White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Speed trap graft prepkit

Facility

$490.32

Hospital Charge Code	8602528
Hospital Revenue Code	270
Rate for Payer: Cash Price	$333.42

Speed trap graft prepkit

Facility

$490.32

Hospital Charge Code	8602528
Hospital Revenue Code	270
Min. Negotiated Rate	$44.13
Max. Negotiated Rate	$353.03
Rate for Payer: Amerigroup CHIP/Medicaid	$44.13
Rate for Payer: BCBS of TX Blue Advantage	$147.10
Rate for Payer: BCBS of TX Blue Essentials	$176.52
Rate for Payer: BCBS of TX PPO	$196.13
Rate for Payer: Cash Price	$333.42
Rate for Payer: Cigna Medicaid	$353.03
Rate for Payer: Molina CHIP/Medicaid	$353.03
Rate for Payer: Multiplan Auto	$318.71
Rate for Payer: Multiplan Commercial	$318.71
Rate for Payer: Multiplan Workers Comp	$318.71
Rate for Payer: Parkland Medicaid	$353.03
Rate for Payer: Scott and White EPO/PPO	$245.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$353.03
Rate for Payer: Superior Health Plan EPO	$66.68

SPEEDTRAP GRAFT PREP SYSTEM

Facility

$562.96

Hospital Charge Code	131971
Hospital Revenue Code	272
Min. Negotiated Rate	$50.67
Max. Negotiated Rate	$405.33
Rate for Payer: Amerigroup CHIP/Medicaid	$50.67
Rate for Payer: BCBS of TX Blue Advantage	$168.89
Rate for Payer: BCBS of TX Blue Essentials	$202.67
Rate for Payer: BCBS of TX PPO	$225.18
Rate for Payer: Cash Price	$382.81
Rate for Payer: Cigna Medicaid	$405.33
Rate for Payer: Molina CHIP/Medicaid	$405.33
Rate for Payer: Multiplan Auto	$365.92
Rate for Payer: Multiplan Commercial	$365.92
Rate for Payer: Multiplan Workers Comp	$365.92
Rate for Payer: Parkland Medicaid	$405.33
Rate for Payer: Scott and White EPO/PPO	$281.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$405.33
Rate for Payer: Superior Health Plan EPO	$76.56

SPEEDTRAP GRAFT PREP SYSTEM

Facility

$562.96

Hospital Charge Code	131971
Hospital Revenue Code	272
Rate for Payer: Cash Price	$382.81

SPHINCTRTOME/HYDRATOME -- DHF

Facility

$1,770.60

Hospital Charge Code	80341126
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,204.01

SPHINCTRTOME/HYDRATOME -- DHF

Facility

$1,770.60

Hospital Charge Code	80341126
Hospital Revenue Code	272
Min. Negotiated Rate	$159.35
Max. Negotiated Rate	$1,274.83
Rate for Payer: Amerigroup CHIP/Medicaid	$159.35
Rate for Payer: BCBS of TX Blue Advantage	$531.18
Rate for Payer: BCBS of TX Blue Essentials	$637.42
Rate for Payer: BCBS of TX PPO	$708.24
Rate for Payer: Cash Price	$1,204.01
Rate for Payer: Cigna Medicaid	$1,274.83
Rate for Payer: Molina CHIP/Medicaid	$1,274.83
Rate for Payer: Multiplan Auto	$1,150.89
Rate for Payer: Multiplan Commercial	$1,150.89
Rate for Payer: Multiplan Workers Comp	$1,150.89
Rate for Payer: Parkland Medicaid	$1,274.83
Rate for Payer: Scott and White EPO/PPO	$885.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,274.83
Rate for Payer: Superior Health Plan EPO	$240.80

SPINAL DISORDERS AND INJURIES

Facility

$11,084.45

Service Code	APR-DRG 0402
Min. Negotiated Rate	$10,450.81
Max. Negotiated Rate	$11,084.45
Rate for Payer: Amerigroup CHIP/Medicaid	$10,450.81
Rate for Payer: Cigna Medicaid	$10,450.81
Rate for Payer: Molina CHIP/Medicaid	$10,450.81
Rate for Payer: Parkland Medicaid	$10,450.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,084.45

SPINAL DISORDERS AND INJURIES

Facility

$5,139.95

Service Code	APR-DRG 0401
Min. Negotiated Rate	$4,846.13
Max. Negotiated Rate	$5,139.95
Rate for Payer: Amerigroup CHIP/Medicaid	$4,846.13
Rate for Payer: Cigna Medicaid	$4,846.13
Rate for Payer: Molina CHIP/Medicaid	$4,846.13
Rate for Payer: Parkland Medicaid	$4,846.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,139.95

SPINAL DISORDERS AND INJURIES

Facility

$14,349.40

Service Code	APR-DRG 0403
Min. Negotiated Rate	$13,529.12
Max. Negotiated Rate	$14,349.40
Rate for Payer: Amerigroup CHIP/Medicaid	$13,529.12
Rate for Payer: Cigna Medicaid	$13,529.12
Rate for Payer: Molina CHIP/Medicaid	$13,529.12
Rate for Payer: Parkland Medicaid	$13,529.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,349.40

SPINAL DISORDERS AND INJURIES

Facility

$22,134.58

Service Code	APR-DRG 0404
Min. Negotiated Rate	$20,869.26
Max. Negotiated Rate	$22,134.58
Rate for Payer: Amerigroup CHIP/Medicaid	$20,869.26
Rate for Payer: Cigna Medicaid	$20,869.26
Rate for Payer: Molina CHIP/Medicaid	$20,869.26
Rate for Payer: Parkland Medicaid	$20,869.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,134.58

SPINAL DISORDERS AND INJURIES WITH CC/MCC

Facility

$33,835.20

Service Code	MSDRG 052
Min. Negotiated Rate	$14,623.44
Max. Negotiated Rate	$33,835.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,035.15
Rate for Payer: Amerigroup Medicare	$18,035.15
Rate for Payer: BCBS of TX Medicare	$18,035.15
Rate for Payer: Cigna Commercial	$22,936.70
Rate for Payer: Cigna Medicare	$18,035.15
Rate for Payer: Employer Direct Commercial	$18,035.15
Rate for Payer: Humana Medicare/TRICARE	$18,035.15
Rate for Payer: Molina Dual Medicare/Medicaid	$18,035.15
Rate for Payer: Molina Medicare	$18,035.15
Rate for Payer: Multiplan Auto	$33,835.20
Rate for Payer: Multiplan Commercial	$33,835.20
Rate for Payer: Multiplan Workers Comp	$33,835.20
Rate for Payer: Scott and White EPO/PPO	$15,582.00
Rate for Payer: Scott and White Medicare	$18,035.15
Rate for Payer: Superior Health Plan EPO	$18,035.15
Rate for Payer: Superior Health Plan Medicare	$18,035.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,035.15
Rate for Payer: Universal American Medicare	$18,035.15
Rate for Payer: Wellcare Medicare	$18,035.15
Rate for Payer: Wellmed Medicare	$18,035.15

SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC

Facility

$18,604.80

Service Code	MSDRG 053
Min. Negotiated Rate	$7,861.26
Max. Negotiated Rate	$18,604.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,936.66
Rate for Payer: Amerigroup Medicare	$11,936.66
Rate for Payer: BCBS of TX Medicare	$11,936.66
Rate for Payer: Cigna Commercial	$12,612.10
Rate for Payer: Cigna Medicare	$11,936.66
Rate for Payer: Employer Direct Commercial	$11,936.66
Rate for Payer: Humana Medicare/TRICARE	$11,936.66
Rate for Payer: Molina Dual Medicare/Medicaid	$11,936.66
Rate for Payer: Molina Medicare	$11,936.66
Rate for Payer: Multiplan Auto	$18,604.80
Rate for Payer: Multiplan Commercial	$18,604.80
Rate for Payer: Multiplan Workers Comp	$18,604.80
Rate for Payer: Scott and White EPO/PPO	$8,568.00
Rate for Payer: Scott and White Medicare	$11,936.66
Rate for Payer: Superior Health Plan EPO	$11,936.66
Rate for Payer: Superior Health Plan Medicare	$11,936.66
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,936.66
Rate for Payer: Universal American Medicare	$11,936.66
Rate for Payer: Wellcare Medicare	$11,936.66
Rate for Payer: Wellmed Medicare	$11,936.66

SPINAL DISORDERS & INJURIES W CC/MCC

Facility

$33,835.20

Service Code	MSDRG 052
Min. Negotiated Rate	$14,623.44
Max. Negotiated Rate	$33,835.20
Rate for Payer: BCBS of TX Blue Advantage	$14,623.44
Rate for Payer: BCBS of TX Blue Essentials	$17,546.43
Rate for Payer: BCBS of TX PPO	$19,496.79

SPINAL DISORDERS & INJURIES W/O CC/MCC

Facility

$18,604.80

Service Code	MSDRG 053
Min. Negotiated Rate	$7,861.26
Max. Negotiated Rate	$18,604.80
Rate for Payer: BCBS of TX Blue Advantage	$7,861.26
Rate for Payer: BCBS of TX Blue Essentials	$9,432.60
Rate for Payer: BCBS of TX PPO	$10,481.07

SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W CC

Facility

$113,298.90

Service Code	MSDRG 457
Min. Negotiated Rate	$48,463.80
Max. Negotiated Rate	$113,298.90
Rate for Payer: BCBS of TX Blue Advantage	$56,283.56
Rate for Payer: BCBS of TX Blue Essentials	$67,533.73
Rate for Payer: BCBS of TX PPO	$75,040.38

SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W MCC

Facility

$159,664.60

Service Code	MSDRG 456
Min. Negotiated Rate	$66,348.81
Max. Negotiated Rate	$159,664.60
Rate for Payer: BCBS of TX Blue Advantage	$78,476.72
Rate for Payer: BCBS of TX Blue Essentials	$94,162.94
Rate for Payer: BCBS of TX PPO	$104,629.54

SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W/O CC/MCC

Facility

$79,279.40

Service Code	MSDRG 458
Min. Negotiated Rate	$35,341.17
Max. Negotiated Rate	$79,279.40
Rate for Payer: BCBS of TX Blue Advantage	$44,042.32
Rate for Payer: BCBS of TX Blue Essentials	$52,845.66
Rate for Payer: BCBS of TX PPO	$58,719.68

SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES

Facility

$11,469.94

Service Code	APR-DRG 3212
Min. Negotiated Rate	$10,814.26
Max. Negotiated Rate	$11,469.94
Rate for Payer: Amerigroup CHIP/Medicaid	$10,814.26
Rate for Payer: Cigna Medicaid	$10,814.26
Rate for Payer: Molina CHIP/Medicaid	$10,814.26
Rate for Payer: Parkland Medicaid	$10,814.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,469.94

SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES

Facility

$14,935.55

Service Code	APR-DRG 3213
Min. Negotiated Rate	$14,081.76
Max. Negotiated Rate	$14,935.55
Rate for Payer: Amerigroup CHIP/Medicaid	$14,081.76
Rate for Payer: Cigna Medicaid	$14,081.76
Rate for Payer: Molina CHIP/Medicaid	$14,081.76
Rate for Payer: Parkland Medicaid	$14,081.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,935.55

SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES

Facility

$22,751.29

Service Code	APR-DRG 3214
Min. Negotiated Rate	$21,450.71
Max. Negotiated Rate	$22,751.29
Rate for Payer: Amerigroup CHIP/Medicaid	$21,450.71
Rate for Payer: Cigna Medicaid	$21,450.71
Rate for Payer: Molina CHIP/Medicaid	$21,450.71
Rate for Payer: Parkland Medicaid	$21,450.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,751.29

SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES

Facility

$9,059.33

Service Code	APR-DRG 3211
Min. Negotiated Rate	$8,541.45
Max. Negotiated Rate	$9,059.33
Rate for Payer: Amerigroup CHIP/Medicaid	$8,541.45
Rate for Payer: Cigna Medicaid	$8,541.45
Rate for Payer: Molina CHIP/Medicaid	$8,541.45
Rate for Payer: Parkland Medicaid	$8,541.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,059.33

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC

Facility

$113,298.90

Service Code	MSDRG 457
Min. Negotiated Rate	$48,463.80
Max. Negotiated Rate	$113,298.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$48,463.80
Rate for Payer: Amerigroup Medicare	$48,463.80
Rate for Payer: BCBS of TX Medicare	$48,463.80
Rate for Payer: Cigna Commercial	$76,804.73
Rate for Payer: Cigna Medicare	$48,463.80
Rate for Payer: Employer Direct Commercial	$48,463.80
Rate for Payer: Humana Medicare/TRICARE	$48,463.80
Rate for Payer: Molina Dual Medicare/Medicaid	$48,463.80
Rate for Payer: Molina Medicare	$48,463.80
Rate for Payer: Multiplan Auto	$113,298.90
Rate for Payer: Multiplan Commercial	$113,298.90
Rate for Payer: Multiplan Workers Comp	$113,298.90
Rate for Payer: Scott and White EPO/PPO	$52,177.12
Rate for Payer: Scott and White Medicare	$48,463.80
Rate for Payer: Superior Health Plan EPO	$48,463.80
Rate for Payer: Superior Health Plan Medicare	$48,463.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$48,463.80
Rate for Payer: Universal American Medicare	$48,463.80
Rate for Payer: Wellcare Medicare	$48,463.80
Rate for Payer: Wellmed Medicare	$48,463.80

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC

Facility

$159,664.60

Service Code	MSDRG 456
Min. Negotiated Rate	$66,348.81
Max. Negotiated Rate	$159,664.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$66,348.81
Rate for Payer: Amerigroup Medicare	$66,348.81
Rate for Payer: BCBS of TX Medicare	$66,348.81
Rate for Payer: Cigna Commercial	$108,235.79
Rate for Payer: Cigna Medicare	$66,348.81
Rate for Payer: Employer Direct Commercial	$66,348.81
Rate for Payer: Humana Medicare/TRICARE	$66,348.81
Rate for Payer: Molina Dual Medicare/Medicaid	$66,348.81
Rate for Payer: Molina Medicare	$66,348.81
Rate for Payer: Multiplan Auto	$159,664.60
Rate for Payer: Multiplan Commercial	$159,664.60
Rate for Payer: Multiplan Workers Comp	$159,664.60
Rate for Payer: Scott and White EPO/PPO	$73,529.75
Rate for Payer: Scott and White Medicare	$66,348.81
Rate for Payer: Superior Health Plan EPO	$66,348.81
Rate for Payer: Superior Health Plan Medicare	$66,348.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$66,348.81
Rate for Payer: Universal American Medicare	$66,348.81
Rate for Payer: Wellcare Medicare	$66,348.81
Rate for Payer: Wellmed Medicare	$66,348.81

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC

Facility

$79,279.40

Service Code	MSDRG 458
Min. Negotiated Rate	$35,341.17
Max. Negotiated Rate	$79,279.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35,341.17
Rate for Payer: Amerigroup Medicare	$35,341.17
Rate for Payer: BCBS of TX Medicare	$35,341.17
Rate for Payer: Cigna Commercial	$53,743.09
Rate for Payer: Cigna Medicare	$35,341.17
Rate for Payer: Employer Direct Commercial	$35,341.17
Rate for Payer: Humana Medicare/TRICARE	$35,341.17
Rate for Payer: Molina Dual Medicare/Medicaid	$35,341.17
Rate for Payer: Molina Medicare	$35,341.17
Rate for Payer: Multiplan Auto	$79,279.40
Rate for Payer: Multiplan Commercial	$79,279.40
Rate for Payer: Multiplan Workers Comp	$79,279.40
Rate for Payer: Scott and White EPO/PPO	$36,510.25
Rate for Payer: Scott and White Medicare	$35,341.17
Rate for Payer: Superior Health Plan EPO	$35,341.17
Rate for Payer: Superior Health Plan Medicare	$35,341.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$35,341.17
Rate for Payer: Universal American Medicare	$35,341.17
Rate for Payer: Wellcare Medicare	$35,341.17
Rate for Payer: Wellmed Medicare	$35,341.17

SPINAL FUSION EXCEPT CERVICAL W MCC

Facility

$73,208.12

Service Code	MSDRG 459
Min. Negotiated Rate	$54,909.28
Max. Negotiated Rate	$73,208.12
Rate for Payer: BCBS of TX Blue Advantage	$54,909.28
Rate for Payer: BCBS of TX Blue Essentials	$65,884.75
Rate for Payer: BCBS of TX PPO	$73,208.12

Know your out-of-pocket cost for care.

All Charges