White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SPINAL FUSION EXCEPT CERVICAL W/O MCC

Facility

$46,293.97

Service Code	MSDRG 460
Min. Negotiated Rate	$34,722.50
Max. Negotiated Rate	$46,293.97
Rate for Payer: BCBS of TX Blue Advantage	$34,722.50
Rate for Payer: BCBS of TX Blue Essentials	$41,662.96
Rate for Payer: BCBS of TX PPO	$46,293.97

Spinal Muscular Atrophy (SMA) SO

Facility

$702.75

Service Code	HCPCS 81329
Hospital Charge Code	9164982
Hospital Revenue Code	300
Rate for Payer: Cash Price	$477.87

Spinal Muscular Atrophy (SMA) SO

Facility

$702.75

Service Code	HCPCS 81329
Hospital Charge Code	9164982
Hospital Revenue Code	300
Min. Negotiated Rate	$53.43
Max. Negotiated Rate	$505.98
Rate for Payer: Amerigroup CHIP/Medicaid	$53.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$137.00
Rate for Payer: Amerigroup Medicare	$137.00
Rate for Payer: BCBS of TX Blue Advantage	$210.82
Rate for Payer: BCBS of TX Blue Essentials	$252.99
Rate for Payer: BCBS of TX Medicare	$137.00
Rate for Payer: BCBS of TX PPO	$281.10
Rate for Payer: Cash Price	$477.87
Rate for Payer: Cash Price	$477.87
Rate for Payer: Cigna Medicaid	$505.98
Rate for Payer: Cigna Medicare	$137.00
Rate for Payer: Employer Direct Commercial	$137.00
Rate for Payer: Humana Medicare/TRICARE	$137.00
Rate for Payer: Molina CHIP/Medicaid	$505.98
Rate for Payer: Molina Dual Medicare/Medicaid	$137.00
Rate for Payer: Molina Medicare	$137.00
Rate for Payer: Multiplan Auto	$456.79
Rate for Payer: Multiplan Commercial	$456.79
Rate for Payer: Multiplan Workers Comp	$456.79
Rate for Payer: Parkland Medicaid	$505.98
Rate for Payer: Scott and White EPO/PPO	$171.25
Rate for Payer: Scott and White Medicare	$137.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$505.98
Rate for Payer: Superior Health Plan EPO	$137.00
Rate for Payer: Superior Health Plan Medicare	$137.00
Rate for Payer: Universal American Dual Medicare/Medicaid	$137.00
Rate for Payer: Universal American Medicare	$137.00
Rate for Payer: Wellcare Medicare	$137.00
Rate for Payer: Wellmed Medicare	$137.00

Spinal, per interval cumulative, 15 Minutes

Facility

$2,105.00

Hospital Charge Code	9900042
Hospital Revenue Code	370
Min. Negotiated Rate	$189.45
Max. Negotiated Rate	$1,515.60
Rate for Payer: Amerigroup CHIP/Medicaid	$189.45
Rate for Payer: BCBS of TX Blue Advantage	$631.50
Rate for Payer: BCBS of TX Blue Essentials	$757.80
Rate for Payer: BCBS of TX PPO	$842.00
Rate for Payer: Cash Price	$1,431.40
Rate for Payer: Cigna Medicaid	$1,515.60
Rate for Payer: Molina CHIP/Medicaid	$1,515.60
Rate for Payer: Multiplan Auto	$1,368.25
Rate for Payer: Multiplan Commercial	$1,368.25
Rate for Payer: Multiplan Workers Comp	$1,368.25
Rate for Payer: Parkland Medicaid	$1,515.60
Rate for Payer: Scott and White EPO/PPO	$1,052.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,515.60
Rate for Payer: Superior Health Plan EPO	$286.28

Spinal, per interval cumulative, 15 Minutes

Facility

$2,105.00

Hospital Charge Code	9900042
Hospital Revenue Code	370
Rate for Payer: Cash Price	$1,431.40

Spinal, per unit cumulative, 15 Minutes

Facility

$625.00

Hospital Charge Code	9900043
Hospital Revenue Code	370
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$450.00
Rate for Payer: Amerigroup CHIP/Medicaid	$56.25
Rate for Payer: BCBS of TX Blue Advantage	$187.50
Rate for Payer: BCBS of TX Blue Essentials	$225.00
Rate for Payer: BCBS of TX PPO	$250.00
Rate for Payer: Cash Price	$425.00
Rate for Payer: Cigna Medicaid	$450.00
Rate for Payer: Molina CHIP/Medicaid	$450.00
Rate for Payer: Multiplan Auto	$406.25
Rate for Payer: Multiplan Commercial	$406.25
Rate for Payer: Multiplan Workers Comp	$406.25
Rate for Payer: Parkland Medicaid	$450.00
Rate for Payer: Scott and White EPO/PPO	$312.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$450.00
Rate for Payer: Superior Health Plan EPO	$85.00

Spinal, per unit cumulative, 15 Minutes

Facility

$625.00

Hospital Charge Code	9900043
Hospital Revenue Code	370
Rate for Payer: Cash Price	$425.00

SPINAL PROCEDURES

Facility

$7,573.96

Service Code	APR-DRG 0231
Min. Negotiated Rate	$7,140.99
Max. Negotiated Rate	$7,573.96
Rate for Payer: Amerigroup CHIP/Medicaid	$7,140.99
Rate for Payer: Cigna Medicaid	$7,140.99
Rate for Payer: Molina CHIP/Medicaid	$7,140.99
Rate for Payer: Parkland Medicaid	$7,140.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,573.96

SPINAL PROCEDURES

Facility

$22,434.07

Service Code	APR-DRG 0233
Min. Negotiated Rate	$21,151.63
Max. Negotiated Rate	$22,434.07
Rate for Payer: Amerigroup CHIP/Medicaid	$21,151.63
Rate for Payer: Cigna Medicaid	$21,151.63
Rate for Payer: Molina CHIP/Medicaid	$21,151.63
Rate for Payer: Parkland Medicaid	$21,151.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,434.07

SPINAL PROCEDURES

Facility

$11,012.79

Service Code	APR-DRG 0232
Min. Negotiated Rate	$10,383.24
Max. Negotiated Rate	$11,012.79
Rate for Payer: Amerigroup CHIP/Medicaid	$10,383.24
Rate for Payer: Cigna Medicaid	$10,383.24
Rate for Payer: Molina CHIP/Medicaid	$10,383.24
Rate for Payer: Parkland Medicaid	$10,383.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,012.79

SPINAL PROCEDURES

Facility

$46,081.56

Service Code	APR-DRG 0234
Min. Negotiated Rate	$43,447.31
Max. Negotiated Rate	$46,081.56
Rate for Payer: Amerigroup CHIP/Medicaid	$43,447.31
Rate for Payer: Cigna Medicaid	$43,447.31
Rate for Payer: Molina CHIP/Medicaid	$43,447.31
Rate for Payer: Parkland Medicaid	$43,447.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,081.56

SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS

Facility

$64,820.40

Service Code	MSDRG 029
Min. Negotiated Rate	$27,139.02
Max. Negotiated Rate	$64,820.40
Rate for Payer: BCBS of TX Blue Advantage	$27,139.02
Rate for Payer: BCBS of TX Blue Essentials	$32,563.67
Rate for Payer: BCBS of TX PPO	$36,183.26

SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS

Facility

$64,820.40

Service Code	MSDRG 029
Min. Negotiated Rate	$27,139.02
Max. Negotiated Rate	$64,820.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29,763.78
Rate for Payer: Amerigroup Medicare	$29,763.78
Rate for Payer: BCBS of TX Medicare	$29,763.78
Rate for Payer: Cigna Commercial	$43,941.41
Rate for Payer: Cigna Medicare	$29,763.78
Rate for Payer: Employer Direct Commercial	$29,763.78
Rate for Payer: Humana Medicare/TRICARE	$29,763.78
Rate for Payer: Molina Dual Medicare/Medicaid	$29,763.78
Rate for Payer: Molina Medicare	$29,763.78
Rate for Payer: Multiplan Auto	$64,820.40
Rate for Payer: Multiplan Commercial	$64,820.40
Rate for Payer: Multiplan Workers Comp	$64,820.40
Rate for Payer: Scott and White EPO/PPO	$29,851.50
Rate for Payer: Scott and White Medicare	$29,763.78
Rate for Payer: Superior Health Plan EPO	$29,763.78
Rate for Payer: Superior Health Plan Medicare	$29,763.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$29,763.78
Rate for Payer: Universal American Medicare	$29,763.78
Rate for Payer: Wellcare Medicare	$29,763.78
Rate for Payer: Wellmed Medicare	$29,763.78

SPINAL PROCEDURES WITH MCC

Facility

$114,157.70

Service Code	MSDRG 028
Min. Negotiated Rate	$46,223.28
Max. Negotiated Rate	$114,157.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$48,795.08
Rate for Payer: Amerigroup Medicare	$48,795.08
Rate for Payer: BCBS of TX Medicare	$48,795.08
Rate for Payer: Cigna Commercial	$77,386.90
Rate for Payer: Cigna Medicare	$48,795.08
Rate for Payer: Employer Direct Commercial	$48,795.08
Rate for Payer: Humana Medicare/TRICARE	$48,795.08
Rate for Payer: Molina Dual Medicare/Medicaid	$48,795.08
Rate for Payer: Molina Medicare	$48,795.08
Rate for Payer: Multiplan Auto	$114,157.70
Rate for Payer: Multiplan Commercial	$114,157.70
Rate for Payer: Multiplan Workers Comp	$114,157.70
Rate for Payer: Scott and White EPO/PPO	$52,572.62
Rate for Payer: Scott and White Medicare	$48,795.08
Rate for Payer: Superior Health Plan EPO	$48,795.08
Rate for Payer: Superior Health Plan Medicare	$48,795.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$48,795.08
Rate for Payer: Universal American Medicare	$48,795.08
Rate for Payer: Wellcare Medicare	$48,795.08
Rate for Payer: Wellmed Medicare	$48,795.08

SPINAL PROCEDURES WITHOUT CC/MCC

Facility

$41,708.80

Service Code	MSDRG 030
Min. Negotiated Rate	$18,711.02
Max. Negotiated Rate	$41,708.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,848.76
Rate for Payer: Amerigroup Medicare	$20,848.76
Rate for Payer: BCBS of TX Medicare	$20,848.76
Rate for Payer: Cigna Commercial	$28,274.18
Rate for Payer: Cigna Medicare	$20,848.76
Rate for Payer: Employer Direct Commercial	$20,848.76
Rate for Payer: Humana Medicare/TRICARE	$20,848.76
Rate for Payer: Molina Dual Medicare/Medicaid	$20,848.76
Rate for Payer: Molina Medicare	$20,848.76
Rate for Payer: Multiplan Auto	$41,708.80
Rate for Payer: Multiplan Commercial	$41,708.80
Rate for Payer: Multiplan Workers Comp	$41,708.80
Rate for Payer: Scott and White EPO/PPO	$19,208.00
Rate for Payer: Scott and White Medicare	$20,848.76
Rate for Payer: Superior Health Plan EPO	$20,848.76
Rate for Payer: Superior Health Plan Medicare	$20,848.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,848.76
Rate for Payer: Universal American Medicare	$20,848.76
Rate for Payer: Wellcare Medicare	$20,848.76
Rate for Payer: Wellmed Medicare	$20,848.76

SPINAL PROCEDURES W MCC

Facility

$114,157.70

Service Code	MSDRG 028
Min. Negotiated Rate	$46,223.28
Max. Negotiated Rate	$114,157.70
Rate for Payer: BCBS of TX Blue Advantage	$46,223.28
Rate for Payer: BCBS of TX Blue Essentials	$55,462.56
Rate for Payer: BCBS of TX PPO	$61,627.46

SPINAL PROCEDURES W/O CC/MCC

Facility

$41,708.80

Service Code	MSDRG 030
Min. Negotiated Rate	$18,711.02
Max. Negotiated Rate	$41,708.80
Rate for Payer: BCBS of TX Blue Advantage	$18,711.02
Rate for Payer: BCBS of TX Blue Essentials	$22,451.05
Rate for Payer: BCBS of TX PPO	$24,946.58

Spinal puncture, lumbar, diagnostic

Facility

$2,221.07

Service Code	HCPCS 62270
Hospital Charge Code	8912630
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$1,510.33
Rate for Payer: Cash Price	$1,510.33
Rate for Payer: Cash Price	$1,510.33
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$1,599.17
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$1,599.17
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$1,599.17
Rate for Payer: Scott and White EPO/PPO	$1,311.84
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,599.17
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

Spinal puncture, lumbar, diagnostic

Facility

$2,221.07

Service Code	HCPCS 62270
Hospital Charge Code	8912630
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,510.33

Spinal puncture, lumbar, diagnostic

Facility

$2,221.07

Service Code	HCPCS 62270
Hospital Charge Code	9900741
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$1,510.33
Rate for Payer: Cash Price	$1,510.33
Rate for Payer: Cash Price	$1,510.33
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$1,599.17
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$1,599.17
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$1,599.17
Rate for Payer: Scott and White EPO/PPO	$1,311.84
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,599.17
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

Spinal puncture, lumbar, diagnostic

Facility

$10,000.00

Service Code	CPT 62270
Hospital Charge Code	36062270
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$1,311.84
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

Spinal puncture, lumbar, diagnostic

Facility

$2,221.07

Service Code	HCPCS 62270
Hospital Charge Code	9900741
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,510.33

Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)

Facility

$3,172.95

Service Code	HCPCS 62272
Hospital Charge Code	2161020
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$2,157.61
Rate for Payer: Cash Price	$2,157.61
Rate for Payer: Cash Price	$2,157.61
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$2,284.52
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$2,284.52
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$2,284.52
Rate for Payer: Scott and White EPO/PPO	$1,311.84
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,284.52
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)

Facility

$3,172.95

Service Code	HCPCS 62272
Hospital Charge Code	2161020
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,157.61

Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)

Facility

$10,000.00

Service Code	CPT 62272
Hospital Charge Code	36062272
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$1,311.84
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

Know your out-of-pocket cost for care.

All Charges