Rate	$8,982.00
Rate for Payer: Amerigroup CHIP/Medicaid	$8,468.55
Rate for Payer: Cigna Medicaid	$8,468.55
Rate for Payer: Molina CHIP/Medicaid	$8,468.55
Rate for Payer: Parkland Medicaid	$8,468.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,982.00

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

OTHER OPEN CRANIOTOMY

Facility

$14,941.21

Service Code	APR-DRG 0272
Min. Negotiated Rate	$14,087.10
Max. Negotiated Rate	$14,941.21
Rate for Payer: Amerigroup CHIP/Medicaid	$14,087.10
Rate for Payer: Cigna Medicaid	$14,087.10
Rate for Payer: Molina CHIP/Medicaid	$14,087.10
Rate for Payer: Parkland Medicaid	$14,087.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,941.21

OTHER O.R. PROCEDURES FOR INJURIES W CC

Facility

$39,073.50

Service Code	MSDRG 908
Min. Negotiated Rate	$17,138.08
Max. Negotiated Rate	$39,073.50
Rate for Payer: BCBS of TX Blue Advantage	$17,138.08
Rate for Payer: BCBS of TX Blue Essentials	$20,563.70
Rate for Payer: BCBS of TX PPO	$22,849.44

OTHER O.R. PROCEDURES FOR INJURIES WITH CC

Facility

$39,073.50

Service Code	MSDRG 908
Min. Negotiated Rate	$17,138.08
Max. Negotiated Rate	$39,073.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,382.95
Rate for Payer: Amerigroup Medicare	$19,382.95
Rate for Payer: BCBS of TX Medicare	$19,382.95
Rate for Payer: Cigna Commercial	$25,698.18
Rate for Payer: Cigna Medicare	$19,382.95
Rate for Payer: Employer Direct Commercial	$19,382.95
Rate for Payer: Humana Medicare/TRICARE	$19,382.95
Rate for Payer: Molina Dual Medicare/Medicaid	$19,382.95
Rate for Payer: Molina Medicare	$19,382.95
Rate for Payer: Multiplan Auto	$39,073.50
Rate for Payer: Multiplan Commercial	$39,073.50
Rate for Payer: Multiplan Workers Comp	$39,073.50
Rate for Payer: Scott and White EPO/PPO	$17,994.38
Rate for Payer: Scott and White Medicare	$19,382.95
Rate for Payer: Superior Health Plan EPO	$19,382.95
Rate for Payer: Superior Health Plan Medicare	$19,382.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,382.95
Rate for Payer: Universal American Medicare	$19,382.95
Rate for Payer: Wellcare Medicare	$19,382.95
Rate for Payer: Wellmed Medicare	$19,382.95

OTHER O.R. PROCEDURES FOR INJURIES WITH MCC

Facility

$73,448.30

Service Code	MSDRG 907
Min. Negotiated Rate	$32,898.41
Max. Negotiated Rate	$73,448.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$32,898.41
Rate for Payer: Amerigroup Medicare	$32,898.41
Rate for Payer: BCBS of TX Medicare	$32,898.41
Rate for Payer: Cigna Commercial	$49,450.18
Rate for Payer: Cigna Medicare	$32,898.41
Rate for Payer: Employer Direct Commercial	$32,898.41
Rate for Payer: Humana Medicare/TRICARE	$32,898.41
Rate for Payer: Molina Dual Medicare/Medicaid	$32,898.41
Rate for Payer: Molina Medicare	$32,898.41
Rate for Payer: Multiplan Auto	$73,448.30
Rate for Payer: Multiplan Commercial	$73,448.30
Rate for Payer: Multiplan Workers Comp	$73,448.30
Rate for Payer: Scott and White EPO/PPO	$33,824.88
Rate for Payer: Scott and White Medicare	$32,898.41
Rate for Payer: Superior Health Plan EPO	$32,898.41
Rate for Payer: Superior Health Plan Medicare	$32,898.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$32,898.41
Rate for Payer: Universal American Medicare	$32,898.41
Rate for Payer: Wellcare Medicare	$32,898.41
Rate for Payer: Wellmed Medicare	$32,898.41

OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC

Facility

$25,929.30

Service Code	MSDRG 909
Min. Negotiated Rate	$11,398.44
Max. Negotiated Rate	$25,929.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,380.89
Rate for Payer: Amerigroup Medicare	$14,380.89
Rate for Payer: BCBS of TX Medicare	$14,380.89
Rate for Payer: Cigna Commercial	$16,907.58
Rate for Payer: Cigna Medicare	$14,380.89
Rate for Payer: Employer Direct Commercial	$14,380.89
Rate for Payer: Humana Medicare/TRICARE	$14,380.89
Rate for Payer: Molina Dual Medicare/Medicaid	$14,380.89
Rate for Payer: Molina Medicare	$14,380.89
Rate for Payer: Multiplan Auto	$25,929.30
Rate for Payer: Multiplan Commercial	$25,929.30
Rate for Payer: Multiplan Workers Comp	$25,929.30
Rate for Payer: Scott and White EPO/PPO	$11,941.12
Rate for Payer: Scott and White Medicare	$14,380.89
Rate for Payer: Superior Health Plan EPO	$14,380.89
Rate for Payer: Superior Health Plan Medicare	$14,380.89
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,380.89
Rate for Payer: Universal American Medicare	$14,380.89
Rate for Payer: Wellcare Medicare	$14,380.89
Rate for Payer: Wellmed Medicare	$14,380.89

OTHER O.R. PROCEDURES FOR INJURIES W MCC

Facility

$73,448.30

Service Code	MSDRG 907
Min. Negotiated Rate	$32,898.41
Max. Negotiated Rate	$73,448.30
Rate for Payer: BCBS of TX Blue Advantage	$36,258.46
Rate for Payer: BCBS of TX Blue Essentials	$43,505.94
Rate for Payer: BCBS of TX PPO	$48,341.80

OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC

Facility

$25,929.30

Service Code	MSDRG 909
Min. Negotiated Rate	$11,398.44
Max. Negotiated Rate	$25,929.30
Rate for Payer: BCBS of TX Blue Advantage	$11,398.44
Rate for Payer: BCBS of TX Blue Essentials	$13,676.80
Rate for Payer: BCBS of TX PPO	$15,197.04

OTHER O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS

Facility

$9,621.34

Service Code	APR-DRG 6811
Min. Negotiated Rate	$9,071.33
Max. Negotiated Rate	$9,621.34
Rate for Payer: Amerigroup CHIP/Medicaid	$9,071.33
Rate for Payer: Cigna Medicaid	$9,071.33
Rate for Payer: Molina CHIP/Medicaid	$9,071.33
Rate for Payer: Parkland Medicaid	$9,071.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,621.34

OTHER O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS

Facility

$10,126.39

Service Code	APR-DRG 6812
Min. Negotiated Rate	$9,547.52
Max. Negotiated Rate	$10,126.39
Rate for Payer: Amerigroup CHIP/Medicaid	$9,547.52
Rate for Payer: Cigna Medicaid	$9,547.52
Rate for Payer: Molina CHIP/Medicaid	$9,547.52
Rate for Payer: Parkland Medicaid	$9,547.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,126.39

OTHER O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS

Facility

$81,777.59

Service Code	APR-DRG 6814
Min. Negotiated Rate	$77,102.78
Max. Negotiated Rate	$81,777.59
Rate for Payer: Amerigroup CHIP/Medicaid	$77,102.78
Rate for Payer: Cigna Medicaid	$77,102.78
Rate for Payer: Molina CHIP/Medicaid	$77,102.78
Rate for Payer: Parkland Medicaid	$77,102.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81,777.59

Know your out-of-pocket cost for care.

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