White Rock Medical Center

All Charges

Charge

Type

Setting

Price

REHABILITATION

Facility

$3,223.08

Service Code	APR-DRG 8601
Min. Negotiated Rate	$3,038.83
Max. Negotiated Rate	$3,223.08
Rate for Payer: Amerigroup CHIP/Medicaid	$3,038.83
Rate for Payer: Cigna Medicaid	$3,038.83
Rate for Payer: Molina CHIP/Medicaid	$3,038.83
Rate for Payer: Parkland Medicaid	$3,038.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,223.08

REHABILITATION

Facility

$10,546.58

Service Code	APR-DRG 8604
Min. Negotiated Rate	$9,943.69
Max. Negotiated Rate	$10,546.58
Rate for Payer: Amerigroup CHIP/Medicaid	$9,943.69
Rate for Payer: Cigna Medicaid	$9,943.69
Rate for Payer: Molina CHIP/Medicaid	$9,943.69
Rate for Payer: Parkland Medicaid	$9,943.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,546.58

REHABILITATION

Facility

$6,764.88

Service Code	APR-DRG 8603
Min. Negotiated Rate	$6,378.17
Max. Negotiated Rate	$6,764.88
Rate for Payer: Amerigroup CHIP/Medicaid	$6,378.17
Rate for Payer: Cigna Medicaid	$6,378.17
Rate for Payer: Molina CHIP/Medicaid	$6,378.17
Rate for Payer: Parkland Medicaid	$6,378.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,764.88

REHABILITATION

Facility

$4,641.31

Service Code	APR-DRG 8602
Min. Negotiated Rate	$4,375.99
Max. Negotiated Rate	$4,641.31
Rate for Payer: Amerigroup CHIP/Medicaid	$4,375.99
Rate for Payer: Cigna Medicaid	$4,375.99
Rate for Payer: Molina CHIP/Medicaid	$4,375.99
Rate for Payer: Parkland Medicaid	$4,375.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,641.31

REHABILITATION W CC/MCC

Facility

$28,598.80

Service Code	MSDRG 945
Min. Negotiated Rate	$11,738.14
Max. Negotiated Rate	$28,598.80
Rate for Payer: BCBS of TX Blue Advantage	$11,738.14
Rate for Payer: BCBS of TX Blue Essentials	$14,084.40
Rate for Payer: BCBS of TX PPO	$15,649.94

REHABILITATION WITH CC/MCC

Facility

$28,598.80

Service Code	MSDRG 945
Min. Negotiated Rate	$11,738.14
Max. Negotiated Rate	$28,598.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,109.81
Rate for Payer: Amerigroup Medicare	$16,109.81
Rate for Payer: BCBS of TX Medicare	$16,109.81
Rate for Payer: Cigna Commercial	$19,945.97
Rate for Payer: Cigna Medicare	$16,109.81
Rate for Payer: Employer Direct Commercial	$16,109.81
Rate for Payer: Humana Medicare/TRICARE	$16,109.81
Rate for Payer: Molina Dual Medicare/Medicaid	$16,109.81
Rate for Payer: Molina Medicare	$16,109.81
Rate for Payer: Multiplan Auto	$28,598.80
Rate for Payer: Multiplan Commercial	$28,598.80
Rate for Payer: Multiplan Workers Comp	$28,598.80
Rate for Payer: Scott and White EPO/PPO	$13,170.50
Rate for Payer: Scott and White Medicare	$16,109.81
Rate for Payer: Superior Health Plan EPO	$16,109.81
Rate for Payer: Superior Health Plan Medicare	$16,109.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,109.81
Rate for Payer: Universal American Medicare	$16,109.81
Rate for Payer: Wellcare Medicare	$16,109.81
Rate for Payer: Wellmed Medicare	$16,109.81

REHABILITATION WITHOUT CC/MCC

Facility

$21,329.40

Service Code	MSDRG 946
Min. Negotiated Rate	$8,967.22
Max. Negotiated Rate	$21,329.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,165.02
Rate for Payer: Amerigroup Medicare	$13,165.02
Rate for Payer: BCBS of TX Medicare	$13,165.02
Rate for Payer: Cigna Commercial	$14,770.78
Rate for Payer: Cigna Medicare	$13,165.02
Rate for Payer: Employer Direct Commercial	$13,165.02
Rate for Payer: Humana Medicare/TRICARE	$13,165.02
Rate for Payer: Molina Dual Medicare/Medicaid	$13,165.02
Rate for Payer: Molina Medicare	$13,165.02
Rate for Payer: Multiplan Auto	$21,329.40
Rate for Payer: Multiplan Commercial	$21,329.40
Rate for Payer: Multiplan Workers Comp	$21,329.40
Rate for Payer: Scott and White EPO/PPO	$9,822.75
Rate for Payer: Scott and White Medicare	$13,165.02
Rate for Payer: Superior Health Plan EPO	$13,165.02
Rate for Payer: Superior Health Plan Medicare	$13,165.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,165.02
Rate for Payer: Universal American Medicare	$13,165.02
Rate for Payer: Wellcare Medicare	$13,165.02
Rate for Payer: Wellmed Medicare	$13,165.02

REHABILITATION W/O CC/MCC

Facility

$21,329.40

Service Code	MSDRG 946
Min. Negotiated Rate	$8,967.22
Max. Negotiated Rate	$21,329.40
Rate for Payer: BCBS of TX Blue Advantage	$8,967.22
Rate for Payer: BCBS of TX Blue Essentials	$10,759.62
Rate for Payer: BCBS of TX PPO	$11,955.60

Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft

Facility

$15,408.22

Service Code	CPT 24342
Hospital Charge Code	36024342
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft

Facility

$23,096.00

Service Code	HCPCS 24342
Hospital Charge Code	9900248
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$16,629.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$15,705.28
Rate for Payer: Cash Price	$15,705.28
Rate for Payer: Cash Price	$15,705.28
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$16,629.12
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$16,629.12
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$16,629.12
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,629.12
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft

Facility

$23,096.00

Service Code	HCPCS 24342
Hospital Charge Code	9900248
Hospital Revenue Code	360
Rate for Payer: Cash Price	$15,705.28

Release foot/toe nerve

Facility

$10,000.00

Service Code	CPT 64726
Hospital Charge Code	36064726
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$3,266.71
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Release foot/toe nerve

Facility

$10,526.34

Service Code	HCPCS 64726
Hospital Charge Code	9900843
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,157.91

Release foot/toe nerve

Facility

$10,526.34

Service Code	HCPCS 64726
Hospital Charge Code	9900843
Hospital Revenue Code	360
Min. Negotiated Rate	$659.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$659.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$2,871.31
Rate for Payer: BCBS of TX Blue Essentials	$3,438.70
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$4,332.76
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cash Price	$7,157.91
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$7,578.96
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$7,578.96
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$7,578.96
Rate for Payer: Scott and White EPO/PPO	$3,266.71
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,578.96
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Release Hand/Finger Tendon

Facility

$25,038.00

Service Code	HCPCS 26445
Hospital Charge Code	9900343
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$18,027.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$17,025.84
Rate for Payer: Cash Price	$17,025.84
Rate for Payer: Cash Price	$17,025.84
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$18,027.36
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$18,027.36
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$18,027.36
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,027.36
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Release Hand/Finger Tendon

Facility

$25,038.00

Service Code	HCPCS 26445
Hospital Charge Code	9900343
Hospital Revenue Code	360
Rate for Payer: Cash Price	$17,025.84

Release Hand/Finger Tendon

Facility

$10,000.00

Service Code	CPT 26445
Hospital Charge Code	36026445
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

RELOAD

Facility

$495.98

Hospital Charge Code	992369
Hospital Revenue Code	272
Min. Negotiated Rate	$44.64
Max. Negotiated Rate	$357.11
Rate for Payer: Amerigroup CHIP/Medicaid	$44.64
Rate for Payer: BCBS of TX Blue Advantage	$148.79
Rate for Payer: BCBS of TX Blue Essentials	$178.55
Rate for Payer: BCBS of TX PPO	$198.39
Rate for Payer: Cash Price	$337.27
Rate for Payer: Cigna Medicaid	$357.11
Rate for Payer: Molina CHIP/Medicaid	$357.11
Rate for Payer: Multiplan Auto	$322.39
Rate for Payer: Multiplan Commercial	$322.39
Rate for Payer: Multiplan Workers Comp	$322.39
Rate for Payer: Parkland Medicaid	$357.11
Rate for Payer: Scott and White EPO/PPO	$247.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$357.11
Rate for Payer: Superior Health Plan EPO	$67.45

RELOAD

Facility

$495.98

Hospital Charge Code	992369
Hospital Revenue Code	272
Rate for Payer: Cash Price	$337.27

RELOAD 45MM PURPLE

Facility

$304.97

Hospital Charge Code	992364
Hospital Revenue Code	272
Min. Negotiated Rate	$27.45
Max. Negotiated Rate	$219.58
Rate for Payer: Amerigroup CHIP/Medicaid	$27.45
Rate for Payer: BCBS of TX Blue Advantage	$91.49
Rate for Payer: BCBS of TX Blue Essentials	$109.79
Rate for Payer: BCBS of TX PPO	$121.99
Rate for Payer: Cash Price	$207.38
Rate for Payer: Cigna Medicaid	$219.58
Rate for Payer: Molina CHIP/Medicaid	$219.58
Rate for Payer: Multiplan Auto	$198.23
Rate for Payer: Multiplan Commercial	$198.23
Rate for Payer: Multiplan Workers Comp	$198.23
Rate for Payer: Parkland Medicaid	$219.58
Rate for Payer: Scott and White EPO/PPO	$152.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$219.58
Rate for Payer: Superior Health Plan EPO	$41.48

RELOAD 45MM PURPLE

Facility

$304.97

Hospital Charge Code	992364
Hospital Revenue Code	272
Rate for Payer: Cash Price	$207.38

RELOAD 60MM TAN

Facility

$569.28

Hospital Charge Code	992363
Hospital Revenue Code	272
Min. Negotiated Rate	$51.24
Max. Negotiated Rate	$409.88
Rate for Payer: Amerigroup CHIP/Medicaid	$51.24
Rate for Payer: BCBS of TX Blue Advantage	$170.78
Rate for Payer: BCBS of TX Blue Essentials	$204.94
Rate for Payer: BCBS of TX PPO	$227.71
Rate for Payer: Cash Price	$387.11
Rate for Payer: Cigna Medicaid	$409.88
Rate for Payer: Molina CHIP/Medicaid	$409.88
Rate for Payer: Multiplan Auto	$370.03
Rate for Payer: Multiplan Commercial	$370.03
Rate for Payer: Multiplan Workers Comp	$370.03
Rate for Payer: Parkland Medicaid	$409.88
Rate for Payer: Scott and White EPO/PPO	$284.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$409.88
Rate for Payer: Superior Health Plan EPO	$77.42

RELOAD 60MM TAN

Facility

$569.28

Hospital Charge Code	992363
Hospital Revenue Code	272
Rate for Payer: Cash Price	$387.11

RELOAD CURVED TIP

Facility

$440.51

Hospital Charge Code	992365
Hospital Revenue Code	272
Rate for Payer: Cash Price	$299.55

RELOAD CURVED TIP

Facility

$440.51

Hospital Charge Code	992365
Hospital Revenue Code	272
Min. Negotiated Rate	$39.65
Max. Negotiated Rate	$317.17
Rate for Payer: Amerigroup CHIP/Medicaid	$39.65
Rate for Payer: BCBS of TX Blue Advantage	$132.15
Rate for Payer: BCBS of TX Blue Essentials	$158.58
Rate for Payer: BCBS of TX PPO	$176.20
Rate for Payer: Cash Price	$299.55
Rate for Payer: Cigna Medicaid	$317.17
Rate for Payer: Molina CHIP/Medicaid	$317.17
Rate for Payer: Multiplan Auto	$286.33
Rate for Payer: Multiplan Commercial	$286.33
Rate for Payer: Multiplan Workers Comp	$286.33
Rate for Payer: Parkland Medicaid	$317.17
Rate for Payer: Scott and White EPO/PPO	$220.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$317.17
Rate for Payer: Superior Health Plan EPO	$59.91

Know your out-of-pocket cost for care.

All Charges