White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$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

$32,832.00

Service Code	MSDRG 580
Min. Negotiated Rate	$13,672.28
Max. Negotiated Rate	$32,832.00
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

$61,531.50

Service Code	MSDRG 579
Min. Negotiated Rate	$24,061.08
Max. Negotiated Rate	$61,531.50
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

$27,418.90

Service Code	MSDRG 581
Min. Negotiated Rate	$10,633.04
Max. Negotiated Rate	$27,418.90
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

$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 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

$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 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

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 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

$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 VASCULAR PROCEDURES W CC

Facility

$49,316.40

Service Code	MSDRG 253
Min. Negotiated Rate	$22,310.98
Max. Negotiated Rate	$49,316.40
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

$49,316.40

Service Code	MSDRG 253
Min. Negotiated Rate	$22,310.98
Max. Negotiated Rate	$49,316.40
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	$49,316.40
Rate for Payer: Multiplan Commercial	$49,316.40
Rate for Payer: Multiplan Workers Comp	$49,316.40
Rate for Payer: Scott and White EPO/PPO	$22,711.50
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

$66,277.70

Service Code	MSDRG 252
Min. Negotiated Rate	$28,034.28
Max. Negotiated Rate	$66,277.70
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	$66,277.70
Rate for Payer: Multiplan Commercial	$66,277.70
Rate for Payer: Multiplan Workers Comp	$66,277.70
Rate for Payer: Scott and White EPO/PPO	$30,522.62
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

$33,852.30

Service Code	MSDRG 254
Min. Negotiated Rate	$15,566.00
Max. Negotiated Rate	$33,852.30
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	$33,852.30
Rate for Payer: Multiplan Commercial	$33,852.30
Rate for Payer: Multiplan Workers Comp	$33,852.30
Rate for Payer: Scott and White EPO/PPO	$15,589.88
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

$66,277.70

Service Code	MSDRG 252
Min. Negotiated Rate	$28,034.28
Max. Negotiated Rate	$66,277.70
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

$33,852.30

Service Code	MSDRG 254
Min. Negotiated Rate	$15,566.00
Max. Negotiated Rate	$33,852.30
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	$180.00
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	$180.00
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

$22,461.80

Service Code	MSDRG 152
Min. Negotiated Rate	$8,962.06
Max. Negotiated Rate	$22,461.80
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	$22,461.80
Rate for Payer: Multiplan Commercial	$22,461.80
Rate for Payer: Multiplan Workers Comp	$22,461.80
Rate for Payer: Scott and White EPO/PPO	$10,344.25
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

Know your out-of-pocket cost for care.

All Charges