White Rock Medical Center

All Charges

Charge

Type

Setting

Price

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC

Facility

$40,688.50

Service Code	MSDRG 857
Min. Negotiated Rate	$17,687.62
Max. Negotiated Rate	$40,688.50
Rate for Payer: BCBS of TX Blue Advantage	$17,687.62
Rate for Payer: BCBS of TX Blue Essentials	$21,223.09
Rate for Payer: BCBS of TX PPO	$23,582.12

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC

Facility

$86,425.30

Service Code	MSDRG 856
Min. Negotiated Rate	$38,097.62
Max. Negotiated Rate	$86,425.30
Rate for Payer: BCBS of TX Blue Advantage	$38,599.38
Rate for Payer: BCBS of TX Blue Essentials	$46,314.77
Rate for Payer: BCBS of TX PPO	$51,462.85

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC

Facility

$26,465.10

Service Code	MSDRG 858
Min. Negotiated Rate	$11,868.86
Max. Negotiated Rate	$26,465.10
Rate for Payer: BCBS of TX Blue Advantage	$11,868.86
Rate for Payer: BCBS of TX Blue Essentials	$14,241.25
Rate for Payer: BCBS of TX PPO	$15,824.23

POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE

Facility

$25,475.72

Service Code	APR-DRG 7114
Min. Negotiated Rate	$24,019.40
Max. Negotiated Rate	$25,475.72
Rate for Payer: Amerigroup CHIP/Medicaid	$24,019.40
Rate for Payer: Cigna Medicaid	$24,019.40
Rate for Payer: Molina CHIP/Medicaid	$24,019.40
Rate for Payer: Parkland Medicaid	$24,019.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,475.72

POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE

Facility

$5,964.11

Service Code	APR-DRG 7111
Min. Negotiated Rate	$5,623.17
Max. Negotiated Rate	$5,964.11
Rate for Payer: Amerigroup CHIP/Medicaid	$5,623.17
Rate for Payer: Cigna Medicaid	$5,623.17
Rate for Payer: Molina CHIP/Medicaid	$5,623.17
Rate for Payer: Parkland Medicaid	$5,623.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,964.11

POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE

Facility

$14,131.76

Service Code	APR-DRG 7113
Min. Negotiated Rate	$13,323.92
Max. Negotiated Rate	$14,131.76
Rate for Payer: Amerigroup CHIP/Medicaid	$13,323.92
Rate for Payer: Cigna Medicaid	$13,323.92
Rate for Payer: Molina CHIP/Medicaid	$13,323.92
Rate for Payer: Parkland Medicaid	$13,323.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,131.76

POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE

Facility

$7,649.02

Service Code	APR-DRG 7112
Min. Negotiated Rate	$7,211.76
Max. Negotiated Rate	$7,649.02
Rate for Payer: Amerigroup CHIP/Medicaid	$7,211.76
Rate for Payer: Cigna Medicaid	$7,211.76
Rate for Payer: Molina CHIP/Medicaid	$7,211.76
Rate for Payer: Parkland Medicaid	$7,211.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,649.02

POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC

Facility

$34,650.30

Service Code	MSDRG 862
Min. Negotiated Rate	$15,718.22
Max. Negotiated Rate	$34,650.30
Rate for Payer: BCBS of TX Blue Advantage	$15,718.22
Rate for Payer: BCBS of TX Blue Essentials	$18,860.04
Rate for Payer: BCBS of TX PPO	$20,956.41

POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC

Facility

$18,960.10

Service Code	MSDRG 863
Min. Negotiated Rate	$8,469.28
Max. Negotiated Rate	$18,960.10
Rate for Payer: BCBS of TX Blue Advantage	$8,469.28
Rate for Payer: BCBS of TX Blue Essentials	$10,162.15
Rate for Payer: BCBS of TX PPO	$11,291.72

POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS

Facility

$14,631.16

Service Code	APR-DRG 7214
Min. Negotiated Rate	$13,794.77
Max. Negotiated Rate	$14,631.16
Rate for Payer: Amerigroup CHIP/Medicaid	$13,794.77
Rate for Payer: Cigna Medicaid	$13,794.77
Rate for Payer: Molina CHIP/Medicaid	$13,794.77
Rate for Payer: Parkland Medicaid	$13,794.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,631.16

POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS

Facility

$7,275.98

Service Code	APR-DRG 7213
Min. Negotiated Rate	$6,860.04
Max. Negotiated Rate	$7,275.98
Rate for Payer: Amerigroup CHIP/Medicaid	$6,860.04
Rate for Payer: Cigna Medicaid	$6,860.04
Rate for Payer: Molina CHIP/Medicaid	$6,860.04
Rate for Payer: Parkland Medicaid	$6,860.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,275.98

POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS

Facility

$2,900.96

Service Code	APR-DRG 7211
Min. Negotiated Rate	$2,735.13
Max. Negotiated Rate	$2,900.96
Rate for Payer: Amerigroup CHIP/Medicaid	$2,735.13
Rate for Payer: Cigna Medicaid	$2,735.13
Rate for Payer: Molina CHIP/Medicaid	$2,735.13
Rate for Payer: Parkland Medicaid	$2,735.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,900.96

POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS

Facility

$4,149.08

Service Code	APR-DRG 7212
Min. Negotiated Rate	$3,911.90
Max. Negotiated Rate	$4,149.08
Rate for Payer: Amerigroup CHIP/Medicaid	$3,911.90
Rate for Payer: Cigna Medicaid	$3,911.90
Rate for Payer: Molina CHIP/Medicaid	$3,911.90
Rate for Payer: Parkland Medicaid	$3,911.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,149.08

POST-OP SHOE, SQUARE TOE, MEN, XL, EA

Facility

$228.59

Service Code	HCPCS L3260
Hospital Charge Code	993832
Hospital Revenue Code	274
Min. Negotiated Rate	$20.57
Max. Negotiated Rate	$164.58
Rate for Payer: Amerigroup CHIP/Medicaid	$20.57
Rate for Payer: BCBS of TX Blue Advantage	$68.58
Rate for Payer: BCBS of TX Blue Essentials	$82.29
Rate for Payer: BCBS of TX PPO	$91.44
Rate for Payer: Cash Price	$155.44
Rate for Payer: Cigna Medicaid	$164.58
Rate for Payer: Molina CHIP/Medicaid	$164.58
Rate for Payer: Multiplan Auto	$114.30
Rate for Payer: Multiplan Commercial	$114.30
Rate for Payer: Multiplan Workers Comp	$114.30
Rate for Payer: Parkland Medicaid	$164.58
Rate for Payer: Scott and White EPO/PPO	$114.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$164.58
Rate for Payer: Superior Health Plan EPO	$31.09

POST-OP SHOE, SQUARE TOE, MEN, XL, EA

Facility

$228.59

Service Code	HCPCS L3260
Hospital Charge Code	993833
Hospital Revenue Code	274
Min. Negotiated Rate	$20.57
Max. Negotiated Rate	$164.58
Rate for Payer: Amerigroup CHIP/Medicaid	$20.57
Rate for Payer: BCBS of TX Blue Advantage	$68.58
Rate for Payer: BCBS of TX Blue Essentials	$82.29
Rate for Payer: BCBS of TX PPO	$91.44
Rate for Payer: Cash Price	$155.44
Rate for Payer: Cigna Medicaid	$164.58
Rate for Payer: Molina CHIP/Medicaid	$164.58
Rate for Payer: Multiplan Auto	$114.30
Rate for Payer: Multiplan Commercial	$114.30
Rate for Payer: Multiplan Workers Comp	$114.30
Rate for Payer: Parkland Medicaid	$164.58
Rate for Payer: Scott and White EPO/PPO	$114.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$164.58
Rate for Payer: Superior Health Plan EPO	$31.09

POST-OP SHOE, SQUARE TOE, MEN, XL, EA

Facility

$228.59

Service Code	HCPCS L3260
Hospital Charge Code	993832
Hospital Revenue Code	274
Min. Negotiated Rate	$57.15
Max. Negotiated Rate	$114.30
Rate for Payer: Cash Price	$155.44
Rate for Payer: Cigna Commercial	$57.15
Rate for Payer: Multiplan Auto	$114.30
Rate for Payer: Multiplan Commercial	$114.30
Rate for Payer: Multiplan Workers Comp	$114.30
Rate for Payer: Scott and White EPO/PPO	$114.30

POST-OP SHOE, SQUARE TOE, MEN, XL, EA

Facility

$228.59

Service Code	HCPCS L3260
Hospital Charge Code	993833
Hospital Revenue Code	274
Min. Negotiated Rate	$57.15
Max. Negotiated Rate	$114.30
Rate for Payer: Cash Price	$155.44
Rate for Payer: Cigna Commercial	$57.15
Rate for Payer: Multiplan Auto	$114.30
Rate for Payer: Multiplan Commercial	$114.30
Rate for Payer: Multiplan Workers Comp	$114.30
Rate for Payer: Scott and White EPO/PPO	$114.30

POST PAD PERINEAL REVOLUTION PARADIGM

Facility

$3,282.69

Hospital Charge Code	146730
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,232.23

POST PAD PERINEAL REVOLUTION PARADIGM

Facility

$3,282.69

Hospital Charge Code	146730
Hospital Revenue Code	272
Min. Negotiated Rate	$295.44
Max. Negotiated Rate	$2,363.54
Rate for Payer: Amerigroup CHIP/Medicaid	$295.44
Rate for Payer: BCBS of TX Blue Advantage	$984.81
Rate for Payer: BCBS of TX Blue Essentials	$1,181.77
Rate for Payer: BCBS of TX PPO	$1,313.08
Rate for Payer: Cash Price	$2,232.23
Rate for Payer: Cigna Medicaid	$2,363.54
Rate for Payer: Molina CHIP/Medicaid	$2,363.54
Rate for Payer: Multiplan Auto	$2,133.75
Rate for Payer: Multiplan Commercial	$2,133.75
Rate for Payer: Multiplan Workers Comp	$2,133.75
Rate for Payer: Parkland Medicaid	$2,363.54
Rate for Payer: Scott and White EPO/PPO	$1,641.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,363.54
Rate for Payer: Superior Health Plan EPO	$446.45

POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES

Facility

$32,106.20

Service Code	MSDRG 769
Min. Negotiated Rate	$12,537.94
Max. Negotiated Rate	$32,106.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,144.67
Rate for Payer: Amerigroup Medicare	$17,144.67
Rate for Payer: BCBS of TX Medicare	$17,144.67
Rate for Payer: Cigna Commercial	$21,764.62
Rate for Payer: Cigna Medicare	$17,144.67
Rate for Payer: Employer Direct Commercial	$17,144.67
Rate for Payer: Humana Medicare/TRICARE	$17,144.67
Rate for Payer: Molina Dual Medicare/Medicaid	$17,144.67
Rate for Payer: Molina Medicare	$17,144.67
Rate for Payer: Multiplan Auto	$32,106.20
Rate for Payer: Multiplan Commercial	$32,106.20
Rate for Payer: Multiplan Workers Comp	$32,106.20
Rate for Payer: Scott and White EPO/PPO	$14,785.75
Rate for Payer: Scott and White Medicare	$17,144.67
Rate for Payer: Superior Health Plan EPO	$17,144.67
Rate for Payer: Superior Health Plan Medicare	$17,144.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,144.67
Rate for Payer: Universal American Medicare	$17,144.67
Rate for Payer: Wellcare Medicare	$17,144.67
Rate for Payer: Wellmed Medicare	$17,144.67

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES

Facility

$12,439.30

Service Code	MSDRG 776
Min. Negotiated Rate	$5,667.40
Max. Negotiated Rate	$12,439.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,558.39
Rate for Payer: Amerigroup Medicare	$9,558.39
Rate for Payer: BCBS of TX Medicare	$9,558.39
Rate for Payer: Cigna Commercial	$8,432.54
Rate for Payer: Cigna Medicare	$9,558.39
Rate for Payer: Employer Direct Commercial	$9,558.39
Rate for Payer: Humana Medicare/TRICARE	$9,558.39
Rate for Payer: Molina Dual Medicare/Medicaid	$9,558.39
Rate for Payer: Molina Medicare	$9,558.39
Rate for Payer: Multiplan Auto	$12,439.30
Rate for Payer: Multiplan Commercial	$12,439.30
Rate for Payer: Multiplan Workers Comp	$12,439.30
Rate for Payer: Scott and White EPO/PPO	$5,728.62
Rate for Payer: Scott and White Medicare	$9,558.39
Rate for Payer: Superior Health Plan EPO	$9,558.39
Rate for Payer: Superior Health Plan Medicare	$9,558.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,558.39
Rate for Payer: Universal American Medicare	$9,558.39
Rate for Payer: Wellcare Medicare	$9,558.39
Rate for Payer: Wellmed Medicare	$9,558.39

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE

Facility

$2,053.42

Service Code	APR-DRG 5612
Min. Negotiated Rate	$1,936.03
Max. Negotiated Rate	$2,053.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1,936.03
Rate for Payer: Cigna Medicaid	$1,936.03
Rate for Payer: Molina CHIP/Medicaid	$1,936.03
Rate for Payer: Parkland Medicaid	$1,936.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,053.42

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE

Facility

$6,674.74

Service Code	APR-DRG 5614
Min. Negotiated Rate	$6,293.18
Max. Negotiated Rate	$6,674.74
Rate for Payer: Amerigroup CHIP/Medicaid	$6,293.18
Rate for Payer: Cigna Medicaid	$6,293.18
Rate for Payer: Molina CHIP/Medicaid	$6,293.18
Rate for Payer: Parkland Medicaid	$6,293.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,674.74

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE

Facility

$3,405.26

Service Code	APR-DRG 5613
Min. Negotiated Rate	$3,210.60
Max. Negotiated Rate	$3,405.26
Rate for Payer: Amerigroup CHIP/Medicaid	$3,210.60
Rate for Payer: Cigna Medicaid	$3,210.60
Rate for Payer: Molina CHIP/Medicaid	$3,210.60
Rate for Payer: Parkland Medicaid	$3,210.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,405.26

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE

Facility

$1,249.63

Service Code	APR-DRG 5611
Min. Negotiated Rate	$1,178.19
Max. Negotiated Rate	$1,249.63
Rate for Payer: Amerigroup CHIP/Medicaid	$1,178.19
Rate for Payer: Cigna Medicaid	$1,178.19
Rate for Payer: Molina CHIP/Medicaid	$1,178.19
Rate for Payer: Parkland Medicaid	$1,178.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,249.63

Know your out-of-pocket cost for care.

All Charges