White Rock Medical Center

All Charges

Charge

Type

Setting

Price

RESPIRATORY NEOPLASMS WITHOUT CC/MCC

Facility

$16,862.50

Service Code	MSDRG 182
Min. Negotiated Rate	$6,837.86
Max. Negotiated Rate	$16,862.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,284.70
Rate for Payer: Amerigroup Medicare	$10,284.70
Rate for Payer: BCBS of TX Medicare	$10,284.70
Rate for Payer: Cigna Commercial	$9,582.72
Rate for Payer: Cigna Medicare	$10,284.70
Rate for Payer: Employer Direct Commercial	$10,284.70
Rate for Payer: Humana Medicare/TRICARE	$10,284.70
Rate for Payer: Molina Dual Medicare/Medicaid	$10,284.70
Rate for Payer: Molina Medicare	$10,284.70
Rate for Payer: Multiplan Auto	$16,862.50
Rate for Payer: Multiplan Commercial	$16,862.50
Rate for Payer: Multiplan Workers Comp	$16,862.50
Rate for Payer: Scott and White EPO/PPO	$7,765.62
Rate for Payer: Scott and White Medicare	$10,284.70
Rate for Payer: Superior Health Plan EPO	$10,284.70
Rate for Payer: Superior Health Plan Medicare	$10,284.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,284.70
Rate for Payer: Universal American Medicare	$10,284.70
Rate for Payer: Wellcare Medicare	$10,284.70
Rate for Payer: Wellmed Medicare	$10,284.70

RESPIRATORY NEOPLASMS W MCC

Facility

$32,184.10

Service Code	MSDRG 180
Min. Negotiated Rate	$14,585.60
Max. Negotiated Rate	$32,184.10
Rate for Payer: BCBS of TX Blue Advantage	$14,585.60
Rate for Payer: BCBS of TX Blue Essentials	$17,501.02
Rate for Payer: BCBS of TX PPO	$19,446.34

RESPIRATORY NEOPLASMS W/O CC/MCC

Facility

$16,862.50

Service Code	MSDRG 182
Min. Negotiated Rate	$6,837.86
Max. Negotiated Rate	$16,862.50
Rate for Payer: BCBS of TX Blue Advantage	$6,837.86
Rate for Payer: BCBS of TX Blue Essentials	$8,204.64
Rate for Payer: BCBS of TX PPO	$9,116.62

Respiratory Profile, PCR SO

Facility

$348.00

Service Code	HCPCS 87581
Hospital Charge Code	1709070
Hospital Revenue Code	306
Rate for Payer: Cash Price	$236.64

Respiratory Profile, PCR SO

Facility

$348.00

Service Code	HCPCS 87581
Hospital Charge Code	1709070
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$250.56
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$104.40
Rate for Payer: BCBS of TX Blue Essentials	$125.28
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$139.20
Rate for Payer: Cash Price	$236.64
Rate for Payer: Cash Price	$236.64
Rate for Payer: Cigna Medicaid	$250.56
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$250.56
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$226.20
Rate for Payer: Multiplan Commercial	$226.20
Rate for Payer: Multiplan Workers Comp	$226.20
Rate for Payer: Parkland Medicaid	$250.56
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$250.56
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

RESPIRATORY SIGNS AND SYMPTOMS

Facility

$15,378.60

Service Code	MSDRG 204
Min. Negotiated Rate	$6,601.36
Max. Negotiated Rate	$15,378.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,677.54
Rate for Payer: Amerigroup Medicare	$10,677.54
Rate for Payer: BCBS of TX Medicare	$10,677.54
Rate for Payer: Cigna Commercial	$10,399.31
Rate for Payer: Cigna Medicare	$10,677.54
Rate for Payer: Employer Direct Commercial	$10,677.54
Rate for Payer: Humana Medicare/TRICARE	$10,677.54
Rate for Payer: Molina Dual Medicare/Medicaid	$10,677.54
Rate for Payer: Molina Medicare	$10,677.54
Rate for Payer: Multiplan Auto	$15,378.60
Rate for Payer: Multiplan Commercial	$15,378.60
Rate for Payer: Multiplan Workers Comp	$15,378.60
Rate for Payer: Scott and White EPO/PPO	$7,082.25
Rate for Payer: Scott and White Medicare	$10,677.54
Rate for Payer: Superior Health Plan EPO	$10,677.54
Rate for Payer: Superior Health Plan Medicare	$10,677.54
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,677.54
Rate for Payer: Universal American Medicare	$10,677.54
Rate for Payer: Wellcare Medicare	$10,677.54
Rate for Payer: Wellmed Medicare	$10,677.54

RESPIRATORY SIGNS & SYMPTOMS

Facility

$15,378.60

Service Code	MSDRG 204
Min. Negotiated Rate	$6,601.36
Max. Negotiated Rate	$15,378.60
Rate for Payer: BCBS of TX Blue Advantage	$6,601.36
Rate for Payer: BCBS of TX Blue Essentials	$7,920.86
Rate for Payer: BCBS of TX PPO	$8,801.30

RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES

Facility

$8,416.22

Service Code	APR-DRG 1444
Min. Negotiated Rate	$7,935.11
Max. Negotiated Rate	$8,416.22
Rate for Payer: Amerigroup CHIP/Medicaid	$7,935.11
Rate for Payer: Cigna Medicaid	$7,935.11
Rate for Payer: Molina CHIP/Medicaid	$7,935.11
Rate for Payer: Parkland Medicaid	$7,935.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,416.22

RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES

Facility

$3,369.43

Service Code	APR-DRG 1442
Min. Negotiated Rate	$3,176.82
Max. Negotiated Rate	$3,369.43
Rate for Payer: Amerigroup CHIP/Medicaid	$3,176.82
Rate for Payer: Cigna Medicaid	$3,176.82
Rate for Payer: Molina CHIP/Medicaid	$3,176.82
Rate for Payer: Parkland Medicaid	$3,176.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,369.43

RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES

Facility

$6,666.44

Service Code	APR-DRG 1443
Min. Negotiated Rate	$6,285.35
Max. Negotiated Rate	$6,666.44
Rate for Payer: Amerigroup CHIP/Medicaid	$6,285.35
Rate for Payer: Cigna Medicaid	$6,285.35
Rate for Payer: Molina CHIP/Medicaid	$6,285.35
Rate for Payer: Parkland Medicaid	$6,285.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,666.44

RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES

Facility

$2,101.70

Service Code	APR-DRG 1441
Min. Negotiated Rate	$1,981.55
Max. Negotiated Rate	$2,101.70
Rate for Payer: Amerigroup CHIP/Medicaid	$1,981.55
Rate for Payer: Cigna Medicaid	$1,981.55
Rate for Payer: Molina CHIP/Medicaid	$1,981.55
Rate for Payer: Parkland Medicaid	$1,981.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,101.70

Respiratory Syncytial Virus (RSV)

Facility

$202.00

Service Code	HCPCS 87807
Hospital Charge Code	1604271
Hospital Revenue Code	306
Rate for Payer: Cash Price	$137.36

Respiratory Syncytial Virus (RSV)

Facility

$202.00

Service Code	HCPCS 87807
Hospital Charge Code	1604271
Hospital Revenue Code	306
Min. Negotiated Rate	$5.11
Max. Negotiated Rate	$145.44
Rate for Payer: Amerigroup CHIP/Medicaid	$5.11
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.10
Rate for Payer: Amerigroup Medicare	$13.10
Rate for Payer: BCBS of TX Blue Advantage	$60.60
Rate for Payer: BCBS of TX Blue Essentials	$72.72
Rate for Payer: BCBS of TX Medicare	$13.10
Rate for Payer: BCBS of TX PPO	$80.80
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cigna Medicaid	$145.44
Rate for Payer: Cigna Medicare	$13.10
Rate for Payer: Employer Direct Commercial	$13.10
Rate for Payer: Humana Medicare/TRICARE	$13.10
Rate for Payer: Molina CHIP/Medicaid	$145.44
Rate for Payer: Molina Dual Medicare/Medicaid	$13.10
Rate for Payer: Molina Medicare	$13.10
Rate for Payer: Multiplan Auto	$131.30
Rate for Payer: Multiplan Commercial	$131.30
Rate for Payer: Multiplan Workers Comp	$131.30
Rate for Payer: Parkland Medicaid	$145.44
Rate for Payer: Scott and White EPO/PPO	$16.38
Rate for Payer: Scott and White Medicare	$13.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.44
Rate for Payer: Superior Health Plan EPO	$13.10
Rate for Payer: Superior Health Plan Medicare	$13.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.10
Rate for Payer: Universal American Medicare	$13.10
Rate for Payer: Wellcare Medicare	$13.10
Rate for Payer: Wellmed Medicare	$13.10

RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS

Facility

$49,401.90

Service Code	MSDRG 208
Min. Negotiated Rate	$20,961.64
Max. Negotiated Rate	$49,401.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24,905.38
Rate for Payer: Amerigroup Medicare	$24,905.38
Rate for Payer: BCBS of TX Medicare	$24,905.38
Rate for Payer: Cigna Commercial	$35,403.26
Rate for Payer: Cigna Medicare	$24,905.38
Rate for Payer: Employer Direct Commercial	$24,905.38
Rate for Payer: Humana Medicare/TRICARE	$24,905.38
Rate for Payer: Molina Dual Medicare/Medicaid	$24,905.38
Rate for Payer: Molina Medicare	$24,905.38
Rate for Payer: Multiplan Auto	$49,401.90
Rate for Payer: Multiplan Commercial	$49,401.90
Rate for Payer: Multiplan Workers Comp	$49,401.90
Rate for Payer: Scott and White EPO/PPO	$22,750.88
Rate for Payer: Scott and White Medicare	$24,905.38
Rate for Payer: Superior Health Plan EPO	$24,905.38
Rate for Payer: Superior Health Plan Medicare	$24,905.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$24,905.38
Rate for Payer: Universal American Medicare	$24,905.38
Rate for Payer: Wellcare Medicare	$24,905.38
Rate for Payer: Wellmed Medicare	$24,905.38

RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS

Facility

$22,146.65

Service Code	APR-DRG 1302
Min. Negotiated Rate	$20,880.64
Max. Negotiated Rate	$22,146.65
Rate for Payer: Amerigroup CHIP/Medicaid	$20,880.64
Rate for Payer: Cigna Medicaid	$20,880.64
Rate for Payer: Molina CHIP/Medicaid	$20,880.64
Rate for Payer: Parkland Medicaid	$20,880.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,146.65

RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS

Facility

$25,332.01

Service Code	APR-DRG 1303
Min. Negotiated Rate	$23,883.91
Max. Negotiated Rate	$25,332.01
Rate for Payer: Amerigroup CHIP/Medicaid	$23,883.91
Rate for Payer: Cigna Medicaid	$23,883.91
Rate for Payer: Molina CHIP/Medicaid	$23,883.91
Rate for Payer: Parkland Medicaid	$23,883.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,332.01

RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS

Facility

$37,307.39

Service Code	APR-DRG 1304
Min. Negotiated Rate	$35,174.71
Max. Negotiated Rate	$37,307.39
Rate for Payer: Amerigroup CHIP/Medicaid	$35,174.71
Rate for Payer: Cigna Medicaid	$35,174.71
Rate for Payer: Molina CHIP/Medicaid	$35,174.71
Rate for Payer: Parkland Medicaid	$35,174.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37,307.39

RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS

Facility

$18,960.91

Service Code	APR-DRG 1301
Min. Negotiated Rate	$17,877.01
Max. Negotiated Rate	$18,960.91
Rate for Payer: Amerigroup CHIP/Medicaid	$17,877.01
Rate for Payer: Cigna Medicaid	$17,877.01
Rate for Payer: Molina CHIP/Medicaid	$17,877.01
Rate for Payer: Parkland Medicaid	$17,877.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,960.91

RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS

Facility

$124,752.10

Service Code	MSDRG 207
Min. Negotiated Rate	$48,129.90
Max. Negotiated Rate	$124,752.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$51,920.17
Rate for Payer: Amerigroup Medicare	$51,920.17
Rate for Payer: BCBS of TX Medicare	$51,920.17
Rate for Payer: Cigna Commercial	$82,878.94
Rate for Payer: Cigna Medicare	$51,920.17
Rate for Payer: Employer Direct Commercial	$51,920.17
Rate for Payer: Humana Medicare/TRICARE	$51,920.17
Rate for Payer: Molina Dual Medicare/Medicaid	$51,920.17
Rate for Payer: Molina Medicare	$51,920.17
Rate for Payer: Multiplan Auto	$124,752.10
Rate for Payer: Multiplan Commercial	$124,752.10
Rate for Payer: Multiplan Workers Comp	$124,752.10
Rate for Payer: Scott and White EPO/PPO	$57,451.62
Rate for Payer: Scott and White Medicare	$51,920.17
Rate for Payer: Superior Health Plan EPO	$51,920.17
Rate for Payer: Superior Health Plan Medicare	$51,920.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$51,920.17
Rate for Payer: Universal American Medicare	$51,920.17
Rate for Payer: Wellcare Medicare	$51,920.17
Rate for Payer: Wellmed Medicare	$51,920.17

RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS

Facility

$49,401.90

Service Code	MSDRG 208
Min. Negotiated Rate	$20,961.64
Max. Negotiated Rate	$49,401.90
Rate for Payer: BCBS of TX Blue Advantage	$20,961.64
Rate for Payer: BCBS of TX Blue Essentials	$25,151.53
Rate for Payer: BCBS of TX PPO	$27,947.23

RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS OR PERIPHERAL EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility

$124,752.10

Service Code	MSDRG 207
Min. Negotiated Rate	$48,129.90
Max. Negotiated Rate	$124,752.10
Rate for Payer: BCBS of TX Blue Advantage	$48,129.90
Rate for Payer: BCBS of TX Blue Essentials	$57,750.28
Rate for Payer: BCBS of TX PPO	$64,169.47

RESPIRATORY THERAPY- EA 15 MIN Units

Facility

$27.00

Service Code	HCPCS 94760
Hospital Charge Code	6030239
Hospital Revenue Code	410
Rate for Payer: Cash Price	$18.36

RESPIRATORY THERAPY- EA 15 MIN Units

Facility

$27.00

Service Code	HCPCS 94760
Hospital Charge Code	6030239
Hospital Revenue Code	410
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$19.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2.43
Rate for Payer: BCBS of TX Blue Advantage	$8.10
Rate for Payer: BCBS of TX Blue Essentials	$9.72
Rate for Payer: BCBS of TX PPO	$10.80
Rate for Payer: Cash Price	$18.36
Rate for Payer: Cash Price	$18.36
Rate for Payer: Cigna Medicaid	$19.44
Rate for Payer: Molina CHIP/Medicaid	$19.44
Rate for Payer: Multiplan Auto	$17.55
Rate for Payer: Multiplan Commercial	$17.55
Rate for Payer: Multiplan Workers Comp	$17.55
Rate for Payer: Parkland Medicaid	$19.44
Rate for Payer: Scott and White EPO/PPO	$3.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.44
Rate for Payer: Superior Health Plan EPO	$3.67

RESPIRATORY THERAPY - GROUP SESS Units

Facility

$87.00

Hospital Charge Code	6030415
Hospital Revenue Code	460
Min. Negotiated Rate	$7.83
Max. Negotiated Rate	$62.64
Rate for Payer: Amerigroup CHIP/Medicaid	$7.83
Rate for Payer: BCBS of TX Blue Advantage	$26.10
Rate for Payer: BCBS of TX Blue Essentials	$31.32
Rate for Payer: BCBS of TX PPO	$34.80
Rate for Payer: Cash Price	$59.16
Rate for Payer: Cigna Medicaid	$62.64
Rate for Payer: Molina CHIP/Medicaid	$62.64
Rate for Payer: Multiplan Auto	$56.55
Rate for Payer: Multiplan Commercial	$56.55
Rate for Payer: Multiplan Workers Comp	$56.55
Rate for Payer: Parkland Medicaid	$62.64
Rate for Payer: Scott and White EPO/PPO	$43.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.64
Rate for Payer: Superior Health Plan EPO	$11.83

RESPIRATORY THERAPY - GROUP SESS Units

Facility

$87.00

Hospital Charge Code	6030415
Hospital Revenue Code	460
Rate for Payer: Cash Price	$59.16

Know your out-of-pocket cost for care.

All Charges