White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER RESP SYSTEM O.R. PROCEDURES W/O 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: BCBS of TX Blue Advantage	$11,537.76
Rate for Payer: BCBS of TX Blue Essentials	$13,843.97
Rate for Payer: BCBS of TX PPO	$15,382.79

OTHER SIGNIFICANT HIP AND FEMUR SURGERY

Facility

$10,261.05

Service Code	APR-DRG 3092
Min. Negotiated Rate	$9,674.48
Max. Negotiated Rate	$10,261.05
Rate for Payer: Amerigroup CHIP/Medicaid	$9,674.48
Rate for Payer: Cigna Medicaid	$9,674.48
Rate for Payer: Molina CHIP/Medicaid	$9,674.48
Rate for Payer: Parkland Medicaid	$9,674.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,261.05

OTHER SIGNIFICANT HIP AND FEMUR SURGERY

Facility

$7,287.67

Service Code	APR-DRG 3091
Min. Negotiated Rate	$6,871.07
Max. Negotiated Rate	$7,287.67
Rate for Payer: Amerigroup CHIP/Medicaid	$6,871.07
Rate for Payer: Cigna Medicaid	$6,871.07
Rate for Payer: Molina CHIP/Medicaid	$6,871.07
Rate for Payer: Parkland Medicaid	$6,871.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,287.67

OTHER SIGNIFICANT HIP AND FEMUR SURGERY

Facility

$14,457.28

Service Code	APR-DRG 3093
Min. Negotiated Rate	$13,630.83
Max. Negotiated Rate	$14,457.28
Rate for Payer: Amerigroup CHIP/Medicaid	$13,630.83
Rate for Payer: Cigna Medicaid	$13,630.83
Rate for Payer: Molina CHIP/Medicaid	$13,630.83
Rate for Payer: Parkland Medicaid	$13,630.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,457.28

OTHER SIGNIFICANT HIP AND FEMUR SURGERY

Facility

$19,087.65

Service Code	APR-DRG 3094
Min. Negotiated Rate	$17,996.50
Max. Negotiated Rate	$19,087.65
Rate for Payer: Amerigroup CHIP/Medicaid	$17,996.50
Rate for Payer: Cigna Medicaid	$17,996.50
Rate for Payer: Molina CHIP/Medicaid	$17,996.50
Rate for Payer: Parkland Medicaid	$17,996.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,087.65

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS

Facility

$1,979.87

Service Code	APR-DRG 3851
Min. Negotiated Rate	$1,866.69
Max. Negotiated Rate	$1,979.87
Rate for Payer: Amerigroup CHIP/Medicaid	$1,866.69
Rate for Payer: Cigna Medicaid	$1,866.69
Rate for Payer: Molina CHIP/Medicaid	$1,866.69
Rate for Payer: Parkland Medicaid	$1,866.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,979.87

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS

Facility

$7,285.03

Service Code	APR-DRG 3853
Min. Negotiated Rate	$6,868.58
Max. Negotiated Rate	$7,285.03
Rate for Payer: Amerigroup CHIP/Medicaid	$6,868.58
Rate for Payer: Cigna Medicaid	$6,868.58
Rate for Payer: Molina CHIP/Medicaid	$6,868.58
Rate for Payer: Parkland Medicaid	$6,868.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,285.03

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS

Facility

$13,913.75

Service Code	APR-DRG 3854
Min. Negotiated Rate	$13,118.37
Max. Negotiated Rate	$13,913.75
Rate for Payer: Amerigroup CHIP/Medicaid	$13,118.37
Rate for Payer: Cigna Medicaid	$13,118.37
Rate for Payer: Molina CHIP/Medicaid	$13,118.37
Rate for Payer: Parkland Medicaid	$13,118.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,913.75

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS

Facility

$3,341.52

Service Code	APR-DRG 3852
Min. Negotiated Rate	$3,150.50
Max. Negotiated Rate	$3,341.52
Rate for Payer: Amerigroup CHIP/Medicaid	$3,150.50
Rate for Payer: Cigna Medicaid	$3,150.50
Rate for Payer: Molina CHIP/Medicaid	$3,150.50
Rate for Payer: Parkland Medicaid	$3,150.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,341.52

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC

Facility

$32,987.80

Service Code	MSDRG 580
Min. Negotiated Rate	$13,672.28
Max. Negotiated Rate	$32,987.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,424.63
Rate for Payer: Amerigroup Medicare	$17,424.63
Rate for Payer: BCBS of TX Medicare	$17,424.63
Rate for Payer: Cigna Commercial	$22,256.64
Rate for Payer: Cigna Medicare	$17,424.63
Rate for Payer: Employer Direct Commercial	$17,424.63
Rate for Payer: Humana Medicare/TRICARE	$17,424.63
Rate for Payer: Molina Dual Medicare/Medicaid	$17,424.63
Rate for Payer: Molina Medicare	$17,424.63
Rate for Payer: Multiplan Auto	$32,987.80
Rate for Payer: Multiplan Commercial	$32,987.80
Rate for Payer: Multiplan Workers Comp	$32,987.80
Rate for Payer: Scott and White EPO/PPO	$15,191.75
Rate for Payer: Scott and White Medicare	$17,424.63
Rate for Payer: Superior Health Plan EPO	$17,424.63
Rate for Payer: Superior Health Plan Medicare	$17,424.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,424.63
Rate for Payer: Universal American Medicare	$17,424.63
Rate for Payer: Wellcare Medicare	$17,424.63
Rate for Payer: Wellmed Medicare	$17,424.63

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC

Facility

$59,882.30

Service Code	MSDRG 579
Min. Negotiated Rate	$24,061.08
Max. Negotiated Rate	$59,882.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,495.13
Rate for Payer: Amerigroup Medicare	$28,495.13
Rate for Payer: BCBS of TX Medicare	$28,495.13
Rate for Payer: Cigna Commercial	$41,711.88
Rate for Payer: Cigna Medicare	$28,495.13
Rate for Payer: Employer Direct Commercial	$28,495.13
Rate for Payer: Humana Medicare/TRICARE	$28,495.13
Rate for Payer: Molina Dual Medicare/Medicaid	$28,495.13
Rate for Payer: Molina Medicare	$28,495.13
Rate for Payer: Multiplan Auto	$59,882.30
Rate for Payer: Multiplan Commercial	$59,882.30
Rate for Payer: Multiplan Workers Comp	$59,882.30
Rate for Payer: Scott and White EPO/PPO	$27,577.38
Rate for Payer: Scott and White Medicare	$28,495.13
Rate for Payer: Superior Health Plan EPO	$28,495.13
Rate for Payer: Superior Health Plan Medicare	$28,495.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,495.13
Rate for Payer: Universal American Medicare	$28,495.13
Rate for Payer: Wellcare Medicare	$28,495.13
Rate for Payer: Wellmed Medicare	$28,495.13

OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC

Facility

$26,818.50

Service Code	MSDRG 581
Min. Negotiated Rate	$10,633.04
Max. Negotiated Rate	$26,818.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,336.60
Rate for Payer: Amerigroup Medicare	$15,336.60
Rate for Payer: BCBS of TX Medicare	$15,336.60
Rate for Payer: Cigna Commercial	$18,587.13
Rate for Payer: Cigna Medicare	$15,336.60
Rate for Payer: Employer Direct Commercial	$15,336.60
Rate for Payer: Humana Medicare/TRICARE	$15,336.60
Rate for Payer: Molina Dual Medicare/Medicaid	$15,336.60
Rate for Payer: Molina Medicare	$15,336.60
Rate for Payer: Multiplan Auto	$26,818.50
Rate for Payer: Multiplan Commercial	$26,818.50
Rate for Payer: Multiplan Workers Comp	$26,818.50
Rate for Payer: Scott and White EPO/PPO	$12,350.62
Rate for Payer: Scott and White Medicare	$15,336.60
Rate for Payer: Superior Health Plan EPO	$15,336.60
Rate for Payer: Superior Health Plan Medicare	$15,336.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,336.60
Rate for Payer: Universal American Medicare	$15,336.60
Rate for Payer: Wellcare Medicare	$15,336.60
Rate for Payer: Wellmed Medicare	$15,336.60

OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES

Facility

$5,002.28

Service Code	APR-DRG 3642
Min. Negotiated Rate	$4,716.33
Max. Negotiated Rate	$5,002.28
Rate for Payer: Amerigroup CHIP/Medicaid	$4,716.33
Rate for Payer: Cigna Medicaid	$4,716.33
Rate for Payer: Molina CHIP/Medicaid	$4,716.33
Rate for Payer: Parkland Medicaid	$4,716.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,002.28

OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES

Facility

$18,605.60

Service Code	APR-DRG 3644
Min. Negotiated Rate	$17,542.01
Max. Negotiated Rate	$18,605.60
Rate for Payer: Amerigroup CHIP/Medicaid	$17,542.01
Rate for Payer: Cigna Medicaid	$17,542.01
Rate for Payer: Molina CHIP/Medicaid	$17,542.01
Rate for Payer: Parkland Medicaid	$17,542.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,605.60

OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES

Facility

$3,244.96

Service Code	APR-DRG 3641
Min. Negotiated Rate	$3,059.46
Max. Negotiated Rate	$3,244.96
Rate for Payer: Amerigroup CHIP/Medicaid	$3,059.46
Rate for Payer: Cigna Medicaid	$3,059.46
Rate for Payer: Molina CHIP/Medicaid	$3,059.46
Rate for Payer: Parkland Medicaid	$3,059.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,244.96

OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES

Facility

$9,286.02

Service Code	APR-DRG 3643
Min. Negotiated Rate	$8,755.18
Max. Negotiated Rate	$9,286.02
Rate for Payer: Amerigroup CHIP/Medicaid	$8,755.18
Rate for Payer: Cigna Medicaid	$8,755.18
Rate for Payer: Molina CHIP/Medicaid	$8,755.18
Rate for Payer: Parkland Medicaid	$8,755.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,286.02

OTHER SKIN, SUBCUT TISS & BREAST PROC W CC

Facility

$32,987.80

Service Code	MSDRG 580
Min. Negotiated Rate	$13,672.28
Max. Negotiated Rate	$32,987.80
Rate for Payer: BCBS of TX Blue Advantage	$13,672.28
Rate for Payer: BCBS of TX Blue Essentials	$16,405.15
Rate for Payer: BCBS of TX PPO	$18,228.65

OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC

Facility

$59,882.30

Service Code	MSDRG 579
Min. Negotiated Rate	$24,061.08
Max. Negotiated Rate	$59,882.30
Rate for Payer: BCBS of TX Blue Advantage	$24,061.08
Rate for Payer: BCBS of TX Blue Essentials	$28,870.50
Rate for Payer: BCBS of TX PPO	$32,079.57

OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC

Facility

$26,818.50

Service Code	MSDRG 581
Min. Negotiated Rate	$10,633.04
Max. Negotiated Rate	$26,818.50
Rate for Payer: BCBS of TX Blue Advantage	$10,633.04
Rate for Payer: BCBS of TX Blue Essentials	$12,758.41
Rate for Payer: BCBS of TX PPO	$14,176.56

OTHER SMALL AND LARGE BOWEL PROCEDURES

Facility

$5,140.33

Service Code	APR-DRG 2231
Min. Negotiated Rate	$4,846.48
Max. Negotiated Rate	$5,140.33
Rate for Payer: Amerigroup CHIP/Medicaid	$4,846.48
Rate for Payer: Cigna Medicaid	$4,846.48
Rate for Payer: Molina CHIP/Medicaid	$4,846.48
Rate for Payer: Parkland Medicaid	$4,846.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,140.33

OTHER SMALL AND LARGE BOWEL PROCEDURES

Facility

$8,932.21

Service Code	APR-DRG 2233
Min. Negotiated Rate	$8,421.60
Max. Negotiated Rate	$8,932.21
Rate for Payer: Amerigroup CHIP/Medicaid	$8,421.60
Rate for Payer: Cigna Medicaid	$8,421.60
Rate for Payer: Molina CHIP/Medicaid	$8,421.60
Rate for Payer: Parkland Medicaid	$8,421.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,932.21

OTHER SMALL AND LARGE BOWEL PROCEDURES

Facility

$6,493.69

Service Code	APR-DRG 2232
Min. Negotiated Rate	$6,122.47
Max. Negotiated Rate	$6,493.69
Rate for Payer: Amerigroup CHIP/Medicaid	$6,122.47
Rate for Payer: Cigna Medicaid	$6,122.47
Rate for Payer: Molina CHIP/Medicaid	$6,122.47
Rate for Payer: Parkland Medicaid	$6,122.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,493.69

OTHER SMALL AND LARGE BOWEL PROCEDURES

Facility

$29,608.96

Service Code	APR-DRG 2234
Min. Negotiated Rate	$27,916.36
Max. Negotiated Rate	$29,608.96
Rate for Payer: Amerigroup CHIP/Medicaid	$27,916.36
Rate for Payer: Cigna Medicaid	$27,916.36
Rate for Payer: Molina CHIP/Medicaid	$27,916.36
Rate for Payer: Parkland Medicaid	$27,916.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,608.96

OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$15,799.32

Service Code	APR-DRG 2223
Min. Negotiated Rate	$14,896.15
Max. Negotiated Rate	$15,799.32
Rate for Payer: Amerigroup CHIP/Medicaid	$14,896.15
Rate for Payer: Cigna Medicaid	$14,896.15
Rate for Payer: Molina CHIP/Medicaid	$14,896.15
Rate for Payer: Parkland Medicaid	$14,896.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,799.32

OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$7,205.44

Service Code	APR-DRG 2222
Min. Negotiated Rate	$6,793.54
Max. Negotiated Rate	$7,205.44
Rate for Payer: Amerigroup CHIP/Medicaid	$6,793.54
Rate for Payer: Cigna Medicaid	$6,793.54
Rate for Payer: Molina CHIP/Medicaid	$6,793.54
Rate for Payer: Parkland Medicaid	$6,793.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,205.44

Know your out-of-pocket cost for care.

All Charges