White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$21,711.00

Service Code	APR-DRG 6813
Min. Negotiated Rate	$20,469.89
Max. Negotiated Rate	$21,711.00
Rate for Payer: Amerigroup CHIP/Medicaid	$20,469.89
Rate for Payer: Cigna Medicaid	$20,469.89
Rate for Payer: Molina CHIP/Medicaid	$20,469.89
Rate for Payer: Parkland Medicaid	$20,469.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,711.00

OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC

Facility

$79,239.50

Service Code	MSDRG 958
Min. Negotiated Rate	$35,643.86
Max. Negotiated Rate	$79,239.50
Rate for Payer: BCBS of TX Blue Advantage	$35,946.28
Rate for Payer: BCBS of TX Blue Essentials	$43,131.36
Rate for Payer: BCBS of TX PPO	$47,925.59

OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC

Facility

$79,239.50

Service Code	MSDRG 958
Min. Negotiated Rate	$35,643.86
Max. Negotiated Rate	$79,239.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35,643.86
Rate for Payer: Amerigroup Medicare	$35,643.86
Rate for Payer: BCBS of TX Medicare	$35,643.86
Rate for Payer: Cigna Commercial	$54,275.03
Rate for Payer: Cigna Medicare	$35,643.86
Rate for Payer: Employer Direct Commercial	$35,643.86
Rate for Payer: Humana Medicare/TRICARE	$35,643.86
Rate for Payer: Molina Dual Medicare/Medicaid	$35,643.86
Rate for Payer: Molina Medicare	$35,643.86
Rate for Payer: Multiplan Auto	$79,239.50
Rate for Payer: Multiplan Commercial	$79,239.50
Rate for Payer: Multiplan Workers Comp	$79,239.50
Rate for Payer: Scott and White EPO/PPO	$36,491.88
Rate for Payer: Scott and White Medicare	$35,643.86
Rate for Payer: Superior Health Plan EPO	$35,643.86
Rate for Payer: Superior Health Plan Medicare	$35,643.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$35,643.86
Rate for Payer: Universal American Medicare	$35,643.86
Rate for Payer: Wellcare Medicare	$35,643.86
Rate for Payer: Wellmed Medicare	$35,643.86

OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC

Facility

$140,799.50

Service Code	MSDRG 957
Min. Negotiated Rate	$60,606.53
Max. Negotiated Rate	$140,799.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$60,606.53
Rate for Payer: Amerigroup Medicare	$60,606.53
Rate for Payer: BCBS of TX Medicare	$60,606.53
Rate for Payer: Cigna Commercial	$98,144.31
Rate for Payer: Cigna Medicare	$60,606.53
Rate for Payer: Employer Direct Commercial	$60,606.53
Rate for Payer: Humana Medicare/TRICARE	$60,606.53
Rate for Payer: Molina Dual Medicare/Medicaid	$60,606.53
Rate for Payer: Molina Medicare	$60,606.53
Rate for Payer: Multiplan Auto	$140,799.50
Rate for Payer: Multiplan Commercial	$140,799.50
Rate for Payer: Multiplan Workers Comp	$140,799.50
Rate for Payer: Scott and White EPO/PPO	$64,841.88
Rate for Payer: Scott and White Medicare	$60,606.53
Rate for Payer: Superior Health Plan EPO	$60,606.53
Rate for Payer: Superior Health Plan Medicare	$60,606.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$60,606.53
Rate for Payer: Universal American Medicare	$60,606.53
Rate for Payer: Wellcare Medicare	$60,606.53
Rate for Payer: Wellmed Medicare	$60,606.53

OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC

Facility

$48,805.30

Service Code	MSDRG 959
Min. Negotiated Rate	$21,076.02
Max. Negotiated Rate	$48,805.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,337.47
Rate for Payer: Amerigroup Medicare	$26,337.47
Rate for Payer: BCBS of TX Medicare	$26,337.47
Rate for Payer: Cigna Commercial	$37,920.01
Rate for Payer: Cigna Medicare	$26,337.47
Rate for Payer: Employer Direct Commercial	$26,337.47
Rate for Payer: Humana Medicare/TRICARE	$26,337.47
Rate for Payer: Molina Dual Medicare/Medicaid	$26,337.47
Rate for Payer: Molina Medicare	$26,337.47
Rate for Payer: Multiplan Auto	$48,805.30
Rate for Payer: Multiplan Commercial	$48,805.30
Rate for Payer: Multiplan Workers Comp	$48,805.30
Rate for Payer: Scott and White EPO/PPO	$22,476.12
Rate for Payer: Scott and White Medicare	$26,337.47
Rate for Payer: Superior Health Plan EPO	$26,337.47
Rate for Payer: Superior Health Plan Medicare	$26,337.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,337.47
Rate for Payer: Universal American Medicare	$26,337.47
Rate for Payer: Wellcare Medicare	$26,337.47
Rate for Payer: Wellmed Medicare	$26,337.47

OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC

Facility

$140,799.50

Service Code	MSDRG 957
Min. Negotiated Rate	$60,606.53
Max. Negotiated Rate	$140,799.50
Rate for Payer: BCBS of TX Blue Advantage	$65,347.10
Rate for Payer: BCBS of TX Blue Essentials	$78,408.92
Rate for Payer: BCBS of TX PPO	$87,124.40

OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC

Facility

$48,805.30

Service Code	MSDRG 959
Min. Negotiated Rate	$21,076.02
Max. Negotiated Rate	$48,805.30
Rate for Payer: BCBS of TX Blue Advantage	$21,076.02
Rate for Payer: BCBS of TX Blue Essentials	$25,288.77
Rate for Payer: BCBS of TX PPO	$28,099.73

OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC

Facility

$39,012.70

Service Code	MSDRG 803
Min. Negotiated Rate	$14,810.06
Max. Negotiated Rate	$39,012.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,384.00
Rate for Payer: Amerigroup Medicare	$18,384.00
Rate for Payer: BCBS of TX Medicare	$18,384.00
Rate for Payer: Cigna Commercial	$23,942.63
Rate for Payer: Cigna Medicare	$18,384.00
Rate for Payer: Employer Direct Commercial	$18,384.00
Rate for Payer: Humana Medicare/TRICARE	$18,384.00
Rate for Payer: Molina Dual Medicare/Medicaid	$18,384.00
Rate for Payer: Molina Medicare	$18,384.00
Rate for Payer: Multiplan Auto	$39,012.70
Rate for Payer: Multiplan Commercial	$39,012.70
Rate for Payer: Multiplan Workers Comp	$39,012.70
Rate for Payer: Scott and White EPO/PPO	$17,966.38
Rate for Payer: Scott and White Medicare	$18,384.00
Rate for Payer: Superior Health Plan EPO	$18,384.00
Rate for Payer: Superior Health Plan Medicare	$18,384.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,384.00
Rate for Payer: Universal American Medicare	$18,384.00
Rate for Payer: Wellcare Medicare	$18,384.00
Rate for Payer: Wellmed Medicare	$18,384.00

OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC

Facility

$72,428.00

Service Code	MSDRG 802
Min. Negotiated Rate	$28,785.92
Max. Negotiated Rate	$72,428.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$33,959.65
Rate for Payer: Amerigroup Medicare	$33,959.65
Rate for Payer: BCBS of TX Medicare	$33,959.65
Rate for Payer: Cigna Commercial	$51,315.21
Rate for Payer: Cigna Medicare	$33,959.65
Rate for Payer: Employer Direct Commercial	$33,959.65
Rate for Payer: Humana Medicare/TRICARE	$33,959.65
Rate for Payer: Molina Dual Medicare/Medicaid	$33,959.65
Rate for Payer: Molina Medicare	$33,959.65
Rate for Payer: Multiplan Auto	$72,428.00
Rate for Payer: Multiplan Commercial	$72,428.00
Rate for Payer: Multiplan Workers Comp	$72,428.00
Rate for Payer: Scott and White EPO/PPO	$33,355.00
Rate for Payer: Scott and White Medicare	$33,959.65
Rate for Payer: Superior Health Plan EPO	$33,959.65
Rate for Payer: Superior Health Plan Medicare	$33,959.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$33,959.65
Rate for Payer: Universal American Medicare	$33,959.65
Rate for Payer: Wellcare Medicare	$33,959.65
Rate for Payer: Wellmed Medicare	$33,959.65

OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC

Facility

$23,974.20

Service Code	MSDRG 804
Min. Negotiated Rate	$10,582.30
Max. Negotiated Rate	$23,974.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,698.25
Rate for Payer: Amerigroup Medicare	$14,698.25
Rate for Payer: BCBS of TX Medicare	$14,698.25
Rate for Payer: Cigna Commercial	$17,465.28
Rate for Payer: Cigna Medicare	$14,698.25
Rate for Payer: Employer Direct Commercial	$14,698.25
Rate for Payer: Humana Medicare/TRICARE	$14,698.25
Rate for Payer: Molina Dual Medicare/Medicaid	$14,698.25
Rate for Payer: Molina Medicare	$14,698.25
Rate for Payer: Multiplan Auto	$23,974.20
Rate for Payer: Multiplan Commercial	$23,974.20
Rate for Payer: Multiplan Workers Comp	$23,974.20
Rate for Payer: Scott and White EPO/PPO	$11,040.75
Rate for Payer: Scott and White Medicare	$14,698.25
Rate for Payer: Superior Health Plan EPO	$14,698.25
Rate for Payer: Superior Health Plan Medicare	$14,698.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,698.25
Rate for Payer: Universal American Medicare	$14,698.25
Rate for Payer: Wellcare Medicare	$14,698.25
Rate for Payer: Wellmed Medicare	$14,698.25

OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W CC

Facility

$39,012.70

Service Code	MSDRG 803
Min. Negotiated Rate	$14,810.06
Max. Negotiated Rate	$39,012.70
Rate for Payer: BCBS of TX Blue Advantage	$14,810.06
Rate for Payer: BCBS of TX Blue Essentials	$17,770.35
Rate for Payer: BCBS of TX PPO	$19,745.60

OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W MCC

Facility

$72,428.00

Service Code	MSDRG 802
Min. Negotiated Rate	$28,785.92
Max. Negotiated Rate	$72,428.00
Rate for Payer: BCBS of TX Blue Advantage	$28,785.92
Rate for Payer: BCBS of TX Blue Essentials	$34,539.76
Rate for Payer: BCBS of TX PPO	$38,379.00

OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W/O CC/MCC

Facility

$23,974.20

Service Code	MSDRG 804
Min. Negotiated Rate	$10,582.30
Max. Negotiated Rate	$23,974.20
Rate for Payer: BCBS of TX Blue Advantage	$10,582.30
Rate for Payer: BCBS of TX Blue Essentials	$12,697.53
Rate for Payer: BCBS of TX PPO	$14,108.91

OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES

Facility

$16,294.56

Service Code	APR-DRG 0292
Min. Negotiated Rate	$15,363.09
Max. Negotiated Rate	$16,294.56
Rate for Payer: Amerigroup CHIP/Medicaid	$15,363.09
Rate for Payer: Cigna Medicaid	$15,363.09
Rate for Payer: Molina CHIP/Medicaid	$15,363.09
Rate for Payer: Parkland Medicaid	$15,363.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,294.56

OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES

Facility

$22,053.11

Service Code	APR-DRG 0293
Min. Negotiated Rate	$20,792.44
Max. Negotiated Rate	$22,053.11
Rate for Payer: Amerigroup CHIP/Medicaid	$20,792.44
Rate for Payer: Cigna Medicaid	$20,792.44
Rate for Payer: Molina CHIP/Medicaid	$20,792.44
Rate for Payer: Parkland Medicaid	$20,792.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,053.11

OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES

Facility

$25,024.23

Service Code	APR-DRG 0294
Min. Negotiated Rate	$23,593.72
Max. Negotiated Rate	$25,024.23
Rate for Payer: Amerigroup CHIP/Medicaid	$23,593.72
Rate for Payer: Cigna Medicaid	$23,593.72
Rate for Payer: Molina CHIP/Medicaid	$23,593.72
Rate for Payer: Parkland Medicaid	$23,593.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,024.23

OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES

Facility

$15,391.57

Service Code	APR-DRG 0291
Min. Negotiated Rate	$14,511.72
Max. Negotiated Rate	$15,391.57
Rate for Payer: Amerigroup CHIP/Medicaid	$14,511.72
Rate for Payer: Cigna Medicaid	$14,511.72
Rate for Payer: Molina CHIP/Medicaid	$14,511.72
Rate for Payer: Parkland Medicaid	$14,511.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,391.57

OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES

Facility

$42,517.88

Service Code	APR-DRG 1824
Min. Negotiated Rate	$40,087.34
Max. Negotiated Rate	$42,517.88
Rate for Payer: Amerigroup CHIP/Medicaid	$40,087.34
Rate for Payer: Cigna Medicaid	$40,087.34
Rate for Payer: Molina CHIP/Medicaid	$40,087.34
Rate for Payer: Parkland Medicaid	$40,087.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42,517.88

OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES

Facility

$7,780.65

Service Code	APR-DRG 1821
Min. Negotiated Rate	$7,335.87
Max. Negotiated Rate	$7,780.65
Rate for Payer: Amerigroup CHIP/Medicaid	$7,335.87
Rate for Payer: Cigna Medicaid	$7,335.87
Rate for Payer: Molina CHIP/Medicaid	$7,335.87
Rate for Payer: Parkland Medicaid	$7,335.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,780.65

OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES

Facility

$10,887.94

Service Code	APR-DRG 1822
Min. Negotiated Rate	$10,265.53
Max. Negotiated Rate	$10,887.94
Rate for Payer: Amerigroup CHIP/Medicaid	$10,265.53
Rate for Payer: Cigna Medicaid	$10,265.53
Rate for Payer: Molina CHIP/Medicaid	$10,265.53
Rate for Payer: Parkland Medicaid	$10,265.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,887.94

OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES

Facility

$14,425.59

Service Code	APR-DRG 1823
Min. Negotiated Rate	$13,600.95
Max. Negotiated Rate	$14,425.59
Rate for Payer: Amerigroup CHIP/Medicaid	$13,600.95
Rate for Payer: Cigna Medicaid	$13,600.95
Rate for Payer: Molina CHIP/Medicaid	$13,600.95
Rate for Payer: Parkland Medicaid	$13,600.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,425.59

OTHER PNEUMONIA

Facility

$4,573.04

Service Code	APR-DRG 1393
Min. Negotiated Rate	$4,311.62
Max. Negotiated Rate	$4,573.04
Rate for Payer: Amerigroup CHIP/Medicaid	$4,311.62
Rate for Payer: Cigna Medicaid	$4,311.62
Rate for Payer: Molina CHIP/Medicaid	$4,311.62
Rate for Payer: Parkland Medicaid	$4,311.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,573.04

OTHER PNEUMONIA

Facility

$1,861.43

Service Code	APR-DRG 1391
Min. Negotiated Rate	$1,755.02
Max. Negotiated Rate	$1,861.43
Rate for Payer: Amerigroup CHIP/Medicaid	$1,755.02
Rate for Payer: Cigna Medicaid	$1,755.02
Rate for Payer: Molina CHIP/Medicaid	$1,755.02
Rate for Payer: Parkland Medicaid	$1,755.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,861.43

OTHER PNEUMONIA

Facility

$7,849.68

Service Code	APR-DRG 1394
Min. Negotiated Rate	$7,400.95
Max. Negotiated Rate	$7,849.68
Rate for Payer: Amerigroup CHIP/Medicaid	$7,400.95
Rate for Payer: Cigna Medicaid	$7,400.95
Rate for Payer: Molina CHIP/Medicaid	$7,400.95
Rate for Payer: Parkland Medicaid	$7,400.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,849.68

OTHER PNEUMONIA

Facility

$2,892.29

Service Code	APR-DRG 1392
Min. Negotiated Rate	$2,726.95
Max. Negotiated Rate	$2,892.29
Rate for Payer: Amerigroup CHIP/Medicaid	$2,726.95
Rate for Payer: Cigna Medicaid	$2,726.95
Rate for Payer: Molina CHIP/Medicaid	$2,726.95
Rate for Payer: Parkland Medicaid	$2,726.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,892.29

Know your out-of-pocket cost for care.

All Charges