White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Shiga Toxin II

Facility

$117.00

Service Code	HCPCS 87899
Hospital Charge Code	4107909
Hospital Revenue Code	306
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$84.24
Rate for Payer: Amerigroup CHIP/Medicaid	$6.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.07
Rate for Payer: Amerigroup Medicare	$16.07
Rate for Payer: BCBS of TX Blue Advantage	$35.10
Rate for Payer: BCBS of TX Blue Essentials	$42.12
Rate for Payer: BCBS of TX Medicare	$16.07
Rate for Payer: BCBS of TX PPO	$46.80
Rate for Payer: Cash Price	$79.56
Rate for Payer: Cash Price	$79.56
Rate for Payer: Cigna Medicaid	$84.24
Rate for Payer: Cigna Medicare	$16.07
Rate for Payer: Employer Direct Commercial	$16.07
Rate for Payer: Humana Medicare/TRICARE	$16.07
Rate for Payer: Molina CHIP/Medicaid	$84.24
Rate for Payer: Molina Dual Medicare/Medicaid	$16.07
Rate for Payer: Molina Medicare	$16.07
Rate for Payer: Multiplan Auto	$76.05
Rate for Payer: Multiplan Commercial	$76.05
Rate for Payer: Multiplan Workers Comp	$76.05
Rate for Payer: Parkland Medicaid	$84.24
Rate for Payer: Scott and White EPO/PPO	$20.09
Rate for Payer: Scott and White Medicare	$16.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.24
Rate for Payer: Superior Health Plan EPO	$16.07
Rate for Payer: Superior Health Plan Medicare	$16.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.07
Rate for Payer: Universal American Medicare	$16.07
Rate for Payer: Wellcare Medicare	$16.07
Rate for Payer: Wellmed Medicare	$16.07

SHOE CST WALKNG -- DHF

Facility

$181.91

Hospital Charge Code	81144156
Hospital Revenue Code	270
Min. Negotiated Rate	$16.37
Max. Negotiated Rate	$130.98
Rate for Payer: Amerigroup CHIP/Medicaid	$16.37
Rate for Payer: BCBS of TX Blue Advantage	$54.57
Rate for Payer: BCBS of TX Blue Essentials	$65.49
Rate for Payer: BCBS of TX PPO	$72.76
Rate for Payer: Cash Price	$123.70
Rate for Payer: Cigna Medicaid	$130.98
Rate for Payer: Molina CHIP/Medicaid	$130.98
Rate for Payer: Multiplan Auto	$118.24
Rate for Payer: Multiplan Commercial	$118.24
Rate for Payer: Multiplan Workers Comp	$118.24
Rate for Payer: Parkland Medicaid	$130.98
Rate for Payer: Scott and White EPO/PPO	$90.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$130.98
Rate for Payer: Superior Health Plan EPO	$24.74

SHOE CST WALKNG -- DHF

Facility

$181.91

Hospital Charge Code	81144156
Hospital Revenue Code	270
Rate for Payer: Cash Price	$123.70

SHOE ORTHOPEDIC -- DHF

Facility

$689.34

Hospital Charge Code	81144206
Hospital Revenue Code	271
Min. Negotiated Rate	$62.04
Max. Negotiated Rate	$496.32
Rate for Payer: Amerigroup CHIP/Medicaid	$62.04
Rate for Payer: BCBS of TX Blue Advantage	$206.80
Rate for Payer: BCBS of TX Blue Essentials	$248.16
Rate for Payer: BCBS of TX PPO	$275.74
Rate for Payer: Cash Price	$468.75
Rate for Payer: Cigna Medicaid	$496.32
Rate for Payer: Molina CHIP/Medicaid	$496.32
Rate for Payer: Multiplan Auto	$448.07
Rate for Payer: Multiplan Commercial	$448.07
Rate for Payer: Multiplan Workers Comp	$448.07
Rate for Payer: Parkland Medicaid	$496.32
Rate for Payer: Scott and White EPO/PPO	$344.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$496.32
Rate for Payer: Superior Health Plan EPO	$93.75

SHOE ORTHOPEDIC -- DHF

Facility

$689.34

Hospital Charge Code	81144206
Hospital Revenue Code	271
Rate for Payer: Cash Price	$468.75

SHOE POST-OP A/S -- DHF

Facility

$46.80

Hospital Charge Code	81144255
Hospital Revenue Code	271
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$33.70
Rate for Payer: Amerigroup CHIP/Medicaid	$4.21
Rate for Payer: BCBS of TX Blue Advantage	$14.04
Rate for Payer: BCBS of TX Blue Essentials	$16.85
Rate for Payer: BCBS of TX PPO	$18.72
Rate for Payer: Cash Price	$31.82
Rate for Payer: Cigna Medicaid	$33.70
Rate for Payer: Molina CHIP/Medicaid	$33.70
Rate for Payer: Multiplan Auto	$30.42
Rate for Payer: Multiplan Commercial	$30.42
Rate for Payer: Multiplan Workers Comp	$30.42
Rate for Payer: Parkland Medicaid	$33.70
Rate for Payer: Scott and White EPO/PPO	$23.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.70
Rate for Payer: Superior Health Plan EPO	$6.36

SHOE POST-OP A/S -- DHF

Facility

$46.80

Hospital Charge Code	81144255
Hospital Revenue Code	271
Rate for Payer: Cash Price	$31.82

SHOE, POST-OP, MALE, L, SIZE 11-13

Facility

$24.79

Hospital Charge Code	992955
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.86

SHOE, POST-OP, MALE, L, SIZE 11-13

Facility

$24.79

Hospital Charge Code	992955
Hospital Revenue Code	270
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$17.85
Rate for Payer: Amerigroup CHIP/Medicaid	$2.23
Rate for Payer: BCBS of TX Blue Advantage	$7.44
Rate for Payer: BCBS of TX Blue Essentials	$8.92
Rate for Payer: BCBS of TX PPO	$9.92
Rate for Payer: Cash Price	$16.86
Rate for Payer: Cigna Medicaid	$17.85
Rate for Payer: Molina CHIP/Medicaid	$17.85
Rate for Payer: Multiplan Auto	$16.11
Rate for Payer: Multiplan Commercial	$16.11
Rate for Payer: Multiplan Workers Comp	$16.11
Rate for Payer: Parkland Medicaid	$17.85
Rate for Payer: Scott and White EPO/PPO	$12.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.85
Rate for Payer: Superior Health Plan EPO	$3.37

SHOE, POST-OP, MALE, M, SIZE 9-11

Facility

$24.79

Hospital Charge Code	992956
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.86

SHOE, POST-OP, MALE, M, SIZE 9-11

Facility

$24.79

Hospital Charge Code	992956
Hospital Revenue Code	270
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$17.85
Rate for Payer: Amerigroup CHIP/Medicaid	$2.23
Rate for Payer: BCBS of TX Blue Advantage	$7.44
Rate for Payer: BCBS of TX Blue Essentials	$8.92
Rate for Payer: BCBS of TX PPO	$9.92
Rate for Payer: Cash Price	$16.86
Rate for Payer: Cigna Medicaid	$17.85
Rate for Payer: Molina CHIP/Medicaid	$17.85
Rate for Payer: Multiplan Auto	$16.11
Rate for Payer: Multiplan Commercial	$16.11
Rate for Payer: Multiplan Workers Comp	$16.11
Rate for Payer: Parkland Medicaid	$17.85
Rate for Payer: Scott and White EPO/PPO	$12.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.85
Rate for Payer: Superior Health Plan EPO	$3.37

SHOE, POST-OP, MALE, S, SIZE 7-9

Facility

$24.79

Hospital Charge Code	992957
Hospital Revenue Code	270
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$17.85
Rate for Payer: Amerigroup CHIP/Medicaid	$2.23
Rate for Payer: BCBS of TX Blue Advantage	$7.44
Rate for Payer: BCBS of TX Blue Essentials	$8.92
Rate for Payer: BCBS of TX PPO	$9.92
Rate for Payer: Cash Price	$16.86
Rate for Payer: Cigna Medicaid	$17.85
Rate for Payer: Molina CHIP/Medicaid	$17.85
Rate for Payer: Multiplan Auto	$16.11
Rate for Payer: Multiplan Commercial	$16.11
Rate for Payer: Multiplan Workers Comp	$16.11
Rate for Payer: Parkland Medicaid	$17.85
Rate for Payer: Scott and White EPO/PPO	$12.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.85
Rate for Payer: Superior Health Plan EPO	$3.37

SHOE, POST-OP, MALE, S, SIZE 7-9

Facility

$24.79

Hospital Charge Code	992957
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.86

SHOE, POST-OP, MALE, XL, SIZE 13 AND GREATER

Facility

$164.46

Hospital Charge Code	993096
Hospital Revenue Code	270
Min. Negotiated Rate	$14.80
Max. Negotiated Rate	$118.41
Rate for Payer: Amerigroup CHIP/Medicaid	$14.80
Rate for Payer: BCBS of TX Blue Advantage	$49.34
Rate for Payer: BCBS of TX Blue Essentials	$59.21
Rate for Payer: BCBS of TX PPO	$65.78
Rate for Payer: Cash Price	$111.83
Rate for Payer: Cigna Medicaid	$118.41
Rate for Payer: Molina CHIP/Medicaid	$118.41
Rate for Payer: Multiplan Auto	$106.90
Rate for Payer: Multiplan Commercial	$106.90
Rate for Payer: Multiplan Workers Comp	$106.90
Rate for Payer: Parkland Medicaid	$118.41
Rate for Payer: Scott and White EPO/PPO	$82.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.41
Rate for Payer: Superior Health Plan EPO	$22.37

SHOE, POST-OP, MALE, XL, SIZE 13 AND GREATER

Facility

$164.46

Hospital Charge Code	993096
Hospital Revenue Code	270
Rate for Payer: Cash Price	$111.83

SHOE POST-OP SPEC1 -- DHF

Facility

$116.00

Hospital Charge Code	81144230
Hospital Revenue Code	271
Min. Negotiated Rate	$10.44
Max. Negotiated Rate	$83.52
Rate for Payer: Amerigroup CHIP/Medicaid	$10.44
Rate for Payer: BCBS of TX Blue Advantage	$34.80
Rate for Payer: BCBS of TX Blue Essentials	$41.76
Rate for Payer: BCBS of TX PPO	$46.40
Rate for Payer: Cash Price	$78.88
Rate for Payer: Cigna Medicaid	$83.52
Rate for Payer: Molina CHIP/Medicaid	$83.52
Rate for Payer: Multiplan Auto	$75.40
Rate for Payer: Multiplan Commercial	$75.40
Rate for Payer: Multiplan Workers Comp	$75.40
Rate for Payer: Parkland Medicaid	$83.52
Rate for Payer: Scott and White EPO/PPO	$58.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83.52
Rate for Payer: Superior Health Plan EPO	$15.78

SHOE POST-OP SPEC1 -- DHF

Facility

$116.00

Hospital Charge Code	81144230
Hospital Revenue Code	271
Rate for Payer: Cash Price	$78.88

SHOULDER AND ELBOW JOINT REPLACEMENT

Facility

$9,856.33

Service Code	APR-DRG 3222
Min. Negotiated Rate	$9,292.89
Max. Negotiated Rate	$9,856.33
Rate for Payer: Amerigroup CHIP/Medicaid	$9,292.89
Rate for Payer: Cigna Medicaid	$9,292.89
Rate for Payer: Molina CHIP/Medicaid	$9,292.89
Rate for Payer: Parkland Medicaid	$9,292.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,856.33

SHOULDER AND ELBOW JOINT REPLACEMENT

Facility

$21,082.98

Service Code	APR-DRG 3224
Min. Negotiated Rate	$19,877.77
Max. Negotiated Rate	$21,082.98
Rate for Payer: Amerigroup CHIP/Medicaid	$19,877.77
Rate for Payer: Cigna Medicaid	$19,877.77
Rate for Payer: Molina CHIP/Medicaid	$19,877.77
Rate for Payer: Parkland Medicaid	$19,877.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,082.98

SHOULDER AND ELBOW JOINT REPLACEMENT

Facility

$8,172.55

Service Code	APR-DRG 3221
Min. Negotiated Rate	$7,705.37
Max. Negotiated Rate	$8,172.55
Rate for Payer: Amerigroup CHIP/Medicaid	$7,705.37
Rate for Payer: Cigna Medicaid	$7,705.37
Rate for Payer: Molina CHIP/Medicaid	$7,705.37
Rate for Payer: Parkland Medicaid	$7,705.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,172.55

SHOULDER AND ELBOW JOINT REPLACEMENT

Facility

$13,264.61

Service Code	APR-DRG 3223
Min. Negotiated Rate	$12,506.33
Max. Negotiated Rate	$13,264.61
Rate for Payer: Amerigroup CHIP/Medicaid	$12,506.33
Rate for Payer: Cigna Medicaid	$12,506.33
Rate for Payer: Molina CHIP/Medicaid	$12,506.33
Rate for Payer: Parkland Medicaid	$12,506.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,264.61

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC

Facility

$37,601.00

Service Code	MSDRG 511
Min. Negotiated Rate	$15,886.78
Max. Negotiated Rate	$37,601.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,000.06
Rate for Payer: Amerigroup Medicare	$20,000.06
Rate for Payer: BCBS of TX Medicare	$20,000.06
Rate for Payer: Cigna Commercial	$26,782.67
Rate for Payer: Cigna Medicare	$20,000.06
Rate for Payer: Employer Direct Commercial	$20,000.06
Rate for Payer: Humana Medicare/TRICARE	$20,000.06
Rate for Payer: Molina Dual Medicare/Medicaid	$20,000.06
Rate for Payer: Molina Medicare	$20,000.06
Rate for Payer: Multiplan Auto	$37,601.00
Rate for Payer: Multiplan Commercial	$37,601.00
Rate for Payer: Multiplan Workers Comp	$37,601.00
Rate for Payer: Scott and White EPO/PPO	$17,316.25
Rate for Payer: Scott and White Medicare	$20,000.06
Rate for Payer: Superior Health Plan EPO	$20,000.06
Rate for Payer: Superior Health Plan Medicare	$20,000.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,000.06
Rate for Payer: Universal American Medicare	$20,000.06
Rate for Payer: Wellcare Medicare	$20,000.06
Rate for Payer: Wellmed Medicare	$20,000.06

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC

Facility

$54,873.90

Service Code	MSDRG 510
Min. Negotiated Rate	$23,498.64
Max. Negotiated Rate	$54,873.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,897.41
Rate for Payer: Amerigroup Medicare	$26,897.41
Rate for Payer: BCBS of TX Medicare	$26,897.41
Rate for Payer: Cigna Commercial	$38,904.04
Rate for Payer: Cigna Medicare	$26,897.41
Rate for Payer: Employer Direct Commercial	$26,897.41
Rate for Payer: Humana Medicare/TRICARE	$26,897.41
Rate for Payer: Molina Dual Medicare/Medicaid	$26,897.41
Rate for Payer: Molina Medicare	$26,897.41
Rate for Payer: Multiplan Auto	$54,873.90
Rate for Payer: Multiplan Commercial	$54,873.90
Rate for Payer: Multiplan Workers Comp	$54,873.90
Rate for Payer: Scott and White EPO/PPO	$25,270.88
Rate for Payer: Scott and White Medicare	$26,897.41
Rate for Payer: Superior Health Plan EPO	$26,897.41
Rate for Payer: Superior Health Plan Medicare	$26,897.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,897.41
Rate for Payer: Universal American Medicare	$26,897.41
Rate for Payer: Wellcare Medicare	$26,897.41
Rate for Payer: Wellmed Medicare	$26,897.41

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$30,523.50

Service Code	MSDRG 512
Min. Negotiated Rate	$13,090.06
Max. Negotiated Rate	$30,523.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,892.55
Rate for Payer: Amerigroup Medicare	$16,892.55
Rate for Payer: BCBS of TX Medicare	$16,892.55
Rate for Payer: Cigna Commercial	$21,321.55
Rate for Payer: Cigna Medicare	$16,892.55
Rate for Payer: Employer Direct Commercial	$16,892.55
Rate for Payer: Humana Medicare/TRICARE	$16,892.55
Rate for Payer: Molina Dual Medicare/Medicaid	$16,892.55
Rate for Payer: Molina Medicare	$16,892.55
Rate for Payer: Multiplan Auto	$30,523.50
Rate for Payer: Multiplan Commercial	$30,523.50
Rate for Payer: Multiplan Workers Comp	$30,523.50
Rate for Payer: Scott and White EPO/PPO	$14,056.88
Rate for Payer: Scott and White Medicare	$16,892.55
Rate for Payer: Superior Health Plan EPO	$16,892.55
Rate for Payer: Superior Health Plan Medicare	$16,892.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,892.55
Rate for Payer: Universal American Medicare	$16,892.55
Rate for Payer: Wellcare Medicare	$16,892.55
Rate for Payer: Wellmed Medicare	$16,892.55

SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W CC

Facility

$37,601.00

Service Code	MSDRG 511
Min. Negotiated Rate	$15,886.78
Max. Negotiated Rate	$37,601.00
Rate for Payer: BCBS of TX Blue Advantage	$15,886.78
Rate for Payer: BCBS of TX Blue Essentials	$19,062.29
Rate for Payer: BCBS of TX PPO	$21,181.14

Know your out-of-pocket cost for care.

All Charges