White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS

Facility

$11,154.61

Service Code	APR-DRG 4052
Min. Negotiated Rate	$10,516.96
Max. Negotiated Rate	$11,154.61
Rate for Payer: Amerigroup CHIP/Medicaid	$10,516.96
Rate for Payer: Cigna Medicaid	$10,516.96
Rate for Payer: Molina CHIP/Medicaid	$10,516.96
Rate for Payer: Parkland Medicaid	$10,516.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,154.61

OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS

Facility

$12,824.05

Service Code	APR-DRG 4053
Min. Negotiated Rate	$12,090.96
Max. Negotiated Rate	$12,824.05
Rate for Payer: Amerigroup CHIP/Medicaid	$12,090.96
Rate for Payer: Cigna Medicaid	$12,090.96
Rate for Payer: Molina CHIP/Medicaid	$12,090.96
Rate for Payer: Parkland Medicaid	$12,090.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,824.05

OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS

Facility

$23,484.92

Service Code	APR-DRG 4054
Min. Negotiated Rate	$22,142.40
Max. Negotiated Rate	$23,484.92
Rate for Payer: Amerigroup CHIP/Medicaid	$22,142.40
Rate for Payer: Cigna Medicaid	$22,142.40
Rate for Payer: Molina CHIP/Medicaid	$22,142.40
Rate for Payer: Parkland Medicaid	$22,142.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,484.92

OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS

Facility

$9,485.17

Service Code	APR-DRG 4051
Min. Negotiated Rate	$8,942.95
Max. Negotiated Rate	$9,485.17
Rate for Payer: Amerigroup CHIP/Medicaid	$8,942.95
Rate for Payer: Cigna Medicaid	$8,942.95
Rate for Payer: Molina CHIP/Medicaid	$8,942.95
Rate for Payer: Parkland Medicaid	$8,942.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,485.17

OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS

Facility

$40,737.17

Service Code	APR-DRG 6514
Min. Negotiated Rate	$38,408.43
Max. Negotiated Rate	$40,737.17
Rate for Payer: Amerigroup CHIP/Medicaid	$38,408.43
Rate for Payer: Cigna Medicaid	$38,408.43
Rate for Payer: Molina CHIP/Medicaid	$38,408.43
Rate for Payer: Parkland Medicaid	$38,408.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40,737.17

OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS

Facility

$5,316.10

Service Code	APR-DRG 6511
Min. Negotiated Rate	$5,012.21
Max. Negotiated Rate	$5,316.10
Rate for Payer: Amerigroup CHIP/Medicaid	$5,012.21
Rate for Payer: Cigna Medicaid	$5,012.21
Rate for Payer: Molina CHIP/Medicaid	$5,012.21
Rate for Payer: Parkland Medicaid	$5,012.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,316.10

OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS

Facility

$7,326.52

Service Code	APR-DRG 6512
Min. Negotiated Rate	$6,907.70
Max. Negotiated Rate	$7,326.52
Rate for Payer: Amerigroup CHIP/Medicaid	$6,907.70
Rate for Payer: Cigna Medicaid	$6,907.70
Rate for Payer: Molina CHIP/Medicaid	$6,907.70
Rate for Payer: Parkland Medicaid	$6,907.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,326.52

OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS

Facility

$8,829.62

Service Code	APR-DRG 6513
Min. Negotiated Rate	$8,324.87
Max. Negotiated Rate	$8,829.62
Rate for Payer: Amerigroup CHIP/Medicaid	$8,324.87
Rate for Payer: Cigna Medicaid	$8,324.87
Rate for Payer: Molina CHIP/Medicaid	$8,324.87
Rate for Payer: Parkland Medicaid	$8,324.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,829.62

OTHER RESPIRATORY AND CHEST PROCEDURES

Facility

$9,328.64

Service Code	APR-DRG 1212
Min. Negotiated Rate	$8,795.37
Max. Negotiated Rate	$9,328.64
Rate for Payer: Amerigroup CHIP/Medicaid	$8,795.37
Rate for Payer: Cigna Medicaid	$8,795.37
Rate for Payer: Molina CHIP/Medicaid	$8,795.37
Rate for Payer: Parkland Medicaid	$8,795.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,328.64

OTHER RESPIRATORY AND CHEST PROCEDURES

Facility

$35,384.85

Service Code	APR-DRG 1214
Min. Negotiated Rate	$33,362.08
Max. Negotiated Rate	$35,384.85
Rate for Payer: Amerigroup CHIP/Medicaid	$33,362.08
Rate for Payer: Cigna Medicaid	$33,362.08
Rate for Payer: Molina CHIP/Medicaid	$33,362.08
Rate for Payer: Parkland Medicaid	$33,362.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35,384.85

OTHER RESPIRATORY AND CHEST PROCEDURES

Facility

$6,695.48

Service Code	APR-DRG 1211
Min. Negotiated Rate	$6,312.73
Max. Negotiated Rate	$6,695.48
Rate for Payer: Amerigroup CHIP/Medicaid	$6,312.73
Rate for Payer: Cigna Medicaid	$6,312.73
Rate for Payer: Molina CHIP/Medicaid	$6,312.73
Rate for Payer: Parkland Medicaid	$6,312.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,695.48

OTHER RESPIRATORY AND CHEST PROCEDURES

Facility

$19,137.06

Service Code	APR-DRG 1213
Min. Negotiated Rate	$18,043.09
Max. Negotiated Rate	$19,137.06
Rate for Payer: Amerigroup CHIP/Medicaid	$18,043.09
Rate for Payer: Cigna Medicaid	$18,043.09
Rate for Payer: Molina CHIP/Medicaid	$18,043.09
Rate for Payer: Parkland Medicaid	$18,043.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,137.06

OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES

Facility

$8,432.06

Service Code	APR-DRG 1434
Min. Negotiated Rate	$7,950.04
Max. Negotiated Rate	$8,432.06
Rate for Payer: Amerigroup CHIP/Medicaid	$7,950.04
Rate for Payer: Cigna Medicaid	$7,950.04
Rate for Payer: Molina CHIP/Medicaid	$7,950.04
Rate for Payer: Parkland Medicaid	$7,950.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,432.06

OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES

Facility

$3,434.68

Service Code	APR-DRG 1432
Min. Negotiated Rate	$3,238.34
Max. Negotiated Rate	$3,434.68
Rate for Payer: Amerigroup CHIP/Medicaid	$3,238.34
Rate for Payer: Cigna Medicaid	$3,238.34
Rate for Payer: Molina CHIP/Medicaid	$3,238.34
Rate for Payer: Parkland Medicaid	$3,238.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,434.68

OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES

Facility

$2,380.82

Service Code	APR-DRG 1431
Min. Negotiated Rate	$2,244.72
Max. Negotiated Rate	$2,380.82
Rate for Payer: Amerigroup CHIP/Medicaid	$2,244.72
Rate for Payer: Cigna Medicaid	$2,244.72
Rate for Payer: Molina CHIP/Medicaid	$2,244.72
Rate for Payer: Parkland Medicaid	$2,244.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,380.82

OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES

Facility

$5,329.30

Service Code	APR-DRG 1433
Min. Negotiated Rate	$5,024.65
Max. Negotiated Rate	$5,329.30
Rate for Payer: Amerigroup CHIP/Medicaid	$5,024.65
Rate for Payer: Cigna Medicaid	$5,024.65
Rate for Payer: Molina CHIP/Medicaid	$5,024.65
Rate for Payer: Parkland Medicaid	$5,024.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,329.30

OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC

Facility

$33,839.00

Service Code	MSDRG 205
Min. Negotiated Rate	$13,053.94
Max. Negotiated Rate	$33,839.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,179.53
Rate for Payer: Amerigroup Medicare	$18,179.53
Rate for Payer: BCBS of TX Medicare	$18,179.53
Rate for Payer: Cigna Commercial	$23,583.28
Rate for Payer: Cigna Medicare	$18,179.53
Rate for Payer: Employer Direct Commercial	$18,179.53
Rate for Payer: Humana Medicare/TRICARE	$18,179.53
Rate for Payer: Molina Dual Medicare/Medicaid	$18,179.53
Rate for Payer: Molina Medicare	$18,179.53
Rate for Payer: Multiplan Auto	$33,839.00
Rate for Payer: Multiplan Commercial	$33,839.00
Rate for Payer: Multiplan Workers Comp	$33,839.00
Rate for Payer: Scott and White EPO/PPO	$15,583.75
Rate for Payer: Scott and White Medicare	$18,179.53
Rate for Payer: Superior Health Plan EPO	$18,179.53
Rate for Payer: Superior Health Plan Medicare	$18,179.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,179.53
Rate for Payer: Universal American Medicare	$18,179.53
Rate for Payer: Wellcare Medicare	$18,179.53
Rate for Payer: Wellmed Medicare	$18,179.53

OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC

Facility

$16,974.60

Service Code	MSDRG 206
Min. Negotiated Rate	$7,426.10
Max. Negotiated Rate	$16,974.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,657.42
Rate for Payer: Amerigroup Medicare	$11,657.42
Rate for Payer: BCBS of TX Medicare	$11,657.42
Rate for Payer: Cigna Commercial	$12,121.37
Rate for Payer: Cigna Medicare	$11,657.42
Rate for Payer: Employer Direct Commercial	$11,657.42
Rate for Payer: Humana Medicare/TRICARE	$11,657.42
Rate for Payer: Molina Dual Medicare/Medicaid	$11,657.42
Rate for Payer: Molina Medicare	$11,657.42
Rate for Payer: Multiplan Auto	$16,974.60
Rate for Payer: Multiplan Commercial	$16,974.60
Rate for Payer: Multiplan Workers Comp	$16,974.60
Rate for Payer: Scott and White EPO/PPO	$7,817.25
Rate for Payer: Scott and White Medicare	$11,657.42
Rate for Payer: Superior Health Plan EPO	$11,657.42
Rate for Payer: Superior Health Plan Medicare	$11,657.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,657.42
Rate for Payer: Universal American Medicare	$11,657.42
Rate for Payer: Wellcare Medicare	$11,657.42
Rate for Payer: Wellmed Medicare	$11,657.42

OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC

Facility

$33,839.00

Service Code	MSDRG 205
Min. Negotiated Rate	$13,053.94
Max. Negotiated Rate	$33,839.00
Rate for Payer: BCBS of TX Blue Advantage	$13,053.94
Rate for Payer: BCBS of TX Blue Essentials	$15,663.21
Rate for Payer: BCBS of TX PPO	$17,404.24

OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC

Facility

$16,974.60

Service Code	MSDRG 206
Min. Negotiated Rate	$7,426.10
Max. Negotiated Rate	$16,974.60
Rate for Payer: BCBS of TX Blue Advantage	$7,426.10
Rate for Payer: BCBS of TX Blue Essentials	$8,910.46
Rate for Payer: BCBS of TX PPO	$9,900.89

OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC

Facility

$36,120.90

Service Code	MSDRG 167
Min. Negotiated Rate	$16,319.36
Max. Negotiated Rate	$36,120.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,977.24
Rate for Payer: Amerigroup Medicare	$17,977.24
Rate for Payer: BCBS of TX Medicare	$17,977.24
Rate for Payer: Cigna Commercial	$23,227.79
Rate for Payer: Cigna Medicare	$17,977.24
Rate for Payer: Employer Direct Commercial	$17,977.24
Rate for Payer: Humana Medicare/TRICARE	$17,977.24
Rate for Payer: Molina Dual Medicare/Medicaid	$17,977.24
Rate for Payer: Molina Medicare	$17,977.24
Rate for Payer: Multiplan Auto	$36,120.90
Rate for Payer: Multiplan Commercial	$36,120.90
Rate for Payer: Multiplan Workers Comp	$36,120.90
Rate for Payer: Scott and White EPO/PPO	$16,634.62
Rate for Payer: Scott and White Medicare	$17,977.24
Rate for Payer: Superior Health Plan EPO	$17,977.24
Rate for Payer: Superior Health Plan Medicare	$17,977.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,977.24
Rate for Payer: Universal American Medicare	$17,977.24
Rate for Payer: Wellcare Medicare	$17,977.24
Rate for Payer: Wellmed Medicare	$17,977.24

OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC

Facility

$69,650.20

Service Code	MSDRG 166
Min. Negotiated Rate	$30,082.80
Max. Negotiated Rate	$69,650.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$32,153.78
Rate for Payer: Amerigroup Medicare	$32,153.78
Rate for Payer: BCBS of TX Medicare	$32,153.78
Rate for Payer: Cigna Commercial	$48,141.58
Rate for Payer: Cigna Medicare	$32,153.78
Rate for Payer: Employer Direct Commercial	$32,153.78
Rate for Payer: Humana Medicare/TRICARE	$32,153.78
Rate for Payer: Molina Dual Medicare/Medicaid	$32,153.78
Rate for Payer: Molina Medicare	$32,153.78
Rate for Payer: Multiplan Auto	$69,650.20
Rate for Payer: Multiplan Commercial	$69,650.20
Rate for Payer: Multiplan Workers Comp	$69,650.20
Rate for Payer: Scott and White EPO/PPO	$32,075.75
Rate for Payer: Scott and White Medicare	$32,153.78
Rate for Payer: Superior Health Plan EPO	$32,153.78
Rate for Payer: Superior Health Plan Medicare	$32,153.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$32,153.78
Rate for Payer: Universal American Medicare	$32,153.78
Rate for Payer: Wellcare Medicare	$32,153.78
Rate for Payer: Wellmed Medicare	$32,153.78

OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC

Facility

$26,934.40

Service Code	MSDRG 168
Min. Negotiated Rate	$11,537.76
Max. Negotiated Rate	$26,934.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,774.46
Rate for Payer: Amerigroup Medicare	$14,774.46
Rate for Payer: BCBS of TX Medicare	$14,774.46
Rate for Payer: Cigna Commercial	$17,599.23
Rate for Payer: Cigna Medicare	$14,774.46
Rate for Payer: Employer Direct Commercial	$14,774.46
Rate for Payer: Humana Medicare/TRICARE	$14,774.46
Rate for Payer: Molina Dual Medicare/Medicaid	$14,774.46
Rate for Payer: Molina Medicare	$14,774.46
Rate for Payer: Multiplan Auto	$26,934.40
Rate for Payer: Multiplan Commercial	$26,934.40
Rate for Payer: Multiplan Workers Comp	$26,934.40
Rate for Payer: Scott and White EPO/PPO	$12,404.00
Rate for Payer: Scott and White Medicare	$14,774.46
Rate for Payer: Superior Health Plan EPO	$14,774.46
Rate for Payer: Superior Health Plan Medicare	$14,774.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,774.46
Rate for Payer: Universal American Medicare	$14,774.46
Rate for Payer: Wellcare Medicare	$14,774.46
Rate for Payer: Wellmed Medicare	$14,774.46

OTHER RESP SYSTEM O.R. PROCEDURES W CC

Facility

$36,120.90

Service Code	MSDRG 167
Min. Negotiated Rate	$16,319.36
Max. Negotiated Rate	$36,120.90
Rate for Payer: BCBS of TX Blue Advantage	$16,319.36
Rate for Payer: BCBS of TX Blue Essentials	$19,581.33
Rate for Payer: BCBS of TX PPO	$21,757.88

OTHER RESP SYSTEM O.R. PROCEDURES W MCC

Facility

$69,650.20

Service Code	MSDRG 166
Min. Negotiated Rate	$30,082.80
Max. Negotiated Rate	$69,650.20
Rate for Payer: BCBS of TX Blue Advantage	$30,082.80
Rate for Payer: BCBS of TX Blue Essentials	$36,095.86
Rate for Payer: BCBS of TX PPO	$40,108.07

Know your out-of-pocket cost for care.

All Charges