White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$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

$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 SYSTEM DIAGNOSES WITH MCC

Facility

$34,789.00

Service Code	MSDRG 205
Min. Negotiated Rate	$13,053.94
Max. Negotiated Rate	$34,789.00
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	$34,789.00
Rate for Payer: Multiplan Commercial	$34,789.00
Rate for Payer: Multiplan Workers Comp	$34,789.00
Rate for Payer: Scott and White EPO/PPO	$16,021.25
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

$17,880.90

Service Code	MSDRG 206
Min. Negotiated Rate	$7,426.10
Max. Negotiated Rate	$17,880.90
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	$17,880.90
Rate for Payer: Multiplan Commercial	$17,880.90
Rate for Payer: Multiplan Workers Comp	$17,880.90
Rate for Payer: Scott and White EPO/PPO	$8,234.62
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

$34,789.00

Service Code	MSDRG 205
Min. Negotiated Rate	$13,053.94
Max. Negotiated Rate	$34,789.00
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

$17,880.90

Service Code	MSDRG 206
Min. Negotiated Rate	$7,426.10
Max. Negotiated Rate	$17,880.90
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

$34,264.60

Service Code	MSDRG 167
Min. Negotiated Rate	$15,779.75
Max. Negotiated Rate	$34,264.60
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	$34,264.60
Rate for Payer: Multiplan Commercial	$34,264.60
Rate for Payer: Multiplan Workers Comp	$34,264.60
Rate for Payer: Scott and White EPO/PPO	$15,779.75
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

$71,016.30

Service Code	MSDRG 166
Min. Negotiated Rate	$30,082.80
Max. Negotiated Rate	$71,016.30
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	$71,016.30
Rate for Payer: Multiplan Commercial	$71,016.30
Rate for Payer: Multiplan Workers Comp	$71,016.30
Rate for Payer: Scott and White EPO/PPO	$32,704.88
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

$25,961.60

Service Code	MSDRG 168
Min. Negotiated Rate	$11,537.76
Max. Negotiated Rate	$25,961.60
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	$25,961.60
Rate for Payer: Multiplan Commercial	$25,961.60
Rate for Payer: Multiplan Workers Comp	$25,961.60
Rate for Payer: Scott and White EPO/PPO	$11,956.00
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

$34,264.60

Service Code	MSDRG 167
Min. Negotiated Rate	$15,779.75
Max. Negotiated Rate	$34,264.60
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

$71,016.30

Service Code	MSDRG 166
Min. Negotiated Rate	$30,082.80
Max. Negotiated Rate	$71,016.30
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

OTHER RESP SYSTEM O.R. PROCEDURES W/O CC/MCC

Facility

$25,961.60

Service Code	MSDRG 168
Min. Negotiated Rate	$11,537.76
Max. Negotiated Rate	$25,961.60
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

$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 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

$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 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

$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

$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

$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

$32,832.00

Service Code	MSDRG 580
Min. Negotiated Rate	$13,672.28
Max. Negotiated Rate	$32,832.00
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	$32,832.00
Rate for Payer: Multiplan Commercial	$32,832.00
Rate for Payer: Multiplan Workers Comp	$32,832.00
Rate for Payer: Scott and White EPO/PPO	$15,120.00
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

$61,531.50

Service Code	MSDRG 579
Min. Negotiated Rate	$24,061.08
Max. Negotiated Rate	$61,531.50
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	$61,531.50
Rate for Payer: Multiplan Commercial	$61,531.50
Rate for Payer: Multiplan Workers Comp	$61,531.50
Rate for Payer: Scott and White EPO/PPO	$28,336.88
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

$27,418.90

Service Code	MSDRG 581
Min. Negotiated Rate	$10,633.04
Max. Negotiated Rate	$27,418.90
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	$27,418.90
Rate for Payer: Multiplan Commercial	$27,418.90
Rate for Payer: Multiplan Workers Comp	$27,418.90
Rate for Payer: Scott and White EPO/PPO	$12,627.12
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

$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

Know your out-of-pocket cost for care.

All Charges