White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES

Facility

$6,201.36

Service Code	APR-DRG 3121
Min. Negotiated Rate	$5,846.86
Max. Negotiated Rate	$6,201.36
Rate for Payer: Amerigroup CHIP/Medicaid	$5,846.86
Rate for Payer: Cigna Medicaid	$5,846.86
Rate for Payer: Molina CHIP/Medicaid	$5,846.86
Rate for Payer: Parkland Medicaid	$5,846.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,201.36

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES

Facility

$9,349.01

Service Code	APR-DRG 3122
Min. Negotiated Rate	$8,814.57
Max. Negotiated Rate	$9,349.01
Rate for Payer: Amerigroup CHIP/Medicaid	$8,814.57
Rate for Payer: Cigna Medicaid	$8,814.57
Rate for Payer: Molina CHIP/Medicaid	$8,814.57
Rate for Payer: Parkland Medicaid	$8,814.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,349.01

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES

Facility

$27,147.42

Service Code	APR-DRG 3124
Min. Negotiated Rate	$25,595.54
Max. Negotiated Rate	$27,147.42
Rate for Payer: Amerigroup CHIP/Medicaid	$25,595.54
Rate for Payer: Cigna Medicaid	$25,595.54
Rate for Payer: Molina CHIP/Medicaid	$25,595.54
Rate for Payer: Parkland Medicaid	$25,595.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,147.42

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES

Facility

$14,475.76

Service Code	APR-DRG 3123
Min. Negotiated Rate	$13,648.25
Max. Negotiated Rate	$14,475.76
Rate for Payer: Amerigroup CHIP/Medicaid	$13,648.25
Rate for Payer: Cigna Medicaid	$13,648.25
Rate for Payer: Molina CHIP/Medicaid	$13,648.25
Rate for Payer: Parkland Medicaid	$13,648.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,475.76

SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W CC

Facility

$50,363.30

Service Code	MSDRG 577
Min. Negotiated Rate	$21,579.12
Max. Negotiated Rate	$50,363.30
Rate for Payer: BCBS of TX Blue Advantage	$21,579.12
Rate for Payer: BCBS of TX Blue Essentials	$25,892.43
Rate for Payer: BCBS of TX PPO	$28,770.49

SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W MCC

Facility

$93,122.80

Service Code	MSDRG 576
Min. Negotiated Rate	$40,681.11
Max. Negotiated Rate	$93,122.80
Rate for Payer: BCBS of TX Blue Advantage	$41,974.02
Rate for Payer: BCBS of TX Blue Essentials	$50,363.94
Rate for Payer: BCBS of TX PPO	$55,962.11

SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W/O CC/MCC

Facility

$30,521.60

Service Code	MSDRG 578
Min. Negotiated Rate	$13,155.42
Max. Negotiated Rate	$30,521.60
Rate for Payer: BCBS of TX Blue Advantage	$13,155.42
Rate for Payer: BCBS of TX Blue Essentials	$15,784.97
Rate for Payer: BCBS of TX PPO	$17,539.54

SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$34,148.05

Service Code	APR-DRG 3614
Min. Negotiated Rate	$32,195.98
Max. Negotiated Rate	$34,148.05
Rate for Payer: Amerigroup CHIP/Medicaid	$32,195.98
Rate for Payer: Cigna Medicaid	$32,195.98
Rate for Payer: Molina CHIP/Medicaid	$32,195.98
Rate for Payer: Parkland Medicaid	$32,195.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34,148.05

SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$14,793.35

Service Code	APR-DRG 3613
Min. Negotiated Rate	$13,947.69
Max. Negotiated Rate	$14,793.35
Rate for Payer: Amerigroup CHIP/Medicaid	$13,947.69
Rate for Payer: Cigna Medicaid	$13,947.69
Rate for Payer: Molina CHIP/Medicaid	$13,947.69
Rate for Payer: Parkland Medicaid	$13,947.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,793.35

SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$7,094.93

Service Code	APR-DRG 3611
Min. Negotiated Rate	$6,689.34
Max. Negotiated Rate	$7,094.93
Rate for Payer: Amerigroup CHIP/Medicaid	$6,689.34
Rate for Payer: Cigna Medicaid	$6,689.34
Rate for Payer: Molina CHIP/Medicaid	$6,689.34
Rate for Payer: Parkland Medicaid	$6,689.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,094.93

SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$13,269.51

Service Code	APR-DRG 3612
Min. Negotiated Rate	$12,510.96
Max. Negotiated Rate	$13,269.51
Rate for Payer: Amerigroup CHIP/Medicaid	$12,510.96
Rate for Payer: Cigna Medicaid	$12,510.96
Rate for Payer: Molina CHIP/Medicaid	$12,510.96
Rate for Payer: Parkland Medicaid	$12,510.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,269.51

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W CC

Facility

$65,956.60

Service Code	MSDRG 574
Min. Negotiated Rate	$26,194.74
Max. Negotiated Rate	$65,956.60
Rate for Payer: BCBS of TX Blue Advantage	$26,194.74
Rate for Payer: BCBS of TX Blue Essentials	$31,430.64
Rate for Payer: BCBS of TX PPO	$34,924.29

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$65,956.60

Service Code	MSDRG 574
Min. Negotiated Rate	$26,194.74
Max. Negotiated Rate	$65,956.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,202.06
Rate for Payer: Amerigroup Medicare	$30,202.06
Rate for Payer: BCBS of TX Medicare	$30,202.06
Rate for Payer: Cigna Commercial	$44,711.63
Rate for Payer: Cigna Medicare	$30,202.06
Rate for Payer: Employer Direct Commercial	$30,202.06
Rate for Payer: Humana Medicare/TRICARE	$30,202.06
Rate for Payer: Molina Dual Medicare/Medicaid	$30,202.06
Rate for Payer: Molina Medicare	$30,202.06
Rate for Payer: Multiplan Auto	$65,956.60
Rate for Payer: Multiplan Commercial	$65,956.60
Rate for Payer: Multiplan Workers Comp	$65,956.60
Rate for Payer: Scott and White EPO/PPO	$30,374.75
Rate for Payer: Scott and White Medicare	$30,202.06
Rate for Payer: Superior Health Plan EPO	$30,202.06
Rate for Payer: Superior Health Plan Medicare	$30,202.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,202.06
Rate for Payer: Universal American Medicare	$30,202.06
Rate for Payer: Wellcare Medicare	$30,202.06
Rate for Payer: Wellmed Medicare	$30,202.06

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$124,476.60

Service Code	MSDRG 573
Min. Negotiated Rate	$45,162.90
Max. Negotiated Rate	$124,476.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$52,775.46
Rate for Payer: Amerigroup Medicare	$52,775.46
Rate for Payer: BCBS of TX Medicare	$52,775.46
Rate for Payer: Cigna Commercial	$84,382.03
Rate for Payer: Cigna Medicare	$52,775.46
Rate for Payer: Employer Direct Commercial	$52,775.46
Rate for Payer: Humana Medicare/TRICARE	$52,775.46
Rate for Payer: Molina Dual Medicare/Medicaid	$52,775.46
Rate for Payer: Molina Medicare	$52,775.46
Rate for Payer: Multiplan Auto	$124,476.60
Rate for Payer: Multiplan Commercial	$124,476.60
Rate for Payer: Multiplan Workers Comp	$124,476.60
Rate for Payer: Scott and White EPO/PPO	$57,324.75
Rate for Payer: Scott and White Medicare	$52,775.46
Rate for Payer: Superior Health Plan EPO	$52,775.46
Rate for Payer: Superior Health Plan Medicare	$52,775.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$52,775.46
Rate for Payer: Universal American Medicare	$52,775.46
Rate for Payer: Wellcare Medicare	$52,775.46
Rate for Payer: Wellmed Medicare	$52,775.46

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$31,038.40

Service Code	MSDRG 575
Min. Negotiated Rate	$14,294.00
Max. Negotiated Rate	$31,038.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,930.35
Rate for Payer: Amerigroup Medicare	$17,930.35
Rate for Payer: BCBS of TX Medicare	$17,930.35
Rate for Payer: Cigna Commercial	$21,040.77
Rate for Payer: Cigna Medicare	$17,930.35
Rate for Payer: Employer Direct Commercial	$17,930.35
Rate for Payer: Humana Medicare/TRICARE	$17,930.35
Rate for Payer: Molina Dual Medicare/Medicaid	$17,930.35
Rate for Payer: Molina Medicare	$17,930.35
Rate for Payer: Multiplan Auto	$31,038.40
Rate for Payer: Multiplan Commercial	$31,038.40
Rate for Payer: Multiplan Workers Comp	$31,038.40
Rate for Payer: Scott and White EPO/PPO	$14,294.00
Rate for Payer: Scott and White Medicare	$17,930.35
Rate for Payer: Superior Health Plan EPO	$17,930.35
Rate for Payer: Superior Health Plan Medicare	$17,930.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,930.35
Rate for Payer: Universal American Medicare	$17,930.35
Rate for Payer: Wellcare Medicare	$17,930.35
Rate for Payer: Wellmed Medicare	$17,930.35

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W MCC

Facility

$124,476.60

Service Code	MSDRG 573
Min. Negotiated Rate	$45,162.90
Max. Negotiated Rate	$124,476.60
Rate for Payer: BCBS of TX Blue Advantage	$45,162.90
Rate for Payer: BCBS of TX Blue Essentials	$54,190.23
Rate for Payer: BCBS of TX PPO	$60,213.70

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC

Facility

$31,038.40

Service Code	MSDRG 575
Min. Negotiated Rate	$14,294.00
Max. Negotiated Rate	$31,038.40
Rate for Payer: BCBS of TX Blue Advantage	$15,123.96
Rate for Payer: BCBS of TX Blue Essentials	$18,146.99
Rate for Payer: BCBS of TX PPO	$20,164.11

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$34,084.10

Service Code	MSDRG 623
Min. Negotiated Rate	$15,696.62
Max. Negotiated Rate	$34,084.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,907.63
Rate for Payer: Amerigroup Medicare	$17,907.63
Rate for Payer: BCBS of TX Medicare	$17,907.63
Rate for Payer: Cigna Commercial	$23,105.43
Rate for Payer: Cigna Medicare	$17,907.63
Rate for Payer: Employer Direct Commercial	$17,907.63
Rate for Payer: Humana Medicare/TRICARE	$17,907.63
Rate for Payer: Molina Dual Medicare/Medicaid	$17,907.63
Rate for Payer: Molina Medicare	$17,907.63
Rate for Payer: Multiplan Auto	$34,084.10
Rate for Payer: Multiplan Commercial	$34,084.10
Rate for Payer: Multiplan Workers Comp	$34,084.10
Rate for Payer: Scott and White EPO/PPO	$15,696.62
Rate for Payer: Scott and White Medicare	$17,907.63
Rate for Payer: Superior Health Plan EPO	$17,907.63
Rate for Payer: Superior Health Plan Medicare	$17,907.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,907.63
Rate for Payer: Universal American Medicare	$17,907.63
Rate for Payer: Wellcare Medicare	$17,907.63
Rate for Payer: Wellmed Medicare	$17,907.63

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$67,624.80

Service Code	MSDRG 622
Min. Negotiated Rate	$30,845.56
Max. Negotiated Rate	$67,624.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,845.56
Rate for Payer: Amerigroup Medicare	$30,845.56
Rate for Payer: BCBS of TX Medicare	$30,845.56
Rate for Payer: Cigna Commercial	$45,842.50
Rate for Payer: Cigna Medicare	$30,845.56
Rate for Payer: Employer Direct Commercial	$30,845.56
Rate for Payer: Humana Medicare/TRICARE	$30,845.56
Rate for Payer: Molina Dual Medicare/Medicaid	$30,845.56
Rate for Payer: Molina Medicare	$30,845.56
Rate for Payer: Multiplan Auto	$67,624.80
Rate for Payer: Multiplan Commercial	$67,624.80
Rate for Payer: Multiplan Workers Comp	$67,624.80
Rate for Payer: Scott and White EPO/PPO	$31,143.00
Rate for Payer: Scott and White Medicare	$30,845.56
Rate for Payer: Superior Health Plan EPO	$30,845.56
Rate for Payer: Superior Health Plan Medicare	$30,845.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,845.56
Rate for Payer: Universal American Medicare	$30,845.56
Rate for Payer: Wellcare Medicare	$30,845.56
Rate for Payer: Wellmed Medicare	$30,845.56

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$23,786.10

Service Code	MSDRG 624
Min. Negotiated Rate	$10,954.12
Max. Negotiated Rate	$23,786.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,935.29
Rate for Payer: Amerigroup Medicare	$13,935.29
Rate for Payer: BCBS of TX Medicare	$13,935.29
Rate for Payer: Cigna Commercial	$16,124.47
Rate for Payer: Cigna Medicare	$13,935.29
Rate for Payer: Employer Direct Commercial	$13,935.29
Rate for Payer: Humana Medicare/TRICARE	$13,935.29
Rate for Payer: Molina Dual Medicare/Medicaid	$13,935.29
Rate for Payer: Molina Medicare	$13,935.29
Rate for Payer: Multiplan Auto	$23,786.10
Rate for Payer: Multiplan Commercial	$23,786.10
Rate for Payer: Multiplan Workers Comp	$23,786.10
Rate for Payer: Scott and White EPO/PPO	$10,954.12
Rate for Payer: Scott and White Medicare	$13,935.29
Rate for Payer: Superior Health Plan EPO	$13,935.29
Rate for Payer: Superior Health Plan Medicare	$13,935.29
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,935.29
Rate for Payer: Universal American Medicare	$13,935.29
Rate for Payer: Wellcare Medicare	$13,935.29
Rate for Payer: Wellmed Medicare	$13,935.29

SKIN GRAFTS FOR INJURIES W CC/MCC

Facility

$69,788.90

Service Code	MSDRG 904
Min. Negotiated Rate	$27,743.60
Max. Negotiated Rate	$69,788.90
Rate for Payer: BCBS of TX Blue Advantage	$27,743.60
Rate for Payer: BCBS of TX Blue Essentials	$33,289.09
Rate for Payer: BCBS of TX PPO	$36,989.32

SKIN GRAFTS FOR INJURIES WITH CC/MCC

Facility

$69,788.90

Service Code	MSDRG 904
Min. Negotiated Rate	$27,743.60
Max. Negotiated Rate	$69,788.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$31,680.32
Rate for Payer: Amerigroup Medicare	$31,680.32
Rate for Payer: BCBS of TX Medicare	$31,680.32
Rate for Payer: Cigna Commercial	$47,309.53
Rate for Payer: Cigna Medicare	$31,680.32
Rate for Payer: Employer Direct Commercial	$31,680.32
Rate for Payer: Humana Medicare/TRICARE	$31,680.32
Rate for Payer: Molina Dual Medicare/Medicaid	$31,680.32
Rate for Payer: Molina Medicare	$31,680.32
Rate for Payer: Multiplan Auto	$69,788.90
Rate for Payer: Multiplan Commercial	$69,788.90
Rate for Payer: Multiplan Workers Comp	$69,788.90
Rate for Payer: Scott and White EPO/PPO	$32,139.62
Rate for Payer: Scott and White Medicare	$31,680.32
Rate for Payer: Superior Health Plan EPO	$31,680.32
Rate for Payer: Superior Health Plan Medicare	$31,680.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$31,680.32
Rate for Payer: Universal American Medicare	$31,680.32
Rate for Payer: Wellcare Medicare	$31,680.32
Rate for Payer: Wellmed Medicare	$31,680.32

SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC

Facility

$27,204.20

Service Code	MSDRG 905
Min. Negotiated Rate	$12,528.25
Max. Negotiated Rate	$27,204.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,631.95
Rate for Payer: Amerigroup Medicare	$15,631.95
Rate for Payer: BCBS of TX Medicare	$15,631.95
Rate for Payer: Cigna Commercial	$18,441.58
Rate for Payer: Cigna Medicare	$15,631.95
Rate for Payer: Employer Direct Commercial	$15,631.95
Rate for Payer: Humana Medicare/TRICARE	$15,631.95
Rate for Payer: Molina Dual Medicare/Medicaid	$15,631.95
Rate for Payer: Molina Medicare	$15,631.95
Rate for Payer: Multiplan Auto	$27,204.20
Rate for Payer: Multiplan Commercial	$27,204.20
Rate for Payer: Multiplan Workers Comp	$27,204.20
Rate for Payer: Scott and White EPO/PPO	$12,528.25
Rate for Payer: Scott and White Medicare	$15,631.95
Rate for Payer: Superior Health Plan EPO	$15,631.95
Rate for Payer: Superior Health Plan Medicare	$15,631.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,631.95
Rate for Payer: Universal American Medicare	$15,631.95
Rate for Payer: Wellcare Medicare	$15,631.95
Rate for Payer: Wellmed Medicare	$15,631.95

SKIN GRAFTS FOR INJURIES W/O CC/MCC

Facility

$27,204.20

Service Code	MSDRG 905
Min. Negotiated Rate	$12,528.25
Max. Negotiated Rate	$27,204.20
Rate for Payer: BCBS of TX Blue Advantage	$15,215.12
Rate for Payer: BCBS of TX Blue Essentials	$18,256.37
Rate for Payer: BCBS of TX PPO	$20,285.65

SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC

Facility

$34,084.10

Service Code	MSDRG 623
Min. Negotiated Rate	$15,696.62
Max. Negotiated Rate	$34,084.10
Rate for Payer: BCBS of TX Blue Advantage	$16,539.52
Rate for Payer: BCBS of TX Blue Essentials	$19,845.50
Rate for Payer: BCBS of TX PPO	$22,051.41

Know your out-of-pocket cost for care.

All Charges