White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Rescue Fixed Screw, 4.5x14mm

Facility

$903.61

Service Code	HCPCS C1713
Hospital Charge Code	992221
Hospital Revenue Code	278
Min. Negotiated Rate	$81.32
Max. Negotiated Rate	$650.60
Rate for Payer: Amerigroup CHIP/Medicaid	$81.32
Rate for Payer: BCBS of TX Blue Advantage	$271.08
Rate for Payer: BCBS of TX Blue Essentials	$325.30
Rate for Payer: BCBS of TX PPO	$361.44
Rate for Payer: Cash Price	$614.45
Rate for Payer: Cigna Medicaid	$650.60
Rate for Payer: Molina CHIP/Medicaid	$650.60
Rate for Payer: Multiplan Auto	$451.81
Rate for Payer: Multiplan Commercial	$451.81
Rate for Payer: Multiplan Workers Comp	$451.81
Rate for Payer: Parkland Medicaid	$650.60
Rate for Payer: Scott and White EPO/PPO	$451.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$650.60
Rate for Payer: Superior Health Plan EPO	$122.89

Resection, condyle(s), distal end of phalanx, each toe

Facility

$7,783.60

Service Code	HCPCS 28153
Hospital Charge Code	9900484
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: Cash Price	$5,292.85
Rate for Payer: Cash Price	$5,292.85
Rate for Payer: Cash Price	$5,292.85
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$5,604.19
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	$5,604.19
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	$5,604.19
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	$5,604.19
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

Resection, condyle(s), distal end of phalanx, each toe

Facility

$7,783.60

Service Code	HCPCS 28153
Hospital Charge Code	9900484
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,292.85

Resection, condyle(s), distal end of phalanx, each toe

Facility

$10,000.00

Service Code	CPT 28153
Hospital Charge Code	36028153
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

RESP FUNCT OTH IND 15MIN Minutes

Facility

$158.00

Service Code	HCPCS G0238
Hospital Charge Code	6030238
Hospital Revenue Code	419
Min. Negotiated Rate	$12.72
Max. Negotiated Rate	$113.76
Rate for Payer: Amerigroup CHIP/Medicaid	$14.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29.06
Rate for Payer: Amerigroup Medicare	$29.06
Rate for Payer: BCBS of TX Blue Advantage	$47.40
Rate for Payer: BCBS of TX Blue Essentials	$56.88
Rate for Payer: BCBS of TX Medicare	$29.06
Rate for Payer: BCBS of TX PPO	$63.20
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cigna Commercial	$61.41
Rate for Payer: Cigna Medicaid	$113.76
Rate for Payer: Cigna Medicare	$29.06
Rate for Payer: Employer Direct Commercial	$29.06
Rate for Payer: Humana Medicare/TRICARE	$29.06
Rate for Payer: Molina CHIP/Medicaid	$113.76
Rate for Payer: Molina Dual Medicare/Medicaid	$29.06
Rate for Payer: Molina Medicare	$29.06
Rate for Payer: Multiplan Auto	$102.70
Rate for Payer: Multiplan Commercial	$102.70
Rate for Payer: Multiplan Workers Comp	$102.70
Rate for Payer: Parkland Medicaid	$113.76
Rate for Payer: Scott and White EPO/PPO	$12.72
Rate for Payer: Scott and White Medicare	$29.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$113.76
Rate for Payer: Superior Health Plan EPO	$29.06
Rate for Payer: Superior Health Plan Medicare	$29.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$29.06
Rate for Payer: Universal American Medicare	$29.06
Rate for Payer: Wellcare Medicare	$29.06
Rate for Payer: Wellmed Medicare	$29.06

RESP FUNCT OTH IND 15MIN Minutes

Facility

$158.00

Service Code	HCPCS G0238
Hospital Charge Code	6030238
Hospital Revenue Code	419
Rate for Payer: Cash Price	$107.44

Respiratory Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107033
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$222.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$92.70
Rate for Payer: BCBS of TX Blue Essentials	$111.24
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$123.60
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cigna Medicaid	$222.48
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$222.48
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$222.48
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.48
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

Respiratory Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107033
Hospital Revenue Code	306
Rate for Payer: Cash Price	$210.12

RESPIRATORY FAILURE

Facility

$3,877.88

Service Code	APR-DRG 1332
Min. Negotiated Rate	$3,656.20
Max. Negotiated Rate	$3,877.88
Rate for Payer: Amerigroup CHIP/Medicaid	$3,656.20
Rate for Payer: Cigna Medicaid	$3,656.20
Rate for Payer: Molina CHIP/Medicaid	$3,656.20
Rate for Payer: Parkland Medicaid	$3,656.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,877.88

RESPIRATORY FAILURE

Facility

$7,324.63

Service Code	APR-DRG 1333
Min. Negotiated Rate	$6,905.92
Max. Negotiated Rate	$7,324.63
Rate for Payer: Amerigroup CHIP/Medicaid	$6,905.92
Rate for Payer: Cigna Medicaid	$6,905.92
Rate for Payer: Molina CHIP/Medicaid	$6,905.92
Rate for Payer: Parkland Medicaid	$6,905.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,324.63

RESPIRATORY FAILURE

Facility

$2,488.69

Service Code	APR-DRG 1331
Min. Negotiated Rate	$2,346.43
Max. Negotiated Rate	$2,488.69
Rate for Payer: Amerigroup CHIP/Medicaid	$2,346.43
Rate for Payer: Cigna Medicaid	$2,346.43
Rate for Payer: Molina CHIP/Medicaid	$2,346.43
Rate for Payer: Parkland Medicaid	$2,346.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,488.69

RESPIRATORY FAILURE

Facility

$10,636.73

Service Code	APR-DRG 1334
Min. Negotiated Rate	$10,028.68
Max. Negotiated Rate	$10,636.73
Rate for Payer: Amerigroup CHIP/Medicaid	$10,028.68
Rate for Payer: Cigna Medicaid	$10,028.68
Rate for Payer: Molina CHIP/Medicaid	$10,028.68
Rate for Payer: Parkland Medicaid	$10,028.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,636.73

RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC

Facility

$20,653.00

Service Code	MSDRG 178
Min. Negotiated Rate	$9,511.25
Max. Negotiated Rate	$20,653.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,913.21
Rate for Payer: Amerigroup Medicare	$11,913.21
Rate for Payer: BCBS of TX Medicare	$11,913.21
Rate for Payer: Cigna Commercial	$12,570.88
Rate for Payer: Cigna Medicare	$11,913.21
Rate for Payer: Employer Direct Commercial	$11,913.21
Rate for Payer: Humana Medicare/TRICARE	$11,913.21
Rate for Payer: Molina Dual Medicare/Medicaid	$11,913.21
Rate for Payer: Molina Medicare	$11,913.21
Rate for Payer: Multiplan Auto	$20,653.00
Rate for Payer: Multiplan Commercial	$20,653.00
Rate for Payer: Multiplan Workers Comp	$20,653.00
Rate for Payer: Scott and White EPO/PPO	$9,511.25
Rate for Payer: Scott and White Medicare	$11,913.21
Rate for Payer: Superior Health Plan EPO	$11,913.21
Rate for Payer: Superior Health Plan Medicare	$11,913.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,913.21
Rate for Payer: Universal American Medicare	$11,913.21
Rate for Payer: Wellcare Medicare	$11,913.21
Rate for Payer: Wellmed Medicare	$11,913.21

RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC

Facility

$33,818.10

Service Code	MSDRG 177
Min. Negotiated Rate	$15,574.12
Max. Negotiated Rate	$33,818.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,213.15
Rate for Payer: Amerigroup Medicare	$16,213.15
Rate for Payer: BCBS of TX Medicare	$16,213.15
Rate for Payer: Cigna Commercial	$20,127.58
Rate for Payer: Cigna Medicare	$16,213.15
Rate for Payer: Employer Direct Commercial	$16,213.15
Rate for Payer: Humana Medicare/TRICARE	$16,213.15
Rate for Payer: Molina Dual Medicare/Medicaid	$16,213.15
Rate for Payer: Molina Medicare	$16,213.15
Rate for Payer: Multiplan Auto	$33,818.10
Rate for Payer: Multiplan Commercial	$33,818.10
Rate for Payer: Multiplan Workers Comp	$33,818.10
Rate for Payer: Scott and White EPO/PPO	$15,574.12
Rate for Payer: Scott and White Medicare	$16,213.15
Rate for Payer: Superior Health Plan EPO	$16,213.15
Rate for Payer: Superior Health Plan Medicare	$16,213.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,213.15
Rate for Payer: Universal American Medicare	$16,213.15
Rate for Payer: Wellcare Medicare	$16,213.15
Rate for Payer: Wellmed Medicare	$16,213.15

RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC

Facility

$14,922.60

Service Code	MSDRG 179
Min. Negotiated Rate	$6,872.25
Max. Negotiated Rate	$14,922.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,293.50
Rate for Payer: Amerigroup Medicare	$10,293.50
Rate for Payer: BCBS of TX Medicare	$10,293.50
Rate for Payer: Cigna Commercial	$9,724.40
Rate for Payer: Cigna Medicare	$10,293.50
Rate for Payer: Employer Direct Commercial	$10,293.50
Rate for Payer: Humana Medicare/TRICARE	$10,293.50
Rate for Payer: Molina Dual Medicare/Medicaid	$10,293.50
Rate for Payer: Molina Medicare	$10,293.50
Rate for Payer: Multiplan Auto	$14,922.60
Rate for Payer: Multiplan Commercial	$14,922.60
Rate for Payer: Multiplan Workers Comp	$14,922.60
Rate for Payer: Scott and White EPO/PPO	$6,872.25
Rate for Payer: Scott and White Medicare	$10,293.50
Rate for Payer: Superior Health Plan EPO	$10,293.50
Rate for Payer: Superior Health Plan Medicare	$10,293.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,293.50
Rate for Payer: Universal American Medicare	$10,293.50
Rate for Payer: Wellcare Medicare	$10,293.50
Rate for Payer: Wellmed Medicare	$10,293.50

RESPIRATORY INFECTIONS & INFLAMMATIONS W CC

Facility

$20,653.00

Service Code	MSDRG 178
Min. Negotiated Rate	$9,511.25
Max. Negotiated Rate	$20,653.00
Rate for Payer: BCBS of TX Blue Advantage	$10,959.84
Rate for Payer: BCBS of TX Blue Essentials	$13,150.53
Rate for Payer: BCBS of TX PPO	$14,612.27

RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC

Facility

$33,818.10

Service Code	MSDRG 177
Min. Negotiated Rate	$15,574.12
Max. Negotiated Rate	$33,818.10
Rate for Payer: BCBS of TX Blue Advantage	$15,830.88
Rate for Payer: BCBS of TX Blue Essentials	$18,995.22
Rate for Payer: BCBS of TX PPO	$21,106.61

RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC

Facility

$14,922.60

Service Code	MSDRG 179
Min. Negotiated Rate	$6,872.25
Max. Negotiated Rate	$14,922.60
Rate for Payer: BCBS of TX Blue Advantage	$7,924.90
Rate for Payer: BCBS of TX Blue Essentials	$9,508.96
Rate for Payer: BCBS of TX PPO	$10,565.92

RESPIRATORY MALIGNANCY

Facility

$11,411.10

Service Code	APR-DRG 1364
Min. Negotiated Rate	$10,758.78
Max. Negotiated Rate	$11,411.10
Rate for Payer: Amerigroup CHIP/Medicaid	$10,758.78
Rate for Payer: Cigna Medicaid	$10,758.78
Rate for Payer: Molina CHIP/Medicaid	$10,758.78
Rate for Payer: Parkland Medicaid	$10,758.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,411.10

RESPIRATORY MALIGNANCY

Facility

$8,018.28

Service Code	APR-DRG 1363
Min. Negotiated Rate	$7,559.92
Max. Negotiated Rate	$8,018.28
Rate for Payer: Amerigroup CHIP/Medicaid	$7,559.92
Rate for Payer: Cigna Medicaid	$7,559.92
Rate for Payer: Molina CHIP/Medicaid	$7,559.92
Rate for Payer: Parkland Medicaid	$7,559.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,018.28

RESPIRATORY MALIGNANCY

Facility

$5,669.15

Service Code	APR-DRG 1362
Min. Negotiated Rate	$5,345.07
Max. Negotiated Rate	$5,669.15
Rate for Payer: Amerigroup CHIP/Medicaid	$5,345.07
Rate for Payer: Cigna Medicaid	$5,345.07
Rate for Payer: Molina CHIP/Medicaid	$5,345.07
Rate for Payer: Parkland Medicaid	$5,345.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,669.15

RESPIRATORY MALIGNANCY

Facility

$4,262.99

Service Code	APR-DRG 1361
Min. Negotiated Rate	$4,019.30
Max. Negotiated Rate	$4,262.99
Rate for Payer: Amerigroup CHIP/Medicaid	$4,019.30
Rate for Payer: Cigna Medicaid	$4,019.30
Rate for Payer: Molina CHIP/Medicaid	$4,019.30
Rate for Payer: Parkland Medicaid	$4,019.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,262.99

RESPIRATORY NEOPLASMS W CC

Facility

$21,540.30

Service Code	MSDRG 181
Min. Negotiated Rate	$9,811.74
Max. Negotiated Rate	$21,540.30
Rate for Payer: BCBS of TX Blue Advantage	$9,811.74
Rate for Payer: BCBS of TX Blue Essentials	$11,772.95
Rate for Payer: BCBS of TX PPO	$13,081.56

RESPIRATORY NEOPLASMS WITH CC

Facility

$21,540.30

Service Code	MSDRG 181
Min. Negotiated Rate	$9,811.74
Max. Negotiated Rate	$21,540.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,609.47
Rate for Payer: Amerigroup Medicare	$12,609.47
Rate for Payer: BCBS of TX Medicare	$12,609.47
Rate for Payer: Cigna Commercial	$13,794.48
Rate for Payer: Cigna Medicare	$12,609.47
Rate for Payer: Employer Direct Commercial	$12,609.47
Rate for Payer: Humana Medicare/TRICARE	$12,609.47
Rate for Payer: Molina Dual Medicare/Medicaid	$12,609.47
Rate for Payer: Molina Medicare	$12,609.47
Rate for Payer: Multiplan Auto	$21,540.30
Rate for Payer: Multiplan Commercial	$21,540.30
Rate for Payer: Multiplan Workers Comp	$21,540.30
Rate for Payer: Scott and White EPO/PPO	$9,919.88
Rate for Payer: Scott and White Medicare	$12,609.47
Rate for Payer: Superior Health Plan EPO	$12,609.47
Rate for Payer: Superior Health Plan Medicare	$12,609.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,609.47
Rate for Payer: Universal American Medicare	$12,609.47
Rate for Payer: Wellcare Medicare	$12,609.47
Rate for Payer: Wellmed Medicare	$12,609.47

RESPIRATORY NEOPLASMS WITH MCC

Facility

$32,184.10

Service Code	MSDRG 180
Min. Negotiated Rate	$14,585.60
Max. Negotiated Rate	$32,184.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,703.13
Rate for Payer: Amerigroup Medicare	$17,703.13
Rate for Payer: BCBS of TX Medicare	$17,703.13
Rate for Payer: Cigna Commercial	$22,746.08
Rate for Payer: Cigna Medicare	$17,703.13
Rate for Payer: Employer Direct Commercial	$17,703.13
Rate for Payer: Humana Medicare/TRICARE	$17,703.13
Rate for Payer: Molina Dual Medicare/Medicaid	$17,703.13
Rate for Payer: Molina Medicare	$17,703.13
Rate for Payer: Multiplan Auto	$32,184.10
Rate for Payer: Multiplan Commercial	$32,184.10
Rate for Payer: Multiplan Workers Comp	$32,184.10
Rate for Payer: Scott and White EPO/PPO	$14,821.62
Rate for Payer: Scott and White Medicare	$17,703.13
Rate for Payer: Superior Health Plan EPO	$17,703.13
Rate for Payer: Superior Health Plan Medicare	$17,703.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,703.13
Rate for Payer: Universal American Medicare	$17,703.13
Rate for Payer: Wellcare Medicare	$17,703.13
Rate for Payer: Wellmed Medicare	$17,703.13

Know your out-of-pocket cost for care.

All Charges