White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ANKLE DISTRACTOR STRAP

Facility

$340.50

Hospital Charge Code	992597
Hospital Revenue Code	272
Rate for Payer: Cash Price	$231.54

ANKLE DISTRACTOR STRAP

Facility

$340.50

Hospital Charge Code	992597
Hospital Revenue Code	272
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$245.16
Rate for Payer: Amerigroup CHIP/Medicaid	$30.64
Rate for Payer: BCBS of TX Blue Advantage	$102.15
Rate for Payer: BCBS of TX Blue Essentials	$122.58
Rate for Payer: BCBS of TX PPO	$136.20
Rate for Payer: Cash Price	$231.54
Rate for Payer: Cigna Medicaid	$245.16
Rate for Payer: Molina CHIP/Medicaid	$245.16
Rate for Payer: Multiplan Auto	$221.32
Rate for Payer: Multiplan Commercial	$221.32
Rate for Payer: Multiplan Workers Comp	$221.32
Rate for Payer: Parkland Medicaid	$245.16
Rate for Payer: Scott and White EPO/PPO	$170.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$245.16
Rate for Payer: Superior Health Plan EPO	$46.31

Ankle foot orthosis (AFO), plastic or other material, prefabricated, includes fitting and adjustment

Facility

$150.00

Service Code	HCPCS L1930
Hospital Charge Code	990951
Hospital Revenue Code	272
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$433.76
Rate for Payer: Amerigroup CHIP/Medicaid	$13.50
Rate for Payer: BCBS of TX Blue Advantage	$45.00
Rate for Payer: BCBS of TX Blue Essentials	$54.00
Rate for Payer: BCBS of TX PPO	$60.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cigna Medicaid	$108.00
Rate for Payer: Molina CHIP/Medicaid	$108.00
Rate for Payer: Multiplan Auto	$97.50
Rate for Payer: Multiplan Commercial	$97.50
Rate for Payer: Multiplan Workers Comp	$97.50
Rate for Payer: Parkland Medicaid	$108.00
Rate for Payer: Scott and White EPO/PPO	$433.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.00
Rate for Payer: Superior Health Plan EPO	$20.40

Ankle foot orthosis (AFO), plastic or other material, prefabricated, includes fitting and adjustment

Facility

$150.00

Service Code	HCPCS L1930
Hospital Charge Code	990951
Hospital Revenue Code	272
Rate for Payer: Cash Price	$102.00

Anoscopy; with removal of foreign body

Facility

$3,646.84

Service Code	HCPCS 46608
Hospital Charge Code	994169
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,479.85

Anoscopy; with removal of foreign body

Facility

$3,646.84

Service Code	HCPCS 46608
Hospital Charge Code	994169
Hospital Revenue Code	360
Min. Negotiated Rate	$328.50
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$328.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$934.20
Rate for Payer: Amerigroup Medicare	$934.20
Rate for Payer: BCBS of TX Blue Advantage	$1,275.68
Rate for Payer: BCBS of TX Blue Essentials	$1,527.76
Rate for Payer: BCBS of TX Medicare	$934.20
Rate for Payer: BCBS of TX PPO	$1,924.98
Rate for Payer: Cash Price	$2,479.85
Rate for Payer: Cash Price	$2,479.85
Rate for Payer: Cash Price	$2,479.85
Rate for Payer: Cigna Commercial	$1,974.73
Rate for Payer: Cigna Medicaid	$2,625.72
Rate for Payer: Cigna Medicare	$934.20
Rate for Payer: Employer Direct Commercial	$934.20
Rate for Payer: Humana Medicare/TRICARE	$934.20
Rate for Payer: Molina CHIP/Medicaid	$2,625.72
Rate for Payer: Molina Dual Medicare/Medicaid	$934.20
Rate for Payer: Molina Medicare	$934.20
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	$2,625.72
Rate for Payer: Scott and White EPO/PPO	$1,546.34
Rate for Payer: Scott and White Medicare	$934.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,625.72
Rate for Payer: Superior Health Plan EPO	$934.20
Rate for Payer: Superior Health Plan Medicare	$934.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$934.20
Rate for Payer: Universal American Medicare	$934.20
Rate for Payer: Wellcare Medicare	$934.20
Rate for Payer: Wellmed Medicare	$934.20

ANOXIC AND OTHER SEVERE BRAIN DAMAGE

Facility

$20,878.54

Service Code	APR-DRG 0594
Min. Negotiated Rate	$19,685.02
Max. Negotiated Rate	$20,878.54
Rate for Payer: Amerigroup CHIP/Medicaid	$19,685.02
Rate for Payer: Cigna Medicaid	$19,685.02
Rate for Payer: Molina CHIP/Medicaid	$19,685.02
Rate for Payer: Parkland Medicaid	$19,685.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,878.54

ANOXIC AND OTHER SEVERE BRAIN DAMAGE

Facility

$12,059.86

Service Code	APR-DRG 0593
Min. Negotiated Rate	$11,370.46
Max. Negotiated Rate	$12,059.86
Rate for Payer: Amerigroup CHIP/Medicaid	$11,370.46
Rate for Payer: Cigna Medicaid	$11,370.46
Rate for Payer: Molina CHIP/Medicaid	$11,370.46
Rate for Payer: Parkland Medicaid	$11,370.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,059.86

ANOXIC AND OTHER SEVERE BRAIN DAMAGE

Facility

$6,470.68

Service Code	APR-DRG 0591
Min. Negotiated Rate	$6,100.78
Max. Negotiated Rate	$6,470.68
Rate for Payer: Amerigroup CHIP/Medicaid	$6,100.78
Rate for Payer: Cigna Medicaid	$6,100.78
Rate for Payer: Molina CHIP/Medicaid	$6,100.78
Rate for Payer: Parkland Medicaid	$6,100.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,470.68

ANOXIC AND OTHER SEVERE BRAIN DAMAGE

Facility

$8,019.42

Service Code	APR-DRG 0592
Min. Negotiated Rate	$7,560.99
Max. Negotiated Rate	$8,019.42
Rate for Payer: Amerigroup CHIP/Medicaid	$7,560.99
Rate for Payer: Cigna Medicaid	$7,560.99
Rate for Payer: Molina CHIP/Medicaid	$7,560.99
Rate for Payer: Parkland Medicaid	$7,560.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,019.42

ANS BREATH/CIR -- DHF

Facility

$487.79

Hospital Charge Code	81711350
Hospital Revenue Code	270
Rate for Payer: Cash Price	$331.70

ANS BREATH/CIR -- DHF

Facility

$487.79

Hospital Charge Code	81711350
Hospital Revenue Code	270
Min. Negotiated Rate	$43.90
Max. Negotiated Rate	$351.21
Rate for Payer: Amerigroup CHIP/Medicaid	$43.90
Rate for Payer: BCBS of TX Blue Advantage	$146.34
Rate for Payer: BCBS of TX Blue Essentials	$175.60
Rate for Payer: BCBS of TX PPO	$195.12
Rate for Payer: Cash Price	$331.70
Rate for Payer: Cigna Medicaid	$351.21
Rate for Payer: Molina CHIP/Medicaid	$351.21
Rate for Payer: Multiplan Auto	$317.06
Rate for Payer: Multiplan Commercial	$317.06
Rate for Payer: Multiplan Workers Comp	$317.06
Rate for Payer: Parkland Medicaid	$351.21
Rate for Payer: Scott and White EPO/PPO	$243.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$351.21
Rate for Payer: Superior Health Plan EPO	$66.34

ANTEGRADE NEPHROSTOGRAM

Facility

$433.00

Service Code	HCPCS 74425
Hospital Charge Code	4614425
Hospital Revenue Code	320
Rate for Payer: Cash Price	$294.44

ANTEGRADE NEPHROSTOGRAM

Facility

$433.00

Service Code	HCPCS 74425
Hospital Charge Code	4614425
Hospital Revenue Code	320
Min. Negotiated Rate	$135.99
Max. Negotiated Rate	$843.89
Rate for Payer: Amerigroup CHIP/Medicaid	$135.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX Medicare	$350.46
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$294.44
Rate for Payer: Cash Price	$294.44
Rate for Payer: Cash Price	$294.44
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$311.76
Rate for Payer: Cigna Medicare	$350.46
Rate for Payer: Employer Direct Commercial	$350.46
Rate for Payer: Humana Medicare/TRICARE	$350.46
Rate for Payer: Molina CHIP/Medicaid	$311.76
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$281.45
Rate for Payer: Multiplan Commercial	$281.45
Rate for Payer: Multiplan Workers Comp	$281.45
Rate for Payer: Parkland Medicaid	$311.76
Rate for Payer: Scott and White EPO/PPO	$167.68
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$311.76
Rate for Payer: Superior Health Plan EPO	$350.46
Rate for Payer: Superior Health Plan Medicare	$350.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$350.46
Rate for Payer: Universal American Medicare	$350.46
Rate for Payer: Wellcare Medicare	$350.46
Rate for Payer: Wellmed Medicare	$350.46

ANTEPARTUM WITH O.R. PROCEDURE

Facility

$7,156.41

Service Code	APR-DRG 5473
Min. Negotiated Rate	$6,747.31
Max. Negotiated Rate	$7,156.41
Rate for Payer: Amerigroup CHIP/Medicaid	$6,747.31
Rate for Payer: Cigna Medicaid	$6,747.31
Rate for Payer: Molina CHIP/Medicaid	$6,747.31
Rate for Payer: Parkland Medicaid	$6,747.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,156.41

ANTEPARTUM WITH O.R. PROCEDURE

Facility

$4,081.56

Service Code	APR-DRG 5472
Min. Negotiated Rate	$3,848.24
Max. Negotiated Rate	$4,081.56
Rate for Payer: Amerigroup CHIP/Medicaid	$3,848.24
Rate for Payer: Cigna Medicaid	$3,848.24
Rate for Payer: Molina CHIP/Medicaid	$3,848.24
Rate for Payer: Parkland Medicaid	$3,848.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,081.56

ANTEPARTUM WITH O.R. PROCEDURE

Facility

$15,865.32

Service Code	APR-DRG 5474
Min. Negotiated Rate	$14,958.38
Max. Negotiated Rate	$15,865.32
Rate for Payer: Amerigroup CHIP/Medicaid	$14,958.38
Rate for Payer: Cigna Medicaid	$14,958.38
Rate for Payer: Molina CHIP/Medicaid	$14,958.38
Rate for Payer: Parkland Medicaid	$14,958.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,865.32

ANTEPARTUM WITH O.R. PROCEDURE

Facility

$2,952.26

Service Code	APR-DRG 5471
Min. Negotiated Rate	$2,783.49
Max. Negotiated Rate	$2,952.26
Rate for Payer: Amerigroup CHIP/Medicaid	$2,783.49
Rate for Payer: Cigna Medicaid	$2,783.49
Rate for Payer: Molina CHIP/Medicaid	$2,783.49
Rate for Payer: Parkland Medicaid	$2,783.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,952.26

ANTEPARTUM WITHOUT O.R. PROCEDURE

Facility

$1,705.65

Service Code	APR-DRG 5662
Min. Negotiated Rate	$1,608.15
Max. Negotiated Rate	$1,705.65
Rate for Payer: Amerigroup CHIP/Medicaid	$1,608.15
Rate for Payer: Cigna Medicaid	$1,608.15
Rate for Payer: Molina CHIP/Medicaid	$1,608.15
Rate for Payer: Parkland Medicaid	$1,608.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,705.65

ANTEPARTUM WITHOUT O.R. PROCEDURE

Facility

$2,696.90

Service Code	APR-DRG 5663
Min. Negotiated Rate	$2,542.73
Max. Negotiated Rate	$2,696.90
Rate for Payer: Amerigroup CHIP/Medicaid	$2,542.73
Rate for Payer: Cigna Medicaid	$2,542.73
Rate for Payer: Molina CHIP/Medicaid	$2,542.73
Rate for Payer: Parkland Medicaid	$2,542.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,696.90

ANTEPARTUM WITHOUT O.R. PROCEDURE

Facility

$1,251.89

Service Code	APR-DRG 5661
Min. Negotiated Rate	$1,180.33
Max. Negotiated Rate	$1,251.89
Rate for Payer: Amerigroup CHIP/Medicaid	$1,180.33
Rate for Payer: Cigna Medicaid	$1,180.33
Rate for Payer: Molina CHIP/Medicaid	$1,180.33
Rate for Payer: Parkland Medicaid	$1,180.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,251.89

ANTEPARTUM WITHOUT O.R. PROCEDURE

Facility

$4,940.04

Service Code	APR-DRG 5664
Min. Negotiated Rate	$4,657.65
Max. Negotiated Rate	$4,940.04
Rate for Payer: Amerigroup CHIP/Medicaid	$4,657.65
Rate for Payer: Cigna Medicaid	$4,657.65
Rate for Payer: Molina CHIP/Medicaid	$4,657.65
Rate for Payer: Parkland Medicaid	$4,657.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,940.04

Anterior Tibialis

Facility

$16,873.49

Service Code	HCPCS C1734
Hospital Charge Code	992293
Hospital Revenue Code	278
Min. Negotiated Rate	$4,218.37
Max. Negotiated Rate	$8,436.75
Rate for Payer: Cash Price	$11,473.97
Rate for Payer: Cigna Commercial	$4,218.37
Rate for Payer: Multiplan Auto	$8,436.75
Rate for Payer: Multiplan Commercial	$8,436.75
Rate for Payer: Multiplan Workers Comp	$8,436.75
Rate for Payer: Scott and White EPO/PPO	$8,436.75

Anterior Tibialis

Facility

$16,873.49

Service Code	HCPCS C1734
Hospital Charge Code	992293
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.61
Max. Negotiated Rate	$12,148.91
Rate for Payer: Amerigroup CHIP/Medicaid	$1,518.61
Rate for Payer: BCBS of TX Blue Advantage	$5,062.05
Rate for Payer: BCBS of TX Blue Essentials	$6,074.46
Rate for Payer: BCBS of TX PPO	$6,749.40
Rate for Payer: Cash Price	$11,473.97
Rate for Payer: Cigna Medicaid	$12,148.91
Rate for Payer: Molina CHIP/Medicaid	$12,148.91
Rate for Payer: Multiplan Auto	$8,436.75
Rate for Payer: Multiplan Commercial	$8,436.75
Rate for Payer: Multiplan Workers Comp	$8,436.75
Rate for Payer: Parkland Medicaid	$12,148.91
Rate for Payer: Scott and White EPO/PPO	$8,436.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,148.91
Rate for Payer: Superior Health Plan EPO	$2,294.79

Antibody elution (RBC), each elution

Facility

$297.00

Service Code	HCPCS 86860
Hospital Charge Code	9232979
Hospital Revenue Code	302
Rate for Payer: Cash Price	$201.96

Know your out-of-pocket cost for care.

All Charges