White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$22,419.74

Service Code	APR-DRG 2224
Min. Negotiated Rate	$21,138.11
Max. Negotiated Rate	$22,419.74
Rate for Payer: Amerigroup CHIP/Medicaid	$21,138.11
Rate for Payer: Cigna Medicaid	$21,138.11
Rate for Payer: Molina CHIP/Medicaid	$21,138.11
Rate for Payer: Parkland Medicaid	$21,138.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,419.74

OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$3,635.35

Service Code	APR-DRG 2221
Min. Negotiated Rate	$3,427.53
Max. Negotiated Rate	$3,635.35
Rate for Payer: Amerigroup CHIP/Medicaid	$3,427.53
Rate for Payer: Cigna Medicaid	$3,427.53
Rate for Payer: Molina CHIP/Medicaid	$3,427.53
Rate for Payer: Parkland Medicaid	$3,427.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,635.35

OTHER VASCULAR PROCEDURES W CC

Facility

$50,806.00

Service Code	MSDRG 253
Min. Negotiated Rate	$22,310.98
Max. Negotiated Rate	$50,806.00
Rate for Payer: BCBS of TX Blue Advantage	$22,310.98
Rate for Payer: BCBS of TX Blue Essentials	$26,770.58
Rate for Payer: BCBS of TX PPO	$29,746.24

OTHER VASCULAR PROCEDURES WITH CC

Facility

$50,806.00

Service Code	MSDRG 253
Min. Negotiated Rate	$22,310.98
Max. Negotiated Rate	$50,806.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,783.30
Rate for Payer: Amerigroup Medicare	$23,783.30
Rate for Payer: BCBS of TX Medicare	$23,783.30
Rate for Payer: Cigna Commercial	$33,431.33
Rate for Payer: Cigna Medicare	$23,783.30
Rate for Payer: Employer Direct Commercial	$23,783.30
Rate for Payer: Humana Medicare/TRICARE	$23,783.30
Rate for Payer: Molina Dual Medicare/Medicaid	$23,783.30
Rate for Payer: Molina Medicare	$23,783.30
Rate for Payer: Multiplan Auto	$50,806.00
Rate for Payer: Multiplan Commercial	$50,806.00
Rate for Payer: Multiplan Workers Comp	$50,806.00
Rate for Payer: Scott and White EPO/PPO	$23,397.50
Rate for Payer: Scott and White Medicare	$23,783.30
Rate for Payer: Superior Health Plan EPO	$23,783.30
Rate for Payer: Superior Health Plan Medicare	$23,783.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,783.30
Rate for Payer: Universal American Medicare	$23,783.30
Rate for Payer: Wellcare Medicare	$23,783.30
Rate for Payer: Wellmed Medicare	$23,783.30

OTHER VASCULAR PROCEDURES WITH MCC

Facility

$63,522.70

Service Code	MSDRG 252
Min. Negotiated Rate	$28,034.28
Max. Negotiated Rate	$63,522.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,325.92
Rate for Payer: Amerigroup Medicare	$30,325.92
Rate for Payer: BCBS of TX Medicare	$30,325.92
Rate for Payer: Cigna Commercial	$44,929.30
Rate for Payer: Cigna Medicare	$30,325.92
Rate for Payer: Employer Direct Commercial	$30,325.92
Rate for Payer: Humana Medicare/TRICARE	$30,325.92
Rate for Payer: Molina Dual Medicare/Medicaid	$30,325.92
Rate for Payer: Molina Medicare	$30,325.92
Rate for Payer: Multiplan Auto	$63,522.70
Rate for Payer: Multiplan Commercial	$63,522.70
Rate for Payer: Multiplan Workers Comp	$63,522.70
Rate for Payer: Scott and White EPO/PPO	$29,253.88
Rate for Payer: Scott and White Medicare	$30,325.92
Rate for Payer: Superior Health Plan EPO	$30,325.92
Rate for Payer: Superior Health Plan Medicare	$30,325.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,325.92
Rate for Payer: Universal American Medicare	$30,325.92
Rate for Payer: Wellcare Medicare	$30,325.92
Rate for Payer: Wellmed Medicare	$30,325.92

OTHER VASCULAR PROCEDURES WITHOUT CC/MCC

Facility

$34,741.50

Service Code	MSDRG 254
Min. Negotiated Rate	$15,566.00
Max. Negotiated Rate	$34,741.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,818.19
Rate for Payer: Amerigroup Medicare	$17,818.19
Rate for Payer: BCBS of TX Medicare	$17,818.19
Rate for Payer: Cigna Commercial	$22,948.30
Rate for Payer: Cigna Medicare	$17,818.19
Rate for Payer: Employer Direct Commercial	$17,818.19
Rate for Payer: Humana Medicare/TRICARE	$17,818.19
Rate for Payer: Molina Dual Medicare/Medicaid	$17,818.19
Rate for Payer: Molina Medicare	$17,818.19
Rate for Payer: Multiplan Auto	$34,741.50
Rate for Payer: Multiplan Commercial	$34,741.50
Rate for Payer: Multiplan Workers Comp	$34,741.50
Rate for Payer: Scott and White EPO/PPO	$15,999.38
Rate for Payer: Scott and White Medicare	$17,818.19
Rate for Payer: Superior Health Plan EPO	$17,818.19
Rate for Payer: Superior Health Plan Medicare	$17,818.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,818.19
Rate for Payer: Universal American Medicare	$17,818.19
Rate for Payer: Wellcare Medicare	$17,818.19
Rate for Payer: Wellmed Medicare	$17,818.19

OTHER VASCULAR PROCEDURES W MCC

Facility

$63,522.70

Service Code	MSDRG 252
Min. Negotiated Rate	$28,034.28
Max. Negotiated Rate	$63,522.70
Rate for Payer: BCBS of TX Blue Advantage	$28,034.28
Rate for Payer: BCBS of TX Blue Essentials	$33,637.88
Rate for Payer: BCBS of TX PPO	$37,376.87

OTHER VASCULAR PROCEDURES W/O CC/MCC

Facility

$34,741.50

Service Code	MSDRG 254
Min. Negotiated Rate	$15,566.00
Max. Negotiated Rate	$34,741.50
Rate for Payer: BCBS of TX Blue Advantage	$15,566.00
Rate for Payer: BCBS of TX Blue Essentials	$18,677.39
Rate for Payer: BCBS of TX PPO	$20,753.46

OT Iontophoresis Assistant Units

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	5810015
Hospital Revenue Code	430
Rate for Payer: Cash Price	$75.48

OT Iontophoresis Assistant Units

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	5810015
Hospital Revenue Code	430
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$33.30
Rate for Payer: BCBS of TX Blue Essentials	$39.96
Rate for Payer: BCBS of TX PPO	$44.40
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$79.92
Rate for Payer: Molina CHIP/Medicaid	$79.92
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Parkland Medicaid	$79.92
Rate for Payer: Scott and White EPO/PPO	$23.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.92
Rate for Payer: Superior Health Plan EPO	$15.10

OT Iontophoresis Units

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	5815272
Hospital Revenue Code	430
Rate for Payer: Cash Price	$75.48

OT Iontophoresis Units

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	5815272
Hospital Revenue Code	430
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$33.30
Rate for Payer: BCBS of TX Blue Essentials	$39.96
Rate for Payer: BCBS of TX PPO	$44.40
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$79.92
Rate for Payer: Molina CHIP/Medicaid	$79.92
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Parkland Medicaid	$79.92
Rate for Payer: Scott and White EPO/PPO	$23.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.92
Rate for Payer: Superior Health Plan EPO	$15.10

OTITIS MEDIA AND URI WITH MCC

Facility

$22,756.30

Service Code	MSDRG 152
Min. Negotiated Rate	$8,962.06
Max. Negotiated Rate	$22,756.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,424.46
Rate for Payer: Amerigroup Medicare	$13,424.46
Rate for Payer: BCBS of TX Medicare	$13,424.46
Rate for Payer: Cigna Commercial	$15,226.74
Rate for Payer: Cigna Medicare	$13,424.46
Rate for Payer: Employer Direct Commercial	$13,424.46
Rate for Payer: Humana Medicare/TRICARE	$13,424.46
Rate for Payer: Molina Dual Medicare/Medicaid	$13,424.46
Rate for Payer: Molina Medicare	$13,424.46
Rate for Payer: Multiplan Auto	$22,756.30
Rate for Payer: Multiplan Commercial	$22,756.30
Rate for Payer: Multiplan Workers Comp	$22,756.30
Rate for Payer: Scott and White EPO/PPO	$10,479.88
Rate for Payer: Scott and White Medicare	$13,424.46
Rate for Payer: Superior Health Plan EPO	$13,424.46
Rate for Payer: Superior Health Plan Medicare	$13,424.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,424.46
Rate for Payer: Universal American Medicare	$13,424.46
Rate for Payer: Wellcare Medicare	$13,424.46
Rate for Payer: Wellmed Medicare	$13,424.46

OTITIS MEDIA AND URI WITHOUT MCC

Facility

$13,119.50

Service Code	MSDRG 153
Min. Negotiated Rate	$6,041.88
Max. Negotiated Rate	$13,119.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,170.37
Rate for Payer: Amerigroup Medicare	$10,170.37
Rate for Payer: BCBS of TX Medicare	$10,170.37
Rate for Payer: Cigna Commercial	$9,508.02
Rate for Payer: Cigna Medicare	$10,170.37
Rate for Payer: Employer Direct Commercial	$10,170.37
Rate for Payer: Humana Medicare/TRICARE	$10,170.37
Rate for Payer: Molina Dual Medicare/Medicaid	$10,170.37
Rate for Payer: Molina Medicare	$10,170.37
Rate for Payer: Multiplan Auto	$13,119.50
Rate for Payer: Multiplan Commercial	$13,119.50
Rate for Payer: Multiplan Workers Comp	$13,119.50
Rate for Payer: Scott and White EPO/PPO	$6,041.88
Rate for Payer: Scott and White Medicare	$10,170.37
Rate for Payer: Superior Health Plan EPO	$10,170.37
Rate for Payer: Superior Health Plan Medicare	$10,170.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,170.37
Rate for Payer: Universal American Medicare	$10,170.37
Rate for Payer: Wellcare Medicare	$10,170.37
Rate for Payer: Wellmed Medicare	$10,170.37

OTITIS MEDIA & URI W MCC

Facility

$22,756.30

Service Code	MSDRG 152
Min. Negotiated Rate	$8,962.06
Max. Negotiated Rate	$22,756.30
Rate for Payer: BCBS of TX Blue Advantage	$8,962.06
Rate for Payer: BCBS of TX Blue Essentials	$10,753.43
Rate for Payer: BCBS of TX PPO	$11,948.72

OTITIS MEDIA & URI W/O MCC

Facility

$13,119.50

Service Code	MSDRG 153
Min. Negotiated Rate	$6,041.88
Max. Negotiated Rate	$13,119.50
Rate for Payer: BCBS of TX Blue Advantage	$6,121.48
Rate for Payer: BCBS of TX Blue Essentials	$7,345.06
Rate for Payer: BCBS of TX PPO	$8,161.50

OT Manual Therapy Assistant Units

Facility

$136.00

Service Code	HCPCS 97140
Hospital Charge Code	4300006
Hospital Revenue Code	430
Rate for Payer: Cash Price	$92.48

OT Manual Therapy Assistant Units

Facility

$136.00

Service Code	HCPCS 97140
Hospital Charge Code	4300006
Hospital Revenue Code	430
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$40.80
Rate for Payer: BCBS of TX Blue Essentials	$48.96
Rate for Payer: BCBS of TX PPO	$54.40
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$97.92
Rate for Payer: Molina CHIP/Medicaid	$97.92
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Parkland Medicaid	$97.92
Rate for Payer: Scott and White EPO/PPO	$33.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.92
Rate for Payer: Superior Health Plan EPO	$18.50

OT Manual Therapy Units

Facility

$136.00

Service Code	HCPCS 97140
Hospital Charge Code	4300117
Hospital Revenue Code	430
Rate for Payer: Cash Price	$92.48

OT Manual Therapy Units

Facility

$136.00

Service Code	HCPCS 97140
Hospital Charge Code	4300117
Hospital Revenue Code	430
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$40.80
Rate for Payer: BCBS of TX Blue Essentials	$48.96
Rate for Payer: BCBS of TX PPO	$54.40
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$97.92
Rate for Payer: Molina CHIP/Medicaid	$97.92
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Parkland Medicaid	$97.92
Rate for Payer: Scott and White EPO/PPO	$33.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.92
Rate for Payer: Superior Health Plan EPO	$18.50

OT Neuromuscular Reeducation Assistant Units

Facility

$129.00

Service Code	HCPCS 97112
Hospital Charge Code	4300009
Hospital Revenue Code	430
Rate for Payer: Cash Price	$87.72

OT Neuromuscular Reeducation Assistant Units

Facility

$129.00

Service Code	HCPCS 97112
Hospital Charge Code	4300009
Hospital Revenue Code	430
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$38.70
Rate for Payer: BCBS of TX Blue Essentials	$46.44
Rate for Payer: BCBS of TX PPO	$51.60
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$92.88
Rate for Payer: Molina CHIP/Medicaid	$92.88
Rate for Payer: Multiplan Auto	$83.85
Rate for Payer: Multiplan Commercial	$83.85
Rate for Payer: Multiplan Workers Comp	$83.85
Rate for Payer: Parkland Medicaid	$92.88
Rate for Payer: Scott and White EPO/PPO	$41.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.88
Rate for Payer: Superior Health Plan EPO	$17.54

OT Neuromuscular Reeducation Units

Facility

$129.00

Service Code	HCPCS 97112
Hospital Charge Code	4300125
Hospital Revenue Code	430
Rate for Payer: Cash Price	$87.72

OT Neuromuscular Reeducation Units

Facility

$129.00

Service Code	HCPCS 97112
Hospital Charge Code	4300125
Hospital Revenue Code	430
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$38.70
Rate for Payer: BCBS of TX Blue Essentials	$46.44
Rate for Payer: BCBS of TX PPO	$51.60
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$92.88
Rate for Payer: Molina CHIP/Medicaid	$92.88
Rate for Payer: Multiplan Auto	$83.85
Rate for Payer: Multiplan Commercial	$83.85
Rate for Payer: Multiplan Workers Comp	$83.85
Rate for Payer: Parkland Medicaid	$92.88
Rate for Payer: Scott and White EPO/PPO	$41.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.88
Rate for Payer: Superior Health Plan EPO	$17.54

OT Non-Selective Wound Debridement Assistant Units

Facility

$358.00

Service Code	HCPCS 97602
Hospital Charge Code	5817623
Hospital Revenue Code	430
Rate for Payer: Cash Price	$243.44

Know your out-of-pocket cost for care.

All Charges