White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SENSOR, SPO2, SHORT, NELLCOR COMPAT

Facility

$327.06

Hospital Charge Code	993197
Hospital Revenue Code	270
Min. Negotiated Rate	$29.44
Max. Negotiated Rate	$235.48
Rate for Payer: Amerigroup CHIP/Medicaid	$29.44
Rate for Payer: BCBS of TX Blue Advantage	$98.12
Rate for Payer: BCBS of TX Blue Essentials	$117.74
Rate for Payer: BCBS of TX PPO	$130.82
Rate for Payer: Cash Price	$222.40
Rate for Payer: Cigna Medicaid	$235.48
Rate for Payer: Molina CHIP/Medicaid	$235.48
Rate for Payer: Multiplan Auto	$212.59
Rate for Payer: Multiplan Commercial	$212.59
Rate for Payer: Multiplan Workers Comp	$212.59
Rate for Payer: Parkland Medicaid	$235.48
Rate for Payer: Scott and White EPO/PPO	$163.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$235.48
Rate for Payer: Superior Health Plan EPO	$44.48

SENSOR URETERORENOSCOPE STERILE SINGLE USE

Facility

$6,356.00

Hospital Charge Code	146125
Hospital Revenue Code	272
Min. Negotiated Rate	$572.04
Max. Negotiated Rate	$4,576.32
Rate for Payer: Amerigroup CHIP/Medicaid	$572.04
Rate for Payer: BCBS of TX Blue Advantage	$1,906.80
Rate for Payer: BCBS of TX Blue Essentials	$2,288.16
Rate for Payer: BCBS of TX PPO	$2,542.40
Rate for Payer: Cash Price	$4,322.08
Rate for Payer: Cigna Medicaid	$4,576.32
Rate for Payer: Molina CHIP/Medicaid	$4,576.32
Rate for Payer: Multiplan Auto	$4,131.40
Rate for Payer: Multiplan Commercial	$4,131.40
Rate for Payer: Multiplan Workers Comp	$4,131.40
Rate for Payer: Parkland Medicaid	$4,576.32
Rate for Payer: Scott and White EPO/PPO	$3,178.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,576.32
Rate for Payer: Superior Health Plan EPO	$864.42

SENSOR URETERORENOSCOPE STERILE SINGLE USE

Facility

$6,356.00

Hospital Charge Code	146125
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,322.08

SEPTIC ARTHRITIS W CC

Facility

$23,022.30

Service Code	MSDRG 549
Min. Negotiated Rate	$10,602.38
Max. Negotiated Rate	$23,022.30
Rate for Payer: BCBS of TX Blue Advantage	$10,700.12
Rate for Payer: BCBS of TX Blue Essentials	$12,838.90
Rate for Payer: BCBS of TX PPO	$14,266.00

SEPTIC ARTHRITIS WITH CC

Facility

$23,022.30

Service Code	MSDRG 549
Min. Negotiated Rate	$10,602.38
Max. Negotiated Rate	$23,022.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,607.68
Rate for Payer: Amerigroup Medicare	$13,607.68
Rate for Payer: BCBS of TX Medicare	$13,607.68
Rate for Payer: Cigna Commercial	$15,548.74
Rate for Payer: Cigna Medicare	$13,607.68
Rate for Payer: Employer Direct Commercial	$13,607.68
Rate for Payer: Humana Medicare/TRICARE	$13,607.68
Rate for Payer: Molina Dual Medicare/Medicaid	$13,607.68
Rate for Payer: Molina Medicare	$13,607.68
Rate for Payer: Multiplan Auto	$23,022.30
Rate for Payer: Multiplan Commercial	$23,022.30
Rate for Payer: Multiplan Workers Comp	$23,022.30
Rate for Payer: Scott and White EPO/PPO	$10,602.38
Rate for Payer: Scott and White Medicare	$13,607.68
Rate for Payer: Superior Health Plan EPO	$13,607.68
Rate for Payer: Superior Health Plan Medicare	$13,607.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,607.68
Rate for Payer: Universal American Medicare	$13,607.68
Rate for Payer: Wellcare Medicare	$13,607.68
Rate for Payer: Wellmed Medicare	$13,607.68

SEPTIC ARTHRITIS WITH MCC

Facility

$36,858.10

Service Code	MSDRG 548
Min. Negotiated Rate	$16,974.12
Max. Negotiated Rate	$36,858.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,911.69
Rate for Payer: Amerigroup Medicare	$18,911.69
Rate for Payer: BCBS of TX Medicare	$18,911.69
Rate for Payer: Cigna Commercial	$24,869.99
Rate for Payer: Cigna Medicare	$18,911.69
Rate for Payer: Employer Direct Commercial	$18,911.69
Rate for Payer: Humana Medicare/TRICARE	$18,911.69
Rate for Payer: Molina Dual Medicare/Medicaid	$18,911.69
Rate for Payer: Molina Medicare	$18,911.69
Rate for Payer: Multiplan Auto	$36,858.10
Rate for Payer: Multiplan Commercial	$36,858.10
Rate for Payer: Multiplan Workers Comp	$36,858.10
Rate for Payer: Scott and White EPO/PPO	$16,974.12
Rate for Payer: Scott and White Medicare	$18,911.69
Rate for Payer: Superior Health Plan EPO	$18,911.69
Rate for Payer: Superior Health Plan Medicare	$18,911.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,911.69
Rate for Payer: Universal American Medicare	$18,911.69
Rate for Payer: Wellcare Medicare	$18,911.69
Rate for Payer: Wellmed Medicare	$18,911.69

SEPTIC ARTHRITIS WITHOUT CC/MCC

Facility

$19,917.70

Service Code	MSDRG 550
Min. Negotiated Rate	$7,944.68
Max. Negotiated Rate	$19,917.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,166.38
Rate for Payer: Amerigroup Medicare	$11,166.38
Rate for Payer: BCBS of TX Medicare	$11,166.38
Rate for Payer: Cigna Commercial	$11,258.41
Rate for Payer: Cigna Medicare	$11,166.38
Rate for Payer: Employer Direct Commercial	$11,166.38
Rate for Payer: Humana Medicare/TRICARE	$11,166.38
Rate for Payer: Molina Dual Medicare/Medicaid	$11,166.38
Rate for Payer: Molina Medicare	$11,166.38
Rate for Payer: Multiplan Auto	$19,917.70
Rate for Payer: Multiplan Commercial	$19,917.70
Rate for Payer: Multiplan Workers Comp	$19,917.70
Rate for Payer: Scott and White EPO/PPO	$9,172.62
Rate for Payer: Scott and White Medicare	$11,166.38
Rate for Payer: Superior Health Plan EPO	$11,166.38
Rate for Payer: Superior Health Plan Medicare	$11,166.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,166.38
Rate for Payer: Universal American Medicare	$11,166.38
Rate for Payer: Wellcare Medicare	$11,166.38
Rate for Payer: Wellmed Medicare	$11,166.38

SEPTIC ARTHRITIS W MCC

Facility

$36,858.10

Service Code	MSDRG 548
Min. Negotiated Rate	$16,974.12
Max. Negotiated Rate	$36,858.10
Rate for Payer: BCBS of TX Blue Advantage	$17,777.92
Rate for Payer: BCBS of TX Blue Essentials	$21,331.44
Rate for Payer: BCBS of TX PPO	$23,702.52

SEPTIC ARTHRITIS W/O CC/MCC

Facility

$19,917.70

Service Code	MSDRG 550
Min. Negotiated Rate	$7,944.68
Max. Negotiated Rate	$19,917.70
Rate for Payer: BCBS of TX Blue Advantage	$7,944.68
Rate for Payer: BCBS of TX Blue Essentials	$9,532.69
Rate for Payer: BCBS of TX PPO	$10,592.29

SEPTICEMIA AND DISSEMINATED INFECTIONS

Facility

$3,477.31

Service Code	APR-DRG 7202
Min. Negotiated Rate	$3,278.53
Max. Negotiated Rate	$3,477.31
Rate for Payer: Amerigroup CHIP/Medicaid	$3,278.53
Rate for Payer: Cigna Medicaid	$3,278.53
Rate for Payer: Molina CHIP/Medicaid	$3,278.53
Rate for Payer: Parkland Medicaid	$3,278.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,477.31

SEPTICEMIA AND DISSEMINATED INFECTIONS

Facility

$14,135.53

Service Code	APR-DRG 7204
Min. Negotiated Rate	$13,327.48
Max. Negotiated Rate	$14,135.53
Rate for Payer: Amerigroup CHIP/Medicaid	$13,327.48
Rate for Payer: Cigna Medicaid	$13,327.48
Rate for Payer: Molina CHIP/Medicaid	$13,327.48
Rate for Payer: Parkland Medicaid	$13,327.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,135.53

SEPTICEMIA AND DISSEMINATED INFECTIONS

Facility

$2,410.99

Service Code	APR-DRG 7201
Min. Negotiated Rate	$2,273.17
Max. Negotiated Rate	$2,410.99
Rate for Payer: Amerigroup CHIP/Medicaid	$2,273.17
Rate for Payer: Cigna Medicaid	$2,273.17
Rate for Payer: Molina CHIP/Medicaid	$2,273.17
Rate for Payer: Parkland Medicaid	$2,273.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,410.99

SEPTICEMIA AND DISSEMINATED INFECTIONS

Facility

$5,801.17

Service Code	APR-DRG 7203
Min. Negotiated Rate	$5,469.54
Max. Negotiated Rate	$5,801.17
Rate for Payer: Amerigroup CHIP/Medicaid	$5,469.54
Rate for Payer: Cigna Medicaid	$5,469.54
Rate for Payer: Molina CHIP/Medicaid	$5,469.54
Rate for Payer: Parkland Medicaid	$5,469.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,801.17

SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS

Facility

$129,027.10

Service Code	MSDRG 870
Min. Negotiated Rate	$54,139.58
Max. Negotiated Rate	$129,027.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55,416.85
Rate for Payer: Amerigroup Medicare	$55,416.85
Rate for Payer: BCBS of TX Medicare	$55,416.85
Rate for Payer: Cigna Commercial	$89,023.98
Rate for Payer: Cigna Medicare	$55,416.85
Rate for Payer: Employer Direct Commercial	$55,416.85
Rate for Payer: Humana Medicare/TRICARE	$55,416.85
Rate for Payer: Molina Dual Medicare/Medicaid	$55,416.85
Rate for Payer: Molina Medicare	$55,416.85
Rate for Payer: Multiplan Auto	$129,027.10
Rate for Payer: Multiplan Commercial	$129,027.10
Rate for Payer: Multiplan Workers Comp	$129,027.10
Rate for Payer: Scott and White EPO/PPO	$59,420.38
Rate for Payer: Scott and White Medicare	$55,416.85
Rate for Payer: Superior Health Plan EPO	$55,416.85
Rate for Payer: Superior Health Plan Medicare	$55,416.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$55,416.85
Rate for Payer: Universal American Medicare	$55,416.85
Rate for Payer: Wellcare Medicare	$55,416.85
Rate for Payer: Wellmed Medicare	$55,416.85

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC

Facility

$37,186.80

Service Code	MSDRG 871
Min. Negotiated Rate	$15,965.04
Max. Negotiated Rate	$37,186.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,996.71
Rate for Payer: Amerigroup Medicare	$18,996.71
Rate for Payer: BCBS of TX Medicare	$18,996.71
Rate for Payer: Cigna Commercial	$25,019.40
Rate for Payer: Cigna Medicare	$18,996.71
Rate for Payer: Employer Direct Commercial	$18,996.71
Rate for Payer: Humana Medicare/TRICARE	$18,996.71
Rate for Payer: Molina Dual Medicare/Medicaid	$18,996.71
Rate for Payer: Molina Medicare	$18,996.71
Rate for Payer: Multiplan Auto	$37,186.80
Rate for Payer: Multiplan Commercial	$37,186.80
Rate for Payer: Multiplan Workers Comp	$37,186.80
Rate for Payer: Scott and White EPO/PPO	$17,125.50
Rate for Payer: Scott and White Medicare	$18,996.71
Rate for Payer: Superior Health Plan EPO	$18,996.71
Rate for Payer: Superior Health Plan Medicare	$18,996.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,996.71
Rate for Payer: Universal American Medicare	$18,996.71
Rate for Payer: Wellcare Medicare	$18,996.71
Rate for Payer: Wellmed Medicare	$18,996.71

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC

Facility

$19,532.00

Service Code	MSDRG 872
Min. Negotiated Rate	$8,995.00
Max. Negotiated Rate	$19,532.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,259.87
Rate for Payer: Amerigroup Medicare	$12,259.87
Rate for Payer: BCBS of TX Medicare	$12,259.87
Rate for Payer: Cigna Commercial	$13,180.10
Rate for Payer: Cigna Medicare	$12,259.87
Rate for Payer: Employer Direct Commercial	$12,259.87
Rate for Payer: Humana Medicare/TRICARE	$12,259.87
Rate for Payer: Molina Dual Medicare/Medicaid	$12,259.87
Rate for Payer: Molina Medicare	$12,259.87
Rate for Payer: Multiplan Auto	$19,532.00
Rate for Payer: Multiplan Commercial	$19,532.00
Rate for Payer: Multiplan Workers Comp	$19,532.00
Rate for Payer: Scott and White EPO/PPO	$8,995.00
Rate for Payer: Scott and White Medicare	$12,259.87
Rate for Payer: Superior Health Plan EPO	$12,259.87
Rate for Payer: Superior Health Plan Medicare	$12,259.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,259.87
Rate for Payer: Universal American Medicare	$12,259.87
Rate for Payer: Wellcare Medicare	$12,259.87
Rate for Payer: Wellmed Medicare	$12,259.87

SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS OR PERIPHERAL EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility

$129,027.10

Service Code	MSDRG 870
Min. Negotiated Rate	$54,139.58
Max. Negotiated Rate	$129,027.10
Rate for Payer: BCBS of TX Blue Advantage	$54,139.58
Rate for Payer: BCBS of TX Blue Essentials	$64,961.20
Rate for Payer: BCBS of TX PPO	$72,181.91

SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC

Facility

$37,186.80

Service Code	MSDRG 871
Min. Negotiated Rate	$15,965.04
Max. Negotiated Rate	$37,186.80
Rate for Payer: BCBS of TX Blue Advantage	$15,965.04
Rate for Payer: BCBS of TX Blue Essentials	$19,156.19
Rate for Payer: BCBS of TX PPO	$21,285.48

SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC

Facility

$19,532.00

Service Code	MSDRG 872
Min. Negotiated Rate	$8,995.00
Max. Negotiated Rate	$19,532.00
Rate for Payer: BCBS of TX Blue Advantage	$9,054.94
Rate for Payer: BCBS of TX Blue Essentials	$10,864.88
Rate for Payer: BCBS of TX PPO	$12,072.55

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement wit

Facility

$10,000.00

Service Code	CPT 30520
Hospital Charge Code	36030520
Hospital Revenue Code	360
Min. Negotiated Rate	$886.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Amerigroup Medicare	$3,330.57
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicare	$3,330.57
Rate for Payer: Employer Direct Commercial	$3,330.57
Rate for Payer: Humana Medicare/TRICARE	$3,330.57
Rate for Payer: Molina Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Molina Medicare	$3,330.57
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	$5,447.31
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan EPO	$3,330.57
Rate for Payer: Superior Health Plan Medicare	$3,330.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Universal American Medicare	$3,330.57
Rate for Payer: Wellcare Medicare	$3,330.57
Rate for Payer: Wellmed Medicare	$3,330.57

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement wit

Facility

$19,154.73

Service Code	HCPCS 30520
Hospital Charge Code	9900598
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,025.22

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement wit

Facility

$19,154.73

Service Code	HCPCS 30520
Hospital Charge Code	9900598
Hospital Revenue Code	360
Min. Negotiated Rate	$886.62
Max. Negotiated Rate	$13,791.41
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Amerigroup Medicare	$3,330.57
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cash Price	$13,025.22
Rate for Payer: Cash Price	$13,025.22
Rate for Payer: Cash Price	$13,025.22
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicaid	$13,791.41
Rate for Payer: Cigna Medicare	$3,330.57
Rate for Payer: Employer Direct Commercial	$3,330.57
Rate for Payer: Humana Medicare/TRICARE	$3,330.57
Rate for Payer: Molina CHIP/Medicaid	$13,791.41
Rate for Payer: Molina Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Molina Medicare	$3,330.57
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	$13,791.41
Rate for Payer: Scott and White EPO/PPO	$5,447.31
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,791.41
Rate for Payer: Superior Health Plan EPO	$3,330.57
Rate for Payer: Superior Health Plan Medicare	$3,330.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Universal American Medicare	$3,330.57
Rate for Payer: Wellcare Medicare	$3,330.57
Rate for Payer: Wellmed Medicare	$3,330.57

Serfas energy 90-s cruise

Facility

$893.56

Hospital Charge Code	993581
Hospital Revenue Code	272
Rate for Payer: Cash Price	$607.62

Serfas energy 90-s cruise

Facility

$893.56

Hospital Charge Code	993581
Hospital Revenue Code	272
Min. Negotiated Rate	$80.42
Max. Negotiated Rate	$643.36
Rate for Payer: Amerigroup CHIP/Medicaid	$80.42
Rate for Payer: BCBS of TX Blue Advantage	$268.07
Rate for Payer: BCBS of TX Blue Essentials	$321.68
Rate for Payer: BCBS of TX PPO	$357.42
Rate for Payer: Cash Price	$607.62
Rate for Payer: Cigna Medicaid	$643.36
Rate for Payer: Molina CHIP/Medicaid	$643.36
Rate for Payer: Multiplan Auto	$580.81
Rate for Payer: Multiplan Commercial	$580.81
Rate for Payer: Multiplan Workers Comp	$580.81
Rate for Payer: Parkland Medicaid	$643.36
Rate for Payer: Scott and White EPO/PPO	$446.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$643.36
Rate for Payer: Superior Health Plan EPO	$121.52

serfas energy 90-s max

Facility

$839.90

Hospital Charge Code	993257
Hospital Revenue Code	270
Min. Negotiated Rate	$75.59
Max. Negotiated Rate	$604.73
Rate for Payer: Amerigroup CHIP/Medicaid	$75.59
Rate for Payer: BCBS of TX Blue Advantage	$251.97
Rate for Payer: BCBS of TX Blue Essentials	$302.36
Rate for Payer: BCBS of TX PPO	$335.96
Rate for Payer: Cash Price	$571.13
Rate for Payer: Cigna Medicaid	$604.73
Rate for Payer: Molina CHIP/Medicaid	$604.73
Rate for Payer: Multiplan Auto	$545.93
Rate for Payer: Multiplan Commercial	$545.93
Rate for Payer: Multiplan Workers Comp	$545.93
Rate for Payer: Parkland Medicaid	$604.73
Rate for Payer: Scott and White EPO/PPO	$419.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$604.73
Rate for Payer: Superior Health Plan EPO	$114.23

Know your out-of-pocket cost for care.

All Charges